Does Lenox Care Center have any serious inspection findings?

Yes, Lenox Care Center has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 47 total deficiencies from recent inspections.

What are the staffing levels at Lenox Care Center?

Lenox Care Center has a one-star staffing rating from CMS with 0.89 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 Lenox Care Center located?

Lenox Care Center is located in LENOX, IA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Lenox Care Center have?

Lenox Care Center has 36 certified beds.

Who owns Lenox Care Center?

Lenox Care Center is a for profit - partnership facility and is part of the ARBORETA HEALTHCARE chain.

What questions should families ask when visiting Lenox Care Center?

Families visiting Lenox Care Center should ask about 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 Lenox Care Center compare to other nursing homes?

Lenox Care Center has a 1-star overall rating, which is below average compared to other nursing homes in IA. Families should carefully review inspection findings and consider alternatives.

Lenox Care Center

Name: Lenox Care Center
Address: 111 EAST VAN BUREN, LENOX, IA, 50851, US
Telephone: (641) 333-2226
Rating: 1.0

111 EAST VAN BUREN, LENOX, IA 50851 · (641) 333-2226

For profit - Partnership 36 Beds ARBORETA HEALTHCARE Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#361 of 392 in IA

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Lenox Care Center nursing home in LENOX, IA - Photo 1 of 3

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Last Inspection: February 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Lenox Care Center has received a Trust Grade of F, indicating significant concerns about its care quality, which places it in the bottom tier of facilities. Ranked #361 out of 392 in Iowa, it is in the bottom half of all nursing homes, and only one other facility in Taylor County is available for comparison. The facility is worsening, with the number of reported issues increasing from 9 in 2024 to 14 in 2025. Staffing is a relative strength, with a turnover rate of 0%, which is much lower than the state average, and the center has good RN coverage, exceeding 96% of other Iowa facilities. However, the facility has incurred fines totaling $40,054, which is concerning and indicates potential compliance issues. Recent critical findings include staff failing to prevent abuse that resulted in mental anguish for residents and not reporting significant accidents, which placed residents in immediate jeopardy. Overall, while there are some strengths in staffing, the facility has serious issues that families should consider carefully.

Trust Score: F
In Iowa: #361/392
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: Turnover data not reported for this facility.
Penalties: $40,054 in fines. Lower than most Iowa facilities. Relatively clean record.
Skilled Nurses: Each resident gets 53 minutes of Registered Nurse (RN) attention daily — more than average for Iowa. RNs are trained to catch health problems early.
Violations: 47 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 9 issues

2025: 14 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Iowa average (3.0)

Significant quality concerns identified by CMS

Federal Fines: $40,054

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: ARBORETA HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 47 deficiencies on record

3 life-threatening 1 actual harm

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Electronic Health Record (EHR) review, resident interview, staff interview, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed follow physician ordered interventions for a resident with no bowel movement for 3 days and 5 days for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 25 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented no Brief Interview for Mental Status (BIMS) indicating Resident #2 was rarely/never understood. The MDS also documented a diagnosis of constipation. The MDS further documented Resident #2 was always incontinent of bowel. Review of Resident #2's EHR titled, Bowel Elimination from 5/21/25 - 6/24/25 documented no bowel movement from 5/24/25 through 5/29/25. The previous bowel movement was recorded on 5/23/25 at 12:15 PM. The next bowel movement was recorded on 5/30/25 at 1:40 PM. No bowel movements were recorded from 6/18/25 - 6/19/25. The previous bowel movement was recorded on 6/17/25 at 9:20 AM. The next bowel movement was recorded 6/20/25 at 1:01 PM. No bowel movements were recorded from 6/21/25 - 6/22/25. The previous bowel movement was recorded on 6/20/25 at 9:59 PM. The next bowel movement was recorded 6/23/25 at 1:59 PM. Review of Resident #2's EHR titled, Orders documented current physician's orders for milk of magnesia suspension 1200 mg/15 mL give 30 mL by mouth as needed for constipation daily. Review of Resident #2's MAR-TAR for the month of May documented milk of magnesia was given as needed on 5/27/25 and 5/30/25. Review of Resident #2's MAR-TAR for the month of June lacked documentation that milk of magnesia was given as needed at all. Review of Resident #2's EHR titled, Care Plan documented interventions initiated 5/22/25 to document bowel movements every shift, follow facility protocol for administration of stool softeners / laxatives / enemas as indicated and observe for s/s of constipation (abdomen distention, nausea / vomiting, anorexia, decreased bowel sounds etc) and report to physician as indicated. Review of Resident #2's EHR titled, Progress Notes documented PRN milk of magnesia was given on 5/27/25 and was ineffective. Progress Notes also documented PRN milk of magnesia was given on 5/30/25 and was effective. On 6/24/25 at 4:38 PM Staff A, Assistant Director of Nursing (ADON) / Social Services stated she spoke to Staff B on 6/24/25 and she said on 5/27/25 Resident #2 had hypoactive bowel sounds. Staff A stated Staff B said the hospice Certified Nursing Assistant (CNA) reported on the 5/28/25 and 5/29/25 Resident #2 was smearing and that was in an email from the CNA to Staff B. Staff A stated Staff B told her that a nurse that worked at the facility gave milk of magnesia on 5/27/25. On 6/25/25 at 12:00 PM Staff B, Registered Nurse (RN) for hospice provider acknowledged Resident #2 was on her caseload. Staff B stated she had Resident #2 scheduled for 3 times a week for nursing visits. Staff B stated the hospice bowel protocol generally started on the 3rd day of no bowel movement. Staff B stated if milk of magnesia had been given and the results were ineffective on day 3 without a BM she would expect that the milk of magnesia would have been given every day after the 3rd day with no bowel movement. Staff B stated she had documented in her notes that milk of magnesia was given on 5/27/25. Staff B stated her hospice Certified Nursing Aide (CNA) reported Resident #2 was smearing BM during the bath on 5/28/25 and again on 5/29/25 but no bowel movement. Staff B stated there was a time where he was not eating much so it would be less of a concern than no bowel movement at all but still remained a concern. Staff B stated she would expect that an assessment would be expected and possibly the milk of magnesia PRN order given until notable BM depending on the assessment results. 2. The MDS dated [DATE] for Resident #3 documented a BIMS of 12 indicating moderate cognitive impairment. The MDS also documented diagnoses of malnutrition, depression, bipolar, and a history of falling. Review of Resident #3's EHR titled, Bowel Elimination from 5/16/25 - 6/23/25 documented no bowel movement from 5/23/25 through 5/25/25. Previous bowel movement recorded on 5/22/25 at 1:59 PM. Next bowel movement recorded on 5/26/25 at 1:08 PM. Review of Resident #3's EHR titled, Orders documented a current physician's order that started 12/16/24 of milk of magnesia 400 mg/5 mL to give 30 mL by mouth every 24 hours as needed for constipation, Miralax powder started 10/11/24 to give 17 grams by mouth every 24 hours as needed for complaints of constipation, bisacodyl rectal suppository 10 mg insert 1 suppository rectally every 24 hours as need for constipation and milk of magnesia to give 30 mL if no BM for 3 days, give bisacodyl suppository if no bowel movement for 4 days, contact PCC if no BM in 5 days as needed for bowel movement function bowel movement protocol for facility. Review of Resident #3's MAR-TAR for the month of May documentation that both orders for milk of magnesia, the order for Miralax and the order for bisacodyl were given on 5/11/25 and 5/26/25 only for the month of May. Review of Resident #3's EHR titled, Progress Notes documented both orders for milk of magnesia, the order for Miralax and the order for bisacodyl were refused. Progress Notes further lacked documentation of any assessment related to constipation. Review of Resident #3's EHR, Assessments, lacked documentation for abdominal assessment or change in condition. Review of Resident #3's EHR titled, Care Plan documented Resident #3 had potential for episodes of bowel obsessions. On 6/25/25 at 11:30 AM Staff C, Registered Nurse (RN) stated if a resident had gone 24 hours without a BM she would typically follow the bowel protocol that starts at 48 hours for milk of magnesia unless there was s/s of constipation. Staff C stated the protocol that starts at 48 hours was the order and that order superseded any 24 hours order unless the resident requested the medication or had s/s of constipation such as abdominal pain or distention. Staff C stated if an as needed medication was given for constipation and was ineffective she would follow the facility's bowel protocol. Staff C stated if the as needed medication for constipation was ineffective an abdominal assessment would be required. Staff C stated she would chart the results of the abdominal assessment in the Progress Notes. Staff C stated the bowel report was being completed every day shift. Staff C stated the report that she was using prior to the system switching over was accurate but now the bowel report that she utilized was not. Staff C stated the report showed people that had a bowel movement that day and also left residents off that had no bowel movement for 3 or 4 days. Staff C stated the facility found a different report to run that was accurate and that was started 6/24/25. On 6/24/25 at 11:15 AM the Director of Nursing (DON) stated the facility does have a protocol. The DON stated the night nurse was doing the resident bowel movement reports and then the nurses were told to run it on every shift by her. The DON stated the resident bowel movement report lets the nurse know which resident had been 3 or more days without a bowel movement. The DON stated the bowel protocol started on the third day of no bowel movement. The DON acknowledged Resident #3 had orders on the MAR-TAR for PRN constipation. The DON stated she would expect the milk of magnesia would have been given daily to Resident #2 if there was no BM in 24 hours and the order read that way. The DON acknowledged Resident #2 had 5 days without a bowel movement. The DON stated a change in condition assessment should have been completed or a Progress Note with bowel sounds or an abdominal assessment should have been completed. The DON stated a change in condition assessment would not be appropriate but a Progress Note with bowel sounds or an abdominal assessment in the Progress Notes because the as needed medication was utilized especially if the medication was ineffective. The DON stated the assessments should have been completed in the Progress Note when an as needed suppository or milk of magnesia related to constipation was given. On 6/24/25 at 4:23 PM the DON acknowledged the bowel report was not working appropriately. The DON stated there was a concern with the bowel report because the nursing staff had to select the exact right report or the report does not report anybody. The DON explained there were several options for bowel reports to be run. The DON acknowledged the facility noted the report was a problem on 6/24/25. On 6/25/25 at 1:00 PM the Administrator stated Resident #2 was in hospice and intake was very poor some days. The Administrator stated Resident #2 did not eat in the hospital prior to admission for a couple of weeks. The Administrator stated they did not have a bowel protocol policy. The Administrator stated the nurses are to follow the physician orders and that was the residents bowel protocol. The Administrator stated the facility did not have a policy for when an assessment should be completed. The Administrator stated the facility did not have a medication administration policy.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 25 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 documented no Brief Interview for Mental Status (BIMS) indicating Resident #2 was rarely/never understood. The MDS also documented utilization of an indwelling catheter. The MDS further documented Resident #2 was always incontinent of bowel. On 6/24/25 at 4:02 PM an observation of personal care and catheter care completed on Resident #2 with the Director of Nursing (DON) present revealed both Staff D, Certified Nursing Assistant (CNA) and Staff E, Certified Nursing Assistant (CNA) completed hand hygiene, applied gloves and donned gowns. Staff D applied lift cloth, full body mechanical lift utilized, Staff D utilized the controls of the mechanical lift, Staff E directed Resident #2 to the bed. The full body mechanical lift was removed from the bedside, Resident #2 assisted with turning to the right by Staff D, lift cloth rolled under, resident assisted to the left by Staff D, lift cloth removed by Staff D, Staff D did not change gloves or perform hand hygiene. Staff D obtained an alcohol wipe from sink area, Staff D cleansed Resident #2's meatus with the alcohol wipe, Staff D then utilized the alcohol wipe to cleanse down the catheter tubing from penis. Staff E removed gloves, completed hand hygiene, and applied gloves. Staff D walked towards the bathroom and opened the curtain, Staff D obtained the graduate and returned to the bedside, Staff D handed Staff E the graduate, Staff D opened an alcohol wipe, Staff E removed the catheter tip from catheter bag, Staff E did not cleanse the catheter tubing tip, Staff E emptied 100 cc of urine from catheter bag, Staff D handed Staff E the alcohol wipe, Staff E cleansed the tip of the catheter tubing, Staff D emptied the graduate into the toilet, Staff D placed a clear garbage bag around the graduate, Staff E removed their gown, removed gloves and completed hand hygiene, Staff D opened Resident #2's bedroom door, Staff D left Resident #2's room with the graduate in a bag with gloves and gown on, Staff D walked down the east hall towards the nurses station toward the utility on the north hall, walked into the residents common area past 4 residents seated near the television, Staff D walked down the north hall to the utility room, Staff D entered the utility room, Staff D removed gloves, and gown and completed hand hygiene. On 6/24/25 at 4:23 PM the DON stated she did have a concern with the personal care and catheter cares provided to Resident #2. The DON stated her expectation was hand hygiene would have been completed when gloves were changed, when moving between tasks, when moving from a dirty area of the body to clean area, after catheter cares, before and after emptying urine from the catheter bag. The DON stated her expectation was that gloves would have been removed and hand hygiene would have been completed before opening the curtain to the bathroom and before leaving the residents room. The DON stated her expectation was that the gown and gloves would have been removed and hand hygiene would have been completed before the staff exited Resident #2's room, before walking down the hall to the dirty utility room. The DON stated her expectation was alcohol would have been utilized to cleanse the catheter tip before opening to drain and after draining urine from the catheter bag. Review of policy dated 3/25/24 titled, Enhanced Barrier Precautions documented EBP's are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied before performing high-contact resident care activities (as opposed to before entering the room). Personal protective equipment (PPE) was changed before caring for another resident. Examples of high-contact resident care activities requiring the use of a gown and gloves include transferring, providing hygiene, changing briefs or assisting with toileting and indwelling device care such as urinary catheters. Review of policy dated 6/19 titled, Handwashing / Hand Hygiene documented hand hygiene should be completed in situations such as before and after handling an invasive device (e.g. urinary catheters), before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, after handling contaminated equipment, after removing gloves and before and after entering isolation precaution settings.

Feb 2025 12 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

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Based on facility document review, family interview, staff interviews, personnel file review and policy review, the facility staff failed to report suspected abuse between a staff member and a resident (#15) within two (2) hours after the observed behavior. The facility reported a census of 24. Findings include: On 2/24/25, a facility-reported incident indicated Staff K, Certified Nurse Aide (CNA) witnessed Staff L, CNA tickle Resident #15's nipple while they helped the resident get dressed. On 2/24/25 at 12:32 PM, Resident #15's relative stated Staff M, Licensed Practical Nurse (LPN) notified him on 2/23/25 at 4:46 PM that Resident #15 was inappropriately touched just before lunch. On 2/25/25 at 1:17 PM, Staff K stated she witnessed the incident at 12:30 PM on 2/23/25 and notified Staff N, CNA around 2:50 PM of the incident. She also stated she waited until after 3:10 PM to notify the Assistant Director of Nursing (ADON). At 2:46 PM, the Director of Nursing (DON) verified the ADON was the on-call leadership staff on 2/23/25. She also stated all staff receive online abuse prevention training upon hire. At 3:21 PM, the ADON verified Staff K notified her of the suspected abuse on 2/23/25 at 3:40 PM. She also stated she notified the Administrator at 3:45 PM. On 2/27/25 at 11:53 AM, staff file reviews revealed Staff K completed a 3-year valid Dependent Adult Abuse training on 3/11/22. On 2/27/25 at 3:18 PM, the Administrator stated the staff should've called the Administrator immediately after the observed behavior. A policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy revised 4/2023 indicated all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Administrator. It also indicated all allegations of resident abuse shall be reported to the appropriate state entity not later than two (2) hours after the allegation is made.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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2. The MDS for Resident #5, dated 12/27/2024 did not document a BIMS. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The MDS also documented diagnoses of athetoid cerebral palsy, abnormal posture, contracture of right hand, contracture of left hand, contracture unspecified ankle, contracture unspecified knee, contracture unspecified hip, unspecified quadriplegia, and unspecified dystonia. Review of Resident #5's Electronic Heath Record (EHR) titled, Care Plan documented no focus, goal, or intervention in place for restorative, physical therapy, or occupational therapy (OT). The Care Plan also did not document a focus, goal or intervention for repositioning Resident #5. On 2/25/25 at 1:55 PM Staff Q, CNA stated Resident #5 does not get repositioned. Staff Q stated Resident #5 only had stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 1:55 PM Staff A, CNA stated Resident #5 does not get repositioned. Staff A stated Resident #5 only stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 2:10 PM the DON stated Resident #5 did not get repositioned from side to side. The DON stated Resident #5 only laid on his back while in bed. The DON stated the air flow mattress provided enough change in position that Resident #5 did not need repositioning. The DON acknowledged there was no Care Plan focus, goals, or interventions in place related to Resident #5's positioning. The DON acknowledged there should be a Care Plan with focus, goal, or intervention for positioning. On 2/26/25 at 9:37 AM the DON stated a restorative program was on the EHR but fell off in September of 2024. The DON acknowledged there was a system error that led to the restorative program falling off the EHR. The DON stated they would get OT involved to find out if the restorative was appropriate and repositioning was needed. On 2/26/25 at 9:40 AM the Administrator stated it was the facility 's expectation that staff would reposition Resident #5. The Administrator stated Resident #5 was on a restorative program and still should have been. The Administrator acknowledged that the restorative program was on the EHR but fell off in September of 2024. The Administrator acknowledged there was a system error that led to the restorative program falling off the EHR. On 2/26/25 at 5:49 PM the DON stated that Resident #5 was repositioned when care was completed. The DON stated that personal cares were Resident #5's repositioning. On 2/26/25 at 5:51 PM the Administrator stated she would have expected something with therapy would have been completed. The Administrator acknowledged Resident #5 should have a Care Plan in place for positioning and restorative care. The Administrator acknowledged Resident #5 did not have either Care Plan in place. Review of policy revised 7/17 titled, Restorative Nursing Services documented residents will receive restorative nursing care as needed to help promote optimal safety and independence. The document also states the restorative goals and objectives are individualized and resident - centered, and are outlined in the resident's plan of care. Review of policy dated 5/13 titled, Repositioning documented the purpose of this procedure was to provide guidelines for the evaluation of the residents repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Residents who are in bed should be on at least an every 2 hour repositioning schedule. Review of policy dated 3/22/22 titled, Care Plans, Comprehensive Person - Centered documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are derived from a thorough analysis of the information gathered as part of comprehensive assessment. Review of policy revised 3/18 titled, Activities of Daily Living (ADL), supporting documents that residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain food nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care including appropriate support and assistance with bathing and mobility. Care and services to prevent and or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. The resident's ability to perform ADL's will be measured using clinical tools, including the MDS. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Based on clinical record review, staff interviews, and policy review the facility failed to develop and implement a Comprehensive Care Plan for 2 of 12 residents (Resident #16, and #5) reviewed. The facility reported a census of 24 residents. 1. The Minimum Data Set (MDS) for Resident #16 dated 1/28/25 identified a Brief Interview for Mental Status (BIMS) score of 2/15 indicating a severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia, depression, psychotic disorder, and hypertension. The MDS did not identify a diagnosis for use of oxygen. The MDS indicated Resident #16 did not utilize oxygen during the reporting period. The Electronic Medical Record (EMR) Physician Orders dated 2/25/25 revealed Resident #16 was ordered on 11/20/22 oxygen at 2 liters/minute via nasal cannula as needed to keep saturations above 90%. The Physician Orders failed to identify times for monitoring of oxygen saturations. The EMR vitals oyxgen saturation summary revealed saturations were monitored weekly. The Care Plan revised 1/14/25 revealed lack of documentation related to respiratory compromise. The facility failed to develop a Comprehensive Care Plan with goals and interventions related to oxygen. On 2/25/25 at 12:18 PM Staff A, Certified Nursing Assistant (CNA), stated Resident #16 did use oxygen but not all the time. On 2/25/25 at 2:31 PM Staff B, CNA, stated she had not seen Resident #16 out of breath, and did not know when the resident used oxygen. On 2/25/25 at 2:37 PM Staff P, the Assistant Director of Nursing (ADON)/Social Worker/Licensed Practical Nurse (LPN), stated Resident #16 began using oxygen around Thanksgiving when the resident's oxygen would randomly drop for no apparent reason. Staff P stated saturations should be monitored on each shift which would be twice a day to ensure saturations were stable. Staff P stated the Care Plan should identify the use of oxygen as well as the signs/symptoms for use, what to do, who is responsible, and when to do it. Staff P stated Care Plans should be able to provide instructions for anyone new to working with the resident. On 2/25/25 at 2:55 PM the Director of Nursing (DON) stated she was aware that all of the Care Plans may not be completely up to date and there were likely problems. The DON stated the facility was working to correct this and that Care Plans should reflect the needs of the residents.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, observations and policy reviews the facility failed to review and revise the Care Plan interventions for 3 of 12 residents reviewed (Resident #12, #19, and #2). The facility failed to revise Care Plan Interventions for a resident who smoked, a resident who utilized a power wheelchair (w/c), and failed to include a family representative in the Care Plan Conference. The facility reported a census of 24 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #12 scored 15/15 on the Brief Interview for Mental Status (BIMS) indicating normal cognition. The resident had diagnoses of hypertension, anxiety disorder, depression, and morbid (severe) obesity. The resident required total staff assistance for toilet hygiene, bathing, footwear and substantial/maximal assistance for lower body dressing. Resident #12 completed bed mobility independently, transferred bed to w/c and toilet independently and walked 10 feet. The document revealed ambulation of 50 feet or greater with 2 turns was not attempted due to medical condition or safety concerns. The document revealed the resident utilized a motorized w/c for 150 feet with independence. The Electronic Medical Record (EMR) Progress Notes revealed the resident refused 19/30 opportunities of walk to dine restorative nursing program. The document revealed on 8/9/24 an order was received for discontinuation of the walk to dine restorative nursing program. Resident #12's Care Plan revised 2/3/25 with a focus area of risk of falling revealed an intervention for walking to meals. The facility failed to update the intervention upon discontinuation of the restorative nursing program on 8/9/24. On 2/25/25 at 2:47 PM Staff P, the Assistant Director of Nursing (ADON)/Social Worker/Licensed Practical Nurse (LPN) stated she did not believe Resident #12 walked to the dining room for meals. The staff stated she was not sure if that was on the Care Plan. 2. According to the MDS dated [DATE] Resident #19 scored 11/15 on the BIMS indicating moderate cognitive impairment. The resident had diagnoses of coronary artery disease, hypertension (high blood pressure), Non-Alzheimer's Disease, anxiety, depression, psychotic disorder, and nicotine dependence. The EMR Smoking Data Collection dated 12/2/24 revealed Resident #19 required smoking interventions of a smoker's apron, and supervised smoking. Resident #19's Care Plan revised 10/31/24 revealed a focus area for risk for injury related to smoking. Interventions for staff to follow included that the resident is not required to wear a smoker's apron at this time. The facility failed to update the Care Plan with the interventions from the Smoking Data Collection dated 12/2/24. On 2/25/25 at 2:43 PM Staff P stated she and the Director of Nursing (DON) primarily completed the assessments in the EMR, but sometimes floor nurses may complete an assessment. Staff P stated the smoking assessment was completed upon admission and then quarterly thereafter. Staff P stated the interventions recommended from the smoking assessment should be on the Care Plan. On 2/25/25 at 2:55 PM the DON stated she was aware that the Care Plans may not be completely up to date and there were likely problems. The DON stated the facility was working to correct this and that Care Plans should reflect the needs of the residents. Observed Resident #19 on 2/25/25 at 3:04 PM wearing a smoker's apron while smoking. 3. The MDS for Resident #2 dated 1/7/24 documented a BIMS score of 0 indicating severe cognitive impairment. On 2/24/25 at 3:09 PM Resident #2's Power of Attorney (POA) stated she spoke to Staff P, a couple months ago about when Resident #2's care conferences would be. The POA stated Staff P told her that she was not sure. The POA stated she had not been invited to the care conference held in January 2025. Review of the EHR titled, Progress Notes entry by Staff P on 1/7/2025 at 10:01 AM documented a Care Plan meeting was held with resident, POA, DON, SSD, and charge nurse. No concerns voiced, no request for transfer to another facility, meds reviewed, no change in code status was desired. On 2/25/25 at 10:56 AM Staff P stated Resident #2 usually stated that she did not want to attend the care conferences. Staff P stated she notifies Resident #2 about the care conferences in advance. Staff P stated Resident #2 and Resident #2's POA was not present at the Care Plan meeting that was held 1/7/25. Staff P acknowledged that was inaccurately documented. Staff P stated she did not document when family members were notified of the care conference. Staff P stated she usually calls the resident family or POA. Staff P stated she spoke with Resident #2's POA about the Christmas party being scheduled. Staff P stated she did not remember if she reached out to the POA after that to invite her to the care conference. Staff P acknowledged that care conferences had not been done at all prior to her starting in her position in June of 2024. Staff P acknowledged she did not know what was supposed to be included in the care conference even now. Staff P stated the facility has in-services called lunch and learns and most recently she just found out she was supposed to be documenting who was present at the meetings. On 2/25/25 at 12:16 PM the DON acknowledged Care Plan conferences were not being completed appropriately prior to Staff P starting in her current position in June 2024. The DON stated care conferences should be completed every 3 months with the resident, resident family member, or POA if possible. The DON stated the facility's expectation was that accurate documentation of who was present at the care conferences would be completed. The DON stated the facility's expectation was the resident and/or residents POA would be invited to the care conference. Review of policy dated 3/22 titled, Care Planning - Interdisciplinary Team documented the resident, the resident's family and / or the resident's legal representative / guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan.

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

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Based on Electronic Health Records (EHR) review, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower and reposition 1 of 12 residents reviewed (Resident #5). The facility reported a census of 24 residents. Finding include: The Minimum Data Set (MDS) for Resident #5, dated 12/27/24 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The MDS also documented diagnoses of athetoid cerebral palsy, abnormal posture, contracture of right hand, contracture of left hand, contracture unspecified ankle, contracture unspecified knee, contracture unspecified hip, unspecified quadriplegia, and unspecified dystonia. Review of Resident #5's Care Plan documented Resident #5 had a self-care deficit and required assistance with Activities of Daily Living (ADLs). Resident #5 required 2 people to assist and encourage bathing 2 x weekly. Resident #5 required 2 person assistance with bed mobility. Resident #5 mobility was described as bed bound. The Care Plan documented Resident #5 was at risk for pain/discomfort and increased risk for injury from decreased function related to dx of cerebral palsy. The Care Plan also documented to attempt and document any of non-pharmacological interventions used as appropriate such as repositioning, heat pack, and massage. Encourage Resident #5 to shift weight, if able, every 2 hours to assist with skin integrity. On 2/25/25 at 1:55 PM Staff Q, Certified Nursing Assistant (CNA) stated Resident #5 does not get repositioned. Staff Q stated Resident #5 only had stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 1:55 PM Staff A, CNA stated Resident #5 does not get repositioned. Staff A stated Resident #5 only stuffed animals under his arm. Staff Q stated Resident #5 laid only on his back in bed. Staff Q stated Resident #5 would grimace when repositioned. On 2/25/25 at 2:10 PM the Director of Nursing (DON) stated Resident #5 did not get repositioned from side to side. The DON stated Resident #5 only laid on his back while in bed. The DON stated the air flow mattress provided enough change in position that Resident #5 did not need repositioning. On 2/26/25 at 9:40 AM the Administrator stated it was the facility's expectation that staff would reposition Resident #5. On 2/26/25 at 10:06 AM Staff R, Certified Occupational Therapy Assistant (COTA) / Director of Rehab stated he was familiar with Resident #5. Staff R stated the pressure relief mattress would be enough to prevent breakdown. Staff R stated the pressure relief mattress was to offload weight. Staff R stated he did not think repositioning would benefit the resident. Staff R stated there was a current order to evaluate. On 2/26/25 at 5:49 PM the DON stated that Resident #5 was repositioned when care was completed. The DON stated that personal cares were Resident #5's repositioning. Review of documents titled, Bathing Records for the last 90 days revealed 24 opportunities for baths. The clinical record lacked documentation of baths being given on 12/20, 12/13, and 11/29/24. Bathing records revealed Resident #5 received only one bath a week for 3 out of 4 weeks and was not given a bath on Friday 3 out of 4 of the same weeks. The weeks were 11/24/24 - 12/21/24. On 2/27/25 at 9:06 AM the DON stated the facility's expectation for baths was Resident #5 would have received 2 baths a week on Tuesday and Friday and made up if the bath was missed. The DON acknowledged baths were missed on 12/20, 12/13, and 11/29/24. The DON acknowledged Resident #5 did not get a bath 3 out of 4 weeks on Fridays. Review of policy dated 5/13 titled, Repositioning documented the purpose of this procedure was to provide guidelines for the evaluation of the residents repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed or chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Residents who are in bed should be on at least an every 2 hour repositioning schedule. Review of policy revised 3/18 titled, Activities of Daily Living (ADL), documented that residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL's). Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain food nutrition, grooming and personal and oral hygiene. Appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care including appropriate support and assistance with bathing and mobility. Care and services to prevent and or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. The resident's ability to perform ADL's will be measured using clinical tools, including the MDS. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on Electronic Health Records (EHR), staff interview, and policy review the facility failed to provide restorative cares to promote range of motion to 1 out of 1 residents reviewed (Residents #5). The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) for Resident #5, dated 12/27/24 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The MDS also documented diagnoses of athetoid cerebral palsy, abnormal posture, contracture of right (R) hand, contracture of left (L) hand, contracture unspecified ankle, contracture unspecified knee, contracture unspecified hip, unspecified quadriplegia, and unspecified dystonia. Review of Resident #5's EHR titled, Care Plan documented no focus, goal, or intervention in place for restorative, physical therapy, or occupational therapy. Review of Resident #5's EHR revealed Resident #5 had no restorative therapy, physical therapy, or occupational therapy. Review of document dated 6/16/24 titled, Occupational Therapy OT Evaluation and Plan of Treatment documented for assessment summary clinical impressions were Resident #5 unable to communicate or actively move upper extremities and lower extremities. Resident #5 dependent for all cares and positioning with good staff support. Review of document dated 6/16/24 titled, Occupational Therapy OT Recert, Progress Report, and Updated Therapy documented continued OT services are necessary in order to assess use of palm protectors for both hands to reduce risk of skin breakdown and ROM to prevent further contracture. The document also documented Resident #5 demonstrated good rehab potential as evidenced by supportive caregivers/staff. Review of document dated, 7/6/24 titled, Occupational Therapy Treatment Encounter Notes documented Resident #5 would benefit from a trial of carrot hand orthosis to improve ROM and reduce contracture. Review of document dated, 7/10/24 titled, Occupational Therapy Treatment Encounter Notes documented Resident #5 would benefit from palm protectors to decrease skin breakdown and prevent contractures from getting worse. Order form given to DON for both R and L. Review of document dated, 7/14/24 titled, Occupational Therapy Treatment Encounter Notes documented palm protectors ordered for both hands to decrease risk of skin breakdown. Recertification completed to continue therapy. Review of Resident #5's EHR titled Treatment Administration Record (TAR) documented no splint orders and no carrot hand orthosis orders. Review of the TAR also revealed no orders for restorative therapy. Review of document titled, Occupational Therapy OT Discharge Summary documented the reason for Resident #5's discharge was because Resident #5 discharged to the hospital. The document also revealed Resident #5 progress was there was no progress to report. Resident #5 was unable to tolerate a gentle range of motion to bilateral upper extremities. Ordered palm protectors as the best options to prevent contractures from worsening and reduce risk of skin breakdown. On 2/26/25 at 9:37 AM the DON stated a restorative program was on the EHR but fell off in September of 2024. The DON acknowledged there was a system error that led to the restorative program falling off the EHR. The DON stated the facility would get occupational therapy (OT) involved to find out if the restorative was appropriate. On 2/26/25 at 9:40 AM the Administrator stated Resident #5 was on a restorative program and still should have been. The Administrator acknowledged that the restorative program was on the EHR but fell off in September of 2024. The Administrator acknowledged there was a system error that led to the restorative program falling off the EHR. On 2/26/25 at 10:06 AM Staff R, Certified Occupational Therapy Assistant (COTA) / Director of Rehab stated he was familiar with Resident #5. Staff R stated Resident #5 was on therapy a couple of times to prevent contractures in the past. Staff R stated Resident #5 was on occupational therapy (OT) from 6/24 to 7/24. Staff R stated Resident #5 was on evaluation only for physical therapy (PT) and was referred for contracture management for PT and then OT picked Resident #5 up. Staff R stated Resident #5's short term goal was trial of orthotic splints for the palms of Resident #5's hands. Staff R stated there was an ordered request given to the DON for purchase of palm protectors. Staff R stated Resident #5 was discharged from OT when he was discharged to the hospital. Review of policy revised 7/17 titled, Restorative Nursing Services documented residents will receive restorative nursing care as needed to help promote optimal safety and independence. The document also states the restorative goals and objectives are individualized and resident - centered, and are outlined in the resident's plan of care.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 1 resident (#1) reviewed for nutrition. This failure resulted in Resident #1 experiencing a weight loss of 11.05% in 6 months. The facility reported a census of 24 residents. Findings include: On 2/24/25 at 11:27 AM, Resident #1 was observed asleep in her bed. At 2:22 PM, Resident #1 got up, walked to the kitchen, knocked on the kitchen door, and got a tray of food the kitchen staff heated up. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. It included diagnoses of diabetes mellitus, Alzheimer's Disease, non-Alzheimer's dementia, bipolar disorder, psychotic disorder, schizoaffective disorder, and anxiety. It indicated she required moderate assistance with bathing and was independent with all other Activities of Daily Living (ADLs). It also indicated she had a 10% or more weight loss in the previous 6 months and was not on a physician-prescribed weight-loss regimen. The Care Plan dated 8/21/24 indicated Resident #1 had a potential nutritional problem related to her schizoaffective disorder, Alzheimer's Disease, bipolar disorder, anxiety, and diabetes mellitus. It directed staff to monitor/record/report to the medical doctor (MD) as needed (PRN) signs and symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs in 1 week, >5% in 1 month, >7.5% in 3 months, or >10% in 6 months. It also directed staff to provide, serve diet as ordered: Regular diet with thin liquids. Monitor intake and record every meal. A weight change note authored by the Registered Dietitian (RD) dated 2/05/25 at 12:48 PM revealed Resident #1 experienced a significant weight loss of 7.3% in 30 days, 7.5% in 90 days and 11% in 180 days. It indicated with available information, continue same and monitor as needed. On 2/25/25 at 9:05 AM, the resident was observed asleep in her room. At 11:53 AM, Resident #1 got up, walked to the kitchen, knocked on the kitchen door, and got something to drink. She walked back to her room then returned and sat in the dining room. On 2/26/25 at 7:20 AM and 9:14 AM, Resident #1 was observed asleep in her room. At 9:29 AM, the RD stated she generates a Weights and Vitals Exception Report on Wednesdays when she is at the facility and reviews meal intake amounts, labs, and nurses' notes. She also stated she talks to the Certified Nursing Aides (CNAs) and kitchen staff to see if the resident had been asking for meals, and selecting the regular menu and not a bowl of soup, etc. She confirmed she had not been notified that staff had not been waking the resident for breakfast. She stated had she been told staff hadn't been waking the resident for meals, she would've rechecked the resident's weight and directed staff to attempt to awaken the resident for each meal and document resident refusals or ineffective attempts to awaken the resident. She stated with the available information, she didn't feel a nutrition supplement was necessary because the resident remained above Ideal Body Weight Range (IBWR). On 2/26/25 at 10:05 AM, Staff F, Certified Medication Aide (CMA) stated she had not been instructed to not wake the resident up for meals. She also stated she was not aware of the resident's significant weight loss. At 10:40 AM, Resident #1 walked up to the nurses' station and asked about food. Staff G, Activities Supervisor, told her lunch was not for another hour and 20 minutes. Resident #1 walked to the kitchen entrance, knocked on the kitchen door, and asked Staff H, AM cook, for some lunch. Staff H told Resident #1 lunch was in 1 hour and 20 minutes and offered Resident #1 something to drink. Resident #1 went into the dining room and sat down. At 10:42 AM, Resident #1 stated she was hungry but said staff wasn't getting her any food for another hour. Staff H brought Resident #1 some punch. Resident #1 drank it and went back to her room. On 2/26/25 at 10:54 AM, Staff A, Certified Nurse Aide (CNA) did not identify Resident #1 as not wanting to be awakened for meals. At 10:59 AM, Staff J, CNA stated Resident #1 did not like to be awakened for meals. She also indicated she was not aware of Resident #1's significant weight loss. At 11:08 AM, Resident #1 stated she never asked staff to not awaken her for meals and added she would not get mad if they did. At 1:48 PM, Staff H stated she was told the resident refused breakfast Monday (2/24/25), Tuesday (2/25/25), and Wednesday (2/26/25). She stated she prepared a breakfast plate for Resident #1 on those days but threw it away just before lunch time. She confirmed she does not document resident meal refusals and had not been made aware of the resident's significant weight loss. The Electronic Health Record (EHR) Meal Eaten Response History dated 1/28/25 to 2/25/25 did not include any documented breakfast responses. On 2/27/25 at 3:11 PM, the Administrator stated staff should have given the resident a snack and provided an alternative. She added staff should attempt to wake the resident for breakfast and lunch and document if it's refused. A policy titled Assistance with Meals revised March 2022 indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 28 opportunities for errors resulting in an error rate of 7.14% (Residents #178). The facility identified a census of 24 residents. Findings include: On 2/25/25 beginning at 7:16 AM, Staff F, Certified Medication Aide (CMA) prepared the following medications to administer to Resident #178: a) One (1) Oxycodone/APAP 5/525 milligrams (mg) tablet b) Miralax 17 grams c) gabapentin 2 milliliters (mL) d) One (1) celecoxib 100 mg capsule e) One (1) citalopram 40 mg tablet f) One (1) azathioprine 50 mg tablet g) One (1) Lisinopril 10 mg tablet h) One (1) Omeprazole 40 mg capsule i) One (1) multivitamin (MVI) tablet j) One (1) vitamin C 500 mg tablet k) One (1) Ocuvite gummy Staff F confirmed there were 11 medications, she then administered them to Resident #178. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not documented. It indicated the resident had memory problems and severely impaired decision-making ability. It included diagnoses of diabetes mellitus, anxiety disorder, immunodeficiency, Alzheimer's Disease, and dementia. The Electronic Health Record (EHR) included a physician's two (2) orders for a) Vitamin C oral tablet 1000 mg; give 1 tablet by mouth one time a day for promote wound healing, and b) Omeprazole oral capsule delayed release 20 mg; give 1 capsule by mouth every morning. The Medication Administration Record (MAR) revealed staff acknowledged administering one (1) Omeprazole oral capsule delayed release 20 mg by mouth one time a day between 2/01/25 through 2/27/25. The pharmacy supplied Omeprazole 40 mg; take 1 capsule by mouth every morning. The Care Plan dated 1/19/25 indicated the resident had an unstageable pressure ulcer on her left heel and included Vitamin C 1000 mg order obtained to promote wound healing. On 2/27/25 at 9:25 AM, Staff F stated the resident received one (1) 500 mg tablet by mouth Tuesday, 2/25/25 during medication pass observation. She confirmed the stock medication bottle was 500 mg tablets. On 2/27/25 at 11:38 AM, the Assistant Director of Nursing (ADON) stated the Omeprazole order was supposed to be 40 mg and was incorrectly entered into the resident's EHR. At 3:46 PM, the Director of Nursing (DON) stated staff should have been looking at the MAR and should have clarified the order with the physician. A policy titled Medication Therapy revised April 2007 indicated all medication orders will be supported by appropriate care processes and practices.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, Electronic Health Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing appropriate hand hygiene when personal care was completed for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 24 residents. Finding include: The Minimum Data Set (MDS) for Resident #5, dated 12/27/2024 did not document a Brief Interview for Mental Status (BIMS) score. The MDS documented Resident #5 was rarely/never understood. The MDS documented Resident #5 required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. On 2/25/25 at 11:11 AM the Director of Nursing (DON) present during observation of tracheostomy care completed on Resident #5 by Staff M, Licensed Practical Nurse (LPN). Observation revealed Staff M completed hand hygiene, applied gloves, obtained materials for suctioning and tracheostomy cares. Staff M removed Gaze 4x4 around tracheostomy, removed metal trachea appliance. Staff M then removed gloves and applied sterile gloves. Staff M picked up sterile water off the bed, opened the bottle, poured the sterile water into the tracheostomy tray, picked up gauze 4x4, and put gauze in the sterile water in the tray. Staff M removed moistened 4x4, cleansed tracheostomy stoma, applied lube to clean tracheostomy appliance and reinserted. Staff M obtained a gauze 4x4 4 from the night stand and applied it to tracheostomy stoma. Staff M gathered trash and removed it from the bed. Staff M removed gloves, completed hand hygiene, applied gloves, initiated suctioning to clear tracheostomy. Staff M checked oxygen saturation with an oximeter with 94% on 8 L recorded. Staff M removed gloves, completed hand hygiene, applied gloves and completed cleaning of previously inserted tracheostomy appliances. Staff M removed gloves, doffed gown, completed hand hygiene, and exited the room with trash. On 2/25/25 at 11:39 AM the DON acknowledged missed opportunities for hand hygiene during tracheostomy care completed by Staff M. The DON stated the facility's expectation was that hand hygiene would be completed with all glove changes. The DON acknowledged Staff M did not complete hand hygiene with the glove change after initial removal of the tracheal appliance. An observation on 2/26/25 at 4:39 PM revealed Staff O, Certified Nursing Assistant (CNA) and Staff N, CNA knocked on Resident #5 room door, entered the room, completed hand hygiene, applied gloves and donned gowns. Staff O completed peri care to Resident #5's penis with peri wash and wet wipe. Staff O then utilized an alcohol wipe to cleanse catheter tubing and catheter stoma site. Resident #5 was assisted to the right side by Staff N. Staff O then cleansed Resident #5's buttocks and hips. Staff O applied barrier cream to Resident #5's buttocks. Gloves removed by Staff O, hand hygiene completed, gloves applied, assisted Resident #5 to the right side, assisted in helping Staff N apply new brief and completed care. Gloves and gown doffed by both and hand hygiene completed. On 2/26/25 at 5:30 PM the DON acknowledged missed opportunities for hand hygiene when Staff O completed personal cares on Resident #5. The DON stated hand hygiene and glove change should have been completed before moving from peri area to suprapubic catheter stoma, before moving from catheter stoma to buttocks and prior to application of barrier cream. Review of the policy revised 8/19 titled, Handwashing/Hand Hygiene documented hand hygiene should have been completed before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, and after removing gloves.

CONCERN (E)

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

Deficiency F0567 (Tag F0567)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the clinical record review, resident interview, staff interview and policy review the facility failed to provide access to personal funds managed by the facility for 1 of 1 residents reviewed. The facility reported a census of 24 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 2/24/25 at 11:55 AM Resident #11 stated she wanted to have some money on the weekend recently to buy soda but it is not available from personal funds at the facility on the weekends or in the evenings. On 2/25/25 at 2:28 PM Staff C, Business Office Manager stated the facility did have money in a lockbox available for the residents. Staff C stated the facility kept $110.00 in the lockbox. Staff C stated she and the Administrator are the only staff that had access to the petty cash. Staff C stated the residents could not have money if she was not in the building unless it was an emergency. Staff C stated she worked at the facility 8:00 AM to 4:30 PM or 5:00 PM. Staff C stated she worked Monday through Friday. Staff C stated the residents at the facility did not have access to their money in the evening or on the weekend. Staff C acknowledged yesterday a resident wanted to break a $10.00 bill for $10.00's in change but she was not at the facility. Staff C stated the resident did not get the $10.00 bill broken. Staff C stated a CNA told her this morning. On 2/25/25 at 2:55 PM Staff B, CNA stated she works the 2-10 PM shift and every other weekend. Staff B stated a resident asked just the other day if she could have money in the evening. Staff B stated residents did not have access to get money from the resident trust in the evening or on the weekends. Staff B stated the only person that has access to resident funds was Staff C. On 2/25/25 at 3:08 PM the Administrator stated the residents could ask the staff to call the Administrator or Staff C to come in and get money for the residents. The Administrator acknowledged she had not been asked to come in on the weekends or in the evening. The Administrator stated she thought Staff C works sometimes on the weekend. The Administrator acknowledged the residents at the facility did not have access to funds on the weekends or in the evening when the Administrator or Staff C had left. Review of policy revised 3/21 titled, Deposit of Residents' Personal Funds documented that if a resident chose for the facility to hold personal funds, the facility would provide the resident access to funds of 100 dollars (fifty dollars for Medicaid residents) or less within twenty-four hours, and access to funds in excess of 100 dollars (fifty dollars for Medicaid residents) within three banking days.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents by not serving residents on a mechanical soft diet the appropriate amount of meat according to the menu for 4 of 24 residents reviewed. The facility reported a census of 24 residents. Findings include: On 2/26/25 at 11:50 AM Staff H, AM [NAME] obtained 8 meatballs and placed them in the food processor. Staff H processed the meatballs and removed them from the processor into a plastic container. Staff H then placed the plastic storage container in a pan in the steam table. Lunch was served. Tongs were utilized for serving mechanical soft meatballs. The last plate was for a resident with a mechanical soft diet. Staff H measured 1/3 cup for the remaining mechanical soft meatballs. Review of document titled, Diet Spreadsheets Week 3 Wednesday documented 2 ground meatballs for mechanical soft diets. On 2/26/25 at 1:10 PM Staff I, Certified Dietary Manager (CDM) acknowledged all of the mechanical soft meatballs should have been served. Staff I stated there should not have been 1/3 cup leftover after lunch service. Staff I stated there were 4 servings processed and all of the mechanical soft meatballs should have been served. On 2/26/25 at 3:56 PM Staff E, Contract Registered Dietitian stated all of the mechanical soft meatballs should have been served. Staff E stated there should not have been 1/3 cup leftover after lunch service. Review of the undated policy titled, Portion Control documented food would be served according to standard portion sizes to ensure adequate servings of food and to provide portions that are equal in size for those residents that do not require specialized dietary modifications. Portion control equipment will be used at meal times. Ounce scales will be available to weigh meat portions after they are cooked. Residents on diets that require portion variations will have the required information either stated on their tray card or it could be found on the diet spreadsheet under the diet they are on.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview and policy review the facility failed to provide food at an appetizing temperature when the mechanical soft meatballs temperature was 95 degrees in the steam table. The facility reported a census of 24 residents. Findings include: During continuous observation of lunch service on 2/26/25 at 11:50 AM - 1:00 PM Staff H, AM Cook, completed lunch service with the last plate for a resident on a mechanical soft diet. Staff H obtained a temperature of 95 degrees on the remaining mechanical soft meatballs left in the steam table. On 2/26/25 at 1:00 PM Staff H acknowledged the mechanical meatball temperature of 95 degrees was unacceptable. Staff H stated food in the steam table should have had a holding temperature of 135 degrees or higher. On 2/26/25 at 1:10 PM Staff I, Certified Dietary Manager (CDM) stated the mechanical meatball temperature of 95 degrees was unacceptable. Staff I stated the mechanical soft meatballs in the steam table should have had a holding temperature of 135 degrees or higher. On 2/26/25 at 3:56 PM Staff E, Contract Registered Dietitian stated she would have expected the mechanical meatballs to have a holding temperature of 135 degrees or higher in the steamtable. Review of the undated policy titled, Food Temperatures documented hot food temperatures must read no less than 140 degrees when residents are served.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open food items and discarding leftovers. The facility also failed to sanitize a thermometer prior to use. The facility reported a census of 24 residents. Findings include: During a continuous observation on 2/24/25 from 10:00 AM - 10:25 AM revealed a white stand up refrigerator/freezer had containers of cut lettuce dated 2/19, cut tomatoes dated 2/19, cut tomatoes dated 2/18, turkey gravy dated 2/18, bread stuffing (dressing) dated 2/16, cut ham dated 2/19, and cut lettuce dated 2/18. A stand up double door refrigerator had a plastic bag of ham dated 2/4. A double door stand up refrigerator for liquids had a pitcher of lemonade dated 2/14. The same double door stand up refrigerator for liquids also had undated pitchers of grape drink and pitchers of tea. On 2/24/25 at 10:30 AM Staff I, Certified Dietary Manager (CDM) stated the facility's expectation was that open food in containers would be thrown away after 3 days. Staff I acknowledged the containers of tomatoes, lettuce, cut ham, bread stuffing (dressing) and the plastic bag of ham should have been disposed of. Staff I stated the drink pitchers should have been dated and after 3 days should also have been disposed of. A continuous observation on 2/26/25 from 11:50 AM - 1:00 PM revealed Staff I obtained a thermometer and checked the mechanical meatball temperature in the plastic container. A temperature of 109 was revealed for the mechanical soft meatball. The plastic container with mechanical soft meatballs was removed from the table, thermometer placed on the table where the plastic container was, the plastic container with the mechanical meatballs was placed in the microwave, the container was removed from the microwave and taken to the table, the thermometer was picked up, the container was placed where the thermometer was, the mechanical soft meatballs temperature was rechecked. A temperature of 144 was obtained. The process was completed over again until the mechanical soft meatballs in the microwave reached a temperature of 165. On 2/26/25 at 1:10 PM Staff I stated the thermometer should have been cleaned/sanitized prior to rechecking the mechanical meatballs after being microwaved. On 2/26/25 at 3:56 PM Staff E, Contract Registered Dietitian, stated she would expect the food to have been thrown out after 3 days. Staff E stated there should have been dates on items/drinks when they were made. Staff E stated she would have expected the food thermometer would have been sanitized before checking the temperature of foods. Review of policy revised 7/14 titled, Food Receiving and Storage documented all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).

Mar 2024 9 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and facility policy review the facility failed to provide dignity by leaving a catheter bag uncovered and easily visible from the hallway for 1 of 1 resident reviewed (Resident #4). The facility reported a census of 17 residents. Findings Include: The Minimum Data Set Assessment (MDS) dated [DATE] documented Resident #4 did not have a Brief Interview for Mental Status completed due to rarely/never understood, and indicated impairment with short-term and long-term memory, memory/recall ability, and moderately impaired cognitive skills for daily decision making. The MDS documented an indwelling catheter, and diagnosis of neurogenic bladder, retention of urine, and Lennox-Gastaut Syndrome, intractable without status epilepticus. Observation on 3/4/24 at 12:32 PM revealed the resident lying in bed with a catheter bag hanging from the side of the bed without a privacy bag in place, a basin beneath it, and easily viewable from the hall. Observation on 3/5/24 at 10:24 AM revealed the resident lying in bed with a catheter bag lying in the basin on the floor without a privacy bag and viewable from the hall. On 3/5/24 at 3:05 PM the Administrator stated the expectation is for catheter bags to be placed in a dignity bag no matter where the location and should not be on the floor. On 3/5/24 at 3:15 PM the Director of Nursing (DON) stated the catheter bag placement depended on the situation, wheelchair versus bed. The DON stated while the individual was in the room the expectation was the catheter bag would be covered. The DON stated she was unsure why the catheter bag was in a basin unless there was leakage and to prevent the catheter from touching the floor. The facility policy Catheter Care - Indwelling dated 01/13 revealed to position the drainage bag from view or cover with a privacy bag.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review the facility failed to complete an assessment on a resident who had fallen prior to moving the resident with a mechanical lift from the floor for 1 of 1 residents (Resident #170) reviewed. The facility reported a census of 17 residents. Findings include. Review of Resident #170's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. The MDS further revealed diagnosis of coronary artery disease, heart failure, hypertension, stroke, non-Alzheimer's dementia, muscle weakness, and difficulty in walking. Review of Resident #170's electronic progress notes dated 10/23/23 at 5:13 AM revealed Resident #170 was found lying on the floor in his room. The resident stated he was getting up to go to the bathroom by himself and fell. Resident #170's vitals taken while on the floor and then mechanically lifted by Staff D Registered Nurse (RN) and the CNA working the night shift. Staff D then addressed Resident #170's laceration above his left eye and called the emergency department for transfer to an outside hospital for evaluation. The electronic progress notes dated 10/27/23 at 7:08 PM revealed an entry detailing the resident had undergone a left hip replacement at an outside facility on 10/24/23. During an interview on 3/06/24 at 9:37 AM Staff D revealed Resident #170 had fallen around 4:00 AM and the CNA went into his room where she found him on the floor with blood around him. Staff D then revealed the resident would try and transfer himself, and that she obtained vitals on him while he was on the floor. Staff D further revealed she did not attempt any range of motion on Resident #170. Staff D did reveal the resident was complaining of neck pain. Staff D stated the CNA and herself mechanically lifted the resident from the floor to bed. Staff D explained she did not assess range of motion or look for shortening, external, or internal rotation of the upper or lower extremities prior to mechanically lifting Resident #170 from the floor. Staff D stated the only assessment information would be in the electronic progress notes. During an interview on 3/06/24 at 1:48 PM the Medical Doctor (MD) stated with a hip fracture it is an unstabilized fracture, and a resident should be immobilized prior to being moved then EMS should be called. The MD stated moving a resident would not be helpful for a resident with a hip fracture, but that it was unlikely to cause more harm or trauma. The MD stated a resident complaining of neck pain should also be immobilized prior to being moved. During an interview on 3/06/24 at 2:29 PM with Staff C Licensed Practical Nurse (LPN) revealed that if a resident was found on the floor she would assess the resident prior to moving and if there was complaints of pain that she would notify EMS and try an keep the resident as comfortable as possible until the resident could be seen by the physician at the hospital via ambulance. During an interview on 3/06/24 at 2:40 PM with the Director of Nursing (DON) revealed her expectation would be for a full assessment to be completed prior to moving residents found on the floor after a fall. Review of a facility provided policy titled, Fall Risk and Management, with a revision date of 4/2013 revealed: a. Avoid moving the resident until injury evaluation is complete and it is determined that it is clinically appropriate to move the resident. b. Evaluate resident for any additional injury which would require medical intervention. This evaluation would include the condition of trunk and extremities to assess joints for change in normal range of motion, abnormal limb alignment, and internal or external rotation of the hip.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, therapy discharge notes, staff interview and facility policy, the facility failed to provide 1 of 1 residents (Resident #12) reviewed with an individualized Restorative Program in order to prevent a further reduction in range of motion and optimize skin integrity and minimize pain during cares. The facility reported a census of 17. Findings include: The Minimum Data Set (MDS) of Resident #12 dated 11/13/23 identified a Brief Interview of Mental Status score of 6, indicating severe cognitive impairment. The MDS coded the resident required substantial/maximal assistance for eating, and was completely dependent on staff for dressing, oral hygiene and personal hygiene. The MDS also coded the resident was completely dependent on staff for bed mobility, transfers, and locomotion in a manual wheelchair. The MDS coded a functional limitation in range of motion (ROM) with impairment present on one side of the resident's body of the the upper extremity and both sides of the body of the lower extremity. The MDS documented diagnoses that included stroke, dementia, and hemiplegia (the loss of ability to move [paralysis] of one side of the body). The MDS documented the resident began Occupational Therapy on 9/7/23 and Physical Therapy on 9/18/23. The MDS of Resident #12 dated 12/21/23 documented the resident received no restorative nursing program during the seven day look-back period. The Care Plan Focus Area of activities of daily living (ADL) dated 8/27/23 documented the resident to be paralyzed on the left side and having contractures. Observation on 3/4/24 at 1:40 pm revealed the resident to have a contracture to her left wrist (a chronic loss of joint motion that prevents normal movement of the wrist). Review of the resident's medical record failed to reveal the resident to have any restorative nursing program documented. On 3/5/24 at 4:44 pm, the Director of Nursing (DON) stated the facility does not have a restorative aide. She stated some of the residents get assistance to walk to meals but otherwise it's just fit it in however they can. On 3/5/24 at 4:55 pm, the DON stated she could not locate any documentation of Resident #12 having received a restorative program after being discharged from therapy. The Physical Therapy Discharge summary dated [DATE] documented a restorative program was established and trained for restorative range of motion to bilateral lower extremities. On 3/6/24 at 1:25 pm the Physical Therapist who signed the Discharge Summary stated she does not do the writing of the program or the teaching of it. She stated she does not come to the physical building and someone in the building would be responsible for the writing and teaching of the restorative program. On 3/6/24 at 1:31 pm, the former Director of Therapy stated he did not believe the Physical Therapy restorative program was ever completed. He stated be believed the Discharge Summary was completed in error documenting restorative. The Occupational Therapy Discharge Summary documented dates of service of therapy as 9/7/23 - 12/14/23. Short term goal #1 documented as Patient will safely perform self feeding tasks supervised with use for grasp/release of items and for location of food and utensils in order to decrease risk of malnutrition. Short term goal #2 documented as Patient will tolerate resting hand splint for 2 hours with no skin integrity issues or pain. The Occupational Therapy Discharge Summary documented a restorative program not indicated at the time of discharge. On 3/7/24 at 11:02 am, the Occupational Therapist stated the reason a restorative program not recommended was because the facility does not have a Restorative Aide to perform the program. She clarified she 100% would have recommended a program if the facility had the appropriate staff for it. The facility document Clinical Programs Manual, Restorative Nursing, documented: • The facility strives to enable residents/patients to attain and maintain their highest practicable level of physical, mental and psychosocial functioning. The interdisciplinary team works with the resident/patient and family/responsible party to identify measurable restorative goals and practical interventions that can be implemented and achieved with nursing support. • A licensed nurse manages the restorative nursing process with assistance of nursing assistants trained in providing restorative care. Additionally, the manual stated the resident meets the criteria for a restorative program if: A. The resident requires contracture prevention and management (including passive or active range of motion or splint/brace assistance) B. The resident requires skill practice and/or training in activities of daily living such as bathing, dressing, grooming, or dining, which includes eating, swallowing.

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

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Based on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (Resident #13) of three residents reviewed. The facility reported a census of 17 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #13, dated 2/7/24, included diagnoses of blindness, non-Alzheimer's dementia, and psychotic disorder. The MDS identified the resident dependent on staff for toilet hygiene, always incontinent of urine and occasionally incontinent of bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 7, indicating moderate cognitive impairment. During an observation on 3/5/24 at 11:42 AM, Staff F, Certified Nurse Aide washed her hands, gloved, and assisted Resident #13 from a recliner to the bathroom. Resident's pants were visibly wet on the left side/hip area and the back/ buttock area of pants, and the pad in the recliner with a wet brown area. Staff F removed the resident's pants and pull-up, with a large amount of loose stool in the pull-up, then changed gloves and washed hands. Staff F cleansed between buttocks and to mid buttocks, but did not cleanse outer and upper buttocks and hips. Staff F removed gloves, did not wash hands, and proceeded to touch the resident's clothing, walker, gait belt, and assisted resident to walk to the dining room and applied a clothing protector on the resident. Review of facility's policy, Perineal Care revised 04/13, documented clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping front to back. Interview on 3/06/24 at 3:57 PM, the Director of Nursing stated expectation to cleanse buttocks and hips with incontinence care.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and policy review the facility failed to properly label enteral feeding bottles and water bags prior to beginning a feeding for 1 of 1 residents (Resident #4) reviewed. The facility reported a census of 17 residents. Findings include: Review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed diagnosis of aphasia, cerebral palsy, quadriplegia, dysphagia, and gastrostomy status. During an observation on 3/5/24 at 10:18 AM revealed Resident #4's formula bottle and water bag for enteral (tube) feeding not labeled with date, time, or initials. During a follow up observation 3/6/24 at 12:14 PM revealed the resident's formula bottle and water bag for enteral feeding not labeled. During an interview on 3/6/24 at 12:14 PM with Staff C License Practical Nurse (LPN) revealed that the formula bottle and the water bag should be labeled and dated at the time it is spiked and prior to feedings. During an interview on 3/06/24 at 2:00 PM with the Director of Nursing (DON) revealed her expectations would be for feeding bags and water bags to be labeled with date, time, and initials when spiked for enteral feedings. Review of a facility provided policy titled, Enteral Feeding with a revision date of 5/2016 revealed: a. Label the feeding container to include date, time, resident name, formula name, strength and rate, and nurse's initials.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observations, staff interviews, and policy reviews the facility failed to prepare, serve, distribute, and store food in accordance with professional standards. The facility reported a census of 17 residents. Findings include: 1. Continuous observations on 3/4/24 at 11:15 AM noted a juice pitcher in the double refrigerator without a date, it appeared to be grape juice, with orange juice spilled around the seal of the lid and pitcher. In the dry pantry noted expired cornbread boxes and 3 packages of outdated stuffing with best by dates observed: Stove Top 10/23/23, Stove Top 11/6/23, Croutons 4/28/22. A second refrigerator contained a plastic bag of ham dated 2/23 without being sealed, an opened package of undated lunch meat, an opened undated package of cheese, and a dated bag of brown lettuce. Observed incomplete temperature logs on the refrigerators. The Kitchen Supervisor (KS) entered the kitchen and moved around the kitchen without a hairnet. 3. On 3/5/24 at 10:16 AM observed the resident refrigerator in the dining area. Unlabeled ice cream in the freezer not completely sealed. An item in the refrigerator had a first name but neither a last name or date. 4. Continuous observation on 3/5/24 at 11:25 AM of the kitchen and mealtime revealed the following: -The grape juice pitcher in the refrigerator did not have a date and had orange juice spilled around the lid/pitcher seal. -A lemonade pitcher did not have a prepared date. -The KS prepared the alternative meal of ham salad sandwich. The supervisor completed hand hygiene, donned gloves, and proceeded to touch the blade of the food processor, packaging of ham, slices of ham, the lid of processor, the sleeve of her shirt, condiments and slices of bread. The KS removed gloves, completed hand hygiene, and replaced gloves. The supervisor completed the assembly of the sandwiches while touching multiple surfaces including the bread. The KS removed gloves, completed hand hygiene and donned gloves. The supervisor removed a new package of lettuce from the refrigerator, unwrapped it, removed the outside leaves, hit the lettuce on the sink counter, removed the core, and rinsed it off in the food prep sink. The KS placed the lettuce in a new container, removed single leaves, and placed them on a plate. -Staff A, Cook/Dietary, donned gloves without washing her hands, and began the meal service. Throughout the meal service the staff only used utensils for the bacon and french fries. Gloved hands touched the bread package, bread, lettuce, tomatoes, utensils, and deviled eggs. Staff A inconsistently changed her gloves throughout the service without hand hygiene. On 3/4/24 at 3:10 PM the KS stated the expectation was that expired items be discarded. The supervisor stated she had spoken with staff regarding this issue. The supervisor expected kitchen staff to write the date opened on packages. Left overs were to be dated with date prepared, and either discarded by 3rd day or placed in the freezer. On 3/4/24 at 3:28 PM the Administrator stated she expected kitchen items to be monitored and discarded at time of expiration. On 3/5/24 at 2:19 PM the KS stated the expectation is for gloves to be worn at the steam table. On 3/5/24 at 2:52 PM the Administrator stated she had spoken with the kitchen staff before regarding infection control. She stated the expectation for hand hygiene to be followed in the kitchen included use of gloves and washed hands. The facility policy Food Brought into Room from Outside Sources dated 6/2015 revealed that food that is not eaten will be labeled, dated, and stored in the nursing unit's refrigerator. If not eaten within 3 days, it will be discarded. The facility policy Sanitation - Personal Hygiene dated 6/2015 revealed use of a hair restraint at all times and all hair is to be covered, gloves were to be used when handling potentially hazardous foods, changed often once a task had been completed, and when gloves were removed, hands were to be washed before proceeding.

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

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Based on observations, clinical record review, policy review, and staff interview the facility failed to complete proper hand hygiene between assisting residents to dine, after completing incontinence care for one of three residents reviewed (Resident #13) and failed to apply a glove before touching popcorn provided to a resident to maintain standard precaution for infection control. The facility reported a census of 17 residents. Findings include: 1. Observation on 3/05/24 at 12:20 PM, observed Staff G wipe a resident's nose with a tissue with her right hand, did not complete hand hygiene, and then with the same hand proceeded to assist another resident with dining, touching that resident's arm, silverware, straw, and glass. 2. The Minimum Data Set (MDS) assessment for Resident #13, dated 2/7/24, included diagnoses of blindness, non-Alzheimer's dementia, and psychotic disorder. The MDS identified the resident dependent on staff for toilet hygiene, always incontinent of urine and occasionally incontinent of bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 7, indicating moderate cognitive impairment. During an observation on 3/5/24 at 11:42 AM, Staff F, Certified Nurse Aide washed her hands, gloved, and assisted Resident #13 from a recliner to the bathroom. Resident's pants visibly wet on the left side/hip area and the back/ buttock area of pants, and the pad in the recliner with a wet brown area. Staff F removed the resident's pants and pull-up, with a large amount of loose stool in the pull-up, then changed gloves and washed hands. Staff F cleansed between buttocks and to mid buttocks, did not cleanse outer and upper buttocks and hips. Staff F removed gloves, did not wash hands, and proceeded to touch the resident's clothing, walker, gait belt, and assisted resident to walk to the dining room and applied a clothing protector on the resident. 3. Observation on 3/04/24 at 2:40 PM, observed the Activity Director scoop popcorn into a cup with her bare hand and give the cup of popcorn to a resident. Facility policy Hand Hygiene, reviewed 3/2022, documented healthcare providers must perform hand hygiene immediately before touching a resident or the resident's immediate environment, immediately after glove removal, and after blowing nose. Interview on 3/06/24 at 3:57 PM, the Director of Nursing stated expectation to wash hands after removing gloves after completing incontinence care and to complete hand hygiene between assisting residents.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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Based on observations, resident interviews, clinical record review, facility record review and staff interviews the facility failed to provide activities to meet the interests, and the physical, mental, and psychosocial well-being of the residents for 3 of 3 reviewed (Resident #7, #10 and #11). The facility reported a census of 17 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #7, dated 1/2/24, documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment for decision-making. Interview on 3/04/24 at 1:54 PM, Resident #7 stated they have activities when someone is here to do them and would attend more activities if they had them. Interview on 3/05/24 at 10:25 AM, Resident #7 in room coloring and stated they did not have or attend an activity this morning unless they didn't tell her. Interview on 3/06/24 at 9:30 AM, Resident #7 stated they did not have scheduled 6PM craft activity last night, as would have attended. 2. The MDS assessment for Resident #10, dated 12/22/23, documented the resident had a BIMS score of 15, indicating no cognitive impairment for decision-making. Interview on 3/04/24 at 1:15 PM, Resident #10 stated she attended bingo this morning, they do have some activities, but would like to have activities such as painting, drawing, or crafts. Observation on 3/05/24 at 10:18 AM, Resident #10 playing checkers with another resident, only 2 residents in the activity area, and no scheduled activity at this time. The facility activity calendar for March 2024, listed activity for 3/5/24 at 10 AM, Coffee and Oldies but Goodies and at 6 PM Crafts. Interview on 3/06/24 at 9:30 AM, Resident #10 stated they did not have a scheduled 6PM craft activity last night, as would have attended as she really likes crafts. 3. Interview on 3/06/24 at 10:35 AM, Resident #11 stated has been at the facility about 2 months and they have started having a few activities in the past couple weeks. Resident #11 stated the activity calendar is not followed. Interview on 3/06/24 at 10:00 AM, Staff C, Licensed Practical Nurse works fulltime 6A - 6P and started at the facility about 2 months ago. Staff C stated the facility has started having activities in the past few weeks, maybe 1 a day. Interview on 3/6/24 at 11:14AM, the Activity Director (AD) stated she tries to do activities 2 times a day, a small one in the AM and larger one in the PM. The AD stated with the scheduled evening activities, the certified nurse aides have to do the activity, and she tries to leave something out for the activity. The AD stated she did not leave out anything for the scheduled craft activity last night. The AD stated she follows the schedule to the best she can and the weekend activities are radio church and sports television (TV) and the staff are to turn on the radio and TV for these activities. Interview on 3/06/24 at 11:59 AM, Staff F, Certified Nurse Aide stated the activities are not happening, can ask any resident, was supposed to be much better with the change in staff but has not, and have only been doing the activities since the surveyors came in this week. Interview on 3/07/24 at 9:30 AM, the Regional Nurse stated she was aware of problems with activities prior to the survey and her expectation for the facility is to provide activities 7 days a week and at scheduled times.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and policy review the facility failed to prepare and serve food in accordance with appropriate temperatures. The facility reported a census of 17 residents. Findings include: 1. Observation on 3/5/24 at 11:25 A.M. of the noon mealtime preparation revealed Staff A, Dietary Cook, removed the bacon from the oven, and placed it on the steam table. The bacon had a temperature over 160 degrees upon removal from the oven. Staff A removed the french fries from the oven and placed them on the steam table without taking the temperature. Observed the meal service begin at 12:05 PM and end at 12:35 PM on 3/5/24. Temperatures not taken prior to initiating the meal service. At the end of the meal service, requested Staff A and the Kitchen Supervisor (KS) complete temperatures of the food left on the steam table. Temperatures as follows: bacon 120° Fahrenheit (F), french fries 120° F, deviled eggs 73.9° F, coleslaw 61.3° F, and tomatoes 64.4° F. The KS on 3/5/24 at 2:19 PM stated temperatures on the steam table were to be held at 135° F. The KS acknowledged the final plate was not at the required temperatures. The supervisor not aware temperatures were not taken prior to meal service initiation. On 03/05/24 at 2:52 PM the Administrator (ADM) stated the expectation would be temperatures taken before and after serving meals. 2. Review of Resident #8's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. During an interview on 3/04/24 at 1:18 PM with Resident #8 revealed that the food is cold often when it should be warm. Review of a facility provided policy titled, Sanitation and Food Production Holding, dated 6/2015 revealed hot-holding equipment, including steam tables, were to be utilized to maintain foods above 140° F, internal food temperatures should be taken prior to serving residents, and cold foods should be placed in cold holding equipment that keeps foods at 41° F or lower.

May 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 F0602 (Tag F0602)

Could have caused harm · This affected 1 resident

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Based on record review, staff interviews, facility investigative file review and facility policy review the facility failed to failed to prevent the misappropriation of 2 of 3 resident's (Resident #1 and #2) liquid morphine (treatment of moderate to severe pain). The facility reported a census of 17 residents. Finding include: The facility investigation included the following: - On 5/7/23 during the nurse shift change, Staff A, Agency Licensed Practical Nurse (LPN) refused to complete the narcotic count with the oncoming nurse. At 10:22 PM the Director of Nursing (DON) received a call from Staff B Agency Registered Nurse (RN) about 20 mg/mL of liquid morphine missing. The DON arrived to the facility at 10:25 PM and completed a narcotic count with Staff B. The narcotic count at that time revealed over 19 mL of liquid morphine had been missing. The police were notified at 12:44 AM on 5/8/23. Staff A's statement included, drug test obtained, and is suspended pending further investigation. - The DON and Staff B found Resident #2's liquid morphine was short by 10.57 mL and they noted Staff A was the only nurse that had ever signed out the PRN medication in the last 3 months. During her interview Staff A admitted to not looking at the liquid morphine when she did her counts at shift change. - The DON and Staff B found Resident #1's liquid morphine was short by 9.6 mL and noted Staff A was the only nurse that had signed out medication in the last month. - Staff B wrote the following statement: on the evening of May 7, 2023, she arrived to the facility. During shift change, the day nurse refused to count the narcotics. Following her departure from the building Staff B tended to the necessary cares of her residents and then reviewed the narcotics in the drawer with the Certified Nursing Assistant (CNA) as her witness. Staff B discovered 20 mL of oral solution morphine missing-the total amount missing from two different oral solution morphine bottles. The Administrator and DON also reviewed the discrepancy with her and verified the 20 mL of missing and unaccounted for morphine solution. The statement was signed by Staff B. - Staff C CNA wrote the following statement: she was working the overnight shift on 5/7/23 when the night nurse was counting narcotics and noticed that some medications were missing; 20 mL of morphine. The statement was signed by Staff C. - Staff A wrote the following statement on 5/9/23: when counting medications each day by herself before shift change, she did not look at the morphine bottles. She only counted the pills. She had not looked at the morphine since the last time she gave it to a resident. - Staff A will no longer be assigned hours at the facility. - The facility sent Staff A to the clinic for a drug test on 5/8/23, test positive for marijuana. - Coaching provided to Staff A - she admitted to not counting narcotics. When approached about not signing out the Lorazepam she indicated the resident was sleeping and could not wake her so she destroyed the medication putting in in the sharps box. - All nurses to be re-educated on procedures for counting narcotics. 1. The admission Minimum Data Set (MDS) with a reference date of 4/20/23 documented Resident #1 was unable to completed the Brief Interview of Mental Status (BIMS). The MDS indicated she had severely impaired cognitive skills for daily decision making. Resident #1 received an as needed (PRN) pain medication or one was offered and declined. The MDS listed the following diagnoses: dementia, cancer, and anxiety. The care plan focus area with an initiation date of 4/28/23 indicated she had been placed on hospice services. Review of Resident #1's May 2023 Medication Administration Record (MAR) revealed she had the following PRN order: -Morphine 20 milligrams (mg)/milliliter (mL); give 0.2 mL by mouth every 1 hours PRN for pain, with a start date of 4/14/23. Review of Resident #1's morphine 20 mg/mL PRN Controlled Drug Record revealed Staff A signed out the medication as given on 4/19/23 and 5/1/23. The last dose given on 5/1/23 by Staff A documented 29.6 mL remained. On 5/7/23 at 10:45 PM Staff B documented count correction with 20 mL as the remaining amount. An incident report dated 5/8/23 documented on 5/8/23 resident's morphine was short 9.6 mL. The State Agency, law enforcement, and corporate notified and the nurse was suspended. In the other information section, the DON documented Staff A was the only nurse that had signed off on the medication sheet and admitted to not looking at the medication for the count. 2. The Quarterly MDS with a reference date of 3/20/23 documented Resident #2 had a BIMS score of 6. A BIMS score of 6 suggested severe cognitive impairment. The MDS documented she received a scheduled pain medication regimen due to her occasional pain in the last 5 days of the review period. The MDS listed the following diagnoses for Resident #2: stroke, dementia, depression, and insomnia. The care plan focus area with an initiation date of 1/17/23 indicated she was placed on hospice services. Review of Resident #2's May 2023 MAR revealed she had the following PRN order: -Morphine 20 mg/mL; give 0.13 mL every 4 hours as needed for pain, with a start date of 12/20/22. Review of Resident #2's morphine 20 mg/mL; give 0.13 mL every 4 hours order Controlled Drug Administration Record Liquid revealed the physician wrote the order on 12/20/22. The count sheet showed Staff A had signed out the order the last four doses for her PRN order on: 2/11/23, 2/18/23, 4/15/23, and 4/16/23. The last dose given on 4/16/23 at 5:00 AM by Staff A documented 18.63 mL remained. On 5/7/23 at 10:45 PM Staff B documented count correction with 8.3 mL as the remaining amount. An incident report dated 5/11/23 documented on 5/8/23 resident's morphine was short 10.57 mL. The State Agency, law enforcement, and corporate notified and the nurse was suspended. In the other information section, the DON documented Staff A was the only nurse that had signed off on the medication sheet and admitted to not looking at the medication for the count. The Pharmacy Consultant sent the following email to the DON, Administrator, and MDS Coordinator on 5/14/23 at 7:25 PM: when he visited the facility on 4/12/23, noticed a significant (approximately 5 mL less in the bottle than the on-hand sheet said) discrepancy in the volume of a liquid morphine bottle during an audit of the medication cart's controlled substances. He informed the DON about this discrepancy and advised her to review the administration history and cross reference with the Electronic Health Record (EHR) in case the doses weren't being record on the on-hand sheet by mistake. When he visited the facility on 5/11/23 the DON showed him an on-hand sheet for a different morphine bottle where she had noticed a nurse had written a corrected volume of 20 mL without a corroborating witness signature. This nurse was the only one administrating this medication the last few times after the correction. It had been subsequently determined that this nurse was the one who had diverted liquid morphine in both instances. The DON said that when she was alerted last month about the discrepancy, she kept a closer eye on the on-hand sheets, which is how it was determined to not be a mistake, rather intentional diversion by that nurse. It appeared that the problem of a staff member diverting controlled substances had been resolved, though more attention needs to be paid by the nurses while doing inventory counts at shift change. On 5/17/23 at 10:24 AM Staff D LPN stated the narcotic counts are completed at shift change, with two nurses. On 5/17/23 at 11:53 AM Staff C stated she witnessed Staff B complete the count the night in question. She indicated Staff B placed the bottle of morphine on top of the nurse's station, on a level area, to see how much was left in the bottles. She then poured it out to measure it more accurately because what was in the bottle and on the count sheet were two different numbers. When asked how she was to work with, she stated Staff A was not good as a nurse but as a CNA she would be good. When asked if she ever saw her take medications she indicated she had not and would not think she would take medications. On 5/17/23 at 1:43 PM the DON indicated she received a call from Staff B, that worked that night on 5/7/23. The call came in at 10:22 PM that evening, she had asked Staff A to do the narcotic count with her but had refused because Staff A indicated she already did it. The DON stated Staff A had signed off that the narcotics were counted and accounted for. This is to be completed between the two nurses at shift change and documented together. Staff B stated she did the count by herself, while Staff C witnessed her. At that time Staff B found a discrepancy with roughly 20 mL of morphine from two different resident's bottles to be missing; it was just gone. The DON came in, completed a count and found that it was gone too. When they looked at narcotic count sheets only two doses had been taken from she believes Resident #1's bottles. She should have had 29.6 mL left but it was at 20 mL. Resident #2's morphine was off almost as much but does not remember exactly. When she looked at the narcotic count sheet, Staff A was the only staff that had given her the morphine. She reported her findings to corporate office and the Administrator the next morning. Staff B offered to do a drug test but they set up a drug test to be completed on Staff A. Staff A missed two appointments that had been set up for her to get the drug test done and was 46 minutes late when she actually showed up for the test to be completed. The test results came back and did not show morphine, just tetrahydrocannabinol (THC) (a psychoactive substance found in the Cannabis sativa plant). The DON stated Staff A's husband is disabled and in pain, but did not think she would use it the medication. The DON indicated the month prior to this, while the pharmacy consultant was here doing an audit, he found a morphine bottle to be off 3-5 mLs of morphine. She had been watching it and Staff A. She was the only nurse giving the morphine to those residents. First time the count was off she thought it was no big deal, took it as a spill but 20 mL was a bit much that time around. She indicated she had no real issues with Staff A prior to this. When asked how she was as a nurse the DON indicated she's had better nurses. When asked to explain, she indicated Staff A had trimmed a nail on a diabetic resident, cut their toe and just left it. The DON indicated the bed was covered in blood and the resident told them what Staff A had done. The DON indicated Staff A was an agency nurse and was not there that long. On 5/18/23 at 12:39 PM DON was asked how nurses are expected to complete the narcotic count that's to be completed with two nurses at shift change. She indicated one will take the narcotic book and the other will go to the narcotic draw. The nurse that is at the drawer will count the narcotic packets or bottles. The nurse that has the narcotic book will verify how any count sheets they have compare to the packets or bottles on hand. These two numbers have to match up. Staff are to look at each individual medication and look at: the resident name, the dose and number of doses are left, then make sure it matches on the paper. She acknowledged it is not getting done on every shift. At 12:40 PM the DON acknowledged there were issues with how the nurses completed the narcotic counts between shifts. She provided an education sheet that she started on 5/8/23: I have been educated by the DON on the proper way to do narcotic count at the beginning and end of shift. On 5/19/23 at 1:46 PM DON was asked what she did to keep a closer eye on the liquid morphine amounts after the pharmacy consultant noticed a discrepancy in April. She started watching to see who was signing out meds, watch the resident's pain levels, and watch administration of the narcotics. Discussed the issue in their morning meetings with the department heads. When they noticed the PRN narcotics were always given by Staff A numerous times, they switched her from the overnight shift to day shift to keep a closer eye on her. This happened within days of talking with the pharmacy consultant. While on the day shift and during medication pass if she noticed the PRN narcotics had been administered, the DON would go in and talk with the resident about their pain levels before and after the administration. She acknowledged the use of the pain narcotics had slowed down and was not being given while Staff A was there. The DON indicated Staff A had numerous write ups and coaching. The MDS Coordinator coached her but she was just not learning. The DON indicated she had been watching the narcotic counts being completed between both shifts to ensure it was getting done. The DON was asked if Staff B would be available to speak to due to the team being unable to reach her via telephone. She indicated she was out of the country for a wedding. On 5/17/23 at 2:20 PM the responding police officer stated his report is not done and he has not spoken to the nurse in question. He reported things have been crazy busy. On 5/18/23 at 9:49 AM Staff A stated she worked the day shift and worked at the facility for a couple months. She acknowledged narcotic counts are to be completed at the beginning and end of the shift with two nurses. She denied the facility utilized Certified Medication Aides (CMA). Staff A stated they are to document on a paper at the front of the narcotic binder. When asked why she was not currently working at the facility she stated apparently there was some morphine missing, does not remember how much was missing but the DON had told her about it. Staff A was asked why she did not want to do the narcotic count on 5/7/23 with the oncoming nurse and she stated most of time they count ahead of time then just hand the medication cart keys off to the next shift. Staff A was asked to clarify what she did that day, she counted the narcotics by herself then gave the next nurse the keys. When asked if this should be done by two nurse she sated a lot of nurses will do the counts ahead of time, alone. When asked what nurses did that, she acknowledged all of them. Staff A stated she assumed she documented that she completed the count on 5/7/23 but can't remember because it's been so long. Staff A admitted to administering morphine since being here roughly two times but could not think of which resident it was for. She denied taking the unaccounted morphine from the facility and denied ever hearing of another staff member taking the unaccounted morphine. She added if she knew someone did, she would have reported it. On 5/18/23 at 12:45 PM the MDS Coordinator stated when he works the floor, some nurses will say they already did the count but he will still do the count with the nurse present. On 5/19/23 at 2:33 PM the Pharmacy Consultant stated he went to the facility in April to completed his monthly audit of the narcotics on the medication cart and noticed a morphine bottle was significantly lower than what sheet stated. There was 5 mL missing, unaccounted for but could not remember which resident had the missing medication. He reported this to the DON so she could look in to it further; poor documentation or a drug diversion. The DON told him she would look in to it. The facility's Abuse Prevention Program and Reporting Policy with a revision date of 8/2019 indicated the facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of resident/patient property by anyone including but not limited to: staff, family or friends. Residents have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. The policy defined misappropriation of resident/patient property as deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/patient's belongings or money without the resident/patient's consent.

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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on record review, facility investigation review, staff interviews and facility policy review the facility failed to appropriately complete narcotic counts at shift change with two nurses, failed to complete narcotic counts at shift change, failed to have a system that documented each individual narcotic was accounted for and accurate at the end of shift change, and failed to appropriately document a resident's controlled substance was not administered then failed to dispose of the controlled substance appropriately. The facility reported a census of 17 residents. Findings include: The facility investigation included the following: - On 5/7/23 during the nurse shift change, Staff A Agency Licensed Practical Nurse (LPN) refused to complete the narcotic count with the oncoming nurse. At 10:22 PM the Director of Nursing (DON) received a call from Staff B Agency Registered Nurse (RN) about 20 mg/mL of liquid morphine missing. The DON arrived to the facility at 10:25 PM and completed a narcotic count with Staff B. The narcotic count at that time revealed over 19 mL of liquid morphine had been missing. The police were notified at 12:44 AM on 5/8/23. Staff A's statement included, drug test obtained and is suspended pending further investigation. - The DON and Staff B found Resident #2's liquid morphine was short by 10.57 mL and they noted Staff A was the only nurse that had ever signed out the PRN medication in the last 3 months. During her interview Staff A admitted to not looking at the liquid morphine when she did her counts at shift change. - The DON and Staff B found Resident #1's liquid morphine was short by 9.6 mL and noted Staff A was the only nurse that had signed out medication in the last month. - Staff B wrote the following statement: on the evening of May 7, 2023, she arrived to the facility. During shift change, the day nurse refused to count the narcotics. Following her departure from the building Staff B tended to the necessary cares of her residents and then reviewed the narcotics in the drawer with the Certified Nursing Assistant (CNA) as her witness. Staff B discovered 20 mL of oral solution morphine missing-the totally amount missing from two different oral solution morphine. The Administrator and DON also reviewed the discrepancy with her and verified the 20 mL of missing and unaccounted for morphine solution. The statement was signed by Staff B. - Staff C CNA wrote the following statement: she was working the overnight shift on 5/7/23 when the night nurse was counting narcotics and noticed that some medications were missing; 20 mL of morphine. The statement was signed by Staff C. - Staff A wrote the following statement on 5/9/23: when counting medications each day by herself before shift change, she did not look at the morphine bottles. She only counted the pills. She had not looked at the morphine since the last time she gave it to a resident. - Staff A will no longer being assigned hours at the facility. - The facility sent Staff A to the clinic for a drug test on 5/8/23, test positive for marijuana. - Coaching provided to Staff A - she admitted to not counting narcotics. When approached about not signing out the liquid morphine she indicated the resident was sleeping and could not wake her so she destroyed the medication putting in in the sharps box. - All nurses to be re-educated on procedures for counting narcotics. Review of the Master Count Sheet Record contained the following instructions: - Two licensed nurses must reconcile all doses of controlled substances stored in the medication cart and/or refrigerator at the change of each shift. - The on-coming nurse shall inspect each package of controlled medications and read the remaining quantity in each package. - The off-going nurse shall read the remaining quantity documented on each resident Individual Controlled Substance Count Sheet record for their findings (example: reconciled). - Each nurse performing the reconciliation shall place his/her signature on the appropriate line for the date and shift. - If the quantities do not match, notify the Nursing Supervisor immediately to initiate an investigation. The Master Count Sheet Record included the following areas to be documented: date, time, number of containers, number of count sheets, nurse signature and a second nurse's signature. This form does not have an area for two nurses to document the amount remaining during the narcotic counts that are completed at shift change. Review of the Master Count Sheet Record from 4/25/23 6:00 PM through 5/16/23 at 6:00 PM revealed the counts were not completed on: 5/2/23 at 6:00 PM, 5/5/23 at 6:00 PM, 5/6/23 at 6:00 AM and 6:00 PM, and 5/10/23 at 6:00 PM. The number of containers was not documented on 4/27/23 at 6:00 PM. The number of containers and number of count sheets do not match on 5/14/23 at 6:00 PM. The facility's Controlled Drug Administration Record Tablet included the following areas to be documented: date, time, dose amount used, amount wasted and witnessed, administered by, and amount remaining. This form does not have an area for two nurses to document the amount remaining during the narcotic counts that are completed at shift change. On 5/17/23 at 10:24 AM Staff D LPN stated the narcotic counts are completed at shift change, with two nurses. On 5/17/23 at 11:53 AM Staff C stated she witnessed Staff B complete the count the night in question. She indicated Staff B placed the bottle of morphine on top of the nurse's station, on a level area, to see how much was left in the bottles. She then poured it out to measure it more accurately because what was in the bottle and on the count sheet were two different numbers. On 5/17/23 at 1:43 PM the DON indicated she received a call from Staff B, that worked that night on 5/7/23. The call came in at 10:22 PM that evening, she had asked Staff A to do the narcotic count with her but had refused because Staff A indicated she already did it. The DON stated Staff A had signed off that the narcotics were counted and accounted for. This is to be completed between the two nurses at shift change and documented together. Staff B stated she did the count by herself, while Staff C witnessed her. At that time Staff B found a discrepancy with roughly 20 mL of morphine from two different resident's bottles to be missing; it was just gone. The DON came in, completed a count and found that it was gone too. When they looked at narcotic count sheets only two doses had been taken from she believes Resident #1's bottles. She should have had 29.6 mL left but it was at 20 mL. Resident #2's morphine was off almost as much but does not remember exactly. When she looked at the narcotic count sheet, Staff A was the only staff that had given her the morphine. She reported her findings to corporate office and the Administrator the next morning. The DON indicated the month prior to this, while pharmacy consultant was here doing an audit, he found a morphine bottle to be off 3-mils of morphine. She had been watching it and Staff A. She was the only nurse giving the morphine to those residents. First time the count was off she thought it was not big took it as a spill but 20 mL's was a bit much that time around. She indicated she had no real issues with Staff A prior to this. On 5/18/23 at 12:39 PM DON was asked how nurses are expected to complete the narcotic count, she stated that's to be completed with two nurses at shift change. She indicated one will take the narcotic book and the other will go to the narcotic drawer. The nurse that is at the drawer will count the narcotic packets and/or bottles. The nurse that has the narcotic book will verify how any count sheets they have compared to the packets or bottles on hand. These two numbers have to match up. Staff are to look at each individual medication and look at: the resident name, the dose and number of doses are left, then make sure it matches on the paper. She acknowledged it is not getting done on every shift. At 12:40 PM the DON acknowledged there were issues with how the nurses completed the narcotic counts between shifts. She provided an education sheet that she started on 5/8/23: I have been educated by the DON on the proper way to do narcotic count at the beginning and end of shift. On 5/19/23 at 1:46 PM DON was asked what she did to keep a closer eye on the liquid morphine amounts after the pharmacy consultant noticed a discrepancy in April. She started watching to see who was signing out medications, watch the resident's pain levels, and watch administration of the narcotics. Discussed the issue in their morning meetings with the department heads. When they noticed the PRN narcotics were always given by Staff A numerous times, they switched her from the overnight shift to day shift to keep a closer on eye her. This happened within days of talking with the pharmacy consultant. While on the day shift and during medication pass if she noticed the PRN narcotics had been administered, the DON would go in and talk with the resident about their pain levels before and after the administration. She acknowledged the use of the pain narcotics had slowed down and was not being given while Staff A was there. The DON indicated Staff A had numerous write ups and coaching. The MDS Coordinator coached her but she was just not learning. The DON indicated she had been watching the narcotic counts being completed between both shifts to ensure it was getting done. When asked how does the facility know the nurses have counted each individual controlled substance during their change of shift count, she acknowledged there is no way of actually verifying that the counts are correct and verified between the two nurses. She added she had been watching both change in shifts complete their narcotic counts. The DON agreed the form just asks for the nurses to document the number of controlled substance packets and count sheets. The form does not include the actual amount remaining with each medication be counted. The DON was asked if Staff B would be available to speak to due to the team being unable to reach her via telephone. She indicated she was out of the country for a wedding. On 5/18/23 at 9:49 AM Staff A stated she worked the day shift and worked at the facility for a couple months. She acknowledged narcotic counts are to be completed at the beginning and end of the shift with two nurses. She denied the facility utilized Certified Medication Aides (CMA). Staff A stated they are to document on a paper at the front of the narcotic binder. When asked why she was not currently working at the facility she stated apparently there was some morphine missing, does not remember how much was missing but the DON had told her about it. Staff A was asked why she did not want to do the narcotic count on 5/7/23 with the oncoming nurse and she stated most of time they count ahead of time then just hand the medication cart keys off to the next shift. Staff A was asked to clarify what she did that day, she counted the narcotics by herself then gave the next nurse the keys. When asked if this should be done by two nurse she sated a lot of nurses will do the counts ahead of time, alone. When asked what nurses did that, she acknowledged all of them. Staff A stated she assumed she documented that she completed the count on 5/7/23 but can't remember because it's been so long. On 5/18/23 at 12:45 PM the MDS Coordinator stated when he works the floor, some nurses will say they already did the count but he will still do the count with the nurse present. 2. The Significant Change Minimum Data Set (MDS) with a reference date of 4/28/23 documented Resident #3 had moderately impaired cognitive skills for daily decision making. The MDS documented she received an antipsychotic 6 days of the 7 day review period. The MDS listed the following diagnoses for Resident #3: stroke, dementia, depression, and psychotic disorder. The care plan focus area with an initiation date of 9/8/22 documented Resident #3 had a history of behavior problems and potential for behaviors due to vascular dementia and a history of a brain tumor. The care plan instructed staff to administer her medications are ordered. Review of Resident #3 May 2023 Medication Administration Record (MAR) revealed she had the following order: -Lorazepam 0.5 milligram (mg) give one tablet twice a day (BID) for increased anxiety. The order was not signed out as being given at lunch on 5/6/2023. -Resource three times a day (TID) for decreased appetite, give 4 ounces (oz) 3 times a day. The order was not signed out as being given at lunch on 5/6/23. -Tylenol Extra Strength 500 mg, give 2 tablets TID. The order was not signed out as being given at lunch on 5/6/23. The progress notes were reviewed and there were no notes documented on 5/6/23 for Resident #3. Review of Resident #3's Controlled Drug Administration Record Tablet for her lorazepam 0.5 mg order revealed it was signed out as given on 5/6/23 at 11:00 AM by Staff A Under the Amount Wasted and Witnessed category the number 0 was documented. The facility completed the following Medication Error Report: On 5/6/23 Resident #3's lorazepam 0.5 mg tab due at noon was signed out on the narcotic sheet. The medication was not signed out on the MAR. The facility was not able to determine if the resident received the medication or not. Staff A was the nurse they documented as involved in the medication error. On 5/17/23 at 1:43 PM the Director of Nursing (DON) stated on 5/7/23 she noticed Resident #3's lorazepam order was given, was not signed out on the MAR but signed out on the narcotic sheet by Staff A. When they questioned Staff A she indicated she put the pill in the sharps container, with no witness. When they pulled the sharps container out, it was full of pills. When asked how nurses are to waste medications she stated two nurses are to be present to witness them being destroyed in the drug buster in the medication room. Both nurses are to sign off on the count sheet that the medication was wasted. On 5/18/23 at 9:49 AM Staff A Agency Licensed Practical Nurse (LPN) when asked why Resident #3's Lorazepam order was left blank on the MAR but signed out as given on the count sheet, she questioned if she really left the order blank on the MAR. She added the resident was sleeping and was hoping she would wake up to take the medication. When asked if she should have documented the resident refused the medication on the MAR, she again questioned the order being left blank on the MAR. Staff A acknowledged she does place refused medications in the sharps container but there is a drug buster in the medication room where they can destroy the medication. Staff A was asked what the facility expected staff to do when destroying medications, she stated she never asked how to destroy them. The facility's Controlled Substances Policy with an effective date of 9/2018 indicated medications classified as controlled substances by the Drug Enforcement Administration (DEA) are subject to special handling, storage, disposal and record keeping in the facility in accordance with state and federal laws and regulations. Policies developed by the facility in accordance with state regulations may supersede the procedures outlined in this policy. The DON and the consultant pharmacist collaborate to maintain the facility's compliance with federal and state laws and regulations regarding the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications. When a dose of a controlled medication is removed from the container for administration but is refused by the resident or not given for any reason, the dose is not placed back in inventory. The dose must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose.

Apr 2023 22 deficiencies 3 IJ

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and policy review the facility failed to prevent abuse in the facility when staff documented unreasonable intimidation and punishment which resulted in mental anguish for 2 of 2 residents reviewed, (Resident #4 and #6). A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 2, 2022 on March 30, 2023 at 3:15 PM. The facility staff removed the Immediate Jeopardy on March 31, 2023 through the following actions: 1. Director of Nursing was suspended on 3/31/23 for alleged abuse pending the investigation. Resident #4 was interviewed by the Regional Director Clinical services on 3/30/23 to ensure resident rights are being honored including providing food including second portions, smoking breaks and incontinent care without any intent to discipline the resident. 2. Residents with a BIMS's of 13 or above were interviewed by Regional Director of Clinical Services and Social Service Director on 3/30/2023 related to any concerns of withholding food or smoking privileges with no voiced concerns noted. Residents with a BIMS of 12 or lower had a skin assessment completed by the Registered Nurse on 3/31/23 with no signs or symptoms of abuse noted. 3. The Administrator was educated on 3/31/2023 by the Regional Director of Operations related to requirements of abuse reporting, investigating potential abuse, abuse prevention, and resident's rights including providing goods and services free from disciplinary intent. Facility staff were reeducated by the Regional Director of Clinical Services beginning 3/30/23 on Abuse Prevention and Resident Rights including providing goods/services including food and smoking privileges without disciplinary intent. Employees will complete this training prior to the beginning of their next shift. 4. Regional Director of Operations or Regional Director of Clinical Services will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure the abuse policy continues to be followed including investigating potential withholding of goods and services with disciplinary intent and abuse investigations/reports including fractures continue completed as required. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Administrator is responsible for monitoring and follow-up as needed. The scope was lowered from a J to D after the surveyor verified the facility implemented education and their policy and procedures. The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview for Mental Status (BIMS) score of 12 suggesting moderately impaired cognition. The MDS documented need for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Progress Note Review Progress Note dated 5/20/2022 at 2:20 AM written by Staff H, Registered Nurse (RN) for Resident #4 revealed the following: Resident #4 refused her shower yesterday and signed a contract stating that she would not get cigarettes all day, but kept putting her light on wanting a cigarette. Resident #4 has been reminded about her signing a contract to have no cigarettes all day and wanted to talk to the person that had her sign the contract. The writer of this Progress Note asked her why and Resident #4 stated well they can say I can have a cigarette. Writer of this Progress Note told her that was not how that worked she can't unsign it. Writer of this Progress Note told her she was not going outside. The writer of this Progress Note then informed Resident #4 she had not had a shower since 5/13/22 and it was unacceptable she needs to shower twice a week no matter what. Resident #4 stated she changed her underwear several times a day. Writer of this Progress Note provided education that does not replace a shower. Progress Note dated 6/3/2022 at 1:51 AM written by Staff H for Resident #4 revealed the following: Resident #4 refused her shower, reminders that she signed a contract that if she doesn't get out of bed to take her shower she agrees to not go out to smoke. Reminders of this given to her at 7:50 PM. Resident #4 also asks for multiple snacks every night, gave two (2) oatmeal creme pies and complained it wasn't enough and wanted more and more and kept asking for a cigarette. Progress Note dated 6/17/2022 at 3:50 AM written by Staff H for Resident #4 revealed the following: Resident #4 continues with behaviors and not wanting to eat meals and just eat sweets. Resident #4 refused her shower and education given and reminder on contract she signed about getting up for meals and taking her showers. Resident #4 stated I want to talk to the person in charge. Writer of this Progress Note told her it was her and report given by day shift and unfortunately with rules Resident #4 was unable to go out to smoke. Progress Note dated 6/17/2022 at 1:18 PM written by the Director of Nursing (DON) for Resident #4 revealed the following: Resident #4 refused a bath yesterday and has refused to come out to meals today. Informed her she will not be smoking all weekend due to her choices. Progress Note dated 6/18/2022 at 1:30 PM written by the DON for Resident #4 revealed the following: Resident #4 refused to get out of bed for lunch or breakfast. She laid in her bed and wet it until all blankets were soaked. She has been told she is not going out to smoke all weekend due to her refusing her bath and there is nothing she can do until Monday until she can get a bath. Resident #4 signed a contract she would take a bath or she could not go out to smoke. Progress Note dated 6/18/2022 at 4:25 PM written by the DON for Resident #4 revealed the following: Resident #4 came out of her room at 3:00 PM to smoke and the writer of this Progress Note told her she is not smoking all weekend due to a contract she signed with the Director of Nursing (DON) stating she will take her bath or she doesn't get to smoke. She is angry and yelling. Resident #4 proceeded to go back to her room and had a bowel movement all over the bathroom, and a Certified Nurse Aide (CNA) had to mop up the mess. Resident #4 then said she was not coming out to supper. Progress Note dated 1/2/2023 at 4:19 PM written by Staff A, Licensed Practical Nurse (LPN), for Resident #4 revealed the following: Resident #4 had an agreement with the therapy department that she would go out to smoke then stay in her wheelchair until after supper. Resident #4 called her brother and told him that she was hurting so bad and staff were refusing to put her in the recliner. Staff talked to her brother and explained the situation while Resident #4 was yelling I didn't agree to that. Progress Note dated 2/4/23 at 5:12 PM written by Staff A, for Resident #4 revealed the following: Resident #4 was very rude to staff and yelling and screaming at them because they won't push her wheelchair to the dining room. Staff explained that it was part of her therapy and she needed to do it herself. Resident #4 threatened to tell her brother and have this place shut down. Resident #4 yelling at the CNA, when the CNA explained again they are not pushing her due to her therapy program Resident #4 made a physical gesture of flipping the CNA off. Progress Note dated 2/8/23 at 1:19 PM written by Staff A for Resident #4 revealed the following: CNA's entered Resident #4 room to answer her call light when Resident #4 voiced that she pooped her pants because no one would push her. Progress Note dated 3/3/2023 at 8:00 PM written by Staff I, LPN for Resident #4 revealed the following: Resident #4 at the dining room table tonight asked for second helpings of food. Resident #4 was shown paper on the table reminding her that she agreed with the Dietician that she would not ask for second helpings of food. Resident #4 then cussed at the staff while stating that she was going to get an attorney to shut the facility down. Resident #4 asked for second helpings four more times and each time staff would show her the paper and she would cuss at staff. After the fifth time staff came to the charge nurse (writer of this Progress Note) for assistance. The writer of this Progress Note informed that with this type of behavior there could be consequences and to let Resident #4 know she wasn't going out to smoke. Resident continued sitting at the dining room table and talked to another resident and bad mouthed and cussed about the staff to the other resident, stated she was going to have staff put in jail. At 7:50 PM she asked staff when they would be going out to smoke. The writer of this Progress Note went and told Resident #4 she would not be going out to smoke, when Resident #4 asked why the writer of this Progress Note reminded her she had asked five times for more food and each time she was shown the paper and reminded her of her agreement not to ask for second helpings of food and each time she began to cuss at staff and was inappropriate and after so many episodes she was advised there would be a consequence to such behavior. Resident #4 again cussed at the writer of this Progress Note and asked her for her name. Resident then stopped took a deep breath and then began saying please let me go out for just a little cigarette. The writer of this Progress Note stated no, and Resident #4 immediately started cussing and stated she was going to call her brother and have the facility shut down because she wasn't being treated right. The writer of this Progress Note asked why she wasn't being treated right and Resident #4 stated the CNA's were not appropriate to her, but could not provide specific details or name or describe which CNA. The writer of this Progress Note informed her that if someone wasn't appropriate that next time she needs to tell the nurse on duty and they will make sure there are consequences for them instead of her being rude and inappropriate and having consequences. After several moments of Resident #4 cussing at the writer of this Progress Note Resident #4 again took a deep breath and then began pleading with the writer of this Progress Note that she wouldn't cuss at staff again if she could just go out for a cigarette, the writer of this Progress Note quietly stated no and then stated she was going back to work unless there was something else Resident #4 wanted to discuss. Record review of a contract provided by the facility titled, Nutrition Therapy Recommendations dated 1/25/23 documented Resident #4 agreed to not ask for seconds at meals and decrease snacks. The contract was not signed by the resident, dietician, or an employee of the facility. During an observation on 3/30/23 at 1:18 PM in Resident #4's room a sign posted stated, you agreed with the dietitian that you will not ask for extra food at meal times and extra snacks as you have had substantial weight gain. The sign was signed by the Director of Nursing. During an interview on 3/30/23 at 1:45 PM, Resident #4 revealed she has had sadness or will get upset with staff not letting her go out to smoke, she revealed she has gotten mad several times when she was not allowed to smoke. Resident #4 also discussed that she was not allowed to have extra food at meals if she was still hungry, she revealed sometimes she might get a snack and sometimes not. During an interview on 3/30/23 at 2:40 PM with the DON revealed she does not recall a bathing contract for Resident #4 and doesn't know why Resident #4 wouldn't get to smoke if she refused a shower. She revealed the Dietician talked to Resident #4 and she agreed to not eat seconds at meals. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA stated the DON instructed if Resident #4 would not get out of bed or refused her bath that she would not be allowed to smoke. Staff D revealed she thought this was a rule and what they were supposed to do, because that was what their DON said. Staff D informed Resident #4 was usually not allowed to smoke a couple times a week, she added everyone followed that direction because the DON said to. Staff D then informed she was not sure if it was care planned or not. During an interview on 4/5/23 at 10:12 AM with Staff F, Certified Medication Aide (CMA) revealed Resident #4 was on a no seconds at meals and a no snacks contract. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating she was cognitively intact. The MDS documented needs for extensive assistance (resident involved in activity, staff provide weight-bearing support) of two person physical assist with bed mobility, transfers, dressing, and toilet use. The MDS documented diagnoses of cerebral palsy, hypertension, anxiety disorder, depression, and mixed incontinence. Progress Notes Review Progress Note for Resident #6 dated 5/2/22 at 3:21 AM written by Staff H revealed the following: Resident #6 put her light on at 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM and 10:45 PM staff into room all of these times. Resident #6 was incontinent of urine at 4:00 PM, 6:00 PM and 10:45 PM and incontinent of bowel at 8:00 PM. Resident #6 educated that there was no reason for her to be incontinent at all as she was the youngest resident here and has had no children. Her control was amazing and can go from 11:00 PM to 7:00 AM without ever urinating and if doing activities she likes can go up to 6 hours during the day without voiding. Resident #6 only has accidents for attention and when she was mad and she doesn't get her way on something, which she didn't get her way on her coffee, she can only have two cups a day period according to her sister who was very mad at her due to all her behaviors and manipulating CNA's to allow her finish a show. The writer of this Progress Note went to Resident #6 room at 11:10 PM and educated her again to not manipulate staff to allow her do things she wasn't supposed to do. Progress Note for Resident #6 dated 6/12/22 at 2:15 AM written by Staff H revealed the following: Resident #6 was very rude and snarky with CNA's, she was incontinent for no apparent reason. Resident #6 had always done this for attention even before she came to this facility. She was like this at home and where she lived before coming to the facility. Resident #6 was very demanding and pouting that she had to wait till 7:00 PM to go to bed. Staff have explained to her numerous times that there are other residents here that need care too and her patience would be greatly appreciated. Resident #6 mumbles under her breathe, being mean and nasty to staff then lying about her cares when staff have been in her room two at a time due to her behaviors and lying. The writer of this Progress Note stood outside her room and listened and intervened to her pouting. Progress Note for Resident #6 dated 6/13/22 at 3:03 AM written by Staff H revealed the following: Resident #6 continued to be rude and demanding to staff. She was on her call light every two (2) hours by the clock. She was incontinent for no reason other than thinks she can get changed and go to bed or her skin will breakdown so she can lay in bed all the time. Resident #6 has the mentality of a teenager related to her diagnosis of cerebral palsy. Her family is aware of her behaviors but not lately, she has the best bladder control of all residents at the facility. Progress Note for Resident #6 dated 6/13/22 at 8:45 AM written by the DON revealed the following: Resident #6 ate her breakfast and had coffee then went back to her room and pooped her pants. Her sister was coming to bring her some stuff and was told what she did. Progress Note for Resident #6 dated 6/17/22 at 1:14 PM written by the DON revealed the following: Resident #6 went back from lunch and soiled her pants. She already asked if she could go to bed early tonight and the writer of this progress note told her it was based on her behaviors. Progress Note for Resident #6 dated 8/6/22 at 8:00 PM written by Staff H revealed the following: Resident #6 was incontinent of urine right before staff put her on the commode and after they put her to bed was incontinent of bowels. The writer of this progress note asked her why she was incontinent when she has best bladder control out of everyone at the facility and definitely has the best bowel control out of everyone here. The writer of this progress note told her there was no excuse other than she wanted to go to bed right away and didn't want to sit on the commode. Resident #6 folded her arms across her chest and said nothing just had a pout on her face. Progress Note for Resident #6 dated 8/10/22 at 3:05 PM written by Staff A revealed the following: Resident #6 very upset and pouting as she had to get weighed after she had already eaten breakfast. Resident #6 wanted to be weighed before she ate and staff didn't have time to weigh her before breakfast. Resident #6 pouted all day and would hardly answer staff when they talked to her, she sat in her room with her arms crossed over her chest and looked at the floor anytime staff entered. Progress Note for Resident #6 dated 8/12/22 at 2:21 AM written by Staff H revealed the following: Resident #6 had an increase in behaviors when she doesn't get her own way, like she didn't last night, and was incontinent of bowel and bladder. She was increasingly incontinent for no reason other than for attention and/or she was mad. Her sister was very upset with her and each time she is incontinent added 15 minutes on her time of laying down early on Sunday which she was already unable to lay down at 4:00 PM Sunday due to incontinence, her sister was very upset with her. Progress Note for Resident #6 dated 8/17/22 at 1:52 AM written by Staff H revealed the following: Resident #6 continued to manipulate staff and incontinent for attention. Anxiety when she doesn't get what she wants. Progress Note for Resident #6 dated 1/26/23 1:11 PM written by Staff A revealed the following: Resident #6 up to the dining room for breakfast and started to go back to her room at 7:30 AM, when asked where she was going she replied she was going back to here room. Staff told her it was time for breakfast and she needed to stay. Resident #6 then said she wanted to move to a different table, when asked her why she refused to answer and sat in the middle of the walkway and pouted. Progress Note for Resident #6 dated 2/9/23 at 1:14 PM written by Staff A revealed the following: Resident #6 very needy and manipulative today. Call light on to have staff put her exercise bar away when she knew that she was supposed to wait until staff come to her room then she can ask to put it away. She has turned on her call light to ask staff to get things for her. She had asked multiple times for multiple things while staff were trying to complete the first request. Repeatedly stated I've been good today I haven't bothered you at all today have I. Staff encouraged her to come out of her room, but prefers to isolate herself in her room. Progress Note for Resident #6 dated 2/18/23 at 12:58 PM written by Staff A revealed the following: Resident #6 very upset and pouting when she got her coffee this morning. The cup wasn't filled to the brim and she didn't think she was getting her full cup. Staff attempted to explain that it was dangerous to carry a cup too full and could get burned Resident #6 dropped her head and wouldn't talk anymore. Progress Note for Resident #6 dated 2/28/23 at 1:08 PM written by Staff A revealed the following: Resident #6 stayed in the dining room too long after breakfast this morning and pooped her pants, resident went to her room and noted to be smiling and grinning and said to CNA's I know you're going to be mad at me. Staff explained to Resident #6 that she needed to start coming to her room sooner Resident #6 continued to smile and said I know. Progress Note for Resident #6 dated 3/15/23 at 8:58 AM written by the DON revealed the following: Resident #6 was incontinent of bowel two times yesterday. Not allowed to have coffee today. Progress Note dated 3/16/2023 at 8:55 AM written by the DON for Resident #6 revealed the following: Resident #6 had behaviors and lost her coffee privileges today. Resident #6 soiled her pants yesterday and it was not loose. She then got on her tablet until 2:00 AM. Told her it would be at the nurses station. During an interview on 3/30/23 at 9:40 AM Resident #6 revealed she was on a toileting program and can go once every two hours, she revealed the toileting program doesn't bother her as she has a weak bladder and they are trying to strengthen it. She revealed sometimes she gets sad about it because she might have an accident, and then they let her go. She revealed if she had an accident then she can not have any coffee for the day. She revealed she wouldn't give a name because she didn't want to get the person in trouble. She informed yesterday she lost three (3) cups of coffee since she had an accident on 3/28/23. She revealed her sister put a limit to two (2) cups a day, but she wants three (3) cups of coffee a day. She revealed she would like to have two (2) cups in the morning and one (1) at lunch, she revealed she loves her coffee. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA revealed the DON told her that Resident #6's sister wanted her to get less coffee if she was incontinent. The DON told Staff D this was the resident's sister's rule. Staff D was unsure if this was care planned. During an interview on 4/5/23 at 10:48 AM with Staff D, CNA she revealed Resident #6 goes to the bathroom every two hours, and if she made a mess then we would take her coffee away for that day. We were told it was her sisters rule. Before you came in to do the survey we enforced that. During an interview on 4/5/23 at 10:12 AM Staff F, CMA, revealed Resident #6 was on a toileting program for every two hours and the facility was not giving her extra coffee because that was what the Activities Director and Resident #6 sister decided on to help control some of her behaviors During an interview on 3/31/23 at 11:15 AM Staff G, Maintenance Supervisor, revealed he did not feel like he could tell another staff member if he had witnessed another staff member abuse or mistreat a resident. He indicated he had reported issues before and he would get told they were short staffed, what do you want us to do, he revealed they would tell him they would talk to the staff members in question, but nothing would change. Staff G then revealed he has heard the DON tell a resident if they took their bath staff would bring them out for lunch. He revealed he had also heard her tell residents to stay in their rooms and that she didn't have time for them. When asked if he would at least tell the Administrator, he stated she was only in the building two times a month because she was at the corporations other facility. Review of the facilities policy titled, Abuse Prevention Program and Reporting Policy, last reviewed on 08/2019 instructed staff on the following instructions and definitions: The facility prohibits the mistreatment, neglect, and abuse of residents by anyone including but not limited to: staff, family, or friends. Resident have the right to be free from verbal, sexual, and mental abuse, neglect, misappropriation of resident property corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse: Includes, but not limited to intimidation with resulting mental anguish. Punishment with resulting mental anguish. Verbal Abuse: Oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental/Emotional Abuse: Include, but is not limited to humiliation, harassment, and threats of punishment or deprivation.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Report Alleged Abuse (Tag F0609)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to report to the Department of Inspections and Appeals (DIA) an accident with major injury for 1 of 1 residents (Resident #4). The facility also failed to identify and report to DIA abuse for 2 of 2 residents reviewed (Resident #4 and #6). A determination was made that the facility's noncompliance placed the residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 2, 2022 on March 30, 2023 at 3:00 PM. The Facility Staff removed the Immediate Jeopardy on March 31, 2023 through the following actions: 1. Director of Nursing was suspended on 3/31/23 for alleged abuse pending the investigation. Resident #4 was interviewed by the Regional Director Clinical services on 3/30/23 to ensure resident rights are being honored including providing food including second portions, smoking breaks and incontinent care without any intent to discipline the resident. 2. Residents with a BIMS's of 13 or above were interviewed by Regional Director of Clinical Services and Social Service Director on 03/30/2023 related to any concerns of withholding food or smoking privileges with no voiced concerns noted. Residents with a BIMS of 12 or lower had a skin assessment completed by the registered nurse on 03/31/23 with no signs or symptoms of abuse noted. 3. The Administrator was educated on 3/31/2023 by the Regional Director of Operations related to requirements of abuse reporting, investigating potential abuse, abuse prevention, and resident's rights including providing goods and services free from disciplinary intent. Facility staff were reeducated by the Regional Director of Clinical Services beginning 03/30/23 on Abuse prevention and resident rights including providing goods/services including food and smoking privileges without disciplinary intent. Employees will complete this training prior to the beginning of their next shift. 4. Regional Director of Operations or Regional Director of Clinical Services will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure the abuse policy continues to be followed including investigating potential withholding of goods and services with disciplinary intent and abuse investigations/reports including fractures continue completed as required. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Administrator is responsible for monitoring and follow-up as needed. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she has diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Review of untitled document with an admit date of 12/16/22 from the local hospital informed Resident #4 was admitted to the local hospital due to a left hip fracture from an unwitnessed fall at the facility. The document explained the wishes of the resident's Power of Attorney (POA) to proceed with surgery that included pinning of left femoral neck fracture (surgical procedure using wire or pins to hold a broken bone (fracture) together and keeps it still until it heals) Review of the facilities DIA self reports on 3/27/23 revealed the facility failed to report Resident #4 fall with major injury that occurred on 12/16/22. During an interview on 03/30/23 at 8:50 AM the Administrator revealed the physician determined if Resident #4's fall on 12/16/22 met the criteria for a major injury. During the interview the Administrator acknowledged Resident #4 fell at the facility and sustained a hip fracture and was out of the facility multiple days. Review of the facilities policy titled, Fall Risk Reduction and Management last revised on 12/2015 lacked instruction to staff on when and who would report resident falls to DIA. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she has diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Progress Note Review Progress Note dated 5/20/2022 at 2:20 AM written by Staff H, Registered Nurse (RN) for Resident #4 revealed the following: Resident #4 refused her shower yesterday and signed a contract stating that she would not get cigarettes all day, but kept putting her light on wanting a cigarette. Resident #4 had been reminded about her signed contract to have no cigarettes all day and wanted to talk to the person that had her sign the contract. The writer of this progress note asked her why and Resident #4 stated well they can say I can have a cigarette. Writer of this progress note told her that was not how that worked and she can't unsign it. Writer of this progress note told her she was not going outside. The writer of this progress note then informed Resident #4 she has not had a shower since 5/13/22 and it was unacceptable she needed to shower twice a week no matter what. Resident #4 stated she changed her underwear several times a day. Writer of this progress note provided education that does not replace a shower. Progress Note dated 6/3/2022 at 1:51 AM written by Staff H for Resident #4 revealed the following: Resident #4 refused her shower, reminded that she signed a contract that if she doesn't get out of bed to take her shower she agreed to not go out to smoke. Reminders of this given to her at 7:50 PM. Resident #4 also asked for multiple snacks every night, gave two (2) oatmeal creme pies and complained it wasn't enough and wanted more and more and continued to ask for a cigarette. Progress Note dated 6/17/2022 3:50 AM written by Staff H for Resident #4 revealed the following: Resident #4 continued with behaviors and not wanting to eat meals and just eat sweets. Resident #4 refused her shower and education given and reminder on contract she signed to get up for meals and take her showers. Resident #4 stated I want to talk to the person in charge. Writer of this progress note told her it was her and report given by day shift and unfortunately with rules Resident #4 was unable to go out to smoke. Progress Note dated 6/17/2022 at 1:18 PM written by the Director of Nursing (DON) for Resident #4 revealed the following: Resident #4 refused a bath yesterday and has refused to come out to meals today. Informed her she would not be smoking all weekend due to her choices. Progress Note dated 6/18/2022 at 1:30 PM written by the DON for Resident #4 revealed the following: Resident #4 refused to get out of bed for lunch or breakfast. She laid in her bed and wet it until all blankets were soaked. She had been told she was not going out to smoke all weekend due to her refusal to take her bath and there was nothing she could do until Monday until she can get a bath. Resident #4 signed a contract she would take a bath or she could not go out to smoke. Progress Note dated 6/18/2022 at 4:25 PM written by the DON for Resident #4 revealed the following: Resident #4 came out of her room at 3:00 PM to smoke and the writer of this progress note told her she was not allowed to smoke all weekend due to a contract she signed with the Director of Nursing (DON) that stated she would take her bath or she wouldn't get to smoke. She was angry and yelling. Resident #4 proceeded to go back to her room and had a bowel movement all over the bathroom, and a Certified Nurse Aide (CNA) had to mop up the mess. Resident #4 then said she was not coming out to supper. Progress Note dated 1/2/2023 at 4:19 PM written by Staff A, Licensed Practical Nurse (LPN), for Resident #4 revealed the following: Resident #4 had an agreement with the therapy department that she would go out to smoke then stay in her wheelchair until after supper. Resident #4 called her brother and told him that she was hurting so bad and staff were refusing to put her in the recliner. Staff talked to her brother and explained the situation while Resident #4 was yelling I didn't agree to that. Progress Note dated 2/4/23 at 5:12 PM written by Staff A, for Resident #4 revealed the following: Resident #4 was very rude to staff and yelled and screamed at them because they wouldn't push her wheelchair to the dining room. Staff explained that it was part of her therapy and she needed to do it herself. Resident #4 threatened to tell her brother and have this place shut down. Resident #4 yelled at the CNA, when the CNA explained again they would not push her due to her therapy program Resident #4 made a physical gesture of flipping the CNA off. Progress Note dated 2/8/23 at 1:19 PM written by Staff A for Resident #4 revealed the following: CNA's entered Resident #4 room to answer her call light when Resident #4 voiced that she pooped her pants because no one would push her. Progress Note dated 3/3/2023 at 8:00 PM written by Staff I, LPN for Resident #4 revealed the following: Resident #4 at the dining room table tonight asked for second helpings of food. Resident #4 was shown paper on the table and reminded her that she agreed with the dietician that she would not ask for second helpings of food. Resident #4 began to cuss at the staff and stated that she was going to get an attorney to shut the facility down. Resident #4 asked for second (2nd) helpings four (4) more time and each time staff would show her the paper and she would cuss at staff. After the fifth (5th) time staff came to the charge nurse (writer of this progress note) for assistance. The writer of this progress note informed that with this type of behavior there could be consequences and to let Resident #4 know she wasn't going out to smoke. Resident continued sitting at the dining room table and talked to another resident and bad mouthed and cussed about the staff to the other resident, stated she was going to have staff put in jail. At 7:50 PM she asked staff when they would be going out to smoke. The writer of this progress note went and told Resident #4 she would not be going out to smoke, when Resident #4 asked why the writer of this progress note reminded her she had asked five (5) times for more food and each time she was shown the paper and reminded her of her agreement not to ask for second (2nd) helpings of food and each time she began to cuss at staff and was inappropriate and after so many episodes she was advised there would be a consequence to such behavior. Resident #4 began to cuss at the writer of this progress note and asked her for her name. Resident then stopped took a deep breath and then said please let me go out for just a little cigarette. The writer of this progress note stated no, and Resident #4 immediately started to cuss and stated she was going to call her brother and have the facility shut down because she wasn't being treated right. The writer of this progress note asked why she wasn't being treat right and Resident #4 stated the CNA's were not appropriate to her, but could not provide specific details or name or describe which CNA. The writer of this progress note informed her that if someone wasn't appropriate that next time she needed to tell the nurse on duty and they would make sure there are consequences for them instead of her being rude and inappropriate and have consequences. After several moments of Resident #4 cussing at the writer of this progress note Resident #4 again took a deep breath and then began to plead with the writer of this progress note that she wouldn't cuss at staff again if she could just go out for a cigarette the writer of this progress note quietly stated no and then stated she was going back to work unless there was something else Resident #4 wanted to discuss. Record review of a contract provided by the facility titled, Nutrition Therapy Recommendations dated 1/25/23 documented Resident #4 agreed to not ask for seconds at meals and decrease snacks. The contract was not signed by the resident, dietician, or an employee of the facility. During an observation on 3/30/23 at 1:18 PM in Resident #4 room a sign posted stated, you agreed with the dietitian that you will not ask for extra food at meal times and extra snacks as you have had substantial weight gain. The sign was signed by the Director of Nursing. During an interview on 3/30/23 at 1:45 PM with Resident #4 revealed she has had sadness or would get upset with staff who don't allow her go out to smoke, she revealed she had gotten mad several times when she was not allowed to smoke. Resident #4 also discussed that she was not allowed to have extra food at meals if she was still hungry, she revealed sometimes she might get a snack and sometimes not. During an interview on 3/30/23 at 2:40 PM with the DON revealed she does not recall a bathing contract for Resident #4 and doesn't know why Resident #4 wouldn't get to smoke if she refused a shower. She revealed the Dietician talked to Resident #4 and she agreed to not eat seconds at meals. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA informed the DON instructed if Resident #4 would not get out of bed or refused her bath that she would not be allowed to smoke. Staff D revealed she thought this was a rule and what they were supposed to do, because that was what their DON said. Staff D informed Resident #4 was usually not allowed to smoke a couple times a week, she added everyone followed that direction because the DON said to. Staff D then informed she was not sure if it was care planned or not. During an interview on 4/5/23 at 10:12 AM with Staff F, Certified Medication Aide (CMA) revealed Resident #4 was on a no seconds at meals and a no snacks contract. 3. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact. The MDS documented needs for extensive assistance (resident involved in activity, staff provide weight-bearing support) of two person physical assist with bed mobility, transfers, dressing and toilet use. The MDS documented diagnoses of cerebral palsy, hypertension, anxiety disorder, depression, and mixed incontinence. Progress Notes Review Progress Note for Resident #6 dated 5/2/22 at 3:21 AM written by Staff H revealed the following: Resident #6 put her light on at 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM and 10:45 PM staff into room all of these times. Resident #6 was incontinent of urine at 4:00 PM, 6:00 PM and 10:45 PM and incontinent of bowel at 8:00 PM. Resident #6 educated that there was no reason for her to be incontinent at all as she was the youngest resident here and has had no children. Her control was amazing and can go from 11:00 PM to 7:00 AM without ever urinating and if doing activities she liked can go up to 6 hours during the day without voiding. Resident #6 only had accidents for attention and when she was mad and she doesn't get her way on something, which she didn't get her way on her coffee, she could only have two (2) cups a day period according to her sister who was very mad at her due to all her behaviors and manipulating CNA's to allow her finish a show. The writer of this progress note went to Resident #6 room at 11:10 PM and educated her again to not manipulate staff to allow her do things she wasn't supposed to do. Progress Note for Resident #6 dated 6/12/22 at 2:15 AM written by Staff H revealed the following: Resident #6 was very rude and snarky with CNA's she was incontinent for no apparent reason. Resident #6 had always done this for attention even before she came to this facility. She was like this at home and where she lived before coming to the facility. Resident #6 was very demanding and pouted that she had to wait till 7:00 PM to go to bed. Staff have explained to her numerous times that there are other residents here that need care too and her patience would be greatly appreciated. Resident #6 mumbles under her breathe being mean and nasty to staff then lied about her cares when staff have been in her room two (2) at a time due to her behaviors and lying. The writer of this progress note stood outside her room and listened and intervened to her pouting. Progress Note for Resident #6 dated 6/13/22 at 3:03 AM written by Staff H revealed the following: Resident #6 continued to be rude and demanding to staff. She was on her call light every two (2) hours by the clock. She was incontinent for no reason other than she thought she could get changed and go to bed or her skin will breakdown so she can lay in bed all the time. Resident #6 has the mentality of a teenager related to her diagnosis of cerebral palsy. Her family was aware of her behaviors but not lately, she had the best bladder control of all residents at the facility. Progress Note for Resident #6 dated 6/13/22 at 8:45 AM written by the DON revealed the following: Resident #6 ate her breakfast and had coffee then went back to her room and pooped her pants. Her sister was coming to bring her some stuff and was told what she did. Progress Note for Resident #6 dated 6/17/22 at 1:14 PM written by the DON revealed the following: Resident #6 went back from lunch and soiled her pants. She already asked if she could go to bed early tonight and the writer of this progress note told her it was based on her behaviors. Progress Note for Resident #6 dated 8/6/22 at 8:00 PM written by Staff H revealed the following: Resident #6 was incontinent of urine right before staff put her on the commode and after they put her to bed was incontinent of bowels. The writer of this progress note asked her why she was incontinent when she had best bladder control out of everyone at the facility and definitely had the best bowel control out of everyone here. The writer of this progress note told her there was no excuse other than she wanted to go to bed right away and didn't want to sit on the commode. Resident #6 folded her arms across her chest and said nothing just had a pout on her face. Progress Note for Resident #6 dated 8/10/22 at 3:05 PM written by Staff A revealed the following: Resident #6 very upset and pouted as she had to get weighed after she had already eaten breakfast. Resident #6 wanted to be weighed before she ate and staff didn't have time to weigh her before breakfast. Resident #6 pouted all day and would hardly answer staff when they talked to her, she sat in her room with her arms crossed over her chest and looked at the floor anytime staff entered. Progress Note for Resident #6 dated 8/12/22 at 2:21 AM written by Staff H revealed the following: Resident #6 having increased behaviors when she doesn't get her own way, like she didn't last night, and was incontinent of bowel and bladder. She was increasingly incontinent for no reason other than for attention and/or she was mad. Her sister was very upset with her and each time she was incontinent added 15 minutes on her time to lay down early on Sunday which already was unable to lay down at 4:00 PM Sunday due to incontinence, her sister was very upset with her. Progress Note for Resident #6 dated 8/17/22 at 1:52 AM written by Staff H revealed the following: Resident #6 continued to manipulate staff and incontinent for attention. Anxiety when she doesn't get what she wants. Progress Note for Resident #6 dated 1/26/23 1:11 PM written by Staff A revealed the following: Resident #6 up to the dining room for breakfast and started to go back to her room at 7:30 AM, when asked where she was going she replied she was going back to here room. Staff told her it was time for breakfast and she needed to stay. Resident #6 then said she wanted to move to a different table, when asked her why she refused to answer and sat in the middle of the walkway and pouted. Progress Note for Resident #6 dated 2/9/23 at 1:14 PM written by Staff A revealed the following: Resident #6 very needy and manipulative today. Call light on to have staff put her exercise bar away when she knew that she was supposed to wait until staff come to her room then she can ask them to put it away. She had turned on her call light to ask staff to get things for her. She was asking multiple times for multiple things while staff was trying to complete the first request. Repeatedly stated I've been good today I haven't bothered you at all today have I. Staff encouraged her to come out of her room, but prefers to isolate herself in her room. Progress Note for Resident #6 dated 2/18/23 at 12:58 PM written by Staff A revealed the following: Resident #6 very upset and pouted when she got her coffee this morning. The cup wasn't filled to the brim and she didn't think she was getting her full cup. Staff attempted to explain that it was dangerous to carry a cup too full and could get burned Resident #6 dropped her head and wouldn't talk anymore. Progress Note for Resident #6 dated 2/28/23 at 1:08 PM written by Staff A revealed the following: Resident #6 stayed in the dining room too long after breakfast this morning and pooped her pants, resident went to her room and noted to be smiling and grinning and said to CNA's I know you're going to be mad at me. Staff explained to Resident #6 that she needed to start coming to her room sooner Resident #6 continued to smile and said I know. Progress Note for Resident #6 dated 3/15/23 at 8:58 AM written by the DON revealed the following: Resident #6 was incontinent of bowel two times yesterday. Not allowed to have coffee today. Progress Note dated 3/16/2023 at 8:55 AM written by the DON for Resident #6 revealed the following: Resident #6 had behaviors and lost her coffee privileges today. Resident #6 soiled her pants yesterday and it was not loose. She then got on her tablet until 2:00 AM. Told her it would be at the nurses station. During an interview on 3/30/23 at 9:40 AM Resident #6 revealed she was on a toileting program and can go once every two hours, she revealed the toileting program doesn't bother her as she has a weak bladder and they are trying to strengthen it. She revealed sometimes she gets sad about it because she might have an accident, and then they let her go. She revealed if she had an accident then she can not have any coffee for the day. She revealed she wouldn't give a name because she didn't want to get the the person in trouble. She stated yesterday she lost three (3) cups of coffee since she had an accident on 3/28/23. She revealed her sister put a limit to two (2) cups a day, but she wanted three (3) cups of coffee a day. She revealed she would like to have two (2) cups in the morning and one (1) at lunch, she revealed she loved her coffee. During an email correspondence on 4/7/23 at 10:16 AM the facilities Regional Nurse Consultant revealed they have reported to DIA abuse concerns with the Director of Nursing and Staff I, Licensed Practical Nurse (LPN). During an interview on 4/4/23 at 1:04 PM with the facilities corporations Regional [NAME] President informed she would expect the Administrator to report abuse to DIA within two hours of identifying it or sooner. She had provided the facilities Administrator with training for Abuse and her direct care expectations. She revealed she would want it within two hours of the incident so help and support could be given and an investigation could be completed. She revealed she could help the Administrator with notifying DIA regarding falls with major injury as well.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0741 (Tag F0741)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interviews, and policy review the facility failed to ensure staff members posses the basic competencies and skill sets to meet the behavioral health needs of residents for whom the facility has assessed with identified behaviors for 2 of 2 residents reviewed (Resident #4 and #6). A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of May 2, 2022 on March 30, 2023 at 3:15 PM. The Facility Staff removed the Immediate Jeopardy on March 31, 2023 through the following actions: 1. Director of Nursing was suspended on 3/31/23 for alleged abuse pending the investigation. Resident #4 is currently followed by a contracted Psychiatric Services group with an appointment scheduled for 4/4/2023. Resident #4 was interviewed by the Regional Director Clinical services on 3/30/23 and offered to get a call for an earlier appointment. Resident #4 declined the need for an earlier appointment. 2. An audit was completed by the Regional Director of Clinical Services on 03/31/2023 to ensure staff have received training on resident rights and behavioral management with appropriate interventions. Any staff member that has not received the training will receive training prior to the beginning of their next scheduled shift. 3. Facility staff were reeducated by the Regional Director of Clinical Services beginning 3/30/23 on behavioral management with examples of appropriate interventions and resident rights including providing goods/services including food and smoking privileges without disciplinary intent. Employees will complete this training prior to the beginning of their next shift. 4. Interim Director of Nursing and Social Service Director will complete interviews of (3) residents and (3) staff weekly for 12 weeks to ensure staff continue to receive and follow behavior management training including providing appropriate interventions. Results of these audits will be presented to the QAPI meeting monthly for 3 months for review and recommendations as needed. The Interim Director of Nursing and Social Services Director are responsible for monitoring and follow-up as needed. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Progress Notes Progress Note dated 5/20/2022 at 2:20 AM written by Staff H, Registered Nurse (RN) for Resident #4 revealed the following: Resident #4 refused her shower yesterday and signed a contract which stated that she would not get cigarettes all day, but kept putting her light on wanting a cigarette. Resident #4 had been reminded about her signed contract to have no cigarettes all day and wanted to talk to the person that had her sign the contract. The writer of this progress note asked her why and Resident #4 stated well they can say I can have a cigarette. Writer of this progress note told her that was not how that worked she can't unsign it. Writer of this progress note told her she was not going outside. The writer of this progress note then informed Resident #4 she has not had a shower since 5/13/22 and it was unacceptable she needed to shower twice a week no matter what. Resident #4 stated she changed her underwear several times a day. Writer of this progress note provided education that does not replace a shower. Progress Note dated 6/3/2022 at 1:51 AM written by Staff H for Resident #4 revealed the following: Resident #4 refused her shower, reminded that she signed a contract that if she doesn't get out of bed to take her shower she agreed to not go out to smoke. Reminder of this given to her at 7:50 PM. Resident #4 also asks for multiple snacks every night, given two (2) oatmeal creme pies and complained it wasn't enough and wanted more and more and continued to ask for a cigarette. Progress Note dated 6/17/2022 3:50 AM written by Staff H for Resident #4 revealed the following: Resident #4 continued with behaviors and not wanting to eat meals and just eat sweets. Resident #4 refused her shower and education given and reminder on contract she signed about getting up for meals and taking her showers. Resident #4 stated I want to talk to the person in charge. Writer of this progress note told her it was her and report given by day shift and unfortunately with the rules Resident #4 was unable to go out to smoke. Progress Note dated 6/17/2022 at 1:18 PM written by the Director of Nursing (DON) for Resident #4 revealed the following: Resident #4 refused a bath yesterday and had refused to come out to meals today. Informed her she would not be allowed to smoke all weekend due to her choices. Progress Note dated 6/18/2022 at 1:30 PM written by the DON for Resident #4 revealed the following: Resident #4 refused to get out of bed for lunch or breakfast. She laid in her bed and wet it until all blankets were soaked. She had been told she was not going out to smoke all weekend due to her refusal of her bath and there was nothing she could do until Monday until she could get a bath. Resident #4 signed a contract she would take a bath or she could not go out to smoke. Progress Note dated 6/18/2022 at 4:25 PM written by the DON for Resident #4 revealed the following: Resident #4 came out of her room at 3:00 PM to smoke and the writer of this progress note told her she was not allowed to smoke all weekend due to a contract she signed with the Director of Nursing (DON) that stated she would take her bath or she doesn't get to smoke. She was angry and yelling. Resident #4 proceeded to go back to her room and had a bowel movement all over the bathroom, and a Certified Nurse Aide (CNA) had to mop up the mess. Resident #4 then said she was not coming out to supper. Progress Note dated 1/2/2023 at 4:19 PM written by Staff A, Licensed Practical Nurse (LPN), for Resident #4 revealed the following: Resident #4 had an agreement with the therapy department that she would go out to smoke then stay in her wheelchair until after supper. Resident #4 called her brother and told him that she was hurting so bad and staff were refusing to put her in the recliner. Staff talked to her brother and explained the situation while Resident #4 yelled I didn't agree to that. Progress Note dated 2/4/23 at 5:12 PM written by Staff A, for Resident #4 revealed the following: Resident #4 was very rude to staff and yelled and screamed at them because they wouldn't push her wheelchair to the dining room. Staff explained that it was part of her therapy and she needed to do it herself. Resident #4 threatened to tell her brother and have this place shut down. Resident #4 yelled at the CNA, when the CNA explained again they would not push her due to her therapy program Resident #4 made a physical gesture of flipping the CNA off. Progress Note dated 2/8/23 at 1:19 PM written by Staff A for Resident #4 revealed the following: CNA's entered Resident #4 room to answer her call light when Resident #4 voiced that she pooped her pants because no one would push her. Progress Note dated 3/3/2023 at 8:00 PM written by Staff I, LPN for Resident #4 revealed the following: Resident #4 at the dining room table tonight asked for second helpings of food. Resident #4 was shown paper on the table and reminded her that she agreed with the dietician that she would not ask for second helpings of food. Resident #4 began to cuss at the staff and stated that she was going to get an attorney to shut the facility down. Resident #4 asked for second (2nd) helpings four (4) more time and each time staff would show her the paper and she would cuss at staff. After the fifth (5th) time staff came to the charge nurse (writer of this progress note) for assistance. The writer of this progress note informed that with this type of behavior there could be consequences and to let Resident #4 know she wasn't going out to smoke. Resident continued sitting at the dining room table and talked to another resident and bad mouthed and cussed about the staff to the other resident, stated she was going to have staff put in jail. At 7:50 PM she asked staff when they would be going out to smoke. The writer of this progress note went and told Resident #4 she would not be going out to smoke, when Resident #4 asked why the writer of this progress note reminded her she had asked five (5) times for more food and each time she was shown the paper and reminded her of her agreement not to ask for second (2nd) helpings of food and each time she began to cuss at staff and was inappropriate and after so many episodes she was advised there would be a consequence to such behavior. Resident #4 began to cuss at the writer of this progress note and asked her for her name. Resident then stopped took a deep breath and then said please let me go out for just a little cigarette. The writer of this progress note stated no, and Resident #4 immediately started to cuss and stated she was going to call her brother and have the facility shut down because she wasn't being treated right. The writer of this progress note asked why she wasn't being treat right and Resident #4 stated the CNA's were not appropriate to her, but could not provide specific details or name or describe which CNA. The writer of this progress note informed her that if someone wasn't appropriate that next time she needed to tell the nurse on duty and they would make sure there are consequences for them instead of her being rude and inappropriate and have consequences. After several moments of Resident #4 cussing at the writer of this progress note Resident #4 again took a deep breath and then began to plead with the writer of this progress note that she wouldn't cuss at staff again if she could just go out for a cigarette the writer of this progress note quietly stated no and then stated she was going back to work unless there was something else Resident #4 wanted to discuss. Record review of a contract provided by the facility titled, Nutrition Therapy Recommendations dated 1/25/23 documented Resident #4 agreed to not ask for seconds at meals and decrease snacks. The contract was not signed by the resident, dietician, or an employee of the facility. During an observation on 3/30/23 at 1:18 PM in Resident #4 room a sign posted stated, you agreed with the dietitian that you will not ask for extra food at meal times and extra snacks as you have had substantial weight gain. The sign was signed by the Director of Nursing. During an interview on 3/30/23 at 1:45 PM with Resident #4 revealed she has had sadness or will get upset with staff not letting her go out to smoke, she revealed she had gotten mad several times when she was not allowed to smoke. Resident #4 also discussed that she was not allowed to have extra food at meals if she was still hungry, she revealed sometimes she might get a snack and sometimes not. Record review of Resident #4 current Care Plan documented an intervention with a date of initiation on 5/13/2022 instructed staff she will attempt to actively fabricate and manipulate staff in regard to her pain medications, smoking privileges, and reasons to stay in her room. The care plan lacked active or resolved interventions of food restrictions for second (2nd) helpings and not being allowed to smoke if she did not shower. During an interview on 3/30/23 at 2:40 PM the DON revealed she does not recall a bathing contract for Resident #4 and doesn't know why Resident #4 wouldn't get to smoke if she refused a shower. She revealed the Dietician talked to Resident #4 and she agreed to not eat seconds at meals. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA stated the DON instructed them if Resident #4 would not get out of bed or refused her bath that she would not be allowed to smoke. Staff D revealed she thought this was a rule and what they were supposed to do, because that was what their DON said. Staff D stated that Resident #4 was usually not allowed to smoke a couple times a week, she added everyone followed that direction because the DON said to. Staff D then informed she was not sure if it was care planned or not. During an interview on 4/5/23 at 10:12 AM Staff F, Certified Medication Aide, (CMA) revealed Resident #4 was on a no seconds at meals and a no snacks contract. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #6 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated she was cognitively intact. The MDS documented needs for extensive assistance (resident involved in activity, staff provide weight-bearing support) of two person physical assist with bed mobility, transfers, dressing and toilet use. The MDS documented diagnoses of cerebral palsy, hypertension, anxiety disorder, depression, and mixed incontinence. Progress Notes Review Progress Note for Resident #6 dated 5/2/22 at 3:21 AM written by Staff H revealed the following: Resident #6 put her light on at 4:00 PM, 6:00 PM, 8:00 PM, 10:00 PM and 10:45 PM staff into room all of these times. Resident #6 was incontinent of urine at 4:00 PM, 6:00 PM and 10:45 PM and incontinent of bowel at 8:00 PM. Resident #6 educated that there was no reason for her to be incontinent at all as she was the youngest resident here and has had no children. Her control was amazing and can go from 11:00 PM to 7:00 AM without ever urinating and if doing activities she liked can go up to 6 hours during the day without voiding. Resident #6 only had accidents for attention and when she was mad and she doesn't get her way on something, which she didn't get her way on her coffee, she can only have two (2) cups a day period according to her sister who was very mad at her due to all her behaviors and manipulated CNA's to let her finish a show. The writer of this progress note went to Resident #6 room at 11:10 PM and educated her again to not manipulate staff to let her do things she wasn't supposed to do. Progress Note for Resident #6 dated 6/12/22 at 2:15 AM written by Staff H revealed the following: Resident #6 was very rude and snarky with CNA's, she was incontinent for no apparent reason. Resident #6 had always done this for attention even before she came to this facility. She was like this at home and where she lived before coming to the facility. Resident #6 was very demanding and pouted that she had to wait till 7:00 PM to go to bed. Staff have explained to her numerous times that there are other residents here that need care too and her patience would be greatly appreciated. Resident #6 mumbles under her breathe being mean and nasty to staff then lies about her cares when staff have been in her room two (2) at a time due to her behaviors and lying. The writer of this progress note stood outside her room and listened and intervened to her pouting. Progress Note for Resident #6 dated 6/13/22 at 3:03 AM written by Staff H revealed the following: Resident #6 continued to be rude and demanding to staff. She was on her call light every two (2) hours by the clock. She was incontinent for no reason other than thinks she can get changed and go to bed or her skin will breakdown so she can lay in bed all the time. Resident #6 has the mentality of a teenager related to her diagnosis of cerebral palsy. Her family was aware of her behaviors but not lately, she had the best bladder control of all residents at the facility. Progress Note for Resident #6 dated 6/13/22 at 8:45 AM written by the DON revealed the following: Resident #6 ate her breakfast and had coffee then went back to her room and pooped her pants. Her sister was coming to bring her some stuff and was told what she did. Progress Note for Resident #6 dated 6/17/22 at 1:14 PM written by the DON revealed the following: Resident #6 went back from lunch and soiled her pants. She already asked if she could go to bed early tonight and the writer of this progress note told her it was based on her behaviors. Progress Note for Resident #6 dated 8/6/22 at 8:00 PM written by Staff H revealed the following: Resident #6 was incontinent of urine right before staff put her on the commode and after they put her to bed was incontinent of bowels. The writer of this progress note asked her why she was incontinent when she has best bladder control out of everyone at the facility and definitely has the best bowel control out of everyone here. The writer of this progress note told her there was no excuse other than she wanted to go to bed right away and didn't want to sit on the commode. Resident #6 folded her arms across her chest and said nothing just had a pout on her face. Progress Note for Resident #6 dated 8/10/22 at 3:05 PM written by Staff A revealed the following: Resident #6 very upset and pouted as she had to get weighed after she had already eaten breakfast. Resident #6 wanted to be weighed before she ate and staff didn't have time to weigh her before breakfast. Resident #6 pouted all day and would hardly answer staff when they talked to her, she sat in her room with her arms crossed over her chest and looked at the floor anytime staff entered. Progress Note for Resident #6 dated 8/12/22 at 2:21 AM written by Staff H revealed the following: Resident #6 having an increase in behaviors when she doesn't get her own way, like she didn't last night, and was incontinent of bowel and bladder. She was increasingly incontinent for no reason other than for attention and/or she was mad. Her sister was very upset with her and each time she was incontinent added 15 minutes on her time to lay down early on Sunday which was already unable to lay down at 4:00 PM Sunday due to incontinence, her sister was very upset with her. Progress Note for Resident #6 dated 8/17/22 at 1:52 AM written by Staff H revealed the following: Resident #6 continued to manipulate staff and incontinent for attention. Anxiety when she doesn't get what she wants. Progress Note for Resident #6 dated 1/26/23 1:11 PM written by Staff A revealed the following: Resident #6 up to the dining room for breakfast and started to go back to her room at 7:30 AM, when asked where she was going she replied she was going back to here room. Staff told her it was time for breakfast and she needed to stay. Resident #6 then said she wanted to move to a different table, when asked her why she refused to answer and sat in the middle of the walkway and pouted. Progress Note for Resident #6 dated 2/9/23 at 1:14 PM written by Staff A revealed the following: Resident #6 very needy and manipulative today. Call light on to have staff put her exercise bar away when she knew that she was supposed to wait until staff come to her room then she can ask them to put it away. She has turned on her call light to ask staff to get things for her. She was asking multiple times for multiple things while staff were trying to complete the first request. Repeatedly stated I've been good today I haven't bothered you at all today have I. Staff encouraged her to come out of her room, but prefers to isolate herself in her room. Progress Note for Resident #6 dated 2/18/23 at 12:58 PM written by Staff A revealed the following: Resident #6 very upset and pouted when she got her coffee this morning. The cup wasn't filled to the brim and she didn't think she was getting her full cup. Staff attempted to explain that it was dangerous to carry a cup too full and could get burned Resident #6 dropped her head and wouldn't talk anymore. Progress Note for Resident #6 dated 2/28/23 at 1:08 PM written by Staff A revealed the following: Resident #6 stayed in the dining room too long after breakfast this morning and pooped her pants, resident went to her room and noted to be smiling and grinning and said to CNA's I know you're going to be mad at me. Staff explained to Resident #6 that she needed to start coming to her room sooner, Resident #6 continued to smile and said I know. Progress Note for Resident #6 dated 3/15/23 at 8:58 AM written by the DON revealed the following: Resident #6 was incontinent of bowel two times yesterday. Not allowed to have coffee today. Progress Note dated 3/16/2023 at 8:55 AM written by the DON for Resident #6 revealed the following: Resident #6 had behaviors and lost her coffee privileges today. Resident #6 soiled her pants yesterday and it was not loose. She then got on her tablet until 2:00 AM. Told her it would be at the nurses station. During an interview on 3/30/23 at 9:40 AM with Resident #6 revealed she was on a toileting program and can go once every two hours, she revealed the toileting program doesn't bother her as she has a weak bladder and they are trying to strengthen it. She revealed sometimes she gets sad about it because she might have an accident, and then they let her go. She revealed if she had an accident then she can not have any coffee for the day. She revealed she wouldn't give a name because she didn't want to get the person in trouble. She stated yesterday she lost three (3) cups of coffee since she had an accident on 3/28/23. She revealed her sister put a limit to two (2) cups a day, but she wants three (3) cups of coffee a day. She revealed she would like to have two (2) cups in the morning and one (1) at lunch, she revealed she loves her coffee. During an interview on 4/4/23 at 1:37 PM with Staff D, CNA revealed the DON told her that Resident #6's sister wanted her to get less coffee if she was incontinent. The DON told Staff D this was the resident's sister's rule. Staff D was unsure if this was care planned. During an interview on 4/5/23 at 10:48 AM with Staff D, CNA she revealed Resident #6 goes to the bathroom every two hours, and if she made a mess then we would take her coffee away for that day. We were told it was her sisters rule. Before you came in to do the survey we enforced that. During an interview on 4/5/23 at 10:12 AM with Staff F, CMA revealed Resident #6 was on a toileting program for every two hours and the facility was not giving her extra coffee because that was what the Activities Director and Resident #6 sister decided on to help control some of her behaviors. Record review of Resident #6 current Care Plan on 4/3/23 documented the following active and resolved interventions. a. Resolved, Resident currently have two to three (2-3) caffeinated beverages a day with no caffeine after 3:00 PM. See previous resolved intervention. Subject to change per resident/family/staff agreement. Date Initiated: 04/03/2023. Resolved Date: 04/03/2023. b. Resolved, Per agreement, resident may lay down early 1 day a week, usually chooses Sunday. Date Initiated: 04/03/2023. Resolved Date: 04/03/2023. c. Active, Resident had originally agreed upon in conjunction between herself, her guardian, and interdisciplinary team to limit herself to three (3) caffeinated beverages a day. If she asks for more may educate her regarding possible repercussions but may give her extra. Date Initiated: 04/03/2023. The facility provided a Behavior Management policy dated 5/2014. The policy was directed only to residents with dementia and failed to direct staff on how to care for resident behaviors when they are not due to dementia.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and policy review the facility failed to provide root cause analysis interventions of previous falls to prevent 1 of 1 residents (Resident #4) from sustaining a major injury. The facility also failed to provide adequate supervision for 2 of 2 residents (Resident #2 and #11) after residents sustained falls in the facility. The facility reported a census of 18 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Record review of a Progress Note dated 11/21/22 at 4:24 AM revealed the following, Resident #4 yelling out for help in her room and found sitting on the floor against the side of the cabinet by the door. Resident assessed and had no injuries identified. Record review of the facilities Assessments for Resident #4 lacked documentation that a fall report had been completed for her 11/21/22 at 4:24 AM fall. Record review of a Progress Note dated 11/25/22 at 5:34 AM revealed the following, Resident #4 was yelling out for help and found sitting on the floor with her back against her room door. She was unable to remember what she had tried to do prior to the fall. Resident assessed and had no injuries identified. Record review of the facilities Assessments for Resident #4 lacked documentation that a fall report had been completed for her 11/25/22 at 5:34 AM fall. Record review of a Progress Note dated 12/16/2022 at 7:23 PM documented Resident #4 fell at 6:30 PM in her room and was found on the floor on her left side, Staff used a hoyer lift (mechanical device to lift a resident) with two (2) assist to transfer her from the floor to bed. Resident #4 complained of pain to her hip and screamed with movement to her left lower extremity. Resident left facility at 7:35 PM to go to the local emergency room (ER). Record review of an untitled incident report for Resident #4 dated 12/16/22 regarding the fall at 7:23 PM revealed the following: Staff were at the nurses station when Resident #4 screamed from her room. Upon entering Resident #4 room staff found her on the floor on her left side. The nurse completed vital signs and an assessment was obtained. Resident #4 stated she was trying to go to the bathroom. Staff transferred her from the floor to the bed with a hoyer lift with two (2) people. The resident screamed with minimal movement to her leg. The nurse received an order from the doctor to send her to the ER to get evaluated. Review of untitled document with an admit date of 12/16/22 from local hospital informed Resident #4 was admitted to the local hospital due to a left hip fracture from an unwitnessed fall at the facility. The document explained the wishes of the resident's Power of Attorney (POA) to proceed with surgery that included pinning of left femoral neck fracture (surgical procedure using wire or pins to hold a broken bone (fracture) together and keeps it still until it heals). Record review of Resident #4 Care Plan dated 3/29/2023 lacked implementation of fall interventions regarding the root cause for the reason of the falls on 11/21/22, 11/25/22, and 12/16/22. 2. The MDS dated [DATE] for Resident #2 documented a Brief Interview of Mental Status (BIMS) of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Record review of a Progress Note dated 11/5/2022 at 2:13 PM for Resident #2 documented she was found on the floor in her room bleeding above her right eye. The facility provided first aide. Record review of a Progress Note dated 11/8/22 at 2:26 AM by Staff L, LPN documented Resident #2 was found at 1:30 AM sitting on the floor in her room. Record review of a Progress Note dated 11/25/22 at 2:20 PM revealed, Staff A, Licensed Practical Nurse (LPN) entered Resident #2 room and saw her lying on the floor in her room. Staff A documented she identified several raised areas to her face and one in the center of her forehead was bleeding. The facility provided first aid, removed her grab bar from her bed, and placed a fall mat on the floor. Record review of Resident #2 current Care Plan on 4/3/2023 lacked documentation for root cause analysis interventions for repeated falls in Resident #2 room. 3. The MDS dated [DATE] for Resident #11 documented a BIMS of 3 which suggested severe cogitative impairment. The MDS documented need for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with toilet use and personal hygiene. The MDS documented she was independent with transfers and walking in her room. The MDS revealed she had diagnoses of cerebral infarction, hypertension, and chronic pain. Record review of a Progress Note dated 3/7/2023 at 1:15 PM by Staff I, LPN documented Resident #11 was observed stumbling and then fell in the hallway outside of her room. The nurse documented when she lost her balance it caused her to fall into the rail on the wall and then back hitting her head on the wall before landing on the floor. Resident #11 complained of pain to the back center of her head, her left shoulder, and her left hip. Resident #11 was transferred to the emergency room for evaluation. Record review of Resident #11 current Care Plan on 4/13/2023 lacked root cause analysis of why her fall occurred on 3/7/23 or interventions to prevent further falls. Record review of the facilities policy titled Fall Risk Reduction and Management last revised on 12/2015 instructed staff of the following: a. Revise the Care Plan to indicate changes in interventions with each fall and as indicated. b. Modify and document goals and interventions with each fall and as indicated. During an interview on 04/12/23 at 12:44 PM the facilities Regional Nurse Consultant revealed she would expect staff to implement an intervention regarding why she fell to hopefully prevent future falls. She revealed she would also expect staff to update the care plan and communicate to the staff on the changes made.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on record review, staff interview, and policy review the facility failed to ensure 1 of 8 residents (Resident #6) Iowa Physician Orders for Scope of Treatment (IPOST) was signed correctly by Resident #6's physician for her wishes for Do Not Attempt Resuscitation (DNR). The facility reported a census of 18 residents. Findings include: Record review of Resident #6 IPOST documented her wishes of DNR signed on 1/3/2019. The document lacked a signature by the resident's Physician in the appropriate spot on the form, an illegible name without a title was at the bottom of the form. During an interview on 3/29/2023 at 8:18 AM with the Director of Nursing (DON), she provided Resident #6 IPOST and revealed it was not signed by the physician. Record review of the facilities policy titled Emergency Care, reviewed on 11/2019 instructed the following: a. In the absence of Advanced Directives or physician orders, the resident will be considered a Full Code status. b. Obtain Advance Directive decision making documents at the time of admission when available. If not available, request the resident representative/legally authorized party to bring copies to the facility as soon as possible. Inform the resident/resident representative/legally authorized party of the requirement for the forms to be available and complete in order for staff to execute any Advance Directives. During an interview on 4/12/2023 at 2:13 PM with the facilities Regional Nurse Consultant revealed Resident #6 IPOST was signed by her physician at the bottom of the form. She also revealed they have updated the form and the signature is in the correct spot now.

CONCERN (D)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on record review, staff interviews, and policy review the facility failed to implement their abuse policy when documentation in 2 of 2 residents (Resident #4 and #6) records revealed facility staff using intimidation and punishment causing mental anguish. The facility reported a census of 18 residents. Findings include: 1. Record review of Resident #4 Progress Notes from 5/20/2022 to 4/4/2023 documented withholding of smoking privileges and not being allowed seconds at meal service. Progress Notes also revealed Resident #4 would get upset with staff and cuss at them when they wouldn't allow her smoke. 2. Record review of Resident #6 Progress Notes from 5/2/2022 to 4/4/2023 documented the resident was incontinent as a behavior and staff would tell her it was unacceptable. The Progress Notes also revealed the facility would withhold coffee from her if she was incontinent. During an email correspondence on 4/7/23 at 10:16 AM with the facilities Regional Nurse Consultant revealed they have reported to the Department of Inspections and Appeals (DIA) abuse concerns with the Director of Nursing and Staff I, Licensed Practical Nurse (LPN). During an interview on 4/4/23 at 1:04 PM with the facilities corporations Regional [NAME] President informed she would expect the Administrator to report abuse to DIA within two hours of identifying it or sooner. She had provided the facilities Administrator with training for Abuse and her direct care expectations. She revealed she would want it within two hours of the incident so help and support could be given and an investigation could be completed. Review of the facilities policy titled Abuse Prevention Program and Reporting Policy, last reviewed on 08/2019 instructed staff on the following definitions Abuse: Includes, but not limited to intimidation with resulting mental anguish. Punishment with resulting mental anguish. Verbal Abuse: Oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident or their families or within their hearing distance, regardless of their age, ability to comprehend, or disability. Mental/Emotional Abuse: Include, but is not limited to humiliation, harassment, and threats of punishment or deprivation.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to revise the resident care plans with root cause analysis interventions for 3 of 3 residents reviewed for falls (Resident #4, #2, and #11). The facility reported a census of 18 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #4 documented a Brief Interview of Mental Status (BIMS) score of 12 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Record review of a Progress Note dated 11/21/22 at 4:24 AM revealed Resident #4 fell in her room. Record review of a Progress Note dated 11/25/22 at 5:34 AM revealed Resident #4 fell in her room. Review of an untitled document with an admit date of 12/16/22 from the local hospital informed Resident #4 was admitted to the local hospital due to a left hip fracture from an unwitnessed fall at the facility. Record review Resident #4 current Care Plan on 3/29/23 lacked implementation of fall interventions regarding the root cause of falls on 11/21/22, 11/25/22, and 12/16/22. 2. The MDS dated [DATE] for Resident #2 documented a Brief Interview of Mental Status (BIMS) score of 08 which suggested moderately impaired cognition. The MDS documented needs for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with bed mobility, transfers, walking, and personal hygiene. The MDS revealed she had diagnoses of non-traumatic brain dysfunction, hypertension, and muscle weakness. Record review of a Progress Note dated 11/5/2022 at 2:13 PM for Resident #2 documented she was found on the floor in her room bleeding above her right eye. The facility provided first aide. Record review of a Progress Note dated 11/8/22 at 2:26 AM by Staff L, LPN documented Resident #2 was found at 1:30 AM sitting on the floor in her room. Record review of Resident #2 current Care Plan on 4/3/2023 lacked implementation for root cause analysis interventions for repeated falls in Resident #2 room. 3. The MDS dated [DATE] for Resident #11 documented a BIMS of 3 which suggested severe cogitative impairment. The MDS documented need for limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of one person physical assist with toilet use and personal hygiene. The MDS documented she was independent with transfers and walking in her room. The MDS revealed she had diagnoses of cerebral infarction, hypertension, and chronic pain. Record review of Resident #11 current Care Plan on 4/13/2023 lacked root cause analysis of why her fall occurred on 3/7/23 or interventions to prevent further falls. Record review of the facilities policy titled Fall Risk Reduction and Management last revised on 12/2015 instructed staff of the following: a. Revise the Care Plan to indicate changes in interventions with each fall and as indicated. b. Modify and document goals and interventions with each fall and as indicated. During an interview on 04/12/23 at 12:44 PM the facilities Regional Nurse Consultant revealed she would expect staff to implement an intervention regarding why she fell to hopefully prevent future falls. She revealed she would also expect staff to update the care plan and communicate to the staff on the changes made.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on record review and staff interviews the facility failed to ensure 1 of 1 residents with a tracheostomy had nursing care and services provided to them by nurses who completed tracheostomy competency training at the facility (Resident #3). The facility reported a census of 18 residents. Findings include: Record review of an undated competency document provided by the facility titled, Tracheostomy Checklist, Tracheostomy Care Using Modified Sterile Technique Check, revealed the facility had a process in place to train staff on Tracheostomy care. The facility was unable to produce Staff A, Licensed Practical Nurse (LPN) and Staff B, Registered Nurse (RN)'s completed competency Tracheostomy Checklist, Tracheostomy Care Using Modified Sterile Technique Check form. During an interview with the Director of Nursing (DON) on 3/29/23 at 2:15 PM, she revealed she was unable to locate training or competency evaluations for all staff who provide care and services to residents with tracheostomy needs. During an interview on 4/4/23 at 1:42 PM Staff B revealed the Director of Nursing (DON) would provide training to nurses and tell the nurses this was what she did and that was it. She revealed the facility does not complete audits to ensure staff complete tracheostomy cares and treatments appropriately. During an interview on 4/12/2023 at 2:13 PM the facilities Regional Nurse Consultant revealed the Interim Director of Nursing moving forward will complete competency evaluations for all nurses on tracheostomy care.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on record review and staff interviews the facility failed to document for 1 of 1 residents, or their representative was provided education regarding the benefits and potential side effects of influenza immunization; and the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for the 2022 flu season (Resident #13). The facility also failed to document for 1 of 1 residents, or their representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization; and if the resident either received the immunization or did not receive the immunization due to medical contraindications or refusal (Resident #17). The facility reported a census of 18 residents. Findings include: Record review of a document titled, Immunization Report dated 3/27/2023 lacked documentation whether Resident #13 received or refused the Influenza vaccine. The report also lacked documentation if Resident #17 received or refused the pneumococcal vaccine. During an interview on 3/29/2023 at 10:07 AM the Assistant Director of Nursing (ADON) revealed the prior Director of Nursing (DON) would complete a declination form that documented resident refusals of vaccines. He reported that was not currently happening here. He revealed he documented the vaccine status on all of the Residents in the building on their Minimum Data Set (MDS) when he completed them. He revealed he gave a list to the Director of Nursing, (DON) about a month or two ago of residents that were not up to date on their vaccines.

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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Based on record review, staff interviews, and Centers for Medicare and Medicaid Services (CMS) QSO-21-19-NH memo review the facility failed to document 1 of 1 residents was provided with education of the COVID-19 vaccine prior to making her decision to refuse (Resident #13). The facility reported a census of 18 residents. Findings include: Record review of Resident #13 Immunizations on 4/4/2023 revealed she had not received the COVID-19 vaccine. Record review of Resident #13 current Progress Notes on 4/4/23 lacked documentation she received education regarding the COVID-19 vaccine. During an interview on 03/28/23 at 10:37 AM the Director of Nursing (DON) stated Resident #13 had not received the COVID-19 vaccine. During an interview on 3/29/2023 at 10:07 AM the Assistant Director of Nursing (ADON) revealed the prior Director of Nursing (DON) would complete a declination form that documented resident refusals of vaccines. Review of CMS QSO-21-19-NH memo dated 5/11/21 instructed facilities of the following: The residents medical record must include documentation that indicates, at a minimum, that the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and the resident (or representative) either accepted and received the COVID-19 vaccine or did not receive the vaccine due to medical contradictions, prior vaccination, or refusal. If there is a contraindication to the resident having the vaccination, the appropriate documentation must be made in the resident's medical record. Documentation should include the date the education and offering took place, and the name of the representative that received the education and accepted or refused the vaccine, if the resident has a representative that makes decisions for them. Facilities should also provide samples of the education materials that were used to educate residents.

CONCERN (E)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

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Based on record review, staff and resident interviews the facility failed to provide activities on a routine basis for 2 of 2 residents (Resident #1 and #6) reviewed. The facility reported a census of 18 residents. Findings include: Record review of the facilities Activity Calendars for March and April of 2023 documented 2-3 activities provided to the residents a day. During an interview on 4/06/23 at 12:13 PM Resident #6 revealed the facility had not provided activities at all this week that she can recall. She stated they are ok when they actually do them. She revealed the Activity Director does them when she wants to otherwise she will just sit in her office or run around doing paperwork. During an interview on 4/06/23 at 12:13 PM Resident #1 revealed the facility had not provided activities at all this week. She stated they are usually pretty good when they actually do them. She informed the Activity Director does them only when she wants to. During an interview on 4/6/23 at 11:39 AM with Staff J, title kept confidential, revealed the facility had only provided two (2) activity programs to the residents in the past two (2) weeks. She revealed she feels sorry for the residents, they need more activities in their lives. Record review of the facilities Activity Log forms provided by the facility from 3/15/23 to 4/11/2023 documented the facility completed activities on the following dates: 3/15/23, 3/16/23, 3/17/23, 3/20/23, 3/27/23, 3/28/23, 3/29/23, 3/30/23, 3/31/23, 4/7/23 4/8/23, and 4/11/23. During an interview on 4/12/2023 at 2:13 PM the facilities Regional Nurse Consultant revealed the facility has had staffing issues recently and the Activities Director had been pulled to the floor occasionally, but other staff would assist with activities as needed.

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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Based on record review and staff interviews the facility failed to have sufficient nursing staff at the facility from October 1 - December 31, 2022. The facility reported a census of 18 residents. Findings include: 1. Record review of the facilities Payroll Based Journal (PBJ) Staffing Data Report for, October 1- December 31, 2022. Documented the facility failed to have or to submit to the PBJ licensed nursing coverage 24 hours a day on the following dates: 10/11 (TU); 10/17 (MO); 10/20 (TH); 10/24 (MO); 10/25 (TU); 11/04 (FR); 11/05 (SA); 11/06 (SU); 11/07 (MO); 11/08 (TU); 11/09 (WE); 11/10 (TH); 11/11 (FR); 11/12; (SA); 11/13 (SU); 11/14 (MO); 11/15 (TU); 11/18 (FR); 11/19 (SA); 11/20 (SU); 11/22 (TU); 11/23 (WE); 11/24 (TH); 11/25 (FR); 11/26 (SA); 11/27 (SU); 11/28 (MO); 11/29 (TU); 12/01 (TH); 12/02 (FR); 12/03 (SA); 12/04 (SU); 12/06 (TU); 12/07 (WE); 12/08 (TH); 12/09 (FR); 12/10; (SA); 12/11 (SU); 12/12 (MO); 12/13 (TU); 12/15 (TH); 12/16 (FR); 12/17 (SA); 12/18 (SU); 12/19 (MO); 12/20 (TU); 12/21 (WE); 12/22 (TH); 12/24 (SA); 12/26 (MO); 12/27 (TU); 12/30 (FR); and 12/31 (SA). During an interview on 3/31/23 at 11:15 AM Staff G, Maintenance Supervisor, stated one time on night shift a nurse was not in the building when he came in early for about 25 minutes. He revealed he told the Director of Nursing (DON) the situation and the DON asked him, what was she supposed to do. Record review of an untitled undated documented provided by the facility documented the DON covered 25 of the missing nursing coverage shifts from October 1 - December 31, 2022. During an interview on 4/12/2023 at 12:44 PM the facilities Regional Nurse Consultant revealed she was unaware of a nurse ever not being in the facility. When asked about missing 24 hour nursing coverage from October 1 - December 31, 2022 she revealed she was unable to provide proof for 25 days the DON covered the floor, she stated the DON was salary and did not clock in or out. She then revealed the facility used to complete daily staffing assignment sheets, but stopped back in August of 2022, she stated she does not know why the facility stopped completing them. She then revealed daily staffing assignment sheets are back in place now for situations like this.

CONCERN (F)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on record review and staff interviews the facility failed to maintain proof of Registered Nurse (RN) coverage for 1 of 31 days reviewed in March 2023. The facility also failed to have RN coverage on multiple days from October 1 - December 31, 2022. The facility reported a census of 18 residents. Findings include: Record review of the facilities March 2023 nursing schedule lacked documentation of RN coverage on 3/19/23. During email correspondence on 4/4/23 at 12:19 PM the Administrator revealed she had no documentation of RN coverage to provide for 3/19/23. She however, did reveal the Director of Nursing (DON) would provide coverage when needed but did not use the time clock system. The Payroll Based Journal (PBJ) Report (a facility submitted dataset to show daily staffing coverage at the facility) for October 1 - December 31, 2022 documented the facility had no RN coverage or failed to accurately submit RN coverage on the following dates: 10/02/22 (SU); 10/06/22 (TH); 10/25/22 (TU); 11/06/22 (SU); 11/12/22 (SA); 11/13/22 (SU); 11/26/22 (SA); 11/27/22 (SU); 12/10/22 (SA); 12/11/22 (SU) Record review of an undated document titled RN Coverage, revealed the DON provided 8 hours of RN coverage on 11/6, 11/12, 11/13. 11/26. and 11/27. During an interview on 4/12/2023 at 12:44 PM the facilities Regional Nurse Consultant revealed she is unable to provide proof the DON provided RN coverage on 11/6/22, 11/12/22, 11/13/22, 11/26/22, and 11/27/22 She stated the DON was salary and did not clock in or out. She then revealed the facility used to complete daily staffing assignment sheets, but stopped back in August of 2022, she stated she does not know why the facility stopped completing them. She then revealed daily staffing assignment sheets are back in place now for situations like this.

CONCERN (F)

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

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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Based on record review and staff interviews the facilities administration failed to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility reported a census of 18 residents. Findings include: During record review of Resident #6 Progress Notes as of 4/13/23 documented in the past year times when staff would refuse to give the resident coffee due to having incontinence episodes During record review of Resident #4 Progress Notes as of 4/6/23 the facility documented in the past year times staff would refuse to let the resident go out to smoke due to refused showers or been provided seconds (2nd's) at meal service when she would request food. Her Progress Notes also documented repeat falls in her room that resulted in a fracture that the facility administration failed to report to the Department of Inspections and Appeals (DIA) and the facility administration also failed to ensure root cause analysis interventions were in place for each fall. Record review of the facilities Quality Assurance Performance Improvement (QAPI) revealed facility Administration failed to implement, track, and provide routine follow up and oversight for facility concerns from March 2022 to February 2023. During an interview on 3/31/23 at 11:15 AM Staff G, Maintenance Supervisor, revealed he had reported issues before and he would get told they were short staffed, what do you want us to do, he revealed they would tell him they would talk to the staff members in question, but nothing would change. When asked if he would at least tell the Administrator, he stated she was only in the building two times a month because she was at the corporations other facility. During an interview on 4/6/2023 at 11:39 AM with Staff J, title kept confidential, revealed the Administrator was present in the building maybe once or twice every two weeks. During an interview on 4/13/23 at 9:27 AM with Staff K, Dietary Aide revealed she would rarely see the Administrator. She said she might have worked once a week at the facility. During an interview on 4/4/23 1:04 PM the facilities corporations Regional [NAME] President informed she provides support to the administrators in nine (9) buildings she oversees. She revealed due to the census size the Administrator was overseeing this facility and another facility. She revealed they would expect the Administrator to be in the facility 20 hours a week. She revealed they are currently looking at having an Administrator for this facility only and not overseeing two buildings.

CONCERN (F)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

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Based on record review, staff interviews, and policy review the facility failed to produce Quality Assurance Performance Improvement (QAPI) documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities from March 2022 to February 2023. The facility reported a census of 18 residents. Findings include: Record review of the facilities last 12 months of QAPI monthly meetings revealed a binder that had only one month worth of documentation and performance improvement plans, March 2023. During an interview on 4/13/23 at 12:23 PM the facilities Regional [NAME] President revealed she was unable to locate documentation from March 2022 to February 2023 regarding the facilities Quality Assurance program. Record review of a policy titled, QAPI Meeting Management, revised on 08/2019 instructed the facility to complete written minutes of each meeting and to document items discussed and the proposed action plans.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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Based on record review, staff interviews, and policy review the facility failed to implement their Quality Assurance Performance Improvement (QAPI) Meeting Management policy from March 2022 to February 2023. The facility reported a census of 18 residents. Findings include: Record review of the facilities last 12 months of QAPI monthly meetings revealed a binder that had only one month worth of documentation and performance improvement plans for March 2023. During an interview on 4/13/23 at 12:23 PM with the facilities Regional [NAME] President, revealed she was unable to locate documentation from March 2022 to February 2023 regarding the facilities Quality Assurance program. Record review of a policy titled, QAPI Meeting Management, revised on 08/2019 instructed the facility to complete written minutes of each meeting and to document items discussed and the proposed action plans.

CONCERN (F)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected most or all residents

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Based on record review, staff interviews, and policy review the facility failed to maintain a process for periodic review of resident antibiotic use in the facility from August 2022 to present (March 2023). The facility reported a census of 18 residents. Findings include: Record review of a Progress Note for Resident #6 dated 2/26/2023 at 3:38 PM documented the following: Resident #6 complained of pain to the right side of her face down the right nostril and under the right eye that was tender to soft palpation. Resident also with pain to her right ear and down throat into the jaw line. Writer of this progress noted called Resident #6 doctor and received a new order for Augmentin 875 mg twice a day for 10 days. The facility was unable to produce antibiotic tracking for the month of February that included Resident #6 Augmentin use and if it met appropriate criteria for usage of an antibiotic. During an interview on 03/28/2023 at 10:54 AM the Director of Nursing revealed she had never done anything with an Antibiotic Stewardship program. During an interview on 03/28/2023 at 10:50 AM the facilities Assistant Director of Nursing (ADON) revealed he had made a binder and would be following the McGreer's criteria but nothing was in place as of now.

CONCERN (F)

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

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

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Based on record review and staff interviews the facility failed to employ, at least part time, an Infection Preventionist who completed specialized training in infection prevention and control. The facility reported a census of 18 residents. Findings include: Record review of infection prevention training provided by the facility on 3/28/2023 revealed the Assistant Director of Nursing (ADON) had not completed the Infection Preventionist course. During an interview on 3/29/23 at 10:01 AM the ADON revealed he was enrolled in an Infection Preventionist course, however it was not completed, he revealed it would be his top priority when Minimum Data Set (MDS) assessments were caught up. During an interview on 3/29/2023 at 10:03 AM, the ADON revealed the prior Director of Nursing (DON) who had not worked in the facility since July 2022, was the last Infection Preventionist the facility had.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0838 (Tag F0838)

Minor procedural issue · This affected most or all residents

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Based on record review and staff interview the facility failed to ensure the facilities, Facility Assessment, accurately reflected the needs of the residents at the facility for 1 of 1 residents (Resident #3) who's Tracheostomy needs were not reflected on the assessment. The facility reported a census of 18. Findings include: Record review on 3/30/2023 at 11:58 AM of the facilities, Facility Assessment updated on 3/27/23 documented in the Special Treatments and Conditions section zero (0) residents with tracheostomy needs. Record review on 4/3/23 of Resident #3 current Physician Orders documented an order for tracheostomy cares to be completed two times a day since 10/26/2020. During an interview on 3/30/23 at 3:10 PM the Director of Nursing (DON) stated she did not have knowledge of the Facility Assessment, and did not participate in the annual update of the form. During an interview on 4/12/23 at 2:13 PM the facilities Regional Nurse Consultant revealed she would expect the DON to know what the Facility Assessment was and assist with routine review and updating of it.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Data (Tag F0851)

Minor procedural issue · This affected most or all residents

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Based on record review and staff interviews the facility failed to submit accurate direct care staffing information to the Centers of Medicare and Medicaid Services (CMS), Payroll Based Journal (PBJ) Staffing Data. The facility reported a census of 18 residents. Findings include: 1. Record review of the facilities Payroll Based Journal (PBJ) Staffing Data Report for, October 1 - December 31 of 2022. Documented the facility failed to have licensed nursing coverage 24 hours a day or failed to submit accurate staffing data on the following dates: 10/11 (TU); 10/17 (MO); 10/20 (TH); 10/24 (MO); 10/25 (TU); 11/04 (FR); 11/05 (SA); 11/06 (SU); 11/07 (MO); 11/08 (TU); 11/09 (WE); 11/10 (TH); 11/11 (FR); 11/12; (SA); 11/13 (SU); 11/14 (MO); 11/15 (TU); 11/18 (FR); 11/19 (SA); 11/20 (SU); 11/22 (TU); 11/23 (WE); 11/24 (TH); 11/25 (FR); 11/26 (SA); 11/27 (SU); 11/28 (MO); 11/29 (TU); 12/01 (TH); 12/02 (FR); 12/03 (SA); 12/04 (SU); 12/06 (TU); 12/07 (WE); 12/08 (TH); 12/09 (FR); 12/10; (SA); 12/11 (SU); 12/12 (MO); 12/13 (TU); 12/15 (TH); 12/16 (FR); 12/17 (SA); 12/18 (SU); 12/19 (MO); 12/20 (TU); 12/21 (WE); 12/22 (TH); 12/24 (SA); 12/26 (MO); 12/27 (TU); 12/30 (FR); 12/31 (SA). 2. The PBJ data report for October 1 - December 31, 2022 also documented the facility had no RN coverage or failed to accurately submit RN coverage on the following dates: 10/02 (SU); 10/06 (TH); 10/25 (TU); 11/06 (SU); 11/12 (SA); 11/13 (SU); 11/26 (SA); 11/27 (SU); 12/10 (SA); 12/11 (SU) Record review of an untitled and undated document provide by the facility documented the facility had 24 hours of nursing coverage and RN coverage for all dates missing on the PBJ data report for October 1 - December 31, 2022 During an interview on 4/12/2023 at 12:44 PM the facilities Regional Nurse Consultant revealed the facility didn't have proof of RN coverage and 24 hours of nursing coverage on the dates missing for the PBJ data report from October 1 - December 31, 2022.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0868 (Tag F0868)

Minor procedural issue · This affected most or all residents

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Based on record review and staff interviews the facility failed to have an Infection Preventionist in attendance during the facilities quarterly meetings for Quarter 3 and Quarter 4 meeting of 2022 and also for Quarter 1 of 2023. The facility reported a census of 18 residents. Findings include: Record review of the facilities Quality Assurance Process Improvement (QAPI) committee meeting agenda/minutes revealed an Infection Preventionist was not in attendance during the facilities quarterly meetings for Quarter 3 and Quarter 4 of 2022 and Quarter 1 of 2023. Record review of Infection Preventionist training for Assistant Director of Nursing (ADON) provided by the facility on 3/28/2023 revealed the ADON had not completed the Infection Preventionist course. During an interview on 3/29/23 at 10:01 AM the ADON revealed he was enrolled in an Infection Preventionist course, however it was not completed, he revealed it would be his top priority when Minimum Data Set (MDS) assessments are caught up. During an interview on 3/29/2023 at 10:03 AM, the ADON revealed the prior Director of Nursing (DON) who had not worked in the facility since July 2022 and was the last Infection Preventionist the facility had.

MINOR (C)

Minor Issue - procedural, no safety impact

Infection Control (Tag F0880)

Minor procedural issue · This affected most or all residents

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Based on staff interviews the facility failed to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in the facilities building water systems such as by having a documented water management program. The facility also failed to have an assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread and measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. The facility reported a census of 18 residents. Findings include: The facility was unable to produce documentation of measures it had taken to track, assess, and prevent Legionella in the facility. During an interview on 03/28/23 at 10:54 AM the Director of Nursing (DON) revealed she had never done anything regarding Legionellla in the facility. During an interview on 03/29/23 at 11:20 AM the Maintenance Supervisor revealed the facility does not have a map of the water pipes. He revealed the pipes run in the ceiling, but they do not have anything that puddles water or water just sits there that he knew of. He revealed the facility does have rooms that have not been used for over six (6) months.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), 1 harm violation(s), $40,054 in fines, Payment denial on record. Review inspection reports carefully.
• 47 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $40,054 in fines. Higher than 94% of Iowa facilities, suggesting repeated compliance issues.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is Lenox Care Center's CMS Rating?

CMS assigns Lenox Care Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Iowa, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Lenox Care Center Staffed?

CMS rates Lenox Care Center's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.

What Have Inspectors Found at Lenox Care Center?

State health inspectors documented 47 deficiencies at Lenox Care Center during 2023 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 39 with potential for harm, and 4 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Lenox Care Center?

Lenox Care Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ARBORETA HEALTHCARE, a chain that manages multiple nursing homes. With 36 certified beds and approximately 25 residents (about 69% occupancy), it is a smaller facility located in LENOX, Iowa.

How Does Lenox Care Center Compare to Other Iowa Nursing Homes?

Compared to the 100 nursing homes in Iowa, Lenox Care Center's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Lenox Care Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.

Is Lenox Care Center Safe?

Based on CMS inspection data, Lenox Care Center has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Iowa. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Lenox Care Center Stick Around?

Lenox Care Center has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Lenox Care Center Ever Fined?

Lenox Care Center has been fined $40,054 across 1 penalty action. The Iowa average is $33,479. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Lenox Care Center on Any Federal Watch List?

Lenox Care Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 36
Avg. Residents: 25
Occupancy: 69.7%
Ownership: For profit - Partnership
Chain: ARBORETA HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
3 Immediate Jeopardy citations: -36
1 Actual Harm citation: -5
47 Deficiencies: -10
Fines ($40,054): -5
Final Score: 0/100

Nearby Alternatives

Bedford Specialty Care 4-star

View all in LENOX →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 165235