What is MATTOON REHAB & HCC's CMS rating?

MATTOON REHAB & HCC has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does MATTOON REHAB & HCC have any serious inspection findings?

Yes, MATTOON REHAB & HCC has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 55 total deficiencies from recent inspections.

What are the staffing levels at MATTOON REHAB & HCC?

MATTOON REHAB & HCC has a one-star staffing rating from CMS with 0.46 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MATTOON REHAB & HCC located?

MATTOON REHAB & HCC is located in MATTOON, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MATTOON REHAB & HCC have?

MATTOON REHAB & HCC has 148 certified beds.

Who owns MATTOON REHAB & HCC?

MATTOON REHAB & HCC is a for profit - corporation facility and is part of the TUTERA SENIOR LIVING & HEALTH CARE chain.

Is MATTOON REHAB & HCC safe?

MATTOON REHAB & HCC has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Was MATTOON REHAB & HCC ever fined?

Yes, MATTOON REHAB & HCC has been fined $374,037 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is MATTOON REHAB & HCC on any federal watch list?

No, MATTOON REHAB & HCC is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at MATTOON REHAB & HCC?

Medicare inspectors have found 55 deficiencies at MATTOON REHAB & HCC: 1 critical, 4 serious, 50 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting MATTOON REHAB & HCC?

Families visiting MATTOON REHAB & HCC should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MATTOON REHAB & HCC compare to other nursing homes?

MATTOON REHAB & HCC has a 1-star overall rating, which is below average compared to other nursing homes in IL. Families should carefully review inspection findings and consider alternatives.

MATTOON REHAB & HCC | 0/100 (Grade F)

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during wound treatments for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to prevent cross contamination during wound treatments for one of three residents (R3) reviewed for infected wounds on the sample list of three. Findings include: R3's current Diagnoses sheet documents the following: ) Lymphedema, Not Elsewhere Classified and Non-Pressure Chronic Ulcer of Unspecified Part Of Right Lower Leg With Unspecified Severity. R3's Minimum Data Set (MDS) dated [DATE] documents the following Brief Interview of Mental Status score of 15 out of 15, indicating no cognitive impairment. The same MDS documents R3 is at risk for pressure ulcers, and had two venous and arterial ulcers. R3's Physician Order Sheet (POS) dated 3/5/25 documents the following wound treatment orders: Wound Care: (L) calf: Cleanse w/ wound cleanser. Apply Santyl 250 UNIT/GM (gram)(Collagenase) ointment on wound bed followed by Calcium alginate (cut to fit) on wound bed. Cover with Superabsorbent dressing. Wrap with gauze wrap. Secure with tape. Change daily and PRN (as needed) soiling, slippage & unscheduled removal of dressing. Santyl External Ointment ) and Wound Care: (R) Medial Malleolus: Cleanse with wound cleanser. Apply Santyl ointment on wound bed followed by Calcium alginate (cut to fit) on wound bed. Cover with Superabsorbent dressing. Wrap with gauze wrap. Secure with tape. Change daily & PRN soiling, slippage and unscheduled removal of dressing. The same POS documents the following antibiotic medication order: Meropenem Intravenous Solution Reconstituted 500 MG (milligrams). Use 500 mg intravenously two times a day for Multi-Organism Wound Infection (R) medial malleolus for 10 Days -Start Date- 02/21/2025. R3's Antimicrobial Stewardship: Molecular Lab Result Wound Culture collected 2/17/25 with results 2/19/25 documents the following bacteria are present but not quantified, in R3's right ankle wound, Wound Antibiotic Resistance Organism Detected: *Bacteroides fragilis *Escherichia coli *Klebsiella pneumoniae *Proteus mirabilis *Pseudomonas aeruginosa *Staphylococcus aureus The same report documents: The detected organisms can be pathogenic when found in wound samples. Resistance genes were detected in multiple classes which may limit available treatment options. TMP-SMX Extended-Spectrum Beta-Lactamase Beta-lactam Tetracycline Antimicrobial Resistance High. On 3/6/25 at 10:35 am a sign was present on R3's door stating Enhanced Barrier Precaution/Contact Isolation See Nurse. PPE (personal protective equipment) supplies and hand sanitizer were present in the door caddy. V4, Wound Licensed Practical Nurse (LPN) and V11, LPN completed hand hygiene and donned gowns before they entered R3's room. V11, LPN had a draped, clean field set up with dressing supplies on R3's bedside table. R3 was lying in bed with the head of her bed slightly elevated. R3 had bilateral lower extremities compression stockings on. R3's right lower legs compression stocking had wet wound drainage at the right inner (medial) ankle joint bone (Malleolus) that had seeped through the gauze wrap covering R3's wound dressing. R3's left lower leg compression stocking had numerous dry, ring-shaped stains scattered on the front and back of the compression stocking covering R3's left posterior calf wound. V11, LPN acknowledge the compression stockings were soiled. V11 removed both of R3's compression stockings. V11, LPN placed a disposable linen savor under R3's bilateral lower legs. V11 removed her soiled gloves, repeated hand hygiene and donned new gloves. V11, LPN removed the clean scissors from the bedside table and cut off R3's soiled wet gauze wrap on the right lower leg, placing the scissors on the bedside table and next to the clean dressing supplies. V11 then removed a thick wet cotton dressing that overlayed R3's right Malleolus. V11 then removed beige wound drainage saturated calcium alginate from the wound bed. V11 disposed the soiled wound dressing items. V11, LPN removed her soiled gloves and went into the bathroom, washed her hands with soap and water and donned clean gloves. V11 cleansed R3's quarter sized open ankle wound with wound cleaner and four by four gauze and patted the area dry. V11 removed her soiled gloves, used hand sanitizer, donned new gloves. V11, LPN removed calcium alginate medicated pad and the soiled contaminated scissor from the bedside table. V11, LPN cut the calcium alginate pad to the wound bed size, using the same contaminated scissors she had cut the soiled gauze wrap off with. V11, LPN sat the soiled scissors on the bedside table. V11, LPN applied Santyl medicated ointment to the calcium alginate pad and placed it directly into R3's wound bed. V11 removed a Superabsorbent cotton dressing from the bedside table and covered the inner calcium alginate wound dressing. V11 applied moisturizer Ointment around the dressing and over R3's full right lower leg and foot. V11 then wrapped R3's lower right leg with gauze wrap and applied dated tape to secure. V11 removed and disposed of her gloves and returned to the bathroom and washed her hands. V11, LPN donned clean gloves and removed the same contaminated scissors off the bedside table. V11 cut off the gauze wrap dressing on R3's left lower leg. R3 had a four inch by four-inch dressing over the posterior aspect of her left calf. V11, LPN removed the soiled outer dressing and soiled calcium alginate from a quarter size left calf wound. There was scant serous drainage noted on the calcium alginate. V11, LPN removed the soiled gloves and went into the bathroom and washed her hands and donned new gloves. V4, Wound Nurse assisted R3 in holding her leg off the bed while V11 cleansed R3's left calf wound with wound cleanser and patted the area dry. V11 removed her soiled gloves, used hand sanitizer, donned new gloves. V11, LPN removed calcium alginate medicated pad and the soiled contaminated scissor from the bedside table. V11, LPN cut the calcium alginate pad to the wound bed size, using the same contaminated scissors. V11, LPN sat the soiled scissors on the bedside table. V11, LPN applied Santyl medicated ointment to the calcium alginate pad and placed it directly into R3's wound bed. V11 removed a Superabsorbent cotton dressing from the bedside table and covered the inner calcium alginate wound dressing. V11 applied moisturizer Ointment around the dressing and over R3's full left lower leg and foot. V11 then wrapped R3's lower right leg with gauze wraps and applied dated tape to secure. V11 removed and disposed of her gloves and returned to the bathroom and washed her hands after removing protective gown. On 3/6/25 at 11:05 am V11, LPN stated I thought about the scissors after the fact. I should have cleaned them with an alcohol wipe or bleach wipe after I cut off the (gauze wraps) and for sure before I cut the calcium alginate for both of those wounds. On 3/6/25 at 11:10 am V4, Wound Nurse stated I saw it too. The scissors should have been cleaned several times. (R3) just finished IV (intravenous) antibiotics for an infection in her right ankle wound. On 3/6/25 at 3:05 pm V2, Director of Nursing (DON) provided the facility policy Pressure Injury Assessment and Treatment Guideline - QA (Quality Assurance) Document dated January 2025. V2 stated the procedure in this policy V2 provided is the same for pressure ulcers as well and any wound treatment. Wound dressing needs to be cut to size using clean or sterile scissors to prevent cross-contamination, and the dressing should be dated and initialed by the nurse that completes the treatment. V2, DON stated We have bleach wipes in the building, those scissors used on (R3) treatment should have been cleaned each time they were contaminated.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete physician ordered pressure ulcer treatments fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete physician ordered pressure ulcer treatments for one of three residents (R2) reviewed for infected wound/pressure ulcers on the sample list of three. Findings include: R2's current Diagnoses Sheet documents the following: Acquired Absence Of Left Leg, Above the Knee, Acquired Absence Of Right Leg, Below the Knee, Peripheral Vascular Disease, and Pressure Ulcer Of Sacral Region Stage IV. R2's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status score of 15 out of a possible 15, indicating no cognitive impairment. The same MDS documents R2 has one Pressure Ulcer Stage III and one Pressure Ulcer Stage IV. R2's Physician Order Sheet (POS) dated 3/5/25 documents the following orders: Wound Care: (R) Trochanter wound (pressure ulcer Stage III): Cleanse with wound cleanser. Apply sureprep to periwound. Place Santyl in the wound bed. Loosely fill wound bed with Opticell gelling fiber. Cover with Superabsorbent dressing. Secure with bordered gauze. Change daily and PRN (as needed) soiling, Wound Care Coccyx wound (Pressure Ulcer Stage IV): Cleanse with wound cleanser. Apply sureprep to periwound. Place Santyl in the wound bed. Loosely fill wound bed with Opticell gelling fiber. Cover with Superabsorbent dressing. Secure with bordered gauze. Change daily and PRN soiling every day shift and as needed, and Refer resident (R2) to Infectious Disease and General Surgery for Osteomyelitis of right Trochanter and coccyx. R2's same POS documents the following antibiotic medication order: Amoxicillin-Pot Clavulanate Tablet 875-125 MG, Give 1 tablet by mouth every morning and at bedtime for wound infection for two Weeks -Start Date- 02/24/2025. R2's Hospital records dated 10/10/24 document an Magnetic Resonance Imagining (MRI) of the pelvis shows findings concerning for Osteomyelitis of the Greater Trochanter of the Right Femur and also of the Sacral Vertebral Body, The results were discussed with the nursing home staff. The patient will be offered referral to the wound clinic or to a general surgeon. He is seeing a wound provider (V8, Wound Nurse Practitioner) at the nursing home. He has completed a course of Meropenem (intravenous antibiotic medication). He does not have a Wound VAC in place. R2's Wound Specialist V8, Nurse Practitioner Progress Note dated 2/17/25 documents: Presence of bacteria (not specified) was identified No fluorescing was apparent on indicative of bacterial burden, in real-time visual wound imaging an excess of 10,000 Colony Forming Units per gram. R2's Treatment Administration Record dated 3/6/25 does not document a nurse's initials on 3/5/25, to indicate R2's Pressure Ulcer treatments were completed. On 3/6/25 at 2:20 pm an Enhanced Barrier Precaution/Contact Isolation See Nurse sign was on R2's door. Personal Protective Equipment supplies and hand sanitizer were present in the door caddy. V4, Wound LPN set-up a clean, draped field with R2's wound dressing supplies on a bedside table and placed it next to R2's bed. V4 used hand sanitizer and donned gloves and a gown and entered R2's room to complete R2's Pressure Ulcer Dressing changes. R2 was able to position himself using the left bedside rail to a partial left side side lying position. R2's Right Trochanter (hip region) was clearly visible. R2 had a heavily saturated bordered gauze dressing that was seeping beige drainage from the distal aspect of the right Trochanter Stage III Pressure ulcer wound dressing. R2's dressing was dated 3/4/25 and had V4's initials. V4 stated I guess nobody changed his dressings yesterday. I did it Tuesday (3/4/25) when I did rounds and measurement with (V8, Wound Nurse Practitioner). R2 then stated I waited and waited, expecting one of the nurses to come in and change these (pressure ulcer dressings) yesterday. I finally went to sleep and forgot all about it till this morning when you (surveyor) came in. V4, Wound LPN removed R2's right Trochanter bordered gauze dressing, absorbent pad and the wound bed strips. R2's right Trochanter was approximately a half dollar sized open wound. V4 removed and discarded the soiled dressings and then went into the bathroom and washed her hands with soap and water, donned new gloves and cleansed R2's right Trochanter Stage III pressure ulcer with four inch by four inch cotton pads and wound cleanser. V4 patted the areas dry, using a cotton tip to push the gauze under the edges of R2's Stage III wound. V4 stated R2 has undermining from three o'clock all the way around to nine o'clock. V4 removed gloves, washed hands in the bathroom and donned new gloves. V4 cut opti-gell fiber gelling material in a spiral like fashion, applied Santyl to the wound bed and inserted the spiraled material into the wound bed and tucked it below the undermining tissue. V4 applied Sureprep around the outside of the pressure ulcer, applied a thick cotton dressing and secured the dressing with dated bordered gauze. V4 removed gloves, washed her hands with soap and water, donned new gloves and assisted R2 to lay completely over, face and left abdomen down to expose R2's coccyx pressure ulcer dressing. R2's pressure ulcer dressing was dated 3/04/25 and had V4's initials to indicate when it was last changed. V4 stated (R2's) dressings need to be changed every day. (R2) is currently on antibiotic for Osteomyelitis, caused by these wounds. V4, Wound LPN removed R2's Coccyx Stage IV Pressure Ulcer Dressing bordered gauze dressing, absorbent pad and the wound bed strips. R2's coccyx had two, half-moon shaped, approximately two and a half inch opened wounds, connected by a half inch of healthy tissue. V4 stated The wound is connected, it is all one. The skin you see is like a bridge. V4 removed and discarded the soiled dressings, washed hands, and donned new gloves and cleansed R2's coccyx Stage IV pressure ulcer with four inch by four inch cotton pads and wound cleanser. V4 used a cotton swab to guide a piece of the gauze with wound cleanser under the bridged skin showing it is one Stage IV pressure ulcer. V4 patted the areas dry. V4 washed her hands donned new gloves. V4 cut opti-gel fiber material in a spiral like fashion, applied Santyl to the wound bed and inserted the spiraled material into the wound bed and tucked below the undermining tissue. V4 applied Sureprep around the outside of the coccyx pressure ulcer, applied an thick cotton dressing and secured the dressing with dated bordered gauze. On 3/6/25 at 2:55 pm V4, Wound/Licensed Practical Nurse stated We had some problems with the floor nurses doing the treatments. I thought we fixed the problem, but apparently not. On 3/6/25 at 3:05 pm V2, Director of Nursing (DON) provided the facility policy Pressure Injury Assessment and Treatment Guideline - QA (Quality Assurance) Document dated January 2025. V2 stated wound dressing should be dated and initialed by the nurse that completes the treatment. There have been some issues with agency nurses not completing the treatments.

Jan 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to keep resident call buttons in an easily accessible area for four of five at risk residents (R2, R3, R4, R5) reviewed for call ...

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Based on observation, interview, and record review the facility failed to keep resident call buttons in an easily accessible area for four of five at risk residents (R2, R3, R4, R5) reviewed for call button accessibility on the sample list of five. Findings Include: 1. R2's Medical Diagnoses List dated January 2025 documents R2 is diagnosed with Chronic Obstructive Pulmonary Disease, Dysphagia, Weakness, Dementia, and Difficulty Walking. R2's Care Plan dated May 2024 documents R2 is at risk for falls and staff should keep her call light within reach and encourage her to use it. R2 also has a communication problem related to Dementia and staff should make sure R2's call light is within reach and avoid isolation. R2 requires two person staff assistance for transfers and toileting. On 1/26/25 at 1:40 PM R2 was laying in her bed. She was the only person in her room. R2 was wearing oxygen by nasal cannula and a wheelchair was parked near her bed. R2's special touch pad call button was laying at the foot of her bed completely out of her reach. 2. R3's Medical Diagnoses List dated January 2025 documents R3 is diagnosed with Unsteadiness on Feet, Dementia, and Dysphagia. R3's Care Plan dated January 2025 documents R3 is at risk for fall related to confusion and gait problems and staff are to keep his call light within reach and encourage him to use it. R3 also has a swallowing problem and should only eat with supervision. On 1/26/25 at 12:50 PM R3 was in the family room sitting in his wheelchair by himself. R3 was attempting to eat his noon meal which consisted of pureed food. There was no access to a call button in R3's reach and no staff supervising R3 while he was eating. When this surveyor entered the room, R3 began to yell out and was attempting to communicate but could not be understood. Staff did not come in the room to attend to R3 for approximately 15 minutes. On 1/26/25 at 2:45 PM R3 was laying in his bed asleep. There was a fall mat on the floor next to his bed and R3's call button was coiled on the other bed completely out of R3's reach. 3. R4's Medical Diagnoses List dated January 2025 documents R4 is diagnosed with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Vascular Dementia, and Difficulty Walking. R4's Care Plan dated December 2024 documents R4 is at risk for falls related to deconditioning, gait/balance problems, history of falls, COPD (Chronic Obstructive Pulmonary Disease), and CHF (Congestive Heart Failure). Staff should keep R4's call button within reach and remind her to use it. On 1/26/25 at 2:18 PM R4 was sitting in her recliner in her room by herself. R4 had slid down in her recliner and her feet were hanging off the footrest. Her recliner was in the middle of two beds. One call button was coiled on one of the beds and the other call light was on the other side of R4's recliner on the floor. On 1/26/25 at 2:18 PM R4 stated she would use her call button to call for help but she couldn't find it. R4 stated she always slides down in her recliner. 4. R5's Medical Diagnoses List dated January 2025 documents R5 is diagnosed with Dementia, History of Falls, Weakness, and Difficulty Walking. R5's Care Plan dated December 2024 documents R5 is at risk for falls related to dementia, muscle weakness, confusion, impulsiveness, and incontinence. Staff should keep R5's call button within reach. On 1/26/25 at 2:10 PM R5 was asleep in his bed. His wheelchair with mechanical lift sling was near his bed. R5's call button was on the floor beside his wheelchair, far from R5's reach. On 1/26/25 at 2:47 PM V3 Assistant Director of Nurses (ADON) confirmed all residents should have a call button within their reach when they are in bed or in a room alone and might need the assistance of staff. V3 confirmed some residents are at higher risk for accidents- for example residents that are at risk for choking while eating, those that need assistance to safely transfer, and those that are unaware of their own physical boundaries.

Dec 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to complete a thorough investigation for one (R1) of six residents reviewed for abuse from a total sample list of 15 residents. Findings includ...

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Based on interview and record review the facility failed to complete a thorough investigation for one (R1) of six residents reviewed for abuse from a total sample list of 15 residents. Findings include: The facility provided Abuse Policy dated 12/2024 documents that the facility Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Steps in the investigation include completing a thorough investigation with two management level staff conducting interview with witnesses or other staff, residents or visitors who could have knowledge of the allegation and witnesses will be asked to assist with completing statements. Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on and if the allegation occurred on a specific shift, all staff for the identified shift only will give a statement if indicated. The facility will immediately remove any alleged perpetrator from any further contact with any resident through suspension, pending the outcome of the facility investigation, prosecution, or disciplinary action against the employee. At the time of suspension, the alleged perpetrator will be interviewed. The facility provided report to the State Agency dated 12/1/24 documents that on 11/25/24 R1's left hand was bruised. An X-ray was performed on 11/25/24 and found the third finger was fractured. According to the facility report, this injury occurred while an unnamed Certified Nursing Assistant (V20 CNA) was dressing R1. The facility investigation report was reviewed for a thorough and complete investigation. No interviews with V20 CNA were obtained. No interviews about V20's care with other residents or customer service were completed with residents or other staff members. V20 CNA's time cards were reviewed. V20 worked at the facility on 11/23/24, 11/24/24, 11/25/24 and on 12/8/24. On 12/16/24 at 11:30AM, V1 Administrator stated that nursing did the investigation of R1's finger injury. On 12/16/24 at 1:15PM, V2 Director of Nursing stated that she didn't investigate who might have injured R1's finger. I just missed it. I was off site and trying to do a bunch of things and just took his word for the fact that it was not an unknown injury and didn't think about it potentially being abuse. I should have asked more questions. V20 CNA was not suspended. On 12/16/24 at 3:30PM, V1 Administrator stated that V20 CNA will no longer be employed at the facility through the employment agency where she was working and that moving forward, V1 will review all investigations for thoroughness and completion.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide nail care for one of six residents (R1) reviewe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide nail care for one of six residents (R1) reviewed for activities of daily living from a total sample list of 15 residents. Findings include: The facility provided report to the State Agency dated 11/26/24 documents that on 11/25/24 a bruise was found on R1's left middle finger and upon X-ray was fractured. The facility report documents the cause of the fracture was due to R1's cracked fingernail snagging his shirt causing the finger to be bent and fractured while R1 was dressed due to left side hemiplegia. R1's care plan dated 11/26/24 documents to keep R1's nails trimmed and short enough to prevent snagging on clothing. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and that R1 is dependent on staff for activities of daily living. On 12/12/24 at 11:45AM, R1's nails on both the right and left hands were nearly an inch past the end of the finger with food and brown matter underneath them. On 12/16/24 at 9:30AM, R1's nails remained long on both hands (nearly an inch past the end of the fingers) with food and brown matter underneath them. On 12/16/24 at 9:31AM, R1 stated that he would like to have his nails clipped.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of four (R1, R12, R13 and R14) of six residents r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the dignity of four (R1, R12, R13 and R14) of six residents reviewed for dignity from a total sample list of 15 residents. Findings include: 1.) The facility provided report to the State Agency dated 11/26/24 documents that on 11/19/24, R1 complained that he did not like the care provided to him by V15 Certified Nursing Assistant (CNA). The facility response documented that V15 CNA would not provide R1 with further care. R1's Minimum Data Set, dated [DATE] documents R1 as cognitively intact and that R1 is dependent on staff for activities of daily living. On 12/16/24 at 10:00AM, V15 CNA stated that he continues to provide care for R1, as directed by the nursing staff. On 12/16/24 at 1:00PM, R1 stated that V15 CNA still cares for him. R1 stated, They just do whatever they want. On 12/16/24 at 3:10PM, V1 Administrator stated that V15 CNA is not supposed to be providing care for R1 and that by doing so, R1's wishes are being disrespected. 2.) The facility provided report to the State Agency dated 11/15/24 documents that R12 complained that while in her room, V13 (Roommate's Boyfriend) walked in on her in a state of undress and did not immediately leave. R12's Minimum Data Set, dated [DATE] documents R12 is cognitively intact. R12's progress notes document discharge from the facility on 12/1/24. On 12/16/24 at 8:15AM, V14 CNA stated that she was in the area when the issue occurred and that she got to R12 as soon as R12 began to yell and removed V13 from the room. V14 CNA stated that she was able to calm R12 after that. V14 stated that nothing like that had ever occurred in the facility before, to her knowledge. On 12/16/24 at 9:15AM, V12 Social Services Director stated that she met with R12 multiple times after the incident and that R12 returned to her baseline. In the moment, R12 was very upset and embarrassed and I'm sure it was a dignity issue for her. 3.) The facility provided report to the State Agency dated 12/4/24 documents that on 11/26/24, R13 complained that R13 was disrespectful to her by not being responsive to her needs. The facility response dated 12/4/24 documents that V4 CNA will not be providing further care for R13. R13's Minimum Data Set, dated [DATE] documents that R13 is cognitively intact. On 12/16/24 at 10:46AM, R13 stated that there is a CNA on nights who just isn't kind. R13 then described V4 CNA, confirmed by V16 LPN. I would ask her to get something for me and she would say, Its just right there. I would definitely say that she was disrespectful. On 12/16/24 at 10:50AM. R13 confirmed that V4 CNA continues to provide her with care. 4.) The facility provided report to the State Agency dated 12/6/24 documents that on 11/30/24 R14 complained that V18 and V19 CNAs were providing R14 with care while laughing and being rude to R14. R14's Minimum Data Set, dated [DATE] documents R14 as cognitively intact. R14's Minimum Data Set, dated [DATE] documents that R14 is dependent on staff for mobility and toileting. On 12/16/24 at 12:01 PM, R14 stated that she had an issue with 2 CNAs recently when she needed to use the restroom and the CNAs came in and started laughing while assisting her with moving her on the lift and to toilet. It was so weird, both my roommate and I asked why they were laughing and they said that it wasn't about me but I didn't believe them. I definitely felt bad and disrespected. On 12/12/24 at 12:00PM, V1 Administrator stated that V18 and V19 CNA's are on the do not hire list because of the complaint.

Aug 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the actual health status after a change in residents condition. This failure affects...

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Based on observation, interview, and record review, the facility failed to revise a resident's care plan to reflect the actual health status after a change in residents condition. This failure affects one resident (R1) out of three residents reviewed for care plans on the sample list of 7. Findings include: R1's Diagnoses Sheet updated 5/14/24 documents R1's Primary, admission Diagnosis for Medical Management was Alcohol Abuse, Uncomplicated. R1's Care Plan updated 7/23/24 with the following interventions: (R1) is at risk for falls. Educate family to provide assistance with transfers and ambulation when out in the community. This same plan of care does not include any mention of the primary diagnosis of medical management Alcohol Abuse, Uncomplicated, or interventions to prevent future exacerbation. R1's SBAR (Situation, Background,Assessment, and Recommendation) note dated 7/22/2024 at 1:09 pm documents the following:Note Text: The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is resident returned from being out in the community with the smell of ETOH (alcohol) and belligerent language. R1's Health Status Note dated 7/22/2024 at 2:00 pm documents the following: Note Text: Resident returned around 12:45 pm from being out in the community w/his female significant other. Resident was being loud in the hallway. Resident smelled of ETOH (Primary diagnoses on 5/14/24 diagnosis documented above) . (R1's treatment plan for alcohol dependency was not entered on R1's care plan or interventions to prevent complications). Resident was slurring his words and being uncooperative. The DON (V6, previous Director of Nursing) and this nurse (V12, Licensed Practical Nurse) went to interview resident. Resident denied use of alcohol or drugs while he was out. (V11, Physician) was notified at 13:05 (1:05 pm) that resident returned with the smell of ETOH. NOR (new orders received) to send resident to (local hospital) ED (hospital, emergency department) for eval (evaluation) & treatment for ETOH & drug screening. Resident was in the hallway being belligerent & yelling profanities. Resident brought up to the nurses station and placed in another room away from his roommate, whom he was belittling and being verbally inappropriate. EMS (Emergency Medical Service) arrived at approximately 1320 (1:20 pm) w/1 (with one) police officer present. Resident was uncooperative, belligerent & verbally inappropriate to EMS & the police officer. At approximately 1340 (1:40 pm), 3 (three) more police officers showed up to the facility. The police officers took resident and placed him on the EMS stretcher. Resident was taken from the facility via stretcher and EMS to (local hospital) ED at approximately 13:55 (1:55 pm). Attempted several times to speak to someone at the ED, but was unable to speak to anyone. R1's Social Service Note dated 7/23/2024 at 1:50 pm documents: Late Entry: Note Text: Meeting (care plan meeting, not updated to guide all staff in prevention) held with (R1). He states that he is sorry for his actions the day before and that he will not do them again that he made a stupid decision. He also states that he is fine with getting education from AA (Alcoholics Anonymous). He is also open to getting information in regard to other facilities that would be able to manage his alcoholism. At present he would like to stay in the facility, but he understands that the facility has to make sure that everyone remains safe. (R1) states that he has a sponsor (proper first name) and that the facility can reach out to him. He gave SSD (V17, Social Service Director) his (sponsors) number. R1 SBAR dated 8/6/2024 (two weeks after the above documented ETOH intoxication and transport to the hospital) at 2:15 pm documents a second event related to R1's intoxication. Note Text: The resident is experiencing a change in condition. See SBAR assessment for further information and family/physician notification. The change in condition the resident is currently experiencing is ETOH intoxication, belligerence, uncooperative. R1's Health Status Note dated 8/6/2024 at 4:15 pm documents in detail the SBAR identified above information: Note Text: This writer noticed a change in resident's behavior. Resident began playing his music loud, being overly verbally affectionate to staff (unidentified). Resident then decided to ambulate w (with)/ his walker. PTA (V19, Physical Therapy Assistant) quickly came to assist resident w/ambulation, trying to get him to stop and sit in his wheelchair. Resident became belligerent, uncooperative, argumentative w/staff/therapy. Staff found 1 (one) empty bottle of Vodka and an open bottle of Vodka. Resident denied drinking or taking anything. MD (V11, Physician) notified. NOR to send resident to ED for eval (evaluation). EMS notified and arrived to facility. EMS departed facility R/T (related to) resident was A/Ox4 ( alert and oriented to person,place,time and event) and refused to go to the ED. (local) PD (police department) notified and arrived to facility. PD unable to assist in removal of resident. Resident became belligerent w/PD. Resident agreed to a breathalyzer, then refused because PD wouldn't take him out of the facility. Resident requested to take his alcohol w/ him if the PD would take him. PD informed him that was not an option. (local) PD departed the facility. Resident then requested to d/c from the facility. MD notified and NOR to d/c. No one was available to come get him. Psych (Psychiatric) NP (V13, Nurse Practitioner) gave the order for a 72 hour psych hold (involuntary hospital admission documented below) at (local hospital). EMS arrived and transported resident to (local hospital) ED. The facility Inpatient (hospitalization) Certificate dated 8/6/24, regarding R1, documents the following: Based on the foregoing examination it is my opinion that he or she is: A person with mental illness who, because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed; I (signed by V13, Psychiatric Nurse Practitioner) believe that the individual is subject to: (second box marked on form ) Involuntary inpatient admission and is in need of immediate hospitalization. On 8/15/24 at 3:00 pm V17, Social Service Director (SSD) stated R1 had a care plan meeting 7/23/24 after his hospital emergency room visit 7/22/24 for ETOH intoxication. V17 stated V17 does not know why the intervention to refrain from going out on pass, and R1 committed to is not on the care plan. V17 said V17 does not know why ETOH is not on R1's 'care plan at all'. On 8/15/24 at 3:05 pm V3, Registered Nurse/ Minimum Data Set/Care Plan Coordinator stated I was not told to update (R1) care plan related to ETOH problem. I would have, had I known. On 8/15/24 at 3:10 pm V2, Regional Nurse reviewed R1's Care Plan and stated V17, SSD, V6, Previous Director of Nursing and V2 were in the care plan meeting 7/23/24 with R1. ETOH was a problem that should have been on the care plan. The facility policy Care Planning - Interdisciplinary Team ' dated January 2017 documents the following: Policy: Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Purpose: 1) To assess each resident's strengths, weaknesses, and care needs 2) To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and well being as possible. 3) To enter this assessment data into a computerized format that will be transmitted to the Center for Medicare/Medicaid Services (CMS). The same care plan policy documents: 1) Upon completion of comprehensive assessments (as defined by the RAI Manual), CAAs (Care Area Assessment) will be triggered to flag areas of concern that may need to be addressed in the POC (plan of care) for that resident. Each triggered CAA will be reviewed by designated staff to determine if a triggered condition affects the resident's function and quality of life or if the resident is at significant risk of developing the triggered condition. 2) CAA documentation will be done following guidelines in the RAI Manual and will state whether or not a care plan is needed to address the triggered area and the rationale for arriving at this decision. 3) While CAA's identify common areas of concern in nursing home residents, the POC is not to be limited to the triggered areas. The comprehensive POC must address all care issues that are relevant to the individual, whether or not they are specifically covered in the MDS/CAA process.

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to employ the services of a full-time Director of Nursing. This failure has the potential to affect all 90 residents residing in ...

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Based on observation, interview, and record review the facility failed to employ the services of a full-time Director of Nursing. This failure has the potential to affect all 90 residents residing in the facility. Findings include: On 08/14/24 at 9:05 there was no Director of Nursing (DON) present in the building to complete entrance paperwork. On 8/14/24 at 9:10 am V3, Registered Nurse/ Minimum Data Set/Care Plan Coordinator stated the facility does not have a full-time Director of Nursing. On 8/14/24 at 9:25 am V2, Regional Nurse completed the entrance paperwork for this survey. V2 stated V2 is not full time in the facility. V2 works in this facility on average two days a week, to help the facility in the absence of a full-time DON. On 8/15/24 at 11:45 am V6, Previous DON stated her last day working in the facility was 7/31/24. The facility 802 Matrix dated 8/14/24 document 90 residents are currently residing in the facility.

Jul 2024 10 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Incontinence Care (Tag F0690)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain a physician's ordered diagnostic test in a time...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to obtain a physician's ordered diagnostic test in a timely manner for one of two residents (R5) reviewed for Urinary Tract Infections on the sample list of 49. This failure extended R5's suffering for a total of six days with the following symptoms: painful and burning urination, abdominal pressure, and overall discomfort. Findings Include: R5's Medical Diagnoses list dated July 2024 documents R5 is diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 6/30/24 documents R5 complained of abdominal pain and burning and pain with urination. V17 Medical Director was notified and ordered a urinalysis and culture and sensitivity to be collected and sent to the lab. R5's Urinalysis Lab dated 7/3/24 documents R5's urine was not sent to the lab until 7/3/24. R5's Urine Culture and Sensitivity Lab finally resulted on 7/6/24. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 7/6/24 documents R5 stated she has had Urinary Tract Infection (UTI) symptoms and she has not gotten any treatment. R5 stated she has abdominal tenderness and burning with urination and symptoms have gotten worse. R5 requested to go to the emergency room. R5 was sent to the emergency room. R5's Health Status Note dated 7/8/24 documents R5 returned from the hospital after being admitted with a Urinary Tract Infection. R5 returned to the facility with a Peripherally Inserted Central Catheter (PICC) line and orders for intravenous antibiotics. On 7/09/24 at 1:16 PM R5 stated she first had symptoms of an UTI on Saturday (6/30/24). R5 told the nurse and an urine culture was ordered however it took many days for it to be completed and then it took six days to get results back. On the sixth day there was still no treatment started so R5 requested to go to the emergency room. R5 stated she was admitted to the hospital with a UTI, had a PICC line inserted and antibiotics were started. R5 stated she had abdominal discomfort, burning, bloating and pain for six days without any relief or treatment. R5 stated she knows her body and she knew she needed to be treated and was tired of waiting. On 7/12/24 at 12:06 PM V17 Medical Director confirmed his expectation is for nursing to implement new orders as they are given and R5's urinalysis should have been sent to the lab on 6/30/24- the day it was ordered, not three days later. V17 confirmed he was waiting for the culture and sensitivity results before treating R5's urinary tract infection and if the urine would have been sent in sooner, treatment could have been provided sooner. V17 confirmed R5 decided to go to the emergency room for treatment on 7/6/24 and was diagnosed with a urinary tract infection and is being treated with intravenous antibiotics.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a complete discharge summary for one of two residents (R101)...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide a complete discharge summary for one of two residents (R101) reviewed for discharge on the sample list of 49. This past noncompliance occurred from 4/10/24-6/1/24. Findings Include: R101's Census Information dated 4/10/24 from the facility's EMR (Electronic Medical Record) documents R101 was admitted to the facility on [DATE] and was discharged on 4/10/24. R101's Medical Diagnosis sheet dated 2/14/24 in the EMR documents R101 is diagnosed with Metabolic Encephalopathy and Unspecified Convulsions. R101's Discharge summary dated [DATE] documents five separate sections with the following titles, Discharge Summary Recapitulation of Stay, Social Service Summary of Resident Stay, Clinical Summary of Resident Stay, Dietary Summary of Resident Stay and Activity Summary of Resident Stay. Of the five sections of R101's Discharge Summary only two sections were completed and the others were left blank. R101's Progress Note dated 4/10/24 documents R101 was discharged to another facility and all personal belongings and medications were sent with R101. The facility's Discharge Summary and Plan policy dated November 2022 documents staff should complete the Discharge Plan, Instructions, and Summary which provides a recapitulation or summary of the resident's stay. On 7/11/24 at 10:30 AM V2 Director of Nurses stated the Discharge Summary or Recapitulation of Stay should be completed and if it is not found under the resident assessment tab then it is not completed. Prior to the survey date the facility took the following actions to correct the noncompliance. 1. In May of 2024 the facility social services consultant identified that the facility was not completing the discharge summary recapitulation of stay assessment. 2. During morning meeting on 5/31/24 the clinical team members were educated about the discharge summary recapitulation of stay assessment process. 3. On 5/31/24 an Ad Hoc Quality Assurance and Performance Improvement meeting was held to review and discuss the education provided. 4. On 6/1/24 a follow up email was sent to each discipline from V2 Director of Nurses, confirming that each discipline, nursing, dietary, activities, and social services, would be responsible for completing their section in the discharge recapitulation prior to the resident discharging. 5. Audits of discharge summaries were initiated beginning on 6/1/24 and continued for five weeks.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to completed treatments as ordered for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample list of 13. Findings inclu...

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Based on interview and record review the facility failed to completed treatments as ordered for two of three residents (R1 and R2) reviewed for pressure ulcers in the sample list of 13. Findings include: The facility's Pressure Ulcer/Pressure Injury Prevention Policy with a revised date of March/2022 documents, If a PU/PI (Pressure Ulcer/Pressure Injury) is present, provide treatment to heal it and prevent the development of additional PU/PI's. 1.) R1's Order Summary Report dated 8/8/24 documents diagnoses including Type 2 Diabetes, Dementia and Pressure Ulcer Right Heel Unstageable. This Order Summary also documents an order dated 8/8/24 for the right heel, cleanse with normal saline, do not scrub or use excessive force, cover with a hydrophilic polyurethane non-adhesive dressing may slightly overlap on new skin, wrap with rolled gauze, change every day and as needed. R1's Treatment Administration Record (TAR) dated 7/1/24 through 7/31/24 documents the order for the right heel dressing change and the treatment is not signed out as completed on 7/25/24 and 7/31/24. R1's TAR dated 8/1/24 through 8/31/24 documents the order for the right heel dressing change and the treatment is not signed out as completed on 8/3/24. On 8/8/24 at 3:05 PM, V2 Corporate Director of Nursing confirmed these treatments are not signed out indicating they were not completed. 2.) R2's Order Summary dated 8/8/24 documents diagnoses including Encephalopathy, Morbid Obesity, Acquired absence of Right Leg Below the Knee and Acquired Absence of the Left Leg Above the Knee. This Order Summary documents an order dated 7/9/24 for a treatment to the Coccyx/Right Buttock to cleanse wound with soap and water, pat dry, apply an enzymatic debriding ointment/Calcium alginate to wound bed, cover with a bordered gauze daily and as needed. This Order Summary also documents an order dated 5/28/24 for a treatment to the Right Trochanter to cleanse with wound cleanser, apply enzymatic debriding ointment and calcium alginate to the wound bed, cover with bordered gauze daily and as needed until healed. R2's TAR dated 7/1/24 through 7/31/24 documents the order for the Coccyx dressing change and the treatment is not signed out as completed on 7/22/24, 7/23/24, 7/25/24, 7/26/24 and 7/30/24. This TAR documents the order for the Right Trochanter dressing change and the treatments is not signed out as completed on 7/22/24, 7/23/24, 7/25/24, 7/26/24 and 7/30/24. R2's TAR dated 8/1/24 through 8/31/24 documents the order for the Right Trochanter dressing change and the treatment is not signed out as completed on 8/3/24 and 8/6/24. This TAR documents the order for the Coccyx dressing change and the treatment is not signed out as completed on 8/3/24 and 8/6/24. On 8/8/24 at 3:05 PM, V2 confirmed these treatments are not signed out indicating they were not completed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess and monitor a Peripherally Inserted Central Cat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess and monitor a Peripherally Inserted Central Catheter (PICC) for one of two residents (R5) reviewed for Intravenous Catheter medication administration on the sample list of 49. Findings Include: R5's Medical Diagnoses list dated July 2024 documents R5 is diagnosed with Bipolar Disorder, Depression, and Neuromuscular Dysfunction of Bladder. R5's Minimum Data Set, dated [DATE] documents R5 is cognitively intact. R5's Situation, Background, Assessment, and Recommendation (SBAR) and Communication Form and Progress Notes dated 7/6/24 documents R5 stated she has had Urinary Tract Infection (UTI) symptoms and R5 requested to go to the emergency room. R5 was sent to the emergency room. R5's Health Status Note dated 7/8/24 documents R5 returned from the hospital after being admitted with a Urinary Tract Infection. R5 returned to the facility with a PICC line and new orders to start intravenous antibiotics. R5's Physician Order Sheet (POS) dated 7/9/24 documents there are no orders regarding R5's PICC line. R5's Medication or Treatment Administration Records dated July 2024 document since readmission on [DATE] R5's PICC line has not been routinely monitored by nursing staff. On 7/10/24 at 10:00 AM R5 stated she returned from the hospital with her PICC line and she hasn't seen the nursing staff assess it except to administer the antibiotic doses. On 7/11/24 at 12:35 PM V2 Director of Nurses (DON) stated when a resident is admitted to the facility with intravenous access the correct order set need to be implemented in order to care for and maintain the intravenous access. V2 confirmed an intravenous site should be monitored and flushed every shift and staff should document the status of the intravenous site.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Based on interview and record reviewed the facility failed to manage a resident's pain by failing to obtain pain medication and administer pain medication for one of one resident (R83) reviewed for pa...

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Based on interview and record reviewed the facility failed to manage a resident's pain by failing to obtain pain medication and administer pain medication for one of one resident (R83) reviewed for pain management in the sample list of 49. Findings Include: R83's undated Face Sheet documents R83's diagnosis as: Bilateral Primary Osteoarthritis of Knee. R83's Physician Order Sheet (POS) dated July 2024 documents Oxycodone-Acetaminophen oral tablet 5-325 milligrams two tablets by mouth every four hours for pain management. R83's Medication Administration Record (MAR) documents on 7/9/24 at 12:00 PM a dose was not given and to see progress note. On 7/9/24 at 4:00 AM the MAR documents a dose not given and to see progress note and the same was documented on 7/9/24 at 8:00 AM. On 7/9/24 at 2:34 PM V11 Licensed Practical Nurse (LPN) stated there was no Oxycodone available to be given to R83 this morning. V11 LPN stated she just found out this morning the medication was not available and placed a call to the doctor so V11 could get the order to the pharmacy. V11 stated there were three doses missed the night before and none of those nurses called the doctor or the pharmacy to get more pain medication for R83. On 7/9/24 at 3:00 PM V2 Director of Nursing (DON) stated the medication cards prompt you when the medications are low so more can be ordered before running out. V2 stated the night shift should have called the doctor and/or pharmacy to get an order for a pain medication that was in our stat safe box until the original medication was obtained. V2 stated there were not notes regarding this medication being ordered, not given, or doctor called.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to place call light devices within resident's reach for f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to place call light devices within resident's reach for four of four residents (R14, R27, R77, R95) reviewed for call lights in the sample list of 49. Findings Include: R14's undated Face Sheet documents R14's diagnoses as: Repeated Falls, Unsteadiness of feet, Muscle Weakness, and unspecified Dementia. R14's Care Plan dated 3/20/24, documents R14 as having a non-traditional call light. R14's Minimum Date Set (MDS) dated [DATE], documents R14 is dependent and requires substantial/maximal assist with moving in bed, rolling, lying, sitting, chair bed transfers, toilet transfers, dressing, and personal hygiene. R14's Brief Interview for Mental Status (BIMS) dated 7/1/24, documents R14 is not cognitively intact. On 07/09/24 at 10:03 AM R14's call light was on the floor near the bed and not within R14's reach. R27's undated Face Sheet documents R27's diagnoses as: Fracture of Superior rim of right Pubis, subsequent encounter, Wedge compression fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, primary generalized Osteoarthritis, difficulty walking, unsteadiness on feet. R27's BIMS dated 7/9/24, documents R27 is not cognitively intact. R27's Care Plan dated 2/16/24, documents be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. On 7/9/24 at 9:40 AM R27 was sitting in R27's recliner, and the call light was hanging on the bed rail approximately three to four feet away from R27's reach. R77's undated Face Sheet documents R77's diagnoses as: Malignant Neoplasm of pelvic bones, sacrum and coccyx, Malignant Neoplasm of body of stomach, Epilepsy, and other reduced Mobility. R77's Care Plan dated 3/31/24, documents to be sure R77's call light is within reach. On 7/9/24 at 9:50 AM R77 was asleep in bed and R77's call light was lying at the end of R77's bed, out of reach for R77. R95's undated Face Sheet documents R95's diagnoses as: Cognitive Social or Emotional Deficit following Cerebral Infarction, Morbid Obesity, and Gout. R95's Care Plan dated 7/9/24, documents be sure R95's call light is within reach. On 7/9/24 at 10:10 AM R95 stated R95 cannot reach the call light. At this same time, R95's call light was at the end of R95's bed, not within R95's reach. On 7/9/24 at 2:34 PM, V11 Licensed Practical Nurse (LPN) stated call lights should be in resident's reach at all times. V11 also stated when the staff start their shift, they should be making rounds to make sure the call lights are within reach for all the residents and when staff are taking a resident back to their room, staff need to make sure they are putting the call light in reach.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review the facility failed to thoroughly address multiple concerns of the resident council and facility grievances regarding laundry services. This failure e...

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Based on observation, interview and record review the facility failed to thoroughly address multiple concerns of the resident council and facility grievances regarding laundry services. This failure effects 5 of 5 residents (R8, R15, R56, R78 and R81) who participated in Resident Council Meeting on the sample list of 49. Findings Include: Resident Council Meeting was held on 7/10/24 at 1:00 PM in the ADL (Activities of Daily Living) room. The Resident Council Members were R8, R15, R56 (Resident Council President), R78 and R81. During the meeting all five residents complained the facility did not return their personal items and clothing back in a timely matter. They also complained the clothes returned to them are not always clean and they appear as though they have not been washed. The Resident Council Meeting minutes dated 1/30/24, 2/27/24, 3/26/24, 4/25/24 and 6/28/24 under the section Laundry Issues/Concerns document complaints regarding the facility's laundry service. Specific complaints included issues such as the laundry taking a long time to be returned, clothes are put into closets poorly, missing laundry and laundry not being labeled, and clothes are returned dirty. The facility's Grievance Log from February 2024 to June 2024 documents numerous concerns about clothing not being returned to the residents timely or at all. On 07/11/24 at 9:28 AM a large bin of clothing full of personal items and other items were hanging in the laundry room. V15 Laundry Attendant stated that a lot of personal items are in the laundry room, just waiting to be returned to the residents. V15 Laundry Attendant stated that she now works half time housekeeping and half time laundry and there is not enough time to get the resident's personal clothing/items returned to them, especially when the Certified Nurses Assistants (CNAs) wait until all of the bins are full and bring them all at once. On 7/11/23 at 1:30 PM V13 Housekeeper/Laundry Supervisor stated the clothes in the bins are unlabeled and the ones hanging on the rack have not been delivered to the residents yet. V13 stated Laundry Hours for employees are one full time person on day shift and one person working 2:00 PM to 10:00 PM Monday through Friday. V13 stated during the weekends only day staff work. V13 stated the facility is using contract services for their laundry and housekeeping departments. On 7/11/24 at 2:00 PM the facility was asked for a Laundry Policy and V1 Administrator stated they did not have a laundry policy.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to maintain proper food storage order, failed to maintain dishwashing equipment to sanitize dish wares, and failed to maintain fo...

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Based on observation, interview, and record review the facility failed to maintain proper food storage order, failed to maintain dishwashing equipment to sanitize dish wares, and failed to maintain food contact equipment in a sanitary manner. These failures have the potential to affect all 99 residents residing in the facility. Findings Include: 1.) On 7/9/24 at 9:50 AM, in the facility's walk-in refrigerator, there was an opaque plastic tub with thawing raw pork sausage sitting on top of and in direct contact with thawing raw hamburger. On 7/9/24 at 9:50 AM, V3, Dietary Manager in Training, stated, Pork should be below hamburger. On 7/10/24 at 1:40 PM, V6, Dietary District Manager, stated, We follow the FDA (Food and Drug Administration) Code for food storage hierarchy. The current FDA Code (2017) documents on page 421, It is the intent of this code to require separation of raw animal foods based on anticipated microbial loads and food type in order to prevent cross-contamination. On page 558, this same FDA Code documents pork is a food associated with Trichinella species (worms) requiring temperature controlled cooking. The facility policy 'Food Storage: Cold Foods' dated 4/2018 documents, All foods will be stored and arranged in a manner to prevent cross-contamination. 2.) On 7/9/24 at 10:03 AM, V3, Dietary Manager in Training processed a tray of plastic cups through the facility dishwasher, V3 conducted a chlorine test by dipping a chemical test strip into the dishwasher rinse cycle. This test strip did not change color, merely appeared to become wet, at best was a nearly imperceptible gray which did not reach the color of the first level of the test color comparison chart, indicating less than 10 parts per million (ppm) of available chlorine. The chlorine supply bucket contained approximately one-quarter to three-eighths of an inch of product. On 7/9/24 at 10:03 AM, V3 stated, The chlorine should be between 10 and 50 (ppm). We just had (dishwasher provider company) out here last Friday (7/5/24) to look at this dishwasher because the temperature gauge wasn't reading correctly. On 7/9/24 at 10:05 AM, V5, Dietary Aide who was operating the dishwasher prior to V3 conducting the chlorine test, at first stated, I tested the dishwasher this morning. V5 then stated, No I tested the dishwasher yesterday but not today so I don't know how long it has been without chlorine, maybe from last night. V5 then replaced the chlorine supply bucket with a full bucket. On 7/9/24 at 1:40 PM, V6, Dietary District Manager, stated, I have tested the dishwasher again and it is at the right amount of chlorine. Our log shows (documents) that the machine was tested this morning. The facility's 'Dish Machine Log' dated for July 2024 had been recorded with a black magic marker, making the log largely illegible, including the column for 7/9/24 breakfast. Additionally, the log had been altered with white-out tape across the sections for 7/9/24 lunch and dinner, which were apparently completed prior to the actual meal times. When this log was originally shown to surveyor, there was not an entry written over the white-out tape for lunch on 7/9/24, but when the copy was provided, there was an entry for lunch on 7/9/24 written over the white-out tape. It is also noted that this entry for lunch on 7/9/24 is recorded as 55 ppm, and the color comparison chart only reads as 10 ppm, 50 ppm, 100 ppm, and 200 ppm. This facility log does document that the manufacturer recommended ppm is 50 - 100. On 7/9/24 at 1:49 PM, V6 stated, The sweet spot for the chlorine should be between 50 - 100 ppm, and that is written right on the log. The gray color (10 ppm) is too low, and the darkest purple (200 ppm) is too high. The manufacturer recommendation provided by V6 documents the chlorine level should be titrated to a level between 50 - 100 ppm, and to adjust the cam timer or digital timer if it is not correct. 3.) On 7/9/24 at 9:54 AM, V3, Dietary Manager in Training, stated, The mixer is all cleaned and ready for use. On 7/9/24 at 9:54 AM, there was a dark brown (color of brownie batter) dried substance on the mixer bowl shield starting as a one-half inch circle and trailing down approximately one and one-half inches to a point. There were no less than six creamy white dried splatters on the bowl shield and wire frame guard. There was a dried bright red substance (color of velvet cake batter) stuck on the wire frame guard at no less than two of the intersections where the horizontal wires and vertical wires crossed. All of these splatters and dried substances were directly over the mixing bowl. The facility's Form 802 Resident Matrix dated 7/9/24 documents 99 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required member...

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Based on interview and record review the facility failed to ensure the required Quality Assurance Performance Improvement (QAPI) meetings were being held quarterly and failed to ensure required members attended quarterly QAPI meetings. This failure has the potential to affect all 99 residents residing in the facility. Findings Include: The facility Long-Term Care Facility Application For Medicare and Medicaid dated 7/10/24 documents 99 residents residing in facility. The facility is unable to provide any documentation that the required quarterly QAPI meeting was held during the first quarter of 2024. The 2023 fourth quarter QAPI meeting sign in sheet, dated 2/23/24, does not document that an Infection Preventionist was present. On 7/10/24 at 2:40 PM V2 Director of Nursing said that they could not locate the minutes or sign in sheets for the 2024 first quarter QAPI meeting. On 7/10/24 at 2:20 PM V2 Director of Nursing confirmed that there was no Infection Preventionist in attendance at the 2/23/24, fourth quarter 2023 QAPI meeting. The undated Quarterly QAPI Committee Meeting Agenda Policy documents that the purpose of quality meetings is to take a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality while involving all caregivers in practical and creative problem solving. Quality meetings will be held quarterly, and the attendees will include: Administrator, Director of Nursing, Infection Preventionist, Social Services, Food Service Director, Activities Director, Maintenance Director, Recruitment/Retention Coordinator, Payroll Clerk, Minimum Data Set Coordinator, Business Office Manager, Environmental Services Director and the Pharmacy Consultant.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to establish a water management program including developing a risk assessment, ensuring that interventions to monitor control limits are met, ...

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Based on interview and record review the facility failed to establish a water management program including developing a risk assessment, ensuring that interventions to monitor control limits are met, and developing a method to audit the program to prevent the growth of Legionella and other water borne pathogens in the building's water systems. This failure has the potential to affect all 99 residents that reside in the facility. Findings Include: The facility Long-Term Care Facility Application for Medicare and Medicaid dated 7/10/24 documents that there are 99 residents who reside in the facility. The undated facility Water Management Program to Reduce Legionella Growth and Spread documents that each facility will complete a risk evaluation to identify if the entire building or parts of the building are at risk for Legionella growth and spread. Additionally, the facility will implement control measures to reduce spread, ensure that the program remains operational and audit the program monthly. The facility could not provide documentation of a Legionella prevention program including a risk evaluation to identify if the building is at risk for Legionella growth and spread, a way to monitor the measures they have in place including testing protocols and acceptable ranges, and ways to intervene when control limits are not met in the building's water systems. On 7/11/24 at 10:55 AM V14 Clinical Director of Operations said that she could not locate any risk assessment, routine testing, nor planned interventions should the control limits not be met. Our Maintenance Director is responsible for this and currently we do not have one on staff. We will be working on this.

Jun 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment for a newly developed skin wound for one (R1) of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment for a newly developed skin wound for one (R1) of three residents reviewed for skin wounds in the sample list of three. Findings include: R1's Physician Order Sheet (POS) dated June 2024, documents R1's diagnoses as: Moderate Protein-Calorie Malnutrition, Muscle Weakness (generalized), other reduced Mobility, and Myasthenia Gravis without acute exacerbation. R1's Minimum Data Set (MDS) dated [DATE], documents R1 requires substantial/maximum assistance with rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed transfers. R1's Nurse Skin Inspection Report dated 6/14/24, documents R1's skin is not clear and intact, has redness, bloody drainage, an open ulcer, and a circle placed on the body drawing indicating where these issues are seen (coccyx/sacrum/buttocks) area, signed by V7 Certified Nursing Assistant (CNA) and signed by V8 Licensed Practical Nurse (LPN). There is no documentation in R1's medical record for any treatment or notification being done on this date (6/14/24) for this skin issue. A treatment for R1's buttock did not begin until 6/18/24, four days after the skin issue was identified. R1's Treatment Administration Record (TAR) dated 6/18/24, documents to cleanse buttock with wound cleaner, apply calcium alginate and cover with border gauze daily and as needed until healed every day shift. On 6/27/24 at 2:30 PM, V2 Assistant Director of Nursing (ADON) stated V8 (LPN) should have let the wound nurse know about R1's findings from R1's shower sheet, and let R1's medical doctor know when the skin issue was identified (on 6/14/24) to get a treatment started right away. On 6/27/24 at 3:11 PM, V8 (LPN) stated if there is a finding on a shower sheet (Nurse Skin Inspection Report) she should review the care plan. V8 also stated if the CNA does not advise me (V8) then how would I (V8) know if there's a skin issue. V8 stated V8 was busy that day and doesn't always have time to look at those sheets so she just signs them. V7 then stated V8 just signed the sheet and did not look at it and that V8 should have reviewed the shower sheet when signing it. On 6/27/24 at 3:30 PM, V1 Administrator stated any time there is a skin issue on a shower sheet, the nurse should immediately do a thorough skin assessment and address the needs. The facility's Pressure Ulcer/Pressure Injury Prevention Policy dated Revised 3/2022, documents if a pressure ulcer is present, provide treatment to heal it to prevent the development of additional pressure ulcers.

May 2024 5 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed ensure for resident rights regarding personal property for one (R1) of three residents reviewed from a sample list of 12. Findings include: The...

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Based on interview and record review the facility failed ensure for resident rights regarding personal property for one (R1) of three residents reviewed from a sample list of 12. Findings include: The facility provided Abuse Prevention and Prohibition Policy, revised date 1/2024 documents that residents have a right to personal property in the facility. The facility provided Resident's Rights for People in Long Term Care Facilities, revised date 3/2017, documents that resident's have a right to privacy. The facility provided grievance dated 5/3/24 documents that R2 complained that V11 CNA was going through R1's drawers when he thought that they were both asleep. On 5/8/24 at 10:30AM, R1 stated, (V11 CNA) went through my drawers and I don't like that. On 5/8/24 at 10:45AM, R2 stated, I caught that guy going through her drawers when he thought that we were asleep. We don't want him in here anymore, going through our drawers. He said he was getting washcloths. On 5/9/24 at 3:33PM, V11 CNA said that he did open R1's drawers to get the rags out and that he didn't ask her if it was ok to do so. On 5/8/24 at 1:00PM, V2 Director of Nursing said that R2 filled out a grievance because she found V11 CNA going through her roommates drawers. We found that he was removing washcloths that he had placed there but decided just to keep him out of that room to prevent any further issues. On 5/13/24 at 11:00AM, V18 Assistant Director of Nursing stated, They should always ask before opening a resident's drawers. On 5/13/24 at 11:05AM, V29 Regional Clinical Director of Operations stated, I agree with that. They should always ask first.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to implement their abuse policy for one (R1) of twelve residents reviewed for abuse from a total sample list of 12. Findings include: The facil...

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Based on interview and record review the facility failed to implement their abuse policy for one (R1) of twelve residents reviewed for abuse from a total sample list of 12. Findings include: The facility abuse policy revised date 1/2024 documents that each resident has the right to be free from abuse and that the facility's abuse prohibition program includes screening, training, prevention, identification, investigation, protection and reporting/response. Resident abuse must be reported immediately to the Administrator. The facility Administrator will ensure a thorough investigation of alleged violation of individual rights and document appropriate action. While a facility investigation is under way, steps will be taken to prevent further abuse. If a person is identified in thru allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress except to meet with the administrator as apart of the investgation. The person identified in the allegation of abuse will have no contact with resident or other employees during the investigation process. On 5/8/23 at 1:17PM, V17 LPN local physician's office said that on Monday, May 6, 2024, R1 told her that there was an employee at the facility where she lived (V11 CNA) that made her feel unsafe and that V17 LPN reported this to the facility immediately after the appointment. On 5/8/24 at 1:10PM, V1 Administrator said that after V17 LPN from the local physicians office called, she spoke to R1 and decided that no abuse had occurred, so she didn't investigate it or report it. The nursing schedule dated 5/7/24 documents that V11 Certified Nursing Assistant worked from 2:00PM to 6:00AM on 5/8/24. On 5/8/24 at 10:30AM, R1 stated, (V11 CNA) worked last night. On 5/9/24 at 10:00AM, V17 Regional Clinical Nurse said that V11 CNA had been suspended pending investigation. On 5/13/24 at 2:10PM, V29 Regional Director of Operations said that any time abuse is alleged, the facility policy says to investigate and report the allegation and the policy was not followed in this case.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to report allegations of physical and potential sexual abuse timely to the State Agency for three (R1, R6, and R7) of 12 residents reviewed for...

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Based on interview and record review the facility failed to report allegations of physical and potential sexual abuse timely to the State Agency for three (R1, R6, and R7) of 12 residents reviewed for abuse from a total sample list of 12 residents. Findings include: The facility policy titled 'Abuse, Prevention and Prohibition Policy' revised January 2024 documents each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility prohibits mistreatment, neglect and abuse of residents. The facility Administrator will be designated as the Abuse Coordinator. If the Administrator is not available to address this role then the Administrator will designate a 'person in charge' in their absence to fulfill the role. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. Initiate an investigation including initial reporting to all required agencies. The facility Administrator or designee who is made aware of any allegation of abuse or neglect shall report to the State Agency. The Administrator will report the allegation of abuse and neglect to the mandated State Agency and law enforcement. The allegation will be reported no later than two hours, or per state regulations, after the allegation is made. 1.) On 5/8/23 at 1:17PM, V17 LPN Local Physician's Office said that she has to ask all patients about feeling safe in their homes. When I asked R1 about this, R1 told me that there was a male CNA at the nursing facility where she was living who might have had an erection when he was giving her a shower and that he went through her drawers and she felt like he was going to steal from her. I reported this to (V2 DON) at the facility immediately after the appointment. On 5/8/24 at 1:10PM, V1 Administrator stated, V17 LPN at Local Physician's office called both myself and V2 DON. She got through to V2 DON first and she had her on speaker phone telling her that R1 had complained at her appointment about about V11 CNA because he was watching her in the shower and that she might have felt an erection on her shoulder. (V11 CNA) was already not allowed to go into R1's room anymore because of her roommate's grievance. I didn't think that it wasn't abuse and I didn't report it. On 5/8/24 at 1:20PM, V2 Director of Nursing stated, When V1 Administrator and I became aware of what R1 said, V1 said that she was going to talk to R1, but I never heard anything more about it. V1 is our abuse coordinator. During this survey the facility was unable to provide documentation of the above incident, an investigation of the incident, or a report to the state agency. On 5/9/24 at 9:00AM, V29 Regional Director of Operations said that the incident had been reported both to the state agency and the police and the investigation had begun as of 5/8/24. On 5/8/24 at 2:20PM, V19 Regional Clinical Nurse said that based on the facility policy, the allegation of abuse should have been reported and an investigation begun immediately. 2.) The Initial Incident Report to State Agency dated 5/5/24 documents a resident to resident altercation between (R3) and (R5) which occurred on 5/5/24. This same report documents staff witnessed residents (R3, R5) have a physical altercation with each other while going down the hallway. The facility was not able to provide documentation of a resident to resident altercation between R3 and R6, nor R3 and R7 which occurred on 5/5/24 being reported to the State Agency. The Final Incident Report to State Agency dated 5/10/24 documents V21 Certified Nurse Aide (CNA) written witness statement which was obtained on 5/5/24 dated 5/5/24 at 7:30 AM which documents V21 witnessed R3 grab R7's Hand and Wrist during a physical altercation between R3 and R7. On 5/8/24 at 2:00 PM V1 Administrator stated R3 punched R6 in the Right Arm on 5/5/24. V1 stated on the same morning R3 punched R5 in the Right Arm and was also in a physical altercation with R7 the same morning. V1 Administrator stated V1 did not report these other two incidents with R3 hitting other residents (R6, R7). V1 Administrator stated I guess I should have but I did not.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's rights to be free from physical abuse by another ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect resident's rights to be free from physical abuse by another resident. This failure affects five (R3, R4. R5, R6, R7) residents of 12 residents reviewed for abuse in a sample list of 12 residents. Findings include: The facility policy titled 'Abuse, Prevention and Prohibition Policy' revised January 2024 documents each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility prohibits mistreatment, neglect and abuse of residents. The facility Administrator will be designated as the Abuse Coordinator. If the Administrator is not available to address this role then the Administrator will designate a 'person in charge' in their absence to fulfill the role. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. A licensed professional nurse will assess the resident for signs of injury and notify the resident's physician and responsible party if any injury occurred. Resident to resident abuse includes the term willful. The term 'willful' means that the individuals actions were deliberate (not inadvertent or accidental), regardless of whether the individual intended to inflict injury or harm. Physical Abuse includes but is not limited to hitting, slapping, punching, biting and kicking. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact. This same MDS documents R3 requires maximum assist for bathing, dependent on staff for dressing and supervision with eating, toileting and personal hygiene. R3's Electronic Medical Record does not include an Abuse Risk Assessment. This same EMR documents R3 propels independently in wheelchair. R3's Behavior Tracking sheet dated April and May 2024 documents R3 had 'hitting' behaviors on 4/16/24, 4/27/24 and 5/3/24. On 5/8/24 at 2:52 PM R3 stated I get mad at them (other residents). They get in my way. I don't like that. When I get mad I yell. Sometimes I hit them. They are in my way. That is not nice. They are in my way. 1.) R7's undated Medical Diagnosis List includes medical diagnoses of Metabolic Encephalopathy, Acute and Chronic Respiratory Failure with Hypoxia and Hypercapnia, Scapholunte Dissociation of Radialcarpal joint of Left Wrist, Nephrogenic Diabetes Insipidus, Diabetes Mellitus Type II, Moderate Intellectual Disability, Schizophrenia, Chronic Obstructive Pulmonary Disease, Hearing Loss, Abnormalities of Gait and Mobility, and Muscle Weakness. R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. This same MDS documents R7 as requiring moderate staff assistance with mobility and transfers. R7's Care Plan initiated 3/6/2024 does not include a focus area, goal nor interventions for R7 being at risk of abuse. R7's Electronic Medical Record (EMR) does not document an Abuse Risk Assessment nor a skin evaluation on 5/5/24. On 5/8/24 at 2:30 PM R7 wearing splint on Left Hand covering Left hand and lower wrist area (medical). On 5/9/24 at 4:00 PM R7 stated (R3) was trying to steal a personal item from the seat of R7's wheelchair while R7 was sitting in it. R7 keeps a personal item next to her in the seat of her wheelchair, and takes it everywhere. R7 stated (R3) came up to me and tried to steal (personal item). That really upset me. I was trying to push (R3) away and he grabbed my wrist and then punched me in the arm. (R7 using her Left hand to show where R3 hit her on her Right wrist and lower forearm). R7 was wearing a splint on her Left Hand/Wrist. R7 stated You can see I can't do anything with my Left Hand. I couldn't have hit him back or anything. R7 further stated, (R3) just kept trying to get R7's (personal item) even when the staff were telling him (R3) to stop it. 2.) R5's undated Medical Diagnosis List documents R5's medical diagnoses as Cognitive Communication Deficit, Paroxysmal Atrial Fibrillation, Muscle Weakness, Reduced Mobility, Dementia, Weakness, Spinal Stenosis and Raynaud's Syndrome. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 requires maximum staff assistance with mobility and transfers. R5's Care Plan initiated 10/8/2019 does not include a focus area, goal nor interventions for R5 being at risk of abuse. R5's Electronic Medical Record (EMR) does not document an Abuse Risk Assessment. R5's Skin Evaluation dated 5/5/24 documents R5 was struck in the Right Deltoid by another resident (R3) with no bruising or skin impairment noted. On 5/9/24 at 3:45 PM R5 stated (R3) is a bully. (R3) hits on people. I have seen (R3) do that before. I was minding my own business and that nurse (V7) drove (R3) right by me and (R3) punched me in my Right arm. (R5 rubbing her upper Right arm just below shoulder). (V7) could have driven (R3) a different direction. There were a lot of residents sitting in the hallway waiting to be driven down to breakfast. (V7) drove (R3) right by those and then (R3) punched me. It hurt but didn't break my arm or anything. I am tough. On 5/9/24 at 3:50 PM V25 (R5's) family member stated (V7) Licensed Practical Nurse (LPN) called me that morning (5/5/) to let me know (R3) punched (R5) in the arm. (V7) LPN told me the whole story. (V7) told me that (R3) was agitated and had been removed from the area of another resident (R7). I don't know why (V7) would wheel (R3) right next to other residents. I like (V7) LPN but that was not a good idea. It put (R5) and the other residents who got hit in danger. 3.) R6's undated Medical Diagnosis List documents R6's medical diagnoses as Cognitive Social or Emotional Deficit Following other Cerebrovascular Disease, Hydrocephalus, Difficulty in Walking, Weakness, Reduced Mobility and Dementia with Agitation. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. This same MDS documents R6 as being dependent on staff for mobility and transfers. R6's Care Plan initiated 5/10/2021 does not include a focus area, goal nor interventions for R6 being at risk of abuse. R6's Electronic Medical Record (EMR) does not document an Abuse Risk Assessment. R6's Skin Evaluation dated 5/5/24 documents R6 was struck in the Right Deltoid by another resident (R3) with no bruising or skin impairment noted. On 5/9/24 at 1:55 PM R6 was laying in his bed watching television. R6 stated I was on my way down this hall (200 hall) to get something to eat when that nurse (V7) Licensed Practical Nurse (LPN) pushed (R3) right by me. (R3) just reached out his arm and punched me right in the arm. I was going to punch him back to (V7) had already taken (R3) away by then. That hurt but not bad. I would have hurt him (R3) worse. That son of a b**** (expletive) can't just go around hitting people. Right before (R3) hit me, he hit some other old lady in a wheelchair (R5). Now what kind of a****** (expletive) hits old ladies in wheelchairs? I hope they (facility) lock him (R3) away somewhere. On 5/9/24 at 1:50 PM V21 Certified Nurse Aide (CNA) stated V21 witnessed R3 grab at R7's (personal item) as R7 was sitting in the 200 hall. V21 stated This all happened right before breakfast on 5/5/24. (R3) was trying to grab (R7's) (personal item). (R3) got upset and started playing too rough trying to get (R7's) (personal item) and (R7) didn't like that. (R7) was yelling out 'stop that'. (V7) Licensed Practical Nurse (LPN) and I walked up to (R3) and (R7). (V7) LPN took (R3) away from (R7). (V7) then wheeled (R3) down the hall to his room but (V7) wheeled (R3) right by them (R5, R6). (R3) then reached out and punched (R5) in the upper arm. (R5) yelled out and said 'ouch! That hurt!'. (V7) kept pushing (R3) in his wheelchair to (R3's) room but then after (R3) hit (R5), (R3) punched (R6) in the arm. There was 10-15 feet between residents. I don't know why (V7) LPN kept pushing (R3) right by them (R5, R6). Looking back, we (V7, V21) should have moved those other residents out of the way so they wouldn't have been punched like that. On 5/9/24 at 3:00 PM V7 Licensed Practical Nurse (LPN) stated V7 was the nurse for R3, R5, R6 and R7 on 5/5/24. V7 LPN stated I was passing medications on the 200 hall before breakfast on 5/5/24. Those residents (R3, R5, R6, R7) all live on the same hall. I had just given (R3) his medications and (R3) pushed himself out of his room. The next thing I know is that I heard yelling from around the nurses station. (R3) was trying to take (R7's) (personal item) away from her. (R7) was yelling out because she was trying to get our attention to get (R3) away from her. I went over there and removed (R3) from (R7). I said 'Hey (R3) what are you doing?'. The hallway was full of residents in wheelchairs waiting to be taken to the dining room for breakfast. I pushed (R3) in his wheelchair down the hall in front of numerous residents. (R3) then all of a sudden reached out and punched (R5) in the Right Deltoid. It just came out of nowhere. So I continued pushing (R3) down the hall trying to get (R3) to his room and we passed another resident (R6). Then (R3) suddenly reached out and punched (R6) in the Right Deltoid too. There was a Certified Nurse Aide (CNA) (V21) there at the same time. I was just trying to get (R3) down to his room. I had no choice but to wheel him right in front of all of those other residents. They (other residents) didn't need to be removed. They were just innocently sitting there. On 5/9/24 at 3:20 PM V2 Director of Nurses (DON) stated R3 attempted to take R7's (personal item) away from R7 and became agitated when R7 would not let R3 have the (personal item). V2 DON stated V7 LPN attempted to remove R3 from the area by wheeling R3 down the hall directly in front of other residents. V2 DON stated R3 subsequently ended up punching two other residents (R5, R6) as V7 LPN was wheeling R3 by them (R5, R6). V2 DON stated V7 LPN should have removed the other residents (R5, R6) from the area before assisting R3 through the hall, called on help from other staff to assist with providing a clear path and/or taken R3 to another private area so as to not provide direct access for R3 to injure anyone else. V2 DON stated R5 and R6 were placed directly in the path of a resident (R3) who was having behaviors which put R5 and R6 at a risk of being hit also. 4.) R4's Minimum Data Set (MDS) dated [DATE] documents R4 as severely cognitively impaired This same MDS documents R4 requires moderate assistance for mobility and transfers. R4's Care Plan dated 8/23/23 does not include a focus area, goal nor intervention for R4 being at risk for abuse. R4's Electronic Medical Record (EMR) does not include an Abuse Risk Assessment. R4's Final Incident Report to State Agency dated 4/23/24 documents On 4/16/23 staff witnessed (R3) and (R4) have a physical altercation with each other while trying to exit the dining room. (V4) Certified Nurse Aide (CNA) reports that he observed (R3) pushing his wheelchair backwards towards the table (R4) was sitting at. (V4) stated he attempted redirection with (R3) however (R3) continued to back his wheelchair into the table where (R4) was sitting at. (R4) pushed (R3's) arm to get (R3) away and then (R3) hit (R4). (V5) Certified Nurse Aide (CNA) stated she did not see (R3) backing into (R4's) table but witnessed (R3) hit (R4). This same report documents R4 stated (R4) stated 'all of a sudden tried to beat me up but I took care of them and it's over now. It is the guy (R3) who causes problems, but we have an understanding now. On 5/9/24 at 3:15 PM V2 Director of Nurses stated R3 hit R4 in the dining room on 4/16/23. V2 DON stated R4 was sitting at his own dining room table and R3 was trying to push through the tables to leave the dining room. V2 stated R4 pushed R3's arm off of R4's wheelchair and then R3 got mad and hit R4 in the arm. V2 stated staff should have redirected and/or assisted R3 away from R4's table. V2 DON stated this incident occurred in the dining room with 'plenty of staff available to intervene'. V2 DON stated this incident could have been avoided all together if staff would have assisted R3 out of the dining room.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R1's Miniumum data set dated [DATE] documents R1 as cognitively intact and requiring clean up assistance with toileting and ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R1's Miniumum data set dated [DATE] documents R1 as cognitively intact and requiring clean up assistance with toileting and partial to moderate assistance with bathing. On 5/8/23 at 1:17PM, V17 Licensed Practical Nurse (LPN) at a local physician's office said that she has to ask all patients about feeling safe in their homes. When I asked R1 about this on Monday, (May 6, 2024), R1 told me that there was a male CNA at the nursing facility where she was living who might have had an erection when he was giving her a shower and that he went through her drawers and she felt like he was going to steal from her. I reported this to (V2 DON) at the facility immediately after the appointment. On 5/8/24 at 1:10PM, V1 Administrator said that V17 LPN at a local physician's office called both myself and V2 DON on May 6, 2024. She got through to V2 DON first and while she had her on speaker phone, I heard her telling V2 DON that R1 had complained at her appointment about about V11 CNA because he was watching her in the shower and that she might have felt an erection on her shoulder. (V11 CNA) was already not allowed to go into R1's room anymore because of her roommate's grievance. I didn't think that it wasn't abuse and I didn't report it. I felt after talking to her that there was no need to investigate further. The facility could not provide documentation of an investigation of the above abuse allegation. On 5/8/24 at 2:20PM, V19 Regional Clinical Nurse said that based on the facility policy, this should have been investigated completely. On 5/9/24 at 9:00AM, V29 Regional Director of Operations said the full investigation was not started until 5/8/24. Based on interview and record review the facility failed to protect residents from physical abuse from another resident with known physical aggression, failed to investigate resident allegations of abuse by another resident and allegation of potential abuse by staff. These failures affect five (R5, R6, R7, R3, R1) residents out of 12 residents reviewed for abuse in a sample list of 12 residents. Findings include: The facility policy titled 'Abuse, Prevention and Prohibition Policy' revised January 2024 documents each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. The facility prohibits mistreatment, neglect and abuse of residents. The facility Administrator will be designated as the Abuse Coordinator. If the Administrator is not available to address this role then the Administrator will designate a 'person in charge' in their absence to fulfill the role. The Administrator will ensure a thorough investigation of alleged violations of individual rights and document appropriate action. While a facility investigation is underway, steps will be taken to prevent further abuse. Initate an investigation including initial reporting to all required agencies. Complete a thorough investigation. Two management level staff will conduct interviews with witnesses or other staff, residents or visitors who could have knowledge of the allegation. Witnesses will be asked to assist in completing statements if indicated. When another resident is the alleged perpetrator of the abuse, a licensed professional shall immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options. Residents will be referred to behavior management when indicated. The Final Incident Report to the State Agency dated 5/10/2024 documents R3 had become agitated when R3 attempted to take R7's (personal item) from R7. R21 Certified Nurse Aide (CNA) Witness Statement dated 5/5/24 at 7:30 AM documents R3 grabbed R7's hand and wrist. This report documents V7 Licensed Practical Nurse (LPN) then assisted R3 in his wheelchair past R5 and R6 where R3 punched R5 and then R6 both in the Right Deltoid. This same report documents Based on staff and resident interviews, the altercations did occur. 1.) R5's Minimum Data Set (MDS) dated [DATE] documents R5 as cognitively intact. This same MDS documents R5 requires supervision with toileting, personal hygiene, bathing, maximum assistance with dressing and transfers. On 5/9/24 at 3:45 PM R5 stated I was minding my own business and that nurse (V7) drove (R3) right by me and (R3) punched me in my Right arm. (R5 rubbing her upper Right arm just below shoulder). (V7) could have driven (R3) a different direction. On 5/9/24 at 3:50 PM V25 (R5's) family member stated (V7) Licensed Practical Nurse (LPN) told me that (R3) was agitated and had been removed from the area of another resident (R7). I don't know why (V7) would wheel (R3) right next to other residents, It put (R5) and the other residents who got hit in danger. 2. R6's Minimum Data Set (MDS) dated [DATE] documents R6 as severely cognitively impaired. This same MDS documents R6 as requiring maximum assistance for bathing, dressing and is dependent on staff for transfers and toileting. On 5/9/24 at 1:55 PM R6 stated I was on my way down this hall (200 hall) to get something to eat when that nurse (V7) pushed (R3) right by me. (R3) just reached out his arm and punched me right in the arm. On 5/9/24 at 3:20 PM V2 Director of Nurses (DON) stated R3 attempted to take R7's (personal item) away from R7 and became agitated when R7 would not let R3 have the (personal item). V2 DON stated V7 LPN attempted to remove R3 from the area by wheeling R3 down the hall directly in front of other residents. V2 DON stated R3 subsequently ended up punching two other residents (R5, R6) as V7 LPN was wheeling R3 by them (R5, R6). V2 DON stated V7 LPN should have removed the other residents (R5, R6) from the area before assisting R3 through the hall, called on help from other staff to assist with providing a clear path and/or taken R3 to another private area so as to not provide direct access for R3 to injure anyone else. V2 DON stated R5 and R6 were placed directly in the path of a resident (R3) who was having behaviors which put R5 and R6 at a risk of being hit also. 3.) R7's Minimum Data Set (MDS) dated [DATE] documents R7 as cognitively intact. This same MDS documents R7 as requiring moderate staff assistance with mobility and transfers. On 5/9/24 at 4:00 PM R7 stated (R3) was trying to steal my (personal item). (R3) came up to me and tried to steal (personal item). I was trying to push (R3) away and he grabbed my wrist and then punched me in the arm. (R5 using her Left hand to show where R3 hit her on her Right wrist and lower forearm). On 5/9/24 at 3:30 PM V2 Director of Nurses (DON) stated the staff responded quickly to the physical altercation between R3 and R7 on the morning of 5/5/24. V2 DON stated after that physical altercation, the staff completed hand written interviews which included V21 Certified Nurse Aide (CNA) written witness statement. V2 DON stated V21's written statement documented R7's allegation of physical abuse from R3. V2 DON stated the allegation of physical abuse should have been investigated, the residents (R3, R7) both should have had physical assessments completed timely and R3 should have been kept away from other residents until the investigation was completed.

Feb 2024 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent falls by failing to assist with ambulation and ensure a bed'...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent falls by failing to assist with ambulation and ensure a bed's wheel locks were in working order for two (R1, R2) of three residents reviewed for falls on the sample list of nine. These failures resulted in R1 sustaining a laceration to the forehead requiring emergency services and a subdural hemorrhage requiring hospitalization. These failures also resulted in R2 sustaining a left hip fracture which required surgical repair. Findings include: 1. R1's hospital records dated 2/1/24 documents on 1/17/24, R1 became dizzy while walking at the facility and fell. R1 sustained a right frontal scalp laceration with contusion and a small acute subdural hemorrhage along the right side of the anterior falx as a result of the fall. R1's medical record documents R1 was admitted to the facility on [DATE]. R1's Physical Therapy notes dated 1/13/24 documents R1 was evaluated and has poor balance. These notes document R1 has a history of falls. These notes document that R1 requires one assist with a walker with transfers and ambulation. R1's Physical Therapy Communication form dated 1/13/24 documents R1 requires one assist with a walker for transfers and ambulation. R1's Nurse's note dated 1/17/2024 at 6:27 PM documents, (R1) was found face down in (R1's) room from a fall in a pool of blood. (R1) had a laceration on (R1's) head and the bridge of (R1's) nose. Glasses were broken due to the fall. (R1) was sent to the hospital for injuries and evaluation. R1's Nurse's note dated 1/17/2024 at 8:56 PM documents, Called (hospital) for report on (R1) nurse was unable to give report but did inform writer that (R1) was transferred to (another hospital) with a brain bleed. V17's Licensed Practical Nurse's Witness statement dated 1/17/24 at 5:45 PM documents, (R1) left the dining room independently with (R1's) walker after supper at 5:15 PM. This statement documents the staff heard loud noise and upon entering room R1 had fallen and had bleeding from R1's head. This statement documents, R1 stated R1 got dizzy and fell to the floor hitting R1's head. This statement documents R1 was sent to the hospital. On 2/6/24 at 3:24 PM, V17 stated she saw R1 leave the dining room with his walker and next thing she knows a Certified Nurse's Assistant came running down the hall and stated R1 fell in his room. V17 stated R1 told her he fell because he felt dizzy. V17 stated it appeared he hit his head on the bed frame. V17 stated he had a laceration on his forehead area. V17 stated she did not know R1 and it was the first day she had taken care of him. V17 stated she did not know his transfer status. V17 stated she did not help him walk to his room. V17 stated he walked independently with his walker to his room. On 2/7/24 at 11:29 AM, V16 Physical Therapy Assistant stated R1 was assessed by Physical Therapy on 1/13/24. V16 stated due to R1's balance it was determined that he should be a one assist with a walker for ambulation. V16 stated the staff should have used a gait belt, walker, and assisted R1 with walking in case he lost his balance. V16 stated these interventions would have helped prevent R1's fall on 1/17/24. V16 stated the nursing staff was provided with the Physical Therapy Communication form on 1/13/24. 2. R2's nurse's notes dated 12/11/2023 at 6:29 AM documents, (R2) had an unwitnessed fall. (R2) found lying on her back, stated she fell while trying to move her bed, complains of pain to (left lower extremity). On 2/5/24 at 9:19 AM, V3 Assistant Director of Nursing stated she was the nurse on duty when R2 fell on [DATE]. V3 stated R2 is alert and oriented. V3 stated when she entered R2's room she was lying on the floor and complained of hip pain. V3 stated she was trying to move her bed to make it even with the nightstand. V3 stated when she tried to move the bed, the bed gave way and she fell out of the wheelchair. V3 stated they discovered that the bed was not locked and the bed lock was not working. On 2/5/24 at 9:30 AM, V2 Director of Nursing stated when they investigated the R2's incident they found out that R2 was pushing her bedframe and the wheel was locked but it was stripped so the bed moved when she was pushing it causing her to fall out of her wheelchair. On 2/5/24 at 9:35 AM, V4 Maintenance Director stated he inspected R2's bed after her fall and found out that the locking mechanism on the bed was worn down and past repair. V4 stated that is why the bed moved when R2 was pushing it. R2's hospital records dated 12/11/23 documents R2 sustained a left hip fracture after a fall in the facility. This documents R2's received a left hip fixation to repair R2's left hip.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to promote the right to respect and dignity during cares for one (R7) of three residents reviewed for improper nursing care on the sample list ...

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Based on interview and record review the facility failed to promote the right to respect and dignity during cares for one (R7) of three residents reviewed for improper nursing care on the sample list of nine. Findings include: R7's incident report dated 1/31/24 at 4:35 PM documents, V18 Certified Nurse's Assistant reported that V6 Certified Nurse's Assistant was extremely rude to R7 for no reason while providing cares. On 2/6/24 at 3:08 PM, V18 stated on the afternoon of 1/31/24, V6 was assisting V18 with transferring R7 into bed. V18 stated R7 likes the privacy curtain shut when receiving cares even if the door is shut. V6 stated R7 asked V6 to close the curtain and V6 grabbed the curtain and flung it forcefully when closing it. V18 stated after that, R7 asked what was wrong and V6 got upset and said, can we just get this done? V18 stated we got R7 into bed using the mechanical lift. V18 stated V18 asked R7 to roll toward the door to tuck the mechanical lift sling under R7. V18 stated V18 then rolled R7 and then asked R7 to roll back the other way and before R7 was able to turn, V6 yanked the mechanical lift sling out from under R7. V18 stated R7 yelled, Ow and then yelled for V6 to get out. V18 stated R7 and V6 then began to argue. V18 stated V6 was saying to R7 that V6 wasn't going to be talked to that way and that V6 was going to tell her supervisor. V18 stated V6 left and V18 finished providing cares and then R7 asked for our names and R7 said R7 was going to report V6 to V1, Administrator. V18 stated V18 walked out of the room and found a nurse and called V1 Administrator. V18 stated V18 feels like V6 was mad and upset about something when V6 pulled the curtain and pulled the sling out from under R7. V18 stated it was very poor customer service. On 2/7/24 at 12:43 PM, R7 stated in regards to the incident on 1/31/24 that V6 was taking care of R7 and was in a hurry or upset or mad about something. R7 stated R7 asked V6 to stop doing what V6 was doing and finally told V6 to stop and get out. R7 stated V6 was jerking the mechanical lift sling and was doing things rough with little regard to how it made R7 feel. R7 stated R7 can not determine what V6's intent was just that V6 was being rough and not careful. R7 stated V6 jerked the curtain closed also. R7 stated R7 was not scared but was concerned that V6's actions could cause R7 pain. R7 stated in R7's opinion V6 was angry at something. R7 stated when R7 told V6 to get out V6 ignored R7 and R7 had to tell V6 multiple times before V6 left R7's room. The facility's report to the state agency dated 2/6/24 documents that R7 is alert and oriented. This report documents that an investigation was completed regarding this incident on 1/31/24 between V6 and R7. This report concludes that the facility has concerns with V6's customer service skills and ability to handle difficult situations. On 2/7/24 at 2:30 PM, V1 Administrator stated she investigated the incident between R7 and V6 that occurred on 1/31/24. V1 stated V6 did not provide good customer service to R7.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to provide physician ordered medications and notify the physician when medications were on backorder for one (R1) of three residents reviewed f...

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Based on interview and record review the facility failed to provide physician ordered medications and notify the physician when medications were on backorder for one (R1) of three residents reviewed for resident injury on the sample list of nine. Findings include: R1's Hospital Discharge Orders dated 1/13/24 includes an order for Valacyclovir 500 milligrams two tablets once a day for viral infection and an order for Liraglutide 18 milligrams per 3 milliliters, inject 1.8 milligrams subcutaneously one time a day for Diabetes. R1's Medication Administration Record dated January 2024 does not document that R1 received the Valacyclovir on 1/13/24, 1/14/24, or 1/15/24. This record does not document that R1 received the Liraglutide from 1/13/24 through 1/17/24. On 2/6/24 at 11:20 AM, V2 confirmed that R1's Valacyclovir was not given on 1/13/24, 1/14/24, or 1/15/24. V2 stated it was backordered and their pharmacy was unable to obtain it. V2 stated the facility did not contact any other pharmacy and the physician was not notified. V2 confirmed that the Liraglutide was not given from 1/13/24 through 1/17/24. V2 stated the physician was not notified until 1/15/24 when he was notified by fax. The physician did not reply until 1/17/24 with an order to discontinue the Liraglutide and replace with Wegovy or Ozempic. V2 stated R1 discharged on 1/17/24 before a new medication was ordered.

Dec 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment for two (R2, R8) of four residents reviewed for cleanliness from a ...

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Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment for two (R2, R8) of four residents reviewed for cleanliness from a total sample list of four. Findings include: The facility provided Five Step Daily Room Cleaning and Seven Step Daily Bathroom Cleaning forms dated 10/25/16 document that the most important area of a patient's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily. A proper mop and germicide solution should be used to disinfect the bathroom floor with the proper amount of solution dwell time, working outward from the room. The facility provided grievance log identifies complaints of the lack of cleanliness of resident rooms and bathrooms on October 26, 2023, 11/20/23 and 11/28/23 with a response to the identified grievance on 11/28/23 as a denial of the floors being dirty by V7 Housekeeping Supervisor. On 12/27/23 at 8:00AM, the facility smelled strongly of urine upon entry. No residents were present in the entryway. On 12/27/23 at 1:04PM, a large spill of dried urine between R8's bed and reclining wheel chair was seen along with an old orange under R8's table by the wall that was layered with dust and debris. On 12/27/23 at 1:00PM, R8 stated, Just look at this floor! That urine has been there for days. They don't mop and if they do, it is because I have asked them to. Can you pick up that old orange under the table? On 12/27/23 at 10:00AM, R2 stated, I have to ask them to mop my floors, I shouldn't have to, but I do. On 12/27/23 at 1:05PM, V3 Director of Therapy Services stated, The floors are consistently dirty in the resident rooms. On 12/27/23 at 11:50AM, V7 Housekeeping Supervisor stated, My staff were just so overwhelmed. We are short 1-2 housekeepers and a floor care person. I'm having to mop the floors. On 12/27/23 at 2:07PM, V12 Housekeeper said that (V7 Housekeeping Supervisor) told her not to mop if the floors aren't dirty. On 12/27/23 at 1:20PM, V1 Administrator stated that the five and seven step cleaning process is expected of housekeeping staff on a daily basis and that the floors are dirty, so that the process is not being followed. This isn't fair to the residents to have dirty floors in their home.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow physician orders for changing a residents indwelling catheter every 30 days. This failure affects one (R6) of three residents review...

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Based on interview and record review, the facility failed to follow physician orders for changing a residents indwelling catheter every 30 days. This failure affects one (R6) of three residents reviewed for indwelling catheters from a total sample list of three. Findings Include: The facility (Indwelling) Catheter Insertion policy dated 01/2017 and (Indwelling) Catheter Removal Policy dated 01/2017 indicates that the nurse will verify the order for the procedure. R6's physician order sheet documents that on 10/29/23, V19 physician ordered an indwelling catheter change for R6 every 30 days and as needed. R6's progress note dated 10/29/23 indicates that R6's indwelling catheter was removed and a new indwelling catheter was inserted as directed by the physician. R6's medical record does not include another indwelling catheter change until 12/10/23. R6's progress notes dated 12/10/23 documents an indwelling catheter change for R6, 12 days after the order required. On 12/27/23 V2 was interviewed. V2 Director of Nursing said that there was an order on 10/29/23 for R6 to have indwelling catheter changes every 30 days and as needed and that it was not completed until 12/10/23.

Sept 2023 11 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to honor a resident's right to privacy during wound treatments administered by facility staff and agents. This failure affects o...

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Based on observation, interview, and record review, the facility failed to honor a resident's right to privacy during wound treatments administered by facility staff and agents. This failure affects one resident (R4) out of one reviewed for privacy on the sample list of 43. Findings include: R4's Electronic Medical Record including Census Details and Minimum Data Set List, document R4 was admitted to the facility 1/7/23, and did have prior stays at the facility. R4's Physician Order Sheet documents R4 is prescribed 3 separate wound treatments to the left posterior calf, middle to lower left leg, and left ankle. On 9/12/23 at 12:15 PM, R4 was seated in her own room while V7, Licensed Practical Nurse/ Wound Nurse, and V11, Advanced Practice Nurse/ Wound Care, administered R4's leg wound treatments. V7 was holding R4's fully exposed left leg up in the air while V11 conducted measuring, Picture taking, debriding, and dressing applications. R4's room door was wide open, exposing R4 to the hallway where V4, Maintenance/ Housekeeping Assistant, was working. On 9/12/23 at 12:20 PM, V1, Administrator, stated, We need to be providing privacy during treatments unless the resident says otherwise, but I am not even going to try to say that because that is not the case. On 9/13/23 at 9:10 AM, V10, Licensed Practical Nurse, was administering R4's leg wound treatments with the room door wide open, exposing R4 to the hallway. On 9/13/23 at 9:32 AM, V1, Administrator, stated, You know, after you caught (V7 and V11) yesterday, we went around and gave every nurse in the building an inservice education about closing the doors during treatments, and (V10) signed the inservice right here. V1 displayed the sign-in sheet for the inservice with V10's signature.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R278's undated Face Sheet documents an admission date of 8/12/23. This same Face Sheet documents medical diagnoses of Maligna...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R278's undated Face Sheet documents an admission date of 8/12/23. This same Face Sheet documents medical diagnoses of Malignant Neoplasm of Right Bronchus of Lung, Dementia, Anxiety, Major Depressive Disorder, Macular Degeneration, Stage 3 Chronic Kidney Disease, Peripheral Venous Insufficiency and Need for assistance with personal cares. R278's Electronic Medical Record (EMR) documents R278's Minimum Data Set (MDS) dated [DATE] as being accepted on 9/14/23. On 9/14/23 at 3:00 PM V1 Administrator stated I know there has been a problem with submitting the resident assessments on time. We (facility) are working on that. Based on record review and interview the facility failed to complete, encode, and transmit a Minimum Data Set Assessment within the required timeframes. This failure affects two residents (R9 and R278) out of two reviewed for Minimum Data Set completion on the sample list of 43. Findings include: 1. R9's Minimum Data Set (MDS) List (undated) documents a quarterly MDS with an assessment reference date (ARD) 8/18/23. This MDS List documents the completion was 10 days overdue, and the status as In Progress. R9's MDS assessment dated [DATE] documents sections A, G, GG, H, I, J, L, N, O, P, and S were in progress, not completed, and there were 265 questions remaining unanswered. On 9/12/23 at 3:59 PM, V20, MDS Coordinator, stated, I have been off work for 3 weeks and I know I have about 4 MDS's I need to get done. They are supposed to be completed within 14 days after the ARD.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement post-fall prevention interventions as docume...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement post-fall prevention interventions as documented on a resident's plan of care. This failure affects one resident (R27) out of five reviewed for accidents on the sample list of 43. Findings include: The facility's Fall Occurrence Log dated from 5/12/23 to 9/12/23 documents R27 experienced eight falls in the four month period. R27's Medical Record documents R27's Fall Risk Assessments, 33 total assessments, dated from 8/11/21 through 9/7/23, with 32 of these assessments documenting R27 is a high risk for falls. R27's fall risk assessment dated [DATE] was incomplete, with R27's fall history and high-risk medications sections not completed and documented low risk. R27's Care Plan for high risk for falls and history of falls dated as initiated 5/22/17, with revisions through 9/7/23, document post fall interventions including placing a call don't fall sign in R27's room, initiated 4/29/22, and placing non-skid strips in front of R27's recliner, initiated 3/20/19, repeated 12/8/21, and repeated 9/7/22. On 9/14/23 at 11:15 AM, there was not a call don't fall sign located in R27's room, and there were no non-skid strips in front of R27's recliner. 9/14/23 at 11:24 AM, V1, Administrator, stated, We just moved (R27's) room a few weeks ago and those interventions must not have made it with her. We have moved her room frequently to find an appropriate roommate because she keeps trying to help them and ends up falling.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to properly date and store oxygen tubing and nebulizer tubing for three (R12, R31, R128) residents out of four residents reviewed ...

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Based on observation, interview and record review the facility failed to properly date and store oxygen tubing and nebulizer tubing for three (R12, R31, R128) residents out of four residents reviewed for respiratory care in a sample list of 43 residents. Findings include: 1.) R12's undated Medical Diagnosis List documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Dependence on Supplemental Oxygen. On 09/12/23 at 11:42 AM observed R12 wearing Oxygen on 2 liters per nasal cannula. R12's Oxygen nasal cannula tubing was undated. R12's nebulizer tubing was dated 8/28/23. Observed R12's nebulizer tubing was laying on top of R12's bedside dresser with the face mask directly touching the contaminated top of the dresser. On 9/12/23 at 11:45 AM R12 stated I am on oxygen 24/7. I can't go without it at all. I know they (staff) are supposed to change that tubing and humidifier every week but I have to beg them to do it. Sometimes I forget. I really should not have to remind them. They (staff) should just do it but some of these girls (nurses) are just lazy and need to be told what to do. 2.) R31's undated Medical Diagnosis List documents medical diagnoses of Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. On 09/12/23 at 11:18 AM observed R31's Nebulizer tubing coiled on the dresser with the mask directly on the bedside dresser. R31's Nebulizer tubing was not dated. On 9/13/23 at 11:15 AM V 2 Director of Nurses stated The Oxygen tubing and Nebulizer tubing should be changed every Sunday night on night shift. I have already inserviced the staff on when and how to do that. It is our (facility) expectation that this be completed and signed off after getting the tubing changed. 3.) On 9/12/23 at 10:45 am R128 was sitting in a chair next to the wall and had a large amount of oxygen tubing coiled on the floor. R128 stated I have to have oxygen on when I go to the bathroom. This is why there is so much tubing. Upon inspection of the tubing no date was available to state when the tubing was changed. R128's oxygen concentrator nebulizer bottle was also undated.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on record review and interview the facility failed to obtain a physician response from a pharmacist recommendation for a medication irregularity. This failure affects one resident (R33) out of f...

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Based on record review and interview the facility failed to obtain a physician response from a pharmacist recommendation for a medication irregularity. This failure affects one resident (R33) out of five reviewed for unnecessary medications on the sample list of 43. Findings include: R33's Note to Attending Physician, prepared by V21, Consultant Pharmacist, dated 7/8/23 documents a request for the attending physician (V22, Medical Director) to provide a medical rationale for R33 receiving prescriptions for more than one anti-depressant medication, Mirtazapine and Sertraline. This form had four optional prepared responses requiring a checkmark from V22. This form had no documented response from V22. R33's Note to Attending Physician dated 9/5/23 documents the same request for V22 to provide a medical rationale for R33 receiving prescriptions for more than one anti-depressant medications, Mirtazapine and Sertraline. This form had the same four optional prepared responses requiring a checkmark response from V22. On 9/13/23 at 1:29 PM, V2, Director of Nursing, stated, I just started here about 4 weeks ago. These forms (Consultant Pharmacist Notes) are given to the Director of Nursing and I send them to (V22). I searched through the records but could not find a response for the July one, I know I sent the September one to (V22) and it is at his office, but this resident discharged home today.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to properly store medications for three (R16, R20, R34) residents out of three residents reviewed for medication storage in a samp...

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Based on observation, interview and record review the facility failed to properly store medications for three (R16, R20, R34) residents out of three residents reviewed for medication storage in a sample list of 43 residents. Findings include: 1. R20's Physician Order Sheet (POS) dated September 2023 documents physician orders for Pantoprazole 20 milligrams (mg) daily at 8:00 AM, Docusate Sodium 100 mg daily at 8:00 AM, Duloxetine Hydrochloride (HCL) Delayed Release (DR) 30 mg daily at 8:00 AM and Gabapentin 300 mg daily at 8:00 AM. On 09/12/23 at 11:56 AM observed R20 sitting up in bed with the bedside table across R20's lap. Observed whole pills in a medicine cup with applesauce sitting on bedside table. No staff were present in R20's room at time of observation. On 9/12/23 at 11:58 AM R20 stated They (staff) do that all the time. (V9) Licensed Practical Nurse (LPN) brought them in earlier. Sometimes other residents walk in and out of my room but nothing has happened yet. Ill take them with my lunch. On 9/12/23 at 12:10 PM V9 Licensed Practical Nurse (LPN) stated R20 has not been assessed to self administer medications. V9 LPN stated I left those pills there on (R20's) bedside table earlier. I should have watched (R20) take the pills. I know I shouldn't have left the pills there. 2. R16's Physician Order Sheet (POS) dated September 2023 documents physician orders for Lyrica 75 milligrams (mg) three times per day and Acetaminophen 650 mg twice per day. R16's Medication Administration Record documents Lyrica is scheduled to be administered at 9:30 AM, 3:30 PM and 9:30 PM. This same MAR documents R16's Acetaminophen is scheduled at 3:30 PM and 7:00 PM and as needed every four hours. On 9/12/23 at 3:25 PM observed two whole pills in a clear medicine cup sitting on R16's bedside table. R16's room door was open. R16 was in the bathroom with the bathroom door closed. As R16 entered the living quarters of R16's room, he sat on the bed next to bedside table. No staff were present in R16's room at the time of the observation. On 9/12/23 at 3:27 PM R16 stated That is my Lyrica and Acetaminophen (Tylenol) in that cup. The nurses bring it in and leave it for me so I can take it when I want. I do get an occasional wandering resident in here (R16's room) but the staff get them out right away. On 9/12/23 at 3:30 PM V14 Licensed Practical Nurse (LPN) stated I got (R16's) medications ready and took them into him. I saw (R16) take the medicine cup and start to bring it to his mouth. I did not actually see (R16) take the pills but I thought he did since he grabbed up the cup. I didn't realize the pills were still in (R16's) room. I should have stayed to make sure I actually saw (R16) take the pills. 3.) R34's Physician Order Sheet (POS) dated September 2023 documents physician orders for Levothyroxine Sodium 100 micrograms (mcg) daily and Docusate Sodium 100 mg twice daily. R34's Medication Administration Record (MAR) dated September 2023 documents R34's Levothyroxine Sodium 100 mg is to be administered at 8:00 PM. This same MAR documents R34's Docusate Sodium 100 mg is to be administered at 8:00 AM and 8:00 PM. On 09/12/23 at 12:13 PM observed a clear medicine cup approximately one-third filled with crushed medication in applesauce sitting on R34's bedside dresser just inside the doorway of the room. This medicine cup also had a used spoon sitting in it. No staff were present in R34's room at the time of the observation. On 9/12/23 at 12:11 PM V9 Licensed Practical Nurse (LPN) stated I gave (R34) her pills in the hallway this morning. The cup of crushed medications in applesauce on (R34's) bedside dresser has been sitting there all night. (R34) does not get any medications over night. There could have been other residents who wander in and out of (R34's) room in the late evening or night. The facility policy titled 'Deliver, Storage and Return of Drugs or Supplies' revised 12/21 documents residents' medications shall be properly labeled and stored at or near the nurses station in a locked cabinet, a locked medication room or in one or more locked mobile medication carts of satisfactory design for such storage. The medications of each resident shall be kept and stored in their originally received containers.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain the cleanliness of resident living quarters an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain the cleanliness of resident living quarters and bathrooms by failing to ensure residents had clean toilets to use and the disposing of soiled incontinence briefs in resident room garbage cans for five (R52, R61, R63, R69, R279) of five residents reviewed for dignity in a sample list of 43 residents. Findings include: 1. R61's Minimum Data Set (MDS) dated [DATE] documents R61 as cognitively intact. R52's Minimum Data Set (MDS) dated [DATE] documents R52 as moderately cognitively intact and requires staff assistance for toileting. On 09/12/23 at 10:24 AM R61 stated I share a bathroom with (R52). (R52) uses a riser on the toilet and has Diarrhea three to four times per day. The staff never clean the (fecal material) off of the riser and don't take the riser off of the toilet so when I have to go to the bathroom, I have to sit on (R52's) riser with (fecal material) all over it. The staff never take out my dirty diaper either. When the staff change me, they (staff) just throw the wet incontinence brief in the garbage bag in the room. It makes my room smell like (urine). It is embarrassing when someone comes in and I can see they hold their breath because it stinks. Look there (pointing at garbage can) you can see there are several incontinence briefs from the overnight and today. Odor and flies accumulate because of that. On 9/12/23 at 10:25 AM observed R61's bathroom toilet with stool riser with brown stool around the sides over halfway up the riser. Observed R61's resident room small garbage can in the living quarters of the room, full with soiled incontinence briefs. A urine odor was noted in R61's room. 2. R63's Minimum Data Set (MDS) dated [DATE] documents R63 as cognitively intact. R279's Minimum Data Set (MDS) dated [DATE] documents R279 as moderately cognitively intact and requires staff assistance for toileting. On 9/12/23 at 10:40 AM observed R63's bathroom toilet with riser in place. The toilet riser was observed to have feces smears over half of the inside of the riser. Observed feces particles on the back of toilet riser and at the base of the toilet. On 09/12/23 at 10:45 AM R63 stated The guy that lives on the other side (R279 shares bathroom) (defecates) all over the toilet every day and the staff don't clean it up. The staff don't take the toilet riser down and me and my roommate (R69) don't need the riser. I wouldn't mind so much if they (staff) cleaned it. Who wants to sit down on that riser with somebody else's (feces) all over it? I sure don't. 3. R69's Minimum Data Set (MDS) dated [DATE] documents R69 as cognitively intact. R279's Minimum Data Set (MDS) dated [DATE] documents R279 as moderately cognitively intact and requires staff assistance for toileting. Facility Resident Council Minutes dated 8/29/23 document Dirty toilets and when asked to be cleaned (staff) do not do it. The Facility Grievance form dated 9/14/23 documents Description: (R69) reports that his bathroom continues to be dirty. Investigation: Staff looked at toilet and interviewed residents. Summary: (R69's) toilet was dirty. On 9/12/23 at 10:40 AM Observed R69's bathroom toilet with riser in place. The toilet riser was observed to have feces smears over half of the inside of the riser. Observed feces particles on the back of the toilet riser and at the base of toilet. On 9/12/23 at 10:42 AM R69 stated (R279) lives on the other side of the bathroom. We (R63, R69, R279) all share one bathroom. (R69) and I both like our room and bathroom clean. The housekeeper comes in and cleans the room but they (staff) won't touch the toilet riser. The Certified Nurse Aides tells us that 'it isn't their job to clean the toilet riser' and the housekeeper says the same thing. I don't care who does it. I just want it done. (R279) can't clean it himself. The staff are supposed to do it. I brought this up in the last resident council meeting but nothing has improved. On 9/13/23 at 11:00 AM V12 Housekeeping Supervisor stated the housekeepers clean all the resident rooms daily. V12 stated If a resident has an accident after the housekeeper has already cleaned the room or on off hours when there is no housekeeper available then the nursing staff is responsible for cleaning the rooms/bathrooms. With the toilet risers, the Certified Nurse Aides should clean the riser and the housekeepers should clean the toilet. Either way the risers need to be cleaned. No resident should have to use a dirty toilet or riser. On 9/13/23 at 11:30 AM V2 Director of Nurses stated There is no reason any resident should be using a toilet or toilet riser that has feces on it. (R63, R69) are both alert and oriented and can ask to have the toilets cleaned but they (R63, R69) should not have to ask. If the riser becomes soiled the staff should automatically clean it or bag it up and replace it. The Certified Nurse Aides should be placing any soiled incontinence brief in a plastic bag and walking it to the soiled utility immediately after cares are provided. Wet incontinence briefs sitting around in resident rooms will cause odors and could draw flies. Our residents should not have to live like that because we (staff) aren't doing their jobs. I will educate the staff on the proper disposal of incontinence briefs and cleaning up the area after a resident uses the bathroom. The facility policy titled 'Resident Rights' dated 2018 documents employees shall treat all residents with kindness, respect and dignity.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Based on record review and interview the facility failed to offer and/or administer Pneumococcal Conjugate Vaccine (PCV) 20 or PCV 15 timely and failed to monitor vaccination status for four (R16, R20...

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Based on record review and interview the facility failed to offer and/or administer Pneumococcal Conjugate Vaccine (PCV) 20 or PCV 15 timely and failed to monitor vaccination status for four (R16, R20, R22, R34) residents out of five residents reviewed for immunizations in a sample list of 40 residents. Findings include: Facility Pneumococcal Vaccination Log dated April 2023 and June-August 2023 do not include R16, R20, R22 nor R34. 1. R16's undated Face Sheet documents an admission date of 4/22/13 and date of birth as 7/26/44. R16's Electronic Medical Record (EMR) documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Malignant Neoplasm of Large Intestine and history of COVID-19. R16's Immunization Record Sheet documents R16's last Pneumococcal vaccination was Pneumococcal Conjugate Vaccine (PCV) 13 administered on 4/23/21. There is no record of R16 being offered or receiving a Pneumococcal vaccination after that date. No consents, documentation or education regarding Pneumococcal vaccinations were documented in R16's Electronic Medical Record (EMR). On 9/13/23 at 3:35 PM R16 stated I would like to have the Pneumonia vaccination if I can. No one has ever talked to me about it. 2. R20's undated Face Sheet documents an admission date of 5/8/2014 and date of birth as 8/1/1948. R20's Electronic Medical Record (EMR) documents medical diagnoses of Surgical Aftercare of Digestive System and Gastroesophageal Reflux Disease (GERD). R20's Immunization Record Sheet documents R20's last Pneumococcal vaccination was Pneumococcal Conjugate Vaccine (PCV) 13 administered on 5/20/21. There is no record of R20 being offered or receiving a Pneumococcal vaccination after that date. No consents, documentation or education regarding Pneumococcal vaccinations were documented in R20's Electronic Medical Record (EMR). On 9/13/23 at 2:00 PM R20 stated I have had a Pneumonia vaccination before but if I am supposed to get another one I surely would. I think that is important for someone like me who doesn't get much exercise and am in a place like this (facility). 3. R22's undated Face Sheet documents an admission date of 4/7/2015 and date of birth as 7/13/1946. R22's Electronic Medical Record (EMR) documents medical diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus and history of COVID-19. R22's Immunization Record Sheet documents R22's last Pneumococcal vaccination was Pneumococcal Conjugate Vaccine (PCV) 13 administered on 3/17/2015. There is no record of R22 being offered or receiving a Pneumococcal vaccination after that date. No consents, documentation or education regarding Pneumococcal vaccinations were documented in R22's Electronic Medical Record (EMR). 4. R34's undated Face Sheet documents an admission date of 3/1/2021 and date of birth as 12/8/1926. R34's Electronic Medical Record (EMR) documents medical diagnoses of Senile Degeneration of the Brain and Hypothyroidism. R34's Immunization Record Sheet documents R34's last Pneumococcal vaccination was PPSV 23 administered on 10/17/2018. There is no record of R34 being offered or receiving a Pneumococcal vaccination after that date. No consents, documentation or education regarding Pneumococcal vaccinations were documented in R34's Electronic Medical Record (EMR). On 09/14/23 at 12:25 PM V3 Assistant Director of Nurses (ADON)/Infection Preventionist (IP) stated I came into a big mess when I started here (facility). I am trying to get things in order. I know there is a problem with the Pneumococcal vaccinations. There was no Pneumococcal vaccination log at all when I started in October of 2022. I have created one but have only reviewed the Pneumococcal vaccinations as the resident careplan comes up. There are only six residents on the log because those are the only ones I have reviewed. All the rest of the residents have not been reviewed yet. We (facility) do not have a mass Pneumococcal vaccination day like we do with the Influenza. Maybe we need to do that just to get caught up. On 9/15/23 at 11:00 AM V1 Administrator stated facility does not have a policy for Pneumococcal Vaccinations.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 83 residen...

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Based on observation, interview, and record review the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 83 residents residing in the facility. Findings include: On 9/12/2023 at 9:45AM, V18 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V18 reported being the full-time manager of the facility food service and reported not being a clinically qualified Certified Dietary Manager or having the equivalent training. The Resident Census and Conditions of Residents report (9/12/2023) documents 83 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food. This failure affects all 83 residents residing in the facility...

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Based on observation, interview, and record review the facility failed to prevent the potential for physical cross-contamination of food. This failure affects all 83 residents residing in the facility. Findings include: On 9/12/2023 at 12:18PM, the kitchen table-mounted can opener had an accumulation of metal shavings where the opener makes contact with cans being opened. The receiving base of the opener was soiled with accumulations of food debris. On 9/14/2023 at 11:55AM, the can opener remained as above. V19 (Dietary District Manager) was present and reported we just need to clean it (the can opener). 09/15/23 at 11:15AM, V18 (Dietary Manager) reported food prepared by the dietary service is available for all facility residents to eat. The Resident Census and Conditions of Residents report (9/12/2023) documents 83 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the hallway handrails were securely fastened to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the hallway handrails were securely fastened to the walls. This failure has the potential to affect all 83 residents residing in the facility. Findings include: On 9/12/23 at 2:22 PM, the section of handrail between resident rooms [ROOM NUMBERS] was loose and easily moveable over 1 inch. The section of handrail between resident rooms [ROOM NUMBERS] was completely unattached on one end and the rail would raise to a near vertical position. The section of handrail next to the ice machine on the resident 200 hallway was loose and easily moveable over 1 inch. On 9/12/23 at 2:31 PM, V5, Maintenance Director, stated, I don't have any system for checking the handrails on a routine basis. After checking the section of handrail between resident rooms [ROOM NUMBERS], V5 stated, I ran up here and tightened that one after I was told someone saw you checking them. V5 stated that the section of handrail between resident rooms [ROOM NUMBERS] was not safe for residents. V5 further stated, If no one tells me about it I won't know it needs fixed. V5 also made no verbal response about the section of handrail next to the ice machine but did use a screwdriver from his back pocket to tighten the rail. The facility's Resident Census and Conditions of Residents dated 9/12/23 documents 83 residents reside in the facility.

Jun 2023 1 deficiency

CONCERN (F) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

Based on record review and interview, the facility failed to provide sufficient Registered Nursing (RN) hours on three of 28 days reviewed for RN staffing. This has the potential to affect all 71 resi...

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Based on record review and interview, the facility failed to provide sufficient Registered Nursing (RN) hours on three of 28 days reviewed for RN staffing. This has the potential to affect all 71 residents in the facility. Findings include: On 6/23/23 V1, Administrator provided a report titled Monthly Staff Schedule dated 6/1/23 through 6/30/23. The staff schedule, was reviewed through the survey date 6/28/23 and documents on 6/06/23 the facility did not have an RN scheduled to work. The corresponding staff posting documents V6, Agency RN was to cover the shift 6/06/23, and work 10:00 pm to 6:30 am. The same posting documents V6, RN called off for this shift leaving the facility without RN coverage for eight consecutive hours in the 24 hour period. The same Monthly Staff Schedule documents on 6/12/23 the facility did not have an RN scheduled to work. The corresponding staff posting documents V5, RN was added to work from 6:00 pm until 10:00 pm, leaving the facility without RN coverage for four of the required eight consecutive hours in this 24 hour period. The same Monthly Staff Schedule documents on 6/15/23 the facility scheduled V7, RN to work. The corresponding staff posting documents V7, RN called off for this shift leaving the facility without RN coverage for eight consecutive hours of RN coverage in the 24 hour period. On 6/28/23 at 12:00 pm V17, Nurse Scheduler reviewed June 2023 Monthly Staff Schedule and corresponding staff posting. V17, confirmed the facility failed to provide eight consecutive hours of RN coverage in the 24 hour period on 6/6/23, 6/12/23 and 6/15/23. The facility Resident Listing Report dated June 23, 23 documents of 71 residents residing in the facility.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent an incident of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent an incident of elopement when behaviors of wandering and exit seeking were present for one of one residents (R2) reviewed for elopement on the sample list of five. Findings include: R2's admission assessment dated [DATE] documents R2 was admitted to the facility on [DATE] with a diagnosis of Dementia and is alert and oriented to person only. On 5/6/23 at 8:10 AM, R2 was walking alone outside with an unsteady gait. R2 walking from around the side of the building. R2 then walked down the side of the front of the building and appeared disoriented. R2 was wearing pajamas. R2 did not have shoes on and was only wearing socks with holes in them. R2 was dripping blood onto the ground. When asked, Do you need help?, R2 did not respond and continued to walk with an unsteady gait to the front door of the facility. R2 was attempting to open the door when V7 Housekeeper came up to the door to let R2 in. V7 was told that R2 was walking around outside and when asked R2's name V7 stated I don't know R2. V6 Housekeeper and V8 Certified Nurse's Assistant (CNA) then came up to assist. V7 then began to yell for a nurse. V10 Licensed Practical Nurse (LPN) then arrived to assess R2. R2 was bleeding from the pinky finger. On 5/6/23 at 8:40 AM, R2 was sitting at the nurse's station in a wheelchair. V11 LPN stated R2's left pinky finger had skin scraped off of it, R2's right knee was scraped, and his right great toe was scraped. V11 stated R2 must have fallen down outside for R2's knee to be scraped. V11 stated we were trying to keep an eye on R2 but R2 was going in and out of rooms and laying down and then getting up. V11 stated R2 ate breakfast around 7:30 to 8:00 AM. V8 and V9 CNA's stated that breakfast was the last time that they had seen him. On 5/6/23 at 9:23 AM, V6 Housekeeper stated this morning I was in the office area cleaning. I was outside checking the garbage and R2 was approaching me and R2 came through the first door. V6 stated that was out the front door and that was the first time R2 tried to get out. V7 Housekeeper came out and turned him around. V6 stated then like 25 minutes later that's when I was by the office cleaning, and I seen R2 and V7 outside trying to get in. V6 stated I think V7 let them know the first time that R2 had gotten out. V6 stated I went back to cleaning. V6 stated the staff knew R2 had been trying to escape. On 5/6/23 at 9:28 AM, V7 Housekeeper stated she got to work at 7:00 AM, that was the first time I met R2, R2 was down on the 100 wing, I took R2 back to his room on the 300 wing. V7 stated then around 7:30 AM, R2 was out the front doors in the foyer and V6 and I brought him back in and I took him to his room and turned on the tv. V7 stated then about 25 minutes later I seen him out the front door. V7 stated that was when I let him in and I yelled for V6 to go get the nurse. I did tell the nurse that he had been out the front door and in the foyer. We didn't know him. We didn't get a report when coming in that someone was wandering around. On 5/6/23 at 9:37 AM, V8 CNA stated she got to work at 5:45 AM. V8 stated V8 was on the 200 hallway and was getting residents up when staff from 300 hallway came down and asked for help. V8 stated V8 went over to the 300 wing around 6:30 AM. V8 stated R2 was up and wandering the hall and that's why they came and got me for help because only V9 CNA was working that hall with the nurse. V8 stated that we were all trying to keep an eye on him while we were getting people up. V8 stated R2 was easy to redirect but probably had to tell him ten times in twenty minutes to stay out of rooms and try to redirect him. V8 stated I attempted to give him coffee but he drank that fast. I did have to go get him from the front once he was walking around the rotunda. V8 stated we were then getting people up and passing breakfast trays. V8 stated then we served him breakfast. V8 stated I went down to toilet another resident and when I came out and the buzzer was going off and V6 was flagging me down to come up front. V8 stated then I ran up there and then seen that R2 had gotten out. V8 stated I shut off the alarm to the front door because it was sounding and then realized the 100 wing door was sounding and so I shut it off and then realized that was the door he must have gotten out. On 5/6/23 at 9:55 AM, V10 LPN stated V10 is working on 100 wing and the front half of 200 wing today. V10 stated he got to work at 6:00 AM. V10 stated V10 seen R2 around 7:45 AM, I had just finished my medication pass on the 100 wing and I was headed to the dining room and seen R2 by the rotunda and so I took him back to the 300 wing dining room and pulled up a chair for him and told him to have a seat. V10 stated I seen the other nurse (V13) and told her he was out by the rotunda. V10 stated so from there I went to the main dining room. I was in the back of the dining room so didn't hear the alarm at that time. V10 stated then V6 Housekeeper came up and told me that they needed help up front. V10 stated I went up front and did a quick assessment to see where the blood was coming from and the blood was coming from his pinky finger on the left hand. He skin on his pinky was tore back. V10 stated then his nurse came and took over and I then went back to passing medications.

Nov 2022 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Pressure Ulcer Prevention (Tag F0686)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, assess, report and treat a facility-acquired sacral pressu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify, assess, report and treat a facility-acquired sacral pressure ulcer for R1. The facility failed to provide daily cares related to preserving intact skin, including cleansing, incontinence care, repositioning, and individualized pressure relieving devices to promote healing for a resident. Significant change notifications were not made to obtain treatment and implement targeted interventions to prevent the development and worsening of a stage four pressure ulcer for a resident. This failure affects one (R1) of three residents reviewed for pressure ulcers. These failures resulted in R1 developing a Stage four facility acquired pressure ulcer contributing to R1's death. These failures resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified on 11/22/22. On 11/22/22 at 3:40PM, V1 Administrator and V2 Director of Nursing were notified of the Immediate Jeopardy situation. While the immediacy was removed on 11/23/22, the facility remained out of compliance at a severity level two. The facility is in the process of re-educating the staff on wound identification, assessment, notification, documentation, the facility pressure injury policy and treatment of pressure injuries. Findings include: The facility Weekly Skin Check Policy revised date 1/2017 documents that it is the policy of the facility to complete skin checks by the licensed nurses for all residents weekly. The nurse will assess the individual resident's skin from head to toe, to determine if there are any new or additional skin issues present. The nurse will document any scars noted over bony prominence's. Any new wounds or skin conditions will be assessed by the nurse finding the wound or skin issue. The Wound Care Nurse will follow-up to ensure all interventions are in place. The nurse will pass information on in report and add information to the communication for continued monitoring and follow-up and the physician and resident representative will be notified of any newly identified issues. Treatment orders will be obtained and new treatments started as ordered. R1's progress notes document R1 admitting to the facility on [DATE]. On the admission date, a skin assessment was completed with R1 being at moderate risk for skin breakdown with no breakdown documented on the sacrum. On 10/22/22, R1's skilled daily assessment documents, a layer of skin on the coccyx/buttock that was compromised. No description, measurements, interventions, or notifications were documented. R1's activities of daily living documentation documents two baths given over the 31 days of admission, one on 10/14/22 and the other on 10/28/22. Toilet use documented on the same record documents R1 as incontinent and on 12 of the 31 days of admission, was toileted two or fewer times in a 24-hour period. R1's Minimum Data Set, dated [DATE] documents that R1 is totally dependent for toileting and bathing. Additionally, R1 requires extensive assistance with bed mobility. On 11/6/22, R1's weekly skin report was filled out and described as a new area of skin impairment on the coccyx with no other description, measurement, or treatment was documented for the wound. R1's physician order sheet dated 11/7/22 documents that the facility physician gave an order to clean the coccyx wound with cleanser, apply calcium alginate to the wound and cover with a border gauze. Additionally, the facility was ordered to obtain a referral to the wound physician. R1's medical records documents that this referral was not obtained. On 11/29/22 at 10:15AM, V1 Administrator stated, They didn't even get a wound consultation because she (R1) was apparently sleeping. On 11/8/22, V3 wound nurse completed R1's only skin and wound evaluation documenting a complete description and measurements of the sacral wound during admission to the facility. Documentation describes the wound as an open lesion of unknown age located on the coccyx, in house acquired, with a size of 8.2 centimeters by 5.5 centimeters by 2 centimeters with 80% of the wound covered by slough and no evidence of infection. On 11/13/22, R1's progress notes document a fever with foul smelling drainage coming from the sacral wound. The facility physician ordered Augmentin 500/125 milligram antibiotic every twelve hours for the wound infection. Later that day, R1 fell out of a wheelchair and complained of pain. R1 was then sent to the emergency room. In the emergency department, surgery was consulted due to the size and infection in the wound, identified in the emergency room as the sacral area rather than coccyx, R1 was subsequently hospitalized to address the sacral wound. R1's surgical notes dated 11/15/22, documents R1's sacral wound as 21 centimeters by 10 centimeters down to and including the periosteum (periosteum is a membranous tissue that covers the outer surfaces of bones) of the sacrum. R1's surgical notes dated 11/15/22 further document that the surgeon observed the wound in the operating room and due to the severity and extensiveness of this wound combined with the urinary and stool incontinence, this wound was not survivable and recommended hospice for the patient. R1's death certificate dated 11/21/22 documents the date of R1's death as 11/20/22 cause of death stage four sacral decubitus ulcer. On 11/21/22 at 3:22PM, V8 Certified Nursing Assistant stated, I had told the nurse's every time I took care of (R1) that (R1's) bottom (sacral wound) was getting worse. At least a week or so after I told other nurses, I finally told an agency nurse and she told me that she was just going to put something on it with or without an order. I think that the nurses were having trouble getting an order for it, but I don't know why, but I always told them. On 11/22/22 at 9:04AM, V3 Wound Nurse stated, (R1's sacral wound) was probably preventable from getting so bad. I just learned about the wound from a third shift nurse on 11/6/22. That's when I got the order. I count on the nurses to let me know what the wounds look like. On 11/22/22 at 9:22AM, V2 Director of Nursing stated, (R1) was at risk for skin breakdown on admission. I would have expected them to reposition (R1) frequently and to keep her dry and to let someone know what it looked like. R1's care plan from 10/13/22 (admission) through 11/13/22 (discharge) does not include interventions such as repositioning nor maintaining a dry environment for R1's skin. On 11/22/22 at 3:10PM V16 Wound Nurse Practitioner stated, I spoke with the family about (R1's) condition and how this sacral wound came to be while she was in the hospital. They stated that she was often urine soaked in the facility and that (R1) would ask them to help her change her clothes. The dressing that the facility was using on the wound was not what we would expect to see on a wound like this. It certainly didn't help with healing. I saw the wound and it was tunneling in both directions from the center. This wound size was absolutely preventable. On 11/29/22 at 10:00AM, V1 Administrator stated, After looking at this failure, I identified that our systems failed. Nurses couldn't have been looking at this wound. We are taking this opportunity to revamp our wound program, holding staff accountable, educating, and changing facility leadership to ensure that this can never happen again. V11 Medical Director came in on November 23, 2022, and we discussed the quality plan. He stated that he did not believe that he had been given an accurate representation of (R1's) wound in size or description and that had it been communicated with him, his decision making would have been different. He would have either laid eyes on the wound himself, or sent (R1) to the emergency department. The Immediate Jeopardy was identified to have begun on 10/13/22 when the facility failed to initiate treatment and services to prevent the development of R1's sacral pressure ulcer. The deficient practice was corrected on 11/23/22 when the facility took the following actions to remove the immediacy and correct the noncompliance. The surveyor confirmed through interview and record review that the facility took the following actions to remove the immediacy: 1. On 11/13/22 R1 went to the Emergency Department, was admitted to the hospital for evaluation and treatment of a stage four sacral pressure ulcer and did not return to the facility. 2. Nursing education was initiated by the Director of Nursing and the Regional Nurse Consultant on 11/23/22 and will continue every Wednesday until completed regarding identification, assessment, notification, documentation, and treatment of pressure injuries. 3. R1 is no longer a resident of the facility. The facility medical director was notified of the immediate jeopardy and approved the action plan on 11/23/22. 4. All Residents in the facility received a head-to-toe skin assessment by nursing management and care plans were evaluated and updated as needed, completed on 11/23/22. 5. The new Director of Nursing provided education for the newly appointed Wound Nurse on assessment needs for those residents at risk for skin breakdown on 11/23/22. 6. The Facility Wound Policies in concert with best practices were reviewed and approved by the Medical Director and Facility Nursing Leadership on 11/23/22. 7. Nursing Management is charged with monitoring the above actions and ensuring that wound identification, assessment, documentation, notification, and treatments are obtained correctly and timely effective date 11/23/22.

Aug 2022 12 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Failures at this level require more than one deficient practice statement. Based on observation, interview and record review, the facility failed to provide interventions to prevent pressure ulcers. T...

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Failures at this level require more than one deficient practice statement. Based on observation, interview and record review, the facility failed to provide interventions to prevent pressure ulcers. This failure affects one of four residents (R68) reviewed for pressure injuries in the sample list of 47. This failure resulted in R68 developing a full skin thickness (stage three) facility acquired pressure injury. Findings include: 1) The facility Pressure Ulcer Prevention Policy dated 3/21 documents, A facility must evaluate resident specific risk factors and changes in the resident's condition that may impact the development and or healing of a pressure injury. The facility must implement, monitor and modify interventions to attempt to stabilize, reduce or removed underlying risk factors. Interventions for those at moderate risk include protecting heels by floating and pressure redistribution support surfaces while in the chair and bed. R68's 8/3/22 skin assessment documents R68 at moderate risk for pressure injury. R68's 8/4/22 wound physician note documents a new wound to the left posterior ankle, sized 0.5 centimeter x 1centimeter x immeasurable in depth with unstageable necrosis. R68's 8/12/22 wound physician note documents the left posterior ankle wound size as 0.3centimeter x 0.8 centimeter x unstageable necrosis. R68's 8/18/22 wound physician note documents the left posterior ankle wound size as increased to 2 centimeter x 2.5 centimeter x 0.1centimeter with a deteriorated condition. On 8/22/22 at 11:00AM, R68 was sitting in her bed without any pillows or pressure reducing devices under her left ankle/leg. Later that day at 12:28PM, R68 was sitting in the dining room in a positioning chair without any pressure relieving mechanism under her left ankle/leg. R68's ankles were resting directly on the leg/foot pedals. On 8/23/22 at 12:00PM R68 was sitting in the dining room with her ankles/legs resting directly on the positioning chair without any pressure relieving mechanism under her left ankle/leg. On 8/24/22 at 8:31AM V19 Certified Nursing Assistant stated, I remember that her left leg/ankle was red for maybe 4-5 days and then it opened and we told the nurses. She always rubbed her leg against the cast. On 8/24/22 at 8:35AM V20 Licensed Practical Nurse stated, I think that she rested that leg on the cast and over time, the pressure caused the wound. On 8/24/22 at 10:00AM, R68 was lying in bed without any pressure relieving mechanism under her left posterior calf wound. V11 Licensed Practical Nurse (LPN) stated, She should have her ankles floated on a pillow. I will do that. On 8/24/22 at 10:04AM V15 LPN and V11 LPN changed the dressing on R68's left posterior ankle. The wound appeared dime sized with yellow slough and had a deep purple, crescent shape below the open wound. On the side of the wound that slough did not cover, tissue could be seen into the fascia (full thickness). The wound was cleansed and dressed per physician order. V11 LPN stated, This was preventable if the legs/ankles had been propped with pressure reducing boots or pillows. On 8/24/22 at 10:05AM R68 stated, Oh that feels better! after V11 LPN placed a pillow under her bilateral ankles and legs. On 8/24/22 at 10:20AM, V2 Director of Nursing stated, I have to say that it was preventable. There should have been something put between the pressure areas and the skin. 2. Based on observation, interview and record review the facility failed to assess a resident for the presence of a pressure ulcer, after being notified the resident had a complaint of coccyx pain due to pressure. This failure affects one (R9) of four residents reviewed for pressure ulcers on the sample list of 47. Findings include: 2 a. R9's Daily Skilled Nurse's Note dated 8/19/2022 at 9:00 pm documents: (R9) is alert and has no memory problems. (R9) can recall all. (R9) does not have delusions, does not hallucinate, and decision making is not impaired. Signs of delirium: none. Other cognitive concerns: none. On 08/21/22 at 3:34 pm R9 reached behind her back and patted her buttocks while sitting in bed. R9 stated R9 has a facility acquired pressure ulcer on R9's coccyx. R9 stated My (R9's) coccyx hurts from sitting on the bedside commode 15 -20 minutes waiting for staff to answer the call light or just come back when they say they will. R9 also stated the following The bandage came off yesterday (8/21/22) while sitting on the bedside commode and a CNA (unidentified, Certified Nursing Assistant) was aware, but no one has put a new one back on. On 8/21/22 at 3:45 pm V15, Licensed Practical Nurse (LPN) was notified by the surveyor that R9 complained of pain and pressure ulcer on R9's coccyx. V15, LPN stated R9 does not have a pressure ulcer and has not complained of pain. There is no documentation in R9's electronic medical record that R9's skin was assessed or treated by V15, LPN after the above interview. On 8/23/22 at 2:05 pm V2, DON stated I was not aware that (R9) had a pressure area. It has not been reported, as far as I know. The CNA's (unidentified) should respond to (R9's) request for transfer from the bedside commode and report her complaints of pain from sitting. She will be assessed right away. R9's Nurse Note dated 8/23/2022 at 2:45 pm, documented by V3, Assistant Director of Nursing (ADON) documents the following Health Status Note Text: This nurse (was) notified by (the) business office manager (V30) that resident (R9) had reported an open area to (R9's) coccyx to her (V3, ADON) at this time, upon assessment, resident observed to have blanchable redness to coccyx area measuring 5cm (centimeters) x 6cm (centimeters), (V3, ADON) spoke with resident (R9) regarding using protective cream to area (coccyx), resident (R9) stated that she would prefer to have a foam bandage applied to area, (V22 , Medical Director) notified, order received for Optifoam Gentle bordered foam, apply to coccyx, change every 3 (three) days et (and) PRN (as needed), if dressing becomes soiled or comes off, resident and husband notified of new orders, dressing applied to area. On 8/23/22 at 5:15 pm V3, Assistant Director of Nursing (ADON) stated I (V3, ADON) did a skin assessment and found (R9) had redness to her coccyx region. We had only been applying ointment. (R9) wanted foam. I applied an Optifoam dressing and got an order from (V22, Physician). I measured the area and documented in the chart.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident was secure in a wheelchair in the facility tr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident was secure in a wheelchair in the facility transport van for one of three residents (R72) reviewed for falls in the sample list of 47. This fall resulted in R72 being transported to the emergency room by the ambulance, sustaining a sprained ankle and injured finger requiring support bandage with splinting. Findings include: R72's Care Plan printed on 8/24/22 documents diagnoses including Bilateral Primary Osteoarthritis of the Knee, Spinal Stenosis, Lumbosacral Region, Muscle Weakness, Difficulty in Walking, History of Falling, Multiple Sclerosis, Morbid Obesity and Pain in Leg. This Care Plan documents R72 is at risk for falls related to impaired mobility with a revised date of 7/30/19. R72's Care Plan documents R72 has an ADL (Activities of Daily Living) Self Care Performance Deficit related to impaired mobility dated 4/30/2019 and documents R72 requires total assist of two staff participation with transfers using a full mechanical lift dated 4/30/2019. R72's Minimum Data Set (MDS) dated [DATE] documents R72 is cognitively intact and required total assist of two staff for transfers and total assist of one staff for locomotion. On 8/22/22 at 10:03 AM, R72 stated about six months ago R72 slid out of the wheelchair in the facility van. R72 stated that R72 injured R72's ankle and finger. R72's finger is crooked at the end after the last knuckle. R72's Occurrence Report dated 3/3/22 documents a fall occurred off premises. This report documents R72 slid from R72's wheelchair during transport back to the facility following an appointment. (V24) Transport Aide reports that (R72) c/o (complained of) foot being uncomfortable during transport and as (V24) slowed down to turn, (R72) fell out of (R72's) wheelchair. (R72) was taken to local ED (Emergency Department) for evaluation. This Report documents R72's statement of what happened as staff at the hospital did not put (R72's) bottom far enough back when they assisted (R72) to the wheelchair. They told (R72) was far enough back. While in the van, (R72) felt like (R72) was sliding down. Reported to transport aide (V24) that (R72's) foot was uncomfortable and as the van began to turn, (R72) slid out of (R72's) wheelchair. On 8/24/22 at 11:43 AM, V2 Director of Nursing stated R72 went out for an infusion and V2 stated R72 told the hospital that R72 was not positioned correctly in the wheelchair and the hospital repositioned R72 and told R72 that R72 was positioned fine. V2 stated R72 told V24 that R72 had the hospital reposition R72 because R72 did not feel positioned correctly in the wheelchair. V2 stated that R72 told V24 that R72 felt like R72 was sliding out of the wheelchair. V2 stated V24 pulled over but R72 was already out of the wheelchair on the van floor. V2 stated V24 is not a CNA (Certified Nursing Assistant) so V24 cannot reposition R72. V2 stated if V24 felt like something was wrong V2 would expect V24 to call the facility. V2 stated as soon as V24 called V2, V2 went to the scene. V2 stated that the ambulance took R72 to the emergency room and performed X-rays. V2 stated that there were no fractures but they applied an elastic wrap on R72's sprained ankle and a splint on R72's injured finger. V2 stated that they determined the cause of the fall was the way that R72 was positioned in the wheelchair. V2 stated they applied a foot cradle to the wheelchair to help prevent it from happening again. On 8/24/22 at 11:57 AM, V24 Transport Aide stated that they were on their way back to the facility from R72's infusion appointment. V24 stated that R72 told V24 that R72 felt like R72 was slipping and R72's foot was uncomfortable. V24 stated that R72 bent forward to try to do something with R72's foot. V24 stated R72 took R72's seatbelt off to reach R72's foot. V24 stated that R72 told V24 R72 felt like R72 was slipping. V24 stated that V24 told R72 that R72 was fine and that R72 wasn't going to slip out of the wheelchair. V24 stated that V24 told R72 that it was just that the sling was underneath R72. V24 stated R72 told V24 that R72 told the hospital that R72 did not feel far enough back in the wheelchair. V24 stated that R72 was too big for V24 to move. V24 stated that R72 appeared stable enough to make the ride back to the facility. V24 stated that V24 was making a turn when R72 started to slide out of the wheelchair. V24 stated that V24 pulled over immediately and called 911. V24 stated that V24 was fairly new and was sure that V24 fastened R72 in the van correctly. R72's emergency room Discharge Instructions dated 3/3/22 documents diagnoses of Fall, Ankle Sprain, Knee Pain, Finger Injury and Hip Pain. Instructions were to rest, take Tylenol as needed for pain, ice the affected area, wrap an elastic bandage on ankle, elevate ankle, wear splint on finger, follow up with orthopedics. R72 was given one Norco 5-325 mg (milligram) (narcotic pain reliever). R72's Physician visit dated 3/8/22 by V22 Physician documents R72 had a fall out of the wheelchair after recent injection injured right ankle, also injured long finger on right hand. Has a splint on the finger. Appears R72 may have a [NAME] finger.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure that dignity was maintained by allowing a reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure that dignity was maintained by allowing a resident's exposed abdomen, thighs and flanks to be in full view of other residents, and staff while dining. This failure affected one resident (R129) of forty-seven residents reviewed for dignity in the sample of 47. Findings include: R129's Minimum Data Set (MDS) dated [DATE] documents the following: R129's Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. R129's same MDS documents R129 requires two-person extensive physical staff assistance with dressing. On 8/23/22 at 4:45 pm, R129 was seated in an oversized wheelchair. R129's wheelchair was pushed up towards the dining room table. There was about an eighteen inch space between the dining table to R129's wheelchair. R129 sat with R129's pants pulled down to just above R129 knees. R129 shirt was rolled up under R129's breast. R129's abdominal pannus (area) torso, flank adipose tissue hung over the top of R129's incontinence brief. R129's bare thighs were also in clear view. R129 bare body areas were in full view of seven residents (unidentified) also seated at dining room tables. Kitchen staff (unidentified), V15, Licensed Practical Nurse (LPN), and V16, Certified Nursing Assistant (CNA) were in the dining room and passed by R129 repeatedly. On 8/23/22 at 4:50 pm V15, LPN stated the following: I will get (R129) back to (R129's) room and get him fully dressed. I need to find help, (R129) is a (mechanical lift) transfer. I wouldn't want my body showing to a bunch of people. Of course, this is a dignity issue. On 8/24/22 at 2:05 pm R129 stated the following: I (R129) am glad the CNA's (unidentified) took me to my room yesterday and fixed my clothes. They have to dress me every day. I can't do it myself. I had no idea my pants were down and everybody in the dining room could see my bare body. I am a big man and have a lot of belly. I like to keep that all private. I was really embarrassed; I am ok now. I wish that hadn't happened.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a residents' choice was honored to shower earlier then 10:30 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a residents' choice was honored to shower earlier then 10:30 pm. This failure affected one of one (R20) resident reviewed for choices on the sample list of 47. Findings include: R20's Daily Skilled Note dated 8/23/22 documents the following: 2. Cognitive/Memory: a. Cognitive Status 1. Alert b. Memory Problems: 1. Has no memory problems. Resident recalls location of own room, staff names or faces, that they are in a nursing home, current season, person, place, time, (and) situation. c. Describe what resident can recall, if none, document none. (The last box documents R20 recalls) All. R20's Minimum Data Set, dated [DATE] documents R20's daily preference for bathing in Very important to R20. On 08/21/22 at 1:00 PM, R20 stated the following The facility gives (R20) showers at 10:30 pm, and (R20) has requested showers earlier, but staff (unidentified) still coming in late. I (R20) refuse to take a shower that late in the evening. On 8/23/22 at 2:15 pm V2, Director of Nursing stated R20 has a right to choose when she receives her showers. On 8/23/22 at 4:25 pm V16, Certified Nursing Assistant (CNA) stated the following: (R20) is scheduled to receive showers on the evening shift, Monday and Thursday each week. V16, CNA reviewed R20's electronic medical record and stated V16, CNA only had access to look back one month. V16, CNA also stated There is no documentation in the last month that (R20) received a shower on (the following days): 7/25/22, 8/4/22, 8/8/22, 8/11/22 or 8/18/22. If it wasn't charted, it was not done. There are no notes to say why (R20) didn't get them (showers) those days. She has a right to refuse but it should be documented as to why. Since she gets showers on evening shift, it could have been because (R20) didn't want to get out of bed to shower that late. R20's Documentation Survey Report ADL (Activities of Daily Living)-Bathing dated July 1-31, 2022 does not document R20 had a bath/shower on the following days: 7/4/22, 7/21/22, and 7/25/22. R20's Documentation Survey Report ADL (Activities of Daily Living)-Bathing dated August 1-31, 2022 does not R20 had a bath/shower on the following days: 8/4/22, 8/8/22, 8/11/22, and 8/18/22.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to maintain a resident wheelchair in a clean and repaired condition. This failure affects one resident (R45) of three reviewed for equipment in ...

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Based on observation and interview, the facility failed to maintain a resident wheelchair in a clean and repaired condition. This failure affects one resident (R45) of three reviewed for equipment in the sample list of 47 residents. Findings include: On 8/22/2022 at 11:14AM, R45's wheelchair was located nearby R45's bed and was soiled throughout the chair with accumulations of dirt and food debris. The padded arm rests of the chair were severely worn and tattered in appearance. The left arm rest had been previously repaired with black utility tape and the tape was shredded in appearance and dangling from the arm rest in multiple locations. On 8/23/2022 at 11:19AM, R45's wheelchair remained as above and V6 (Licensed Practical Nurse) was present and stated it (R45's wheelchair) definitely need cleaned.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers for residents as per their plan of care for three of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide showers for residents as per their plan of care for three of three residents (R12, R40, R59) in the sample list of 47. Findings include: The facility's Grievance Log documents that residents complained about showers on 7/5/22, 7/6/22, 7/26/22, 8/17/22 and R59 filed a Grievance regarding showers on 8/19/22. The Resident Council Meeting Minutes dated 5/31/22 documents showers were a concern at the previous meeting. Resident Council Meeting Minutes dated 6/28/22 documents showers are still not happening. R12's Order Summary Report dated 8/24/22 documents R12 has diagnoses including Chronic Pain Syndrome, Anxiety Disorder, Hypertension, Presence of Cardiac Pacemaker, Sick Sinus Syndrome, Weakness, Difficulty in Walking, Chronic Obstructive Pulmonary Disease and Atrial Fibrillation. R12's Care Plan printed on 8/24/22 documents R12's ADL (Activities of Daily Living) Preferences are to have a shower two times per week with a revised date of 7/22/20. This Care Plan documents R12's ADL Self Care Performance Deficit as requiring one staff assist with bathing and two staff assist with transfers with a revised date of 4/14/21. R12's Minimum Data Set (MDS) dated [DATE] documents that R12 is cognitively intact and requires extensive assistance of one staff for transfers and is totally dependent on one staff for bathing. On 8/22/22 at 2:25 PM, R12 stated that it has been a week since R12 had a shower. R12 stated that R12 has missed a lot of showers. R12's CNA (Certified Nursing Assistant) Task Documentation for June 2022 and July 2022 documents R12 went 14 days from 6/28/22 to 7/12/22 without a shower between those days. This report also documents R12 went for 10 days from 7/12/22 to 7/22/22 without a shower. R12's CNA Task Documentation dated August 2022 documents R12 went 21 days from 8/2/22 to 8/23/22 without a shower. R40's Order Summary Report dated 8/24/22 documents diagnoses including Weakness, Unsteadiness of Feet, Gout, Paroxysmal Atrial Fibrillation, Hypertension, Asthma, Chronic Obstructive Pulmonary Disease, Pain in Left Knee and Abnormalities of Gait and Mobility. R40's Care Plan printed on 8/24/22 documents R40 has a Self Care Performance Deficit and requires one staff assistance for transfers and bathing with a revised dated of 3/12/21. R40's MDS dated [DATE] documents R40 is cognitively intact and requires extensive assistance of one staff for transfers and is totally dependent on one staff for bathing. On 8/22/22 at 2:25 PM, R40 stated that R40 has missed showers sometimes. R40's CNA Task Documentation for June, July and August of 2022 documents R40 went 14 days from 6/28/22 to 7/12/22 without a shower and ten days from 8/2/22 to 8/12/22 without a shower. R59's Order Summary Report dated 8/24/22 documents diagnoses including Anxiety, Epilepsy, Difficulty in Walking, Repeated Falls, Weakness and Visuospatial Deficit and Spatial Neglect Following other Cerebrovascular Disease. R59's Care Plan printed on 8/24/22 documents R59 has a Self Care Performance Deficit and requires one staff assistance for bathing and one staff supervision for transfers. R59's MDS dated [DATE] documents R59 is cognitively intact and requires set up help for transfers and physical help by one staff with bathing. On 8/22/22 at 2:25 PM, R59 stated that R59 has missed some showers and that R59 gets a shower in the evenings. R59's CNA Task Documentation for June, July and August 2022 documents R59 went 12 days from 6/29/22 to 7/11/22 without a shower, 14 days from 7/11/22 to 7/25/22 without a shower, 12 days from 7/27/22 to 8/8/22 without a shower and went nine days from 8/8/22 to 8/17/22 without a shower. On 8/24/22 at 10:43 AM, V2 Director of Nursing stated that residents should receive showers as per their plan of care. V2 stated it should be written on their Care Plan in their preferences. V2 stated if it is not on the Care Plan then they should follow the shower schedules on the halls. Shower Schedules provided by V1 Administrator on 8/24/22 at 12:28 PM documents R12 and R40 are scheduled for showers on Tuesdays and Friday on the 6:00 AM to 2:00 PM shift and R59 is scheduled for showers on Monday, Wednesday, and Friday on the 2:00 PM to 10:00 PM shift.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide intravenous medication consistent with professional practice in one (R135) of one resident reviewed for intravenous med...

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Based on observation, interview and record review the facility failed to provide intravenous medication consistent with professional practice in one (R135) of one resident reviewed for intravenous medication administration from a total sample list of 47. Findings include: On 8/22/22 at 12:59PM V7 Registered Nurse stated while at R135's bedside that she did not know how to get the fluid from the intravenous bag into the Ceftriaxone vial to provide the intravenous medication for R135. V7 Registered Nurse also stated that she did not know which port to administer the antibiotic into and then asked R135 if he knew which one was correct. R135 stated that he did not know which port was the correct one. V7 Registered Nurse then left R135's room. On 8/22/22 at 1:05PM V7 Registered Nurse (RN) returned to R135's room. At this time, V7 RN did not wash her hands nor use hand sanitizer before opening up the lines to flush them and did not use alcohol on the hubs of the catheter before disconnecting and reconnecting the caps from the end of the ports or before connecting the tubing into the port into the peripherally inserted central catheter. The facility provided undated Administration of Medication via an Intravenous Catheter (IV) guide documents, Perform hand hygiene and follow any necessary infection control guidelines prior to medication administration. Wipe the needleless connector on the IV device with an antiseptic swab and allow it to dry. Attach a prefilled saline syringe, check for blood return then flush the line. Detach the syringe and discard it into the appropriate container. Remove the cap from the end of tubing cleanse the needleless connector with an antiseptic swab and connect the tubing to the needleless connector. On 8/22/22 at 1:15PM, after administering the antibiotic, V7 Registered Nurse acknowledged that she forgot to wash her hands upon entering the room the second time and failed to cleanse the catheter hubs with alcohol at any time.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain an order for oxygen administration, an order for...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to obtain an order for oxygen administration, an order for oxygen tubing changes, and failed to date oxygen tubing to indicate when the tubing was changed for two of two residents (R8, R71) reviewed for oxygen in the sample list of 47. Findings include: 1.) R8's Order Summary Report dated 8/23/22 document diagnoses including Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction without Residual Deficits, Hypertension, Sleep Apnea, Atrial Fibrillation, Chronic Diastolic (Congestive) Heart Failure, Heart Disease of Native Coronary Artery without Angina Pectoris, Multiple Sclerosis, Other Toxic Encephalopathy and Symptomatic Epilepsy. This Order Summary documents R8 was admitted to the facility on [DATE] and documents an order for a CPAP (Continuous Positive Airway Pressure) on at HS (night) and off in AM, setting at 15 with a start date of 6/6/22. This Order Summary does not document an order for Oxygen or for Oxygen Tubing changes. On 8/21/22 at 10:31 AM, R8 was lying in bed. There was an oxygen concentrator next to R8's bed and it was turned on. R8 did not have the nasal cannula on. R8 stated that R8 is supposed to have oxygen on but couldn't reach it to put it on when R8 took off the CPAP mask. An unidentified staff member came into R8's room and placed the nasal cannula on R8's face. The oxygen tubing was not dated to indicate when it had been changed. On 8/22/22 at 9:54 AM, R8 had the oxygen on via nasal cannula and the oxygen tubing was not dated to indicate when the oxygen tubing was changed. On 8/23/22 at 10:38 AM, R8 was in bed with oxygen on via a nasal cannula. The oxygen tubing is still not dated to indicate when it was changed. R8 stated that the tubing has not been changed since it was put on R8. On 8/23/22 at 11:51 AM, V6 Licensed Practical Nurse (LPN) confirmed R8 had oxygen on via a nasal cannula and confirmed that R8's oxygen concentrator was set at 3 liters of oxygen. On 8/23/22 at 11:59 AM, V2 Director of Nursing confirmed there was no order for oxygen administration for R8 and there was no order to change R8's oxygen tubing. V2 stated that the expectation is that the oxygen tubing is changed weekly, and the tubing should be dated. V2 stated that back in July, R8's CPAP mask broke so they placed R8 on oxygen. V2 stated evidently there was no order obtained or entered for the oxygen. 2.) R71's Order Summary Report dated 8/23/22 documents diagnoses including Atrial Fibrillation, Hypertension, Dependence on Supplemental Oxygen, Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease. This Order Summary documents an order for Oxygen 2L (liters)/NC (nasal cannula), monitor O2 (oxygen) sats (saturation) every shift with a start date of 7/29/22 and an order for Oxygen Tubing - Change Weekly with a start date of 7/31/22. On 8/21/22 at 1:24 PM, R71 had oxygen on via a nasal cannula but the oxygen tubing did not have a date on it to indicate the date that it was changed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). Of the 26 opportunities there were...

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Based on observation, interview and record review the facility failed to administer medications as ordered to keep the medication error rate below five percent (5%). Of the 26 opportunities there were two medications that were ordered and available but not given resulting in a 7.14 percent medication error rate. This failure affected R12 who is one of ten residents reviewed for medications on the sample list of 35. Findings include: On 8/22/22 at 3:31PM V10 Registered Nurse stated that she was going to administer R12's ordered afternoon medications. R12's physician orders dated 8/13/22 document, Cyclosporine Emulsion drops 0.05%, one in each eye. R12 Registered Nurse did not take the Cyclosporine drops to R12 to administer. R12 Registered Nurse stated, I don't know where they (Cyclosporine drops) are. I was going to give these (Artificial Tears) instead to R12, but I don't know about the other drops. On 8/22/22 at 3:35PM, V10 Registered Nurse identified a physician order for Maalox Suspension 400/400/40 per 5 milliliters for R12 dated 8/13/22. V10 Registered Nurse did not recognize the medication in a generic bottle that included the same ingredients as Maalox identified on the Medication Administration Record. V10 Registered Nurse stated, I will have to see if they have Maalox somewhere else. The facility provided skills checklist for administration of medications documents to compare the label on each medication to the electronic medication administration record and administer medications as ordered. On 8/22/22 at 3:45PM, V2 Director of Nursing stated that medications are to be given as ordered.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to prevent cross-contamination of food and food contact surfaces, failed to properly cover stored food, failed to maintain sanit...

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Based on observation, interview, and record review, the facility failed to prevent cross-contamination of food and food contact surfaces, failed to properly cover stored food, failed to maintain sanitary food storage areas, and failed to maintain functional food storage equipment. These failures have the potential to affect all 77 residents residing in the facility. Findings include: On 8/21/2022 at 8:56AM, the walk-in cooler condensate drain pan was covered with water droplets on the underneath side of the pan. The droplets were actively dripping onto food stored below the condenser, including whole watermelons and celery. Both the watermelon and celery were directly cross contaminated with the water from the condensated pan. Twenty-three individual lettuce salads were also stored below the dripping condenser. Each salad was covered with a lid, with some of the lids wet with the water leaking form the condenser above. Additional boxes of unopened produce were also wet with the water dripping from the above condensate drain pan. The front panel of the walk-in-cooler condenser was covered with a gray, fuzzy growth resembling mold. The condenser fan guard was also soiled with the same gray substance. Powdery, gray-colored deposits resembling mildew contamination were also located throughout the interior walls and ceiling surfaces of the cooler. A pan of whole, cooked pork loin was located on the center shelf of the cooler near the door and was uncovered on one end of the pan, exposing the loin to the environment. A clear, plastic unlabeled food container one-half filled with a white powder was located on the lower shelf of the main food preparation table in the kitchen. A single use plastic condiment cup was located inside of the container and was in full contact with the white powder. On 8/21/2022 at 9:07AM, the walk-in-cooler door seal was twisted outward along the edges of the door preventing an effective seal with the mating surfaces of the door and the body of the cooler. On 8/21/2022 at 9:10AM, an ice scoop was stored in a clear plastic wall caddy adjacent the kitchen area ice maker. The tip of the ice scoop was resting in the bottom of the caddy, immersed in an accumulation of gray, opaque water. On 8/22/2022 at 12:20PM, the evaporator remained as above and was actively dripping onto food stored below which included whole watermelon and a box of open and uncovered celery. The celery was covered with the water and the leaked water was also pooled beneath the celery. V5 (Dietary Manager) was present and reported some of the food contaminated with the condenser drain pan water was ready to eat and would not be cooked. V5 reported the cooler condenser had been dripping for a month or so and viewed the substances resembling mold and mildew growth on the condenser and cooler surfaces and reported it (the cooler) needs cleaned. V5 reported the white powder from above was food thickener and the condiment cup used as a scoop and resting in the product should not be in there. V5 reported the food in the kitchen is available for all residents to eat. The facility Resident Census and Conditions of Residents report (8/22/2022) documents 77 residents reside in the facility.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to follow transmission based precautions when entering a resident's room for two (R134, R135) of four residents reviewed for tran...

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Based on observation, interview and record review, the facility failed to follow transmission based precautions when entering a resident's room for two (R134, R135) of four residents reviewed for transmission based precautions from a total sample list of 47. This failure has the potential to affect all 77 residents residing in the facility. Findings include: On 8/20/22 R134 and R135 were admitted to the facility. On 8/22/22 at 11:00AM, R134 and R135's room doorway was covered with plastic, had signs indicating droplet isolation on the door, and had an isolation cart with supplies next to the door. The facility's Covid-19 Action Plan dated 7/7/22 documents, that newly admitted or readmitted resident to the community who are NOT Up-to-date with all recommended COVID-19 Vaccine Doses or whose vaccination status is unknown will be placed in the transition/quarantine area, placed in a cohorted or private room and immediately placed on droplet precautions. Maintaining the core principles of infection control every time you enter or exit the transition area including: ensuring a respirator mask, a cover mask, gown, gloves and eye protection. On 8/22/22 at 3:15PM V14 Licensed Practical Nurse walked out of R134 and R135's room without personal protective equipment being worn or having been removed, as the door was open. V14 Licensed Practical Nurse stated, I know that it is an isolation room, I just ran in there for a minute and I didn't even think about it. On 8/23/22 at 8:20AM, V2 Director of Nursing confirmed that staff are to wear gowns, gloves, respirator masks and eye protection for droplet isolation on the transition unit.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to develop and implement an effective antibiotic stewardship program. This failure has the potential to affect all 77 residents residing in th...

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Based on interview and record review, the facility failed to develop and implement an effective antibiotic stewardship program. This failure has the potential to affect all 77 residents residing in the facility. Findings include: On 8/24/2022 at 1:00PM, the facility Infection Control/Antibiotic Surveillance Log (January 2022-present day) fails to document the details of resident infections and antibiotic use in the facility. The log does not document the causative organism for an infection and does not document the criteria used to determine the necessity of antibiotics. The same record fails to document the antibiotic type, dose, and duration of treatment for resident infections, or any non-pharmacological interventions attempted prior to antibiotic use. On 8/24/2022 at 1:50PM, V2 (Director of Nursing) reported the above log contained all the information the facility was tracking for infections and antibiotic use in the facility. The facility Antibiotic Stewardship policy (2019) documents if antibiotic therapy is ordered for a resident, facility documentation will include the diagnosis, medication, dose, route, and duration. The same record documents the facility will communicate the criteria for antibiotic use to the resident's medical provider, including any prior non-pharmacological interventions attempted for the resident, before antibiotics are initiated. The facility Resident Census and Conditions of Residents report (8/22/2022) documents 77 residents reside in the facility.

MATTOON REHAB & HCC

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