Does Aspire of Muscatine have any serious inspection findings?

Yes, Aspire of Muscatine has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 58 total deficiencies from recent inspections.

What are the staffing levels at Aspire of Muscatine?

Aspire of Muscatine has a two-star staffing rating from CMS with 0.55 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 Aspire of Muscatine located?

Aspire of Muscatine is located in Muscatine, IA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Aspire of Muscatine have?

Aspire of Muscatine has 100 certified beds.

Who owns Aspire of Muscatine?

Aspire of Muscatine is a for profit - limited liability company facility and is part of the BEACON HEALTH MANAGEMENT chain.

What questions should families ask when visiting Aspire of Muscatine?

Families visiting Aspire of Muscatine should ask about staff retention and training programs, 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 Aspire of Muscatine compare to other nursing homes?

Aspire of Muscatine 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.

Aspire of Muscatine

Name: Aspire of Muscatine
Address: 2002 Cedar Street, Muscatine, IA, 52761, US
Telephone: (563) 264-2023
Rating: 1.0

2002 Cedar Street, Muscatine, IA 52761 · (563) 264-2023

For profit - Limited Liability company 100 Beds BEACON HEALTH MANAGEMENT Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

1/100

#324 of 392 in IA

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Aspire of Muscatine has received a Trust Grade of F, indicating significant concerns about the quality of care provided, which places it in the bottom tier of nursing homes. It ranks #324 out of 392 in Iowa and #4 out of 5 in Muscatine County, showing that it is not one of the better options available locally. The facility is currently worsening, with the number of issues increasing from 17 in 2024 to 25 in 2025. Staffing is a weakness, rated at 2 out of 5 stars, with a concerning turnover rate of 56%, which is higher than the state average. Additionally, there are serious incidents reported, including a critical failure to have emergency tracheostomy equipment available for a resident and a lack of supervision leading to a burn for another resident during meals.

Trust Score: F
In Iowa: #324/392
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $24,564 in fines. Higher than 85% of Iowa facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for Iowa. RNs are the most trained staff who monitor for health changes.
Violations: 58 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 17 issues

2025: 25 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

Staff Turnover: 56%

Near Iowa avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $24,564

Below median ($33,413)

Minor penalties assessed

Chain: BEACON HEALTH MANAGEMENT

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (56%)

8 points above Iowa average of 48%

The Ugly 58 deficiencies on record

1 life-threatening 1 actual harm

May 2025 17 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 observation, clinical record review, resident and staff interviews, the facility failed to ensure staff treated a resident with dignity and respect when they provided encouragement for a resident to take a shower for 1 of 1 residents (Resident #33) reviewed for dignity. The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #33 cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS list of diagnoses included: chronic obstructive pulmonary disease exacerbation, benign prostatic hyperplasia (enlarged prostate), and urinary tract infection. The MDS indicated Resident #33 required partial/moderate assistance from staff to shower with showers. A review of a facility reported incident, dated 5/8/25 revealed a staff member called a resident a stinky [expletive], and repeatedly asked the resident why he had not paid his bill to the facility and where was he spending his money. The facility report identified the resident as Resident #33, and the staff member as the Senior Revenue Cycle Manager. During an interview on 5/13/25 at 9:29 AM, Resident #33 reported he could not recall an incident when a staff member using profanity with him. He was able to recall an incident he described as staff ganging up on him about not paying his rent and not taking a shower. Resident #33 observed to be wearing clean clothing and well groomed. During an interview on 5/14/25 at 8:34 AM, the Senior Revenue Cycle Manager (SRCM) stated a staff nurse asked her to talk to Resident #33 about taking a shower. The SRCM explained she used to work as the Social Services Designee. She denied using profanity. During an interview on 5/14/25 at 11:15 AM, the former Administrator stated it had been reported by the current Social Services Director that the SRCM (also the former Social Services Director) had used profanity with Resident #33. She explained the incident occurred on 5/6/25. The former Administrator stated the report indicated the SRCM kept bugging him [Resident #33] about taking a shower and he kept refusing. She then said she would tell people that he said f__ taking a shower During an interview on 5/15/25 at 9:59 AM, the Social Services Director stated on 5/6/25 she and the SRCM walked into Resident #33's room and the SRCM said to the resident hey are you gonna shower today, stinky [expletive]? The Social Services Director stated she had just started working at the facility and was unsure of what to do. She stated she did tell the former Administrator the next day. During an interview on 5/15/25 at 11:10 AM, Staff M, Licensed Practical Nurse (LPN) stated on 5/6/25, she had asked the Senior Revenue Cycle Manager to talk to Resident #33 as she had been able to talk him into taking showers before. Staff M stated she was in the room, with the current Social Services Director when the SRCM talked to Resident #33 about taking a shower. Staff M denied profanity had been used.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to include the use of an anticoagulant medication on the Care Plan for 1 of 3 residents (Resident #33) reviewed for Care Plans. The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #33 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS list of diagnoses included chronic obstructive pulmonary disease, benign prostatic hyperplasia (enlarged prostate), urinary tract infection. The MDS identified Resident #33 took an anticoagulant medication. The MDS indicated Resident #33 admitted to the facility on [DATE]. Review of the Physician Orders revealed an order, dated 2/10/25, revealed an order for Apixaban (generic name for Eliquis, an anticoagulant medication) Oral Tablet 5 mg (milligrams) give one tablet by mouth two times a day for blockage of blood vessel to lung by particle. Review of the May 2025 Medication Administration Record revealed Resident #33 administered apixaban 5 mg 1 tab twice daily on all days May 1, 2025 to May 14, 2025 when present in the facility. Review of the Care Plan revealed a lack of a Focus area to address the use of an anticoagulant medication. During an interview on 5/21/25 at 1:02 PM, the Director of Nursing (DON) stated she would expect the use of an anticoagulant to be included on the Care Plan. The DON stated the MDS Coordinator is responsible to updating the plan. The DON stated the current MDS Coordinator started at the facility three weeks ago so was not present when the plan was developed in February 2025. Review of the facility policy, titled Comprehensive Care Plans, effective March 2025 revealed, in part: The Comprehensive Care Plan is based on a thorough assessment that includes, but is not limited to the MDS and physician orders.

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 observation, clinical record review, resident and staff interviews, the facility failed to update the Care Plans to reflect current to reflect current care areas and/or service needs for 2 of 2 residents (Residents #1 and Resident #8). The facility reported a census of 32 residents. Findings include: 1. Review of the Minimum Data Set (MDS) dated [DATE], identified Resident #1 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS list of diagnoses included neurogenic bladder, multiple sclerosis and anxiety disorder. Review of the Care Plan revealed a Focus area to address [Name redacted} has surgery on Bilateral ankles and is wearing casts .Created on 5/26/24. During an observation on 5/13/25 at 7;13 AM, Resident #1 in his wheelchair wearing non-skid shoes. No cast noted on either ankle/foot. During an interview on 5/21/25 at 12:12 PM, Staff M, Licensed Practical Nurse (LPN) stated Resident #1 has bilateral casts removed almost of year ago. She stated the Care Plan should no longer identify he has casts. During an interview on 5/21/25 at 1:02 PM, the Director of Nursing (DON) stated she was not the DON at the time Resident #1 had bilateral casts on his ankles. She stated if Resident #1 no longer had casts then they should not be addressed on the Care Plan. 2. Review of the MDS dated [DATE], identified Resident #8 as cognitively intact with a BIMS score of 13 out of 15. The MDS list of diagnoses included arthritis, multiple sclerosis and malnutrition. The MDS documented Resident #8 required substantial/maximal assistance with eating. The MDS indicated Resident #8 received hospice services. Review of the Care Plan, revealed a Focus area to address activities of daily living. Interventions included, in part EATING: [Name redacted] is able to: feed himself. Revision on: 4/8/24. Review of an Order Summary Report, dated 5/13/25 revealed an active order to Admit to [provider name redacted] Hospice, Order Date 4/5/25. Review of Resident #8's Care Plan revealed a lack of a Focus area and Interventions to address hospice services. A review of the facility policy titled Comprehensive Care Plans, effective date March 2025, revealed a Guidelines section which directed, in part: 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS and physician orders. Assessments of residents are ongoing and Care Plans are revised as information about the resident and resident's condition change.

CONCERN (D)

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, the facility staff failed to provide eating assistance for 1 of 2 residents (Resident #8) reviewed for activities of daily living. The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) dated [DATE], identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. The MDS list of diagnoses included arthritis, multiple sclerosis and malnutrition. The MDS assessed Resident #8 required substantial/maximal assistance with eating, and to transfer from chair/bed-to chair, and sit to lying. The MDS documented Resident #8 received hospice services. The MDS documented Resident #8 weighed 138 pounds. Review of an Order Summary Report, dated 5/13/25 revealed an active order to Admit to [provider name redacted] Hospice, Order Date 4/5/25. Review of the Care Plan, Revision on 1/9/25 revealed a Focus area to address I have an ADL (activities of daily living) self-care performance deficit r/t Musculoskeletal impairment. [Name redacted] is at risk for declines in late loss ADL's (bed mobility). Interventions included, in part: EATING: [Name redacted] is able to: feed himself. Revision on: 4/8/24. Review of the Vitals/Weights in the electronic health record revealed Resident #8 weighed 106 pounds on 5/2/25. Observations of the meal service provided to Resident #8 in his room revealed: a. On 5/12/25 at 12:25 PM, Staff P, Certified Nursing Assistant (CNA) delivered a lunch tray to Resident #8. Resident #8 in bed sleeping. Staff P set tray on the over the bed table and left without letting the resident know his meal had been served. b. On 5/14/25 at 12:29 PM, Staff N, CNA delivered a lunch tray to Resident #8. She placed the tray on the over the bed table. Staff N then exited the room without offering the resident assistance. Resident #8 attempted to reposition to his side and reach over the side rail to eat his food. The call light was out of reach on the nightstand near the foot of his bed. During an interview on 5/15/25 at 9:47 AM, Staff K, Hospice Registered Nurse stated she had been aware of Resident #8 weight lose prior to starting hospice and has continued to lose weight. Staff K stated his intake has been poor, and he has refused appetite stimulants. Staff K stated the weight lose is anticipated. During an interview on 5/15/25 at 11:10 AM, Staff M, Licensed Practical Nurse stated staff should assist Resident #8 to sit up for his meal. She stated he will eat lying on his side. Staff M stated that sometimes Resident #8 requires assistance with eating. During an interview on 5/21/25 at 7:21 AM, Staff E, CNA stated that staff need to make sure Resident #8 sits up with the head of his bed up and help him eat. She stated if he refused to eat what is served she would get him something different to eat. She stated if he continued to refuse she would inform the nurse. During an interview on 5/21/25 at 10:15 AM, Staff I, CNA stated Resident #8 should be positioned in bed for meals with the head of his bed up. She stated Resident #8 requires supervision while eating. During an interview on 5/21/25 at 1:02 PM, the Director of Nursing stated she would expect staff to assist Resident #8 to sit up and stay with him during the meal to assist him, when he wants to eat. Review of the facility policy titled Dining Environment, approved October 2024, revealed a Guidelines section which directed, in part: 8. Nursing Services Personnel will help to seat and position residents and to identify factors that might adversely affect food intake.

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, facility policy review and staff interviews, the facility failed to assess a resident, with a known history of substance abuse, after they returned to the facility under the influence for 1 of 1 resident (Resident #33) reviewed. The facility reported a census of 32 residents. Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #33 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS list of diagnoses included chronic obstructive pulmonary disease, benign prostatic hyperplasia (enlarged prostate), urinary tract infection. The MDS indicated Resident #33 admitted to the facility on [DATE]. Review of an admission Summary entered on 2/10/25 revealed, in part .Arrived to ED (emergency room) on 2/4/25 unresponsive, resident reported to ED to have used methamphetamines' and ecstasy prior to unresponsive episode .Resident Hx (history): .alcohol abuse, substance abuse .Discharge summary faxed to [provider name redacted], aware of admission. Review of the Care Plan, Date Initiated: 4/2/25 revealed a Focus area to address Impaired Coping: Hospice status & Known Substance Use. Interventions included, in part: a. 2/28/25: Found intoxicated in his room with a bottle of vodka. Date Initiated: 4/7/25. b. 4/16/25: Resident had water bottle with vodka in it at bedside and empty syringe fell from chair in dining room matching syringes found in room substance found in syringe baggy and turned over to police. Date Initiated: 4/16/25. c. 4/4/25: Leaving facility without signing out and returning intoxicated. Date Initiated: 4/7/25. Review of the electronic health record revealed: a. Order Note entered on 4/4/25 at 6:15 PM, revealed New orders from St. Croix Hospice to place all narcotics on hold in system for 72 hours d/t resident leaving the facility without signing out and past incident. Resident notified of new orders and not happy. This DON also educated resident & ride on the procedure of signing out each time he is leaving the facility. b. Incident Note entered on 4/16/25 at 1:13 PM, revealed Multiple staff and resident approached this nurse with concerns for resident stating they feel he is under the influence of an unknown substance d/t appearance and strange behavior. This nurse observed resident from nurse station before going into residents room with CMA (Certified Medication Assistant) [initials redacted] where a bottle of water was seen on bed side table a little over half full. Both this nurse and CMA smelled the contents in water bottle, smelling alcohol. This nurse and CMA informed DON (Director of Nursing) and administrator of reported and finding. 1/1 monitoring in on-going with resident. c. Lab Note entered on 4/16/25 at 13:32, revealed UA results received, abnormal results as follow: Opiates - Detected Amphetamines - Detected Benzos - Detected Clarity - Cloudy Ketones 15 Blood - Trace Nitrate - Pos WBC - >50 H RBC - 5 H WBC Clumps - Present Faxed to [provider name redacted] No N.O (new orders) at this time. Resident informed. d. Health Status Note entered on 4/16/25 at 2:54 PM, revealed EMS (emergency medical services) arrived to facility to transport resident to ED fir evaluation. Review of the electronic health record revealed a lack of nursing assessment completed on 4/4/25 and 4/16/25 after the resident returned to the facility and suspected of having been under the influence. During an interview on 5/19/25 at 12:26 PM, the DON stated she if a resident with a known history of substance use returned to the facility and staff suspected they were under the influence for an assessment to be completed. She stated she would expect this to include vital signs, respiratory effort, eyes, pupils dilated, overall demeanor. She would expect them to check on the resident every 15 minutes throughout the night, or until there was an order for the resident to go to the emergency room for evaluation and treatment. Review of the facility policy titled Change in a Resident's Condition or Status, approved October 2024, revealed a Policy Interpretation and Implementation section which directed, in part: 3. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure the safety of residents when a resident with an oxygen tank secured to a wheelchair sat in the designated smoking area with other residents engaged in smoking a lit cigarette, and then staff physically carried the oxygen tank from the smoking area through the facility to the oxygen storage area for 1 of 6 (Resident #23) residents reviewed for accidents and hazards. The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #23 cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. The MDS list of diagnoses included: which indicated intact cognition. The assessment identified the resident utilized a walker and a wheelchair for mobility. The MDS revealed Resident #23 had shortness of breath or trouble breathing when lying flat and utilized non-invasive mechanical ventilator. Review of the May 2025 Medication Administration Record revealed O2 (oxygen) per nasal cannula (2-4 L [per minute, the rate at which oxygen is to be delivered] with exertion, PRN (as needed). Maintain sats (blood oxygen saturation) > (above) 86% as needed for maintain sats > 86%. Start Date: 10/30/24. Review of undated document titled, Smoking Residents revealed 9 residents in the facility smoked. Resident #23 identified on the list as a smoker. During an observation on 5/12/25 at 1:25 PM, a sign posted on the patio door leading to the designated smoking area listed smoking times of 8:30 AM, 1:30 PM, and 7:00 PM. During an observation on 5/12/25 at 1:27 PM, Resident #23 self-propelled her wheelchair to the designated smoking area. A portable oxygen tank noted to be secured to the back of Resident #23 wheelchair. Five other residents also present in the designated smoking area. At 1:33 PM, the Director of Nursing (DON) brought outside a plastic tote of smoking supplies and handed out cigarettes to the residents, with the exception of Resident #23. At 1:36 PM, the DON assisted the five residents with lighting the cigarettes. Resident #23 remained outside, sitting in her wheelchair approximately two feet from another resident while they smoked a cigarette. Resident #23's oxygen tank not in use during this observation. At approximately 1:38 PM, the State Agency notified the Interim Administrator of Resident #23 sitting outside, with an oxygen tank secured to her wheelchair while other residents are smoking. The Interim Administrator went to the designated smoking area and spoke to the DON. The DON spoke with Resident #23 and then removed the oxygen tank from the back of the resident's wheelchair and handed the unsecured oxygen tank to the Interim Administrator. The oxygen tank meter observed and indicated the tank on empty. The Interim Administrator confirmed the tank on empty. The Interim Administrator then physically carried the unsecured oxygen tank to the facilities oxygen room. During an interview on 5/13/25 at 9:00 AM, Resident #23 stated she had screwed up the other day and had an oxygen tank on her wheelchair when she went to out [to the smoking area]. Resident #23 stated she had not realized the oxygen tank was on back of wheelchair as it was empty and she planned to give the tank to the nursing staff. Resident #23 stated she would typically not have an oxygen tank on the back of her wheelchair or be outside during designated smoking times. Resident #23 stated she no longer smoked. During an interview on 5/15/25 at 11:09 AM, Staff M, Licensed Practical Nurse (LPN), stated Resident #23 does not often go outside during smoking times, and she no longer smoked. Staff M reported Resident #23's oxygen order was for as needed use, when oxygen saturations went below normal levels. Staff M revealed that Resident #23 would typically keep an oxygen tank on back of wheelchair and notify nursing staff when tank was empty or she needed a new tank. When queried, Staff M reported she would remove the oxygen tank if seen near residents smoking and stated that even if oxygen tank was empty, it may still be flammable due to chance for residual oxygen in tank. During an interview on 5/21/25 at 10:15 AM, Staff I, CNA, recalled one instance in the past one to two months, unable to recall a date, in which Resident #23 was going outside to the smoking area and resident's portable oxygen tank had been on back of the wheelchair. Staff I reported she removed the tank and left it inside the facility while Resident #23 went outside to visit with other residents during a smoking time. During an interview on 5/21/25 at 1:11 PM, the Director of Nursing (DON), stated Resident #23 did not often utilize oxygen unless she had an asthmatic episode. The DON stated that on 5/12/25 she had been pulled to supervise the 1:30 PM smoking time and didn't see or realize Resident #23 had been outside until the Interim Administrator came outside to notify her of the oxygen tank. When queried, DON reported she would not allow Resident #23 to go outside during smoking times with an oxygen tank on her wheelchair or would remove the portable oxygen tank before the resident went outside. DON explained that even if tank was empty, an oxygen tank would not be safe around residents smoking due to tank being flammable or had the potential to blow up. Review of the undated facility policy, titled Smoking Policy included a Policy statement which declared, in part: It is the policy of this facility to comply with all federal and state regulations and implement proper systems to ensure that all residents and staff are monitored for compliance. The facility policy titled, Oxygen Administrator, effective 10/2024, revealed a Purpose statement which declared The purpose of this procedure is to provide guidelines for safe oxygen administration. The Steps in the Procedure section directed, in part: 4. Remove all potentially flammable items (e.g., lotions, oils, alcohol, smoking articles, petroleum jelly products, etc) from the immediate area where oxygen is to be administered. The Oxygen Administration policy did not address safe transport of oxygen tanks.

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, staff interviews, clinical record review, and facility policy review, the facility failed to identify a weight loss, notify the physician and ensure Registered Dietician follow up for 1 of 3 (Resident #9) residents identified for weight loss. The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) Assessment, dated 3/12/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated a moderate cognitive impairment. The MDS list of diagnoses included cerebrovascular accident (a stroke), diabetes mellitus, contracture of left forearm and left hand, and gastro-esophageal reflux disease (GERD). The MDS indicated Resident #9 had one sided impairment of his upper and lower extremity, utilized wheelchair for mobility, and required set up assistance to eat. The MDS documented a weight of 222 pounds, with no weight loss of gain within the last six months. Review of the Care Plan, Date Initiated: 10/17/24 revealed a Focus area to address I require assistance with ADL's (activities of daily living) r/t (related to) Impaired balance, Limited Mobility and Stroke. Interventions included, in part: EATING: The resident requires assistance by staff to eat. Date Initiated: 10/17/24. Review of the Weight Summary in the electronic health record revealed a weight of 222.4 Lbs (pounds) on 3/12/25, and 207.0 Lbs on 4/1/25, 4/2/25, and 4/4/25. Review of the electronic health record did not reveal notification of the physician regarding the weight loss, or interventions. Review of a N Adv - Long Term Care Evaluation entered on 4/2/25 at 9:37 AM revealed, in part: Vitals: 207 pounds by mechanical lift. Nutrition: Taking nutrition and hydration orally. No complaints of thirst. No signs/symptoms of a swallowing disorder. Mucous membranes moist. Review of Nutrition/Dietary Note entered on 5/10/25 at 8:37 AM revealed He triggered for a significant weight loss at 6.9% (15.4 lbs) in 30 days and 9.7% (22.2 lbs) in 90 days. Etiology of significant weight loss is incorrect weight for April 2025. Weight: His current weight of 207.0 lbs (4 April 2025), 222.4 lbs (12 March 2025), 229.4 (2 January 2025) and 228.8 lbs (2 October 2025). He has lost 15.4 lbs (6.9%) in 30 days, 22.2 lbs (9.7%) in 90 days and 21.8 lbs. (9.5%) in 180 days. Question his April 2025. His BMI (body mass index a calculated measure of weight relative to height) is 28.9 kg/m2 (kilograms/meters squared) which is in the overweight class. His IBWR (ideal body weight range) is 155-189 lbs. Adjusted for males >[AGE] years old. Diet: He is on a regular diet, regular texture with thin consistency liquids. His po (oral intake) is 51 - 100% of meals. He dines independently with occasional supervision .Recommendations: No recommendations at this time. Continue to monitor po intake, weight, and nutritional parameters and refer to RD (registered dietician) prn (as needed). During an observation on 5/13/25 at 11:38 AM, Resident #9 ate lunch in the dining room. The resident sat in high back wheelchair, with the right side of his body parallel to the table. The wheelchair tilted back into a semi-reclined position. Resident #9's head and neck flexed upwards towards the ceiling, with no support. Resident #9 stretched his right arm out straight to reach the plate on dining room table and feed him self-lunch. Staff present in the dining room did not intervene to reposition, or provide the resident assistance. During an observation on 5/14/25 at 11:44 AM, Resident #9 sat in a geri chair, with a rolled towel behind his head for positioning. Staff placed a tray in front of Resident #9 so his meal sat in front of him rather to the side as on 5/13/25. Resident #9 fed himself. Staff present in the dining room did not provide the resident assistance. During an interview on 5/14/25 at 1:40 PM, the Registered Dietitian (RD) confirmed being aware of Resident #9's weight loss of 15.4 pounds since April 2025. The RD stated she believed April's weight to be incorrect. She stated she should have asked the facility to reweigh Resident #9 in April. The RD stated she had visited the facility on 5/09/25 and did not put in to place any weight loss interventions for Resident #9 until a reweight from April had been recorded. Review of a Nutrition/Dietary Note, completed by the RD, entered on 5/14/25 at 10:03 PM, revealed that Resident #9 had been reweighed on this date with same weight as previous month which triggered for 30-day significant weight change. The RD recommendation for Resident #9 to receive Mighty Shakes twice per day with the goal for weight to remain within 3% of current weight. An email sent by the Director of Nursing (DON) on 5/15/25 at 12:48 PM revealed the facility recalibrated the mechanical lift scale to ensure accuracy and Resident #9's re-weight after the calibration was 204.6 pounds. During an interview on 5/15/25 at 11:09 AM, Staff M, Licensed Practical Nurse (LPN), stated Resident #9 preferred to sit in a reclined position and often refused to sit upright at meals. Staff M stated Resident #9 had oral secretions and occasional coughing during meals but had no choking, aspiration, or pneumonia. Staff M reported that Resident #9 would refuse supper meals one to two times per week due to fatigue and request to go to bed early. During an interview on 5/21/25 at 10:15 AM, Staff I, Certified Nursing Assistant (CNA), stated Resident #9 had secretions and coughed when he smoked, but during meals. Staff I stated Resident #9 would sometimes go to bed in the evening and not eat supper depending on if he liked the meal. During an interview on 5/21/25 at 1:11 PM, the DON stated she would expect nursing staff to identify and follow up if a resident lost weight to ensure accuracy. She stated she would expect interventions to be put in place when a weight loss is identified. Review of the facility policy, titled Weight Assessment and Intervention, effective 10/2024, revealed a Policy statement which declared The Interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain. The Guidelines, Weight Assessment section directed, in part: 3. Re-weights will be obtained as needed within 24 hours and recorded per community protocol. If the weight change is significant (as identified in point #5) the RD and MD (medical doctor) will be notified. 5. The threshold for significant unplanned and undesired weight changes will be based on the following criteria a. 1 month - 5% weight change is significant; greater than 5% is severe.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview the facility failed to provide oxygen therapy in accordance with professional standards as evidenced by a lack of a physician's order to direct the use of oxygen, and the failure to include oxygen therapy on the Care Plan for 1 of 1 resident (Resident #20). The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set, dated [DATE], revealed Resident #20 a Brief Interview for Mental Status score of 14 out of 15, which indicated intact cognition. The MDS list of diagnoses included Guillain-Barre Syndrome, anemia, and obesity. The MDS documented Resident #20 required oxygen therapy while a resident. During an observation on 5/13/25 at 10:20 AM, Resident #20 wore a nasal cannula connected to an oxygen concentrator with the flow set at 4 liters of oxygen per minute. Review of the May 2025 Mediation Administration Record revealed an order, Start Date 5/18/24 to Check O2 (oxygen) sat (saturation, a measure to indicate the oxygenation of blood) every shift, apply O2 to keep sat above 90%. Every shift for low O2 sats. On 5/21/15 a review of Medication Review Reported revealed a lack of an order to direct the amount of oxygen [typical ordered by liters per minute] to deliver, the method [such as a nasal cannula, or face mask] for delivery of the oxygen, and if oxygen therapy to be delivered as needed or continuous. Review of the Care Plan revealed a lack of a Focus area and Interventions to address Resident #20 required oxygen therapy. During an interview on 5/21/25 at 12:12 PM, Staff M, Licensed Practical Nurse (LPN), recalled that Resident #20 has an order for oxygen since last year when she had been out to the hospital. During an interview on 5/21/25 at 1:11 PM, the Director of Nursing (DON) revealed the expectation that oxygen usage would be reflected by a Physician's order and would be included in 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

Deficiency F0710 (Tag F0710)

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, interview, clinical record review, and facility policy review, the facility failed to notify the physician of changes in condition for 2 of 3 resident (#8 and #9) reviewed for physician notification. The facility reported a census of 32 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment, dated 3/12/25, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. The MDS revealed no weight loss or gain identified during the assessment period with weight recorded as 222 pounds. Diagnoses included cerebrovascular accident (stroke), diabetes mellitus, contracture of left forearm and left hand, and muscle wasting of multiple sites. Review of facility recorded weights revealed on 3/12/25, Resident #9 weighed 222.4 pounds and on 4/01/25, 4/02/25, and 4/04/25, Resident #9 weighed 207 pounds. Documented weights indicated Resident #9 had a weight loss of 15.4 pounds (6.92% loss of body weight) in one month. Review of Nutrition/Dietary Note entered on 5/10/25 at 8:37 AM revealed He triggered for a significant weight loss at 6.9% (15.4 lbs) in 30 days and 9.7% (22.2 lbs) in 90 days. Etiology of significant weight loss is incorrect weight for April 2025. Weight: His current weight of 207.0 lbs (4 April 2025), 222.4 lbs (12 March 2025), 229.4 (2 January 2025) and 228.8 lbs (2 October 2025). He has lost 15.4 lbs (6.9%) in 30 days, 22.2 lbs (9.7%) in 90 days and 21.8 lbs. (9.5%) in 180 days. Question his April 2025. His BMI (body mass index a calculated measure of weight relative to height) is 28.9 kg/m2 (kilograms/meters squared) which is in the overweight class. His IBWR (ideal body weight range) is 155-189 lbs. Adjusted for males >[AGE] years old. Diet: He is on a regular diet, regular texture with thin consistency liquids. His po (oral intake) is 51 - 100% of meals. He dines independently with occasional supervision .Recommendations: No recommendations at this time. Continue to monitor po intake, weight, and nutritional parameters and refer to RD (registered dietician) prn (as needed). Review of the electronic health record revealed a lack of physician notification of Resident #9 weight loss. During an interview on 5/21/25 at 1:11 PM, the Director of Nursing stated it is expected the physician would be notified of resident's significant weight loss. Review of the facility policy, titled Weight Assessment and Intervention, effective 10/2024, revealed a Policy statement which declared The Interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain. The Guidelines, Weight Assessment section directed, in part: 3. Re-weights will be obtained as needed within 24 hours and recorded per community protocol. If the weight change is significant (as identified in point #5) the RD and MD (medical doctor) will be notified. 5. The threshold for significant unplanned and undesired weight changes will be based on the following criteria a. 1 month - 5% weight change is significant; greater than 5% is severe.

CONCERN (D)

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

Deficiency F0741 (Tag F0741)

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, resident and staff interviews, the facility failed to provide training to the staff to address behavioral health care needs for 1 of 1 resident (Resident #33) with a substance use disorder, The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE], revealed Resident #33 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS list of diagnoses included chronic obstructive pulmonary disease, benign prostatic hyperplasia (enlarged prostate), urinary tract infection. The MDS indicated Resident #33 admitted to the facility on [DATE]. Review of an admission Summary entered on 2/10/25 revealed, in part .Arrived to ED (emergency room) on 2/4/25 unresponsive, resident reported to ED to have used methamphetamines' and ecstasy prior to unresponsive episode .Resident Hx (history): .alcohol abuse, substance abuse .Discharge summary faxed to [provider name redacted], aware of admission. Review of the Care Plan, Date Initiated: 4/2/25 revealed a Focus area to address Impaired Coping: Hospice status & Known Substance Use. Interventions included, in part: a. 2/28/25: Found intoxicated in his room with a bottle of vodka. Date Initiated: 4/7/25. b. 4/16/25: Resident had water bottle with vodka in it at bedside and empty syringe fell from chair in dining room matching syringes found in room substance found in syringe baggy and turned over to police. Date Initiated: 4/16/25. c. 4/4/25: Leaving facility without signing out and returning intoxicated. Date Initiated: 4/7/25. d. Determine Resident's coping methods. Date Initiated: 4/7/25. e. Encourage participation in self-calming behaviors such as breathing exercises, meditation or guided imagery. Date Initiated: 4/7/25. During an interview on 5/21/25 at 10:15 AM, Staff I, Certified Nursing Assistant (CNA) stated when a resident who has a history of drug/alcohol abuse, the type kind of behavior she would look for that might alert you that the resident might be under the influence would be slurred speech, extremely tired, or agitation, tick with the mouth, and she would report this to a nurse. Staff I stated she did not remember receiving any type of training on how to deal with residents who appear to be under the influence of drugs or alcohol. During an interview on 5/21/25 at 11:38 AM, Staff Q, CNA when asked about Resident #33 Care Plan stated when she sees that kind of behavior that might indicate he was under the influence of drugs/alcohol she does not know what to do. Staff Q stated she did not receive any training from the facility regarding how to deal with that type of situation. During an interview on 5/21/25 at 1:02 PM, the Director of Nursing reported she could not recall that the staff had been provided education on what to do if a resident with substance abuse history has behaviors of being under the influence and reported the facility did not have a policy to address resident substance abuse.

CONCERN (D)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected 1 resident

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Based on observations, kitchen record review and staff interviews, the facility failed to ensure kitchen staff were trained and able to perform their job duties as required. The facility reported a census of 32 residents. Findings include: During an observation on 5/13/2025 at 10:52 AM, the [NAME] prepared a pureed meal for one resident with a pureed diet order. The [NAME] pureed a peanut butter and jelly sandwich with milk added. When asked, the [NAME] did not know how much milk was added but estimated a quarter of a cup. The [NAME] then shared that the puree mixture was too runny and added another peanut butter and jelly sandwich. The [NAME] continued to puree until she believed it was the desired consistency. When asked what else would be pureed for the meal, the [NAME] stated the resident doesn't like very many things and will usually only eat peanut butter and jelly sandwiches. The [NAME] stated sometimes she will give the resident some ice cream or pudding but the resident won't eat the other menu items. During an interview on 05/14/25 at 1:45 PM the Dietary Manager (DM) stated he was not sure what training and skill competencies the [NAME] had, but she had worked at the facility for long time. He stated most of the kitchen staff had not worked at the facility for very long. He stated the kitchen staff were not ServeSafe certified. When asked about the puree process observed on 5/13/25, the Dietary Manager stated he did not necessarily watch the cook but from what he has observed the staff did a pretty good job. The Dietary Manager was unable to name the desired consistency but indicated it should be similar to the consistency of apple sauce. The DM stated the menu binders with the meal recipes include the portion sizes which he stated is what the facility follows. The DM stated the kitchen staff does not use the puree chart posted on the wall for portion/scoop sizes. The Dietary Manager was then asked about nutrition and substitutions. The DM stated most of the time if a resident doesn't like the meal they ask for something else. The DM stated the facility will typically have left overs and that can be headed up for a resident. The DM stated the facility does not have an alternative menu but they always have some sort of soup and sandwich they can make the resident. The Dietary Manager stated it is expectation staff make several attempts to offer the resident something else if they don't want what is on the menu. When asked about nutritional requirements the DM stated the facility would start making an alternative vegetable as they hadn't been doing that. The DM then shared, residents complain they have fish too often so they would be offered a soup or sandwich. The DM stated food substitutions are logged and the dietician signs off of them every other week when they are at the facility. Review of the substitution list revealed two entries for in the last month, neither signed off by the dietician. When queried about the staff not taking and recording food temperatures, the Dietary Manager stated staff would need additional training. The DM stated he did not know who was in charge of tracking resident intake. During an interview on 05/19/25 at 09:01 AM, the Registered Dietician (RD) stated she had worked with staff on the puree process but had not watched them do the puree process for a while. She stated she knew the facility had the puree process chart up and they followed that. She advised she had not worked side by side with the Dietary Manager. When observations regarding the puree process, lack of food temperatures, lack of an alternative menu were shared with the RD she advised those practices would not meet her expectations. She advised the kitchen staff should contact her if they had to make a substitution, but rarely do. The RD stated if there is a substitution she would also sign off on it when she is at the facility. The RD advised either the dietary staff or nursing staff track resident food intake and she would receive a notice if there were a significant change or concern. When queried the RD advised she had not seen evidence of insects or rodents but it would be concerning to her if there were any roach or insect traps on the counters. It is the RD's expectation that there would not be any insect or rodent traps in any area where there is food. During an interview on 05/20/25 at 08:50 AM, the [NAME] stated she may have not done the puree correctly (observed on 5/13/25), but she was nervous. She stated she should have used the puree chart and measured her portions. Instead of adding another peanut butter and jelly sandwich she should have used the thickener. The [NAME] stated she should offer more alternatives if a resident does not like the meal. During an interview on 5/21/25 at 02:05 PM, after learning of observations of the food service and kitchen processes, and interviews with the kitchen staff, the Director of Nursing (DON) and the Interim Administrator stated they have much higher expectations for the kitchen staff. They stated an audit will be completed and all kitchen staff will be required to have additional training. All policies and procedures are expected to be followed. Upon request the facility did not submit a policy regarding kitchen staff training and competency.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on kitchen record review, facility policy review and staff and resident interviews, the facility failed to ensure the dietician approved menu is followed and adequate quantities of substitutions are available to all residents. The facility reported a census of 32 residents. Findings include: During an interview on 5/13/2025 at 10:52 AM, the [NAME] stated when she is making the lunch meal sometimes she does not have everything she needs and has to make substitutions. She explained it is usually the vegetable or fruit she has to substitute. The cook stated when it is a minor substitution she does not need permission, but when it is something that isn't similar she is expected to contact the Dietary Manager for approval. The [NAME] stated once the substitution is approved it is then written on the substitution log and the Registered Dietician will sign off when she is at the facility. The [NAME] shared that the residents don't like noodles back to back so recently instead of the beef macaroni casserole she served goulash. The [NAME] shared a lot of times if a resident does not like something they are having or doesn't want the fruit or vegetables, they want more of the main course. The [NAME] stated this is provided if they have enough left after the first serving. During an interview on 05/19/25 at 09:01 AM the Registered Dietician stated she had not worked side by side with the Dietary Manager. She advised the kitchen staff had not contacted her if they had to make a substitution. If there is a substitution she would also sign off on it when she is at the facility. The RD advised it is her expectation that the planned menus are followed to meet the resident's nutritional needs. During an interview on 05/20/25 at 12:40 PM, two residents stated they there were not happy with the food. The residents stated there not very many food options or choices. One resident stated he did not feel the portions were big enough and the kitchen should hire someone that knows how to cook. During an interview on 05/21/25 at 02:05 PM the Director of Nursing (DON) and the Interim Administrator stated it is their expectation that the menus are followed. The facility provided a policy titled, Resident Food Preferences, effective October 2024, revealed a Guidelines section which directed, in part: 7. The Food Services Department will offer food substitutes for individuals who do not want to eat the primary meal. Substitutions offered will be of similar nutritive value.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

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, facility policy review, resident and staff interviews, the facility failed to provide food per the resident's preferences for1 of 3 residents reviewed (Resident #29). The facility reported a census of 32 residents. Findings include: Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #29 as cognitively intact with a Brief Interview for Mental Status score of 15 out of 15. During an interview on 5/15/25 at 8:00 AM, Resident #29 stated he was served rice and corn yesterday and he does not like these two food items. He stated he to the Dietary Manager before about this and if he had to talk to him about this again, he would not eat their food again. He was getting tired of getting served food he did not like. The resident stated the last time he saw the dietitian was last year. Review of the Resident #29 meal tray card identified he did not like rice and corn. During an interview on 5/19/25 at 1:08 PM, the Registered Dietitian stated she was not aware that Resident #29 did not like rice and corn. She stated when she has spoken to Resident #29 he stated he was not getting enough carbohydrates. During an on 5/21/25 at 7:21 AM, Staff E, Certified Nursing Assistant (CNA) stated Resident #29 had complained to her that he does not like corn or rice when it is served to him. Staff E stated when resident has reported he does not like a certain food, which is identified on the tray card, the staff should return the tray to the kitchen and get him something he likes. Review of the facility policy titled Resident Food Preferences, effective October 2024 revealed a Guidelines section which directed, in part: 1. Upon the resident's admission the Food Service Manager, Dietitian, or nursing staff will review the resident's likes and dislikes with the resident or family member, if the resident is unable to communicate his/her needs. 6. The Food Service Manager, Dietitian, or nursing staff will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests.

CONCERN (D)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on review of the CMS CASPER (Certification and Survey Provider Enhanced Reporting) report, facility policy review and staff interviews, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address and prevent repeated deficiencies in three required areas. The facility reported a census of 32. Findings include: A review of the CMS CASPER (Certification and Survey Provider Enhanced Reporting) Report Provider History Profile revealed the facility has had repeated deficiencies in the following areas: a. Food Procurement, Store/Prepare/Serve: F812 cited on surveys that occurred April 2023, June 2024 and the current survey. b. Quality Improvement Program: F868 cited on surveys that occurred April 2023, June 2024 and the current survey. c. Infection Prevention & Control: F880 cited on surveys that occurred April 2023, June 2024 and the current survey. During an interview on 05/21/25 at 02:05 PM the Director of Nursing (DON) and the Interim Administrator stated they have much higher expectations for the facility and they are working on improvements. They explained the facility had high staff turnover but continue to want the facility to be the best that it can be. They stated additional staff training has been provided, and they expect all policies and procedures are followed. Review of the facility policy titled Quality Assessment and Performance Improvement Plan and Program, effective August 2024 revealed a Policy statement which declared The facility shall develop, implement, and maintain an effective, comprehensive, data driven Quality Assessment and Performance Improvement program (QAPI) that focuses on indicators of the outcomes of care and quality of life. The Guidelines section, included the Purpose of the QAPI Program, which included: a. Ensuring care delivery systems function consistently, accurately, and incorporate current and evidenced based practice standards when available; b. Preventing deviation from care processes, to the extent possible; c. Identifying issues and concerns with facility systems, as well as identifying opportunities for improvement; and d. Developing and implementing plans to correct and/or improve identified areas.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility policy review, and staff interviews, the facility failed to implement infection control practices to minimize the risk of infections due to a failure to change gloves during wound care for 1 of 2 residents (Resident #8) reviewed for wounds, failure to keep a urinary catheter bag and tubing off the floor and follow Enhanced Barrier Precautions when draining a catheter bag for 1 of 1 resident (Resident #29) reviewed for catheter care. The facility reported a census of 32 residents. Findings include: 1. Review of the Minimum Data Set (MDS) dated [DATE], identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. The MDS list of diagnoses included arthritis, multiple sclerosis and malnutrition. The MDS assessed Resident #8 dependent on staff for toileting and bathe/showers, and required substantial/maximal assistance with eating, oral hygiene, dressing, personal hygiene and repositioning. The MDS documented Resident #8 with two Stage 2 pressure ulcers. Review the Order Summary Report dated 5/13/25, revealed an order to cleanse wound with soap and water, pat dry, apply zinc oxide to open area and over with Optifoam (type of wound dressing) every night shift for wound care. Start Date: 4/18/25 Review of the Care Plan, Date Initiated: 4/5/25, revealed a Focus area to address I have actual impairments to skin r/t (related to) lack of nutritional intake. Interventions included, in part: Left Buttock - cleanse with soap & water, apply zinc oxide, & cover with optifoam. Date Initiated: 4/5/25. During an observation of wound care on 5/13/25 at 9:40 AM, Staff B, Registered Nurse washed her hands, donned gloves and cleansed the wound going from the inside to the outside of the wound bed. Wearing the same gloves, Staff B then applied zinc oxide and the optifoam dressing to the wound. During an interview on 5/21/25 at 1:02 PM, the Director of Nursing (DON) stated she would expect nursing staff to remove gloves and wash their hands after cleansing a wound, then apply new gloves prior to applying a treatment and new dressing. Review of the facility policy titled Wound Care Guidelines, approved April 2024 included a Purpose statement which declared The purpose of this procedure is to provide guidelines for the care of wounds and to promote healing. The Steps in the Procedure section directed, in part: 4. Wash and dry your hands thoroughly. 6. Apply disposable gloves. Loosen tape and remove dressing. 7. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 8. Put on disposable gloves 12. Wear disposable gloves when physically touching the wound or holding a moist surface over the wound. 2. Review of the MDS dated [DATE], identified Resident #29 as cognitively intact with a BIMS score of 15 out of 15. The MDS list of diagnoses included heart failure, neurogenic bladder (lack of control due to nerve damage) and diabetes mellitus. The MDS documented Resident #29 utilized an indwelling urinary catheter. Review of the Care Plan, Date initiated: 6/13/24, revealed a Focus area to address [Name redacted] is at risk for infection r/t (related to) CAUTI (catheter-associated urinary tract infection) d/t (due to) res (resident) places catheter bag above bladder and constantly needs reminders to not touch drainage system. [Name redacted] drags the bag on the floor at times. [Name redacted] can be incompliant with his drainage bag, staff often encourage resident to keep it in its designated area. Interventions included, in part: a. Advanced barrier precautions d/t catheter with all catheter cares using gown and gloves and draining while in room. Date Initiated: 6/13/24 b. Staff to intervene that catheter bag is not dragging on floor. Date Initiated: 6/13/24 During observations on 5/13/24 the following noted regarding Resident #29 catheter bag & tubing placement and care: a. At 10:40 AM, observed sign posted on Resident #29 room door which directed Enhanced Barrier Precautions. A caddy stocked with gloves and gowns located near the door. b. At 10:40 AM, Resident #29 asleep in bed, with the catheter bag and tubing lying on the floor beside his bed. c. At 5/13/25 at 10:57 AM, Staff C, Certified Nursing Assistant (CNA) walked by Resident #29 room as she pushed a cart in the hallway. Resident's catheter and tubing position remained on the floor. d. At 5/13/25 at 11:05 AM, Staff A, CNA entered Resident #29's room to ask about his plan for lunch. Staff A picked up the catheter bag from the floor and placed it in a dignity cover. Staff A then placed the bag and tubing back on the floor. e. At 5/13/25 at 12:12 PM, Resident #29 was asleep in bed. The catheter bag, in a dignity cover, and tubing rested on the room floor. During an observation of catheter care on 5/13/25 at 1:26 PM Staff Q, CNA donned gloves. Without wearing an isolation gown, Staff Q entered Resident #29's room. Staff Q placed paper towels on the floor and placed a graduated cylinder on top. Staff Q then drained the catheter bag into the graduated cylinder. Without cleaning the spigot with an alcohol wipe, Staff Q clamped it and placed in the holder area on the catheter bag. Staff Q attached the catheter bag and tubing off the floor, attached to the bed frame. During an interview on 5/13/25 at 2:06 PM, Staff H, CNA stated urinary catheter bags and tubing should never be on the floor, and Enhanced Barrier Precautions are used with all catheter care. Staff H stated after emptying a catheter bag an alcohol wipe should be used on the spigot. During an interview on 5/21/25 at 1:02 PM, the DON stated she would expect the staff to check the placement of catheter bags and tubing every shift and as needed as they should never be on the floor. The DON stated PPE (personal protective equipment) should be worn when emptying a catheter bag. The DON stated this would include the use of gloves and a gown. Review of the facility policy titled Enhanced Barrier Precautions, effective April 2025 included the following definition related to Enhanced Barrier Precautions: Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer for MDROs (multidrug-resistant organisms) to staff hands and clothing .Nursing home resident with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well for residents with MDRO infection or colonization. The Identification and Application Guideline sections #3. Indwelling Medical Devices are defined as (but not limited to): b. Indwelling urinary catheters. Review of the facility policy titled Indwelling Urinary Catheters, effective May 2025, revealed an Infection Control section which directed, in part: 2. Maintain clean technique when handling or manipulating the catheter, tubing and drainage bag. b. Be sure the catheter tubing and drainage bag are kept off the floor

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

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, and resident and staff interviews, the facility failed to place the call lights within the reach for 2 of 3 residents reviewed (Residents #8 and #29). The facility reported a census of 32 residents. Findings include: 1. Review of the Minimum Data Set (MDS) dated [DATE] identified Resident #8 as cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13 out of 15. The MDS list of diagnoses included arthritis, multiple sclerosis and malnutrition. The MDS indicated Resident #8 dependent on staff for toileting and bathe/showers; substantial/maximal assistance with eating, oral hygiene, dressing, personal hygiene and repositioning. Review of the Care Plan, Revision on 1/9/25, revealed a Focus area to address I have elected to have transfer bar on my bed. I have a diagnosis of MS (multiple sclerosis) and need transfer bar to help with bed mobility. [Name redacted] has been educated on the risk and benefits of side rails. Interventions included, in part: Make sure resident call light in within reach while in bed. During an observation on 5/13/25 at 9:40 AM, Staff B, Registered Nurse (RN), after providing wound care, left the room with the call light still on top of nightstand by Resident # 8 foot, out of his reach. During an observation on 5/14/25 at 9:00 AM, 9:45 AM, and 10:39 AM Resident #8 asleep in his bed with the call light located near his feet, out of his reach. On 5/14/25 at 12:29 PM, Staff N, Certified Nursing Assistant (CNA), observed leaving Resident #8's room, the call light located on the resident's nightstand near the foot of his bed. During an observation on 5/15/25 at 7:56 AM, Resident #8 asleep in his bed with the call light located on the nightstand near the foot of his bed. 2. Review of the MDS dated [DATE] identified Resident #29 as cognitively intact with a BIMS score of 15 out of 15. The MDS list of diagnoses included disorder autonomic nervous system, syncope and collapse (temporary loss of consciousness caused by a sudden drop in blood flow to the brain), and urinary retention. The MDS identified Resident #25 dependent on staff for toileting and lower body dressing; and required substantial/maximal assist with bathe/showering, putting on and removing footwear and personal hygiene. The MDS indicated Resident #29 utilized an indwelling urinary catheter. Review of the Care Plan, Revision on 8/8/24, revealed a Focus area to address [Name redacted] is a moderate risk for falls r/t (related to) hypotension (low blood pressure) and autonomic nervous system dysfunction (the autonomic nervous system regulates involuntary functions like heart rate, breathing, and digestion). Interventions included, in part: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 2/7/23. During an observation on 5/13/24 at 1:26 PM, Staff Q, CNA exited Resident #29's room with the call light located on the floor, out of the residents reach. At 2:45 PM, Resident 29 sat in his wheelchair sitting near the doorway to his room with the call light located on the floor near his bed. At 3:24 PM, Resident #29 in bed asleep with the call light located on the floor by his bed. During an observation on 5/14/25 at 9:03 AM, Resident #29 lying in his bed with the call light on the floor beside his bed. During an interview on 5/13/25 at 2:06 PM, Staff H, CNA stated before she leaves a resident room she would make sure the call light, table and water pitcher are in the residents reach. During an interview on 5/15/25 at 11:10 AM, Staff M, Licensed Practical Nurse stated staff should ensure that the call light is placed within the resident's reach. Most of them like it placed on the bedside table. During an interview on 5/21/25 at 1:02 PM, the Director Of Nursing stated she would expect nursing staff to check that all call light are within the residents' reach any time they are in the resident's room. Review of the facility policy titled, Answering the Call Light, approved October 2024 included Purpose statement which declared The purpose of this procedure is to respond to the resident's requests and needs. The General Guidelines section directed, in part: 5. When the resident is in bed or confirmed to a chair be sure the call light is within easy reach of the residents.

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 observations, facility policy review and staff interviews, the facility failed to safe thawing practices and use of insect traps in an attempt to minimize the potential for food borne illness. The facility reported a census of 32. Findings include: During an initial kitchen tour on 5/12/25 at approximately 12:30 PM, the following conditions were revealed: a. A package of raw hamburger thawing in the refrigerator next to a box of lettuce. The hamburger was not in a drip pan and had been placed directly on the refrigerator rack. b. A insect trap placed on the kitchen counter work space. During an observation of the noon meal service in the kitchen on 5/13/25 at 11:46 AM, two insect traps visible on the counter behind the coffee pots. During an interview on 5/13/25 at 11:46 AM, the [NAME] stated she had taken out the raw hamburger out of the refrigerator to use. When queried about the location of the hamburger thawing in the refrigerator on 5/12/25, she stated she did not think it was an issue because the hamburger was sealed and the lettuce box was closed. During an interview on 5/14/25 at 1:45 PM, the Dietary Manager (DM) stated he was not aware of the hamburger being next to the lettuce. He reported the hamburger should have been in some sort of a pan and should not have been near the lettuce due to the possibility of cross contamination. When queried about the insect traps the DM advised he didn't realize they were there. He also advised they have pest control come into the facility but he was not aware of any current issues. During an interview on 05/19/25 at 09:01 AM, the facility Registered Dietician stated she had not seen evidence of insects or rodents but it would be concerning to her if there were any insect traps on the counters. She stated it is her expectation that insect or rodent traps are not in an area where there is food being prepared. Review of the facility policy titled Food Preparation and Service, effective October 2024, revealed a Thawing Frozen Food section which directed, in part: 1. Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container; Review of the facility policy titled Pest Control, effective October 2024, did not address the use of insect traps in the kitchen.

Jan 2025 8 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 clinical record review, facilty policy, resident and staff interviews, the facility failed to ensure residents are treated in a dignified manner as evidenced by a staff members use of an expletive when requesting a resident move their belongings for 1 of 7 residents reviewed for dignity (Resident #1). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment completed for Resident #1 on 12/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. During an interview on 1/6/25 at 10:29 a.m., Resident #1 stated she had an issue with the activity lady. She stated she had a blue flowered [NAME] and the activity lady said she would help Resident #1 finish it and when she came in with it the activity lady told her You need to get that f***ing thing off my table. Resident #1 stated she said whoa, I didn't disrespect you and you told me to go and get my [NAME]. Resident #1 said the activity lady was the one with the glue gun. Resident #1 stated she told the nurse and they did a report on it. Resident #1 asked what the activity personnel did after the encounter and she said the activity lady walked out of the room and took her [NAME] back to her room and that was the end of it. The Grievance Form dated 12/23/24 for Resident #1 and reported by [name redacted] revealed the following: a. Who made the report: Patient b. Nature of Grievance: I had left a project on the table in the activity room and went to my room to get something for it and [name redacted] to me to get my f**king shit off her table but she took it upon her self to take it back in my room and I was not happy about it made me cry, my family don't even talk to me like that and I don't except no one else to talk to me like that. c. Signed by Resident #1 on 12/22/24 and the Admin signed on 12/26/24 During an interview on 1/6/25 at 1:15 p.m., Staff E, Activities Director queried on any complaints against her from residents stated she had one complaint from a resident. She stated the resident took it the wrong way. Staff E explained she said something about getting her f**king things off my table. Staff E stated while making Christmas wreaths, the resident had a different [NAME] and had it sitting on the table. Staff E stated she moved the [NAME], and the resident brought the same [NAME] back to the table. She stated she made the remark in a sarcastic kind of way, not a rude way. Staff E stated in the grievance the resident stated she was upset. Staff E stated she didn't mean to hurt her feelings and that day she stayed in the activity area. She stated the resident took the remark the wrong way. Staff E stated she messed up and sometimes you had connections with people. She stated she never directly cussed at anyone. Staff E stated she didn't know she offended the resident until the grievance form and Social Services spoke to her and informed her she couldn't speak to the residents in that matter even if it was in a joking matter. During an interview on 1/7/25 at 12:46 p.m., Staff F, Social Services queried on Resident #1 and she stated she recalled a grievance that Resident #1 wrote. Staff F stated grievances usually went to her, but this grievance went to the DON (Director of Nursing) and the DON brought it to her office and they discussed it. Staff F confirmed the grievance named Staff E and documented Staff E said something to the effect of get your s**t off my table or along those lines. Staff F stated the grievances documented inappropriate language. Staff F asked if they investigated it and she stated yes, they started talking with Resident #1 and then spoke to Staff E. Staff F stated education completed with Staff E about language like that in the workplace was not appropriate. Staff F asked this situation reported and she stated the Administrator notified of it and she believed they reported it to our office, but wasn't completed sure. During an interview on 1/8/25 at 11:40 a.m., Staff E confirmed Resident #1 submitted a grievance on her for swearing at her to get things off her desk. During an interview on 1/8/25 at 2:48 p.m., Resident #1 queried on the incident between her and Staff E and how that made her feel and she stated Not to good, I wanted to run my mouth back, but I didn't know how they would take it if I responded back the way I wanted to. Resident #1 asked if it made her feel fearful or intimated and she stated she felt intimated, and she didn't know how you could talk to someone like that. Resident #1 queried if she minded being around Staff F and she stated it would take a little time to get that back. Resident #1 asked if she went to the activity room much and she stated she didn't see Staff E much lately and didn't know if she had time off. During an interview on 1/9/25 at 10:35 a.m., the DON (Director of Nursing) queried on the incident between Resident #1 and Staff E and she stated she thought they were making a mountain out of a mole hill. The DON stated the situation should of never happened in healthcare. The DON stated she spoke to Resident #1 and she stated she didn't like being talked to like that and no one talked to her like that, not even her family. The DON stated Resident #1 was fine with it, just not Staff E tone. The DON stated she believed Staff E intentions are pure. The DON stated she watched Resident #1 and Staff E for a few days and she thought Staff E misinterpreted the relationship and in her mind it wasn't a bad thing. The DON stated she spoke with Staff E and they 100% addressed the situation. The DON stated she believed the Administrator did the investigation. The DON stated potty mouths don't belong in healthcare. During an interview on 1/9/25 at 12:12 p.m., the Administrator queried on the incident between Resident #1 and Staff E and she stated it started out as a grievance. The Administrator stated she wondered if the incident happened because Resident #1 was pretty truthful. The Administrator stated the DON talked to her the next day and then she talked to Resident #1 as well. The Administrator stated Resident #1 was more concerned with Staff E tone and Resident #1 was not afraid of Staff E and Resident #1 was heavily involved in activities. The Facility Resident's Rights Policy dated 12/24 revealed the following information: a. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure residents are free from resident to resident (with Resident's #8, #9 and #17) altercations involving a resident (Resident #7) known to have difficulty managing his verbal and physical behavior. The facility reported a census of residents 35. Findings include: 1. A review of a facility self-reported incident report, dated 10/8/24, revealed on 10/7/24 while outside smoking, Resident's #7 accused Resident #8 of stealing his cigarettes. Resident #7 then threw his walker at Resident #8, hitting him on the right shoulder. Resident #7 hit Resident #8 on the right cheek with his fist. Resident #8 punched Resident #7 in the stomach. Resident #7 then yelled at Resident #9 calling her names and stating he was going to punch her lights out. Resident's #8 and #9 went inside the facility and went to a nurse. Resident #7 followed them into the building. The nurse separated Resident #8 and #9 from Resident #7. Resident #7 remained in the dining room and continued to yell profanities. Corrective Action per the facility self-report: The residents were separated by nursing staff, DON (Director of Nursing) and Social Services. Police were notified of the incident and came to the building. Resident #7 as sent by ambulance to [hospital name redacted] evaluated. Resident #8 had a skin assessment completed and trauma assessment completed. Resident #9 denied being hurt but a trauma assessment was being completed. The facility reported incident, identified: a. Resident #7 as Severely Impaired Cognition. No injuries. HX (history): [Name redacted] has a history of accusing staff and residents of stealing items from him. He also has a history of making physical violence threats. b. Resident # 9 as Alert and Oriented. No injuries. No HX per facility. c. Resident #8 as Alert and Oriented. No Injury. No HX per facility. The Minimum Data Set (MDS) Assessment for Resident #7, dated 9/2/24 revealed no cognitive assessment completed. Resident #7 identified as usually able to make himself understood, always understood others and without behaviors. The electronic health record Medical Diagnosis list for Resident #7, dated 12/23/24 included, in part: unspecified dementia, unspecified severity with behavioral disturbance as secondary diagnosis on 7/16/24, and violent behavior as secondary diagnosis on 7/16/24. Resident #7's Care Plan, initiated on 6/22/24 included a Focus area to address [Name redacted] is a risk for increased verbal and physical behaviors r/t (related to) increasing depression r/t being in facility, accuchecks (blood sugar checks) not in control and other health concerns. The Focus area included, in part: a. [Name redacted] has been involved in a res (resident) to res altercation. b. [Name redacted] hit and injured a staff member and was sent out via ambulance and police called on 7-15-24 c. 10/7/24 Resident hit and threatened residents and accusing them of stealing his cigarettes. d. 10-8-24 Resident was verbally aggressive towards other in the dining room. Date initiated: 6/22/24. e. [Name redacted] has had an altercation and was the recipient of physical aggression. Dated initiated: 10/7/24. Interventions included, in part: a. Referral to [provider name redacted] psychological/psychiatric services as first available appointment. Dated initiated: 6/22/24 b. Separate from others res for safety. Date Initiated: 6/22/24 c. 10-8-24 Referrals being sent to CCDI (Chronic Confusion and Dementing Illness) Units in Iowa that are more appropriate for his needs. Dated initiated: 10/8/24. During an interview on 12/23/24 at 9:08 a.m., the former Director of Nursing (DON) stated she was in the hallway near the dining room on 10/7/24 when Resident's #7, #8 and #9 were outside smoking, Resident #7 accused them of stealing his cigarettes. She stated that was a common thing he [Resident #7] believed but that was not true as staff secured the cigarettes. She stated Resident #7 punched Resident #8 on his shoulder and his head, Resident #8 hit Resident #7 in the stomach as Resident #7 threw his walker at him, and Resident #9 came back into the facility and yelled for help. The former DON stated she and another staff responded and were able to separate the residents. She stated Resident #7 was sent to the hospital for a psychiatric evaluation, and then returned. The former DON stated prior to that incident, the residents could smoke on the patio, unsupervised, whenever they wanted. Afterwards, the DON stated things were changed to three set times which the residents could smoke outside, staff provided supervision, resident's that smoked had to have a smoking safety assessment completed, and sign a consent for acceptance of the smoking rules and restrictions. The former DON stated they also made sure that Resident #7 was supervised 1:1 with staff and was not outside when other residents were outside smoking. The DON stated the Social Worker was responsible for completing the smoking safety assessments and getting the consents. During an interview on 12/31/24 at 12:18p.m., Staff S, Registered Nurse (RN) stated Resident #7 can be a ticking timebomb, unpredictable and aggressive, not easily redirected when he's escalating. Staff S stated staff have to keep an eye on him, and be ready to separate him if he goes after another resident. She stated there is no redirecting him when he is that agitated, they try to guide him to his room to cool down and keep him away from other residents. During an interview on 12/31/24 at 12:47 p.m., Resident #8 stated when he smoked outside there was a day that Resident #7 yelled at him, accused him of stealing his cigarettes, hit him in the face and shoulder with his fist then threw his walker at him. Resident #8 stated he wasn't hurt when Resident #7 hit him because Resident #7 hits like a girl, and then laughed. Resident #8 stated the residents couldn't go outside to smoke on their own after that, there are set times for residents to smoke now and a staff member has to be present. The MDS, dated [DATE] revealed Resident #8 BIMS score of 15 out of 15 which indicated intact cognition. A Nursing Progress Note transcribed by Staff S, RN on 10/7/24 at 6:15 p.m. stated: Head-to-toe assessment performed. Slight redness noted to resident's [Resident #8] face. No further concerns at this time. During an interview on 1/7/24 at 11:39 a.m. Resident #9 stated Resident #7 yelled at her many times, called her horrible things and threw whatever he could get a hold of when he was agitated, there was no rhyme or reason when that would occur. The MDS, dated [DATE] revealed Resident #9 BIMS score as 15 out of 15 which indicated cognition intact. A Nursing Progress Note transcribed by the previous DON on 10/7/24 at 4:53 p.m. stated: Resident [Resident #9] was in courtyard when another resident came outside yelling and accusing them of stealing his cigarettes. He then started hitting another resident. He also waived his fist at this resident, called her a profane name and threatened her. She removed herself from the situation and asked the nurse for help with the other resident. 2. A review of a facility self-reported incident, dated 1/11/25 at 10:25 p.m., revealed Resident #7 and Resident #17 were in the dining room by the coffee station. [Staff name redacted], Licensed Practical Nurse (LPN) came around the corner from the nurse's station and saw Resident #7 grab Resident #17's shoulder, and called him a racial slur and hit him with a closed fist to the right side of his head. He [Resident #7] swung a couple of times but only connected one time. [Staff name redacted], LPN linked her arm in Resident #7's arm and redirected him back to his room. Corrective Action per the facility self-report: Residents immediately separated. Resident #7 was redirected to his room and a staff member remained in the line of sight of him. Resident #17 was assessed and sent to the ER for evaluation and treatment .Resident #7 was sent to the ER for evaluation and treatment. The facility self-report identified: a. Resident #7 as Moderately Impaired Cognitively. No injury. HX: Yes, [resident name redacted] has had other resident to resident altercations within the last 3 months. b. Resident #17 as Alert and Oriented. Injury: Swelling to the right side of face. HX; No history of similar events. A review of a Nursing Progress Notes transcribed by Staff T, LPN on 1/12/24 at 8:40 a.m., revealed this nurse heard yelling while down the hall, ran to the common area and discovered [Name redacted (Resident #7)] physically grabbing another resident's shoulder. Resident [#7] yelled a yelled [racial slur] and close palm punched resident [Resident #17] on the right side of his head. This nurse and two CNA's separated the two residents . A review of the hospital Emergency Department Physician Progress Note dated 1/11/25 revealed Resident #7 arrived at 9:24 p.m., treated for aggressive behavior due to dementia after he hit another resident at the nursing home, the resident remained calm and cooperative in the Emergency Department, discharged back to the facility on 1/12/25 at 12:25 a.m. with a prescription for oral Lorazepam 0.5 milligrams (mg) tablets administered every 6 hours as needed for anxiety, 5 tablets dispensed, the resident received 1 dose while in the Emergency Department. During an interview on 1/21/25 at 2:10 p.m., Staff T, LPN, stated she worked the 6 p.m. to 6 a.m. night shift on 1/11/25. She stated during the evening she was on the South hall when she heard yelling at 8:40 p.m. and ran to the sound. Resident #7 stood near the kitchen door in the dining room, Resident #17 was in his wheelchair and was wheeling away, Resident #7 was hitting him with a closed fist on his head. She tried to get between them and escorted Resident #7 to his room. Resident #17 had a red mark on his right upper cheek. She called both the Administrator and DON after the incident, they wanted Resident #7 sent to the ER for a psychiatric assessment, called the police in case he escalated and remained with Resident #7 in his room until EMS got there to transport. The DON directed her to check him every 15 minutes, she didn't remember if it was for 24 or 48 hours. Resident #17 was also sent to the hospital ER for evaluation. Resident #7 came back from the ER early in the morning, they had medicated him in the ER, he was tired went to bed, he remained calm and asleep throughout the rest of her shift, she checked on him often. She notified the Administrator that he was back and she said they were supposed to keep him for 24 hours in the ER before they sent him back. She had not been directed to move Resident #17 to a different room, he remained in the same hall as Resident #7. When she came back to work the next day, they had moved Resident #17 to a different hall. 3. A review of a facility self-reported incident, dated 1/12/25 at 10:09 a.m., revealed Resident #17 sat in his wheelchair on hall 1, near the dining room. Resident #7 came out of his room, headed towards the dining room and came up behind Resident #17 wheelchair. When Resident #17 did not move right away Resident #7 raised his walker 6 inches off the ground and hit Resident #17 left arm with it. This nurse intervened as Resident #7 and Resident #17 were in line of sight as soon as Resident #7 left his room. Resident #17 went to his room. Resident #7 came out of the dining room as if nothing had occurred. Corrective Action per the facility self-report: Resident #7 was assessed, and his PRN (as needed) Haldol (antipsychotic medication) was administered. Administrator notified. Resident #7 is being kept in line of sight .Resident #7 being sent to ER for evaluation and treatment. The facility self-report identified: a. Resident #7 with Moderately Impaired Cognition. No injury. HX: Yes, Resident #7 has had other resident to resident altercations within the last three months. b. Resident #17 as Alert and Oriented. No Injury. HX He has been involved in another resident to resident with this individual. A review of a Nursing Progress Note transcribed by Staff S, RN on 1/12/25 at 10:48 a.m., revealed: Med aide had stopped Resident #17 on hall one d/t (due to) resident going down the hallway backwards. Resident #17 was sitting on hall 1 in a wheelchair waiting on other resident to pass. Resident #7 walked up behind him with a walker. When Resident #17 did not move right away Resident #7 walked around to residents left side almost as if to pass him. When he was directly on the left side of Resident #17, Resident #7 raised the walker slightly and hit Resident #17 with it. This nurse intervened. Resident #17 went to his room. Resident #7 came out to the dining room as if nothing had occurred. PRN Haldol PO (by mouth) given to Resident #7. Administrator informed. DON informed. Medical Director informed. This nurse instructed by administrator to call police and have resident sent to ED (emergency department) for evaluation and treatment. When EMS arrived resident in room sleeping. Resident went willingly to ED. POA (power of attorney) and significant other informed. During an interview on 1/23/25 at 12:50 p.m., Staff S, RN, stated she worked the 6 a.m. to 6 p.m. day shift on 1/12/25. She was directed to provide 1 to 1 staffing with Resident #7 if possible, and if not, he was supposed to be in line of site of a staff member at all times. That morning he was in his room, initially asleep, then woke up around the time of the first resident smoking break. Staff O, CMA was standing at the Med cart, Resident #17 was in his wheelchair, he pushed himself backwards as he left the dining room going down the hall to his room. Staff O told him that he needed to turn around so he didn't run into someone and got him turned around. Resident #7 had been in his room up to that point, and Staff S was positioned at the Nurse's Station and could see if he came out of his room. He was coming out of his room as Resident #17 was in the hall, between the kitchen door and the set of fire doors area. Resident #7 walked with his walker towards the dining room, and it looked like he was going to go right past Resident #17 without incident, Staff S was ready to intervene if needed, and when he was right next to Resident #17 that's when he switched and he took his walker and tried to hit him with it. Staff S couldn't get there before that happened, got Resident #17 to go to his room and Resident #7 went to the dining room. She gave Resident #7 oral Haldol medication (antipsychotic) 2 milligrams, ordered oral every 4 hours as needed, notified the DON and the Administrator, the Administrator said to send him out, she got the orders and he went to the ER. He was back from the ER by 1 p.m. with no new orders. While Resident #7 was in the ER they moved Resident #17 back to his old room on the South hall. They kept Resident #7 within line of sight at all times upon his return. During an interview on 1/23/25 at 1:14 p.m., when asked about the recent incident with another resident that occurred near the dining room, Resident #7 stated that the other resident came up to him, rammed his (Resident #7's) walker into him, it didn't hurt, the other resident took off and Resident #7 kept doing what he was doing in the dining room. Resident #7 denied that he hit the other resident or had done anything to him, either then or at any other time. Resident #7 stated he had been upset 1 other time about a resident there, but doesn't remember which resident it was or what he was upset about. Resident #7 stated he felt safe at the facility. During an interview on 1/23/25 at 1:22 p.m., when asked about the recent incidents with another resident that occurred near the dining room, Resident #17 stated that the other resident [Resident #7] was very unpredictable, out of nowhere that resident punched him and tried to hit him with his walker. During an interview on 1/23/25 at 1:38 p.m., Staff O, CNA, stated she had worked at the facility several years, she received dementia training at another facility several years ago, but had not had any behavior management training at the facility since she worked there. She learned the best approach with Resident #7 was to have 1 staff calmly respond to him verses several staff at the same time, and to gently try to guide him to his room to calm down in a quiet area. During an interview on 1/27/25 at 3:40 p.m., the Administrator stated she directed staff to send Resident #7 to the ER (emergency room) on 1/11/25. She stated they were supposed to hold him there for 24 hours, and she wasn't aware that he returned until she received a call from Staff S on the morning of 1/12/25 when he hit Resident #17 with his walker. She had directed staff to keep him in their line of sight at all times. The Administrator stated they didn't move Resident #17 on 1/11/25 because it was late, but staff moved to his old room in a different hall the next day [1/12/25]. The Administrator stated some of the resident's [Resident #7] agitation and aggression are because he wants to go home, the family want to have him at home, and they are exploring options to see if they can make that possible. A review of the facility policy, revised on 8/2024, titled Abuse Prevention Program revealed a Policy statement which declared: Residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, exploitation and involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical condition.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, staff and resident interviews, the facility failed to report allegations of abuse for 2 of 5 residents reviewed for abuse (Resident #1 and Resident #6). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 12/4/24 revealed Resident #1 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. During an interview on 1/6/25 at 10:29 a.m., Resident #1 stated she had an issue with the activity lady. She stated she had a blue flowered [NAME] and the activity lady said she would help Resident #1 finish it and when I came in with it the activity lady told her You need to get that [redacted expletive] thing off my table. Resident #1 stated she said whoa, I didn't disrespect you and you told me to go and get my [NAME]. Resident #1 said the activity lady was the one with the glue gun. Resident #1 stated she told the nurse and they did a report on it. Resident #1 asked what the activity personnel did after the encounter and she said the activity lady walked out of the room and took her [NAME] back to her room and that was the end of it. During an interview on 1/6/25 at 1:15 p.m., Staff E, Activities Director queried on any complaints against her from residents and she stated she had one complaint against her from a resident and the resident took it the wrong way. Staff E asked what she said to the resident and she stated she said something about getting her [redacted expletive] things off my table .Staff E stated she didn't know she offended the resident until the grievance form and Social Services spoke to her and informed her she couldn't speak to the residents in that matter even if it was in a joking matter. A review of a Grievance, dated 12/23/24 for Resident #1 and reported by [name redacted] revealed the following: a. Who made the report: Patient b. Nature of Grievance: I had left a project on the table in the activity room and went to my room to get something for it and [name redacted] to me to get my [expletive redacted]off her table but she took it upon herself to take it back in my room and I was not happy about it made me cry, my family don't even talk to me like that and I don't except no one else to talk to me like that. c. Signed by Resident #1 on 12/22/24, and Administrator signed on 12/26/24 During an interview on 1/9/25 at 12:12 p.m., the Administrator queried if she reported the incident with Resident #1 and Staff E as an allegation of abuse stated the allegation came in as a grievance and when she spoke with Resident #1 she was not afraid of Staff E and they handled the incident in house. The Administrator stated she saw it as a grievance, but now she understands no gray, just black and white and needs to report. 2. The MDS assessment dated [DATE] revealed Resident #6 scored a 12 out of 15 on the BIMS exam, which indicated cognition moderately impaired. The MDS revealed medical diagnoses for anxiety and bipolar disorder. A review of an email, dated 12/13/24 at 2:20 p.m., from Staff I, MDS Coordinator to the facility Administrator revealed: I am sending this because I was just pull aside by 2 CNAs (Certified Nurse Aide) that informed me of something very disturbing. Both of them stated that Staff K, Maintenance Staff was in a res. (resident) room with [name redacted] and she stroked his beard and stated to the res. look his beard is very soft wouldn't you like to sit on it. I was floored and appalled, to top it off Staff K preceded to go to the nurse's station and tell the CNAs this and thought it was funny. Do something this is highly inappropriate. A review of an email, dated 12/16/24 at 11:28 a.m., from Staff A, Certified Nursing Assistant (CNA) to the facility Administrator revealed: On Wednesday December 11th, 2024 myself, [name redacted] the nurse, and [name redacted] the other CNA we at the station 1 nurses' desk when [name redacted] the maintenance guy approached the desk. I had started a discussion about a resident [initial redacted], because she had said how she had felt [name redacted] beard and it was really soft. [Name redacted] had laughed and said that he and [name redacted] (our social worker) had been in [initial redacted] room and that [name redacted] had said how [name redacted] beard was really soft she would feel it and she did saying that it was soft. He proceeded to laugh while telling us saying [name redacted] had then said I bet you'd like to sit on his face wouldn't you [initial redacted] and [name redacted] had told us that [name redacted] face had gotten bright red and didn't have anything to say about it. During an interview on 1/9/25 at 12:12 p.m., the Administrator queried if she reported the incident with Resident #1 stated the allegation came in as a grievance. She explained when she talked to Resident #1, Resident 1 stated she was not afraid of Staff E and they handled the incident in house. The Administrator queried on the incidents with Resident #6 stated she didn't know about the second incident with Resident #6. The Administrator stated she stated a staff member called her and said they was an allegation of abuse concerning Resident #1 and the Administrator asked for a written statement. The Administrator stated she didn't ask about the situation on the phone, wanted a written statement for it. The Administrator stated if the situation happened on the 11th, why did she not get notified until the 13th. The Administrator confirmed she did not report any of the incidents discussed to the office. A review of the facility policy, dated 10/2024, titled Reporting of Abuse Allegations included a Policy statement which declared: All suspected violations and all substantiated sources and misappropriate will be immediately reported to the appropriate state agencies and other entities or individuals as may be required by law.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility policy review and staff interviews, the facility failed to use the appropriate slings size for 2 of 3 residents observed during transfers (Resident #2 and Resident #4); and failed to complete regular assessments for resident safety related to smoking for 3 of 3 residents (Resident's #7, #8 and #9). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS revealed the resident had impairment on both sides of her lower extremities; used a walker and a wheelchair; and needed partial/moderate assistance with transfers from chair/bed to chair. The MDS listed diagnoses included: chronic obstructive pulmonary disease (COPD), unspecified and heart failure. The MDS Medication section identified Resident #2 took an anticoagulant. The Care Plan, date initiated 9/1/24 included a Focus area to address [Name redacted] requires assistance with ADL's (activities of daily living) r/t (related to) activity intolerance, limited physical mobility, and is at risk for self-care deficit. Interventions included, in part, Transfer: [Name reacted] requires 1 staff to move between surfaces as necessary. Uses walker and wheelchair transfer and mobility through the facility, dated initiated 9/1/24. A review of Physician Orders revealed an order for Eliquis (name brand of an anticoagulant) oral tablet 2.5 mg (milligrams), give 1 tablet by mouth two times a day for anticoagulant therapy. A review the Weight Summary, dated 1/7/25 revealed Resident #2 weighed 422.8 Lbs. (pounds) on 1/3/24 at 8:57 a.m. During an interview on 1/6/25 at 12:33 p.m., Resident #2 stated she couldn't walk right now but she wanted to go home. She stated she currently didn't do physical therapy because she was placed in hospice services. The Care Plan did not address the residents change in mobility, or associated interventions. During an observation on 1/6/25 at 12:33 p.m., Resident #2 sat in a Broda (a specific brand of chairs or wheelchairs used for comfort and positioning) in the dining room. Resident #2 had a mechanical lift sling under her in the wheelchair. The sling had green [NAME] with a royal blue center. During an observation on 1/6/25 at 2:45 p.m., Staff A, CNA (Certified Nursing Assistant) and Staff B, CNA transferred the resident from the Broda chair to the bed using a mechanical lift. Prior to the transfer, Staff A informed Staff B that day shift used too small of a sling for the resident today. The sling had green [NAME] and a royal blue center. She added another staff member got the resident a different sling that was supposed to stay with her and it was grayish in color. Staff A and Staff B proceeded with the transfer to the bed. The transfer went smoothly and the sling removed once the resident laid in bed. During an interview on 1/6/25 at 3:15 p.m., Staff A, CNA queried on how she knew what size of mechanical sling size to use for each resident stated the slings were colored coded to the maker and some had tags on them with the weights. Staff A stated the weight was not the only factor, it depended on how wide the resident was too. Staff A stated the green corded sling was mid-level and the royal blue were the biggest ones and Resident #4 and Resident #5 needed the largest ones. Staff A stated she wasn't able to get Resident #5 out of bed twice due to no slings available. During an interview on 1/8/25 at 3:00 p.m., Staff A, CNA queried on what size sling Resident #2 needed for mechanical lift transfers. Staff A went into the bathroom and looked at the slings and lifted a tan sling with reddish border with a #73 and XXL (2x-large) written on it with permanent marker. 2. The MDS assessment dated [DATE] revealed Resident #4 scored a 11 out of 15 on the BIMS exam, which indicated cognition moderately impaired. The MDS revealed impairment in both lower extremities; used a wheelchair; and dependent with transfers from chair/bed to chair transfers. The MDS revealed diagnoses of Guillain- Barre syndrome and depression. The Care Plan, date initiated 9/9/20 included a Focus area to address [Name redacted] has an ADL self-care performance deficit related to impaired balance, limited mobility. Interventions included, in part: TRANSFERS with Hoyer and 2 aides, dated initiated 9/9/20. The Care Plan, date initiated 6/1/22 included a Focus area to address [Name redacted] is Risk for Falls r/t (related to) need for assistance for ADL's, incontinence, diagnosis, hallucinations, delusions and high-risk medications. Interventions included, in part: Transfer with Hoyer and 2 aids, make sure to open legs of Hoyer before lowering resident into w/c (wheelchair). Make sure Hoyer is operating properly before use and inform maintenance if Hoyer is not operating properly. Do not use Hoyer if not operating properly. Make sure Hoyer is rated for weight of resident, dated initiated 7/7/23. A review the Weight Summary, dated 1/7/25 revealed Resident #4 weighed 295.9 pounds on 1/4/25 at 8:58 p.m. During an observation on 1/6/25 at 1:37 p.m., Staff C, CNA and Staff D, CNA transferred Resident #4 with the mechanical lift. The sling had green [NAME] and a royal blue center. The sling did not cover the left side of the resident bottom. The transfer went without incident. During an interview on 1/7/25 at 9:42 a.m., Staff D, CNA queried on how she knew what size of mechanical lifts slings to use on each resident stated they used the bigger slings on the larger residents. Staff D stated they used a large or x-large on Resident #4. Staff D stated the sling size marked on the top of the sling by the [NAME]. Staff D held up a black corded sling with mesh in the center and stated that sling was a full body sling and they used it for residents 350 pounds and larger. Staff D held up a green corded sling with blue mesh and stated this sling used for residents who weighed between 200-250 pounds. Staff D asked if the green corded sling big enough for Resident #4. Staff D stated the other ones were dirty and Resident #4 needed a shower and they needed to put her in the shower chair so they used the smaller one. Staff D stated they don't do that normally, but she wanted her shower done. Staff D asked if she thought it was safe to use a smaller sling and she stated she didn't do it by herself, someone with her. During an interview on 1/7/25 at 10:03 a.m., Staff C, CNA queried on the sizes of the mechanical lift slings stated the black ones are the larger ones, but it depends on the company. Staff C stated they used the black edging the most. Staff C stated the green [NAME] was a medium size. Staff C asked if she used a green [NAME] on Resident #4 yesterday and she stated she didn't remember but she thought for Resident #4 the green one fit her well, it just depended on how we placed her. During an interview on 1/7/25 at 10:21 a.m., Staff J, CNA queried on how she knew what size of mechanical sling to use for each resident stated she didn't know the sizes. Staff J stated she held up the slings and knew the sizes by looking at them. Staff J asked if the green corded slings appropriate to use with Resident #4 and she stated no, because she would be hanging out of it. Staff J asked what size she would use for Resident #2 and she stated she used the gray one with black trim. During an interview on 1/7/25 at 11:11 a.m., Staff L, Central Supply queried about the ordering of slings in the last month and she stated she had a sling coming in this week and had put in a request order a couple of weeks ago and they were denied. Staff L stated she didn't know why they were denied and assumed due to budget and pushed them back through again and they were denied again with a comment they would get from a sister facility. Staff L stated she ordered a full body sling on 1/3/25 and it would arrive this week. During an interview on 1/9/25 at 10:35 a.m., the DON (Director of Nursing) queried on how they knew if they had enough slings stated a staff member told her in verbal report that a staff member threw the slings away and asked how were they supposed to know what they needed if staff just threw them away. The DON asked the staff if knew which sling to use on which resident and she stated it should be on the resident's care plan or [NAME]. After the DON informed the sling sizes for Resident #2 and Resident #4 were not found on their Care Plans, she stated they needed to be. The DON stated they needed to put new processes in place and needed a binder with the sling sizes for each resident. The DON stated she recognized the concern. The DON confirmed the sling used to transfer Resident #2 and Resident #4 were too small and the staff should have used a larger sling for each resident to ensure safety. During an interview on 1/9/25 at 12:12 p.m., the Administrator queried on the the order for slings in December being denied and she stated because they had plenty of slings on hand and they used to have 80 people in the facility and the facility was oversupplied. The Administrator stated she didn't know they had a CNA throwing slings away, and they usually took the slings to Staff L when they were torn and Staff L put in a request when we needed more slings, but they take a few days to get slings in so she brought some from the other building. The Administrator stated she brought 4 the first time and brought another 10 another day and waited on the ones ordered. The Administrator stated the ordered had been denied for new slings because she was told they had enough in the building. The Administrator stated the housekeeper kept track of the slings. The Administrator stated she didn't know how the housekeeper kept track of the sling sizes, and now the DON will have a binder and that made more sense because she would know what the residents needed. The Administrator informed of the transfers with inappropriate sling sizes used, and confirmed the practice wasn't safe. The facility did not submit information regarding the weight recommendations for the mechanical lift slings used at the facility as requested. A review of the policy, dated 10/24, titled The Safe Lifting and Movement of Resident included a Policy Statement which declared: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move resident. The Policy Interpretation and Implementation section directed staff, in part to: 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 9. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings. 3. A review of a facility self-reported incident, dated 10/8/24 revealed an incident between Resident #7, Resident #8 and Resident #9 when the residents were outside smoking without staff supervision. An undated facility policy, titled Smoking Policy included the following directives: a. The IDCP (Interdisciplinary Care Plan) team will review all residents who are participating in the smoking program on a one to one basis. Failure to comply with the smoking policy will result in counseling and may result in suspension of their smoking privileges. b. Residents will be assessed for safety using the Smoking Assessment Form. This is done prior to allow them to smoke and quarterly or with a significant change in condition thereafter. The assessment will also determine if the resident is in need of special provisions. c. Residents will be required to sign a copy of this policy and procedures to participate in this program. A review of the electronic health record revealed: a. The MDS assessment for Resident #7, dated 9/2/24 revealed no cognitive assessment completed. The 10/8/24 facility self-reported incident identified Resident #7 as Severely Impaired Cognition. HX (history): [Name redacted] has a history of accusing staff and residents of stealing items from him. He also has a history of making physical violence threats. A review of a Smoking Safety Assessment, dated 6/17/24 indicated Resident #7 had balance problems while sitting or standing, followed the facility's smoking protocols, and able to smoke independently. The electronic health record lacked an updated Smoking Safety Assessment. Resident#7 electronic health record included a signed acknowledgment, dated 10/14/24 indicating he read and understood the rules of the facility in regard to smoking. b. The MDS assessment for Resident #8, dated 8/1/24 revealed a BIMS score of 15 out 15, which indicated intact cognition. The MDS indicated the resident unable to ambulate, and required substantial assistance for position changes. A review of the Smoking Safety Assessment, dated 12/6/23 indicated Resident #8 followed the facility's smoking policy, and determined the resident could smoke safely alone. The electronic health record lacked an updated Smoking Safety Assessment, and a signed acknowledgment of the facility smoking policy rules. c. The MDS assessment for Resident #9, dated 7/17/24 revealed a BIMS score of 15 out of which indicated intake cognition. A review of the Smoking Safety Assessment, dated 4/18/24 revealed no identified concerns and Resident #9 could smoke independently. The electronic health record lacked an updated Smoking Safety Assessment, and a signed acknowledgement of the facility smoking policy rules. During an interview on 12/23/24 at 9:07 a.m., the former DON stated the new smoking policy was put into place right after the 10/7/24 incident. She stated there were 3 set times the residents could smoke outside, they had to be supervised by staff, and the resident's that smoked had to have a smoking safety assessment completed, and sign a consent for acceptance of the smoking rules and restrictions. The DON stated the Social Worker was who was responsible for completing the smoking safety assessments and getting the consents, and the assessments were supposed to be competed quarterly and as needed. During an interview on 1/7/25 at 2:39 p.m., Staff F, facility Social Worker, stated she completed the resident smoking assessments and got the Smoking Policy forms signed by the residents, she was supposed to do the assessments yearly, or if she noticed a change and she was the one who supervised the resident's smoking at least 1 of the times on the day shift and she would know if residents had any change in their ability to smoke independently. When asked where the Smoking Policy forms/consents would be located for Resident's #8 and #9, Staff F stated they might be in her desk, she would have to check on that. Updated Smoking Safety Assessments and signed Smoking Policy forms were not provided by the facility.

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 F0741 (Tag F0741)

Could have caused harm · This affected multiple residents

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Based on clinical record review, facility assessment, and staff interviews, the facility failed to ensure facility staff had the sufficient competencies and skills sets to provide nursing and related services for residents with mental health diagnoses, and behavioral disturbances requiring intervention. The facility has 12 of 35 residents with Level II Pre-admission Screening and Resident Review (PASRR) in place. Findings include: A Level II Pre-admission Screening and Resident Review (PASRR) Evaluation is a comprehensive assessment that determines if a person required long-term care in a nursing facility and completed for people who test positive on a Level I PASRR Screening. The Level II PASRR Evaluation confirms that a person has a serious mental illness, and identifies the types of specialized services required by the person that may include a) behavior monitoring and management, b) monitoring of psycho-active medications to determine the effects on behavioral symptoms, c) therapeutic counseling by facility staff, and d) on-going service integration that could include regular care by a Psychiatrist or Psychiatric Nurse Practitioner to manage the person's medication regimen for optimization on the targeted symptoms. The Level II PASRR document directs the care that is required for the individual when they are admitted to a long-term care facility. The Facility Assessment, dated 12/3/24 revealed the Common Diagnoses/Conditions for the category Psychiatric/Mood Disorders the facility indicated they are may accept included: Psychosis (Hallucinations, Delusions, etc), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e, Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder (PTSD), Anxiety Disorder, Behavior that Needs Intervention. The Assessment Special Treatment and Conditions identified for the problem of Mental Health, with a Special Treatment of Behavioral Health Needs indicated the Number/Average or Range of Residents as 18 (eighteen), with the Special Treatment of Active or Current Substance Use Disorders Number/Average or Range of Residents as 2 (two). The Assessment identified the Services Provided Based on Resident Need for the General Care area of Mental health and behavior, Specific Care or Practices included: a. Management of medical conditions and medication-related issues causing psychiatric symptoms and behaviors. b. Identify and implement interventions to support individuals with issues such as dealing with anxiety. 3. Care for residents with cognitive impairment, depression, psychiatric diagnoses and trauma/PTSD. The Facility Assessment identified Staff Competency to be completed on annually, on hire and PRN (as needed) in the areas of: Caring for People with Dementia, Alzheimer's and Cognitive Impairments, Caring for residents with Mental and Psychosocial disorders, Non-pharmacological management of Responsive Behaviors Staff training/education and competencies required for care of their residents that included, in part: Care/management for persons with dementia, Alzheimer's disease and cognitive impairment. The facility's undated Certified Nursing Assistant Skills Competency Validation Checklist, completed upon hire and annually, did not list behavior management, care for residents with cognitive impairment or dementia symptoms, mental illness, trauma or PTSD as required skills. Review of education and training topics provided for facility staff during the previous 12 months did not include education on the identified topics. A review of facility self reported incidents revealed resident to resident altercations involving Resident #7 with three other residents. The Minimum Data Set (MDS) Assessment for Resident #7, dated 9/2/24 revealed no cognitive assessment completed. Resident #7 identified as usually able to make himself understood, always understood others and without behaviors. The electronic health record Medical Diagnosis list for Resident #7, dated 12/23/24 included, in part: unspecified dementia, unspecified severity with behavioral disturbance as secondary diagnosis on 7/16/24, and violent behavior as secondary diagnosis on 7/16/24. Resident #7's Care Plan, initiated on 6/22/24 included a Focus area to address [Name redacted] is a risk for increased verbal and physical behaviors r/t (related to) increasing depression r/t being in facility, accuchecks (blood sugar checks) not in control and other health concerns. The Focus area included, in part: a. [Name redacted] has been involved in a res (resident) to res altercation. b. [Name redacted] hit and injured a staff member and was sent out via ambulance and police called on 7-15-24 c. 10/7/24 Resident hit and threatened residents and accusing them of stealing his cigarettes. d. 10-8-24 Resident was verbally aggressive towards other in the dining room. Date initiated: 6/22/24. e. [Name redacted] has had an altercation and was the recipient of physical aggression. Dated initiated: 10/7/24. Interventions included, in part: a. Referral to [provider name redacted] psychological/psychiatric services as first available appointment. Dated initiated: 6/22/24 b. Separate from others res for safety. Date Initiated: 6/22/24 c. 10-8-24 Referrals being sent to CCDI (Chronic Confusion and Dementing Illness) Units in Iowa that are more appropriate for his needs. Dated initiated: 10/8/24. During an interview on 12/31/24 at 2:22 p.m., Staff A, Certified Nursing Assistant (CNA) stated Resident #7 had aggressive behaviors towards other residents and staff, he was unpredictable, threw things, at times she was afraid of him and didn't know what to do to calm him when he was so agitated. During an interview on 1/9/25 at 7:21 p.m., Staff P, Licensed Practical Nurse (LPN) stated she had worked at the facility both as an employee and through agency for 3 to 4 years, there were several residents at the facility that had behaviors, some were difficult to manage and redirect, the resident's that had behaviors effect the other residents and staff and can cause behaviors in other residents. Staff at the facility did not receive training or support to manage resident behaviors, if a resident required 1 to 1 supervision for safety due to behaviors there was seldom enough staff at the facility to accomplish that. During an interview on 1/23/25 at 1:38 p.m., Staff O, CNA, stated she had worked at the facility several years, she received dementia training at another facility several years ago, but had not had any behavior management training at the facility since she worked there. She learned through working there that when Resident #7 was aggressive, the best approach was calmly by 1 person, not to have several staff respond at the same time, and to gently try to guide him to his room to calm down in a quiet area. During an interview on 1/23/25 at 1:41 p.m. Staff N, CNA, stated she had worked at the facility for 2 weeks, had not had any training about resident behaviors or what to do. She thought if a resident had behaviors she would yell for help if she needed to. Staff N stated she was not aware and had not been directed to monitor Resident #7 for behaviors or if there were any residents that they were supposed to keep him away from other residents. During an interview on 1/23/25 at 2:54 p.m. Staff G, CNA, stated she worked at the facility for a year, had not had any training on resident behaviors or what to do, and if a resident had behaviors she would get the nurse. During an interview on 1/23/25 at 2:57 p.m. Staff B, CNA, stated she had not had any training at the facility to manage resident behaviors, if a resident had behaviors or got aggressive she would get the nurse and stay away from them. During an interview on 1/23/25 at 3:18 p.m., the Interim Administrator stated the Director of Nursing (DON) had planned to provide staff education on behavior management of residents in December, 2024 and provided some program materials for the education that included 10 Ways to Defuse Disruptive and Abusive Resident Behavior, Managing Behaviors and Managing Resident Counterproductive Behaviors. During an interview on 1/28/25 at 1:06 p.m., the Interim Administrator stated the Behavior Management in-service was scheduled on 1/30/25, it was mandatory for the nursing staff, and the DON would provide the education.

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, staff interviews, and clinical record review the facility failed to ensure sufficient staff were on duty, including a licensed nurse, to meet the needs of the residents. The nurse on duty left the faciity on [DATE] and 12/16/24, and 6 of 6 insulin-dependent diabetic residents (Resident's #1, #5, #12, #15, #16 and #17) did not receive their insulin or have their blood sugars assessed for their lunch and supper time doses. On 12/31/24 the night shift nurse was alone in the facility for approximately 45 minutes until a staff member returned to work. On at least 4 occasions (10/23/24, 12/13/24, 12/14/24 and 12/24/24) the scheduled nurse on duty was forced to work in excess of 17 hours without replacement. The facility reported a census of 35 residents. Findings include: 1. The Daily Staff Assignment sheet dated 12/13/24 revealed the following: The Director of Nursing (DON) identified as Registered Nurse (RN) coverage. Day nurse (6 a.m. to 6 p.m.) Staff S, RN's name was crossed through, and Staff I, Licensed Practical Nurse (LPN) assigned. Certified Medication Aide (CMA) 6 a.m. to 2 p.m. Staff J, CMA Certified Nursing Assistant (CNA) 6 a.m. to 2 p.m. Staff D, CNA, Staff U, CNA CMA 2 p.m. to 10 p.m. Staff V, CMA CNA 2 p.m. to 10 p.m. Staff A, CNA, Staff M, CNA Night nurse (6 p.m. to 6 a.m.) Staff H, LPN's name crossed through, and Staff P, Agency LPN assigned. CNA 10 p.m. to 6 a.m. Staff W, CNA, Staff X, CNA Review of Payroll Reports revealed the following: Staff H, LPN worked from 6:30 p.m. on 12/12/24 to 7:15 a.m. on 12/13/24, and Staff I, LPN worked on 12/13/24 from 7:15 a.m. to 11:45 p.m., Staff P, agency LPN worked from 10 p.m. on 12/13/24 to 5:00 p.m. on 12/14/24, and Staff S, RN, worked from 5 p.m. on 12/14/24 to 6:15 a.m. on 12/15/24. Staff H, LPN worked from 6:00 a.m. to 6:40 p.m. on 12/16/24. Observation on 12/31/25 at 9:23 a.m. revealed a sign posted on the Medication Room door at the Nurse's Station that stated: Reminder, if you are the only nurse in the facility you are not allowed to leave the premises. During an interview on 12/31/25 at 9:55 a.m., Staff D, CNA, stated she worked the day shift on 12/13/24, Staff I, LPN was the nurse on duty for 6 a.m. to 6 p.m. shift and left the facility between 10:30 a.m. and 10:45 a.m. The DON was in her office with the door closed, staff realized the DON left the facility between 11:30 a.m. and 12 p.m. when they looked for her in Staff I's absence. There was no nurse in the facility at that time and staff messaged the Administrator. The Administrator called back before Staff D left work, said she spoke to Staff I and she was on her way back to the facility, but Staff D didn't see Staff I in the facility when she left for the day at approximately 2:15 p.m. During an interview on 12/31/24 at 11:38 a.m., Staff I, LPN, stated when she was called in to cover a nursing shift there were a few times she had to leave the facility as she had prior appointments scheduled. When she did that she let the DON know and gave her the keys to the medication carts, and she had the DON's authorization to leave the facility. Staff I couldn't recall the dates, stated one of the times it was 2 hours for a doctor appointment and the other time it was for 4 hours for a car appointment. Staff I stated she knew they always had to have a nurse at the facility. During an interview on 1/2/25 at 11:01 a.m. the DON stated Staff I, LPN, never gave her the keys to the medication carts when she was the nurse on duty, or told her that she had to leave the facility. The DON stated Staff I left on breaks and thought she left the keys in their office. When asked if she left the faciity on [DATE], the DON stated she had to check her calendar. At 11:08 a.m. the DON stated she was off on 12/13/24 and was not in the facility on that day. During an interview on 1/2/25 at 11:40 a.m., Staff M, CNA stated one day when she came in for her 2 p.m. shift, there was no nurse there. Staff I, LPN was supposed to be there as the nurse but she wasn't, and the DON wasn't there either. The day shift said Staff I had been gone since before 11 a.m., there was a CMA there who spoke to the Administrator on the phone about it. Staff I did come in around 3 p.m. that day. During an interview on 1/2/25 at 12:02 p.m., Staff A, CNA, stated she usually worked on the evening shift, there were at least two times that Staff I, LPN, left the facility when she was the only nurse on duty. One time was 12/13/24. Staff I wasn't in the facility when she arrived to work at 2:00 p.m. that day. She came in by 3:00 p.m. and there was another time that she left to go a store and came back with pizza for some of the residents, she wasn't sure of the date but it was within a week of the other time. During an interview on 1/2/25 at 12:35 p.m. Staff V, CMA, stated she remembered there was a day when Staff I was the nurse and she was gone for a while. One of the CNA's called the Administrator and let her know she was gone. Staff V worked the evening 2 p.m. to 10 p.m. shift on 12/13/24 when that occurred. During an interview on 1/9/25 at 11:15 a.m. the DON stated the Administrator notified her that Staff I, LPN, was leaving the facility, as staff were reporting it to the Administrator and not to her. She addressed this with Staff I, instructed her that she couldn't leave the facility if she was the only nurse on duty. The DON stated she thought the staff lied about Staff I leaving while on duty, that she didn't leave. The DON stated Staff I reported to her, and didn't know what time she would be at work today as she set her own hours (Staff I not in the facility as of the time of this interview and scheduled as the MDS nurse on this day). The DON stated she didn't post the sign about the requirement for a nurse to remain in the facility, she thought the Administrator posted the sign. During an interview on 1/9/25 at 1:04 p.m., the Administrator stated she was notified one time by one staff, Staff A, CNA, on 12/13/24 at 2:14 p.m. via text message that Staff I wasn't in the facility. The only other information she knew about that day was a message from Staff I at 3:05 p.m., that said to read her email. The Administrator did not offer the email message for documentation. The Administrator stated she did not post the sign about the requirement for a nurse to remain in the facility, and would take it down. She expected nursing staff to remain in the facility if they were the only nurse on duty. Resident record review revealed the following insulin-dependent diabetic residents had not received their scheduled lunch and supper time insulin, or had their blood sugar checked at those times as ordered on 12/13/24 and 12/16/24: A). Resident #1 had physician orders that included: Check blood sugar (BS) 3 times daily before meals and at hour of sleep (HS). Administer Lispro insulin subcutaneous (fat cells below the skin) per sliding scale 3 times daily before meals and at hour of sleep. B). Resident #12 had physician orders that included: Check BS 3 times daily before meals. Administer 55 units of Lantus insulin subcutaneous every morning and afternoon. Administer Humalog insulin per sliding scale order 3 times daily before meals. C). Resident #14 had physician orders that included: Check BS 3 times daily before meals and at HS. Administer 52 units Tresiba insulin subcutaneous every morning and afternoon. Administer 27 units Lispro insulin subcutaneous 3 times daily before meals. Administer Lispro insulin subcutaneous per sliding scale 3 times daily before meals. D). Resident #15 had physician orders that included: Check BS before meals and at HS. Administer 20 units Lispro insulin 20 units 3 times daily before meals. E). Resident #17 had physician orders that included: Check BS 3 times daily before meals. Administer 12 units Lispro insulin subcutaneous 3 times a day before meals. Administer Lispro insulin subcutaneous per sliding scale 3 times a day before meals. 2. The Daily Staff Assignment sheet dated 10/23/24 revealed the following: Day Nurse (6 a.m. to 6 p.m.) Staff P, LPN and Staff BB, RN Night Nurse (6 p.m. to 6 a.m.) Staff AA, RN The October, 2024 Employee Termination Report revealed Staff AA, RN, resigned from employment on 10/16/24. During an interview on 12/23/24 at 9:07 a.m., the former DON, the Regional Nurse Consultant for the facility's corporation, stated on 10/23/24, Staff P, LPN notified her that there was no nurse coverage for the night shift, and she had to return to the facility as they could not find another nurse to work. The former DON stated she had already taken her medication when Staff P contacted her, and had to wait before she returned to work for safety reasons. She returned to the facility around 11:30 p.m. and didn't see Staff P, she had already left and left the keys to the medication carts at the Nurse's Station. The DON stated as she worked that night she learned that Staff P had not administered any evening medications, and she was terminated as a result of that and she had left the facility before she got there. The former DON documented the following Nursing Progress Note entry in every resident's record that had evening medication or treatment orders that had not been completed by Staff P, LPN on 10/23/24: On 10/24/24 at 7:44 a.m. it appears that multiple residents did not receive their evening/HS medications. Total of 27 Residents were affected. The nurse on duty was terminated and there was no adverse effect from missing meds during that time. Education to be conducted to all nursing staff and an adhoc QAPI will be conducted. During an interview on 1/9/25 at 7:21 p.m., Staff P, LPN, stated she was scheduled to work 6 a.m. to 6 p.m. on 10/23/24. The assignment sheet said Staff AA, RN was scheduled to work 6 p.m. to 6 a.m., the problem was Staff AA had quit the week before. She said something about the schedule to the DON before she left for the day, and she told Staff P that Staff I, LPN was going to cover it. Staff P stated she was friends with Staff I and knew she had been sick. When Staff I didn't come in at 6 p.m. she called her and Staff I said she was sick and the DON knew that she wasn't able to work that night. Staff P stated she called the Administrator and the DON, and had to leave a message for the DON. When the DON called back she said she would try to find someone to come in, there was still no relief nurse at 10 p.m. Staff P called the Administrator and the DON again, the DON said she would come in, she wasn't there at 11 p.m. Staff P called her again and she said she was on her way. Staff P stated the DON arrived around 11:30 p.m., after Staff P had been on duty for 17 and a half hours. 3. The Daily Staff Assignment sheet dated 12/14/24 revealed the following: Staff S, RN identified as RN Coverage Day Nurse Staff S, RN's name crossed through, Staff P, LPN assigned CMA 6 a.m. to 2 p.m. Staff O, CMA CNA 6 a.m. to 2 p.m. Staff D, CNA, Staff Y, CNA's name listed as called in CNA 2 p.m to 10 p.m. Staff B, CNA, Staff Z, CNA Night Nurse Staff Q, LPN's name crossed through, Staff S, RN assigned During an interview on 1/9/25 at 7:21 p.m., Staff P, LPN, stated she had to work over 17 hours again when she worked at the facility as an agency nurse. She relieved Staff I, LPN at midnight on 12/13/24, Staff I had been there since that morning as the only nurse. There was an ice storm predicted for 12/14/24, it had been predicted for at least 2 or 3 days. When she was the Assistant Director of Nursing (ADON) at the facility, if there was bad weather, management planned around it, knowing there was a good chance some staff would not make it in. They either offered overtime for staff to work double shifts, or the managers planned to be at work to help, but that is not the case with the current DON. When Staff P worked the overnight shift on 12/13 to 12/14/24, she was scheduled to work on 12/14/24 from 6 p.m. to 6 a.m. at another facility through her staffing agency, she needed to get home to sleep. On the morning of 12/14/24, the nurse scheduled to work the day shift called in sick. Staff P stated she immediately called the DON who said she lived too far away and there was an ice storm, she would not come to the facility. Staff P called the Administrator who said she would try to find someone. Staff P stated the nurse scheduled to work the night shift on 12/14/24 was off work for a health problem and there was no coverage for that either. She spoke to the Administrator a few times, who kept telling her she was working on it, and yet there was no relief staff for her throughout the day. Staff P's staffing agency told her to call the police and turn the facility keys over to them, they would evacuate the facility then. The Administrator called her later and said Staff S, RN would come in to relieve her, she didn't get there until nearly 5 p.m., after Staff P had worked 17 hours straight without relief. During an interview on 1/9/25 at 1:04 p.m., the Administrator stated on 12/14/24, she spoke to Staff P and informed her she would try to find coverage. She made several phone calls to staff at both the facility and sister-facility, and while making the calls her phone was being blown up by Staff P's staffing agency, who demanded that Staff P turn the keys over to the police and they were going to evacuate the facility if the Administrator couldn't get staff there to relieve her. The Administrator was able to get Staff S to the facility to relieve Staff P. The Administrator had checked with staffing agencies for coverage and there were no staff available that day. 4. The Daily Staff Assignment sheet dated 12/24/24 revealed the following: Day Nurse Staff R, LPN Night Nurse Staff H, LPN name crossed though and Staff I, LPN assigned Review of Payroll Records revealed Staff R, LPN worked on 12/24/24 from 6:00 a.m. to 11:00 p.m. During an interview on 12/31/24 at 10:44 a.m., Staff R, LPN stated on 12/24/24, she had to work for 17 hours. The nurse scheduled to work the 6 p.m. to 6 a.m. night shift was in the hospital and they had not found anyone to cover her shift, she was forced to stay until she was relieved by Staff I, LPN, who had to come in to relieve her. She tried to call the DON, but didn't get an answer and she didn't return her call. She contacted the Administrator about it and she said she was working on it, and that is how she was relieved by Staff I. Per staff interviews and facility records, the nurse on duty had to work a minimum of 17 hours without relief due to lack of nurse coverage on 10/23/24, 12/13/24, 12/14/24 and 12/24/24. 5. The Daily Staff Assignment sheet dated 12/31/24 revealed the following: DON listed as RN Coverage Day Nurse Staff R, LPN CNA 2 p.m. to 10 p.m. Staff M, CNA, Staff B, CNA, and Staff A, CNA scheduled for 2 p.m. to 6 p.m. for showers. Night Nurse Staff Q, LPN's name was crossed through, Staff I, LPN's name was assigned. CNA 10 p.m. to 6 a.m. Staff DD, CNA's name crossed through, Staff M CNA's name written as replacement, and an agency CNA A Payroll Report revealed Staff M, CNA, worked from 2:00 p.m. on 12/31/24 to 6:00 a.m. on 1/1/25, and had not clocked out at the conclusion of her scheduled 2 p.m. to 10 p.m. shift. During an interview on 1/2/25 at 9:10 a.m., Staff I, LPN, stated on 12/31/24 she worked as the MDS nurse until 3:30 p.m., left and returned at 6:30 p.m. to be the nurse on duty for the night shift. There were 2 CNA's scheduled for the 10 p.m. to 6 a.m. night shift that had called off. Staff M worked as a CNA on the 2 p.m. to 10 p.m. evening shift, she left at 10 p.m., came back about an hour and a half later, then worked with her until 6 a.m. on 1/1/25. When Staff I was alone in the facility, she answered call lights, didn't transfer any residents to or from bed, and she had called the Administrator to get help when she learned the scheduled night shift CNA's wouldn't be there. During an interview on 1/2/25 at 11:40 a.m. Staff M, CNA, stated she was on duty for the 2 p.m. to 10 p.m. evening shift on 12/31/24, both of the CNA's scheduled for the 10 p.m. to 6 a.m. night shift had called in, Staff I, LPN was the nurse on duty, she'd called the Administrator and DON for help but couldn't get help. Staff M stated she felt horrible that Staff I would have to work as the only staff, Staff M had to go home at the end of her shift to care of her dogs, then returned to the facility 30 to 45 minutes later to work with Staff I until 6 a.m. so she wouldn't be there alone. During an interview on 1/2/25 at 11:01 a.m., the DON stated staff did not notify her the scheduled night shift CNA's on 12/31/24 had called in, they called the Administrator, and she wouldn't have been able to help as she was out of town. During an interview on 1/8/25 at 2:48 p.m., Staff M, CNA, stated when she worked the double shift on 12/31/24, she did not clock out when she went home at 10 p.m. because she had not had a break that evening, and used her break to go home and then return to the facility for the night shift. During an interview on 1/9/25 at 1:04 p.m., the Administrator stated on 12/31/24 she was on the phone for quite a while with the Staffing Agency, as the CNA assigned had not shown up. The Staffing Agency initially reported that he drove to the wrong facility and was on his way there, and then at 1 a.m. when he had not reported to work, the Staffing Agency canceled the

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected most or all residents

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Based on facility document record review, observations and staff interviews, the facility failed to provide 8 consecutive hours of staffing by a Registered Nurse (RN) daily as required by regulation on at least 6 days in December, 2024 (12/1/24, 12/4/24, 12/13/24, 12/21/24, 12/24/24 and 12/31/24). The facility reported a census of 35 residents. Findings include: Review of nursing schedules and payroll records revealed nursing staff worked 12-hour shifts, from 6:00 a.m. to 6:00 p.m. and from 6 p.m. to 6 a.m. The documents reviewed for the month of December, 2024 revealed the following: On 12/1/24 Staff P, Licensed Practical Nurse (LPN) worked the day shift and Staff Q, LPN worked the night shift. On 12/4/24 Staff R, LPN worked from 6 a.m. to 7:15 p.m., Staff I, LPN worked from 7:15 p.m. to 12:15 a.m. and Staff P, LPN worked from 12:01 a.m. to 8:22 a.m. on 12/5/24. On 12/12/24 Staff H, LPN worked from 6:30 p.m. to 7:15 a.m. On 12/13/24, Staff R, LPN worked from 7:15 a.m. to 11:45 p.m., Staff P, LPN worked from 10:00 p.m. to 5:00 p.m. on 12/14/24. On 12/20/24 Staff I, LPN, worked from 6:30 p.m. to 6:00 a.m. On 12/21/24, Staff R, LPN worked from 6:00 a.m. to 7:30 p.m. and Staff I, LPN worked from 7:15 p.m. to 6:00 a.m. on 12/21/24. On 12/24/24 Staff R, LPN worked from 6:00 a.m. to 11:00 p.m., and Staff I, LPN worked from 11:00 p.m. to 6:00 a.m. on 12/25/24. The Director of Nursing (DON) was not in the facility and worked from home. On 12/30/24 Staff Q, LPN worked the night shift, Staff R, LPN worked the day shift on 12/31/24, and Staff I, LPN worked the night shift until 6:00 a.m. on 1/1/25. Observations on 12/31/24 revealed the DON arrived at the facility at 9:10 a.m., and left the facility for the day at 2:45 p.m. During a telephone interivew on 12/24/24 at 9:10 a.m., the DON stated she was working from home that day. During an interview on 12/31/24 at 11:01 a.m., the DON stated she did not work/was not in the facility on 12/13/24. During an interview on 12/31/24 at 9:55 a.m., Staff D, CNA, stated the DON usually arrived after 9 a.m., left by 3 p.m. and was usually in her office with the door closed. During an interview on 1/9/25 at 11:15 a.m., the DON stated she drove 1 hour and 40 minutes each way to work, she had 4 children at home every other week, could not be at the facility for 8 hours on those days and going forward she would coordinate her schedule with Staff S, the facility's only RN, to ensure the facility had 8 hours of RN coverage daily.

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected most or all residents

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Based on clinical record review, facility document review, resident interview, staff and physician interviews, the facility failed to administer evening insulin medication to insulin-dependent diabetic residents and failed to assess resident blood sugars as ordered by the physician as many as 14 times during the month of December, 2024 for 5 of 5 residents with evening insulin orders (Resident's #1, #5, #7, #15 and #16). The facility reported a census of 35 residents. Findings include: 1. Resident #1's Minimum Data Set Assessment tool dated 12/4/24 revealed the resident scored 15 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated no cognitive impairment or symptoms of delirium present, and always able to make herself understood and always understood others. The Clinical Physician Orders for Resident #1 last reviewed 12/3/24 included: Check blood sugar (BS) 3 times per day before meals and at hour of sleep (HS). Administer 40 units Glargine insulin subcutaneously (in the fat cell area under the skin) every morning and HS. Administer Lispro insulin subcutaneously per sliding scale 3 times daily before meals and at HS. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for December 2024 revealed: -No HS insulin or BS checks completed on 12/2/24, 12/9/24, 12/11/24, 12/12/24, 12/13/24, 12/16/24, 12/18/24, 12/21/24, 12/23/241 and 12/25/24. -BS not checked/no sliding scale insulin at noon and supper on 12/13/24 and 12/16/24. -Staff H documented she completed the resident's HS insulin administration and BS check on 12/10/24, 12/17/24 and 12/19/24. The Care Plan included a Diabetes Mellitus problem, initiated 9/17/24 that directed staff: a). Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 9/17/24. b). Monitor/document/report as needed any signs or symptoms of hyperglycemia (high blood sugar): increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, acetone breath (smells fruity), stupor, coma, initiated 9/17/24. c). Monitor/document/report as needed any signs or symptoms of hypoglycemia (low blood sugar): Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait, initiated 9/17/24. During an interview on 1/2/25 at 2:49 p.m., the resident stated there were times recently that staff didn't administer her insulin after supper or check her blood sugar, and she told the nurses that she hadn't received it. 2. The Clinical Physician Orders for Resident #5 last reviewed 12/3/24 included: Check BS twice daily in the morning and at HS. Administer Jardiance 25 milligrams (mg) oral daily (oral hypoglycemic medication for diabetics). Administer 22 units Lantus insulin subcutaneously every HS The MAR and TAR dated December 2024 revealed: -No HS insulin or BS checks were completed on 12/9/24, 12/10/24, 12/11/24, 12/12/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/21/24, 12/23/24 and 12/25/24. -Staff H documented she completed the resident's HS BS check and insulin administration on 12/2/24. The Care Plan for Resident #5 included an Insulin Dependent Diabetes problem initiated 2/22/23 that directed staff: a). Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 2/22/23. b). Monitor/document/report as needed any signs or symptoms of hyperglycemia (high blood sugar): increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, acetone breath (smells fruity), stupor, coma, initiated 2/22/23. 3. The Clinical Physician Orders for Resident #7 last reviewed 12/3/24 included: Check BS twice daily in the morning and HS. Administer 13 units Lantus insulin subcutaneously every morning and HS. The MAR and TAR dated December 2024 revealed: -No HS insulin or BS checks on 12/2/24, 12/9/24, 12/10/24, 12/11/24, 12/12/24, 12/17/24, 12/18/24, 12/19/24, 12/21/24, 12/23/24 and 12/25/24. -Staff H, LPN documented she administered the HS insulin and completed the BS check on 12/16/24. The Care Plan included a Diabetes Mellitus problem initiated 4/2/24 that directed staff: a). Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 4/2/24. b). Monitor/document/report as needed any signs or symptoms of hyperglycemia (high blood sugar): increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, acetone breath (smells fruity), stupor, coma, initiated 4/2/24. 4. The Clinical Physician Orders for Resident #15 last reviewed 12/3/24 included: Check BS 3 times daily before meals and at HS. Administer 20 units Lispro insulin subcutaneously 3 times daily before meals. Administer 85 units Tresiba insulin subcutaneously every morning and HS The MAR and TAR dated December 2024 revealed: -No HS BS completed or insulin administered on 12/2/24, 12/9/24, 12/11/24, 12/12/24, 12/13/24, 12/16/24, 12/17/24. 12/18/24, 12/19/24, 12/21/24, 12/23/24 and 12/25/24. -No noon or supper insulin was administered on 12/13/24 and 12/16/24 Staff H, LPN documented she checked the resident's HS BS and administered HS insulin on 12/10/24. The Care Plan for Resident #15 had a Diabetes Mellitus problem initiated 9/6/18 that directed staff: a). BS checks per MD orders, initiated 2/6/20. b). Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 9/6/18. c). Follow facility protocols for high and low blood glucose levels, initiated 5/16/24. d). Glucagon per order for symptomatic if BS < 60, initiated 5/16/24. 5. The Clinical Physician Orders for Resident #16 last reviewed 12/3/24 included: Check BS daily on the night shift (order start 12/9/24) Administer 21 units Lantus insulin subcutaneously every HS. The MAR and TAR dated December 2024 revealed: -No HS insulin was documented as administered on 12/2/24, 12/9/24, 12/10/24, 12/11/24, 12/12/24, 12/16/24, 12/17/24, 12/19/24, 12/21/24, 12/23/24, 12/25/24 and 12/31/24. -The resident's BS was not checked 12/9/24,12/10/24, 12/11/24, 12/12/24, 12/16/24, 12/17/24, 12/19/24, 12/21/24, 12/23/24 and 12/25/24. -Staff H, LPN documented she administer the resident's insulin on 12/2/24 and 12/18/24. The Care Plan for Resident #16 included a Diabetes Mellitus problem initiated 10/27/24 that directed staff: a). Administer diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness, initiated 10/17/24. The Payroll Records revealed Staff H, LPN, worked on the 6 p.m. to 6 a.m. night shifts on the following dates in December: 12/2/24 12/9/24 12/10/24 12/11/24 12/12/24 12/16/24 12/17/24 12/18/24 12/19/24 12/21/24 12/23/24 12/25/24 During an interview on 12/31/24 at 12:18 p.m. Staff S, RN stated the evening insulins and blood sugars weren't being done when Staff H, LPN worked. Resident blood sugars are impacted, higher, 300+ the next day. Staff H says she doesn't care, she can't get them done when she's the only nurse, but that's not true, as all the nurses are the only nurses on duty and they can manage to get them done so Staff H should be able to do so as well. There was no reason not to give resident insulin or complete blood sugar assessments and Staff S thought this was a dangerous practice. Staff S stated she felt she wasn't Staff H's supervisor; the DON should do something about Staff H not giving insulin and checking blood sugars. During an interview on 1/2/25 at 11:01 a.m., the Director of Nursing (DON) stated she expected staff to administer medications, insulin and provide treatments as ordered by the physician, unless there was a contraindication and they should consult with the provider for direction if so. The DON stated she was not aware that Staff H didn't administer the diabetic resident's evening insulin or check their blood sugars as ordered until the Surveyor brought the matter to her attention, and expected staff to administer insulin, complete the ordered treatments, document they had done so and all staff were educated to do so today. The DON denied that staff or residents had notified her that Staff H had not administered insulin or checked blood sugars when she worked. The DON stated failure to administer a resident's ordered insulin without cause would be a medication error, and stated she had notified their Medical Director that Staff H had not administered HS insulin's or completed HS blood sugars as ordered. During an interview on 1/2/25 at 11:40 a.m., Staff M, Certified Nursing Assistant (CNA) stated she worked the 2 p.m. to 10 p.m. evening shift, had worked with Staff H several times, never saw her administer insulin or check resident blood sugars. There was a resident that asked for his insulin 1 night and she told Staff H. Staff H said she would do it, but the same resident asked again a couple hours later for it, said the nurse never came and didn't check his blood sugar either. During an interview on 1/2/25 at 6:05 p.m., Staff H, LPN, stated she worked at the facility for approximately 1 month on the 6 p.m. to 6 a.m. night shift, she transferred from a sister facility where she had worked on the same shift for about a year. Staff H stated she thought it was weird that the diabetics didn't have physician orders for evening insulin or blood sugar checks, and found out recently that their insulin and blood sugar orders were in a different part of the computer. She stated they weren't that way at the sister facility, she didn't know to check there, and said she never asked other staff why the residents wouldn't have evening insulin or blood sugar checks. When asked if any resident had asked for their insulin, Staff H stated no, then laughed. When asked if any staff had asked her or indicated that a resident wanted their evening insulin, Staff H stated staff had not said anything to her about residents wanting insulin. During an interview on 1/7/25 at 6:03 a.m., Staff Q, LPN, stated she worked at the facility's sister facility through staffing agency, worked at this facility for about 2 months, and medication, insulin and blood sugar orders were in the same place in the computer at both facilities. During an interview on 1/7/25 at 2:09 p.m. the facility's Medical Director Physician stated there was a lot of staff turnover at the facility and it was hard to know who was responsible for oversight of resident care there. The physician said he was not informed that the evening/night nurse did not administer HS insulin's or check HS blood sugars, and that was concerning to him. He would have to take that into account if any of the diabetics had HgA1C lab work (blood work that measures the blood sugar trend over a long period of time) in the near future. The physician stated he would speak with the DON about the issue. During an interview on 1/9/25 at 11:15 a.m. when copies of the Medication Error Report form for the non-administered insulin by Staff H were requested, the DON stated she had not completed any Medication Error Reports for the insulin not administered, staff were educated and Staff H no longer worked there.

Oct 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0635 (Tag F0635)

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, facility policy review, hospice provider interviews, and staff interviews the facility failed to obtain Physician Orders for admission, diet. medications, and resident care for 1 of 3 residents reviewed for admissions (Resident #7). The facility reported a census of 33 residents. Findings Include: Per the facilities Admission/Discharge report, Resident #7 admitted to the facility on two separate occasions for respite services: a. admitted on [DATE], and discharged on 9/22/24 b. admitted on [DATE], and discharged on 9/29/24. On 9/30/24 a review of Physician Orders revealed an order for carbidopa-levodopa extended release tablet 50-200 mg (milligrams), give 1.5 tablet by mouth two times a day for Parkinson's disease. The review of the electronic health record (EHR) and paper charts revealed a lacked Physician Orders for: admission, diet, additional medications, code status, and routine care. Also lacking from the record were contact information for a provider, assessments related to current health status, fall risk, elopement risk, and name and contact for hospice provider. The clinical record did include a hand-written note from the Resident #7 family. The note outlined the residents daily schedule, name of provider and the statement no food allergies. An informational sheet, typed and signed by the Administrator, provided staff with the following information: a. [Resident Name} - Respite Care Only This weekend b. September 20-September 22, 2024 1. Check in Friday Night at 6:00 PM 2. Check out Sunday Afternoon around 4:00 PM c. Diet: Regular. He is to eat in the main dining room Saturday breakfast Lunch and Dinner. and Sunday Breakfast and Lunch. Family will be back before Supper. d. Activity Level: Ambulatory needs minimal assistance. Wears Depends at night please check on him. Family is bringing an overnight bag with his own depends, and changes of clothes and his own disposable bed pads. e. He does sometimes wonder in the night f. Family will shower him tonight here. e. Medication: Carb/levo ER 50-200 mg ER 1.5 tablets before breakfast and 1 and ½ tab supper. Medication will be in original bottle at Nurse Station f. DX (diagnosis): Parkinson's, Early Memory Loss e. Emergency Contacts: 1. [Name Redacted, phone number redacted] 2. [Name Redacted, phone number redacted] f. [Name redacted] was a [profession redacted] and likes to draw and work on things. He has some memory loss and likes to interact w/(with) people. Also like westerns on TV. [Name reacted] is trying a stay here for this weekend lets roll out the red carpet to see how he does. A Health Status Note dated 9/21/24 at 3:52 p.m., transcribed by Staff G, Licensed Practical Nurse (LPN) documented, Resident started out in a good mood this morning, received in report that he was up for the majority of the night. slept for about an hour this morning and was up. Resident walked the halls and then started to try and get into the med carts and the nurse's desk. Redirected to bed room. Right before lunch resident tried to go out the front door. Staff was able to catch resident before he got outside. Resident then continued to pace the hallways trying to get into other residents' rooms. During lunch resident did not want to take his medication, he was also picking up the plates of other resident and trying to eat the food off their plates. Family called to check on resident and this nurse asked if he was on any other medications before he came. Family stated that resident go out the front door and try to go to the mailbox. Asked if the resident was on any medications at home for anxiety, they stated that resident is on hospice and that he was on Xanax and lorazepam (antianxiety medications), but felt like it made him angry. Discussed getting a hold of hospice to see what they thought would help with his anxiety. An Incident Note dated 9/28/24 at 12:38 p.m., transcribed by Staff I, Registered Nurse documented, Resident in dining room after meal, attempting to pick up plates off of the table to clean up after himself and fell. Resident fell forward out of his wheelchair on to the right hip. Vitals obtained. B/P 117/81 P 89 T 98.0 R19 O2 96. Head to toe completed. Right hip area slightly reddened from fall. No injuries noted. Family informed. Doctor informed. Administrator informed. PRN (as needed) morphine administered per resident's request. A Discharge Summary note note dated 9/29/24 at 5:56 p.m., transcribed by Staff I, RN documented, Resident picked up by family after weekend stay. No concerns at this time. Resident home with family. During an interview on 10/2/24 at 3:48 p.m., Staff F, RN, stated she worked the 6:00 p.m. to 6:00 a.m. shift starting on 9/20/24, and the resident was already at the facility when she arrived for her shift. Staff F stated the resident was not listed in the computer, the off-going nurse Staff B, RN instructed her that she didn't have to do anything for him because he wasn't listed as a resident, Staff F didn't think that sounded correct but Staff B had been in management there in the past so she didn't pursue the matter. The next morning when she gave report to Staff G, LPN, Staff G said that wasn't right, he had to be listed in the computer, they needed orders, and Staff G said she would take care of it. During an interview on 10/2/24 at 1:05 p.m., Staff H, LPN, stated the resident had a bottle of Roxonal (brand name of morphine, an opioid) kept in the narcotic compartment of the medication cart when he was there, and she recorded the dose that she administered to him on the facility's pink narcotic inventory sheet. During an interview 10/1/24 at 1:13 p.m., Staff N, sister facility Administrator stated there should have been physician orders for the resident's admissions and discharges, and orders that directed his care that would have included his code status while at the facility, and staff should have handled it as any other admission, with all the required assessments. During an interview on 10/3/24 at 9:56 a.m., the Administrator stated the resident's family toured the facility and wanted Respite care for him on the weekends, possibly placement, he notified the DON of the admissions on 9/18/24, and it would have been up to the DON to get the orders and direct the nursing staff with appropriate care and requirements for his admission. During an interview on 10/2/24 at 4:21 p.m., Staff A, DON at the time of the resident's admissions, stated the Administrator coordinated the resident's admissions, she didn't have anything to do with it, and thought the Administrator spoke to the resident's Hospice about it. During an interview on 10/2/24 at 1:46 p.m., Staff L, current facility DON, stated staff should have had physician orders that directed the resident's admission and care while at the facility, including medication administration, and staff should follow physician orders unless there is a contraindication, and they should obtain clarification from the physician if so. During an interview on 10/2/24 at 9:29 a.m., the Nursing Coordinator for the resident's hospice provider stated they were unaware of the resident's 9/20/24 admission to the facility until his nursing visit by their staff on 9/26/24. Their staff communicated with the resident's family about the provisions of their program and that Respite care at a nursing home should have been coordinated by his hospice provider. The staff was unaware the resident was at the facility again from 9/27/24 to 9/29/24. A facility policy, dated 3/2026, titled admission & Discharge Process directed admission to the facility is completed based on the facility's ability to provide care and services as directed by the attending physician's orders. The pollicy inl the following Procedure: 1. Review the resident care needs and physician orders. 2. Notify the referring agency of admission determination. 3. Determine bed placement based on clinical needs. 4. Obtain equipment and supplies as needed. The facility's undated Respite Care in Nursing Facility policy directed Resident are admitted into Respite care for a short term basis to relieve caregivers of care management duties. The policy included the following Procedure: a. admission of resident with Physician orders for medications/treatments b. Baseline care plan for Activities of Daily Living c. Face sheet with resident demographics/emergency contact information d. Consent to Treat Completed e. Quick ADT (Admit/Discharge/Transfer) for short term admission

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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Based on clinical record review, resident family interviews and staff interviews the facility failed to properly implement the application and maintenance of a wound VAC (vacuum-assisted closure) wound drainage system for 1 of 1 resident's reviewed with surgical wounds (Resident #6). The facility reported a census of 33 residents. Findings include: A review of the facility document, titled admission Notification, indicated Resident #6 admitted from local hospital. admission Date not indicated. Primary DX (diagnosis) of cholelithiasis (gallstones). Equipment Needed: Wound Vac. Note Regarding Special Equipment - wound vac: to midline incision. ELOS (Expected Length of Stay); Short Term DC (discharge) Disposition (place): SNF (Skilled Nursing Facility) to home. A hospital discharge document, dated 9/12/24 revealed Resident #6 procedure history: colostomy in 2001, cholecystectomy (removal of gallbladder) on 9/3/24, and exploratory laparotomy on 9/4/24 for suspected wound infection. The hospital discharge document included the following wound care instructions, in-part: a. ABD (abdominal) -cleanse with saline, non-contact layer over exposed suture, black foam to wound bed, (wound VAC) pressure @125mm/hg (millimeters of mercury, the measurement used for pressure), low intensity, change 2-3x weekly & prn (as needed). b. L (left) JP drain (Jackson Pratt drain - a tube inserted under the skin during surgery to allow fluid to drain into a collection reservoir outside of the body) - cleanse with saline, cover staples with single layer of xeroform & silicone dressing, change with VAC dressing & prn. c. R (right) JP drain - cleanse with saline, cover staples with single layer of xeroform & silicone dressing, change with VAC dressing & prn. The hospital discharge orders also included: May use Tylenol of Advil as written on bottle for mild pain. A clinical record review on 9/17/24 revealed a lack of documentation of the resident's admission to the facility on 9/12/24, or the care the resident received while at the facility A Nursing Progress Note transcribed by Staff H, Licensed Practical Nurse (LPN) on 9/13/24 at 7:04 a.m. stated: Arrived for shift, no mention of resident in the facility during report from the night shift nurse. Certified Medication Aide's (CMA's) mentioned there was a new admission. Resident's room found empty, bed untouched, no belongings in room. During an interview on 9/18/24 at 9:40 AM, Staff A, Interim Director of Nursing (DON) stated she admitted Resident #6 to the facility. The DON stated she is unsure of the date, but it was around lunch time. The DON stated she worked the floor that day as the nurse. She explained the resident had a long abdominal incision, and two stab-wound punctures, on either side of the incision, from the previous JP drain sites. The DON stated the resident also had a colostomy appliance making the application of the wound VAC difficult. She stated after the equipment [wound VAC and supplies] arrived, she attempted to put apply the wound VAC. She estimated this was around 2:00 p.m. The [NAME] stated the wound Vac worked for a while, then it was not working. She stated Staff B, RN relieved her for the 2:00 p.m. shift. She stated they both tried to reapply the wound VAC and could not get the drainage system to seal (a wound Vac will not provide the necessary suction if the dressing and connected collection system is not sealed). Staff A stated she couldn't enter a Nursing Progress Note related to the resident's admission or the care she provided because the resident was not listed in the computer software program as a current resident at the time of the care she provided. Staff A stated she received a phone call from Staff B around 5:30 p.m., to inform her the resident's family was not happy that the wound Vac was not working and they called an ambulance for the resident, she [Resident #6] was admitted to the hospital at that time. During an interview on 9/19/24 at 6:51 p.m., Staff B, Registered Nurse (RN) stated on 9/12/24 the facility called her in to relieve the DON from 2:00 p.m. to 6:00 p.m. She stated the DON had been the only nurse on duty. Staff B stated the DON informed her Resident #6 wound VAC was not working. She stated she examined the resident with the DON at between 2:45 p.m. and 3:00 p.m Staff B stated the reason the wound VAC was not working was because the DON incorrectly applied the adhesive dressing over the top of the colostomy bag. She stated all of the adhesive dressings applied to the resident's abdomen needed to be removed and reapplied, the resident had visible signs of pain and the resident stated she was in pain at the time. Staff B stated her first thought was to administer pain medication to the resident, allow the medication to work and then change the dressing, but she could not find the written physician orders for the resident and notified medical records staff (Staff M) that she needed the orders. Staff B stated the resident's family members arrived and were upset because the wound VAC was not working and the resident was in pain. Staff B stated she had other care priorities at the same time and had been unable to see the physician orders for Resident #6, that would have included pain management medication. Staff B stated around 4:30 p.m. the family asked if they should take the resident back to the hospital so she could get the care needed, they called an ambulance, the resident left in the ambulance around 5:00 p.m. and was admitted to the hospital. Staff B stated she was unable to document the care of the resident because the resident was not a current resident in the computer system. During an interview on 9/19/24 at 1:39 p.m., Staff E, RN, Nurse Case Manager from the referring hospital stated the resident left the hospital at 10:30 a.m. on 9/12/24, transported in a wheelchair van to the facility. She stated all physician orders were faxed to both an admission Coordinator for the facility's corporation, and to a fax number at the facility on 9/12/24 at 9:13 a.m. per her records. The resident had a wound VAC while at the hospital, however the device had been removed by hospital staff prior to the 10:30 a.m. discharge/transfer to the facility. The wound VAC removed as property of the hospital. During an interview on 9/17/24 at 10:09 a.m., a family member stated they arrived at the facility at approximately 4:00 p.m. on 9/12/24, another family member was already there. Both family members were very concerned because the resident was in pain, staff stated they [the facility] did not have physician orders to administer pain medication and would have to obtain the orders, and the wound VAC was not working, there was no suction to the wound area. When they addressed their concerns with the nurse on duty, the nurse had other resident's that also needed care at the same time and couldn't tell them when she would have pain medication for the resident or when she would be able to fix the wound VAC dressing, and they decided to take the resident back to the hospital where she would get the care she needed. A Health Status Note transcribed 9/19/24 at 8:42 a.m., recorded as a Late Entry by Staff A, Interim DON [position listed on note MDS Coordinator]: a. At 9/12/24 12:00 p.m. Resident arrived via transportation services in wheelchair. Resident brought to room and assisted into bed, 4+ pitting edema (severe swelling with fluid retention, when pressure applied to the area with a finger the indentation in the skin made by the finger does not return to normal after 60 seconds) noted to bilateral lower extremities, resident reports edema worsened since left hospital, bilateral lower extremities elevated on pillows in bed, lungs clear to auscultation, heart rate regular, denies pain, reports exhaustion from trip, orientated to room, lunch tray provided. Wet to dry dressing intact, Wound Vac supplies being delivered today, colostomy intact, vital signs stable, T 98.0, P 72, R 16, BP 124/78, O2 97% on room air, abdomen distended, bowel sounds active, dressing to previous Jackson Pratt drain sites intact, up with assist of one and walker, therapy to eval and treat, resident requested to sleep before any treatments or therapies due to the long ride wearing her out, orders faxed. b. At 9/12/24 2:00 p.m. Wound Vac supplies arrived, therapy working with resident will come back once done. c. At 9/12/24 2:30 p.m. Wound Vac and supplies delivered and applied to resident, no leaks noted, Wound Vac patent. d. At 9/12/24 3:00 p.m. Wound Vac dressing leaking, dressing reinforced without success then removed and new dressing applied without success, multiple attempts by multiple nurses made to apply Wound Vac, colostomy and Jackson Pratt dressings interfering with suction, plan for Staff B, RN to remove all dressings and colostomy bag and reapply all starting with Wound Vac dressing.

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 F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on clinical record review, and staff and resident family interviews, the facility failed to have competent nursing staff to apply and manage a wound VAC (vacuum - assisted closure) wound drainage system, a device commonly used after complicated surgical procedures, for 1 of 1 resident's reviewed with surgical wounds (Resident #6). The facility reported a census of 33 residents. Findings include: A review of the facility document, titled admission Notification, revealed Resident #6 admitted from a local hospital for short term staff for skilled nursing care with the goal of returning home. The date on the admission Notification was not indicated. The document revealed the Equipment Needed: Wound Vac, with Note Regarding Equipment - wound vac: to midline incision. A hospital discharge document, dated 9/12/24 documented Admit to Skilled Nursing/Long Term Care Facility. The discharge document included wound care instructions, in part: Abdominal Wound: Cleanse with normal saline, place non-contact layer over exposed sutures, black foam to wound bed, and apply Wound Vac with pressure at 125 mm/hg, (millimeters of mercury, the measurement used for pressure) low intensity, change Monday, Wednesday, Friday, and PRN (as needed). During an interview on 9/18/24 at 9:40 a.m., Staff A, Interim Director of Nursing (DON) Director of Nursing (DON) stated she worked the floor the day of Resident #6's admission. The DON stated she tried to put the wound VAC on the resident. She explained the resident had long abdominal incision, with two stab-wound punctures from the previous JP drain sites, one on each side of the incision. The DON stated the resident also had a colostomy appliance (opening in abdominal wall to divert colon contents to outside of the body into a collection bag). The DON stated this made the wound VAC application difficult. She estimated she applied the Wound Vac around 2:00 p.m., it worked for a while, then it wasn't working. Staff A stated she was relieved by Staff B, RN and they attempted to reapply the wound VAC but were unsuccessful. During an interview on 9/19/24 at 6:51 p.m., Staff B, RN, stated relieved the DON on 9/12/24. Staff B stated the DON informed her Resident #6 had a wound VAC and it was not working. She stated she examined the resident with the DON between 2:45 p.m. and 3:00 p.m Staff B stated the reason the wound VAC was not working was because the DON applied the adhesive dressing over the top of the resident's colostomy bag, which is not a correct application for the device. She stated the adhesive dressings applied to the resident's abdomen would have to be removed and then correctly applied. Staff B stated the DON attempted to add additional adhesive dressing on top of the dressing to obtain a seal, but that did not work. During an interview on 9/19/24 at 8:31 a.m., Staff D, Certified Nursing Assistant (CNA) stated on 9/12/24 at approximately 4:05 p.m., the resident's call light was on, she entered the room, family members were present and said the wound VAC machine was not working. Her family member had pulled up her gown to show her stomach area, and Staff D saw that the wound VAC dressing had been applied over the top of the resident's colostomy bag, that was a problem for both the wound VAC machine, and she wasn't sure how she could empty the colostomy bag when needed. Staff D went to get the nurse, Staff B, she was aware it wasn't working and said she was waiting for orders from the doctor. During an interview on 9/17/24 at 10:09 a.m., a family member stated they arrived at the facility at approximately 4:00 p.m. on 9/12/24. The family member stated they and another family member present were very concerned because the resident was in pain and the wound VAC was not working. They explained the dressing had been applied over the colostomy bag which was incorrect, and there was no suction to the wound area because of the incorrect dressing application When they addressed their concerns with the nurse on duty, Staff B, RN. The family member stated Staff B states she was aware the wound VAC was not working and did not know when she would be able to apply the dressing correctly due to other responsibilities she had at the same time. The family called for an ambulance at 4:50 p.m. so the resident could go back to the hospital where she would get the care she needed. The family member stated they had observed hospital nursing staff apply the Wound Vac dressing to the resident, they didn't put it over the colostomy bag, it was applied to her skin and covered the long incision. A Health Status Note transcribed 9/19/24 at 8:42 a.m., recorded as a Late Entry by Staff A, DON documented: 9/12/24 12:00 p.m., Resident arrived via transportation services in wheelchair. Resident brought to room and assisted into bed, 4+ pitting edema (severe swelling with fluid retention, when pressure applied to the area with a finger the indentation in the skin made by the finger does not return to normal after 60 seconds) noted to bilateral lower extremities, resident reports edema worsened since left hospital, bilateral lower extremities elevated on pillows in bed, lungs clear to auscultation, heart rate regular, denies pain, reports exhaustion from trip, orientated to room, lunch tray provided. Wet to dry dressing intact, Wound Vac supplies being delivered today, colostomy intact, vital signs stable, T 98.0, P 72, R 16, BP 124/78, O2 97% on room air, abdomen distended, bowel sounds active, dressing to previous Jackson Pratt drain sites intact, up with assist of one and walker, therapy to eval and treat, resident requested to sleep before any treatments or therapies due to the long ride wearing her out, orders faxed. 9/12/24 2:00 p.m., Wound Vac supplies arrived, therapy working with resident will come back once done. 9/12/24 2:30 p.m., Wound Vac and supplies delivered and applied to resident, no leaks noted, Wound Vac patent. 9/12/24 3:00 p.m., Wound Vac dressing leaking, dressing reinforced without success then removed and new dressing applied without success, multiple attempts by multiple nurses made to apply Wound Vac, colostomy and Jackson Pratt dressings interfering with suction, plan for Staff B, RN to remove all dressings and colostomy bag and reapply all starting with Wound Vac dressing.

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 F0849 (Tag F0849)

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, facility policy review, hospice provider interviews, and staff interviews, the facility failed to identify a new admission for respite services received established in-home hospice services and to coordinate the services with the already contracted hospice provider for 1 of 2 residents (Resident #7) reviewed for hospice services. The facility reported a census of 33 residents. Findings include: The facility's Admission/Discharge listing report, dated 9/30/24, revealed Resident #7 to the facility on two separate occasions. a. admitted on [DATE], discharged on 9/22/24. b. admitted on [DATE], discharged on 9/29/24. A clinical record review on 9/30/24 revealed a lack of: physician orders for admission, medical history, and name and contact number for hospice provider. The record review revealed two sources of information regarding Resident #7: a. A handwritten note provided by the family outlined a daily schedule, with the name of the primary provider and the statement no food allergies b. An informational sheet, typed and signed by the Administrator, provided staff with the following information: 1. [Resident Name} - Respite Care Only This weekend 2. September 20-September 22, 2024 - Check in Friday Night at 6:00 PM; Check out Sunday Afternoon around 4:00 PM 3. Diet: Regular. He is to eat in the main dining room Saturday breakfast Lunch and Dinner. and Sunday Breakfast and Lunch. Family will be back before Supper. 4. Activity Level: Ambulatory needs minimal assistance. Wears Depends at night please check on him. Family is bringing an overnight bag with his own depends, and changes of clothes and his own disposable bed pads. 5. He does sometimes wonder in the night 6. Family will shower him tonight here. 7. Medication: Carb/levo ER 50-200 mg ER 1.5 tablets before breakfast and 1 and ½ tab supper. Medication will be in original bottle at Nurse Station 8. DX (diagnosis): Parkinson's, Early Memory Loss 9. Emergency Contacts: a. [Name Redacted, phone number redacted] b. [Name Redacted, phone number redacted] 10. [Name redacted] was a [profession redacted] and likes to draw and work on things. He has some memory loss and likes to interact w/(with) people. Also like westerns on TV. [Name reacted] is trying a stay here for this weekend lets roll out the red carpet to see how he does. Neither the handwritten note or the information sheet identified Resident #7 received hospice services. A Health Status Note, dated 9/21/24 at 3:52 p.m., transcribed by Staff G, Licensed Practical Nurse (LPN) revealed, in part .Family called to check on resident and this nurse asked if he was on any other medications before he came. Family stated that resident go out the front door and try to go to the mailbox. Asked if the resident was on any medications at home for anxiety, they stated that resident is on hospice and that he was on Xanax and lorazepam (anti-anxiety medications), but felt like it made him angry. Discussed getting a hold of hospice to see what they thought would help with his anxiety. During an interview on 10/2/24 at 3:48 p.m., Staff F, Registered Nurse (RN), stated she worked the 6:00 p.m. to 6:00 a.m. shift starting on 9/20/24, and the resident was already at the facility when she arrived for her shift. Staff F stated the resident was not listed in the computer, the off-going nurse Staff B, RN instructed her that she didn't have to do anything for him because he wasn't listed as a resident, Staff F didn't think that sounded correct but Staff B had been in management there in the past so she didn't pursue the matter. Staff F stated she gave report to the oncoming nurse, Staff G, LPN the next morning. She stated Staff G informed her that it wasn't right, the resident had to be listed in the computer, they needed orders. Staff F stated she was called into work after 6:00 p.m. on 9/27/24. Resident #7 was at the facility for a second Respite stay. Staff F stated she called the DON (Director of Nursing) because as before, the resident wasn't in the computer and there were no physician orders for him. Staff F reported the DON stated he was there for Respite so she didn't have to admit him, and his hospice would have his orders if she did need something. During an interview on 10/2/24 at 12:06 p.m., Staff G, LPN, stated she worked the 6 a.m. to 6 p.m. shift on 9/21/24, the resident had arrived at the facility the evening before, he wasn't listed in the computer and there were no physician orders for him in the computer. She stated she called the DON to ask why the resident was not in the computer and the DON told her that it would have been up to the admission Coordinator, or the Administrator to put the resident in the computer. Staff G stated the DON didn't provide much assistance over the phone, it was a weekend and Staff G did what she could, but they needed physician orders, the resident's history and medication list, things you normally have with an admission, and they didn't have that. During an interview on 10/2/24 at 4:21 p.m., Staff A, DON, stated the Administrator coordinated the resident's admissions, she didn't have anything to do with it, and thought the Administrator spoke to the resident's hospice about the admission. During an interview on 10/3/24 at 9:56 a.m., the Administrator stated the resident's family toured the facility and wanted Respite care for him on the weekends, possibly placement, he notified the DON of the admissions on 9/18/24, and it would have been up to the DON to get the orders and direct the nursing staff with appropriate care and requirements for his admission, and it would have been up to the DON to communicate with the resident's hospice for coordination. During an interview on 10/2/24 at 9:29 a.m., the Nursing Coordinator for the resident's hospice provider stated they were unaware of the resident's 9/20/24 admission to the facility until his nursing visit at his home by their staff on 9/26/24. Their staff communicated with the resident's family about the provisions of their program and that Respite care at a nursing home should have been coordinated by his hospice provider. The staff was unaware the resident was admitted to the facility again from 9/27/24 to 9/29/24. When they refer their hospice residents to nursing homes for Respite care, there are strict protocols to follow for physician orders, coordination of care and reimbursement for services, and facility staff have to communicate with hospice staff about the resident's care. They had not received any communication from facility staff about either of the resident's admissions to their facility, his family member was who told his nurse that he had been at the nursing home over the weekend. The Nursing Coordinator stated their hospice staff always visit the nursing home prior to the resident's placement for Respite care, to ensure the facility would be able to meet the care needs of the resident, and they always visit the resident within 4 hours of admission to the facility to make sure everything was going as planned, or to address any needs. The resident lived an hour from the facility and it was not the facility that they would have placed the resident at for Respite care due to the distance from his home. A facility policy, dated 3/2026, titled admission & Discharge Process directed admission to the facility is completed based on the facility's ability to provide care and services as directed by the attending physician's orders. The policy included the following Procedure: 1. Review the resident care needs and physician orders. 2. Notify the referring agency of admission determination. 3. Determine bed placement based on clinical needs. 4. Obtain equipment and supplies as needed. The facility's undated Respite Care in Nursing Facility policy directed Resident are admitted into Respite care for a short-term basis to relieve caregivers of care management duties. The policy included the following Procedure: a. admission of resident with Physician orders for medications/treatments b. Baseline care plan for Activities of Daily Living c. Face sheet with resident demographics/emergency contact information d. Consent to Treat Completed e. Quick ADT (Admit/Discharge/Transfer) for short term admission Neither policy addressed the need to identify if resident has established hospice services and the need to coordinate services.

Jun 2024 6 deficiencies 1 IJ

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Respiratory Care (Tag F0695)

Someone could have died · This affected 1 resident

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Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure emergency equipment such as an obturator (used to insert a tracheostomy tube, a tube inserted through the neck into the windpipe enabling a resident to breathe) was available at the bedside and staff were aware of how to replace the tube for 1 of 1 residents with a tracheostomy tube (Resident #15). Due to this failure, a serious adverse outcome was likely to have occurred if the resident experienced an extubation, therefore causing an Immediate Jeopardy (IJ) to the health, safety, and security of the resident. The facility also failed to carry out physician orders related to the resident's tracheostomy by not changing the tubing as ordered. The State Agency informed the facility of the IJ that began as of June 24, 2024 on June 26, 2024 at 10:50 a.m. The facility staff removed the IJ on June 27, 2024 through the following actions: a. Placement of an emergency tracheostomy kit in Resident #15's room. b. Staff education regarding the location of the emergency kit. c. Staff education regarding how to insert a tracheostomy tube. 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 36 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 5/15/24, listed diagnoses for Resident #15 which included respiratory failure, heart failure, and anxiety disorder. The MDS stated the resident received tracheostomy care and listed his Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A 6/6/24 Care Plan entry stated the resident had a tracheostomy, was at risk for respiratory distress, and would have no complications related to the tracheostomy. Observations of the residents room on 6/25/24 at 9:44 a.m. and 10:36 a.m. revealed no emergency tracheostomy set with obturator. On 6/25/24 at 9:44 a.m. Resident #15 sat in a chair in his room with a tracheostomy tube in place. On 6/25/24 at 2:58 p.m., Staff A Registered Nurse (RN) was queried regarding the location of an emergency tracheostomy set for Resident #15. Staff A stated she needed to ask the Director of Nursing (DON) and went into her office. She came out of the office at 3:00 p.m. and stated she would place the set in the locked medication room. On 6/25/24 at 3:11 p.m., the DON stated she would keep the extra set in the medication room and stated they could also use the inner cannula if needed. The DON went into the resident's room and there was no set present at the bedside. The DON then stated there was possibly a spare set in the back storage room. She went to the room and spent approximately 1 minute trying to find the correct key to the room. Upon entering the room, she could not locate a spare set. She stated she would have to check the policy related to where the tracheostomy set should be located. At 4:05 p.m., the DON stated the facility would keep the kit at the bedside. On 6/26/24 at 7:46 a.m. Staff C, RN stated they had some tracheostomy supplies in the medication room, otherwise she would check central supply. She stated she did not know if there was anything at the bedside and stated she did not have training but the night nurse told her there was a packet for her to review. She stated she was not given direction to carry out the training prior to the start of her shift. On 6/26/24 at 8:20 a.m., Staff B, Licensed Practical Nurse (LPN) stated the spare tracheostomy set was located either in central supply or in the oxygen room, one of those two places. She stated she had never seen an extra set. A 6/26/24 Care Plan entry stated an inner cannula (the inner tube inserted into a tracheostomy tube) was hung at bedside for emergency purposes. On 6/26/24 at 8:25 a.m., an emergency tracheostomy kit hung on the wall in the residents room. The June Medication Administration Record (MAR) listed the following orders: a. A 6/7/24 order to change outer cannula (exterior tube) every 90 days with a Shiley #6 (a type of tracheostomy tube). The MAR lacked documentation of a tubing change completed from 6/7/24-6/27/24. b. A 4/17/23 order to change the inner cannula (interior tube) twice daily with a Shiley 6 millimeter(mm). The following dates lacked staff initials to indicate staff completed the change: morning entries on 6/11/24, 6/14/24, 6/15/24, 6/16/24, 6/20/24, 6/21/24 and bedtime entries on 6/15/24, 6/16/24, 6/19/24, 6/20/24, and 6/25/24. On 6/27/24 at 9:24 a.m., when queried as to what she would do if the resident's tracheostomy came out, Staff B LPN staled she always worked with Staff C and would summon her if this happened. When asked if Staff C was in the building currently, she said she was running late. She stated there was a time when the facility was out of inner cannulas. On 6/27/224 at 9:27 a.m., the DON stated staff had not changed the resident's tracheostomy set since the 6/6/24 order due to the facility not having the supplies. She said she only had the one tracheostomy kit and she did not want to use the emergency one. She stated she would order a kit. The October 2023 facility policy Respiratory System Management listed the required equipment to include a sterile tracheostomy tube. The policy described the process of how nurses should replace the tube. The policy did not address where the tracheostomy set would be located. On 6/27/24 at 12:10 p.m., the Nurse Consultant stated the facility educated nurses regarding how to insert a tracheostomy tube. She stated they would be able to educate all nurses except 2 today and for those not educated, they had planned to do this before their shifts. On 6/27/24 at 1:06 p.m., the DON stated emergency equipment should be readily available and staff should be trained on how to insert a tracheostomy tube.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observations, staff interview, and policy review, the facility failed to ensure residents had a clean, well-maintained and homelike environment. The facility reported a census of 36 residents. Findings include: On 6/24/24 at 3:35 PM, a brown stain was noted on the floor at the entrance to Hall 1. On 6/25/24 at 10:17 AM, Staff G, Housekeeper mopped the Hall 1 floor and the stain was gone. On 6/27/24 on 7:50 AM, brown stains were noted on the north side of Hall 1. At 8:28 AM, Staff G stated she was the only housekeeper scheduled. She stated she was assigned to clean Halls 3 and 5 only and Staff H was scheduled to clean Halls 1 and 2 on 6/28/24. At 8:31 AM, Staff I, Housekeeping Supervisor stated she could help clean Halls 1 and 2 but the housekeeper who was scheduled to clean those halls was off today. She stated there was no staff scheduled to perform housekeeping duties for halls 1 and 2 today. At 11:02 AM, the Regional [NAME] President of Operations (RVPO) stated someone should be scheduled every day to clean each hall. A document titled Housekeeping Cleaning Principles dated 6/2016 indicated the facility would maintain common areas and resident rooms in a clean and sanitary condition. It also indicated cleaning of resident rooms would be performed daily.

CONCERN (D)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

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Based on observation, resident interview, and policy review, the facility failed to respond to resident call lights within 15 minutes for 1 of 3 residents reviewed (#10). The facility reported a census of 36. Findings include: On 6/24/24 at 3:36 PM, Resident #11 stated the staff does not respond within 15 minutes when the call light was used. During a continuous observation on 6/24/24 at 3:39 PM Resident #10's hallway call light was illuminated. Staff D, Certified Nursing Assistant responded to the call light on 6/24/24 at 4:05 PM. A total call response time of 26 minutes. During the observation on 6/24/24 at 4:02 PM, Resident #10 remarked staff frequently do not respond to call lights within 15 minutes. On 6/27/24 at 10:41 AM, the Administrator stated staff should respond to resident call lights within 15 minutes. A document titled Call Light Standard dated 8/2023 directed staff to answer the resident's call light as soon as practicable. Emergency call lights should be answered within one minute.

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, policy review, and staff interviews, the facility failed to store and prepare food under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 36 residents. Findings include: Observations on 6/24/24 at 2:19 p.m. during the initial kitchen tour revealed the following: a. [NAME] drips covered the floor near the coffee pot. b. White, greasy-appearing fingerprints covered the outside of the Atosa refrigerator. The vent on the interior right hand ceiling was covered with a black substance. This was located directly above beverage pitchers. A pink liquid covered the bottom left interior floor of the refrigerator. c. A yellow substance covered the inside shelves of the Avatco refrigerator. There were cheese shreds and crumbs on the bottom floor of the fridge. A towel saturated with liquid was on the bottom of the fridge and a bag of lettuce sat on the towel. Multicolored splatters covered the bottom threshold of the door. d. Heavy dust particles hung down from all parts of the fire suppression system directly above the stove burners and above a boiling pot of carrots. e. Dark brown stains on the floor and a black buildup between the floor and the wall of the dry storage room. f. Large red and brown spills on the floor of the white Frigidaire located in the back hallway. Bags of frozen corn sat next to the spills. g. Dark smudges covered the outside of the refrigerator. h. Thick black dust particles on the Air King fan which blew towards the middle of the kitchen. During a follow-up observation of the kitchen on 6/25/24 at 12:35 p.m., the above conditions remained. The observation also revealed the following: a. Upper cupboards on the right hand side of the kitchen contained plastic cups which sat upside down on blue cupboard liner. The liner was covered by multiple dark drips and stains. b. Plastic pitchers sat on the floor of the bottom cupboards on the right hand side of the kitchen. The floor of the cupboard was covered with black spots and crumbs. The undated facility policy Sanitation/Infection Control, stated the Dietary Manager was responsible for supervising all sanitation and housekeeping procedures within the Dietary Department. The policy stated all work and storage areas were to be clean including overhead pipes, walls, hoods, shelves, refrigerators, and freezers. The policy did not include a specific cleaning schedule. On 6/25/24 at 12:35 p.m., the Dietary Manger stated he would agree the above areas required cleaning. He stated he would look at the cleaning schedule and add some items to it. On 6/25/24 at 12:42 p.m., the Administrator stated she expected kitchen surfaces to be cleaned and sanitized.

CONCERN (E)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected multiple residents

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Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance committee was attended by the required members, including the Nursing Home Administer or representative, Director of Nursing, Medical Director representative, Infection Preventionist, and two other members of the facility's staff present on a minimum of a quarterly basis. The facility reported a census of 36 residents. Findings include: On 6/26/24 at 2:15 PM, the Administrator stated Quality Assurance Performance Improvement (QAPI) meeting sign-in sheets were not available. On 6/27/24 at 1:31 PM, a review of three QAPI folders lacked documentation of required meeting frequency and attendees. On 6/27/24 at 10:41 AM, the Regional [NAME] President of Operations stated QAPI meetings should occur quarterly and include required attendees. A document titled Quality Assurance Performance Improvement Management dated 1/2024 indicated for the QAPI Committee to successfully achieve its mission, the members should meet at least monthly and more often as needed to identify issues with respect to which QAPI activities are necessary.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review the facility failed to implement infection control practices to prevent cross contamination of invasive medical devices, failed to perform on-going Infection Control (IC) surveillance, and failed to implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens. The facility reported a census of 36 residents. Findings include: On 6/25/24 at 12:43 PM, Resident #31 wheeled himself through the dining room in his wheelchair while his indwelling catheter drainage bag dragged behind him on the floor. The drainage bag was ½ full of urine. At 12:47 PM, Staff E, Certified Nurse Aide (CNA) and Staff F, CNA emptied Resident #31's indwelling catheter drainage bag. They both performed hand hygiene and donned a protective gown and gloves. Staff E placed the urinal and graduated cylinder on the floor then put a paper towel under them. She held the drainage bag with her left hand and opened the drainage port with her right hand. After she emptied the drainage bag, Staff F grabbed an alcohol swab from Staff E wiped the drainage port with her right hand. At 12:52 PM, Staff F raised the drainage bag above the resident's bladder and placed the drainage bag in a dignity bag. The Minimum Data Set (MDS) dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of Obstructive Uropathy (blockage of the urinary tract), Renal Insufficiency, Diabetes Mellitus, and Stage 3 Chronic Kidney Disease. The Care Plan revealed the resident had an indwelling catheter and was at risk for a Urinary Tract Infection (UTI). At 12:55 PM, Staff E stated her right hand was not contaminated with urine when she emptied the drainage bag so it was ok to use the same hand to clean the port. She also stated the resident's catheter drainage bag shouldn't touch the ground and must remain below the resident's bladder. At 1:02 PM, Staff F stated the resident's drainage bag must remain below the resident's bladder. At 1:39 PM, the Director of Nursing (DON) stated she noted Staff E did not perform hand hygiene between emptying the resident's drainage bag and cleaning the drainage port and Staff F raised the drainage bag above the resident's bladder. She stated staff was educated about indwelling catheter care during the morning huddle. On 6/26/24 at 10:22 AM, Staff B, Licensed Practical Nurse (LPN) and Staff C, Registered Nurse (RN) replaced Resident #15's tracheostomy inner cannula. Staff B and Staff C performed hand hygiene, donned gowns and gloves. Staff B removed the inner cannula from the resident's tracheostomy site and discarded it into a biohazard bag. She removed her gloves, performed hand hygiene and donned new gloves. She grabbed the sealed replacement cannula package from the resident's bedside table, opened it, removed the inner cannula and inserted it into the resident's tracheostomy site. The MDS dated [DATE] indicated the resident had a BIMS of 15 out of 15 which indicated completely intact cognition. It included diagnoses of acute respiratory failure with hypoxia (decreased oxygen), morbid obesity, dysphagia (difficulty swallowing), and anxiety disorder. The Care Plan indicated the resident was at risk for ineffective airway clearance related to a tracheostomy. On 6/26/24 at 4:00 PM, the facility's Infection Control surveillance data was not available for review. The Infection Preventionist (IP) and DON stated infection control surveillance, data analysis, and follow-up activity had not been completed due to administrative staff turn-over. On 6/27/24 at 7:14 AM, Staff J, Maintenance Director stated documentation to identify and prevent Legionella growth and other waterborne pathogens was not available. On 6/27/24 at 10:41 AM, the Regional [NAME] President of Operations (RVPO) stated staff should secure indwelling catheters and monitor to ensure drainage bags stay secured and do not contact the floor. She also stated staff should have changed gloves between closing the drainage port and obtaining an alcohol swab to clean it. She affirmed staff should have opened the replacement cannula packaging prior to donning clean gloves to access it. She indicated IC surveillance should be done monthly as well as audits for trending concerns. She also indicated random water temperature checks should be performed daily throughout the facility and minimally used water lines should be routinely flushed. An undated document titled Incontinence Management indicated a resident, with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible. A document titled Infection Prevention Handwashing dated 6/2016 directed staff to perform hand hygiene after contact with contaminated items or surfaces and when initiating a clean procedure. A document titled Respiratory System Management dated 10/2023 directed staff to open the tracheostomy packaging before donning new gloves when performing tracheostomy care. A document titled Infection Surveillance dated 6/2016 indicated the facility will use a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determining factors of a given disease or event. An undated document titled Legionella Water Management Plan Review directed staff to identify areas where Legionella could grow and spread, document how it will be monitored, and how often routine monitoring and testing would be completed.

Mar 2024 7 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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Based on clinical record review, facility policy review, and staff interviews the facility failed to provide needed staff supervision to residents requiring assistance to safely eat during a meal resulting in a burn from spilled food for one of three residents (Resident #2) reviewed. The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 8/15/23, listed diagnosis for Resident #2 included type 2 diabetes, cerebrovascular accident (stroke), and muscle contractures. The MDS assessed Resident #2 required limited physical assistance from one staff member to eat. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 13 out of 15, indicating intact cognition. The Care Plan revealed a Focus Area for ADL (Activities of Daily Living) self-care performance deficit related to a history of a stroke created on 3/9/19. The plan included an intervention for Eating with the resident able to feed herself with supervision for staff, with an initiation date of 10/6/23. A clinical record review revealed a 10/6/23 incident note documenting Resident #2 placed her left hand in a plate of pasta causing a burn with blistering of the skin and reported pain of 10 out of 10. The facility Nurse Practitioner notified of the incident and verbally ordered the resident be sent to the emergency room for evaluation and treatment. A Burn Unit provider note, dated 10/10/23, revealed Resident #2 sustained a scald burn involving less than 10% body surface on her left hand. The burn wound appeared to be superficial mixed with deep partial-thickness that may require surgical intervention. The Burn Unit provider note, dated 10/17/23, revealed a new diagnosis of acute pain due to trauma. The wound showed interval healing, and at the time did not require any surgical intervention, with a recommendation to continue wound care application of silvadene. During an interview on 3/21/24 at 12:09 PM, Staff J, [NAME] stated 10/6/23 she made Shrimp [NAME] for lunch. Staff J stated she served a plate to Resident #2, placing it slightly out of reach and telling her to wait to eat as the plate needed to cool. Staff J stated Resident #2 grabbed for the plate and her left hand had a spasm and got stuck in the plate causing a burn. Staff J stated there were no staff at the table when she served Resident #2 her lunch. She stated the CNA's (Certified Nursing Assistant) were assisting other residents from their rooms to the dining room for lunch. Staff J stated a nurse and a medication aide were at the nursing station when the resident placed her hand in the food. Staff J stated after this incident, as staff needs to be at the table before Resident #2 is served her meal. During an interview on 3/26/24 at 10:07 AM, Staff K, Licensed Practical Nurse (LPN) stated she had been at the nurses station when Resident #2 put her hand in her food. Staff K stated she heard the resident yell, and within 10 seconds she was able to lift her hand out of the food. Staff K stated when she lifted Resident #2 hand out of the food, she immediately noted blisters on the resident's hand. Staff K stated the palm and side of the residents left hand blistered. Staff K stated looked Resident #2 Care Plan in the Electronic Health REcord (EHR). She stated she had not been able to determine what assistance the resident required to eat. Staff J stated the resident did not have eating addressed on her care plan. She stated the resident now is care planned to have a staff assist with eating. During an interview on 3/26/24 at 11:31 AM, Staff L, CNA stated Resident #2 required a staff member to sit with her when eating. She stated the resident did not have control of her left hand and due to spasms she could spill hot food on herself. Staff L stated the resident required total assistance to eat foods that require a spoon or a fork. During an interview on 3/26/24 at 10:53 AM, Staff F, LPN stated Resident #2 has always needed a staff member present at the table prior to her hand. Staff F stated the CNA's have a sheet for each hallway listing what assistance residents need, including in the area of eating. A review of the Hall 2 sheet revealed Resident #2 listed as an ADR (Assisted Diner Resident). During an interview on 3/28/24 at 2:11 PM, the Director of Nursing (DON) stated if a resident requires limited assistance to eat when would expect a staff to be at the table prior to a plate being served. The facility policy, dated August 2021, titled Nutrition and Weight Management Standard lacked staff direction on providing limited physical assistance to residents to safely eat meals.

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 resident interview, staff interviews, the admission Agreement Packet, and the facility policy, the facility failed to ensure a respectful and dignified environment when staff called the resident a name referring to her anatomy for 1 of 4 residents reviewed dignity (Resident #6). The facility reported a census of 36 residents. Findings Include: The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which revealed cognition intact. During an interview on 3/21/24 at 1:18 PM, Resident #6 stated a nurse and two CNAs (Certified Nurse Aide) called her double D because she had big breasts. She stated she told the nurse she didn't like it and she stopped doing it. She stated they used to call her that in the dining room but don't anymore. She stated it made her feel like they don't think she had feelings and embarrassed by it. She stated one time her and a CNA at an appointment in the hospital and another CNA called and when they spoke on the phone referred to her as double D. During an interview on 3/26/24 at 12:54 PM, Staff B, RN (Registered Nurse) queried if she knew of any resident called double D and she stated yes and stated she knew someone called Resident #6 that. Staff B stated sometimes likes to joke around and other days she doesn't. Staff B asked if she thought it was appropriate to call a resident double D and she stated no, probably not. During an interview on 3/26/24 at 3:40 PM, Staff A, CNA queried if she ever heard a resident called double D and she stated Resident #6. She stated she heard another staff member called her that when she was in the dining area. Staff A asked if she thought the name appropriate to call the resident and she stated no, especially since other residents can hear them. During an interview on 3/28/24 at 10:02 AM, the DON (Director of Nursing) queried about a resident called double D and she stated it was inappropriate and the facility needed education on boundaries and what was appropriate. During an interview on 3/28/24 at 12:03 PM, the Provisional Administrator queried on her thoughts on the a resident called double D and she stated she didn't think they should make nicknames for the residents. The admission Packet (no date provided) revealed the following information: a. Dignity, respect, and freedom 1. Residents had the right to be treated with consideration, respect, and dignity b. Privacy and confidentiality: 1. Residents have the right to private and unrestricted communication with any person of their choice; and privacy and confidentiality regarding medical, personal or financial affairs. The Facility Resident Rights Policy dated 10/2023 revealed the following information: a. Resident's Rights 1. Our facility will make every effort to assist each resident in exercising their rights to assure that the residents were always treated with respect, kindness, and dignity. b. Dignity standard: each resident shall be cared for in a manner that promoted quality of life, dignity, and respect and individuality. 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident assisted in maintaining and enhancing his or her self-esteem and self-worth. 3. Demeaning practices and standards of care that compromised dignity were prohibited. Staff shall promote dignity and assist residents as needed. 4. Staff shall treat cognitively impaired residents with dignity and sensitivity.

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 clinical records, facility policy, and staff interviews the facility failed to protect a resident's monetary funds from financial exploitation or one of three (Resident #7) residents reviewed. The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment tool, dated 2/5/24, listed diagnosis for Resident#7 included paranoid schizophrenia, vascular dementia, and epilepsy. The MDS listed the resident s Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A review of clinical records revealed an Order of Appointment of Guardian 8/28/20. The documented found the determination of the need for the appointment of a Guardian as requested is supported by clear and convincing evidence that the Respondent [Resident #7] decision making capacity is so impaired that she is unable to make, communicate or carry out important decisions pertaining to her personal safety or need to or provide for necessities such as food, shelter, clothing or medical care without physical injury or illness might occur or becoming subject to abuse by other persons. The review of the clinical record revealed Resident #7 had an assigned Representative Payee provider. During an interview on 3/26/24 at 4:05 PM, the assigned Representative Payee provider stated they have not provided payee services to Resident #7 since February of 2022. On 3/26/24 at 4:45 PM, the Administrator sent an email listing residents for whom the facility provided Representative Payee services. The listed included Resident #7. The Administrator provided A Resident Fund Management Service Authorization and Agreement signed by the Resident #7 Legal Guardian on 5/18/21. During an interview on 3/27/24 at 12:34 PM, Staff I, former employee, stated during her employment at the facility she assisted residents with their funds. Staff I stated in November of 2023 she had been instructed by the former Administrator, to assist Resident #7 with closing a community-based bank account. Staff I stated she assisted the resident, and a check for approximately $8500 had been sent to the facility. After the check arrived, Staff I stated she emailed the former Administrator to inform her the check arrived. Staff I stated the former Administrator instructed her to put the check in the locked money bin until she [former Administrator] could pick it up. Staff I stated the former Administrator also instructed her to not tell Resident #7 the check arrived. Staff I stated when she arrived to work the following day, the check was not in the locked money bin. A review of the Resident #7 Resident Statements for the month of November 2023 and December 2023 revealed a lack of a deposit for approximately $8500. During an interview on 3/27/24 at 3:37 PM, the Provisional Administrator of a sister facility stated a staff member brought her information regarding a concern with Resident #7 funds. The Provisional Administrator stated she reported the concern to the [NAME] President of Human Resources. During an interview on 3/28/24 at 10:15 AM, the [NAME] President of Human Resources (VP of HR) stated she interviewed the former Administrator regarding Resident #7 funds. The VP of HR stated the former Administrator stated she assisted Resident #7 with depositing a check for $8523.40 into her personal bank account. The former Administrator provided a breakdown of expenses from the $8523.40 The expenditures included $3500 to Resident #7 Resident Funds. The Resident Statement included a credit on 12/8/23 from a personal check in the amount of $3500. On 12/11/23 the statement revealed a $1500 debit transfer to burial fund. The Resident Statement included a credit on 2/1/24 from a cashier's check in the amount of $3201.71. The VP of HR stated $632.68 of Resident #7 money cannot be accounted for after the investigation. The facility policy, dated 11/6/23, titled Resident Trust Fund revealed the policy has been established to assure compliance with maintaining a complete and accurate accounting of resident funds. Resident funds are maintained in a separate interest-bearing bank account that is the sole property of the residents separate from any facility accounts. The facility policy, dated October 2023, titled Freedom of Abuse, Neglect and Exploitation defined Misappropriate of Resident property as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of residents' belongings or money without the residents' 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on clinical records, facility policy, and staff interviews the facility failed to report an incident of possible financial exploitation to the State Agency for one of three (Resident#7) residents reviewed. The facility reported a census of 34 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 2/5/24, listed diagnosis for Resident#7 included paranoid schizophrenia, vascular dementia, and epilepsy. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. A clinical record review revealed Resident#7 had Representative Payee services. The Administrator provided A Resident Fund Management Service Authorization and Agreement signed by the Resident #7 Legal Guardian on 5/18/21. During an interview on 3/26/24 at 4:05 PM, the assigned Representative Payee provider stated they have not provided payee services to Resident #7 since February of 2022. During an interview on 3/27/24 at 12:34 PM, Staff I, former employee, stated during her employment at the facility she assisted residents with their funds. Staff I stated in November of 2023 she had been instructed by the former Administrator, to assist Resident #7 with closing a community-based bank account. Staff I stated she assisted the resident, and a check for approximately $8500 had been sent to the facility. After the check arrived, Staff I stated she emailed the former Administrator to inform her the check arrived. Staff I stated the former Administrator instructed her to put the check in the locked money bin until she [former Administrator] could pick it up. Staff I stated the former Administrator also instructed her to not tell Resident #7 the check arrived. Staff I stated when she arrived to work the following day, the check was not in the locked money bin. A review of the Resident #7 Resident Statements for the month of November 2023 and December 2023 revealed a lack of a deposit for approximately $8500. During an interview on 3/27/24 at 3:37 PM, the Provisional Administrator of a sister facility stated a staff member brought her information regarding a concern with Resident #7 funds. The Provisional Administrator stated she reported the concern to the [NAME] President of Human Resources. During an interview on 3/28/24 at 10:15 AM, the [NAME] President of Human Resources (VP of HR) stated she interviewed the former Administrator regarding Resident #7 funds. The VP of HR stated the former Administrator stated she assisted Resident #7 with depositing a check for $8523.40 into her personal bank account. The former Administrator provided a breakdown of expenses from the $8523.40. The expenditures included $3500 to Resident #7 Resident Funds. The Resident Statement included a credit on 12/8/23 from a personal check in the amount of $3500. On 12/11/23 the statement revealed a $1500 debit transfer to burial fund. The Resident Statement included a credit on 2/1/24 from a cashier's check in the amount of $3201.71. The VP of HR stated $632.68 of Resident #7 money cannot be accounted for after the investigation. The VP of HR denied notifying local law enforcement or the State Agency of possible financial exploitation. During an interview on 3/28/24 at 1:04 PM, the Regional [NAME] President (VP) of Operations stated the investigation of potential financial exploitation regarding Resident #7 funds occurred a month prior to her employment with the facility. The VP of Operations stated she does not know that anything had been reported to local law enforcement or the State Agency. The facility policy, dated October 2023, titled Freedom of Abuse, Neglect and Exploitation directed staff to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

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 F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and the facility policy, the facility failed to implement the Preadmission Screening and Resident Review (PASRR) Level II recommendations on the Care Plan, implement a crisis plan, and designate a POA (Power of Attorney) in a timely manner for 1 of 3 residents reviewed for inadequate nursing supervision (Resident #3). The facility reported a census of 36 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed the medical diagnoses of anxiety disorder, depression, and schizophrenia. The MDS revealed the resident took antipsychotic medications. The PASRR Level II completed on 1/26/24 revealed the following information: a. Mental Health Diagnoses: Schizoaffective disorder, Major Depression, Personality Disorder, and Anxiety Disorder b. Rehabilitative services: You needed to be provided the following services and/or supports: 1. Development by the nursing facility in conjunction with the individual and behavioral health providers of a Crisis Intervention/Safety Plan to identify triggers and symptoms, best methods for management of challenges, action steps to be taken by all parties in order to reduce risk of hospitalization. 2. The individual needed to designate [NAME] of Attorney for Healthcare (POAH) and Financial matters in order to serve as substitute decision makers in the event of incapacity, assist with decision making, and support the individuals health, resource management, and/or safety. c. Supportive Counseling from the nursing facility staff. 1. You may benefit from supportive counseling with nursing facility providers for emotional and behavioral support, monitor you for mood changes or increased symptoms, and help you to build and maintain meaningful and trusting relationships with providers to enhance your feelings of empowerment, quality of life, and dignity. Obtain Psychiatric/Mental Health Records Because you have a history of mental health diagnoses and symptoms it may be helpful for providers to obtain information about your recent and historical treatment to help ensure you are receiving the services and supports that you require and to be able to provide this information to your treatment providers so they are able to make informed decisions about your care. d. Crisis Plan: 1. You have a history of having thoughts of wanting to end your life, and taking actions to do so. While it has been a long time since you tried to end your life or reported thoughts of wanting to harm yourself. Because of your history, a crisis plan should be created, with you, to help caregivers at the nursing facility understand your illness, how your illness shows up, what signs to look out for that may mean your symptoms are getting worse, and interventions for staff (how can they support you if your symptoms are worse). The Care Plan revealed a focus area dated 2/26/24 of risk of harm for self directed or other directed incident on 3/7/24. The interventions dated 2/26/24 revealed encourage resident to verbalize aggression; if resident posed a potential threat to injure self or others notify provider; and monitor for signs/symptoms of agitation. The interventions dated 3/6/24 revealed removed all soda cans from the room and provide more frequent supervision and sent to the emergency department upon verbalization of self harm. The Care Plan lacked documentation of the resident's Level II PASRR. The EMR (Electronic Medical Record) lacked documentation for a Power of Attorney (POA) or POAH for the resident and a crisis plan implemented with the resident. During an interview on 3/26/24 at 9:50 AM, Staff H, LPN (Licensed Practical Nurse) queried if a crisis plan implemented for the resident and she stated she was probably not the person to talk to about it. She stated she didn't know if they had a crisis plan in place. Staff H stated she didn't know of any set of rules or guidelines set or brought to her attention. During an interview on 3/26/24 at 12:54 PM, Staff B, Registered Nurse (RN) queried if a crisis plan put in place for Resident #3 and she stated she wasn't sure and all she knew was they needed to do 15 minute checks and make sure nothing sharp in her room. During an interview on 3/26/24 at 4:05 PM, the Provisional Administrator queried if Resident #3 crisis plan and she stated she was new to her position and relied on the Director of Nursing (DON) to be more on top of things. She stated she knew the PASRR needed to be on the care plan. During an interview on 3/28/24 at 10:02 AM, the DON queried about Resident #3 PASRR not being addressed for the residents plan of care and the DON stated she was currently working on the resident's care plan and updated it with the PASRR and putting a crisis plan together for her. The DON asked what her expectations were for a resident with a PASRR level II and she stated when the facility received the referral they needed to know put things in place for it and not just focus on the baseline. During an interview on 3/28/24 at 12:03 PM, the Provisional Administrator queried on her expectations following the PASRR Level II and she stated moving forward she give them to the MDS Coordinator on admission. The Facility Department of Health Care Services Clinical Assurance and Administrative Support Division Preadmission Screening and Resident Review Guide to Completing the PASRR Level I Screening Policy dated May 2018 did not address what the facility needed to do when a resident received a Level II PASRR. The Facility Behavioral Management Standard revised in 2022 Policy did not address when a resident received a Level II PASRR.

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 F0774 (Tag F0774)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, record review, and the facility policy, the facility failed to provide transportation for residents to go to their doctor's appointments for 2 of 3 residents reviewed for transportation (Resident #6 and Resident #13). The facility reported a census of 36 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #6 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which revealed cognition intact. The Care Plan revealed a focus area for acute/chronic pain dated 6/29/23. The interventions dated 6/29/23 revealed evaluate pain. The EMR (Electronic Medical Record) revealed the following medical diagnosis: a. other chronic pain dated 6/9/23 The Progress Note dated 10/4/23 at 10:18 AM, revealed an Orthopedics appointment on 10/16/23 at 2:30 PM for bilateral shoulder pain and possible osteoporosis injection. The Progress Note (Health Status Note) dated 10/9/23 at 12:16 PM, revealed an Orthopedics appointment on 10/26/23 at 1:15 PM for bilateral shoulder pain and possible osteoporosis injection. The Progress Note dated 11/10/23 at 11:22 AM, revealed 11/16/23 appointment at [name of doctor and location redacted] at 12:30 for cataract consultation and set up a surgery date. At this appointment you will talk with the surgeon that will be removing your cataracts. She will go over all the details with you and then you will set up the dates for the surgeries and follow up appointments. She will also prescribe you several types of eye drops to use before surgery, and after surgery. The Progress Note dated 11/16/23 at 11:19 AM, revealed the residents cataract consult rescheduled due to no vehicle to take her at this time, ours taken to the shop today to be fixed. [Location redacted] aware, and they scheduled her back with [doctor name redacted] for the cataract consult Feb. 29th at 1:30, resident also placed on the cancellation list, so if someone called appointment off she will be called to come in earlier than [DATE]th. During an interview on 3/21/24 at 1:18 PM, Resident #6 stated she missed her appointments five times. She stated one time her appointment missed due to weather. She stated she was three years late for her osteoporosis shot. Resident #6 stated she missed her eye appointment on November 16th and she might of already had surgery on her eyes if she didn't miss that appointment. 2. The MDS dated [DATE] revealed Resident #13 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. The Care Plan revealed a focus area dated 12/6/15 for nutritional problem related to obesity and a peanut allergy. The interventions dated 12/6/15 revealed monitored, documented, and reported any signs or symptoms of dysphagia as needed. The EMR revealed the following information medical diagnosis: a. dysphagia, pharyngoesophageal phase dated 2/1/24 The Progress Note dated 3/5/24 at 10:27 AM revealed on 3/11/24 resident scheduled an appointment with Radiology at 10:30 AM for a video swallow study. The Progress Note dated 3/19/24 at 1:49 PM revealed resident refused lunch on day shift, and denied need for pureed diet any longer. The Nurse Practitioner (NP) notified. The Progress Note dated 3/20/24 at 9:00 AM revealed on 3/29/24 resident scheduled an appointment with Radiology at 11:15 for a video swallow study. During an interview on 3/26/24 at 8:33 AM, Staff E, Medical Records/Transportation queried if Resident #6 had appointments canceled and she stated Resident #6 had an appointment canceled on 11/16/23 due to the facility van in the shop. Staff E stated the appointment made for an evaluation of cataract surgery. She stated the appointment rescheduled for February and the resident put on the cancellation list for earlier openings. Staff E stated the cataract surgery delayed because the resident scheduled for retinal detachment surgery this week. During an interview on 3/26/24 at 10:36 AM, Staff F, LPN (Licensed Practical Nurse) queried if resident's appointments canceled due to transportation and she stated yes because no gas in the van or the van overbooked. Staff F stated it happened often. Staff F stated Resident #13 missed his scheduled swallow study because of no fuel in the van. Staff F asked if she documented the cancellation and she stated no, but typically there should be a note. Staff F asked if Resident #6 missed any appointments and she stated Resident #6 missed several. Staff F asked if the resident ever refused and she stated no, the resident wouldn't refuse to go. During an interview on 3/26/24 at 12:54 PM, Staff B, RN (Registered Nurse) queried if appointments canceled due to transportation and she stated yes a few of the appointments canceled due to the facility van not able to be used. She stated Staff E emailed them when appointments canceled due to the the van or us not being able to transport them. Staff B asked if they documented when a resident went to their appointment or when the appointments canceled and rescheduled and she stated they only documented when a resident returned from an appointment with new orders or needed a follow up appointment. During an interview on 3/26/24 at 3:10 PM, Staff E queried if Resident #6 orthopedics appointment scheduled 10/16/23 rescheduled to 10/26/23 and she stated yes, it got moved. Staff E asked the reason the appointment moved and she didn't know, she would look into it. Staff E queried about the rescheduling of Resident #13 video swallow test and she stated the resident didn't want to go, and by the time he got to the bus he would be late to the appointment and his wheelchair was too big to fit on the ramp. During an interview on 3/27/24 at 11:14 AM, Staff G, Maintenance queried on the last time the van taken to the shop and he stated the van not taken to the shop in quite awhile. He stated he did the maintenance on the van due to the budget. He stated he knew they missed appointments due to gas in the van so they started to use the non-emergent medical transport. During an interview on 3/27/24 at 12:05 PM, Staff G stated he didn't see anything about the van doing to the shop on November 16th. He stated he went to another facility that day. He stated in the past they shared a van with another facility. Staff G provided an invoice for 9/30/22 and stated that was the last time the van taken to the shop that he was aware of. During an interview on 3/27/24 at 12:36 PM, Resident #13 queried if he went to his video swallow test and he stated no he couldn't because they didn't have a way to get him there. He stated his wheelchair was too big for the van so they rescheduled his appointment. During an interview on 3/28/24 at 10:02 AM, the DON (Director of Nursing) queried on the expectation for availability of transportation for the residents to go to their appointments and she stated she expected the residents to make the appointments in a timely manner and the facility needed to find appropriate transportation for the residents. During an interview on 3/28/24 at 12:03 PM, the Provisional Administrator queried on her expectations for availability of transportation for the residents and she stated if the residents had scheduled appointments, the facility needed to get them to them. Per an email sent by the Provisional Administrator on 3/28/24 at 1:50 PM, she confirmed Resident #13 didn't' go to his appointment because the wheelchair didn't fit in the van and the appointment needed to be rescheduled. She also stated on 11/16/23 the van wasn't at the shop and the old Administrator told the maintenance man to use the van to go to another facility because the Fire Marshall was at the other facility. The Facility Transportation Policy dated 2/2015 revealed the facility staff assisted the residents in arranging transportation to physician appointments and for diagnostic services. a. communicate frequently with nursing staff regarding residents requiring transportation out of the facility for physician appointments and/or diagnostic services. Appointments refused or missed were to be rescheduled as available.

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 F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on facility schedule review, policy review and staff interviews, the facility failed to have an active Director of Nursing (DON) on site for 15 of 16 days in March of 2024, and consistently utilize the service of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week for a day, 7 days a week for 11 of 25 days in March of 2024. The facility reported a census of 34 residents. Findings include: During an interview on 3/20/24 at 2:25 PM, the Administrator stated the DON resigned effective 3/8/24. The Administrator stated the Regional [NAME] President of Operations assumed Interim DON duties on 3/9/24. During an interview on 3/20/24 at 2:53 PM, Staff F, Licensed Practical Nurse (LPN) stated the Interim DON has not been at the facility on a daily basis. Staff F stated the nursing staff have not been given a contact number for the Interim DON. Staff F stated if there is a clinical concern nursing staff contact the Administrator and she contacts the Interim DON, and the Administrator relays information back to the facility. Staff F stated the Administrator is not a nurse Staff F stated she had not contact with the Interim DON. During an interview on 3/20/21 at 3:10 PM, the Administrator stated after the previous DON resigned effective 3/8/24, the Assistant Director of Nursing (ADON) continued to work until 3/16/24. The Administrator stated the ADON held a LPN license. On 3/20/24 at 3:39 PM, the Regional [NAME] President of Operations (RVPO). Registered Nurse (RN) sent an email outlining the DON coverage for the facility. Per the email, the RVPO assumed Interim DON coverage on 3/9/24. The RVPO had not been in the facility the week of 3/11/24 but reviewed and assisted remotely. The emailed reviewed ADON had been on site the week of 3/11/24 as well as the Regional Nurse Consultant. The RVPO stated she worked on site on 3/20/24, plans to be at the facility on 3/21/24. The email revealed a new DON is scheduled to start on 3/25/24. During an interview on 3/28/24 at 1:04 PM, the RVPO stated it is the expectation the DON should be at the facility to supervise and direct all resident care. The Director of Nurse Job Summary, dated 7/12/23, indicated the primary purpose of the DON position is to plan, organize, develop and direct the overall operation of the Nursing Department to ensure the highest degree of quality care is maintained at all times. The Working Conditions of the Job Summary revealed the DON works in an office area as well as throughout the facility. A review of the facility nursing schedule for the period of 3/1/24 to 3/25/24 revealed a lock of 8 consecutive hours of RN coverage for the following days: 3/3/24, 3/9/24, 3/10/24, 3/13/24, 3/14/24, 3/18/24, 3/19/24, 3/20/24, 3/22/24, 3/23/24, and 3/24/24. During an interview on 3/28/24 at 2:03 PM, the newly hired DON stated it is an expectation a RN will be scheduled for at least 8 consecutive hours a day, 7 days a week. A facility policy, dated December 2023, titled Clinical Staffing revealed Procedure #4. Staffing will include a Registered Nurse 8 hours a day.

Jul 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on a review of clinical records, facility policy and staff and resident interviews the facility failed to report an incident of possible abuse to the state agency for one of one (Resident #6) residents in the sample. The facility reported a census of 34 residents. Findings include: The Annual Minimum Data Set (MDS) assessment tool, dated 5/6/23, listed diagnosis for Resident #6 included: cerebral infarction (stroke), morbid obesity, and heart failure. The MDS assessed the resident required the extensive assistance of two staff for: bed mobility, dressing, and personal hygiene. The resident assessed as total dependence on staff for: transfers, and toilet use. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15, which indicated intact cognition. A review of the Electronic Health Record (EHR) revealed on 6/2/23 the resident weighed 328 pounds. The MDS listed a height of 68 inches. The residents Body Mass Index (BMI) is 49.9. A BMI above 30.0 is considered obese. During an interview on 7/3/23 at 1:25 PM, Resident #6 stated Staff A, Certified Nursing Assistant (CNA) told her she weighed too much, and needed to lose weight. The resident stated that Staff A then grabbed areas on her stomach, legs and pubic area. The resident stated she responded by kicking Staff A away. The resident reported the staff then hit her on her arm and leg. The resident stated this incident made her angry as she had lost weight since admission. The resident denied having any injury or bruises from the incident. During an interview on 7/3/23 at 2:45 PM, the Administrator denied being aware of the allegation made by Resident #6. She stated she would immediately start an investigation. During an interview on 7/5/23 at 4:25 PM, the Administrator stated she completed an interview of the allegation made by Resident #6. She denied making a self report of the allegation due to inconsistent information given by the resident, and a history of the resident making false allegations. The Administrator stated the resident did not deny the incident occurred. During an interview on 7/6/23 at 12:29 PM, the Administrator stated she had not completed a self report to the State Agency (SA). The Administrator stated she did not feel the incident met the criteria for reporting. The Regional Nurse Consultant stated the report would be made immediately, and Staff A sent home. During an interview on 7/10/23 at 11:32 AM, the Acting Director of Nursing (DON) stated any allegation of abuse needs to be reported to the State Agency within two hours. The facility policy, dated August 2022, titled Freedom Of Abuse, Neglect And Exploitation; Abuse Prevention : Fast Alerts, Overview section [page 10] directed staff to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Some facilities are conducting an investigation of an allegation prior to reporting it to required officials. While it may be necessary for a facility to make an initial evaluation as to whether or not an incident potentially meets one or more of the reporting criteria, the thorough investigation should be completed after reporting the allegation.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on equipment observation, facility policy, resident and staff interviews the facility failed to ensure a bariatric hoyer lift worked properly prior to use for 1 of 3 (Resident #6) residents in the sample. The facility reported a census of 34 residents. Findings include #1. The Annual Minimum Data Set (MDS) assessment tool, dated 5/6/23, listed diagnosis for Resident #6 included: cerebral infarction (stroke), morbid obesity, and heart failure. The MDS assessed the resident required the extensive assistance of two staff for: bed mobility, dressing, and personal hygiene. The resident assessed as total dependence on staff for: transfers, and toilet use. The MDS listed the Brief Interview for Mental Status) BIMS score as 15 out of 15, which indicated intact cognition. During an interview on 7/3/23 at 1:25 PM, Resident #6 reported last Thursday [6/29/23] the Hoyer lift used to transfer her from the bed to her wheelchair tipped over. The resident stated the legs on the Hoyer did not open all the way which is what caused the tip. The resident denied having an injury, other than being sore. The resident stated Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA assisted with the transfer on 6/29/23 when the Hoyer tipped over. An Incident Report dated 6/29/23 at 5:13 PM revealed while Staff A, and Staff B were transferring Resident #6 to her wheelchair the Hoyer tipped onto its side. The resident, while still in the Hoyer sling, tipped backwards in the wheelchair, with Staff A pinned underneath. Staff B noted to be hit in the head by the Hoyer, and attempted to hold up the Hoyer to prevent further injury. During an interview on 7/3/23 at 2:50 PM, the Administrator stated the facility rents hoers from a medical supply company. She stated if a mobility device is not working properly, it is pulled form the floor and the supply company picks it up, and delivers new equipment. The Administrator stated she had ordered a new bariatric Hoyer that has yet to be delivered. Upon request, the Administrator provided a list from the supply company documenting the quality inspections of mobility lifts. The document included two lifts, inspected on 3/20/23, and 2/27/23 respectively. During an interview on 7/5/23 at 2:36 PM, Staff C, CNA stated the bariatric Hoyer had been broken since February 2023, until it was taken off the floor on the evening of 6/29/23. Staff C stated the bariatric Hoyer had been kept in a hallway. She stated another staff informed her there had been an out of order note on the device, and was unsure if the lift worked. Staff C stated the Hoyer did not have an out of order note when she got it from the hallway. Staff C stated she did not ask the Administrator, Maintenance Director or the Director of Nursing if the lift had been fixed. Staff C stated when she went to the residents room she tested the legs and they did not open all of the way. Staff C stated she told the nurse on duty the legs did not open. Staff C stated she did not know she should also report to the Maintenance Director. During an interview on 7/5/23 at 3:17 PM, Staff A, CNA confirmed her presence in assisting Resident #6 on 6/29/23 when the bariatric Hoyer tipped over. Staff A stated she and Staff B, CNA used the bariatric Hoyer to transfer Resident #6. Staff A stated the Hoyer did not have an out of order note attached. Staff A stated she and Staff B used the same bariatric Hoyer to transfer the resident's roommate without any concerns with the operation of the Hoyer legs. Staff A explained the legs of the bariatric Hoyer were under the bed, closed, while securing Resident #6 in the sling. She then activated the lift to raise the resident off the bed. With Staff B guiding the resident she moved the lift to the side of the wheelchair. She stated when she went to extend the legs of the bariatric Hoyer one side failed to extend. The Hoyer became unstable and tipped. Staff A stated she had heard one Hoyer needed to be fixed but did not know which one. Staff A denied asking anyone if the Hoyer used on 6/29/23 needed repair. Staff A stated if equipment is not operating it is usually taken off the floor. She stated if she see's equipment on the floor she assumes it is working. During an interview on 7/5/23 at 3:42 PM, the Maintenance Director stated he only works on the Hoyer lifts owned by the facility. He added the facility rents mobility lifts from a medical supply provider and these are serviced by the providers. The Maintenance Director stated the facility does own a bariatric Hoyer. He stated this Hoyer does not work as there is a short in the wires. He denied being informed the legs on the lift do not fully open. The Maintenance Director stated the facility Hoyer lifts are old and they do not work. He stated all transfer equipment are rentals. The Maintenance Director stated he does monthly checks on all equipment. If an issue is discovered the device is sent back to the rental company. The Maintenance Director added if the legs of the Hoyer used on 6/29/23 did not open all of the way, it was not that the device was broken, rather the staff pulled on the cord of the remote which caused a disconnection, thus the legs did not open properly. During an interview on 7/6/23 at 11:29 AM, Staff B, CNA confirmed her presence in assisting Resident #6 on 6/29/23 when the bariatric Hoyer tipped over. Staff B stated the Hoyer tipped over because both legs failed to fully extend out. Staff B denied having heard the bariatric Hoyer did not work properly, and did not see an out of order note on the equipment prior to using it. Staff B denied using the lift to transfer the roommate prior to transferring Resident #6. She explained the bariatric Hoyer is too big for the roommate, and she did not get up on 6/29/23. Staff B stated the legs of the bariatric Hoyer were not tested prior to transferring Resident #6 During an observation of the bariatric Hoyer lift on 7/6/23 at 3:35 PM, the Maintenance Director and Administrator verified the lift, brand name Wok model 235649, is owned by the facility. They explained the facility acquired the device from a sister facility. He stated that due to flooding the records and manual were destroyed. The Maintenance Director stated sometimes when the remote is used, the connections are pulled and then the mechanisms, such as the extending the legs, do not work properly. During an interview on 7/6/23 at 3:40 PM, Staff B identified Wok (235649) as the bariatric Hoyer used to transfer Resident #6 on 6/29/23, and tipped due to the legs not fully extending out. #2. The Annual Minimum Data Set (MDS) assessment tool, dated 5/12/23, listed diagnosis for Resident #6 included: morbid obesity, acute respiratory failure with hypoxia (low oxygen level), and heart failure. The MDS assessed the resident required the extensive assistance of two staff for: bed mobility, dressing, and personal hygiene. The resident assessed as total dependence on staff for transfers. The MDS listed the Brief Interview for Mental Status) BIMS score as 15 out of 15, which indicated intact cognition. During an interview on 7/3/23 at 1:55 PM, Resident #7 stated she is not currently getting out of bed because the bariatric Hoyer is broken. The resident stated Hoyer's are an issue at the facility. She explained staff complained the legs of the bariatric Hoyer did not open all of the way prior to the resident falling the previous week. Resident #7 stated staff complained of this Hoyer for several months. During an interview on 7/10/23 at the Acting Director of Nursing, and MDS Coordinator stated if equipment is not working properly she expects staff to report the issue immediately and put a note on the equipment alerting others not to use equipment. The facility provided maintenance inspection records for mobile lifts completed on 1/18/23, 2/15/23, 3/21/23, 4/13/23, 5/17/23, and 6/17/23. The lifts listed as inspected on each recorded included: a. Lumex (LF1090) b. Lumex (LF2090) c. Wok (235649) Each inspection report documented the date, the lifts inspected and the name of the person completing the inspection. They lacked documentation of the outcome (passed or needed repair/maintenance of each area inspected on each lift. The facility failed to present any additional maintenance records for the Wok (235649) lift upon request. The facility documented, dated August 2021, titled Lifting and Transferring Residents Guidelines directed staff should use a full sling mechanical lift when lifting or transferring a resident who is assessed as Total Dependent, The document did not provide instruction on how to use the lift, or what to do, or who to tell if the equipment failed to work properly. Upon request of a policy for Equipment Maintenance, the facility provided a document, dated 2021, titled Facility Environment Policy/Facility Maintenance. The document indicated the Maintenance Director ensures facility work orders are checked daily, followed through with the administrator for any outside vendor needs. Work orders are turned back into the administrator after completion and reviewed in the morning meeting for any issues.

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 clinical records, facility policy, staff and resident interviews the facility failed to complete incontinence care as needed for 1 of 3 residents (Resident #6) in the sample. The facility reported a census of 34 residents. Findings include: #1. The Annual Minimum Data Set (MDS) assessment tool, dated 5/6/23, listed diagnosis for Resident #6 included: cerebral infarction (stroke), morbid obesity, and heart failure. The MDS assessed the resident required the extensive assistance of two staff for: bed mobility, dressing, and personal hygiene. The resident assessed as total dependence on staff for: transfers, and toilet use. The MDS listed the Brief Interview for Mental Status) BIMS score as 15 out of 15, which indicated intact cognition. A review of the MDS revealed the resident assessed to always be incontinent of urine. The residents Care Plan included a focus area of increased risk of sustaining alteration of skin integrity related to a mobility impairment and incontinence. The plan included an intervention to check and change AC (before meals), PC (after meals), HS (before bedtime, and PRN (as needed). During an interview on 7/3/23 at 1:25 PM, Resident #6 reported staff come to her room every two hours to check and change her incontinence briefs, and her if needed. The resident stated she takes lasix and frequently urinates large amounts. The resident stated several staff do not change her outside of the two hour check and change schedule. She stated these staff say they just changed her, and she needs to wait until the two hours check. During an interview on 7/5/23 at 2:40 PM, Staff C, Certified Nursing Assistant (CNA) stated Resident #6 asks to be changed frequently. She stated some nights it could be every 15 to 20 minutes. Staff C stated she has heard staff tell the resident she needed to wait until the two hour check as they just changed her brief. During an interview on 7/6/23 at 12:46 PM, Staff D, CNA stated Resident #6 is on a two hour check and change schedule. She stated the resident drinks large amounts of water or kool aid, and urinates large amounts frequently. Staff D stated the resident will often use her call light to be rechecked within 20 minutes after being changed. She stated sometimes she is not wet, but other times she is soaked. Staff D stated she will change the resident if she is wet, but has also told her she needs to wait until the next scheduled check and change. Staff D stated this is not uncommon as other aides will tell the resident she needed to wait until the next check and change. During an interview on 7/10/23 at 11:32 AM, the Acting Director of Nursing (DON) stated if a resident is on a two hour check and change hour schedule she would expect the staff to follow through with this support. The Acting DON stated she would expect a resident is changed every time they are incontinent. She stated it is a concern if staff are telling a resident to wait until the next scheduled time to be changed, if they have been incontinent. The facility policy, dated August 2021, titled Incontinence Management Standard documented the intent of the program for a resident with bladder incontinence to receive appropriate treatment and services to prevent urinary tract infections, and restore as much normal bladder function as possible.

Apr 2023 11 deficiencies

CONCERN (D)

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

Transfer Notice (Tag F0623)

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, staff interview, and review of facility policy, the facility failed to notify the resident and resident's representative of transfers or discharges including the reasons for the move; the effective date of the transfers; the location of the transfer; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman in writing. This involved two of two residents (Resident (R) 9 and R38) reviewed for hospitalizations. Findings include: 1. Review of a progress note under the Progress Notes tab in the Electronic Medical Record (EMR) revealed R38 was transferred to the hospital on [DATE] and readmitted to the facility on [DATE]. The progress note dated 01/01/23 and timed 12:37 PM stated R38 was found lying on the floor in her room. According to the note, 911 was called and R38 was taken to the emergency room (ER) due to a head injury. An admission summary progress note dated 01/07/23 and timed 6:24 PM stated the resident was returned to the facility. The EMR was reviewed in its entirety and was silent to R38 and/or family being notified in writing of the resident's transfer/discharge to the hospital. 2. Review of the progress notes under the Progress Notes tab in the EMR revealed R9 was transferred to the hospital on [DATE] due to abdominal pain and readmitted to the facility on [DATE]. Further review of the progress notes revealed R9 was transferred to the hospital on [DATE] due to abdominal pain and readmitted to the facility on [DATE]. The EMR was reviewed in its entirety and was silent to R9 and/or family being notified in writing of the resident's transfer/discharge to the hospital. The facility failed to have a policy reflecting that the resident or resident's representative must be notified in writing after a facility transfer. On 04/05/23 at 9:01 AM, Central [NAME] Office Staff stated she had been the business office manager for five and a half years and was not aware she was supposed to send out a written discharge/transfer notice. She stated no written transfer/discharge notices were sent to the residents and/or families.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

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 interviews, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two residents (Resident (R) R35 and R30) out of 24 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/19, indicated, It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment . 1. Review of the RAI Manual, dated 10/01/19, indicated, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. Review of R35's electronic medical records (EMR) titled admission Record indicated the resident was admitted to the facility on [DATE]. Review of R35's EMR titled Clinical Physician Orders, located under the Orders tab dated 11/12/22 indicated the physician ordered to the resident to be administered clopidogrel bisulfate, commonly known as Plavix (an antiplatelet). Review of R35's quarterly MDS with an Assessment Reference Date (ARD) of 01/20/23 indicated the resident was on an anticoagulant medication. During an interview on 04/03/23 at 3:58 PM, the MDS Coordinator confirmed the physician ordered R35 to be placed on Plavix and the medication was an antiplatelet and not an anticoagulant. 2. Review of R30's EMR titled admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE]. Review of R30's quarterly MDS with an ARD of 03/21/23 indicated the resident used a pressure reducing device for her chair. During an observation on 04/03/23 at 4:09 PM, R30 was observed in the main dining room, sitting in a wheelchair and there was no pressure reducing device underneath her. During an observation on 04/04/23 at 9:27 AM, R30 was observed in the main dining room, sitting in a wheelchair and there was no pressure reducing device underneath her. During an interview on 04/04/23 at 12:33 PM, Registered Nurse (RN) 1 stated R30 was at low risk for the development of pressure ulcers and did not use a pressure reducing device under her while in her wheelchair. During an interview on 04/04/23 at 12:48 PM, the MDS Coordinator was asked where she located the information on R30 and the use of a pressure reducing device. The MDS Coordinator stated she will look at the resident during the assessment period to see if any devices were being used. During an interview on 04/04/23 at 1:01 PM, Certified Nursing Assistant (CNA) 6 stated R30 never used a pressure reducing device on her wheelchair bottom. During an interview on 04/04/23 at 4:52 PM, the Director of Nursing (DON) stated the MDS was to be accurate and confirmed R30 never utilized a pressure reducing device in her chair.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review. and policy review the facility failed to ensure a resident with a Continuous Positive Airway Pressure (CPAP, machine used to keep airways open during sleep) machine was in use using physician orders for pressure settings and oxygen flow for one of one resident (Resident (R)13) reviewed for CPAP use. As a result of this deficient practice, the residents had the potential for adverse effects without the correct pressure or oxygen flow. Findings include: Review of facility policy titled Respiratory System Management, undated, revealed CPAP/BIPAP (bilevel positive airway pressure) is provided to residents who have a physician order. Respiratory Therapist must perform the initial set-up. Verify the physician order noting pressure(s) and any orders for supplemental oxygen. [When applied] make appropriate settings as ordered by physician and attach to resident hose. Review of R13's electronic medical record (EMR) undated admission Record, located under the Profile tab, indicated R13 was admitted to the facility on [DATE] with diagnoses including morbid obesity, chronic obstructive lung disease, and obstructive sleep apnea. An observation on 04/03/23 at 10:08 AM, R13 was in bed sleeping, oxygen being delivered by nasal canula at 2 liters (L) per minute, and a CPAP machine was located on the bedside table, near the resident. An observation on 04/04/23 at 11:26 AM, the CPAP machine was located on the bedside table and the mask was near the sink, drying on a paper towel. R13 verbally confirmed using the CPAP machine at night, applied by the nursing staff, and staff wash the mask every morning after use. Review of Orders tab for R13 revealed a physician order dated 07/29/23 wash the CPAP mask with soap and water in the morning for maintenance and lacked a physician's order for CPAP pressure settings or oxygen flow. During an interview on 04/05/23 at 10:27 AM, the Registered Nurse (RN) 1 verbalized the CPAP machine was set, oxygen connected, and turned on by the evening nurse. RN1 confirmed the physician orders for R13 lacked an order for the settings and oxygen flow for the CPAP. During an interview on 04/05/23 at 10:44 AM, RN1 confirmed there should be a physician's order for CPAP usage, pressure settings, and oxygen flow and the orders for R13 lacked documentation of orders for CPAP use, pressure setting, or oxygen flow. During an interview on 04/05/23 at 10:06 AM, the Assistant Director of Nursing (ADON) confirmed there should be a physician's order for application of the CPAP machine to include settings and oxygen flow.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure an as needed (PRN) psychotropic medication had a stop date after 14 days or had a current physician evaluation/rationale documented for one of six residents (Resident (R) 26) reviewed for unnecessary medications. The facility's failure had the potential for the resident to receive PRN psychotropic medication not necessary to treat a diagnosed specific condition. Findings include: Review of the facility policy titled Behavior Management, undated, revealed resident psychoactive medication that is ordered per physician as PRN will be reviewed for discontinue order on 14th day. PRN psychoactive medications are not to exceed 14 days. Review of R26's electronic medical record (EMR) undated admission Record, located under the Profile tab, indicated R26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including encephalopathy, unspecified and paranoid schizophrenia. During an interview on 04/03/23 at 1:31 PM, R26 explained had graduated from hospice services about a month ago. Review under the Orders tab in the EMR a physician's order dated 09/12/22 documented lorazepam PRN [as needed] 0.25 ml [milliliters] PRN [every] 2 hours. Give 0.25 ml sublingually every 2 hours as needed for Anxiety/Restlessness with an indefinite end date. Review of the Progress Notes tab in the EMR dated 03/06/23 at 10:43 AM, revealed, [R26] to be discharged from hospice services effective 3/8/2023. Documentation from [hospice company] uploaded in chart. Review of Pharmacy Consultation for September 2022 documented R26 had a PRN order for an anxiolytic, without a stop date: Ativan (lorazepam) 0.5 milligrams (mg) every 2 hours as needed (PRN) for anxiety. Rationale for Recommendation: CMS [Centers for Medicare Services] requires that PRN orders for non-antipsychotic-psychotropic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period for the duration for the PRN order. The Physician response, dated 09/27/22, recommendation from pharmacist: Declined recommendation box was checked and documented due to Resident is on hospice. Review of the Medication Administration Record [MAR], located in the EMR, for March 2023 and April 2023, revealed lorazepam was administered 12 times since being discharged from hospice services. During an interview on 04/05/23 at 10:35 AM, the Director of Nursing (DON) explained the PRN orders for anxiety for residents on hospice were to be discontinued when resident was removed from hospice care. During an interview on 04/05/23 at 10:57 AM, Registered Nurse (RN) 1 confirmed R26 continued to occasionally receive lorazepam in the evenings for anxiety. RN1 verbalized being unaware of the 14-day limit on PRN dosing of lorazepam and order should have been discontinued after resident was discharged from hospice.

CONCERN (E)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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Based on interviews, review of facility documents, and policy review, the facility failed to ensure resolution was provided to the members (Residents (R) 34, R7, and R15) of the resident council when concerns were identified related to food complaints. During the council meeting multiple residents had verbal complaints related to food. This had the potential to affect care and services to 43 residents who currently reside in the facility. Findings include: Review of a policy provided by the facility titled Resident Rights dated 2018 indicated .The Resident Council has the opportunity to voice group recommendations . The facility staff listens and seriously attempts to the extent practicable, to accommodate all Council recommendations and respond to the Council in writing of the decision . All grievances and concerns are to be addressed to resolution. Review of a policy provided by the facility titled Resident Council Meetings, undated indicated . The Dietary manager will attend the Resident's Council meeting upon invitation, for the purpose of improving dietary services . Review of documents provided by the facility titled Resident Council, dated 10/27/22, indicated residents who participated in the resident council meeting voiced complaints about food being overcooked, burnt, room tray meals were cold, and the food served in the main dining room was lukewarm. Review of a document provided by the facility titled Resident Council Meeting, dated 11/13/22, failed to indicate any resolution regarding food complaints identified from the previous month's resident council meeting members, other than the room trays were getting better,. The document revealed the residents voiced they would like to be informed what was going to be served for each meal and asked that dietary follow the dietary cards, specifically for food related allergies. Review of a document provided by the facility titled Resident Council, dated 12/22/22, failed to indicate any resolution regarding food complaints identified from the previous month's resident council meeting members. In addition, the resident council members voiced complaints of raw chicken served with waffles. Review of a document provided by the facility titled Resident Council Meeting, dated 01/26/23, failed to indicate any resolution regarding food complaints identified from the previous month's resident council meeting members. The document revealed the dietary issues had improved, but there was no written evidence from the facility. Review of a document provided by the facility titled Resident Council Meeting, dated 02/23/23, indicated the members of the resident council voiced complaints of a Smokey film on the dishes after the dishes come from the dishwasher. The resident council members complained the dietary department needed more staff and the current staff were not being trained properly. In addition, the members of the resident council complained of meal times varied and the drink cart was not always offered between or after meals. Review of a document provided by the facility titled Resident Council Meeting, dated 03/23/23, failed to indicate any resolution regarding food complaints identified from the previous month's resident council meeting members. The document indicated additional food complaints of menus were not always consistent, residents were served cold food at times, and the desire for more fresh fruit served with the meals. A random interview was conducted on 04/03/23 at 10:53 AM with R34. R34 confirmed she was the president of resident council. R34 stated the resident council members complained about the food served and there was no feedback provided by the facility. During a subsequent interview conducted on 04/04/23 at 9:30 AM, R34 stated administrative staff have attended resident council in the past but not attended recently. R34 stated there has been no resolution, in writing, made to the members of the resident council in response to the food complaints. During a random interview on 04/05/23 at 9:58 AM, R7 stated she attended the resident council meetings. R7 stated she was aware of the complaints of food coming from members of the resident council and stated the facility staff never came to the council meeting to resolve food complaints. During a random interview on 04/05/23 at 10:00 AM, R15 confirmed she attended the resident council meetings. R15 stated the members of the resident council had food complaints and no facility staff attended to resolve the complaints. During an interview on 04/04/23 at 5:01 PM, the Administrator stated the facility was without a Dietary Manager for over a month. The Administrator stated she was not aware of food complaints generated from the resident council members. The Administrator stated her expectation was to request, from the resident council members, to have the dietary manager attend the council meeting and provide a resolution.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment. Specifically, the facility failed to provide ensure a homelike environment for eight of 24 sample residents (Resident (R) 34, R25, R16, R27, R15, R38, R32, R2, and R245) and failed to provide housekeeping services to ensure rooms and shared resident bathrooms were clean and in good repair. The facility failed to ensure two hallways of five hallways were routinely buffed. The facility failed to ensure a visitor's bathroom was maintained and R243's room door latched securely. Findings include: Review of a policy provided by the facility titled Environmental/ Plant Operations, dated March 2016, failed to contain evidence that addressed general day to day repairs in the resident environment. Review of a document provided by the facility titled Deep Cleaning List undated indicated a schedule broken down to Week 1.Week 2.Week 3.Week 4. This form instructs housekeeping to .When deep cleaning follow daily cleaning list, in addition to moving out furniture to clean behind, and under it, this includes sweeping and mopping. Review of a document provided by the facility titled Infection Control Manual dated April 2016 indicated to .Maintain equipment in good repair or replace as indicated.Clean bathrooms at least daily.Give special attention to the toilet and fixtures. Review of a document provided by the facility titled Residents Bathroom, undated indicated .Report mold and cracked, leaking or damaged areas for repair. 1. During a random interview on 04/03/23 at 12:15 PM, R16 stated the housekeeping staff did not come into her room to clean and referred to the toilet she shared with another room/resident. During this interview, R16's toilet was observed. The toilet had heavy rust stains with thick lines dripping from the inside rim of the toilet. The inter-most bottom of the toilet bowl had heavy rust stains. In addition, an observation under R16's bed, were three remnants of adhesive left from previous anti-slid devices. During an interview on 04/04/23 at 9:56 AM, Housekeeping 2 stated she received a cleaning schedule at the beginning of her shift. During this interview, entered R16's bathroom and she confirmed the toilet had rust in it and needed to be repaired. During this interview on 04/04/23 at 12:00 PM, the Housekeeping Director (HD) entered R16's bathroom and confirmed the rust in the toilet and stated there was a product that she had, and the stains would come out and then return. During this observation/interview, the HD confirmed R16 had three strips of old adhesive from previous anti-slip devices and again stated the adhesive could be scraped off the floor. The HD stated she did not consistently audit the rooms of the residents. The HD was asked to produce the housekeeping audits. The audits were not produced prior to the exit of the survey. 2. During a random interview on 04/04/23 at 10:05 AM, R32 stated he had a problem with the three tiles located in front of his bed. R32 stated one of the tiles had been loose and housekeeping took it away just today and he had complained about this for the past two weeks. Housekeeping 2 was present during this interview. Housekeeping 2 confirmed she moved one of R32's tiles and placed in next to his dresser today. Housekeeping 2 confirmed there was remanent of adhesive left from the third tile on the floor next to R32's bed and stated she could not scrap the old adhesive off. R25 who was his roommate and present during this interview, stated the toilet in the bathroom leaked. Entered the residents' bathroom. Housekeeping 2 was present. In front of the toilet was old adhesive, two strips in front of the toilet. Housekeeping 2 stated she could not scrap the old adhesive off the floor. During this interview/observation, the surveyor donned (put on) a glove, reached down to the old adhesive and was successfully able to remove part (with fingers) of the adhesive from the floor. During this observation there was a blanket under the toilet's tank. Housekeeping 2 stated any time there was a repair needed she reported it to her supervisor who would intern report the issue to Maintenance Director. Housekeeping 2 stated she had replaced the towel daily under the tank. During this observation/interview, both R32 and R25 told Housekeeping 2 she did not come and clean their bathroom daily and did not replace the towel under the tank on a regular basis. During an interview on 04/04/23 at 12:05 PM, the HD entered R32 and R25's room and confirmed the missing tile and the remaining adhesive on R32's floor next to his bed. The HD stated the old adhesive could be scraped off. The HD then entered the bathroom and stated she was not aware of the leaking tank in the resident's bathroom. 2. On 04/03/23 at 3:51 PM, 04/04/23 at 3:43 PM, and 04/05/23 at 10:32 AM the string on the call light located on the wall next to the toilet in the bathroom between R2 and R3's room and R33 and R36's room was soiled with a brown substance and there was a brown buildup of dirt around the base of the toilet. On 04/04/23 at 3:43 PM, the HD verified the string on the call light was soiled and the floor around the toilet was soiled. On 04/04/23 at 4:03 PM, Certified Nursing Assistant (CNA) 4 stated she frequently cared for the residents and stated R2 used the bathroom as he was able to toilet himself independently. Review of R2's quarterly Minimum Data Set [MDS] assessment with an Assessment Reference Date (ARD) of 02/02/23, located under the MDS tab of the electronic medical record (EMR), revealed he was independent with walking and toilet use. 3. On 04/03/23 at 3:53 PM, 04/04/23 at 9:11 AM and 3:43 PM, and 04/05/23 at 10:33 AM the string on the call light located on the wall next to the toilet in the bathroom between resident rooms R15 and R38's room and R27's room was soiled with a brown substance and there was a brown buildup of dirt around the base of the toilet. On 04/04/23 at 3:43 PM, the HD verified the string on the call light was soiled and the floor around the toilet was soiled. On 04/04/23 at 4:03 PM, CNA4 stated she frequently cared for the residents in these rooms and stated R15 and R38 used the bathroom. R15's quarterly MDS assessment with an ARD of 03/21/23, located under the MDS tab of the EMR, was coded to indicate she was independent with walking and toilet use. R16's annual MDS assessment with an ARD of 01/14/23, located under the MDS tab of the EMR, was coded to indicate she required limited assistance with walking and toilet use. 4. On 04/03/23 at 3:53 PM, 04/04/23 at 9:11 AM and 3:43 PM and 04/05/23 at 10:33 AM the counter around the sink was soiled with a pink substance and there was heavy black dirt buildup along the walls in R38's room. On 04/04/23 at 3:43 PM, the HD verified this observation. 5. During a random interview on 04/03/23 at 1:15 PM, R34 stated the housekeeping staff did not move her items on the floor and clean. The resident pointed to a plastic bin to the left of her bed and stated the bin was lightweight and was never moved along with a cloth bag located under her bedside commode. R34 stated she preferred to be present when staff were in her room to clean. R34 gave permission to move her electric reclining chair. Once the recliner was moved from the corner of her room, underneath were large black marks, crumbs, and a white Lifesaver candy. In the corner of the area, located under the heating vent, was an unidentified large brown item that had the appearance of a twisted viny material. During an interview on 04/04/23 at 11:49 AM, the HD stated her expectations for the housekeeping staff were to follow the cleaning schedule she developed. The HD stated she was aware of the old adhesive in some of the resident rooms and confirmed she was able to scrap these areas off the floor. The HD stated housekeeping staff were to contact her with repairs that were needed, and she would then notify, verbally, the Maintenance Director of the needed repairs. During this same interview on 04/04/23 at 12:05 PM, the HD stated R34 preferred to be present when staff were in her room, and stated more than likely the housekeeping staff did not move R34's personal items on the floor to clean underneath these areas. During an interview on 04/05/23 at 10:34 AM, the Maintenance Director stated many times he was notified of repairs from other staff and residents and by word of mouth. The Maintenance Director stated the facility had a system called TELS in which the staff could notify him electronically of needed repairs and he then receives an alert. The Maintenance Director stated this was not being used by facility staff. 6. During an interview with R245 on 04/03/23 at 11:52 AM, R245 stated the door did not stay closed unless one fiddles with the handle to catch the latch secure. During an interview on 04/04/23 at 2:59 PM, Registered Nurse (RN) 1 verbalized the door did not close easily, the latch did not work unless one worked the latch to be sure it closed. RN1 confirmed the Maintenance Director would be notified of this type of issue and notification was done verbally, by writing the concern on a piece of paper and putting it under the door of the maintenance office or to write in the maintenance book. RN1 confirmed the door not latching had not been reported to maintenance by RN1 and should have notified maintenance of the issue. Review on 04/04/23 at 3:05 PM, the binder marked Maintenance Log revealed the last maintenance request dated 05/02/22. The binder contained blank papers to report maintenance issues. During a phone interview on 04/05/23 at 1:41 PM, the Maintenance Director confirmed being unaware of the loose door latch on R245's room. The Maintenance Director was notified of issues verbally, by notes on the office door, and there was a maintenance book on each nursing station and the Maintenance Director did not usually use the maintenance book. The facility was unable to provide a policy for facility maintenance. 7. During an observation on 04/03/23 at 04/03/23 at 11:30 AM, the floors units 300 A and 300 B were dull and grungy in appearance. During an on 04/04/23 at 12:05 PM, the HD stated the floors on 300 A and 300 B were grimy looking and dull and stated they had not been buffed. 8. During an observation on 04/03/23 at 2:25 PM, the women's visitor bathroom had no handle for the use of cold water. There was a blanket under the sink which was damp to touch. The water was turned on and a drip came from the exposed pipes under the sink. During an interview on 04/04/23 at 11:49 AM, the HD stated housekeeping staff were to contact her with repairs that were needed, and she would then verbally notify the Maintenance Director of the needed repairs. The HD confirmed she was aware of the leak in the women's visitor bathroom. The HD stated it had been leaking for quite a while and confirmed she was aware of the towel under the pipes to collect the dripping water. The HD stated she was not aware of a maintenance log and just communicated to the Maintenance Director verbally. The HD stated she was aware of the missing cold-water handle in the bathroom and forgot to inform the Maintenance Director.

CONCERN (E)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected multiple residents

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Based on observations, record review, and interviews, the facility failed to ensure the Dietary Manager (DM) who was designated to act as the director of food and nutrition services was qualified in accordance with the requirements of 42CFR483.60(a)(2) and per the facility's policy. This had the potential to affect 43 of 43 residents in the facility. Findings include: Review of the DM's personnel file revealed an undated job description signed by the DM and titled Dietary Manager stated the job requirements included being a graduate of an accredited course in dietetic training approved by the American Dietetic Association or a graduate of another course in food service supervision with 90 or more hours in classroom instructions with on-the-job counseling by a registered dietitian and having a minimum of one years' experience in a supervisory capacity in a hospital, skilled nursing care, or other related medical facility. On 04/03/23 at 1:12 PM, the DM was queried about her qualifications as the director of dietary. She stated she needed to complete 2 more classes to become Certified. She stated she had never acted as the director of a dietary department in a healthcare facility but she was a cook and dietary aide for a number of years. On 04/04/23 at 4:30 PM, the Administrator was queried about the qualifications of the current dietary manager. The Administrator stated the last dietary manager resigned on 01/27/23 and [NAME] 1 was the acting dietary manager from 01/27/23 through 03/23/23 when the current DM started. The Administrator stated the current DM acted as a cook in local nursing homes from 2008 through 2013 and had not worked in food service or a health care facility since that date. The Administrator provided certificates stating the DM participated in seven foodservice related training courses at a local college with the most current training occurring on 03/14/12. The Administrator stated the DM had not completed any course work since 2012 and was not enrolled in an approved course to become qualified. On 04/05/23 at 11:54 AM, the Dietitian was interviewed via telephone. The Dietitian stated she consulted at the facility once a week for 4-6 hours. The dietitian stated her primary function was to monitor the residents' weights and nutritional status and she attempted to do a kitchen audit once a month. The dietitian stated the last kitchen audit she completed was in January 2023 and at that time she noticed such things as the microwave and can opener were soiled.

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, staff interviews, record review, and policy review, the facility failed to ensure the menu was followed for residents on all diets in the facility. The deficient practice had the potential to affect 43 of 43 residents in the facility, and resulted in residents being served smaller portions than the menu specified. Findings include: Review of an undated facility policy titled Menu Alternatives revealed it was the facility policy to follow the menu and to have an alternate meat or entrée, an alternate vegetable, and an alternate starch provided at every meal in the event of personal food preferences or refusals. Review of the menu titled Beacon Aspire Fall/Winter 2022 Diet Spread Sheet revealed the residents on all the diets listed on the spreadsheet were supposed to be given an 8-ounce serving of spaghetti and meat sauce, 4-ounces of California vegetables, one roll, one margarine spread, six orange slices, and one cup of milk. Cook (C) 1 was observed serving the noon meal in the kitchen from 11:19 AM through 12:30 PM and 12:55 PM to 1:05 PM on 04/04/23. At 11:19 AM, C1 placed a pan of spaghetti and meat sauce and a pan of California vegetables in the steam table well. C1 placed a 4-ounce serving utensil in the vegetables and a 6-ounce scoop in the pan of spaghetti and meat sauce. C1 verified the utensils she was using to serve the food items. At 11:42 AM, C1 began serving the food for the residents in the dining room. C1 gave the first nine residents each one 6-ounce scoop of spaghetti and meat sauce, and she gave six of the nine residents a 4-ounce serving of California vegetables. She did not give Resident (R) 7, R24, and R34 vegetables. C1 stated she did not give three of the residents' vegetables because they did not like vegetables. C1 stated she did not have or provide an alternate because they did not like vegetables. The residents were also given a roll and six orange slices. None of the residents received margarine per the menu until 12:05 PM after R34 came to the kitchen door and asked C1 for margarine and requested they get margarine when they get rolls. After the resident requested the margarine, C1 began placing the margarine on the trays. On 04/04/23 at 12:31 PM, the DM stated the residents who do not like vegetables should be given an alternate and verified the cook had not made and the residents were not offered an alternate for the vegetable. On 04/04/23 at 1:10 PM, C1 verified she had used the 6-ounce scoop to serve the spaghetti throughout the entire meal. The menu was reviewed with the DM and C1, and they verified the menu stated each resident was supposed to receive an 8-ounce serving of spaghetti. The DM stated she would have expected the menu to be reviewed and followed for all meals. Review of the Resident Council meeting minutes for the past six months revealed on 03/23/23 the residents stated the menus were not always followed and condiments are not always served with food. During a confidential resident interview on 04/03/23 at 10:39 AM, one resident stated at times not enough food is served at meals.

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, interviews, and record review the facility failed to ensure palatable food was served at appetizing temperatures. This had the potential to affect 43 of 43 residents in the facility. Findings include: An undated policy titled Food Preparation stated it was the facility policy to prepare foods by methods that enhance flavor and maintain attractive appearance. An undated policy titled Food Presentation stated meals are prepared and served in a manner that enhances the appetite and eye appeal. Under procedures it stated Food are prepared by method to prevent over and/or under cooking of foods; Food items must be checked for proper temperature, taste, and consistency prior to serving time; Foods will be served at proper temperatures and hot foods are hot and cold food are cold. 1. On 04/04/23 at 11:29 AM, [NAME] (C) 1 pureed 6-ounces of spaghetti and meat sauce with a roll and soy milk. After she pureed it in the robot coupe (professional food processor), she poured it in to a plastic measuring cup and placed it on the counter. C1 then pureed the California vegetables with water and thickener and put it in a separate measuring cup and placed it on the counter. The measuring cups of the pureed items remained on the counter until 12:16 PM when C1 placed them in the microwave to heat them up. At 12:17 PM, C1 took the temperature of the food items. The pureed spaghetti and meat sauce was 113 degrees Fahrenheit (F) and pureed California vegetables was 129 degrees F. C1 placed the items on the plate for Resident 12 without ensuring they were heated up to a safe and palatable temperature level. Review of Resident (R) 12's electronic medical record revealed he had a physician's order (under the orders Tab) for a - Regular diet, Pureed texture, Nectar consistency and according to the quarterly Minimum Data Set [MDS] with an assessment reference date of 02/09/23, located under the MDS tab in the EMR, he required extensive assistance for eating. Attempts to interview R12 were unsuccessful. 2. On 04/04/23 at 12:31 PM, a regular test tray was placed on the first room tray cart. There were food trays for 14 residents on the open cart. At 12:47 PM, when the last hall tray was passed the temperature of the food items was obtained with the facility thermometer and the assistance of the Dietary Manager (DM). The California vegetable blend was 117 degrees F and was mushy in appearance. The vegetables were not warm and tasted mushy. Review of resident council meeting minutes, provided by the facility, for the past six months revealed the residents voiced concerns related to over-cooked food, burned food, and cold food on 10/27/22 and on 03/23/23. The following confidential resident interviews were conducted on 04/03/23: At 9:52 AM a resident revealed the food was not palatable. At 10:13 AM, a resident revealed the food was not palatable. At 10:53 AM, a resident complained of cold food. At 10:55AM, a resident complained of cold food. At 1:04 PM, a resident revealed the food was not palatable.

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 observations, record review, and staff interview the facility failed to ensure food was prepared, stored, and served in a sanitary manner and in accordance with facility policies. This had the potential to increase the prevalence and spread of foodborne illnesses and infection 43 of 43 residents in the facility. Findings include: 1. The manufacturer's instructions on the Ecolab Ultra San stated the product should be at 100 parts per million (ppm) for sanitizing tableware. The instructions stated, This product degrades with age. Once opened use the entire contents within 30 days. The instructions stated to test the concentration level three to four times a day using a chlorine test kit. The Ecolab Ultra San was the sanitizer used for the rinse cycle of the low temperature dishwasher. On 04/03/23 at 9:20 AM, the surveyor requested the staff test the chlorine level of the low temperature dishwasher. [NAME] (C) 1 stated they did not have any test strips and she thought some had been ordered. On 04/03/23 at 1:12 PM, the Dietary Manager (DM) attempted to test the chlorine sanitizer with the test strips for Quat sanitizer and not chlorine sanitizer. After testing it with the wrong test strips and being informed they were the wrong test strips she produced two containers of the correct test strips and stated the strips looked like they were very old because the labels were worn, however they were the only ones she had. The DM tested the sanitizer with one test strip from each bottle and the color of the strips remained white indicating the chlorine was zero parts per million (ppm). A log hanging on a bulletin board next to the door indicated the last time the sanitizer level of the dishwasher was tested and recorded was 01/28/23. When the dietary staff were queried about the last time, they had test strips available C2 stated it had been at least a month. C1 continued using the dishwasher to wash the cutting board and the soiled dishes. On 04/23/23 at 4:19 PM, a technician from the Ecolab company was in the kitchen checking the low temperature dishwasher. The Ecolab Technician tested the chlorine sanitizer level of the dishwasher with new test strips, and it measured zero ppm. The five-gallon container of chlorine sanitizer located under the clean end of the dishwasher contained three inches of fluid and was not dated to indicate when it was opened. The Ecolab Technician stated it did not look like sanitizer because sanitizer is yellow and the fluid in the container was clear. He tested the fluid in the container, and it measured zero ppm of chlorine. 2. Review of an undated facility policy titled Pest control listed the different types of pests. It stated Fruit flies breed in small cracks in unsanitary or infrequently cleaned areas. The policy stated to control Fruit flies the facility must maintain a high level of cleanliness. On 04/03/23 at 9:11 AM and 1:12 PM and 04/04/23 at 12:00 PM small insects were flying around the dishwasher and in the kitchen. The kitchen floor was noted to have cracked ceramic tiles throughout the kitchen and there was a buildup of dirt between the cracks, along the walls and under the food service equipment. On 04/03/23 at 1:12 PM, the DM verified the observations of the insects and the cracked/soiled floor. On 04/04/23 at 9:37 PM, the Administrator verified they had a problem with fruit flies. She stated the insects were coming from the cracks in the ceramic tile flooring. She stated the problem would not be resolved until the floor was replaced. The Administrator stated they were working on getting new flooring however two other facilities were in front of them. 3. Review of an undated facility policy titled Guidelines for Storage revealed it was the facility policy to date all products with a use by date. According to this policy, ground spices were to be used within 6 months of opening and whole spices were to be used withing one to two years of opening. According to this policy, frozen poultry parts were to be used within six to nine months of being placed in the freezer and beef was to be used within nine to 12 months of being placed in the freezer. Review of an undated facility policy titled Food Storage revealed the facility required food to be stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. The policy stated all food must be stored in sealed containers and all containers must be legibly and accurately labeled. The facility failed to follow their policies as food was not dated and labeled and/or stored by methods that prevent potential contamination as evidenced by the following: a. On 04/03/23 at 9:17 AM, the chest freezer located next to the furnace contained cookie dough in a large bag that was open to air and not sealed, labeled, or dated. C1 verified the frozen cookie dough was not sealed and was not labeled or dated. b. On 04/03/23 at 9:19 AM, a chest freezer contained a two-gallon bag of frozen diced potatoes with a use-by- date of 12/25/22. C1 verified the potatoes had expired. c. On 04/03/23 at 9:19 AM, the chest freezer contained three clear two-gallon size plastic bags of frozen chicken breast and a vacuum-packed package of beef. The bags were not dated or labeled. C1 verified there were no dates on the bags. C1 stated the beef was stew beef. C1 stated the date would have been on the box they were delivered in but because they were removed from the box they were no longer dated or labeled. d. On 04/03/23 at 9:20 AM, the reach-in-refrigerator contained an open container of apple juice that was not dated. C1 verified this observation. e. On 04/04/23 at 10:35 AM, the shelves of the two cabinets containing the spices and food items were soiled with a gritty sticky feeling substance. The cabinets contained the following items: A 16-ounce container of thyme leaves. The container was soiled and sticky and was not dated to indicate when it was open. The container was 1/4th full and no use by date was located on the bottle. The bottle contained a sticker from the food delivery company stating it was delivered on 04/10/17. A 16-ounce container of nutmeg. The container was soiled and sticky and was not dated to indicate when it was open. The manufacturer's use by date on the bottle was 07/20/20. A 16-ounce container of Italian Seasoning was not dated with an open or use by date. The outside of the bottle was soiled with dried sticky substances. A 16-ounce container of ground thyme was not labeled with an open or use by date. The outside of the bottle was soiled with dried sticky substances. A 16-ounce container of crushed red peppers had the manufacturer's expiration date of 11/16/18. The container was about 1/3 full and did not have an open date. The outside of the bottle was soiled with dried sticky substances. The cabinet contained a one-gallon bag of dehydrated onions dated 04/02/23. The bag was not sealed shut. 4. Review of an undated policy titled Sanitation/Infection Control procedure stated the facility should maintain high environmental sanitation standards by ensuring all work and storage areas are kept clean; walls, ceilings, and floors are cleaned routinely; all food contact surfaces including plates and kitchenware, and all surfaces of equipment are washed, rinsed, and sanitized after each use to prevent potential cross-contamination. The policy stated the can opener, floors, outside doors of the refrigerators and ovens are cleaned daily. The policy stated the floors, and the walls were to be cleaned monthly and more often as needed to ensure they were clean. Review of an undated policy titled Cleaning and Sanitizing Dietary Areas and Equipment stated All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup of food, grease, or other soil. The facility will provide sanitary foodservice that meets state and federal regulations. The policy stated the DM would be responsible for ensuring that all procedures regarding cleaning of equipment are followed by staff and assuring manufacturer's instructions are followed for cleaning equipment. Review of an undated policy titled Food Preparation stated it was the facility policy to prepare foods by methods that enhance flavor and maintain attractive appearance. The policy stated all foods will be stored, prepared, cooked, and held by methods to ensure safe foods for clients. Under the procedure section of the policy, it stated food preparation equipment must be cleaned and sanitized after each use. a. On 04/03/23 at 9:19 AM, on 04/04/23 at 11:55 AM, and on 04/05/23 at 11:18 AM, the wall behind the magnetic knife holder hanging on the wall was dusty and soiled and one of the knifes hanging on the magnetic knife holder was visibly soiled with a dried white substance. On 04/05/23 at 11:18 AM, the DM verified the observation and stated she did not know why they even had it because no one used the knives. b. On 04/03/23 at 9:19 AM, 04/04/23 at 11:55 AM and on 04/05/23 at 11:20 AM, the pot and pan rack mounted to the side of the oven hood was soiled with a buildup of dust on the top and bottom portion of the rack. The rack contained six pairs of tongs, seven pots, nine whisks, and three slotted spoons. On 04/05/23 at 11:16 AM, the DM verified the rack was dirty. c. On 04/03/23 at 9:20 AM and 1:15 PM and 04/04/23 at 10:30 AM, the front and handles of the two ovens and two reach in refrigerator units were soiled with sticky food residue. On 04/03/23 at 1:15 PM and on 04/04/23 at 10:30 AM, the DM verified the observations and verified they needed to be cleaned. d. On 04/03/23 at 9:21 AM and on 04/04/23 at 11:36 AM, the can opener blade, side and top were soiled with a buildup of dried sticky food. The can opener was mounted on the side of the cook's food preparation counter. The DM was made aware of the soiled can opener on 04/04/23 at 11:36 AM. She looked at the can opener and stated it was disgusting. C1 stated the can opener had not been cleaned in a long time. e. On 04/04/23 at 10:51 AM, the utensil drawers contained three soiled spatulas and five soiled scoops. The DM stated the utensils in the drawers should have been clean and verified they were dirty. f. On 04/04/23 at 11:51 AM, C1 was observed placing plates of food on the top of a metal cart. The top of the cart was soiled with brown spills and what appeared to be string. C2 verified the cart was not clean prior to C1 placing the plate of food on the cart. g. On 04/04/23 at 12:09 PM, C1 started serving/placing the room trays on a tall open metal food cart. The cart was soiled with a wet tan substance on two of the rungs and a dried yellow substance on one of the rungs. At 12:11 PM, the DM was informed resident trays were being placed on the soiled cart. The DM verified it was soiled and stated she would have expected it to be cleaned and sanitized between each meal. C1 continued putting the food trays on the soiled cart. A total of 14 food trays were placed on the soiled cart prior to it being sent to the units for tray delivery. The DM stated the cart was used to send out the residents' food trays and to return the soiled dishes to the kitchen after the residents finished eating. 5. An undated policy titled Pot and Pan washing stated pots and pans should be washed to reduce the possibility of food contamination. The policy stated the pans were to be washed, rinsed, and sanitized and then air dried. After the pans/pots are air dried they must be inspected and stored in a clean, dry, protected area. On 04/04/23 at 10:53 AM, two metal steam table pans on the clean pan shelf were stacked wet. One of the pans was soiled with a brown substance on the top and the second pan was soiled with wet white specks. The DM verified the pans were wet and soiled and stated they should have been cleaned thoroughly and then allowed to air dry prior to stacking together. 6. Review of an undated policy titled Sanitation/Infection Control stated all potentially hazardous foods are kept at an internal temperature of 45 degrees F or lower; or 140-degrees F or higher while being held and served. On 04/04/23 at 11:30 AM, C1 was observed to puree the spaghetti and meat sauce with the bread and soy milk in the robot coupe blender. After she finished pureeing up the spaghetti and bread, she poured it into a plastic measuring cup and placed it on the counter and then she pureed up the California mixed vegetables. After the vegetables were pureed, she placed them in a plastic measuring cup and placed it on the food preparation counter next to the cup of pureed spaghetti. The cups remained on the counter until 12:16 PM. At 12:16 PM, she microwaved the items and took the temperature of the items, and the puree meat sauce was 113 degrees Fahrenheit, and the puree vegetables were 129 degrees Fahrenheit. C1 verified each of the temperatures and placed the food on a plate and it was sent out to the dining room for Resident 12 without ensuring it was heated to a safe and palatable temperature level. 7. Review of an undated policy titled Sanitizing Flatware stated to wash the silverware on a flat rack and then place in the cylinders with the mouthpiece up and wash them a second time and after running them through the dishwasher a second time place a cylinder over the mouth pieces and turn it over so the handles of the silverware is pointing up. The policy stated do not handle the silverware by the mouthpiece after they had been cleaned and sanitized. On 04/04/23 at 11:30 AM, C2 was observed picking the spoons and forks up by the mouthpieces and rolling them in paper napkins. The silverware was in the cylinders with the eating portion up. She was not wearing gloves. At 11:32 AM, C2 opened the dishwasher door and removed a rack of clean dishes and returned to touching silverware with her bare hands and without washing her hands. On 04/04/23 at 11:40 AM, the DM was informed of this observation and stated the staff should be wearing gloves when touching clean silverware.

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and policy review the facility failed to ensure the contaminated laundry bags (yellow isolation bags), were disposed of in red biohazard bags once linen was emptied into the washer in the laundry room. As a result of this deficient practice the potential of spreading bacteria by improper disposal of contaminated plastic laundry bags. Findings include: Review of the facility policy titled Infection Control-Laundry, dated 06/2016, revealed The facility will strive to protect residents and employees from nosocomial facility acquired infections and to reduce the risk of cross-infection by utilizing hygienic practices for the handling and processing of soiled linens. Regardless of the use of in-house or off-site contract services, appropriate procedures will be followed to minimize potential nosocomial and occupational risks associated with soiled linen handling. An observation in the laundry room on 04/05/23 at 10:55 AM, a regular trash container was used for clear laundry bags and a contaminated yellow isolation (used laundry bag). During an interview on 04/05/23 11:00 AM, Housekeeper 3 explained the process when moving contaminated isolation linen (in yellow bags) into the washer was to wear a gown, gloves, and mask, and place the empty yellow bag in the regular trash bin; other linens were in clear bags and once emptied were placed in the regular trash. Housekeeper 3 confirmed there were no red bags available on the dirty laundry side to place the yellow contaminated isolation linen bags in once emptied. During an interview on 04/05/23 at 12:00 PM, the Director of Nursing (DON) verbalized once linens were removed from the yellow isolation linen bags, the empty yellow bags need to be disposed of inside of red biohazard bag and properly disposed of in the designated area.

Jan 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 F0558 (Tag F0558)

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, record review, resident, and staff interview the facility failed to provide equipment for 1 of 3 residents reviewed to perform at the highest practicable individual level (Resident#2). The facility reported a census of 41. Findings Include: A Quarterly Minimum Data Set (MDS) for Resident#2 dated 12/25/22 documented a Brief Interview for Mental Status (BIMS) total score of 15 which indicated the resident as cognitively intact. The MDS documented Resident #2 needed extensive assist of two staff members for transfers, bed mobility and personal hygiene. limited assistance for locomotion off of the unit and dressing. The MDS also documented that the resident used a wheelchair for a mobility device. Physical Therapy in Patient Examination dated 6/20/22 anticipate needs as follows; bed mobility training, and transfer training. Patient reported goal to return to the community. Occupational Therapy In Patient Examination dated 6/20/22 anticipated needs documented as follows; balance activities, basic activities of daily living, home program, mobility training, patient education, and safety education. Patient reported independent ambulation at home. The Care Plan for Resident#2 with initiated date of 6/24/22 documented the following; that the resident did not use a bathroom and preferred to use a bedpan, commode or incontinence briefs instead. The Care Plan directed staff to assist the resident to maintain dignity. The Care Plan documented a goal with the initiated date of 7/25/22 as follows; focus on rehabilitation and plan to move or return to the community. Please arrange for physical therapy (PT) evaluation. The interventions with this goal had documented the following response as follows; Resident's payor source did not cover occupational therapy (OT), but restorative therapy (5 times per week) starting on: no date listed. Social Service Progress Note dated 7/28/22 documented as follows; that the Resident's significant other did ask if the facility could pick up the resident's motorized chair from her home. The facility reported that they did not have a vehicle that could transport the motorized chair. The Resident's significant other indicated that he would attempt to bring the motorized chair when he rents a UHAUL in the upcoming weeks. The Social Service Progress Notes dated 7/28/22 to 1/25/23 lacked documentation of follow up to check if the resident's motorized chair had arrived at the facility. An After Visit Summary dated 11/08/22 included the documentation for activity as tolerated. A Physician's Progress Note dated 12/07/22 documented that the resident continued to bedridden due to not having a wheelchair that fits her body size. The resident reports her overall mood is stable, but she would like to get up and attend some activities and go to meals in the dining room. The note documented that the resident had diagnoses which included schizoaffective disorder, major depressive disorder, anxiety disorder and insomnia. A Providers Order dated 12/07/22 directed staff to obtain a Physical Therapy and Occupational Therapy to evaluate Resident #2 for mobility and a wheelchair. Social Service Progress Note dated 1/25/23 at 9:52 a.m. documented as follows; resident seen by psych services provider wrote order for Physical Therapy and Occupational Therapy evaluation so resident can receive an electric wheelchair. Observation on 1/24/23 at 9:00 a.m. of Resident#2's bathroom revealed a toilet affixed to the wall without a support leg at the front of stool. The bathroom had a grab bar on each side placed and the right side had not been anchored to the floor. On 1/24/2023 at 9:00 AM During an interview with Resident #2 the subject of goals had been discussed. A mode of ambulation had been discussed with Resident #2. Resident #2 had stated the goal had been to return to her home in [NAME], Iowa. Resident #2 had further stated there had not been a wheelchair at the facility that could accommodate her general weight and proportion size. Still, further discussion had led to Resident #2 verbalizing the manual wheelchair sitting in the room did not work for her as the chair tires had not stayed inflated. Resident #2 had stated having a powered chair at her home in [NAME], Iowa that had been equipped for personal needs within the last five years. The walker observed in the room had been Resident #2 equipment from home and used to transfer from the power chair to the toilet or bed. The interview continued with discussion of personal hygiene needs as Resident #2 had stated using a bedpan had been the only option since admission. When asked about being out of bed, Resident #2 had stated that she had not been since prior to Thanksgiving (11/24/22). Resident #2 had stated that a bed pan had to be used to meet her bowel and bladder needs. Resident #2 further stated the bathroom adjoining the resident room would not hold her weight. During an interview with Resident #2 the subject of goals had been discussed. Resident #2 had stated the goal had been to return to her home in [NAME], Iowa. Further discussion had led to Resident #2 verbalizing the manual wheelchair sitting in the room did not work for her as the chair tires had not stayed inflated. When discussing personal hygiene needs Resident #2 had stated using a bedpan had been the only option since admission. On 1/24/23 at 8:45 a.m. Staff D, Restorative Aide stated Resident #2 had not been out of bed due to not having a wheelchair that can accommodate the resident weight and body proportion. On 1/24/23 at 11:43 AM an interview had taken place with Staff G, Occupational Therapy Aide reported stated there had not been documentation of an evaluation as ordered on 12/7/22. On 1/24/23 at 11:55 a.m. the Director of Nursing (DON) reported that Resident #2 had a PT/OT evaluation completed as ordered on 12/7/22 by the resident provider, the DON then stated there had been a document from therapy of why the order had not been completed. The DON further stated having evaluated the resident for facility admission at the residents' home in [NAME], Iowa in June of 2022. The DON had verbalized further that Resident #2 had a personal motorized wheelchair at the home property. Pink in color, customized for the resident and purchased within the last five years. When asked about the reason Resident #2 had not had the personal motorized wheelchair transported to the facility then the DON stated there had not been facility transportation available. The DON further stated the facility did not have access to a van that could accommodate the wheelchair size for transport. The DON went on to state Resident #2 had been advised to let facility staff know when there would be access to the personal wheelchair and a responsible individual at the home in [NAME], Iowa to arrange for wheelchair pick up and transport to the facility. The DON had stated the most recent discussion with Resident #2 concerning the personal wheelchair and transport to the facility had been approximately two weeks ago. When asked if there had been documentation of the conversation, the DON then stated there had not been. The DON had been asked where documentation of the therapy evaluation could be located and the DON responded by verbalizing a copy would be provided for review. On 1/24/23 at 3:00 PM the facility Director of Nursing (DON) provided an email copy that had been dated 12/8/22 at 9:04 AM. The email had been sent from Staff E, Physical Therapy Aide, and had stated the resident did not complete evaluation for wheelchair mobility due to having a power wheelchair at home.

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

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, facility staff interview and hospice provider staff interview the facility failed to follow provider orders, consistent with professional standards of practice for respiratory care for 1 of 2 residents reviewed that had a tracheostomy (opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia. (Resident#1). The facility reported a census of 41 residents. Findings include: The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident#1 had diagnoses which included, chronic respiratory failure, obstructive sleep apnea, anxiety, and depression. The MDS indicated that the resident had difficulties of movement to one upper extremity and both lower extremities. The MDS documented that the resident required extensive assistance of two staff members for transfers, and extensive assistance of one staff member for bed mobility. The MDS indicated that the resident had scored a 15 out of 15 for the brief interview for mental status review, which indicated intact cognitive skills for daily decision making. The Care Plan with initiated date of 8/01/22 documented a focus are as follows; Tracheostomy (Trach) change every 90 days. The Care Plan directed staff to change the trach XL#6 with inner disposable cannulas every 90 days, and to change as needed. A Physician Detailed Written Order Tracheostomy dated 7/6/21 with a sticker in all captalized letters DO NOT THIN FROM CHART directed staff as follows; products to be used product# 60XLTCD brand Shiley trach tube 6XLT without cuff schedule type 90 days, 60XLTIN brand Shiley inner cannula XLT size 6 extra-long 30/each schedule type monthly, TRCHST trach care kit 30/each schedule type monthly The October 2022 Medication Administration Record and Treatment Administration Record (MAR/TAR) had shown Resident #1 tracheostomy had been changed on October 23,2022 and the provider order signed off had been the aforementioned provider order that had been a permanent part of the residents' chart. A Health Status Note dated 10/23/22 at 12:18 p.m. documented the following; Resident had issues with her trach, feeling that it was too short. Offered her different trach kit options. The resident chose a Shiley Adult Flexible Tracheostomy Tube Cuffles (7.5 millimeter I.D 10.8 O.D 74 millimeter). The resident expressed satisfaction with the current trach. St. Croix Hospice notified about change of type of trach used by fax. This Health Status Note lacked documentation of a respiratory assessment. The October MAR/TAR lacked documentation of the different trach size used for the date 10/23/22. The medical record also lacked notification to the physician of the change in trach size used for the date 10/23/22. On 1/24/23 at 12:15 PM Staff B, Health Information Manager (HIM) from St. Croix Hospice stated that the Hospice Provider had not received the fax the facility was to have sent on 10/23/22. Staff B further stated the facility had been supplied with tracheostomy kits that had contained the original order of tracheostomy supplies as ordered by Resident #1 provider. Staff B reported the tracheostomy kit used on 10/23/22 had not been provided by Hospice as only the ordered provider size had been supplied. Staff B further stated Resident #1 Hospice Provider records within the hospice office contained documentation afterwards of the facility changing the tracheostomy to a 'bigger-size' found at the facility and the larger tracheostomy had been left in place until the tracheostomy equipment fell out requiring the resident to be sent to the emergency room. Staff B stated the facility staff had been verbally made aware due to changing the resident tracheostomy equipment prior to a provider order that the facility needed to contact the provider for an order. On 1/30/23 at 11:00 AM the Director of Nursing (DON) stated a tracheostomy order is needed for changing a resident tracheostomy equipment to another size. The DON further stated she had been unaware the provider order had not been obtained when facility staff changed Resident #1's to a larger size tracheostomy which had deviated from the provider order.

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?"
"What safeguards are in place to prevent abuse and neglect?"
"Why is there high staff turnover? How do you retain staff?"
"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: Federal abuse finding, 1 life-threatening violation(s), 1 harm violation(s), Payment denial on record. Review inspection reports carefully.
• 58 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $24,564 in fines. Higher than 94% of Iowa facilities, suggesting repeated compliance issues.
• Grade F (1/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Aspire Of Muscatine's CMS Rating?

CMS assigns Aspire of Muscatine 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 Aspire Of Muscatine Staffed?

CMS rates Aspire of Muscatine's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Iowa average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 86%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Aspire Of Muscatine?

State health inspectors documented 58 deficiencies at Aspire of Muscatine during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 56 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Aspire Of Muscatine?

Aspire of Muscatine 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 BEACON HEALTH MANAGEMENT, a chain that manages multiple nursing homes. With 100 certified beds and approximately 32 residents (about 32% occupancy), it is a mid-sized facility located in Muscatine, Iowa.

How Does Aspire Of Muscatine Compare to Other Iowa Nursing Homes?

Compared to the 100 nursing homes in Iowa, Aspire of Muscatine's overall rating (1 stars) is below the state average of 3.0, staff turnover (56%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Aspire Of Muscatine?

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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.

Is Aspire Of Muscatine Safe?

Based on CMS inspection data, Aspire of Muscatine has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (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 Aspire Of Muscatine Stick Around?

Staff turnover at Aspire of Muscatine is high. At 56%, the facility is 10 percentage points above the Iowa average of 46%. Registered Nurse turnover is particularly concerning at 86%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Aspire Of Muscatine Ever Fined?

Aspire of Muscatine has been fined $24,564 across 1 penalty action. This is below the Iowa average of $33,325. 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 Aspire Of Muscatine on Any Federal Watch List?

Aspire of Muscatine 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: 100
Avg. Residents: 32
Occupancy: 32.6%
Ownership: For profit - Limited Liability company
Chain: BEACON HEALTH MANAGEMENT
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
1 Immediate Jeopardy citation: -12
1 Actual Harm citation: -5
58 Deficiencies: -10
Fines ($24,564): -2
Abuse Finding: -15
Final Score: 1/100

Nearby Alternatives

Wilton Retirement Community 5-star Simpson Memorial Home 4-star Accura Healthcare of Muscatine 3-star

View all in Muscatine →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 165585