Middle River Health And Rehabilitation Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide evidence that all alleged violations are thoroughly investigated for an injury of unknown cause.-Facility did not conduct interviews for other staff and residents.-Facility did not complete education in relation to the incident-Facility did not ensure a Registered Nurse (RN) completed an assessment after a Licensed Practical Nurse (LPN) completed the initial assessment.-Facility did not investigate further after becoming aware of fracture.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15 which indicates severe cognitive impairment.R1's care plan in part includes a focus of self-care deficit related to polyneuropathy, frequent falls, failure to thrive, weakness, and decreased mobility with interventions of high fall risk last revised on 11/22/25. Prior to the incident R1's care plan stated R1 required assist of 1 with the stand aid for transfers and assist of 2 with stand aid for toileting.Surveyor reviewed staff interviews:CNA C stated CNA C was finishing last rounds and went into R1's room and noticed R1 needed to be changed. CNA C got R1 in the stand aid and stated R1 couldn't stand any longer and R1's feet slipped off the stand aid platform. CNA C reported trying to help R1 get R1's feet back on the stand aid platform but was unsuccessful so CNA C eased R1 to the floor. CNA C stated CNA D then came in to help CNA C.CNA D stated CNA D was on the way to change R2 when CNA D noticed R1's room door was shut and stopped to open it. CNA D observed R1 on the floor and CNA C present in the room. CNA D stated CNA C was trying to move R1 before LPN E could assess R1. CNA C stated CNA C stated not to get LPN E because R1 did not fall and did not need blood pressure checked. CNA D went and notified LPN E of the fall.LPN E stated LPN E was notified to go to R1's room. Upon entry to R1's room, LPN E observed R1 sitting upright on the floor. LPN E stated R1 showed no signs of distress and had no complaints of pain. Certified Nursing Assistant (CNA) C reported to LPN E that R1 had been standing on the stand aid when R1's legs/knees became week causing R1 to go down onto R1's knees. CNA C reported CNA C could not hold R1 up and lowered R1 to the floor in a controlled manner. CNA C reported CNA C was in the process of pulling down R1's pants to change R1's brief at the time of the incident. After R1 had been assisted via Hoyer lift and 3 staff, LPN E completed an assessment of R1. LPN E stated R1 did not complain of pain and vitals were stable. DON B was notified, and a voicemail was left for POA.On 02/03/26 at 11:15 AM, Surveyor interviewed R1. R1 is not a good historian. R1 reported falling and breaking her foot but was unable to recall the events or staff present at the time of the incident.On 02/03/26 at 11:41 AM, Surveyor interviewed CNA C. CNA C stated each resident has a care plan which CNAs can access on their charting program in the computer and there is also a book at the desk they can review if unsure about care. CNA C stated they get verbal report when changes are made as well.On 02/03/26 at 11:48 AM, Surveyor observed CNA C talking with R1. CNA C stated, You remembered to tell her how you were glad I was there to help you, right? Because I would never let you fall. R1 replied, I just told her I jumped off the bed.On 02/03/26 at 11:50 AM, Surveyor interviewed RN H. RN H stated care plans are updated by nurses or Director of Nursing (DON) as changes occur. RN H showed Surveyor the binder at the nurse's station that includes all resident care plans. RN H stated all CNAs have access to this if they are unsure and also get verbal report of changes to resident care.On 02/03/26, Surveyor reviewed stand aid competency checklist for CNA C which indicates CNA C has demonstrated use of the stand aid and could use it correctly and was dated 01/12/26.On 02/03/26 at 1:23 PM, Surveyor observed CNA C and CNA G transfer R2 with the stand aid. No concerns.On 02/03/26 at 1:30 PM, Surveyor interviewed CNA G. CNA G stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA G would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 1:32 PM, Surveyor interviewed CNA C. CNA C stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA C would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 2:51 PM, Surveyor interviewed Rehab Director (RD) J. RD J stated the stand aid is only to be used as a way to transfer a resident and should not be used to stand a resident that requires changing of incontinent products.On 02/03/26 at 3:45 PM, Surveyor interviewed CNA D. CNA D stated CNA D walked into R1's room on 01/18/26 because the door was closed and R1 is a fall risk. CNA D stated R1 was on the floor and CNA C was present. CNA D stated CNA C told CNA D not to get a nurse and R1 did not need a blood pressure check. CNA D stated CNA D went and got LPN E because CNA C was trying to move R1 prior to being assessed by a nurse. CNA D reported not being sure if CNA C would have reported the incident if CNA D had not entered the room. CNA C did not call for assistance. CNA D stated if a resident's care plan stated 1 assist for transfer and 2 assist for toileting, CNA D would not change a resident's incontinence brief alone, as that is considered toileting.LPN E was unavailable for interview.On 02/03/26 at 3:49 PM, Surveyor interviewed DON B. DON B stated DON B's expectations include nurses reporting incidents to management immediately. DON B stated RNs are sometimes hard to come by but DON B would expect an LPN to have an RN assess the resident as soon as possible after the LPN completed their initial assessment. DON B stated DON B is working with staff in knowing their roles and scopes of practice. DON B stated DON B was informed of this incident on 01/18/26 at 5:30 PM that day. DON B acknowledged that CNA C did not follow R1's care plan and further investigating should have been completed. DON B stated no education related to the incident had been completed at this time but DON B was in the process of putting together education for nurses and planned to have a meeting for CNAs this week. DON B acknowledged other potentially affected residents and other staff should have been interviewed after the incident. DON B stated the reporting and investigation process in long term care is new to DON B and acknowledged the need to improve.On 02/03/26 at 4:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A with Nursing Consultant (NC) I present. NHA A stated the initial report was submitted on 01/20/26 as that was the day the facility was aware of an injury. NHA A stated the facility did not investigate the incident as an abuse allegation as NHA A believed CNA C had followed the care plan. NHA A acknowledged CNA C had followed the care plan for transfers, but not for toileting. NHA A acknowledged from the information in the interview with CNA D, further investigation should have been completed regarding the incident. NHA A acknowledge further interviews and education should also have been completed. NHA A was made aware of conversation between CNA C and R1 on day of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received person-centered care according to the comprehensive care plan.-A facility staff member did not follow R1's care plan for toileting resulting in a fall.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15 which indicates severe cognitive impairment.Care plan includes in part; Transfers: stand aid assist of 1. Toileting: 2 assist before morning cares, at bedtime, and every 2-3 hours while awake and upon request.On 01/18/26 at 1:45 PM, Certified Nursing Assistant (CNA) C entered R1's room for incontinence care. CNA C assisted R1 to a standing position in the stand aid with no other staff. While R1 was standing in the stand aid, CNA C attempted to pull down R1's pants to change incontinent brief. R1 stated R1 could no longer stand and R1's feet slipped off the stand aid platform. CNA C stated CNA C attempted to assist R1 put R1's feet back on the platform, but was unable to, and had to lower R1 to the floor.On 02/03/26 at 11:15 AM, Surveyor interviewed R1. R1 is not a good historian. R1 reported falling and breaking her foot but was unable to recall the events or staff present at the time of the incident.On 02/03/26 at 11:41 AM, Surveyor interviewed CNA C. CNA C stated each resident has a care plan which CNAs can access on their charting program in the computer and there is also a book at the desk they can review if unsure about care. CNA C stated they get verbal report when changes are made as well.On 02/03/26 at 11:50 AM, Surveyor interviewed Registered Nurse (RN) H. RN H stated care plans are updated by nurses or Director of Nursing (DON) as changes occur. RN H showed Surveyor the binder at the nurse's station that includes all resident care plans. RN H stated all CNAs have access to this if they are unsure and also get verbal report of changes to resident care.On 02/03/26, Surveyor reviewed stand aid competency checklist for CNA C which indicates CNA C has demonstrated use of the stand aid and could use it correctly.On 02/03/26 at 1:23 PM, Surveyor observed CNA C and CNA G transfer R2 with the stand aid. No concerns.On 02/03/26 at 1:30 PM, Surveyor interviewed CNA G. CNA G stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA G would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 1:32 PM, Surveyor interviewed CNA C. CNA C stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA C would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 2:51 PM, Surveyor interviewed Rehab Director (RD) J. RD J stated the stand aid is only to be used as a way to transfer a resident and should not be used to stand a resident that requires changing of incontinent products.On 02/03/26 at 4:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated it would be NHA A's expectation staff would follow the resident's plan of care and acknowledged CNA C should have had assistance with incontinent care for R1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure 1 of 4 residents reviewed (R1) received adequate supervision and assistance devices to prevent accidents.Certified Nursing Assistant (CNA) C did not use stand aid correctly causing a fall resulting in R1 sustaining a fracture.Findings include:R1 was admitted to the facility on [DATE].On 09/30/25, R1 had a Brief Interview for Mentals Status (BIMS) score of 6/15, which indicates severe cognitive impairment.Care plan includes in part: a focus of self-care deficit related to polyneuropathy, frequent falls, failure to thrive, weakness, and decreased mobility with interventions of high fall risk last revised on 11/22/25. Transfers: stand aid assist of 1. Toileting: 2 assist before morning cares, at bedtime, and every 2-3 hours while awake and upon request.On 01/18/26 at 1:45 PM, CNA C entered R1's room for incontinence care. CNA C assisted R1 to a standing position in the stand aid with no other staff assistance. While R1 was standing in the stand aid, CNA C attempted to pull down R1's pants to change incontinent brief. R1 stated R1 could no longer stand and R1's feet slipped off the stand aid platform. CNA C stated CNA C attempted to assist R1 by placing R1's feet back on the platform, but was unable to, and CNA C had to lower R1 to the floor. CNA D was walking past room and noticed the door was shut and opened it. CNA D called Licensed Practical Nurse (LPN) E to the room. LPN E assessed R1. CNA C, CNA D, and LPN E assisted R1 back to bed with the use of the Hoyer lift.On 01/18/26 at 7:30 PM, R1 reported pain in the right ankle/foot. Registered Nurse (RN) F assessed R1. Provider ordered x-rays.On 01/20/26, R1 was sent to the emergency room (ER) for x-rays and assessment. R1 was found to have an acute comminuted, minimally displaced, extra-articular fracture of the right posterior calcaneal tuberosity.On 01/20/26, R1 returned to the facility from the hospital. R1 previously was a 1 person assist with the stand aid and 2 assist with stand aid for toileting before the fall, and since return from the hospital, diagnosis of right posterior calcaneal tuberosity fracture, is now non-weight bearing on the right foot and requires the use of a Hoyer lift for all transfers with assist of 2 staff. R1 wears a prevalon protective boot when in bed, and a CAM boot when up out of bed.On 02/03/26 at 11:15 AM, Surveyor interviewed R1. R1 is not a good historian. R1 reported falling and breaking R1's foot but was unable to recall the events or staff present at the time of the incident.On 02/03/26, Surveyor reviewed the stand aid competency checklist for CNA C, which indicates CNA C has demonstrated use of the stand aid and could use it correctly dated 01/12/26.On 02/03/26 at 1:23 PM, Surveyor observed CNA C and CNA G transfer R2 with the stand aid. No concerns.On 02/03/26 at 1:30 PM, Surveyor interviewed CNA G about lift use and toileting. CNA G stated if a resident's care plan stated they were an assist of 1 for transfers, but an assist of 2 with toileting, CNA G would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 1:32 PM, Surveyor interviewed CNA C. CNA C stated if a resident's care plan stated they were assist of 1 for transfers, but assist of 2 with toileting, CNA C would not use the stand aid alone to change an incontinent resident.On 02/03/26 at 2:51 PM, Surveyor interviewed Rehab Director (RD) J. RD J stated the stand aid is only to be used as a way to transfer a resident and should not be used to stand a resident who requires changing their incontinent products.On 02/03/26 at 4:27 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated it would be NHA A's expectation that the staff would follow the resident's plan of care and acknowledged CNA C should have had assistance with incontinence care for R1.The facility did not provide education for the staff. Facility did not interview any other residents. R1's care was delayed because an RN did not assess R1 after the LPN assessed R1. An RN, RN F, did not assess R1 for 6 hours after the fall had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicate and Medicaid [NAME] (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system. This has the potential to affect all 45 residents residing in the facility.Findings:Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows:Fiscal Quarter, Date range: October 1 - December 31 (quarter 1), January 1 - March 31 (quarter 2), April 1 - June 30 (quarter 3), July 1 - September 30 (quarter 4).PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal Year Quarter 2 2025 (January 1- March 31) indicate the following: Excessively low weekend staffing and 8 hour registered nurse coverage on the date specified 02/23/2025.On 08/12/2025 at 8:46 AM, Surveyor asked Director of Nursing (DON) B to explain the report provided for only 7.45 hours of RN coverage and low weekend staffing noted on 02/23/2025. DON B replied, The issue that we found was that our system works on 30-minute intervals and if the nurse would not provide that she worked her lunch she would only get credit for 7.45 hours worked and that would trigger this even though she worked the full 8 hours. The program automatically removes a lunch break for the staff.On 08/13/2025 at 10:00 AM, DON B informed Surveyor the nursing staff shifts will now overlap. So instead of 6:00 to 2:00 the shifts now run from 6:00 to 2:30 to make sure this does not happen again.

Based on observation, staff interview and record review, the facility did not ensure drugs and biologicals were stored under proper temperature controls. This practice had the potential to affect 5 of 5 residents.Staff were not monitoring the refrigerator temperatures for both first and third floor medication rooms.Findings:Form titled Temperature Log for Refrigerator- Fahrenheit stated in part: Monitor temperatures closely1. Write your initials below in Staff initials: and note the time in exact time.2. If using a temperature monitoring device that records min/max temps document current and min/max once each workday, preferably in the morning. If using a temperature monitoring device that does not record min/max temps, document current temps twice, at beginning and end of each workday. On 08/11/2025 at 2:13 PM, Surveyor noted the refrigerator temperatures were missing on the first-floor refrigerator temperature log. Dates in July missing temperatures were: 17, 18, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, 31. The August log has no entries. R15 had a FlexTouch 100-unit insulin pen and R8 had Latanoprost 0.05% eye drops in this refrigerator. Surveyor asked Registered Nurse (RN) D, Who is supposed to monitor and document the temperatures for the refrigerators in the medication room? RN D replied, That is the nursing staff's job for both the AM and PM shifts.On 08/11/2025 at 2:28 PM, Surveyor noted the refrigerator temperatures were missing on the third-floor refrigerator temperature log. Dates in July missing temperature documentation were: 1-8, 11-14, 17-31. August missing temperature dates: 1-6, 10 and 11. R33 had a Shingrix vaccine, R42 had Lantus 100 units insulin and R41 had Latanoprost 0.05% eye drops in this refrigerator.On 08/12/2025 at 8:51 AM, Surveyor interviewed Director of Nursing (DON) B regarding observations of temperature log being incomplete on the first and third floor medication rooms. Surveyor asked DON B, Who is responsible to monitor and document the refrigerator temperatures in the medication rooms? DON B replied, It is the nursing staff's responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (R27) reviewed. The facility failed to follow up on recommendation for urology consult due to history of frequent UTIs. This is evidenced by:R27 was admitted to the facility on [DATE] and has diagnoses of acute renal failure, morbid obesity, type II diabetes and urinary tract infections.R27's Minimum Data Set (MDS) assessment, dated 06/26/25, indicated that R27 is frequently incontinent and has no urinary toileting program. R27 has a BIMS score of 15/15, meaning cognitively intact.R27's care plan, dated 06/05/25, states that R27 has functional bladder incontinence related to activity intolerance. The identified Intervention/Tasks states in part. R27 prefers a bedpan while in bed. monitor/document/report PRN any possible causes of incontinence: bladder infection. loss of bladder tone, decreased bladder capacity, diabetes.R27's nurses notes, dated 06/09/25 at 5:13 PM, stated R27 had complaint of urinary frequency and pain with urination and R27 stated she gets UTIs all the time. R27's nurses notes, dated 06/11/25 at 8:42 AM, stated in part, Received orders from provider.Consider urology referral due to repeat UTI.R27's physician orders notes, dated 08/11/25 at 8:00 PM, indicated physician orders for oral antibiotic for recurrent UTI.On 08/12/25 at 1:17 PM, Surveyor interviewed R27 asking if a urology referral was offered. R27 stated no urology referral was offered nor was there a urology consult conducted at any time during stay at facility.On 08/12/25 at 2:28 PM, Surveyor interviewed Director of Nursing (DON) B and asked if a urology referral was provided for R27. DON B stated R27 was seen by a covering provider on 06/11/25 as R27's preferred provider was out of office. DON B stated there was no referral placed by preferred provider's office, yet provider was aware of urology suggestion. DON stated no follow up by facility staff was done to inquire about urology consult in consideration of repeat UTI since 06/11/25.

Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (R42 and R11) reviewed. R42's record review noted an unwitnessed fall when staff did not implement interventions of a fall mat per plan of care resulting in an emergency room (ER) visit. R42 was observed being transferred with a mechanical lift with an assist of 1 staff member. R42 requires assistance of 2 per plan of care. R11 had a fall where staff did not follow the facility protocols to do a complete assessment post fall.
This is evidenced by:
The facility policy titled Falls and Fall Risk, managing, states: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under section titled Prioritizing approaches to managing falls and fall risk, states in part, .6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling.
Example 1
R42 was admitted to facility on 11/08/21 with diagnoses that include Alzheimer's disease.
R42's Minimum Data Set (MDS) quarterly assessment, dated 07/12/25, indicated that R42 is dependent on staff for transfers.
R42's Activities of Daily Living Care Plan, initiated on 11/08/21, with a target date of 08/11/25, indicates interventions of
Transfers - Sit to stand with two-assist. Dated 08/29/24.
Mat onto bed while in bed for safety. Dated 01/21/23.
Record review indicated that R42 had an unwitnessed fall on 10/13/24, wherein R42 fell from bed onto floor hitting head, no visible injuries; however, R4 complained of neck pain and was sent to ER for evaluation (of note, no negative outcome noted).
Nursing assessment at time of fall indicated R42 did not have a floor mat or bed in lowest position per plan of care. This intervention was listed on the care plan and not in place at the time of the fall.
On 08/12/2025 at 1:50 PM, Surveyor observed Certified Nursing Assistant (CNA) E, transfer R42 from wheelchair to and from toilet with a sit to stand lift with assist of another staff member.
On 08/13/2025 at 9:52 AM, Surveyor interviewed CNA E regarding how R42 should be transferred. CNA E stated R42 is transferred with a sit to stand lift. Surveyor asked how many staff members are required. CNA E stated she believed R42 was a 1 person assist, unless it changed. Surveyor asked CNA E how staff are aware of care plan approaches, and CNA E stated it is in the computer. CNA E showed Surveyor computer which stated R42 requirement of 2-person assist with transfers and sit to stand lift since 08/09/24. CNA E stated the expectation would be to follow the plan of care.
On 08/13/2025 at 1:35 PM, Surveyor shared above observation with DON B, observation of CNA E and concerns regarding R42's fall on 10/13/24, wherein fall mat was not in place per plan of care. DON B stated the expectation would be to follow the plan of care to prevent falls.
Example 2
R11 was admitted to facility on 12/27/20.
On 08/12/25 at 7:25 AM, record review indicates R11 sustained a fall forward out of wheelchair onto the floor while reaching down to pick up a dropped object on 08/11/25 at 4:23 PM. R11 had blunt trauma to right side of forehead and was sent to the Emergency Department (ED) via ambulance for further evaluation. There is no further documentation in R11's medical record following return to facility from the ED for post fall assessments or physician orders.
On 08/12/25 at 8:00 AM, R11 was observed by Surveyor to be in room sitting in wheelchair with large hematoma to right forehead region with one steri-strip in place.
On 8/12/25 at 7:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H on what follow up assessments staff is doing for R11's post fall with head trauma. LPN H stated there is paper documentation for neuro checks and R11's Eliquis (anticoagulant) is to be held for 24 hours. Surveyor asked LPN H how these orders are communicated to staff when no documentation is in the chart. LPN H stated the night nurse gave verbal report.
On 08/13/25 at 1:15 PM, Surveyor interviewed DON B what the expectations of staff are for assessing residents post fall per the facility fall protocols. DON B stated there are standing orders post falls including notifying MD immediately, neuro checks, and documenting assessments and/or physician orders in medical record. DON B was aware there is no documentation in chart following R11's return from the ED on 08/11/25. DON B stated, We have a traveling nurse working that shift and have had problems with her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure each resident (R), or their representative had the right to participate in the care planning process for 7 of 13 residents (R3, R5, R25, R42, R1, R4, R11) reviewed for care conferences.
This is evidenced by:
Facility policy titled Resident Care Conference, revised 5/25, states in part: Policy: To have a multi-disciplinary approach to evaluate and make assessments of a resident's needs and goals and to implement the assessment into a resident's total plan of care.Procedure. All residents shall have a care conference every quarter or more if necessary. a reminder will be sent to the resident and/or their responsible party when the care conference is scheduled. Each department gives a brief report of how the resident is doing. The resident and/or their responsible party is welcome to ask questions or for clarification on anything discussed during the care conference. The staff attending the care conference will evaluate the effectiveness of the care plan and make any necessary changes to the document.
The facility policy titled, Care Plans- Comprehensive, reviewed 5/2025, states in part:.10. The resident has the right to refuse to refuse to participate in the development of his/her care plan and medical and nursing treatments. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies.
Example 1
R3 was admitted on [DATE] with diagnoses that include cerebral infarction, aphasia, type II diabetes mellitus, expressive language disorder, epilepsy, vascular dementia, anxiety disorder, and metabolic encephalopathy. R3's most recent Minimum Data Set (MDS) of 7/26/25 indicated impairment on one side, uses walker and a wheelchair, is independent in repositioning ambulation and transfers. R3 scored a 10/15 on a Brief Interview for Mental Status (BIMS), which indicates moderate impaired cognition.
On 8/11/25 at 12:04 PM, Surveyor interviewed R3, who indicated she has not had any care plan meetings to discuss her care goals, needs, or accommodations. R3 reports no one in the facility asked if she wanted to attend a meeting to discuss her goals for her future.
R3's medical record showed her last a care conference meeting was on 1/30/24 with no subsequent meetings. R3's care plan was reviewed and updated on 8/9/2024, 11/11/2024, 2/11/2025, 5/9/2025, and 8/8/2025. A multidisciplinary care conference note from 8/14/25 indicated dietary was the only team member included on the note.
Surveyor noted various documentation and reports from dietary, nursing, therapies, and activity staff but no evidence of a multidiscipline care conference or evidence that resident or her representatives were invited to and/or refused to participate in a care conference over the past year.
On 8/12/25, Surveyor requested documentation from Assistant Director of Nursing (ADON) C to support R3 has had quarterly care conference meetings or evidence to show resident and/or resident's representative was invited to and/or refused to be included on quarterly care conferences.
Example 2
R5 was admitted to facility on 01/30/25.
The facility completed an admission MDS dated [DATE] with a care conference held with IDT on 02/12/25. R5 and/or representative was not in attendance and facility was unable to support if R5 was invited or declined invitation
The facility completed a quarterly MDS on 05/03/25 with a care conference held with IDT on 04/08/25 prior to completion of the MDS. R5 was not in attendance and facility was unable to provide evidence if R5 and/or representative was invited or declined invitation.
The facility completed a significant change MDS on 06/01/25 with no care conference held with the Interdisciplinary Team (IDT) until 07/01/25. R5 was not in attendance and facility was unable to show evidence if R5 and/or the representative was invited or declined invitation.
Example 3
R25 was admitted to facility 8/30/23.
The facility completed a quarterly MDS dated [DATE]. No documentation to support a care conference was held with IDT, wherein R25 was in attendance and/or facility was unable to support if R25 and/or representative was invited or declined invitation
The facility completed a quarterly MDS dated [DATE]. No documentation to support a care conference was held with IDT, wherein R25 was in attendance and/or facility was unable to support if R25 and/or representative was invited or declined invitation.
Example 4
R42 was admitted to facility on 11/08/21.
R42 had 5 MDS's completed since last survey (Quarterly MDS dated [DATE], Quarterly MDS dated [DATE], Annual MDS dated [DATE], Quarterly MDS dated [DATE], Quarterly MDS dated [DATE]) with no documentation to support a care conference was held with IDT and/or R42 and/or representative was invited or declined invitation.
Example 5
R1 was admitted to facility on 12/27/20.
The facility completed a quarterly MDS assessment on 07/08/25 with no care conference held by Interdisciplinary Team (IDT).
The facility completed a comprehensive MDS assessment on 03/01/25 with a care conference not held with IDT until 05/30/25. R1 and/or representative were not in attendance and no supporting documentation if R1 and/or representative were invited or declined invitation.
The facility completed a quarterly MDS assessment on 12/16/24 with no facility documentation of care conference held by IDT.
The facility completed a quarterly MDS assessment on 09/13/24 with no facility documentation of care conference held by IDT.
The facility completed a quarterly MDS assessment on 06/21/24 with no care conference held by IDT. Last documented care conference held by IDT was 09/05/23 with no supporting evidence R1 was in attendance. Facility has documentation that R1's representative was connected via phone for conference.
Example 6
R4 was admitted to facility on 07/22/20
The facility completed a Quarterly MDS Assessment on 06/02/25. A care conference with IDT was held on 05/12/25 with no supporting documentation that R4 and/or representative were in attendance, invited, or declined invitation to attend conference.
The facility completed a quarterly MDS assessment on 02/25/25 with no facility documentation of care conference held by IDT.
The facility completed a quarterly MDS assessment on 12/16/24 with no facility documentation of care conference held by IDT.
The facility completed a Comprehensive MDS Assessment on 09/05/24 with no facility documentation of care conference held by IDT.
The facility completed a quarterly MDS assessment on 06/09/24. A care conference was held by IDT on 06/05/25 with R4's representative in attendance via phone. No supporting documentation if R4 was in attendance, invited, or declined invitation.
Example 7
R11 was admitted on [DATE].
Th facility completed a quarterly MDS assessment on 07/26/25. No facility documentation of care conference held by IDT.
The facility completed a quarterly MDS assessment on 04/26/25. Care conference was held with IDT on 04/10/25 with no supporting documentation by facility indicating R11 or R11's representative was in attendance, invited, or declined invitation to attend care conference.
The facility completed a quarterly MDS assessment on 11/08/24. No facility documentation of care conference held by IDT.
The facility completed a quarterly MDS assessment on 08/12/24. A care conference was held by IDT on 07/23/24 with R11 and R11's representative in attendance after the assessment had been completed.
On 8/13/25 at 12:24 PM, Surveyor interviewed ADON C and Registered Nurse (RN) G, regarding R3's care conferences. ADON C reported care conferences should be done quarterly before care plans are revised and should include the resident and when possible the family/representative. ADON C reports the facility does not have documentation to support this is being offered and/or refused. RN G reported care conferences that include the resident and/or representative and a multidisciplinary team, are not being done for many of the residents in the facility. RN G reported the facility is aware of this and has implemented a performance improvement plan as of 2/2025 to work on correcting this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure development and implementation of a comprehensive person-centered care plan to address the resident's history of recurring urinary tract infections (UTI), for 1 of 13 residents (R) R27 whose care plans were reviewed, This is evidenced by:The facility's policy titled: Care Plans - Comprehensive, states in part: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Section 3 states, each resident's comprehensive care plan is designed to: (a) Incorporate identified problem areas.(e) Reflect treatment goals, timetables, and objectives in measurable outcomes, and (i) Reflect currently recognized standards of practice for problem areas and conditions. R27 was admitted to the facility on [DATE] and has diagnoses that include acute renal failure, morbid obesity, diabetes, and urinary tract infections.R27's Minimum Data Set (MDS) assessment, dated 06/26/25, indicated that R27 has a BIMS of 15/15, meaning cognitively intact. R27 was identified to have frequent urinary incontinence, and no urinary toileting program was in effect. Surveyor reviewed R27's medical record and found R27 has had 5 urinary tract infections since January 2025, three since admission to facility in March 2025. Each UTI incidence has required R27 to be treated with oral antibiotics. Provider note, dated 08/13/25 at 7:15 AM, states in part, R27 has been dealing with on and off dysuria (burning with urination) and has had urine frequency and incontinence. Surveyor reviewed R27's medical record finding no implementation of care plan recognizing R27 as high risk for urinary tract infections and no interventions for treatment and prevention were established. Last care plan revision for R27 was done 06/26/25.On 08/13/25 at 1:20 PM, Surveyor interviewed Director of Nursing (DON) B and asked what expectations are for prevention/intervention of residents who have a diagnosis of UTIs. DON B stated, There should be at least a temporary care plan in place. DON B stated after personal review of R27's medical record, there was no current or recovered care plan developed recognizing R27's recurrent UTIs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the bed hold notice. This has the potential to affect 1 of 2 residents (R), R51.R51 received a bed hold notice with no daily rate documented.Findings:R51 was admitted to the facility on [DATE] with a Brief Interview of Mental Status (BIMS) score of 14 which indicated that R51 was cognitively intact (but this did decline while in the facility). R51 had diagnoses of dementia, Alzheimer's, hallucinations, irritability and anger.R51 had a care plan for behaviors indicating physical/verbal aggression dated 7/5/25.R51 had a minimum data set (MDS) dated [DATE] titled Discharge Return Anticipated.On 07/11/25 at 10:41 PM, progress note revealed R51 became aggressive with staff both physically and verbally and police were notified. At 8:20 PM, R51 left the facility with officers and went to the emergency room.On 08/12/25 at 2:14 PM, Surveyor asked Nursing Home Administrator (NHA) A for a copy of the bed hold.On 08/12/25 at 3:44 PM, Surveyor was provided a copy of the bed hold signed and dated 07/11/25, which indicated, I choose to hold my bed on all incidents of hospitalizations or therapeutic leaves from the facility. Surveyor noted there was no dollar amount on this bed hold form indicating how much the resident would be charged.On 08/13/25 at 8:00 AM, Surveyor interviewed R51's Power of Attorney (POA) who indicated that R51 had declined mentally very quickly. R51's POA also indicated that she did not even notice if there was a dollar amount on the bed hold.On 08/13/25 at 8:00 AM, Surveyor interviewed Director of Nursing (DON) B regarding the dollar amount not placed on the bed hold notice. DON B showed Surveyor a draft of their new bed hold to include the dollar amount, where the resident will go, reason for the transfer and how to appeal the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being by not assessing and/or treating a post-medication error for 1 out of 3 residents (R) reviewed for medication errors, R8.
-R8 was given the wrong medications of Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. R8 was not assessed every 4 hours for 24 hours as per physician order.
Findings include:
Example 1
R8 was admitted to the facility on [DATE], with diagnoses including Parkinson disease, Alzheimer's disease unspecified, unspecified dementia, irritable bowel syndrome with constipation, essential hypertension, obstructive sleep apnea, and spinal stenosis.
Surveyor reviewed medication error, dated 06/14/25, which stated, in part, incident details include R8 was given wrong medications listed as Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. The resolution for this error was that R8's provider gave an order for monitoring R8 every 4 hours for the next 24 hours.
Surveyor reviewed vitals and assessments for R8, which states in part,
-On 06/15/25 at 4:07 AM, R8 is monitored for medication error. Baseline neurologically, vital signs blood pressure 106/69, heart rate 71, respirations 20, and oxygen 97% on room air. R8 has no complaints at this time and will continue to monitor.
Surveyor found no other documentation of vitals and assessments completed every 4 hours for the next 24 hours for R8.
On 06/24/25 at 3:40 PM, Surveyor interviewed DON B and asked DON B what the expectation is for staff to monitor R8 after a medication error as provider orders stated monitor every 4 hours for the next 24 hours. DON B reported to Surveyor that the nursing staff should have monitored R8 every 4 hours for 24 hours including vital signs and head to toe assessment. DON B reported to Surveyor that the assessments and vitals were not completed for R8 every 4 hours as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure medications were administered under professional standards of clinical practices for 3 of 3 residents (R) reviewed for medication errors, R6, R8 and R7.
-R6 received ciprofloxacin 500 mg twice a day for 3 days and should have received 250 mg twice a day for 3 days, and ciprofloxacin did not have an expiration label on it.
-R8 received the wrong medications, including Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg.
-R7's self-administration assessment stated R7 required assistance and nurse left Eliquis, melatonin, omeprazole, and metoprolol in a medicine cup at R7's bedside, left the room, and did not ensure R7 took the medications.
Example 1
Surveyor reviewed medication error, dated 06/16/25, which stated, in part, R6 received the wrong dose of ciprofloxacin 500mg twice a day on 06/14/25, 06/15/25, and 06/16/25. R6 was supposed to receive ciprofloxacin 250 mg twice a day for 3 days. Incident details include Registered Nurse (RN) I, who transcribed physician orders incorrectly with no expiration date placed in the Electronic Health Record (EHR). Licensed Practical Nurse (LPN) F administered extra doses of ciprofloxacin twice a day on 06/14/25, 06/15/25, and 06/16/25. The resolution for this error was that education was given to RN I and LPN F about residents' rights of medication administration.
On 06/24/25 at 10:10 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what kind of education RN I received pertaining to R6's medication error of incorrect dose and no expiration label for ciprofloxacin. DON B reported to Surveyor that on the medication error report, DON B noted that resident's rights of medication administration education was given to RN I and LPN F. Surveyor asked DON B if RN I was educated on the transcription error, as it was not documented on the medication incident report form. DON B reported to Surveyor that DON B did not document that transcription education was provided but would go provide education to RN I and document this education.
Example 2
Surveyor reviewed medication error, dated 06/14/25, which stated, in part, that R8 received wrong medications. R8 received Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. Incident details include R8 was given the wrong medications but had no effects, vitals stable, and sleeping. The resolution was that R8's provider gave an order for the nurse to monitor R8 every 4 hours for the next 24 hours.
Surveyor did not find any documentation of vital signs being monitored every 4 hours for the next 24 hours and any education provided to LPN G after the medication error.
On 06/24/25 at 10:10 AM, Surveyor interviewed DON B and asked DON B if any education was provided to LPN G. DON B reported that documentation of education was not on the medication incident report, but education was completed.
On 06/24/25 at 10:19 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if any education was provided to LPN G. NHA A reported to Surveyor that this event was not the first incident LPN G had, so LPN G was terminated at some point after finding multiple medication errors. Evidence of education was not provided to Surveyor.
Example 3
R7 was admitted to the facility on [DATE], with diagnoses including essential hypertension, end stage renal disease, contracture of left and right hand, anxiety disorder, noncompliance with medication regimen, unstable angina, diabetes mellitus type 2, and congestive heart failure.
R7's minimum data set (MDS) assessment, completed on 05/20/25, confirmed R7 scored 15/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R7 requires supervision and set-up assistance with eating and oral hygiene. R7 requires substantial maximal assistance with transferring, dressing lower body, putting on/taking off footwear, personal hygiene, showering/bathing, and toileting.
Surveyor reviewed R7's self-administration of medication assessment which stated in part,
.-On 03/02/25, all questions such as administering of medications answer- b) Assistance required .
Surveyor reviewed medication error, dated 06/20/25, which stated, in part, incident details include R7 has order for self-administration of medications, nurse left night medications at bedside, and did not follow up to check that R7 took medications of Eliquis, melatonin, omeprazole, and metoprolol. The resolution was educating nurse on self-administration orders and to follow up in one hour to ensure R7 received medications.
On 06/24/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B process for self-administering medications. DON B reported to Surveyor that nurses are supposed to assess residents first to make sure they can safely administer their own medications. Surveyor asked DON B if R7 had a self-administer assessment completed. DON B reported to Surveyor that R7 has a physician order that R7 can self-administer medications, but that DON B would investigate the self-administering further. DON B reviewed self-administer medication assessment completed on 03/02/25 and reported to Surveyor that DON B reviewed and R7 was deemed to require assistance with medications. DON B reported to Surveyor that DON B will have staff re-evaluate self-administering abilities and update R7's chart as needed. DON B reported to Surveyor that staff should have followed up with R7 to make sure R7 did not miss R7's important medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 48 residents (R).
Physical Therapy Assistant (PTA) C and Registered Nurse (RN) O entered R5's room without proper Personal Protective Equipment (PPE) who is on airborne precautions for parainfluenza infection.
Findings include:
Surveyor reviewed facility policy titled, Isolation-Initiating Transmission Based Precautions, states in part,
.-Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions.
#5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall:
a.
Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need .
Surveyor reviewed facility policy titled, Personal Protective Equipment, states in part,
.- Objectives:
1. To prevent the spread of infections;
2. To prevent soiling of clothing with infectious material;
-Miscellaneous:
1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room.
2. Clean reusable or disposable gowns may be worn in most circumstances.
3. Use gowns only when indicated or as instructed.
4. Follow established handwashing procedures.
6. When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident.
7. Gowns shall be large enough to cover all of the wearer's clothing, and they must be tightly cuffed at the sleeves.
8. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room.
10. Soiled gowns must not be worn in break rooms, lobbies, or into any area in which contamination of equipment is likely to occur .
R5 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, polyneuropathy, diabetes mellitus type 2, bacterial infection unspecified, and heart failure.
Surveyor reviewed R5's progress notes, which state in part,
-On 06/23/25 at 1:26 PM, R5 having a cough this morning, Robitussin administered, COVID tested and negative, DON notified, R5 placed on droplet precautions.
-On 06/24/25 at 9:45 AM, Writer obtained nasal swab for respiratory panel ordered per provider, sent to lab.
-On 06/24/25 at 6:48 PM, Received respiratory panel back today, parainfluenza 3 virus detected. R5 on droplet precautions and will remain on for 7 days until 07/01/25.
On 06/24/25 at 9:17 AM, Surveyor observed PTA C enter R5's room with no PPE on. PTA C started working with R5 in room on Physical Therapy (PT) exercises.
On 06/24/25 at 9:28 AM, Surveyor observed RN O standing outside R5's room. Surveyor interviewed RN O and asked RN O what precautions R5 is on. RN O reported to Surveyor that R5 is on droplet precautions. Surveyor informed RN O that PTA C is in R5's room with no PPE on. RN O immediately reported to Surveyor that PTA C is supposed to have PPE on before entering R5's room. RN O called PTA C out of R5's room and explained to PTA C that PTA C needs mask, shield, gown, and gloves on when providing cares in R5's room. PTA C reported to RN O that she did not realize this and PTA C applied PPE and entered back into R5's room.
On 06/24/25 at 9:33 AM, Surveyor observed PTA C exit R5's room and doffed gown, face shield, and gloves. Surveyor observed PTA C continue walking down hallway and exited the unit without proper hand hygiene or removing face mask from R5's room.
On 06/24/25 at 9:36 AM, Surveyor observed RN O donning a face shield, gown, and gloves. RN O entered R5's room to swab R5 for a respiratory panel.
Surveyor did not observe RN O apply a face mask under the face shield before entering R5's room.
On 06/24/25 at 9:45 AM, Surveyor observed RN O exit R5's room and doffed PPE. Surveyor did not observe RN O doff a face mask. Surveyor interviewed RN O and asked if RN O was supposed to have placed a mask on under the face shield when in R5's room on droplet precautions. RN O reported to Surveyor that RN O applied face mask while inside R5's room but should have applied outside room before entering R5's room to decrease chances of spreading infection.
On 06/24/25 at 10:18 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what the expectations are for proper PPE usage with R5 on droplet precautions. DON B reported to Surveyor that all staff are to use appropriate PPE such as mask, face shield, gown, and gloves with droplet precautions. Surveyor informed DON B of observation of RN O and PTA C not utilizing appropriate PPE when entering R5's room. DON B reported that staff should have worn the appropriate PPE before entering R5's room and when exiting doffing the PPE entirely and sanitizing hands before walking onto the next task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to reconcile accurately. This affected 12 out of 49 residents (R) in the facility. (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) The facility did not ensure medications were administered under professional standards of clinical practices for residents. This had the potential to affect all residents on 1 of 2 floors in the facility.
Findings include:
Facility policy titled, Administering Medications, dated 2019, states in part,
.#22. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones.
#23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:
g. The signature and title of the person administering the drug .
Facility policy titled, Documentation of Medication Administration, dated 2022 reviewed on, states in part,
.#2. Administration of medication is documented immediately after it is given.
#3. g. initials, signature and title of the person administering the medication .
Example 1
Surveyor reviewed medication errors for the past 6 months.
-On 03/30/35, medication error report indicates staff did not give R7 Lorazepam medication as it was not signed out on narcotic count sheet. Director of Nursing (DON) B indicated staff to not sign out medication on the narcotic book until medication is given to R7.
- On 03/30/35, medication error report indicates staff did not give R4 Clonazepam medication as it was not signed out on narcotic count sheet. DON B indicated staff to not sign out medication on the narcotic book until medication is given to R4.
-On 04/13/25, medication error report indicates staff gave R5 an extra dose of oxycodone due to staff prepping medication in advance and another nurse not knowing it was prepped ahead and gave another ½ dose to R5. DON B educated nurses on not prepping medications ahead of time before administering.
-On 04/13/25, medication error report indicates R6 was given an extra dose of tramadol. One nurse set up medication and the second nurse went to administer medications and took out an extra tramadol tab. DON B educated nurses on not prepping medications ahead of time before administering and only administering medications in which the individual nurse prepares themselves. DON B indicated to sign out medication on the narcotic book when the narcotic is removed from the pill pack.
Surveyor reviewed facility's investigation pertaining to narcotic diversion that occurred on 03/03/25. Facility reviewed R1, R8, R9, R10, R11, R12, R13, R14, and R4's MAR from 03/03/25 and found controlled medications signed out, which indicated that Licensed Practical Nurse (LPN) L administered R1, R8, R9, R10, R11, R12, R13, R14, and R4's-controlled medications to residents on 03/03/25. Through investigation, the facility found R1 who was in hospital on [DATE], and R8, R9, R10, R11, R12, R13, R14, and R4 did not receive the controlled medications signed out by LPN L on 03/03/25 as documented. Facility called police and notified Department of Health Services within two hours of the facility knowing that there were missing narcotics. Police found LPN L had oxycodone, lorazepam, and hydrocodone in LPN L's possession. Facility terminated LPN L and began pain assessments on R8, R9, R10, R11, R12, R13, R14, and R4. Facility found no concerns with R8, R9, R10, R11, R12, R13, R14, and R4's pain levels. DON B started narcotic reconciliation audits weekly.
On 04/28/25 at 12:43 PM, Surveyor observed LPN D sitting at the nurse's station with two narcotic books on desk and LPN D signing out narcotics and documenting quantity of narcotics left in locked narcotic box.
On 04/28/25 at 12:45 PM, Surveyor interviewed LPN D and asked what LPN D was doing with the narcotic books. LPN D indicated that LPN D gave narcotics to several residents and was currently signing out R4's Clonazepam. Surveyor asked LPN D what the normal process is for signing out narcotics after giving narcotics to residents. LPN D stated, I know this process isn't right and I should have signed the narcotics out as I gave each one to each resident. LPN D indicated that LPN D just knows when LPN D gave the controlled medications and leaves sticky notes for self on the medication cart across the nurse's station if LPN D forgets.
Surveyor asked LPN D to show Surveyor the locked narcotic box located in the medication cart across from the nurse's station. LPN D got up from the nurses' station and walked across the nurse's station to the medication cart and unlocked the narcotic box. Surveyor asked LPN D to show Surveyor R4's Clonazepam card. Surveyor observed R4's Clonazepam card that was labeled with 30 tabs on the card. Surveyor asked LPN D to show Surveyor R4's Clonazepam count sheet out of the narcotic book. Surveyor observed on R4's Clonazepam count sheet quantity started with 30 tabs and noted LPN D signed out, Gave 1 tab of Clonazepam at 12:00 PM. Surveyor asked LPN D how there were 30 tabs accounted for in R4's Clonazepam card, but the count sheet that LPN D signed, indicated 29 tabs of Clonazepam left in R4's Clonazepam card. LPN D immediately apologized to Surveyor and stated, Well I did not give this medication yet, but I was signing it out. LPN D indicated that LPN D did the documentation incorrectly and was going to go back and give the Clonazepam but did not yet. Surveyor asked LPN D it was normal to sign controlled medications out of the count book before pulling from the card. LPN D indicated that LPN D performed the wrong process and knows that LPN D should not have done that, but LPN D stated, It has just been so busy here today. LPN D indicated that facility process is to sign out the narcotic or controlled medication once the medication is pulled and administered to R4. LPN D indicated that LPN D should not have signed out before giving the medication.
On 04/28/25 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what is DON B's expectation for signing out narcotic count sheets when administering a controlled medication. DON B indicated that LPN D approached DON B and let DON B know that LPN D messed up by signing out a controlled medication before giving the controlled medication making the count off in the narcotic book. DON B indicated that DON B's expectation is that nurses do not prep medications ahead of time or sign out medications that have not been given first. DON B's expectation was that LPN D give R4's Clonazepam and sign out the medication in the narcotic book once the medication was administered. DON B indicated that LPN D should have counted how many tabs were left in R4's Clonazepam card then documented the correct quantity on narcotic count sheet. Surveyor asked DON B how often DON B audits to make sure the narcotic count sheets are accurate, and they are being signed out appropriately. DON B indicated that audits started back in beginning of March 2025, and DON B performs the audits weekly.
Surveyor tried reviewing narcotic count sheets and DON B indicated the narcotic count sheets were being audited as we were speaking. Surveyor asked DON B if there are any discrepancies with the narcotic sign out count sheets. DON B indicated that in fact there were some missing signatures on narcotic count for shift change. Surveyor requested a copy of the narcotic sign out sheet. DON B indicated that DON B understands that LPN D still is not utilizing the correct process for narcotic count to prevent narcotic diversion and will handle the situation immediately. Surveyor asked if DON B thinks there is still an issue with narcotic count and facility's process. DON B indicated that DON B has educated staff, but DON B can see that staff are still having issues and DON B will reeducate.
On 04/28/25 at 2:55 PM, Surveyor reviewed narcotic sign out sheets and observed on 04/10/25 missing second signature on night shift for narcotic count. On 04/25/25, day shift was missing two signatures for narcotic count.
Example 2
On 04/29/25 at 10:42 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if facility was aware of any delegation of tasks, treatments, and/or administering of medications from nurses to Certified Nurse Assistants (CNA)s. NHA A indicated there was a recent event in March where a resident observed LPN C delegating medication administration to a CNA. NHA A indicated that Trained Medication Aide (TMA) M was acting as a CNA on 03/19/25 but then stayed about two hours after day shift to help LPN C pass medications.
On 04/29/25 at 10:47 AM, Surveyor interviewed LPN C and asked if LPN C had ever delegated medication administration to a CNA. LPN C indicated that LPN C has never allowed a CNA to pass medications. LPN C indicated the facility has TMAs. LPN C indicated that on 03/19/25 LPN C was overwhelmed with a recent fall on that evening shift and asked TMA M to stay and help pass medications. LPN C indicated that LPN C prepped all medications and would hand them to TMA M to administer the medications to whichever residents LPN C delegated the medication pass. Surveyor asked LPN C if LPN C followed TMA M in the rooms while TMA M passed medications. LPN C stated, Well I was in close proximity like in the room next to the other room [TMA M] was in. I did not physically go into the rooms [TMA M] administered medications but that shouldn't matter as [TMA M] is trained to administer medications.
Surveyor asked LPN C what the process is for preparing and administering medication to residents. LPN C indicated that medications are to be prepared right when LPN C is about to administer the medications to residents and should be the nurse who is prepping the medication to administer the medication. Surveyor asked if LPN C remembers which residents TMA M administered medications to on 03/19/25. LPN C indicated that LPN C had TMA M help with most of all medications needing to be administered. Surveyor asked LPN C who signed out the medications in the MAR. LPN C indicated that LPN C documented that LPN C administered all medications on the evening shift of 03/19/25. Surveyor asked LPN C if LPN C did not administer the medications, why was it documented that LPN C administered the medications. LPN C indicated that LPN C knew better, and TMA M should have signed the medications that TMA M administered. Surveyor asked LPN C what the process for medication administration is and not falsifying documentation. LPN C indicated that LPN C should have had TMA M prep, administer, and document the medications that TMA administered. LPN C indicated next time LPN C will not prepare medications ahead and delegate someone else to give the medications.
On 04/29/25 at 11:43 AM, Surveyor interviewed DON B and asked DON B's expectation for medication administration. DON B indicated nurses are to follow facility policy. Surveyor asked DON B if it was acceptable for LPN C to prepare residents medications and then delegate TMA M to administer the medications. DON B indicated that TMA M can administer medications as TMA M is trained. Surveyor asked DON B what the process or expectation for documenting medications when administered to residents. DON B indicated that LPN C should have not prepared medications ahead and delegated TMA M to administer medications and LPN C should not have documented that LPN C gave the medications when TMA M is the one who administered the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs. Behavioral monitoring was not completed as outlined in the comprehensive care plan to determine effectiveness of the medication for 1 of 3 residents (R) reviewed (R2).
Findings include:
The facility policy titled, Behavioral Assessment, Intervention, and Monitoring, dated 03/2019, states in part:
.Management
-#1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care.
-#10. When medications are prescribed for behavioral symptoms, documentation will include:
b. potential underlying causes of the behavior,
c. other approaches and interventions tried prior to use of antipsychotic medications.
e. specific target behaviors and expected outcomes.
h. monitor for efficacy and adverse consequences.
Monitoring
-#1. If the resident is being treated for altered behavior or mood, the team will seek and document any improvements or worsening in the individual's behavior, mood, or function.
-#2. New or emergent symptoms will be documented and reported.
-#3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment .
R2 was admitted to the facility on [DATE] and had diagnosis that include unspecified dementia, mild with behavioral disturbance, ischemic cardiomyopathy, and congestive heart failure.
R2's Minimum Data Set (MDS) assessment, dated 08/16/24, indicated that R2 has a Brief Interview for Medical Status of 00, which indicates R2 has a severe impairment.
R2's care plan included the following interventions:
BEHAVIORS care plan:
-Update provider on progressing dementia behaviors of wandering, invading other personal space initiated on 11/16/22.
-Re-direct R2 from going into other rooms/spaces, re-direct R2 from other residents at the table when eating initiated on 06/07/24.
-Administer behavior medications as ordered by provider. Assess for effectiveness and for side effects on medication on-going, update provider as needed initiated on 09/14/24.
-Discuss with family best approaches initiated on 09/14/24.
-Provide diversional activities during episodes of inappropriateness/disruptive behavior initiated on 09/14/24.
-Re-direct R2 from male residents, when sitting at table, do not place her next to male, only across the table initiated on 09/14/24.
-Refer to interdisciplinary team for review as needed initiated on 09/14/24.
R2's doctors' orders read:
-Monitor and document any increased behaviors due to Seroquel decrease every shift.
-Behavior monitoring: targeted behavior: wandering, getting into others personal space leading to altercations, kicking at staff, history of slapping to others, Interventions: Redirect from others, offer food, reassure her. If behavior is present, document in nurses' notes: Behavior, interventions used and effectiveness of the interventions every shift.
-Lorazepam give 0.5mg by mouth every 4 hours as needed for anxiety/behavioral disturbances related to Dementia.
-Lorazepam give 0.5mg by mouth in the afternoon related to Dementia.
-Citalopram Hydrobromide 10 mg tab by mouth in the evening related to Dementia.
-Seroquel 25mg tab, give 12.5 mg by mouth two times a day related to Dementia with mild behavioral disturbances.
Surveyor reviewed R2's medication administration record (MAR) and Treatment Administration Record (TAR) for September, October, November, and December. Documentation on MAR and TAR for all 4 months periodically present that R2 had behaviors but no documentation found on specific behaviors, interventions utilized, and the effectiveness of the interventions.
Surveyor reviewed R2's progress notes for September, October, November, and December. R2's progress notes did not have documentation noted when behaviors occurred, what behaviors were assessed, what interventions were implemented, and how effective were the interventions put into place to decrease R2's behaviors.
On 12/02/24 at 9:25 AM, Surveyor interviewed R3 and asked R3 if R3 ever had any residents wander into R3's room or any inappropriate behavior occur to R3. R3 indicated that R3 has a stop sign velcroed to door because other residents wander into R3's room, but sometimes R2 blows right through the door into R3's room. R3 indicated that last night on 12/01/24 in the evening time R2 wheeled into R3's room and began trying to rub R3's hand and kissing R3's arm. R3 told R2 no and to leave. R3 indicated R3 told staff shortly after R2 wheeled back out of R3's room.
On 12/02/24 at 11:50 AM, Surveyor interviewed Registered Nurse (RN) C and asked if RN C knew of any instances of inappropriate behaviors and wandering with R2 in the past and from 12/01/24 in the evening into R3's room. RN C indicated that earlier in the afternoon on 12/01/24 RN C was walking into R3's room to pass medications. RN C stated, [R2] did wander into [R3's] room and [RN C] redirected [R2] out of [R3's] room, and then [RN C] wheeled [R2] out of [R3's] room. RN C indicated that R2 always wanders into other rooms, and that the floor is a memory care unit. Surveyor asked RN C why this episode was not charted in the nurse progress notes or on the MAR/TAR. RN C indicated that RN C's usual process is RN C will monitor for inappropriate behaviors and wandering from R2 and then redirect if need be and document the behaviors in the Electronic Health Record (EHR). RN C indicated that since RN C was right there with R2 that RN C felt the behavior was observed and did not need to be charted. Surveyor asked RN C if it was facility policy to not document behaviors. RN C indicated the facility policy is that behaviors are documented in the MAR/TAR and then a progress note will be attached to that documentation so that progress notes show intervention being utilized and if effective for that set behavior.
On 12/02/24 at 12:15 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what expectation was for behavior charting and monitoring inappropriate behaviors to decrease incidents from happening. DON B indicated that it is DON B's expectation that all behaviors are documented in the TAR and then in the progress notes the exact behavior needs to be documented with what intervention was implemented, and how effective was the intervention. DON B indicated documentation of behaviors assists the team with ordering and changing psychotropic medications to make sure the medications are working properly. Surveyor asked DON B if DON B was aware of R2 wandering into R3's room on 12/01/24 and the lack of documentation noted in the EHR. DON B indicated that DON B was not aware but conversed with RN C who admitted that RN C did not document in R2's chart the behavior from 12/01/24. Surveyor asked DON B why R2 has yes documented in the MAR/TAR for behaviors throughout September, October, November, and December chart but no other documentation on what the behavior was at that time, what interventions were placed, and how effective the intervention was that was implemented. DON B indicated that DON B did not realize staff were not documenting accurately as provider ordered for R2.

Based on interview and observation, the facility failed to have qualified onsite dietary manager. This has the ability to affect 40 out of 40 residents.
Facility has not had a Dietary Manager since 07/06/2023.
Findings include:
On 08/29/23 at 10:50 a.m., Surveyor entered kitchen and [NAME] D stated if Surveyor was looking for the dietary manager, the facility does not have one.
On 08/29/23 at 12:30 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the Dietary Manager. NHA A stated the facility has not had a Dietary Manager since 07/06/23. NHA A stated NHA A checks on dietary and has Human Resources (HR) L supervise dietary part-time. NHA A and HR L do not have a dietary certification. NHA A stated Dietary Aide (DA) M orders food for the dietary department and updates the resident tray tickets regarding diets and likes/dislikes. NHA A stated NHA A consults and refers to the facility Dietician as needed, and the Dietician is onsite at the facility every two weeks. NHA A stated the Dietician works remotely as well and reviews changes in resident conditions, updates diets, etc. NHA A stated a Dietary Manager will be starting in two weeks. NHA A stated the Dietary Manager is in a program for certification and has a preceptor, but has not completed the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure the resident environment is free from accidents for safe smoking, affecting 2 of 2 residents reviewed for smoking (R12 and R37).
R12 indicated she maintains her smoking materials in her coat pocket or dresser drawer in her room and goes out to smoke on her own without any devices worn for smoking. R12's smoking assessment was not complete, to ensure safety interventions were in place on R12's smoking care plan.
R37 indicated she maintains her smoking materials in her room and does not wear any apron or other devices while smoking. R37's smoking assessment was not complete, to ensure safety interventions were in place on R37's smoking care plan to prevent injury while smoking.
This is evidenced by:
Surveyor reviewed the facility policy titled Accident Prevention-Smoking Policy dated as last reviewed on 10/2022. The policy in part reads:
Policy: The facility shall establish and maintain safe resident smoking practices.
Guidelines:
Any smoking-related privileges, restrictions and concerns shall be noted in the care plan and all personnel caring for the resident shall be alerted to the issues.
Example 1
On 06/05/23 at 10:07 AM, Surveyor observed R12 outside from the end of hallway. R12 was smoking a cigarette. R12 smoked the cigarette without issues and extinguished the cigarette in an ashtray.
On 6/05/23 at 10:18 AM, Surveyor spoke with R12 regarding smoking at the facility. R12 indicated she maintains her cigarettes and lighter in her room, sometimes in the dresser drawer and sometimes in her jacket pocket. R12 further expressed she is able to go outside to the smoking area at the end of her hall when she wants. R12 expressed she does not wear a smoking apron or any other device while smoking.
Surveyor reviewed R12's record and noted the following:
R12's most recent annual Minimum Data Set (MDS) assessment and noted she understands, is understood and is cognitively intact. R12 requires extensive staff assistance for dressing and has limited range of motion of both upper and lower extremities.
R12's most recent Smoking Safety Evaluation completed 04/28/23 notes:
Does resident do or have the following: poor vision or blindness, balance problems while sitting or standing, total or limited range of motion in arms or hands, insufficient fine motor skills needed to safely hold cigarette, lethargic/falls asleep easily during tasks or activities, burns skin, clothing, furniture or other, drops ashes on self. All are marked no.
Follow the facility policy on location and time of smoking: marked yes
Concerns: Does the resident display any of the following safety concerns: unable to light cigarette safely, unable to hold a cigarette safely, unable to extinguish a cigarette safely, unable to extinguish a cigarette safely, unable to use an ashtray and extinguish a cigarette. All marked no.
Evaluation: Resident utilizes tobacco, poor vision or blindness-no, balance problems while sitting or standing-no, total or limited range of motion in arms or hands-no, insufficient fine motor skills needed to safely hold cigarette-no, lethargic/falls asleep easily during tasks or activities-no, burns skin, clothing, furniture or other-no, drops ashes on self-no. Follow the facility policy. Concerns: able to light cigarette safely, able to hold a cigarette safely, able to extinguish a cigarette safely, able to use an ashtray and extinguish a cigarette.
Comments: There are no comments.
R12's care plan indicated:
Focus: Smoking: potential for injury related to smoking, date initiated: 5/28/2021.
Goal: Will be free of injury related to smoking through next review date.
Interventions/Tasks:
All smoking materials to be kept at the nurse's station
Check for burns on hands daily on the afternoon shift, report to charge nurse of social services.
Encourage/Assist with smoking apron or any other adaptive equipment to promote safety while smoking.
R12's Certified Nursing Assistant (CNA) care plan ([NAME]) indicates:
Safety: all smoking materials to be kept at the nurse's station.
On 6/06/23 at 12:34 PM, Surveyor spoke with Certified Nursing Assistants (CNA) H and O and Registered Nurse (RN) P about R12's smoking. CNAs H and O and RN P indicated they work with R12 routinely. All indicated R12 maintains her cigarettes and lighter in her room. R12 goes out to smoke when she wants without supervision or any adaptive equipment, such as a smoking apron, and has since she moved to their floor about a year ago. CNAs H and O and RN P expressed R37 is also able to go out when she wants to smoke without supervision or adaptive wear such as an apron. R37 also maintains her smoking materials in her room.
Example 2
On 6/05/23 at 10:49 AM, Surveyor spoke with R37 about smoking. R37 expressed she goes out to smoking area to smoke when she wants without supervision. R37 expressed she keeps her smoking materials in room and does not wear any adaptive wear such as a smoking apron.
Surveyor reviewed R37's record and noted:
R37's most recent quarterly MDS dated [DATE] notes she understands, is understood and is cognitively intact. R37 has range of motion impairments to both upper and lower extremities.
R37's most recent Smoking Safety Evaluation completed 6/28/22 notes:
Does resident do or have the following: poor vision or blindness, balance problems while sitting or standing, insufficient fine motor skills needed to safely hold cigarette, lethargic/falls asleep easily during tasks or activities, burns skin, clothing, furniture or other, drops ashes on self. All are marked no.
Follow the facility policy on location and time of smoking: marked no
Total or limited range of motion in arms or hands: yes
Concerns: Does the resident display any of the following safety concerns: unable to light cigarette safely, unable to hold a cigarette safely, unable to extinguish a cigarette safely, unable to extinguish a cigarette safely, unable to use an ashtray and extinguish a cigarette. All marked no.
There is no evaluation, summary, or comments for recommendations on R37's safe smoking recommendations.
R37's care plan indicated:
Focus: Smoking: potential for injury related to smoking, date initiated: 06/23/2022.
Goal: Will be free of injury related to smoking through next review date.
Interventions/Tasks:
Check for burns on hands daily on the afternoon shift, report to charge nurse of social services.
Encourage/Assist with smoking apron or any other adaptive equipment to promote safety while smoking.
Of note: the care plan does not indicate where R37's smoking materials are to be maintained.
R37's Certified Nursing Assistant (CNA) care plan ([NAME]) does not indicate any interventions related to R37's safe smoking.
On 06/06/23 at 1:02 pm, Surveyor spoke with Director of Nursing (DON) B about R12 and R37's smoking. DON B indicated both R12 and R37 go out to smoke on their own and do not need supervision while smoking. Surveyor and DON B reviewed R12's and R37's smoking assessments. DON B expressed the assessment summaries/comments are not complete but should include recommendations for safe smoking that are care planned for the residents. DON B expressed she would expect staff to follow R12's and R37's care plans for safe smoking. DON B further expressed R12 and R37 need to be reassessed for smoking as the assessments are not complete as she was unaware on how to complete the summary/comments in the point click care system for R12 and R37's safe smoking recommendations. The care plans will need to be updated once the assessments are completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility did not ensure each resident received care consistent to prevent Pressure Injuries (PIs) from developing for 1 of 2 sampled residents (R)2.
R2 is at moderate risk for PI development. R2 was observed in bed with both heels on the mattress.
This is evidenced by:
R2 was admitted to facility on 01/22/21. Diagnoses include dementia with behavioral disturbance, Type 2 Diabetes Mellitus, repeated falls, depression, weakness, and need for assistance with personal cares. R2's Power of Attorney (POA) is activated.
Minimum Data Set (MDS), dated [DATE], indicated R2's cognition is severely impaired. R2 is at risk for development of pressure related injuries. R2 requires a Hoyer (mechanical lift) for transfers and has recently been using a Broda chair (positional wheelchair) for mobility.
R2 scored 13 during Braden Scale for Predicting Pressure Sore Risk, completed on 04/26/23, indicating moderate risk for development of PI.
R2's nutritional assessment, completed on 04/23/23, confirmed a recent significant and unintended weight loss.
R2's care plan included the following:
ACTIVITIES OF DAILY LIVING: Self-care deficit related to diagnoses/conditions including advanced Alzheimer's Disease, anxiety, aggressive behavior, weakness, and decreased mobility as evidenced by her need for assistance with her Activities of Daily Living. Date Initiated: 01/22/2021, Revision on 08/02/2021.
PRESSURE RELIEF: has a pressure relief mattress, and cushion in wheelchair. Float her heels on a pillow when she is in bed.
REPOSITIONING: Every 2-3 hours.
06/06/23 from 7:28 AM-9:50 AM, Surveyor observed R2 in her bed, R2's heels were not floated on a pillow and were directly on the mattress.
06/06/23 at 9:50 AM, interview with Certified Nursing Assistant (CNA) E. CNA E stated that R2 has a wedge pillow to float her heels on while in bed. CNA E and Surveyor observed that R2's heels were not placed on a pillow and were directly on the mattress. CNA E could not locate the wedge pillow.
06/06/23 at approximately 9:55 AM, interview with Licensed Practical Nurse (LPN) D. LPN D stated that R2 is to have her heels floated on a pillow while in bed. LPN D stated that maybe R2's wedge pillow was in the laundry. During this interview CNA E stated that she had found R2's wedge pillow in her bed near R2's headboard.
06/06/23 at 4:23 PM, interview with Assistant Director of Nursing (ADON) C and Director of Nursing (DON) B confirmed that R2's heels should be floated on a pillow when R2 is in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide written notice of the facility bed-hold policy for 2 of 3 residents (R) reviewed for hospital transfer (R19 and R40).
R19 was transferred to hospital on [DATE] and 05/07/23. A bed-hold notice was not provided to R19 or his representative.
R40 was transferred to hospital on [DATE]. A bed-hold notice was not provided to R40.
This is evidenced by:
Surveyor reviewed Bed Hold Policy Acknowledgement, as part of facility admission packet. Policy reads in part .At the time of transfer to the hospital you or your legal representative will be asked to make a decision whether or not you would like your bed held here at the facility. This will be done with every transfer to the hospital.
Surveyor reviewed R19's record and noted Minimum Data Set (MDS) Discharge Return Anticipated dated 04/26/23 indicating an unplanned transfer to hospital. Progress notes confirm R19 readmitted to facility on 05/04/23 and was re-hospitalized from [DATE]-[DATE]. Surveyor reviewed R19's record and no written or verbal notice of facility bed-hold policy was located.
Surveyor reviewed R40's record and noted MDS Discharge Return Anticipated dated 02/13/23 indicating an unplanned transfer to the hospital. Surveyor reviewed R40's record and no written or verbal notice of facility bed-hold policy was located.
On 06/07/23 at 10:03 AM, interview with Assistant Director of Nursing (ADON) C. ADON C stated that she was not able to locate bed-hold notifications for R19 and R40. ADON C reported that bed-hold notifications were not being completed for residents at time of transfer. The facility is implementing a process to ensure that bed-hold notifications are completed at time of transfer.

Based on record review and interviews, the facility did not implement their abuse policy in regard to screening for 7 of 8 employees.
Caregiver and criminal background checks were not completed for Certified Nursing Assistant (CNA) (CNA H, I, J, and K), Licensed Practical Nurse (LPN) L, Dietary Manager (DM) M, and Laundry Aide (LA) N.
Out of state background checks were not completed for DM M and LA N.
Findings include:
The facility policy, entitled Abuse Prevention Program, Screening of Employees with a last revised date of 08/2022 reads in part, Background checks are completed per state guidelines on each employee.
On 06/05/23, Surveyor requested Caregiver and Criminal background checks for a sample of 8 employees. On 06/06/23, the employee background information was reviewed.
CNA H, J, and LPN L were all hired on 10/01/22. Caregiver and criminal background checks were not completed until 06/05/23. The Background Information Disclosure (BID) was not completed by the employees until 06/05/23.
CNA K was hired on 10/25/22. Caregiver and criminal background checks were not completed.
CNA I was hired on 11/10/22. Caregiver and criminal background checks were not completed until 06/05/23. The BID was not completed by the employees until 06/05/23.
DM M was hired on 05/22/23 and indicated on the BID they had lived in Florida and Arizona. Surveyor requested the background checks for the other states from the Business Office Manager (BOM) G. BOM G was not aware that the other states needed to be checked.
LA N was hired on 05/15/23 and indicated on the BID that they lived in Indiana. Surveyor requested the background check for the other state from BOM G. BOM G was not aware that the other states needed to be checked.
On 06/06/23 at about 11:15 AM, Surveyor interviewed BOM G and asked if they ran the background checks for the employees after Surveyor gave them the sample of eight staff. BOM G indicated yes.
On 06/06/23 at about 11:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the background checks being run upon hire. NHA A indicated that they were hired on 03/06/23 as a contract staff and was not aware the background checks were not completed until an employee requested to look at their personal file and things were missing. NHA A indicated that they started an audit on all employee files but were not able to complete it before we entered.

Based on observation, record review, and staff interview, the facility did not post the daily required information related to nurse staffing levels. This practice could potentially affect all 43 residents.
On 06/05/23 the daily nurse staff posting that was displayed was dated 05/22/23. The faciity did not ensure the daily nurse staff posting was posted daily and updated each shift.
This is evidenced by:
On 06/05/23 at 11:41 AM Surveyor observed the staff listing titled Aspen Health and Rehab posting for daily care staffing dated 05/22/23.
The posting read:
Date 05/22/23
Shift 6 am - 2 pm
1 RN (Register Nurse) first floor (8hr), 2 RN third floor (16hr)
2 CNA's (Certified Nursing Assistant) 1st floor (8hr), 2 CNA's third floor (16hr)
Shift 2 pm - 10 pm
1 LPN (Licensed Practical Nurse) first floor (8hr), 2 RN's third floor (16hr)
3 CNA's first floor (24hr), 2 CNA's third floor (16hr)
Shift 10 pm - 6 am
1 LPN first floor (4hr), 1 LPN third floor (4hr)
1 CNA first floor (8hr), 1 CNA third floor (8hr)
On 06/06/23 at 8:08 AM, Surveyor observed a new posting dated 06/06/23 with no issues noted in the posting related to the level of staffing.
On 06/07/23 review of previous postings revealed that postings from 05/22/23 to 06/05/23 had been completed but had not been posted daily.
On 06/07/23 Interview with Medical Records Coordinator (MRC) F, who is responsible for the daily postings, revealed that the posting did not get posted with everything going on in the facility and the other roles they are responsible for. MRC F's expectation would be for the posting to be posted daily at the entry of the facility.

Based on observation, interview and record review, the facility did not prepare, store, or distribute foods in a safe and sanitary manner. The facility practices have the potential to affect all 43 residents.
Facility staff do not cover beverages that are poured by staff on the wings and delivered to residents in their rooms.
Cook Q did not allow the thermometer to air dry after wiping with alcohol and before inserting into resident foods.
Dietary Aide (DA) T used alcohol-based hand rub (ABHR) as a means to sanitize her hands in the kitchen. ABHR is not an approved means to sanitize hands when food handling in the kitchen.
The refrigerators and freezers where resident foods are brought into the facility do not have complete logs of monitoring for safe storage temperatures. The freezer on the first floor showed evidence of melted ice cream in the freezer. The temperature of the refrigerator was outside parameters for safe storage of foods.
The facility did not monitor water temperatures for the water heater that is stored in the basement and circulates water to the basement kitchen and basement laundry area. Surveyor monitored water temperatures and identified fluctuations within conditions where Legionella and other opportunistic pathogens grow best (77-108 degrees Fahrenheit).
This is evidenced by:
Example 1
On 06/05/23 at 11:52 AM, Surveyor observed meal service for lunch on the first floor. Surveyor observed Certified Nursing Assistants (CNA) H and CNA I preparing resident food trays at the food cart. CNA H and CNA I poured beverages of milk, juice and coffee and placed the beverages on the trays of the residents served in the dining room. CNA H and CNA I proceeded to pour beverages for resident room trays. The beverages were placed on resident trays and transported to them in their room up the hallway. The beverages were not covered during distribution to residents in their rooms.
On 06/06/23 at 8:18 AM, Surveyor observed meal service on the first floor for breakfast. Surveyor observed staff, including Medical Records/CNA F distribute trays and the beverages were not covered when distributed to residents in their rooms. Beverages included milk, juice, and coffee.
Following the observation, Surveyor spoke with CNA F about the observation. CNA F expressed she assists with passing of trays on an ability basis. The beverages that are poured on the wing are not covered during transport to residents in their rooms as there is nothing sent up from the kitchen on the cart to cover them with. CNA F expressed this has been the facility procedure since she can remember and has been on staff a couple of years.
On 06/07/23 at 9:12 AM, Surveyor spoke with Dietary Manager (DM) R and Nursing Home Administrator (NHA) A about the observations. DM R expressed the facility will be looking at different means of distributing resident room trays. Staff should not transport resident meal trays up the hall without foods and fluids being covered as it poses a risk of contamination.
Surveyor requested and received a list of residents who routinely eat in their rooms that the observed practice could potentially affect. Surveyor was provided a list including the following residents (R26, R32, R28, R244, R38, R29, R9, R7, R31, R14, R36, R21, R13, R33, R16, R24, R19, R39, R6, R23, R20, R37 and R12).
Surveyor requested the facility policy on safe food distribution. At time of exit nothing was provided.
Example 2
On 06/06/23 at 7:10 AM, Surveyor observed [NAME] Q placing foods on the steam table in preparation for breakfast service. [NAME] Q used a thermometer to take the food temperatures. Surveyor observed [NAME] Q wipe the thermometer with an alcohol preparation pad and immediately insert into food items to check the temperatures. Surveyor asked [NAME] Q if she needed to allow the thermometer probe to air dry after wiping with alcohol and before inserting into foods. [NAME] Q responded she was not aware of the need to wait and has never seen a policy about needing to air dry the thermometer before inserting into foods. [NAME] Q expressed she has been on staff 6-7 months, comes from a restaurant background and has received little to no training since starting.
On 06/06/23 at 1:29 PM, Surveyor spoke with DM R about the observation. DM R expressed she had just started employment a few weeks ago and her background is in restaurants. DM R further expressed she would expect the probe to be fully air dried with no residual alcohol. She would expect staff to wait 10-15 seconds to allow the thermometer to air dry of alcohol before inserting into resident foods to prevent contamination.
Surveyor requested and received the facility policy titled Food Temperatures dated 02/25/2019. The policy states in part:
Food temperatures will be taken and recorded when food is removed from oven or refrigerator, at the start and end of service at each meal. Wipe thermometer with alcohol pad and wait 10 seconds before putting in foods.
Example 3
On 06/06/23 at 7:10 AM, Surveyor observed Dietary Aide (DA) T with readying foods and other items in preparation of breakfast meal service. DA T removed her gloves and used ABHR to clean her hands after filling pitchers with water and proceeding to another task. Surveyor asked DA T about the observation. DA T indicated she is trained in safe serve food handling and believes hand sanitizer is an okay method for hand hygiene in the kitchen.
On 6/06/23 at 1:13 PM, Surveyor spoke with DM R about the observation. DM R indicated she believes the facility uses Wisconsin Food Code for the kitchen policies. The expectation is for staff to wash their hands using soap and water in the kitchen per the food code. Surveyor requested and received the kitchen's staff hand washing procedure titled Hand Washing dated 06/25/2012. The policy in part states: Policy: Food service employees shall keep their hands clean. The procedure outlines hand washing with the use of soap and water. The policy does not include the use of ABHR as a means for food service workers to clean their hands.
Example 4
On 06/06/23 at 1:58 PM, Surveyor and NHA A observed the first-floor freezer/refrigerator where resident foods are stored. The freezer showed dried residual melted ice cream on the bottom and side shelves. The refrigerator with resident food items thermometer read 50 degrees Fahrenheit. Surveyor and NHA A proceeded to the third floor and observed the refrigerator and freezer clean and temperatures within safe storage range.
Surveyor requested and reviewed the logs of the first and third floor refrigerator/freezer temperatures that were logged. The logs noted Temperature standards: 40 degrees Fahrenheit or below for cooler and 0 degrees Fahrenheit or below for freezer. The logs were void of any recorded temperatures for the months of March and April 2023. The logs for May 2023 noted the following:
First floor: recorded 14 of 31 days with temperatures above the noted temperature standards as:
05/04/23, 05/15/23 and 05/17/23: freezer at 10 degrees Fahrenheit.
05/06/23: Freezer at 14 degrees Fahrenheit.
05/07/23: Freezer at 12 degrees Fahrenheit.
05/22/23: Freezer at 6 degrees Fahrenheit.
05/25/23: Freezer at 8 degrees Fahrenheit.
Third floor: recorded 13 of 31 days with temperatures above the noted temperature standards as:
05/07/23, 05/16/23 and 05/21/23: freezer at 8 degrees Fahrenheit and 05/22/23 at 10 degrees Fahrenheit.
05/04/23: Refrigerator above 40 degrees Fahrenheit 11 of the 13 days recorded ranging from 42-52 degrees Fahrenheit.
On 6/07/23 at 9:12 AM, Surveyor spoke with DM R and NHA A about the observation. DM R indicated dietary staff should be checking the refrigerators daily for cleanliness and appropriate temperatures. If the refrigerators and freezers are not clean bacteria, germs and mold can grow and contaminate residents' foods. Temperatures should be logged when they are checked to ensure the storage temperature is safe. If the temperature is out of range, it needs to be reported immediately and action taken. DM T further stated she needs to establish a routine where staff monitor the refrigerators and freezers daily and communicate any concerns so action can be taken immediately to ensure residents foods are stored safely.
Surveyor reviewed the policy titled Water Management, Legionella Testing which is dated as most recently reviewed on 10/2022. The policy in part states:
The facility handles and maintains its water supply in accordance with recommendations of the CDC (Centers of Disease Control). The community will demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in the building water systems through a documented water management program.
Surveyor requested and received the CDC publication titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated 06/05/2017. The publication in part reads: Legionnaires Disease is a serious type of pneumonia caused by bacteria called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from buildings water systems that are not adequately maintained.
Factors internal to buildings that lead to Legionella growth: Water temperature fluctuations: Provide conditions where Legionella grows best (77-108 degrees Fahrenheit).
Water Pressure changes: Can cause biofilm to dislodge.
On 06/06/23 at 7:05 AM, Surveyor entered the kitchen and proceeded to the hand washing sink to wash hands. Surveyor noted the water temperature to be cooler than expected. Surveyor allowed the water to run for one minute and checked the temperature of the water. The water temperature was noted as 81 degrees Fahrenheit. Surveyor observed [NAME] Q and Dietary Aide (DA) T wash their hands in the sink several times. Surveyor asked [NAME] Q and DA T to allow the water to run and again checked the temperature. The temperature ranged from 80-85 degrees Fahrenheit.
Surveyor observed [NAME] Q using a sink near the food preparation area. The water temperature was checked and noted to be 105 degrees Fahrenheit after allowing the water to run.
Surveyor observed the dishwasher machine log of wash and rinse temperatures and noted wash and rinse temperatures which were much higher and within the acceptable hot water dish machine temperatures.
Surveyor asked [NAME] Q and DA T what other sinks are used in the kitchen. [NAME] Q expressed the 3-compartment sink is not used as it leaks.
Surveyor spoke with [NAME] Q and DA T about the water temperatures in the sinks observed. Both indicated the water temperatures fluctuate and have been low for several months. [NAME] Q expressed she has been on staff 6-7 months and the water has been like that since she started. DA T indicated she has been on staff a few years and the water issues were worse before they replaced a water heater several months ago. The water has not improved with replacing the water heater. Surveyor asked [NAME] Q and DA T if they had reported the water concerns to anyone. Both indicated their manager had just started a few weeks ago. They did not report the concern to their former or current manager. Surveyor asked if either had reported the concern to maintenance and both reported they had not. During the observation Surveyor observed DA T filling water pitchers intended for resident consumption from the sink in the kitchen.
On 06/06/23 at 8:52 AM, Surveyor and Maintenance Director (MD) U reported to the kitchen. Surveyor asked MD U about acceptable water temperatures. MD U indicated the water temperatures in the building should be 110 degrees Fahrenheit for Legionella prevention. The facility's water management plan indicates water temperatures should be 110-115 degrees Fahrenheit. Surveyor took the temperature of the sink in the food preparation area and the temperature fluctuated between 97-99 degrees Fahrenheit after a good run of water. The hand washing sink in the dish room ranged from 82-84 degrees Fahrenheit after running the water. The hand washing sink in the kitchen was much the same in fluctuation as noted above when checked by the Surveyor. MD U expressed this is the first hearing of sink water temperature concerns in the kitchen. MD U expressed several months ago the facility had issues with the water temperatures. The facility replaced the water heater several months ago and he was not aware the water temperatures were a problem after replacing the water heater. Surveyor requested and received the facility policy for water management.
On 06/06/23 at 1:15 PM, Surveyor spoke with Dietary Manager (DM) R about the water temperatures. DM R confirmed she had started employment a couple weeks ago and was aware of the cold-water issues but had not contacted maintenance about the water.
Surveyor requested and received an invoice showing the facility was billed for installing one hot water heater on 01/01/23.
On 06/07/23 at 9:45 AM, MD U spoke with Surveyor while touring the basement water system. MD U showed Surveyor where the water heater and water holding tank were located. MD U explained the facility had previously had two water heaters that fed the basement laundry and kitchen. When the hot water heater had issues several months ago two water heaters were replaced with one. The building's basement is supposed to operate with two. MD U suspects that when the laundry wash machine is running it is pulling the hot water from the holding tank that is being circulated as it is closest to the tank. Surveyor observed the tank to be located just outside the laundry department. The water that remains in the tank circulating has to travel 65-70 yards to feed the kitchen. The water temperatures are fluctuating and not being maintained above the requirement to prevent the spread of Legionella as the one water heater is not sufficient to do so.

Based on observation, interview and record review, the facility did not ensure nutritional values are maintained when altering food consistencies to minced and moist and pureed consistencies. This has the potential to affect 12 of 43 sampled and supplemental residents who eat this food consistency (R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292).
Cook Q was observed pureeing scrambled eggs and bacon using hot water as a thinning agent. [NAME] Q expressed there are no recipes, no policy or any directions that tell her what she is to use to modify food to ensure nutritional value.
This is evidence by:
On 06/06/23 at 7:10 AM, Surveyor observed [NAME] Q pureeing scrambled eggs and bacon. [NAME] added the eggs to the robocoup to puree then proceeded to the hot water thermos to pour water to pitcher. [NAME] Q did not measure the water and added it to the eggs to puree the consistency. [NAME] Q repeated this process with bacon. Surveyor asked [NAME] Q how she knows what and how much liquid she needs to add to foods to modify the consistency. [NAME] Q expressed the facility is in the process of updating menus and recipes. There are no directions on what to use and how much to use to modify the food consistency. [NAME] Q further expressed she uses hot water to modify all hot foods to maintain the temperature of the foods. Surveyor asked [NAME] Q how she knows she is maintaining food's nutritional values. [NAME] Q indicated she has had no training on modifying foods and what and how much liquid should be used. [NAME] further expressed she does not know, and her background is in restaurants with starting in nursing home approximately 6-7 months ago. The Dietary Manager recently started employment and the former manager did not train her.
On 6/06/23 at 1:29 PM, Surveyor and Dietary Manager (DM) R reviewed the recipes used in the kitchen and noted the recipes do not include any instructions on modifying food items to ensure the proper nutrition is maintained. DM R expressed the recipes should include instructions for both the minced and moist and puree diets. DM R further expressed she has not been trained on recipes needed to modify food consistencies as her background is in the restaurant field. DM R expressed there are no other directions in the kitchen to direct staff on proper methods needed to modify food consistency to maintain nutritional values. Surveyor requested a list of residents who receive these diets.
On 6/06/23 at 2:23 PM, Surveyor spoke with the facility's consulting Registered Dietician (RD) S who has consulted for the facility 6 years. Surveyor asked RD S about diet modifications of consistency and what should be used to modify the diets to maintain nutritional values. RD S indicated recipes should show directions on amount of food used for servings and the items needed to be added to maintain or improve nutritional values when foods are modified. The recipes should be with all recipes in a book in the kitchen, so the cooks know what to use and how much is needed.
Surveyor asked RD if hot water should be used to modify all hot foods. RD S expressed the menus/recipes are reviewed and signed by a RD to approve and ensure nutritional values are maintained. RD S further expressed the cooks at the facility were making decisions daily on what and how to cook. In December, new menus and recipes were approved which should have included recipe modifications. Food items need to be the proper texture and proper nutrition. Hot water for everything does not sound right. Water is not proper, staff should use something with nutritional value like bread or dairy products. Not water. Staff should have recipes for food items, they need to be printed and in book to be available to the cooks. That's a problem. Guidance and training in kitchen have been an issue. Staff are not ensuring nutritional values for residents.
Surveyor requested the facility policy related to diet modifications and any recipes the facility may have for diet modifications.
On 06/06/23 at 2:53 PM, Nursing Home Administrator (NHA) A informed Surveyor no recipes or policy was found and will be put in place going forward.
On 06/07/23 at 9:30 AM, DM R provided Surveyor with recipe for scrambled eggs she obtained from the facility's food vendor. The recipe indicates whole milk should be used with scrambled eggs when modifying the constancy. The recipe includes instructions on amount of eggs and milk to use when pureeing scrambled eggs.
Surveyor reviewed the list of residents receiving a minced and moist or puree diet. The list included R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292.