Putnam Center

Based on record review and staff interview, the facility failed to thoroughly investigate allegations of neglect This was true for two (2) of nine (9) residents reviewed during the survey process. Resident Identifiers: #47 and #102. Facility census: 116. Findings Include: b) NeglectOn 10/27/25 at approximately 3:00 PM, a review of a FRI dated 07/19/25. The review of the FRI found the allegation of neglect was made by Resident #102 and #47. The allegation was that neither resident had received incontinence care since 5:00 AM on 07/19/25. The residents reported this to NA #116 upon delivery of the lunch trays. NA #116 got another NA #130 to assist with the incontinence care for both residents at 1:00 PM. The assigned NA #135 was noted to be on her personal phone at the nurses' station and was rounding on the other residents on her hall. NA #130 stated, I was told I had to go to the dining room before I finished my last residents. However, NA #130 did not notify the other NAs regarding the need for incontinence care for the residents. After the investigation was completed, NA #135 was terminated. However, the investigation was found to be unverified. Upon completing the review of the investigation, the witness statements as well as the resident statements, did verify the allegation of neglect.An interview was held on 10/28/25 at approximately 10:00 AM, with the Administrator. The Administrator stated, I see what you are saying.

Based on record review, observation and staff interview, the facility failed to ensure a clean, safe, comfortable, home-like environment by not preventing odors throughout the building. This was a random opportunity for discovery and this failed practice had the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census:116.Findings included:a) On 10/27/2025, upon initial entrance to the building, the state surveyors observed a strong, unpleasant odor throughout the building. The odor was identified by the state surveyors during their initial tours and investigations in the facility. On 10/28/2025 at 09:35 AM, the state surveyor again smelled a strong odor throughout the facility when making rounds in the facility.b) On 10/27/2025 at 05:50 PM, the state surveyor interviewed the Corporate Registered Nurse nurse concerning odor/smell in the hallways observed by the state surveyors. The Corporate Registered Nurse confirmed the odor and stated, Almost smells like they have someone that's going somewhere. I'll have them look into it. c) The facility's policy and procedure for Resident Room Cleaning and Floor Care Policy stated, the Healthcare Services Group is committed to providing a safe, clean and hygienic environment for residents, staff, and visitors in accordance with regulatory guidance and industry best practices.

Based on resident interview, staff interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided to dependent residents. This was true for three (3) of three (3) residents reviewed during the survey process. Resident Identifiers: #93, #8, and #102. Facility Census: 116. Findings Include:
a) Resident #93
An interview was held with Resident #93 on 10/30/25 at 10:35 AM. Resident #93 stated, I have been trying to get a shower since Monday (10/27/25) so maybe I will get one tomorrow. I have had problems before with getting my showers but I think they are getting it worked out.
A review of showers from 09/01/25 through 10/30/25 was completed on 10/30/25 at 09/12/25-09/19/25 at 10:50 AM. The review found the following:
No showers from 10/03/25 to 10/14/25 which was 11 days.
No showers from 10/23/25 to 10/30/25 which was seven (7) days.
On 10/30/25 at 10:45 AM, Nurse Aide (NA) #24 was assisting this Surveyor with the shower book and schedule. NA #24 stated, I know why she didn't get one on Monday .the NA left at 3:00 PM and the next NA coming on should have gave her a shower.
On 10/30/25 at 11:00 AM, the Director of Nursing (DON) stated, I recently went around and asked the residents' preferences and redid the shower schedule. understand your concern .it looks like she went a long time without showers.
On 10/30/25 at 12:03PM, the DON stated, we don't have a policy or procedure regarding how often showers or bed baths are to be given .we offer biweekly showers .if the resident wants less or more we will do that .if the resident refuses it should be documented.
b) Resident #8
On 10/30/2025, Resident #8's shower care plan and tasks were reviewed. The resident's care plan indicated the resident was dependent for bathing. No showers were documented for the month of September 2025. and one (1) shower was documented for the month of October on 10/28/2025. On 10/30/25 at 11:03 AM, the Director of Nursing (DON) reported the staff should be documenting a bed bath everyday if no shower was given. It was their policy for a bed bath to be given everyday unless it is a shower day. On 10/30/2025 at 11:59 AM, the DON confirmed Resident#8 did not have showers and /or bed baths documented daily and reported there is no written policy for frequency of bed baths or showers, but residents are to be offered showers two (2) times a week and bed baths daily. Refusals would be documented under responses per the DON.
Resident #8's shower days are listed as every Wednesday and Sunday. No documentation of bed baths and/or showers for September and October were found on the following dates.: 09/01/2025, 02/-2/2025, 09/09/2025, 09/10/2025, 09/11/2025, 09/12/2025, 09/13/2025, 09/15/2025, 09/16/2025, 09//29/2025, 09/30/2025, 10/01/2025, 10/02/2025, 10/03/2025, 10/04/2025, 10/05/2025, 10/06/2025, 10/07/2025, 10/14/2025, 10/16/2025, 10/19/2025, 10/21/2025, 10/22/2025, and 10/27/202.
c) Resident #102
Interviews:
During an interview with Resident's wife on 10/30/25 at 9:30 AM she reported the facility does not give resident enough showers. She stated that she had talked to staff about trying different times with him and they tell her he refuses.
During an interview with Director of Nursing on 10/30/25 at approximately 12:30 PM she reported she had looked for documentation of shower refusals from Resident #102 and could not find any.
Document Review:
A review of Resident #102's Task section GG Bathing, Question 2 (two) for the month of October 2025, Resident had was given a shower on the following days:
10/01/25
10/08/25
10/28/25
On 10/30/25 review of resident's care plan he was up to dependent assist for bathing.
Review of shower schedule on 10/30/25 reveals resident is scheduled to receive showers on Day Shift, Wednesdays and Saturdays.

Based on record review and staff interview, the facility failed to revise a care plan for a residents fall interventions. This failed practice had the potential to affect a limited number of residents . Resident Identifier: #66. Facility Census: 116.Findings included: Resident # 66:On 10/27/2025 at 05:55 PM, an observation was completed for Resident #66. A low bed, fall mats to right side of the bed and the left side of the bed was against the wall. The resident was receiving 1:1 supervision initiated this date as reported by Nursing Assistant #51.The resident was ordered 1:1 for safety every day and night shift with a start date of 10/27/2025, floor mats x2 both right side of bed every day and night shift with a start date of 10:27/2025. No orders for low bed with parameter mattress was found. The only fall intervention on the resident's care plan was for a low bed parameter mattress. Both floor mats to the left side of the bed, bed against the wall or 1:1 supervision were not documented in the resident's care plan. On 10/28/2025 at 12:15 PM, the orders and care plan were confirmed by the Director of Nursing and the Corporate Registered Nurse

Based on record review and staff interview, the facility failed to ensure residents were free from neglect, and verbal abuse. This was true for seven (2) of nine (9) residents reviewed during the survey process. Resident Identifiers: #47, and #102. Facility Census: 116.
Findings include:
b) Resident #47 and #102
On 10/27/25 at approximately 3:00 PM, a review of a FRI dated 07/19/25. The review of the FRI found the allegation of neglect was made by Resident #102 and #47. The allegation was that neither resident had received incontinence care since 5:00 AM on 07/19/25. The residents reported this to NA #116 upon delivery of the lunch trays. NA #116 got another NA #130 to assist with the incontinence care for both residents at 1:00 PM. Asigned NA #135 was noted to be on her personal phone at the nurses' station and was rounding on the other residents on her hall. NA #135 stated, I was told I had to go to the dining room before I finished my last residents. However, NA #135 did not notify the other NAs regarding the need for incontinence care for the residents. After the investigation was completed, NA #135 was terminated. However, the investigation was found to be unverified. Upon completing the review of the investigation, the witness statements as well as the resident statements, did verify the allegation of neglect.
On 10/30/25 at 9:30 AM an interview with Resident # 102's wife was held via telephone about an incident she reported on 08/04/25.
She reported she walked into resident's room after lunch time on the morning of the incident. Resident's brief was so full it was crumbling and laying in pieces after having fallen apart. She stated a nurse was cleaning it up from the floor and cleaning her husband. She stated that he was red down there and the nurse was angry stating this was not acceptable. Resident's wife stated resident very rarely had redness in the groin area while living at home and they treated it but his skin was not red when he entered the facility. She stated no one told her the facility did not substantiate the complaint. She reported when she spoke with the administrator, he stated that he would take care of it and she has had no further complaints about her husband's care in that regard. She reported that he is not being bathed often.
An Interview on 10/30/25 at 10:52 AM with Licensed Practical Nurse (LPN) #36 revealed the following
LPN #36 reported she had been completing nursing duties earlier in the day and passing meds around 8:30 AM when she encountered Resident #102 who was covered with blankets. She did not check him or see anyone check him at this time, although she did see a nurse aide go into his room. She reported she took over nurse aide duties around 11:30 AM and was not given report before she took over the assignment. When she walked into Resident 102's room, he was wearing no brief, it smelled of foul odor of urine, parts of the brief all over the floor, and she had to ask housekeeping to help her clean it up. She stated that resident was a little reddened and she did not remember if the facility had already been giving him nystatin at that point or if he was prescribed a cream after.
An interview with Administrator on 10/30/25 12:30 PM revealed:
Administrator reported they do not always review the results of the incident investigations with the complainants unless they ask. He stated that he did try to take all sides into consideration and if there were other witnesses or if the alleged perpetrator was involved in any other investigations.
Review of Documentation on 10/30/25 for Resident #102 found:
Review of Progress Note dated 08/08/25 at 8:57 AM revealed a new, acquired in-house wound to the groin/genital area and describes it as Moisture Associated Skin Damage: Incontinence Associated Dermatitis MASD: IAD.
Review of document titled Five-day Follow-up dated for 08/07/25 revealed an interview with alleged perpetrator, who is no longer employed by the facility, reported that she had checked to see if resident was dry twice on the day of the incident before 8:00 AM and once again at 9:30 AM.

Based on observation, record review and staff interview, the facility failed to provide an environment free of accident hazards due to medication being at bedside for Resident #60. This was a random opportunity for discovery. Resident Identifier: #60. Facility Census: 116. Findings Include:a) Resident #60On 10/27/25 at 5:40 PM, an observation was made of the medication Clotrimazole & Betamethasone % cream in a tube at bedside. At this time, Licensed Practical Nurse (LPN) #69 was notified and removed the medication from the nightstand.On 10/27/25 at 5:48 PM, the Corporate Registered Nurse # 132 was notified and stated, let me have them check that there is no other medications at bedside.

Based on observation, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to serve meals in a sanitary manner by serving a cup that had been dropped on the floor to a resident during meal time. This was true during a random opportunity of discovery for Resident #102. Facility Census 116.Findings Included: a) On 10/29/25 at 11:52 AM Registered Nurse RN #130 was observed walking out of the kitchen holding a cup can a lid. She dropped the lip the the floor of the dining room, bent down to pick it up. She then placed it on the counter as she filled the cup with ice and drink and handed it to Nurse Aide #81 who had just walked over to her. Nurse Aide #81 then placed the lid onto the cup and handed it to Resident #102. This Surveyor asked Nurse Aide to replace the drink before resident drank out of it as it had been dropped in the floor and Nurse Aide did so. b) Interview with Director of Nursing on 10/29/25 at approximately 1:20 PM who acknowledged failure to maintain sanitary eating environment for this resident. c) Interview with RN #130 on 10/29/25 at approximately 3:20 PM, when asked about giving resident the dropped cup she reported that she did not realize she had done it until after. She stated that it was stupid.

Based on record review and staff interview, the facility failed to ensure the resident's medical record was accurate for physician orders for fall interventions and the medication route does not follow the physician's order for NPO (nothing by mouth). This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #66, #93, and #8. Facility Census: 116. Finding included:a) Resident # 66:On 10/27/2025 at 05:55 PM, an observation was completed for Resident #66. A low bed, fall mats to right side of the bed and the left side of the bed was against the wall. The resident was receiving 1:1 supervision initiated this date as reported by Nursing Assistant #51.The resident was ordered 1:1 for safety every day and night shift with a start date of 10/27/2025, floor mats x2 both right side of bed every day and night shift with a start date of 10:27/2025. No orders for low bed with parameter mattress was found. The only fall intervention on the care plan was for a low bed parameter mattress. The orders and care plan were confirmed by the Director of nursing and the Corporate Registered Nurse on 10/28/2025 at 12:15 PM.The resident had an order for NPO (nothing by mouth) diet NPO texture, NPO consistency, for Diet. Review of the resident's order summary revealed the resident had an order for Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable conscious and able to swallow and an order for Milk of Magnesia Suspension400MG/5ML (Magnesium Hydroxide) Give 30ml by mouth as needed for Constipation give at bedtime of no BM in 3 days. On 10/28/2025, at 12:15 PM, the orders were confirmed by the Director of Nursing and the Corporate Registered Nurse.The resident's order for NPO remained effective 05/10/2025 to current date. A review of the Medication Administration Record from 5/10/2025 to 10/28/2025 revealed the following medications were documented as given by mouth:1) Xanax from 05/27/2025 through 06/24/2025.2) Miralax Powder from 05/10/2025 through 06/26/2025.3) Prozac from 05/30/2025 through 06/01/2025.4) Vistaril from 05/24/2025 through 05/26/2025.5) Potassium from 07/08/2025.b) Resident #93:The resident was NPO from 07/31/25 through 09/25/2025. The Medication Administration Record had PO (oral) meds given in the month of August 2025 for Acetaminophen Tablet 325mg -Give 2 tablet by mouth every 6 hours as needed for pain, Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression, and Lasix Oral Tablet 40 MG - Give 1 tablet by mouth one time a day for Acute hypoxic respiratory failure. The Medication Administration Record had an PO meds given in the month of September 2025 for Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.c) Resident #8:The resident had an NPO order from 11/04/2024. with the most recent order clarified on 07//16/2025. The Medication Administration Record for 07/15/2025 through 10/28/2025 (discharged by mouth after surveyor intervention) had BusPiRone 5 mg 1 tablet by mouth every 12 hours for anxiety. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.

Based on record review and staff interview, the facility failed to ensure the pharmacist reported any irregularities to the attending physician, the facility's medical director and the director of nursing and the reports were acted upon. This failed practice was identified for three (3) out of three (3) residents with an NPO (nothing by mouth) order. Resident Identifier: #66, #93, and #8. Facility Census: 116. Findings included:a) The facility's Policy and Procedure for Medication Monitoring: Medication Regimen Review and Reporting stated, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regiment and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist by utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Sheet (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care.b) On 10/29/2025 at 12:24 PM, Pharmacist #138 was interviewed by a state surveyor via phone. The pharmacist reported the resident's ordered medications were reviewed for dosage and route and reported. Pharmacist #138 reported we look closely at the physician's order and if there is a discrepancy, we reach out to the facility or make a comment on our review. The pharmacist reported if she found documentation concerning discrepancies for Resident #66, Resident #8 and Resident #93's medication routes she would contact the state surveyor. c) The following orders and MARs were incorrect for the NPO (nothing by mouth) residents who were ordered medication by mouth:1. Resident #66:The resident had an order for NPO (nothing by mouth) diet NPO texture, NPO consistency, for Diet. Review of the resident's order summary revealed the resident had an order for Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable conscious and able to swallow and an order for Milk of Magnesia Suspension400MG/5ML (Magnesium Hydroxide) Give 30ml by mouth as needed for Constipation give at bedtime of no BM in 3 days. On 10/28/2025, at 12:15 PM, the orders were confirmed by the Director of Nursing and the Corporate Registered Nurse.The resident's order for NPO remained effective 05/10/2025 to current date. A review of the Medication Administration Record from 5/10/2025 to 10/28/2025 revealed the following medications were documented as given by mouth:- Xanax from 05/27/2025 through 06/24/2025.- Miralax Powder from 05/10/2025 through 06/26/2025.- Prozac from 05/30/2025 through 06/01/2025.- Vistaril from 05/24/2025 through 05/26/2025.- Potassium from 07/08/2025.No route discrepancies were indicated or reported on the resident's Medication Regimen Reviews.2. Resident #93:The resident was NPO from 07/31/25 through 09/25/2025. The Medication Administration Record had PO (oral) meds given in the month of August 2025 for Acetaminophen Tablet 325mg -Give 2 tablet by mouth every 6 hours as needed for pain, Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression, and Lasix Oral Tablet 40 MG - Give 1 tablet by mouth one time a day for Acute hypoxic respiratory failure. The Medication Administration Record had an PO meds given in the month of September 2025 for Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.No route discrepancies were indicated or reported on the resident's Medication Regimen Reviews.3. Resident #8:The resident had an NPO order from 11/04/2024. with the most recent order clarified on 07//16/2025. The Medication Administration Record for 07/15/2025 through 10/28/2025 (discharged by mouth after surveyor intervention) had BusPiRone 5 mg 1 tablet by mouth every 12 hours for anxiety. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.No route discrepancies were indicated or reported on the resident's Medication Regimen Reviews.

Based on record review, staff interview, and resident interview, the facility failed to ensure continuity of care by not seeking order clarification from the physician regarding oral medication orders for a resident who was NPO (nothing by mouth) and failed to ensure respiratory equipment was obtained for a newly admitted resident. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #66, #93, #8 and #121. Facility Census: 116.Findings included:The facility's policy and procedure for Medication Administration stated, Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record. The Job Aid: Physician Review v2004, given to the state surveyor by the facility, stated the physician orders will be reviewed on a nightly basis to ensure accuracy, completeness: compliance with State, Federal and JACHO requirements and that they are accurate and true reflection of the plan of care. )n 10/29/2025, the Director of Nursing reported there is no monthly review of orders by the nursing staff and the orders are just left for the physician to sign.a) Resident #66:The resident had an order for NPO (nothing by mouth) diet NPO texture, NPO consistency, for Diet. Review of the resident's order summary revealed the resident had an order for Insta-Glucose Gel 77.4% (Glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable conscious and able to swallow and an order for Milk of Magnesia Suspension400MG/5ML (Magnesium Hydroxide) Give 30ml by mouth as needed for Constipation give at bedtime of no BM in 3 days. On 10/28/2025, at 12:15 PM, the orders were confirmed by the Director of Nursing and the Corporate Registered Nurse.The resident's order for NPO remained effective 05/10/2025 to current date. A review of the Medication Administration Record from 5/10/2025 to 10/28/2025 revealed the following medications were documented as given by mouth:1) Xanax from 05/27/2025 through 06/24/2025.2) Miralax Powder from 05/10/2025 through 06/26/2025.3) Prozac from 05/30/2025 through 06/01/2025.4) Vistaril from 05/24/2025 through 05/26/2025.5) Potassium from 07/08/2025.b) Resident #93:The resident was NPO from 07/31/25 through 09/25/2025. The Medication Administration Record had PO (oral) meds given in the month of August 2025 for Acetaminophen Tablet 325mg -Give 2 tablet by mouth every 6 hours as needed for pain, Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression, and Lasix Oral Tablet 40 MG - Give 1 tablet by mouth one time a day for Acute hypoxic respiratory failure. The Medication Administration Record had an PO meds given in the month of September 2025 for Escitalopram Oxalate Tablet 10 MG - Give by mouth one time a day for Depression. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.c) Resident #8:The resident had an NPO order from 11/04/2024. with the most recent order clarified on 07//16/2025. The Medication Administration Record for 07/15/2025 through 10/28/2025 (discharged by mouth after surveyor intervention) had BusPiRone 5 mg 1 tablet by mouth every 12 hours for anxiety. On 10/29/2025 at 11:00 AM, the DON reported the medication was given via tube and that all the nurses know the patients that are NPO.d) Resident #21:On 10/27/2025 at 01:55 PM during an interview conducted by phone, Resident #121 reported the facility couldn't hook up the (Continuous Positive Airway Pressure) CPAP machine until next day and that there were no orders for me to even be there per nursing staff. Orders were reviewed from the hospital consult from 07/04/2025: The orders stated: Obstructive sleep apnea - Continue patient's home CPAP. On 10/28/2025 at 10:15 AM, the Director of Nursing (DON) stated that she wasn't sure if there was an order for the CPAP machine in the resident's admission orders. The policy is to have the equipment here when the patient arrives. The DON reported she was going to look at the paper trail. The DON also stated, Sometimes they don't have the settings for the C-Pap because Lincare sends them to the facility preset according to order from the hospital. On 10/28/2025 at 11:26 AM, the DON reported Lincare did not send the CPAP nor did they have the order. On 10/28/2025 at 01:25 PM , the DON confirmed the resident was discharged back to the hospital before physician orders, diagnosis list and care plan were initiated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This was a random opportunity for discovery. Resident Identifiers: room [ROOM NUMBER]A, 150A, 155, 156A, 161, 162A. Facility Census: 119.Findings Include:a) Bedside water cupsOn 09/18/25 at 12:30 PM during a walk through at the facility it was observed that several residents on the 100 hallway did not have fresh, if any, water at bedside. Residents in rooms #148A, 150A, 155, 156A, 161 and 162 had no, or room temperature water at bedside. Observation on 09/18/25 at 12:38 PM found the resident in 150A had been at bedside eating his noon meal. He had just finished. He had no drink with his meal. There were two staff members at the door and told the Resident they were taking him for an appointment. The surveyor ask the facility van driver (as identified on his name tag) if the resident was not allowed to have a drink. He stated, he has one around here some where. He took a cup from the night stand and placed it on the over the bed table as they took the resident out the door. It was confirmed with the Driver that the resident had no drink with his noon meal at that time, he agreed.On 09/18/25 at 12:30 PM the resident in room [ROOM NUMBER]A ask the surveyor for some ice. She stated she would like her Ginger Ale. (She had a can in her hand). The surveyor stated she would have someone check on it. The surveyor also ask the resident if they had passed fresh water and/or ice this morning. She stated No, the cup showed up sometime while I was asleep last night and there has been no fresh water or ice since. See, (as she shook her cup) it is empty.On 09/18/25 at 12:33 PM observation of the water cup for the resident in room [ROOM NUMBER]A found it to be empty. He ask the surveyor for some ice water. He states they do not bring fresh water very often and you just have to wait for lunch or dinner. Observation of rooms 148A, 155 and 156 also found the water cups to be either empty or just a small amount of water in the cup. The residents states that is warm water.On 09/18/25 at 12:38 PM when Nurse Aide #1 was ask when they pass ice/water she states usually every shift, with meals and as needed. But today I didn't finish my run until 11:00 AM and I have not had time to pass any today. But I have a nourishment tray to pass drinks with trays when they come. (Note: 11:00 AM to 12:38 PM was one hour and 38 minutes since she had finished her run.)It was confirmed on 09/18/25 at 12:38 PM with the Administrator and Nurse Aide #2 that the residents needed fresh water and/or ice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide a safe, clean, comfortable and homelike environment for the residents. This was a random opportunity for discovery. Resident Identifiers: Facility. Facility Census: 119Findings Included:a) Facility cleanlinessOn 09/18/25 at 12:25 PM observation found the floors in the facility to be cluttered with particles of paper, dust and spilled dried liquid in need of being swept and mopped. Trash cans were full and personal items were in the foor to the point of housekeeping not being able to sweep in some rooms. During a walk through with the Administrator he agreed, that in particular, the following rooms on that unit were the worst. room [ROOM NUMBER], 152, 153 and 154. On 09/18/25 at 12:45 PM he confirmed the faciity auto scrubber was down and the floors needed swept and mopped. b) Ceiling tilesOn 09/18/25 at 12:35 PM observation found that there were two (2) ceiling tiles outside the activity room that were dark in color as if something had leaked on them and they needed replaced. Also at the corner of the Nurses Station on the 100 unit there was a large ceiling trap door to the attic that was open. There was hot air coming into the facility from the attic. It was confirmed with the Administrator at this time that maintenance had been working in the attic on 09/17/25 and left the door open. He also verified the two ceiling tiles by the activity room needed replaced.c) LinensOn 09/18/25 at 12:50 PM observation found that several beds on the 100 hall were not made. Nurse Aide #1 stated Sorry, I would have made the beds but we are out of linen. When ask if this was a one time situation or if it happens often, she stated well, it happens sometimes. Observation of the clean linen closet found there were no fitted or flat sheets and no blankets. The Administrator verified the above and stated the laundry is working to get the back log out here.

Based on observation and staff interview the facility failed to follow Physicians orders by not placing heel boots on a resident to help prevent pressure ulcers to her heels. This was a random oportunity for discovery. Resident Identifier: #1 Facility Census: 119 Findings Include:a) Resident #1On 09/18/25 at 3:15 PM observation found that Resident #1 did not have her heel boots on as ordered from the Physician. On 09/18/25 at 3:25 PM Nurse Aide (NA) # 2 was asked if she could tell the surveyor why the resident did not have them on. NA #2 stated she did not know because she had just picked up that hall at noon. The surveyor ask NA #2 if she would please try and place the boots on the resident. When NA #2 obtained the boots from under the sink and ask Resident #1 if she wanted the boots on, the resident stated Yes, go ahead. On 09/18/25 at 3:30 PM it was confirmed with NA #2 and the Director of Nursing that Resident #1 did not have her heel boots on as ordered by the Physician.

Based on observation and staff interview, the facility failed to ensure Resident #264 was treated in a dignified manner due to being exposed, and in view of passersby and, by failing to knock before entering his room. This was a random opportunity for discovery. Resident identifier: #264. Facility census: 114.
Findings include:
a) Resident #264
At approximately 10:15 PM on 4/30/2025, Resident #264 was observed in his bed, uncovered, with his buttocks exposed and his catheter tubing visible coming from his groin area. Resident #264's door was open, and his curtain was not pulled, leaving him exposed to anyone that would pass by his room and look inside.
The Infection Prevention (IP) Nurse was in the hallway at the time and confirmed the resident was exposed. The IP nurse then entered the room to check on the resident, however, she did not knock before entering. When she entered the room, she asked Resident #264 if he was cold, to which he stated ,Yes. The IP nurse then asked Resident #264 if he needed her help covering himself up, to which he stated, Yes. Upon exiting the room, the IP nurse was asked if she knocked before entering the room, to which she stated No, I don't believe I did.

b) Resident #33
A record review on 05/05/25 at 12:31 PM, of Resident #33's Activity care plan dated 03/17/25 reads as follows:
Focus:
Prefers to be called (Resident #33 nickname), she is at risk for limited and/or meaningful
engagement r/t highly impaired vision. Prefers not to wear identification bracelet.
Goal
(Resident #33 nickname) will consistently accept and/or utilize adaptations and modifications to enable participation in activities of interest ongoing and through next review.
Interventions:
Offer room visits for socialization/talking/reminiscing, beauty/nail painting, daily chronicle reading, trivia if unavailable for group setting.
Encourage participation in activity preferences such as music/singing, coffee club, games/trivia, special/holiday events.
Provide resident/patient with opportunities for choice during care/activities to provide a sense of control.
Provide and review calendars with resident to identify interests and preferences.
Invite and assist resident/patient, as needed, to activities of interest.
Utilize adaptive techniques/equipment/modifications: such as reading aloud to resident, hand over hand guidance, clock method, provide 1:1 assistance/direction during preferred activities to enable participation.
Allergies Novocain, Strawberries, soap D.O
Provide appropriate cueing through physical prompt, physical assist, verbal direction, to enable successful participation in activity.
Guide hand, describe program and offer tactile, olfactory and auditory opportunities in a group and/or 1:1 setting.
Further record review of Resident #33's Activity Participation Records for the months of 11/2024, 12/2024, 01/2025, 02/2025, 03/2025, and 04/2025 revealed that the resident had only 6 days that she participated in group activities. The Activity Participation record further revealed that Resident #33 was not regularly receiving one to one visits, not getting the daily chronicle read to her as her care plan reads, and is not consistently getting assistance turning on TV/radio.
During an interview on 05/05/25 at 1:00 PM, The Activity Director (AD) stated,No, she is not on one to one visits, because we socialize with her when we are there. She was coming out and did coffee hour quite a bit. Her participation has gone down and I missed it. The AD further confirmed that the careplan for Resident #33 was not being followed.
Based on record review and staff interview, the facility failed to implement the care plans for Resident #87 related to non-pharmacological interventions before administration of PRN Ativan, and the care plan related to activities for Resident #33. This was true for two (2) of 31 care plans reviewed during the survey process. Resident identifiers: #87, and #33. Facility census: 114.
Findings include:
a) Resident #87
During a review of Resident #87's electronic health record on 5/1/2025, it was noted he had been prescribed Ativan on an as needed basis, four (4) times since October 2025. The orders were as follows:
-Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed for anxiety for three (3) months. Start date- 10/25/2024 10:00 AM. Discontinue date- 12/11/2024 10:45 PM.
-Ativan injection solution 2MG/ML. Inject 0.5 ml intramuscularly every 24 hours as needed for acute anxiety for 30 days. Start date- 10/25/2024 10:00 AM. This was discontinued on 11/24/2024.
-Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed for anxiety as evidenced by restlessness and agitation for three (3) months. Start date- 12/11/2024 10:45 PM. Discontinued on 3/11/2025
-Ativan oral tablet 0.5 MG. Give one (1) tablet by mouth every six (6) hours as needed for dementia. Start Date 3/26/2025 12:45 PM. Discontinue date 4/18/2025 1:02 PM. This order was discontinued after a pharmacy recommendation on 3/30/2025, which was responded to by the physician on 4/18/2025.
During the review of the Medication Administration Record (MAR) for Resident #87's PRN Ativan, it was noted there five (5) dates the resident was given the medication and non-pharmacological interventions were not attempted before it was administered. The dates were:
-11/12/24 at 8:30 PM
-11/14/24 at 8:42 AM
-11/14/24 at 8:23 PM
-11/16/24 at 9:22 AM
-3/26/25 at 12:50 PM
-3/27/25 at 10:30 AM
Non-pharmacological interventions were not tracked on the MAR at this time, instead they were documented in the resident's progress notes in his health record, under eMAR administration notes. The notes for the preceding days were reviewed and they stated the following (typed as written in the record):
11/12/2024 10:58 PM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Resident reports not feeling good. Reports he feels worried. Medication given per order.
11/14/2024 8:43 AM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Complaint of anxiety.
11/14/2024 8:23 PM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Anxious, worried about (resident's representative's name).
11/16/2024 9:22 AM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Complaint of anxiety.
3/26/2025 12:56 PM
Note Text:
Ativan oral tablet 0.5 MG
Give one (1) tablet by mouth every six (6) hours as needed for dementia.
Resident experiencing symptoms of psychosis. Medication administered per MD order.
3/27/2025 10:31 AM
Note Text:
Ativan oral tablet 0.5 MG
Give one (1) tablet by mouth every six (6) hours as needed for dementia.
Resident experiencing symptoms of psychosis. Medication administered per MD order.
The following was noted after reviewing the resident's care plan section related to mood and behaviors:
Focus:
(Resident #87's name) exhibits or is at risk for distressed/fluctuating mood symptoms related to: Sadness/depression, anxiety/fear, persistent anger/agitation caused by recent environmental changes (admission from LT psychiatric hospital placement), dx of Bipolar D/O, psychosis
and hallucinations
Date Initiated: 03/27/2024
Created on: 08/28/2023
Revision on: 03/27/2024
Goal:
(Resident #87's name) will respond to redirected (sic) when proved (sic) by staff in a calm manner daily through next review.
Date Initiated: 08/28/2023
Created on: 08/28/2023
Revision on: 04/09/2025
Goal:
(Resident #87's name) will express anxieties/fears to staff and daughter as he is able or on a
daily basis through next review.
Date Initiated: 08/28/2023
Created on: 08/28/2023
Revision on: 04/09/2025
Intervention:
Observe for pain and effectiveness of current interventions. Attempt nonpharmacologic interventions
Date Initiated: 08/28/2023
Created on: 08/28/2023
An interview was conducted with the Director of Nursing (DON) at approximately 1:00 PM on 5/6/2025. During the interview, the DON acknowledged no non-pharmacological interventions were attempted on the aforementioned dates and was unable to provide any proof those took place.
The DON acknowledged Resident #87's care plan stating non-pharmacological interventions would be attempted under mood and behavior. The DON acknowledged non-pharmacological interventions did not take place on the aforementioned days.
b) Resident #33
A record review on 05/05/25 at 12:31 PM, of Resident #33's Activity care plan dated 03/17/25 reads as follows:
Focus:
Prefers to be called (Resident #33 nickname), she is at risk for limited and/or meaningful
engagement r/t highly impaired vision. Prefers not to wear identification bracelet.
Goal
(Resident #33 nickname) will consistently accept and/or utilize adaptations and modifications to enable participation in activities of interest ongoing and through next review.
Interventions:
Offer room visits for socialization/talking/reminiscing, beauty/nail painting, daily chronicle reading, trivia if unavailable for group setting.
Encourage participation in activity preferences such as music/singing, coffee club, games/trivia, special/holiday events.
Provide resident/patient with opportunities for choice during care/activities to provide a sense of control.
Provide and review calendars with resident to identify interests and preferences.
Invite and assist resident/patient, as needed, to activities of interest.
Utilize adaptive techniques/equipment/modifications: such as reading aloud to resident, hand over hand guidance, clock method, provide 1:1 assistance/direction during preferred activities to enable participation.
Allergies Novocain, Strawberries, soap D.O
Provide appropriate cueing through physical prompt, physical assist, verbal direction, to enable successful participation in activity.
Guide hand, describe program and offer tactile, olfactory and auditory opportunities in a group and/or 1:1 setting.
Further record review of Resident #33's Activity Participation Records for the months of 11/2024, 12/2024, 01/2025, 02/2025, 03/2025, and 04/2025 revealed that the resident had only 6 days that she participated in group activities. The Activity Participation record further revealed that Resident #33 was not regularly receiving one to one visits, not getting the daily chronicle read to her as her care plan reads, and is not consistently getting assistance turning on TV/radio.
During an interview on 05/05/25 at 1:00 PM, The Activity Director (AD) stated,No, she is not on one to one visits, because we socialize with her when we are there. She was coming out and did coffee hour quite a bit. Her participation has gone down and I missed it. The AD further confirmed that the careplan for Resident #33 was not being followed.

Based on observation, record review, and staff interview the facility failed to provide a program of activities to meet the needs and interest of the residents. This failed practice was found true for (1) one of (4) four residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier #33. Facility Census 114.
Findings Include:
a) Resident #33
Resident #33
During the initial observation on 04/29/25 at 12:41 PM, revealed Resident #33 lying in bed, still in her nightgown with the lights off. No television (TV) or radio was playing. Resident #33 was talking out loud to herself.
Further observation of Resident #33 on 04/29/25 at 3:10 PM, revealed Resident #33 lying in bed, continues to be in her nightgown. No TV or radio was playing. Resident #33 was holding and rubbing the sides of a cup.
An observation on 05/05/25 at 11:30 AM revealed Resident #33 lying in her bed. No TV or radio was on in the room and the room was dark.
A record review on 05/05/25 at 12:31 PM, of Resident #33's Activity care plan dated 03/17/25 reads as follows:
Focus:
Prefers to be called (Resident #33 nickname), she is at risk for limited and/or meaningful engagement r/t highly impaired vision. prefers not to wear identification bracelet.
Goal
(Resident #33 nickname) will consistently accept and/or utilize adaptations and modifications to enable participation in activities of interest ongoing and through next review.
Interventions:
Offer room visits for socialization/talking/reminiscing, beauty/nail painting, daily
chronicle reading, trivia if unavailable for group setting.
Encourage participation in activity preferences such as music/singing, coffee club,
games/trivia, special/holiday events.
Provide resident/patient with opportunities for choice during care/activities to
provide a sense of control.
Provide and review calendars with resident to identify interests and preferences.
Invite and assist resident/patient, as needed, to activities of interest.
Utilize adaptive techniques/equipment/modifications: such as reading aloud to resident, hand over hand guidance, clock method, provide 1:1 assistance/direction during preferred activities to enable participation.
Allergies Novocain, Strawberries, soap D.O
Provide appropriate cueing through physical prompt, physical assistance, verbal direction, to enable successful participation in activity.
Guide hand, describe program and offer tactile, olfactory and auditory opportunities in a group and/or 1:1 setting.
Further record review of Resident #33's, Minimum Data Set (MDS), with an Assessment Reference Date of 03/14/25, Section F, Question FO500, is marked that is very important for resident to, listen to music, do things with groups of people, participate in favorite activities, and participate in religious services or practices.
Further record review of Resident #33's Activity Participation Records for the months of 11/2024, 12/2024, 01/2025, 02/2025, 03/2025, and 04/2025 revealed that the resident had only 6 days that she participated in group activities. The Activity Participation record further revealed that Resident #33 was not regularly receiving one-to-one visits, not getting the daily chronicle read to her as her care plan reads and is not consistently getting assistance turning on TV/radio.
An observation on 05/05/25 at 12:46 PM revealed Resident #33 lying in her bed with no stimulation on in the room. The resident was talking out loud to herself.
During an interview on 05/05/25 at 1:00 PM, The Activity Director (AD) stated, No, she is not on one-to-one visits, because we socialize with her when we are there. She was coming out and did coffee hour quite a bit. Her participation has gone down, and I missed it.

Based on record review, resident interview and staff interview the facility to follow the Physicians orders relating to administering medications in a timely manner, obtaining blood lab orders and following the hypoglycemia protocol as written. Resident Identifiers: #12, #24 and #101. Facility Census: 114
Findings Include:
a) Resident #12
On 05/01/25 at 12:20 PM record review of laboratory results for Resident #12 shows an Ammonia level drawn on 03/07/25 at 5:53 AM had abnormal results indicating an elevated Ammonia level. This was addressed by the Unit Manager with a Physicians order to increase Lactulose to 15 ml twice a day and repeat the ammonia level in one week.
Review of the following laboratory results for the rest of March, 2025 found no repeat ammonia level was completed.
On 05/05/25 at 8:30 AM the above information was discussed with the Administrator who confirmed that the repeat Ammonia level was not completed as ordered.
b) Resident #24
On 05/05/25 at 12:58 PM record review of the Medication Administration Record shows that Resident #24 had a documented blood glucose level of 47 on 03/29/25 at 5:50 AM.
Further review shows a Physicians order for:
Hypoglycemia Protocol Observe sign/symptoms of hypoglycemia as needed if blood glucose is less than 70 mg/dl or ordered low parameter follow hypoglycemia protocol.
Glucagon Emergency kit 1 mg (Glucagon (rDNA) Inject 1 mg intramuscularly as needed for blood glucose (BG) less than 70 not arousable conscious or able to swallow. Hold all diabetic medications until provider authorizes resumption, remain with patient and keep in bed/chair for safety. Repeat blood glucose in 15 min.
Glucagon Emergency kit 1 mg (Glucagon (rDNA) Inject 1 mg intramuscularly as needed for blood glucose (BG) less than 70 not arousable conscious or able to swallow. If repeat blood glucose is below 70 mg/dl and pt is NOT arousable, conscious or able to swallow. Continue to hold all diabetic medications until provider authorizes resumption, remain with patient and keep in bed/chair for safety.
Insta-Glucose Gel 77.4% (glucose) Give 1 dose by mouth as needed for BG less than 70. Pt arousable, conscious and able to swallow. Hold all diabetic medications until provider authorizes resumption, remain with patient and keep in bed/chair for safety. Repeat blood glucose in 15 min.
Insta-Glucose Gel 77.4% (glucose) Give 1 dose by mouth as needed fro BG less than 70. Pt arousable, conscious and able to swallow. If repeat blood glucose is below 70 mg/dl and pt is arousable, conscious and able to swallow. Continue to hold all diabetic medications until provider authorizes resumption, remain with patient and keep in bed/chair for safety.
Record review of the Medication Administration Record for March revealed the hypoglycemia protocol was not followed.
The medical record reflected the resident's blood sugar later came up but the record did not indicate the protocol listed above was followed.
The care plan contained a focus for a diagnosis of diabetes requiring insulin, oral hypoglycemic medications and lab monitoring. There were interventions on the care plan to administer hypoglycemic medications as ordered and follow the hypoglycemia Protocol.
On 05/05/25 at 1:00 PM the above findings were confirmed with the Regional Resource Registered Nurse who agreed the Physicians orders for hypoglycemia were not followed.
c) Resident #101
On 04/29/25 at 9:10 AM Resident #101 stated she did not receive her medications on time.
On 05/05/25 at 11:19 AM record review of the Medication Administration Record showed the following medications for Resident #101 were not administered in a timely manner according to professional standards of Nursing care and the facility policy for medication administration. The policy stated the medications were to be passed an hour prior or an hour after the scheduled administration time.
03/24/25 Biotin Oral Liquid Give 1 spray by mouth four times a day for saliva oral balance. Scheduled for 5:00 PM. Not administered.
03/25/25 Pancrelipase (Lip-Prot-Amyl) Oral Tablet 10440-39150 Unit, Give 1 tablet by mouth three times a day for Pancrelipase Scheduled for 8:00 AM, administered at 12:41 PM.
03/28/25 Cetirizine HCL Tablet 10 mg give 1 tablet by mouth one time a day for Allergies. Scheduled for 9:00 PM, administered at 10:40 PM.
04/02/25 Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for Pneumonia for 14 days. Scheduled for 9:00 AM, administered at 11:34 AM.
04/12/25 Prednisone Oral Tablet 20 mg Give 1 tablet by mouth one time a day for Pneumonia for 14 days. Scheduled for 9:00 AM, administered at 11:22 AM
04/21/25 Insulin Lispro 100 units. ml pen. Inject as per sliding scale: if 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units 351-400 = 10 units, 401-450 = 12 units. If below 70 or above 450 call MD for further orders, subcutaneous two times a day for DM. Scheduled for 5:00 PM, administered on 4/22/25 at 1:07 PM.
04/24/25 Pancrelipase (Lip-Prot-Amyl) Oral Tablet 10440-39150 Unit, Give 1 tablet by mouth three times a day for Pancrelipase Scheduled for 8:00 AM, administered at 9:43 AM
On 05/05/25 at 8:30 AM the above information was discussed with the Administrator who confirmed the above orders were late or not administered.

Based on observation, resident interview, and staff interview the facility failed to provide reasonable accommodations of needs by not ensuring residents could turn the over-bed light on and off by their own free will. This failed practice was a random opportunity for discovery and the potential to affect a limited number of residents. Resident identifier #1. Facility census: 114.
Findings Include
a) Resident #1
During the initial interview and observation on 04/29/25 at 10:55 AM, Resident #1 stated, Last night I had to sleep with this light on above my bed, because the light switch is not long enough for me to reach. During the interview an observation of the light string above the bed showed that the string was about an inch long and that the resident could not reach it to turn it off and on.
During an interview and observation, on 04/29/25 at 11:30 AM, the Director of Nursing (DON), confirmed that he could not reach the light string.
During an interview, on 04/30/25 at 3:15 PM, the administrator stated, We fixed his lights and did an audit and fixed the rest that were not long enough in the

Based on record review, resident interview and staff interview the facility failed to provide residents a choice regarding bathing preferences. This was true for two (2) of eight (8) residents reviewed for Activities of Daily Living (ADL). Resident identifiers: #101 and #81. Facility Census: 114
Findings included:
a) Resident #101
On 04/29/25 at 2:34 PM Resident #101 states she only gets one shower a week. She prefers a shower over a bed bath but does not always get that.
On 04/30/25 at 11:48 AM the facility provided a North Unit Shower Schedule which indicates Resident #101 is scheduled for her showers on Tuesday and Friday, evening shift.
On 04/30/25 at 12:10 PM a review of Resident #101's care plan indicates It is important for me to choose between a tub bath, shower, bed bath or sponge bath, I prefer a shower.
On 4/30/25 at 11:50 AM a review of the GG Bathing task report for the last thirty (30) days, (04/01/25 through 04/30/25) documentation shows that Resident #101 received three (3) showers and seventeen (17) bed bath/sponge.
On 05/05/25 at 3:30 PM it was confirmed with the Administrator that Resident #101 was not receiving her ADL care according to her preference.
b) Resident #81
During the initial interview on 04/29/25 at 11:11 AM, Resident #81 stated, Showers are always a problem. I do not like the way they do it here. I am supposed to get a shower twice a week. That does not always happen. Sometimes they give me bed baths instead.
Record review revealed a care plan for Resident #81 that reads as follows:
Focus:
While in the facility resident prefers to be called {Resident #81 named}, He is at risk for limited engagements due to diagnosis with history of CVA with left hemiplegia, anoxic brain injury, history of craniotomy, C-spinal stenosis, myelopathy, confusion, impaired mobility, and weakness. He has potential to limit his participation in activities. He will become frustrated and agitated and calls out. Resident refuses Medications.
Goal:
{Resident #81 named} will plan and choose to engage in preferred activities.
It is important for me to choose between a tub bath, shower, bed bath or sponge
bath, prefer shower, prefers shower.
A review of the shower schedule showed that Resident #81 was scheduled to receive showers on Wednesdays and Saturdays on evening shift.
Further record review of the bathing task from 03/01/25 TO 04/30/25 revealed there were 17 opportunities for Resident #81 to have a shower. Out of the 17 opportunities he only received (4) four showers. The rest were bed baths. (4) four refusal notes were noted to be in the medical record related to showers. (9) nine of the bed baths given, instead of a shower, had no note showing that Resident #81 had refused the shower.
During an interview, on 05/05/25 at 11:56 AM, the administrator confirmed that Resident #81's care plan indicated he preferred showers and that he had not received showers per his preference.

Based on observation, resident interview, family interview, and staff interview the facility failed to maintain a clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifiers #52, #24, #128. Facility census 114.
Findings Include:
a) Resident #52
An observation on 04/29/25 at 11:32 AM, found Resident #52's bathroom that adjoins next door to have 3 briefs that appeared to be soiled in the floor, along with 4 articles of clothing. On the floor and commode seat there was a brown, dried substance.
During an interview on 04/29/25 at 11:32 AM, Resident #52 stated, I don't use that bathroom and my roommate doesn't either. It must be the people next door. There is always shit in there.
During an interview and observation on 04/29/25 at 11:45 AM, The Infection Preventionist (IP) confirmed that the bathroom was dirty and needed to be cleaned. The IP further stated, That definitely needs to be cleaned. I will get it taken care of.
b) Resident #24
On 04/29/25 at 8:30 AM it was noted that there was cereal spilled on the floor on the left side of her bed. The floor throughout the room was dirty and had two spots of spilled fluid that had dried but had not been cleaned up.
Upon two additional observations on 04/29/25 at 1:20 PM and 4:25 PM, the floor remained the same as it was found at 8:30 AM.
On 04/29/25 at 4:27 PM it was confirmed with the Regional Resource Registered Nurse that the dirty floors were not conclusive with a clean homelike environment at which time she agreed.
c) Resident #158
04/30/25 8:38 AM it was noted that there was food on the floor on the right side of his bed. There were ants on and around the food.
Upon two additional observations throughout the day, one at 1:35 PM and one at 4:25 PM, the food and ants remained on the floor.
On 04/29/25 at 4:27 PM it was confirmed with the Regional Resource Registered Nurse that the dirty floors were not conclusive with a clean homelike environment at which time she agreed.
At approximately 7:40 AM on 04/29/25, the hallway on the north side of the facility was observed to be littered with trash and debris. During a walkthrough of the hallway, two (2) straw wrappers and two (2) plastic wrappers were scattered about. Under the medication cart at the end of the hallway, near the nurses station, plastic wrappers, other trash and debris were found. More trash and debris were found scattered around the treatment cart that sat beside the medication cart. Throughout the length of the entire hallway, large amounts of debris were noted to be on the floor. Beside the north nurses' station, beside the exit door, there was a visible puddle on the floor. This puddle was stepped on and was noted to have dried and had become sticky. Registered Nurse (RN) #30 acknowledged the trash and debris in the hallway and the sticky puddle by the nurses' station.

Based on record review and staff interview, the facility failed to ensure Resident #87 was free from chemical restraints by failing to ensure a PRN (as needed) order for Ativan did not last longer than 14 days, and by failing to attempt non-pharmacological interventions before the administration of PRN Ativan. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: #87. Facility census: 114.
Findings include:
a) Resident #87
During a review of Resident #87's electronic health record on 05/01/25, it was noted he had been prescribed Ativan on an as needed basis, four (4) times since October 2025, with all four (4) orders being longer than 14 days. The orders are as follows:
-Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed for anxiety for three (3) months. Start date- 10/25/2024 10:00 AM. Discontinue date- 12/11/2024 10:45 PM.
-Ativan injection solution 2MG/ML. Inject 0.5 ml intramuscularly every 24 hours as needed for acute anxiety for 30 days. Start date- 10/25/2024 10:00 AM. This was discontinued on 11/24/2024.
-Lorazepam oral tablet one (1) MG. Give one tablet by mouth every six (6) hours as needed for anxiety as evidenced by restlessness and agitation for three (3) months. Start date- 12/11/2024 10:45 PM. Discontinued on 3/11/2025
-Ativan oral tablet 0.5 MG. Give one (1) tablet by mouth every six (6) hours as needed for dementia. Start Date 3/26/2025 12:45 PM. Discontinue date 04/18/25 1:02 PM. This order was discontinued after a pharmacy recommendation on 3/30/2025, which was responded to by the physician on 4/18/2025.
Resident #87 Non-Pharmacological Interventions
During the review of the Medication Administration Record (MAR) for Resident #87's PRN ativan, it was noted there five (5) dates the resident was given the medication and non-pharmacological interventions were not attempted before it was administered. The dates were:
-11/12/24 at 8:30 PM
-11/14/24 at 8:42 AM
-11/14/24 at 8:23 PM
-11/16/24 at 9:22 AM
-3/26/25 at 12:50 PM
-3/27/25 at 10:30 AM
Non-pharmacological interventions were not tracked on the MAR at this time, instead they were documented in the resident ' s progress notes in his health record, under eMAR administration notes. The notes for the preceding days were reviewed and they stated the following (typed as written in the record):
11/12/2024 10:58 PM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Resident reports not feeling good. Reports he feels worried. Medication given per order.
11/14/2024 8:43 AM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Complaint of anxiety.
11/14/2024 8:23 PM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Anxious, worried about (resident's representative's name).
11/16/2024 9:22 AM
Note Text:
Lorazepam oral tablet 1 MG
Give one (1) tablet by mouth every six (6) hours as needed for anxiety for three (3) months.
Complaint of anxiety.
3/26/2025 12:56 PM
Note Text:
Ativan oral tablet 0.5 MG
Give one (1) tablet by mouth every six (6) hours as needed for dementia.
Resident experiencing symptoms of psychosis. Medication administered per MD order.
3/27/2025 10:31 AM
Note Text:
Ativan oral tablet 0.5 MG
Give one (1) tablet by mouth every six (6) hours as needed for dementia.
Resident experiencing symptoms of psychosis. Medication administered per MD order.
The following was noted after reviewing the resident ' s care plan section related to mood and behaviors:
(Resident #87's name) exhibits or is at risk for distressed/fluctuating mood symptoms related to: Sadness/depression, anxiety/fear, persistent anger/agitation caused by recent environmental changes (admission from LT psychiatric hospital placement), dx of Bipolar D/O, psychosis
and hallucinations
Date Initiated: 03/27/24
Created on: 08/28/23
Revision on: 03/27/24
Goal:
(Resident #87's name) will respond to redirected (sic) when proved (sic) by staff in a calm manner daily through next review.
Date Initiated: 08/28/2023
Created on: 08/28/2023
Revision on: 04/09/2025
Goal:
(Resident #87's name) will express anxieties/fears to staff and daughter as he is able or on a
daily basis through next review.
Date Initiated: 08/28/23
Created on: 08/28/23
Revision on: 04/09/25
Observe for pain and effectiveness of current interventions. Attempt nonpharmacologic interventions
Date Initiated: 08/28/23
Created on: 08/28/23
An interview was conducted with the Director of Nursing (DON) at approximately 1:00 PM on 05/06/25. During the interview, the DON acknowledged the orders for PRN ativan that were given for three (3) months, and lasted longer than 14 days. The DON was also unable to provide documented rationale from the physician or practitioner that the PRN order for Ativan was reviewed and determined to be appropriate past the 14 day mark.
The DON also acknowledged no non-pharmacological interventions were attempted on the aforementioned dates and was unable to provide any proof those took place.
The DON acknowledged Resident #87's care plan stating non-pharmacological interventions would be attempted under mood and behavior. The DON acknowledged non-pharmacological interventions did not take place on the aforementioned days and was unable to provide proof those took place.

Based on resident interview, record review and staff interview the facility failed to ensure residents received the correct prescription of reading glasses as ordered by the Ophthalmologist. This failed practice was found true for (1) of (1) residents reviewed for vision services during the Long-Term Care Survey Process. Resident identifier #52. Facility Census 114.
Findings Include:
a) Resident #52
During the initial interview on 04/29/25 at 11:28 AM, Resident #52 stated, The eye doctor checked my eyes six months ago and ordered me glasses and I still have not gotten them. They gave me these, but I can't see good out of them.
A record review revealed Resident #52's last Ophthalmologist appointment was dated 01/16/24.
Final Spectacles Prescription read as follows:
SPH CYL Axis ADD
OD +.50 -0.50 090 +3.00
OS +.50 -0.50 090 +3.00
During an interview on 04/30/25 at 12:57 PM, The Administrator stated, I feel like that is a prescription for reading glasses. Let me go talk to her and I will check on it.
The Administrator further stated, I went back there, and she had +1.75. I went and got her some +3.00s. They are purple. She put them on and looked at her Bible and was very happy and said she could see it really good. The Administrator confirmed that Resident #52 did not have the right prescription of reading glasses ordered by the Ophthalmologist.

Based on observation and staff interview, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible. A mattress was left lying on the floor in the hallway. This was a random opportunity for discovery. Facility census: 117.
Findings include:
A) Mattress observation
At approximately 7:30 AM on 04/29/25 a mattress was observed lying on the floor in the north hallway, in a resident area, in front of the mechanical room and the entrance to the kitchen/service hall.
Nurse Aide (NA) #66 and Registered Nurse (RN) #30 acknowledged the mattress in the floor and stated it should not have been left there. Both acknowledged the mattress was a hazard and a resident could have fallen over it.

Based on observation, resident interview and staff interview the facility failed to offer sufficient fluid intake to maintain proper hydration and health. This was true for two (2) of thirty one (31) residents reviewed for hydration during the Long Term Care Survey Process. Resident Identifiers: #23 and #36. Facility Census: 114
Findings Include:
a) Resident #23
On 04/29/25 at 8:30 AM Resident #23 states it is hard to get water at around here. Observation at that time finds a disposable cup on the over the bed table dated 04/28/25 to be empty.
Further observations on 04/29/25 at 1:20 PM and 04/29/25 at 4:20 PM found a disposable cup on the over the bed table dated 04/28/25 to be empty.
It was confirmed with the Administrator on 04/29/25 at 4:30 PM that this resident has not had proper hydration on 04/29/25. She agreed.
b) Resident #36
On 04/29/25 at 8:15 AM Resident #36 states staff won't always give me water, they tell me I don't need it. Observation at that time finds a disposable cup on the over the bed table dated 04/28/25 to be empty.
Further observations on 04/29/25 at 1:21 PM and 04/29/25 at 4:21 PM found a disposable cup on the over the bed table dated 04/28/25 to be empty.
It was confirmed with the Administrator on 04/29/25 at 4:30 PM that this resident has not had proper hydration on 04/29/25. She agreed.

Based on record review, resident interview, and staff interview the facility failed to provide routine dental services to Medicaid funded residents. This failed practice was found true for (1) one of (1) one residents reviewed for dental services during the Long-Term Care Survey Process. Facility Census 114. Resident identifier: #52.
Findings included:
a) Resident #52
During the initial interview on 04/29/25 at 11:29 AM, Resident #52 stated, I have 3 teeth. One on the top and 2 on the bottom. This top one hurts sometimes so it's hard for me to chew. I have not seen a dentist since I have been here.
A record review on 04/30/25 at 1:00 PM, revealed a dental care plan for Resident #52 created on 10/14/23 that reads as follows:
Focus:
Resident is at risk for oral health problems R/T poor dentition. ** Has 1 upper tooth and 2 bottom teeth with obvious caries noted. Currently denies oral pain or discomfort but states the upper tooth scratches her inner lip at times.
Goals:
The resident will maintain intact oral mucous membranes as evidenced by the absence of discomfort, gum inflammation/infection, oral lesions through next review.
The resident will not have any discomfort or chewing problems related to carious teeth in the through next review.
Interventions related to dental appointments:
- Obtain dental consult as ordered
- Obtain dental referral as needed
Further record review of Resident #52's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/25, Section L, Letter D, is marked yes for obvious or likely cavity or broken natural teeth.
Further review of the medical record revealed that Resident #52 had no dental consults since admission.
During an interview, on 04/30/25 at 3:43 PM, The administrator stated, She was on the list for 360 dental services for June of last year. They did not see her. 360 Dental comes every three (3) months. When she was not seen in June, she did not get put back on the list. The administrator further confirmed that since June of last year Resident had three (3) other opportunities to be put on the 360 dental list and was not.
A review of the policy on 04/30/25 at 2:30 PM, titled Dental Services, under the section titled Routine Dental Services the following was noted:
An annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor partial of full denture adjustments, smoothing of broken teeth, and limited prosthodontic procedures, e.g., taking impression for dentures and fitting dentures.

Based on resident interview, observation and staff interview, the facility failed to serve food that was palatable and at a safe appetizing temperature. This was found true for one(1) resident investigated for the care area of nutrition during the Long-Term Care Survey process. This failed practice had the potential to affect more than a minimal number of residents residing in the facility, Resident identifier: #54 Facility census: 114
Findings include:
a) Resident #54
04/29/25 8:20 AM observed Resident #54 picking at their food, when asked, How is your breakfast this morning? Resident #54 stated, Honey it is cold, I just can't eat it. When asked if this happens often Resident #54 stated, Oh child breakfast and dinner is normally cold when we get it. The carts set out there before they come up from the desk to get it to do.
04/29/25 8:35 AM this surveyor requested the temperature to be taken on the last try to be delivered on the 100 hallways.
The temperatures were recorded as follows:
Oatmeal 112.00 degrees Fahrenheit (F)
Fried Hash-browns 86.2 degrees (F)
Gravy & Biscuits 105.5 degrees (F)
During an Interview with the Culinary Manage (CM) on 04/29/25 at approximately 9:00 AM concerning the temperatures obtained from the breakfast tray, the DM stated temperatures should be at least 120 degrees (F) at the time of delivery to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of the electronic health record was conducted on 04/29/25. During the review it was noted Resident #72 was admitted [DATE] and had suffered seven (7) falls during this time. The falls were on the following dates:
04/14/25,
04/19/25
04/20/25
04/23/25
04/27/25- three (3) times
During a review of, on 04/30/25, of the post fall neurological assessments completed by the facility, it was determined that one that was scanned into the resident's health record did not have correct dates and was not signed, in eight (8) instances, by the nurse completing the assessments.
A neurological assessment was performed for a fall suffered by Resident #72 on 4/23/2025 at 6:00 PM. The directions for the assessment were to evaluate the resident every 15 minutes for the first two (2) hours after the initial evaluation following the fall, then evaluate the resident every 30 minutes for two (2) hours, evaluate the resident every hour for four (4) hours, and lastly, evaluate the resident every eight (8) hours for at least 64 additional hours.
All four (4) signature slots for the 30-minute checks were left blank by the nurse performing the assessment.
All four (4) signature slots for every hour checks were left blank by the nurse performing the assessment.
The initial fall took place at 6:00 PM on 04/23/25, making the second hourly check take place at midnight on 04/24/25, the third hourly check at 1:00 AM on 04/24/25, and the fourth hourly check at 2:00 AM on 04/24/25. These three checks were not dated to reflect the accurate day the assessments were performed .
At approximately 3:00 PM on 04/30/25, the Administrator confirmed the neurological assessments were not signed or dated at the times mentioned above. At approximately 10:30 AM on 05/01/25, the administrator presented a completed neurological assessment for Resident #72's fall on 04/23/25, stating the nurse working the night of the fall was working the night of 04/29/25, so she had the nurse sign the missing days.
At approximately 1:00 PM on 05/06/25, the Director of Nursing (DON) also confirmed the original form was not completed accurately.

Based on observation and staff interview the facility failed to maintain an affective infection control program to prevent the spread of disease and infections. This was true for three (3) of thirty-one (31) residents observed during the long-term survey process and one (1) random opportunity for discovery. Resident identifiers: #69, #158, #264 and #25. Facility Census: 114
Findings include:
a) Resident #69
On 04/29/25 at 8:20 AM during the initial interview of the long-term survey process, it was noted that Resident #69s' Continuous Positive Airway Pressure (C PAP) machine mask was not stored properly to prevent infections or the spread of disease. It was lying on the bedside table outside of the plastic storage bag that was supplied for storage. The resident stated that it is usually where they leave it.
A follow up observation was performed on 04/29/25 at 1:23 PM and again on 04/29/25 at 4:22 PM and found the C PAP mask still on the bedside table outside of the plastic bag that was supplied for storage.
On 04/29/25 at 4:27 PM it was confirmed with the Regional Resource Registered Nurse who agreed at that time that the mask should be stored in the plastic bag for infection control protocol.
b) Resident #158
On 04/29/25 at 8:15 AM during the initial interview of the long-term survey process, it was noted that Resident #158s' Continuous Positive Airway Pressure (C PAP) machine mask was not stored properly to prevent infections or the spread of disease. It was lying on the bedside table outside of the plastic storage bag that was supplied for storage.
Follow up observations were performed on 04/29/25 at 1:24 PM and again on 04/29/25 at 4:23 PM and found the C PAP mask still on the bedside table outside of the plastic bag that was supplied for storage.
On 04/29/25 at 4:27 PM it was confirmed with the Regional Resource Registered Nurse who agreed at that time that the mask should be stored in the plastic bag for infection control protocol.
c) Resident #264
At approximately 1:10 PM on 4/29/25 Resident #264's catheter bag was observed hanging the side of his bed, with the bag and tubing lying on the floor. Registered Nurse (RN) #30 confirmed the catheter bag and tubing were lying on the floor.
At approximately 10:05 PM on 4/30/25, a clean linen cart was observed sitting in the north hallway of the facility, uncovered.
This was confirmed by the Infection Prevention (IP) Nurse, who was present on the hallway at the same time.

Based on record review and staff interview, the facility failed to revise a care plan regarding fall preventions for Resident #13, #32, #120 and regarding food restrictions for Resident #27. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #13. #32, #120 and #27. Facility Census: 114.
Findings Include:
a) Resident #13
On 01/22/25 at 1:00 PM, a record review was completed for Resident #13. The review found the care plan had not been revised regarding fall interventions put in place. The care plan did not include call light within reach.
On 01/22/25 at 2:00 PM, the Administrator confirmed the fall intervention should have been listed in the care plan. The Administrator stated, we have started a house-wide audit regarding fall interventions.
b) Resident #32
On 01/22/25 at 1:15 PM, a record review was completed for Resident #32. The review found the care plan had not been revised regarding fall interventions put in place. The care plan did not include non-skid strips to the right side of the bed or dumped wheelchair.
On 01/22/25 at 2:00 PM, the Administrator confirmed the fall interventions should have been listed in the care plan. The Administrator stated, we have started a house-wide audit regarding fall interventions.
c) Resident #120
On 01/22/25 at 1:30 PM, a record review was completed for Resident #120. The review found the care plan had not been revised regarding fall interventions put in place. The care plan did not include non-skid footwear or call light within reach.
On 01/22/25 at 2:00 PM, the Administrator confirmed the fall interventions should have been listed in the care plan. The Administrator stated, we have started a house-wide audit regarding fall interventions.
d) Resident #27
On 1/22/25 at 5:20 PM, a review of Resident #27's current care plan revealed the resident was unable to tolerate very cold or hot beverages or foods. Resident #27's current diet order stated, the resident can have no cold food or drinks. The Director of Nursing (DoN) confirmed the resident received soups, coffee, tea and hot chocolate. At 5:40 PM on 01/22/25 the DON reported she removed the hot foods and beverages from the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Resident # 106 was free from physical abuse from Resident #118. Resident #106 was physically abused by Resident #118. Resident #106 was a nonverbal resident who was hit on the left side of the face by Resident #118. This is true for one (1) of three (3) residents reviewed for resident to resident abuse. Resident identifiers: #106 and #118. Facility Census: 114.
Findings included:
a) Resident #118
A facility reported incident dated 01/06/25 explained the following:
Resident #118 was witnessed hitting Resident #106 multiple times in the face on the left side. The power of attorney was called for both perpetrator and victim. Resident #106 was sent for a medical evaluation and Resident #118 was sent for a psychiatric evaluation.
The medical record review revealed Resident #118 was immediately separated from Resident #106 by staff. Resident #118 was redirected to his room and staff ensured residents remained separated while conducting assessments. Each resident's health care decision maker and the physician were notified. The assessment completed immediately following the incident found that Resident #106 had visible swelling and bruises developing on the left side of his face. Staff also noted that Resident #106 was grimacing and unable to be consoled. No changes to functional status were noted. Resident #106 was nonverbal and unable to describe the incident. Resident #106 was sent to the emergency department (ED) for further evaluation. Per hospital report, the CT of his head was negative and no acute injuries were identified. Resident #106 was then transported back to the facility. Following his return, he was interacting with staff by smiling, laughing and holding hands with them. Resident #106 was interacting at his baseline. No signs or symptoms of psychosocial distress or fear observed. His mood was noted to be pleasant and stable.
Resident #118 was noted to have no visible injuries or changes in functional status but was displaying physical aggression. He was sent to ER for psychiatric evaluation and remained hospitalized .
On 12/11/2023, Resident #118 had previous incidents of physical aggression towards an unnamed resident no longer in the facility. Resident #118 was observed hitting a resident on the back. Resident #118 was sent to the emergency room (ER) for an evaluation and returned to the facility without findings on the same day. The resident was placed on 1:1 while the facility attempted to complete the mental hygiene process for psychiatric placement. Resident #118 had been refusing his medication at this time. No behaviors noted upon return from the ER.
Provider note dated for 12/11/23 stated [AGE] year old male with schizophrenia, long history of behavioral issues , sent to ER for evaluation after punching a defenseless resident. Resident with chronic noncompliance, chronic refusals of medications. Continues to say that God is doing stuff to my body while I'm asleep. Unable to redirect.
Continue to seek long term psych placement for resident.
Progress notes dated 12/14/23 reported the resident continued to refuse his medication. became agitated over 1:1 and slammed his walking. Stated it was, bullshit that someone has to follow me around. He was changed to fifteen (15) minute checks for visual observation of behavior.
Social Services note dated 01/08/25 stated that Resident #118's sister was informed that he was not expected to return to the facility as he demonstrated he was a danger to himself and others.
During an interview with Administrator #6 on 01/23/25 at approximately 10:35 AM the administrator reported that she had notified the receiving facility that Resident #118 would not be returning to this facility due to his behaviors but the company would consider another facility. She also reported that the facility had made various attempts to place Resident #118 prior to the incident on 01/06/25.
A review of Resident #118's care plan revealed the following:
Focus
Resident exhibits or has the potential to demonstrate physical and verbal behaviors related to: Cognitive deficits due to traumatic brain injury. history of manic episodes, history of verbal outbursts directed toward others, use of abusive language, pattern of challenging/confrontational verbal behavior, ineffective coping skills, poor anger management, moving items from hall into room, pulling trash from medication charts, poor impulse control, combative behavior, psychiatric disorder, unspecified schizophrenia, bipolar disorder and anxiety. Resident has behaviors of entering communal spaces and turning lights off, turning the TV off, closing blinds, wandering without intent, ignoring staff when staff try to communicate with him.
Goal
Resident will have less anxiety starting psychotropic medication through next review.
Resident will demonstrate effective coping skills related to verbal behavior.
Resident will have less than four (4) verbal or physical outbursts toward other weekly.
Resident will demonstrate the ability to seek out staff support when feeling frustrated.
Interventions in the care plan were listed as follows:
-Monitor medical conditions that may contribute to verbal behaviors.
-Staff Visual observation every fifteen (15) minutes time 48 hours for behaviors.
-Monitor medications especially new and changed.
-Monitor for pain.
-Evaluate the nature of circumstances such as triggers.
-Evaluate the need for psychiatric consultation.
-Explain all care.
-Provide consistent, trusted caregiver and structured daily routine.
-Remove resident from environment if needed.
-If resident become combative or resistive, postpone care or activity and allow time for him to regain composure,
-Provide calm, quiet well lit environment.
-Provide an environment that is conducive to the patient's ability to get adequate sleep.
-Acknowledge resident's progress toward goals,
-Allow time for expression of feelings, provide empathy, encouragement and reassurance.
-Provide resident with opportunities for choice to give a sense of control.
-Divert resident by giving objects or activities.
The facility had no further information to share regarding the physical abuse of Resident #118 towards Resident #106.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to maintain appropriate infection control standards for linen storage and ice storage. These were random opportunities for discovery. Facility Census: 114.
Findings Included:
a) Linen carts
On 09/11/23 at 9:09 PM, an observation on the South unit was made noting one (1) linen cart sitting between rooms [ROOM NUMBERS] with the cover flipped over the top, and an additional linen cart sitting by room [ROOM NUMBER] with the cover flipped over the top and a bath basin with water, soap and wash cloths sitting on top of the linen cart.
On 09/11/23 at 9:11 PM, Nurse Aide (NA) #56 and NA #32 acknowledged the linen carts were uncovered and the bath basin should not be sitting on top of the linen cart.
On 09/11/23 at 9:15 PM, Registered Nurse (RN) #2 was notified of the uncovered linen carts and the bath basin sitting on top of the linen cart by room [ROOM NUMBER].
On 09/12/23 at 8:30 AM, the policy entitled Linen Handling, section 1.1 states keep clean linen covered; and, section 8.1 states provide clean, disinfected, covered linen containers.
On 09/12/23 at 8:44 AM, the Director of Nursing (DON) was notified and acknowledged the linen carts should be covered and the bath basin should not be sitting on the uncovered linen cart.
b) Ice Cooler
On 09/11/23 at 3:44 PM, an observation was made on the South unit of Resident #75 getting ice out of the ice cooler. There were no staff present when the incident took place.
On 09/12/23 at 9:18 AM, Resident #75 was interviewed. The resident was asked if the staff bring him plenty of water and ice? The resident stated They do pretty good . sometimes they get busy. The resident was asked do you get the ice on your own? The resident stated, I only do it when they are really busy.
On 09/12/23 at 9:35 AM, the Director of Nursing (DON) was notified about the incident and confirmed the residents should not be getting ice themselves due to infection control issues.
No further information was obtained during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain safe operating equipment kept in a resident area. This was a random opportunity for discovery. Facility Census: 114.
Findings Included:
a) Scoot chair
On 09/12/23 at 12:13 PM, a leaning scoot chair missing a wheel was observed in the walk way at the foot of the beds in room [ROOM NUMBER]. Licensed Practical Nurse (LPN) #64 and Maintenance Director #46 were alerted to the broken chair. LPN #64 and Maintenance Director #46 entered the room and pulled the scoot chair into the hall. The missing wheel was found under bed A. The Maintenance Director #46 stated, the wheel is missing .all the bolts are loose while turning the bolts of the chair. The scoot chair was removed from the hallway and taken out of service. No work order had been placed prior to discovery. On 09/12/23 at 12:29 PM, the Director of Nursing (DON) could not identify which resident uses the scoot chair.
On 09/12/23 at 12:50 PM, the Administrator stated, the work order has been put in.
No further information was obtained during the survey process.

Based on observation, policy review and staff interview, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections when they failed to ensure resident hand hygiene was performed prior to meals. This was true for twenty-eight (28) Residents on the South front hallway. Resident identifiers: Rooms #101-#115. Facility Census: 113
Findings included:
a) Rooms 101-115 on the South front hallway
On 07/24/23 at 11:35 AM during the noon meal pass on the South front hallway, it was observed that staff did not provide hand hygiene prior to the meal. When Certified Nurse Aid (CNA) #89 was interviewed as to how they provide hand hygiene to the Residents prior to a meal, she stated sometimes there is a container of wipes on the cart, but I wash all my residents hands when I bath them, and I did that this morning. When further ask about hand hygiene at this time, right before meal tray pass, she stated, I did not clean their hands but I did this morning when I bathed them. I confirmed with this CNA that hand hygiene must be performed immediately prior to all meal tray passes. This was also confirmed with the Director of Nursing on 07/24/23 at 11:50 AM who stated, they know they are supposed to provide hand hygiene before meals.
The facility policy titled IC209 Patient Hand Hygiene states Staff should assist patients/residents (hereinafter patient) with hand hygiene after toileting and before meals .

.
Based on observation, record review and staff interview the facility failed to maintain a quality assessment and assurance committee (QAPI) consisting of the minimum required members. The infection preventionist failed to attend the monthly QAPI meeting. This failed practice had the potential to affect all residents currently residing at the facility. Facility census: 117.
Findings included:
a) On 05/10/23 at 4:30 PM, the Administrator stated, QA [quality assurance] was not done last year, we didn't have any meetings. I just had the first one since I have been here last week. The Administrator provided surveyor with a copy of the QA sign in sheet with meeting date of 05/03/23. The Infection Preventionist (IP) did not attend the 05/03/23 meeting, as verified by the Administrator. The Administrator stated the IP was on vacation during the time of the meeting.
Record review of the QA sign in sheets showed all required members were at the 05/03/23 meeting with the exception of the facility's IP.
Record review of the facility's policy titled, Center Quality Assurance Performance Improvement Process, revised 10/24/22, showed the Quality Assessment and Assurance committee was composed of the Administrator, Director of Nursing, Medical Director, Infection Preventionist, Consultant Pharmacist, and three (3) other additional staff representatives.
.

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Based on observation and staff interview the facility failed to provide dignity during care for Resident #50. This failed practice was a random opportunity for discovery and was true for only Resident #50. Resident identifier: #50. Facility census: 117.
Findings included:
a) Resident #50
On 05/10/23 at 9:00 AM, surveyor and Director of Nursing (DON) entered Resident #50's room. Nurse Aide (NA) #74 and NA #130 were giving Resident #50 a bed bath. The window blinds were open, and the resident was laying in bed completely nude, exposed to anything outside the window or adjacent rooms. The DON immediately stepped over and closed the blinds.
As the Surveyor and DON left the room at 9:05 AM on 05/10/23, the DON was asked if dignity was provided while providing care to Resident #50? The DON replied, No it wasn't that is why I jumped over there and jerked the blinds closed.

.
Based on observation, resident interview, and staff interview, the facility failed to ensure one (1)resident was provided a clean, sanitary homelike environment. The resident had dirty sheets his bed. This was a random opportunity for discovery during the long term care survey. Resident identifier #11. Census 117.
Findings included:
a) Resident #11
On 05/08/23 at 11:10 AM, the surveyor observed Resident #11 sitting in his wheelchair in his room. The surveyor also observed the sheets on the resident's bed were covered in, what appeared to be, black dirt. The surveyor asked the resident if he was given showers on a regular basis and the resident responded yes, he gives himself a shower. The surveyor asked the resident if he changed his own bed linens too. The resident responded, no and said he had to have help. The surveyor asked how long it had been since they were changed. He said he was not sure but he would have them help change them sometime today.
On 05/09/23 at 11:30 AM, the surveyor entered Resident #11's room and observed the same dirty sheets were still on the resident's bed. The surveyor asked the resident how long had it had been since the sheets were changed. Resident #11 replied, Two (2) or three (3) weeks probably. The resident stated they would probably change them today.
On 5/10/23 at 10:40 AM, an observation found the same dirty sheets on the resident's bed. The resident stated his sheets had not been changed. The resident said he wanted his sheets changed but needed some help.
The Director of Nursing (DON) was asked to come to Resident #11's room to look at his sheets. As the surveyor and the DON were walking to the resident's room, the DON told the Surveyor that Resident #11 had capacity and did not like for staff to touch his things. The surveyor explained to the DON that the resident was not care planned for this type of behavior and the resident had made statements to the surveyor indicating he would like his sheets changed but needed someone to help him.
When the surveyor and the DON entered the resident's room, the resident had his pillow cases off of his pillows and the pillowcases were on the floor. The resident stated he needed help to change his sheet. The resident told the DON he wanted someone to help him with a fitted sheet and he wanted two (2) new pillowcases. The resident said he did not want a top sheet because he did not use it. The surveyor asked the DON if she saw how soiled his bed linens were. The DON responded by nodding her head and saying yes.
.

.
Based on record review and staff interview the facility failed to have an accurate MDS (Minimum Data Set) discharge for Resident #116. This was true for one (1) out of four (4) reviewed for the care area of discharges during the Long Term Care Survey Process. Facility census 117.
Findings included:
a) Resident # 116
A review of the nursing documentation found; Resident # 116 was discharged to home with family. The facility MDS states Resident # 116 was sent to an acute hospital.
Further review of the record found the following nursing note dated 04/21/23:
Note: resident discharged home via family car. Discharge paperwork, bed hold policy and mediations send with resident. All personal belongings sent with resident.
On 05/10/23 at 10:38 AM, the Director of Nursing reviewed the Nursing note dated 04/21/23 and the MDS section A 1800. and agreed the MDS was coded wrong.
I

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening (PAS) for one (1) of three (3) residents reviewed for the category of PASARR (pre admission screening and resident review), during the long term care survey process. Resident identifier #85. Census 117.
Findings Included:
a) Resident #85
On 05/08/23 at 2:14 PM, a record review of Resident #85's electronic medical record (EMR), found the resident's most recent PAS, dated 03/29/21, indicated no level II was needed. It was also noted on this PAS the resident did not have any behaviors. This PAS was completed by a home health agency for his admission to the facility.
The resident was admitted to the facility on [DATE]. At the time of admission he had a diagnosis of Other Schizophrenia, Bipolar Disorder Unspecified, and Mild Intellectual Disabilities, none of which were indicated on section III, number 30 of the PAS dated 03/29/21.
On 05/09/23 a copy of this PAS was provided to the surveyor by Corporate Nurse #127, as being the most recent PAS the facility has for the resident. EMR review indicates the resident received a diagnosis of unspecified psychosis on 09/14/22 and a behavior care plan was developed for him on 06/13/21 which remains in place.
On 05/09/23 at 2:55 PM, a staff interview with social worker (SW) #66, confirmed there was not a PAS completed after the resident began having behaviors and received a psychosis diagnosis.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to implement the care plan for monitoring behaviors for Resident # 117 and failed to develop a care plan for Resident #41's bipolar disorder. This was true for two (2) out of 27 residents reviewed for care plans. Facility census 117.
Findings included:
a) Resident #117
A review of the medical record for Resident #117 found the staff failed to implement the care plan to monitor behaviors for Resident #117. On the TAR (task administration record) the staff wrote yes for having a behavior. There were no other nurses notes describing the behavior observed.
The care plan states the following:
Focus:
Resident is at risk for complications related to the use of psychotropic drugs.
Goal:
Residents will have the smallest most effective dose without side effects by next review.
Interventions:
Monitor changes in mental status and functional level and report to MD as indicated.
Monitor for continued need of medication as related to behavior and mood.
On 05/09/23 at 9:10 AM, Cooperate Nurse (CN) #127 stated she agreed documenting YES is not documenting the behavior and more detailed note would need to be entered describing what behavior was exhibited.
b) Resident #41
On 05/08/23 an electronic medical record (EMR) was conducted. The resident was admitted on [DATE] with a diagnosis of Bipolar Disorder Unspecified. When reviewing the residents' care plans, the surveyor was not able to locate a care plan for this psychiatric disorder. The surveyor located a mood care plan listing her diagnosis of depression. The only care plan which mentioned the resident's bipolar disorder was the Activities of Daily Living (ADL) care plan.
Staff interview with social worker (SW) #66 on 05/09/23 at 2:55 PM, confirmed there was not a care plan for Bipolar Disorder, only a mood care plan which listed her diagnosis of depression.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and resident interviews, the facility failed to revise care plans to reflect the resident's preferences and meet the resident's needs for three (3) of three (3) residents reviewed for the category of activities, during the long term care survey. Resident identifiers #11, #100, and #84. Census 117.
Findings Included:
a) Resident #11
On 05/08/23 during a resident interview the resident stated he doesn't go to activities because he doesn't like BINGO.
A record review was conducted on 05/09/23 of the resident's Recreation Quarterly assessment dated [DATE]. It included, .List independent leisure pursuits: watching TV/movies independently and/or with other residents, resting, reading newspaper/daily chronicle, talking/visiting with office staff and other residents, going outside, smoking, collecting recipes .List the most frequently attended group programs: outings, music related programs, movies .
Record review of the resident's activities care plan does not reflect the resident's preferences from his activities assessment. The activities care plan interventions say provide materials of interest such as daily newspaper, puzzles.
b) Resident #100
Resident interview on 05/08/23 at 1:23 PM, concluded the resident doesn't attend activities due to the fact that there is not a lot to do other than BINGO.
Record review on 05/10/23 of the resident's Recreation Comprehensive Assessment, dated 04/19/23 included, .Describe Other ways resident spends time alone: Cell phone for reading, listening to music & the Bible .
Record review of the resident's activities care plan included the two (2) following interventions: Inform resident of facility happenings via copy of program calendar in room, verbal invitations to center events, and provide materials of interest such as: TV channel guide, list of available supplies/materials.
d) Resident #84
During an interview on 05/08/23 at 12:31 PM, Resident #84 stated there is nothing to do around the facility.
A review of Resident #84's current care plan Dated 05/08/23. This showed the care plan was not updated to reflect the resident's current status and activity preferences.
Focus:
*Strength; Resident #84 initiates and engages in preferred independent leisure pursuits and/or group programs of his choice daily
Goal:
Resident #84 will continue to initiate and engage in preferred independent leisure pursuits and/or group programs of his choice daily.
Interventions:
--Offer invitations and/or reminders of scheduled programs and locations.
--Post program calendar in room.
--Provide, as needed, preferred leisure materials such as writing tablets/pens, books/magazines, movies.
A continued review found Resident #84's Recreation Comprehensive assessment dated [DATE] revealed he enjoys social/special events, exercise, active games, card games, trivia, music/dancing, outings, community meetings, arts/crafts, outdoor programs, religious programs, watching TV/movies, reading, religious practices, and socializing with peers.
During an interview on 05/09/23 at 1:00 PM, the Director of Nursing verified Resident 84's care plans were not updated to reflect his likes and dislikes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, resident observation and staff interview the facility failed to ensure residents who are dependent on staff for carrying out thier Activities of Daily Living (ADL) recieve the necessary services to maintain good nutrtion, grooming, and personal hygiene. The was true for three (3) of three (3) residents reviewed for the care area of ADL care during the long term care survey process. Resident Identifiers: #424, #217, and #70. Facility Census: 117.
Findings included:
a) Resident #424
An observation of Resident #424 on 05/08/23 at 11:44 AM, found her hair was dishelved with part of it pulled up with a hair band on top of her head. The hair was coming out of the hair band and sticking up. It appeared her hair had not been combed recently. The resident was wearing an oversized sweat shirt which was dark blue at the bottom and light blue at the top. She was wearing a pair of dark pants.
On 05/09/23 multiple observations of Resident #424 during the day beginning at 9:00 am and concluding at 3:30 pm found the resident still had the same disheveled hair style and was wearing the same clothes she was wearing during the observation made on 05/08/23.
An interview with Corprate Registered Nurse (RN) #127 at 3:30 pm on 05/09/23, confirmed the residents hair was diseveled. She agreed it did not appear the residents hair had been combed or styled recently. Coporate RN #127 asked Resident #424 if she would like to take a shower and get on clean clothes to which the reisdent replied, Sure I don't see why not.
The corporate RN then asked Nurse Aide (NA) #28 to give the reisdent a shower and to change her clothes.
NA #28 was interviewed at 3:49 pm on 05/09/23. When asked if she had been the residents NA all day she stated, No I just got her at 3:00 pm. She was then asked if she worked with Resident #424 on the previous night. She stated, I was her NA from 3:00 PM to 11:00 PM. When asked if she had changed Resident #424 into sleepware the previous night she stated, No I did not she just walked the halls and went and climbed in bed.
A review of Resident #424's medical record found the resident required assistance of staff for dressing and bathing. Her bathing record was reviewed and found Resident #424 was admitted to the faiclity on 05/03/23. During the time of this review on 05/09/23 the bathing record indicated Resident #424 only recvied one (1) bed bath since the time of her admission. This bed bath was given on 05/04/23 the day after her admission. From 05/04/23 until 05/09/23 the section Not applicable was marked indicating Resident #424 recieved no bed baths or showers.
b) Resident #217
On 05/08/23 at 12:05 PM Resident #217 stated he had not showered for at least 5 days. The Resident further stated he cannot do it by his self, and he told staff this morning he wanted a shower today and they had not been back. The Resident's hair appeared greasy, matted together, and was sticking straight up. Resident #217's black t shirt was visibly soiled and wet with sweat stains under the breast area.
Record review indicated the Resident had only received two (2) showers since he was admitted on [DATE]. Showers were noted to be given on 04/29/23 and 05/05/23. Resident was scheduled to receive showers Tuesday and Fridays.
Review of Resident #217's care plan showed the Resident required assistance at all times for Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting, and ambulation related to left foot osteomyelitis, left foot diabetic ulcer, COPD, bilateral pleural effusions, morbid obesity, depression, anxiety, impaired mobility, and weakness. Interventions included: May require up to extensive assist x 1 with bathing (usually independent after setup assistance) Date Initiated: 05/04/2023.
On 05/09/23 at 12:50 PM the Director of Nursing (DON) stated they started doing shower care audit sheets and if there was a refusal to get showered, they had to make nurses note. No nurse's note was found documenting refusals. The DON verified the Resident did not receive the scheduled showers as ordered.
On 05/09/23 at 1:33 PM, Resident #217 stated he finally got a shower yesterday evening. The Resident said, I needed it [shower] so bad I was sweaty and just nasty. I would like to have one every other day.
c) Resident #70
On 05/08/23 at 11:28 AM Resident #70 stated, she doesn't get her showers or baths as ordered or according to her preference.
A Medical Record Review for Resident #70's Shower documentation found, she only received showers on 04/12/23, 04/22/23, 04/29/23 and 05/03/23 in the last 30 days.
During an Interview on 05/09/23 at 2:30 PM the Director of Nursing (DON) verified there was no documentation to indicate Resident #70 received showers as scheduled.
.

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Based on observation, record review and staff interview the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. An accurate skin assessment was not completed for Resident #4. Appropriate action was not taken in a timely manner for an incident involving injury for Resident #50. These failed practices were a random opportunity for discovery and was true for Resident #4 and Resident #50. Resident identifiers: #4, and #50. Facility census: 117.
Findings included:
a) Resident #4
On 05/08/23 at 11:38 AM, Resident #4 was noted to have open skin areas with partial scabbing to her left forehead area. The Resident stated she told her daughter about it, and they probably should be putting something on it because they won't heal.
Record review showed on 05/08/23 at 1:58 PM, a skin check was performed. No skin injury/wound(s) were noted on the Skin assessment done by Licensed Practical Nurse (LPN) #18.
Record review showed on 05/01/23 at 6:17 AM a skin check was performed, and no skin injury/wound(s) were noted on the skin assessment done by LPN #84.
On 05/10/23 at 8:57 AM observation was made of skin issues to resident's right forehead in presence of the Director of Nursing (DON). The DON agreed the skin issues should have been reported on the skin assessment done Monday (05/08/23) and should have a treatment being done. The DON stated, She is care planned for picking, so that's probably where they came from.
Review of care plan showed resident was at Risk for Skin Breakdown related to Morbid Obesity, Pain, mild confusion at times and a history of dermatitis and pruritus. Resident had a behavior of picking her skin causing open areas at times. Resident had been educated on the risk of continuing to pick at her skin up to and including infection and further compromised skin integrity, resident has verbalized understanding. Evaluate for any localized skin problems. Monitor skin for signs/symptoms of skin. Observe skin condition with ADL care daily and report abnormalities
b) Resident #50
During an interview on 05/08/23 at 11:25 AM Resident #50 stated Nurse Aide (NA) #97 hit his toes on the metal frame of the doorway leading into the shower room and blackened his toes on his left foot. The Resident stated they waited until the next day or two to do an Xray of his foot. Resident #50 said, That metal door frame did not feel good on my toes, they are still black.
Record review indicated a reportable was completed on 4/21/23 for the incident that occurred on 04/19/23 involving the resident's toes. The reportable stated the incident occurred on 04/19/23 and the resident did not complain to staff until 4/21/23. At that time, the Xray was ordered. Xray report was reviewed, and no evidence of acute fracture existed.
During an observation of the resident's left foot on 05/17/23 at 9:00 AM in the presence of the Director of Nursing (DON) it was noted the first three digits of the left foot, first toe (great toe), second toe, and middle toe were all blackened at the base of the toe. The DON was asked why the incident was not reported to someone immediately when it happened. The DON replied, I do not know, maybe it was a weekend. He [resident #50] never complained about it until days later. The DON verified NA #97 should have told the nurse about it, an incident report should have been completed along with a change in condition so they could have kept a better eye on the toes.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, resident interview, and staff interview the facility failed to ensure a resident who has an indwelling urinary catheter receives the care and services needed to ensure the resident did not develop complications related to the indwelling urinary catheter.
The facility staff failed to ensure an anchor device was on Resident #105's catheter to prevent it from becoming dislodged. In addition, the nursing staff failed to identify and/or address serious problems with Resident #105's catheter prior to surveyor intervention on two (2) separate occasions on 05/09/23 and again on 05/10/23. In addition Resident #105 suffered a change in mental status which was also not identified by nursing staff until it was pointed out by the surveyor. Also, nursing staff failed to follow all physician directives pertaining to Resident #105's catheter and his urinary status within a timely manner.
Resident #105 suffered actual physical harm as the result of these failures. He was sent to the emergency room (ER) and returned to the facility with comfort measures in place and a referral to hospice services. When the resident returned to the facility, his diagnosis included: Septic Shock, Pyelonerhritis (an inflammation of the kidney due to a bacterial infection.). A CT (Computed Tomography) of his abdomen while at the hospital showed moderate bilateral hydroureteronephrosis (The swelling of a kidney due to build up of urine. This happens when urine cannot drain out from the kidney to the bladder from a blockage or obstruction.)
The State Agency (SA) determined these failures posed an immediate risk to Resident #105 and placed him in an immediate jeopardy (IJ) situation in addition to the actual harm he had already suffered.
The SA notified the facility of the IJ at 1:30 PM on 05/10/23. The facility submitted their first plan of correction (POC) at 4:17 PM. The SA requested changes to the POC. The second POC was submitted at 5:00 PM. The POC was accepted by the SA at 5:00 PM. This immediate Jeopardy began on the morning of 05/09/23.
The facility Plan of Correction read as follows:
F690
Resident #105 returned to the facility from the hospital at 2:00 PM on 05/10/23. The medical director assessed Resident #105 on 05/10/23 at 2:00 PM.
All residents with indwelling catheters of the facility have the potential to be affected.
The Unit Manager conducted an audit on all indwelling catheters at 1:50 PM on 05/10/23 to ensure all residents with an indwelling urinary catheter to ensure a secured device is in place, proper way to palpate for bladder distention, monitoring urine output color and notification to medical provider regarding abnormal changes, and if medical provider orders related to urinary catheters for possible occlusion are followed as soon as possible (ASAP) with any corrective action immediately upon discovery.
Re-education was provided by the director of nursing (DON)/Designee to all licensed nurses on 05/10/23 at 2:30 PM to ensure all resident with an indwelling urinary catheter received the care and services to ensure the resident did not develop complications related to the indwelling catheter, including ensuring a secured devices was in place, proper way to palpate for bladder distention, monitoring urine output color and notification to medical provider regarding abnormal changes, and medical provider orders related to urinary catheters for possible occlusion are followed as soon as possible (ASAP) . A post-test was done to validate understanding. Any licensed nurses not available during this time frame were provided re-education, including post test and return demonstration by DON/designee upon the beginning of their next shift to work. New Licensed nurses was provided education including post-test during orientation by the DON/designee. Annual in servicing was also provided to licensed nurses regarding the care of indwelling urinary catheters.
The Unit managers (UM) /Designee conducted observations starting on 05/10/23 at 4:00 PM to ensure all residents with an indwelling urinary catheter received the care and services to ensure a secured device is in place, monitor urine output color and notify medical provider of abnormal changes and if orders were received for occlusion, they were followed ASP daily across all shifts for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly there after.
Results of observations were to be reported by the Unit Manager (UM)/Designee monthly to the Quality Improvement Committee (QIC) for any additional follow up and or inservicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
After observation for implementation of the POC the IJ was abated at 6:00 PM on 05/10/23. It was at this time the IJ ended. After the immediacy was removed a deficient practice remained, therefore the scope and severity was reduced from a J to a G because of the actual harm suffered by Resident #105. A deficient practice also remained for Resident #110 related to a diagnosis of a Urinary Tract Infection and the staff failing to get the results of the Urinalysis Culture and Sensitivity to ensure Resident #110 was treated with the correct antibiotic.
These failed practices were true for two (2) of three (3) residents reviewed for the catheter/UTI (Urinary Tract Infection) care area during the long term care survey process. Resident Identifiers: #105 and #110. Facility Census: 117
Findings Included:
A) Resident #105
On 05/0923 at 11:10 am, Resident #105 was observed lying in his bed. His indwelling urinary catheter tubing was red in color and appeared to have dark blood toward the top of the tubing which appeared to be a blood clot. The resident on observation appeared to be uncomfortable. The surveyor entered Resident #105's room after obtaining his permission at 11:13 AM. Resident #105 was then asked how he was doing. Resident #105 stated, I am not doing too good. I was taking
myself to the restroom this morning and my catheter pulled real hard. It felt like it was going to come out of me. Ever since then I have had a lot of pain and discomfort down there. Resident #105 was asked if he had told the staff about this incident. He stated, I told them, but they have not done anything yet. He further stated It felt like that ball just pulled right out of me but I can still feel it so I know it didn't.
At 11:15 AM on 05/09/23 Licensed Practical Nurse (LPN) #126 was asked to accompany the surveyor to Resident #105's room. LPN #126 stated she was aware of Resident #105 pulling his catheter this morning and there was minimal bleeding and she notified the nurse practitioner of the incident.
Upon entering Resident #105's room, LPN #126 was asked to observe Residents #105's catheter tubing with Nurse Surveyor 39751 present. She agreed there was a blood clot in the tubing below the Y- point of the catheter which was blocking urine flow. She stated, We will have to get an order to change the catheter. Again Resident #105 voiced to LPN #126 he was experiencing pain related to his catheter and the incident which happened this morning. LPN #126 confirmed at this time the resident did not have an anchor device on his leg to anchor the tubing to keep it from pulling and dislodging upon movement. Nurse Surveyor 39751 noted the Y-point of the catheter tubing was down to Resident #105's knee. This would indicate the catheter had dislodged from it previous location because the Y-Connecter is usually located in the upper thigh region.
A review of the medical record found the following progress notes related to Resident #105's condition from 11:15 am on 05/09/23 until the surveyors returned to the facility on [DATE]:
-- Note dated 05/09/23 at 9:00 am written by LPN #126 read as follows: Resident reports pain to Foley catheter site, blood tinged urine noted to catheter tubing and BSD (Bed side Draining) bag. Reported to NP (Nurse Practitioner). N/O (new order) to monitor Foley catheter for increased bleeding/pain. RR (responsible party) aware.
--Note dated 05/09/23 at 10:00 am written by LPN #126 read as follows: Foley Catheter patent with blood tinged urine draining to BSD (Bed Side Draining) bad [SIC].
The notes with the times of 9:00 am and 10:00 am were both entered into the EMR (Electronic Medical Record) after the nurse was requested in the Room of Resident #105 by the surveyors.
-- Note dated 05/09/23 at 11:15 am written by LPN #126 read as follows: Resident c/o increased pain to Foley catheter site, catheter not draining, increased bleeding/blood clots noted to tubing. Reported to NP. N/O to change Foley Catheter.
-- A note written by the Nurse Practitioner dated 05/09/23 signed at 11:59 AM read as follows: .Chief complaint /nature of presenting problem Seen today to evaluate hematuria per nurse request. History of present illness: Resident with urinary retention, Foley placed in hospital. Now with hematuria, with some small clots after pulling on Foley, causing some urethral pain as well. Medications reviewed, currently taking aspirin 81 mg daily. Resident with poor safety awareness and some confusion related to dementia Plan: Discontinue Foley today, monitor for voiding. If unable to void, replace per urologist orders. Follow up with urologist as scheduled. Hold aspirin 81 mg X 5 days, monitor hematuria.
-- Note dated 05/09/23 at 1:14 PM written by LPN #126 read as follows: New order to D/C Foley catheter. Resident tolerated well, small amount of blood discharge noted to urethra. Resident has no complaints of pain or discomfort at this time. Will monitor urine output.
-- Note Dated 05/09/23 at 5:51 PM written by LPN #94 read as follows: New orders noted: Straight cath X 1 if resident unable to void after 8 hour (7:45 PM) If resident does not void within 8 hours after straight cath, Approx 3:45 am (on 05/10/23) reinsert indwelling Foley cath.
-- Note dated 05/09/23 at 6:00 PM written by LPN #126 read as follows: Resident has not voided this shift, order obtained to straight cath X 1 if resident is unable to void after 8 hours (7:45 PM) if resident does not void within 8 hours after straight cath, 3:45 am reinsert indwelling Foley cath.
-- Note dated 05/09/23 at 6:25 PM written by LPN #126 read as follows: LATE ENTRY:Resident stated to this nurse that he felt like he needed to void, urinal given to resident. Resident stated that it will take him a few minutes. This nurse passed on to night shift that resident is attempting to void in urinal at this time and if not voided by 7:45 am to straight cath per order. Night shift nurse verbalized understanding.
-- Note dated 05/09/23 at 8:58 PM written by LPN #47 which read as follows: Resident was not able to void during straight Cath only blood was showing. This nurse contacted (Name of Tele health Service Name of Specific Dr.) ordered to discontinue straight cath and to Foley cath and irrigated bladder to flush out any blood.
-- Tele health Evaluation note dated 05/29/23 at 9:11 PM written by Tele health Doctor read as follows: Primary chief complaint: GU Hematuria. : History of present illness: Patient is a [AGE] year old male inadvertently pulled out his Foley Yesterday and Foley was not put in but orders were given to straight cath patient if unable to void. Patient was straight catheterized and thick blood clots mixed with urine was obtained. Patient continues having problems voiding. He has no fever or chills. Diagnosis, assessment plan: Urinary retention, retention of urine, The patients condition is worsening. Put in Foley at this time because of thick clots and repeated straight cath is just damaging urethra more. Obtain UA and culture. Once Foley placed irrigate bladder with saline until clear.
** Please note the medical record was void of any indication the Urine was obtained for the UA C&S as ordered by the tele health physician. The nurse also noted that she got back blood tinged urine. There was no indication in the record she irrigated the bladder until clear as directed by the Tele health physician.
-- Note dated 05/10/23 3:45 am written by LPN #47 read as follows: This nurse inserted 16' Foley catheter return yielded a bright red blood and urine mix at 350 cc's of urine. Cath bag in place with leg strap on left leg. Resident Denies pain will continue to monitor.
An observation of Resident #105 on 05/10/23 at 9:00 am found the resident had an Indwelling catheter. There was a bedside drainage bag which contained less than 5 cc's of blood. The tubing of the catheter again was full of blood and appeared to be clotted. The resident was not responding to verbal stimuli as he had on the previous two (2) days. When the surveyor said his name multiple times the resident just stared at the ceiling and showed no response.
LPN #126 was Resident #105's assigned nurse at this time. The surveyor requested she come to Resident #105's room with this surveyor and Nurse Surveyor #39751. Upon entering the room LPN #126 stated I know about the blood in the tubing I told the Nurse Practitioner and have an order to irrigate it I just have not got to it. Please note when the surveyor approached LPN #126 to enter resident #105's room she was preparing medications for other residents and was not in the process of gathering supplies to irrigate Resident #105's catheter which was obviously obstructed with blood clots. Her own admission revealed she knew about the blood clots but had not done anything to resolve the issue.
LPN #126 was then asked about Resident #105 not responding to verbal stimuli. She stated, I was not aware he was not responding to verbal stimuli. When asked if this was normal for him she stated, No I guess that is a little bit of a change for him. She was then asked if she could irrigate the residents catheter. She left the room at 9:15 am to gather supplies to perform the irrigation.
LPN #83 entered Resident #105's at 9:25 am on 05/10/23 to obtain a set of vitals for the resident. LPN #83 said Resident #105's name loudly several times which warranted no response from the resident. She then performed a sternal rub which also warranted no response from the resident. She then placed her hand under his and asked him to squeeze her hand which he did not do. LPN #83 was asked if this was normal for this resident, She stated no it is not. I have never seen him like this even when he was here previously he was never like this. I think we need to send him to the emergency room. LPN #83 obtained the following vital signs for this resident: Blood Pressure was 176/81, Temperature was 98.2 degrees Fahrenheit, his oxygen saturation was 86. LPN #83 stated, We need to get him on some oxygen.
LPN #83 was then asked to palpate Resident #105's bladder to determine if it was distended. LPN #83 then began pushing on Resident #105's pelvic bones. Nurse Surveyor #39751 then instructed LPN #83 the proper way to palpate the bladder. When LPN #83 performed the palpation correctly she determined Resident #105's bladder was distended. The proper procedure to palpate the bladder is to gently palpate from the umbilicus downward toward the pelvis, feeling for a full bladder.
At 9:40 am on 05/10/23 it was noted LPN #126 had not returned to irrigate Resident #105's bladder. The Director of Nursing was asked to assist LPN #126 in gathering her supplies so Resident #105 could have his catheter irrigated.
At 9:45 am on 05/10/23 thirty minutes after she left the room to gather her supplies, LPN #126 returned to the room to irrigate the catheter. Nurse Surveyor #39751 observed LPN #126 irrigate the catheter. Upon irrigation she flushed in 50 ml (milliliters) of water and only received 5 ml of water on return which was blood tinged. LPN #126 received no urine in return. This indicates the catheter is possibly occluded or not in the bladder. LPN #126 stated, We got orders to send him to the emergency room.
An interview with the Nurse Practitioner at 9:55 am on 05/10/23, revealed she had not completed a head to toe assessment on Resident #105. She stated, About 8:05 am this morning I stuck my head in and the resident was awake and moving. She noted nothing specific to his catheter at this time. When asked what it meant when the nurse only received back 5 ml of the 50 ml or saline she flushed into the catheter she stated, It is probably occluded. She stated, I am going in to see the patient right now. That's what I do.
At 10:10 am on 05/10/23 Resident #105 was observed being loaded onto an ambulance to go to the hospital.
At approximately 2:00 PM on 05/10/23 the Nursing Home Administrator stated, I noticed his catheter had blood in it this morning at about 8:30 am. I told the Nurse about it and she said she would let the Nurse Practitioner know about it.
At 2:14 PM on 05/10/23, the director of nursing entered the following note, Spoke with (Name of Nurse) at (Name of Hospital) taking care of resident. Residents son is at bedside, son wants to keep resident as comfort measures. Residents lactic acid was 12, troponin was 53, D-dimer 58, CT evaluation, lesions on liver, fluid filled esophagus, No urine output at this time, the little bit they had in the tubing was nothing but blood. They are giving morphine for comfort.
A nurses note dated 05/10/23 at 2:17 PM, written by LPN #126 read as follows: Resident arrived to facility via EMS (Emergency Medical Services) from (Name of Local hospital) Resident was discharged with orders to be comfort care only, resident diagnosed with septic shock, pyelonephritis, acute emphysematous cystitis. NP and MD notified. New orders to d/c maintenance medications and start end of life medications. Resident lethargic, unable to verbally respond or follow commands. Blood noted to Foley catheter tubing and BSD bag.
A review of the emergency room report for Resident #105 was reviewed in the evening of 05/10/23 and the following was revealed. Resident #105 was returned to the facility with the following assessment/plan 1. Comfort Measures Only. 2. Septic Shock (life threatening condiiton caused by severe localized or system-wide infection that requires immediate medical attention). 3. Pyelonephritis (inflammation of the kideny). 4. Acute emphysematous prostatis (gas collection and purulent exudates within the prostate). 5. Acute emphysematous cystitis (a potentially life threatening infection characterized by gas within the bladder wall and lumen due to gas forming bacteria). Orders: Morphine As needed for pain.
The resident had a CT of the abdomen pelvis with contrast which yielded the following results:
1. Acute emphysematous cystitis, acute emphysematous prostatis and acute bilateral pyelonephritis.
2. Moderate bilateral hydroureteronephorosis. 3. Acute diffuse colitis and proctitis. 4. Abnormal low density lesion on hepatic dome could represent a hemangioma or other begnin etiology are not excluded. MR exam of the liver without and with intravenous contrast is recommended for further evaluation, which could be performed non emergently depending on clinical scenario.
Further review of the record found the facility staff talked to the son about a hospice referral for this resident. The son agreed and hospice is to evaluate the resident on 05/11/23.
b) Resident #110
A record review of Resident #110's medical record found she had an outside appointment on 04/13/23 and returned to the facility with an order from that Physician for an antibiotic. While at this appointment the office obtained a urinalysis and urine culture. The script was for Cipro 500 mg bid (twice a day) x (times) 10 days d/t (due to) bacteria found in urine. Awaiting urine culture.
When Resident #110 returned to the facility on 4/13/23, the nurse on duty entered the following progress note: (as copied)
04/13/2023 11:04
General
Late Entry:
Note: Resident returned from radiology appointment with orders for Cipro 500 mg BID x 10 days d/t bacteria found in urine. Awaiting culture at this time. NP aware. RP aware.
According to documentation on the Medication Administration Record (MAR) the resident did receive all twenty (20) doses of the antibiotic from 04/13/23 through 04/23/23.
A urine culture was needed to confirm if there is a need for an antibiotic and if the urine bacteria is susceptible to specific antibiotics.
On 05/10/23 at 5:52 PM the Director of Nursing confirmed the facility never obtained the results of the urine culture to confirm if Resident #110 needed the antibiotic or if the resident was on the correct antibiotic for the infection.
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Based on record review and staff interview the facility failed to ensure the resident weights were confirmed by a reweight when there was a 5 pound difference from the previously obtained weight. Failure to confirm the weights made it difficult for the dietician and other healthcare professionals to monitor Resident #82's nutritional status. This was true for one (1) of two (2) residents reviewed for the care area of nutritional status during the Long Term Care survey process . Resident Identifier: #82. Facility Census: 117.
Findings included:
a) Resident #82
A review of Residents #82's medical record on 05/08/23 found the following weights recorded:
-- 04/13/23 95 pounds (Date of admission to facility)
-- 04/18/23 98 pounds
-- 04/26/23 109 pound this was an 11 pound gain
-- 05/04/23 90 pounds this was a 19 pound loss.
-- 05/09/23 99 pounds this was a 9 pound gain.
During and interview with the Director of Nursing (DON) on 05/10/23 at 6:07 PM, she confirmed if there is a 5 pound difference from the previous weight the staff should reweigh the resident to confirm the loss/or gain of 5 pounds or greater. She confirmed this was not done on 04/26/23, 05/04/23 and 05/09/23. She stated, We have no way of knowing if these weights are accurate because the reweigh was not completed.
.

.
Based on observation, policy review and staff interview the facility failed to reconcile the narcotic reconciliation sheets on two (2) of three (3) medication cart narcotic books reviewed. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Facility Census: 117
Findings included:
a) North Hall Narcotic Books
On 05/09/23 at 9:05 AM upon review of North front and back hall hall narcotic book it was found to be incomplete as per the facility Routine Reconciliation of Controlled Substances Policy dated 01/01/22.
Review dates of the narcotic reconciliation books were from 04/01/23 through 05/07/23 for a total of 37 days. Normally there are two (2) entries per day as the nurses work twelve (12) hour shifts and reconcile the narcotic book each shift change (7 AM and 7 PM). This gives them 74 entry possibilities during the time frame reviewed. The North front hall missed thirty eight (38) entries and the North back hall missed twenty three (23) entries.
The following entries were missing or incomplete according to the policy and record review.
--North Front
04/07/23 7 PM missing off nurse signature, total # cards and total # of count sheets
04/09/23 7 AM missing total # cards and total # of count sheets for both on and off nurse
04/09/23 7 PM missing total # cards and total # of count sheets for both on and off nurse
04/14/23 7 AM missing entire entry (2 opportunities)
04/14/23 7 PM missing entire entry (2 opportunities)
04/16/23 7 AM missing on nurse signature, total # cards and total # of count sheets
04/16/23 7 PM missing entire entry (2 opportunities)
04/17/23 7 AM missing entire entry (2 opportunities)
04/21/23 7 PM missing off nurse signature, total # cards and total # of count sheets
04/21/23 7 PM missing on nurse total # cards and total # of count sheets
04/22/23 7 AM missing on nurse total # cards and total # of count sheets
04/22/23 7 AM missing off nurse total # cards and total # of count sheets
04/23/23 7 PM missing off nurse total # cards and total # of count sheets
04/29/23 7 AM missing on nurse total # cards and total # of count sheets
04/30/23 7 AM missing on nurse total # cards and total # of count sheets
05/02/23 7 AM missing on nurse total # cards and total # of count sheets
05/02/23 7 AM missing off nurse total # cards and total # of count sheets
05/02/23 7 PM missing on nurse total # cards and total # of count sheets
05/02/23 7 PM missing off nurse total # cards and total # of count sheets
05/03/23 7 AM missing on nurse total # cards and total # of count sheets
05/03/23 7 AM missing off nurse total # cards and total # of count sheets
05/03/23 7 PM missing on nurse total # cards and total # of count sheets
05/03/23 7 PM missing off nurse total # cards and total # of count sheets
05/04/23 7 AM missing on nurse total # cards and total # of count sheets
05/04/23 7 AM missing off nurse total # cards and total # of count sheets
05/04/23 7 PM missing off nurse total # cards and total # of count sheets
05/05/23 7 PM missing on nurse total # cards and total # of count sheets
05/05/23 11 PM missing off nurse total # cards and total # of count sheets
05/06/23 7 AM missing on nurse total # cards and total # of count sheets
05/06/23 7 PM missing on nurse total # cards and total # of count sheets
05/06/23 7 PM missing off nurse total # cards and total # of count sheets
05/07/23 7 AM missing on nurse total # cards and total # of count sheets
05/07/23 7 AM missing off nurse total # cards and total # of count sheets
05/07/23 7 PM missing on nurse total # of count sheets
05/07/23 7 PM missing off nurse total # cards and total # of count sheets
-- North Back
04/02/23 7 AM missing entire entry (2 opportunities)
04/11/23 7 PM missing on nurse signature , total # cards and total # of count sheets
04/14/23 11 PM missing off nurse signature , total # cards and total # of count sheets
04/17/23 7 AM missing entire entry (2 opportunities)
04/17/23 7 PM missing on nurse signature , total # cards and total # of count sheets
04/18/23 7 AM missing off nurse signature , total # cards and total # of count sheets
04/21/23 7 AM missing on nurse total # cards and total # of count sheets
04/21/23 7 PM missing on nurse signature , total # cards and total # of count sheets
04/22/23 7 AM missing off nurse signature , total # cards and total # of count sheets
04/22/23 11 PM missing off nurse signature , total # cards and total # of count sheets
04/23/23 7 AM missing on nurse total # cards and total # of count sheets
04/23/23 7 AM missing off nurse total # cards and total # of count sheets
04/26/23 11 PM missing on nurse signature , total # cards and total # of count sheets
04/27/23 7 AM missing off nurse signature , total # cards and total # of count sheets
04/28/23 7 AM missing off nurse signature , total # cards and total # of count sheets
04/29/23 7 PM missing off nurse signature
05/05/23 7 PM missing off nurse signature , total # cards and total # of count sheets
05/06/23 7 AM missing on nurse total # cards and total # of count sheets
05/06/23 7 AM missing off nurse total # cards and total # of count sheets
05/06/23 7 PM missing on nurse signature
05/06/23 11 PM missing off nurse signature
According to the Routine Reconciliation of Controlled Substances dated 01/01/22, #5 states To conduct a routine reconciliation of controlled substances, the Facility Staff should compare:
5.1 The total number of doses originally dispensed the pharmacy to
5.2 The number of doses remaining to
5.3 The number of doses recorded as remaining on the medication-specific declining inventory sheet to
5.4 The number of doses administered according to the resident's medication administration record.
The pre-printed Shift Change Controlled Substance inventory Count Sheet provides the layout for date, Shift/time, Nurse Signature. Total # Cards/Containers, Total # of count sheets as well as sheets added or removed.
These finding were confirmed with the Director of Nursing on 05/09/23 at 9:15 AM.

.
Based on record review, policy review, and staff interview, the facility failed to ensure the physician responded timely to monthly drug regimen reviews. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #84. Facility census: 117.
Findings included:
a) Resident #84
Record review of the facility's policy titled, Medication Regimen Review, showed:
--The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident.
a) Resident #84
A medical record review for Resident #84 revealed monthly drug regimen reviews were not responded to by the physician timely.
-02/15/23 Recommendation to evaluate continued use of a long-acting Potassium Chloride product, Potassium Chloride ER 10meg and Benztropine Mesylate 1 mg. This recommendation was not responded to until 03/29/23.
-02/15/23 Recommendation to increase Atorvastatin or adding icosapent ethyl capsules 2 grams twice daily with food. This recommendation was not responded to until 03/29/23.
During an interview on 05/09/23 at 1:02 PM the Director of Nursing (DON) verified that the physician, Nurse Practitioner, or the DON did not sign all recommendations or follow up timely. She stated that the Nurse Practitioner was in the facility daily and should be responding more timely to these recommendations.
.

.
Based on record review and staff interview the facility failed to ensure a resident did not receive unnecessary psychotropic medications (a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior.) This was true for One (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #117. Facility census 117.
Findings included:
a) Resident #117
A review of Resident #117's medical record on 05/10/23 found the resident was ordered to receive the psychotropic medication of Seroquel for hallucinations.
During an interview on 05/10/23 at 10:20 AM, the Director of Nursing (DON) agreed hallucinations were a symptoms of a disease and not a diagnosis of an illness. All psychotropic medications were required to have an appropriate diagnosis for their use.
.

.
Based on record review and staff interview the facility failed to ensure a residents drug regimen was free from unnecessary drugs. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident identified: #117 Facility census 117.
Findings included:
a) Resident #117
A review of medical records for Resident #117 revealed the resident was ordered to receive Macrobid (antibiotic) one (1) tablet once a day for Prophylaxis. The order did not state what they were trying to prevent with this prophylactic medication.
On 05/09/23 at 2:15 PM the Director of Nursing (DON) was asked about the order. (Macrobid) Antibiotic used for Prophylaxis. The DON agreed the order should have included a Urinary Tract Infection.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, staff interview and policy review the facility failed to ensure supplies in the medication storage room were within the expiration date in accordance with currently accepted professional principles. This failed practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census: #117
Findings included:
a) On [DATE] at 4:04 PM during an audit review of the South Medication Room with Licensed Practical Nurse (LPN) #18, there were numerous medical supply items in the storage room that had expired.
According to the facility Storage and Expiration Dating of Medications, Biological's, Syringes, and Needles dated [DATE] revision date, the Facility should ensure medications, biological's and supplies that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the supplier.
On [DATE] at 4:28 PM, the following expired items were confirmed with LPN #18 and were destroyed.
BD Vacutainer green top lab tubes: three (3) tubes expired [DATE].
BD Saf-T-Intima 22 gauge X 0.75 inch: four (4) packages expired 05/2020.
BD Vacutainer Eclipse Blood Collection Needles:
thirteen (13) expired [DATE]
twenty three (23) expired [DATE]
twenty five (25) expired [DATE]
eighteen (18) expired [DATE].
Magellan 1 millimeter TB Safety Syringe: fifty one (51) expired [DATE].
BD Nexiva closed Intravenous Cath System Single port 24 gauge X 0.75 inch: eight (8) expired [DATE].
Replacement Cap: twenty one (21) expired [DATE].
Hypodermic Safety needles:
three (3) boxes expired [DATE]
one (1) box expired [DATE]
three (3) boxes expired [DATE].
Standard Hypodermic Needles:
two (2) boxes of 100 needles per box expired [DATE]

.
Based on record review and staff interview the facility failed to maintain complete and accurate medical records for seven (7) of 27 sampled residents reviewed during the long term care survey process. Resident identifiers: #77, #106, #58, #86, #85, #53, and #11 Facility Census: #117.
Findings included:
On 05/09/23 at 1:15 PM a review of documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes for the four (4) residents presented below. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation.
a) Resident #77
On 05/09/23 a review of Resident #77's medical record found documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation. The following are the dates and entries missed for Resident #77:
04/10/23
missing two (2) entries
04/11/23
missing one (1) entry
04/13/23
missing one (1) entry
04/14/23
missing three (3) entries
04/15/23
missing one (1) entry
04/16/23
missing two (2) entries
04/17/23
missing three (3) entries
04/18/23
missing one (1) entry
04/19/23
missing three (3) entries
04/20/23
missing one (1) entry
04/22/23
missing two (2) entries
04/23/23
missing three (3) entries
04/26/23
missing three (3) entries
04/28/23
missing two (2) entries
04/29/23
missing three (3) entries
04/30/23
missing one (1) entry
05/01/23
missing one (1) entry
05/02/23
missing one (1) entry
Resident #77 had thirty four (34) of ninety (90) opportunities to document missing.
Resident #77's care plan stated:
FOCUS: Resident is at nutritional risk R/T increased nutrient needs R/T skin breakdown; BMI> 25; medical dx that may affect weight, intakes and nutritional states (i.e. COVID 19, HLD)
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
FOCUS: Resident is at risk for gastrointestinal symptoms or complications related to medication effects, constipation, nausea and immobility.
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
FOCUS: Risk for oral health or dental care problems R/T quadriplegia and the need for assist with oral hygiene. Has natural teeth with no obvious issues noted.
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
Without complete and accurate meal intake documentation provided for the dietitian and physician the appropriate GOALS for the Resident can not be met.
This was confirmed with the Director of Nursing on 05/09/23 at 2:10 PM.
b) Resident #106
On 05/09/23 a review of Resident #106's medical record found documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation. The following are the dates and entries missed for Resident #106:
04/10/23
missing two (2) entries
04/11/23
missing one (1) entry
04/14/23
missing one (1) entry
04/17/23
missing one (1) entry
04/18/23
missing three (3) entries
04/19/23
missing two (2) entries
04/21/23
missing three (3) entries
04/22/23
missing one (1) entry
04/23/23
missing three (3) entries
04/24/23
missing two (2) entries
04/25/23
three (3) entries
04/26/23
three (3) entries
04/27/23
missing one (1) entries
04/29/23
three (3) entries
05/03/23
missing one (1) entry
Resident #106 had thirty (30) of ninety (90) opportunities to document missing.
Resident #106's care plan states:
FOCUS: Resident is at risk for gastrointestinal symptoms or complications R/T ,medication effects, GERD, IBS and reduced mobility.
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
FOCUS: Resident is at potential nutritional risk R/T BMI >25; sig weight loss R/T recent AKA, receives therapeutic diet, medical dx that may affect weight, intakes and nitriontional states (i.e. DM, HTN, anemia, hypothyroidism, GERD, IBS, L AKA)
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
Without complete and accurate meal take documentation provided for the dietitian and physician the appropriate GOALS for the Resident can not be met.
This was confirmed with the Director of Nursing on 05/09/23 at 2:10 PM.
c) Resident #58
On 05/09/23 a review of Resident #58's medical record found documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation. The following are the dates and entries missed for Resident #58:
04/10/23
missing two (2) entries
04/11/23
missing one (1) entry
04/12/23
missing one (1) entry
04/14/23
missing one (1) entry
04/17/23
missing one (1) entry
04/18/23
missing three (3) entries
04/19/23
missing two (2) entries
04/21/23
missing three (3) entries
04/22/23
missing one (1) entry
04/23/23
missing three (3) entries
04/24/23
missing two (2) entries
04/25/23
missing three (3) entries
04/26/23
missing one (1) entry
04/27/23
missing one (1) entry
04/29/23
missing three (3) entries
05/02/23
missing one (1) entry
Resident #58 had twenty nine (29) of ninety (90) opportunities to document missing.
Resident #58's care plan states:
FOCUS: Resident is at risk for gastrointestinal symptoms or complications R/T reduced mobility. GERD, constipation and advanced age.
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
FOCUS: Resident is at potential nutritional risk R/T BMI> 25; medical dx that may affect weight, intakes and nitriontional states (i.e. heat disease, HTN, HLD, Vit B 12 deficiency, anemia, GERD, gout)
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
Monitor intake at all meals, offer alternate choices as needed.
Without complete and accurate meal take documentation provided for the dietitian and physician the appropriate GOALS for the Resident can not be met.
This was confirmed with the Director of Nursing on 05/09/23 at 2:10 PM.
d) Resident #86
On 05/09/23 a review of Resident #86's medical record found documentation for a thirty (30) day period from 04/10/23 through 05/09/23 showed incomplete or missing documentation for meal intakes. For this time period, with three (3) meals per day, there were ninety (90) opportunities for documentation. The following are the dates and entries missed for Resident #86:
04/10/23
missing two (2) entries
04/11/23
missing one (1) entry
04/13/23
missing one (1) entry
04/14/23
missing two (2) entries
04/15/23
missing one (1) entry
04/16/23
missing two (2) entries
04/17/23
missing three (3) entries
04/18/23
missing one (1) entry
04/19/23
missing three (3) entries
04/20/23
missing one (1) entry
04/22/23
missing two (2) entries
04/23/23
missing two (2) entries
04/26/23
missing three (3) entries
04/28/23
missing two (2) entries
04/29/23
missing three (3) entries
04/30/23
missing one (1) entry
05/01/23
missing one (1) entry
05/02/23
missing one (1) entry
Resident #86 has thirty two (32) of ninety (90) opportunities to document missing.
Resident #86's care plan states:
FOCUS: Resident is at risk for constipation and gastrointestinal distress R/T GERD with overall functional decline.
INTERVENTION includes: Monitor for changes in nutritional states (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated.
Without complete and accurate meal take documentation provided for the dietitian and physician the appropriate GOALS for the Resident can not be met.
This was confirmed with the Director of Nursing on 05/09/23 at 2:10 PM.
e) Resident #85
On 05/08/23 at 2:24 PM an electronic record review indicated the resident had an incomplete Physician's Order of Scope and Treatment (POST) form, and the resident's code status order contradicted the POST form.
On 05/09/23 at 11:20 AM, the Director of Nursing (DON) provided a copy of the resident's most recent POST form, dated 09/23/21. It is completed indicating Cardiopulmonary Resuscitation (CPR), Full Treatments, No Artificial Means of Nutrition Desired. Also the section of the POST which says Received patient's advance directive to confirm no conflict with POST orders: was left blank. The section of the POST regarding who assisted the individual in completing the POST was blank . Resident's code status order in EMR reads, FULL CODE- no mechanical ventilation or feeding tube, ordered 04/16/21.
On 05/09/23 at 1:03 PM, a staff interview with the Corporate Nurse #127, confirmed the order did not match the POST form and they corrected the order. Corporate Nurse #127 provided copies of the code status order before and after correction. Surveyor also pointed out to corporate nurse #127 there are blank sections of the POST form which needed corrected. Corporate Nurse #127 concurred.
f) Resident #53
Record review on 05/08/23 at 12:52 PM, indicated the resident was ordered Hospice services on 12/05/22 and the order read as follows: Hospice services effective 12/1
On 05/10 at 9:27 AM, during a staff interview with the Director of Nursing (DON), it was confirmed the Hospice order should be clarified with the name of the hospice agency and the reason for Hospice services, such as end of life care.
g) Resident #11
On 05/08/23 at 12:05 PM, a record review of the electronic medical record (EMR), indicated only the front page of the resident's Physician's Order for Scope of Treatment (POST) form was completed.
The POST form was not dated by the resident but the date by the physician's signature was 05/05/18.
Section C of the POST was incomplete; the box for IV fluids for a trial period of no longer than_____ was indicated with an X but was not completed with the time period. Also, there was no address at the top of the form under the resident's name.
A copy of the above mentioned POST was given to the surveyor on 05/09/23 by the corporate nurse #127 as the most recent POST form on file.
On 05/10/23 the Director of Nursing (DON) brought another copy of the same POST form to the surveyor. This time, there was a copy of the front and the back of the form. The date was the same on the doctor's signature and now the date was completed beside the resident's signature as well 05/05/18. There was an address of the resident completed as well. However, Section C still was not completed with the time period for which the IV fluids trail period were to be given.
.

.
Based on staff interview and resident interviews, the facility failed to accurately explain the arbitration agreement to residents and/or their representatives. This failed practice has the potential to affect more than an isolated number of residents currently residing in the facility. Census 117.
a) Staff Interview
On 05/10/23 at 11:05 AM, the Admissions Director (AD) #88 was asked to state to the survey team how she explained the arbitration agreement to new residents and/or their representatives.
AD #88 stated, she most importantly explained to the residents the arbitration agreement was voluntary, meaning they do not have to sign it. AD #88 also stated she explained to the resident if they sign the agreement, they would have a third party arbitrator to help them settle the dispute, but if they could not settle this way, then they could have a judge and jury; an arbitrator was their first step before court. Surveyors explained when a resident signed the arbitration agreement they are waiving their right to have a judge and jury. AD #88 stated that was how she was taught to explain it.
b) Anonymous Resident Interviews
A Resident Council Meeting was held on 05/10/23 at 10:00 AM. The residents did not remember what they had signed upon admission and did not remember having to sign an arbitration agreement to get admitted .
.

.
Based on record review and staff interview the facility failed to maintain an ongoing Quality assurance and performance improvement (QAPI) program. This failed practice had the potential to affect all residents residing at the facility. Facility census: 117.
Findings included:
On 05/10/23 at 4:30 PM, the Administrator stated, QA [quality assurance] was not done last year, we didn't have any meetings. I just had the first one since I have been here last week. The Administrator provided a copy of the QA sign in sheet with a meeting date of 05/03/23.
Record review showed no documentation of QAPI meetings for the past year other than the meeting held 05/03/23.
Record review of the facility's policy titled, Center Quality Assurance Performance Improvement Process, revised 10/24/22, showed the Quality Assessment and Assurance committee meets at least quarterly.
.

.
Based on observation and staff interview the facility failed to maintain a safe, clean, comfortable, and homelike environment by not providing a clean privacy curtain for Resident #68. This was a random opportunity for discovery. Resident identifier: #68 Facility census: 118.
Findings included:
a) Resident #68
On 02/08/22 at 11:45 AM an observation of Resident #68's privacy curtain found the curtain was soiled with a brown dried matter. An immediate interview with Registered Nurse #73 confirmed the curtain required replacement.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital. This was true for one (1) of three (3) Residents reviewed during the Long-Term Survey Process.
Resident Identifier # 111 Facility Census 118
Findings Included:
a) Resident # 111
A record review found Resident # 111 was sent to the local hospital on [DATE] at 5:30 PM. The reason for the transfer was behavioral reasons. A copy of the bed hold notice policy and authorization form shows the Resident's name printed on top of form and a registered nurse signature at the bottom of the page dated 10/17/21. The review found the rest of the form was not complete.
On 02/08/22 at 1:15 PM, the Administrator acknowledged the bed hold paperwork was not filled out and they could not provide proof of what paperwork was sent with Resident # 111 on 10/21/21 at 5:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure transfer documents and appropriate information were communicated with the receiving health care facility. This was true for one (1) of three (3) Residents reviewed during the Long-Term Survey Process.
Resident Identifier # 111 Facility Census 118
Findings Included:
a) Resident # 111
Record review found Resident # 111 was sent to the local hospital on [DATE] at 5:30 PM. A copy of the interact transfer form was provided to the local hospital on [DATE]. The reason for the transfer was behavioral reasons. On 02/08/22 at 1:32 PM, the Corporate Nurse (CN) stated the facility has a check list of items they send to the hospital but the facility doesn't keep a copy of each document sent with the resident to the hospital. The CN provided a copy of the check list with the Resident's name at the top of the check list. The checklist form did contain a place to check the current medication list and or current MAR (medication administration record), but this item was not checked to indicate a current medications list or physician's orders were sent with the resident.
On 02/08/22 at 1:15 PM, the Administrator acknowledged the transfer paperwork was not filled out and they could not provide proof of what paper work was sent with Resident # 111 on 10/21/21 at 5:30 PM.
.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure [NAME] Virginia Physician Orders for Scope of Treatment (POST) forms were completed correctly for three (3) of six (6) residents in the long-term care survey sample. Resident identifier #51, #68 and #63. Facility Census 118
Findings included:
a) Resident #51
A record review found the POST form dated [DATE] directed no CPR (cardiopulmonary resuscitation) - Do not attempt resuscitation with limited additional interventions was not completed appropriately
On [DATE] at 10:15 AM an interview with Social Worker (SW) #69 confirmed the POST form was not completed correctly due to missing information relating to the residents address, date of birth and social security number and the Guardian had not signed the POST form. The POST form contained only a verbal consent from the Guardian.
On [DATE] at 12:10 PM a review of the Physician Determination of Capacity form dated [DATE] indicated the Resident does not have capacity. The Guardian court order dated [DATE] indicates her husband is her Guardian.
On [DATE] at 2:06 PM a record review found the following progress notes:
A note dated [DATE] at 10:19 AM by the Social Worker read as follows: POST form sent out by certified mail on [DATE] to guardian, (first and last name of Guardian), to obtain physical signature.
A note dated [DATE] at 2:06 PM by Social Worker read as follows Spoke with spouse, (first and last name of Guardian), on this date regarding POST form that was sent out on [DATE]. Explained the importance of having a physical signature on this document. He reported that he had not checked his mail in a few weeks, but would check for it and send it back if he found it. He also requested that a new form be sent, in case the previous had not been delivered. Third POST form sent on this date to (first name of Guardian) to obtain physical signature.
A note dated [DATE] 11:12 AM by Social Worker read as follows Called spouse/guardian, (first name of Guardian), to inquire about third POST form that was sent to him on 1/26. Had to leave message. Awaiting call back.
According to [NAME] Virginia Center for End-of-Life Care the following guidelines are to be followed.
2020 directions:
The patient or representative/surrogate and physician/APRN/PA must sign the form in this section.
These signatures are mandatory. A form lacking these signature is NOT valid. The physician/APRN/PA then prints his/her name, phone number, and the date and time the orders were written. The bottom of the form contains a written reminder that the form should accompany the
patient/resident when transferred or discharged . It allows receiving healthcare professionals to
have the same information regarding the person's preferences for life-sustaining treatment and
increases the likelihood that these orders will be respected in the new care setting
2021 edition:
The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity
b) Resident #68
On [DATE] at 3:58 PM a review of Resident #68's records found a Physician Orders for Scope of Treatment (POST) form dated [DATE] with a different signature than the current Health Care Surrogate (HCS) form. The POST form directed Cardiopulmonary Resuscitation- Do not attempt resuscitation (DNR) with comfort measures with no IV fluids or feed tube. The HCS form is dated [DATE].
On [DATE] at 10:15 AM an interview with the Social Worker (SW) #69 confirmed the signatures on the POST form and Health Care Surrogate (HCS) were different names. The SW stated the previous Medical Power of Attorney (MPOA) whose signature was on the POST form has since passed away and they failed to obtain a new POST form with the appropriate signature.
c) Resident #63
On [DATE] at 2:05 PM, a record review of the Physician Orders for Scope of Treatment (POST) form was completed. The POST form was missing the Preparer's signature and the date of preparation.
On [DATE] at 10:15 AM, Social Worker (SW) #69 acknowledged the POST form was completed incorrectly.
No further information was obtained during the long-term care survey process.
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Based on observation and staff interview the facility failed to ensure Resident #93 was provided care in a manner which preserved his dignity. Resident #93 was placed in a full body lift while in the hallway outside of his room. This was random opportunity for discovery. Resident Identifier: #93. Facility Census: 118.
Findings Included:
An observation on 02/08/22 at 11:06 am found Nurse Aide (NA) #36 and NA #111 was in the process of transferring Resident #93 from the shower bed back to his bed. The nurse aides lifted Resident #93 up in the total lift from the shower bed while still in the hallway outside of his room. With Resident #93 still in the sling on the lift the nurse aides pushed the lift into resident #93's room to transfer him back to bed.
An interview with NA # 36 at 11:18 am confirmed she and NA #111 placed Resident #93 in the lift and lifted him from the shower bed in the hall way. When asked why they did so instead of pushing him into his room and then transferring him she stated it is just to tight in there to get the shower bed in there. She stated, Was this a FUBAR (Fucked up beyond all recognition)? I guess it would be dignity issue is that where it will fall?
An interview with the Center Nurse Executive at 11:22 am on 02/08/22 confirmed the shower bed should be placed in the room and then the resident can be transferred from the shower bed to the bed.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure professional standards and practices to maintain accurate and complete medical records. This was true for four (4) of 30 residents reviewed during the Long-Term Care Survey Process. Resident Identifier: #60, #111, #37 and #112. Facility Census: 118.
Findings Included:
a) Resident #60
A review of the medical record for Resident #60 was completed on 02/09/22. This review found a diagnosis list which contained a diagnosis of an unstageable pressure ulcer of left heel. This unstageable pressure ulcer diagnosis was not added until 01/04/22. At which time the onset date was listed as 01/04/22 and resolved date was added for 12/29/21.
A progress note dated 12/29/21 by Registered Nurse (RN) #6 stated Wound rounds completed with NP (Nurse Practitioner), pressure area to left heel resolved. Sureprep treatment continues for preventive measures. [Typed as written.]
The Skin Integrity Report dated December 2021 indicated the Deep Tissue Injury (DTI) to the left heel was resolved on 12/29/21.
The significant change/Medicare-5 (five) day Minimum Data Set (MDS) lists one Unstageable Deep tissue injury (DTI) was present upon admission dated 12/23/21.
On 02/09/22 at 12:38 PM, Corporate Registered Nurse (CRN) #123 verified the diagnosis of pressure ulcer of left heel, unstageable should have a resolved date of 12/29/21. The diagnosis should not have been created on 01/04/22.
On 02/10/22 at approximately 11:00 AM, wound care by Registered Nurse (RN) #6 was observed the DTI to the left heel was resolved.
No further information was obtained during the survey process.
b) Resident #111
A review of Resident #111's medical record reveals weekly skin checks with out documentation of wound assessment on the following days: 01/05/22, 01/12/22, 01/19/22 and 01/26/22.
On 02/08/22 at 3:15 PM, Wound Care Nurse # 6 acknowledged weekly skin assessments should have documentation to show wound progress.
c) Resident #37
A review of Resident #37's medical record on 02/08/22 at 12:19 pm found Resident #37 developed an abrasion/laceration on his right ear on 10/18/21. A review of the Skin integrity report for Resident #37 found the wound developed on 10/18/21 and is still present on Resident #37's right ear. The Skin Integrity reports identify the wounds as a laceration/abrasion and not a pressure ulcer.
The Skin Check assessments dated 11/04/21, 12/16/21, and 01/27/22 all identified the wound to Resident #37's right ear as a pressure ulcer.
An interview with the Center Nurse Executive (CNE) at 12:25 pm on 02/08/22 confirmed the assessments were not accurate. She indicated the wound was an abrasion/laceration and not a pressure ulcer.
d) Resident #112
A review of Resident #112's medical record on 02/07/22 at 2:19 pm found an admission weight of 132 pounds. This weight was entered to the record on 01/22/22 and was then struck out of the record on 02/02/22 by Register Nurse (RN) #63.
A review of Resident #112's nutritional assessment dated [DATE] found the residents weight recorded as 132 pounds. This assessment was completed prior to the weight being struck from the record.
An interview with the Registered Dietician (RD) and RN #63 on 02/09/22 at 11:16 am confirmed the nutritional assessment was incorrect. They stated they had discussed the admission weight and determined it was inaccurate and struck it from the record. They agreed they should have corrected the nutritional assessment when this decision was made and they did not.
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Based on record review and staff interview the facility failed to investigate a fall with a serious bodily injury to determine the cause and to initiate corrective action to prevent similar instances from happening again as required. This was true for one (1) of nine (9) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifier: #55. Facility Census: 118.
Findings included:
a) Resident #55
A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information:
Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor.
Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility.
Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following:
Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis.
The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review.
The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist.
Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction (Hip Fracture). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm.
Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired.
A review of the reportable incident related to this fall found the following information contained on the Immediate Fax reporting of allegations - Nursing Home Program form which was faxed to the Office of Health Facility Licensure and Certification (OHFLAC) on 11/18/21 at 4:05 pm.
Date of Incident: 11/16/21
Time of Incident: 8:20 pm
Brief Description of the incident: Staff witnessed a fall at 8:20 pm on 11/16/21. CNA at bedside had asked resident. who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side, underestimated edge of bed and fell on the right side of the bed onto the floor. Vitals within normal limits at that time, with no complaints of pain. At 12:00 pm on 11/17/21, resident complained of LLE (Left Lower Extremity) discomfort. Xrays ordered and left femoral fracture discovered. Sent to hospital.
There was no investigation associated with this incident. There was not a statement the Nurse Aide and no investigation to determine if and when the resident was able to independently turn successfully. In fact the medical record indicated the opposite to be true.
An interview with Corporate Registered Nurse #123 on the morning of 02/10/22 confirmed the incident had not been thoroughly investigated. She stated, I spoke with (first name of social worker) she stated she thought it was just an unusual occurrence and this is why it was not reported within the two (2) hours nor was it investigated CRN #123 stated, I am going to do some education with her. CRN #123 agreed the medical record conflicted with what was written on the reportable incident and the incident report.
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Based on record review and staff interview the facility failed to ensure all falls which resulted in serious bodily injury was reported to the appropriate state agencies within the required time frames. Resident #55 fell from bed and fractured her left hip. This was not reported within two (2) hours of the facility having knowledge of the fracture (serious bodily injury). This was true for one (1) of nine (9) residents reviewed for the care area of falls during the long term care survey process. Resident Identifier: #55. Facility Census: 118.
Findings Included:
a) Resident #55
A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information:
Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor.
Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility.
Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following:
Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis.
The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review.
The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist.
Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction (Hip Fracture). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm.
Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired.
Review of the reportable incidents for the month of 11/2021 found this incident was reported on 11/18/21. According to the fax confirmation the incident was reported on 11/18/21 at 4:05 pm. This is greater than two (2) hours past the time the facility became aware of the residents fracture.
An interview with the CRN #123 on the morning of 02/10/22 confirmed the incident should have been reported more timely. She agreed it was not within two (2) hours. She stated, I spoke with (first name of social worker) she stated she thought it was just an unusual occurrence and this is why it was not reported within the two (2) hours. CRN #123 stated, I am going to do some education with her.
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Based on record review and staff interview the facility failed to implement there abuse prohibition policy in regards to reporting and the investigation of serious bodily injury. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident Identifier: #55. Facility Census: 118.
Findings Included:
a) Policy Review
A review of the facility's Abuse Prohibition policy with an effective date of 06/01/96 and a review and revision date of 04/09/21 on 02/09/22 found the following:
--7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the CED (Center Executive Director) or designee will perform the following.
--7.3 Report allegations to the appropriate state and local authority (s) involving neglect, exploitation or mistreatment (Including injuries of unknown source), suspected criminal activity, and misappropriation of patient property not later than two (2) hours after the allegation is made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect, or mistreatment.
--7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on:
--7.7.1 whether abuse or neglect occurred and to what extent.
--7.7.2 clinical examination for signs of injuries, if indicated;
--7.7.3 causative factors; and
--7.7.4 interventions to prevent further injury.
--7.8 The investigation will be throughly documented within RMS (Risk Management System). Ensure that documentation of witnessed interviews is included.
--7.8.1 Conduct interviews using the Alleged Perpetrator/Victim Interview Record and witness Interview record.
--7.8.2 Enter a summary of the interviews into RMS.
--7.8.3 Interview forms will be kept confidential in a file in the administrative office.
b) Reporting
A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information:
Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor.
Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility.
Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following:
Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis.
The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review.
The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist.
Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction (Hip Fracture). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm.
Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired.
Review of the reportable incidents for the month of 11/2021 found this incident was reported on 11/18/21. According to the fax confirmation the incident was reported on 11/18/21 at 4:05 pm. This is greater than two (2) hours past the time the facility became aware of the residents fracture.
An interview with the CRN #123 on the morning of 02/10/22 confirmed the incident should have been reported more timely. She agreed it was not within two (2) hours. She stated, I spoke with (first name of social worker) she stated she thought it was just an unusual occurrence and this is why it was not reported within the two (2) hours. CRN #123 stated, I am going to do some education with her.
c) Investigation
A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information:
Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor.
Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility.
Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following:
Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis.
The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review.
The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist.
Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction (Hip Fracture). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm.
Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired.
A review of the reportable incident related to this fall found the following information contained on the Immediate FaX reporting of allegations - Nursing Home Program form which was faxed to the Office of Health Facility Licensure and Certification (OHFLAC) on 11/18/21 at 4:05 pm.
Date of Incident: 11/16/21
Time of Incident: 8:20 pm
Brief Description of the incident: Staff witnessed a fall at 8:20 pm on 11/16/21. CNA at bedside had asked resident. who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side, underestimated edge of bed and fell on the right side of the bed onto the floor. Vitals within normal limits at that time, with no complaints of pain. At 12:00 pm on 11/17/21, resident complained of LLE (Left Lower Extremity) discomfort. Xrays ordered and left femoral fracture discovered. Sent to hospital.
There was no investigation associated with this incident. There was not a statement the Nurse Aide and no investigation to determine if and when the resident was able to independently turn successfully. In fact the medical record indicated the opposite to be true.
An interview with Corporate Registered Nurse #123 on the morning of 02/10/22 confirmed the incident had not been thoroughly investigated. She stated, I spoke with (first name of social worker) she stated she thought it was just an unusual occurrence and this is why it was not reported within the two (2) hours nor was it investigated CRN #123 stated, I am going to do some education with her. CRN #123 agreed the medical record conflicted with what was written on the reportable incident and the incident report.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a person-centered comprehensive care plan was developed. This was true for two (2) of 30 residents reviewed during the long term care survey process. Resident Identifier: #317 and #55. Facility Census: 118.
Findings Included:
a) Resident #317
1) Smoking Status
On 02/07/22 at 3:43 PM, Registered Nurse (RN) # 63 stated there are no current smokers except the one resident who is grandfathered in. Please note that Reisdent #317 is not resident allowed to smoke.
On 02/08/22, a review of Resident #317's Care Plan dated 02/01/22 states resident may smoke independently. The Smoking assessment dated [DATE] states the resident may smoke independently as well. An admission Minimum Data Set (MDS) dated [DATE] Section J1300 was coded as (0) which indicates no tobacco use.
On 02/08/22 at 10:15 AM, Social Worker (SW) #69 verified the resident may not smoke independently due to facility being a non-smoking facility. SW #69 stated there was a mix up between nursing and administration .the resident wanted to smoke when she first got here but administration explained to the resident the facility is non-smoking and she could not smoke while she was in the facility.
2) Medical and Psychological Diagnoses
On 02/08/22, a review of Resident #317's care plan was completed. The care plan did not have documentation of the focus areas for medical and psychological diagnoses as well as goals and interventions. The diagnoses missing were as follows:
--History of Methicillin Resistant Staphylococcus (MRSA)
--History of Vancomycin-Resistant Staphylococcus Enterococcus (VRE)
--Schizophrenia
--Chronic Obstructive Pulmonary Disease (COPD)
--Asthma
--Hyperlipidemia (HLD)
--Anxiety
--Edema
--Parkinson's disease
--Neuropathy
--Allergies
--Gastroesophageal Reflux Disease (GERD)
--Depression
--Urostomy
--Neuromuscular Dysfunction of bladder
--Renal Tubulo-dysfunction of bladder
--Obstructive Sleep Apnea
--Nicotine Dependence
--Iron Deficiency Anemia
--Chronic Sinusitis
--Hypothyroidism
--Polyneuropathy
--Other Cervical Disc Degeneration, unspecified cervical region
--Muscle Weakness, generalized
On 02/09/22 at approximately 11:34 AM, the Corporate Registered Nurse (CRN) #123 verified the care plan did not have focus areas for the medical and psychological diagnoses.
No further information was obtained during the Long-Term Survey Process.
b) Resident #55
A review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility.
Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following:
Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis.
The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review.
The inteventions included: Reisdent requires extensive to dependent assist X 1-2 with bed mobility.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accuratly reflect Resident #55's need for a two (2) person assist for bed mobility.

Based on record review, observation, and staff interview the facility failed to ensure Resident #55's care plan pertaining to falls was revised when the residents condition changed. This was true for one (1) of 30 resident reviewed during the long term care survey process. Resident Identifier: #55. Facility Census: 118.
Findings Included:
Observation of Resident #55 on 02/07/22 01:48 pm found she was a bilateral below the knee amputee.
A record review of Resident #55's medical record on 02/08/22 found the following care plan.
Focus Statement: Risk for further falls and injury related to recent fall with left hip fracture, new right BKA (Below the knee amputation). history of right trimalleolar fx (fracture), cardiac and narcotic medical use, impaired gait balance, incontinence, Dementia, very cluttered room (resident will not comply with keeping room uncluttered), incontinence, impaired vision, history of falls, including history of fall with ankle fracture and left hip fx, left BKA with prothesis use, and history of tib/fib fracture that occurred during transfer. This focus statement was initiated on 06/06/14 and revised on 12/23/21.
Goal associated with this goal read as follows:
Resident will experience no further falls with major injury every shift through next review. This goal had a target date of 03/21/22.
Interventions included: Non Skid foot wear when out of bed. This intervention was added on 06/06/14 and revised on 09/04/20.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the intervention for Non skid footwear was not an appropriate intervention for Resident #55 because she did not have any legs.

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Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #25, the facility failed to follow physician ordered parameters for Midodrine, a medication to treat hypotension and Resident #107, had neurological checks, after a fall, which were incomplete. Resident identifiers: #25 and #107. Facility census: 118.
Findings include:
a) Resident #25
Review of Resident #25's medical records found an order for Midodrine 5 milligrams (mg) by mouth for treatment of orthostatic hypotension with meals three times daily. Hold of systolic blood pressure is greater than 150. Started on 11/18/21, which was the date of admission to the facility.
Review of Medication Administration Record (MAR) for October, November, December 2021 and January and February 2022, found Resident #25's blood pressure (B/P) was taken once daily at 8:00 am. No blood pressures were taken at 12:00 pm and 5:00 pm prior to the medication being administered as directed in the physician ordered parameters.
Additionally, the Consultant pharmacist issued a recommendation to nursing on 12/21/21 which stated (Residents Name) has an order for Midodrine 5 mg with meals to hold of SBP greater than 150, but the MAR only allows for blood pressure documentation once a day. The previous Director of Nursing (DON) signed the recommendation with no changes to obtain the b/p prior to the administration of the medication.
Interview with the DON on 02/09/22 at 2:15 pm, found facility continued to not follow the physician ordered parameters. She immediately corrected this, and the staff was instructed to obtain the b/p prior to the administration of Midodrine after this surveyor's interventions.
b) Resident #107
A review of Resident #107's medical record revealed post fall neurological evaluation flow sheets were not completed for the following dates and times as indicated:
Fall on 11/11/21 neurological checks were not completed on:
11/11/21 Q (every) eight (8) hours evaluation for 7:30 PM.
11/12/21 Q eight (8) hours evaluation for 3:30 AM, 11:30 AM and 7:30 PM.
11/13/21 Q eight (8) hours evaluation for 3:30 AM.
Fall on 11/14/21 neurological checks were not completed on:
11/17/21 Q eight (8) hours evaluation for 2:00 PM.
Fall on 11/20/21 neurological checks not completed on:
11/22/21 Q eight (8) hours evaluation for 9:05 PM.
Fall on 11/29/21 neurological checks not completed:
11/30/21 Q eight (8) hours evaluation for 3:00 PM, 11:00 PM.
12/01/21 Q eight (8) hours evaluation for 7:00 AM, 3:00 PM, and 11:00 PM.
12/02/21 Q eight (8) hours evaluation for 7:00 AM.
Fall on 01/30/22 neurological checks not completed:
02/02/22 Q eight (8) hours evaluation for 1:45 AM.
On 02/09/22 at 3:29 PM, Corporate Nurse (CN) and the Director of Nursing (DON) acknowledged that the neurological checks were not completed per protocol.
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Based on observation, record review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #93 was hoisted in a lift in the hall way outside of his room and then transported in the lift from the hallway to his room where he was placed in his bed by the window. Mechanical lifts are transfer devices only and are not to be used as transport devices due to the risk of serious harm and/or death to residents.
The state agency (SA) determined this to be an immediate jeopardy (IJ) which placed Resident #93 at risk for serious harm and/or death. The facility was notified of the IJ at 3:41 pm on 02/08/22. The facility submitted a Plan of Correction (POC) at 5:24 pm on 02/08/22 at which time it was accepted by the SA. The plan of Correction read as follows:
The Registered Nurse re educated Nurse Aide #36 and #98 on the appropriate use of the total lift with return demonstration on 02/28/22 at 1445 (2:45 pm).
All resident of the facility have the potential to be affected.
The Registered Nurse (RN) conducted an observation round on 02/08/22 at 1656 (4:56 pm) to ensure dependent residents who require a total lift are being transferred appropriately with corrective action upon discovery.
Reeducation will be provided by the Director of Nurses (DON)/designee to all nursing staff on 02/08/22 at 5:00 pm to ensure residents who are dependent for transfers using a total lift are being transferred according to manufacturer guidelines. Posttest with return demonstration completed to validate understanding. Any nursing staff not available during this time frame will be provided reeducation, including posttest and return demonstration by DON/designee upon the beginning of next shift to work. New nursing staff will be provided education, including posttest during orientation by the DON/Designee.
The unit managers (UM)/designee will conduct observations starting on 02/08/22 at 11:00 pm to residents who are dependent for transfers using a total lift are being transferred appropriately and in accordance with manufactures guidelines, appropriately daily across all shifts for 2 weeks including weekends and holidays then 3 times a week for 2 weeks then randomly thereafter.
Results of observation will be reported by the Unit Manager (UM)/Designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and our in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
After observation of implementation of the POC the IJ was abated on 02/09/22 at 6:00 pm at which time a deficient practice remained and the scope and severity was decreased from a J to a G.
A deficient remained for Resident #55 who sustained a hip fracture when she rolled from bed during Activities of Daily Living (ADL) care. The residents care plan did not direct the Nurse Aide (NA) to have two (2) staff members present during bed mobility therefore when the resident rolled away from the NA she rolled unto the floor fracturing her hip. This failed practice resulted in actual harm for Resident #55.
Resident #93 was a random opportunity for discovery. For Resident #55 this was true for one (1) of nine (9) residents reviewed for the care area of accidents during the long term care survey process. Resident Identifiers: #93 and #55. Facility Census: 118.
Findings included:
A) Resident #93
Resident #93 was observed laying on a shower bed which was parked in the hallway outside of his room at 11:06 am on 02/08/22. Nurse Aide (NA) # 36 (who was wearing a name badge indicating she was a new employee) and NA #98 was observed approaching with a full body lift. They proceeded to lift Resident #93 in the lift while still in the hall way. Once he was hoisted above the shower bed in the lift they pushed the shower bed out of the way and proceeded to push the lift with Resident #93 still hoisted in the air into his room to place him in the bed which was placed on the far side of the room.
An interview with NA #36 at 11:18 am confirmed she was the NA assigned to Resident #93. She agreed she and NA #98 had transferred Resident #93 from the shower bed to his bed. When asked why they hoisted Resident #93 in the lift while he was still in the hallway she replied, Its really a tight fit to get the shower bed into his room. So we put him in the lift and pushed him in his room while in the lift. She proceeded to say, Is this a FUBAR (Fucked Up Beyond all recognition). What is this going to fall under a dignity issue.
An interview with NA #23 at 11:13 am on 02/08/22, revealed when she showers Resident #93 she places the shower bed at the foot of his bed and transfers him from surface to surface with both beds in the room. She stated, I don't have any trouble getting the shower bed in his room.
An interview with the Center Nurse Executive (CNE) on 02/08/22 at 11:22 am confirmed the lift should not be used to transport a resident. It is to be used to move the resident from one surface to another surface. She indicated the shower bed should have been placed in the resident's room and the resident should not have been hoisted in the lift while in the hall way. The CNE was then asked to provide the competency check list which showed NA #36 and #98 possessed the competency to operate lifts successfully. On 02/08/22 at 1:35 pm the CNE stated they do not have any evidence to show NA #36 and NA #98 was evaluated for competency to operate the lift.
At 3:00 pm on 02/08/22 all competencies for all NA's was provided, and the following information was found. There was a total of 42 NAs currently working at the facility there were 4 NA's who had their competencies evaluated in the last year those included NA #12 who was evaluated on 05/25/21, NA #35 who was evaluated on 04/20/21, NA #72 who was evaluated on 05/25/21, and NA #119 who was evaluated on 05/19/21. There were seven (7) other NAs who were evaluated on the following dates:
--NA #44 evaluated on 08/11/20.
-- NA # 23 evaluated on 08/19/20
-- NA #19 evaluated on 08/13/20
-- NA #84 evaluated on 08/11/20
-- NA #65 evaluated on 08/19/20
-- NA #98 evaluated on 08/19/20
-- NA #122 evaluated on 08/13/20.
The competencies should be completed yearly.
The following NA's had no competency evaluations related to lifts at all NA #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95.
At 2:13 pm on 02/08/22 the CNE provided a list of residents who require a total lift for transfers. There were a total of 54 residents who required the use of a total lift residing in the facility.
A review of Resident #93's medical record found he has a required the use of a total lift since 05/10/17 according to his lift assessments.
NA #36 has been an employee at this facility since 05/17/21. She was wearing a new employee badge with no name on it because she forgot her name badge at home. She has been an employee with the corporation who owns this facility since 07/29/18.
A review of the Invacare Reliant 450 and 600 Battery Powered Patient Lift manual found the following information:
On Page 5 of the manual the following was contained: 1.1 Symbols Warnings Signal words are used in this manual and apply to hazards or unsafe practices which could result in personal injury or property damage. See the information below for definitions of the signal words.
DANGER: Danger Indicates an imminently hazardous situation which, if not avoided, will result in in death or serious injury.
Warning: Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury.
Caution: Caution Indicates a potentially hazardous situation which, if not avoided, may result in property damage or minor injury or both .
On Page 7 of the manual the following was contained: Warning: The Invacare patient lift is NOT a transport device. It is intended to transfer an individual from one resting surface to another (such as a bed to a wheelchair).
Review of the facility's policy titled, Safe Resident Handling/Transfer Equipment. the following was found,
. Due to the variety of lifts used in centers, manufacturers's instructions will be used. If manufactures' instructions are not available in the center, Contact Risk Management for assistance.
b) Resident #55
A review of Resident #55's medical record on 02/08/22 found the resident had a fall from bed on 11/16/21 which resulted in a fracture to her left hip. A review of the incident report related to this fall contained the following information:
Root Cause/Conclusion: CNA (Nurse Aide) at bedside had asked resident, who could previously turn independently successfully, to turn to right side for linen change. Resident turned to right side underestimated the edge of the bed, and fell on right side of the bed onto the floor.
Further review of Resident #55's medical record on 02/07/22 found the following Minimum Data Sets (MDS) with the Assessment Reference Dates (ARDs) of 03/23/21, 04/01/21, 07/01/21 and 10/01/21. Each MDS was coded to reflect Resident #55 required extensive assist with the assistance of two (2) staff members for bed mobility.
Further review of the medical record found a care plan with an initiation date of 06/06/14 and a revision date of 12/23/21. The care plan contained the following:
Focus Statement: Self care deficit related to recent hospitalization with left hip fracture s/p (status post) surgical repair, new right BKA (below knee amputation), wounds, dementia with behavioral disturbance, memory loss and the need for direction and impaired balance AEB (as evidenced by) requiring physical assistance with all aspects of care and mobility. Resident has left leg prosthesis.
The goal associated with this focus was: Resident will actively participate in dressing with no more than extensive assist X 1-2 daily by next review.
The interventions included: Resident requires extensive to dependent assist X 1-2 with bed mobility. This intervention was added to the care plan on 06/10/14 and revised on 10/29/14.
An interview with the Corporate Registered Nurse (CRN) #123 on 02/09/22 at 11:30 am confirmed the care plan was not correct. She stated, It can't be 1-2 person assist. She indicated it needed to be revised to accurately reflect Resident #55's need for a two (2) person assist for bed mobility. She agreed the MDS assessments indicate Resident #55 has been an extensive assist of two (2) staff members since 03/23/21. She stated, We can't blame the Nurse Aide for this because the care plan directed her to use one or two person assist.
Further review of the record found a Radiology report with an examination date of 11/17/21 which indicated Resident #55 had a Fracture to the LEFT femoral neck with impaction (Hip Fracture). Femoral head appropriately positioned. Joint Space narrowing. Mild Soft tissue swelling. The report date on the Radiology report was reported to the facility 11/17/21 at 2:08 pm.
Further review of the record indicated Resident #55 was sent to a local hospital where her hip was surgically repaired.
By failing to ensure the care plan which guides the residents care was accurate. The NA providing care on 11/16/21 was doing so by herself when the resident required a two (2) person assist for bed mobility. As a result Resident #55 fell from bed and fractured her left hip causing her to be hospitalized for a surgical repair of the hip which is actual harm.
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Based on observation, staff interview and record review the facility failed to maintain an environment appropriate to prevent urinary tract infections and trauma by not having Resident #46's catheter tubing secureed to his leg. This was true for one (1) of one (1) residents investigated for the care area of catheter care. Resident Identifier # 46 Facility Census 118.
Findings Included:
a) Resident # 46
On 02/08/22 at 3:00 PM, this surveyor observed Nursing Aide (NA) #38 complete catheter care on Resident # 46. During catheter care it was observed Resident # 46's catheter tubing was not secured to his leg . When NA #38 was asked what was used to secure Resident #46's catheter tubing, NA #38 stated the RN (Registered Nurse) was in charge of that.
On 02/08/22 at 3:05 PM, RN #113, was asked if Resident # 46 should have a securing device on his catheter. RN # 113 stated she would have to ask. They do not routinely place them on.
A review of the Facility Policy titled: Catheter: Indwelling Urinary-Care of with an effective date of 06/01/96 and a revision date of 06/01/21: Found the following:
.14. Inspect the catheter tube holder daily and change when clinically indicated and as recommended by manufacturer .
In an interview on 02/08/22 at 3:25 PM, Corporate Nurse (CN) , acknowledged it was a professional standard of practice and the facility's policy to secure Residents' foley catheter.
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Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for two (2) of two (2) residents reviewed during the survey process. Resident identifiers: #33, and #82. Facility census: 118
Findings included:
a) Resident #33
Observation on 02/07/22 at 11:43 AM found Resident #33's oxygen tubing for her nasal canula was dated 01/27/22. This was confirmed with Registered Nurse (RN) #73 at 11:45 AM on 02/07/22.
The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date.
b) Resident #82
Observation on 02/07/22 at 11:35 AM found Resident #82's oxygen tubing for her nasal canula was dated 01/27/22. This was confirmed with Registered Nurse (RN) #73 at 11:38 AM on 02/07/22.
The Policy and Procedure states the oxygen tubing and storage containers for all respiratory supplies are to be changed weekly and dated on the change out date.
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Based on observation, staff interview, and medical record review, the facility failed to provide necessary care and services for Resident #39, who required hemodialysis due to end stage renal disease. The facility failed to assess the arteriovenous fistula in the left arm prior to and after receiving dialysis treatments and they obtained blood pressures (b/p) in the left arm eventhough it was a restricted limb. Resident identifier: #39. Facility census: 118.
Findings include:
a) Resident #39
Medical record review found Resident #39 was receiving hemodialysis via an arteriovenous fistula (A/V) in the left arm three (3) days a week, on Mondays, Wednesday, and Fridays, at an offsite Dialysis
center.
The facility was to complete the top half of the communication form, which included the resident's vital signs before the resident left the facility for dialysis, an examination of the access site (bruit/thrill) and any significant changes since last dialysis treatment. The dialysis center was to complete the middle section of the form which also included obtained vital signs, completed lab work, medications given, intake and output, monitoring the access site for location, the condition of the dressing, ports, pain, and any other pertinent information. Upon return to the facility, the facility was to complete the bottom of the form which included a narrative note upon arrival to the facility. The facility failed to consistently record the resident's information pre and post dialysis treatments. Additionally, the resident had blood pressures obtained in the left arm even though she had orders to not draw blood or obtain blood pressures in the left arm.
Review of Hemodialysis Communication Record found ten (10) of nineteen (19) records reviewed the facility failed to access the A/V shunt in the left for bruit and thrill before (pre) and after (post) dialysis treatments. Those dates are as follows:
12/31/22- post
01/05/22- pre
01/07/22-pre and post
01/13/22-pre
01/17/22- pre
01/19/22- pre
01/21/22- pre
01/24/22- pre
01/31/22- pre
02/07/22- post
Additionally, an order for AV fistula/graft location: left arm- Do not draw blood and/or blood pressure in left arm.
Review of Resident #32's blood pressures on the electronic vital sign record found the blood pressure was obtained in the left arm on:
11/01/2021- 110/62 taken in left arm.
02/01/2022- 126/79 taken in left arm
Interview with the Director of Nursing (DON) on 02/09/22 at 3:00 pm. The DON reviewed the dialysis communication forms and she verified on the above dates the A/V shunt was not assessed and she verified the blood pressure was taken in left arm and she verified no blood pressures should be taken in left arm. No further information was provided.
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Based on record review and staff interview the facility failed to ensure that nurse aides we competent to carry out the duties of their job. The facility had a total of 42 nursing assistants working at the facility. Of those 42 only four (4) had competency evaluations completed in the last year. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Staff Identifiers (All Nurse Aides): #44, # 23, #19, #84, #65, #98, #122 , #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95. Facility Census: 118.
Findings Included:
a) NA Competencies
On 02/08/22 at 11:22 am, the Center Nurse Executive (CNE) was asked to provide the competency check list which showed NA #36 and #98 possessed the competency to operate lifts successfully. On 02/08/22 at 1:35 pm the CNE stated they do not have any evidence to show NA #36 and NA #98 was evaluated for competency to operate the lift.
At 3:00 pm on 02/08/22 all competencies for all NA's was provided to the survey team the following information was found. There is a total of 42 NA's currently working at the facility there are 4 NA's who have had their competencies evaluated in the last year those include NA #12 who was evaluated on 05/25/21, NA #35 who was evaluated on 04/20/21, NA #72 who was evaluated on 05/25/21, and NA #119 who was evaluated on 05/19/21. There were seven (7) NA's who were evaluated on the following dates:
-- NA #44 evaluated on 08/11/20.
-- NA #23 evaluated on 08/19/20
-- NA #19 evaluated on 08/13/20
-- NA #84 evaluated on 08/11/20
-- NA #65 evaluated on 08/19/20
-- NA #98 evaluated on 08/19/20
-- NA #122 evaluated on 08/13/20.
The following NA's had no competency evaluations at all NA #42, #33, #15, #46, #9, #39, #7, #24, #22, #4, #20, #79, #78, #60, #75, #83, #85, #86, #52, #68, #50, #49, #103, #118, and #95.
The CNE and Corporate Registered Nurse (CRN) #123 confirmed at 3:15 pm on 02/08/22 these were the only competencies they had to provide.
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Based on record review and staff interview the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic medications. Resident #43 received an as needed (PRN) anti-anxiety medications even though they had demonstrated no target behaviors to warrant the use of the PRN medication and the facility failed to attempt non-pharmacological interventions prior to administering the PRN anti-anxiety medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Long-Term Survey Process Survey (LTCSP). Resident identifier: #43. Facility census: 118.
Findings include:
a) Resident #43
A review of Resident #43's medical record found the following physician's orders for Ativan 0.5 milligrams (mg)- Give 1 tablet by mouth every four (4) hours as needed for anxiety.
Review of Medication Administration Record (MAR) for April, May and June 2021 found Resident #43 was administered this medication on the following dates and times without evidence of non-pharmacological interventions before administration of the medication. Additionally, there was no monitoring of side effects as well as no documentation of the targeted behaviors which warranted the use of the medication:
04/04/21 at 9:00 am
04/05/21 at 8:41 am
04/06/21 at 12:36 pm
04/07/21 at 8:42 am
04/21/21 at 8:22 am
04/27/21 at 8:00 am
05/02/21 at 8:00 am
05/05/21 at 7:57 am
05/10/21 at 8:00 am
05/11/21 at 8:01 am
05/14/21 at 8:33 am
05/16/21 at 9:03 am
05/23/21 at 8:00 am
05/26/21 at 8:08 am
05/28/21 at 8:06 am
05/31/21 at 8:00 am
06/01/21 at 8:30 am
06/02/21 at 8:00 am
06/04/21 at 10:30 am
06/06/21 at 8:00 am
06/07/21 at 7:53 am
06/13/21 at 8:28 am
06/15/21 at 8:20 am
06/16/21 at 8:18 am
06/17/21 at 8:00 am
06/18/21 at 8:20 am
06/19/21 at 8:00 am
06/20/21 at 8:15 am
06/24/21 at 8:15 am
06/25/21 at 8:00 am
06/26/21 at 8:00 am
06/27/21 at 8:00 am
06/28/21 at 8:00 am
06/20/21 at 8:00 am
The Director of Nursing (DON) was interviewed, at 12:15 p.m. on 02/09/22, she was unable to find documentation the resident exhibited any behaviors to warrant the use of Ativan. The DON was also unable to provide evidence of attempts at nonpharmacological interventions prior to the administration of Ativan.
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Based on record review and staff interview, the facility failed to employ a qualified dietitian and/or a certified dietary manager on a full-time basis. This failed practice had the potential to affect all residents currently residing in the facility. Facility census: 118.
Findings include:
Initial kitchen rounds were completed on 02/07/22 at 11:30 am, accompanied by Employee #126 who was introduced as the dietary manager.
On 02/10/22 at 11:00 am, the facilities dietician, Employee #125 and Employee #127, Corporate Dietary Manager came to the room and informed this surveyor that Employee #126 is not a certified dietary manager and was not enrolled in a dietary manager program. Employee #126 was hired at the facility on 06/06/17. The dietician (#125) stated she was full time at the facility, and she stated, yes, I work 24 hours a week. This surveyor referred to the regulation which indicates, Full-time means working 35 or more hours a week.
No further information was provided.
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections including COVID - 19. Nurses failed to maintain infection control procedure during medication pass and the staff failed to dispose of COVID-19 contaminated gowns properly. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers #23 and #90 Facility Census 118
Findings Included:
a) Medication Pass
1)Resident #23
On 02/08/22 at 8:20 AM, this surveyor observed Licensed Practical Nurse (LPN) # 110 shake a Sennosides-Docusate Sodium Tablet 8.6-50 MG from the bottle into her hand then place the pill into Resident #23's medication pill cup. LPN #110 then proceeded to take the medication cup to Resident #23 for administration.
LPN #110 was asked after medication administration if it was a professional standard of practice to touch medication before administration. LPN #110 stated No, I should have just placed it in the cup.
On 02/08/22 at 9:41 AM, the Director of Nursing (DON) acknowledged medication should not be placed in the nurse's hand before administration.
2) Resident #90
On 2/08/22 at 8:30 AM, this surveyor observed Registered Nurse (RN) #109 take Resident #90's medication cup to Resident #90 and give the medication cup to Resident #90. Resident #90 took three pills and needed more water to finish taking the rest of her medication. RN # 109 then took the medication cup from Resident #90 and placed the medication cup on the medication cart in the hall. RN #109 filled up another cup of water then took the medication cup back to Resident #90.
RN #109 was asked if it was professional standard of practice to a place a medication cup that was in the Resident's room on the medication cart without a barrier. RN #109 stated she didn't think about it, but should have used one.
On 02/08/22 at 9:41 AM, the Director of Nursing (DON) acknowledged the medication cup should not be placed on the medication cart after being placed in the Residents' room without using a barrier.
b) Containment of Isolation gowns.
Observations beginning at 4:16 pm on 02/09/22 with the Center Nurse Executive (CNE) found the following issues:
-- Resident #417 is currently roomed in the beauty shop and was admitted to the facility on [DATE] and was positive for COVID-19 on that date. The barrel for the gowns worn by staff in her room was located on the outside of the room. The barrel had dirty gowns in it and were not bagged.
-- Resident #39 is currently residing in room [ROOM NUMBER] and tested positive for COVID - 19 on 02/08/22. The barrel for the gowns worn by staff in her room was on the outside of the room. The barrel had dirty gowns in it and were not bagged.
-- Resident #99 and #80 are in room [ROOM NUMBER]. They both tested positive for COVID-19 on 02/01/22. The barrel for the gowns worn by staff in her room was on the outside of the room. The barrel had dirty gowns in it and were not bagged.
An interview with the CNE indicated the staff are supposed to take the gowns off in the room and bag them and take them out in the hall and place them in the barrel. She indicated unbagged gowns should not be in the barrel.
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Based on record review and staff interview, the facility failed to ensure the Minimum Data Sets (MDS)accurately reflected the resident's status. This was true for two (2) of thirty (30) resident's MDSs reviewed during the Long-Term Survey Process (LTCSP). Resident #43's MDS was inaccurate in the area medication (gradual dose reduction (GDR)). Residents #112s MDS was inaccurate in area of nutritional/weight. Resident's identifiers: #43, and #112. Facility census: 118.
Findings include:
a) Resident #43
Review of Resident #43's physician's orders revealed she was receiving, Risperdal, an antipsychotic, for dementia.
Resident #43's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/09/21, Section N, Item N0410, A, Medications Received, stated the resident received antipsychotic medication seven (7) of the last seven (7) days. Section N, Item N0450, A, Antipsychotic Medication Review, stated the resident had received antipsychotic since the prior assessment. Section N, Item N0450, B, regarding whether a GDR was attempted was answered No. Due to Section N, Item NO450 C was skipped.
During an interview on 02/26/19 at10:22 AM, the Director of Nursing (DON) stated Section N, Item N0450, B, was completed incorrectly. She stated this item should have stated Resident #43 had received antipsychotics, and the information regarding the GDR should have been completed due to resident has had numerous failed GDRs.
No further information was received before the completion of the survey.
b) Resident #112
A review of Resident #112's medical record on 02/07/22 at 2:19 pm found an admission weight of 132 pounds. This weight was entered to the record on 01/22/22 and was then struck out of the record on 02/02/22 by Registered Nurse (RN) #63.
A review of Resident #112's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/22 found under section K0200. Height and Weight Resident #112's weight was recorded as 132 pounds.
An interview with the Registered Dietician (RD) and RN #63 on 02/09/22 at 11:16 am confirmed the MDS was incorrect. They stated they had discussed the admission weight and determined it was inaccurate and struck it from the record. They agreed they should have corrected the MDS when this decision was made and they did not.