What is PARKER NURSING & REHAB CENTER's CMS rating?

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

Does PARKER NURSING & REHAB CENTER have any serious inspection findings?

Yes, PARKER NURSING & REHAB CENTER has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 66 total deficiencies from recent inspections.

What are the staffing levels at PARKER NURSING & REHAB CENTER?

PARKER NURSING & REHAB CENTER has a one-star staffing rating from CMS with 0.71 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 PARKER NURSING & REHAB CENTER located?

PARKER NURSING & REHAB CENTER is located in STREATOR, IL. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PARKER NURSING & REHAB CENTER have?

PARKER NURSING & REHAB CENTER has 102 certified beds.

Who owns PARKER NURSING & REHAB CENTER?

PARKER NURSING & REHAB CENTER is a for profit - limited liability company facility and is part of the INFINITY HEALTHCARE CONSULTING chain.

Is PARKER NURSING & REHAB CENTER safe?

PARKER NURSING & REHAB CENTER has documented safety concerns including a substantiated abuse finding on record, 2 immediate jeopardy citations. Families should ask about corrective actions taken.

Do nurses at PARKER NURSING & REHAB CENTER stick around?

PARKER NURSING & REHAB CENTER has average staff turnover at 39%, which is typical for the nursing home industry.

Was PARKER NURSING & REHAB CENTER ever fined?

Yes, PARKER NURSING & REHAB CENTER has been fined $141,351 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is PARKER NURSING & REHAB CENTER on any federal watch list?

No, PARKER NURSING & REHAB CENTER 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 PARKER NURSING & REHAB CENTER?

Medicare inspectors have found 66 deficiencies at PARKER NURSING & REHAB CENTER: 2 critical, 1 serious, 62 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting PARKER NURSING & REHAB CENTER?

Families visiting PARKER NURSING & REHAB CENTER 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 PARKER NURSING & REHAB CENTER compare to other nursing homes?

PARKER NURSING & REHAB CENTER 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.

PARKER NURSING & REHAB CENTER | 0/100 (Grade F)

Jun 2025 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

Free from Abuse/Neglect (Tag F0600)

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 ensure resident's were free from physical abuse for 2 of 3 residents...

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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 resident's were free from physical abuse for 2 of 3 residents (R1 and R2) reviewed for Abuse in the sample of 3. The findings include: R1's electronic face sheet accessed on 6/27/25 show R1 has diagnoses that include hemiplegia and hemiparesis affecting right side. Anxiety and delusional disorder. R1's facility assessment dated [DATE] show R1 is alert and able to verbalize his needs. R2's electronic face sheet accessed on 6/27/25 show R2 has diagnoses that include traumatic subdural hemorrhage, drug induced parkinsons, and anxiety disorder. R2's facility assessment dated [DATE] show R2 has no cognitive impairment with BIMS of-15 The Facility Reported Incident (FRI) as final dated 6/10/25 (date of incident as 6/6/25) documents, R1 and R2 were in the dining room at their separate tables. R2 began yelling towards the direction of R1's table. R1 came towards R2 making contact with R2's right forearm. R1 lost his balance fell backwards and hit his head on cooler. Body assessment done with no injuries or complaint of pain. R1 and R2 denied police involvement. R1's MD ordered for R1 to be sent to the hospital for eval. CT scan of head with no evidence of acute intracranial process and cervical spine completed with no acute fractures or dislocation of cervical spine. R1 and R2 feel safe at the facility . On 6/27/25 at 9:30 AM, R1 was alert in his room, R1 stated He (R2) started it, we were both in the dining room, he was mouthing off at me, so I went to him and pushed him, I hit him!. he hit me back then I lost my balance and I fell. On 6/27/25 at 11:30 AM, R2 said regarding the incident on 6/6/25, it was during supper, he came at me saying things to me so I told him to F----ed off!, that's when he hit this arm (contracted right arm) I hit him back. He hit me again, so I hit back until they separated us. He fell , then got up and started hitting me again. Then R2 brought this surveyor to the dining room to show where the incident happened. R2 said he was at table 6 and R1 was in table 12. Table 6 and table 12 were next to each other. Camera's were noted in the dining room. On 6/27/25 at 12 PM, this surveyor watched the video surveillance with V1 (Administrator) and V4 (Human Resources.) Video surveillance showed, that both R1 and R2 were in the dining room sitting in their table. R1 got up and walked towards R2. R2 was sitting in his wheelchair in his table. R1 hit R2 numerous times, R2 hit back. R1 fell backwards, V3 (License Practical Nurse-LPN) was now at the scene. R1 got up and again hit R2 while V3 was trying to stop R1. V3 was unable to stop R1 from hitting R2. V4 (Human Resources) and V6 (Cook) were noted to be walking towards R1 and R2. V3 took R2 away in his wheelchair while R1 left the dining room. On 6/27/25 at 10:30 AM, V3 (LPN) said she was the nurse on 6/6/25 when the incident happened. V3 said she was at another table attending to another resident. I turned and I saw R1 approaching R2's table, I yelled, hey stop!, and went towards them. R1 lost his balance and fell backwards hitting his head in the milk cart behind him. R1 got up himself and left the dining room. When a resident hit another resident that is abuse. On 6/27/25 at 10:40 AM, V4 (Human Resources) said on 6/6/25 she was at the facility that evening. It was around suppertime when she heard somebody yelling really loud coming from the dining room hey! stop! V4 said she got up and went to the dining room and saw R1 hit R2's forearm so she hurriedly pulled R2 away from R1. V4 said she called V1 (Administrator) to notify her of the incident. V4 said when a resident hit another resident that is abuse. On 6/27/25 at 10 AM V6 (Cook) said on 6/6/25, he was on break when he heard someone yelling loud coming from the dining room. V6 said he went back to the kitchen then to the dining room. V6 said he saw R1 standing over R2, with R1's hands on R2's chest either pushing R2 or holding R2's shirt. The Nurse (V3) was trying to go in between R1 and R2 yelling stop! stop! Another staff came (V4) and pulled R2 away. V6 said when R1 saw him, R1 stopped and left the dining room probably because he saw another man. V6 said Abuse is when a resident hit another resident. On 6/26/25 at 2PM, V1 (Administrator) said both R1 and R2 have behaviors, there's a company that will be starting soon to come to the facility and provide group therapy to residents with behaviors The Facility on Abuse with a revised date of 1/2019 show, it is the policy of this facility to prohibit and prevent resident abuse neglect exploitation mistreatment and misappropriation of resident property and a crime against a resident in the facility. Physical abuse- hitting, slapping, pinching, kicking, it also include controlling behavior through corporal punishment.

Jun 2025 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

Investigate Abuse (Tag F0610)

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 and investigate an allegation of sexual abuse for two resi...

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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 and investigate an allegation of sexual abuse for two residents (R1 and R3); and failed to protect (R1 and R3) from any further possible alleged sexual abuse. These failures led to R1 and R3 to withdraw from socialization and daily activities. R1 and R3 remained in their rooms to avoid contact with the alleged perpetrator (R2). These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 05/26/2025 when R1 and R3 reported R2 was making sexually explicit remarks to them. The allegations were not investigated immediately and R2 had continued access to R1 and R3. R1 and R3 remained fearful and caused R1 and R3 to withdraw socially in an effort to avoid R2. While the Immediate Jeopardy was removed on 5/30/25, the facility remains out of compliance at a severity level two while additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. Findings Include: The Facility's Abuse Prevention Program, dated 01/2019, documents This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. This policy will define how the investigation of abuse allegations and mistreatment or crimes will be conducted and outline the process of reporting, investigating, and arriving at a conclusion or disposition of the allegation. The Facility's Abuse Prevention Program, dated 01/2019, documents Sexual abuse: Including, but not limited to, sexual harassment, sexual coercion, or sexual assault. The Facility's Abuse Prevention Program, dated 01/2019, documents Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment, or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident is reported to covered individual, covered individuals are notified annually of these reporting requirements. All resident, visitors, volunteers, family members, or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, or mistreatment to the Administrator or an immediate supervisor who immediately reports the allegation to the Administrator. The Facility's Abuse Prevention Program, dated 01/2019, documents All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, approaches, and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. R1's Medical Record documents she was admitted to the facility on [DATE] with diagnoses to include but limited to Anxiety, Paranoid Schizophrenia and Auditory Hallucinations. R1's MDS (Minimum Data Set) Assessment, dated 5/13/25, documents R1 BIMS (Brief Interview for Mental Status) indicates a score of 14 out of possible 15; indicating R1 is cognitively intact. R1's MDS documents that R1 had no hallucinations or delusions. R1's MDS documents R1 did not have any physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or any other behavioral symptoms not directed towards others. R3's Medical Record documents she was admitted to the facility on [DATE] with diagnoses to include but not limited to Epilepsy, Major Depressive Disorder recurrent severe with psychotic symptoms, Schizoaffective Disorder depressive type, Moderate Intellectual Disabilities and Delirium due to known physiological condition, Auditory Hallucinations, and Post-Traumatic Stress Disorder. R3's MDS (Minimum Data Set) Assessment, dated 5/13/25, documents R3's BIMS (Brief Interview for Mental Status) indicates a score of 15 out of possible 15, indicating R3 is cognitively intact. R3's MDS documents that R3 had no hallucinations or delusions. R3's MDS documents R3 did not have any physical behavioral symptoms directed towards others, verbal behavioral symptoms directed towards others, or any other behavioral symptoms not directed towards others. R3's current Care plan, dated 2/18/25, documents (R3)'s history indicates that she has experienced significant trauma during her lifetime and is a trauma survivor. She reports a history of sexual assault/sexual violence as well as the death of her husband. Reinforce with the caregiving team that trauma refers to experiences that cause intense physical and psychological stress reactions. On 5/27/25 at 1:30 PM, R1 stated (On 5/26/25, R2) told me that we (R1 and R3) could masturbate while he masturbates. (R2) also told me to get online and buy a dildo so he can keep me happy with it. We told (V5 Activities Aide) that (R2) was scaring us and saying sexual stuff to us. She (V5/Activity Aide) told us to tell management when they came in on Tuesday. We (R1 and R3) told (V5) that we were scared of (R2) and that we were staying in our room so he couldn't get to us. He has said kind of inappropriate things to us since we have gotten here but he got really bad over the weekend. On 5/27/25 at 1:30 PM, R3 stated (R2) scares me. He said he wants to have sex with me. I have been abused and raped in the past and do not want that to happen again. R3 was tearful and visibly agitated. I don't have to listen to someone talk to me like that, I loved my husband, he is dead now, that does not mean I am available for sex. I told (R2) I just wanted to be friends with him, but he kept trying to tell me that I should want to have sex with him. R3 stated R2 was saying inappropriate things on and off all weekend. On 5/27/25 at 1:30 PM, R4 stated that R1 and R3 complained to her about R2 saying sex stuff on Monday 5/26/25, and R4 stated she took them (R1 and R3) to (V5/Activity Aide) and told them to tell her so they did not have to hide in their room. (V5) told us there was nothing she could do and that we should tell management in the morning. (V5) told me (R4) that I needed to quit stirring up trouble. On 5/27/25 at 2:00 PM, V5 (Activity Aide) confirmed that R1, R3 and another resident (R4) came to her on 5/26/25 at an unknown time and told her that (R2) was saying sexually inappropriate things to them. V5 stated I don't even know what all he supposedly said. V5 stated that R3 told her that she (R3) was scared and was staying in her room to avoid (R2). V5 stated I told her that was a good idea, and she (R3) should just leave him alone. There was no management staff in the facility because it was Memorial Day. What was I going to do? I am not management in the building. They need to tell management or the charge nurse. I did not know who to call, that is why I told them (R1, R3 and R4) to report it the next day. V5 confirmed that she did not alert anyone else of the complaint, nor did V5 talk to any staff members or other residents regarding the allegation. V5 stated (R4) likes to spread rumors, she likes to keep those two (R1 and R3) worked up. V5 was unable to give any examples of what rumors R4 had spread or any disturbance that R4 had caused in the facility. V5 stated I don't know, she is always listening getting into other people's business. R4's Medical Record documents that she was admitted on [DATE] with diagnoses to include but not limited to Cerebral Infarct, Major Depression, and Insomnia. R4's MDS (Minimum Data Set) Assessment, dated 4/16/25, documents R4's BIMS score of 15 out of 15, indicating R4 is cognitively intact. R4's MDS documents R4 had no hallucinations or delusions. R4's MDS documents R4 had no physical behavioral symptoms directed towards others, verbal behavioral symptoms directed toward others, or other behavioral symptoms not directed towards others. On 5/27/25 at 1:30 PM, R1 stated, (R3) has been very upset and hiding in our room. Everyone (staff) seems to think that (R4) has told us to try to get (R2) in trouble and she has not. (R3) has a long history of abuse and rape so I believe she is triggered at this point. (R2) should not be allowed to say things like that to any women. They (V1 Administrator) and (V4 Social Services Director) told us that we always have the right to walk away from conversations that we don't want to be a part of. I told them we (R1 and R3) are scared, that they need to make him (R2) behave, not us. We told (V17/Certified Nurse Aide) and she seemed to be the only one who actually cared. On 5/27/25 at 2:15 PM, V7 (Certified Nurse Aide/CNA) confirmed that R1, R2, R3, and R4 all currently reside on the same hallway in the facility. On 5/27/25 at 1:00 PM, V1 (Administrator) provided all abuse allegations investigated by the facility in the past three months. There was no investigation regarding R1 and R3's allegation of sexual abuse by R2 from 5/26/25. V1 did provide a Concerns/Compliments/Questions/Suggestions form dated 5/28/25 signed by V4 (Social Services Director) that documents (R3) reported to writer that (R2) was talking about sex to her. The form documents Response/Resolution: discussed with (R3) about walking away from conversations she does not want to be part of. On 5/27/25 at 2:45 PM, V4 (Social Services Director) stated she had received the written statements left under management personnel's door when she (V4) arrived at work at approximately 8:30 AM - 8:45 AM on 5/27/25. V4 confirmed that R1, R2, R3 and R4 all reside on the same hallway. V4 was not able to provide any names of other residents or staff members she interviewed after she spoke with R1, R2 and R3 regarding the 5/26/25 incident. V4 confirmed that R3 said she upset when V4 spoke with her, V4 stated but she is always upset about something. R3's Nurse's Note dated 05/27/2025 at 1:13 PM entered by V4 (Social Service Director) documents (R3) approached writer reporting a male resident was talking to her about sex in general. Stated he said to her how can you live without sex? Instructed (R3) to remove herself from these types of conversations if she feels uncomfortable. Reported to writer male resident did not touch her. V1 (Administrator) written statement, dated 5/26/25, documents On 5/26/25 at approximately 11:30 PM I received a phone call from (V14 Certified Nurse Aide) stating that residents (R1 and R3) reported that (R2) had made sexual comments to them. I told (V14) to leave statements from them under my door. V1 confirmed that she did not speak to any other staff member other than V14 on 5/26/25 at around 11:30 PM. V1 confirmed that she did not instruct any staff members to increase monitoring or to begin an investigation with other staff members or residents. V6 (Licensed Practical Nurse) written statement documents On 5/27/25 at approximately 1:00 AM (V17/Certified Nurse Aide) reported (R2) was in (R1 and R3)'s room touching their arms, rubbing their shoulders and making statements such as are you bored, just sitting around here let's go to my room, do you want to have sex, let's go have sex. The women (R1 and R3) told staff about this incident during ice pass tonight, but when the female residents told (V5/Activities Aide) about the incident earlier in the day, (V5) informed the women to tell management or the nurse. The CNA reported it immediately to the nurse (V18/Registered Nurse) before I (V6) arrived and was told 'that's not my problem'. The female residents (R1 and R3) seemed very upset and tearful about this incident. R1's Nurse's Note, dated 5/27/25 at 2:20 AM, documents CNAs reported that during ice pass, 2 female residents stated that this resident was making statements such as are you bored just sitting here, let's go to my room, do you want to have sex, let's go have sex while touching/rubbing both female resident's arms and shoulders. Residents felt like second shift didn't care-they were very tearful and upset about this incident. R3's Nurse's Note, dated 5/27/25 at 2:23 AM and signed by V6 (Licensed Practical Nurse) documents CNAs reported that during ice pass, resident stated a male resident came into her bedroom making statements such as 'are you bored just sitting here, let's go to my room, do you want to have sex, let's go have sex' while touching/rubbing arms and shoulders. This resident appears to be tearful and upset at this time. A written statement signed by V17 (Certified Nurse Aide), V14 (Certified Nurse Aide), and V15 (Certified Nurse Aide) documents during ice pass and first round (on third shift) on 5/26/25 (R1) and (R3) told us that (R2) has been making unwanted sexual advances towards them they stated he told aren't you bored around here? Let's go to my room and have sex. The ladies (R1 and R3) stated they reported it to (V5/Activities Aide) and she told them she would have to tell nursing staff and management about the situation. Both female residents (R1 and R3) were very upset about the issue as well. We (V17, V14, and V15) tried to tell the nurse (V18/Registered Nurse) around 11:00 PM and she said she was leaving, and it wasn't her problem. On 5/29/25 at 12:00 PM, V15 (Certified Nurse Aide) confirmed that she herself and V14 and V17 all reviewed and signed the written statement from 5/26/25. V15 confirmed that V14 (Certified Nurse Aid) reported the allegation to V18 (Registered Nurse) and V18 stated it was not her problem and that she was leaving. V15 reported that V18 then gathered her belongings and left the facility. V15 stated that she was not aware of any ongoing issues with any of the mentioned residents (R1, R2, R3 and R4). V15 stated that V14 (Certified Nurse Aide) then began calling all management staff regarding the incident and that V1 (Administrator) finally called back and said to just leave written statements under her door. V15 stated that she has never been questioned about her written statement or any further concerns from any member of staff at the facility as of 5/29/25 at 12:00 PM. You are the first to ask me any questions about this. On 5/29/25 at 2:15 PM V14 (Certified Nurse Aide) confirmed that she herself and V15 and V17 all reviewed and signed the written statement from 5/26/25. V14 stated that R1 and R3 reported to all three CNAs (V14, V15 and V17) that R2 was in their room rubbing their shoulders and saying inappropriate sexual stuff to them and was making them very uncomfortable. I told (V15 and V17) we need to stop what we are doing and report this. We all three went to (V18/Registered Nurse) and she said she was not reporting anything because she was off at 11:00 PM and it was almost 10:45 PM. That upset all of us, so I started calling the on-call nurse who was V3 (Assistant Director of Nursing) approximately 6 times with no answer or return call, I tried (V2/Director of Nursing) twice with no answer and V1 (Administrator) answered on the second call. But even after I told V1(Administrator) that V18 refused to call her and that R1 and R3 were scared V1 only said well leave a written statement under my door. There is no way for me to know if any of this actually happened but what happened to protecting the residents? I specifically told (V1/Administrator) that (R1 and R3) were scared of (R2). No one came in, no one spoke to (R1 and R3) and reassured them they were safe or anything. I still have not been questioned by anyone at the facility about my written statement. You are the first person to ask any questions about this. On 5/30/25 at 10:00 AM V17 (Certified Nurse Aide) confirmed that she herself and V14 and V15 reviewed and signed the written statement from 5/26/25. V17 stated R1 and R3 reported to all three CNAs that R2 was rubbing their shoulders and saying aren't you bored? Don't you want to go have sex with me? V17 stated that all three CNAs reported R1 and R3's concerns to V18 (Registered Nurse) who stated it was not her problem because she was almost off work. V17 stated that V14 (Certified Nurse Aide) then started calling management staff to report both the fact that the nurse would not report the incident and that R1 and R3 were scared of R2. R2's Medical Record documents that he admitted to the facility on [DATE] with diagnoses to include but not limited to unspecified intracranial injury with loss of consciousness of unspecified duration, cerebral aneurysm non-ruptured, depression, mood disorder due to known physiological condition, insomnia and anxiety. R2's MDS (Minimum Data Set), dated 5/7/25, documents R2's BIMS (Brief Interview for Mental Status) was 15 of 15, indicating R2 is cognitively intact. R2's MDS documents R2 had no hallucinations or delusions. R2 had no physical or verbal behavioral symptoms directed at others or other behavioral symptoms not directed towards others. R2's current Care Plan, dated 7/26/2024, documents (R2) exhibits sexually inappropriate behavioral symptoms related to lack of self-respect, poor self-worth, feelings of inadequacy, Behavioral symptoms are manifested by making crude, sexually oriented, profane or suggestive remarks. Conduct an evaluation of the sexually oriented behavioral symptoms to determine what (R2) is communicating through the behavior, provide supportive interventions needed when inappropriate behavior is observed/reported. On 5/30/25 at 11:44 AM, V1 (Administrator) was notified of the Immediate Jeopardy. On 6/3/25, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R1 and R3 were moved to another unit away from R2 on 5/28/25. 2. R1 and R3 were seen by Psychiatric Provider on 5/30/25. 3. Trauma assessments updated R1 and R3 on 5/28/25. 4. R2's increased location monitoring, every fifteen minutes, starting 5/27/25 at 6:00 PM was reviewed. 5. R2's behavior monitoring started 5/30/25 for inappropriate behaviors, such as sexual misconduct and inappropriate touching of others, was added to the medication administration record, monitored by nurse was reviewed with no inappropriate behaviors documented for R2 since 5/30/25. 6. Inservice for the department heads done by V19 (Regional Director of Operations). 7. Education/Inservice sign in logs for all staff reviewed for 5/30/25. 8. Education/Inservice regarding abuse policy sign in log for V1 (Administrator) dated 5/28/25 reviewed 9. Education/Inservice regarding abuse policy sign in log for V5 (Administrator) dated 5/28/25 reviewed 10. Quality Assurance Meeting Minutes dated 5/30/25 regarding the abuse policy and the Immediate Jeopardy citation were reviewed. 11. On 6/3/25 at 9:45 AM R1 and R3 were in their new room and both R1 and R3 stated they felt safe in the facility.

May 2025 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

Deficiency F0627 (Tag F0627)

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 follow their policy and procedures for discharge plann...

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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 follow their policy and procedures for discharge planning for three residents (R1, R2, and R3) and unplanned discharge for three residents (R1, R4, and R5) of four residents reviewed for discharge in the sample of six. Findings include: The facility's undated, Unplanned Discharge policy and procedure, documents: Policy: For purposes of providing the safest discharge possible, the facility will advise residents of the risks of early, unplanned discharge, and provide appropriate referrals and discharge instructions whenever possible. Discharge Against Medical Advice (AMA) procedure documents to obtain and witness residents' signature on AMA form. If resident refuses to sign, consider AWOL (Absent Without Official Leave) procedure documents: Resident not returning from pass, LOA (leave of absence), or outside appointments as scheduled will be considered AWOL. Resident who leaves the facility with staff knowledge, without following proper procedure and/or without signing AMA will be considered AWOL. This policy documents the Social Worker or Nurse will: Notify Adult Protective Services (APS), if applicable and Make necessary attempts to locate the resident's whereabouts. The Social Service Director (SSD) Job Description, dated 1/29/24, documents the SSD Must assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis; safeguard the health, safety, and welfare of all residents of the facility. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The essential job functions include: Communicates with the elderly with communication problems and relay their needs/concerns to family, facility, and community agencies. 1. The Progress Note for R1, dated 5/9/25 at 12:00 PM, documents R1 is alert and oriented to person, place, time and event and able to make her needs known. R1 reported to Nursing she was leaving via local community transport and did not say where she was going. The Progress Note for R1, dated 5/9/25 at 9:15 PM, documents the day shift reported R1 left the facility via local community transport and at 9:00 PM, R1 had not returned. At 9:15 PM R1's closet was checked revealing all R1's belongings were gone. There are no Progress Notes documenting Adult Protective Services were notified or that anyone tried to locate R1. The Progress Note for R1, dated 5/10/25 at 6:34 AM, documents a night shift CNA/Certified Nursing Assistant called reporting seeing R1 at a local fast-food restaurant with her belongings in a shopping cart that was parked outside the entrance of the establishment. On 5/13/25 at 9:30 AM, R1 was not residing in the facility. On 5/13/25 at 12:00 PM through 12:45 PM, Upon arrival to the local fast-food restaurant this writer noted a shopping cart at the corner of the building, on the entrance side of the establishment, filled with plastic bags with a blue beach chair on top of the cart. Upon entering establishment this writer noted R1 sitting in dining booth, wearing a black hooded sweatshirt with hood pulled up on her head, unkempt, messy, and disheveled, with her legs elevated resting on the booth's seat and with foul odor present. R1 was talking to herself, raising her arms and pointing into the air. Approached R1 in attempt to interview and R1 made no eye contact and did not respond to this writer. On 5/13/25 at 1:30 PM, V5 LPN/Licensed Practical Nurse stated on 5/9/25, at supper time, she asked if R1 had returned to the facility and was told no. On 5/13/25 at 2:00 PM, V8 Receptionist stated R1 was signed out of the facility on 5/9/25 and did not return. On 5/14/25 at 1:36 PM, V10 (R1) Friend stated she just found out she was listed as an emergency contact for R1, her telephone has not been disconnected, and she was not notified on 5/9/25 by the facility that R1 had left the facility and not returned. V11 (R1's) Friend is listed as R1's first emergency contact and was not notified of R1 leaving the facility either. V10 stated she received two missed calls from R1 the night of 5/9/25 and on 5/12/25 was notified by a friend that R1's shopping cart was located outside a local fast-food restaurant. V10 and V11 visited R1 at the local fast-food restaurant on 5/13/25 and R1 said no one has spoken to her from the facility. On 5/13/25 at 11:30 AM, V2 DON (Director of Nurses) stated on Friday night (5/9/25) V2 received a telephone call from the facility that R1 had not returned from her outing on 5/9/25. V2 DON stated the police were not called, no one went to look for R1, R1 never came back to the facility, and was discharged . On 5/14/25 at 9:30 AM, V1 Administrator stated she received a telephone call the night of 5/9/25 that R1 had gone out and didn't return to the facility. V1 Administrator stated nothing else was done after R1 left the facility, there is no investigation, police were not called, and no one looked for R1. 2. The Progress Note for R4, dated 10/21/24 at 10:45 AM documents R4 left with friend to go to doctors' appointment. The Progress Note for R4, dated 10/22/24 at 9:41 AM documents R4 was absent from the facility. The Progress Note for R4, dated 10/22/24 at 11:49 AM documents R4 was contacted and R4 stated she would go to the local emergency room for evaluation before returning to the facility. The Progress Note for R4, dated 10/22/24 at 6:00 PM documents R4 has not returned to the facility and if not back by 8:30 PM would be discharged . There are no Progress Notes indicating Adult Protective Services were notified or that anyone tried to locate R4. On 5/15/25 at 12:45 PM V4 SSD confirmed R4 signed out of the facility on 10/21/24, did not return, and nothing else was done. V4 SSD stated R4 was alert and oriented and it was her right not to return to the facility. On 5/14/25 at 9:33 AM, V1 Administrator confirmed R4 left the faciity on [DATE], did not return to the facility, there is no investigation, police were not called, and no one looked for R4. 3. The Progress Note for R5, dated 10/1/24 at 8:15 AM documents R5 wanting to leave facility AMA, understands risks of leaving, refuses to sign AMA paperwork. The Progress Note for R5, dated 10/1/24 at 12:03 PM documents exit alarm sounded and R5 was noted outside with his belongings. Attempts were made to redirect back inside but R5 refused, stating he would become physically aggressive with staff. On 5/15/25 at 12:48 PM, V4 SSD confirmed R5 left the facility AMA with his personal belongings on 10/1/24 without signing AMA paperwork and nothing else was done. On 5/15/25 at 9:35 AM, V1 Administrator confirmed R5 left the faciity on [DATE] AMA and refused to sign AMA paperwork, did not return to the facility and nothing else was done. On 5/15/25 at 2:00 PM, V1 Administrator confirmed Adult Protective Services should have been notified of R1, R4, and R5's AWOL status and staff should have looked for R1 and R4. The facility's undated Discharge Planning Policy, Protocol, and Procedure documents its purpose: To identify appropriate candidates for inclusion in active discharge planning facilitating the transition to a less structured environment and to coordinate adequate supportive community care services. This nursing facility strongly emphasizes preparation and preparedness. The goals and objectives include: To anticipate and minimize potential problems related to discharge; To assist families and significant others in preparing for discharge; To assure the involvement of the Social Work staff in assessing discharge potential, documenting significant information related to discharge and coordinating community health care services. The Social Service Director Job Description, dated 1/29/24, documents the SSD assists in planning, developing, organizing, implementing, evaluating, and directing social service programs. Must assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. The essential job functions include: Coordinates discharge planning and maintain ongoing notes regarding discharge planning for appropriate residents. 4. The current Care Plan for R1, documents R1 would like to return to the community and live independently. The Quarterly Care Plan for R1, dated 4/19/25, documents there is no active discharge planning occurring for R1. The Progress Notes for R1 do not include any Social Service notes or further discussion regarding active discharge planning being done for R1 after 2/27/24. On 5/13/25 at 12:40 PM, V4 SSD stated R1 stated she did try to help R1 on 2/27/24 with filling out paperwork with the housing authority but R1 backed out and there has been nothing else since then. 5. The current Care Plan for R2 documents R2 expressed the desire to move to a less structured environment, discharge potential and planning needs have been assessed, and R2 demonstrates self-sufficiency skills. The admission MDS (minimum data set) Assessment for R2, dated 2/12/25, documents R2 is cognitively intact and R2's overall goal is to discharge to the community and no active discharge planning occurring. The Discharge Planning Review for R2, dated 5/12/25, documents: R2's discharge potential as Fair; Discharge Status as Personal residence with support services.; and Discharge Plan as Do not initiate. The Progress Notes for R2 do not include any Social Service notes or active discharge planning being done for R2. On 5/13/25 at 1:42 PM, R2 was walking up the hallway independently, was clean, well kept, and without odors. R2 stated she is staying in the facility until she can find a three-bedroom house. R2 stated she has been asked about her discharge plan, but no one is helping her to get out of the facility. 6. The current Care Plan for R3 documents R3 expressed the desire to move to a less structured environment, R3's discharge potential and discharge planning needs have been assessed and R3 demonstrates self-sufficiency skills. The Quarterly MDS Assessment for R3, dated 4/16/25, documents R3 is cognitively intact with no discharge planning occurring. The Discharge Planning Review for R3, dated 4/6/25, documents: R3's Discharge Potential as Fair; Discharge Status as Personal residence with support services; and Discharge Plan as Do not initiate. On 5/13/25 at 1:48 PM, R3 was walking up the hallway independently, was clean, well kempt, and without odors. R3 stated she wants to find a place to live, the facility is aware, and she has asked for help but not getting it. On 5/15/25 at 12:40 PM V4 SSD stated discharge planning is different for every resident and is based on the resident's cognition and done case by case. If a resident is alert and oriented and choses to leave, they have the right to leave if they want to. If a resident or family member is helping a resident with discharging from the facility V4 SSD does not interfere but if asked to assist she will. Once a resident says they are ready or want to leave, V4 will then start the discharge plan, and the documentation would be found in the resident progress notes. V4 SSD stated R2 and R3 are related and are wanting to discharge together and is not sure what their plan is. V4 stated if R2 and R3 want her help she would help them but R2 and R3 have not asked her. V4 SSD confirmed there is currently no discharge plan in place for R2 and R3 and there was no active discharge plan in place for R1 prior to R1 leaving the facility.

Apr 2025 8 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one allegation of abuse was immediately reported to the facility abuse coordinator for one of one resident (R19) reviewed for abuse ...

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Based on interview and record review, the facility failed to ensure one allegation of abuse was immediately reported to the facility abuse coordinator for one of one resident (R19) reviewed for abuse in the sample of 32. FINDINGS INCLUDE: The facility policy, Abuse Prevention Program, dated (revised) 01/2029 directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or an allegation of suspected abuse or neglect of a resident by a third party. Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about or suspect to the (facility) administrator. The facility form, Concerns, dated 3/23/25 and completed by V8/Social Services Director documents, (V11/R19's daughter) called with concerns over (R19) getting a shower after loose stools. Staff educated. Discussed occurrence with CNAs (Certified Nursing Assistants). On 4/7/25 at 1:33 P.M., R19 stated, A while back, in the evening, I had a bad accident. I had loose stools and it was all over my clothes, the toilet, the floors and the walls. I was really embarrassed. One of the CNAs (I don't remember which one) said to me, 'Oh my lord, I have to clean up this shit.' It made me feel really bad. I didn't mean to do it. I can't help it. She told me I need to get up out of my chair and clean it up myself. The other two CNAs were laughing at me. On 4/7/25 at 2:33 P.M., V5/Licensed Practical Nurse stated, I worked the weekend of March 22/23, 2025 and I recall an incident where (R19) had a large, loose stool and had made quite a mess. (R19) didn't tell me about it, but her daughter (V11) called me, later that day. (V11) said (R19) had called her and was very upset and crying and said she had an accident and when the three CNAs were cleaning her up they were laughing and yelling at her. It's not uncommon for R19 to get upset and call her daughter and not tell the nurse if something is bothering her. I did call (V2/DON) and report it to her, right after (V11) called me. On 4/7/25 at 3:25 P.M., V2/Director of Nurses stated, I call the nurses on the weekends to remind them to have the CNAs give (R19) her shower. She gets a shower on Tuesdays and Saturdays. Her daughter (V11) is very particular about (R19's) care. I can't remember if (V5/LPN) called me about the incident involving (R19) on 3/23/25, but I think R19's daughter (V11) texted me. I didn't report the incident to (V1/Administrator). On 4/8/25 at 12:13 P.M., V14/Social Services Director stated she did not report the incident of potential abuse involving R19 to the facility abuse coordinator (V1/Administrator).

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 observation and record review, the facility failed to investigate an allegation of abuse for one of one resident (R19) reviewed for abuse, in the sample of 32. FINDINGS INCLUDE: The facility ...

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Based on observation and record review, the facility failed to investigate an allegation of abuse for one of one resident (R19) reviewed for abuse, in the sample of 32. FINDINGS INCLUDE: The facility policy,Abuse Prevention Program, dated (revised) 01/2019 directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. Upon learning of the report, the Administrator shall initiate an incident investigation. On 4/7/25 at 1:33 P.M., R19 stated, A while back, in the evening, I had a bad accident. I had loose stools and it was all over my clothes, the toilet, the floors and the walls. I was really embarrassed. One of the CNAs (I don't remember which one) said to me, 'Oh my lord, I have to clean up this shit.' It made me feel really bad. I didn't mean to do it. I can't help it. She told me I need to get up out of my chair and clean it up myself. The other two CNAs were laughing at me. On 4/7/25 at 2:33 P.M., V5/Licensed Practical Nurse stated, I worked the weekend of March 22/23, 2025 and I recall an incident where (R19) had a large, loose stool and had made quite a mess. (R19) didn't tell me about it, but her daughter (V11) called me, later that day. (V11) said (R19) had called her and was very upset and crying and said she had an accident and when the three CNAs were cleaning her up they were laughing and yelling at her. It's not uncommon for R19 to get upset and call her daughter and not tell the nurse if something is bothering her. I did call (V2/DON) and report it to her, right after (V11) called me. On 4/8/25 at 3:02 P.M., V1/Administrator stated, I wasn't made aware of an allegation of potential abuse involving (R19) that occurred on 3/23/25. I don't have an investigation.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

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 copy of the bed hold policy for residents discharging to t...

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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 copy of the bed hold policy for residents discharging to the hospital, for two of four residents (R53 and R56) reviewed for bed holds, in the sample of 32. Findings include: The facility's Bed Hold policy, revised 11/28/2016, documents It is the policy of the facility to provide the Resident, Resident's family member and/or the Resident's legal representative, if applicable, in written form and/or by telephone conversation prior to transfer to a hospital or prior to a Resident beginning therapeutic leave, for a duration of 24 hours or longer; certain information regarding the Resident's facility bed status and how the bed will be held. A copy of the Bed Hold policy given to the Resident, Resident's family member and/or the Resident's legal representative will be placed in the Resident's record. This will be documented in the resident's record. R53's medical record documents that R53 was hospitalized on [DATE], 12/3/24 and 3/15/25. R53's medical record does not contain documentation of written notice to R53 or R53's resident representative, of the facility bed hold policy. On 4/7/25 at 10:00am, V2, Director of Nursing, verified that R53 was not given the bed hold policy at the time of the discharge to the hospital. On 04/08/25 at 11:14am, V1 Administrator, stated that the bed hold policy given to the residents on discharge to the hospital should be uploaded into the medical record under the documents tab. V1 verified that R53 did not have any bed hold policy paperwork in his medical record. 2. R56's Progress note for time of transfer, dated 1/18/24 at 1:18 PM, documents R56 was transferred to the local hospital with paramedics for evaluation for pain in both hips and legs after a fall. R56's medical record does not document a bed hold policy was provided to R56 upon being transferred to the hospital on 1/18/25. On 4/9/2025 at 11:00 AM, V1 (Administrator) confirmed R4 was sent to the hospital on 1/18/2025. V1 stated I searched for proof of my nurse that day giving notice of transfer and Bed hold policy, but she did not do it. The nurse working that day should have done it, it is something we missed.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

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 perform a PASRR (Pre-admission Screening and Resident Review) rescr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform a PASRR (Pre-admission Screening and Resident Review) rescreen after the emergence of a newly diagnosed severe mental illness for two of two residents (R19 and R54) reviewed for PASRR screening, in the sample of 32. Findings include: The facility policy, Guidelines For PASRR Process, dated 5/17/2023 documents, PASRR is a federally mandated process that requires all states to pre-screen all residents regardless of their payer source or age who are seeking admission to a Medicaid funded nursing facility. PASRR has three goals (including) To ensure residents receive the required services for mental illness. Residents who are confirmed to have Mental Illness are evaluated to determine the need for specialized services, and appropriate placement options are reviewed. 1. R19's (facility) Face Sheet documents that R19 was admitted to the facility on [DATE] with the following diagnoses: Generalized Anxiety Disorder, and Schizoaffective Disorder, Bipolar Type. R19's Notice of PASRR, dated 4/10/23 documents, No Level 11 required- No Serious Mental Illness. 2. R54's (facility) Face Sheet documents that R45 was admitted to the facility on [DATE] with the following diagnoses: Bipolar Disorder Generalized Anxiety Disorder and Major Depressive Disorder. R54's Notice of PASRR, dated May 13, 2024 documents, No level 11 required- No Serious Mental Illness. On 4/7/25 at 2:27 P.M., V8/Social Services Director verified that R19 and R54 had not had a PASRR rescreen upon the emergence of a newly diagnosed severe mental illness.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure restorative services were being provided for one of two residents (R9) reviewed for restorative and range of motion in...

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Based on observation, interview, and record review, the facility failed to ensure restorative services were being provided for one of two residents (R9) reviewed for restorative and range of motion in a sample of 32. Findings include: The Facility's Range of Motion (ROM) Policy and Procedure, not dated, documents, The Restorative Nurse and/or Nurse Designee will complete a ROM (range of motion) risk assessment for all residents that are admitted to the facility to determine if they have any ROM deficits and/or are at risk for development of a reduction in their current ROM status. Residents that have been assessed to have a reduction in their ROM will be placed in appropriate ROM programming to increase ROM and/or to prevent further decrease in their ROM status. The facility acknowledges that some residents may develop deterioration in their ROM status due to the resident's clinical condition and the reduction in their range of motion is unavoidable. The Restorative Nurse will initiate tracking sheets to record the days/minutes that the ROM programming was completed. R9's Restorative: PROM (passive range of motion) will be able to tolerate up to 10 repititions, 2 sets of PROM to all extremities daily. R9's PROM 30 day look back documents that R9's PROM was not done on the following dates: 3/9/2025, 3/11/2025, 3/26/2025. R9's Care Plan documents R9 would benefit from a splint/brace Restorative Nursing Program as evidenced by the following risk factors and potential contributing Diagnosis: Centrilobular Emphysema, Quadriplegia, Severe Malnutrition, history of fracture of thoracic vertebrae, history of fracture of left femur, contractures of bilateral lower extremities, Anemia, Depression, Metabolic Encephalopathy. Apply my left resting had splint for 6-8 hours daily (day shift) while up in chair, apply right resting hand split at night (night shift) for 6-8 hours when in bed for contracture management unless my disease process causes unavoidable deterioration thru next review. On 4/6/2025 at 10 AM, R9 was in bed, in her room. R9 had bilateral hand contractures and bilateral leg contractures. R9 stated she does not get physical therapy anymore and no one helps her or offers her restorative therapy. R9 was not wearing splint brace on left or right hand. R9 stated while she was in physical therapy she was able to open her hands better and was able to pedal the mechanical bike. R9 was unable to lift her legs and was struggling to use her hands as well. R9 only has use of a few fingers on each hand. On 4/7/25 at 1:50 PM, R9 did not have splint/brace on left or right hand. On 4/8/25 at 1:00 PM, V17 (Assistant Physical Therapist) stated, (R9) has seen me several times since she admitted to the facility back in 2022, but (R9) has insurance that only allowed me to have six visits with her. I know we made a lot of progress and I know we have not had a restorative nurse for close to a year now. I feel that with a successful continuation with restorative therapy (R9) would have more success with her legs, and hands. On 4/8/25 at 1:30 P.M., V1 (Administrator) stated We have had restorative nurses hired but we have had a difficult time with keeping one on staff who is not on medical leave or leaves the position shortly after they have started over the last year. CNAs (certified nursing assistant) should be doing the restorative tasks for (R9).

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to provide medications as ordered for one of five residents (R40) reviewed for medication administration, in a sample of 32. FINDINGS INCLUDE: ...

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Based on interview and record review the facility failed to provide medications as ordered for one of five residents (R40) reviewed for medication administration, in a sample of 32. FINDINGS INCLUDE: The (undated) facility's Drug Administration policy, documents, Medications are administered as prescribed, in accordance with good nursing principals and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. R40's (hospital) After Visit Summary, dated 8/13/25 includes the following diagnoses: Suicidal Ideations and Major Depressive Disorder. This same form includes the following medication orders: Sertraline (Anti depressant) 100 MG (Milligrams) Take two tablets every day. R40's Medication Administration Record, dated August 13, 2024 through August 30, 2024 includes no nursing documentation that R40's prescribed Sertraline were added to R40's Medication Administration Record or administered from 8/13/24 through 8/28/24. On 4/8/25 at 2:38 P.M., V2/Director of Nurses confirmed that R40 did not receive the prescribed Sertraline from 8/13/24 until 8/29/24.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

2. R7's medical record includes the following diagnoses: Type 2 Diabetes Mellitus; Left-sided Hemiplegia, Hemiparesis due to Cerebral Infarction and Morbid Obesity. R7's current Care Plan includes th...

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2. R7's medical record includes the following diagnoses: Type 2 Diabetes Mellitus; Left-sided Hemiplegia, Hemiparesis due to Cerebral Infarction and Morbid Obesity. R7's current Care Plan includes the following: I am on enhanced barrier precautions for Wounds to bilateral heels. Enhanced precautions will be maintained. Follow Enhanced Precaution Guidelines when providing care and coming in direct contact with potentially infected material or devices that put me at risk. Direct Care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs , assisting with toileting and incontinence care. Follow the enhanced precautions guidelines. On 4/8/25 at 9:10am, Enhanced Barrier Precautions signage was in place at R7's door and PPE/Personal Protection Equipment was available in the hall outside R7's door. On 4/8/25 at 9:10am V6 CNA/Certified Nursing Assistant and V7 CNA entered R7's room and did not don gowns prior to or throughout incontinence care for R7. On 4/8/25 at approximately 1:15pm, V3 Assistant Director of Nursing/Infection Preventionist stated staff are to wear gowns when performing incontinence cares for any resident under EBP/Enhanced Barrier Precautions. Based on observation, interview and record review the facility failed to donn personal protective equipment during cares for two of 12 residents (R7, R27) reviewed for enhanced barrier precautions in a sample of 32. Findings include: The facility's Guidelines for Enhance Barrier Precautions-EBP, undated, documents that enhanced barrier precautions are defined as the use of PPE (personal protective equipment) gowns and gloves during high-contact resident care activities that generate opportunities for transfer of MDRO's (Multi-drug Resistant organisms) in the form of blood or body fluids, onto the hands and/or clothing of the rendering caregiver. This form also documents examples of High Contact Resident Care activities at which EBP is to be practiced are dressing care/changes/management of dressings, changing briefs and assisting with toileting. 1. R27's current Physician Order Sheet, documents to cleanse the right great toe with wound cleanser, then apply a medicated dressing and cover with bordered gauze daily. This form also documents Enhanced Barrier Precautions due to AV (arteriovenous) shunt fistula and wounds. On 04/08/25 9:00 AM, V3, Infection Preventionist/Licensed Practical Nurse, used hand sanitizer, applied gloves, then removed R27's dressing to his right great toe. R27's right great toe wound had a serosanguinous drainage noted, with slough noted in the center of the wound. V3 went back to the treatment cart, removed her glove, used hand sanitizer, applied gloves and cleansed R27's right toe wound. V3 removed her gloves, used hand sanitizer, applied gloves and applied medication and dressing to R27's wound. On 04/08/25 at 12:00pm, V3 verified that R27 is on Enhanced Barrier Precautions and PPE is to be worn with direct care. V3 verified that she did not wear a gown during R27's wound care.

CONCERN (E)

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to provide evening snacks for seven of seven residents (R7, R8, R15, R28, R33, R45, R55) reviewed for evening snack provision in the sample of ...

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Based on interview and record review the facility failed to provide evening snacks for seven of seven residents (R7, R8, R15, R28, R33, R45, R55) reviewed for evening snack provision in the sample of 32 residents. Findings include: The facility's HS (evening/hour of sleep) Snacks policy, dated 8/8/2024, documents the following: Snacks are available to residents to offer nourishment at HS. The Food & Nutrition department will send snacks to the nursing stations at HS. Residents may be offered snacks such as graham crackers, cookies, fig newtons, pudding, applesauce (according to the resident's diet order and/or preferences.). The Food & Nutrition department will maintain a system or snack list for labeling & delivering snacks to those residents that receive scheduled snacks as part of their plan of are/preference. Resident Council Meeting Minutes, dated 10/28/24, documents concerns that Snacks and Coffee are not being passed out. On 4/7/25 at 9:45am, during the Survey Group Meeting, every attending resident stated that evening snacks are not being given to residents very often. R7 stated, We don't get evening snacks very often. R33 stated, Sometimes we do get (evening snacks) and sometimes we don't. R28 stated, They either don't bring them or they are delivered late, when we're asleep and we can't eat them. On 4/8/25 at 1:15pm, R8, R15 and R55 verified evening snacks are not being offered on a regular basis. On 4/8/25 at 2:50pm V16 Dietary Manager stated evening snacks should be passed every day around 6:30pm.

Mar 2025 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

Notification of Changes (Tag F0580)

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 ensure the resident's Power of Attorney (POA) was notified post fal...

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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 resident's Power of Attorney (POA) was notified post fall for one of three residents (R2) reviewed for falls. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 3/11/25, were reviewed. The Census Roster documented 60 Residents resided in the Facility. Guidelines for Notification of Change in Residents Condition/Status/Treatment dated 6/29/24 documented the nurse will immediately notify the resident, their physician, and/or the resident's Responsible Party/POA for the following: a) An accident involving the resident, which results in injury and has the potential for requiring physician intervention. B) A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental, or psychosocial status in either life threatening conditions or a clinical complication. Guidelines for Incident/Accidents/Falls dated 6/30/23 documented residents who have an unwitnessed fall must have neurological checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed (by staff) fall. The nurse will notify the resident's attending physician and resident's power of attorney and documented in the progress notes. R2 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarct affecting right dominant side, Morbid Obesity related to excessive caloric intake, Diastolic Congestive Heart Failure, Hypertension, Diabetes Mellitus Type 2 and End Stage Renal Disease dependent on Hemodialysis. R2's Nurse's Progress Note dated 10/7/24 at 10:50 AM documented R2 fell out of his wheelchair while being mechanically lifted in his wheelchair into the NCAT (North Central Area Transport, public transportation service) van. R2 stated he hit his head although refused to go to Emergency Department for evaluation and proceeded to be transported to the off-site dialysis unit and for dialysis treatment. The Dialysis Center's Nurse's note date 10/07/24 at 3:04 PM documented at the beginning of tx (dialysis treatment), pt (R2) stated that he fell while in the (public transportation van) (documented in chairside). I asked pt (patient) if he hit his head, pt (R2) denied. no wounds or welts noted. during tx, pt (R2) stated his back was hurting d/t (due to) the fall, gave prn (as needed) tylenol. pt (R2) then called POA (V18) and told him that he hit his head during the fall. I called pt's (R2) NH (Nursing Home) staff and got the full story. pt (R2) did fall, did not hit head per (the public transportation service/van) driver and pt (R2) was checked out by staff. pt refused to go to the ER and stated that he was fine. Advised NH staff to call pt's (R2) POA (V18) for an update as they had not called him after the fall. R2's Nurse's Progress Note dated 10/7/24 at 4:11 PM (after dialysis unit's staff notified V18 (R2's Power of Attorney/POA) documented an attempt to reach V18 was made and a message was left. On 3/14/25 at 8:08 AM, V17 (Dialysis Clinic Manager) stated R2 told the dialysis nurse about the fall and the dialysis unit was not notified by the Long Term Care Facility prior to initiating dialysis treatment on 10/7/24. R2 requested V18 (R2's POA) to be called/notified of the fall and his increasing pain. V18 stated he had not been called by the Long Term Care Facility and was unaware of R2's fall. On 10/7/24 at 3:05 PM, the dialysis nurse called the Long Term Care Facility to get a report about the fall incident and to inform the Facility about R2's complaints, treatment and the notification made to V18. R2's census data documented R2 was discharged from the facility on 11/8/24. The medical record did not include documentation to describe why R2 left the facility, where R2 was discharged to or that V18 or a physician was notified. R2's Hospital Discharge summary dated [DATE] documented on 11/8/24 R2 presented to the Emergency Department with shortness of breath, generalized weakness, low blood pressure and heart rate; was admitted to the Intensive Care Unit for Septic Shock. The Summary documented R2 continued to deteriorate and V18 transitioned R2 to hospice and passed away on 11/28/24 at 3:15 AM. On 3/13/25 at 12:15 PM, V1 (Administrator) stated the resident's physician and POA's should be notified as soon as possible when a change in condition occurs. V1 also stated she would have expected facility staff to notify the dialysis staff about R2's fall to ensure R2's safety.

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 interview and record review, the facility failed to ensure residents were assessed after a fall per policy and interven...

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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 residents were assessed after a fall per policy and interventions were implemented to prevent further falls for one of three residents (R2) reviewed for falls. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 3/11/25, were reviewed. The Census Roster documented 60 Residents resided in the Facility. Guidelines for Incident/Accidents/Falls dated 6/30/23 documented residents who have an unwitnessed fall must have neurological checks started and continued per policy. Neuro checks will be initiated even if the resident states they did not hit their head in an unwitnessed (by staff) fall. Documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over at least 72 hours or until the resident's condition improves. Neuro checks will be completed after any head trauma as well as after any unwitnessed fall (even if the resident states they did not hit their head) as per policy. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Each fall needs a new care plan intervention rolled out. Based on the results of the incident/accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate intervention in place. The occurrence will be documented. The progress note within the resident's medical record is to be included. Documentation in the medical record should include a description of the occurrence. The Neuro (Neurological) Check policy not dated documented it is the policy of the facility to ensure that if it is known or suspected that a resident has had a blow to the head, neurological complications are assessed to include neuro checks. Neuro checks will be performed for a minimum of 72 hours. Always do neuro checks if the fall was unwitnessed by the staff member even if the resident themselves or other residents state that the resident who fell did not hit their head before or after or during the fall. Vital signs and neurological signs are taken and recorded as follows: Blood Pressure (BP) and pulse and pupil check every 15 minutes for two hours; BP and pulse and pupil check every 30 minutes for two hours; BP and pulse and pupil check every 60 minutes for four hours; then continue vital sign and neurological checks every eight hours until 72 hours have lapsed and resident is stable. Long Term Care Facility Outpatient Dialysis Services Coordination Agreement dated 1/24/18 documented the Renal Dialysis Services shall not include transportation to the ESRD (End Stage Renal Disease) resident to and from the ESRD Dialysis Unit. Transport of the ESRD Resident is the Long Term Care facility's responsibility to arrange for suitable and timely transportation of the ESRD resident to and from the ESRD Dialysis Unit, including the selection of the mode of transportation, qualified personnel to accompany the ESRD Resident, transportation equipment usually associated with this type of transfer or referral in accordance with applicable federal and state laws and regulations and all costs or transportation expenses associated with such transfer. R2 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarct affecting right dominant side, Morbid Obesity related to excessive caloric intake, Diastolic Congestive Heart Failure, Hypertension, Diabetes Mellitus Type 2 and End Stage Renal Disease dependent on Hemodialysis. R2's Nurse's Progress Note dated 10/7/24 at 10:50 AM documented R2 fell out of his wheelchair while being mechanically lifted in his wheelchair into the public transportation van. R2 stated he hit his head although refused to go to Emergency Department for evaluation and proceeded to be transported to the off-site dialysis unit and for dialysis treatment. R2 returned to the facility after dialysis on 10/7/24 approximately 4:00 PM-4:30 PM (5-5 1/2 hours post fall). The medical record did not indicate that dialysis staff were notified of the fall and to conduct neuro checks. The medical record did not indicate neuro checks were conducted or vital signs were monitored until 11:45 PM prior to the transfer to hospital for severe pain related to fall. The Hospital's Discharge Summary documented R2 was admitted on [DATE] with diagnoses of subdural hematoma (brain bleed) and a T8 fracture (a thoracolumbar burst fracture caused by high-energy trauma) and was discharged back to the facility on [DATE]. The Facility Reported Incident dated 10/14/24 documented R2's wheelchair wheeled backwards when the mechanical lift reached the van door due to not having the wheelchair brakes locked. The Care plan was updated to ensure facility staff transport resident in facility bus when available. If facility staff/bus is not available then, facility staff will stay with resident while the public transportation staff load residents into the van to ensure the public transportation staff are doing so in a manner that was safe for the resident. New interventions were discussed with the Interdisciplinary Team, R2 and V18 (R2's Power of Attorney/POA). R2's Care plan dated 9/26/24 revised on 10/3/24 documented R2 was a risk for falls. An intervention initiated on 11/4/24, 23 days after R2 returned from hospital post fall, noted facility staff would accompany R2 out to the bus to ensure driver had locked R2's wheelchair and R2 was situated securely and safely in the bus prior to driver leaving. An intervention dated 9/26/24 documented I would like staff to review information on my past falls and attempt to determine the cause of my fall(s). Record possible root causes on my care plan. Alter/remove any potential causes it (msp. if) possible. Educate me, caregiver and IDT (Interdisciplinary Team) as to the continued risk factors and interventions used to help prevent future falls. The Care plan meeting note dated 10/16/24 documented R2 was in attendance and alert and oriented and able to make his needs known. Takes meds (medications) without difficulty. Has dialysis 3 x (three times) week. No skin issues noted. Appetite good. Does participate in Restorative with ROM (Range of Motion) and Dressing. Needs Limited/Partial assist with ADLs (Activities of Daily Living). BIMS 14/15 (Brief Interview for Mental Status, no cognitive impairment) FULL CODE. The note did not indicate the IDT, R2 or V18 (R2's POA) was notified of the new interventions to ensure a safe transport to dialysis. On 3/12/25 at 11:20 AM, V2 (Director of Nursing) stated We had someone (staff member) go out (outside when R2 was getting on the public transportation van) and physically watch to make sure they (the public transportation staff) put on the brakes (R2's wheelchair) and dialysis made sure brakes were on before he (R2) left there (dialysis facility). V2 stated the facility had not put an intervention in place to ensure all residents in a wheelchair who get into the public transportation van have their brakes on and stated That's not our job. On 3/12/25 at 2:00 PM, V2 verified post fall assessment had not been conducted on R2 after returning to the facility post dialysis. On 3/14/25 at 8:08 AM, V17 (Dialysis Clinic Manager) stated V17 nor dialysis staff were notified or asked by the Long Term Care facility to have the dialysis staff ensure R2's brakes were on prior to transport by the public transportation van. V17 stated We would never agree to that. Our staff does not ever leave the facility to assist with transport. Residents are responsible for their own transportation. On 3/12/25 at 9:25 AM, R5 (Dialysis resident) stated facility staff do not assist him out of the building to the public transportation van or ensure he gets onto the van safely. R5 stated he is independent and puts his own brakes on but he forgot about a month ago and almost fell forward when the public transportation van's ramp was lifting. The public transportation staff put his brakes on at that point. R5 stated he did not fall but it was scary. He previously has had two falls at the facility and stated staff did not assess him after the fall. On 3/14/25 at 11:55 AM, V1 (Administrator) indicated the public transportation service/van is responsible for their staff's education on safety of their equipment. There was not a contract in place between the facility and the public transportation service/van because the public transportation service/van was a public transportation service in which the residents pay for. V1 agreed the dialysis staff should have been notified of R2's fall, post fall assessments should have been conducted, fall interventions should have been implemented and R2 and V18 (R2's POA) should have been notified of the interventions.

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

Medical Records (Tag F0842)

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 ensure documentation was accurate and completed per policy for one ...

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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 documentation was accurate and completed per policy for one of three residents (R2) reviewed for falls. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 3/11/25, were reviewed. The Census Roster documented 60 Residents resided in the Facility. The Guidelines for Nursing Documentation policy dated 5/17/23 documented 6. Be timely in your documentation. It is easy to forget details in the hustle of business. 7. Late notes happen. Should you need to document something out of time do it properly and in orderly manner by first documenting when you are making the late note, then detailing the actual time the event occurred. Never be deceptive and back-date or fake that you are writing at an earlier time. 8. Flow Charts need filled. Every organization has flow charts, do not leave them blank. Also, whenever an unusual event occurs remember to also go to the chart to document your findings. 9. Remember if you did not write it down, you did not do it. If you did not do it, you were negligent. Guidelines for Incident/Accidents/Falls dated 6/30/23 documented documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over at least 72 hours or until the resident's condition improves. The occurrence will be documented. The progress note within the resident's medical record is to be included. The report will be completed as soon as information is obtained. The record should be finished as much as possible before the nurse ends the shift. Documentation in the medical record should include a description of the occurrence. The Neuro (Neurological) Check policy not dated documented that it is the policy of the facility to ensure that if it is known or suspected that a resident has had a blow to the head, neurological complications are assessed to include neuro checks. Neuro checks will be performed for a minimum of 72 hours. Always do neuro checks if the fall was unwitnessed by the staff member even if the resident themselves or other residents state that the resident who fell did not hit their head before or after or during the fall. Observe the resident for obvious injury to the scalp such as laceration/contusion/bruising, confusion, memory loss, difficulty speaking, vomiting, sleepiness/difficult to arouse, seizure or seizure like activity, weakness and/or inability to move an extremity, irregular breathing, gait or balance problems, blurred or double vision and/or periods of coherence alternating with periods of lethargy. Vital signs and neurological signs are taken and recorded as follows: Blood Pressure (BP) and pulse and pupil check every 15 minutes for two hours; BP and pulse and pupil check every 30 minutes for two hours; BP and pulse and pupil check every 60 minutes for four hours; then continue vital sign and neurological checks every eight hours until 72 hours have lapsed and resident is stable. R2 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarct affecting right dominant side, Morbid Obesity related to excessive caloric intake, Diastolic Congestive Heart Failure, Hypertension, Diabetes Mellitus Type 2 and End Stage Renal Disease dependent on Hemodialysis. The Incident Note describing R2's fall dated 10/7/24 at 10:50 AM, although was completed on 10/9/24 at 3:06 PM, greater than two days after R2's fall and discharge to the hospital, by V2 (Director of Nursing). The Progress Note stating R2 refused to be transferred to the hospital was dated 10/7/24 at 10:50 AM, although was competed on 10/10/24 at 7:33 AM, three days after R2's fall and discharge to the hospital, by V2. R2's Medication Administration Record documented on 10/8/24 at 8:00 AM the following Medications were administered and Treatments were provided, although R2 was not in the facility (discharged to hospital on [DATE] at 11:45 PM and returned to the facility on [DATE]): Medications administered: Sevelamer Carbonate, Eliquis, Vitamin D-3, [NAME]-Vit, Jardiance, Gabapentin, Clopidogrel Bisulfate. Treatment administered: monitored hemodialysis arterial-vascular fistula site for redness, swelling, pain, bleeding, bruit and thrill; documented fluid intake as 480 milliliters; was on Enhanced Barrier Precautions and obtained a blood sugar level of 164. The Facility Reported Incident (FRI) dated 10/8/24 documented R2 had a fall and hit his head on 10/7/24, refused to go to the Emergency Department and went to dialysis as scheduled and per dialysis staff R2 denied pain or discomfort during treatment, post return to the facility monitoring of condition continued. R2 was sent to the Emergency Department for complaints of pain on 10/7/24 at 11:45 PM and was admitted with diagnoses of a thoracic spine fracture and subdural hematoma (brain bleed). R2's medical record did not include the time of day R2 returned from dialysis on 10/7/24 or that ongoing monitoring was conducted as documented on FRI. R2's Progress Note dated 10/31/24 at 11:21 PM documented R2 was sent to the Emergency Department. The medical record did not include documentation to describe R2's condition, signs and symptoms or assessments related to the reason for transfer and did not include a note, date or time that R2 returned to the facility or that an assessment was conducted upon return. R2's census data and Minimum Data Set (MDS) documented R2 was discharged from the facility on 11/8/24. The medical record did not include documentation to describe why R2 left the facility, where R2 was discharged to or that any assessments were conducted since a weekly skin check conducted on 11/6/24. On 3/11/25 at 2:50 PM, V2 (Director of Nursing) agreed R2's medical record did not include documentation of post fall assessments on 10/7/24; the time R2 returned to the facility on [DATE]; the reason for the Emergency Department (ED) visit or date, time and assessment of R2's return from the ED visit on 10/31/24 and 11/8/24. On 3/12/24 at 10:00 AM, V11 (Licensed Practical Nurse) stated I must have accidentally charted (on R2's Medication Administration Record). On 3/13/24 at 12:30 PM, V1 (Administrator) stated documentation in R2's medical record was not accurate and was incomplete. V1 stated the expectation is for staff to have their documentation entered by end of shift.

Feb 2025 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

Infection Control (Tag F0880)

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 ensure wounds were cleansed and PPE (personal protecti...

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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 wounds were cleansed and PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 3. The findings include: R1's face sheet printed on 2/6/25 showed diagnoses including but not limited to metabolic encephalopathy, Down syndrome, and early onset Alzheimer's disease. R1's February 2025 physician order report showed an order for: Cleanse wounds on buttocks and apply calcium alginate and dressing everyday shift for wound. The same report showed an order for: Transmission based droplet isolation related to: MRSA (Methicillin resistant staphylococcus aureus) of sputum every shift. The same report showed an order for: doxycycline hyclate (antibiotic) oral tablet 100 milligrams two times a day for 6 days. On 2/6/25 at 10:01 AM, R1 was observed from the hallway lying in bed. The room door was wide open, and a sign was posted on the door showing STOP DROPLET PRECAUTIONS. The sign showed that everyone must have a mask and eye protection on while inside the room. At 10:18 AM, V3 (WCN/ICP-Wound Care Nurse/Infection Control Preventionist) and V5 (Licensed Practical Nurse) donned gloves and gowns to begin R1's dressing change. V3 did not wear a mask or eye protection. V5 wore a surgical mask but no eye protection. R1 was rolled to his side and the dressing on his buttock was removed. R1 had a golf ball size wound on his sacrum, a dime size wound on the right buttock, and a pea size wound on the left buttock. V3 sprayed wound cleanser onto a cotton gauze pad and randomly blotted all three open areas. V3 used the same gauze pad on the three wounds and went back and forth over the areas. V3 and V5 completed the treatment, exited the room, and left the door open. V3 was questioned about the isolation sign on the door and the required PPE. V3 said she thought R1 was past the required number of days needed for droplet precautions and really is only on enhanced barrier precautions due to his buttocks wounds. V3 said gowns and gloves are all that are needed now and only when doing direct care. On 2/6/25 at 11:20 AM, V2 (DON-Director of Nurses) stated R1 is still on droplet precautions due to the MRSA in his sputum. R1 needs to stay on isolation until the completion of the antibiotics. A one week wait period is required and a negative sputum culture is needed before he can come off droplet isolation. V2 said R1 will be retested on [DATE]. On 2/6/25 at 1:20 PM, V2 (DON) stated the sign posted outside R1's room is wrong. It does not show the correct PPE required and is not stringent enough. The sign should show that gowns, gloves, N95 masks, and face shields are required anytime staff enter. V2 said there is a high risk for cross contamination between residents if staff are not wearing the right PPE. V2 supplied a second droplet precaution sign and said this is the one that should have been posted. The sign showed full PPE was required prior to entering the room. On 2/6/25 at 12:05 PM, V3 (WCN/ICP) stated the correct way to cleanse wounds is with a fresh cotton gauze for each sore. Sharing the same gauze pad can cross contaminate the wounds. V3 stated wounds should be wiped in an inward to outward manner. Random blotting can bring germs from the outer edges into the wound bed. On 2/6/25 at 2:45 PM, V7 (Wound Physician) stated wounds should be cleansed individually with fresh pads for each one. The areas need to be wiped from the inner to outer areas. It helps to reduce the risk of infection. The facility's undated Wound Cleansing and Dressings policy states under the procedure section: B. Cleanse starting with the cleaner appearing wounds and move to larger and more contaminated wounds. The facility's undated Guidelines for Prevention/Treatment of Pressure Injuries policy states under the treatment section: A clean field, using clean instruments and prevention of direct contamination of materials and supplies are also required. The facility's undated Infection Control/Isolation Guidelines policy states: A. Isolation precautions shall remain in effect until the condition is ruled out or the criteria for duration have been met.

Sept 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

Deficiency F0676 (Tag F0676)

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 give showers to three (R1, R2, and R3) of three resid...

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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 give showers to three (R1, R2, and R3) of three residents reviewed for activities of daily living in a sample of three. Findings include: Facility Nursing and Rehabilitation Master Shower Schedule, updated 8/13/24, documents R1 gets a shower on Wednesday and Saturday 2-10 PM; R2 gets a shower on Tuesday and Friday 6-2 PM; R3 get a shower on Thursday and Sunday 2-10 PM. Facility Certified Nursing Assistant (CNA) job description, dated April 1, 2023, documents Essential Job Functions are to assist residents with daily bathing functions, and hair and nail hygiene needs. 1. R1's medical record documents she is moderately impaired for cognition. R1's grievance, dated 6/24/24, documents (R1) reported staff were not giving her a shower and response or resolution was staff educated, and resolved on 6/24/24. R1's current care plan documents I usually require extensive assistance and one person support for bathing and dressing. R1's online and paper medical record has no shower documented from 9/1 to 9/6; 9/8 to 9/13; and 9/15 to 9/21/24. On 9/25/24 at 11:20 AM, R1 was alert and oriented, in a manual wheelchair, and stated she needs help with her showers for her feet and back. R1 stated she can bear weight and stand pivot for transfers and has not had a shower for about two weeks. I want my showers twice a week like I am supposed to get. 2. R2's medical record documents he is cognitively intact and was admitted to the facility on [DATE]. R2's current care plan documents I usually require supervision and set- up support for bathing and dressing. R2's online and paper medical record has no shower documented from 8/27 to 9/18; and 9/21 to 9/24/24. On 9/25/24 at 10:50 AM, R2 was alert and oriented, in a manual wheelchair, dressed, left orthotic shoe on, and R2's hair looked wet and was standing straight up in the air. R2 denied a shower, wetting hair, or putting any hair product in his hair. At that same time, R2 stated he had only had two showers since August (2024) when he admitted to the nursing home, unsure when his showers are supposed to be, and states he can do his own shower but needs towels, washcloths, and shampoo/soap set up. I need a shower and want one before my doctor appointment coming up. 3. R3's medical record documents she is cognitively intact. R3's grievance, dated 6/13/24, documents (R3) reported they were not giving her a shower and was referred to V3 prior Administrator with no response or resolution documented on the grievance, and dated 6/13/24 resolved. R3's current care plan documents I require total assistance and one staff for bathing and dressing. R3's 9/14/24 nursing note documents R3 is a mechanical lift and total assist with activities of daily living. R3's online and paper medical record has no shower documented from 9/8 to 9/14/24. On 9/25/24 at 11:12 AM, R3 was alert and oriented, in a manual wheelchair, dressed, and stated she had a concern with showers in June where she is supposed to get showers twice a week. I am to get showers twice a week. On 9/25/24 at 11:20 AM, V7 CNA was filling out a shower sheet and put in the shower book. V7 said the residents get a shower twice a week. On 9/25/24 at 11:40 AM, V6 CNA stated I have residents sign the shower sheet that they refused their shower and then I give the shower sheet to the nurse. (R2) is independent with his shower where he is set up with towels and wash cloths, call light, and the shower bench seat for his showers. I have never had (R2) refuse cares, and everyone gets a (paper) shower sheet filled out and we document in our charting system. Residents are to get showers twice a week as they are on the shower schedule. On 9/25/24 at 1:32 PM, V4 LPN stated I have not heard of R1 or R3 refusing showers. If residents refuse showers, then we re-approach. On 9/25/24 at 2 PM, V2 DON/Director of Nursing stated They (CNAs) do showers, fill out a (paper) shower sheet, hand it in to the nurse, and then the sheets are turned into me. On 9/25/24 at 2:30 PM, V1 Administrator stated We have been working with the staff on charting because if it is not documented it is not done. We have educated and started discipline for this. At that time, V1 verified she had no further documentation to provide for R1-R3's showers, noted R1-R3 were not getting showers weekly/regularly, and would be talking to staff. On 9/25/24 at 2:45 PM, V9 CNA stated I work day shift and (R2) has had a shower twice this month.

May 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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure residents who required thickened liquids had access to fluids at night for two of four residents (R1, R2) reviewed for...

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Based on observation, interview, and record review, the facility failed to ensure residents who required thickened liquids had access to fluids at night for two of four residents (R1, R2) reviewed for hydration on the sample list of 9. Findings Include: R1's May 2024 Physician Orders documents an order for Honey thick liquids. R2's May 2024 Physician Orders document an order for nectar thick liquids. On 5/2/24 at 5:32 am, V5, CNA (Certified Nursing Assistant), stated R1 and R2 both require thickened liquids. V5 stated the nurses ran out of thickener, therefore, neither R1 or R2 were able to have liquids during the night. V5 explained the thickener is kept in the kitchen and the kitchen is locked up at night, so if the nurse doesn't have thickener, then R1 and R2 don't get liquids. V5 stated R1 usually drinks all night long. On 5/2/24 at 5:45 am, R1 was lying in bed awake without any drinks available. There was 1 empty cup on R1's overbed table. At this time, V4, Agency RN (Registered Nurse), confirmed V4 does not have access to thickener in order to give R1 and R2 fluids, and explained V4 ran out of it at the beginning of V4's shift, which was on 5/1/24 at 6:00 pm. On 5/2/24 at 5:58 am, V3, RN, stated V3 does not have any thickener on V3's medication cart either. V3 stated V3 is unsure how long the medication cart has been without thickener, because the container was empty upon V3 coming into work at 6 pm on 5/1/24. On 5/2/24 at 6:35 am, R2 was lying in bed without any drinks available. On 5/2/24 at 8:25 am, V10, Cook, confirmed the kitchen provides nursing staff with the thickener required for R1 and R2's liquids. V10 stated the nurses will tell the kitchen when they are out, and the kitchen replaces it. V10 also stated the nursing staff does not have access to the kitchen or to obtain required thickener at night when kitchen staff aren't present. On 5/2/24 at 11:35 am, V2, DON (Director of Nursing), stated residents should be offered fresh drinks at the beginning of the shift and throughout the shift as needed. V2 also stated the facility needed to ensure nursing staff had access to thickener for those residents who require it.

Mar 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

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 ensure a non-pressure wound treatment was completed 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 ensure a non-pressure wound treatment was completed for 1 of 3 residents (R1) reviewed for quality of care in the sample of 4. The findings include: R1's Face Sheet shows R1 is a [AGE] year old male, with diagnoses including: end stage renal disease, methicillin resistant staphylococcus aureaus infection (MRSA), dependence on renal dialysis, type 2 diabetes mellitus with diabetic polyneuropahy, and excoriation (skin-picking) disorder. R1's Minimum Data Set assessment, completed 1/26/24, shows his cognition and memory are intact. R1's Care Plan shows he has had numerous self inflicted wounds due to picking at his skin. The Care Plan shows he currently has an open area to his left lateral leg and wound care treatments should be administered per physician orders. The facility provided skin and wound report shows R1 current has a non-pressure wound that is open on his left lateral shin, requiring a boarded foam dressing, and R1 had 3 other wounds to his left leg that are now healed. R1's Physician Order Summary shows an active order, effective 2/23/24, to cleanse R1's left lower leg wound with wound cleanser and apply bordered foam dressing every M, W, F (Monday, Wednesday, and Friday) night shift. R1's Treatment Administration Record (TAR) for R1's dressing change to his left lateral leg shows on 2/26/24, the spot to initial when treatment is completed is blank and not signed off as being completed. On 3/1/24, the box to sign off is initialed and coded a 9, which is to see other notes. The e-mar Medication Administration note completed by V6 (Agency Nurse) on 3/2/24 at 5:27 AM, shows the wound care and dressing was not completed due to R1 being out at dialysis. V9 (Assistant Director of Nursing/Corporate) provided the surveyor the names of the nurses who were assigned to R1 and were responsible for the dressing changes on 2/26/24 and 3/1/24, and identified them as (V6)- Agency Nurse and (V4)-Registered Nurse and former DON. On 3/6/24 at 9:35 AM, R1 had just returned from dialysis and was sitting in his room. R1's left pant leg was pulled up, and there was a visible open area to his left outer shin which appeared superficial and only the top layer of skin was exposed. There was no current dressing on the wound. R1 said he does pick his skin all the time out of habit, and takes off dressings and sometimes I do it in my sleep and don't even realize it. R1 said he is not sure what his current treatment orders are, but they do not always put a dressing on his wounds, and he believes he did not have one on when he left for dialysis. On 3/6/24 at 12:55 PM, V6 was interviewed by phone, and said she did write the note about not doing R1's dressing change on 3/1/24. V6 said she likes to do her treatments late in her shift so they are fresh, but when she went to do R1's treatment, he had already left for dialysis, and she did not remember to pass along to the day shift nurse that it was not done. On 3/6/24 at 1:17 PM, V4 was interviewed by phone, and said she probably did R1's dressing change for the 2/26/24 shift, but didn't chart it. The surveyor asked what dressing change she did, and she responded the one to his left shoulder (There was not current orders for a treatment to R1's left shoulder). V4 was unable to recall treatment orders or what dressing was applied to R1's left lower leg. On 3/6/24 at 2:00 PM, V2 (Director of Nursing) said all wound care treatments should be completed as prescribed. V2 said R1 does not go to dialysis until 5 AM, and the night nurses have time to completed the treatments prior to him going. The facility provided Wound Cleasing and Dressing policies and practice, dated 5/19/17, states, It is the policy of this facility to perform wound dressing changes as ordered by the physician.

Feb 2024 6 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 thoroughly investigate an allegation of abuse for two (R11 and R12) of four residents reviewed for abuse in a sample of 31. Findings includ...

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Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for two (R11 and R12) of four residents reviewed for abuse in a sample of 31. Findings include: Facility Abuse Prevention Program, revised 3/26/12, documents, The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident. Investigation: All incidents, allegations or suspicions of abuse against a resident will be documented and will result in an abuse investigation. 1. R11's Final Abuse Report, dated 1/31/24, to the State Agency, documents the following: (R11) reported alleged inappropriate interaction with staff member (V18, Certified Nurse Aid/CNA) . After speaking with staff and resident the alleged inappropriate interaction with a staff member is unsubstantiated. Facility whole abuse investigation conducted by V8, Former Administrator, consists of the following: interviews with R11, V13, Licensed Practical Nurse/LPN, and V18, CNA. No other residents were interviewed regarding staff behaviors/interactions. Facility staffing Daily Assignment Sheet, dated 1/31/24, documents V18, CNA, was working down R11's hallway. On 2/23/24 at 9:44 AM, V8, Former Administrator, stated, (R11) said (V18) CNA put her electric wheelchair in turtle mode and spoke to her inappropriate. I suspended (V18) and started the investigation. Another resident here has an electric wheelchair, but I never interviewed him or any other residents about (V18), or (V18's) interactions with them. When V8 was asked how she would know if any other residents had any concerns with her staff member V18 if they were not interviewed, V8 did not answer. On 2/23/24 at 10:47 AM, R11 was alert and oriented, in bed, a quadriplegic, and stated, My wheelchair was in turtle mode, it was parked in the hallway, and I told (V18) CNA he is to sit in the wheelchair to move it in the room. (V18) told me he was not sitting in the wheelchair, and 'That is not my fucking problem it is in turtle mode'. On 2/23/24 at 11:39 AM, V18, CNA, stated, I was working when (R11) said the chair was put in turtle mode, and I supposedly said something to (R11) inappropriate to (R11). (R11's) electric wheelchair was in the hallway, it was charged, and I turned it on and brought it in the room. (R11) said it was in turtle mode, (R11) said I needed to sit in it to move it, I told (R11) I don't sit in it I stand next to it to move it in the room, and I don't know anything about the chair and changing the speeds. V13, Licensed Practical Nurse/LPN, was unable to be interviewed. 2. R12's Final Abuse Report, dated 1/30/24, documents the following: (R12) reported on 1/25/24 an alleged inappropriate interaction with staff member (V2) DON/Director of Nursing/DON and (V31) RN/Registered Nurse that occurred on 1/22/24. After speaking with staff and resident the alleged inappropriate interaction with a staff member is unsubstantiated. Facility whole abuse investigation conducted by V8, Former Administrator, consists of the following: Interviews with R12, V2, DON, V27, LPN, V3, ADON/Assistant Director of Nursing, and V31, RN. No other residents were interviewed regarding staff behaviors/interactions. Facility staffing Daily Assignment Sheet, dated 1/22/24, documents V31, RN, was working down R12's hallway. R12's nurses note, dated 1/24/2024 at 3:04 PM, documents, At 11:25 AM (R12) came to this nurse telling me she was attacked by several staff members a couple of days ago and she has several bruises on her right leg. This resident pulled up her pant leg to show this nurse the bruising. On assessment I did not see any bruising on her right leg. At 2:34 PM (R12) came back to this nurse with the same circumstance saying several staff members attacked her a couple days ago but this time she stated these staff members held her down on the floor by stepping down on her right leg. No bruising or anything else noted on skin assessment. On 2/22/24 at 2:17 PM, V2, DON, stated, (R12) was in the dining room far corner, walker was to the front door, (R12) stated she was leaving the facility, she was agitated, I was assisting the nurse to give her some medication, she had been refusing her medications, she wanted to leave, the doctor and family had been notified, and I held her arm for the nurse to give her a shot. On 2/23/24 at 9:20 AM, V8, Former Administrator, stated, No other residents were present so they were not interviewed as part of this investigation. I interview everyone with information regarding the abuse allegations. When V8 was asked how she would know if any other residents had any concerns with her staff members, V2 and V31 if they were not interviewed, V8 did not answer. On 2/23/24 at 10:30 AM, R12 stated she was trying to leave the facility with her niece on 1/22/24. The staff didn't hurt me but they bumped my leg. V27, LPN, V31, RN, and V3, ADON, were unable to be interviewed.

CONCERN (D)

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 comprehensive care plan for one (R54) of 19 residents reviewed for care planning in the sample of 31. Findings incl...

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Based on observation, interview, and record review, the facility failed to revise a comprehensive care plan for one (R54) of 19 residents reviewed for care planning in the sample of 31. Findings include: The facility's Comprehensive Care Plans policy and procedure, dated 12/2017, documents, The Comprehensive Care Plans will be reviewed and updated every quarter (90 days) at minimum. The facility may need to review the care plans more frequently based on changes in the resident's condition and/or newly developed health/psychosocial well-being issues. The facility MDS (Minimum Data Set)/Care Plan Coordinators and ancillary MDS staff will attend the department head meeting with in-depth review of the 24-hour report and will establish a new plan of care and/or make revisions to existing care plans to address any acute condition changes or exacerbation of chronic issues that may need revisions to the problem, goals and/or interventions. The face sheet for R54 includes the following diagnoses: Dementia, Alzheimer's Disease, Restlessness and Agitation, Obesity, and Adult Failure to Thrive. The current Order Summary Report for R49, documents the following physician orders as 11/22/23 General diet, Regular texture. Thin liquid consistency; 12/26/23 House Shake with meals; 12/26/23 High calorie supplement three times a day. Also documented on 1/5/24 an order for WBAT (Weight bearing as tolerated) to LLE (left lower extremity.) The current Care Plan for R54 documents R54 is at risk for weight loss, has a diagnosis of Obesity, is at risk for compromised nutritional status, requests to eat in her room, and has a fracture of the left femur with altered weight bearing status. The Weight Summary for R54, documents the following weights: 11/27/23 was 128.0 pounds; 12/4/23 was 128.0 pounds; 12/21/23 was 125.8 pounds; 1/5/24 was 123.2 pounds. There is no documented weight for February. This Weight Summary documents R54 with a gradual weight loss with no known weight documented for February. The Progress Notes for R54, dated December 2023 through February 2024, document R54 with episodes of refusal of meals, medications, and tasks at times. The Progress Note for R54, dated 2/12/24, documents, (R54) has refused her weight for February. The Progress Note, dated 1/2/24, documents Orthopedic office visit and returned orders to be WBAT and to repeat left hip X-ray on 2/4/24 and to send results to Orthopedic surgeon. The Registered Dietician notes for R54, dated 11/27/23, 11/29/23, 12/22/23, and 2/22/24, document R54 eating 50 to 75 percent of meals, supplements added and gradual weight loss noted. The Registered Dietician Note, dated 2/22/24, documents, No noted February weight, resident refused. Noted gradual weight loss, no noted significant changes and Continue current interventions and nutritional management, exceeding calorie needs. Will consider an appetite stimulant if weights or oral intake continue to be an issue. Staff supervision and encouragement at all meals, weight monitoring. On 2/22/24 at 9:57 am, V14, AD (Activity Director), stated she is the Activity Director and her office is at the end of the locked unit hallway. V14, AD, stated she has not seen any behaviors with R54. R54 comes out to most all activities, meals, and has adjusted well to the facility. On 2/22/24 at 10:20 AM, V13, LPN (Licensed Practical Nurse), stated when R54 first came to the facility she wouldn't come out of her room, then one day, she just got up and came out and keeps coming out. R54 walks the halls, comes out to activities and meals, and keeps busy. The only thing R54 still continues to do is refuse her medications, almost always on a daily basis. On 2/20/24 at 10:45 AM, R54 was sitting on the couch with blankets wrapped around her. On 2/21/24 at 9:00 AM, R54 was sitting in a stationary chair in the activity area. On 2/21/24 at 12:30 PM, R54 was sitting in a stationary chair in the dining area eating lunch. On 2/21/24 at 2:52 PM, R54 was sitting in therapy room with other residents and therapy staff. On 2/22/24 at 9:54 AM, R54 was sitting in a stationary chair at the activity table. On 2/22/24 at 11:30 aam, R54 was sitting in the dining room in stationary chair coloring on paper. R54's current Care Plan does not include R54's refusals of meals, known gradual weight loss, no longer eating in her room, refusing medications, or weight bearing as tolerated status. On 2/24/24 at 1:30 PM, V28, CPC (Care Plan Coordinator), stated each department does their own Care Plans and are responsible for updating a resident's plan of care as things change. V28, CPC, confirmed R54's weight bearing status, refusal of meals, refusal of medications,no longer eating meals in her room, and gradual weight loss were not updated on R54's current Care Plan.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure enteral feeding bottles were marked with the date/time that the bottles were changed/started for two of two residents ...

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Based on observation, record review, and interview, the facility failed to ensure enteral feeding bottles were marked with the date/time that the bottles were changed/started for two of two residents (R11 and R37) residents reviewed for tube feedings, in a total sample of 31 residents. FINDS INCLUDE: Facility policy, entitled Guidelines for Enteral Feeding: Adult, dated 7/3/23, document, 3) Maximum formula hang time is Closed System 24 hours; and 5) Closed System-Closed system bottles and tubing must be changed every 24 hours for bolus feeding, resident may be disconnected by the licensed nurse and the tubing capped between feedings. Bottles/containers and feeding tubing must be changed every 24 hours. On 2/20/2024, at 10:45 AM., R37's enteral feeding bottle was not dated/timed. On 2/20/2024, at 10:45 AM, V5/Registered Nurse verified R37's enteral feeding bottle was not dated/timed and feeding bottle should be changed every 24 hours, and the date/time should be written on feeding bottle. 2. R11's February 2024 POS/Physician Order Sheet has an order for tube feeding to infuse via gastrostomy tube at 50cc (cubic centimeters) per hour. On 02/20/24 at 10:34 AM, R11's bottle of tube feeding, water bag and syringe, which was in a plastic bag, were observed hanging on the pole and did not have a date, time, or identification written on them. On 02/20/24 at 11:02 AM, R11's tubing was not dated, R11's bottle of tube feeding was without date or directions, and R11's syringe was not dated.

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

2. R31's current Order Summary Report, dated February, 2024 documents R31 has diagnoses which include major depressive disorder without psychotic features, altered mental status, unspecified dementia,...

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2. R31's current Order Summary Report, dated February, 2024 documents R31 has diagnoses which include major depressive disorder without psychotic features, altered mental status, unspecified dementia, mood disorder, alcohol dependence with alcohol-induced persisting dementia, and brief psychotic disorder. R31's February 2024 Order Summary Report documents R31 is prescribed Risperidone 0.25 milligrams twice daily for a diagnosis of brief psychotic disorder and Risperidone 1.0 milligrams twice daily for a diagnosis of brief psychotic disorder; mood disorder due to known physiological condition. A Note to the Attending Physician from a pharmacy consultant recommends a gradual dose reduction for R31's Risperidone 1.25 milligrams. This note was not signed or dated. Based on observation, interview, and record review, the facility failed to address pharmacy medication recommendations for two (R31 and R49) of nine residents reviewed for psychotropic medications in the sample of 31. Findings include: The facility's undated Medication Regimen Review policy and procedure documents, The consultant pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities exist; The review of the medication regimen will include all medications currently ordered; The Pharmacist will report any apparent irregularities in writing to the attending physician, the director of nursing and the medical director. It is the responsibility of the facility to assure that each recommendation results in a written response by either the physician or nurse, as appropriate. On 2/22/24 at 2:30 PM, V3, ADON (Assistant Director of Nursing), stated, I honestly don't know who is supposed to oversee the psychotropic medications and gradual dose reductions. It used to be the DON (Director of Nursing) The Pharmacy emails the recommendations, the DON would print them and give them to the Nurses. The Nurses would get the physician signature and process the orders and then it is filed in the psychotropic book. On 2/23/24 at 2:17 PM, V3, ADON, stated January and February 2024 have not yet been done and were just sent out to the physician's yesterday (2/22/24). 1. The Face Sheet for R49, includes the following diagnoses: Alzheimer's Disease, Dementia, Encephalopathy, Anxiety, and Major Depressive Disorder. The current Order Summary for R49 documents a physician order on 9/29/23 for Zyprexa 10 mg (milligrams). Give 2 tablets by mouth two times a day related to Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. The Note to Attending Physician/Prescriber for R49, dated 11/15/23, documents, Please clarify supporting diagnosis to justify use of Zyprexa 20 mg (milligrams) BID (twice daily). Note: Dementia is not an appropriate supporting diagnosis for antipsychotic therapy. This Note is blank, no documentation of being reviewed, and not signed or dated from a physician. On 2/24/24 at 2:30 PM, V3, ADON, confirmed there have been no gradual dose reductions attempted for R49 since 7/14/23 admission.

CONCERN (D)

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

Medication Errors (Tag F0758)

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 have appropriate indications for the use of antipsych...

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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 have appropriate indications for the use of antipsychotic/psychotropic medications, failed to identify target behaviors on the consent forms, and failed to attempt Gradual Dose Reductions for three residents (R1, R31, R49) of five residents reviewed for unnecessary psychotropic medications in the sample of 31. Findings include: Facility Policy/Psychotropic Drug Usage (undated) documents, If psychotropic drug therapy is required, the physician, facility staff and pharmacist will assist in choosing the most effective medication for the resident that has the fewest possible side effects, adverse drug reactions, and in the smallest effective dose. Antipsychotics are not to be used if one or more of the following are the only indication: Wandering, poor self-care, restlessness, impaired memory, anxiety, depression (without psychotic features), insomnia, unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness or agitated behaviors which do not represent a danger to the resident or others. Any resident receiving psychotropic medications will have a signed informed consent for the use of the medication. The behavioral management will be included on the consent along with the potential side effects. 1. Current Physician's Order Summary Report indicates R1 is [AGE] years old and has orders for the following medications: Clonazepam (antianxiety) 0.25mg (milligrams) twice daily for Anxiety (date initiated 2/13/24) Depakote (anti convulsant) Extended Release 500mg Every 24 hours for Schizophrenia (date initiated 2/13/24) Risperdal (antipsychotic) 4mg (milligrams) twice daily for Schizophrenia (date initiated 2/4/24). Psychotropic Medication Consent, dated 8/18/22, indicates R1's Guardian signed a consent for R1 to receive Clonazepam 0.5mg and Depakote 500mg (2 tabs) twice daily . Consent does not indicate behaviors R1 is exhibiting that requires the administration of Clonazepam or Depakote. Psychotropic Medication Consent, dated 8/18/22, indicates R1's Guardian signed a consent for R1 to receive Risperdal 4mg twice daily. Consent does not indicate behaviors exhibited that require the administration of Risperdal, an antipsychotic medication. Progress Note, dated 2/13/24 at 1:31PM, indicates physician at facility, R1 assessed for lethargy; physician decreased Clonazepam dose. Progress Note, dated 2/14/24 at 5:54AM, indicates two staff are needed for R1's transfer assist; R1 is slow to respond, unable to name staff or where he is; leaning in wheelchair MD (Medical doctor) updated. Progress Note, dated 2/14/24 at 2:58AM, indicates leaning in chair; decreased alertness. On 2/23/24 at 10:45AM, V16, LPN (Licensed Practical Nurse), stated R1 came back from the hospital on 2/3/24 on 4mg of Risperdal. V16 stated, It was 4.5mg (twice daily) before going to the hospital. I don't know why that high of a dose. Sometimes (R1) is agitated, yells out, he goes on [NAME], tangents, gets mad about smoking rules, [NAME] then goes back to his room. V16 stated R1 was leaning much more before and was almost falling out of his chair. V16 stated she was unaware of any psychotic behavior exhibited by R1. On 2/23/24 at 10:50AM, V13, LPN, stated, That is a high dose (of Risperdal). On 2/20/24 at 10:15AM, R1 was seen in his room, leaning completely forward in his chair. R1 lifted his head up briefly with eyes half closed, spoke softly, almost whispering when spoken to. On 2/21/24, R1 was observed leaning over forward and to the right side in his wheelchair while outside smoking and again later in the day. On 2/22/24 at 2:10PM, R1 was in bed receiving wound care from V13, LPN, and a wound physician. At that time, R1 was asked about his medications. R1 stated he knew what Risperdal was and Doesn't care for it. R1 stated he feels more sleepy groggy all the time and doesn't like it. R1 stated, I wish someone would look at my medications to be sure I'm getting what I'm supposed to. Current Care Plan indicates R1 displays symptoms of Schizophrenia and perceived symptoms of abandonment. Care Plan indicates R1's behavior is manifested by: poor verbal expression and communication; neglectful self-care, poor self maintenance (date initiated 11/3/23). Care Plan indicates R1 requires psychotropic medication to help manage and alleviate: Schizophrenia, Anxiety, Neurosis and Anxiety Disorder. MAR (Medication Administration Record)/Behavior Monitoring, dated January and February 2024, indicates behavior monitoring every shift for restlessness, increased confusion, agitation, cursing, delusions. MAR's indicates R1 exhibited no behaviors in January or February. Pharmacy Recommendations, dated and signed by a physician on 9/30/23, indicates recommendation was made for a dose reduction of Risperdal to 3mg twice daily. The recommendation is check marked both: Condition stable. WILL ATTEMPT dose reduction to: Risperidone 3mg twice daily, and Dose reduction is CONTRAINDICATED because benefits outweigh risks for this patient and a reduction is likely to impair the resident's function and/or cause psychiatric instability. Physician Medication Orders do not indicate any dose reduction of R1's Risperdal prior to 2/22/24. 3. R31's current Order Summary Report, dated February 2024, documents R31 has diagnoses which include Major Depressive Disorder without Psychotic features, Altered Mental status, unspecified Dementia, mood disorder, alcohol dependence with alcohol-induced persisting Dementia, and brief psychotic disorder. R31's February 2024 Order Summary Report documents R31 is prescribed Risperidone 0.25 milligrams twice daily for a diagnosis of brief psychotic disorder and Risperidone 1.0 milligrams twice daily for a diagnosis of brief psychotic disorder; mood disorder due to known physiological condition. R31's MAR/Medication Administration Record documents R31 is monitored for behaviors of wandering, pacing, rummaging, and verbal aggression. R31 had no behaviors documented during the month of January, 2024. R31's MAR's for 01/2024 and 02/2024, next to the medication Risperidone; R31 had no observed behaviors between January 1, 2024 and February 22, 2024. R31's Psychotropic Medication Consent, dated 06/25/23, for Risperidone 1.25 milligrams twice daily, has no marked behaviors in the section titled Behaviors exhibited or history of. R31's power of attorney's name is printed next to the verbal telephone consent and a box at the bottom is marked which documents, The above person has NOT given consent for the use of the medication. On 02/23/24 at 11:26 AM, V19/Certified Nursing Assistant stated R31 displays behaviors of coming out of his room and yelling. V19 stated R31 does not display physical aggression towards staff or other residents. 2. The Face Sheet for R49 includes the following diagnoses: Alzheimer's Disease, Dementia, Encephalopathy, Anxiety, and Major Depressive Disorder. The POS 9/29/23 Zyprexa 10 mg (milligrams). Give 2 tablets by mouth two times a day related to Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; 9/29/23 Depakote 250 mg. Give two tablets by mouth two times a day related to Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance; 9/29/23 Hydroxyzine 50 mg. Give one tablet by mouth three times a day related to Anxiety; 1/4/24 Lorazepam 1 mg. Give one tablet by mouth every 6 hours as needed for anxiety/agitation reordered by hospice; 9/29/23 Sertraline 100 mg. Give one tablet by mouth one time a day related to Major Depressive Disorder; 10/2/23 Trazodone 50 mg, Give four tablets by mouth one time a day related to Alzheimer's Disease and Major Depressive Disorder. The MAR's (Medication Administration Records) for R49, dated October through February, document R49 received Zyprexa daily, do not identify resident specific behaviors, and document R49 only had four behavioral type behaviors during the five month period. These MAR's do not document resident specific behaviors the staff are to monitor R49 for. The most recent Psychotropic Medication Consents for R49 document: 9/29/23 Consent form for the antipsychotic Zyprexa 20 mg to be administered daily for the diagnosis of Alzheimer's Disease; 1/15/24 Consent form for the antianxiety Lorazepam 1 mg to be administered every six hours as needed for anxiety/agitation; 8/25/23 Consent for the hypnotic Trazodone 100 mg at bedtime for Insomnia; and 8/2/23 Consent form for the antidepressant Sertraline 100 mg daily with no documented diagnosis on the form. These same Consent forms do not document behaviors exhibited or history of behaviors and do not document resident specific behaviors identified that staff are to monitor R49 for. The Progress Notes, dated December 2023 through February 2024, document one episode on 12/14/23 of R49 being combative with staff and being hard to redirect. No other behaviors documented. The Psychological Services Physician's Notes for R49, dated 10/26/23, 11/27/23, 12/14/23, 1/11/24, and 2/8/24 document R49 with Anxiety Disorder, Depression and other Sleep Disorder not due to a substance or known physiological condition, and Major Neurocognitive Disorder with Behavioral Disturbance. These same notes document R49 with a history of Dementia with behaviors, Insomnia, Depression, and Anxiety and being treated with Trazodone 200 mg at bedtime, Zyprexa 20 mg twice daily, Depakote 500 mg twice daily, Hydroxyzine 50 mg three times daily, and Lorazepam 1 mg every six hours as needed. Patient does not exhibit signs of Anxiety or Depression. Patient does not exhibit symptoms of grandiosity or hallucinations. He did not endorse any SI/HI (suicidal ideation's or homicidal ideation's) or auditory or visual hallucinations. On 2/20/24 at 10:48AM,, R49 was sitting on the couch looking around the room. On 2/21/24 at 9:00AM, R49 was sitting in a stationary chair in the activity area. On 2/21/24 at 12:30PM, R49 was sitting in a stationary chair eating lunch independently. On 2/21/24 at 2:52PM, R49 was sitting on the couch in the activity area. On 2/22/24 at 9:54AM, R49 was sitting in stationary chair in activity area. On 2/22/24 at 11:31AM, R49 was sitting in a stationary chair in the dining room coloring pictures at the table. On 2/24/24 at 12:00PM, the noon meal was served and resident eventually stopped coloring and began to eat independently. During these observations there were no behaviors noted for R49. On 2/21/24 at 10:48AM, V32, R49's Family Member, stated R49 does have some sundowners, and 99 percent of the staff are wonderful and know how to approach R49 and meet his needs. V32 stated every now and then there are night shift staff who say he is intimidating and aggressive, and they won't do anything for him, and let him lay in the recliner all night. V32 stated, They just need to re-approach him and he will do whatever they need. V32 stated R49 does not appear to be sad or depressed, and does not think R49 even knows what that is. V32 stated R49 knows V32 is familiar, but doesn't remember V32's name. V32 also stated R49 is resistive at times, but has not been aggressive or intimidating to anyone. On 2/22/24 at 9:57AM, V14, Activity Director, stated her office is at the end of the behavioral unit hallway, she assists with activities on the unit, and she has not noted any behaviors with R49. V14 stated R49 had a lot of behaviors awhile ago, when he first came to the facility, and it took R49 a while to adjust. V14 stated she has not seen any behaviors from R49 in a long time, R49 comes out for most all of the activities, likes to sit on the couch and watch television when there is nothing going on, and eats all his meals independently in the dining room. On 2/22/24 at 10:15AM, V13, LPN (Licensed Practical Nurse), stated R49 had behaviors off and on when he first admitted to the facility, and no one knew when R49 was going to have behaviors. V13, LPN, stated R49 sees the Nurse Practitioner from Psychological Services and occasionally the Psychiatrist. V13, LPN, stated R49 is receiving the antipsychotic medication Zyprexa for Alzheimer's and Dementia with behavioral disturbance, and confirmed R49 does not have any other psychological diagnoses. On 2/24/24 at 2:30PM, V3, ADON, stated, I honestly don't know who is supposed to oversee the psychotropic medications and gradual dose reductions. It used to be the DON (Director of Nursing).V3 stated R49 is receiving Zyprexa 10 mg for his Dementia with behaviors, confirmed there is not a diagnosis to support the use of the antipsychotic medication Zyprexa, there are no identified behaviors documented for staff to monitor R49 for, and confirmed that there have been no gradual dose reductions attempted for R49 since R49's 7/14/23 admission to the facility.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure local hospice service documentation was included in one (R49) of one resident reviewed for hospice services in the sam...

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Based on observation, interview, and record review, the facility failed to ensure local hospice service documentation was included in one (R49) of one resident reviewed for hospice services in the sample of 31. Findings include: The facility's undated Hospice policy and procedure, documents, Hospice Care consultants and the facility will communicate in a manner that will ensure collaboration of care. Hospice consultants will be notified and/or will communicate the following: A change in the resident's physical, mental, social, and emotional status; Any time that a revision of the resident's plan of care is warranted; Education/Counseling to the resident or family related to preventative care, medical problems, psychological problems, and spiritual problems; Serve as a nursing resource for consultation and education of the facility IDT (Interdisciplinary Team); and Serve as a resource to provide care to the resident. The current Order Summary Report for R49 documents a physician order, dated 10/7/23, Admit to (local Hospice), diagnosis early onset Alzheimer's disease with behaviors. The Progress Notes for R49, dated October 2023 through February 2024, periodically document the local Hospice company being at the facility to see R49, and R49 receiving local Hospice ordered medications and Physician visits. On 2/23/24 at 9:57AM, V13, LPN (Licensed Practical Nurse), stated she is unaware of the facility having a binder for R49's local Hospice service, and was unable to locate any of R49's hospice assessments or notes. On 2/23/24 at 10:07AM, V2, DON (Director of Nursing), stated she is unable to locate any Hospice documents for R49. It should have been in a binder at the Nurses Station, but it wasn't there. V2 stated she contacted the local Hospice service, and they are looking for R49's notes. On 2/23/24 at 11:03AM, V3, ADON (Assistant Director of Nursing), stated she was unable to locate a binder for R49's hospice paperwork, and was unable to locate any documentation from the local hospice company overseeing R49's care. V3, ADON, stated all of R49's hospice notes should be in R49's medical record or in a hospice binder at the nurses station. On 2/21/24 through 2/23/24, there were no Hospice documents included in R49's electronic health record or his paper chart. There was no hospice contract or hospice notes for R49 in any hospice binder at the nurses station. On 2/23/24 at 2:20PM, V3, ADON, stated the local Hospice service is going fax the notes they have to the facility.

Jan 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

Free from Abuse/Neglect (Tag F0600)

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 physical abuse for three (R3, R4 and R5) of 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 prevent physical abuse for three (R3, R4 and R5) of four residents reviewed for abuse in a sample of nine. Finding include: The facility's Abuse Prevention Program, revised 01/2019, documents, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This policy also states VII. Prevention: The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. This policy continues with Abuse and Crime Reporting Policy: This facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals .For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: 1. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in their definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .4. Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. The facility's Resident Rights, undated, documents, Abuse: You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. 1. R2's Minimum Data Set (MDS), dated [DATE], documents R2 has a BIMS (Brief Interview of Mental Status) score of 6. (MDS indicates on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R2's Current Care Plan documents: (R2) demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming related to the diagnosis(es) of: Dementia, Anxiety, Major Depression. Symptoms are manifested by: Pacing, roaming or wandering in and out of peers' rooms. Becoming agitated, oppositional and combative when re-directed. (R2) displays behavioral symptoms related to: Dementia. (R2) has impaired cognitive function due to diagnosis of dementia with behaviors. (R2) displays mood, behavior and cognitive challenges which appear to be related to his diagnosis/dx of Dementia. These symptoms are manifested by: Verbal and physical abuse towards staff and peers. R2's 12/19/23 Progress Note documents: This resident was seen by staff in the (Unit C) lounge dining room pulling at another resident's hoody sweatshirt by the hood. The resident then began to slap the other resident on the back of his head. They were separated as soon as the staff member could get to them. Administrator and /Director of Nursing/DON notified. Ambulance was called for resident to be assessed. R2's Initial (State) Facility Incident Report Form documents: It was reported to the abuse coordinator that (R2) made contact with (R3). Facility Interview with Certified Nursing Assistant/CNA (V10), dated 12/19/23 documents: (R2) stated, That's my fxxxxxx wife. Immediate action taken: Residents were immediately separated, and both were sent to the hospital per facility policy. R2's Final (State) Facility Incident Report Form documents: Conclusion: After speaking with staff and residents this was found to be substantiated. (R2) was observed to have made contacted (R3); both were separated immediately and were sent to the hospital per facility policy. R3's Minimum Data Set (MDS), dated [DATE], documents R3 has a BIMS (Brief Interview of Mental Status) score of 3. (MDS indicates that on a scale of 0 - 15, 13 to 15 cognitively intact; 8 to 12 moderate impairment; and 0 to 7 severe impairment.) R3's current Care Plan documents; (R3) demonstrates behavioral distress related to: Diagnoses of Dementia, Schizoaffective disorder and Alcohol Dependence. (R3) displays symptoms of catatonia that appear to be related to: A diagnosis of Schizoaffective Disorder. R3's diagnoses include: Alcohol dependence with alcohol induced dementia, anterograde amnesia, unspecified dementia, with other behavioral disturbance, epilepsy, anxiety disorder, convulsions, schizoaffective disorder. R3's Progress Note, dated 12/19/23, documents: Resident was sitting at table in (Unit C) lounge. When a Certified Nursing Assistant/CNA walked into the room, another resident was behind this resident and had him by the hood of his hoody sweatshirt pulling hard. By the time staff got to the other resident he (R2) had slapped this resident (R3) in the back of the head. Residents were separated. Director of Nursing/DON and Administrator informed of incident. On 1/18/24 at 10:25am, viewed the 12/19/23 camera video footage showing R2 and R3's physical altercation: R2 was in his wheelchair on the Memory Care Unit (Unit C), slowly coming up the hall to the activities dining room on the Unit. R3 was sitting at the table at 1:15pm for lunch. R2 wheeled up to the back of R3, grabbed the hood of R3's clothing with his left hand and pulled. R3 reached up with his right upper extremity, seemingly trying to get his clothing free from being pulled. Noted =V10 Certified Nursing Assistant/CNA exited from a room at the front of the hall near the activities dining room and went over to R2 and R3, separated both. At this same time, R2 used his left open hand to reach out and hit the left side of R3's head. On 1/16/24 at 11:35am, V10, Certified Nursing Assistant/CNA, stated she witnessed the 12/19/23 altercation between R2 and R3. V10, CNA, stated she saw R2 grab the hood of R3's jacket from the back of R3, and R3 looked like he was choking; and stated R2 hit R3 in the back of his head. V10, CNA, stated when R2 was asked about this, R2 stated R3 had been Fxxxxxx with (R2's) wife. At this time, V10 stated, (R3) was sliding from his chair; don't know if he was having a seizure; he was straight, stiff, gurgling. I yelled for another CNA to assist; then called for (V3 Licensed Practical Nurse/LPN). Protocol is to send out to hospital when something like this happens; (R2 and R3) have had verbal run-ins before about R2's wife, but nothing physical. On 1/18/24 at 10:30am, V1, Administrator, stated the facility's policy is to send residents to the hospital for evaluation after altercations; and stated both R2 and R3 were seen in the (local hospital's) Emergency Department/ED on 12/19/23. Documentation and interviews indicated both R2 and R3 returned to the facility on the same date; no injuries noted.2. R5's Progress Note, dated 12/24/23, by V9, Licensed Practical Nurse/LPN, documents, Incident Note: This Nurse was walking down C hall when I noticed (R5) stopped by the other resident's door (R4) and said something. The other resident (R4) asked him (R5) to keep moving and he (R5) made a fist in attempt to hit the other resident (R4). They both pushed at each other. The initial Facility Reported Incident regarding R4 and R5, dated 12/23/23, and signed by V1, Administrator, documents, Brief Description of Incident: (R5) allegedly made contact with resident (R4). R4's clinical record documents R4 is cognitively intact, mobilizes in a wheelchair, and has diagnoses including Drug-induced secondary Parkinsonism and Traumatic Subdural Hemorrhage. R5's clinical record documents R5's cognition is moderately impaired, ambulatory, and has diagnoses including Vascular Dementia, unspecified severity with Agitation and Delusional disorder. R5's current Careplan documents: (R5) demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming r/t (related to) the diagnosis of: TBI (Traumatic Brain Injury) and problems understanding the immediate environment. Symptoms are manifested by: Attempting to leave the facility without a responsible escort (elopement), Becoming agitated, oppositional and combative when re-directed. On 1/18/24, at 10:18am, this writer viewed the facility's video recording with V1, Administrator. It showed R5 walking down the hall stopping at R4's doorway. R4 was sitting in a wheelchair in his doorway. R5 said something to R4, then put his fist up like he was going to punch R4, but did not. R5 started pushing R4 and throwing his arms at R4 hitting R4's hand/arm while R4 was pushing R5 away in defense and backing into R4's room. V9, Licensed Practical Nurse/LPN came and separated them. V1 stated the time of this occurrence was 8:26pm on 12/23/23. On 1/16/24, at 12:20pm, R5 stated R5 put his fist up to R4, then pushed R4. R5 stated, (R4) thinks (R4) is God's gift to women and I don't like his attitude. On 1/16/24, at 1:30pm, R4 did not have recollection of being hit by R5. R4 stated they pushed each other. R4 stated R5 comes at me for unknown reason. On 1/18/24, at 12:46pm, V1, Administrator, stated physical contact did occur. I feel that (R5) was intentional with his roughing (R4) around and hitting his arm, but not intending to do harm.

Jan 2024 9 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

Deficiency F0725 (Tag F0725)

A resident was harmed · This affected 1 resident

Based on interview and record review, the facility failed to have sufficient nursing staff on 12/8/23. This failure resulted in cares not being provided timely, and R3 becoming tearful to staff, cryin...

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Based on interview and record review, the facility failed to have sufficient nursing staff on 12/8/23. This failure resulted in cares not being provided timely, and R3 becoming tearful to staff, crying, and stating she feels like a burden. Findings include: Facility Assessment Tool, dated 12/1/23, documents, General Staffing plan to ensure that we have sufficient staff to meet the needs of the residents at any given time. CNAs (Certified Nursing Assistant) day shift 4-7, and One restorative aide. Facility Resident Rights pamphlet, undated, documents, The facility must care for you in a manner and environment that promotes your quality of life. Facility staffing sheets provided by V1, Administrator, documents on 12/8/23 day shift, the following nursing staff were present: V22 nursing from 9:41am-3:52pm; V23 nursing from 5:58am-6:25am; V14 CNA from 5:57am-2:28pm; V24 nursing from 5:58am-6:25am; V15 nursing from 5:57am-6:25am; V26 5:50am-10:00am; On 12/28/23 at 10:45am, R2 was alert and oriented, clean and in bed, and stated, There is not enough staff working here; they use agency staff, and the staff is ok here, but not enough. R2's electronic medical record documents R2 is dependant on staff for cares. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented and stated, I am a quadriplegic and require two persons and they don't have enough staff; sometimes I get dressed; call lights can be on for over an hour; I have been here 1.5 years; the staff here is ok but I have stopped asking for things because there is not enough of them and I feel like a burden (at that same time R3 became tearful and crying); I soaked the bed and linens on 12/8/23 because I was not changed; I wear a brief but I soak through it on 12/8/23 head to toe. At the same time resident was interviewed she was tearful and stated that it didn't matter any more. R3's electronic medical record documents R3 is quadriplegic and dependant on staff for cares. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented and stated, On 12/8/23 there were only two nurse aides (V4 and V14) in the whole facility, where one was on the locked unit per policy. (V4) was not certified until just recently; I can have my call light on for 15-20 minutes up to 1.5 hours, depending on who is working; I can't get out of bed without two people. R1's electronic medical record documents R1 is quadriplegic and dependant on staff for cares. On 12/28/23 at 12:40pm, V10, HR (human resources)/BOM (Business Office Manager) stated, I was doing the CNA/nursing schedule. We have 5-6 CNAs on day shift with restorative and transport who is a CNA. We have been using agency since August or September for Nurses and CNAs. Our CNAs work 8 hour shifts from 6-2 with 5-6 CNAs, 2-10 with 5-6 CNAs, and 10-6am with 3-4 CNAs. We go by the state guidelines. On 12/28/23 at 1:30pm, V2, DON/Director of Nursing, stated, I do the nurse staffing and we had COVID-19 on 12/8/23 in the facility. We try to have five CNAs on first shift, and I did not work 12/8/23 on the floor. On 12/29/23 at 2:00pm, V4, Housekeeping/CNA, stated, I worked on 12/8/23 from 6am-4pm, me and (V14) were the only CNAs. (V1) did not come in because of something with her child. C-hall is a secured unit and supposed to have a CNA down there at all times. There was no CNA on C-hall on 12/8/23, because we had no staff. (V1) did come in on 12/8/23 from 12-1pm and collected lunch trays, but did not perform any cares. On C-hall (V11) Activity Director, (V8) Housekeeping, and (V3) SSW/Social Service Worker were down C-Hall monitoring residents on 12/8/23. (V14) worked on 12/8/23 until 2pm and I worked until 4pm. I am a new CNA; just finished schooling. V4's Health Care Worker Registry provided by V1, Administrator, documents V4 completed CNA/Certified Nurse Aid training on 12/7/23, and Competency Evaluation (certified) was completed on 12/12/23. On 1/2/24 at 10:45am, V8, Housekeeping, stated, I am not a CNA, I work in housekeeping. On December 8th, they needed help taking care of the residents on C hall. Me, (V11), and (V3)were on C-Hall answering call lights and monitoring residents. (V1) was not here on 12/8/23. On 1/2/24 at 9:00am, V14, Transport/CNA, stated, I worked 12/8/23 until 2:45pm, (V4) and I providing cares for the residents for the whole building. The two nurses were here. We changed and fed residents, and the nurses passed trays. On 12/8/23, we couldn't get residents out of bed, dressed, perform incontinent cares, do every two hour checks on residents, and answer call lights in a timely manner with just two of us. On 12/8/23, (R3) was incontinent head to toe when we went to change her, and she was tearful, crying, and stated she feels like a burden. On 1/2/24 at 11:30am, V18, Ombudsman, stated, There are staff shortages all the time, and staffing has been bad since June 2023. On 1/2/24 at 11:55am, V12, R3's daughter/POA (Power Of Attorney), stated, On 12/8/23, when I was on C-wing visiting mom, there were no CNA's on the wing. (V8) Housekeeping was there and answered moms call light, but what good was she when she can't do personal cares. Mom is not getting what she needs if there is no staff. On 1/2/24 at 1:00pm, R3 was alert and oriented and verified on 12/8/23, V11, Activity Director, V4, nurse aid, and V8, Housekeeping, were the only staff on C-hall, with no certified nurse aides because no certified nurse aides were available. On 1/4/24 at 9:00am, V1, Administrator, stated, We use shift key and clipboard agency, and December 8th we only had two of our own CNA's. On 1/5/24 at 10:36am, V1, Administrator, stated On 12/8/23, (V4) and (V14) were CNA's on the flo.r, I had management and department heads helping out as well, my son had an appointment that day, and HR/Human Resources, who is not here anymore, is a CNA and helped out; her primary duty that day was HR.

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 observation, interview, and record review, the facility failed to allow a resident to smoke for two (R1 and R3) of three residents reviewed for smoking in a sample of 17. Findings include: Fa...

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Based on observation, interview, and record review, the facility failed to allow a resident to smoke for two (R1 and R3) of three residents reviewed for smoking in a sample of 17. Findings include: Facility Smokers in the Facility,, dated 1/4/23, documents R1 and R3 are smokers residing in the facility. Smoking times are 9:00am-9:15am; 1:15pm-1:30pm; 3:30pm-3:45pm; and 6:00pm-6:15pm. Facility Concerns form, dated 7/29/23, documents resident concerns because two residents were not getting up to go out and smoke. Facility Concerns form, dated 8/31/23 for R3, documents, (R3) was not up for the 3:30pm smoke break and she had asked the CNA's/Certified Nurse Aides to get her up for smoke break. Facility Resident Council Minutes, dated 12/18/23 documents, Smoke breaks are not getting done. On 12/28/23, 12/29/23, and 1/2/24, between the hours of 9am and 4pm, R1 and R3 did not get out of bed. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented, and stated, I vape, but there is not enough staff to get me out of bed, but I would like to. R1's electronic medical record documents R1 is a Quadriplegic and totally dependent for cares. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented, and stated, I don't get out of bed to vape because there is not enough staff to get me out of bed, but I would like to. At that same time, R3 stated she has been smoking for years. R3's electronic medical record documents R3 is a Quadriplegic and totally dependent for cares. . On 1/4/24 at 9:00am, V1, Administrator, verified R1 and R3 both vape, and have to go outside on the patio to vape, as they do not allow vaping in the nursing 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to provide showers on 12/8/23 for six (R7-R12) of six residents reviewed for showers on 12/8/23 in a sample of 17. Findings include: Facility ...

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Based on interview and record review, the facility failed to provide showers on 12/8/23 for six (R7-R12) of six residents reviewed for showers on 12/8/23 in a sample of 17. Findings include: Facility Resident Shower Schedule, undated and provided as the current schedule by V1, Administrator, documents on 12/8/23 (Friday), R7-R12 are to get a shower on first shift. Facility Resident Rights pamphlet, undated, documents, The facility must care for you in a manner and environment that promotes your quality of life. Facility Certified Nursing Assistant, date April 1, 2023, documents, Assists residents with daily bathing functions. Facility Resident Council Minutes,, dated 9/19/23, documents, Residents are not getting showers on scheduled days. Facility Concerns form, dated 9/19/23, documents a resident stated her showers are not getting done. Facility Concerns form, dated 9/27/23, documents a resident did not have a shower in the past week. R7-R12's electronic record has no documentation R7-R12 were given showers on 12/8/23 first shift, as they are supposed to. On 12/28/23 at 1:05pm, V14, CNA (Certified Nursing Assistant), verified she and V4, CNA, were the only aides working in the whole building during the first shift on 12/8/23, and showers were not given on 12/8/23, due to only one CNA/Certified Nurse Aid and one nurse aid available to provide cares. We changed and fed residents, but they did not get their showers. Residents are to get showers on their shower days, and sometimes they don't get showers because we don't have enough time. These residents deserve good care and to get their showers. On 12/29/23 at 2:00pm, V4, Housekeeping/CNA, stated, On 12/8/23, I was working with (V14), and we did not give showers to anyone that day. They wanted their showers, but we just didn't have enough help to give them.

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide catheter care for one (R2) of three residents reviewed for catheter cares in a sample of 17. Findings include: Facili...

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Based on observation, interview, and record review, the facility failed to provide catheter care for one (R2) of three residents reviewed for catheter cares in a sample of 17. Findings include: Facility Catheters policy, undated, documents, A resident who is incontinent of their bladder is to received appropriate treatment. R2's electronic medical record documents R2 diagnoses as Flaccid Neuropathic Bladder and Stage Three Kidney Disease. R2's current order summary report documents, Suprapubic catheter care every day and night shift. Cleanse area and apply dressing twice a day. 12/28/23 at 10:45am, R2 was alert and oriented, clean and in bed, and stated, Catheter site has only been cleaned once; I got my catheter because I have stage 3 kidney disease; and I have had my suprapubic catheter for five years. R2's catheter was at the edge of the bed draining amber urine. On 1/2/24 at 11:30am, V18, Ombudsman, stated, (R2) had a bad UTI/Urinary tract infection in October. R2's Treatment Administration Record, dated 10/1-10/31/23, has no documentation R2's catheter care was completed on 10/12 and 10/21/23. R2's Treatment Administration Record, dated 11/1-11/30/23, has no documentation R2's catheter care was completed on 11/17 and 11/20/23. R2's Treatment Administration Record, dated 12/1-12/31/23, has no documentation R2's catheter care was completed on 12/6 and 12/13/23. On 12/29/23 at 1:35pm, V2, RN/Registered Nurse DON/Director of Nursing, stated, If treatment orders are not signed off then that indicates the cares were not performed and should be per order.

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 F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to set up/reschedule a dental appointment for one (R1) of one residents reviewed for dental services in a sample of 17. Findings include: Faci...

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Based on interview and record review, the facility failed to set up/reschedule a dental appointment for one (R1) of one residents reviewed for dental services in a sample of 17. Findings include: Facility Resident Rights pamphlet, undated, documents, The facility must care for you in a manner and environment that promotes your quality of life. Facility Director of Social Services, undated, documents, The director of Social Services is responsible for providing related social work services so that each resident may attain the highest practicable level of physical, mental, and psychosocial well-being. R1's Social Service Note, dated 5/23/23, documents, Resident added to dentist list for broken tooth. Dentist does not have a return date, continue to follow. R1's medical record has no documentation a dentist appointment is scheduled. Facility provided documentation R1 did have a dental appointment on December 4, 2023 that was canceled due to facility transportation issues, but has not been rescheduled. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented, quadriplegic, and stated, I was referred to the dentist a month ago by the dentist that came here because my tooth on the bottom back right is rotten, needs removed, and the dentist who came here couldn't do it. On 12/29/23 at 2:30pm, V3, SSD/Social Services Director, verified R1 did not have a dental appointment scheduled.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to keep a door closed and move a COVID-19 positive resident to a private room for one (R4) of three residents reviewed for infec...

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Based on observation, interview, and record review, the facility failed to keep a door closed and move a COVID-19 positive resident to a private room for one (R4) of three residents reviewed for infections in a sample of 17. Findings include: Facility Post Public Health Emergency, revised 5/23/23, documents, The facility will follow CDC/Centers for Disease Control guidelines. Residents with suspected or confirmed COVID-19 infection will be placed in a single person room. R4's electronic medical record documents R4 tested positive for COVID-19 on 12/26/23, and was in a room with a roommate. Facility resident roster, dated 12/28/23, documents R4 is still in his room with a roommate. On 12/28/23 at 1:10pm, R4 was in the secured unit in a double room with his roommate, who was not COVID-19 positive, had contact and droplet precaution signs on the door indicating the door was to remain closed and to wear an N95 mask or higher. At that same time, R4's door was open, and R8 and R9 were ambulating in the hallway past R4's doorway. On 1/2/24 at 1:30pm, R4's room door was open and on droplet/contact precaution for COVID-19. R16 CNA/Certified Nurse Aid stated, We keep the door open to view in to (R4). He is on Droplet/Contact precautions and has been doing some coughing. No residents go in his room, but we do have wanderers on this unit because of the dementia unit. We are to wear N95 mask, gown, and gloves when in the room because his infection is airborne. On 12/29/23 at 2:00pm, V4, Housekeeping/CNA, stated, (R4) was positive for Covid-19 on 12/26/23 and was not moved until 12/28/23. I helped moved his belongings. On 1/2/24 at 10:45am, V8, Housekeeping, stated, I helped move (R4) on 12/28/23 because he was COVID-19 positive, and I was working.

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 F0882 (Tag F0882)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to have a certified Infection Preventionist. This failure has the potential to affect all 54 residents residing in the facility. Findings incl...

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Based on interview and record review, the facility failed to have a certified Infection Preventionist. This failure has the potential to affect all 54 residents residing in the facility. Findings include: Facility Resident List Report, dated 12/28/23, documents 54 residents currently reside in the building. Facility Infection Preventionist, undated, documents Responsible for the Infection Prevention Program. Qualifications: Completion of training on infection prevention. Facility paperwork documents on 12/8/23 the facility was in a COVID-19 outbreak status. V6's employee file does not have her certificate as an IP/Infection Preventionist. Training for IP provided documents 15 of the required 23 IP modules were completed. On 12/28/23 at 2:20pm, V6, LPN/Licensed Practical Nurse/IP stated There was COVID-19 in our building for December 2023. I have completed the 15 modules; did not know their were 23 modules. I don't have my Infection Preventionist certificate. Before helping as an Infection Preventionist, I worked on the floor as a staff nurse. At that same time, V6 verified she was the IP for the facility for the past two months.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility Failures resulted in two deficient practices. A. Based on interview and record review, the facility failed to provide t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Facility Failures resulted in two deficient practices. A. Based on interview and record review, the facility failed to provide transportation to appointments for eight (R14, R2, R3, R1, R17, R16, R5, and R6) of nine residents reviewed for transportation/appointments in a sample of 17. B. Based on observation, interview, and record review, the facility failed to carry out resident's activities of daily living on 12/8/23. This failure resulted in a delay of residents getting out of bed, getting dressed, incontinent cares, every two-hour checks on residents were not done, and call lights couldn't be answered in a timely manner. This failure also resulted in R3 becoming tearful to staff, crying, and stating she feels like a burden. Findings include: A. Facility Vehicle Lift Policy, undated, documents, Resident will be secure and safe during use of transport vehicle, and never transport residents in electric wheelchairs or (reclining chairs); the residents must be transferred to standard wheelchairs before being put on the lift. Facility Resident Escort position, undated, documents, The Resident Escort will assist with maintaining a safe resident transport to and from and within the facility. Facility Resident Council Minutes, dated 9/18/23, documents a residents dialysis appointment was canceled. Facility Calendar documents the following appointments were canceled by the facility due to transportation to the appointments not available by the facility: October 3, 2023 R2 and R14's appointment to the Urologist; October 26, 2023 R6's appointment to behavioral health; November 22, 2023 R5's appointment was canceled by the facility; November 28, 2023 R15's appointment was canceled by the facility; November 29, 2023 R1's appointment was canceled by the facility; November 30, 2023 R16's General Surgery appointment; December 1, 2023 R2's behavioral health appointment; December 4, 2023 R1's Dental and Urology appointments; December 5, 2023 R2's behavioral health appointment; and December 20, 2023 R17's Urology appointment. On 12/28/23, V14 transport verified all the above appointments were canceled by the facility due to the bus being in the shop when the power steering pump went out and it needed new tires, and a policy change to where no (reclining chairs) and no electric wheelchair transport was allowed to be transported by the facility. At that same time, V14 verified they did not offer other transportation to the residents, and was unaware if families were called to assist with transport. Facility paper, dated 1/4/24 and written/verified by V14, CNA (Certified Nursing Assistant)/transport, documents, (R1) had a dentist appointment on 12/4/23 (Monday) but was canceled because (V14) could not take (R1) on the bus in a (reclining) chair, and the bus was in the shop and did not get back until late Monday night. That same day (R1) had an appointment with (V5), but he was not transported. On 12/28/23 at 10:45am, R2 was alert and oriented, clean and in bed, and stated, I have an appointment next week to (facility), and not sure if I will go because the bus has an oil leak, and my appointments get canceled a lot. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented and stated, My doctor appointment was canceled for Botox that I get every three months because they have no way to transport me due to the electric wheelchair and (reclining) chair I was in they say that can't safely transport me in the van/bus. At the same time resident was interviewed, she was tearful and stated that it didn't matter anymore. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented, and stated, My appointment with the dentist for my bad tooth; my Urologist appointments for my catheter; my ENT/Ear Nose and Throat, and my spasms doctor that monitors my Quadriplegia were canceled due to the van/bus being broke; and the van/bus has been broke off and on for a month. I was referred to the dentist a month ago by the dentist that came here because my tooth on the bottom back right is rotten, needs removed, and the dentist who came here couldn't do it. On 12/28/23 at 1:05pm, V14, Transport/CNA, stated, In November 2023, the bus water pump and power steering went out, it was down for about two weeks before it was fixed. The November appointments were canceled and rescheduled. (R1) is not safe in the bus because he has to sit with his feet up and in an electric wheelchair. The residents have to sit face forward and upright to be buckled right in the van. No family can ride, no (reclining) chair, no electric wheelchairs, and no one that can't sit upright. I don't know what the plan is to transport (R1) maybe his family. (V2) DON/Director of Nursing is my supervisor, and she told me no electric wheelchairs, (reclining) chairs, no family can ride, and no one that can't sit upright can be transported by our bus per corporate. (R3's) Botox appointment was missed in Peoria because of the bus. (R3) is also a (reclining) or electric wheelchair, and corporate and (V2) stated we can't put either one of those in the bus. I have been working for two years as a transport driver. We used to take to appointments in a (reclining) chair, but haven't been able to for the past two months. I am the only transport driver, and we only have one bus for residents. The bus has an oil leak now and may be in the shop again. (R1) missed his appointments in November 2023, and (R3) was transported to appointments in her (reclining) chair but I was told by (V2) residents can't be transported for the past two months in a (reclining) chair which was a change. On 12/28/23 at 1:30pm, V2, Director of Nursing/DON, stated, (local transport company) is standard wheelchairs only no (reclining) chairs, or electric wheelchairs; and (local) county transport is too far. At that same time, V2 verified the facility could not take any reclining chairs, or electric wheelchairs per facility transport policy; verified the above appointments were canceled due to the facility bus in the shop; verified there were other means of transporting residents however they were not utilized; and verified they have no plan in place to transport R1, R2 and R3 who use a reclining chairs or electric wheelchairs for mobility needs. On 12/28/23 at 2:00pm, V2, RN/Registered Nurse/DON, stated, (R1) has to be transported by stretcher because we can't lock in his electric wheelchair or a (reclining) chair safely. (R3's) family has a van to transport her to appointments, and she has missed appointments due to her being in a (reclining) chair or electric wheelchair. We don't have any other transport set up other than family, I have not asked anyone about transport, the van/bus has an oil leak, we only have one van/bus; and no back up van/bus from a sister facility has been asked about. On 12/28/23 at 2:30pm, V1, Administrator, stated, We can use (local transport company), and the ambulance here is the local fire department for transports. I am not sure who all the (local transport company) transports, and the local fire department can transport by stretcher, but we have to get medical clearance. On 12/29/23 at 1pm, R3 stated, No one asked me or told me about transporting any other way. I have only gone to appointments by the (facility) bus. I do have a van, but hasn't been run for 1.5 years since I have been in here. On 1/2/24 at 9:00am, V14, Transport/CNA, stated, I have had to cancel appointments because the bus air went out, needed tires, power steering pump went out, and now it has an oil leak it needs to go in for. The bus is about [AGE] years old. These people deserve good care and to go to their doctor appointments. If an appointment is canceled, me or the nurse reschedules. I get yelled at on the phone by doctor offices when canceling appointments. I have been a transport driver for almost two years, the only transport driver here, were only have one bus to transport residents in, we have no other transport vehicles for the facility, and any time they are short on the floor for CNAs they pull me from transports to work the floor and then appointments get canceled. (R5's) appointments have been canceled three times to Urology. (local transport only goes to Peoria twice a month and doesn't take (reclining) chairs or electric wheelchairs so (R1, R2, and R3) are not options for NCAT. (R2) is in a (reclining) chair and (R1 and R3) transport by an electric wheelchair. (R6's) October 26th appointment was canceled because the bus was in the shop. (R6's) POA/Power of Attorney started taking her to appointments because of the missed appointments and paperwork. On 1/2/24 at 10:52am, V5, nurse from Urology office, stated, (R1's) 11/8/23 Urology was canceled; 11/9/23 he was late; and on 12/1/23 we were called by (V14) to cancel his 12/4/23 appointment due them not able to transport by facility van. (R2) was seen in October 2023 for an Ultrasound, but her appointments have been missed more since she has been at the nursing home; and we have seen her five times in a year, and she is supposed to see doctor every month for her suprapubic catheter change, since she has frequent problems with UTI's/Urinary Tract Infections and going septic. On 1/2/24 at 11:30am, V18, Ombudsman, stated, (R1) and others are not getting to their appointments. On 1/2/24 at 11:55am, V12, R3's daughter/POA (Power of Attorney), stated, I am aware (R3's) Botox appointments had to be rescheduled because the bus was in for repairs. They have not talked to me about transports any other way for mom or to use my own van. I work full time and they are responsible to transport mom that is what they get paid for, and why she is in the nursing home, so she gets what she needs. I called (V1) and she stated mom would get transported to her appointments. On 1/2/24 at 1:45pm, R5 was in bed, alert and oriented, and stated, My kidney doctor appointments have been canceled. I need to see my doctor to get a cyst on my kidney removed, but I can't get to my appointment. B. Facility Certified Nursing Assistant, dated April 1, 2023, documents Assists residents with dressing/undressing, ensures incontinent residents are clean and dry, and responds to/answers call lights promptly. Facility Resident Council Minutes, dated 11/22/23, documents, Residents would like the CNA/Certified Nurse Aid to assist more in cares. On 12/28/23 at 10:45am, R2 was alert and oriented, clean and in bed, and stated, I don't get out of bed because I require two people, there is not enough staff working here, and they use agency but not enough. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented and stated, I don't get out of bed; I am a quadriplegic and require two persons and they don't have enough staff; sometimes I get dressed; call lights can be on for over an hour; I have been here 1.5 years; the staff here is ok but I have stopped asking for things because there is not enough of them and I feel like a burden (at that same time R3 became tearful and crying); I have soaked the bed and linens because I was not changed; and I wear a brief but I soak through it on 12/8/23 head to toe. At the same time R3 was interviewed, she was tearful and stated that it didn't matter anymore. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented, and stated, On 12/8/23 there were only two CNA's/certified nurse aides (V4 and V14) in the whole facility where one was on the locked unit per policy. (V4) was not certified until just recently, I can have my call light on for 15-20 minutes up to 1.5 hours depending on who is working, and I can't get out of bed without two people. On 12/28/23 at 12:40pm, V10, HR (Human Resources)/BOM (Business Office Manager), verified on 12/8/23, V14 and V4 were the only staff providing cares, because all the other CNAs called off. On 12/28/23 at 1:30pm, V2, DON, stated, I do the nurse staffing and we had COVID-19 on 12/8/23 in the facility. We try to have five CNAs on first shift, and I did not work 12/8/23 on the floor. On 12/29/23 at 2:00pm, V4, Housekeeping/CNA, stated, I worked on 12/8/23 from 6am-4pm, me and (V14) were the only staff providing cares. I finished CNA school on 12/7/23, but did not take the test and pass until 12/12/23. I changed residents on my own and with (V14). V4's Health Care Worker Registry provided by V1, Administrator, documents V4 Completed CNA/Certified Nurse Aid training on 12/7/23, and Competency Evaluation (certified) was completed on 12/12/23. On 1/2/24 at 9:00am, V14, Transport/CNA, stated, I worked 12/8/23 until 2:45pm. (V4) and I were providing cares for the residents for the whole building. The two nurses were here. We changed and fed residents, and the nurses passed trays. On 12/8/23, we couldn't get residents out of bed, dressed, perform incontinent cares, do every two-hour check on residents, and answer call lights in a timely manner with just two of us. On 12/8/23, (R3) was incontinent head to toe when we went to change her, and she was tearful, crying, and stated she feels like a burden. On 1/2/24 at 11:55am, V12, R3's daughter/POA (Power of Attorney), stated, Sometimes there are no CNAs on C-hall/secured unit. My mom is on C-hall, and she was put there because I was told she would get better care since always two CNAs. On 12/8/23 when I was on C-wing visiting mom, there were no CNAs on the wing. (V8) Housekeeping was there and answered moms call light, but what good was she when she can't do personal cares. Mom is not getting what she needs if there is no staff. On 1/5/24 at 10:36am, V1, Administrator, stated, On 12/8/23 (V4) and (V14) were the only ones providing cares on the floor, and we had two nurses. I did not come in to work because my child had an appointment. I have my CNA certificate.

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 F0729 (Tag F0729)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to verify a Certified Nursing Assistant (V4) was certified before working alone on 12/8/23. This failure has the potential to affect all 54 re...

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Based on interview and record review, the facility failed to verify a Certified Nursing Assistant (V4) was certified before working alone on 12/8/23. This failure has the potential to affect all 54 residents in the building. Findings include: Facility Resident List Report,dated 12/28/23, documents 54 residents currently reside in the building. Facility Certified Nursing Assistant, dated 4/1/23, documents, Must have and maintain an active searchable Certified Nursing Assistant Certification in accordance with the state in which the facility resides. Facility clock in sheets for 12/8/23 documents V4 worked. V4's Health Care Worker Registry provided by V1, Administrator, documents V4 completed CNA/Certified Nurse Aid training on 12/7/23, and Competency Evaluation (certified) was completed on 12/12/23. On 12/28/23 at 10:55am, R3 was in bed in her room, alert and oriented and stated, On 12/8/23 (V4) provided incontinent cares to me. There was no other staff. On 12/28/23 at 12:00pm, R1 was in bed, alert and oriented and stated, On 12/8/23 (V4) provided me cares but was not certified until just recently as a CNA. On 12/29/23 at 2:00pm, V4, Housekeeping/CNA, stated, I was working as a CNA on 12/8/23. I finished CNA school on 12/7/23, but did not take the test and pass until 12/12/23. I worked on 12/8/23 from 6am-4pm, me and (V14) were the only CNAs. I changed residents on my own and with (V14). On 1/2/24 at 9:00am, V14, Transport/CNA, stated, On 12/8/23, (V4) and I provided cares for the residents for the whole building. We changed and fed residents. On 1/5/24 at 10:36am, V1, Administrator, stated On 12/8/23 (V4) and (V14) were the only CNA's on the floor.

Nov 2023 4 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 F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure residents were free of misappropriation of property for two of four residents (R4 and R5) reviewed for misappropriation of property ...

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Based on interview and record review, the facility failed to ensure residents were free of misappropriation of property for two of four residents (R4 and R5) reviewed for misappropriation of property in the sample of seven. Findings Include: The facility's Drug Diversion-Reporting and Response policy, undated, documents the following: It is the practice of the facility to provide guidelines for the identification, reporting and investigation of suspected drug diversion by any employees, residents, or visitors. Drug diversion is the intentional and without proper authorization, using or taking possession of a prescription or a non-prescription medicine or biological from the supply intended for use by the facility staff for the facility residents. Examples of Drug Diversion: A. Medication Theft, B. Using or taking a medication without a valid order or prescription, C. Forging or modifying a prescription, D. Using or taking possession of a medication that was to be returned or destroyed. Controlled Substances: Medications classified as Schedule 1 through Schedule V by the Federal Drug Enforcement Agency and/or applicable state law. Guidelines: D.) Suspicion of a drug diversion may include but not limited to: 1.) A witnessed incident of what appears to be a drug diversion, 3.) Suspicious activity identified during routine monitoring or proactive surveillance, 6.) Narcotic counts/reconciliation of drugs with discrepancy. R4's Physician Order Sheet, dated 11/1/2023 through 11/30/2023, documents, Morphine Sulfate (Concentrate) solution 20MG(milligram)/ML(milliliter) give 0.25ML sublingually every 4 hours as needed for pain or air hunger. R4's Proof of Delivery Report, dated 10/20/2023, documents,(R4) received Morphine Sulfate Solution 100MG/5ML. 30cc delivered 10/28/2023. R4's Controlled Drug Record Disposition Form, dated 10/27/2023, documents,(R4) received Morphine Solution 100/5ML. Quantity received 30 ML. R5's Physician Order Sheet, dated 10/17/2023, documents, Morphine Sulfate (Concentrate) Oral Solution 100MG/5ML. Give 0.5ML by mouth every 2 hours as needed for comfort. R5's Controlled Drug Record Disposition, dated 10/20/2023, documents,(R5) received 30ML Morphine. Solution 100MG/5ML. Give 0.5ML/10MG by mouth every 2 hours as needed. The Disposition Form also documents the bottle had 26ML and none was given to R5. The facilities Initial Report, dated 11/15/2023, documents,(R4) is missing pain medication. The Facility Reported Incident, dated 11/15/2023 at 5:38PM, documents. Incident date: 11/15/2023, victim involved (R4), Incident Category: Drug Diversion, Police notified: resident is missing pain medication. V14's, RN (Registered Nurse) undated typed statement, documents, Upon arriving to work for the 6PM-6AM, I had approached the nursing station on the A/B side to determine which unit I was going to be working. I was told by (V8, RN(Registered Nurse) that she was going to do the A-side, and that I would be on B/C/D nursing unit/medication cart. (V8/RN) told me that the prior shift had left me a report sheet and that two nurses had counted the narcotics in our cart that this nurses was attempting to hand me the keys to which were on a pink lanyard. In response, I stated I am sure the count is okay, but would you mind doing another count with me just to be on the safe side?, in which the other nurse responded sure. As I and (V8) began to perform a narcotic count on the B/C/D medication cart and arrived at checking (R4's) morphine bottles (2 bottles present), I noticed that one bottle of morphine looked a very light pink in color-indicating to me a high possibility for drug dilution. In addition, the count of the liquid seemed off. I immediately brought this to the other nurse's attention, in which she looked at both bottles closely herself, and stated, 'You are right, that is crazy. What do you think we should do about this?' In which I responded that we need to show and immediately inform (V2/Director of Nursing/DON). (V2) was immediately brought into the loop, shown both bottles side-by-side, and was in agreement that the other bottle appeared lighter in color. (V2/DON) then proceeded to ask if there were any other issues noted, in which in which I stated (R5's) morphine was indicated in the narcotic record to have 30ML(milliliter) remaining, but only 26ML was being received at the time the cart was being counted by myself and the other nurse. I did have (V8/RN) sign off with me that I was only receiving 26ML as opposed to the indicated 30ML. I then stated that aside from those (2) issues, all the other bottles of morphine on the cart appeared the proper pink coloration. Upon finishing the count on the B/C/D cart and in the midst of (V2/DON) configuring my login and trying to investigate this narcotic issue further, the other nurse asked me if I would mind helping (V8) complete a narcotic count on the A/B cart, as stating (V8/RN) did not complete after coming in due to being told that staff nurses had completed a narcotic count. I immediately agreed, completed count with (V8 )and had only found that (1) narcotic pill was taped into place-in which the pill was destroyed and documented on due to infection control procedure. (V2/DON) also made aware of this. Aside from that (1) tablet destruction, there were no discrepancies indicated on the A/B cart between me and the other nurse. Later in the evening, writer received a message through the staff (V13, Licensed Practical Nurse/LPN) from (V2/DON) wondering if there were any more issues with the other morphine located on the medication cart. I did not believe so, based upon the coloration of their bottles, but in drawing up the liquid in the bottles aside the staff (V13/LPN) (as the other nurse was sent home pending investigation) I did and confirm with this (V13/ LPN) that although appearing pink in the bottles, once drawn up it was very clear to indicate that there had been a potential tampering of the other bottles of morphine on the cart as well due to the clear state of the liquid once drawn up. There was even visible sediment and a small black hair in one of the morphine bottles that was (R4's). V16's/LPN (Licensed Practical Nurse) written statement, dated, 11/15/2023, documents, I was asked by (V2/DON) to check with (V14/RN) about (R6's) morphine. We went down to C wing to check (R6's) morphine. It looked pink in the bottle when drawn up. We checked other (R4's) looked watered down and had sediment in it. (R5's) morphine appeared pink in color but when drawn up it looked clear. (R5's) Morphine bottle says it has 30ML(millimeter) but only had 26ML in the bottle when we counted the bottle. V8's RN(Registered Nurse) written statement, dated 11/15/2023, documents, I received report from (V13/LPN) and (V7/RN). I had (V13's) team. Both set of keys were left on the desk. Honestly is the best policy, so here is my honesty. I have a past addiction. I saw there was narcotics in the drawer, and it is something that has not bothered me in quite a few months, but that is what addiction is. I thought about diverting. I started to shake, sweat, and went to the bathroom and literally got on my knees and prayed. I also threw up, but I believe in the higher power, and I have ruined my life so many times. I do not want to continue to ruin it. I did not take or tamper with anything. I take suboxone (treats narcotic dependence) 4MG (milligrams) daily. I texted my sponsor right away from the bathroom. I have a past, so I fully understand what this looks like. On 11/20/2023 at 9:50AM, V2/DON stated,(V8/RN) picked up hours November 15th 6PM to 6AM. (V8/RN) was assigned to cart A/B. (V14/RN) was assigned to B/C/D, but was going to be late. (V7/RN) and (V13/LPN) worked 6AM to 6PM and gave report to (V8/RN) and left both sets of keys on the desk. (V14/RN) came in and wanted to do a narcotic count with (V8). The narcotic count was started on B/C/D cart. (V14/RN) brought me 2 bottles of morphine that belonged to (R4). (V14) said, Look at the difference between these 2 bottles. One bottle was full, but the coloring was off and there was a discrepancy in the amount. I immediately called (V1/Administrator) to view the cameras. (V1) saw (V8/RN) take something out of the cart and go to the bathroom with it. When (V8/RN) returned to the cart I could see that (V8) had a white box. (V8) placed it back into the locked narcotic box. The bottle of morphine that (V8) took out of the cart was clear liquid. I used my flashlight to determine if it was lighter than the other bottle of morphine. (V8) placed the bottle of morphine back into the cart and went to the other cart A/B. I immediately took (V8/RN) off the schedule and asked (V8) to write a statement of the occurrences. I also asked (V8) why she went to the other unassigned hall and what was she doing in that cart. (V14) and I counted the narcotics in the B/C/D cart. We found that (R5's) morphine was off count by 4CC and the liquid inside the morphine bottle was clear, like water. (R4's) morphine bottles he had 2 was tampered with and one bottle was left alone. (R6's) the other resident that had an order for morphine liquid concentrate it was not tampered with. On 11/21/2023 at 9:22AM V13/LPN stated, I worked days on 11/15/2023 and gave (V8) report and placed the keys to both carts on the desk. No, I did not count with (V8). I went home and was called back to count the narcotics. I was told by (V2) that there was a suspicion that (R4's) and (R5's) morphine was tampered with. At that time, (V8) was asked to go home. (V2) started the investigation. On 11/21/2023 at 10:11AM, V7/RN stated, I reported off to (V8/RN) and put the keys to both carts on the desk. The other nurse that was scheduled to work was going to be late. So, I get home and I get a text from (V2/DON) to come back to the facility to count narcotics because there has been a potential tampering to the morphine bottles. One of (R4's) two morphine bottles appeared to be tampered with, the liquid inside the bottle was clear. I was interviewed by the police and had to make a statement. On 11/21/2023 at 2:28PM, V1/Administrator stated, I was called by (V2/DON) due to a potential drug diversion. I looked at the video and saw (V8/RN) in B/C/D cart. I could see that (V8) was taking a box out of the locked narcotic box. (V8/RN) went into the bathroom with the white box. A few minutes later (V8/RN) came out of the bathroom and went back into the B/C/D cart and put the box back into the locked narcotic box. (V2/DON) said that there is an issue with (R4's) morphine. (R4) has 2 bottles; one was opened and had a lighter color to it. It looked like water. The other morphine bottle was a normal color. And (R4's) narcotic count for that one bottle was off count. (V8) was immediately sent home and I started the investigation and called the police.

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 F0603 (Tag F0603)

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 ensure a resident was free from involuntary seclusion for one of on...

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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 a resident was free from involuntary seclusion for one of one residents (R1) reviewed for involuntary seclusion in a sample of seven. Findings include: The facility's Abuse Prevention Program, Abuse and Crime Reporting, revised 03/1/21, documents, The facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends, or other individuals. This form also documents that Involuntary Seclusion is separation of the resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's will, or the will or the resident's legal guardian or representative. R1's Minimum Data Set, dated [DATE], documents R1 is severely cognitively impaired. R1's current care plan documents R1's comprehensive assessment reveals a history of suspected abuse, neglect, exploitation, past trauma and/or other factor that may increase his susceptibility to abuse/neglect. R1 demonstrates impaired cognition/communication, R1's goal is to be treated with respect, dignity and reside in the facility free of mistreatment (abuse/neglect). The facility's Incident Investigation form, dated 11/3/23, documents, The allegation of of inappropriate behavior by a staff member is found to be substantiated. The Staff (V3/CNA/Certified Nursing Assistant) had admitted to holding the door closed while (R1) was in the room. (V3) has been terminated. V3's, CNA, Witness Statement form, dated 10/31/23, documents when V1, Administrator, asked if she (V3) ever held the door closed on R1, she said yes. V1 asked V3 why she held the door shut; she (V3) stated, I am tired of him taking my food and other people's food all the time. On 11/20/23 at 8:45 AM, V1 stated V3 and V4, CNA, were suspended pending an investigation. V1 stated after viewing the facility video, it was determined V3 did hold R1's door shut, and would not let him out. V1 stated V3 was terminated after the investigation was completed. On 11/20/23 at 3:00 PM, V4 stated on 10/20/23, V3 was angry at R1 because he ate her food that was on the common room table. V4 stated V3 took R1 to his room and held the door shut. V4 stated she told V3 to let him out of his room, but she did not. On 11/22/23 at 11:40 AM, V18, R7's Visitor, stated she was walking down the hall on 10/20/23, and saw V3 holding R1's door shut. V18 asked V3 and V4 what was going on. V4, CNA, told V18 that R1 ate V3's food. V18 stated she heard V4 tell V3 to let R1 out of his room. V18 said V3 stated I don't give a F**k, I'll hold the door shut all night if I have to. V18 stated this bothered her, so she finally talked to V19, Dietary Aide, about it, and she reported it to V1, Administrator.

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 an allegation of involuntary seclusion to the Administrator immediately for one of six residents (R1) reviewed for abuse in a sample...

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Based on interview and record review, the facility failed to report an allegation of involuntary seclusion to the Administrator immediately for one of six residents (R1) reviewed for abuse in a sample of seven. Findings include: The facility's Abuse Prevention Program, revised 3/1/21, documents, Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment, or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report to to the Administrator. The facility's Incident Investigation form, dated 11/3/23, documents, The allegation of of inappropriate behavior by a staff member is found to be substantiated. The Staff (V3/CNA/Certified Nursing Assistant) had admitted to holding the door closed while (R1) was in the room. (V3) has been terminated. On 11/20/23 at 8:45 AM, V1 stated the incident happened on 10/20/23, but was not reported to her until 10/31/23. V1 stated V19, Dietary Aide, reported the incident to her the day she found out about it. V1 stated V3 and V4, CNA, were suspended pending an investigation. V1 stated after viewing the facility video, it was determined V3 did hold R1's door shut, would not let him out. V1 stated V3 was terminated, and V4 was not allowed to return to work until she reviewed the abuse policy. On 11/20/23 at 3:00 PM, V4 stated on 10/20/23, V3 was angry at R1 because he ate her food that was on the common room table. V4 stated V3 took R1 to his room and held the door shut. V4 stated she told V3 to let him (R1) out of his room, but she did not. V4 stated she did not report the incident at the time it happened. On 11/22/23 at 11:40 AM, V18, R7's Family, stated she was walking down the hall on 10/20/23, and saw V3 holding R1's door shut. V18 asked V3 and V4 what was going on. V4, CNA, told V18 that R1 ate V3's food. V18 stated she heard V4 tell V3 to let R1 out of his room. V18 stated she did not report the incident since other staff were in the area. V18 stated she texted V19, Dietary Aide, about what she seen on 10/31/23, and she reported it.

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 establish a system for the reconciliation of controlled drugs for two of four residents (R4 and R5) reviewed for controlled drugs in a samp...

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Based on interview and record review, the facility failed to establish a system for the reconciliation of controlled drugs for two of four residents (R4 and R5) reviewed for controlled drugs in a sample of seven. Findings Include: The facility policy named, Controlled Substances, with no date, documents, To maintain individual records of receipt and distribution of all controlled drugs in sufficient detail to enable an accurate reconciliation. Controlled substance shall be securely stored, and precautionary measures taken to prevent misuse. 6.) Records shall be maintained by authorized nursing personnel of all scheduled II drugs administered. 7.) An individual Schedule II record in the form of a declining inventory will be initiated when the schedule II drug is delivered to the facility. 8.) Change of shift counts will be conducted by authorized nursing personnel to reconcile drug availability. R4's Controlled Drug and Receipt Record/Disposition Form, dated 10/27/2023, documents R4 received 30ML(milliliter) of Morphine Sulfate Solution 100MG/5ML. Take 0.25ML (5MG) (milligrams) every 6 hours as needed for shortness of breath or pain. A facility Proof of Delivery List Report, dated 10/28/2023, documents,(R4) received Morphine Sulfate Solution 100MG/ 30ML (milliliter). On 11/21/2023 at 9:22AM, V13/LPN (Licensed Practical Nurse) stated, I worked on 11/15/2023 6AM to 6PM. I did not count narcotics with the oncoming nurse. I put my keys on the nurse's desk and left. On 11/21/2023 at 10:11AM, V7/RN (Registered Nurse) stated on 11/15/23, V7 gave V8/RN report and left the keys on the nurse's station. V7 stated she did not feel good, so she left without counting the narcotics. On 11/21/2023 at 9:50AM, V2/DON (Director of Nurses) stated, I was not aware that the day shift nurses on 11/15/2023 did not count with the oncoming nurse. It is expect that every nurse working here to do a narcotic cart at the change of every shift.

Sept 2023 5 deficiencies

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

Resident Rights (Tag F0550)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to deliver resident mail for seven (R1 through R5, R10, and R11) of seven residents reviewed for resident rights in the sample of 17. This fai...

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Based on interview and record review, the facility failed to deliver resident mail for seven (R1 through R5, R10, and R11) of seven residents reviewed for resident rights in the sample of 17. This failure has the potential to affect all 63 residents residing in the facility. Findings include: The facility's undated Resident Rights policy and procedure, documents, Mail - You have the right to send and promptly receive your mail unopened and have access to writing supplies you have requested. On 8/29/23 at 3:40 pm, R1 stated his family member sent his birth certificate to the facility, and the facility held it until the last day to give it to him. R1 stated he kept asking for it, and the facility staff would not give it to him, and he needed it to be able to get his apartment. R1 stated V3 BOM (Business Officer Manager) was at the facility last Sunday, and he approached her again and asked if he had any mail, and he wanted his birth certificate, and V3, BOM, stated it might be in the pile of mail on her desk. V3, BOM, later Sunday night, brought him his mail and said she found in the pile on her desk. R1 stated he does not know why they didn't give it to him. R1 stated he has never seen anyone delivering resident mail on the weekends. On 8/30/23 at 12:15 pm, R2 stated his family member sends him mail all the time, and no one delivers any mail on the weekends. On 8/30/23 at 11:50 am and on 8/31/23 at 3:15 pm, R3 and R4 respectively stated they have never seen anyone deliver mail on the weekend, and have not received any mail on the weekend. On 8/30/23 at 12:00 pm and 12:05 pm, R10 and R11, respectively stated they have not received any mail and have not seen anyone delivering mail on the weekends. On 8/31/23 at 9:10 am, R5 stated she is the President of Resident Council, has lived at the facility for a long time, does not recall the facility ever delivering mail on the weekends, and has never received any mail on the weekends. On 8/30/23 at 11:30 am, V3, BOM, stated, The mail is delivered to me every day, and then after I go through it, I deliver it to the residents. Saturdays, mail is placed on my desk, and I review it on Monday when I come back to work. The residents get mail delivered Monday through Friday, but not on Saturday, because there is no one to deliver it. V3, BOM, stated she was working on Sunday, and R1 told her his family member mailed his birth certificate on a Thursday and was saying it was here, and was asking for it again because he needed it to be able to discharge to his own apartment. V3 stated she found it in the pile of mail on her desk, and gave it to R1 that Sunday evening. On 8/30/23 at 2:46 pm, V1, AIT (Administrator in Training), stated the facility does receive mail on Saturday, and it is put on V3, BOM, desk and is delivered to the residents on Monday after V3, BOM, goes through it, because some mail with residents name on it is not really for them. R1, AIT, stated R1's birth certificate came over the weekend, and he didn't get it right away, and thinks we were keeping it from him. The CMS (Central Management Services) form 672, Resident Census and Conditions of Residents, dated 8/29/23, documents there are currently 63 residents residing in the facility.

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to implement their Abuse Prevention policy and procedures after report of an allegation of verbal abuse for one (R2) of four residents reviewe...

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Based on interview and record review, the facility failed to implement their Abuse Prevention policy and procedures after report of an allegation of verbal abuse for one (R2) of four residents reviewed for abuse in the sample of 17. These failures have the potential to affect all 63 residents residing in the facility. Findings include: The facility's Abuse Prevention Program policy and procedure, revised 1/2019, documents, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. This policy includes the acronym S-T-R-I-I-P-P and is defined as Screen -Train-Report-Identify-Investigate-Protect-Prevent to ensure all areas of Abuse Prevention are covered. This same policy documents: Alleged abuse is to be reported immediately to the Administrator; separate the alleged perpetrator and ensure all residents are safe; investigate the alleged abuse; prevent abuse. This same policy documents The Administrator is the Abuse Coordinator of the facility. Supervisors shall immediately inform the Administrator or in the absence of the Administrator, the DON of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, misappropriation of property, mistreatment or a crime against a resident. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. The Resident Council Meeting Minutes, dated 8/22/23, do not include any allegations made by R2 regarding verbal abuse. The facility Grievances, dated May through August 2023, do not include any allegations of verbal abuse made by R2. On 8/30/23 at 2:46 pm, V1, AIT (Administrator in Training), provided the facility Abuse Investigations that she has completed and reported for August 2023. V1, AIT, confirmed she does not have any abuse investigations for R2, is unaware of any staff member saying inappropriate things about a resident's diagnosis, or that the resident's behavior was why the resident was in the facility and stated, I definitely would consider that verbal abuse. V1, AIT, also stated if someone heard this or a resident reported this, she should have been notified. V1, AIT, stated she would have done an abuse investigation for that type of allegation. On 8/29/23 at 2:08 pm, V9, Facility Ombudsman, stated she attended the facility's Resident Council Meeting on 8/22/23, and R2 made an allegation of verbal abuse from an unknown staff member and V10, Consulting Activity Director, reported this to the facility via email. On 9/1/23 at 9:34 am and 11:02 am, V25, Anonymous Staff Member, and V26, Anonymous Staff member, respectively stated all staff, including V1, AIT, were emailed the Resident Council Minutes by V8, Activity Director, on 8/24/23. This email also included documentation by V10, Consulting Activity Director, that an allegation of verbal abuse was made by a resident during the Resident Council Meeting on 8/22/23. V25 and V26, Anonymous Staff Members, both stated email communication was requested by V1, AIT, for all department heads, and that V1, AIT, responded by email as well. V25 and V26 stated V1, AIT, was aware of the allegation due to conversations being had regarding the allegation, and it not being the first time R2 has made the same allegation. On 9/1/23, V1, AIT, forwarded an email she received on 8/24/23, along with the facility 8/22/23 Resident Council Minutes. This email documents V1, AIT was notified of allegations of abuse made during the Resident Council Meeting on 8/22/23. This email documents, Resident stated that a nurse broke HIPAA (Health Insurance Portability and Accountability Act) talking about his diagnosis in front of others, and was demeaning, condescending and inappropriate to him. Along the lines of 'Well if you weren't out in the streets sleeping with everyone and doing drugs we wouldn't be talking now would we?' The CMS (Central Management Services) form 672, Resident Census and Conditions of Residents, dated 8/29/23, documents there are currently 63 residents residing in the facility.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to report a verbal allegation of abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential ...

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Based on interview and record review, the facility failed to report a verbal allegation of abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential to affect all 63 residents residing in the facility. Findings include: The facility's undated Resident Rights policy and procedure documents, Abuse - You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Staff Treatment - The facility must implement procedures that protect you from abuse, neglect or mistreatment, and misappropriation of your property. In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. Corrective action must be taken. The facility's Abuse Prevention Program, revised 01/2019, documents, The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. Employees are required to immediately report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse, neglect, exploitation, or mistreatment to the administrator or an immediate supervisor who immediately reports the allegation to the Administrator. This same policy documents Verbal Abuse: Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. On 8/30/23 at 12:15 pm and on 8/31/23 at 10:31 am, R2 stated he has controlled HIV (human immunodeficiency virus), and one of the nurses yelled at him one night and told him if he hadn't been f***ing women without a condom he wouldn't been in the situation he is now. R2 stated he does not remember who the Nurse was, he told several of the staff what happened, and has reported it to V1, AIT (Administrator in Training), multiple times and no one has done anything. R2 also stated he said something about it in the Resident Council Meeting and still nothing. R2 stated, They don't talk to anyone else like that, I am sick of it, and I am not going to waste my breath anymore. On 8/30/23 at 2:46 pm, V1, AIT, stated no one reported anything to her about R2 making an allegation of verbal abuse, or she would have started an investigation. V1, AIT, stated V24, Activity Assistant, V9, Facility Ombudsman, and V10, Activity Consultant, should have reported to her R2 made an allegation of verbal abuse. On 8/31/23 at 9:10 am, V5, Dietary Manager, stated she heard R2 complain about one of the Nurses saying something about his diagnosis, and V9, Facility Ombudsman, V10, Activity Consultant, and V24, Activity Assistant, heard him too. On 8/31/23 at 10:17 am, V24, Activity Aide, stated V8, Activity Director, was not working on 8/22/23, so she (V24) attended the August Resident Council Meeting along with V9, Facility Ombudsman, and V10, Activity Consultant, and V10, Activity Consultant, ran the meeting. V24, Activity Aide, stated she heard R2 complain that a Nurse yelled at him that if he wasn't f***ing women without a condom he wouldn't have this problem. V24, Activity Aide, stated, (R2) was pretty upset about it and (V24) does not know if V9, Facility Ombudsman, or V10, Activity Consultant, heard R2 say it. V24, Activity Aide, stated she didn't report it to V1, AIT, because she assumed V9 or V10 would tell V,1 AIT, because they were documenting the minutes. On 8/29/23 at 2:08 pm, V9, Facility Ombudsman, stated she has not spoken to V1, AIT, since July, and did not report R2's allegation of verbal abuse to V1, AIT, because V1 is not approachable, is dismissive, and ignores the residents concerns. On 8/31/23 at 12:15 pm, V1, AIT, stated she had asked V8, Activity Director, to send her the August Resident Council Minutes, which V8 attached to an email; she printed the minutes but did not read the entirety of the email, and was unaware it contained details regarding R2's allegation of verbal abuse. V1, AIT, stated she would have expected V8, Activity Director, to come to here and verbally tell her of the Abuse Allegation versus sending it in an email. The CMS (Central Management Services) form 672, Resident Census and Conditions of Residents, dated 8/29/23, documents there are currently 63 residents residing in the facility.

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to investigate a reported allegation of verbal abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has ...

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Based on interview and record review, the facility failed to investigate a reported allegation of verbal abuse for one (R2) of three residents reviewed for abuse in the sample of 17. This failure has the potential to affect all 63 residents currently residing in the facility. Findings include: The facility's Abuse Prevention Program, revised 1/2019, documents, Verbal Abuse: Any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Investigation: All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will be documented. All incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Once the Administrator or in the absence of the Administrator the DON (Director of Nursing) determines that there is an allegation or a reasonable cause for suspecting abuse, neglect, exploitation, misappropriation of property, or a crime against a resident, the Administrator or appointed investigator will investigate the allegation and obtain a copy of any documentation relative to the incident. The investigative team will follow the investigation procedures outlined in this policy. The facility's undated, Resident Rights policy and procedure, documents, Abuse: You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. All alleged violations must be promptly and thoroughly investigated and the results reported to appropriate agencies. Corrective action must be taken. The facility's Abuse Investigations for August 2023 do not include an investigation being completed for R2's allegation of verbal abuse. On 8/30/23 at 2:46 pm, V1, AIT (Administrator in Training), stated she has not completed an investigation of verbal abuse for R2, because she was not aware R2 had reported an allegation of verbal abuse until 8/30/23. On 9/1/23 at 1:48 pm, V1, AIT (Administrator in Training), forwarded the email she received on 8/24/23 from V8, Activity Director. This email documents V8, Activity Director, sent the email to V1, AIT (Administrator in Training), with attached 8/22/23 Resident Council Meeting Minutes on 8/24/23. This email contained attached 8/22/23 Resident Council Meeting Minutes, and documented, Resident stated that a nurse broke HIPAA (Health Insurance Portability and Accountability Act) talking about his diagnosis in front of others, and was demeaning, condescending and inappropriate to him. Along the lines of 'Well if you weren't out in the streets sleeping with everyone and doing drugs we wouldn't be talking now would we?' On 8/31/23 at 12:25 pm, V8, Activity Director stated she received multiple emails from V1, AIT, requesting the Resident Council Meeting Minutes from 8/22/23. V8, Activity Director, stated she had to call V10, Activity Consultant, on 8/24/23 to get the Minutes sent to her. V8 stated she typed up the Minutes and sent them to all the Department Heads and to V1, AIT, on 8/24/23. V8, Activity Director, stated the email also contained a note from V10, Activity Consultant, that a resident had made an allegation of verbal abuse during the Resident Council Meeting. On 8/31/23 at 10:17 am, V24, Activity Aide, stated she heard R2 make an allegation of verbal abuse during the Resident Council Meeting on 8/22/23. On 8/29/23 at 2:08 pm, V9, Facility Ombudsman, stated R2 made an allegation of verbal abuse on 8/22/23 during the Resident Council Meeting, and V10, Activity Consultant, sent the Resident Council minutes and email on 8/24/23 to V8, Activity Director. On 8/31/23 at 12:15 pm, V1, AIT, stated V8, Activity Director, emailed (V1, AIT) the Resident Council Meeting Minutes from 8/22/23 on 8/24/23. V1, AIT, stated she did not read the email thread to identify the allegation of verbal abuse, and did not start the investigation until 8/30/23. On 9/1/23 at 9:34 am, V25, Anonymous Staff Membe,r stated V8, Activity Director, sent an email to all the department heads on 8/24/23 that contained the 8/22/23 Resident Council Meeting Minutes, and documented a resident made an allegation of verbal abuse during the meeting. V25, Anonymous Staff Member, stated this was not the first time R2 had alleged verbal abuse, and V1, AIT, was already aware of it as there has been conversation about it. On 9/1/23 at 11:02 am, V26, Anonymous Staff Member, stated V1, AIT, requested all department heads communicate through email, and V1 uses email to communicate as well. V26 stated the email was sent out on 8/24/23 to all department heads, with concerns requiring a response, and to V1, AIT, which included not only the Resident Counsel Meeting Meetings from 8/22/23, but also documentation of an allegation of verbal abuse. The CMS (Central Management Services) form 672, Resident Census and Conditions of Residents, dated 8/29/23, documents there are currently 63 residents residing in the facility.

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

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to be administered in a manner to ensure implementation of the facility's Abuse Prevention Program Policy and Procedures and in a manner that ...

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Based on interview and record review, the facility failed to be administered in a manner to ensure implementation of the facility's Abuse Prevention Program Policy and Procedures and in a manner that provides oversite and leadership to the residents and staff. V1 (Administrator in Training) failed to respond to reported allegations of abuse and misappropriation. These failures affected three of nine residents (R50, R58, and R60) reviewed for abuse in the sample of 11 and have the potential to affect all 57 residents residing in the facility. Findings include: The facility's Abuse Prevention Program Policy and Procedure, revised 1/2019 states, Policy: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. This policy includes the acronym S-T-R-I-I-P-P and is defined as Screen -Train-Report-Identify-Investigate-Protect-Prevent to ensure all areas of Abuse Prevention are covered. The Administrator is the Abuse Coordinator of the facility. Protection of Residents: Staff members who are suspected of abuse or misconduct shall immediately (regardless of time left on shift) be barred from any further contact with residents of the facility and suspended from duty, pending the outcome of the investigation, prosecution, or disciplinary action against the employee. After notification of alleged abuse, neglect, or a suspected crime against a resident, the Administrator or DON in the Administrator's absence shall immediately commence an investigation of the incident reported. The Administrator shall either rule-out or substantiate the allegation of abuse. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish of deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Investigation: All incidents, allegations or suspicion of abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or a crime against a resident will result in an abuse investigation. Once the Administrator or in the absence of the Administrator the DON (Director of Nursing) determines that there is an allegation or a reasonable cause for suspecting abuse, neglect, exploitation, misappropriation of property, or a crime against a resident, the Administrator or appointed investigator will investigate the allegation and obtain a copy of any documentation relative to the incident. The investigative team will follow the investigation procedures outlined in this policy. This report shall be made immediately, but no later than two hours after the allegation is made if the event that case the allegation involve abuse or resulted in serious bodily injury. Crimes include but may not be limited to murder, manslaughter, rape, assault and battery, sexual abuse, theft robbery, drug diversion for personal use or gain, identity theft, and fraud and forgery. When an alleged or suspected case of abuse, neglect, exploitation or crime against a resident is reported to the facility Administrator, the Administrator or DON (Director of Nursing) in the Administrator's absence, will notify the following persons or agencies of such incident immediately. Any incident that involves crimes or a significant injury to a resident will be reported within 2 (two) hours of the incident. 1. State Licensing and Certification Agency (i.e., Name of local State Agency). This same policy also documents the Administrator or DON in the absence of the Administrator is responsible for forwarding the final written report of the results of the investigation and of any corrective action taken to the Department of Public Health within five working days of the reported incident. The facility's Administrator Job Description undated states, The Administrator leads and directs the overall operation of the facility in accordance with resident needs, federal and state government regulations and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives. This same Job Description documents the Administrator will be responsible for the following: Complies with Code of Conduct when performing work functions; Conducts regular rounds to ensure resident needs are being met; Maintains a working knowledge and ensures compliance with all governmental regulations; Promotes practices that maintain high morale, including effective communication and prompt problem resolution; Demonstrates knowledge of all local State Agency rules and regulations; Interacts with residents, family members, co-workers, clinical and ancillary staff in a non-judgmental, supportive and calm manner; Aware of Resident Abuse Reporting Law; Must have patience, tact, cheerful disposition and enthusiasm; Creates and maintain an atmosphere of warmth, personal interest; positive emphasis as well as a calm environment throughout the facility; Maintains a productive working relationship with other department directors; Ensures understanding of and compliance with all rules regarding residents' rights; and Addresses residents in a respectful manner. The facility's undated Resident Rights Policy and Procedure states, Abuse - You have the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and involuntary seclusion. Staff Treatment - The facility must implement procedures that protect you from abuse, neglect or mistreatment, and misappropriation of your property. In the event of an alleged violation involving your treatment, the facility is required to report it to the appropriate officials. All alleged violations must be promptly and thoroughly investigated, and the results reported to appropriate agencies. Corrective action must be taken. On 9/27/23 at 9:49 AM, V6 (Social Service Director) provided Grievance Forms document the following: On 9/19/23, R50 reported a missing $50 gift card alleging that it was stolen; On 9/26/23, V17 (R58's Power of Attorney) reported R58's bank card was missing and it had attempted to be used by someone unknown; and on 9/26/23, V7 (Activity Assistant) reported V13 (Certified Nursing Assistant) was rude when redirecting R60. These same Grievances are signed by V1 (Administrator in Training). On 9/26/23 and 9/27/23, the facility's Abuse Investigations since 9/18/23 were requested. V1 (Administrator in Training), who is the facility's Abuse Coordinator, denied there were any completed in that period. 1. On 9/28/23 at 1:13 PM, V17 (R58's Power of Attorney) stated on 9/26/23, V17 reported to the nurse on duty (V16/Registered Nurse) R58's bank card was missing. At this time, V17 denied V1 (Administrator in Training) has spoken with V17 about R58's missing bank card. V17 stated since R58's bank card was found to be missing, R58's bank reported R58's bank card had attempted to be used, and it is not known by whom. On 9/28/23 at 3:32 PM, R58 stated R58's bank card was missing. R58 stated, I keep it in the top drawer of my dresser underneath my phone. It was in my room. I don't know where it is now. On 9/28/23 at 3:02 PM, V16 (Registered Nurse) stated on 9/26/23, V16 had just gotten to work when V17 approached V16 asking V16 to check R58's money in the nursing cart and to look for R58's bank card. V16 stated V17 stated the money was all there, but there was not a bank card for R58. V16 stated V17 stated R58's bank card is missing. V16 stated V16 immediately reported R58's missing bank card to V1 (Administrator in Training), and was told to fill out a concern form. V16 stated R58's missing bank card should have immediately been investigated by V1 and was not. V1 stated V1 does not always immediately investigate allegations of abuse that V1 should. On 9/27/23 at 12:44 PM, V3 (Regional Nurse Consultant) verified R58's missing bank card should have been reported to the local State Agency and the local Police Department within two hours of knowing the bank card was missing. On 9/27/23 at 11:39 AM, V1 stated V1 was made aware of R58's missing bank card. V1 stated V1 did not initiate an investigation into R58's missing bank card because R58's bank card was reported as missing not stolen. V1 stated V1 instructed staff to complete a Grievance Form regarding R58's missing bank card. V1 verified V1 gave the Grievance Forms for V6 to handle when V6 returned to work. 2. The facility's Grievance Log documents on 9/26/23, V7/Activity Assistant stated CNA (V13/Certified Nursing Assistant/CNA) was rude when redirecting R60. The facility's Concern/Compliments/Questions/Suggestions Form dated 9/26/23 documents V7 was concerned how V13 redirected R60. On 9/27/23 at 2:14 PM, V7 (Activity Assistant) stated V7 witnessed (V13/CNA) push (R60) on his back with an open hand while attempting to redirect R60. V7 stated V13 kept pushing R60 to redirect R60 towards his room. V7 stated R60 whipped around trying to throw hands with V13 because V13 was pushing R60. V7 states, Even if it wasn't that serious, I was mind boggled by it because we just had a meeting about all of this. I told (V19/Minimum Data Set Coordinator) and (V19) told me to call (V1), so I did. (V1) said 'ok' and she will 'look at the cameras.' (V1) didn't come in and (V13) wasn't sent home. V7 stated, It should have been looked into. Nothing is changing. Administration has something to do with the lack of changes. On 9/27/23 at 2:39 PM, V13 stated, Recently another staff member (V7/Activity Assistant) thought I was abusive to a resident (R60) after that resident (R60) stole another resident's (unknown) meal. At this time, V13 denied being suspended from work pending an investigation into V7's allegation. V13 stated V1 has worked at the facility for almost two months and V1 (AIT) has yet to introduce herself to V13. V13 stated: V1 is not approachable; the staff do not respect V1, and V13 feels frustrated. V13 stated allegations of theft should absolutely be investigated as potential abuse. On 9/27/23 at 11:39 AM, V1 stated V1 was aware of V7's concerns with how V13 redirected R60. V1 stated V1 did not initiate an investigation into the allegation because V7 did not say V13 was abusive and because V7 and V13 do not get along and V7 is always calling V1 with concerns. V1 stated V1 reviewed the security camera footage from home on V1's cellular phone and determined V13's actions were poor customer service. V1 verified beyond reviewing security camera footage, V1 did not further investigate V7's allegations. V1 stated V13 was not suspended from work pending an investigation into V7's allegations. 3. On 9/26/23 at 1:44 PM, R50 stated last week (on 9/19/23) after R50 returned to the facility after a hospital stay, R50 asked V9 (CNA) to check R50's top drawer of R50's nightstand for R50's $50 gift card. R50 stated R50 was worried someone might have taken it while R50 was in the hospital. R50 stated before R50 was sent to the hospital, R50 had given V5 (Activity Director) money to purchase a $50 gift card and a 12-pack of soda. R50 stated the gift card was a gift for R50's son. R50 stated, It's all in one ear and out the other here. No one listens to me. I told them my $50 card was missing and to this day, I haven't heard a word from anyone about it. It's just like that nurse (unknown) who was talking s**t about my diagnosis. (V1) didn't do anything about that either. V9's written statement, dated 9/19/23 at 9:30 PM, states, (R50) asked me to get a (name of local area shopping store) bag from top drawer of his nightstand closest to (R50's) bed. I first looked there and did not find anything. (R50) tells me it was a $50 gift card for (retailer). I searched through his other drawers and did not locate it. (R50 states (V5/Activity Director) put it in there for him after she purchased it from (name of local area shopping store). (R50) stated he believes people from here are thieves and that he believes it was stolen. I (V9) told (R50) I would report to nurse and management. On 9/26/23 at 2:16 PM, V16 (Registered Nurse) stated V9 (Certified Nursing Assistant/CNA) reported to V16 R50 was alleging R50's $50 gift card had been stolen while R50 was in the hospital. V16 stated, I told my CNA to immediately call the Administrator (V1/AIT) and she did. At this time, V16 stated R50's allegation should have immediately been investigated by V1 as potential theft. V16 stated no one has talked with V16 regarding R50's allegation of theft. On 9/26/23 at 2:27 PM, V9 (Certified Nursing Assistant) verified R50 reported to V9 that a $50 gift card was allegedly stolen out of R50's bedroom. V9 stated V9 immediately reported R50's allegation to V1 (Administrator in Training), who told V9 to write out the concern on a grievance form. V9 stated V9 put V9's written statement in V1's mailbox. V9 stated V9 has not heard anything from anyone since reporting R50's allegation that R50's gift card was stolen. On 9/26/23 at 2:39 PM, V5 (Activity Director) verified V5 was given money from R50 to purchase a $50 gift card and a 12-pack of soda. V5 stated when V5 returned to the facility with the gift card, R50 was in the middle of receiving cares, so V5 placed the gift card in the drawer in R50's room, and put the 12-pack of soda on the floor. V5 stated V1 never questioned V5 regarding R50's gift card. On 9/27/23 at 9:49 AM, V6 (Social Service Director/SSD) stated V6 had recently been out sick for work and 9/27/23 was V6's first day back. V6 stated on 9/27/23, upon V6's return to work, V6 found unresolved Grievances related to possible theft (R50 and R58) and possible abuse (R60) in V6's mailbox. V6 stated R50's, R58's, and R60's allegations should have been investigated as potential abuse by V1, and were not. V6 stated V1 put them in V6's box, and V6 was not aware of allegations reported on 9/26/23 related to R58 and R60 until 9/27/23. On 9/27/23 at 11:39 AM, V1 stated V1 was aware of R50's allegation of theft regarding R50's missing gift card. V1 stated V1 did not investigate R50's allegation of potential theft because R50 has a history of making false accusations and V1 was not sure that R50's gift card ever existed. On 9/26/23 at 12:24 PM, R59 stated R59 is seeking referrals to other skilled nursing facilities because R59 is not happy with the care received at the facility. R59 stated, I feel like I don't get listened to here. On 9/27/23 at 1:40 PM, V10 (Licensed Practical Nurse) stated, Abuse that has anything to do with money gets put on the back burner. A couple (unknown) residents were caught stealing from behind the nurses' station and nothing was done. I feel like she just doesn't care. V10 stated, (V1) has no respect for us and no one respects her either. I have worked here for five years, and I've never seen it so bad. It's been nothing but drama since she started (as the Administrator). On 9/27/23 at 1:52 PM, V11 (Certified Nursing Assistant) stated V11 did not know who the facility's Abuse Coordinator was. On 9/27/23 at 1:55 PM, V12 (Housekeeping) stated, It feels like everything that gets reported to her (V1/AIT), nothing is done. One time, an (unknown) Agency Nurse was yelling at a (unknown) resident. I went to report it to (V1), and she just walked away from me. Every time we go to (V1) she gets an attitude. You can't go to her. She doesn't respect us, and no one respects her. On 9/27/23 at 2:34 PM, V14 (Anonymous Staff Member) stated, When you go to (V1) she has an attitude. She's very cocky. You never know what you can say. She blows off everything and doesn't investigate anything. V14 stated, We don't respect her. This job went to her head. It almost feels like we are disturbing her; everything we bring to her seems like an inconvenience. (V1) thinks the problem is us, but it is (V1). On 9/28/23 at 1:24 PM, V6 tearfully stated V1 makes everything V6's fault and V6 does not feel supported. V6 stated V6 is being asked to do things V1 should be doing. The Resident Room Roster dated 9/26/23 documents 57 residents currently reside in the facility.

Aug 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

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 care plan with the proper transfer technique following an incident for one of three residents (R2) reviewed for resi...

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Based on observation, interview, and record review, the facility failed to revise a care plan with the proper transfer technique following an incident for one of three residents (R2) reviewed for resident injury in the sample of 3. Findings include: The facility's Incidents/Accidents/Falls policy, no date available, documents, Based on the results of the Incident/Accident/fall, the resident's care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place. R2's Point of Care Task list, dated 8/7/23, documents R2's transfer status is extensive assist of two staff members using a stand aid. R2's Incident report, dated 6/6/23, documents, (R2) was being transferred with sit to stand lift. (R2's) legs gave out. He scraped shin area 8 x 1 cm (centimeter). R2's Falls & Accident/Incident Resident Management Review, dated 6/7/23, documents, As a result of the accident/incident (6/6/23), the plan of care has been updated to decrease potential or future falls: Hoyer (mechanical lift). R2's current care plan, provided by V1 (Administrator) on 8/7/23, documents R2 has been assessed and it was determined R2 requires a sit to stand with a standard sling for all transfers. The care plan has no documentation of it being revised following R2's incident on 6/6/23, to change R2 to a mechanical lift. On 8/7/23 at 10:35 a.m., V8 (Licensed Practical Nurse) stated, I'm working as a CNA (Certified Nursing Assistant) on the floor today. It just depends on the resident that day as to how we transfer them. Some residents can be transferred with two assist during the day, but then later in the day they require more assist and they might need the mechanical lift or the sit to stand like (R2). On 8/7/23 at 12:15 p.m., V10 (R2's Power of Attorney) was at R2's bedside while R2 was sleeping in bed. V10 stated, (R2) had a moment that two girls had him up in the sit to stand, and his leg gave out. He scraped the foot rest. On 8/7/23 at 1:30 pm, V7 (CNA) and V11 (CNA) were preparing R2 to get him out of bed. V11 stated, Therapy has to stay in here with me if we are doing a two man transfer because I don't feel comfortable doing it. I normally only transfer him with a Hoyer, but sometimes he is transferred with the sit to stand, and sometimes he's transferred just with two assist. On 8/7/23 at 1:40 p.m., V7 and V11 transferred R2 from his bed to his wheelchair using the mechanical lift. On 8/8/23 at 11:55 a.m., V2 (Director of Nursing) stated, The staff look at the care plan for a resident's transfer status. The transfer status will also go to the staff task listing from the care plan. So they can find the transfer status there as well. V2 confirmed R2's care plan was not revised to ensure R2's proper transfer status was changed to a mechanical lift following R2's incident on 6/6/23.

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

Based on observation, interview, and record review, the facility failed to transfer a resident (R1) using a mechanical stand aid (Sit to Stand) according to their plan of care that resulted in a fall,...

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Based on observation, interview, and record review, the facility failed to transfer a resident (R1) using a mechanical stand aid (Sit to Stand) according to their plan of care that resulted in a fall, and failed to lock a wheelchair and mechanical stand aid during a resident (R1) transfer for one of three residents (R1) reviewed for falls in the sample of three. Findings include: The facility's Sit to Stand Lift policy and procedure, dated 10/10/11, documents, Purpose: To assure that all residents are assessed to require extensive high assistance in transfer are transferred safely with no injury to resident or care handler. Utilizing the lift-Lifting the resident: If the resident is being lifted from a mobile chair make sure to apply the brakes on the chair. Lowering the resident: Move the lift close to the chair or the bed so that the back of the resident's knees almost touch the seat of the chair or the bed. Apply the brakes on the casters of the lift. Press the 'down' button using the hand controller until the resident is comfortably sitting. R1's care plan, dated 6/26/23, documents, (R1) has been assessed and has been determined to need a mechanical lift for transfers Related to: Left AKA (Above the Knee Amputation), Asthma, PVD (Peripheral Vascular Disease), DM (Diabetes Mellitus) Type 2, Old MI (Myocardial Infarction), Anemia, Dementia, Alzheimer's, Anxiety. Will be designated as SIT TO STAND (stand aid) WITH STANDARD SLING, Extensive Assist, more than 26% weight bearing support, minimum weight bear of one leg, good sit balance. The care plan also documents the following interventions: The staff will follow the facility Sit to Stand Policy and Procedure to ensure safety and correct procedure with use of the equipment; R1 will be transferred with a one person assist using a Sit to Stand and a Standard Sling per our Policy and Procedure and manufacturer guidelines. R1's Nurses' note, dated 6/29/23 at 5:06 a.m., documents, (R1) and (V4 CNA-Certified Nursing Assistant) observed on the floor. V4 and R1 state that during transfer from bed to wheelchair, wheelchair moved and both went to the ground. (R1's) head made contact with wheelchair leg. R1's Nurses' notes, dated 6/29/23 at 6:18 a.m., document, (R1) transported to ER (Emergency Room) per facility van. R1's Hospital After Visit Summary, dated 6/29/23, documents, Reason for visit: Fall. Diagnosis: Contusion of Scalp. A facial or scalp contusion is caused by an injury, fall, or trauma to the face or head area. Summary: A facial or scalp contusion is a bruise (contusion) on the face or head. R1's Fall Report, dated 6/29/23 at 4:00 a.m., documents, (V4) was transferring (R1) to wheelchair and wheelchair moved, (R1) and (V4) went to the ground and (R)1 made contact with wheelchair leg according to (R1) and (V4). Nurse observed (R1) and (V4) on the ground and wheelchair behind them. (R1) states that during the transfer the wheelchair and moved back and her body went down, her head bumped the wheelchair leg. Immediate Action Taken: (R1) has pain and small bump with red area to back of her head. On 8/7/23 at 1:20 pm, R1 was alert self propelling in the hallway. R1 has a left above the knee amputation. R1 stated, The CNA (V4) tried to transfer me by herself and she dropped me. She was too weak to transfer me, and they were supposed to be using the stand aid anyways. I bumped my head on the wheelchair and went to the hospital. I remind the staff all the time now to make sure they use the stand aid with me. On 8/7/23 at 2:30 p.m., V3 (Registered Nurse) stated, When (R1) fell, the CNA (V4) was transferring (R1) by herself to the wheelchair. The wheel wasn't locked, and when she went to sit her down the wheelchair moved and she had to lower her to the floor. She did not use the sit to stand. (R1) is supposed to be a sit to stand, but I'm not sure why she didn't use it. On 8/8/23 at 9:30 am, R1 was alert sitting up in her wheelchair with a stand aid sling in place and hooked to a stand aid. Without locking R1's wheelchair, V9 (CNA) lifted R1 to a standing position using the stand aid. V9 moved R1 to the toilet, and while standing over the toilet V9 removed R1's soiled clothes. Then, V9 lowered R1 to the toilet. It wasn't until R1 was sitting on the toilet that V9 locked the stand aid wheels. On 8/8/23 at 9:40 a.m., V9 stated, I don't ever lock the wheelchair wheels during a stand aid transfer so that I can push the wheel chair away once the resident is stood up. I don't lock the stand aid wheels until the resident is completely sat down. I locked them because I didn't want (R1) to lean forward and push the stand aid away. On 8/8/23 at 11:55 a.m., V2 (Director of Nursing) stated, When (R1) fell her transfer status was to use a stand aid. (V4) transferred her by herself and the wheelchair wasn't locked. At that time, staff were supposed to be using a sit to stand to transfer (R1), but (V4) did not use it. She attempted to self transfer (R1) by herself.

Aug 2023 6 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure residents felt safe and comfortable when reporting any complaint to the facility for two of three residents (R3 and R6) reviewed for...

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Based on interview and record review, the facility failed to ensure residents felt safe and comfortable when reporting any complaint to the facility for two of three residents (R3 and R6) reviewed for grievances in a sample of ten. Findings include: The facility's Grievances/Complaints/Missing Property policy/procedure, undated, documents, Policy: It is the policy of the facility to see that the residents and their responsible parties are made aware upon admission and as indicated of the resident's right to express a complaint or a grievance orally, or in writing at any time. This complaint or grievance may also be done anonymously. The facility's Resident Rights policy, undated, documents, Grievances - You may voice grievances concerning your care without fear of discrimination or reprisal. On 7-25-23 at 2:36pm, R3 sat in her room and made the following statements: I got left on the bedpan for two hours last week. I feel neglected. It's ridiculous. I don't care anymore if they want to retaliate. On 7-27-23 at 8:55am, R6 was sitting in a reclining chair by the patio door. R6 stated R6 definitely fears retaliation. R6 said R6 fears That (V1 Administrator) will talk s**t, telling this one what that one said. R6 stated V1 has done that before when it involved R6's family member. On 7-25-23 at 1:58pm, V15, Activity Aide, stated, I have seen residents who have cried due to not being able to vent.

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

Based on observation, interview, and record review, the facility failed to provide resident showers as scheduled for one of one resident (R3) of three residents reviewed for activities of daily living...

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Based on observation, interview, and record review, the facility failed to provide resident showers as scheduled for one of one resident (R3) of three residents reviewed for activities of daily living in a sample of ten. Findings include: The facility's Activities of Daily Living/ADL (Activities of Daily Living) (Routine Care) policy, undated, documents, Policy: Residents are given routine daily are and HS (at bedtime) care by a CNA (Certified Nursing Assistant) or a Nurse to promote hygiene, provide comfort and provide a homelike environment. ADL care is provided throughout the day, evening and night as care planned and/or as needed .ADL care of resident includes: Assisting the resident in personal care such as bathing, showering, dressing, eating, hair care, oral care, nail care, appropriate skin care (as indicated and as per care plan) as well as encouraging participation in physical, social and recreational activities. The facility's Certified Nursing Assistant Job Description, undated, documents, The Certified Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by supervisors. This document also includes C. Role Responsibilities - Personal Nursing Care: 3. Assists residents with bath functions (i.e. bedbath, tub or shower bath, etc.) as directed .18. Assists in transporting resident to/from appointments, activity and social programs, etc, as necessary. On 7-25-23 at 2:09pm, R3 sat in a wheelchair in R3's room. R3's hair on R3's scalp was visibly greasy. On 7-25-23 at 2:10pm, R3 stated R3's showers are scheduled for twice a week on Mondays and Thursdays. R3 stated, I didn't get my shower (yesterday) because they are short staffed. That's all I hear. R3 stated, It makes me feel nasty. At home I took one every day. I don't even get one per week. My hair looks and feels greasy. Residents and staff tell me it looks greasy. My last shower was last week on Wednesday (7-19-23) because I asked for one on pm shift. Thank God he did it. Prior to that it had been a week. I've gone as long as six weeks. The facility's Resident Shower Schedule, undated, documents R3 is to receive a shower on Tuesdays and Fridays on first shift. R3's shower sheets document the following: R3 received a shower on June 26, refused on June 29, then received one on July 3, refused a shower on July 7, then received a shower on July 13 and July 19. R3's shower sheet, dated June 24, documents R3 refused due to wanting to get up to visit with R3's family member who was coming. There is no documentation of R3 being offered again after R3's refusals. On 7-26-23 at 11:35am, R3 denied being offered or refusing a shower on 7-24-23. R3's Minimum Data Set/MDS assessment, dated 4-25-23, documents R3 has moderately impaired cognition and is totally dependent on staff assistance for bathing. On 8-4-23 at 1:00pm, V26, Certified Nursing Assistant/CNA stated, I haven't missed giving resident showers personally, but know others have. I've seen some with greasy hair, (R3), who is one who likes being clean. On 7-25-23 at 1:58pm, V15, Activities Aide, stated the following: The residents say they aren't getting their showers and Residents have cried due to not getting showers or having greasy hair.

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure incontinent residents received incontinence care in a timely manner for two of three (R3 and R4) residents reviewed fo...

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Based on observation, interview, and record review, the facility failed to ensure incontinent residents received incontinence care in a timely manner for two of three (R3 and R4) residents reviewed for incontinence care in a sample of ten. Findings include: The facility's Incontinent Care policy, undated, documents, Policy: It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care. Frequency depends on bladder diary results and/or routine minimal q (every) two hour checks as well as care planning. The facility's Certified Nursing Assistant Job Description, undated, documents, C. Role Responsibilities - Personal Nursing Care: 8. Keep residents dry (i.e. change gowns, clothing, linen, etc., when it becomes wet/soiled. And 11. Assists residents with bowel and bladder functions (i.e., take to bathroom, offer bedpan/urinal, portable commode etc.). 1. R3's Minimum Data Set/MDS assessment, dated 4-25-23, documents R3 is moderately cognitively impaired, requires extensive assist of two persons for toileting, and is always incontinent of bladder. On 7-25-23 at 2:36pm, R3 stated R3 tries to hold her urine, but when it takes them too long to answer R3's call device R3 can't hold it. R3 stated, I don't feel like a good person and it is embarrassing when my pants get soaked. On 7-25-23 at 2:50pm, R3 was lying in bed with the call device on. V24 and V25, Certified Nursing Assistants/CNAs came into R3's room. R3 stated, I already peed. V24 and V25 lowered R3's shorts that were wet with urine, and R3's urine saturated brief prior to performing incontinence care. V25 stated they were told R3 had been changed before the last smoke break. 2. On 8-2-23 at 2:10pm, R4 sat in a wheelchair in R4's room. V27 and V23, CNAs, transferred R4 to bed, then performed incontinence care prior to V13, Licensed Practical Nurse/LPN doing a wound treatment. R4's incontinence brief and coccyx wound dressing were saturated with urine. At this time, V27, CNA, stated when they got R4 up for lunch, (R4's)condom catheter fell off, and they didn't take the time to replace it. On 8-2-23 at 2:32pm, V13, LPN, stated they should have put R4's condom catheter back on because the urine got on R4's wound.

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

Smoking Policies (Tag F0926)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow facility policy for resident smoking times for three of three residents (R1, R3, and R6) reviewed for smoking in a sam...

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Based on observation, interview, and record review, the facility failed to follow facility policy for resident smoking times for three of three residents (R1, R3, and R6) reviewed for smoking in a sample of ten. Findings include: The facility's Smoking Policy, dated 2-8-21, documents, 12. The facility will determine designated smoking locations and times, however this will also be acceptable to the Resident Council, with any changes needing to have their input and agreement. The facility's Resident Smoking Times posted on the patio door throughout this survey documents the resident smoking times as 9:00am-9:15am, 1:15pm-1:30pm, 3:30pm-3:45pm, 6:00pm-6:15pm. 1. R1's current Care Plan includes a focus of (R3) likes to smoke r/t (related to) hx (history of) smoking with interventions including I have been shown the designated smoking area and will be assisted to and from the designated area at break times if needed. On 7-25-23 at 10:00am, R1 sat in R1's room and stated the 6pm smoke break gets canceled all the time. 2. R3's current Care Plan includes a focus of (R3) likes to smoke r/t (related to) hx (history of) smoking with interventions including I have been shown the designated smoking area and will be assisted to and from the designated area at break times if needed. On 7-25-23 at 2:36pm, R3 sat in R3's room and stated, We hardly get our 6pm smoke break. 3. R6 sat in a reclining wheelchair near the patio door to the designated smoking area and stated, We don't always have someone to take us out for the 6pm smoke break, so they will cancel it. On 8-2-23 at 12:30pm, the Interim Director or Nursing/DON stated the posting of smoking times is a part of the smoking policy and is the designated smoking times. There should be staff available to take residents out for all three times.

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

Based on observation, interview, and record review, the facility failed to ensure resident call devices were responded to in a timely manner, failed to ensure resident smoking times were abided by, an...

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Based on observation, interview, and record review, the facility failed to ensure resident call devices were responded to in a timely manner, failed to ensure resident smoking times were abided by, and failed to ensure residents felt safe and comfortable to speak with State Agency for seven of ten residents (R1, R2, R3, R5, R6, R8, and R10) reviewed for Resident Rights in a sample of ten. Findings include: The facility's Resident Council Minutes, dated 7-18-23, documents the following: Everything has gotten worse! Call lights still not being answered in a timely matter. (V1, Administrator) told the receptionist residents have to go to her office first before they can talk to State. They need to address that. It is illegal to say that they can't talk to state and visitors who are staff not to visit. Need 6-8 o'clock smoke break. Evening smoke breaks are not getting done. Call lights are being shut off before the problem is being resolved. 1. The facility's Call Light policy, undated, documents Policy: It is the policy of the facility to have a system in place to allow the staff to respond promptly to a resident's call for assistance and to ensure that the call system is in proper working order. The call system will be available in the resident's room as well as in the resident's bathroom. Procedure: 2. Call lights are to be answered promptly by staff who see that the call light has been activated. 3. Even if you are unable to meet the need of a resident, you can report the need to the appropriate staff member .7. Never make the resident feel as though you are too busy to give assistance. If you yourself cannot provide the requested assistance, assure the resident that you will take their request to the appropriate staff. Follow through with this commitment and follow up to see if the resident had the need met. NEVER TURN OFF A CALL LIGHT THEN FAIL TO SEE THAT THE RESIDENT'S REQUEST WAS ADDRESSED. The facility's Resident Council Minutes, dated 6-20-23, documents Nursing - Call lights are taking too long to be answered. On 7-25-23 at 10:00am, R1 stated R1 has heard (R5) holler out for help from across the hall. R1 has seen staff just walk past R5's call light and don't answer it. On 7-25-23 at 2:36pm, R3 stated, Last night they put me on the bed pan and one and a half hours later night shift took me off. They said they didn't know I was on the bedpan. The call light had been turned off so I had to put it back on. R3 stated, I feel neglected. It's ridiculous. At this time, R3 also stated R3 tries to hold her urine, but when it takes them too long to answer R3's call device, R3 can't hold it. R3 stated, I don't feel like a good person and it is embarrassing when my pants get soaked. On 8-2-23 at 1:20pm, R5 was lying in bed. V28, Certified Nursing Assistant/CNA, assisted V13, Licensed Practical Nurse/LPN, with R5's wound care. At this time, R5 stated V23, CNA, answered R5's call device twice, but didn't fulfill any of R5's requests. R5 stated (V13) brought R5 ice water and adjusted the air conditioning after R5 called the facility phone. V13, LPN, stated R5 called the facility phone because R5's call light had been on for awhile. At this same time, R5 stated V28, CNA, came and changed R5's bed since V23, CNA, didn't come back. V28, CNA, nodded in agreement. On 8-2-23 at 1:46pm, R10's call device was illuminated over R10's door and alarming on the call device panel located across from the nurse's station. At this time, this panel shows R10's call device has been on for 6 minutes. V23, CNA, sat in the lounge area outside of R10's hall charting. At 1:52pm, V23, CNA, brought the charting laptop to the nurse's station and placed it on the desk. R10's call device was still illuminated and alarming as V23 walked past the call device panel and down a different hall. During this same time, V16, Housekeeping aid, had walked down D hall and came out without answering R10's call light. After 12 minutes, R10's call device was answered. On 8-2-23 at 2:44pm, R10 sat in R10's room watching television. R10 stated the following: R10's call light took a little while. R10 was waiting for ice water. They are definitely short staffed; anyone can tell that. On 8-2-23 at 12:30pm, V2, Interim Director of Nursing/DON, stated, Call lights should be answered in a timely manner which I feel would be six minutes. If it is something they can't do they should find someone who can help and let the resident know. They are supposed to get someone immediately and return. Any staff person can and should answer it. On 8-2-23 at 3:05pm, V1, Administrator, stated the following: For call light response time, the time limit should be within five minutes or less. If cannot complete the task they should leave the call light on, and then go get someone to help them and come right back. Or come back to let them know someone is coming back. They can turn it off, but it is common courtesy to go back and let them know you told somebody. 2. The facility's Smoking Policy, dated 2-8-21, documents, 12. The facility will determine designated smoking locations and times, however this will also be acceptable to the Resident Council, with any changes needing to have their input and agreement. The facility's Activity Aid Job Description, undated, documents, Position Summary: The Activity Aide assists the Activity Director in carrying out a planned activity program for residents. They will maintain records, transport residents to and from activities and perform varied clerical and department maintenance functions. The facility's Certified Nursing Assistant Job Description, undated, documents, C. Role Responsibilities - Personal Nursing Care: 18. Assists in transporting residents to/from appointments, activity and social programs, etc., as necessary. On 7-25-23 at 9:55am, the facility's Resident Smoking Times were posted on the patio door. This posting documents the resident smoking times as 9:00am-9:15am, 1:15pm-1:30pm, 3:30pm-3:45pm, 6:00pm-6:15pm. On 7-25-23 at 10:00am, R1 stated the 6pm smoke break gets canceled all the time. On 7-25-23 between 1:25pm and 3:45pm, V11, Registered Nurse/RN, stated the following: Sometimes at 6pm if there are only two CNAs, then I can't let either of them take residents out to smoke because it's not the CNA's purpose and that would only leave one CNA in here. I can't take them because (V11) is passing medications at that time. V11 stated, If I only had two CNAs, it wouldn't be safe to take one CNA to go on the smoke break. They should provide a non-clinical person to take them for 6pm smoke breaks. On 7-25-23 at 1:58pm, V15, Activities Aide, stated, Activities is responsible for all smoke breaks, but I have to do my charting at the end of the day, since they won't pay over time for that. They don't get their 6pm smoke break unless a CNA or the [NAME] can take them out. On 7-25-23 at 2:36pm, R3 stated the following: We hardly get our 6pm smoke break. Sometimes we have to wait until 7 or 8 o'clock until kitchen staff (V17, Cook) takes us out. If (V17) has the weekend off, they'll cancel the 6pm smoke break. R3 also stated, On the weekends especially, there is no one to take us out to smoke, and CNAs say it's not their job. On 7-25-23 at 2:55pm, V30, CNA, stated Smoke breaks are not a CNA's job; it is activities' and receptionists'. On 7-26-23 at 9:00am, V6, Activities Director, stated, I have two assistants. (V15) works 10-6:30pm Monday-Thursday and every other weekend. (V30) works 8:30am - 5:00pm Tuesday -Friday and the opposite weekend. Currently (V15 and V30) are responsible for the 9, 1:15 and 3:30pm smoke breaks. The evening one at 6:00pm is being covered by the receptionist. On 7-26-23 at 9:05am, V4, Business Office Manager/Human Resources Director, stated, I over see the receptionists and their schedules. We have three. They cover 8am -8pm Monday-Friday and 8-4:30pm on Sat/Sunday. They are not supposed to be responsible for any smoke breaks. About a month ago, I learned that the receptionists were doing the 6:15pm smoke break. So I spoke to (V6, Activities Director) about it, and said that smoking is an activity to be covered by activities. On 7-26-23 at 1:35pm, R8 stated, We don't always get the 6pm one (smoke break). Sometimes we have to wait or don't get one at all. It's kind of perturbing to miss it. On 7-27-23 at 8:55am, R6 sat in a reclining wheelchair near the patio doors to the smoking area. R6 stated, We don't always have someone to take us out for the 6pm smoke break so they will cancel it. It makes me mad. On 8-2-23 at 12:30pm, V2, Interim Director of Nursing/DON, stated, The posting of smoking times is a part of the smoking policy and is the designated smoking times. There should be staff available to take residents out for all three times. 3. The facility's Resident Rights undated policy documents, As a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights as designated below. Exercise of Rights: You have the right and freedom to exercise your rights as a resident of this facility and as a citizen or resident of the United States without fear of discrimination, restraint, interference, coercion or reprisal. This policy continues to state Access and Visitation Rights: You have the right and the facility must provide access to visit with any relevant agency of the state or any entity providing health, social, legal or other services. On 7-25-23 at 10:00am, R1 stated the receptionist (V21) told R1 that V1, Administrator told V21 residents are not allowed to speak to State people unless we ask (V1) first. R1 continued to state last week R1 went in to the room to where the surveyor was to talk to the surveyor, and R1 got talked to afterwards for it. On 7-25-23 at 11:31, V21, Receptionist, stated, There was a time when (V1, Administrator) told me to let (V1) know if there was a resident that wanted to speak to surveyors. Not sure why. One time (R1) asked if State was in the room, and then went on in and talked to the surveyor. (V1) said to go get (R1) immediately because 'we don't do it that way.' (R1's) girlfriend overheard (V1) telling me that. On 7-25-23 at 1:29pm, R2 stated R2 has heard it mentioned before we call State we have to call (V1 Administrator) first. On 7-25-23 at 1:50pm, R1 stated the following: R1 felt scared to come knock on the surveyor's door today. (V15, Activity Aide) said during our 1:15pm smoke break on the patio to watch out if State comes through because (V1) is watching to see every resident room State goes to. On 7-25-23 at 1:58pm, V15, Activity Aide, stated, The residents don't feel safe talking to you (State surveyor) for fear (V1, Administrator) will retaliate. (V1) wants to be notified who goes and talks to surveyors. (V1) can see everyone who comes and goes. On 8-2-23 at 12:30pm, V2, Interim Director of Nursing/DON, stated: It is their right to talk to State (Agency). They should be made to feel comfortable to talk to state - it is their right.

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 F0725 (Tag F0725)

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 knowingly failed to have enough staff to accommodate the needs ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility knowingly failed to have enough staff to accommodate the needs of the residents in the facility as evidenced by multiple complaints by residents, staff, and resident council minutes, where residents are not getting call lights answered, toileting, grooming, and smoking needs met for seven of ten residents (R1, R3, R4, R5, R6, R8, and R10) reviewed for issues related to staffing, in a sample of ten. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility Assessment Tool, dated 7-20-23, documents, Staffing Plan: Below describes general staffing plan to ensure that we have sufficient staff to meet the needs of the resident at any given time. Licensed nurses two for each 12 hour shift. Certified Nursing Assistants/CNAs Day shift: 5-7, 1 restorative aid; PM shift: 5-7, Night shift: 4. The facility's Staffing Strategies During Shortage policy, dated December 2021, documents, Policy: When staffing shortages are anticipated, (named facility) will use contingency or crisis strategies to plan and prepare to care for residents by utilization of all nursing staff and non-nursing staff to provide care. Procedure: 1) Identify staffing needs and number of staff to provide safe work environment and resident care. 2) Communicate with regional team local healthcare partners agency usage and federal and state assistance as needed. 3) Adjust staff schedules, hire, and rotate staff to positions to support resident care and provide ADLs (Activities of Daily Living) .B) Address factors that may prevent staff from reporting to work such as housing transportation. The facility's Daily Assignment sheet, dated 7-25-23, documents there are four CNAs (Certified Nursing Assistants) scheduled to work day shift. Six CNAs listed are crossed off as not here (including the Restorative aid); two have union by their names. On 7-25-23 at 10:00am, there are four CNAs on duty for day shift. On 7-25-23 at 9:43am, V11, Registered Nurse/RN, stated V11 worked night shift on 7-12-23, and there were only two CNAs (Certified Nursing Assistants). V11 stated, That is not enough. And there are not enough here today. V11 explained three CNAs were supposed to work today, but they are at a union meeting. V11 stated the facility has been running with 4 CNAs on day shift, five CNAs on evening shift, and three on night shift. On 7-27-23 between 11:05am and 1:39pm, V1, Administrator, stated the following: I prefer to run 5 (on day shift), 5 (on pm shift) and 4 (on night shift). We don't use agency here. We have frequent call offs due to current union negotiations. V1 feels that 5, 5, and 4 isn't enough, but they call in and we do the best we can. V1 would like to have more; Corporate doesn't allow use of agency. On 7-27-23 at 1:40pm, V1 Administrator verified the following staffing hours on facility Daily Assignment sheets all dated in 2023: July 4 - two CNAs on third shift; July 7 - two CNAs on day shift; July 10 - two CNAs on third shift and one CNA scheduled at 2am; July 12 - three CNAs and one Restorative CNA on day shift and two CNAs on third shift; July 15 - four CNAs on day shift, no Restorative CNA; July 16 four CNAs on pm shift; July 17 - four CNAs on pm shift; July 21 - four CNAs and one Restorative CNA on day shift with four CNAs on pm shift; July 25 - four CNAs and no Restorative CNA on day shift. On 8-2-23 at 12:43pm, V4 Business Office Manager (BOM)/Human Resource (HR) Director stated V4 assists with the staffing schedule. V4 stated the following: We don't use agency. CNAs I feel we have enough of them, but right now with the union contract going on and vacations it's a mess. When I try to deny vacations I get a grievance from the union. Our ideal staffing is 6 (on day shift), 6 (on pm shift), and 4 (on night shift), but we have not been able to run that. So we have been staffing with the state requirement from Corporate with a resident to CNA ratio scheduling 4 (on day shift), 4 (on pm shift), and 3 (on night shift). We get an email from Corporate HR who says that nine employees can be off for a union contract meeting in Chicago. Out of those nine there six CNAs. We get one to two day prior notice. They have been in negotiations since June and they are gone two to three days at a time. V4 confirmed that the facility has anticipation of staffing shortages during the CNA's union contract negotiation and vacations occurring. V4 stated that agency use is not allowed by Corporate even though mentioned in the policy for anticipated staffing shortage. The facility's Resident Council Minutes, dated 6-20-23, documents Nursing - Call lights are taking too long to be answered. Concern: Not enough CNAs to help 60 residents. The facility's Resident Council Minutes, dated 7-18-23, documents the following: Everything has gotten worse! Call lights still not being answered in a timely matter. Evening smoke breaks are not getting done. Call lights are being shut off before the problem is being resolved. (R3) is sick and tired of hearing 'we are short' from CNAs. (R3) is being told they are too busy and never come back to help her. On 7-25-23 at 10:00am, R1 stated ,The 6pm smoke break gets canceled all the time because the nurses and CNAs say there isn't enough staff to take us out. On 7-25-23 at 1:25pm, V11, Registered Nurse/RN stated, At times the 6pm smoke break is canceled due to staffing. On 7-25-23 at 1:58pm, V15, Activities Aide, stated, The residents say they aren't getting their showers and Resident have cried due to not being able to vent, not getting showers, or having greasy hair. On 7-25-23 at 2:09pm, R3 stated, I didn't get my shower (yesterday) because they are short staffed. That's all I hear. On 7-25-23 at 2:36pm, R3 stated, Last night they put me on the bed pan and one and a half hours later night shift took me off. They said they didn't know (R3) was on the bedpan. The call light had been turned off so I had to put it back on. R3 stated ,It's ridiculous. I'm sick of hearing 'we are short (staffed).' On 7-25-23 at 2:50pm, R3's shorts were wet with urine and R3's incontinence brief was urine saturated prior to performing incontinence care. On 7-28-23am at 10:20am, V5, Social Service Director, stated V5 is also a CNA, and helps out on the floor at times. V5 stated, I don't like being a CNA on the floor because I can't clean them up and care for them like I like to. I don't believe they have enough staff to get their cares done. We had CNAs who left because of it, and because they feel they can't be the best CNA. Showers have been missed while I've worked the floor short staffed. On 7-28-23 at 11:25am, V23, CNA, stated the following: There is not enough staff to get cares done. Residents aren't always getting their showers. It's happening now. It's crazy on my weekend. Some residents (like R5) may not get fed because we're so short. On 7-28-23 at 11:35am, R5 is a quadriplegic lying in bed with a specially designed call light up to his mouth so R5 can blow into it to make it illuminate. R5 stated the following, Call lights take a long time to be responded to. As a quadriplegic, I get in precarious situations. It's terrible living in fear; having to wait for help if I'm too hot, too cold, need water, need position adjusted, fed or if having a panic attack and need medication. Then by the time they answer the call light and come back with the medicine it doesn't work like it should. Call lights not being answered promptly is due to being short staffed and they won't use agency. They will turn the call light off and don't come back. I hate that. It exacerbates my panic and anxiety. I lay in this room waiting and wondering if I'm ever gonna get help. I have waited one hour to one hour and 20 minutes. I use my phone (via [NAME]) to call my Mom then she calls the facility. I was probably waiting to be fed. I'll order food around 6 or 7 pm then I don't get fed until 10 or 11pm - mostly 11pm. I am starving by then. I even ask what the best time to order is and they say 6 or 7, but then something more important than feeding me comes up. It doesn't take that long to feed me. It only takes 15 minutes. I am getting angry just talking about it. On 8-2-23 at 2:10pm, R4's incontinence brief and coccyx wound dressing was saturated with urine. At this time, V27, CNA, stated when they got R4 up for lunch, R4's condom catheter fell off, and they didn't take the time to replace it. On 8-2-23 at 1:00pm, V26, CNA, stated, There is not enough staff on weekends. During the week with all the union meetings it leaves us short. V26 also stated, We are definitely not able to provide incontinence cares every two hours. We want to but not always able to. We are waiting on another CNA when they have time to help. The facility's Resident Room Roster, provided by V1, Administrator, on 7-25-23, documents that 60 residents reside in the facility.

May 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 F0558 (Tag F0558)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the Facility staff failed to wear identification badges during working hours. This failure has the potential to affect all 59 Residents residing in ...

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Based on observation, interview, and record review, the Facility staff failed to wear identification badges during working hours. This failure has the potential to affect all 59 Residents residing in the Facility. Findings include: Facility Resident Room Roster, dated 5/11/23, documents 59 Residents residing in the Facility. Facility Resident Rights Policy, undated, documents: as a Resident of this Facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The Facility will protect and promote your rights as designated below; you have the right to be fully informed of your total health status; the Facility must care for you in a manner and environment that enhances or promotes our quality of life; and the Facility must treat you with dignity and respect in full recognition of your individuality. On 5/13/23, at 7:40 am, V4 (Social Service Director) did not have an identification name badge on, and then stated, I am the Social Service Director and Manager on Duty. On 5/13/23, at 7:45 am, V5 (Certified Nursing Assistant) did not have an identification name badge on, and stated, I do not have mine (name badge). On 5/13/23, at 7:46 am, V6 (Certified Nursing Assistant) did not have an identification name badge on, and stated, I do not have my name badge, it is in my car. On 5/13/23, at 7:49 am, V7 (Licensed Practical Nurse) did not have an identification name badge on and stated, I do not have mine (name badge) it is in my car. On 5/13/23, at 7:58 am, V7 had a piece of tape attached to V7's top, with name handwritten with marker on it. On 5/13/23, at 7:54 am, V8 (Certified Nursing Assistant) did not have an identification name badge on, and stated, My name badge is in my car. On 5/13/23, at 11:54 am, R1 stated, I do not know anyone's names, half of them do not even wear name tags. On 5/13/23, at 11:37 am, V3 (Business Office Manager) stated, When someone is hired, the Receptionist is responsible for making the name badge. All employees should wear a name badge while working. On 5/13/23, at 11:10 AM, V1 (Administrator) stated, If these people are working, they should all have their name badge on so the residents can identify them.

Apr 2023 13 deficiencies 1 IJ (1 facility-wide)

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Food Safety (Tag F0812)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Based on observation, interview, and record review ,the facility failed to monitor the cooling down process of an undated, cooked pork roast on 4/23/23 at 5:58 am, and attempted to serve it for the no...

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Based on observation, interview, and record review ,the facility failed to monitor the cooling down process of an undated, cooked pork roast on 4/23/23 at 5:58 am, and attempted to serve it for the noon meal on 4/23/23; failed to wear the proper PPE (Personal Protective Equipment) during the preparation of food and during the sanitation of resident utensils; failed to date cooked food items to ensure use before expiration; failed to discard expired food; and failed to monitor and record the required refrigerator, freezer, and milk cooler temperatures, food temperatures of served foods, and the required dishwasher sanitation levels. As a result of these failures, a serious potential of adverse outcome is likely to occur in an outbreak of foodborne pathogen illness when undated/ outdated food, observed on the initial kitchen tour on 4/23/23, and the facility was preparing the pork roast to be served for the noon meal on 4/23/23. These failures have the potential to affect all 55 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/25/2023, the facility remains out of compliance at a Severity Level 2, as the facility implements the following: The facility Dietary Manager needs to be re-educated on cooling of cooked potentially hazardous foods. All facility Dietary Staff need to be educated on the process to follow when cooling down cooked foods to prevent the growth of pathogens A process to ensure facility Cool Down Logs for dietary staff to use are readily available. A Quality Assurance Plan needs to be developed to monitor Cool Down Logs. All kitchen staff need reeducated on the implementation and use of cool down logs Findings Include: The facility policy, Cooling Foods, dated 4/2017, directs staff, The facility will follow sanitary and acceptable techniques of cooling Potentially Hazardous Foods. The rapid cooling process will reduce the growth of pathogens in the temperature danger zone. Cooked foods are cooled rapidly within 2 hours, from 135 degrees to 70 degrees, and within 4 more hours to the temperature of approximately 41 degrees. The total time for cooling should not exceed 6 hours. Several factors including thickness/density of the food, size of food and storage containers will be considered as they can affect the cool down process. The facility policy, Leftover Food, dated 4/2017, directs staff, The facility will follow safe handling and storage of leftover foods. Leftover foods will be kept out of the temperature danger zone following the cooling process. Foods will be rapidly cooled and documentation of rapid cooling will be maintained. Label leftover foods with the common name, date and time of storage. Items can be stored for up to 7 days and then discarded. The facility policy, Glove Use, dated 4/2017, directs staff, The facility will practice safe food handling and avoid cross contamination through proper use of gloves. Single-use gloves should be used and bare-hand contact must be avoided when handling ready to eat foods. The facility policy, Employee Health and Personal Hygiene, dated 4/2017, directs staff, Food service employees shall maintain good personal hygiene and be free from communicable illnesses and infections while working in the facility. Hair restraints will be worn at all times. The facility policy, Dating and Labeling, dated 4/2017, directs staff, The facility will follow safe handling and storage of potentially hazardous foods. Potentially hazardous foods will be stored, dated and labeled in the refrigerator and held at at 41 degrees for a maximum of 7 days. The (undated) facility policy, General Preparation and Cooking Practices directs staff, The facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. The facility policy, Sanitizing Buckets, dated 4/2017, directs staff, The facility will use sanitizing buckets with wipe cloths to sanitize preparation and food service areas. The facility will follow manufacturer's recommendation on the amount of sanitizing solution to use. Sanitizing concentration will be checked using a test kit. Quaternary Ammonia: 150-200 PPM (Parts Per Million). The facility policy, Storage of Refrigerated/Frozen Foods, dated 4/2017, directs staff, The facility will follow safe handling and storage of refrigerated and frozen foods. Monitoring of food temperatures and functioning of the refrigeration/freezer units will be in place. The facility Week AT A Glance Menu for April 23, 2021 documents for the facility Noon Meal: Garlic Herb Pork Roast, New Potatoes in Jackets, Seasoned [NAME] Beans, Frosted Yellow Cake. On 4/23/23 at 6:53 am, the facility Dishmachine Temperature Log, dated April 2023, documents, Please log wash and rinse temperatures when washing dishes, prior to utilizing the dishmachine to ensure that the wash and rinse temperatures are properly monitored and controlled. No breakfast, lunch or supper wash or rinse temperatures are documented after 4/21/23. At that time, V30/Dietary Aid verified the missing documentation. On 4/23/23 at 6:53 am, the facility Dish Machine PPM (Parts Per Million) Log, dated April 2023, does not contain documentation the facility dish machine was checked on 4/15/23 for the Noon Meal and Dinner Meal, or on 4/16/23 for the Breakfast Meal, Noon Meal, or Dinner Meal. On 4/23/23 at 6:53 am, the facility Dietary Department Temperature Log, dated April 2023, does contain documentation the facility kitchen refrigerator, storage room refrigerator, dining room refrigerator, freezer and milk cooler on 4/22/23 was checked. V31/Dietary Aid verified the missing documentation. At that time V30/Dietary Aid stated, Sometimes we forget to do the logs and fill them in when we remember. On 4/23/23 at 5:53 am, V29/Cook and V30/Dietary Aid were present in the facility kitchen. V30, Cook, was placing cooked sausage in the facility blender with ungloved hands. V30/Dietary Aid was washing dishes with the facility dishmachine. V30 had no hair restraint covering her hair. On 4/23/23 at 6:00 am, an observation of the facility refrigerator in the kitchen contained: undated, cooked sausage patties in a plastic bag, a 5# container of Low Fat Cottage Cheese, 2/3/full with an outdate of 4/19/23, a 5 X & metal container of undated cooked ground meat and a 10-12 # undated, cooked pork roast, covered in foil. At that time, V30/Cook verified the presence of the out-dated and undated food and the pork roast. At that time, V30/Cook stated, I cooked it yesterday (4/22/23)afternoon. I am serving it for lunch today. I don't have a cool- down log. I have never seen a cool down log. No completed Food Temperature Log for facility served food, after 4/20/23, was available. On 4/23/23 at 7:34 am, the filled kitchen cleaning bucket, located on the countertop, was checked for the required solution with V4/Dietary Services Manager. The Quandary Ammonia solution did not register on the test strip. (Normal: 200 PPM). At that time, V4/Dietary Services Manager verified the test result, and disposed of the cleaning solution. On 4/23/23 at 7:35 am, V4/DSM verified the undated, cooked pork roast in the facility kitchen refrigerator, and also verified no cool down log for the cooked pork roast was available or completed. At that time, V4/ DSM stated the cool down logs were printed from her computer, if, and when they were needed. V4/DSM also stated she is the only Dietary staff member who has access to print the cool down logs. At that time, V4/DSM was unable to produce any cool down logs for prior use, in the past year. V4/DSM stated, We never use them (cool down logs) because we don't cook food ahead of time. We cook it the day it is to be served. On 4/23/23 at 9:30 am, the undated, improperly cooled pork roast was cooking in the facility oven. At that time, V29/Cook stated, I'm reheating the pork roast to serve for lunch today. On 4/23/23 at 11:15 am, V29/Cook stated, The pork roast is still heating up. The ground pork roast is in the steam table. On 4/23/23 at 11:18 am, surveyor notified V4/Dietary Services Manager the facility was unable to serve the undated, improperly cooled pork roast to the facility residents for the meal. At that time, V4/DSM stated, Why can't we serve the pork roast? At that time, it was explained again, the pork roast was improperly cooled down on 4/22/23. On 4/24/23 at 11:59 am, V31/Cook stated, I removed the pork roast from the oven around 2:00 P.M. (4/22/23) and placed it on top of the stove to cool. I placed it in the refrigerator at 7:00 P.M. At that same time, V31/Cook stated she did not use a cool down log during the time the pork roast sat on the stove top until she placed it in the refrigerator, nor did she check the temperature of the pork roast at any time. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated 4/24/23 and signed by V9/Minimum Data Set Assessment Coordinator, documents 55 residents currently reside in the facility. The Immediate Jeopardy began on 4/22/23 at 2:00 pm, when V31/Cook removed the pork roast from the oven, placed it on top of the stove, and failed to monitor the temperature of the pork roast during the required time/temperature cool down process. V1/Administrator was notified of the Immediate Jeopardy on 4/25/23 at 11:50 A.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: All residents have the potential to be affected by the alleged deficient practice. The Dietician re-educated the Dietary Manager and all Dietary staff on 4/25/23 on the process to follow when cooling down cooked foods to prevent the growth of pathogens and proper documentation on the cool down logs. A initial audit was done on 4/25/23 on the logs and outdated food. Outdated food was removed on 4-23-23. The Dietician in-serviced the Dietary Manager on 4-25-23 on having cool down logs readily available/accessible at all times for dietary staff in the kitchen. Additionally, the Dietician in-serviced the Dietary Manager on 4-25-23 and all dietary staff were in-serviced on 4-25-23 on the following: 1) Wearing proper personal protective equipment during food preparation and sanitation of resident utensils 2) Dating cooked food items to ensure use before expiration and checking daily and discarding expired food, 3) Recording refrigerator, freezer and milk cooler temperatures, 4) Taking and recording food temperatures of foods being served 5) Understanding the required dishwasher sanitation levels and corresponding documentation. Compliance related to this plan will be conducted by the Administrator/dietician/designee 7 days per week. This monitoring will include weekend days. Afterwards, this monitoring will continue 3 days weekly for a period of not less than 3 months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be addressed if found. A member of the Regional Team, (RDO/RNC), will review the audits weekly x 4 weeks for additional oversight to ensure that any needed follow up occurred. Any concerns will be addressed if found. Any Dietary staff who fail to comply with the aforementioned in-servicing will be further educated and/or progressively disciplined as indicated. No staff will work in the Dietary department after April 25, 2023, unless they have been in-serviced. This includes newly hired staff. This education will be conducted by the Dietary Manager/Dietician/ designee. All monitoring done by facility staff as well as by Regional Team staff (RDO/RNC) will be presented to the QAPI Committee at their weekly meetings. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any Action Plan will be monitored weekly by the Administrator until resolved. A member of the Regional Team, (RDO/RNC), will attend the QAPI meetings either in person or remotely for a period of not less than 3 months to serve as additional oversight, reference and support. Note: When the facility is placed back into substantial compliance, QAPI meetings will go to monthly. An Ad-Hoc QAPI meeting was held for the IDT on April 25, 2023, conducted by the Administrator, with input from the Regional Team, (RDO/RNC), to discuss the points of this allegation of compliance.

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure staff were sitting down with residents when assisting with feeding in a dignified manner for one resident (R11) of 14 ...

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Based on observation, interview, and record review, the facility failed to ensure staff were sitting down with residents when assisting with feeding in a dignified manner for one resident (R11) of 14 residents reviewed for dining in a sample of 29. Findings include: The facility's Dignity policy, undated, documents Dining: 9.) Staff will not 'stand' to feed a resident. (Unless there is no other option and this is documented and care planned, such as at the bedside.) R11's Minimum Data Set/MDS assessment, dated 2-14-23, documents R11 is cognitively intact, requires extensive assist with one person for eating, and has the following diagnoses: Traumatic Spinal Cord Dysfunction, Quadriplegia, and Muscle Wasting and Atrophy. On 4/23/23, at 7:55am in one of the facility's dining rooms, R11 sat in a reclining chair situated close to a dining room table. At this time, V8, Certified Nursing Assistant/CNA, stood up in between the table and the side of R11's chair, and spoon fed R11 hot cereal. On 4/23/23, at 11:55am, R11 stated R11 doesn't like that they stand up. R11 stated, They do it all the time. On 4/23/23, at 1:46pm, V8, Certified Nursing Assistant/CNA, stated, Am I not supposed to stand? On 4/27/23, at 12:05pm, V2, Director of Nursing/DON, stated V2 expects staff to sit next to the resident when assisting them to eat.

CONCERN (D)

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, facility staff failed to report an allegation of abuse to the facility Abuse Coordinator for one resident (R42) of three residents, reviewed for abuse, in a sampl...

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Based on interview and record review, facility staff failed to report an allegation of abuse to the facility Abuse Coordinator for one resident (R42) of three residents, reviewed for abuse, in a sample of 29 . FINDINGS INCLUDE: The facility policy, Abuse Prevention Program, dated (revised) 01/2019, directs staff, It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or an allegation of suspected abuse or neglect of a resident by a third party. Employees are required to immediately report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or a crime against a resident they observe, hear about, or suspect, to the Administrator if available, or an immediate supervisor, who must immediately report it to the Administrator. All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse to the Administrator. R42's Psychology Services Behavior Note, dated 4/14/2023 by V17/Licensed Clinical Social Worker, documents, (R42) was alert and engaged in session today. (R42) was very sad today. I asked (R42) what was wrong but (R42) just shook her head. (R42's) roommate told me that one of the staff had yelled at (R42) this morning because (R42)hadn't eaten much off her (breakfast) tray. (R42) stated that she is trying, but it is hard for her to eat much. (R42) stated that she doesn't like to get yelled at. On 4/24/23 at 1:23 pm, V1/Administrator stated, (V17) did not report an allegation of abuse for (R42). I didn't know anything about it. I have not started an investigation.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

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 include smoking care on resident's care plan for one (R27) of two 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 include smoking care on resident's care plan for one (R27) of two residents reviewed for care plans in the sample of 29. Findings include: The facility's Policy and Procedure of Comprehensive Care Plans, Undated, documents: Comprehensive Care Plan will be developed for each resident that include: Problem/need of the resident, measurable objectives and interventions to meet the resident's medical, nursing and mental and psychosocial needs. The facility's Smoking Policy, dated 9/26/19, documents: 5.A. The smoking Assessment will be done by the Social Services Designee with input from the (Interdisciplinary Team) as a care plan will need to be developed that addresses: 1. Significant findings on the Smoking Assessment; 2. Degree of supervision needed for safety; 3. Type of protective equipment needed, if any; 4. Education on Smoking Policy and the opportunity to express desire for cessation of smoking. The care plan will be reviewed quarterly and as needed. R27 was admitted to the facility on [DATE]; the facility's 'Residents That Smoke Log', undated, documents R27 as a smoker. There was no smoking evaluation for R27 documented in the facility's Electronic Health Record. R27's current care plan does not include any focus, goals, or interventions for smoking. On 4/25/23 at 3:05 pm, V5, Social Services Director, stated R27 is a smoker; stated since R27 does smoke, smoking should have been addressed on R27's care plan. At this time V5 stated, If smoking, smoking should be listed on smokers' care plans; smoking was not included on (R27's) care plan prior to today, but I just added it. When I get a list of smokers, I put the info in the care plans; I don't know how this was missed; can't figure out why it's not there; but I did type the info on smoking on his care plan today.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed ensure a recommended splint for contractures was applied for one (R11) of one resident reviewed for limited range of motion in a...

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Based on observation, interview, and record review, the facility failed ensure a recommended splint for contractures was applied for one (R11) of one resident reviewed for limited range of motion in a sample of 29. Findings include: The facility's Range of Motion (ROM) and Splint Policy and Procedure, dated 2/20/15, documents Policy: The Restorative Nurse and/or Nurse Designee will complete a ROM (Range of Motion) risk assessment for all residents that are admitted to the facility to determine if they have any ROM deficits and/or are at risk for development of a reduction in their ROM will be placed in appropriate ROM programming (AROM - Active ROM, AAROM - Active Assisted ROM, or PROM - Passive ROM) to increase ROM and/or to prevent further decrease in their ROM status. The Restorative Nurse and/or Nurse Designee will consult with the Skilled Therapy Department for residents that ay benefit from a splint application .Procedure for Splints: 3. Any resident assessed to have an impaired ROM and/or Loss of Functional Movement and the Restorative Nurse determines that they may be appropriate for splint application will make a referral to the Skilled Therapy Manager for further assessment/evaluation. 4. Once the resident has been evaluated by the Skilled Therapist and facility has recommendations for the split; the Restorative Nurse and Skilled Therapist will select an appropriate splint and order per the current vendor. 5. The Restorative Nurse will write the order for the splint on the POS (Physician Order Sheet). R11's Minimum Data Set/MDS assessment, dated 2-14-23, documents R11 has diagnoses of Traumatic Spinal Cord dysfunction and Quadriplegia with functional limitation in ROM on both left and right sides of upper and lower extremities. This same assessment also documents R11 has contractures to R11's right and left knees. On 4/23/23, at 11:30 am, R11 is in a reclining chair in R11's room. R11 stated, They do not put that purple brace on (R11's) knee because they do not know how. Therapy says I am supposed to have it on. It is right there on the table. At this time, a terrycloth brace/splint was noted on R11's bedside table. On 4/23/23, at 1:46 pm, V8, Certified Nursing Assistant/CNA, stated V8 does not put the brace on R11 because (R11) doesn't like how we put it on. (V10, Restorative CNA) is supposed to show us how to put it on how (R11) likes it, but (V10) hasn't yet. On 4/23/23, at 1:48 pm, V27, CNA, stated, (R11) does not like how we put it on, and V27 doesn't feel comfortable putting the brace on R11. On 4/24/23, at 1:45 pm, R11 is in a reclining chair in R11's room, with no brace on either of R11's knees. On 4/24/23, at 2:25 pm, V10, Restorative CNA, stated that following: The last time I put (R11's) brace on was maybe last Friday. I haven't been able to put it on every day because sometimes I work the floor and don't have time. I do not work weekends. I have not had time to show any CNAs how I put it on. On 4/26/23, between 8:25am and 11:37am, V2, Director of Nursing/DON, stated the following: (R11's) brace was recommended by OT (Occupational Therapy). Someone must have told me in a morning meeting, so I ordered it that day (2-8-23). Then (V9 Restorative Nurse) would put an order in. The brace is to help stretch out (R11's) contractures. The order is usually put in by therapy or (V9). (V9) should have put the order in. (V10, Restorative CNA) would be the one to put it on R11's knee Monday through Friday, and other CNAs could on the weekends. V2 cannot verify whether or not the brace has been applied to R11's knee since it arrived in (February 2023). On 4/26/23, at 3:30 pm, V9, Restorative CNA, stated, (R11) had said that (V30, Occupational Therapist/OT) mentioned a brace, so I asked (V30) about it. (V30) thought it would be beneficial. (V30) and I found a brace (in an order catalog), circled it with R's initials to be ordered, and stuck it in (V2, DON's) box. On 4/26/23, at 8:30am, V2 DON produced the facility's Purchase form for R11. This form is dated 2/8/23 and documents that a Goniometer knee orthoses splint was ordered. This form states allows ROM or set to static position. R11's Restorative Nursing Assessment, dated 2-14-23, and signed by V9, Restorative Nurse, does not document any brace/splint to be used for R11. On 4/26/23, at 10:29 am, V9, Restorative Nurse, stated V9 learned about R11's splint two weeks ago. At that time, V9 did not see an order put in by therapy for it. V9 did not put an order in. On 4/26/23, at 3:35 pm, V13, Physical Therapy Assistant/PTA, stated, The brace may have been mentioned during a screening back in January. (V11) had said that (V11) didn't like her knee being so contracted that it was causing her foot to touch her butt. We thought this might help stretch it out, so that wouldn't happen. On 4/26/23, at 3:44 pm, V30 stated V30 could not recall anything about a splint for R11, but is aware R11 has contractures and has worked with R11.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility staff failed to change gloves, use a clean cloth, and perform hand hygiene during incontinence care for one of one (R11) residents revi...

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Based on observation, interview, and record review, the facility staff failed to change gloves, use a clean cloth, and perform hand hygiene during incontinence care for one of one (R11) residents reviewed for incontinence in a sample of 29. Findings include: The facility's Using Gloves policy, undated, documents Policy: It is the policy of this facility that gloves are used as appropriate following Standard and Transmission Based Precautions to prevent the spread of infection .II. Miscellaneous: F. Use of alcohol based hand rub is recommended prior to application of gloves. Perform hand hygiene after removing gloves; alcohol based hand rub may be used as appropriate. The facility's Incontinence Care policy, undated, Policy: It is the policy of the facility to ensure that resident's receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with routine daily care .Procedure: 12. Cleanse peri-area and buttocks with cleansing agent wiping from front of perineum toward rectum. Use separate area of cloth for each stroke .16. Remove and discard gloves. 17. Perform hand hygiene. The Certified Nursing Assistant/Special Care Unit Job Description, undated, documents Role Responsibilities - Infection Control & Sanitation: 11. Ensures that established infection control and standard precaution practices are maintained when performing nursing procedures. R11's current Physician Order Sheet documents R11 has diagnoses including Quadriplegia and Neuromuscular Dysfunction of Bladder. R11's Minimum Data Set/MDS assessment, dated 2-14-23, documents R11 requires extensive assist with two persons for toileting and is always incontinent of urine. On 4/23/23 at 12:02 pm, V8 and V27, Certified Nursing Assistants/CNAs, assisted R11 into R11's bed to perform incontinence care. With V27 assisting, V8 lowered and removed R11's urine saturated incontinence brief. With the same soiled gloves, V8 cleansed R11's perineal area, then wiped R11's buttocks, including over a reddened area noted. With the same soiled gloves, V8 applied barrier cream to R11's reddened area, placed a clean incontinence brief on R11, then pulled up R11's pants. V8 removed gloves, and did not perform hand hygiene after removing V8's gloves or prior to leaving R11's room. On 4/23/23, at 12:17pm, V8, CNA, stated V8 should have changed her gloves when going from dirty to clean, and should have hand sanitized before leaving the room. V8 stated V8 did not use a clean cleansing cloth or a new area of the cloth during incontinence care, and should have, especially before applying barrier cream to a reddened area. On 4/27/23, at 12:02pm, V2, Director of Nursing/ DON stated, During incontinence care, staff should change gloves when going from dirty to clean, perform hand hygiene after removing gloves and prior to exiting resident's room. Staff should use a new cloth or a new area of the cloth when cleansing during incontinence care and when cleansing over reddened areas on buttocks.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to obtain the required weekly weights for one of one resident (R42) reviewed for feeding tubes in a sample of 29. Findings include: The facili...

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Based on interview and record review, the facility failed to obtain the required weekly weights for one of one resident (R42) reviewed for feeding tubes in a sample of 29. Findings include: The facility policy, Weights, dated 4/2017, directs staff, The facility will have a systemic and interdisciplinary approach for obtaining and monitororing weights. Weights will be obtained upon admission, readmission to facility, then weekly X 4 weeks, then monthly unless ordered. R42's current Physician Order Sheet (April 2023) documents R42's current diagnoses as: Adult Failure to Thrive, Dysphagia and Gastrostomy Tube. This same document includes the following physician orders: (Promote with Fiber) at (95) ML/HR (Milliliters/Hour) for 10 hours daily. R42's Dietary Progress Note, dated 8/24/22 and signed by V18/Registered Dietician, documents, Will continue TF (Tube Feeding) regime due to recent weight loss. Weekly weights. Staff to monitor weights. R42's facility Weight Summary, dated 7/19/22 through 4/24/23, documents R42's weight weekly was not obtained as required the week of August 8, 2022; October 31, 2022; November 14, 2023; April 10, 2023; and April 17, 2023. On 4/26/23 at 9:37 am., V18/Registered Dietician stated, Residents that receive tube feedings are expected to be weighed weekly by staff. I specifically recommended (R42) be weighed weekly due to her history of weight loss.

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 ensure resident assessment was completed pre and post...

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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 resident assessment was completed pre and post nebulizer treatment for one (R2) of one resident reviewed for respiratory in a sample of 14. Findings include: The facility's policy Administering Nebulizer Therapy, undated, documents Purpose: To provide accurate and safe administration of medications requiring nebulization to residents .Procedure: 5. The nurse will obtain pre-treatment lung sounds, pre-treatment pulse rate and pre-treatment respiration rate .8. The nurse will obtain post-treatment lung sounds, post-treatment [NAME] rate and post-treatment respiratory rate. R2's current Physician Order Sheet/POS documents an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligrams)/3ml (millimeters) - 3ml inhale orally four times a day related to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. On 4/25/23, at 11:25 am, R2 was in bed with oxygen infusing per nasal cannula. At this time, V7, Licensed Practical Nurse/LPN, administered a nebulizer treatment with Ipratropium-Albuterol for R2. V7, LPN, did not auscultate R2's lungs or check R2's pulse or respirations prior to the nebulizer treatment. R2 was coughing intermittently during the treatment. On 4/25/23, at 11:35 am, R2's treatment ended. V7 shut off the machine, put R2's mask in a plastic bag, and left R2's room. V7 did not auscultate R2's lungs or check R2's pulse or respirations after this treatment. On 4/25/23, at 2:30 pm, V7 confirmed ]V7 did not listen to R2's lungs and did not check R2's pulse or respirations prior to or after R2's nebulizer treatment. V7 stated, I didn't know I was supposed to. On 4/26/23, at 8:20 am, V2, Director of Nursing/DON, stated V7 should have auscultated R2's lungs, checked R2's pulse, and counted R2's respirations before and after R2's nebulizer treatment.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R26's Psychotropic Consents for the administration of Buspirone 15mg (milligrams) TID (three times per day) for Anxiety and f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R26's Psychotropic Consents for the administration of Buspirone 15mg (milligrams) TID (three times per day) for Anxiety and for Aripiprazole 5mg daily for Schizoaffective Disorder are undated. R26's current clinical record does not include any Psychotropic Drug Reviews since 7/12/22. On 4/27/23, at 12:00 pm, V2 Director of Nursing/DON stated, Psychotropic assessments are to be done every three months, and I am responsible for them. V2 verified at this time, R26 has not had an assessment done since 7/12/22, and should have. V2 also stated R26's consents are not dated, and should have been. Based on observation, record review and interview, the facility failed to complete psychotropic assessments quarterly, failed to complete the required Abnormal Involuntary Movement Scales (AIMS), failed to complete consents with dates, and failed to attempt a gradual dose reduction to warrant the use of psychotropic medications for two (R10, R11) of five residents reviewed for psychotropic medications, in a sample of 29. Findings Include: The (undated) facility policy, Psychotropic Drugs Usage, directs staff, If psychotropic drug therapy is required, the physician, facility staff and pharmacist will assist in choosing the most effective medication for the resident that has the fewest possible side effects, adverse drug reactions and in the smallest effective dose. Based on a comprehensive assessment and only if necessary to treat a specific condition, the resident may be ordered a psychotropic drug. The assessment of side effects for residents receiving antipathetic therapy includes the AIMS test, to be completed every 6 months. Any resident receiving psychotropic medications will have a signed informed consent for the use of the medication. 1.) R10's current Physician Order Sheet documents R10 was admitted to the facility on [DATE] with the following diagnoses: Schizoaffective Disorder, Psychosis. This same document includes the following medications ordered on 4/20/22: Abilify (Antipsychotic) 2 MG (Milligrams) take 1 tablet by mouth one time a day. A review of R10's electronic medical record shows no psychotropic assessment, no AIMS testing, and no gradual dose reduction attempts. On 4/23/23 at 7:00 am, R10 was seated in a wheelchair in his room, feeding himself breakfast. R10 was alert, oriented, and talkative. No behaviors noted. On 4/24/23 at 11:30 am, R10 was seated in a wheelchair in the facility Main Dining Room participating in a Resident Council meeting. R10 was cooperative and polite. No behaviors were noted. On 4/26/23 at 8:50 am, R10 was seated in his room, watching television. R10 was alert, oriented and cooperative. On 4/27/23 at 9:41 am, V2/Director of Nurses (DON) stated, I don't have any psychotropic assessments for (R10). The only AIMS I have for (R10) is one that was done yesterday. (R10) has no attempted GDRs (Gradual Dose Reductions).

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 store medications according to the facility policy for one resident (R11) of 14 residents reviewed for medication storage in ...

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Based on observation, interview, and record review, the facility failed to store medications according to the facility policy for one resident (R11) of 14 residents reviewed for medication storage in a sample of 29. Findings include: The facility's policy Medication Storage in the Facility, undated, documents Policy: Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations .11. Medications requiring 'refrigeration' or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator. Medications requiring storage 'in a cool place' are refrigerated unless otherwise directed on the label. On 4/25/23, at 8:30 am during medication administration with V7, Licensed Practical Nurse/LPN, the facility's A/B medication cart contained R39's unopened vial of Humulin-R Solution 100 units/ml (millimeter). This vial's pharmacy label included R39's name, and date of received on 4/20/23. On 4/25/23 at 8:35am, V7, LPN, stated R39's insulin should have been put in the refrigerator when received from the pharmacy on 4/20/23. V7 stated, They must not have. On 4/25/23, at 2:57 pm, V2, Director of Nursing/DON, stated, When insulin comes from the pharmacy it should be refrigerated until use. At that time, it would be dated and put in the drawer for 30 days.

CONCERN (E)

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to provide snacks between meals and at bedtime for 21 of 29 residents (R2, R3, R5-9, R11, R15, R16, R19, R22, R26, R27, R33, R38, R42, R54, R5...

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Based on interview and record review, the facility failed to provide snacks between meals and at bedtime for 21 of 29 residents (R2, R3, R5-9, R11, R15, R16, R19, R22, R26, R27, R33, R38, R42, R54, R56, R57, R60, R61 residents reviewed for evening snack offerings in the sample of 29. Findings include: The facility policy, Snacks, dated 04/2017, directs staff, Snacks are available to residents to offer nourishment between meals. The Food and Nutrition Department will send snacks to the nursing stations between meals and at bedtime. The Certified Nursing Assistant Job Description documents, Role Responsibilities: Serves between meal and bedtime snacks. On 4/24/23 at 11:20 am, during the survey Group Meeting, R6 stated, We don't get any bedtime snacks. Only diabetic (residents) do. A list of residents that currently receive bedtime snacks, provided by V19/Dietary Services Manager (DSM), includes the following residents (R1, R10, R14, R18, R20, R31, R39, R46, R52, R56 and R59). At that same time, V4/DSM stated, Only diabetic (residents) and residents who are being monitored for weight loss, get a snack, at bedtime. The kitchen doesn't send out snacks at any other time.

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, record review, and interview, the facility failed to recognize and implement the need for proper PPE (Personal Protective Equipment) and isolation for one resident (R54) that was...

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Based on observation, record review, and interview, the facility failed to recognize and implement the need for proper PPE (Personal Protective Equipment) and isolation for one resident (R54) that was positive for(C-Diff) Clostridium Difficile, failed to provide an isolation set-up for disposing of contaminated linens, failed to have the required PPE readily available for staff, failed to don/doff proper PPE and maintain hand hygiene/glove changes, failed to post isolation precaution signage to designate the proper isolation precautions for (R54) on isolation, and failed to use the required disinfectant to clean and sanitize a resident's room who is positive for C-Diff. These failures have the potential to affect all 55 residents currently resident in the facility. Findings Include: The facility policy, named Contact Precautions, dated 7/10/2018, documents, Purpose: To prevent the spread of infection within the facility using contact precautions. Policy: it is the policy of the facility to use contact precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment. B.) Gloves and hand hygiene. Gloves should be worn when entering the room and while providing care for the resident.) Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. E.) Hands should not touch potentially contaminated environmental surfaces or items in the resident's room. Contact Precaution may be considered for Clostridium Difficile. The facility policy named, Infectious Area Cleaning Policies and Procedures Daily Cleaning, documents, Note for Viruses: 1.) For a unit of a Closterium Difficile, use bleach wipes, with a dwell time of 10 minutes for C-Diff. to be left on the surface. On 4/23/2023 at 6:30 am, a tour of D Hall was conducted. R54 had signage on the door that said, Please see nurse at the nurses station. That was the only signage on the door. There was a plastic bin with 3 drawers right outside of R54's room that contained a few rolls of what looked to be plastic bags; no gloves were in the container or on top. Across from the container catty cornered, approximately 6 feet away, there was a metal bracket hanging from the wall with a box of gloves in the bracket. On 4/23/2023 at 9 am, V10/CNA (Certified Nursing Assistant) and V20/CNA were observed during the first day of the survey entering the infected resident's room without donning the required PPE (Personal Protective Equipment). V20 stated they were unsure of what type of isolation R54 was in. On 4/23/2023 at 1:00 pm on D hall, no bins were observed in R54s room, and no signage was on the door to indicate what type of PPE is expected to be worn. On 4/24/2023 at 12:00 pm, an observation was done on D hall. The signage on (R54's) door remained the same. The 3-draw container remained outside the door, with rolls of plastic bags in it. 4/24/2023 at 3:15 pm, V2/DON entered the isolation room of the infected resident, without donning any PPE when entering the room. There was a small 3 drawer container outside R54's room, which contained plastic bags in it. V2 verified the 3-drawer container does not have all the PPE in it that is to be used for this infected resident. V2 also verified the gloves were not in the drawer, but the gloves were located across the hall in a metal bracket hanging on the wall. V2/DON proceeded to enter the infected resident's room to check for the isolation bins. No bins were in the room. V2 left the room without washing her hands, after touching the doorknob of bathroom and the doorknob of the entry door. On 4/24/2023 at 3:25 pm, V3/ADON (Assistance Director of Nurses stated, (V2/DON) said to tell you that the isolation bins for (R54) isolation were in the closet of his room. There is just one isolation bin in the room and that is for paper products. The CNA's (Certified Nursing Assistant) carry plastic bags in their pockets and that is what they use for the soiled linens. On 4/25/2023 at 10:15 am, V3 stated, I didn't mean to tell you that (R54's) isolation bins were in (R54's) closet. I meant the isolation bins are kept in the closet on D hall. On 4/25/2023 at 10:40 am, R54 stated, I have not seen that container in this room since I have been in this facility. This container they just put in the room late last night. Most of the staff that come in here do not wear gloves unless they are taking care of my colostomy bag or catheter. When the CNAs are changing my bed, they do not use gloves. My girlfriend changes my clothes and colostomy at times. No, she has not been trained to change the ostomy bag or empty the urine bag. On 4/25/2023 at 1:00 pm, V10/CNA (Certified Nursing Assistant) stated, I only work on (R54's) hall occasionally. (R54) has MRSA (Methicillin Resistant Staph Aureus) in his urine; gloves are to be worn. On 4/25/2023 at 11:30 am, V23/LPN (Licensed Practical Nurse) stated, I am not sure what type of isolation (R54) is in. I can look it up for you and let you know. On 4/26/2923 at 11:45 am, V24/CNA stated, I don't use any kind of PPE (Personal Protective Equipment) when taking care of (R54). No one informed me I had to. On 4/25/2023 at 9:30 am, V21/Laundry Aide stated, I do not know if (R54) is in isolation. Nobody tells us anything. We are washing his clothes with all the other resident's clothes. I have not seen any red isolation bags come through the laundry at any time. On 4/25/2023 at 9:35 am, V22/Laundry Aide stated, I don't know of anyone that is in isolation at this time. On 4/25/2023 at 9:40 am, V20/Laundry/Housekeeping Supervisor, stated, We have not been informed that there is anybody in isolation at this time. Any linens that come from an isolation room get washed with the regular clothes. They do not get washed separately. But I don't know of anyone that is in isolation currently. The water temperature in the washer gets 150 degree or higher, this will kill the organisms in the linens. If the high temp doesn't kill them, the dryer will. On 4/25/2023 at 11:55 am, V14/CNA stated, I do not use PPE when I am working with (R54). If I empty (R54's) urine bag I will use gloves, but I don't otherwise. On 4/25/2023 at 3:30 pm, V25/ Housekeeper stated, The isolation rooms are cleaned daily. They don't tell us anything about a resident being on isolation. I just try to look at the sign on the door, then I go ask a nurse. We use 2 special disinfectant cleaners to clean the rooms and the bathrooms. It doesn't look like either disinfectant have bleach in them. I don't have any bleach wipes. On 4/25/2023 at 10:45 am, V26/R54's Girlfriend stated, The facility does (R54's) laundry, occasionally I may take it home to wash it. I am here every day and some nights I spend the night. I don't see too many people using gowns or gloves unless they empty his urine bag. R54's Hospital After Visit Summary, dated 3/30/2023, documents, Vancomycin 125MG (Milligram) caps start 3/31/2023. Take one capsule by mouth for 30days. Indication: Clostridium Difficile Infection. R54's Lab Results from the local hospital, dated 2/24/2023, documents, C Diff Toxin B DNA obtained from stool. Results are positive for Clostridium Difficile. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated 4/24/23 and signed by V9/Minimum Data Set Assessment Coordinator, documents 55 residents currently reside in the facility.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

Based on observation and interview, the facility failed to post the most recent survey results in a place accessible to all residents. This failure has the potential to affect all 55 residents residin...

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Based on observation and interview, the facility failed to post the most recent survey results in a place accessible to all residents. This failure has the potential to affect all 55 residents residing in the facility. Findings include: On 04/24/23 at 11:20 am, during the survey Group Meeting, R6 stated she did not know where the facility survey book was located. R6 stated no one had ever made her aware the facility had a survey book. All other residents present at the Meeting agreed they were unaware of the location of the survey book. On 04/24/23 at 1: 20 pm, V1/Administrator stated the facility survey book was located behind the facility receptionist desk. At that time, an unidentified black binder was observed behind the receptionist desk. V1/Administrator verified facility residents and visitors would be unable to identify or reach the survey book in its present location. The facility Resident Census and Conditions Report for Medicare and Medicaid Services (CMS), dated 4/24/23, and signed by V9/Minimum Data Set Assessment Coordinator, documents 55 residents currently reside in the facility.

Mar 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

Pharmacy Services (Tag F0755)

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 administer physician ordered medications as prescribe...

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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 administer physician ordered medications as prescribed for one of three residents (R1) reviewed for medication administration, in a sample of three. Findings Include: The (undated) facility policy, Ordering Medications (Electronic) directs staff, Medications and related products are ordered from (Pharmacy) on a timely basis. Narcotics are ordered from the pharmacy after the pharmacy has received a valid prescription from the prescriber. Reorders are initiated within the electronic medical record system as follows: Reorder medication three days in advance of need to assure an adequate supply is on hand. R1's Facility Transfer Form documents R1 was admitted to the facility on [DATE], with the following diagnoses: Pain related to: Arthropathy, CKD (Chronic Kidney Disease), Dorsalgia, Cervical Spondylosis, Peptic Ulcer, Diverticulosis and Shoulder pain. This same form includes the following medications: Acetaminophen Tablet Give 325 MG (Milligrams) by mouth three times a day for pain; Acetaminophen Tablet Give 325 MG 2 tablets by mouth every 8 hours as needed for pain; Oxycodone 5 MG by mouth three times a day for chronic pain every 8 hours; Fentanyl Patch 12 MCG/HR (Micrograms/Hour) Apply 1 patch transdermally every 72 hours related to pain in shoulder. R1's Pain Management Assessment, dated 01/02/2023, documents, Pain Management: (R1) received a scheduled pain medication regimen, PRN (As needed) pain medications and non-medication interventions for pain, in the past 5 days. Pain Management Recommendations: Continue with current plan of care. R1's Medication Administration Record, dated January 2023, documents R1 received Fentanyl Patch 12 MCG/HR on 1/28/23 at 4:15 A.M. The scheduled dose of Fentanyl due on 1/31/23, 2/3/23 and 2/6/23 were not administered to R1. The next administered dose of R1's pain medication was administered on 2/7/23 at 5:40 A.M. R1's Medication Administration Record, dated February 2023, documents R1 received Fentanyl Patch 12 MCG/HR on 2/17/23 at 5:15 A.M. The scheduled dose of Fentanyl due on 2/20/23 and 2/23/23 were not administered to R1. The next administered dose of R1's pain medication was administered on 2/26/23 at 4:56 A.M. R1's Nursing Progress Notes, dated 1/31/23, 2/3/23, 2/6/23, 2/20/23 and 2/23/23, document, Fentanyl 1 patch transdermally every 72 hours related to pain in shoulder. Awaiting RX (prescription), need new prescription. On 3/20/23 at 10:20 A.M., V2/Director of Nursing (DON), stated, When a resident is admitted to our facility and they have a physician's order for a narcotic, they also have to have a signed prescription form. The orders are only good for 30 days and the prescription gets faxed to the pharmacy. I know we had problems with (R1) receiving her pain patches. We ran into problems with obtaining a signed prescription from R1's physician. At that time, V2/DON verified R1 did not receive the prescribed Fentanyl patch from January 31, 2023, until February 7, 2023, and again from February 20,2023 until February 26, 2023.

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