Monroe Health Services

Based on observation and interview, the facility did not store and prepare food in accordance with professional standards for food service safety. This has the potential to affect all 43 residents. Surveyor observed items opened and undated in the refrigerators and coolers. Surveyor observed food items unsealed and/or unmarked in the freezers. Surveyor observed food items in the freezer with visible freezer burn. Surveyor observed the facility's industrial stand mixer to be unclean. Surveyor observed an unclean ice bin. Surveyor observed staff sanitizing food thermometer with alcohol wipe without allowing it to dry before placing it in another food item during lunch service. Evidenced by: Facility policy, entitled General Food Preparation and Handling dated 8/16/22 states in part, . Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. Policy Explanation and Compliance Guidelines. 2. Food Storage b. i. Food will be covered for storage. c. Food in broken packages. or food with an abnormal appearance or odor will be discarded. 5. Equipment a. All food service equipment should be cleaned, sanitized, air-dried, and reassembled after each use. On 12/1/25 at 8:38 AM, during initial tour of the kitchen, Surveyor observed items opened and not dated in the facility's refrigerators and coolers, including lettuce, egg patties, and pizza crusts. Surveyor observed chicken pieces with no date, no label, and visible freezer burn. Surveyor observed puff pastry and cookies in the freezer with no date or label. Surveyor observed a package of polish sausages stored in the freezer with a hole in the bag. Surveyor observed the facility's industrial stand mixer covered but noted dried white splatters near the mixing blade. Surveyor interviewed [NAME] H who indicated that the food observed undated, unlabeled, and not appropriately sealed were not currently being properly stored according to food safety standards. [NAME] H also noted the freezer burned chicken, which she immediately discarded. [NAME] H indicated that the stand mixer is not normally used and should have been cleaned appropriately before being covered and stored. On 12/1/25 at 11:55 AM, Surveyor observed [NAME] H taking the food temperatures before lunch service. Surveyor observed [NAME] H placing the food thermometer in the cooked cauliflower, noodles, pureed and ground chicken, hamburger patty, chicken breasts, hot dog, pureed cauliflower, mashed potatoes, and tomato soup. Surveyor observed that each time [NAME] H inserted the food thermometer in one food item, cleaned the thermometer with an alcohol wipe, and then immediately insert the food thermometer into the next item. Surveyor observed that [NAME] H did not allow the food thermometer to dry at least 10 seconds before re-inserting the thermometer in the next food item, thereby increasing the risk of cross-contamination. On 12/3/25 at 7:47 AM, Surveyor inspected the ice machine with NHA A (Nursing Home Administrator). Surveyor observed a thin layer of black substance on the inside of the freezer hood. Surveyor interviewed NHA A who indicated that she would expect the ice machine to be clean and free of mold. Surveyor shared with NHA A , Surveyors observations of food that was open, not labeled, and improperly stored during the kitchen tour. NHA A stated that she would expect the food to be properly stored in the freezers and refrigerators. On 12/3/25 at 10:00 AM, Surveyor interviewed KM I (Kitchen Manager). Surveyor shared with KM I her observations of food that was open, not labeled, and improperly stored during the kitchen tour. KM I indicated that she would expect that the food would be prepared and stored in a safe and sanitary manner.

Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 2 residents (R3) reviewed for nutrition of a total sample of 13 residents.R3 has diagnoses including congestive heart failure and Stage 5 renal disease. R3 is dependent on renal (kidney) dialysis. Staff are not obtaining R3's daily weight per Physician orders. R3 had weight gain that was not reported to R3's provider. This is evidenced by:The facility does not have a policy and procedure for weights. The Facility policy, Change in Condition of the Resident, revised 9/20/22, documents the following, in part: A facility should immediately inform the resident; consult with the resident's physician; and notify.a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). When to report to MD (Medical Doctor)/NP (Nurse Practitioner)/PA (Physician Assistant) Immediate Notification - Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and; A Marked Change in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. The facility follows INTERACT, a quality improvement program for managing acute changes in condition, using tools and strategies to prevent hospital transfers, for Change in Condition. INTERACT for Vital signs documents as follows:Vital Signs: Weight GainReport Immediately: 3 lbs (pounds) in 3 days or 5 lbs in 7 days in resident with: Heart Failure, Chronic Renal Failure, other volume overload state. R3 is a long-term resident of the facility. R3 has the following diagnoses: chronic combined systolic (congestive) and diastolic (congestive) heart failure (the heart cannot pump blood efficiently), end stage renal disease-stage 5 (the most severe stage of chronic kidney disease where kidney function is extremely low).R3 is dependent on renal (kidney) dialysis. On 7/7/25 R3's physician ordered the following: WEIGHT - daily - right away in the morning, update provider if weight gain of 3# (pounds) in one day or 5# in one week one time a day for dialysis.On 11/7/25 R3's physician ordered the following: WEIGHT on admit, daily x2 (two times), weekly x3 (three times per week), monthly. Obtain reweight if change of 5 lbs (pounds) since last weight. One time a day every 1 month(s) starting on the 1st for 1 day.The facility did not obtain a daily weight for R3 on the following dates since 10/1/25: 12/2, 11/29, 11/27, 11/26, 11/23, 11/22, 11/18, 11/16, 11/15, 11/11, 11/6, 11/5, 11/4, 10/29, 10/26, 10/25, 10/24, 10/22, 10/18, 10/14, 10/13, 10/12, 10/10, 10/9, 10/8, 10/5, 10/4, 10/2, and 10/1.It is important to note; there is no indication that a re-weight was obtained 9/13/25 - 12/2/25 to confirm or refute whether that weight was accurate or not.R3's Progress Notes, Vital Signs, and MAR (Medication Administration Record) reviewed from 10/1/25 through 12/2/25, there is no documentation that R3's Physician was made aware of R3's weight gain.R3's care plan, Edema/excess fluid volume as evidenced by: cardiac disease, renal disease, dated 9/16/25, documents the following Goal: Will be free from complications r/t (related to) edema/excess fluid volume. Interventions: Report S&S (signs/symptoms) of edema/fluid overload, such as change in mental status, weight gain, neck vein distention, abnormal lung sounds, extremity swelling, etc.R3's care plan for Renal (kidney) insufficiencies, dated 9/16/25, documents the following Goal: No complications r/t (related to) dialysis devices or treatment; Interventions: .Dialysis 3 times /week.On 12/3/25 at 2:30 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, where do staff document weights. DON B stated, under weights (in Vital Signs). DON B stated CNA's (Certified Nursing Assistants) report weights to RN's (Registered Nurses) and LPN's (Licensed Practical Nurses) and the RN's and LPN's document the weight. Surveyor asked DON B, if a resident has an order for a daily weight, do you expect staff to weigh the resident daily. DON B stated, yes. Surveyor shared R3's orders with DON B. Surveyor asked DON B, do you expect staff to obtain a daily weight for R3. DON B stated, absolutely. DON B stated, she last addressed obtaining daily weights in an all staff meeting on 11/19/25. Surveyor requested documentation from the staff meetings. (No further information was provided.) Surveyor asked DON B, what time does R3 leave for dialysis. DON B stated, on 12/1/25 he left at 8:15 AM. Surveyor asked DON B, would you expect staff to obtain R3's daily weight before he goes to dialysis. DON B stated, yes, she would expect him to be weighed on his way to the dining room before breakfast. Surveyor reviewed the following weight increases with DON B. 11/8/25: 221 +11.5 pounds (1 day)11/7/25: 209.5DON B stated, R3 was readmitted to facility on 11/7/25. DON B stated, R3 would have been on 72-hour monitoring. DON B stated, she's not seeing that R3's weight gain was addressed and Physician notified. Surveyor asked DON B, should R3's weight gain of 11.5 pounds in 1 day have been addressed and assessed. DON B stated, absolutely. Surveyor asked DON B, should staff have re-weighed R3. DON B stated, yes, absolutely. DON B stated, it's concerning to her because it is the same nurse. DON B stated, she wonders if it is an error. Surveyor asked DON B, should staff have notified the Physician. DON B stated, yes, because R3's order clearly stated to notify the provider of 3-pound weight gain in 1 day. 11/2/25: 215 +4.8 pounds (1 day)11/1/25: 210.2 Surveyor asked DON B, should staff have re-weighed R3. DON B stated, yes. Surveyor asked DON B, should staff have notified the Physician. DON B stated, yes, absolutely because it is more than a 3 pound weight gain in 1 day. 10/27/25: 217.5 +14.0 pounds (4 days) - went to dialysis - Weighty after dialysis at 1:46 PM is 217.5 10/23/25: 203.5Surveyor asked DON B, would you expect staff to recheck R3's weight. DON B stated, yes, staff should have re-weighed R3 right away. Surveyor asked DON B, should staff have notified the Physician. DON B stated, yes.9/17/25: 236 + 14 pounds (1 day) - readmission 9/16/25: 222Surveyor asked DON B, would you expect staff to re-weigh R3. DON B stated, yes. Surveyor asked DON B, would you expect staff to notify the Physician. DON B stated, absolutely.9/13/25: 238.7 +18.7 pounds ( 5 days)9/8/25: 220Surveyor asked DON B, would you expect staff to re-weigh R3. DON B stated, yes, no questions asked every time they should re-weigh. Surveyor asked DON B, would you expect staff to notify the Physician. DON B stated, yes. Surveyor asked DON B, why is it important to re-weigh R3 in the examples (above). DON B stated, to ensure the weights are accurate. DON B stated, it is important to notify the Physician per Physician Orders due to R3 being in hear failure and retaining fluids. DON B stated, if a resident is retaining fluids they are having a change in condition. DON B stated, staff need to continue monitoring R3. DON B added, if staff had contacted the Physician he or she would more than likely increased the order of furosemide for 3 days, so we are not sending the resident into fluid overload. DON B stated that's why it is important. DON B added, it is capturing the change in condition before it gets worse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 5 Residents (R46) reviewed for notification of change in condition.R46 had a heart rate above the facilities change of condition policy, and facility did not notify the physician timely.Evidenced by:The facility's Change in Condition of the Resident policy, dated 9/20/2022, states in part: Immediate Notification: Immediate notification for any symptom, sing or apparent discomfort that is: ii. A marked change in relation to usual symptoms and signs. Vital Signs, Pulse: Resting pulse > 100, Report Immediately .R46 was admitted to the facility on [DATE] with diagnoses that include displaced fracture of the greater trochanter of R (right) femur (leg bone), Atherosclerotic Heart Disease (plaque buildup inside your hearts arteries, which narrows them and restricts blood flow), and longstanding persistent Atrial Fibrillation (irregular and fast heartbeat).R46's MDS (minimum data set) dated 6/18/25 show a Brief Interview for Mental Status (BIMS) evaluation, with a score of 13, indicating R46 has normal cognitive function.R46's progress notes indicate the following:6/23/2025 09:33 (9:33 AM) Vitals Note Note Text: This writer noted vitals on resident. Resident has increased heart rate at 135. This writer did a head-to-toe assessment. No s/s of infection noted to the resident hip. Resident lungs clear throughout. Resident HR was noted apical to be 130. 6/23/2025 12:38 (12:38 PM) General Note Note Text: This writer did a reassessment on the resident r/t (related to) increase in heart rate. Residents heart rate was still increased at 130.Will continue to monitor resident. 6/23/2025 13:55 (1:55 PM) General Note Note Text: 1305 (1:05 PM) this writer updated the on-call provider with the increased heart rate. Per on call provider she would like to have resident be sent to the ER for a further workout. This writer then went to the resident and talked to him about what the on-call provider stated and suggested him [sic] to be seen in the ER. (Of note: R46's provider was updated approximately 3.5 hours after the elevated pulse was noted.) 6/23/2025 16:35 (4:45 PM) Health Status Note: Note Text: Per ED resident is being admitted to the hospital for PE and UTI. On 12/03/2025 at 1:04 PM, Surveyor asked RN E (Registered Nurse) when she would call the doctor for an abnormal vital signs. RN E stated she would contact the doctor right away after retaking the vitals for a second time. On 12/03/2025 at 1:11 PM, Surveyor asked LPN D (Licensed Practical Nurse) when he would call the doctor for abnormal vital signs. LPN D stated there should be parameters to follow. LPN D stated that his (R46) NP is in the building three times a week, and he will run it by her if he sees something out of the normal for the patient. LPN D stated he can always call the on-call NP or doctor right away too. On 12/03/2025 at 2:43 PM, Surveyor interviewed RN C (Registered Nurse) and asked about what you would consider a change of condition. RN C stated anything outside their baseline. Surveyor asked when you would call the doctor when vital signs are out of range. RN C stated that residents, depending on their baseline, might be running on the lower side. Some residents have parameters on their orders. If it was out of parameters, I would talk to the nurse practitioner or call the on-call nurse. Surveyor asked RN C to explain what happened with R46 on 6/23/25. RN C stated his heart rate was increased so she did a head-to-toe assessment, and he didn't have any other symptoms. RN C reported checking his vitals again and R46's heart rate was still elevated. Surveyor asked why RN C waited so long (approximately 3.5 hours) before calling the doctor. RN C stated that she felt like R46 had metoprolol ordered and she thought she wanted to see if the metoprolol helped first. Surveyor asked what the facility policy was for reporting an abnormal vital sign. RN C stated immediately. RN C stated that she did call the NP on call that day. On 12/03/2025 at 3:18 PM, Surveyor interviewed NP F (Nurse Practitioner). Surveyor asked NP F if she had a record of a call from facility on 6/23/25 regarding R46. NP F stated she has a telephone contact message from RN C to NP on call at 1:30 PM on 6/23/25. Surveyor asked NP F if she would expect the RN to call the doctor with an abnormal HR immediately. NP F stated yes. On 12/03/2025 at 3:21 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked what expectations for nurses are when they have abnormal vital signs. DON B stated that nurses needed to recheck to make sure the reading was accurate. Surveyor asked DON B when she would expect the nurses to call the doctor. DON B stated immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide the right to refuse a transfer to another room in the facility when the purpose of the move is solely for the convenience of staff for 1 of 5 residents (R41) reviewed for room changes.R41 was moved from one unit to another for the convenience of therapy staff without allowing the opportunity to refuse the transfer. This is evidenced by: Facility policy titled Private Rooms, implemented in 2/2018 and reviewed/revised in 07/2022, states, Procedure: Neither Medicare or Medicaid reimburse for a private room. If the facility has all private rooms, this is not an issue. However, when the facility has semi-private rooms, the resident will be admitted to a semi-private room unless the resident wishes to pay out of pocket privately or is deemed to require an isolation room related to an infection control issue. When isolation is no longer needed, the resident will be moved to a different room providing a different level of care. Note: The 400 hall in the facility has private rooms near the therapy wing and the 100 and 200 halls have shared rooms. Surveyor reviewed letters sent to residents residing in the 400 hall of the facility in August 2025, which state, in part: We are writing to inform you of an upcoming room change that will affect your current placement. As part of our ongoing efforts to better serve our residents and improve care delivery, we are designating the 400 Hall for therapy patients. This change will allow us to provide easier and quicker access to therapy services, as the 400 Hall is closest to the therapy department. At this time, you are not being billed for a private room. In order to accommodate this new arrangement, we will be moving residents who are not paying for private accommodations to either the 100 or 200 Halls. These halls continue to offer the same quality of care and comfort.If you would prefer to remain in your current private room on the 400 Hall, you may choose to do so at a rate of $390 per day, which reflects the cost of a private room.Please let us know your preference by Tuesday, August 12th, so we can make the appropriate arrangements. Example 1: R41 was initially admitted to the facility on [DATE]. R41 is insured through Medicaid. R41's quarterly MDS (Minimum Data Set) assessment, dated 8/31/25, indicated that R41 has a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating she has intact cognition. On 12/1/25 at 9:55 AM, Surveyor interviewed R41. R41 indicated she recently moved from the 400 hall of the facility to the 100 hall because the facility was making the 400 hall for rehab residents. R41 told the administrators she did not want to move, but if she did not move, she was told she would have to pay $390 per day. R41 indicated she was the only one on the hallway who had to move. R41 also indicated she was actively participating in physical therapy. On 12/2/25 at 12:21 PM, Surveyor interviewed R41 again. R41 reiterated that she had not wanted to change rooms. Surveyor reviewed R41's admission agreement, signed on 10/22/20. Section G states the following, Short-stay/Rehabilitation stay: If this admission is anticipated to be a short stay for rehabilitation, Resident understands that their room may be within a section of the Center that is programmatically designed to serve the needs unique to residents who are expected to stay at for only a short period of time for purposes of rehabilitation. If your needs require longer than an anticipated short stay, you will be asked to move to a different room within the Center so that we may provide medically and socially appropriate services for a longer stay. You acknowledge in advance, that should your needs require a longer stay, that you will be asked to transfer to a room that is more suited to a longer-term stay. R41's census notes indicate she had been in a room on the 400 hall since 11/21/22. R41 was relocated to the 100 hall on 9/11/25. On 12/2/25 at 12:27 PM, Surveyor interviewed SW G (Social Worker) about the room changes at the facility. SW G indicated the facility wants to turn the 400 wing of the building back into a rehabilitation wing so therapy can save time and steps going back and forth getting people for therapy. The wing is centrally located to be close to the therapy gym. SW G indicated she and another staff member had gone to hand out letters to residents on the 400 wing who would have to move. So far, only two residents had moved from the 400 wing: R41 and another resident who moved due to a decline so more eyes could be on him. SW G was unsure why the other three residents on the wing had not moved yet. SW G indicated R41 had expressed not wanting to move rooms but could not afford to pay the extra private room fee of $390 per day. On 12/2/25 at 2:35 PM, Surveyor interviewed NHA A (Nursing Home Administrator) about room changes at the facility. NHA A indicated the 400 hallway was originally built for therapy. Since therapy is closer to that hallway, the goal is to bring it back to why it was added on in the first place. NHA A indicated she wrote a letter to residents on the 400 hall in August explaining they had to choose whether to pay the private room fee or not. If they chose not to, they would have to move. Room changes occur as rooms open or residents have an increase in care needs and must be more in the front of the building. NHA A indicated reactions have been mixed about moving rooms. NHA A indicated R41 was the first person to move and was not happy about it. NHA A indicated the facility told R41 she had an increase in care and had to be observed more closely. Surveyor asked NHA A what had changed with R41's care. NHA A indicated she was moved to a Hoyer lift, but no longer uses it.(Of note: R41's room on the 100 hall is at the end of the hallway and not close to the nurses' station.) Surveyor asked why other residents on the 400 hall had not moved yet. NHA A indicated two are actively seeking to move out of the facility. The facility is planning on moving the other resident this week. Surveyor asked if this resident had an increase in care needs as a reason for the move. NHA A said no. They had been waiting to move the resident until a room opened and there was a compatible roommate. On 12/2/25 at 3:09 PM, Surveyor spoke with NHA A. NHA A indicated the facility does not have specific beds licensed for Medicare and Medicaid-insured residents. On 12/3/25 at 3:33 PM, Surveyor spoke with NHA A. NHA A acknowledged Surveyor's concern with room transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and review of the facility's policy, the facility failed to ensure residents were free from misappropriation of property for one of three sample residents (Resident (R) 1) reviewed for misappropriation.
Findings include:
Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 07/15/22, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .The facility will have written procedures that include .analyzing the occurrence to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes may be needed to prevent further occurrences .training of staff on changes made and demonstration of staff competency after training is implemented.
Review of R1's undated Resident Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with diagnosis that included chronic respiratory failure, muscle weakness, and diabetes mellitus.
Review of R1's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/24 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the resident was cognitively intact.
Review of the Misconduct Incident Report provided by the facility, documented that the incident was discovered 12/24/24, that R1's phone was missing and said that a housekeeper took it. Patient was worried about her phone. Police were called and [R1] did not want to pursue it with the police. The Administrator was called immediately, and the housekeeper was suspended immediately. Police called. Certified Nursing Assistant (CNA) 1 wrote a witness statement on 12/24/24 that stated, R1 turned her call light on and I answered it .she then asked about her phone saying the house keeper put her phone in her pocket. The actions taken by the Administrator stated, On 12/24/2024 at 1300 [1:00 PM], the administrator was notified that [R1's] phone was missing. [R1] made a comment that she thought it might be the [Housekeeper (HSK) 2] as she thinks she saw her put it in her pocket. [HSK2] was immediately suspended. Staff immediately started searching for it and the police were called. The police started interviewing [R1]. [R1] told the police officer that she did not want anything done. Police Officer . called the administrator and stated that, 'he would not proceed because [R1] did not want anything done' .The Assistant Director of Nursing (ADON) was interviewing staff and searching for the phone. Staff searched the grounds and around cars and saw the phone in [HSK3's] passenger seat. [HSK2] was outside waiting for a ride from [HSK3] and walked with staff to her co-worker's [HSK3] vehicle because she received rides to work and saw the phone was under a package of Kleenex in the front seat, she asked that we not tell [HSK3]. The phone was returned to [R1] immediately. The conclusion documented that, Between staff and resident interviews .[HSK2] was scheduled in [R1's] hallway .[R1] saw housekeeper put it in her pocket. The phone was found with staff and [HSK2] present, in the car that she rode in. [Facility] and the .police department are unable to substantiate the theft of the phone, but due to the evidence provided in the investigation, we are terminating [HSK2].
During an interview on 01/17/25 at 9:45 AM, CNA1 said that she remembered R1 was upset about someone who had cleaned her room and had taken and put something into her pocket, and now she could not find her phone. She said she helped the resident search her room, but it could not be found. She said a lot of staff were looking in her room to find it, but they could not. CNA1 said she reported it and wrote her statement and gave it to management. She said it was the end of her shift and went home. She said she heard the phone was found in the housekeeper's car. She stated she was not aware of any other residents expressing similar concerns.
During an interview on 01/17/25 at 10:10 AM, HSK1 said that she completed a regular background check when she applied to the housekeeping company and had received abuse training. She could not recall if she had received any after the incident with R1, but believed it was after the last facility survey.
During an interview on 01/17/25 at 10:26 AM, the Housekeeping Manager (HSKM) said she did the hiring for the housekeeping staff. She said the process to check for references, and background checks were done by her company, which was separate from the facility itself. She said she was not at the facility that day, but the Administrator told her what happened. She said she called HSK2 who said she did not do it. HSKM said R1 had stated she saw HSK2 take her phone. She said the District Manager of her company had called her to discuss the situation, and that they were doing their own investigation. She stated that since the incident she did not believe there had been any reeducation or training on abuse that she could recall. She stated the facility used Relias and her company used a separate system, but she could not recall any since the misappropriation of property.
During an interview on 01/17/25 at 11:36 AM, the Director of Nursing (DON) said that although he was not at the facility during the incident, he was informed. He said the facility did the self-report and education. He confirmed they interviewed other residents, and none had concerns. He said they sent the report to the contracted housekeeping company that HSK2 worked for, since she was not a direct employee.
During an interview on 01/17/25 at 11:39 AM, the Regional Administrator said he was involved in the termination of the employee. He stated they could not 100% confirm she took the phone, but the evidence suggested that she took it. He confirmed that the contract company she worked for was now handling it.
During an interview on 01/17/25 at 12:05 PM, R1 said that she saw HSK2 in her room and put her cell phone into HSK2's pocket. She said she told the staff, and they found the phone in HSK2's friend's car. She said she knew HSK2 took it, but she did not know why. She said the police came in and asked her if she wanted to press charges. She stated she did not. She said she wanted the housekeeper to come and apologize, but she did not. R1 said it was an unfortunate situation, and she just wished she knew why HSK2 did it.
During an additional interview on 01/17/25 at 12:20 PM, the Regional Administrator said there were no additional findings of missing property, and if there was it would be on the grievance log. There were none reported.
During an interview on 01/17/25 at 12:27 PM, the ADON said it was Christmas Eve in the afternoon and the girls reported to her that R1 could not find her cell phone. She stated they looked everywhere in her room. She stated staff came back and said they could not find it. She stated R1 was very adamant that she saw HSK2 take it. She said she talked to HSK2 who swore she did not take it. She stated HSK2 was carpooling with HSK3. She said she called the Director of Nursing then to see what to do, because she knew there had to be an investigation, and get statements. She stated HSK2 finished her work before HSK3 and went to the car she was carpooling with HSK3, because she had access to it when she was on breaks. She stated that HSK2 came and told her that she saw a phone on the car seat and had taken a picture of it. ADON said she did not know what R1's phone looked like, so another staff member validated that it was hers. She said she had brought HSK3 into the office and asked her about the phone and said she had not taken it; it was not hers. She stated she was not aware of what had happened. ADON said she told the Administrator and Director of Nursing, and they told her to call the police, and get statements. ADON stated when the police came, they interviewed R1, and she said the same thing. She stated R1 got her phone back and identified HSK2 because she could recall what she looked like. She said that the Housekeeping Manager was their supervisor, and she was told to handle it on her end. She said that since then there had been additional education on abuse, and they had the nursing staff sign and review.
During an interview on 01/17/25 at 12:40 PM, the Administrator said the Director of Nursing had nursing meetings, talked with every new hire, and that there was also online training that the staff received to go over all the abuse training. He said they also did in-services for abuse and talked about it, that it was ongoing. He confirmed that housekeeping services was a contracted company and that the Housekeeping Manager was to provide abuse education to her staff as well.
A review of the abuse training on 12/26/24 revealed the HSKM had attended, but not the housekeeping staff.
During an interview on 01/17/25 at 12:49 PM, HSKM said she had brought in the available training that was completed for her housekeeping staff. She confirmed that none of the housekeeping staff had received abuse reeducation since the incident.
A review of the housekeeping staff training revealed none of the staff had received abuse training since the incident with HSK2 and R1.
During a concurrent interview on 01/17/25 at 12:52 PM with the Administrator, Regional Administrator, and DON, they confirmed the misappropriation of R1's property had occurred, and that they had provided retraining on abuse to the facility staff. They confirmed HSKM had attended this reeducation, and that she would have been responsible for educating the housekeepers since they were a contracted company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not immediately consult with the resident's physician when there was a need to alter treatment for 1 of 3 residents (R1) reviewed for physician notification.
R1's provider was not notified of abnormal lab results.
This is evidenced by:
The facility policy titled, Change in Condition of the Resident, reviewed/revised 9/20/22, indicates, in part: Policy: A facility should immediately inform the resident; consult with the resident's physician .when there is .a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) .3. Notify resident's physician - Use Interact Change in condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant) as a guideline .
The facility Interact Version 4.5 Tool - Change in Condition: When to report to the MD/NP/PA, indicates, in part, the following lab results should be reported immediately: .Chemistry: Blood/Urea/Nitrogen (BUN) >60mg/dl .
R1 was admitted to the facility on [DATE] with diagnoses that include, in part: Chronic Kidney Disease, Stage 4 (Severe), Anemia in Chronic Kidney Disease, Malignant Neoplasm of Overlapping Sites of Left Female Breast, Type 2 Diabetes, Chronic Heart Failure and Metabolic Encephalopathy (when the brain is not functioning properly because of an imbalance in the body's chemicals).
R1's most recent MDS (Minimum Data Set), dated 10/29/24, indicates a BIMS (Brief Interview for Mental Status) score of 9, indicating R1's cognitive status is moderately impaired.
R1's physician orders indicate the following:
BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) without diff one time only for Lab Monitoring until 10/28/24.
Order date: 10/26/24. Start Date: 10/28/24.
Surveyors reviewed the lab results from 10/28/24, which included, in part:
--BUN: 83 (Blood Urea Nitrogen)
Normal Range: 7-19mg/dl
--Creatinine: 4.17
Normal Range: 0.57 - 1.11 mg/dl
--GFR: 10 (Glomerular Filtration Rate -- a measure of how well your kidneys are working)
Normal Range: >=60 ml/min/1.73m2)
Of note, surveyors could not find evidence in R1's medical record that the lab results were called to nor reviewed by a provider.
On 11/25/24 at 3:00 PM, Surveyor interviewed NP (Nurse Practitioner) C who indicated she saw R1 once, on the day of admission [DATE]. NP C indicated she ordered labs for 10/28/24 and that they were completed. NP C indicated her notes show that there was not a provider who reviewed the results. NP C indicated she was on vacation and there was another NP taking her calls. NP C indicated if the facility would have notified her or the on-call provider of the lab results they would have discussed options of sending to the hospital versus remaining at the facility. NP C reviewed with Surveyor R1's previous labs and noted that they were trending down prior to admission.
On 11/25/24 at 3:12 PM, Surveyor interviewed DON B who indicated that when an order is received for labs it is put into the system and put into a file box at the nurse's station. DON B indicated usually he, ADON E (Assistant Director of Nursing), or the lab will come and complete the draw and take the sample(s) to the hospital. DON B indicated, usually UM D (Unit Manager) pulls up the lab results and either her or the nurse call the provider or NP C. If NP C is not at the facility then we contact (Physician Name) or whoever is on call. DON B indicated they do not have an exact timeframe for how long they wait to check for lab results and that there are always outliers but would expect within that day.
On 11/25/24 at 3:30 PM, Surveyor interviewed UM (Unit Manager) D who indicated she is responsible for ensuring orders are completed for labs and that the results are taken off the fax and follow up occurs. UM D indicated she will make sure NP C reviews the results because NP C is often in the building. UM D indicated she does not recall R1's labs for 10/28/24. UM D indicated she would look into the follow up for R1's labs on 10/28/24. It is important to note no further documentation was provided by UM D.
On 11/25/24 at 3:40 PM, DON (Director of Nursing) B indicated if UM D is not in facility any of the nurses can take lab results off of the fax machine. DON B indicated staff know if they take something off the printer they should give it to the nurse or the DON. DON B indicated he does not see anything in the documentation regarding results for R1's labs on 10/28/24. DON B indicated he would expect someone at the facility to follow up with the provider once the lab results are received. DON B indicated if the lab results were not received he would expect someone at the facility to follow up.
R1's provider was not contacted regarding R1's Lab results from 10/28/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2:
R11 was admitted on [DATE] with diagnoses of orthopedic aftercare following surgical amputation, acute osteomyelitis (right hand,) and peripheral vascular disease.
July 2024 Treatment of Administration (TAR) record indicates the following:
Arterial wound left 2nd finger, full thickness, apply iodosorb gel and cover with bordered gauze once daily for 30 days (start 7/13/24, D/C (discontinue) date 7/19/24) is blank/not signed out on the TAR for night shift on 7/19/24.
Arterial wound left 2nd finger, full thickness, apply iodosorb gel and cover with bordered gauze once daily for 30 days (start 7/20/24, D/C (discontinue) date 7/30/24)
Wound care: Monitor left hand tip of thumb and thumb nail is necrotic. Apply betadine once daily, leave open to air one time a day for wound care (start date 7/14/24) is blank/not signed out on the TAR for PM shift on 7/17/24.
Wound care: Right hand, daily dressing changes. Cleanse with normal saline, pat dry, apply xeroform over the sutures, and wrap with a rolled gauze followed by ace wrap one time a day for wound care (start date: 7/3/24) is blank/not signed out on AM shift on 7/17/24 and 7/24/24.
No documentation was provided to show that R11's wound care treatments were done on the dates that were blank/not signed out on the TAR.
On 8/8/24 at 3:18 PM, Surveyor interviewed DON B (Director of Nursing) regarding R11's treatments. When informed that R11 has blanks/dates not signed out for treatments on his TAR, DON B stated, If it's not documented it's not done.
Example 3
The facility policy, titled Fall Prevention and Management Guidelines, with a reviewed/revised date of 7/18/24, indicates, in part: .Policy Explanation and Compliance Guidelines: .7. When any resident experiences a fall, the facility will: a. Complete a post-fall assessment and review: 1) Physical assessment with vital signs . 4) Resident and/or witness statements regarding fall .e. Document all assessments and actions .
R15 was admitted to the facility on [DATE], diagnoses include, in part: Hemiplegia (one sided paralysis) and Hemiparesis (one sided partial weakness) following cerebral infarction (stroke) affecting right dominant side, difficulty in walking, age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases and can increase the risk of fractures), and Parkinsonism.
R15's Minimum Data Set (MDS) with a target date of 5/21/24 indicates a Brief Interview for Mental Status (BIMS) summary score of 12, indicating R15's cognition is moderately impaired.
R15's Nursing Progress Notes indicate the following, in part:
--5/9/24 12:47 PM - Clinical Follow-up: Note Text: The current status is sitting in w/c (wheelchair) eating lunch. monitor per policy.
--5/9/24 1:44 PM - Communication with Physician: Situation: recent fall at 11AM - c/o (complains of) right hip pain. Background: reaching for snack and fell out of w/c. Assessment (RN)/Appearance(LPN): right hip swollen. Assessment: requesting to go to ER (Emergency Room). Recommendations: Response: Order received to send to ER.
--5/9/24 2:00 PM - General Note: Note Text: requesting to be sent to ER d/t (due to) c/o right hip/leg pain .EMS (Emergency Medical Services) arrived at 1:50 PM .
On 8/8/24 Surveyor was unable to locate a Fall Report/Investigation for R15 in the medical record and requested this from the facility.
On 8/8/24 the facility provided the following, in part, and indicated it was from their risk management documentation:
The document indicates Risk Management at the top of the document with an effective date of 5/9/24. There is no complete patient name on the document, only a first name in the note text and there is no documentation of who the author is.
Note Text indicates: R15's family brought in cupcakes for his birthday. R15 was eating one and dropped it on the floor. Patient reached for cupcake on the floor and fell. Resident States, I was reaching for a cupcake that my brother brought me for my birthday. Patient showed no signs or symptoms of pain or discomfort and was transferred back to wheel chair. Education on call light was given immediately. Patient stated I know I should of used by call light to ask for help Patient transferred back to bed with 2 person full body lift where he started to complain of pain in hip. Orders to send to ER for eval (evaluation).
R15's Post Fall Assessment, with an effective date and time of 5/9/24 at 12:38 PM, includes, in part: Date and Time of Fall 5/9/24 00:00 (Of note, this time differs from the 5/9/24 1:44 PM nursing progress note that indicated the fall occurred at 11:00 AM) .Current vitals: Blood Pressure 175/79, Pulse 61, Respiration 20 . The document is electronically signed by RN E (Registered Nurse)
It is important to note, this document does not include a full physical assessment such as range of motion, shortening of extremity concerns, internal or external rotation concerns, level of pain in general or pain with palpation, obvious signs of injury, etc.
R15's Post Event Observation, with an effective date and time of 5/9/24 at 12:47 PM, includes, in part:
A. Focus 1. Reason. 2. Fall .
A. Focus 6. Most Recent Pain Level: Pain Level: 0 Date: 5/9/24 6:39 AM (Of note, this time is prior to the time the fall was documented as occurring.)
6a. Pain location: right leg.
7. Current status: sitting in w/c eating lunch.
8. Action taken: monitor per policy.
This document is electronically signed by RN E.
R15's Hospital Discharge Summary for admission dates 5/9/24 to 5/15/24 indicate, in part: Clinical Resume: R15 .was admitted with Right Intertrochanteric Fracture due to a combination of osteoporosis and trauma, as trauma alone would not have caused the fracture .
On 8/8/24 at 9:57 AM, Surveyor interviewed RN E via telephone regarding R15's fall on 5/9/24. During the interview RN E indicated that if the facility had not provided the risk management documentation to us that some of her documentation would be in there. RN E indicated R15's brother had brought him cupcakes and R15 reached over to get one, the container was closed, and he ended up tipping out of his chair when he went to get one. RN E indicated she was up by the nurse's station assisting another resident when someone alerted there was a resident on the floor. RN E indicated that she saw NHA A (Nursing Home Administrator), who she states is also an LPN (Licensed Practical Nurse), go down and that as soon as she was done assisting the resident she was with she went down to the room. RN E indicated that NHA A cannot do an assessment because he is an LPN. RN E indicated by the time she got to the room R15 had already been picked up off the floor so she did not know what position he was in and couldn't assess him on the floor as he had already been moved. RN E indicated R15 had been moved into a wheelchair and that a CNA (Certified Nursing Assistant) and NHA A were in the room when she arrived. RN E could not recall who the CNA was. RN E indicated she brought the vitals machine and completed neuro checks per protocol but did not complete a full assessment. RN E indicated that she asked R15 if he was having pain and he said a little bit in his right leg. RN E indicated R15 said he just wanted to go to lunch and to get him to lunch and refused further assessment. RN E indicated she told R15 she needed to assess him but he didn't want to and kept saying just get me to lunch. RN E indicated after lunch he started to complain of more pain in the right leg and so she messaged the provider and got an order to send him out for evaluation to the ER. Surveyor asked RN E if she was able to assess R15's leg after lunch. RN E indicated she was not able to assess his leg after lunch either because he was sitting in the w/c and she asked him and he refused for her to assess the hip and so she asked him if he wanted an x-ray and he said yes. Surveyor asked RN E if R15 stayed in his w/c until EMS (Emergency Medical Services) arrived. RN E indicated they put him in bed as EMS was getting there. Surveyor asked RN E if she recalled how they got R15 into bed. RN E indicated she did not remember and that she may not have been there because she may have been getting paperwork ready. Surveyor asked RN E if she would have given approval for staff to move R15 from the w/c to the bed. RN E indicated she did not recall if she did or not. Surveyor asked RN E with the amount of pain R15 was in if he should have been moved or left in the w/c for EMS to assist. RN E indicated, they should have left him in the w/c where he was.
It is important to note that R15 was moved, after a fall, on two separate occasions without evidence of a complete RN assessment.
On 8/8/24 at 10:36 AM, Surveyor interviewed R15 regarding the fall on 5/9/24. R15 was not able to provide details from the fall or post fall other than that he recalled he was reaching for a cupcake and fell out of his w/c and broke his hip. R15 indicated he could not recall staff assisting him after the fall or recall being moved or refusing to allow staff to physically assess him.
On 8/8/24 at 3:51 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the expectation of nursing staff is immediately after a resident has a fall. DON B indicated: Risk management documentation and follow-up; An assessment, to included: vital signs, a head to toe assessment, and depending on the incident, range of motion; Contact physician, DON, family, MCO (Managed Care Organization). Surveyor asked DON B if any staff member should move a resident prior to a RN assessment. DON B indicated, no.
Surveyor asked DON B what he knew of R15's fall on 5/9/24. DON B indicated it was reported to him that it was R15's birthday and he dropped a cupcake on his floor and was reaching for it, slid out of his w/c, and landed on his bottom. They put R15 into his bed, he had no complaints of pain or injury. DON B indicated he could not give an exact time but he thought about 2 hours later he began complaining of right leg pain. DON B indicated he went in and assessed R15's leg and he had pain in the pelvis area and 911 was called and he was transported. Surveyor asked DON B if as far as he was aware R15 went directly to his bed after the fall. DON B indicated he was aware of RN E doing an assessment and then her and the CNA laying R15 back in bed. Surveyor asked DON B if he documented his assessment or if he had documentation of RN E's assessment. DON B indicated he was not sure and began looking in the facility EHR (Electronic Medical Record). DON B indicated he was unable to locate documentation of the assessments and that they should be documented in the medical record.
On 8/8/24 at 4:18 PM Surveyor interviewed NHA A and asked what he knew of R15's fall on 5/9/24. NHA A indicated that R15 was reaching for a cupcake because it was his birthday and he fell reaching for it. NHA A indicated he assisted with the post fall risk management information. Surveyor asked NHA A if he went to R15's room when he fell. NHA A indicated he thought he went after the fact, just to see where it happened. Surveyor asked NHA A if he cared for R15 at anytime between the fall and when he was moved. NHA A indicated, not that he recalled. Surveyor asked NHA A if he recalled what nurse went to take care of R15 after the fall. NHA A indicated, I believe it was RN E, the documentation I saw was her. Surveyor asked NHA A if he knew who moved R15 after the fall. NHA A indicated he believed it was a CNA and RN E. Surveyor asked NHA A if he was able to find documentation of an RN assessment prior to R15 being moved. NHA A indicated he could not see one and there should have been one completed. Surveyor asked NHA A if he, at any time, moved R15. NHA A indicated, no.
There is no evidence documented of a complete physical assessment by a Registered Nurse prior to R15 being moved from the floor to the w/c after a fall.
Based on observation, interview, and record review, the facility did not ensure that residents (R) receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, or per resident's choice for 2 of 5 residents (R35 & R11) reviewed for non-pressure wounds and 1 of 5 residents (R15) reviewed for change in condition out of a total sample of 16 Residents.
R35 has blanks on his Treatment Administration Record (TAR) indicating R35's wound care had not been completed.
R35 sees the wound doctor weekly. On 5/2/24 the wound doctor had ordered a treatment to R35's left shin and the order did not get transcribed onto the TAR or completed.
R11 had blanks on his TAR indicating R11's wound care was not completed on those days.
R15 sustained a fall. R15 was moved off the floor, after a fall, without a thorough assessment by an RN (Registered Nurse) and was later found to have a fracture.
Evidenced by:
The facility's policy, entitled Pressure Injuries and Non pressure Injuries, dated 7/20/22, states, in part: .Policy: . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity . Policy Explanation and Compliance Guidelines: .2. Weekly: .iii. Initiate treatment per order .
The facility policy, entitled Non-Controlled Medication Orders, dated 1/23, states, in part: .Policy: Medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe .
Documentation of the Medication Order: .
2. Each medication order is documented in the resident's medical record .
a. New orders .
-Order is recorded on the MAR (Medication Administration Record)/TAR (Treatment Administration Record) .
d. Orders faxed from the prescriber's office.
-The nurse on duty at the time the faxed order is received notes the order and enters it into the medical record .
-Order is recorded on the MAR/TAR .
Example 1:
R35 admitted to the facility on [DATE], and has diagnoses that include Encounter for orthopedic aftercare following surgical amputation, Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (a long-term condition in which the body has trouble controlling blood sugar and using it for energy. Polyneuropathy is a complication of type 2 diabetes mellitus that occurs when the body's peripheral nerves malfunction).
R35's Minimum Data Set (MDS) Quarterly Assessment, dated 5/10/24, shows R35 has a Brief Interview of Mental Status (BIMS) score of 14, indicating R35 is cognitively intact.
R35's Specialty Physician (wound physician) Initial Wound Evaluation and Management Summary, dated 5/2/24, includes: Non-Pressure Wound of the Left Shin . Dressing Treatment Plan: Primary Dressing: Leptospermum (flower from the manuka plant) Honey apply once daily for 30 days. Secondary Dressing: Gauze island with border once daily for 30 days.
R35's May 2024 TAR includes the following:
-Wound Care to blister on LLE (left lower extremity): Paint intact blister on LLE with betadine daily. One time a day for wound care- blister Start Date: 5/7/24 . D/C (discontinue) Date: 5/17/24 . Dates 5/8/24, 5/12/24, 5/13/24, 5/14/24 and 5/16/24 are left blank/not signed out on the TAR for this order.
-Wound Care to LLE: Cleanse open wounds to LLE with soap and water, pat dry, then apply Foam dressing with border. Change every 3 days, and PRN (as needed) until healed one time a day every 3 days for wound care. Start Date: 5/7/24 . D/C Date: 5/17/24 . Dates: 5/13/24 and 5/16/24 are left blank/not signed out on the TAR for this order.
Note: There is no order on TAR for the ordered Primary Dressing: Leptospermum honey apply once daily for 30 days. Secondary Dressing: Gauze island with border once daily for 30 days to Left Shin as ordered on 5/2/24.
R35's July TAR includes the following: Apply skin prep to areas on left toe once daily one time a day for skin. (Start Date: 6/14/24.) Dates 7/12/24 and 7/17/24 are left blank/not signed out on the TAR for this order.
R35's Care Plan, dated 2/2/24, states, in part: .Focus: At risk for alteration in skin integrity related to: recent surgery, decreased mobility, diabetes .Interventions: . Treatment as ordered per MD (medical doctor). See wound MD as needed. Date Initiated: 5/2/24.
No documentation was provided to show that R35's wound care treatments were done on the dates that were left blank/not signed out on the TAR.
On 8/8/24 at 1:22 PM, Surveyor interviewed IP D (Infection Preventionist/Wound Nurse). Surveyor asked IP D what the process is when the wound doctor comes to the facility and writes new orders for wound care. IP D indicated she does rounds with him. The wound doctor's notes go under the miscellaneous tab in PCC (Point Click Care). The next day IP D looks at the orders and if there are changes IP D updates the TAR. IP D indicated she took over as wound care nurse in June and she is responsible for entering orders into the TAR.
On 8/8/24 at 3:10 PM, Surveyor interviewed DON B (Director of Nursing) and asked what the process is when the wound doctor comes to the facility and writes new orders for wound care and who is responsible. DON B indicated IP D is responsible for entering the orders into the TAR. DON B indicated at the end of the day when the wound doctor is at facility, IP D is responsible for entering the new orders into the TARS. DON B indicated the new orders are expected to be started the next day. Surveyor asked DON B, looking at the wound doctor's orders dated 5/2/24, were these orders entered into the TAR and completed. DON B looked through the TAR in the computer and indicated no, the orders are not in the TAR and were not completed. Surveyor asked if the orders should have been entered into the TAR on 5/2/24 and DON B indicated yes. DON B indicated he would have expected the orders to be started the next day on 5/3/24. Surveyor asked DON B if there are blanks on the TAR what does that indicate. DON B indicated if not documented it is not done. Surveyor showed DON B the blanks on R35's TAR (5/8, 5/12, 5/13, 5/14, 5/16) and asked if these treatments were completed and DON B indicated if not documented it is not done.
R35's wound treatments were not completed per MD orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, no later than 24 hours if the events that cause the suspicion do not result in serious bodily harm for 1 of 3 sampled residents reviewed (R10).
R10 was found to have a injury of unknown origin (bruise) on her upper right arm on 7/7/24. This was not reported to the State Agency until 7/11/24.
This is evidenced by:
According to §483.12(c)(1) of the State Operations Manual; all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
The facility policy entitled, Abuse, Neglect, and Exploitation, dated 7/15/22, includes in part:
IV. Identification of Abuse, Neglect, and Exploitation .
B. Possible indicators of abuse include, but are not limited to: .
2. Physical marks such as bruises or patterned appearances .
3. Physical injury of a resident, of unknown source .
VII. Reporting/Response
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:
a. Immediately, but not later than 3 hours after the allegation is made, if the vents that cause the allegation involve abuse or result in serious bodily injury, or
b. Not later than 24 hours if the event that causes the allegation do not involve abuse and do not result in serious bodily injury .
R10 was admitted to the facility on [DATE], with diagnosis that include, in part: Alzheimer's disease, osteoporosis, dementia, generalized anxiety disorder, and major depressive disorder.
Review of R10's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/24 indicates R10 has no Brief Interview for Mental Status (BIMS) score due to the resident is rarely or never understood.
Progress note dated 7/7/24 at 10:07 PM states: [CNA] reported to this writer that resident was in pain every time[sic] she/they repositioned her. Noted bruise on her right upper arm 3.5cm x 8.5cm. This writer lift [sic] resident's arm slowly and she flinched[sic], with facial grimacing noted. This writer notified hospice and talked to [Nurse], and that she will send someone tomorrow morning to assess her, to notify her family since its not urgent, and to update her medications; to give her some tylenol for now for pain prn (as needed).
Progress note dated 7/11/24 at 8:19 AM, states: This writer heard resident's daughter [Name], in resident's room talking loudly towards staff doing cares. This writer asked her to come to SS (Social Services) office to discuss further. Daughter continued to express her frustrations to SS; Admin. also introduced himself to daughter; offered care conference with family. SS will contact APOA (Activated Power of Attorney) [Name] to schedule.
The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was initially submitted by NHA A (Nursing Home Administrator) on 7/11/24 at 9:56 AM. The Allegation type is listed as injury of unknown source: injury was not observed and is suspicious because of the extent or location. (of note, this is over the required reporting time)
The final investigation was submitted on 7/17/24 at 3:00 PM.
R10's Physician Progress note, dated 7/16/24, indicates an x-ray was conducted on 7/12/24 that indicates a fracture with displacement of the humeral head with osteoporosis. The note also states, She has contractures. I suspect that during routine care (dressing/bathing), the upper arm may have been manipulated to change her clothing or provide hygiene and she developed a pathological fracture due to osteoporosis.
On 8/8/24 at 1:43 PM, Surveyor interviewed NHA A. Surveyor asked NHA A what his process is for reporting and investigating injuries of unknown origin. NHA A states that if we suspect anything we suspend employees as necessary and notify family. NHA A also states he could guess what I was referring to and states that R10's family did not want anything done at first, and when they did the facility started with x-ray and labs. The Physician then ordered R10 adaptive clothing due to the discovery of a pathologic fracture. Surveyor asked NHA A how soon injuries of unknown origin should be reported to the State Agency. NHA A states as soon as we know there was an injury, NHA A also states that he did report it and DON B (Director of Nursing) also knew about it right away and when he assessed it, DON B determined that the bruise was from changing R10's clothing so it was not an injury of unknown origin. Surveyor asked NHA A when the injury was discovered. NHA A stated 7/7/24, but DON B determined that the injury was not of unknown origin as it came from changing R10's clothes. Surveyor asked NHA A when his initial report was submitted. NHA A states, 7/11/24. NHA A also states the only reason he reported this incident at all was because R10's family came in and was yelling at facility staff, alleging abuse.
On 8/8/24 at 4:02 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how he was notified about R10's bruise. DON B states he was called immediately after the injury was discovered. DON B states that a CNA found the bruise and that it was small, about the size of a 50-cent coin. DON B gestured a small circle with his hand, roughly the same size as a 50-cent coin. Surveyor asked DON B if he would consider this bruise an injury of unknown origin. DON B states, I guess I would call it that. The next day when I came back in to reassess the resident the bruise was halfway down her arm. DON B gestures from the middle of his upper arm down to just below the elbow area. DON B also states that R10 has a long history of osteoporosis. Surveyor asked DON B what made the facility decide to further pursue an x-ray after the family initially denied it. DON B states because the bruise got bigger. DON B also states that he has seen multiple injuries in the past where a shoulder can be injured that can also cause these types of bruises to grow. Surveyor asked DON B when the decision was made to report this injury to the State Agency. DON B states when a family member came in screaming and alleging abuse. Surveyor asked DON B how soon abuse or injuries of unknown origins need to be reported. DON B states, immediately, especially when alleging physical harm.
Of note, according to DON B, the bruise became significantly bigger on 7/8/24 and the injury was still not reported until 7/11/24, after R10's family member alleged abuse.
R10's injury of unknown origin was not reported within the required timeframe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for 1 sampled resident (R35) of 5 reviewed for unnecessary medications.
Surveyor reviewed R35's comprehensive care plan. There is no care plan indicating the use of Melatonin for insomnia.
The facility does not have a sleep assessment or sleep tracking for R35's Melatonin use.
Evidenced by:
The facility policy, entitled Comprehensive Care Plan, dated 9/23/22, states, in part: . POLICY: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.
Definitions: .Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .
Policy Explanation and Compliance Guidelines: .
1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care .
3. The comprehensive care plan will describe, at a minimum, the following:
a. The services that are to be furnished to attain or maintain the resident's
highest practicable physical, mental, and psychosocial well-being .
f. Resident specific interventions that reflect the resident's needs and
preferences .
R35 admitted to the facility on [DATE], and has diagnoses that include weakness, obstructive sleep apnea (intermittent airflow blockage during sleep), and depression.
R35's Minimum Data Set (MDS) Quarterly Assessment, dated 5/10/24, shows R35 has a Brief Interview of Mental Status (BIMS) score of 14, indicating R35 is cognitively intact.
R35's Physician's Orders, dated 6/4/24 and 5/14/24, states, in part: .
Melatonin Oral Tablet 3 MG (milligrams) (Melatonin) Give 2 tablets by mouth one time a day for Sleep . Order Status: Active Order Date: 3/28/24 Start Date: 3/28/24 .
R35's Care Plan, dated 2/11/24, states, in part: .
Focus: Sleep cycle issues as evidenced by poor sleep r/t (related to) depression. Date Initiated: 2/11/24. Revision on: 2/11/24.
Goal: Resident will exhibit fewer signs of adequate sleep by review date. Date Initiated: 2/11/24. Target Date: 11/3/24.
Interventions: Administer medications as ordered. Date Initiated: 2/11/24 .
Surveyor reviewed R35's electronic health record and there is no documented sleep assessment from February 2024.
Surveyor reviewed R35's Medication Administration Record (MAR) from May 2024 through July 2024 and there is no sleep tracking or effectiveness of Melatonin documented.
On 8/8/24 at 1:15 PM, Surveyor interviewed VPS F (Vice President of Success). VPS F informed Surveyor the facility does not have a sleep assessment for R35.
On 8/8/24 at 3:05 PM, Surveyor interviewed DON B (Director of Nursing) and asked if DON B would expect a sleep assessment for a resident on Melatonin for sleep. DON B indicated probably so. Surveyor asked DON B if a resident receiving Melatonin for sleep, would you expect sleep monitoring. DON B indicated yes; you would want to see if the Melatonin was effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of quality for 1 of 1 Residents (R40) reviewed for weights out of a total sample of 16.
R40 had an order for daily weights for seven (7) days. Weights were not completed 3 out of 7 days.
Evidenced by:
The facility policy, entitled Weight Monitoring, dated 12/21/22, states, in part: .The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.routine weights will be measured montly thereafter, unless ordered more frequently by the physician. Weights will be recorded in the individual's electronic health record. The nursing staff will notify the individual or responsible party, physician, and RDN (Registered Dietician Nutritionist) or designee of any individual with an unintended significant weight change.
R40 was admitted to the facility on [DATE] with diagnoses that includes in part, essential hypertension (high blood pressure).
R40's Minimum Data Set (MDS) dated [DATE], shows that R40 has a Brief Interview of Mental Status (BIMS) score of 12, indicating that R40's cognition is moderately impaired.
R40's physician orders, dated 7/24/24, state;
*Daily weights for next 7 days
R40's Medication Administration Record (MAR) states, in part: daily weights for next 7 days, notify MD if > (greater than) 3# (pounds) in 1 day or 5# in 1 week . start 7/25/24.
R40's Weights and Vitals Summary shows:
*7/26/24 268 Lbs (pounds)
*7/27/24 267 Lbs
*7/30/24 266.8 Lbs
*7/31/24 265.6 Lbs
Important to note: There is no documentation of weight for 7/25/24, 7/28/24, or 7/29/24 though the MAR has signatures for the 7 dates of 7/25/24 through 7/31/24.
On 8/7/24 at 4:33 PM, Surveyor interviewed RN C (Registered Nurse) and asked where weights are documented. RN C stated on the MAR or under vitals in PCC (Point Click Care--facility's electronic health record system).
On 8/8/24 at 8:06 AM, Surveyor interviewed DON B and asked where weights are documented. DON B stated in PCC, as a rule; the CNAs (certified nursing assistants) write the weight on a weight sheet and the nurses document in PCC. Surveyor asked when the nurse is to document the weight in PCC. DON B stated same day. Surveyor asked if daily weights should be documented in PCC every day. DON B stated yes. Surveyor asked if staff would be aware of need to update the physician regarding change in weight if the weight was not documented in PCC. DON B stated no. Surveyor showed DON B that weights had not been documented in PCC for 3 of the 7 ordered dates. Surveyor asked DON B if facility would expect that all weights be documented in PCC to ensure that nurses would know when to update the physician. DON B stated yes. DON B asked if the facility expected that weights be documented in PCC if staff have signed for them on the MAR. DON B stated yes.
The facility did not ensure that physician orders were followed for R40's daily weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not implement professional standards of practice to promote healing or prevent pressure injury (PI) development for 1 of 2 residents reviewed for PIs out of a sample of 16 residents (R147).
On 5/23/24 the wound doctor ordered Leptospermum honey (honey from the flowers of the Manuka bush) apply once daily for 23 days. Secondary Dressing: Gauze island with border apply once daily for 23 days for R147. This order did not get entered/transcribed onto R147's Treatment Administration Record (TAR) and was not completed as ordered on multiple days.
Evidenced by:
The facility's policy, entitled Pressure Injuries and Non pressure Injuries, dated 7/20/22, states, in part: .Policy: . For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .
Policy Explanation and Compliance Guidelines: .
2. Weekly: .
iii. Initiate treatment per order .
The facility policy, entitled Non-Controlled Medication Orders, dated 1/23, states, in part: .Policy: Medications are administered only upon the receipt of a clear, complete and signed order by a person lawfully authorized to prescribe .Documentation of the Medication Order: .2. Each medication order is documented in the resident's medical record .
a. New orders .
-Order is recorded on the MAR (Medication Administration Record)/TAR (Treatment Administration Record) .
d. Orders faxed from the prescriber's office.
-The nurse on duty at the time the faxed order is received notes the order and enters it into the medical record .
-Order is recorded on the MAR/TAR .
R147 admitted to the facility on [DATE], and has diagnoses of osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down), paraplegia (a chronic condition that causes a loss of muscle function in the lower half of the body, including the legs, feet, toes, and sometimes abdomen), and weakness.
R147's Specialty Physician Wound Evaluation and Management Summary, dated 5/23/24, states, in part: .Stage 3 Pressure Wound of the Left Calf . Dressing Treatment Plan: Primary Dressing: Leptospermum honey apply once daily for 23 days. Secondary Dressing: Gauze island with border apply once daily for 23 days. (until 6/14/24) .
R147's Care Plan, dated 4/16/24, states, in part: . Focus: The resident has healing pressure ulcer Right and Left Calf r/t (related to) paraplegia .Interventions: .Administer treatments as ordered and monitor for effectiveness. Date Initiated: 4/16/24 .Weekly treatment documentation to include measurement .Date Initiated: 4/16/24 .
R147's May TAR includes:
Wound Care to left calf. Cleanse area and pat dry. Apply medihoney and cover with bordered gauze daily. One time a day. Start Date: 4/19/24 . D/C (discontinue) Date: 5/21/24 . Note: TAR shows no treatment to left calf from 5/21/24 through 5/31/24.
R147's June TAR includes: Left Calf- Cleanse wound and apply medihoney and cover with bordered gauze once daily one time a day. Start Date: 6/7/24. D/C Date: 6/28/24.
Note: TAR shows no treatment to the left calf from 6/1/24 - 6/6/24.
(Of note: R147's wound was present upon admit and did not worsen during the time frames that the wound care was not completed.)
On 8/8/24 at 3:35 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor reviewed the wound doctor orders dated 5/23/24 with DON B and asked if these orders were entered onto R147's TAR and completed as ordered. DON B indicated the orders were not on R147's TAR from 5/21/24- 6/6/24. Surveyor asked DON B if these orders should be on R147's May TAR and DON B indicated yes, he would expect them to be on the TAR and completed. Surveyor asked DON B if these orders had been completed and DON B indicated if it was not documented it was not done.
Treatment to R147's pressure injury was not completed per physician orders on multiple days.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 34 opportunities that affected 2 out of 2 residents (R12 and R35) included in the medication pass task, which resulted in an error rate of 5.88%.
RN C (Registered Nurse) did not assess the resident's heart rate or blood pressure prior to administration according to physician orders.
LPN G (Licensed Practical Nurse) administered a medication with breakfast instead of one hour before breakfast according to physician orders.
This is evidenced by:
Facility policy entitled, Medication Administration, dated 01/2023, states in part: Policy: Medications are administered as prescribed in accordance with manufacturers' specifications . Procedures: Medication Preparation: . 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record .Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . 2. Obtain and record any vital signs as necessary prior to medication administration. 3. Medication administration timing parameters include the following: a. Medications to be given on an empty stomach or before meals are to be scheduled for administration 30 minutes to 2 hours prior to meals . 14. Medication are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes .
Example 1:
R12's Physician Orders state, in part:
Lisinopril Oral Tablet 10 MG (milligram) (Lisinopril) Give 1 tablet by mouth one time a day related to HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE (I11.9) hold if SBP (systolic blood pressure) <100 (less than 100) or DBP (diastolic blood pressure) <60 or HR (heart rate) <60 and notify MD (medical doctor). (Start date: 7/20/2024)
On 8/7/24 at 8:00 AM, Surveyor observed RN C prepare 22 medications for R12, including one Lisinopril 10 MG tablet. Surveyor observed this medication be added to the small, plastic medication cup and administered to the resident. After reviewing R12's physician orders, it was found that R12's Lisinopril order included parameters to hold the medication for a blood pressure under 100 systolic and 60 diastolic, as well as orders to hold for a heart rate less than 60.
Of note: Surveyor did not observe R12 assess the resident's vital signs prior to medication administration. The last vital signs recorded for R12 were taken on 8/5/24.
On 8/7/24 at 11:38 AM, Surveyor interviewed RN C. Surveyor asked RN C how often R12's vital signs should be taken. RN C states that it used to be daily, but about a month ago that was discontinued, and RN C believes that now it is once a week. Surveyor asked RN C if she took R12's vital signs this morning. RN C states no, she did not. Surveyor asked RN C to review R12's Lisinopril order and asked what the order indicates. RN C states that there are hold orders for vital sign parameters. Surveyor asked RN C, knowing this, should R12's vital signs been taken this morning prior to the Lisinopril being administered. RN C stated, yes, absolutely.
Example 2:
R35's Physician Orders state, in part:
Omeprazole Oral Tablet Delayed Release 20 MG (Omeprazole) Give 1 tablet by mouth one time a day for GERD (Gastroesophageal Reflux Disease) Give one hour before breakfast.
On 8/7/24 at 8:14 AM, Surveyor observed LPN G prepare 12 medications for R35, including one Omeprazole 20 MG tablet. Surveyor observed this medication be added to the small, plastic medication cup and administered to the resident. While in R35's room, Surveyor observed the resident sitting upright in a wheelchair in front of a bedside table with his breakfast tray on top and uncovered. After reviewing R35's physician orders, it was found that R35's Omeprazole order included instructions that the medication be administered 1 hour before breakfast.
On 8/7/24 at 11:47 AM, Surveyor interviewed LPN G. Surveyor asked LPN G if I what R35's Omeprazole order states. LPN G states that the Omeprazole should be administered one hour before breakfast. Surveyor asked LPN G if R35 had his breakfast tray when the medications were administered. LPN G states, yes. Surveyor asked LPN I if R35 was administered his omeprazole one hour before he ate breakfast. LPN G states, no. Surveyor asked LPN G if R35's Omeprazole should have been administered one hour before he ate breakfast. LPN G states, yes.
On 8/7/24 at 12:55 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if it is his expectation that medications be administered as ordered. DON B states, yes. Surveyor asked DON B if he would expect vital signs to be taken if medication have a hold order with vital sign parameters. DON B states, yes. Surveyor asked DON B if he would expect a medication with orders to be given one hour before breakfast to be administered as ordered. DON B states, yes. Surveyor asked DON B if he would consider administering the lisinopril without taking vital signs and administering omeprazole with breakfast instead of one hour before medication errors. DON B states, yes and that he has already started the facility medication error process including notifying the physician. Surveyor asked DON B if vital signs should have been taking prior to administering lisinopril. DON B states, yes. Surveyor asked DON B if omeprazole should have been given an hour before breakfast. DON B states, yes.
R12 and R35's medications were not administered per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not maintain medical records on each resident that are complete; accurately documented; readily accessible, and systematically organized for 1 of 16 sampled residents (R39) reviewed for fall risk.
R39's medical record contains inaccurate fall risk assessments following five (5) falls within the facility over the span of three (3) months.
This is evidenced by:
R39 was admitted to the facility on [DATE] with diagnosis that include in part: encephalopathy (brain disease or dysfunction that causes and altered mental state), vascular dementia, and polyneuropathy (peripheral nerve damage causing weakness, numbness, and pain).
R39's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 7/25/24, indicates a Brief Interview of Mental Status (BIMS) of 3 out of 15, indicating R39 is severely cognitively impaired. Section GG indicates the resident utilizes a wheelchair for mobility. GG0170: Mobility indicates R39 requires partial/moderate assistance to move from sitting to standing. It also indicates R39 requires substantial/maximal assistance for chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. GG0170 also indicates that the facility could not attempt to have R39 walk 10 feet due to a medical condition or safety concerns.
R39's Comprehensive Care Plan indicates, in part: Focus: R39 is a high risk for falls due to a history of falls, medications, weakness, decreased mobility, and a recent hospitalization. Date initiated: 4/19/24. Interventions include: room move if family is ok, lay down after meals, toilet after meals, bed in low position, dycem in w/c (wheelchair). Focus: R39 will use w/c while eating and in activities. Date initiated: 4/19/24. Interventions include: encourage to transfer and change positions slowly, FALL RISK (FYI), Have commonly used articles within easy reach, reinforce need to call for assistance, reinforce w/c safety as needed such as locking brakes, report development of pain, bruises, change in mental status, ADL (activities of daily living) function, appetite or neurological status post fall, sign to ask for help when getting up by recliner.
R39's falls include:
Post Fall assessment dated [DATE] at 12:00 PM. Assessment indicates that a fall occurred on 5/9/24 at 11:40 AM. Progress notes indicate that the fall was unwitnessed, and resident was found on the floor. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 22 indicating high fall risk.
Post Fall assessment dated [DATE] at 11:42 PM. Assessment indicates a fall occurred on 5/9/24 at 7:00 PM. Progress notes indicate a second unwitnessed fall that was believed to have occurred when R39 attempt to use the bathroom by himself. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 10 indicating low fall risk.
Post Fall assessment dated [DATE] at 2:40 AM. Assessment indicates a fall occurred on 5/10/24 at 7:10 PM. Progress note indicates that this is the third unwitnessed fall. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 15 indicating moderate fall risk.
Post Fall assessment dated [DATE] at 2:11 PM. Assessment indicates a fall occurred on 6/5/24 at 1:00 PM. Assessment indicates that this is the fourth unwitnessed fall. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 9 indicating low fall risk.
Of note: This Fall Risk Assessment indicates that R39 had no falls in the past 30 days and 1-2 falls in the past 90 days, when they actually had 3 falls. Additionally, it does not indicate the medications that R39 is has physician orders for that increase fall risk including a diuretic, a laxative, a psychotropic medication, and an antidepressant that are indicated on some prior assessments.
Post Fall assessment dated [DATE] at 6:01 PM. Assessment indicates a fall occurred on 8/1/24 at 6:00 PM. Assessment indicates that this is the fifth unwitnessed fall. The Fall Risk Assessment, which is included with the Post Fall Assessment, indicates a score of 10 indicating low fall risk.
Of note: This Fall Risk Assessment indicates that R39 had 1-2 falls in the past 90 days and 1-2 falls in the past 180 days, when the resident actually had 4 falls in the past 90 days. Additionally, it does not indicate the medications that R39 is has physician orders for that increase fall risk including a diuretic, a laxative, a psychotropic medication, and an antidepressant that are indicated on some prior assessments.
On 8/8/24 at 8:44 AM, Surveyor interviewed LPN H (Licensed Practical Nurse). Surveyor asked LPN H what the process is after a resident falls. LPN H states, we get vitals, do an assessment, make sure nothing is hurting, utilize a hoyer lift to get them back up. Once the resident is off the floor, we ask them what happened, ask witnesses what happened, do notifications for the physician and HCPOA (Healthcare Power of Attorney), and then we do the fall risk assessment and continue neurological checks. Surveyor asked LPN H if recent falls increase someone's fall risk. LPN H states of course they do, along with a resident BIMS and medications. Surveyor asked LPN H if R39 is a high fall risk. LPN H states yes, due to his BIMS score, he has a sore ankle, and his recent intervention of the sign next to his chair is hit or miss for effectiveness.
On 8/8/24 at 8:55 AM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C what the process is after a resident falls. RN C states, after I am notified, I go right to the room, assess for injury, ask what happened and if the resident hit their head. After that, RN C would start neurologic checks, assess vital signs, assist the resident off the floor, notify the physician and HCPOA, assess for skin issues, notify DON (Director of Nursing) and NHA (Nursing Home Administrator), and do a post fall and risk assessment. Surveyor asked RN C if previous falls increase resident fall risk. RN C states, absolutely. Surveyor asked RN C if R39 was a high fall risk. RN C states, yes.
On 8/8/24 at 3:52 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what his expectations were for staff after a resident falls. DON B states staff are to do an incident report, risk management, document the fall, notify family, the physician, and himself. Surveyor asked DON B what the assessment includes. DON B states vital signs, head-to-toe assessment, and range of motion. Surveyor asked if this would also include a fall risk assessment. DON B states, yes, I would expect them to be filled out. Surveyor discussed with DON B that 3 out of 5 of R39's post fall assessments, R39 was determined to be a low fall risk. Surveyor then asked DON B if he would consider these to be accurate fall risk assessments. DON B states, no. Surveyor asked DON B if these assessments should be accurate. DON B states, yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 (R2) supplemental residents reviewed for antibiotic stewardship.
R2 was given an antibiotic before all test results were returned and continued to take it after results despite lack of appropriate indications for its use.
This is evidenced by:
The facility policy titled, Antibiotic Stewardship Program, with a reviewed date of 1/24/24, indicates, in part: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the updated McGeer criteria to define infections .b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made .
On 8/7/24 and 8/8/24 Surveyor reviewed the facility's Infection Control Line List documentation as part of the facility's Infection Control Program review.
R2 was admitted to the facility on [DATE] and the July 2024 Infection Control Line List indicated the following for R2:
Type of Infection: UTI (Urinary Tract Infection) .Signs and Symptoms: dysuria, urgency and abdominal pain. Criteria Met: Yes. Date of Onset: 7/12/24. Results/Organism: >=100,000 mixed flora .Treatment: Cefuroxime .Notes: UTI treated with cefuroxime x 7 days.
An electronic encounter (a communication with the provider via electronic messaging), electronically signed by the physician on 7/12/24 at 2:31 PM, indicates the following: Looks like a UTI. Until culture is back, let's treat with cefuroxime 250 mg bid (twice a day) x 7 days with 0 refills.
A Urine Culture Order with a collected date of 7/12/24 and a last resulted date of 7/13/24 indicates the following: Result Note: Urine Culture >= 100,000 CFU/ml (colony forming units/ml). No further workup performed. Mixed multiple morphologies present including potential uropathogens; suggest recollection if clinically indicated.
R2's Medication Administration Record (MAR) indicates the following:
Cefuroxime Axetil .Give 250mg (milligrams) by mouth two times a day for UTI until 7/19/24 .Start Date: 7/13/24. This medication is marked as administered twice daily from 7/13/24 through 7/18/24 and once in the AM of 7/19/24.
On 8/8/24 at 8:59 AM, Surveyor interviewed ADON/IP D (Assistant Director of Nursing/Infection Preventionist) and DON B (Director of Nursing). Surveyor reviewed the above information regarding R2 and asked if it met criteria for treating with an antibiotic. ADON/IP indicated that she just went by the >100,000 for treatment. Surveyor reviewed the note on the urine culture indicating: No further workup performed. Mixed multiple morphologies present including potential uropathogens; suggest recollection if clinically indicated, with ADON/IP D and DON B. DON B indicated in the interview that his expectation with this culture result would have been for the physician to be contacted to discuss the results and to collect a new urine sample if needed.
R2 was started on an antibiotic for suspected UTI prior to urine culture results being finalized.
R2 was kept on an antibiotic after urine culture results indicated mixed flora (no specific bacteria was isolated) and that no further work-up would be performed. Therefore, a sensitivity, which would determine the effectiveness of the antibiotic against the microorganisms (germs) such as bacteria, was not performed. A recollection was not obtained or discussed with the Physician.

Based on staff/resident interview and record review, the facility did not make prompt efforts to resolve grievances for 1 of 3 sampled residents (R1).
R1 reported to DON B (Director of Nursing) multiple times regarding call light wait times and being left wet for long periods of time, as well as concerns regarding demeanor of two (2) staff members. DON B did not report these grievances to NHA A (Nursing Home Administrator), the Grievance Officer. Therefore, the grievances were not documented on the grievance log, and there is no documented follow-up with R1. The facility did not ensure prompt resolution of voiced grievances.
As evidenced by:
The facility's policy Grievance Policy, revised 7/2022, states as follows: The facility will seek to resolve concerns, complaints or grievances and provide residents, responsible parties, staff and other feedback and resolution in a timely manner per 483.10 (J)(1). The resident has a right to voice grievances without fear or retaliation.
Residents, residents' families and responsible parties, facility staff and facility contractors will be in-serviced on the Grievance procedure, how to initiate a grievance, who the Grievance Officer is and how resolutions will be communicated.
When a Complaint/Grievance Report is initiated: A copy of the initiated concern form will be placed in the Grievance Notebook as a reminder that the Grievance is still being investigated and resolved. The original form will then be forwarded to the department head for which the Grievance pertains to (i.e. Dietary Manager for food and dining related issues, DON for any nursing or clinical related issues The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance.
The Grievance Officer will ensure: During the investigation, the Grievance Officer will prevent any potential or further violation of resident rights. The receipt of the concern will immediately report allegation or neglect and/or abuse .
Once resolution of the grievance is achieved, the Grievance Officer will ensure that follow up with the concerned party, explanation of the investigation and the resolution and document of the concerned party's response to the resolution take place.
The Grievance Officer will ensure .written grievance resolution decisions include the date when the original concern was received, a summary statement of concern, steps taken to investigate, a summary of findings or conclusions regarding the concern, whether the concern was confirmed or not, any corrective action taken and the date the written decision was issued. By using the Grievance Report form - these action items should be achieved.
On 2/7/24 at 9:10 AM and 11:35 AM, Surveyor spoke with R1. Surveyor asked R1, are staff taking good care of you. R1 stated, she thinks there are a lot of good CNA's (Certified Nursing Assistants) here. R1 stated she has concerns regarding her call light response time and being left soiled. R1 stated sometimes she waits around 40 minutes. R1 was unable to recall further details. Surveyor asked R1, did you you tell anybody regarding your concerns. R1 stated, she spoke with DON B. R1 stated she also had a concern regarding a staff member and shared that concern with DON B. Surveyor asked R1, do you feel safe at the facility. R1 stated, Yes.
On 2/7/24 at 10:34 AM, Surveyor spoke to NHA A (Nursing Home Administrator). Surveyor asked NHA A, are there any grievances, investigations or a soft file for R1. NHA A stated, No. (Note there is only 1 grievance for R1 regarding food). Surveyor asked NHA A, does the facility have call light wait time logs. NHA A stated, no.
On 2/7/24 at 4:23 PM, Surveyor spoke with DON B (Director of Nursing). DON B stated, R1 and I (DON B) are friends, she tells me everything that's going on with her. DON B stated, he talks with R1, 2-3 times per week or more. Surveyor asked DON B, has R1 shared concerns with you regarding the facility. DON B stated, Yes, everything about A to Z. Surveyor asked DON B, has she voiced concerns to you. DON B stated, Yes. Surveyor asked DON B, who is the Grievance Officer. DON B stated, NHA A is the Grievance Officer. Surveyor asked DON B, did R1 share concerns with you regarding a staff member. DON B stated, R1 shared concerns regarding the demeanor of two (2) staff members. DON B added, R1's concerns were regarding the way the staff members talked and interacted. DON B stated, it was residents rights and customer service concerns. Surveyor asked DON B, what date(s) did R1 voice the concerns regarding staff. DON B stated, he is unsure as he did not document the information, and did not document when he followed up with R1. Surveyor asked DON B, did R1 voice concerns regarding call light response time and being left soiled. DON B stated, yes, R1 voiced concerns regarding call light response time and being left wet, not soiled. Surveyor asked DON B, what date did R1 voice the concerns call lights and being left wet. DON B stated, he is unsure as he did not document the information, and did not document when he followed up with R1. DON B stated, R1 has reported multiple concerns to him regarding call light response time. DON B stated, R1 did not want to file a grievance and stated, she doesn't want to get anybody in trouble.
On 2/7/24 at 4:40 PM, Surveyor spoke with R1. Surveyor asked R1, when you shared your concerns regarding call light wait times and a staff member, did DON B ask if you wanted to file a grievance. R1 stated, No. R1 asked Surveyor, what is a grievance? R1 asked, is it like suing? Surveyor explained what a grievance is and the process to file a grievance.
R1 was not offered to file a grievance for her concerns, the grievance officer was not made aware of R1's concerns and there is no evidence of facility staff following up with R1 with a resolution to her concerns that were voiced to DON B.

Based on interview and record review, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (R1).
R1's Physician Orders dated 1/17/24 indicate the following order: Decrease lasix to 20 mg (milligrams) twice daily. The facility did not enter the updated order nor administer the updated lasix dose until 1/19/24. This is a medication error.
Evidenced by:
The facility policy, Medication Administration, dated 1/2023, indicates, in part, as follows: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices Medications are administered in accordance with written orders of the prescriber.
R1 was admitted to the facility 1/2/24 with diagnoses including, but not limited to: acute on chronic congestive heart failure, chronic respiratory failure, acute kidney failure, and CKD (chronic kidney disease) stage 3b (moderate to severe loss of kidney function).
On 1/17/24, R1 had an appointment with a Nephrologist (a Physician that specializes in kidney disease). The Physician documented the following order: Decrease lasix to 20 mg (milligrams) twice daily. Note, this order was in bold with a large font on R1's physician orders to emphasize the medication order change. R1's visit diagnosis: Stage 4 chronic kidney disease - Acute renal failure superimposed on stage 3b chronic kidney disease.
R1's Medication Administration Record (MAR) documents the following medication administration:
Furosemide Oral Tablet 20 mg (milligrams) (Start Date: 1/19/24) - Give 1 tablet by mouth two times a day for edema (AM and PM). R1's MAR indicates Furosemide 20 mg was not administered until 1/19/24 (2 days after it was prescribed).
Furosemide Oral Tablet 40 mg (Start Date: 1/2/24 Discontinue Date: 1/18/24) - Give 1 tablet by mouth two times a day for edema (AM and PM). It is important to note, R1 did not receive any furosemide on 1/18/24.
On 2/7/24 at 4:23 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, is it your expectation that staff follow Physician orders. DON B stated, Yes. Surveyor asked DON B, does the facility have any medication errors. DON B stated, no. Surveyor shared R1's physician orders on 1/17/24 with DON B. Surveyor stated that R1's lasix order was changed on 1/17/24 and the new order was not entered or administered until 1/19/24. Surveyor asked DON B, would you have expected R1's order for lasix to be entered and administered prior to 1/19/24. DON B stated, Yes. Surveyor asked DON B, how soon would you have expected staff to enter and start administering the new order. DON B stated, Within a 24 hour period or before. DON B was unaware of this medication error.

Based on observation, interview, and record review, the facility did not ensure 1 of 1 sampled residents (R1) reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing.
R1 was admitted with an unstageable pressure injury (PI) to her right heel. Treatment orders were not completed as ordered.
Findings include:
R1 was admitted to the facility 1/2/24 with diagnoses including, but not limited to: acute on chronic congestive heart failure, chronic respiratory failure, acute kidney failure, and chronic kidney disease (CKD) stage 3.
R1's Minimum Data Set (MDS) with an Assessment Reference Date of 1/9/24 indicates a Brief Interview of Mental Status score of 14 indicating she is cognitively intact. Section GG of the MDS indicates R1 requires supervision or touching assistance to roll left and right. Section M of the MDS indicates R1 has a unstageable PI due to coverage of wound bed by slough and/or eschar upon admission to the facility. R1 is at risk for pressure injuries.
R1's comprehensive care plan, dated 1/11/24, indicates, in part, as follows: The resident has pressure ulcer to right heel r/t (related to) decreased mobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions: .Administer treatments as ordered and monitor of effectiveness.
The wound physician assessed R1 for the first time on 1/4/23.
On 1/11/24 the wound physician assessed R1 and documented the following:
Unstageable (Due to Necrosis) of the Right Heel, Full Thickness
Wound Size: 2.5 x 3.0 x Not Measurable cm (centimeters) (Length x width x depth) - Depth is unmeasurable due to presence of nonviable tissue and necrosis. Stage: Unstageable Necrosis
Stage: Unstageable Necrosis
Duration: Greater than 17 days
Exudate (drainage): Moderate Sero-Sanguineous (composed of red blood cells and serous fluid, known as blood serum)
Thick adherent devitalized necrotic (dead) tissue: 10%
Granulation tissue: 90%
Wound Progress: Not at Goal
Dressing Treatment Plan: Primary Dressing: Alginate calcium with silver apply once daily for 30 days. Secondary Dressing: Gauze island with bdr (border) apply once daily for 23 days.
R1's Treatment Administration Record (TAR) indicates the following: (Start Date 1/11/24) Wound care to right heel. Cleanse wound with gentle soap and water, rinse thoroughly and gently dry area. Apply calcium alginate with silver to wound bed and cover with bordered gauze daily and as needed.
R1's TAR indicates R1's treatment was not completed on 1/15/24.
On 2/7/24 at 3:19 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B, do you expect staff to follow physician orders. DON B stated, Yes. Surveyor shared with DON B that R1's dressing change to her right heel was not completed on 1/15/23 per physician orders. Surveyor asked DON B, should staff have documented and completed R1's treatment per R1's physician orders. DON B stated, Yes. DON B added, As we know, if it's not documented it's not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure therapy services were provided for 1 of 6 residents (R1) reviewed for therapy services.
R1 had an order for physical therapy (PT) and occupational therapy (OT) evaluation and treatment on discharge orders from hospital on 9/7/23. R1 was not evaluated and did not receive PT/OT services.
This is evidenced by:
R1 was admitted to the facility on [DATE] with diagnoses that include Calcinosis Cutis (a condition in which calcium salts are deposited in the skin and subcutaneous tissue), Type 2 Diabetes Mellitus (a condition that affects the way the body processes blood sugar. The body either doesn't produce enough insulin, or it resists it.), and Varicose Veins (gnarled, enlarged veins, most commonly appearing in the legs and feet) of Right Lower Extremity.
R1's Hospital Discharge summary, dated [DATE], states, in part: . Ambulatory Referral to occupational eval (evaluation) and treat . Ambulatory Referral to physical therapy eval and treat .
R1's September 2023 Physician's Orders includes:
*OT (Occupational Therapy) eval and treat as indicated
*PT (Physical Therapy) eval and treat as indicated.
R1's Client Coordination Note Report from Hospice, dated 9/8/23, states, in part: . Note: 1. Reason admission did not occur: Patient/Family wanting to pursue therapy and further extensive evaluation of current conditions .
Of note: There are no PT/OT notes around 9/7/23 or after. There was no evidence of an evaluation assessment being completed for R1.
On 12/5/23, at 3:45 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) and asked if they would expect physician orders to be followed. DON B indicated yes. Surveyor asked, when R1 returned to facility from hospital with discharge orders for physical and occupational therapy eval and treat on 9/7/23 would you expect those orders to be carried out. DON B and NHA A indicated yes. NHA A indicated he would look for documentation and consult with corporate and get back to Surveyor.
No documentation was provided regarding therapy evaluation and treatment being completed for R1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not consult with the Resident's physician for 1 of 2 residents (R13) reviewed for hospitalization of 16 sampled residents.
R13 reported signs and symptoms of a Urinary Tract Infection (UTI) such as hematuria (blood in urine) and urgency to void to facility staff, and facility staff did not make attempts to contact the physician after the initial call was not returned. R13's Physician was not updated/consulted when R13 was not given all doses of her antibiotic.
This is evidenced by:
Facility policy titled Change in Condition of the Resident last reviewed on 9/20/22 states in part, .When a resident presents with a possible change of condition, after a fall or other possible trauma, or noted changes in mental or physical functioning:1. Assess the resident's need for immediate care/ medical attention .2. Assess/ evaluate the resident. This assessment/ evaluation could include, but is not limited to, the following: a. Vital signs, oxygen saturation, blood glucose level .c. Pain- location, type, intensity, duration, causative factors .o. Bleeding .Active bleeding from any location .3. Notify resident's physician- Use INTERACT Change in Condition: When to report to the MD (Medical Doctor)/ NP (Nurse Practitioner)/ PA (Physician's Assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden in onset, and: ii. A marked change (i.e., more severe) in relation to unusual symptoms and signs .If no response from provider and condition warrants, call the center medical director. If no response from the center medical director, contact the DON (Director of Nursing) for further guidance .
R13 was admitted to the facility on [DATE] with diagnoses that include Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and chronic kidney disease, stage 3.
R13's most recent Minimum Data Set (MDS) dated [DATE] states that R13 has a Brief Interview of Mental Status (BIMS) of 15/15 indicating that R13 is cognitively intact; it also states that R13 currently requires extensive 2 assist for toileting and transfers. The MDS dated [DATE] states the R13 requires supervision and set up assistance for toileting and transfers.
Nurse's notes state the following:
12/18/22 1:37 AM: Resident called nurse to bathroom resident has slight blood-tinged urine. No c/o (complaints of) pain. Stated small urge to go to the bathroom even though just urinating. Resident vss (vital signs stable). This nurse called on call, awaiting phone call back in regards .
12/18/22 5:40 AM: this nurse has not received call back from dr (doctor). Pt (patient) is aware and stable, with no c/o at this time. Urine remains the same. VSS. Will pass along to AM (morning) nurse.
12/20/22 12:43 PM: Resident c/o blood in urine. I encouraged her to call staff so we could visualize it to report to physician. Urine was obtained and appears cloudy. No hematuria at this time. Resident reports frequency and burning with urination. Vitals obtained and remain WNL (Within normal limits).
12/21/22 5:12 PM: Resident starting ABT (antibiotic) for UTI. Culture with 50,000-100, 000 CFU (colony forming unit)/ml(milliliter) of E. Coli (Escherichia coli (bacteria)). Due to symptoms MD ok to start ABT for 5 days. Updated resident. Updated MAR (Medication Administration Record).
It is important to note that facility staff did not attempt to contact R13's physician or the on-call physician after the initial attempt on 12/18/22.
On 12/20/23, R13 was visited by her physician. The physician notes states in part, .presents with dysuria (painful or difficult urination), urgency, and frequency for a few days .having gross hematuria with clots .Patient does not have a history of UTI.
On 12/21/22 at 3:02 PM, the facility received an order to start nitrofurantoin 100mg for 5 days for UTI. This order was noted by DON B (Director of Nursing).
Surveyor reviewed R13's December 2022 MAR and found that the antibiotic was scheduled to start on 12/22/22.
Surveyor reviewed the facility's contingency medication list and it indicated that R13's antibiotic is available in the box. DON B provided Surveyor with documentation that inticated that facility nurses used the contingency antibiotic for 2 doses on 12/22/23.
On 4/25/23 at 9:49 AM, Surveyor interviewed DON B. Surveyor asked DON B what the process is for when a resident reports signs and symptoms (s/sx) of a UTI, DON B stated that the nurse should do an assessment, notify the MD, and follow McGeer's Criteria. Surveyor asked DON B if she would expect staff to document what they did, DON B stated yes. Surveyor asked DON B if she would expect staff to follow up with the physician prior to his visit on 12/20/22 when R13's initial report of symptoms was on 12/18/22, DON B stated that she was not sure if she was even aware and would get back to Surveyor with the answer. Surveyor asked DON B if not following up with the physician would be considered a delay in treatment, DON B stated that R13 was barely symptomatic and that she didn't have a fever. Surveyor asked DON B why R13's antibiotic was not scheduled until the day after the order was received, DON B stated that she didn't know why it wouldn't have been started and that they may not have had any in contingency. Surveyor asked DON B if she would expect the nurses to document if a medication was unavailable, DON B stated yes. Surveyor asked DON B why R13 was not given the last dose of her antibiotic, DON B stated that she would look into it.
It is important to note that Surveyor was not supplied additional documentation or rationale as to why the physician was not notified, why the medication was not scheduled to start on 12/21/22, or why R13's Physician was not updated on R13 not receiving her last dose of antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a resident with dignity and respect for 1 of 2 Residents (R5) reviewed for dignity out of a total of 16 residents sampled.
R5 required staff assistance to meet her needs in toileting and her commode was left in her room with feces on and in the commode. R5 stated she was embarrassed when Surveyors conducted an interview.
The findings included:
Facility's policy, entitled Resident Rights, includes, in part: Residents do not leave their individual personalities or basic human rights behind when they move to a long term care facility. Residents will be treated with respect and dignity. Care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality .
R5 was admitted to the facility on [DATE] with diagnoses including: chronic respiratory failure with hypoxia, morbid obesity, unsteady on feet, abnormal gait and mobility, muscle weakness, neuromuscular dysfunction of bladder, acute kidney failure, anxiety, and demyelinating disease (condition that results in damage to the protective covering (myelin sheath) that surrounds nerve fibers) of the central nervous system.
R5's Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 4/2/23, indicates R5 is cognitively intact with a Brief Interview For Mental Status (BIMS) score of 15 out of 15. R5's MDS also indicates she requires extensive physical assistance of 2 or more staff to meet her needs in the following areas: bed mobility, transfer, toileting, dressing, and personal hygiene.
R5's Care Plan, initiated on 1/12/23, includes:
bed mobility: 2 assist with four wheeled walker
toileting: 2 assist
transfer: 2 assist stand pivot with gait belt, walker, and dycem under feet
On 4/23/23 at 11:21 AM Surveyor knocked on R5's door. R5 invited Surveyor into her room. Surveyor observed R5's commode to be in the middle of her room with a large amount of feces on the seat and hanging on the edge of the commode bucket. R5 indicated she was a Certified Nursing Assistant (CNA) for years and she had high expectations of the care she is in need of. R5 indicated she was sorry for the dirty commode left in her room and she was embarrassed by the mess.
On 4/23/23 at 11:30 AM RN C (Registered Nurse) entered R5's room. R5 indicated again she was embarrassed by the unclean commode in the center of her room while all of this company is here. Surveyor asked RN C if the commode could be cleaned up. During an interview RN C indicated R5 needs assistance by 1 to 2 staff members to meet her toileting needs and those staff are to clean up after the task is completed and didn't. RN C indicated she would flag down another staff member to clean the commode.
On 4/25/23 at 2:30 PM during an interview R5 apologized for the messy commode in her room again indicating she should have tried to hide it before letting Surveyor and other guests in her room. R5 stated, I am embarrassed. R5 and Surveyor reviewed R5's care plan together, focusing on the care level required to meet R5's needs at this moment. R5 voiced understanding that 2 staff are to assist to meet her needs in toileting and the task includes clean up.
On 4/25/23 at 2:38 PM during an interview, DON B indicated staff are to clean R5's commode after each use and it will be stored in the corner of her room covered when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain grooming or personal hygiene for 1 of 3 residents (R3) that were reviewed for ADLs, out of a total sampled of 16.
R3 did not have fingernail care completed and nails were noted to be long and sharp; food particles were observed on R3's face and R3's face was not shaved.
This is evidenced by:
The facility policy, entitled Activities of Daily Living (ADLs), dated 7/26/22, states in part: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . Policy Explanation and Compliance Guidelines: . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
R3 is a long-term resident of the facility with admission date of 3/29/19. R3 has the following diagnosis: Multiple Sclerosis (a disease that damages the nerve cells in the brain and spinal cord), Contracture of muscle multiple sites (a condition that shortens and hardens the muscles, tendons or other tissue often leading to deformity and rigidity of the joints), Dysphagia (difficulty swallowing), Functional Quadriplegia (the complete inability to move due to severe disability), and Major Depressive Disorder.
R3's most recent Minimum Data Set (MDS) dated [DATE], documents that he is moderately impaired cognitively and R3 requires total dependence for personal hygiene.
R3's Care Plan dated 6/18/20, I have an ADL self-care deficit r/t (related to) physical limitations d/t (due to) Dx (diagnosis) of MS (Multiple Sclerosis), documents in part: I will be clean, dressed, and well groomed daily to promote dignity and psychosocial wellbeing through the review date. ADL preference: Resident is particular about who he will allow to provide his ADLs . Bathing/Showering: Assist of 1 to 2. Resident prefers showers or bed baths, Personal Hygiene: Assist of 1. Note: Bathing/Showering and Personal Hygiene was initiated on 4/23/23 in the care plan.
The facilities shower schedule indicates R3 is scheduled for weekly showers on Sunday morning. Surveyor reviewed the personal hygiene documentation that indicated there are no refusals of care in the last 30 days.
On 4/23/23 at 10:20 AM, Surveyor observed R3 returning from his Sunday morning shower in his room, with white and brown substances around his mouth, unshaven, and with long, sharp fingernails.
On 4/24/23 at 10:36 AM, Surveyor observed R3 with yellow and brown substances around his mouth to his chin, unshaved and nails long and appeared sharp.
On 4/25/23 at 10:44 AM, Surveyor interviewed CNA F (Certified Nursing Assistant). Surveyor asked CNA F when nail care is done and CNA F indicated on his shower day. Surveyor asked CNA F if R3's hand is moist and if the nails are digging into his skin. CNA F indicated to the Surveyor that the left hand is moist and one of the nails is digging into R3's skin. CNA F asked R3 if he wanted his nails cut, R3 stated you bet. Surveyor asked CNA F to describe the substance on R3's face, CNA F indicated it was food from breakfast and his face should be wiped. CNA F asked R3 if she could wipe his face, R3 indicated yes.
On 4/25/23 at 10:59AM, Surveyor interviewed CNA G in R3's room together. Surveyor asked CNA G to describe what is on R3's face. CNA G indicated it was probably food particles from this morning's feeding and indicated it should be wiped. Surveyor asked CNA G to describe his nails, CNA G indicated R3's nails are sharp, and they should be cut. Surveyor asked CNA G how often nail care is done, she indicated the nails get checked twice per week. Surveyor asked CNA G if R3 should be shaved, CNA G indicated to the Surveyor that R3 will resist cares and then we inform the DON (Director of Nursing).
On 4/25/23 at 2:54 PM, Surveyor interviewed LPN H (Licensed Pracitcal Nurse). Surveyor asked LPN H to describe the procedure for showers for R3. LPN H indicated the CNAs wash the resident's hair, face, do a head-to-toe wash, clean nails if R3 allows, a shower sheet is filled out and the CNAs inform us if R3 refuses. Surveyor asked LPN H to describe the process if R3 refuses, LPN H indicated the CNAs try more than once to approach, explain to R3 the reasoning and then a shower sheet is filled out whether the cares are completed or not. Surveyor asked LPN H if R3 has concerns with shaving, LPN H indicated she has not heard complaints regarding shaving. Surveyor asked LPN H if R3 has had any change in his ADLs and indicated that R3 has had no changes and is stable.
On 4/25/23 at 2:56 PM, Surveyor interviewed DON B (Director of Nursing) regarding ADL cares. DON B indicated to the Surveyor that a resident's mouth should be wiped after meals and as needed, nails should be trimmed to avoid scratches and pressure to the skin, and residents should be shaved by their preference. Surveyor asked DON B to explain the cares performed. DON B indicated hair washing, cleaning the body, check skin, shave and nails are cut after the shower. Surveyor discussed observations of R3 of food particles around the mouth, unshaved, and long sharp nails. DON B indicated R3 should receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 33 residents residing in the facility.
Surveyor observed dust collecting on piping above food preparation area in the facility's stove hood unit.
Surveyor observed a dust covered fan within 6 inches of food preparation area while food was being prepared.
Surveyor observed a dust covered radio and desk top file folder holder above open prepared food.
This is evidenced by:
The facility policy, entitled Nutrition Services Practice Manual dated July 2015, states: .Promote a clean and sanitary environment for its employees, residents, and visitors. The entire nutrition services team maintains clean and sanitary kitchen centers and equipment. Walls, floors, ceilings, equipment, and utensils are clean, sanitized, and in good working order .Procedure 1. Complete the nutrition services cleaning schedule (copy form) to ensure equipment and kitchen cleanliness .
(It is important to note the Facility Dining services daily opening checklist, Dining services daily closing checklist, and Daily cleaning log failed to include the cleaning of fan and items stored on the kitchen shelfing, above the food preparation area, including the radio and desktop file folder to the facility's nutrition services cleaning schedules.)
Example 1
Stove Hood
On 4/23/23 at 10:16 AM Surveyor observed dust collecting on loose plumber's tape at the joints of the pipes located in the facility's stove hood unit directly above where food was being prepared and behind the stove unit. Surveyor also observed dust on shelving connected to the stove, electrical cords hanging above the food prep table.
On 4/23/23 at 10:16 AM during an interview, DM D (Dietary Manager) indicated there is dust that has attached itself to the plumber's tape that was used to seal the joints and there is potential for the dust to fall into food being prepared on the stove. DM D also indicated the dust behind the stove unit and on the hanging electrical cords could dislodge and contaminate the food being prepared under them.
Example 2
Fan
On 4/23/23 at 10:16 AM Surveyor observed an oscillating pedestal fan placed within 6 inches of the stove. Dust was visible on the plastic covering of the engine, the cage, and fan blades. Surveyor also observed food particles speckled throughout the unit.
On 4/25/23 at 4:13 PM DM D (Dietary Manager) indicated the fan has dust and food particles on it. DM D also indicated the facility does not have a schedule for cleaning the fan and they should.
Example 3
Radio/File Folder Holder
On 4/25/23 at 10:15 AM Surveyor observed an uncovered cake cooling on a food prep work surface below a grated wire shelfing with openings. On the shelf was a radio with visible dust on the topside and a desktop file folder holder with visible dust on the base.
On 4/25/23 at 10:29 AM Surveyor interviewed [NAME] E who indicated there is a potential for the dust to fall off the radio and onto the food below.
On 4/25/23 at 04:13 PM Surveyor interviewed DM D who indicated that there is potential for the dust to fall on food being prepared on the surface below the radio and file folder holder.