What is Pines Retirement Center of Baton Rouge's CMS rating?

Pines Retirement Center of Baton Rouge has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does Pines Retirement Center of Baton Rouge have any serious inspection findings?

Yes, Pines Retirement Center of Baton Rouge has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 73 total deficiencies from recent inspections.

What are the staffing levels at Pines Retirement Center of Baton Rouge?

Pines Retirement Center of Baton Rouge has a three-star staffing rating from CMS with 0.28 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 Pines Retirement Center of Baton Rouge located?

Pines Retirement Center of Baton Rouge is located in BATON ROUGE, LA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Pines Retirement Center of Baton Rouge have?

Pines Retirement Center of Baton Rouge has 85 certified beds.

Who owns Pines Retirement Center of Baton Rouge?

Pines Retirement Center of Baton Rouge is a for profit - limited liability company facility and operates independently (not part of a chain).

Is Pines Retirement Center of Baton Rouge safe?

Pines Retirement Center of Baton Rouge has documented safety concerns including a substantiated abuse finding on record, 3 immediate jeopardy citations, placement on the CMS Special Focus Facility list. Families should ask about corrective actions taken.

Do nurses at Pines Retirement Center of Baton Rouge stick around?

Pines Retirement Center of Baton Rouge has high staff turnover at 70%. High turnover can mean less continuity of care as staff change frequently.

Was Pines Retirement Center of Baton Rouge ever fined?

Yes, Pines Retirement Center of Baton Rouge has been fined $174,517 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Pines Retirement Center of Baton Rouge on any federal watch list?

Pines Retirement Center of Baton Rouge is currently an SFF Candidate, meaning CMS is monitoring it for potential placement on the Special Focus Facility list due to a history of serious quality issues.

What have inspectors found at Pines Retirement Center of Baton Rouge?

Medicare inspectors have found 73 deficiencies at Pines Retirement Center of Baton Rouge: 3 critical, 70 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Pines Retirement Center of Baton Rouge?

Families visiting Pines Retirement Center of Baton Rouge should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Pines Retirement Center of Baton Rouge compare to other nursing homes?

Pines Retirement Center of Baton Rouge has a 1-star overall rating, which is below average compared to other nursing homes in LA. Families should carefully review inspection findings and consider alternatives.

Pines Retirement Center of Baton Rouge | 0/100 (Grade F)

Jul 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews, the facility failed to ensure services provided by the facility met profes...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation, and interviews, the facility failed to ensure services provided by the facility met professional standard of quality by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#R2) of 7 (#1, #2, #3, #4, #R1, #R2 and #R3) residents reviewed for pharmaceutical services.Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation:7. The individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.19. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Resident #R2Review of Resident #R2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #R2's current Physician Orders revealed the following, in part:Start date: 03/05/2025 - Regular Insulin Injection Solution 100 unit/mL, inject as per sliding scale: if 0 - 200 = 0 do not administer; 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351 - 400 = 8 units; 401 - 999 = 10 units and notify MD, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus. Resident #R3Review of Resident #R3's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #R3's current Physician Orders revealed the following, in part:Start date: 10/01/2024 - Regular Insulin Injection Solution 100 unit/mL, inject as per sliding scale: if 61 - 200 = 0 units; 60 or less notify MD; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 999 = 12 units and notify MD, subcutaneously four times a day related to Type 2 Diabetes Mellitus. An observation was made on 07/23/2025 at 10:30 a.m. of S2LPN administering medications to Resident #R2. S2LPN removed a vial of regular insulin, labelled with Resident #R3's name, from her medication cart. S2LPN withdrew insulin from Resident #R3's insulin vial to administer to Resident #R2. An interview was conducted with S2LPN at that time. S2LPN reviewed the insulin vial and package and confirmed the insulin belonged to Resident #R3. S2LPN stated Resident #R2's insulin vial was available in the facility's medication room. S2LPN confirmed she used Resident #R3's insulin vial to prepare an insulin dose for Resident #R2 and should not have. An interview was conducted with S1DON on 07/24/2025 at 11:41 a.m. S1DON stated every resident had their own insulin vial ordered from the pharmacy, and emergency house stock was available to use if a resident's vial was not available. S1DON was made aware of the above observation. S1DON stated a nurse should never use one resident's insulin vial to administer to a different resident.

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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure it was free of significant medication errors ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure it was free of significant medication errors for 1 (#R2) of 2 (#R1 and #R2) residents reviewed for medications. The deficient practice had the potential to affect the 56 residents residing in the facility who received medications.Review of the facility's undated policy titled, Medications - Administering revealed the following, in part:Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation:7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #R2Review of Resident #R2's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Neuropathic Arthropathy. Review of Resident #R2's current Physician Orders revealed the following, in part:Start date: 03/05/2025 - Regular Insulin Injection Solution 100 unit/mL, inject as per sliding scale: if 0 - 200 = 0 do not administer; 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350 = 6 units; 351 - 400 = 8 units; 401 - 999 = 10 units and notify MD, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Neuropathic Arthropathy. An observation was made on 07/23/2025 at 10:34 a.m. of S2LPN administering medications to Resident #R2. S2LPN stated Resident #R2's blood glucose reading was 212 mg/dL, and Resident #R2 required 2 units of regular insulin per the sliding scale. S2LPN withdrew 5 units of regular insulin from a multi-dose vial. An interview was conducted with S2LPN at that time. S2LPN reviewed the syringe and stated she had drawn up 2 units. S2LPN placed the security cap over the needle for transport to Resident #R2's room. Prompt intervention was initiated and facility administration was sought. An interview was conducted with S5CRN on 07/23/2025 at 10:39 a.m. S5CRN observed the insulin syringe S2LPN withdrew, and confirmed the amount as 5 units. S5CRN confirmed preparation of 5 units when the insulin order was for 2 units was a medication error. An interview was conducted with S1DON on 07/24/25 at 11:41 a.m. S1DON stated insulin doses should be prepared to the amount of units ordered by the physician per the sliding scale. S1DON confirmed preparation of 5 units when the order is 2 units was not an acceptable practice.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#R4) of 8 (#1, #2, #3, #4, #R1, #R2, #R3, and #R4) residents observed for infection control practices. The facility failed to ensure:1. Staff used proper personal protective equipment when emptying Resident #R4's urinal; and2. Staff transported linens in a manner to prevent spread of infection.Review of the facility's policy, dated January 2025, titled, Infection Prevention and Control Program revealed the following, in part:Policy: This facility has established and maintains an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Policy Explanation and Compliance Guidelines:5. All staff are responsible for following all policies and procedures related to the program.14. Linens:a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. Review of the facility's policy, dated January 2025, titled, Enhanced Barrier Precautions revealed the following, in part:Policy: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO).Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).Policy Explanation and Compliance Guidelines:46. Enhanced Barrier Precautions-a. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices:i. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.48. High-contact resident care activities include:d. Providing hygienef. Changing briefs or assisting with toileting Review of Resident #R4's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included: Other Fracture of Right Lower Leg, Initial Encounter for Open Fracture Type I or II with External Fixator to Right Lower Leg Review of Resident #R4's current Physician Orders revealed the following, in part:Order date 05/05/2025 Enhanced Barrier Precautions. On 07/23/2025 at 10:21 a.m., an observation was made of S3CNA entering Resident #R4's room. Enhanced Barrier Precaution sign observed hanging eye level on room door. S3CNA was observed to donn gloves. S3CNA did not donn a gown. S3CNA proceeded to remove Resident #R4's urinal from resident's bedside table and empty it into the toilet. On 07/23/2025 at 10:25 a.m., an observation was made of S3CNA removing clean linen from the linen cart on the hallway. S3CNA was observed carrying the clean linen, pressed against her clothing on her upper body, proceeding down the unit hallway, making entry into a resident's room. On 07/24/2025 at 11:30 a.m., an interview was conducted with S4CNA. S4CNA confirmed she provided care for Resident #R4. S4CNA stated she would donn gown and gloves for high-contact activities for Resident #R4, including emptying his urinal. S4CNA stated there were linen bags available on the linen cart to transport clean linen to a resident's room. S4CNA stated she would not have held clean linen against her body while transporting it to a resident's room. On 07/24/2025 at 11:48 a.m., an interview was conducted with S1DON. S1DON confirmed she would expect staff to follow Enhanced Barrier Precautions procedures during high-contact resident activities, including emptying a resident's urinal. S1DON confirmed clean linen should have been transported from the linen cart to a resident's room inside a clean linen bag and not pressed against a staff member's clothing.

Feb 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was d...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure a resident's comprehensive plan of care was developed and implemented for 2 (#1 and #3) of 3 (#1, #2 and #3) residents reviewed for care plans. The facility failed to ensure: 1. Resident #1's care plan was revised for the use of a geri chair; 2. Resident #3's care plan was implemented for neurological assessments after two unwitnessed falls; and 3. Resident #3's care plan was revised for a fall on 12/07/2024. Findings: 1. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses, which included Non-Alzheimer's Dementia, Muscle Weakness and Muscle Atrophy. Review of Resident #1's current care plan revealed no documented evidence to reflect the current use of Resident #1's geri chair. On 02/03/2025 observations were made throughout the day of Resident #1 sitting up in a geri chair in front of nurse's station. On 02/04/2025 at 2:30 p.m., an interview was conducted with S5LPN. She stated Resident #1 was bed bound and used a geri chair when out of bed due to poor trunk control. On 02/04/2025 at 1:45 p.m., an interview was conducted with S3MDS. She stated she was responsible for updating resident care plans to reflect their current needs. She stated Resident #1 used a geri chair due to poor trunk control. S3MDS reviewed Resident #1's care plan and confirmed the care plan had not been revised to reflect his current use of a geri chair and should have been. On 02/04/2025 at 3:25 p.m., an interview was conducted with S2DON. She stated Resident #1 used a geri chair due to poor trunk control. S2DON reviewed Resident #1's care plan and confirmed the care plan had not been revised to reflect his current use of a geri chair and should have been. 2. Review of the clinical record revealed Resident #3 was admitted to the facility on [DATE]. Resident #3 had diagnoses which included Liver Cell Carcinoma, Cirrhosis, Anxiety, Malnutrition, Insomnia and [NAME] Johnson's Syndrome. Review of the admission MDS with an ARD of 11/19/2024, revealed Resident #3 had a BIMS of 9 which indicated moderate cognitive impairment. Review of Resident #3's Incident Reports revealed the following: 12/18/2024 at 7:30 p.m. - unwitnessed fall 12/19/2024 at 3:00 a.m. - unwitnessed fall Review of Resident #3's Care Plan revealed the following: Goal: Resident will be free of falls. Interventions: 12/18/2024- Neurological Assessments x72 hours. 12/19/2024- Neurological Assessments x72 hours. Review of Resident #3's neurological documentation revealed assessments were performed on the following dates and times: 12/18/2024-7:00 p.m. 12/19/2024- 3:00 a.m., 11:00 a.m. 12/20/2024- 11:00 a.m. On 02/04/2025 at 10:30 a.m., an interview was conducted with S2DON. She stated neurological assessments should be implemented with each separate fall, even if the falls occur back to back. She stated she expected nursing staff to follow the resident's care plan. S2DON reviewed Resident #3's current Care Plan, Incident Reports and Neurological Assessment sheets dated 12/18/2024 and 12/19/2024, and confirmed neurological assessments had not been completed for the full 72 hours. She stated the nursing staff did not implement the interventions on Resident #3's Care Plan and should have. 3. Review of Resident #3's nurse's notes dated 12/07/2024 revealed Resident #3 had a fall and was found on the floor with a laceration above his left eyebrow. Review of Resident #3's current care plan revealed he was at risk for falls. Further review revealed no documented evidence of a revision to include the fall which occurred on 12/07/2024. On 02/04/2025 at 1:45 p.m., an interview was conducted with S3MDS. She stated she was responsible for revising care plans. She stated every morning the Interdisciplinary Team met and reviewed nurse's notes to discuss any areas of concerns, including falls. She stated the process was to revise the care plan and place a new intervention with every fall. S3MDS reviewed the nurse's notes dated 12/07/2024 and confirmed Resident #3 had a fall with injury. She confirmed the care plan had not been revised to reflect the fall on 12/07/2024 and should have been. On 02/04/2024 at 3:25 p.m., an interview was conducted with S4DON. She reviewed Resident #3's care plan and nurse's notes dated 12/07/2024. S4DON confirmed Resident #3's care plan had not been revised to reflect the fall on 12/07/2024 and should have.

Oct 2024 14 deficiencies 3 IJ (2 facility-wide)

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident remained free from verbal and mental abuse f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident remained free from verbal and mental abuse for 3 (#42, #46, and #52) of 7 (#18, #26, #42, #46, #51, #52, and #111) residents reviewed for abuse. The facility failed to prevent: 1. S4CNA and S5CNA from yelling, cursing, and pointing at Resident #52 while surrounding the wheelchair and preventing the resident from getting away; and 2. S6CNA from yelling and cursing at Resident #52 in the hall; and 3. S13LPN from intimidating and threatening Resident #42; and 4. S6CNA from following and verbally threatened Resident #46 in her room. This deficient practice resulted in an Immediate Jeopardy situation for Resident #52 on 09/04/2024, when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. Resident #52 reported he no longer felt safe in the facility. It continued on 09/14/2024, when Resident #46 witnessed and reported to S1ADM, S6CNA yelled and cursed at Resident #52 in the hallway. It continued on 09/23/2024, when Resident #42 reported S13LPN stood in front of her wheelchair, pointed and demanded she get off the hall. Resident #42 reported she felt intimidated by S13LPN. It continued on 09/24/2024 when S6CNA followed Resident #46 to her room, yelled, pointed her finger and threatened Resident #46. Resident #46 reported she felt threatened by S6CNA. S1ADM did not remove S4CNA, S5CNA, S6CNA and S13LPN from resident care, provide additional training or complete any monitoring following each individual incident. S1ADM was notified of the Immediate Jeopardy situation on 10/09/2024 at 9:35 a.m. The Immediate Jeopardy was removed on 10/10/2024 at 12:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 59 residents residing in the facility. Findings: Review of the facility's undated policy titled Abuse, Neglect and Exploitation revealed the following, in part: Policy: it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. Definitions: Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. 1. A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Acquired Absence of Right Leg Above the Knee, Acquired Absence of Left Leg Above the Knee and Adjustment Disorder. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. On 10/07/2024 at 8:35 a.m., an interview was conducted with Resident #52. He stated a few weeks ago he asked S4CNA to empty his urinal and she told him he could do it himself. S4CNA told him, tell your mammy to empty it. Resident #52 responded by saying S4CNA could drink it, then S4CNA responded tell that b**** to empty it. He stated he and S4CNA continued verbally arguing. He stated he attempted to call S2DON but she did not answer the call, so he rolled his wheelchair to S2DON's office. He said when he got to S2DON's office, S4CNA and S5CNA were standing in front of S2DON's door and stopped him from entering. He stated S4CNA and S5CNA continued to yell and curse at him while he was outside of S2DON's office door. He stated S2DON was in her office and told S4CNA and S5CNA to just ignore him and he would go away. He stated he was angry, overwhelmed and felt intimidated. He stated S17SW intervened, and brought him outside to calm down. On 10/08/2024 at 10:15 a.m., an interview was conducted with S17SW. She stated on 09/04/2024 at approximately 5:30 p.m., she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She reported S5CNA was standing in front of Resident #52 and S4CNA was standing behind Resident #52 preventing him from entering S2DON's office. She stated Resident #52, S4CNA, and S5CNA yelled and cursed at each other at the same time so loudly she did not know what they said only heard cursing back and forth. She stated S5CNA pointed her finger in Resident #52's face. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She stated she intervened, removed Resident #52, and brought him to the outside patio. She stated Resident #52 was upset and angry and she sat with him until he calmed down. She stated yelling, cursing and pointing a finger at a residents face is abuse and she reported it to S1ADM on the next day. She stated on 09/05/2024, she recommended S1ADM provide training on de-escalation and S1ADM responded, training was not needed because Resident #52 cursed at his staff. On 10/08/2024 at 11:08 a.m., an interview was conducted with S18LPN. She stated on 09/04/2024, she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She reported S5CNA was standing in front of Resident #52 and S4CNA was standing behind Resident #52 preventing him from entering S2DON's office. She stated Resident #52, S4CNA and S5CNA yelled and cursed at each other at the same time so loudly she did not know what they said only heard cursing back and forth. She stated S5CNA pointed her finger in Resident #52's face and told him he was capable of emptying his urinal. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She stated she intervened and assisted S17SW with removing Resident #52, and bringing him to the outside patio. She stated yelling, cursing and pointing a finger at a residents face is abuse. She stated staff should not have treated Resident #52 in that manner and S4CNA, S5CNA continued to provide care at the facility. On 10/08/2024 at 11:16 a.m., an interview was conducted with S19CNA. She stated on 09/04/2024, she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She reported S5CNA was standing in front of Resident #52 and S4CNA was standing behind Resident #52 preventing him from entering S2DON's office. She stated Resident #52, S4CNA and S5CNA yelled and cursed at each other at the same time so loudly she did not know what they said only heard cursing back and forth. She stated S5CNA pointed her finger in Resident #52's face and told him he was capable of emptying his urinal. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. On 10/09/2024 at 4:20 p.m., an interview was conducted with S26OMB. She stated Resident #52 reported to her that he asked S4CNA to empty his urinal and she told him, Tell your mammy to do it and they argued back and forth. She stated Resident #52 reported he felt vulnerable because he does not have any legs and he did not feel safe at the facility after the incident. On 10/09/2024 at 4:30 p.m., an interview was conducted with S4CNA. She stated on 09/04/2024, Resident #52 told her to empty his urinal and make his bed immediately. She denied arguing, yelling or cursing at Resident #52. She stated 09/07/2024 was the last day she provided care to Resident #52, but continued to provide care to other residents in the facility until 09/24/2024. She stated her last abuse training was in June 2024. On 10/09/2024 at 4:35 p.m., an interview was conducted with S5CNA. She stated she was never assigned to Resident #52 but would help S4CNA with his care. She stated on 09/04/2024, Resident #52 told S4CNA to empty his urinal and make his bed immediately. She denied arguing, yelling or cursing at Resident #52. She stated she provided care to other residents in the facility until she was moved to another facility on 09/26/2024, with a plan to return to the facility when Resident #52 was discharged . She stated her last abuse training was in June 2024. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated on 09/04/2024, Resident #52 asked S4CNA to empty his urinal and she told him he could do it himself. She stated Resident #52 rolled his wheelchair to the doorway of her office, parked his wheelchair, and yelled and cursed at her and S4CNA. S2DON stated she did not hear the 2 CNAs yell or curse at the resident. She stated staff cursing and pointing a finger at a resident was abuse. She confirmed S4CNA continued to provide care to residents in the facility until 09/24/2024 and S5CNA continued to provide care to residents in the facility until 09/26/2024 when S1ADM removed them. She confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #52 reported on 09/25/2024, he asked S4CNA on 09/05/2024 to empty his urinal. Resident #52 reported S4CNA refused to empty his urinal, yelled and cursed at her. S1ADM explained Resident #52 had aggressive behaviors, which included, yelling and cursing with other residents and staff. He stated S4CNA and S5CNA triggered Resident #52's behaviors so they were moved to another facility on 09/24/2024 and 09/26/2024, with a plan to return when Resident #52 was discharged . He stated S4CNA was not assigned to Resident #52 after 09/07/2024 but did provide care to other residents at the facility until 09/24/2024. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. 2. On 10/08/2024 at 9:31 a.m., an interview was conducted with S20LPN. She stated on 09/14/2024 she witnessed S6CNA yell and curse at Resident #52 but could not remember exactly what was said. She confirmed arguing, yelling and cursing with a resident was abuse and she reported it to administration. She further stated she had witnessed multiple staff curse at Resident #52 and some of those employees still worked at the facility even after notifying administration of the abuse. On 10/08/2024 at 9:54 a.m., an interview was conducted with S21CNA. She stated on 09/14/2024, she witnessed S6CNA curse and argue with Resident #52 but could not remember exactly what was said. She stated S1ADM was made aware of the incident. She confirmed cursing at a resident was abuse. On 10/08/2024 at 11:45 p.m., an interview was conducted with Resident #46, a cognitively intact resident. She stated on 09/14/2024, she was in the hall and witnessed S6CNA yell and curse at Resident #52. She stated S6CNA told Resident #52, F*** you. She stated she reported the incident immediately to S1ADM. She stated S6CNA continued to provide care at the facility on her hall until 09/24/2024, when S6CNA threatened her. On 10/09/2024 at 2:01 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/09/2024 at 4:45 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 approached him on 09/14/2024 and notified him of the incident with Resident #52 and S6CNA. He stated S6CNA was not removed from the facility and continued to provide care to Resident #46 and Resident #52 until S6CNA was removed on 09/26/2024. He stated on 09/24/2024, S6CNA was involved in another incident with Resident #46 and S6CNA was terminated but not related to the allegation. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors. He confirmed the last abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. 3. A review of Resident #42's Clinical Records revealed Resident #42 was admitted to the facility on 01/16/2024 with diagnoses which included, Depression, Anxiety, and Muscle Wasting. A review of Resident #42's MDS with an ARD of 08/07/2024 revealed Resident #42 had a BIMS of 14, which indicated Resident #42 was cognitively intact. A review of Resident #42's grievance, dated 09/23/2024, revealed the following: Statement of concern: Resident #42 stated S13LPN displayed poor customer service and asked Resident #42 to leave the hall and return to her room. Investigation: Resident #48 was witness Conclusion: S13LPN educated on customer service and residents right to be invited to other rooms. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she and Resident #48 were friends and she visited Resident #48's room frequently. She stated on 09/22/2024, she was in her wheelchair, rolling down the hall, when S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. She stated on the same day after leaving the smoking patio and going back to her room, she heard S13LPN call her white trash. Resident #42 stated she felt intimidated and threatened by S13LPN and reported the incident to S1ADM on 09/23/2024. She stated again on 10/05/2024, S13LPN told her to get in Resident #48's room or get off the hall in a stern voice. On 10/10/2024 at 2:26 p.m., an interview was conducted with Resident #48, a mildly cognitively impaired resident. He stated on 09/22/2024, he witnessed S13LPN stand in front of Resident #42's wheelchair and tell her You can't come down this hall in a stern voice. He stated again on 10/05/2024, S13LPN told him and Resident #42 to get in Resident #48's room or get off the hall in a stern voice. On 10/09/2024 at 3:53 p.m., an interview was conducted with S13LPN. She stated Resident #42 was loud, made too much noise on the hall and always visited Resident #48 on her hall. She stated on 09/22/2024 she told Resident #42 she could not go down the hall. She stated on 10/05/2024, Resident #42 was again visiting Resident #48 on her hall. She stated she told them either to get in Resident #48's room or get off the hall. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He said on 09/23/2024 Resident #42 reported that on 09/22/2024, S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. He confirmed Resident #42 should not have been stopped and been allowed to visit Resident #48. He stated he did not report it because it was a customer service issue and not abuse. He stated he was made aware of the 10/05/2024 incident by the state surveyor on 10/09/2024. He confirmed S13LPN was not removed from the facility after 09/22/2024 and provided care at the facility when another incident occurred on 10/05/2024. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. 4. A review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, Depression and Weakness. A review of Resident #46's MDS, with an ARD of 07/11/2024, revealed Resident #46 had a BIMS of 15, which indicated Resident #46 was cognitively intact. A review of Resident #46's grievance, dated 09/24/2024, revealed the following: Statement of concern: Resident #46 stated S6CNA approached her and asked, If you have something to say, say it to me Investigation: S6CNA confirmed Resident #46's statement Conclusion: S6CNA terminated On 10/08/2024 at 11:45 a.m., an interview was conducted with Resident #46. She stated on 09/24/2024, she and Resident #52 were talking in the hall. She stated when she finished talking with Resident #52, she went to her room, and S6CNA followed her to her room, stood in the doorway and yelled while shaking and pointing her finger toward her, if you have something to say, say it to my face. She stated she felt threatened by S6CNA and reported this to S1ADM the same day. On 10/09/2024 at 2:01 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/09/2024 at 4:45 p.m., an interview was attempted with S6CNA, unable to leave a message. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 notified him of the incident with S6CNA on 09/24/2024. He stated he did not report it because it was a customer service issue and not abuse. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. F-600 Plan of Removal 1. On 10/09/2024 Residents #46 and #52 were re-assessed for any signs of psychosocial harm. Both residents declined any need for counseling or psychosocial services. All interviewable residents were assessed for signs of abuse or allegations of being mistreated by Administrator/SSD/Designee on 10/9/24. Beginning on 10/07/2024 and completing on 10/10/2024 any non-interviewable residents were assessed by a weekly body audit and daily skin checks. Any abnormal findings will be documented by licensed staff and the Administrator/DON will be notified. 2. S4CNA no longer works in the facility as of 09/24/2024. S5CNA no longer works in facility as of 09/25/2024. S6CNA no longer works in facility as of 09/26/2024. 3. All staff will be re-trained on verbal abuse including yelling, cursing, threatening residents as well as immediately reporting verbal abuse to the Administrator if it is witnessed. The Corporate Office retrained Administrator/Designee initially on 10/09/2024 at 12:45pm. Administrator/Designee began retraining facility staff on 10/09/2024. After retraining, staff will be tested for competency / understanding. No staff member will be allowed to work a shift without receiving re-training and successfully completing a competency test. All staff will receive abuse training on hire and at least annually, including training on verbal abuse. 4. On 10/09/2024 Administrator/ DON/ or SSD will interview 5 random residents weekly with BIMS above 8 to ensure no allegations of abuse for 8 weeks and randomly thereafter. As of 10/09/2024, the facility asserts the likelihood for serious harm to any recipient no longer exists.

CRITICAL (L) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Report Alleged Abuse (Tag F0609)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations of abuse were reported to the state...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure all alleged violations of abuse were reported to the state survey agency. The facility failed to: 1. Ensure allegations of verbal and physical abuse were reported to the State Survey Agency, immediately but not later than 2 hours after the allegation was made for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse; and 2. Report the results of the investigations within 5 working days with appropriate corrective actions implemented for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 09/04/2024 when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. It continued on 09/14/2024, when Resident #46 witnessed and reported to S1ADM, S6CNA yelled and cursed at Resident #52 in the hallway. It continued on 09/23/2024, when Resident #42 reported S13LPN stood in front of her wheelchair, pointed and demanded she get off the hall. It continued on 09/24/2024 when S6CNA followed Resident #46 to her room, yelled, pointed her finger and threatened Resident #46. S1ADM did not report, investigate, report investigation findings or initiate any corrective actions for any of the above abuse allegations. S1ADM was notified of the Immediate Jeopardy Situation on 10/09/2024 at 1:53 p.m. The Immediate Jeopardy was removed on 10/10/2024 at 12:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the other 59 residents residing in the facility. Cross Reference F600. Findings: Review of the facility's undated policy titled, Abuse Neglect and Exploitation revealed the following, in part: Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: b. Establish policies and procedures to investigate any such allegations VII. Reporting/Response A. The facility will have written procedures that include 1. Reporting of all alleged violations to the Administrator, state agency, and all other required agencies within specified time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . 1. Resident #52 A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE]. A review of Resident #52's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of the facility's Self-Reported Incidents dated 09/25/2024 revealed the following: Incident Occurred: 09/05/2024 at 2:00 p.m. Incident Discovered: 09/25/2024 at 12:30 p.m. Incident Reported on: 09/25/2024 12:33 p.m. Incident Description: Resident #52 reported to S1ADM, S4CNA and S5CNA were asked to empty his urinal and refused. CNAs responded to Resident #52 that he capable of emptying his own urinal. Resident #52 alleged CNAs told him, tell your mammy to do it, yeah tell that b**** to do it. On 10/08/2024 at 10:15 a.m., an interview was conducted with S17SW. She stated on 09/04/2024 at approximately 5:30 p.m., she saw Resident #52 in the doorway of S2DON's office where S4CNA and S5CNA yelled, cursed, pointed their finger, and argued with Resident #52. She confirmed yelling, cursing, and pointing your finger at a residents face was abuse and she reported it to S1ADM on 09/05/2024. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated staff cursing and pointing a finger at a resident was abuse and should be reported to administration immediately. She stated S1ADM was responsible for reporting to the State Agency. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated if staff witnessed Resident #52, S4CNA and S5CNA yell, argue and curse it should have been reported to him immediately. He stated the incident involving S4CNA, S5CNA, and Resident #52 was not reported to him until 09/25/2024. He stated any allegation of abuse should be reported to him immediately. He stated he was responsible for reporting the allegation to State Agency within 2 hours. A review of the facility's Self-Reported Incidents dated 09/24/2024 revealed the following: Incident Occurred: 09/14/2024 at 9:00 a.m. Incident Discovered: 09/24/2024 at 2:30 p.m. Incident Reported on: 09/25/2024 4:00 p.m. Incident Description: Resident #46 reported S6CNA and Resident #52 cursed and yelled at each other in the hall. On 10/08/2024 at 9:31 a.m., an interview was conducted with S20LPN. She stated on 09/14/2024 she witnessed S6CNA yell and curse at Resident #52. She confirmed arguing, yelling and cursing with a resident was abuse and she reported it to administration on 09/14/2024. On 10/08/2024 at 11:45 p.m., an interview was conducted with Resident #46, a cognitively intact resident. She stated on 09/14/2024, she was in the hall and witnessed S6CNA yell and curse at Resident #52. She stated S6CNA told Resident #52, F*** you. She stated she contacted S1ADM and reported the incident immediately. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 approached him on 09/14/2024 and notified him of the incident with S6CNA. He confirmed he did not report the allegation of abuse or conduct an investigation until 09/24/2024. Resident #42 A review of Resident #42's Clinical Record revealed Resident #42 was admitted to the facility on [DATE]. A review of Resident #42's Quarterly MDS with an ARD of 08/07/2024 revealed Resident #42 had a BIMS of 14, which indicated Resident #42 was cognitively intact. A review of the facility's Self-Reported Incidents dated September 2024 revealed no entries for the 09/22/2024 incident with Resident #42 and S13LPN. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she and Resident #48 were friends and she visited Resident #48's room frequently. She stated on 09/22/2024, she was in her wheelchair, rolling down the hall, S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. Resident #42 stated she felt intimidated and threatened by S13LPN and reported the incident to S1ADM on 09/23/2024. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #42 notified him of the incident with S13LPN on 09/23/2024 and he completed a grievance. He confirmed he did not report or investigate the incident because it was a customer service issue. Resident #46 A review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE]. A review of Resident #46's admission MDS, with an ARD of 07/11/2024, revealed Resident #46 had a BIMS of 15, which indicated Resident #46 was cognitively intact. A review of Resident #46's grievance, dated 09/24/2024, revealed the following: Statement of concern: Resident #46 stated S6CNA approached her and asked, If you have something to say, say it to me A review of the facility's Self-Reported Incidents revealed no entries for the 09/24/2024 incident with Resident #46 and S6CNA. On 10/08/2024 at 11:45 a.m., an interview was conducted with Resident #46. She stated on 09/24/2024, she and Resident #52 were talking in the hall. She stated when she finished talking with Resident #52, she went to her room, and S6CNA followed her to her room, stood in the doorway and yelled while shaking and pointing her finger toward her, if you have something to say, say it to my face. She stated she felt threatened by S6CNA and reported this to S1ADM the same day. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 notified him of the incident with S6CNA on 09/24/2024. He confirmed he did not report or investigate the incident. Resident #35 A review of Resident #35's Clinical Record revealed he was admitted to the facility on [DATE]. A review of Resident #35's admission MDS with an ARD of 09/20/2024, revealed Resident #35 had a BIMS of 15, which indicated Resident #35 was cognitively intact. Resident #51 A review of Resident #51's Clinical Record revealed she was admitted to the facility on [DATE]. A review of Resident #51's admission MDS with an ARD of 07/11/2024, revealed Resident #51 had a BIMS of 15, which indicated Resident #51 was cognitively intact. A review of the facility's Self-Reported Incidents dated October 2024 revealed no entries for the 10/02/2024 incident with Resident #35 and #51. On 10/08/2024 at 9:15 a.m., an interview was conducted with Resident #51. He stated about one week ago Resident #35 yelled at him and pushed him against the wall. He stated he reported it to S11LPN. On 10/08/2024 at 9:30 a.m., an interview was conducted with S11LPN. She stated on 10/02/2024 at approximately 10:00 a.m., she heard yelling as Resident #35 entered his shared room with Resident #51. S11LPN stated when she went into the room, Resident #51 told her Resident #35 grabbed him by the wrist and pushed him against the dresser. She stated she reported the incident on 10/02/2024 to S1ADM and S2DON immediately. On 10/09/2024 at 12:45 p.m., an interview was conducted with S1ADM. He stated he was aware of the incident on 10/02/2024 between Resident #35 and #51. He stated he did not feel that this incident rose to the reportable level, therefore he did not investigate or report. 2. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated S1ADM was responsible for investigating abuse allegations. She confirmed no corrective actions were placed for any of the above incidents. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated he was responsible for conducting an investigation and reporting the investigation findings within 5 days following any allegations of abuse. He stated the following employees were not removed following the above incidents and continued to provide care to residents: S4CNA, S5CNA, S6CNA, and S13LPN. He confirmed he did not conduct an investigation or place any corrective actions for any of the above incidents. F609 Plan of Removal 1. On 10/9/24 Administrator has opened SIMS reports for all cited incidents. 2. All interviewable residents were assessed for signs of abuse or allegations of being mistreated by Administrator/ SSI)/ Designee on 10/9/24. Beginning on 10/7/24 and completing on 10/10/24 any non-interviewable residents were assessed by a weekly body audit and daily skin checks. Any abnormal findings will be documented by licensed staff and the Administrator/ DON will be notified. 3. Administrator will receive 1:1 education by Regional Administrator on 10/9/2024 on requirement of reporting allegations of verbal abuse to state survey agency within 2 hours. Administrator will be tested for understanding / competency. All staff will be re-trained by the Administrator on reporting abuse allegations in a timely manner. After retraining, staff will be tested for competency / understanding. No staff member will be allowed to work a shift without receiving re-training and successfully completing a competency test. All staff will receive abuse training on hire and at least annually, including training on reporting abuse allegations in a timely manner. 4. Beginning on 10/9/24, the Regional Administrator or Regional Nurse will review all allegations of abuse at least weekly for 8 weeks then randomly for an additional 8 weeks to ensure the reporting requirement is met. As of 10/9/24, the facility asserts the likelihood for serious harm to any recipient no longer exists.

CRITICAL (L) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Administration (Tag F0835)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled its resource...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure it was administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective system in place to: 1. Ensure residents remained free from verbal and mental abuse for 3 (#42, #46, and #52) of 7 (#18, #26, #42, #46, #51, #52, and #111) residents reviewed for abuse; and 2. Ensure allegations of verbal and physical abuse were reported to the State Survey Agency, immediately but not later than 2 hours after the allegation was made for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse; and 3. Report the results of the investigations within 5 working days with appropriate corrective actions implemented for 5 (#35, #42, #46, #51, and #52) of 19 sampled residents reviewed for abuse. Cross Reference F600 and F609 This deficient practice resulted in an Immediate Jeopardy situation on 09/04/2024 when multiple staff witnessed S4CNA and S5CNA curse, yell, and point in Resident #52's face. It continued on 09/14/2024, when Resident #46 witnessed and reported to S1ADM, S6CNA yelled and cursed at Resident #52 in the hallway. It continued on 09/23/2024, when Resident #42 reported S13LPN stood in front of her wheelchair, pointed and demanded she get off the hall. It continued on 09/24/2024 when S6CNA followed Resident #46 to her room, yelled, pointed her finger and threatened Resident #46. It continued on 10/02/2024 when Resident #51 reported to staff Resident #35 grabbed him by the wrist and pushed him against the dresser. S1ADM did not report timely, report investigation findings or initiate any corrective actions for any of the above abuse allegations. The facility failed to protect residents from any further abuse following the incidents. S1ADM was notified of the Immediate Jeopardy situation on 10/09/2024 at 1:53 p.m. The Immediate Jeopardy was removed on 10/10/2024 at 12:33 p.m., as confirmed by onsite verification through observations, interviews, and record reviews the facility implemented an acceptable Plan of Removal prior to the survey exit. This deficient practice continued at a potential for more than minimal harm for the 59 residents currently residing in the facility. Findings: Review of the facility's undated policy titled, Abuse Neglect and Exploitation revealed the following, in part: Policy Statement: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: b. Establish policies and procedures to investigate any such allegations; and VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, State agency, and all other required agencies within specified time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by State agencies. Resident #52 A review of Resident #52's Clinical Record revealed he was admitted on [DATE] with diagnoses which included, Acquired Absence of Right Leg Above Knee, Acquired Absence Of Left Leg Above Knee, And Adjustment Disorder, Unspecified. A review of Resident #52's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. Review of the facility's Self-Reported Incident Reports, dated 09/05/2024, revealed the following: Occurred: 09/05/2024 at 2:00 p.m. Discovered: 09/25/2024 at 12:30 p.m. Incident Reported on: 09/25/2024 12:33 p.m. Description: Resident #52 reported to S1ADM S4CNA and S5CNA were asked to empty his urinal. CNA's responded with Resident #52 was capable of emptying his own urinal. Resident #52 became angry and began yelling. Resident #52 alleged CNA's told him, tell your mammy to do it, yea tell that b**** to do it. On 10/08/2024 at 10:15 a.m., an interview was conducted with S17SW. She stated on 09/04/2024 at approximately 5:30 p.m., she saw Resident #52 in the doorway of S2DON's office where S4CNA and S5CNA yelled, cursed, pointed their finger, and argued with Resident #52. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She confirmed yelling, cursing, and pointing your finger at a residents face was abuse and she reported it to S1ADM on 09/05/2024. On 10/08/2024 at 11:08 a.m., an interview was conducted with S18LPN. She stated on 09/04/2024, she saw Resident #52 in the doorway of S2DON's office in his wheelchair. She stated Resident #52, S4CNA and S5CNA yelled and cursed at each other. She stated S5CNA pointed her finger in Resident #52's face and told him he was capable of emptying his urinal. She stated S2DON was in her office, could see and hear the altercation, and did not intervene. She stated yelling, cursing and pointing a finger at a residents face is abuse. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated on 09/04/2024, Resident #52 asked S4CNA to empty his urinal and she told him he could do it himself. She stated Resident #52 rolled his wheelchair to the doorway of her office, parked his wheelchair, and yelled and cursed at her and S4CNA. S2DON stated she did not hear the 2 CNAs yell or curse at the resident. She stated staff cursing and pointing a finger at a resident was abuse. She confirmed S4CNA continued to provide care to residents in the facility until 09/24/2024 and S5CNA continued to provide care to residents in the facility until 09/26/2024 when S1ADM removed them. She confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #52 reported on 09/25/2024, he asked S4CNA on 09/05/2024 to empty his urinal. Resident #52 reported S4CNA refused to empty his urinal, yelled and cursed at her. S1ADM explained Resident #52 had aggressive behaviors, which included, yelling and cursing with other residents and staff. He stated S4CNA and S5CNA triggered Resident #52's behaviors so they were moved to another facility on 09/24/2024 and 09/26/2024, with a plan to return when Resident #52 was discharged . He stated S4CNA was not assigned to Resident #52 after 09/07/2024 but did provide care to other residents at the facility until 09/24/2024. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors or monitoring completed following the incident on 09/04/2024. Review of the facility's Self-Reported Incident Reports dated 09/05/2024 revealed the following: Occurred: 09/14/2024 at 9:00 a.m. Discovered: 09/24/2024 at 2:30 p.m. Description: Resident #46 reported S6CNA and Resident #52 were cursing and yelling at each other in the hall. On 10/08/2024 at 11:45 p.m., an interview was conducted with Resident #46, a cognitively intact resident. She stated on 09/14/2024, she was in the hall and witnessed S6CNA yell and curse at Resident #52. She stated S6CNA told Resident #52, F*** you. She stated she reported the incident immediately to S1ADM. She stated S6CNA continued to provide care at the facility on her hall until 09/24/2024, when S6CNA threatened her. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 approached him on 09/14/2024 and notified him of the incident with Resident #52 and S6CNA. He stated S6CNA was not removed from the facility and continued to provide care to Resident #46 and Resident #52 until S6CNA was removed on 09/26/2024. He stated on 09/24/2024, S6CNA was involved in another incident with Resident #46 and S6CNA was terminated but not related to the allegation. He confirmed no additional education was provided to staff on de-escalation for residents with behaviors. He confirmed the last abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. Resident #42 A review of Resident #42's Clinical Record revealed Resident #42 was admitted to the facility on [DATE]. A review of Resident #42's Quarterly MDS with an ARD of 08/07/2024 revealed Resident #42 had a BIMS of 14, which indicated Resident #42 was cognitively intact. A review of the facility's Self-Reported Incidents dated September 2024 revealed no entries for the 09/22/2024 incident with Resident #42 and S13LPN. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she and Resident #48 were friends and she visited Resident #48's room frequently. She stated on 09/22/2024, she was in her wheelchair, rolling down the hall, when S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. She stated on the same day after leaving the smoking patio and going back to her room, she heard S13LPN call her white trash. Resident #42 stated she felt intimidated and threatened by S13LPN and reported the incident to S1ADM on 09/23/2024. She stated again on 10/05/2024, S13LPN told her to get in Resident #48's room or get off the hall in a stern voice. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He said on 09/23/2024 Resident #42 reported that on 09/22/2024, S13LPN stopped her, stood in front of her wheelchair and stated, Get off my hall, you're not allowed over here in a stern voice. He confirmed Resident #42 should not have been stopped and been allowed to visit Resident #48. He stated he did not report it because it was a customer service issue and not abuse. He stated he was made aware of the 10/05/2024 incident by the state surveyor on 10/09/2024. He confirmed S13LPN was not removed from the facility after 09/22/2024 and provided care at the facility when another incident occurred on 10/05/2024. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. Resident #46 A review of Resident #46's Clinical Record revealed she was admitted on [DATE] with diagnoses which included, Depression and Weakness. A review of Resident #46's MDS, with an ARD of 07/11/2024, revealed Resident #46 had a BIMS of 15, which indicated Resident #46 was cognitively intact. On 10/08/2024 at 11:45 a.m., an interview was conducted with Resident #46. She stated on 09/24/2024, she and Resident #52 were talking in the hall. She stated when she finished talking with Resident #52, she went to her room, and S6CNA followed her to her room, stood in the doorway and yelled while shaking and pointing her finger toward her, if you have something to say, say it to my face. She stated she felt threatened by S6CNA and reported this to S1ADM immediately. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated Resident #46 notified him of the incident with S6CNA on 09/24/2024. He stated he did not report it because it was a customer service issue and not abuse. He confirmed abuse training was conducted during the staff meeting on 10/01/2024 but S4CNA, S5CNA, S6CNA and S13LPN did not attend the meeting for the abuse training. Resident #35 A review of Resident #35's Clinical Record revealed he was admitted on [DATE] with diagnoses which included, Unqualified Visual Loss of Left Eye and Depressive Episodes. A review of Resident #35's MDS, with an ARD of 09/20/2024, revealed Resident #35 had a BIMS of 15, which indicated Resident #35 was cognitively intact. Resident #51 A review of Resident #51's Clinical Record revealed he was admitted on [DATE] with diagnoses which included, Depressive Disorder, Anxiety Disorder, and Personal history of other Mental and Behavioral Disorders. A review of Resident #51's MDS, with an ARD of 07/11/2024, revealed Resident #51 had a BIMS of 15, which indicated Resident #51 was cognitively intact. On 10/08/2024 at 9:15 a.m., an interview was conducted with Resident #51. He stated about one week ago Resident #35 yelled at him and pushed him against the wall. On 10/08/2024 at 9:30 a.m., an interview was conducted with S11LPN. She stated on 10/02/2024 at approximately 10:00 a.m., she heard yelling as Resident #35 entered his shared room with Resident #51. She stated when she went into the room, Resident #51 told her Resident #35 grabbed him by the wrist and pushed him against the dresser. She stated she reported the incident on 10/02/2024 to S1ADM and S2DON. On 10/09/2024 at 12:45 p.m., an interview was conducted with S1ADM. He stated he was aware of the incident on 10/02/2024 between Resident #35 and #51. He stated he did not feel that this incident rose to the reportable level, therefore he did not investigate or report. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She stated staff cursing, pointing a finger and intimidating a resident was abuse and should be reported to administration immediately. She stated S1ADM was responsible for reporting to the State Agency. She confirmed no corrective actions were placed for any of the above incidents. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated any allegation of abuse should be reported to him immediately. He stated he was responsible for reporting within 2 hours and reporting the investigation within 5 days. He stated the following employees were not removed following the above incidents and continued to provide care to residents: S4CNA, S5CNA, S6CNA, and S13LPN. He confirmed he did not report, conduct an investigation, or place any corrective actions for any of the above incidents. Plan of Removal: 1. On 10/09/2024 Residents #46 and #52 were re-assessed for any signs of psychosocial harm. Both residents declined any need for counseling or psychosocial services. S4CNA no longer works in the facility as of 09/24/2024. S5CNA no longer works in facility as of 09/25/2024. S6CNA no longer works in facility as of 09/26/2024. 2. All interviewable residents were assessed for signs of abuse or allegations of being mistreated by Administrator/SSD/Designee on 10/9/24. Beginning on 10/07/2024 and completing on 10/10/2024 any non-interviewable residents were assessed by a weekly body audit and daily skin checks. Any abnormal findings will be documented by licensed staff and the Administrator/DON will be notified. 3. All staff will be re-trained on verbal abuse including yelling, cursing, threatening residents as well as immediately reporting verbal abuse to the Administrator if it is witnessed. The Corporate Office retrained Administrator/Designee initially on 10/09/2024. The Corporate Office retrained the Administrator on verbal abuse on 10/09/2024. Administrator/Designee began retraining facility staff on 10/09/2024. After retraining, staff will be tested for competency / understanding. No staff member will be allowed to work a shift without receiving re-training and successfully completing a competency test. All staff will receive abuse training on hire and at least annually, including training on verbal abuse and reporting abuse allegations in a timely manner. All incidents and accidents and nurses notes will be reviewed by corporate to ensure that any potential incidents have been reported accurately and timely. This will begin on 10/10/2024 and continue for 8 weeks 3x per week then randomly for 8 weeks thereafter. 4. Beginning on 10/09/2024, Administrator/DON/ or SSD will interview 5 random residents weekly for 8 weeks then randomly for an additional 8 weeks with BIMS above 8 to ensure no allegations of abuse. As of 10/09/2024, The Pines Retirement Center of [NAME] asserts the likelihood for serious harm to any recipient no longer exists.

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 F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to promote and facilitate residents' self-determination through supp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to promote and facilitate residents' self-determination through support of the residents' choice about aspects of his or her life in the facility which were significant to the resident for 3 (#42, #48, and #52) of 24 residents reviewed in the initial pool. The facility failed to ensure residents had rights as evidenced by: 1. Staff did not allow Resident #42 to visit Resident #48; 2. Staff did not allow Resident #48 out of his room; and 3. Staff did not wear gloves at Resident #52's request. Findings: Review of the facility's undated policy titled, Resident Rights revealed the following: 1. Resident Rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 5. Respect and dignity. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. 6. Self Determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 1. Resident #42 A review of Resident #42's Clinical Records revealed she was admitted to the facility on [DATE] with diagnoses which included, Depression, Anxiety, and Muscle Wasting. A review of Resident #42's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/2024 revealed Resident #42 had a Brief Interview for Mental Status (BIMS) of 14, which indicated Resident #42 was cognitively intact. On 10/09/2024 at 3:28 p.m., an interview was conducted with Resident #42. She stated she visited Resident #48 in his room frequently. Resident #42 stated on 09/24/2024, S13LPN did not allow her to visit Resident #48 and told her to go back to her room. On 10/09/2024 at 3:53 p.m., an interview was conducted with S13LPN. She stated she told Resident #42 she could not go into Resident #48's room on 09/24/2024. She further stated on 10/05/2024 she told Resident #42 and #48, get in Resident #48's room or get off the hall. 2. Resident #48 A review of Resident #48's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses which included, Depressive Disorder, Anxiety Disorder, and Mental Disorder. A review of Resident #48's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/20/2024 revealed Resident #48 had a Brief Interview for Mental Status (BIMS) of 11, which indicated Resident #48 was mildly cognitively impaired. On 10/10/2024 at 2:26 p.m., an interview was conducted with Resident #48. He stated on 10/05/2024, S13LPN told him to get in his room or off the hall. On 10/09/2024 at 3:53 p.m., an interview was conducted with S13LPN. She stated on 10/05/2024 she told Resident #48, get in your room or get off the hall, and should not have. 3. Resident #52 A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, Acquired Absence of Right Leg Above the Knee, Acquired Absence of Left Leg Above the Knee and Adjustment Disorder. A review of Resident #52's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. On 10/09/2024 at 3:53 p.m., an interview was conducted with S13LPN. She stated when she was assigned to Resident #52, he requested she wore gloves for medication pass. S13LPN confirmed she did not wear gloves for the medication pass and Resident #52 refused his medication. On 10/10/2024 at 2:40 p.m., an interview was conducted with S1ADM. He confirmed residents had the right to visit other residents, be on the hall if they choose to, and to request staff to wear gloves for medication pass.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident's assessment accurately reflected the Discharge Status for 1 (#62) of 24 residents reviewed in the final sample. Findings: Review of Resident #62's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #62's Discharge MDS, with an ARD of 08/24/2024, indicated, in part, the following; Section A: discharge date : [DATE]. Discharge Status: 1. Home/Community. Review of Resident #62's Nurses Notes revealed, in part, a note written on 08/24/2024 at 11:38 p.m. by S8LPN indicating Resident #62 was transferred to a local hospital by ambulance. On 10/09/2024 at 10:55 a.m., an interview was conducted with S7RN. She confirmed she was responsible for entering MDS Assessments for the facility. She reviewed Resident #62's Discharge MDS and Nurses Notes dated 08/24/2024. She confirmed the resident was discharged to the hospital, not home/community and the MDS was coded inaccurately. On 10/09/2024 at 11:07 a.m., an interview was conducted with S2DON. She reviewed Resident #62's Discharge MDS and Nurses Notes dated 08/24/2024. She confirmed the resident was discharged to the hospital, not home/community and the MDS was coded inaccurately.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents remained free of accidents by failing to ensure ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents remained free of accidents by failing to ensure residents were transferred with proper transfer assistance and devices for 1 (#5) of 19 sampled residents reviewed for accidents. Findings: Review of the facility's undated policy titled, Safe Resident Handling/Transfers revealed the following: Policy: It is the policy of this facility to ensure residents are handled and transferred safely to prevent or minimize risks for injury, and provide and promote a safe, secure, and comfortable experience for the resident, while keeping the employees safe, in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized, dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 26. Two staff members must be utilized when transferring residents with a mechanical lift. Review of Resident #5's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included: Cerebral Palsy, Muscle Weakness, History of Falling, and Unspecified Lack of Coordination. Review of Resident #5's most recent MDS, with ARD of 09/04/2024, revealed Resident #5 had a BIMS of 15 indicating he was cognitively intact. Further review of MDS Section GG revealed Resident #5 was dependent on staff for the following: chair/bed-to-chair transfers, upper and lower body dressing, personal hygiene, rolling left and right, and sit to lying. Review of Resident #5's Care Plan revealed the following: Date: 05/10/2022 Resident Problem: ADLs: Requires assistance for all ADLs Further review revealed no interventions were documented for Resident #5's transfer status. Review of Resident #5's Nursing Progress Notes dated 10/06/2024 to 10/07/2024 revealed the following, in part: On 10/06/2024 at 10:50 a.m., Mobile x-ray ordered for Resident #5 related to complaint of bilateral lower extremity pain, onset from previous night. -signed S20LPN. On 10/07/2024 at 7:21 a.m., Late entry from 10/6/2024 at 5:30 a.m.- resident complained of pain to left knee. States CNA fell (lean) on his leg last evening. Resident requested pain medication-signed S13LPN. On 10/07/2024 at 7:33 a.m., Spoke with S12NP who gave order to send to Emergency Department for evaluation and treatment of leg fracture. - signed S11LPN. On 10/07/2024 at 4:10 p.m. Resident #5 returned from emergency room. Resident #5 diagnosed with Plateau Fracture of Left Knee, immobilizer intact and in place- signed S24LPN. On 10/08/24 at 9:22 a.m., an interview was conducted with S11LPN. She stated Resident #5 informed her S14CNA was transferring him without assistance and fell on top of him on 10/05/2024. On 10/08/2024 at 10:00 a.m., an interview was conducted with Resident #5. He stated S14CNA transferred him back into bed, without assistance, and fell on his leg on the night of 10/05/2024. On 10/08/24 at 11:39 a.m., a telephone interview was conducted with S25CNA. She stated on 10/05/2024 at approximately 5:30 a.m. Resident #5 informed her S14CNA fell on him. Resident #5 reported his leg was hurting and he needed medication for pain. On 10/08/24 at 12:00 p.m., an interview was conducted with S20LPN. Resident #5 informed her while his brief was being changed, S14CNA fell on him. She stated Resident #5 was a 2 person mechanical lift transfer. On 10/09/24 at 09:00 a.m., an interview was conducted with S14CNA. She stated on 10/5/2024 at approximately 8:30 p.m. she went into Resident #5's room and transferred him into his bed by herself using the mechanical lift. She further stated she was short and did have to reach across resident in order to turn him and may have leaned on Resident #5's leg. S14CNA stated she was aware Resident #5 was a 2 person mechanical lift transfer. On 10/09/2024 at 12:42 p.m., an interview was conducted with S2DON. S2DON confirmed all mechanical lift transfers should be performed by two nursing staff in order to ensure resident safety. On 10/10/2024 at 4:40 p.m., an interview was conducted with S3CRN. S3CRN confirmed all mechanical lift transfers should be performed by two nursing staff in order to ensure resident safety and to prevent accidents. S3CRN confirmed it was unacceptable for one staff member to perform mechanical lift transfers.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety, as determined by resident assessments and individual plans of care. The facility failed to ensure: 1. All nursing staff were competent to implement a resident's assessed transfer needs for 1 (#5) of 19 sampled residents reviewed for transfer status. This deficient practice had the potential to affect 14 residents residing in the facility who required mechanical lift transfers. Findings: Review of the facility's undated policy titled, Safe Resident Handling/Transfers revealed the following: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury, and provide and promote a safe, secure and comfortable experience for the resident, while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized, dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 26. Two staff members must be utilized when transferring residents with a mechanical lift. Review of Resident #5's Clinical Records revealed he was admitted on [DATE] with diagnoses, which included: Cerebral Palsy, Cognitive Communication Deficit, Muscle Weakness, History of Falling, and Unspecified Lack of Coordination. Review of Resident #5's most recent MDS (Minimum Data Set), with ARD (Assessment Reference Date) of 09/04/2024, revealed Resident #5 had a BIMS (Brief Interview of Mental Status) of 15, indicating Resident #5 was cognitively intact. Review of Resident #5's Care Plan revealed he required assistance for all ADLs. Further review revealed there was no documentation of the amount of assistance, supervision, and/or assistive devices required for Resident #5's transfers. On 10/08/24 at 11:55 a.m., an interview was conducted with S23TD. S23TD confirmed Resident #5 had been assessed and required a 2 person assist mechanical lift transfer. On 10/09/24 at 09:00 a.m., an interview was conducted with S14CNA. She stated on 10/5/2024 at approximately 8:30 p.m. she went into Resident #5's room and transferred him into his bed by herself using the mechanical lift, while S15CNA stood in the doorway spotting her. S14CNA stated she was aware of Resident #5's 2 person assist mechanical lift transfer status. On 10/09/2024 at 10:24 a.m., an interview was conducted with S15CNA. She confirmed she was standing in Resident #5's door on 10/05/2024, while S14CNA transferred Resident #5 independently using the mechanical lift. S15CNA stated she was aware of Resident #5's 2 person assist mechanical lift transfer status On 10/09/2024 at 12:42 p.m., an interview was conducted with S2DON, she confirmed 2 nursing staff should perform all mechanical lift transfers. On 10/10/2024 at 4:40 p.m., an interview was conducted with S3CRN. S3CRN confirmed 2 nursing staff should perform all mechanical lift transfers. S3CRN confirmed it was unacceptable for one staff member to perform mechanical lift transfers.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent...

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Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure S8LPN disinfected the glucometer between resident use for 1 (#1) of 3 (#1, #26, and #55) residents observed during blood glucose monitoring. Findings: Review of the facility's policy titled, Glucometer Disinfection, dated 05/2023, revealed in part, the following: Policy Explanation and Compliance Guidelines: 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use. 2. The glucometers will be disinfected with a wipe pre-saturated with a registered healthcare disinfectant. An observation was made on 10/07/2024 at 9:00 a.m. of S8LPN. S8LPN performed a blood glucose check on Resident #1. S8LPN then wiped the glucometer with an incontinence wipe, without disinfectant, and placed the glucometer in the top drawer of the medication cart. An interview was conducted on 10/07/2024 at 9:02 a.m. with S8LPN. S8LPN confirmed she cleaned the glucometer with an incontinence wipe, without disinfectant, and not a disinfecting wipe. An interview was conducted on 10/07/2024 at 9:35 a.m. with S2DON. S2DON confirmed the glucometer should be cleaned before and after each resident's use with approved disinfecting wipes or cleaning agent.

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to notify the physician when a resident had aggressive behaviors towa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to notify the physician when a resident had aggressive behaviors toward staff and other residents for 1(#52) of 6 (#18, #26, #42, #51, #52, and #111) residents reviewed for behaviors. Findings: A review of the facility's undated policy, Change in a Resident's Condition or Status revealed the following: 1. The nurse supervisor/Charge Nurse will notify the resident's attending physician or on call physician when there has been: a. An accident or incident involving the resident; d. A significant change in the resident's physical/emotional/mental condition. A review of Resident #52's Clinical Records revealed he was admitted to the facility on [DATE] and diagnosed with Adjustment Disorder, Unspecified. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of Resident #52's Clinical Record revealed no documentation his psychiatric NP was notified of his aggressive behaviors toward other residents and staff beginning 08/15/2024 through 10/08/2024. Review of Resident #52's Psychiatric NP Notes revealed the following: Date: 08/15/2024 Diagnosis: Adjustment disorder, Unspecified. Staff reports improved behaviors. Date: 09/17/2024 Diagnosis: Adjustment disorder, Unspecified. Staff reports no behavior issues. On 10/08/2024 at 3:43 p.m., an interview was conducted with S1ADM. He confirmed Resident #52 had aggressive behaviors with multiple staff and residents. He stated he was not aware if S22NP had been notified but due to his aggressive behaviors he was issued a 30 day discharge. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She confirmed Resident #52 had aggressive behaviors with multiple staff and residents. She further stated S22NP was made aware of his behaviors. On 10/10/2024 at 4:06 p.m., an interview was conducted with S22NP. She stated she was not aware Resident #52 was having behaviors and should have been made aware. She confirmed she was not aware of Resident #52 threatening staff.

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 F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the resident's care plan was reviewed and revised for 2 (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the resident's care plan was reviewed and revised for 2 (#5 and #52) of 19 sampled residents reviewed for care plans. The facility failed to ensure: 1. Resident #5's transfer status was documented on his care plan; and 2. Resident #52's care plan was reviewed and revised for behaviors. Findings: Review of the facility's undated policy titled Care Plans - Comprehensive revealed, in part: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 8. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. f. Resident specific interventions that reflect the resident's needs. 10. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 13. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 1. Review of Resident #5's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included: Cerebral Palsy, Muscle Weakness, History of Falling, and Unspecified Lack of Coordination. Review of Resident #5's most recent MDS, with ARD of 09/04/2024, revealed Resident #5 had a BIMS of 15, indicating he was cognitively intact. Further review of MDS Section GG revealed Resident #5 was dependent on staff for the following: Chair/bed-to-chair transfer, upper and lower body dressing, Personal hygiene, rolling left and right, and sit to lying. Review of Resident #5's Care Plan revealed the following, in part: Date: 05/10/2022 Resident Problem: ADLs: Requires assistance for ADLs Further review revealed there were no interventions noted for Resident #5's transfer status. 2. Review of Resident #52's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses, which included: Adjustment Disorder, Unspecified. Review of Resident #52's most recent MDS, with ARD of 08/05/2024, revealed Resident #52 had a BIMS of 15, indicating he was cognitively intact. Review of Resident #52's Care Plan revealed the following, in part: Date: 06/24/2024 Resident Problem: Behavior: Verbally aggressive behavior. Further review revealed there were no updated interventions noted for Resident #5's behavior/s. An interview was conducted on 10/10/2024 at 2:10 p.m. with S7RN and S16LPN. Both stated they were responsible for MDS and review and revision of care plans. S7RN stated she was not aware Resident #52 had behaviors. S7RN further stated Resident #5 required 2 person mechanical lift transfers. S7RN confirmed Resident #5 was not care planned for 2 person mechanical lift transfers, and Resident #52 had not had any behavior interventions updated, and should have. An interview was conducted on 10/10/2024 at 2:23 p.m. with S3CRN. S3CRN confirmed a resident's transfer status should be included in their care plan, and interventions should have be updated for Resident #52's behaviors.

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (#28) of 19 residents reviewed in the final sample. The facility failed to ensure Resident #28 received her required HIV medication. Findings: Review of Resident #28's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included HIV. Review of Resident #28's discharge instructions from a local rehabilitation center dated 06/19/2024 revealed an order for Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily. Review of Resident #28's MAR dated 06/10/2024-10/10/2024 revealed no documentation of Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily. On 10/10/2024 at 2:02 p.m., an interview was conducted with S8LPN. She stated Resident #28 had a diagnosis of HIV. She stated Resident #28's HIV medication was discontinued. She stated she discontinued the medication after the clinic visit. She reviewed Resident #28's orders and confirmed she did not see an order to discontinue HIV medication. On 10/10/2024 at 2:04 p.m., an interview was conducted with S2DON. She stated Resident #28 was readmitted to the facility from a rehabilitation center. She stated she was responsible for inputting admission orders. She stated she was unaware of discharge orders from local rehabilitation facility. She confirmed HIV medication for Resident #28 was not reordered. On 10/10/2024 at 2:30 p.m., a telephone interview was conducted with S12NP. He stated he was unaware of HIV medications for Resident #28. He reviewed the medication list and confirmed there was no order for HIV medication. On 10/10/2024 at 4:42 p.m., an interview was conducted with S13CRN. She reviewed Resident #28's physician orders along with the rehabilitation facility's discharge instructions dated 06/19/2024 and confirmed an order for the following HIV medication, Bictegravir/Emtricitabine/Alafenamide 50mg/200mg/25mg one tablet by mouth daily 2and further confirmed the medication was not reordered and should have been.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure direct care staff had appropriate competencies and skills to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure direct care staff had appropriate competencies and skills to assure resident safety and maintain the highest practicable physical, mental, and psychological well-being of each resident. The facility failed to ensure all direct care staff had competency training in crisis prevention interventions (CPI) for a resident (Resident #52) who displayed aggressive threatening behaviors. The deficient practice had the potential to effect all 59 residents that resided in the facility. Findings: A review of Resident #52's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Adjustment Disorder. A review of Resident #52's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) of 15, which indicated Resident #52 was cognitively intact. A review of Resident #52's Psychiatric NP Notes, dated 09/17/2024 revealed the following, in part: Diagnosis: Adjustment disorder. A review of Resident #52's NP Progress Notes, dated 09/04/2024 revealed the following, in part: Confrontational with staff, Aggressive behaviors. On 10/08/2024 at 9:31 a.m., an interview was conducted with S20LPN. She stated Resident #52 had behaviors and was aggressive with staff. She further stated she had not received behavior health training, which included CPI, upon hire. On 10/09/2024 at 4:25 p.m., an interview was conducted with S4CNA. She stated Resident #52 had behaviors and was aggressive with staff. She further stated she had not received behavior health training, which included CPI, upon hire. On 10/09/2024 at 8:37 a.m., an interview was conducted with S2DON. She confirmed Resident #52 had behaviors and was aggressive with staff. S2DON confirmed the facility had not provided direct care staff with behavior health training, which included CPI. On 10/10/2024 at 10:51 a.m., an interview was conducted with S1ADM. He stated the facility was aware of Resident #52's diagnosis of Adjustment Disorder on admit. S1ADM confirmed Resident #52 had behaviors and was aggressive with staff. S1ADM confirmed the facility had not provided direct care staff with behavior health training, which included CPI. On 10/10/2024 at 4:06 p.m., an interview was conducted with S22NP. She confirmed staff needed CPI training before providing care to Resident #52 due to his diagnosis of Adjustment Disorder.

CONCERN (E)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected multiple residents

Based on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have...

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Based on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff. This deficient practice had the potential to affect the 56 residents who consumed food from the kitchen. Findings: On 10/09/2024 at 1:10 p.m., an interview was conducted with S9DM. He stated he was hired one month ago. S9DM stated he had not received a dietary manager certification. On 10/09/2024 at 1:30 p.m., an interview was conducted with S10RD. She stated she was hired by the facility as a Consultant Dietitian and worked 20 hours per week. S10RD stated she was not a full-time employee at the facility. On 10/09/2024 at 11:22 a.m., an interview was conducted with S1ADM. He stated S9DM was hired one month ago. S1ADM confirmed S9DM did not have a dietary manager certification and should have.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 56 re...

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Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 56 residents who consumed food from the kitchen. Findings: On 10/07/2024 at 08:27 a.m., an observation was made of the kitchen food preparation area with S9DM, which revealed the following items: 2-12oz containers of parsley flakes opened and unlabeled. 1-18oz container of celery salt opened and unlabeled. 1-18oz container of ground cinnamon opened and unlabeled. 1-32oz bottle of lemon juice opened and unlabeled. 1 16oz box of brown sugar opened and unlabeled. On 10/07/2024 at 08:32 a.m., an observation was made of the dry storage area, which revealed the following items: 1-50lb bag of white granular sugar opened and unlabeled. 1-25lb bag of brown rice opened and unlabeled. On 10/07/2024 at 8:34 a.m., an interview was conducted with S9DM. He confirmed all opened container should have been labeled with open date and were not. On 10/07/2024 at 9:30 a.m., an interview was conducted with S1ADM. He was notified of the aforementioned findings. S1ADM confirmed opened containers should be labeled with open date.

Aug 2024 10 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's physician was notified after a change in physi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's physician was notified after a change in physical and mental status occurred for 1 (#2) of 4 (#1, #2, #11, and #12) residents reviewed for notification of change. Findings: Review of the facility's policy titled, Change in a Resident's Condition or Status revealed the following, in part: Policy Statement: Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse will notify the resident's attending Physician or on-call physician when there has been: d. A significant change in a resident's physical/emotional/mental condition; 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. 6. 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. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Acute Embolism and Thrombosis of Unspecified Deep Veins of Right Lower Extremity, Chronic Atrial Fibrillation, Essential Hypertension, Age-Related Physical Debility, Muscle Wasting and Atrophy, Unspecified Dementia, Adult Failure to Thrive, Chronic Venous Hypertension with Ulcer of Left Lower Extremity, and (08/09/2024) Urinary Tract Infection. Review of Resident #2's MDS with an ARD of 07/05/2024 revealed a BIMS of 2, which indicated severe cognitive impairment. Review of Resident #2's Physician Orders dated August 2024 revealed the following, in part: Start date: 07/02/2024 - Vital signs every shift Review of Resident #2's Vital Sign History dated August 2024 revealed the following, in part: 08/05/2024 at 3:00 p.m. by S16LPN: Blood Pressure 74/42 mmHg 08/06/2024 at 2:07 p.m. by S8LPN: Blood Pressure 82/56 mmHg, Heart Rate 40 beats per minute (bpm) Review of Resident #2's Nurses' Notes dated August 2024 revealed, in part, no documentation a doctor and/or Nurse Practitioner was notified of abnormal vital signs and/or a change in mental status. Review of Resident #2's Clinical Record revealed no documented evidence of Skilled Nursing Notes dated August 2024. An interview was conducted with S16LPN on 08/28/2024 at 2:33 p.m. She stated a low blood pressure for Resident #2 would be in the 80s/50s mm/Hg range. She reviewed Resident #2's documented blood pressures dated 08/05/2024. She confirmed she documented Resident #2's blood pressure as 74/42 mm/Hg on 08/05/2024 at 3:00 p.m. She confirmed this was a low blood pressure and S10NUP should have been notified. She stated she thought she notified S10NUP. She confirmed there was no documentation she notified anyone of the abnormal blood pressure. She stated Resident #2 was pleasantly confused at baseline. She stated, on 08/09/2024, Resident #2 was exhibiting increased confusion. She stated Resident #2 was asking her on multiple occasions to put her back in the bed but she was already in the bed. She stated during her shift on 08/09/2024, Resident #2 continued to have increased confusion, which was more than her baseline. She stated she did not notify the doctor and/or NP of Resident #2's increased confusion/altered mental status. She confirmed she should have notified S10NUP of Resident #2's altered mental status since it was a deviation from her baseline. An interview was conducted with S8LPN on 08/29/2024 at 2:45 p.m. She reviewed Resident #2's documented blood pressure and heart rate dated 08/06/2024 at 2:07 p.m. She confirmed she documented Resident #2's blood pressure as 82/56 mm/Hg and heart rate as 40 bpm. She stated she should have notified S10NUP of the vital signs because they were considered low. She confirmed there was no documented evidence she notified S10NUP and there should have been. She stated physician notification would have been documented in a nurse's note or skilled nursing note. An interview was conducted with S2DON on 08/28/2024 at 2:56 p.m. She stated she expected the nurses to use their judgement regarding when to notify the doctor or Nurse Practitioner. An interview was conducted with S2DON on 08/29/2024 at 8:52 a.m. She confirmed there were no Skilled Nursing Notes in Resident #2's Clinical Record for the month of August 2024. An interview was conducted with S10NUP on 08/29/2024 at 8:40 a.m. He stated, generally, he expected to be notified of blood pressures in the low 90s/50s mm/Hg range. He reviewed Resident #2's vital signs dated 08/05/2024 through 08/06/2024. He confirmed he should have been notified of Resident #2's blood pressure of 74/42 mm/Hg on 08/05/2024 at 3:00 p.m. and blood pressure of 82/56 mm/Hg and heart rate of 40 bpm on 08/06/2024 at 2:07 p.m. He confirmed he was not notified of these vital signs. He stated if the nurse identified increased confusion or altered mental status in Resident #2 that was not improving or worse from her baseline, he would have expected to be notified, and he was not.

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the reason for transfer in the resident's Medical Record f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the reason for transfer in the resident's Medical Record for 1 (#2) of 3 (#1, #2, and #10) residents reviewed with hospital transfers. Findings: Review of the facility's undated policy titled, Transfer or Discharge Documentation revealed the following, in part: Policy Statement: When a resident is transferred or discharged , the reason for the transfer or discharge will be documented in the medical record. Policy Interpretation and Implementation: 1. Information pertaining to the transfer or discharge of a resident will be documented in the resident's medical record. Review of Resident #2's Medical Record revealed an admission date of 05/28/2024 and a discharge date of 08/11/2024. Review of the facility's Emergency Transfer Log dated August 2024 revealed Resident #2 was transferred to the hospital on [DATE] for a medical transfer and did not return. Review of Resident #2's Nurses' Notes dated August 2024 revealed no documentation of the reason Resident #2 was transferred to the hospital. An interview was conducted with S2DON on 08/29/2024 at 1:01 p.m. She stated Resident #2 was transferred to the hospital on [DATE]. She reviewed Resident #2's Medical Record and confirmed there was no documentation to indicate Resident #2 was sent to the hospital and/or why she was transferred, and there should have been.

CONCERN (D) 📢 Someone Reported This

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

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means rece...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (#7) of 2 (#7, and #8) residents reviewed for enteral feedings. The facility failed to ensure: 1. Enteral feeding solution bags were changed every 24 hours; and 2. Opened enteral feeding solution was labeled with the date and time. Findings: Review of the clinical record for Resident #7 revealed he was admitted to the facility on [DATE] with diagnoses which included Dysphagia and Gastrostomy Status. Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/22/2024 revealed, in part, a Brief Interview for Mental Status exam score of 4 which indicated Resident #7 was severely cognitively impaired. Further review of Section K revealed Resident #7 had a feeding tube. Review of the current Physician Orders for Resident #7, revealed, in part, the following: Jevit Provify 1.5 @ 70 ml/hr. x 22 hours via gastrostomy tube. An observation was made on 08/27/2024 at 10:00 a.m. of Resident #7 in his room. Resident #7's tube feeding solution of Jevit Provify 1.5 was observed infusing at 70ml/hr. with a label dated 08/25/2024 at 6:00 a.m. On the table in the resident's room, a container of Jevit Provify was opened, 50% empty and not labeled with date/time opened. On 08/27/2024 at 10:02 a.m., an observation and interview was conducted with S9LPN. She confirmed she had initiated the tube feeding on 08/27/2024 at 6:00 a.m. She confirmed the bag was dated 08/25/2024, and should have been changed. She further confirmed the opened bottle of tube feeding was left in the resident's room, was not labeled with date and time opened, and should have been. An interview and observation was conducted on 08/27/2024 at 10:05 a.m. with S2DON in Resident #7's room. She confirmed the bag of tube feeding solution was hanging for longer than 24 hours and should have been replaced. She further confirmed the open container of Jevit Provify was available for use and should have been labeled with the date/time opened, and was not. An interview and observation was conducted on 08/27/2024 at 10:05 a.m. with S1ADM in Resident #7's room. He confirmed the aforementioned findings and stated the tube feeding bag should have been replaced after 24 hours. He further confirmed the open container of Jevit Provify should have been labeled with the date/time opened, and was not.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's Medication Administration Record (MAR) was accu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's Medication Administration Record (MAR) was accurately documented for 1 (#8) of 12 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) sampled residents reviewed. Findings: A review of Resident #8's Clinical Record revealed he was admitted on [DATE] with diagnoses that included Diabetes Insipidus, Muscle Wasting and Atrophy, Congestive Heart Failure, Oropharyngeal Dysphagia, Hydrocephalus, Hypertensive heart disease with heart failure, and presence of gastrostomy tube. A review of the current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/08/2024 revealed that Resident #8 had a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. A review of Resident #8's Medication Administration Record (MAR) dated August 2024 revealed medications and treatments were not administered and documented consistent with physician's orders. Further review revealed: 1. Levothyroxine 112 mcg: administer one tablet by mouth daily at 6:00 a.m., not documented as administered on 08/26/2024. 2. Diabetasource AC 0.06 gram 1.2kcal/ml oral liquid: gastrostomy tube once an evening with 100 ml water every 6 hours @ 8:00 p.m., not documented as administered on 08/26/2024. 3. Diabetasource AC 0.06 gram 1.2kcal/ml oral liquid: gastrostomy tube once an evening with 100 ml water every 6 hours stop feeding @ 6:00 a.m., not documented as administered on 08/26/2024. 4. Humalog Quick Pen (U100) - Administer subcutaneously four times daily per sliding scale - document blood sugar: 0-50 give orange juice and notify MD, 51-199 - No insulin , 200-250 = 2 units, 251-300 = 4 units , 301-350 = 6 units, 351-400 = 8 units, greater than 400 = 10 units and call MD , no blood sugar or insulin administration documented on 08/26/2024 at 5:00 a.m. 5. Lantus Solostar u-100 insulin 100u/ml (3ml) subcutaneous pen: Administer 7 units subcutaneously once an evening daily at 9:00 p.m., not documented as administered on 8/25/2024 at 9 p.m. 6. Amantadine HCL 50 mg/5ml oral solution: Administer 10 ml gastrostomy tube twice daily, not documented as administered on 08/25/2024 at 9:00 p.m. 7. Eliquis 5 mg tablet: administer one tablet via gastrostomy tube twice daily, not documented as administered on 08/25/2024 at 9:00 p.m. On 08/27/2024 at 2:30 p.m., an interview was conducted with S17LPN. She confirmed she was the nurse caring for Resident #8 on 08/25/2024. She stated she administered the aforementioned medications and did not go back into the medication administration record to document them and should have. On 08/27/2024 at 2: 35 p.m., a third attempt was made to contact S18LPN, unable to make contact. On 08/27/2024 at 2:00 p.m., an interview was conducted with S2DON. After review of the Medication Administration Record for Resident #8. She confirmed she investigated the aforementioned medications and they were administered. She stated the aforementioned medications were not documented as being administered and should have been.

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure that residents had a clean and safe environment for 1 (#7) ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure that residents had a clean and safe environment for 1 (#7) of 7 (#1,#3,#7, #8,#9,#10, and #11) residents reviewed for environment. The facility failed to ensure the following: 1. Resident #7's blanket and floor mattress were clean and free of debris. 2. Hall A and Hall C were clean and free of debris. Findings On 08/28/2024, review of the facility's undated policy titled Homelike Environment, revealed, in part: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and homelike environment. 3. The facility will maintain a clean environment. 1. On 08/26/2024 at 11:50 a.m., an observation was made of Resident #7 in his room. Multiple areas of dried tube feeding were observed on a soiled, uncovered mattress on the floor beside Resident #7's bed. Further observation revealed a blanket soiled with three walnut-sized areas of a yellow, moist substance laying on the floor by the bed. On 08/26/2024 at 11:55 a.m., an interview was conducted with S2DON. She stated housekeeping should clean mattresses and cover them with a fitted sheet daily. She confirmed the mattress was soiled with dried tube feeding and the blanket on the floor was soiled, and should not have been. On 08/26/2024 at 11:55 a.m., an interview and observation of Resident #7's room with S1ADM. He confirmed the mattress on the floor was uncovered and soiled with dried tube feeding solution, and the blanket on the floor was soiled and should not have been. 2. On 08/26/2024 at 6:10 a.m., an observation was made of Hall A. Hall A contained a smell consistent with urine. The floor which lead into Hall A had 2 large, brown, splatters of a dried substance. On 08/26/2024 at 6:11 a.m., an interview was conducted with S4LPN. She confirmed the brown stains on the floor on Hall A were coffee. She stated residents wasted coffee on the floor in Hall A between 6:00 p.m. and 6:00 a.m., and housekeeping was not available to clean it up. On 08/26/2024 at 6:12 a.m., an observation was made of Hall C. Two thin, long, brown streaks spanned more than half of Hall C and two large, black shoe print stains were observed in the middle of Hall C and proceeded to the exit door to the smoker's patio. On 08/27/2024 at 8:56 a.m., an interview was conducted with S13HSK. She stated no housekeeping was in the building between the hours of 6:00 p.m. to 6:00 a.m. She stated spills are always on the floors when housekeeping entered the facility at 6:00 a.m. She stated it was not acceptable to have stains on the floors. On 08/27/2024 at 9:08 a.m., an interview was conducted with S14HSK. She stated the expectation was nursing staff were responsible for cleaning up spills between the hours of 6:00 p.m. to 6:00 a.m. She confirmed when housekeeping staff arrived to the facility on [DATE] at 6:00 a.m., the floors on Hall A and Hall C were stained and dirty. On 08/27/2024 at 9:22 a.m., an interview was conducted with S15HSK. He confirmed the aforementioned observations of coffee stains in Hall A and dirty floors on Hall C. He further stated the facility should be clean and it was not. On 08/27/2024 at 10:24 a.m., an interview was conducted with S1ADM. He stated it was the responsibility of the nursing staff, specifically the CNAs, to clean up spills after hours to promote a safe, homelike environment. S1ADM further stated he expected everyone in the building to pick up debris and wipe up spills immediately when observed.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed implement a resident's comprehensive person-centered care plan by fa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed implement a resident's comprehensive person-centered care plan by failing to implement Physician's Orders for 2 (#6 and #10) of 12 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) residents reviewed for comprehensive care plans. The facility failed to ensure the following: 1. MRI orders were implement per Physician's Orders for Resident #6, and 2. Oxygen orders were implemented per Physician's Orders for Resident #10. Findings: 1. Review of Resident #6's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Low Back Pain and Fibromyalgia. Review of Resident #6's Yearly MDS with an ARD of 07/16/2024 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #6's Physician Progress Note dated 04/02/2024 by S6MED revealed the following, in part: Tests and procedures to be scheduled: MRI Cervical Spine without contrast MRI Lumbar Spine without contrast MRI Shoulder without contrast An interview was conducted with Resident #6 on 08/16/2024 at 2:36 p.m. She stated approximately four months ago, her pain management doctor ordered MRIs. She stated she had not received the MRIs. An interview was conducted with a representative at Resident #6's pain management clinic on 08/27/2024 at 8:35 a.m. She reviewed Resident #6's most recent progress note completed by S6MED dated 04/02/2024. She confirmed, on 04/02/2024, S6MED ordered MRIs to be completed for Resident #6. She stated the pain management clinic was initially responsible for scheduling Resident #6's MRI. She stated, on 04/03/2024, a staff member from Resident #6's nursing facility contacted the pain management clinic and asked for the MRI orders to be sent to the nursing facility so the nursing facility could schedule the MRIs. She stated the MRIs then became the responsibility of the nursing facility. She stated S6MED wanted Resident #6's MRIs to be completed and she was unsure if they had been completed. An interview was conducted with S7WDC on 08/27/2024 at 8:48 a.m. She stated she was responsible for scheduling resident appointments. She confirmed she was aware of Resident #6's MRI orders from April 2024. She stated she called Resident #6's pain management clinic in April 2024 regarding Resident #6's MRIs and was told Resident #6's insurance would not cover them. She stated the orders were then sent to the facility, and the facility should have scheduled Resident #6's MRIs. She stated Resident #6's MRIs fell through the cracks and had not been scheduled nor completed. An interview was conducted with S1ADM on 08/27/2024 at 8:54 a.m. He stated he was unaware of any orders for Resident #6 to have an MRI. He stated if the facility was made aware of MRI orders for Resident #6, the facility should have attempted to find an MRI location where Resident #6's insurance would be accepted. He stated in the event the facility was unable to find a location where Resident #6's insurance would cover her MRIs ordered by the physician, the facility would have been liable for the cost of the MRIs. He confirmed Resident #6's MRIs should have been scheduled and completed. 2. Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Acute Respiratory Failure with Hypoxia and Chronic Systolic Congestive Heart Failure. Review of Resident #10's current MDS with an ARD of 08/21/2024 revealed the resident had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #10's Physician's Orders dated 08/16/2024 revealed the following, in part: Oxygen 4 liters via nasal cannula, maintain oxygen saturation 92% or above. Review of Nurses Documentation dated 08/16/2024 through 08/19/2024 revealed the following, in part: At 10:19 a.m. late entry for 08/16/2024 at 1:34 p.m. Resident #10 receiving 10 Liters per nasal per concentrator. Documentation was signed By: S9LPN Review of Resident #10's Vital Sign Sheet dated 08/16/2024 at 11:43p.m. through 08/25/2024 at 09:43 a.m. revealed the following, in part: Oxygen at 10 liters per minute via nasal cannula Signed By: S9LPN An interview was conducted with S9LPN on 8/28/2024 1:31 p.m. She stated she was told in morning report that Resident #10 was on oxygen at 10 liters per nasal cannula. She confirmed she placed Resident #10 on 10 liters of oxygen per nasal cannula and documented it in her notes. An interview was conducted with S10NUP on 08/29/2024 at 9:25 a.m. He stated he reviewed the discharge instructions he received from the transferring hospital and continued the same orders, including oxygen at 4 liters per nasal cannula to keep Resident #10's oxygen saturation levels at 92% or above. He stated nursing staff input the orders in the computer system and he reviewed and signed them. He confirmed he did not place an order for Resident #10 to have 10 liters of oxygen per nasal cannula. An interview was conducted with S2DON on 08/29/2024 at 2:12 p.m. She reviewed the nurses notes dated 08/19/2024 at 10:19 a.m. S2DON confirmed S9LPN had documented in the nurses' note she had placed Resident #10 on 10 liters of oxygen per nasal cannula. She further confirmed oxygen was ordered at 4 liters per nasal cannula to keep oxygen saturation at or above 92%.

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 F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services provided by the facility met profe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure services provided by the facility met professional standards of quality by failing to ensure nursing staff did not borrow medications from one resident to administer to another resident for 1 (#R4) of 7 (#5, #6, #7, #R1, #R2, #R3, and #R4) residents reviewed for pharmaceutical services. Findings: Review of the facility's undated policy titled, Medications - Administering revealed the following, in part: Policy interpretation and Implementation: 7. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 19. Medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the Director of Nursing Services. Review of Resident #R4's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Human Immunodeficiency Virus Disease. Review of Resident #R4's current Physician Orders revealed the following, in part: Order date: 08/16/2024 - Biktarvy 50-200-25 mg tablet by mouth daily Review of Resident #6's MAR dated August 2024 revealed Biktarvy was administered daily as ordered. An interview was conducted with S9LPN on 08/27/2024 at 9:51 a.m. She stated Resident #R4 had Biktarvy ordered but it had never been filled. She stated she borrowed doses of Biktarvy from another resident to give to Resident #R4. An observation was made of Resident #R4's nurses' medication cart on 08/27/2024 at 9:51 a.m., and there was no Biktarvy present for Resident #R4. There was another resident's Biktarvy 50-200-25 mg prescription bottle present with a fill date of 07/20/2024 for 30 tablets. S9LPN confirmed Resident #R4's Biktarvy had never been filled and was not available for administration. An interview was conducted with S10NUP on 08/27/2024 at 10:31 a.m. He stated he was unaware of Resident #R4's Biktarvy not being filled. He stated it was not acceptable for nurses to borrow medications from one resident to administer to another resident. A telephone interview was conducted with S11PHM on 08/27/2024 at 10:00 a.m. She stated the pharmacy had not received an order for Biktarvy for Resident #R4. She stated the pharmacy should have been made aware of Resident #R4's Biktarvy order when it was received. An interview was conducted with S12LPN on 08/27/2024 at 11:33 a.m. She stated Resident #R4's Biktarvy had never been available. She stated she borrowed Biktarvy from another resident to administer to Resident #R4. She confirmed medications should not have been borrowed from one resident to give to another resident. An interview was conducted with S2DON on 08/28/2024 at 9:59 a.m. She stated she was made aware on 08/27/2024 of Resident #R4's Biktarvy having never been available in the facility and another resident's medication was used for Resident #R4. She stated nurses should not have borrowed medications from one resident to give to another resident.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each for 2 (#6 and #R4) of 7 (#5, #6, #7, #R1, #R2, #R3, and #R4) residents reviewed for pharmaceutical services. The facility failed to ensure Resident #6 and #R4's prescribed medications were available for administration. Findings: Review of the facility's undated policy titled, Pharmacy Services revealed the following, in part: Policy: It is the policy of this facility to ensure that pharmaceutical services are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Definitions: Pharmaceutical services refers to: The process of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, using and/or disposing of all medications . Compliance and Guidelines: 1. The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. 7. The pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that support residents' healthcare needs, goals, and quality of life that are consistent with current standards of practice and meet state and federal requirements. 8. The pharmacist, in collaboration with the facility and medical director, should include within its services to: f. Strive to assure that medications are requested, received and administered in a timely manner as ordered by the authorized prescriber . Resident #6 Review of Resident #6's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Low Back Pain, Gastroesophageal Reflux Disease, and Fibromyalgia. Review of Resident #6's Yearly MDS with an ARD of 07/16/2024 revealed she had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #6's Physician Orders dated August 2024 revealed the following, in part: Order date: 03/09/2024, Discontinue date: 08/26/2024 - Norco 7.5-325 mg by mouth every four hours as needed for pain Order date: 11/09/2022, Discontinue date: 08/26/2024 - Nexium DR 40 mg by mouth daily Review of Resident #6's MAR dated August 2024 revealed, in part, Norco was last given on 06/14/2024. An interview was conducted with Resident #6 on 08/26/2024 at 11:33 a.m. She stated the facility was currently out of her Nexium. She stated they had been out of it for two to three days and she was having acid reflux at night. She stated at one time, the facility was out of her Nexium for a month. An interview was conducted with Resident #6 on 08/26/2024 at 2:36 p.m. She stated she had not had any Norco in a few months. An observation was made of Resident #6 nurses' medication cart with S9LPN present on 08/26/2024 at 12:35 p.m. There was no Nexium and/or Norco present in the medication cart for Resident #6. S9LPN confirmed Nexium and Norco were active orders for Resident #6 and there was no Nexium and/or Norco available for Resident #6. S9LPN stated Resident #6's Norco had not been available for a few months. An interview was conducted with S2DON on 08/26/2024 at 12:41 p.m. She confirmed Resident #6 had active orders for Nexium and Norco. She reviewed Resident #6's Clinical Record and stated Resident #6 had not received Norco since 06/14/2024. She confirmed ordered medications should have been available for administration. An interview was conducted with S10NUP on 08/26/2024 at 12:53 p.m. He confirmed he was the facility's Nurse Practitioner and provided care for Resident #6. He stated the pain management provider ordered Resident #6's Norco. He stated he was not made aware of any issues with Resident #6's Nexium. He stated the nurse asked him today to change Resident #6's Nexium to Protonix. He stated prior to today, he had been documenting on his progress note to continue Nexium, as he thought she was receiving it daily as ordered. An interview was conducted with S11PHM on 08/26/2024 at 1:58 p.m. She confirmed Resident #6 had an order for Nexium 40 mg daily. She stated Nexium 40 mg was filled for Resident #6 on 05/11/2024 for 30 doses and on 08/06/2024 for 14 doses. She stated Resident #6's Nexium was not filled between those two dates. She stated on 08/22/2024, the facility was notified of Resident #6's insurance plan limit for Nexium was exceeded and the over the counter item would have to be used. She stated once the facility was notified, it was their responsibility to get the over the medication or obtain a different order from the doctor. She stated Resident #6's Norco was filled on 04/28/2024 for 120 tablets. She stated there had not been a new hard script sent to the pharmacy for Norco since then. Resident #R4 Review of Resident #R4's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Human Immunodeficiency Virus Disease. Review of Resident #R4's current Physician Orders revealed the following, in part: Order date: 08/16/2024 - Biktarvy 50-200-25 mg tablet by mouth daily An interview was conducted with S9LPN on 08/27/2024 at 9:51 a.m. She stated Resident #R4 had Biktarvy ordered, but it had never been filled. An observation was made of Resident #R4's nurses' medication cart at that time and there was no Biktarvy present for Resident #R4. S9LPN confirmed Resident #R4's Biktarvy had never been filled and was not available for administration. A telephone interview was conducted with S11PHM on 08/27/2024 at 10:00 a.m. She stated the pharmacy had not received an order for Biktarvy for Resident #R4. She stated the pharmacy should have been made aware of Resident #R4's Biktarvy order when it was received. An interview was conducted with S12LPN on 08/27/2024 at 11:33 a.m. She stated Resident #R4's Biktarvy had never been available in the facility. An interview was conducted with S2DON on 08/28/2024 at 9:59 a.m. She stated she was made aware on 08/27/2024 of Resident #R4's Biktarvy having never been available in the facility. An interview was conducted with S10NUP on 08/27/2024 at 10:31 a.m. He stated he was unaware of Resident #R4's Biktarvy not being filled. He stated Resident #R4 needed his Biktarvy and it should have been 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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a record review, observations, and interviews, the facility failed to maintain an infection prevention and control prog...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a record review, observations, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) for 1(#8) of 2 (#7 and #8) residents who were on Enhanced Barrier Precautions (EBP). Findings: Review of the facility policy titled Enhanced Barrier Precautions, dated May 2023, revealed the following: It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 47. Implementation of Enhanced Barrier Precautions a. Gowns and gloves will be available 48. High Contact resident care activities include: f. Changing briefs or assisting with toileting. Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses of Dysphagia, Oropharyngeal Phase, and Gastrostomy Tube. An observation was made on 08/26/2024 at 8:12 a.m. of the Enhanced Barrier Precautions sign posted on Resident #8's door. Signage indicated the following: Gown required for direct, hands on care for this resident. An observation was made on 08/26/2024 at 8:15 a.m. of S3CNA, without a gown, as she changed Resident #8's soiled incontinent brief. An interview was conducted on 08/26/2024 at 8:20 a.m. with S3CNA. She stated residents on EBP required a gown and gloves when soiled briefs are changed. She stated she was not wearing a gown while changing Resident #8's soiled incontinent brief and should have been. An interview was conducted on 08/26/2024 at 11:58 a.m. with S2DON. S2DON confirmed Resident #8 was on EBP and S3CNA should have worn a gown when she changed Resident #8's incontinent brief.

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 F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pest and insects. The deficient practice had the p...

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Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure the facility was free of pest and insects. The deficient practice had the potential to affect 67 residents who resided in the facility. Findings: An observation was made of Resident #6's room on 08/26/2024 at 11:33 a.m. There were two almond sized roaches crawling from under her wheelchair to under her bed. An interview was conducted with Resident #6 at that time. Resident #6 stated saw roaches in her room daily. An observation was made of Rm D 08/26/2024 at 1:30 p.m. There were four dead, peanut sized roaches inside the toilet paper roll in Rm D. An observation was made of Resident #3's bathroom on 08/27/2024 at 8:20 a.m. There were three live, brown, almond sized roaches crawling between the toilet and the baseboard. An interview was conducted with Resident #3 at that time. Resident #3 stated roaches were present in the bathroom every day. An observation was made of Rm C on 08/27/2024 at 8:56 a.m. There were two almond sized roaches and one small and round roach on the walls. An interview was conducted with S13HSK in Rm C at that time. S13HSK confirmed the bugs on the walls to be live roaches. S13HSK stated there are roaches all over the facility. An observation was made of Resident #9's room on 08/28/2024 at 10:50 a.m. There were seven gnats on Resident #9's bed and five gnats and three almond sized roaches crawling on Resident #9's night stand. An interview was conducted with S17CNA on 08/28/2024 at 10:57 a.m. S17CNA confirmed there were gnats and roaches in Resident #9's room daily. An interview was conducted with S2DON on 08/28/2024 at 11:03 a.m. S2DON confirmed there were gnats in Resident #9's room daily. S2DON stated the facility has attempted to remove the gnats, but were unsuccessful. An interview was conducted with a representative from the local pest control company on 08/28/2024 at 12:43 p.m. He stated all resident rooms were not treated for pest regularly. He stated if there were pests in a particular room, the facility should notify him, and he would treat the room. An interview was conducted with S1ADM on 08/27/2024 at 10:24 a.m. He was made aware of the aforementioned findings above. S1ADM stated he has contacted the pest control company frequently. He confirmed all rooms in the facility had not been treated for pest. He confirmed infestations of pest of any kind should be treated appropriately.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with pressure ulcers received necessary treatmen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (#1) of 2 (#1 and #2) residents reviewed for medical appointments. The facility failed to ensure Resident #1 attended their follow up outpatient wound clinic appointment as scheduled. Findings: Review of Facility's current policy titled, Skin Program, Pressure Ulcers & Other Wounds revealed in part: Care of Residents with Wounds (Pressure & Non-Pressure Related) c. Obtain treatment order from physician if needed or implement the facility's protocol if appropriate. Review of Resident #1's Clinical Record revealed he was admitted on [DATE]. His Diagnoses included the following: Type 2 Diabetes Mellitus with Foot Ulcer, Non Pressure Chronic Ulcer of Other Part of Left Foot with Fat Layer Exposed, Morbid Obesity Due to Excessive Calories, and Non-Compliance with Medication Regimen. Review of Resident #1's Quarterly MDS with ARD of 06/18/2024 revealed a BIMS of 15, which indicated the resident was cognitively intact. Review of Resident #1's Physician Orders dated June 2024 - current revealed the following in part: Diabetic ulcer to left heel: Dressing to be changed on Mondays by outpatient wound clinic and changed on Thursdays and PRN by facility. Review of Resident #1's Wound and Hyperbaric Center Orders dated 06/17/2024 revealed the following in part: Return Appointment in 1 week. Appointment scheduled for 06/24/2024 at 8:00 a.m. Review of Resident #1's Nurse's Notes dated June 2024 revealed no evidence he attended the scheduled follow up appointment with outpatient wound clinic on 06/24/2024 as ordered. On 07/08/2024 at 12:25 p.m., an interview was conducted with Resident #1. He stated he had an initial appointment with outpatient wound clinic on 06/17/2024 and was supposed to have a scheduled a follow up appointment on 06/24/2024. He stated he missed his follow up appointment. On 07/09/2024 at 11:49 a.m., an interview was conducted with S3WC. She stated she was responsible for scheduling appointments as ordered. She verified Resident #1 did not have a scheduled appointment documented on the facility calendar for 06/24/2024, and Resident #1 missed his follow up appointment. On 07/09/2024 at 1:05 p.m., an interview was conducted with S2LPN. She stated Resident #1 did have an appointment scheduled with outpatient wound care on 06/24/2024 at 8:00 a.m. She stated the facility could not find the after visit summary with the date and time of appointment and appointment was missed. On 07/09/2024 at 1:20 p.m., an interview was conducted with S1DON. She stated that Resident #1 did have an appointment with the outpatient wound clinic scheduled for 06/24/2024 and it was missed.

Jun 2024 2 deficiencies

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. Room A was clean and...

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Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. Room A was clean and free of debris. This had the potential to affect any of the 60 residents residing in the facility who used Room A, and; 2. The ceiling tiles were clean and free of stains for 1 (Room B) of 20 rooms observed on Hall A. Findings: On 06/10/2024 at 9:00 a.m., an observation of Room A was made with S2DON. There were three walnut size hair balls, a toothbrush, open tube of toothpaste, and a hair comb in the first sink, and hair was noted on the floor. The second shower stall was observed with open shampoo bottles on the floor. The third shower stalls hot and cold control knobs were non-functional and dripping a steady stream of water .The shower head was laying on the floor in the fourth shower stall. S2DON confirmed there had been no resident showers that morning, and the shower was left in this condition by the weekend staff. She confirmed the shower should be cleaned and sanitized daily by housekeeping staff and the CNAs were responsible for cleaning and disinfecting in between residents, and this had not been done. On 06/10/2024 at 9:10 a.m., during inspection of rooms on Hall A, two ceiling tiles in Room B were noted to have dinner plate sized brown colored stains. On 06/10/2024 at 9:15 a.m., an interview was conducted with Resident R1. He stated the ceiling tiles had been stained for a long period of time, and he had requested they be changed. On 06/10/2024 at 9:20 a.m., an observation and interview was conducted with S2DON. She confirmed the ceiling tiles in Room B were stained, and should have been changed. On 06/11/2024 at 11:07, an observation of Room A was made with S2DON. There was a disposable razor with the safety cover removed on the floor of Room A. S2DON confirmed the disposable razor did not have a safety cover, appeared to be used, and should not have been left on the floor of Room A. On 06/11/2024 at 11:30 a.m., an interview was conducted with S1ADM. He confirmed Room A should be cleaned daily by housekeeping staff and CNAs should clean and disinfect in-between residents, and ceiling tiles that were stained should be replaced, and they were not.

CONCERN (E) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect all residents who were serve...

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Based on observations and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect all residents who were served from the kitchen. Findings: On 06/10/2024 at 8:00 a.m., an initial tour of the kitchen was conducted with S3DW. The following observations were made and confirmed: -One bulk storage container contained an open bag of sugar. A paper cup was in the bag of sugar. The lid of the container was left open. -One bulk storage container contained opened bags of flour and rice. The lid of the container was left open. On 06/10/2024 at 8:34 a.m., an interview was conducted with S4DM. She was notified of the aforementioned findings made with S3DW. She confirmed the bulk storage containers should be securely closed and should not contain a paper cup. On 06/10/2024 at 9:30 a.m., an interview was conducted with S1ADM. He was notified of the aforementioned findings. He confirmed the bulk storage containers should be securely closed, and should not contain a paper cup.

Mar 2024 6 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (#5) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) reside...

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Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 (#5) of 8 (#1, #2, #3, #4, #5, #6, #7, and #8) residents reviewed for abuse. The facility failed to ensure Resident #5 was free from physical abuse by Resident #4. Findings: Review of the facility's Abuse Prevention Program Policy with a revision date of 12/2016 revealed the following, in part: Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of the facility's Abuse and Neglect - Clinical Protocol with a revision date of 03/2018 revealed the following, in part: Definitions Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #4 Review of Resident #4's clinical record revealed an admission date of 12/01/2021. Resident #4 had diagnoses which included Major Depressive Disorder, Unspecified Psychosis, Anxiety Disorder, Epilepsy, and Vascular Dementia with behavior disturbance. Review of Resident #4's MDS with an ARD of 01/22/2024 revealed a BIMS of 7, which indicated Resident #4 had severe cognitive impairment. Review of Resident #4's progress note dated 01/09/2024 at 10:58 a.m. by S5LPN revealed, in part, a call was placed to the hospice provider regarding Resident #4 being angry and fighting at staff. Review of Resident #4's progress note dated 01/09/2024 at 2:05 p.m. by S5LPN revealed, in part, S5LPN received report that Resident #4 had choked another resident when their wheelchairs interlocked. On 03/11/2024 at 10:14 a.m., an interview was conducted with Resident #4. He stated he got into it with another resident and hit them a while back. Resident #5 Review of Resident #5's clinical record revealed an admission date of 02/19/2021. Resident #5 had diagnoses which included Cognitive Communication Deficit, Unspecified Mood Affective Disorder, and Other Recurrent Depressive Disorders. Review of Resident #5's MDS with an ARD of 02/07/2024 revealed a BIMS of 7, which indicated Resident #5 had severe cognitive impairment. Review of Resident #5's Incident Report dated/timed 01/09/2024 at 10:55 a.m. revealed the following, in part: It was reported Resident #5 had been choked by Resident #4. On assessment resident found to have red scratches to the right neck. First Aid by: S5LPN Type of Aid: Scratch to neck, redness only no break in skin. On 03/11/2024 at 10:22 a.m., an interview was conducted with S10CNA. S10CNA stated, on 01/09/2024, she saw Resident #4's hands around Resident #5's neck when their wheelchairs were tangled together. On 03/11/2024 at 11:22 a.m., an interview was conducted with Resident #5. Resident #5 stated Resident #4 choked her 2 months ago. Resident #5 stated she was on the way to the cafeteria, and Resident #4 choked her. Resident #5 stated she had no injuries but it made her feel mad, and she wanted to kick Resident #4's a**. On 03/11/2024 at 1:32 p.m., an interview was conducted with S8DM. S8DM stated, on 01/09/2024, she saw Resident #4 and #5 in front of the cafeteria. She stated Resident #4 had both hands on Resident #5's face and neck. S8DM stated Resident #4's wheelchair and Resident #5's wheelchairs had collided and gotten entangled. S8DM stated Resident #5 was nervous and confused. S8DM confirmed Resident #4's action towards Resident #5 was abusive and willful. On 03/11/2024 at 1:47 p.m., an interview was conducted with S7M. S7M stated, on 01/09/2024, he witnessed Resident #4 had his hands on Resident #5's neck and shoulder. S7M stated Resident #5 looked surprised during the incident. On 03/12/2024 at 10:25 a.m., an interview was conducted with S5LPN. S5LPN confirmed she was working on 01/09/2024 when Resident #4 and #5 had their incident. S5LPN stated she did not witness the incident. S5LPN stated it was reported Resident #4's wheelchair and Resident #5's wheelchairs interlocked and Resident #5 was trying to unlock the chairs when Resident #4 choked her. S5LPN stated Resident #5 had scratches on her neck after the incident. S5LPN stated Resident #5 was upset and was crying when she was assessed. On 03/12/2024 at 12:40 p.m., an interview was conducted with S3ADON. S3ADON stated she was working on 01/09/2024 but did not witness the incident between Resident #4 and #5. S3ADON stated it was reported Resident #5 backed into Resident #4, and Resident #4 thought she was hitting him with her chair. S3ADON stated it was reported Resident #4 put his hands around Resident #5's neck. S3ADON stated Resident #5 was assessed, and redness was noted to her neck. S3ADON stated Resident #5 was emotional and weepy for an hour after the incident. S3ADON also stated Resident #5 had not had any emotional changes since the incident on 01/09/2024. S3ADON stated Resident #4's reaction was willful. S3ADON stated Resident #5 was not fearful of Resident #4 and was able to sit at the same table with Resident #4 during lunch. On 03/12/2024 at 1:50 p.m., an interview was conducted with S2DON. She stated Resident #4's actions towards Resident #5 on 01/09/2024 was abuse. She also stated Resident #4's actions were willful. On 03/12/2024 at 4:47 p.m., an interview was conducted with S1ADM. S1ADM stated he was aware of the incident between Resident #4 and Resident #5 on 01/09/2024. S1ADM stated it was reported Resident #4 put his hands around Resident #5's neck and shoulders to push Resident #5 away.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure new interventions were implemented following an allegation of physical abuse for 1 (#5) of 3 (#1, #4, and #5) sampled residents re...

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Based on record reviews and interviews, the facility failed to ensure new interventions were implemented following an allegation of physical abuse for 1 (#5) of 3 (#1, #4, and #5) sampled residents reviewed for abuse. Findings: Review of Resident #5's clinical record revealed an admission date of 02/19/2021. Resident #5 had diagnoses which included Cognitive Communication Deficit, Unspecified Mood Affective Disorder, and Other Recurrent Depressive Disorders. Review of Resident #5's MDS with an ARD of 02/07/2024 revealed a BIMS of 7, which indicated Resident #5 had severe cognitive impairment. Review of Resident #5's Incident Report dated/timed 01/09/2024 at 10:55 p.m. revealed the following, in part: It was reported to this nurse resident was choked by another resident. On assessment resident found to have red scratches to neck. First Aid by: S5LPN Type of Aid: Scratch to neck, Redness only no break in skin. Review of Resident #5's Care Plan revealed no documentation of the incident with Resident #4 on 01/09/2024. Further review of the care plan revealed no documentation of any changes to her care plan after the 01/09/2024 incident, and the facility failed to provide any documented evidence. On 03/13/2024 at 3:23 p.m., an interview was conducted with S4MDS. S4MDS stated she was the only staff who updated resident care plans. S4MDS stated she was made aware Resident #5 was choked by another resident on 01/09/2024. S4MDS reviewed Resident #5's care plan and confirmed it was not updated for the incident with Resident #4 and should have been. On 03/13/2024 at 1:50 p.m., an interview was conducted with S2DON. S2DON reviewed the care plan for Resident #5. S2DON confirmed Resident #5's care plan was not updated after the 01/09/2024 incident with Resident #4 and should have been.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, the facility failed to ensure new interventions were implemented following a resident's fall to prevent future falls for 1(#8) of 3 (#1, #7, and #8) sampled res...

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Based on record reviews and interviews, the facility failed to ensure new interventions were implemented following a resident's fall to prevent future falls for 1(#8) of 3 (#1, #7, and #8) sampled residents reviewed for falls. Findings: Review of the facility's Fall and Fall Risk Policy with a revision date of 09/2017 revealed the following, in part: Policy Statement The staff and physicians shall collaborate to address fall risk, falling, and fall-related complications. Procedure The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Treatment/Management Based on the preceding assessment (including the nature, causes, and category of falling) the staff and physician will identify and implement pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Monitoring The staff and physician will monitor and document the individual's response to the interventions intended to reduce falling or the consequences of falling. Review of Resident #8's clinical record revealed an admission date of 04/27/2022. Resident #8 had a diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, muscle weakness, and other lack of coordination. Review of Resident #8's MDS with an ARD of 01/23/2024 revealed, in part, Resident #8 had a BIMS score of 15 which indicated no cognitive impairment. Review of Resident #8's Incident Report dated 01/29/2024 revealed, in part, CNA found Resident #8 lying on the floor and immediately notified the nurse. Review of Resident #8's current care plan revealed she was at risk for falls and sustained a fall with injury on 01/29/2024. Further review revealed the following interventions were implemented on 01/30/2024: neuro checks as specified and x-ray of left arm and hip. The facility failed to provide documented evidence of new interventions implemented after the 01/29/2024 fall to help prevent future falls for Resident #8. On 03/13/2024 at 10:45 a.m. an interview was conducted with S6CNA. S6CNA stated she was not aware of Resident #8 having any falls. On 03/13/2024 at 10:50 a.m. an interview was conducted with Resident #8. She stated she fell sometime in January 2024. She also stated she hit her head and had a black eye. On 03/13/2024 at 12:49 p.m., an interview was conducted with S4MDS. S4MDS stated Resident #8 had a fall a little over a month ago and sustained bruising to the left eye. S4MDS stated the care plan interventions implemented included neuro checks and x-rays, and she confirmed these interventions would not help prevent another fall. S4MDS stated neuro checks and x-rays were follow up assessments for the fall that occurred on 01/29/2024. On 03/13/2024 at 4:11 p.m., an interview was conducted with S3ADON. S3ADON stated the interventions implemented on Resident #8's care plan after Resident #8's fall that occurred on 01/29/2024 were not appropriate to prevent falls. On 03/13/2024 at 4:36 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #8's care plan and confirmed Resident #8's care plan did not have any new interventions implemented to prevent falls after the 01/29/2024 fall. S2DON stated new interventions should have been implemented to prevent falls.

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to post the required nurse staffing information on a daily basis. Findin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to post the required nurse staffing information on a daily basis. Findings: Observation 03/11/2024 at 5:20 a.m. revealed the posted staffing data near the nurse's station was dated 03/09/2024. Observation on 03/11/2024 at 10:21 a.m. revealed the posted staffing data near the nurse's station was dated 03/10/2024. Observation on 03/11/2024 at 1:20 p.m. revealed the posted staffing data near the nurse's station was dated 03/10/2024. On 03/12/2024 at 2:27 p.m., an interview was conducted with S9WC. She stated when she arrived to work on 03/12/2024 the staffing data for 03/10/2024 was posted. On 03/12/2024 at 2:29 p.m., an interview was conducted with S1ADM. He stated the staffing data should have been posted for the current day within two hours of the start of the day shift. He also stated if the surveyor observed the posted staffing data for 03/09/2024 upon entrance to the facility on [DATE], and the staffing data for Sunday 03/10/2024 displayed on 03/11/2024, the staffing data was not posted according to the regulation. He also stated on 03/11/2024 S9WC should have posted the staffing data for Monday 03/11/2024.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on interviews and record review, the facility failed to acquire and ensure medications were available for administration as ordered by the physician for 1 (#6) of 3 (#1, #6, and #7) sampled resi...

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Based on interviews and record review, the facility failed to acquire and ensure medications were available for administration as ordered by the physician for 1 (#6) of 3 (#1, #6, and #7) sampled residents reviewed for discharges. Findings: Review of Resident #6's clinical record revealed an admission date of 01/23/2024. Further review revealed Resident #6 had diagnoses which included Acquired Absence of Right Leg Above the Knee and Unspecified Intracapsular Fracture of Unspecified Femur Sequela. Review of Resident #6's Telephone Orders dated 01/24/2024 revealed the following, in part: Lidocaine 5% patch apply to left knee daily. Remove after 12 hours. Review of Resident #6's Physician's Orders for January 2024 revealed no documentation of the order for Lidocaine 5% patch apply to left knee daily. Remove after 12 hours. Review of Resident #6's Medication Administration Record for January 2024 revealed no documentation of the order for Lidocaine 5% patch apply to left knee daily. Remove after 12 hours. On 03/12/2024 at 9:55 a.m., an interview was conducted with Resident #6. Resident #6 stated he left the facility because the facility was unable to acquire his medication, but he could not provide the name of the medication. Resident #6 stated staff would just kept telling him the medication was coming, but he never received the medication. On 03/13/2024 at 3:47 p.m., an interview was conducted with a pharmacy technician with the facility's pharmacy supplier. The pharmacy technician reviewed Resident #6's orders and confirmed the order for the Lidocaine 5% patch was not received from the facility. On 03/13/2024 at 4:07 p.m., an interview was conducted with S3ADON. S3ADON reviewed the telephone orders and confirmed she had entered the orders written on 01/24/2024. S3ADON reviewed Resident #6's Medication Administration Record and Physician's Orders for January 2024 and confirmed the Lidocaine 5% patch was not reflected. S3ADON stated there was no reason for the Lidocaine 5% patch not to be entered into the electronic medical record system. S3ADON confirmed Resident #6's Lidocaine 5% patch was not ordered from the pharmacy. On 03/13/2024 at 4:41 p.m., an interview was conducted with S2DON. S2DON confirmed there was no documentation of Resident #6's Lidocaine 5% patch being entered into the electronic medical record system or ordered from the pharmacy. She confirmed other medication orders had been entered for Resident #6 on 01/24/2024, but the Lidocaine 5% patch was not. S2DON confirmed she was not aware the Lidocaine 5% patch had been missed.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's fall was documented in the nurse's notes for 1...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's fall was documented in the nurse's notes for 1 (#7) of 3 (#1, #6, and #7) sampled residents reviewed for discharges. Findings: Review of the facility's policy titled Falls and Fall Risk revealed the following, in part: Procedure: Recognition: 4. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the events, etc. Falls should be categorized as: a) those that occur while trying to rise from a sitting or lying to an upright position, b) those that occur while upright and attempting to ambulate, and c) other circumstances such as sliding out of a chair or rolling from a low bed to the floor. They should also be identified ass witnessed or unwitnessed event. Review of Resident #7's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Age-Related Physical Debility, Chronic Diastolic (Congestive) Heart Failure, and Chronic Respiratory Failure with Hypoxia. Review of Resident #7's admission MDS with an ARD of 02/06/2024 revealed a BIMS of 11 which indicated moderately impaired cognition. Review of the Problem Area Falls revealed Resident #7 had no falls documented. Review of Resident #7's Physician's Progress Note with an encounter date of 02/05/2024 revealed the following, in part: Chief Complaint: Resident #7 presents with fall .Nursing staff reports Resident #7 experienced a fall this morning attempting to get out of bed. Resident #7 stated she just fell out of bed onto her buttocks. Review of Resident #7's Nurse's Notes from 01/31/2024 to 02/21/2024 revealed no documentation of a fall. Review of the Incident/Accident Log from 01/01/2024 to 03/11/2024 revealed no documentation of Resident #7 having a fall. On 03/12/2024 at 4:19 p.m., an interview was conducted with Resident #7. Resident #7 stated she had a fall while in the facility. Resident #7 stated she fell and hit the floor. Resident #7 stated one of the staff assisted her to get up and onto the side of the bed. On 03/13/2024 at 10:45 a.m., an interview was conducted with S6CNA. S6CNA stated about a month ago Resident #7 had pushed the call light and when she entered the room the resident was on the floor. S6CNA stated she got S5LPN to assist her getting Resident #7 off the floor. On 03/13/2024 at 10:52 a.m., an interview was conducted with S5LPN. S5LPN stated Resident #7 did have a history of falls, but was unable to recall any specific falls. S5LPN stated if she received a report of a fall or resident being on the floor, a nurse's note should have been entered with notification to the physician and the family and an incident report started. On 03/13/2024 at 4:20 p.m., an interview was conducted with S3ADON. S3ADON confirmed she did not know Resident #7 had a fall. S3ADON reviewed the Physician Progress Note dated 02/05/2024 and confirmed staff reported Resident #7's fall to the Nurse Practitioner. S3ADON reviewed and confirmed there was no documentation of Resident #7's fall in the nurse's notes. S3ADON stated staff should have documented the fall and completed an incident report on Resident #7's fall instead of just reporting it to the Nurse Practitioner. On 03/13/2024 at 4:36 p.m., an interview was conducted with S2DON. S2DON stated she would expect staff to report falls and for the nurse to initiate an incident report. She confirmed she was not aware Resident #7 had a fall. S2DON confirmed Resident #7's fall should have been reported. On 03/13/2024 at 1:47 p.m., an interview was conducted with S1ADM. He stated he would expect if a resident fell for the nurse to assess the resident, assist the resident to bed, start an incident report, and document it in the Nurse's Notes. S1ADM confirmed there was no incident report filed for Resident #7's fall on 02/05/2024.

Dec 2023 10 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's right to be free from verbal abuse by S4CN...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect the resident's right to be free from verbal abuse by S4CNA for 1 (#9) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents reviewed for abuse. Findings: Review of the facility's policy titled, Abuse Prevention Program revealed the following, in part: Policy Statement: Our residents have the right to be free from abuse .This includes verbal abuse. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone, including facility staff . Review of Resident #9's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses which included Paraplegia - Complete, Schizophrenia, Other Neuromuscular Dysfunction of Bladder, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Muscle Wasting and Atrophy, Other Lack of Coordination, Cognitive Communication Deficit, and Neurogenic Bowel. Review of Resident #9's MDS with an ARD of 11/21/2023 revealed a BIM of 13, which indicated he was cognitively intact. Review of Resident #9's Incident Report revealed the following, in part: Incident Occurred: 12/05/2023 at 9:00 p.m. Incident Discovered: 12/07/2023 at 2:00 p.m. Incident Description: On 12/07/2023 at 2:00 p.m., Resident #9 alleged S4CNA raised her voice at him. Accused: S4CNA Accused Allegation: Verbal Abuse Accused allegation finding: Substantiated Investigation Findings: .Resident #9 alleged S4CNA verbally abused him during incontinence care. Resident #9 had voice recording of the incident. S1AA was able to listen to the recording and verify S4CNA was raising her voice at the resident and telling him to roll over, and she stated, you're not going to do me like that. An interview was conducted with Resident #9 on 12/12/2023 at 9:29 a.m. He stated on the night of 12/05/2023, S4CNA was assigned to him. He stated him and S4CNA were yelling back and forth at each other. He stated he had an audio recording of the incident, and he allowed S1AA to listen to the recording. A telephone interview was conducted with S4CNA on 12/13/2023 at 3:04 p.m. She stated on the night of 12/05/2023, she entered Resident #9's room to provide incontinence care, and he started yelling at her. She stated she began yelling back at Resident #9 but was unable to recall what she said back to him. She explained she should not have engaged with Resident #9 and should have walked away and notified the nurse. She stated S3CNA witnessed the incident. She stated it was never acceptable to yell at a resident. She confirmed yelling at a resident was verbal abuse. She confirmed she verbally abused Resident #9. An interview was conducted with S3CNA on 12/13/2023 at 3:24 p.m. She stated on 12/05/2023 around 8:00 p.m., she was on the hallway talking with another resident's family member when she heard yelling. She stated she went into Resident #9's room, and S4CNA and Resident #9 were yelling at each other. She stated S4CNA was yelling loud at Resident #9. She stated S4CNA was saying, you don't have to holler at me, and you don't have to yell at me because you cannot do this yourself. She confirmed yelling at a resident was verbal abuse and S4CNA verbally abused Resident #9. An interview was conducted with S1AA on 12/12/2023 at 1:58 p.m. He stated on the afternoon of 12/07/2023, Resident #9 reported an altercation between himself and S4CNA. S1AA stated Resident #9 had the incident on audio recording, and he was able to listen. He stated in the audio recording, S4CNA was yelling things such as, you're not going to play me for a fool, and you're not going to do me like that. He stated there was no acceptable reason for a staff member to ever yell at a resident. An interview was conducted with S1AA on 12/13/2023 at 5:21 p.m. He confirmed S4CNA verbally abused Resident #9 on 12/05/2023.

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain housekeeping and maintenance services necessary to maintai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to ensure: 1. trash was not overflowing from the facility's dining room trash can; 2. supper meal trays were not left in the facility's dining room or in Room g overnight; 3. the kitchen floor and baseboards were free of any food or debris; 4. the kitchen entry door frame was free of any brown, flaky substances; 5. the baseboard and sheetrock were not separated from the frame of the kitchen door; 6. the black rubber baseboard measuring 4 inches in length was not missing from Room a's bedroom wall next to the in-room bathroom door; 7. the bedroom wall of Room b was free of a baseball-sized brownish yellow stain above the lower third of Resident #12's bed; 8. the privacy curtain ceiling track for Room e was properly secured to the ceiling above the foot of Resident #4's bed; 9. ceiling panels and ceiling grid covers in Room e were free of rust colored stains throughout the room; 10. the privacy curtain ceiling track for Room h was properly secured to the ceiling above the foot of Resident #8's bed; 11. one ceiling tile was not drooping above the head of Resident #8's bed in the left corner of Room h; 12. the floor in Room d was free of a yellow stain the length of the bottom half of Resident #2's bed; 13. one ceiling tile in the far right corner of Room f to the right of the window was not missing, exposing insulation and wires; and 14. one electrical socket in Room f was not exposed without a socket plate cover to the right of Resident #1's bariatric bed. This had the potential to affect all 50 residents currently residing in the facility. Findings: Review of the facility policy titled, Quality of Life - Homelike Environment revealed, in part, the following: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; On 12/11/2023 at 5:01 a.m., an observation was made of the facility's dining room. There was a trash can overflowing with trash and a brown, liquid substance and straws on the floor. There was a table with a plate of potato chips and an open, clear glass of a yellow liquid. There was a table with two supper trays from 12/10/2023 with meal cards for Resident #2 and Resident #R4. On 12/11/2023 at 5:02 a.m., S1AA confirmed the above observations. He confirmed the two meal trays were left out from supper the night before, and the other tray was from snacks the night before. On 12/11/2023 at 7:11 a.m., an observation was made of the kitchen entrance door from the facility's dining room. There was a brown, flaky substance at the base of both sides of the door frame, and the sheetrock and baseboard were separating from the wall on the left side of the door frame. On 12/11/2023 at 7:14 a.m., an observation was made of the facility's kitchen. There was food, including a French fry, and debris lining the baseboards and extending approximately four inches from the baseboards by the dishwasher and three compartment sink in the kitchen. On 12/11/2023 at 7:16 a.m., an interview was conducted with S15DS in the facility's kitchen. S15DS confirmed there was food and debris on the floor lining the baseboards behind the dishwasher and three compartment sink. S15DS stated kitchen staff were responsible for cleaning the kitchen, including kitchen floors at least daily. S15DS confirmed the food and debris lining the baseboards in the kitchen had been present for a while, and it should not have been. On 12/11/2023 at 7:26 a.m., an observation was conducted of the facility's kitchen with S1AA present. An interview was conducted with S1AA at that time. S1AA confirmed there was food and debris lining the baseboards in the facility's kitchen. He stated kitchen staff were responsible for cleaning the kitchen, including kitchen floors, no less than daily. On 12/13/2023 at 1:18 p.m., an observation was made of the kitchen entrance from the facility's dining room with S1AA present. S1AA confirmed there was rust at the base of both sides of the door frame, and the sheetrock and baseboard were separating from the wall on the left side of the door frame. On 12/12/2023 at 9:07 a.m., an observation was made of Room g. Resident #9's supper tray was open on his bedside table in front of a stationary chair and adjacent to the television in his room. The meal card read 12/11/2023 chicken [NAME], roasted zucchini, parslied noodles. The tray contained approximately one cup of noodles covered with red sauce and ¼ cup zucchini. The tray was completely open and exposed. On 12/12/2023 at 9:29 a.m., an interview was conducted with Resident #9. He confirmed the food tray in his room was from last night. He stated staff never picked up the tray. On 12/12/2023 at 9:56 a.m., an interview was conducted with S3CNA. S3CNA observed Resident #9's room at that time. S3CNA confirmed the meal tray in Resident #9's room was from supper the previous night, was uncovered, and should have been picked up on the 2 p.m.-10 p.m. shift last night. On 12/12/2023 at 12:20 p.m., an interview was conducted with S2DON. She stated Resident #9's meal tray should not have been in his room this morning and should have been removed last night when he finished eating. On 12/13/2023 at 11:38 a.m., an interview was conducted with S1AA. He stated supper trays should be put up and cleaned after supper and not left out overnight. He stated supper trays being left out overnight could contribute to pests. On 12/11/2023 at 2:00 p.m., an observation was made of Room a. A section of black rubber baseboard measuring 4 inches in length was missing from the bedroom wall to the right of the in-room bathroom door. On 12/13/2023 at 1:05 p.m., an interview was conducted with S1AA in Room a. He stated the section of black rubber floor board should not be missing. On 12/13/2023 at 1:06 p.m., an interview was conducted with S11MM. He confirmed the missing section of the floor board in Room a should not be missing. On 12/11/2023 at 2:05 p.m., an observation was made of Room b. There was a baseball-sized brownish yellow colored stain on the wall above the lower third portion of Resident #12's bed. On 12/13/2023 at 1:09 p.m., an interview was conducted with S1AA in Room b. He stated the baseball-sized stain on the wall should not have been there. On 12/11/2023 at 2:50 p.m., an observation was made of Room e. The curtain track on the ceiling to the right of the Resident #4's bed was hanging from the ceiling. Rust colored stains were observed on all of the ceiling panels and grid track throughout the room. On 12/13/2023 at 1:20 p.m., an interview was conducted with S1AA in Room e. He stated the privacy curtain track to the right of Resident #4's bed should be properly secured to the ceiling. He also stated the ceiling panels and grid track should be clean and free of rust colored stains. On 12/13/2023 at 10:50 a.m., an observation was made of Room h. A drooping ceiling tile in the right corner above the head of Resident #8 bed was noted. The privacy curtain track was not hanging from the ceiling on the right side near the window. On 12/13/2023 at 1:10 p.m., an interview was conducted with S1AA in Room h. He stated the ceiling tile above the head of Resident #8's bed should not be drooping. He also stated the privacy curtain track should be properly secured to the ceiling. On 12/12/2023 at 1:40 p.m., an observation was made of Room d. To the left of the bottom half of Resident #2's bed on the floor there was a yellow stain. On 12/12/2023 at 1:41 p.m., an interview was conducted with Resident #2, who resided in Room d. She stated her catheter draining bag had ruptured during the late hours of 12/11/2023. She stated she mentioned it to night shift nurse before she left the facility early that morning. On 12/13/2023 at 1:15 p.m., an interview was conducted with S1AA in Room d. He stated housekeeping should have mopped up the stain when they cleaned Room d the morning of 12/12/2023 and 12/13/2023. On 12/11/2023 at 10:35 a.m., an observation was made of Room f. The ceiling tile to the right of the window was missing with exposed insulation hanging from the ceiling. The electrical socket Resident #1's bed was plugged into was exposed and did not have a socket plate cover on it. On 12/11/2023 at 10:36 a.m., an interview was conducted with Resident #1. He stated the ceiling tile had fallen during the rain storm a week ago. He stated he called the nurses' station immediately when the ceiling tile fell to inform the staff of the missing ceiling tile. He stated no one came to look at the missing ceiling or repair it. He stated the electrical socket his bed was plugged into had been exposed and not covered for as long as he could remember. He stated he had mentioned it to staff when they came into his room, but nothing had been done about it so he stopped mentioning it. On 12/13/2023 at 1:25 p.m., an interview was conducted with S1AA in Room f. He stated the ceiling tile should not be missing, and insulation should not be exposed from the ceiling. He stated the electrical outlet should not be exposed and should have a cover plate on it.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported to the facility ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure allegations of verbal abuse were reported to the facility administrator immediately, but not later than 2 hours after abuse occurred and/or an allegation was made for 1 (#9) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13) residents reviewed for abuse. The facility failed to ensure the following: 1. S13CNA and S4CNA reported an allegation S12CNA verbally abused Resident #9; and 2. S3CNA reported an allegation S4CNA verbally abused Resident #9 Findings: Review of the facility's policy titled, Abuse Investigation and Reporting revealed the following, in part: Policy Statement All reports of resident abuse shall be promptly reported to local, state, and federal agencies (as defined by current regulations) Reporting: 2. Any alleged violation of abuse will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse . Review of Resident #9's Clinical Record revealed he was readmitted to the facility on [DATE] and diagnoses which included Paraplegia - Complete, Schizophrenia, Other Neuromuscular Dysfunction of Bladder, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Muscle Wasting and Atrophy, Other Lack of Coordination, Cognitive Communication Deficit, and Neurogenic Bowel. Review of Resident #9's MDS with an ARD of 11/21/2023 revealed a BIM of 13, which indicated he was cognitively intact. Review of Resident #9's Incident Report reported to the State Survey Agency revealed the following, in part: Incident Discovered: 12/12/2023 at 2:00 p.m. Incident Description: An allegation was made S12CNA raised her voice at Resident #9. An interview was conducted with Resident #9 on 12/12/2023 at 9:29 a.m. He stated a couple weeks ago, himself and S12CNA got into a verbal altercation in the facility's dining room. He stated he called S12CNA a baby murderer. He explained S12CNA then began yelling at him. A telephone interview was conducted with S12CNA on 12/12/2023 at 2:08 p.m. She stated there was an incident involving herself and Resident #9 in the dining room on 11/25/2023. She explained another resident was in the dining room and asked that Resident #9 turn his music down. She stated she proceeded to ask Resident #9 to turn the music down for the other resident, and Resident #9 called her a B**** and a baby killer. She stated she then yelled at Resident #9 that he was wrong. An interview was conducted with S13CNA on 12/12/2023 at 3:15 p.m. She stated on the morning of 11/25/2023, she was in the dining room for breakfast. She explained Resident #9 was in the dining room playing loud, vulgar music. She stated S12CNA asked Resident #9 to turn the music down and then there was an altercation between them. She stated Resident #9 and S12CNA yelled at each other. She stated S12CNA told Resident #9, say something else about my child again and you're not going to get away with it. She stated she did not report the incident to anyone. She stated all allegations and potential abuse incident should be reported to the facility administrator immediately. A telephone interview was conducted with S4CNA on 12/13/2023 at 3:04 p.m. She stated a couple weeks ago there was an incident between Resident #9 and S12CNA. She stated she heard commotion in the facility's dining room, walked in, and saw them arguing. She stated they were both hollering and Resident #9 stated f*** you and you're a murderer. She stated S12CNA yelled she was not a murderer. She stated she did not report the incident to administration and should have. An interview was conducted with S1AA on 12/12/2023 at 1:58 p.m. He stated he was not notified of a staff member yelling in the dining room on 11/25/2023. He stated if a staff member was yelling at a resident, he should have been notified immediately so he could file a report with the State Survey Agency and conduct an investigation to determine if abuse occurred. Review of Resident #9's Incident Report reported to the State Survey Agency revealed the following, in part: Incident Occurred: 12/05/2023 at 9:00 p.m. Incident Discovered: 12/07/2023 at 2:00 p.m. Incident Description: On 12/07/2023 at 2:00 p.m., Resident #9 alleged S4CNA raised her voice at him. Accused: S4CNA Accused Allegation: Verbal Abuse Accused allegation finding: Substantiated Investigation Findings: .Resident #9 alleged S4CNA verbally abused him during incontinence care. Resident #9 had voice recording of the incident. S1AA was able to listen to the recording and verify S4CNA was raising her voice at the resident and telling him to roll over, and she stated, you're not going to do me like that. An interview was conducted with Resident #9 on 12/12/2023 at 9:29 a.m. He stated on the night of 12/05/2023, S4CNA was assigned to him. He stated him and S4CNA were yelling back and forth at each other. He explained he had an audio recording of the incident, and, on 12/07/2023, he allowed S1AA to listen to the recording. A telephone interview was conducted with S4CNA on 12/13/2023 at 3:04 p.m. She stated on the night of 12/05/2023, she entered Resident #9's room to provide incontinence care, and he started yelling at her. She stated she began yelling back at Resident #9 but was unable to recall what she said back to him. She confirmed yelling at a resident was verbal abuse. She confirmed she verbally abused Resident #9. She stated S3CNA witnessed the incident. An interview was conducted with S3CNA on 12/13/2023 at 3:24 p.m. She stated on 12/05/2023 around 8:00 p.m., she was on the hallway talking with another resident's family member when she heard yelling. She stated she went into Resident #9's room, and S4CNA and Resident #9 were yelling at each other. She stated S4CNA was yelling loud at Resident #9. She confirmed yelling at a resident was verbal abuse. She stated she did not report the situation to anyone and should have notified S1AA immediately. An interview was conducted with S1AA on 12/12/2023 at 1:58 p.m. He stated on the afternoon of 12/07/2023, Resident #9 reported an altercation between himself and S4CNA. S1AA stated Resident #9 had the incident on audio recording. He stated in the audio recording, S4CNA was yelling at Resident #9. He confirmed this was abuse. He stated he was unaware of the incident until Resident #9 brought it to his attention. He confirmed S3CNA should have reported the verbal abuse to him immediately and she did not.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide both facility-sponsored group and individua...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide both facility-sponsored group and individual activities for 3 (#1, #2, and #R1) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #R1, #R2, #R3 and #R4) sampled residents. The total facility census was 50. Findings: Review of the facility policy titled Activity Program revealed, in part, the following: Policy Statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation 3. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 11.Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g. bedbound or visually impaired residents). 12. Individualized and group activities are provided that: a. Reflect the schedules, choices and rights of the residents; Review of the December 2023 Activities Calendar revealed the following activities were scheduled: 12/11/2023 - 10:00 a.m. - Sittercise 12/11/2023 - 2:30 p.m. - Fun-n-Games 12/12/2023 - 10:30 a.m. - Meditation w/[NAME] 12/13/2023 - 10:30 a.m. - Hangman On 12/11/2023 at 10:05 a.m., an observation was conducted of the facility dining room where facility-sponsored activities were scheduled to take place. No staff or residents were observed engaging in Sittercise. On 12/11/2023 at 2:40 p.m., an observation was conducted of the facility dining room where the facility-sponsored activities were schedule to take place. No staff or games were observed for the scheduled Fun-n-Games activity. On 12/12/2023 at 10:38 a.m., an observation was made of the facility dining room where the facility-sponsored activities were scheduled to take place. The scheduled meditation activity was not observed to take place. On 12/13/2023 at 10:30 a.m., an observation was made of the facility dining room where the facility-sponsored activities were scheduled to take place. No staff or residents were observed participating in the scheduled Hangman activity. Resident #1: Review of the Clinical Record for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease with Dyskinesia, Cognitive Communication Deficit, and Major Depression Disorder. Review of Resident #1's quarterly MDS with an ARD of 11/27/2023 revealed Resident #1 had a BIMS of 11 which indicated moderate cognitive impairment. Review of Resident #1's current Care Plan revealed the following, in part: Resident will attend and participate in 3-4 out of room group activities per week to promote socialization, physical functioning, and sensory stimulation. On 12/11/2023 at 10:35 a.m., an observation was made of Resident #1's room. No monthly activities calendar was seen. No individual in-room activities were seen in his room. An interview was conducted with Resident #1 on 12/11/2023 at 10: 35 a.m. He stated he would love to attend activities, but never received a monthly activities calendar. He stated he had not been provided with individual activities to do in his room. He stated staff did not notify him of activities. Resident #2: Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Complete Paraplegia, Major Depressive Disorder and Generalized Anxiety Disorder. Review of Resident #2's quarterly MDS with an ARD of 10/27/2023 revealed Resident #2 had a BIMS of 14, which indicated intact cognition. Review of Resident #2's current Care Plan revealed the following, in part: Resident will self-initiate activities of interest 3-4 times per week. On 12/11/2023 at 2:07 p.m., an interview was conducted with Resident #2. She stated there was an Activities Director who had been in the facility for years, but left a few months ago. She stated the facility had hired a replacement Activities Director, but this person was only employed with the facility for about a month prior to quitting. She stated the most recent Activities Director started in early November, but within one or two days at the facility, she quit. She stated there has not been anyone in the Activities Director role. She stated she loved participating in the activities when they were available and would participate in activities if provided by the facility. She confirmed the facility had not provided activities for 2 or 3 months. On 12/12/2023 at 10:43 a.m., an interview was conducted with S7LPN. She confirmed the Activities Director quit last month. Random Resident R1: Review of Resident #R1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Anxiety Disorder, and Cerebral Infarction. Review of Resident #R1's quarterly MDS with an ARD of 10/20/2023 revealed Resident #R1 had a BIMS of 12, which indicated moderate cognitive impairment. Review of Resident #R1's current Care Plan revealed the following, in part: Resident will attend and participate in 3-4 out of room group activities per week to promote socialization, physical functioning, and sensory stimulation. On 12/13/2023 at 12:18 p.m., an interview was conducted with Resident #R1. She stated there have been no scheduled activities since late September or early October when the Activities Director quit. She stated BINGO on Monday 12/11/2023 was the first activity the facility had since the facility's initial Activities Director quit back in late September/early October. She stated scheduled activities do not occur because there is no one in charge of activities. She stated she desired to participate in activities. She confirmed the facility had not routinely offered activities since the Activity Director quit in September or early October. On 12/12/2023 at 9:16 a.m., an interview was conducted with S14CNA. She confirmed there was no designated Activities staff in the facility. On 12/12/2023 at 1:30 p.m., an interview was conducted with S8PCA. She stated about a month ago, S1AA asked her to assist in the facilitation of facility activities. She stated she did not receive training on the activities, there were activities on the calendar she was unfamiliar with, and did not know how to facilitate them. She stated she was is not always able to host the activities at the time they were are scheduled because of her duties as a PCA. She stated she was unsure who was responsible for passing out the monthly activities calendars to the residents, but she had not provided each resident with a copy. She confirmed she was not able to conduct activities each day with the residents. On 12/13/2023 at 1:58 p.m., an interview was conducted with S1AA. He confirmed there had not been a qualified Activities Director working in the facility since 11/17/2023. He stated he delegated planning and hosting of activities to various facility staff in addition to their hired and scheduled responsibilities. He stated he was not aware of any missed activities. He was made aware of the observations and interview with S8PCA regarding the activities being missed. He confirmed he should know if activities were not being held as scheduled on the monthly activities calendar. He confirmed all activities should be taking place as scheduled on the monthly activities calendar. He stated the activities calendar was managed by S6CD remotely. On 12/13/2023 at 2:38 p.m., a telephone interview was conducted with S6CD. She stated she worked remotely from another state and was most recently at the facility on 11/27/2023 and 11/28/2023 to complete the activities calendar. She confirmed the facility did not have a qualified Activities Director to oversee the facility's daily activity program. She confirmed she created the monthly activities calendar for December 2023, but did not know if the residents were informed of the activities or if the activities were being conducted.

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 F0680 (Tag F0680)

Could have caused harm · This affected multiple residents

Based on interviews, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice had the potential to affect a census of 50 residents. Findi...

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Based on interviews, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice had the potential to affect a census of 50 residents. Findings: On 12/12/2023 at 1:30 p.m., an interview was conducted with S8PCA. She stated about a month ago, she was assigned to assist with facility activities in addition to her duties as a PCA. She stated she did not receive training regarding the activities and confirmed she was not a qualified therapeutic recreation specialist or a licensed activities professional. On 12/12/2023 at 11:10 a.m., an interview was conducted with S1AA. He confirmed the facility did not have a qualified activities director and they should. He stated there had not been a qualified activities professional working in the facility since 11/17/2023. He stated he was acting as the Activities Director in the interim. He confirmed he was not a qualified therapeutic recreation specialist or a licensed activities professional. He stated he delegated the planning and hosting of facility sponsored activities to various unqualified facility staff and the activities calendar was being managed by S6CD remotely. On 12/13/2023 at 2:38 p.m., an interview was conducted with S6CD. She confirmed she worked remotely in Florida for Corporate and was not at the facility daily. She confirmed the facility did not have a qualified activities professional to oversee the facility's daily activity program and they should.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means rece...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (#7 and #13) of 3 (#7, #12, and #13) residents reviewed for tube feedings. The facility failed to ensure: 1. Enteral feeding solution bags were changed every 24 hours; 2. Enteral feeding solution and free water were infusing at ordered rate. Findings: Review of the facility's policy entitled Enteral Tube Feeding revealed in part, the following: Steps in the procedure: 5. Check the order to verify the type, amount, method, and rate of administration. Initiate Feeding: 3. On the formula label document initials, date and time the formula was hung/administered. 1. Resident #13 Review of the clinical record for Resident #13 revealed she was admitted to the facility on [DATE] with diagnoses which included Dysphagia Following Cerebral Infarction and Functional Quadriplegia. Review of the current Physician Orders for Resident #13, revealed, in part, the following: Isosource 1.5 at 40mL/hr per peg tube continuously daily with water flushes at 200mL/4hr. Further review revealed an order to change peg feeding bag every 24 hours. An observation was made on 12/11/2023 at 9:40 a.m. of Resident #13 in her room. Resident #13's tube feeding solution of Isosource 1.5 was observed infusing with a label dated 12/10/2023 6:00 a.m. The tube feeding solution bag had a label Do not use for greater than 24 hours. An observation was made on 12/11/2023 at 2:57 p.m. of Resident #13 in her room. Resident #13's tube feeding solution of Isosource 1.5 was observed infusing with a label dated 12/10/2023 6:00 a.m. The tube feeding solution bag had a label Do not use for greater than 24 hours. An interview was conducted on 12/11/2023 at 2:57 p.m. with S18LPN in Resident #13's room. She stated the night shift nurse was responsible for changing tube feeding solution, bags, and tubing. She confirmed the bag of tube feeding solution was hanging for longer than 24 hours and should have been replaced. An interview was conducted on 12/12/2023 at 10:45 a.m. with S19LPN. She stated the night shift nurse was responsible for changing tube feeding solution, bags, and tubing. She confirmed she did not change Resident #13's feeding tube solution bag on 12/11/2023. She confirmed the bag of tube feeding solution was hanging for longer than 24 hours and should have been replaced. 2. Resident #7 Review of the clinical record for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses which included Dysphagia and Cognitive Communication Deficit. Review of the current Physician Orders for Resident #7, revealed, in part, the following: Isosource 1.5 at 55mL/hr per peg tube continuously daily. An observation was made on 12/12/2023 at 9:20 a.m. of Resident #7 in her room. Resident #7's tube feeding solution of Isosource 1.5 was infusing via pump at 50mL/hr. Resident #13 An observation was made on 12/12/2023 at 9:25 a.m. of Resident #13 in her room. Resident #13's water flush was infusing via pump at 200mL/21hr. An interview was conducted on 12/12/2023 at 9:30 a.m. with S20LPN in Resident #7's room. She confirmed Resident #7's tube feeding solution was ordered to infuse at 55mL/hr, and it was infusing at 50mL/hr. She confirmed it was her responsibility to ensure each shift that all tube feeding pumps are accurately infusing as ordered. An interview was conducted on 12/12/2023 at 9:32 a.m. with S20LPN in Resident #13's room. She confirmed Resident #13's water flush was ordered to infuse at 200mL/4hr, and it was infusing at 200mL/21hr. She confirmed it was her responsibility to ensure each shift that all tube feeding pumps are accurately infusing as ordered. An interview was conducted on 12/12/2023 at 9:33 a.m. with S2DON. She confirmed all feeding solution bags should be replaced every 24 hours. She confirmed it was the nurses' responsibility to ensure each shift that all tube feeding pumps are accurately infusing as ordered. An interview was conducted on 12/12/2023 at 10:33 a.m. with S21NP. She confirmed all feeding solution bags should be replaced every 24 hours. She confirmed it was the nurses' responsibility to ensure each shift that all tube feeding pumps are accurately infusing as ordered. An interview was conducted on 12/12/2023 at 10:45 a.m. with S1AA. He confirmed all feeding solution bags should be replaced every 24 hours. He confirmed it was the nurses' responsibility to ensure each shift that all tube feeding pumps are accurately infusing as ordered.

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

Based on an observation and interview, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed ...

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Based on an observation and interview, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 50 residents residing in the facility. Findings: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers revealed the following, in part: Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. On 12/11/2023 at 5:05 a.m., an observation was made of the staffing data sheet posted on the wall across from the nurses' station desk, which revealed it was dated for Friday, 12/08/2023. On 12/11/2023 at 5:09 a.m., an interview was conducted with S1AA. He confirmed the staffing data sheet posted on the wall across from the nurses' station desk was dated for Friday, 12/08/2023. He confirmed the staffing data sheet should be posted daily and it was not.

CONCERN (E) 📢 Someone Reported This

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

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

Administration (Tag F0835)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to be administered in a manner that enabled it to use i...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident residing in the facility. The facility failed to have an effective system in place to: 1. Ensure a qualified activities professional was hired to direct the facility's Activity Program; and 2. Ensure facility policies and procedures were implemented for an effective Activities Program. This deficient practice had the potential to affect a census of 50 residents. Cross Reference F679, F680. Findings: 1. On 12/12/2023 at 1:30 p.m., an interview was conducted with S8PCA. She stated a month ago, S1AA asked her to assist in conducting facility activities in addition to her hired role as a PCA. She stated she had not received training regarding the activities, and she was unfamiliar with multiple activities on the calendar and how to facilitate them. On 12/13/2023 at 1:58 p.m., an interview was conducted with S1AA. He stated there had not been a qualified activities professional working in the facility since 11/17/2023. He stated he had been acting as the Activities Director for the facility in the interim. He confirmed he was not a qualified therapeutic recreation specialist or a licensed activities professional. On 12/13/2023 at 2:38 p.m., a telephone interview was conducted with S6CD. She confirmed the facility did not have a qualified Activities Director to oversee the facility's daily activity program. 2. Review of the facility policy titled, Activity Program revealed, in part, the following: Policy Statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation 3. The Activities Program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. 6. Activities are scheduled 7 days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. 11.Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g. bedbound or visually impaired residents). 12. Individualized and group activities are provided that: a. Reflect the schedules, choices and rights of the residents; Review of the December 2023 Activities Calendar revealed the following activities were scheduled: 12/11/2023 - 10:00 a.m. - Sittercise 12/11/2023 - 2:30 p.m. - Fun-n-Games 12/12/2023 - 10:30 a.m. - Meditation w/[NAME] 12/13/2023 - 10:30 a.m. - Hangman On 12/11/2023 at 10:05 a.m., an observation was conducted of the facility dining room where facility-sponsored activities were scheduled to take place. No staff or residents were observed engaging in Sittercise. On 12/11/2023 at 2:40 p.m., an observation was conducted of the facility dining room where the facility-sponsored activities were schedule to take place. No staff or games were observed for the scheduled Fun-n-Games activity. On 12/12/2023 at 10:38 a.m., an observation was made of the facility dining room where the facility-sponsored activities were scheduled to take place. The scheduled meditation activity was not observed to take place. On 12/13/2023 at 10:30 a.m., an observation was made of the facility dining room where the facility-sponsored activities were scheduled to take place. No staff or residents were observed participating in the scheduled Hangman activity. On 12/12/2023 at 1:30 p.m., an interview was conducted with S8PCA. She stated she was not always able to host the activities at the time they were scheduled because of her duties as a PCA. She confirmed she was unable to conduct the missed activities on 12/11/2023 and 12/13/2023 and the missed activity on 12/12/2023 was not conducted because the outside facilitator did not show up. She confirmed S1AA was aware this activity would be cancelled and did not instruct her to facilitate a different activity at that time. She confirmed she was not able to conduct activities each day with the residents. On 12/13/2023 at 1:58 p.m., an interview was conducted with S1AA. He stated all activities had been facilitated as outlined on the monthly activities calendar created by S6CD. He stated he delegated planning and hosting of facility sponsored activities to various facility staff. He was made aware of the observations and interview with S8PCA regarding the missed activities. He confirmed he was not aware of any missed activities, and stated he should have been notified if activities were not being held as scheduled on the monthly activities calendar.

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure low air loss mattresses were functioning cor...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure low air loss mattresses were functioning correctly for 3 of 3 (#9, #11, and #R2) residents reviewed with air mattresses. Findings: Review of the Operation Manual for Proactive Medical Products Protekt Aire 2000 revealed the following, in part: Product Functions: Control Unit: The functions of the control unit are described below. Normal Pressure Indicator: A visible indicator (green) tells the pressure has reached a present or user-defined level. Low Pressure Indicator: A visible indicator (orange) warns the pressure is below a preset or user-defined level. Resident #9 Review of Resident #9's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses which included Paraplegia - Complete, Pressure Ulcer of Other Site - Stage 4, Pressure Ulcer of Right Hip - Stage 3, Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Pressure Ulcer of Left Hip - Stage 4, Muscle Wasting and Atrophy, Other Lack of Coordination, and Pressure Ulcer of Unspecified Site - Stage 3. Review of Resident #9's current Physician Orders revealed, in part, an order for a low air loss alternating mattress - ensure working properly. An observation was made of Resident #9 on 12/13/2023 at 2:03 p.m. Resident #9 was lying in bed on his left side with a low air mattress in place. The low air loss mattress pump read Proactive 2000/3000. Resident #9's low pressure air loss mattress revealed an orange light illuminated adjacent to the low pressure indicator. There was no light illuminated adjacent to the normal pressure indicator. An observation was made of Resident #9 with S1AA present on 12/13/2023 at 2:05 p.m. S1AA confirmed Resident #9's low air loss mattress pump revealed a low pressure indicator. Resident #11 Review of Resident #11's Clinical Record revealed she was admitted to the facility 09/05/2023 with diagnoses which included Pressure Ulcer of Sacral Region - Stage 2. Review of Resident #11's current Physician Orders revealed, in part, an order for a low air loss alternating mattress - ensure working properly. An observation was made of Resident #11 on 12/12/2023 at 8:10 a.m. She was lying in bed on a low air loss mattress. The low air loss mattress pump read Proactive 2000/3000. Resident #11's low air loss mattress revealed an orange light illuminated adjacent to the low pressure indicator. There was no light illuminated adjacent to the normal pressure indicator. An observation was made of Resident #11 on 12/12/2023 at 3:52 p.m. She was lying in bed on a low air loss mattress. The low air loss mattress pump read Proactive 2000/3000. Resident #11's low air loss mattress revealed an orange light illuminated adjacent to the low pressure indicator. There was no light illuminated adjacent to the normal pressure indicator. An observation was made of Resident #11 on 12/13/2023 at 10:46 a.m. Resident #11's low air loss mattress revealed an orange light illuminated adjacent to the low pressure indicator. There was no light illuminated adjacent to the normal pressure indicator. An interview was conducted with S20LPN on 12/13/2023 at 10:47 a.m. She stated Resident #11 had a Physician's Order to check the function of her low air loss mattress daily on day shift. An interview was conducted with S20LPN on 12/13/2023 at 10:50 a.m. in Resident #11's room. S20LPN observed Resident #11's low air loss mattress and confirmed the low pressure indicator was illuminated. Resident #R2 Review of Resident #R2's Clinical Record revealed he admitted to the facility on [DATE] with diagnoses which included Pressure Ulcer of Sacral Region Unspecified Stage. Review of Resident #R2's current Physician Orders revealed, in part, an order for a low air loss mattress to bed. An observation was made of Resident #R2 on 12/12/2023 at 8:10 a.m. She was lying in bed on a low air loss mattress. The low air loss mattress pump read Proactive 2000/3000. Resident #R2's low air loss mattress revealed an orange light illuminated adjacent to the low pressure indicator. There was no light illuminated adjacent to the normal pressure indicator. An interview was conducted with S2DON on 12/13/2023 at 4:00 p.m. in Resident #R2's room. S2DON confirmed Resident #R2's low air loss mattress revealed a low pressure indicator and should have had a normal pressure indicator. An interview was conducted with S11MM on 12/13/2023 at 1:28 p.m. He stated low air loss mattresses were for prevention of Pressure Ulcers. He stated the nurses and CNAs were responsible for checking residents' air mattresses daily. He stated the nurses and CNAs should notify him any time there was a malfunction with the mattress. He stated when an air mattress low pressure indicator light was illuminated, that meant the mattress was not inflated correctly.

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 F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility was free of insects. This deficient practice had the potential to affect any of the 50 residents residing in the facility. Findings: Review of the facility's policy, titled, Pest Control revealed the following, in part: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. The facility maintains an on-going pest control program to ensure the building is kept free of insects . 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. On 12/11/2023 at 5:01 a.m., an observation was made of the facility's dining room. There was a table with a plate of potato chips and an open, clear glass of a yellow liquid. There was a table with two supper trays from 12/10/2023 with meal cards for Resident #2 and Resident #R4. On 12/11/2023 at 5:10 a.m., an interview was conducted with S10ACNA. She stated she was an agency CNA and this was her second shift working in the facility. She stated she saw many live roaches within the facility during her shift. She stated she saw them in residents' rooms, and in clean supply and linen rooms. She stated during her shift on the night of 12/09/2023, she saw a roach inside a resident's brief. On 12/11/2023 at 7:11 a.m., surveyor opened the kitchen entrance door from the facility's dining room. When the door shut, a brown bug the size of a black bean scurried from under the baseboard into the dining room while residents were present in the dining room. S7LPN was present in the dining room. S7LPN identified the bug as a roach. On 12/11/2023 at 8:14 a.m., an interview was conducted with Resident #11. She stated she had been seeing roaches in her room on the floor and on the wall. On 12/11/2023 at 9:20 a.m., an interview was conducted with Resident #5. She stated last week she had a roach in her bed, alive and crawling around under the covers. She stated she often saw roaches crawling on the walls. On 12/11/2023 at 10:34 a.m., an observation was made of Room f. There was a live roach the size of kidney bean. The roach was observed scurrying on the floor when the CNA moved the trash can by the door to the room. The roach ran under the door into the bathroom. On 12/11/2023 at 2:07 p.m., an interview was conducted with Resident #2. She stated she had seen numerous live roaches all around the facility. On 12/11/2023 at 2:55 p.m., an interview was conducted with Resident #4. She stated she constantly saw roaches in the facility. On 12/12/2023 at 9:07 a.m., an observation was made of Room g. Resident #9's supper tray from the previous night was open on his bedside table in front of a stationary chair and adjacent to the television in his room. The meal card read 12/11/2023 chicken [NAME], roasted zucchini, parslied noodles. The tray contained approximately one cup of noodles with red sauce and ¼ cup zucchini. The tray was completely open and exposed. On 12/12/2023 at 9:29 a.m., an interview was conducted with Resident #9. He confirmed the meal tray in his room was from last night. He stated the staff never picked up the tray. On 12/12/2023 at 9:56 a.m., an interview was conducted with S3CNA. She confirmed the meal tray in Resident #9's room was from supper last night, was uncovered, and should have been picked up on the 2:00 p.m. to 10:00 p.m. shift last night. On 12/12/2023 at 12:20 p.m., an interview was conducted with S2DON. She stated Resident #9's meal tray should not have been in his room this morning and should have been removed last night when he finished eating. She stated Resident #9 had a history of roaches in his room. On 12/12/2023 at 9:49 a.m., an observation was made in Room g. There was a brown bug the size of an almond crawling on the floor from the bathroom. S17HSK entered Room g and identified the bug as a roach. On 12/12/2023 at 10:43 a.m., an interview was conducted with S7LPN. She stated there had been a roach and pest issue within the facility. On 12/13/2023 at 2:03 p.m., an observation was made in Room g. There was a brown bug the size of an almond on Resident #9's repositioning wedge. S1AA entered Room g and identified the bug as a roach. He put on a glove, killed the roach, and disposed of it in the garbage can. On 12/13/2023 at 2:13 p.m., an observation was made of Room g. There was a brown bug the size of a kidney bean crawling from under Resident #R3's night stand. S16FT entered Room g and identified the bug as a roach. On 12/13/2023 at 2:14 p.m., an interview was conducted with Resident #9. Resident #9 stated he saw roaches in his room all the time. Resident #9 stated he would prefer not to have roaches in his room. On 12/13/2023 at 2:14 p.m., an observation was made of a brown bug the size of a grain of rice crawling under Resident #R3's bed. S3CNA identified the bug as a roach. On 12/13/2023 at 2:15 p.m., an observation was made of Resident #R3's nightstand with S3CNA present. There was a brown bug the size of an almond in the bottom of the nightstand and a brown bug the size of a pecan in the top drawer of Resident #R3's nightstand. S3CNA identified the bugs in Resident #R3's nightstand as roaches. On 12/13/2023 at 2:17 p.m., an interview was conducted with S3CNA. She stated she saw roaches every shift she worked. On 12/13/2023 at 2:48 p.m., an observation was made of Room g. There were two small brown bugs the size of a grain of rice crawling on the floor by Resident #R3's bed and dresser, and there was one brown bug the size of an almond crawling on the wall by Resident #R3's side rail of his bed. Resident #R3 was lying in his bed with his eyes closed. On 12/13/2023 at 3:55 p.m., an observation was made of a roach crawling on the floor in Hall A. On 12/11/2023 at 1:39 p.m., an interview was conducted with two representatives from the facility's pest control company. They stated there had been issues with roaches in the facility. They both confirmed keeping food or meal trays in resident rooms or the dining area overnight would contribute to the roach problem in the facility. On 12/13/2023 at 11:38 a.m., an interview was conducted with S1AA. He stated supper trays should be put up and cleaned after supper and not left out overnight. He confirmed Resident #9's supper tray should not have been in his room the following morning. He stated supper trays being left out overnight could contribute to pests. He stated he was aware of there being roaches in the facility.

Oct 2023 3 deficiencies

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comforta...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure the residents had a safe, functional, sanitary, and comfortable environment. The facility failed to ensure: 1. The bathroom floor tiles and grout between the tiles were free of discoloration and a gray/black substance in Room a; and 2. The shower room, Room b was clean and free of debris. This had the potential to affect any of the 39 residents residing in the facility who used Room b. Findings: 1. Review of the Clinical Record for Resident #4 revealed she was admitted to the facility on [DATE]. On 10/23/2023 at 1:45 p.m., an interview was conducted with Resident #4 in Room a. She said she used her bathroom daily. She said when she admitted to the facility the bathroom floors used to be cleaner, looked whiter and now they looked dirty and awful. On 10/23/2023 at 8:13 a.m., an observation was made of Room a. The bathroom floor tiles were observed to be discolored with a black and gray substance on the tiles and in the grout. On 10/23/2023 at 1:13 p.m., an interview was conducted with S8HK. She said there was a black and gray substance on Room a's bathroom floor which she cleaned today. She said she reported a few weeks ago to either S9MA or S10MS that Room a's bathroom floor needed to be stripped and waxed. She said there was no more she could do for the floors. On 10/23/2023 at 1:15 p.m., an observation was made of Room a with S8HK. She observed Room a's bathroom floors and confirmed the tiles and grout were still discolored with a black and gray substance. On 10/23/2023 at 1:20 p.m., an interview was conducted S9MA. He said he made environmental rounds almost daily. He said he had not observed any black and gray substances or discoloration to any resident room or bathroom floors. On 10/23/2023 at 1:23 p.m., an observation and interview was conducted with S9MA. He observed Room a's bathroom and stated the bathroom floor was old, dingy and discolored with a black and gray substance on the tiles and in the grout. He said the floor needed to be cleaned, stripped, and waxed by housekeeping. He said no one had notified him of this issue. On 10/23/2023 at 1:35 p.m., an interview was conducted with S11HM. She said the floor tech typically buffed and waxed the facility floors weekly on Wednesday's. She said the floor tech called in today. She said the housekeeping staff should let her know if they cannot get the floors clean. On 10/23/2023 at 1:40 p.m., an observation and interview was conducted with S11HM. She observed Room a's bathroom floor and stated it needed to be stripped and waxed. She confirmed the bathroom floor was discolored with a black and gray substance on the tiles and in the grout. She said she would have expected housekeeping staff to notify her of the condition of the bathroom floor in Room a prior to now. On 10/23/2023 at 4:05 p.m., an observation was made of Room a's bathroom with S1AA. He said housekeeping staff cleaned each resident's room and bathroom daily, including mopping the floors. He said the housekeeping floor tech buffed and waxed the floors, including resident's bathrooms, but was not sure how often. He confirmed Room a's bathroom floor was discolored with a black and gray substance on the tiles and in the grout. He said he did not know when or if the bathroom floor had been waxed and buffed. He said no one had notified him of this. 2. On 10/23/2023 at 1:13 p.m., an interview was conducted with S8HK. She said the CNAs were responsible for cleaning Room b before and after each resident. On 10/23/2023 at 1:35 p.m., an interview was conducted with S11HM. She said the CNAs were responsible for cleaning Room b before and after each resident. On 10/23/2023 at 1:45 p.m., an interview was conducted with Resident #4. She said staff assisted her with showers in Room b. She said the shower room drains needed to be cleaned out and the shower benches did not look clean. She said every time she had to go to Room b to take a shower, she dreaded it. On 10/23/2023 at 2:22 p.m., an interview was conducted with S4CNA. She said the CNAs were responsible for cleaning Room b before and after each resident. On 10/23/2023 at 4:00 p.m., an observation of Room b was made with S1AA. Two toilets were observed on the right back corner of Room b with a wall separating them. There was a small amount of debris and black substances on the floors surrounding the toilets near the baseboards. A silver metal screw was observed on the floor by the back wall of Room b near the toilet stalls. The first shower stall was observed with a permanently affixed shower bench with a white laminate surface containing a small amount of a grayish black substance. The second shower stall was observed with a permanently affixed shower bench with a white laminate surface with trash scattered on the floor and on the drain. The third shower stall was observed with a permanently affixed shower bench with a white laminate surface with 4 strands of black hair on it and trash consisting of a white material on the floor near the drain. He said housekeeping cleaned the shower room daily and the CNAs were responsible for cleaning and disinfecting in between the residents. He confirmed Room b needed to be cleaned by housekeeping right away.

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident who was unable to carry out activities of daily living without assistance received the necessary services to maintain good grooming and personal hygiene for 2 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. Findings: Review of the facility's policy titled, Bath, Shower/Tub revealed the following, in part: Documentation: 1. The date and time the shower/bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/bath. 5. If the resident refused the shower/bath . 6. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the shower/bath. Resident #4 Review of the Clinical Record for Resident #4 revealed she was admitted to the facility on [DATE] and had diagnoses which included Hypertensive Heart Disease without Heart Failure, Permanent Atrial Fibrillation, Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, and History of Falling. Review of the MDS with an ARD of 09/11/2023 for Resident #4 revealed she had a BIMS of 12, which indicated she was moderately cognitively impaired. Further review revealed she required one person physical assist for bathing. Review of the Nurses Notes for Resident #4 dated October 2023 revealed no documentation she had refused baths or showers. Review of the Bath Schedule provided by the facility revealed Resident #4 had baths/showers scheduled three times weekly on Mondays, Wednesdays, and Fridays. Review of the Bath Documentation for Resident #4 dated October 2023 revealed no documentation Resident #4 received a bath or shower from 10/01/2023 through 10/14/2023. Further review revealed she had not received a bath three times weekly the week of 10/15/2023 through 10/21/2023. There was no documentation of refusals for the month of October 2023 for Resident #4. On 10/23/2023 at 1:45 p.m., an interview was conducted with Resident #4. She said she was supposed to receive a shower on Mondays, Wednesdays, and Fridays. She said she required staff assistance to shower. She said staff did not always offer her a shower on her scheduled shower days and she had only been receiving one shower a week. She said she had asked staff, but could not recall who, for a shower on her scheduled days and she was told they would get to it but then never did. She said she reported not getting her showers to her family. On 10/23/2023 at 2:22 p.m., an interview was conducted with S4CNA. She said the CNAs were responsible for documenting each time they bathed or showered a resident. She said Resident #4 was supposed to receive a shower on Mondays, Wednesdays, and Fridays. She said Resident #4 did not refuse any showers for her. She said she was not sure the last time Resident #4 was showered. On 10/23/2023 at 3:16 p.m., an interview was conducted with S5LPN. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She said if Resident #4 refused a shower, the CNA would notify her. She said she would then document the refusal in her Nurses' Notes. She said Resident #4 required staff assistance with showering. She said she was not aware of Resident #4 refusing any showers. On 10/24/2023 at 9:30 a.m., a telephone interview was conducted with a family member of Resident #4. She said Resident #4 should receive a shower three times a week. She said Resident #4 was of sound mind and told her when she did not get a bath. She said Resident #4 had only been receiving one shower a week. On 10/24/2023 at 11:47 a.m., an interview was conducted S6CNA. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She said Resident #4 was supposed to receive a shower on Mondays, Wednesdays, and Fridays. She said Resident #4 did not refuse care. On 10/24/2023 at 12:30 p.m., an interview was conducted with S7CNA. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She said Resident #4 was supposed to receive a shower on Mondays, Wednesdays, and Fridays. She said Resident #4 did not refuse any showers. She said she did not know the last time Resident #4 was showered. Resident #5 Review of the Clinical Record for Resident #5 revealed he was admitted to the facility on [DATE] and had diagnoses which included Other Cerebral Infarction, Infection following a Procedure, Type 2 Diabetes Mellitus without Complications, Other Chronic Pain, and Multiple Myeloma in Remission. Review of the MDS with an ARD of 10/01/2023 for Resident #5 revealed he had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he required extensive assistance of one staff member for bed mobility and one staff member physical assistance for bathing. Review of the Nurses Notes for Resident #5 dated September 2023 to October 2023 revealed no documentation he had refused baths or showers. Review of the Bath Schedule provided by the facility revealed Resident #5 had baths/showers scheduled three times weekly on Tuesdays, Thursdays, and Saturdays. Review of the Bath Documentation for Resident #5 dated September 2023 to October 2023 revealed he had not received a bath three times weekly the weeks of 09/24/2023 through 10/21/2023. On 10/23/2023 at 8:20 a.m., an interview was conducted with Resident #5. He said he was supposed to receive a bath on Tuesdays, Thursdays, and Saturdays. He said he had not had a bath in 7 days and no staff had offered to bathe him. He said he reported to a nurse, but not sure who or when, that he had not received a bath. On 10/23/2023 at 2:22 p.m., an interview was conducted with S4CNA. She said the CNAs were responsible for documenting each time they bathed or showered a resident. She said Resident #5 required total assistance with ADLs. She said Resident #5 was supposed to receive a bed bath on Tuesdays, Thursdays, and Saturdays. She said Resident #5 did not refuse any baths for her. She said she was not sure the last time Resident #5 was bathed. On 10/23/2023 at 2:58 p.m , an interview was conducted with S5LPN. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She said if Resident #5 refused a bath, the CNA would notify her. She said she would then document the refusal in her Nurses' Notes. She said Resident #5 required total assistance with ADLs and should receive a bed bath three days a week. She said she was not aware of Resident #5 refusing any baths. On 10/24/2023 at 11:37 a.m., an interview was conducted with S6CNA. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She said Resident #5 was supposed to receive a bed bath on Tuesdays, Thursdays, and Saturdays. She said Resident #5 did not refuse baths for her. She did not know the last time Resident #5 was bathed. On 10/24/2023 at 12:23 p.m., an interview was conducted with S7CNA. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She said Resident #5 was supposed to receive a bed bath on Tuesdays, Thursdays, and Saturdays. She said she did not know the last time Resident #5 was bathed. On 10/23/2023 at 5:20 p.m., an interview was conducted with S3ADON. He said staff should offer the residents baths or showers three times weekly on their scheduled days. He said the CNAs were responsible for documenting when they gave each resident a bath or shower. He reviewed the provided bath/shower documentation dated October 2023 for Resident #4. He confirmed there was no documentation Resident #4 received a bath or shower from 10/01/2023 through 10/14/2023. He confirmed Resident #4 had not received a bath three times weekly the week of 10/15/2023 through 10/21/2023. He confirmed there was no documentation of refusals for Resident #4 for the month of October 2023. He reviewed the provided bath/shower documentation dated September 2023 to October 2023 for Resident #5. He confirmed Resident #5 had not received a bath three times weekly the weeks of 09/24/2023 through 10/21/2023. He confirmed the only documented bath refusal for Resident #5 was on 10/04/2023. On 10/23/2023 at 5:23 p.m., an interview was conducted with S2DON. She said staff should offer the residents baths or showers three times weekly on their scheduled days. She said the CNAs were responsible for documenting when they gave each resident a bath or shower. She reviewed the provided bath/shower documentation dated October 2023 for Resident #4. She confirmed there was no documentation Resident #4 received a bath or shower from 10/01/2023 through 10/14/2023. She confirmed Resident #4 had not received a bath three times weekly the week of 10/15/2023 through 10/21/2023. She confirmed there was no documentation of refusals for Resident #4 for the month of October 2023. She reviewed the provided bath/shower documentation dated September 2023 to October 2023 for Resident #5. She confirmed Resident #5 had not received a bath three times weekly the weeks of 09/24/2023 through 10/21/2023. She confirmed the only documented bath refusal for Resident #5 was on 10/04/2023. She confirmed Resident #4 and Resident #5 did not receive baths or showers appropriately and should have. On 10/23/2023 at 5:27 p.m., an interview was conducted with S1AA. He said the CNAs were responsible for documenting when they gave each resident a bath or shower. He reviewed the provided bath/shower documentation dated October 2023 for Resident #4. He confirmed there was no documentation Resident #4 received a bath or shower from 10/01/2023 through 10/14/2023. He confirmed Resident #4 had not received a bath three times weekly the week of 10/15/2023 through 10/21/2023. He confirmed there was no documentation of refusals for Resident #4 for the month of October 2023. He reviewed the provided bath/shower documentation dated September 2023 to October 2023 for Resident #5. He confirmed Resident #5 had not received a bath three times weekly the weeks of 09/24/2023 through 10/21/2023. He confirmed the only documented bath refusal for Resident #5 was on 10/04/2023.

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct iden...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement and monitor appropriate plans of action to correct identified quality deficiencies. The facility failed to ensure staff were monitored for providing and documenting ADL care for 2 (#4 and #5) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. This failed practice had the potential to effect all 53 residents who currently resided in the facility. Findings: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program revealed the following, in part: Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Policy Interpretation and Implementation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes for our residents. Five Strategic Elements: 2. Governance and leadership: c. Members of the facility leadership are accountable for QAPI efforts. 3. Feedback, data systems, and monitoring: a. Systems are in place to monitor care and services. c. Care processes and outcomes are monitored using performance indicators. e. Action plans are implemented to prevent recurrence of adverse events. Review of facility's Plan of Action/Continuous Quality Improvement, dated 09/19/2023, revealed the following, in part: Problem Area Identified: Opportunity for Improvement in ADL charting. Actions: Request MDS coordinator to assist with training sessions to improve upon accurate coding, using visual-aides and short training sessions. S2DON or designee to incorporate weekly audits into your quality assurance program, please track your data so that we can be sure that we are heading in the correct direction. Discuss progress with QA committee and continue to monitor until substantial compliance is achieved. Review of facility's Plan of Action/Continuous Quality Improvement, dated 09/19/2023, revealed the following, in part: 1. Residents state that showers are not being given according to the schedule. 4. S2DON/designee to audit a sample of 10 residents weekly to ensure they were offered a bath, and that it was documented appropriately three times a week for 4 weeks. The results of the audit will be reviewed by the interdisciplinary team at QAPI for three months. Revisions will be implemented if needed. Resident #4 Review of the Clinical Record for Resident #4 revealed she was admitted to the facility on [DATE] and had diagnoses which included Other Sequelae of Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, and History of Falling. Review of the MDS with an ARD of 09/11/2023 for Resident #4 revealed she had a BIMS of 12, which indicated she was moderately cognitively impaired. Further review revealed she required one person physical assist for bathing. Review of the Nurses Notes for Resident #4 dated October 2023 revealed no documentation she had refused baths or showers. Review of the Bath Schedule provided by the facility revealed Resident #4 had baths/showers scheduled three times weekly on Mondays, Wednesdays, and Fridays. Review of the Bath Documentation for Resident #4 dated October 2023 revealed no documentation Resident #4 received a bath or shower from 10/01/2023 through 10/14/2023. Further review revealed she had not received a bath three times weekly the week of 10/15/2023 through 10/21/2023. There was no documentation of refusals for the month of October 2023 for Resident #4. On 10/23/2023 at 1:45 p.m., an interview was conducted with Resident #4. She said she was supposed to receive a shower on Mondays, Wednesdays, and Fridays. She said she required staff assistance to shower. She said staff did not always offer her a shower on her scheduled shower days and she had only been receiving one shower a week. She said she had asked staff, but could not recall who, for a shower on her scheduled days and she was told they would get to it but then never did. She said she reported not getting her showers to her family. Resident #5 Review of the Clinical Record for Resident #5 revealed he was admitted to the facility on [DATE] and had diagnoses which included Other Cerebral Infarction, Other Chronic Pain, and Multiple Myeloma in Remission. Review of the MDS with an ARD of 10/01/2023 for Resident #5 revealed he had a BIMS of 15, which indicated he was cognitively intact. Further review revealed he required one staff member physical assistance for bathing. Review of the Nurses Notes for Resident #5 dated September 2023 to October 2023 revealed no documentation he had refused baths or showers. Review of the Bath Schedule provided by the facility revealed Resident #5 had baths/showers scheduled three times weekly on Tuesdays, Thursdays, and Saturdays. Review of the Bath Documentation for Resident #5 dated September 2023 to October 2023 revealed he had not received a bath three times weekly on the weeks of 09/24/2023 through 10/21/2023. On 10/23/2023 at 8:20 a.m., an interview was conducted with Resident #5. He said he was supposed to receive a bath on Tuesdays, Thursdays, and Saturdays. He said he had not had a bath in 7 days and no staff had offered to bathe him. He said he reported to a nurse, but not sure who or when, that he had not received a bath. On 10/24/2023 at 9:10 a.m., an interview was conducted with S3ADON. He said the facility identified problems with residents receiving and staff documenting baths and showers in September 2023. He said a QAPI plan was in place to ensure residents received their baths and showers as scheduled. He said a second QAPI plan was in place to ensure staff were documenting scheduled baths and showers for each resident. He said no specific staff member was in charge of monitoring and managing open/active QAPI plans for the facility, instead it was a collaborative effort. He said no specific staff member was made responsible for monitoring and tracking the documentation of the residents' scheduled baths and showers. He said a new paper documentation tool was implemented for the CNAs to complete after each residents' bath or shower in addition to the electronic documentation. He confirmed the new documentation tools reviewed in the morning meetings could not be located as no specific staff member was made responsible for the forms. He confirmed the QAPI plans had not been implemented or monitored as planned. On 10/24/2023 at 10:00 a.m., an interview was conducted with S2DON. She said the facility identified problems with residents receiving and staff documenting baths and showers in September 2023. She said on 09/19/2023, a QAPI plan was implemented to ensure residents received their baths and showers. She said on 09/19/2023, a second QAPI plan was implemented to ensure the staff were documenting baths and showers for each resident. She said a new paper documentation tool was implemented for the CNAs to complete after each residents' bath or shower in addition to the electronic documentation. She confirmed the new documentation tools reviewed in the morning meetings could not be located as no specific staff member was made responsible for the forms. She said no specific staff member was in charge of monitoring and managing open/active QAPI plans for the facility. She said it was a collaborative effort between herself, S3ADON, and S1AA. She confirmed she had not audited, tracked, or monitored resident baths and showers or the staff documentation of baths and showers per the QAPI plan. She confirmed the facility should follow their policy and procedure for their QAPI process. She confirmed their QA/QAPI system had not been effective. On 10/24/2023 at 2:40 p.m., an interview was conducted with S1AA. He said the facility identified problems with residents receiving and staff documenting baths and showers in September 2023. He said a bath/shower QA was implemented on 09/19/2023 and was currently ongoing. He said a second QA for documenting residents' baths/showers was implemented on 09/19/2023 and was currently ongoing. He said a new paper documentation tool was implemented for the CNAs to complete after each residents' bath or shower in addition to the electronic documentation. He confirmed the new documentation tools reviewed in the morning meetings could not be located as no specific staff member was made responsible for the forms. He confirmed there was no documentation of monitoring or auditing per the facility's plan of action for the QAPI plans. He said no training, mentioned in the action plan, had been provided to staff. He confirmed there were continued problems identified with bath/shower documentation which indicated the facility's QAPI process needed to be updated and modified.

Sept 2023 7 deficiencies

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 F0576 (Tag F0576)

Could have caused harm · This affected multiple residents

Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays for 3 (#12, #18, and #26) of 5 (#9, #12, #18, #20, and #26) residents reviewed for mail during...

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Based on record review and interviews, the facility failed to ensure residents received mail on Saturdays for 3 (#12, #18, and #26) of 5 (#9, #12, #18, #20, and #26) residents reviewed for mail during resident council. This deficient practice had the potential to affect 49 residents residing in the facility. Findings: Review of the facility's policy titled, Mail and Electronic Communication revealed the following, in part: Policy Interpretation and Implementation: 4. Mail packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). On 09/18/2023 at 1:43 p.m., during the Resident Council Meeting, Residents #12, #18, and #26 voiced concerns of not receiving mail on Saturdays. Residents #12, #18, and #26 stated mail delivered from the postal service on Saturdays was delivered to the residents on Mondays. On 09/18/2023 at 3:25 p.m., an interview was conducted with S3AD. She stated she was responsible for delivering mail to residents Monday through Friday. She stated mail delivered on Saturday was placed in S2SW's office mail box and delivered on Monday. She confirmed residents did not receive mail on Saturdays. On 09/18/2023 at 3:30 p.m., an interview was conducted with S2SW. She stated she was not responsible for resident mail, but she sometimes had mail in her office on Mondays. On 09/18/2023 at 3:46 p.m., an interview was conducted with an assisted living PCA for the facility. She stated she worked Saturdays and Sundays from 6:00 a.m. - 2:00 p.m. She stated the mail carrier put the mail in S2SW's mailbox Monday through Saturday. She stated the mail stayed in S2SW's office until Monday morning. On 09/18/2023 at 3:48 p.m., an interview was conducted with S1AA. He stated there was not a designated person or process to ensure residents received their mail on Saturdays. He confirmed the residents should have received mail on Saturdays.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and record reviews, the facility failed to ensure services were provided to meet quality professional standards for 7 (#7, #12, #21, #38, #39, #43, and #46) of 13 (#...

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Based on observations, interviews, and record reviews, the facility failed to ensure services were provided to meet quality professional standards for 7 (#7, #12, #21, #38, #39, #43, and #46) of 13 (#7, #12, #20, #21, #23, #26, #34, #38, #39, #43 #46, #154, and #155) residents reviewed for medication administration. Findings: Review of the facility's policy titled, Administering Medications revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 15) If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 16) The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. Review of the facility's policy titled, Documentation of Medication Administration revealed the following, in part: Policy Interpretation and Implementation: 2. Administration of medication must be documented immediately after it is given. An interview was conducted with S12LPN on 09/19/2023 at 8:04 a.m. She stated she had given all of her assigned residents their morning medications. An interview was conducted with S11ADON on 09/19/2023 at 8:19 a.m. He stated he expected the nurses to sign medications as administered as they were given. S11ADON reviewed the medication administration records for the following residents and confirmed their morning medications had already been given and were not signed as they were given: Resident #7: Ferrous Sulfate 325mg PO QD, Atenolol 100mg PO QD, Flonase Allergy Relief 50mcg two sprays into each nare QD, Lasix 40mg PO QD, Potassium CL ER 20meq PO QD, Lisinopril 20mg PO QD, Jardiance 25mg PO QD, Flomax 0.4mg PO QD, Gemfibrozil 600mg PO BID, Cymbalta 50mg PO BID, Metformin HCL 1,000mg PO BID, Gabapentin 100mg PO TID, and Methocarbamol 1,000 mg PO TID Resident #12: Amlodipine Besylate 10mg PO QD, Lisinopril 20mg PO QD, Multivitamin with Iron PO QD, Cetirizine HCl 10mg PO QD, Flonase Allergy 50mcg one spray in each nare QD, Clonidine HCl 0.1mg PO BID, Famotidine 20mg PO BID, Metformin HCl 1000mg PO BID Resident #21: Miralax Powder 17gm daily with water, HCTZ 25mg PO QD, Zinc Sulfate 50mg PO QD, Allopurinol 100mg PO QD, Colestipol HCl 1gm PO BID, Lisinopril 20mg PO BID, Vitamin C 500mg PO BID, and Gabapentin 300mg PO TID Resident #38: Flonase Allergy Relief 50mcg spray two sprays into each nare QD, Zyrtec 10mg PO QD, Norvasc 10mg PO QD, Miralax Powder one capful 17gm mixed well with 8 ounces of water daily, Labetalol HCL 100mg PO BID, Baclofen 20mg PO TID, Senna 8.6mg PO QD, and Multivitamin PO QD Resident #39: Biktarvy 50-200-25 mg tablet one tablet QD, Clopidogrel 75 mg one tablet PO QD, Miralax Powder one capful 17gm mixed well with 8 ounces of water QD, Cranberry 450 mg one tablet PO QD, Spiriva Inhaler 18 mcg cap, inhale two puffs into lungs QD, Metoprolol Succ ER 100 mg PO QD, Flomax 0.4 mg PO QD, Vimpat 100mg PO BID, Topamax 50mg PO BID, and Gabapentin 100mg one capsule PO TID Resident #43: Nicorette 2mg chewing gum every two hours x 6 weeks Resident #46: Lidocaine Patch An interview was conducted with S12LPN on 09/19/2023 at 8:25 a.m. She explained she had already given all residents on her hall their morning medications but she had not signed them as administered. She confirmed she had not signed the above residents' medications as she gave them and should have.

CONCERN (E)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

Based on policy review, observations and interviews, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked...

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Based on policy review, observations and interviews, the facility failed to ensure nurse staffing data, including facility name, current date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, was posted in a prominent location readily accessible to residents and visitors. This deficient practice had the potential to affect any of the 49 residents residing in the facility. Findings: Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers revealed the following, in part: Policy Statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: a. The name of the facility b. The date for which the information is posted c. The resident census at the beginning of the shift for which the information is posted. d. Twenty four (24) hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, CNA) and category (licensed or non- licensed) of nursing staff working during that shift. g. The actual time worked during that shift for which category and type of nursing staff. h. Total number of licensed and non- licensed nursing staff working for the posted shift. 7. The previous shift's forms shall be maintained with the current shift form for a total of 24 hours of staffing information in a single location. Once a form is removed, it shall be forwarded to the Director of Nursing Services' office and filed as a permanent record. 8. Records of staffing information for each shift will be kept for a minimum of eighteen (18) months or as required by state law (whichever is greater). An observation was made on 09/20/2023 at 9:15 a.m. of all common area walls visible to residents and visitors within the facility with no staffing information posted. An interview was conducted with Resident #12 on 09/20/2023 at 1:26 p.m. She stated she had never seen nursing staffing posted anywhere. She stated she would want to see how many CNAs and Nurses were working that day or for a certain shift. She stated it would help her determine how many to look for. An interview was conducted with Resident #18 on 09/20/2023 at 1:32 p.m. She stated she had never seen nursing staffing posted. She stated she would want to be able to see how many CNAs were present on any given day. An interview was conducted with S8DON on 09/20/2023 at 9:30 a.m. She stated the only place staffing was posted was in the CNA and Nurse Assignment book at the nurses' station. She confirmed the assignment book was not visible to residents or visitors and did not include the number and type of staff present, actual hours worked, or resident census. An interview was conducted with S11ADON on 09/20/2023 at 9:35 a.m. He confirmed the facility did not post nurse staffing information for the residents and visitors. An observation was conducted of the common areas of the facility with S1AA present on 09/20/2023 at 9:39 a.m. An interview was conducted with S1AA at that time. S1AA confirmed nurse staffing information was not posted. He stated prior to today, the total staffing of LPNs, RNs, and CNAs had not been posted in an area visible to the facility's residents and visitors and should have been.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on record reviews, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biolog...

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Based on record reviews, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure: 1. Insulin pen needles were primed prior to administration of insulin for 3 (#26, #34, and #155) of 3 (#26, #34, and #155) residents observed for insulin administration; 2. Physician Orders were verified prior to medication administration for 1 (#23) of 7 (#7, #20, #23, #26, #34, #154, and #155) residents observed during medication pass; and 3. A system was in place for nursing staff to accurately document the amount of insulin administered to each resident for 4 (#13, #26, #39, and #46) of 5 (#13, #26, #31, #39, and #46) residents reviewed for insulin administration. This had the potential to affect the 14 residents who received insulin in the facility. Findings: 1. Review of Novolin R Flexpen's Manufacturer's Insert revealed the following, in part: Instructions for use: Preparing you Novolin R Flexpen: A. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. Giving the airshot between each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: E. Turn the dose selector to select 2 units. F. Hold your Novolin R FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. Review of the NovoLog Flexpen's Manufacturer Insert revealed the following, in part: Preparing your NovoLog® FlexPen: A. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. B. Attaching the needle: Giving the airshot before each injection: Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units. F. Hold your NovoLog® FlexPen® with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. Review of the Humalog Kwikpen's Manufacturer's Insert revealed the following, in part: Preparing your Pen: Step 1: Pull the Pen Cap straight off. Wipe the Rubber Seal with an alcohol swab. Step 3: Select a new Needle. Pull off the Paper Tab from the Outer Needle Shield. Step 4: Push the capped Needle straight onto the Pen and twist the Needle on until it is tight. Priming your Pen: Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. Resident #26 Review of Resident #26's current Physician Orders revealed, in part, an order for Humalog 100units/mL per sliding scale. On 09/19/2023 at 11:49 a.m., and observation was made of S6LPN preparing and administering Resident #26's Humalog Insulin. S6LPN dialed up 6 units of Humalog Insulin. S6LPN did not prime the insulin pen needle prior to administering insulin to Resident #26. Resident #34 Review of Resident #34's current Physician Orders revealed, in part, an order for Novolog 100units/mL per sliding scale. On 09/18/2023 at 4:00 p.m., an observation was made of S15LPN preparing and administering Resident #34's Novolog Insulin. S15LPN dialed up 4 units of Novolog Insulin. S15LPN did not prime the insulin pen needle prior to administering insulin to Resident #34. On 09/18/2023 at 4:05 p.m., an interview was conducted with S15LPN. S15LPN confirmed she did not prime Resident #34's insulin pen needle prior to administering the dose and should have. Resident #155 Review of Resident #155's current Physician Orders revealed, in part, an order for Novolin R 100units/mL per sliding scale. On 09/20/2023 at 11:16 a.m., an observation was made of S12LPN preparing and administering Resident #155's Novolin R Insulin. S12LPN dialed up 8 units of Novolin R Insulin. S12LPN did not prime the needle prior to dialing the insulin. S12LPN administered Resident #155's insulin. On 09/20/2023 at 11:20 a.m., an interview was conducted with S12LPN. S12LPN confirmed she did not prime the insulin pen needle prior to dialing the insulin dose. S12LPN stated priming the insulin pen needle was not required. On 09/20/2023 at 11:23 a.m., an interview was conducted with S14RRN. S14RRN was made aware of the above observations. S14RRN stated insulin pen needles should have been primed prior to dialing up the dose to be administered. 2. Review of the facility's policy titled, Administering Medications revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 3.) Medications are administered in accordance with prescriber orders, including any required time frame. Resident #23 Review of Resident #23's current Physician Orders revealed, in part, an order for Senna Plus 8.6mg give two tablets to equal 17.2mg by mouth daily. On 09/20/2023 at 7:08 a.m., an observation was made of S12LPN preparing and administering medications for Resident #23. S12LPN removed Resident #23's medication blister packs and bottles from the medication cart. S12LPN proceeded to remove one tablet from each blister pack and medication bottle without checking the Administration Record for dosing. S12LPN failed to verify the number of tablets she administered was consistent with the Physician's Order. S12LPN administered the medications to Resident #23, omitting a tablet of Senna. On 09/20/2023 at 8:10 a.m., an interview was conducted with S12LPN. S12LPN confirmed she omitted one of Resident #23's Senna tablets. She confirmed she did not sign the medications as she prepared them. She confirmed Resident #23's physician order read to administer two Senna tablets to equal 17.2 mg. On 09/20/2023 at 8:19 a.m., an interview was conducted with S11ADON. He stated he expected the nurses to verify medications per Physicians' Orders as they were prepared. 3. Review of the facility's policy titled, Medication Administration revealed the following, in part: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. 3.) The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to ensure that it corresponds with the order on the medication sheet and the physician's order. Documentation: 2.) The dose and concentration of the insulin injection. Resident #13 Review of Resident #13's Medical Record revealed he was admitted to facility on 01/17/2012 with diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathic Arthropathy. Review of Resident #13's Physician's Orders revealed the following orders: 04/16/2022 Accuchecks AC/HS 04/16/2022 Administer Novolin R per the following sliding scale: <200 no coverage, 200-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, and >400 give 12 units and notify NP or MD. Review of Resident #13's August 2023 and September 2023 MARs revealed insulin was administered on the following dates without notation of the amount administered: 08/01/2023, 08/02/2023, 08/3/2023, 08/04/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/11/2023, 08/12/2023, 08/13/2023, 08/14/2023, 08/15/2023, 08/18/2023, 08/19/2023, 08/21/2023, 08/22/2023, 08/23/2022, 08/24/2023, 08/24/2023, 08/25/2023, 08/28/2023, 08/29/2023, 08/29/2023, 08/30/2023, 08/31/2023, 09/01/2023, 09/04/2023, 09/05/2023, 9/06/2023, 09/12/2023, 09/13/2023, 09/16/2023, 09/17/2023, 09/18/2023. Insulin administration was indicated by a documented injection site and initials on the MAR. Resident #26 Review of Resident #26's medical record revealed she was admitted to facility on 07/23/2023 with diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #26's Physician's Orders revealed the following: 08/03/2023 Accuchecks AC/HS 08/03/2023 Administer Novolin R per the following sliding scale: <200 no coverage, 200-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, and >400 give 12 units and notify NP or MD. Review of Resident #26's August 2023 and September 2023 MARs revealed insulin was administered on the following dates without notation of the amount administered: 08/02/2023, 08/03/2023, 09/04/2023, 09/05/2023, 09/06/2023, 09/07/2023., and 09/08/2023. Insulin administration was indicated by a documented injection site and initials on the MAR. On 09/20/2023 at 3:00 p.m., an interview was conducted with S18LPN. She stated insulin administration was documented on the electronic MAR. She confirmed the MAR did not have a place to document the actual dose of insulin administered to each resident. On 09/19/2023 at 2:30 p.m., an interview was conducted with S14RRN. She explained the process for nursing staff to document Sliding Scale Insulin administration on the Medication Administration Record. She stated the nursing staff would documented the time insulin was administered and the injection site, but there was no place that required the nurses to document the actual dose of insulin given. She confirmed the nurses had not been documenting the actual amount of insulin administered to a resident prior to today. On 09/19/2023 at 2:35 p.m., an interview was conducted with S11ADON. He stated when nursing staff document Sliding Scale Insulin on the Medication Administration Record they would document the time and the injection site, but there was no place to document the actual dose of insulin given. He confirmed the nurses had not been documenting the actual amount of insulin administered to a resident prior to today. On 09/19/2023 at 2:40 p.m., an interview was conducted with S8DON. She stated when nursing staff document Sliding Scale Insulin on the Medication Administration Record they would document the time and the injection site, but there was no place to document the actual dose of insulin given. She confirmed the nurses had not been documenting the actual amount of insulin administered to a resident prior to today. Resident #39 Review of Resident #39's Medical Record revealed she was admitted to facility on 02/19/2021 with diagnoses which included Type II Diabetes Mellitus with Hyperglycemia and Type II Diabetes Mellitus with Diabetic Polynephropathy. Review of Resident #39's Physician's Orders revealed the following: 08/24/2023 Accuchecks AC/HS. 08/24/2023 Administer Novolin R per the following sliding scale: <200 no coverage, 200-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, and >400 give 12 units and notify NP or MD. Review of Resident #39's August 2023 and September 2023 MARs revealed insulin was administered on the following dates without notation of the amount administered: 08/16/2023, 08/27/2023, 08/28/2023, 08/30/2023, 09/03/2023, 09/09/2023, 09/11/2023, and 09/16/2023. Insulin administration indicated by a documented injection site and initials on the MAR. On 09/19/2023 at 12:00 p.m., an interview was conducted with S10LPN. S10LPN stated she administered insulin to Resident #39 when her accucheck reading was above 200. She confirmed there was not a place on the MAR or in the resident's record to document the actual dose of insulin administered. On 09/19/2023 at 1:08 p.m., an interview was conducted with S9LPN. S9LPN stated she administered insulin to Resident #39 when her accucheck reading was above 200. She confirmed there was not a place on the MAR or in the resident's record to document the actual dose of insulin administered. On 09/19/2023 at 1:12 p.m., an interview was conducted with S5LPN. S5LPN stated she administered insulin to Resident #39 when her accucheck reading was above 200. She confirmed there was not a place on the MAR or in the resident's record to document the actual dose of insulin administered. On 09/19/2023 at 3:55 p.m., an interview was conducted with S1AA. S1AA confirmed, prior to today, he did not know the nurses were not documenting the insulin dose administered to the resident. On 09/20/2023 at 10:57 a.m., an interview with S1AA. He reported the facility added in a place for the nurses to document the actual insulin dose administered on the MARs. On 09/20/2023 at 11:49 a.m., interview with S6LPN. S6LPN confirmed prior to today, she was unable to document the actual dose of insulin administered to residents on the MAR. Resident #46 Review of Resident #46's Medical Record revealed she was admitted to facility on 04/03/2023 with diagnoses which included Type II Diabetes. Review of Resident #46's Physician's Orders revealed the following orders: 06/22/2023 Accuchecks AC/HS 06/22/2023 Administer Novolin R per the following sliding scale: <200 no coverage, 200-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, and >400 give 12 units and notify NP or MD. Review of Resident #46's August 2023 and September 2023 MARs revealed insulin was administered on the following dates without notation of the amount administered: 08/16/2023, 08/25/2023, 08/20/2023, 09/02/2023, and 09/04/2023. Insulin administration was indicated by a documented injection site and initials on the MAR. 09/20/2023 at 2:16 p.m., an interview was conducted with S12LPN. S12LPN confirmed she administered insulin to Resident #46 on 09/04/2023, for a blood sugar of 223 to the LLQ. She demonstrated the process for documentation of insulin administration on the electronic MAR. She confirmed there was no place to document the amount of Insulin administered. On 09/20/2023 at 02:03 p.m., an interview was conducted with S8DON. S8DON reviewed the MAR's for Resident's #13, #26, #39 and #46. She confirmed the residents received insulin on the above dates and there was no documentation to show the amount administered. She confirmed the amount of insulin should be documented when administered to ensure accurate dosing.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations and interviews, the facility failed to ensure drugs and biologicals used in the facility we...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart B) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure: 1.Inhalers, Insulin pens and Insulin vials were labeled with the date opened; 2.Insulin pens were labeled with the resident's name; and 3.Injectable Glucagon was not past the manufacturer's expiration date. Findings: Review of the facility's policy titled, Administering Medications revealed the following, in part: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 10) The expiration/ beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. An observation was conducted of Cart B on [DATE] at 9:50 a.m. The following was observed: Resident #33 -Spiriva Respimat 2.5 mcg per actuation. The medication was open, in use, and not dated to indicate when it was opened. Resident #27 -Wixela inhaler 250/50mcg per actuation. The medication was open, in use, and not dated to indicate when it was opened. Resident #2 -Dulera 200mcg/5mcg per actuation. The medication was open, in use, and not dated to indicate when the inhaler was opened -Combivent 20mcg/100mcg. The medication was open, in use, and not dated to indicate when the inhaler was opened. Resident #31 - Humalog Kwikpen 100units/mL was open, in use, and not dated to indicate when the insulin pen was opened. - Lantus Solostar 100unit/mL was open, in use, and not dated to indicate when the insulin pen was opened. Resident #24 - Lantus Solostar pen 100 units/mL was open, in use, and not dated to indicate when the pen was opened. Resident #34 - Novolog Flexpen 100units/mL was open, in use, and not dated to indicate when the insulin pen was opened. Resident #26 - Humalog Kwikpen - The name on the pharmacy label on the pen was illegible. Resident #31 - Humulin R 100unit vial was open, in use, and not dated to indicate when the vial was opened. Resident #11 - Humulin R 100 unit vial was open, in use, and not dated to indicate when the vial was opened. Resident #28 - Humulin R 100 unit vial was open, in use, and not dated to indicate when the vial was opened. House Account Glucagon Kit 1mg - The manufacturers label revealed an expiration date of [DATE]. An interview was conducted with S14RRN on [DATE] at 9:55 a.m. She confirmed the above listed insulin pens and vials were not labeled with the open date and should have been. She stated insulins should have been discarded 28 days after opening per the sticker on the insulins. She confirmed the Glucagon Kit was expired, and should not have been available for use on the medication cart. An interview was conducted with S13LPN on [DATE] at 10:15 a.m. She confirmed the above inhalers were not labeled with the open date and should have been. S13LPN verified she was unable to identify the name on the label of Resident #26's insulin pen. S13LPN confirmed the insulin pen should have been labeled.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professiona...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practice for 4 (#13, #26, #39,#46) of 14 sampled residents reviewed for documentation of insulin doses. The facility failed to complete, and accurately document, the insulin dosage administered to residents per the medication administration record. Findings: Review of the facility's policy titled, Insulin Administration revealed the following, in part: Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes. Documentation: 2.) The dose and concentration of the insulin injection. Resident #13 Review of Resident #13's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathic Arthropathy. Review of Resident #13's Physician Orders revealed an active order as of 04/15/2022 for Accuchecks AC/HS with Novolin R per sliding scale, not to be administered for blood glucose less than 200. Review of the current September 2023 MAR revealed the following: 09/02/2023 at 5:00 a.m. CBG of 106 documented as administered to left upper quadrant. On 09/20/2023 at 3:00 p.m., an interview was conducted with S18LPN. She confirmed she was working in the facility on 09/02/2023 and she was caring for Resident #13. She stated she did not give insulin for a blood sugar of 106. She stated she charted it that way due to the blood sugar needed to be documented. She stated the system allowed you to pick a site, and you must pick a site to move forward with documentation. S18LPN was unable to verify why she documented the Accucheck incorrectly. On 09/20/2023 at 3:10 p.m., an interview was conducted with Resident #13. He stated he was on several diabetic medications, including insulin to sliding scale. He stated he was aware when he received all of his medications, including insulin. He stated he would not let a nurse give him insulin if his blood sugar was less than 200. On 09/19/2023 at 2:30 p.m., an interview was conducted with S11ADON. He confirmed nursing staff was charting insulin administration on the MAR for Resident #13, and should have documented not given and entered a progress note. Resident #26 Review of Resident #26's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #26's Physician Orders revealed an active order as of 08/03/2023 for Accuchecks AC/HS with Novolin R per sliding scale, not to be administered for blood glucose less than 200. Review of Resident #26's Medication Administration Records for August/September 2023 revealed inaccurate documentation of insulin administered on: 08/04/2023 at 11:00 a.m. CBG 143 documented as administered to Right Lower Quadrant 08/07/2023 at 11:00 a.m. CBG 132 documented as administered to Left Upper Quadrant 08/08/2023 at 11:00 a.m. CBG 154 documented as administered to Right Lower Quadrant 08/09/2023 at 11:00 a.m. CBG 149 documented as administered to Right Lower Quadrant 08/11/2023 at 11:00 a.m. CBG 144 documented as administered to Right Lower Quadrant 08/14/2023 at 11:00 a.m. CBG 144 documented as administered to Right Lower Quadrant 08/15/2023 at 11:00 a.m. CBG 111 documented as administered to Right Lower Quadrant 08/16/2023 at 11:00 a.m. CBG 132 documented as administered to Left Lower Quadrant 08/18/2023 at 11:00 a.m. CBG 176 documented as administered to Right Lower Quadrant 08/21/2023 at 11:00 a.m. CBG 187 documented as administered to Right Lower Quadrant 08/22/2023 at 11:00 a.m. CBG 133 documented as administered to Left Upper Quadrant 08/23/2023 at 11:00 a.m. CBG 121 documented as administered to Right Lower Quadrant 08/24/2023 at 11:00 a.m. CBG 133 documented as administered to Right Lower Quadrant 08/25/2023 at 11:00 a.m. CBG 143 documented as administered to right Lower Quadrant 08/31/2023 at 11:00 a.m. CBG 190 documented as administered to Right Lower Quadrant 09/01/2023 at 11:00 a.m. CBG 164 documented as administered to Left Upper Quadrant 09/04/2023 at 11:00 a.m. CBG 166 documented as administered to Left Thigh On 09/19/2023 at 2:30 p.m., an interview was conducted with S11ADON. He confirmed nursing staff was charting insulin administration on the MAR for Resident #26, and should have documented not given and entered a progress note. Resident #39: Review of Resident #39's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Hyperglycemia, Type II Diabetes Mellitus with Diabetic Polynephropathy. Review of Resident #39's Physician Orders revealed an active order as of August 24, 2023 for Accuchecks AC/HS with Novolin R per sliding scale, not to be administered for blood glucose less than 200. Review of Resident #39's August and September 2023 MARs revealed inaccurate documentation of insulin administered on the following dates: 08/15/2023 at 8:00 p.m. CBG of 151 documented as administered to left lower quadrant 08/26/2023 at 4:00 p.m. CBG of 189 documented as administered to left lower quadrant 09/02/2023 at 11:00 a.m. CBG of 176 documented as administered to right lower quadrant 09/05/2023 at 11:00 a.m. CBG of 156 documented as administered to right lower quadrant 09/05/2023 at 8:00 p.m. CBG of 138 documented as administered to left upper quadrant 09/06/2023 at 11:00 a.m. CBG of 176 documented as administered to right lower quadrant 09/07/2023 at 8:00 p.m. CBG of 191 documented as administered to left upper quadrant 09/10/2023 at 5:00 a.m. CBG of 133 documented as administered to left thigh 09/10/2023 at 8:00 p.m. CBG of158 documented as administered to right thigh 09/11/2023 at 5:00 a.m. CBG of 131 documented as administered to left medial thigh 09/13/2023 at 8:00 p.m. CBG of 164 documented as administered to left upper arm 09/14/2023 at 8:00 p.m. CBG of 154 documented as administered to right upper arm 09/17/23023 at 5:00 a.m. CBG of 127 documented as administered to left upper quadrant On 09/19/2023 at 2:30 p.m., an interview was conducted with S11ADON. He confirmed nursing staff was charting insulin administration on the MAR for Resident #39, and should have documented not given and entered a progress note. On 09/20/2023 at 3:08 p.m., an interview was conducted with S10LPN. She confirmed she did not administer insulin to Resident #39 when her CBG was less than 200. On 09/20/2023 at 3:14 p.m., an interview was conducted with S17LPN. She confirmed she did not administer insulin to Resident #39 when her CBG was less than 200. On 09/20/2023 at 3:25p.m., an interview was conducted with S9LPN. She confirmed she did not administer insulin to Resident #39 when her CBG was less than 200. Resident #46 Review of Resident #46's medical record revealed he was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Diabetic Neuropathic arthropathy. Review of Resident #46's Physician Orders revealed an active order as of 06/22/2023 for Accuchecks AC/HS with Novolin R per sliding scale, not to be administered for blood glucose less than 200. Review of Resident #46's Medication Administration Records for August/September 2023 revealed inaccurate documentation of insulin administration on the following dates: 08/07/2023 at 11:00 a.m. CBG 178 documented as administered to Left Lower Quadrant 08/12/2023 at 8:00 p.m. CBG 113 documented as administered to Right Lower Quadrant 08/20/2023 at 5:00 a.m. CBG 121 documented as administered to Right Upper Quadrant 08/20/2023 at 11:00a.m. CBG 153 documented as administered to Right Lower Quadrant 08/21/2023 at 5:00 a.m. CBG 146 documented as administered to Right Upper Quadrant 09/08/2023 at 5:00 a.m. CBG 184 documented as administered to Right Lower Quadrant 09/10/2023 at 5:00 a.m. CBG 119 documented as administered to Right Upper Quadrant 09/11/2023 at 5:00 a.m. CBG 122 documented as administered to Right Thigh On 09/19/2023 at 2:30 p.m., an interview was conducted with S11ADON. He confirmed nursing staff was charting insulin administration on the MAR for Resident #46, and should have documented not given and entered a progress note. On 09/19/2023 at 2:30 p.m., an interview was conducted with S14RRN. She stated when nursing staff documented Sliding Scale Insulin on the MAR they documented the time and the site, but there was no system in place that required them to document the actual dose of insulin given. She stated they should be documenting the dose in the progress notes, and have not been. She also confirmed if a resident's Blood Sugar was less than 200, and no insulin was indicated per doctors' orders, they should document not given and the blood sugar reading obtained. On 09/19/2023 at 2:30 p.m., an interview was conducted with S11ADON. He stated if Insulin was not given, it should be documented on the medication administration record as not given with the blood sugar reading obtained. On 09/19/2023 at 2:30 p.m., an interview was conducted with S8DON. She confirmed if nursing staff did not give insulin due to sliding scale results, they should document not given. She confirmed their documentation system, AHT, was not set up to require an automatic entry for a dose administered. She confirmed the system should require an administration dose be documented.

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

Based on record reviews, observations, and interviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment...

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Based on record reviews, observations, and interviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 3 of 3 (#26, #34, and #155) residents reviewed for insulin administration. Findings: Review of the NovoLog Flexpen Manufacturer Insert revealed the following, in part: Preparing your NovoLog® FlexPen: A. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. Review of the Humalog Kwikpen Manufacturer's Insert revealed the following, in part: Preparing your Pen: Step 1: Pull the Pen Cap straight off. Wipe the Rubber Seal with an alcohol swab. Review of the Novolin R Flexpen Manufacturer's Insert revealed the following, in part: Instructions for use: Preparing your Novolin R Flexpen: A. Pull off the pen cap. Wipe the rubber stopper with an alcohol swab. Resident #26 Review of Resident #26's current Physician Orders revealed, in part, an order for Humalog 100units/mL per sliding scale. An observation was made on 09/18/2023 at 3:29 p.m. of S15LPN preparing and administering Resident #26's Humalog insulin. S15LPN removed Resident #26's insulin pen cap and attached the insulin pen needle without sanitizing the rubber stopper end of the pen. S15LPN administered Resident #26's insulin. Resident #34 Review of Resident #34's current Physician Orders revealed, in part, an order for Novolog 100units/mL per sliding scale. An observation was made on 09/18/2023 at 4:00 p.m. of S15LPN preparing and administering Resident #34's Novolog insulin. S15LPN removed Resident #34's insulin pen cap and attached the insulin pen needle without sanitizing the rubber stopper end of the pen. S15LPN administered Resident #34's insulin. An interview was conducted with S15LPN on 09/18/2023 at 4:05 p.m. She confirmed she administered insulin to Resident #26 and Resident #34 without sanitizing the stopper prior to attaching the needle. She confirmed she should have sanitized the stopper prior to attaching the needle. Resident #155 Review of Resident #155's current Physician Orders revealed, in part, an order for Novolin R 100units/mL per sliding scale. An observation was made on 09/20/2023 at 11:16 a.m. of S12LPN preparing and administering Resident #155's Novolin R insulin. S12LPN removed Resident #155's insulin pen cap and attached the insulin pen needle without sanitizing the rubber stopper end of the pen. S12LPN administered Resident #155's insulin. An interview was conducted with S12LPN on 09/20/2023 11:20 a.m. She confirmed she did not sanitize the insulin pen stopper prior to applying the insulin pen needle. S12LPN stated the insulin pen stopper did not have to be sanitized since the needle she was applying was sterile. An interview was conducted with S16RRN on 09/20/2023 at 11:22 a.m. She was notified of the above observations for Resident #26, #34, and #155. She stated insulin pen stoppers should have been sanitized prior to applying the insulin pen needle.

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's right to be free from neglect for 1 (Resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure a resident's right to be free from neglect for 1 (Resident #2) of 3 (Residents #1, #2, and #3) sampled residents reviewed for abuse and neglect. S5CNA failed to provide incontinent care to Resident #2 after a bowel movement. Findings: Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnosis, which included Alzheimer 's Disease with Late Onset. Review of the most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/12/2023, revealed Resident #2 had a BIMS (Brief Interview of Mental Status) of 4, which indicated she had severe cognitive impairment. Review of Resident #2's current care plan revealed she was incontinent of bowel and bladder and currently unable to improve continence status. Interventions included checking and changing the resident every 2 hours and maintaining the residents' dignity by keeping her clean and dry. On 08/10/2023 at 10:20 a.m., an interview was conducted with S4CNA. She said she remembered the incident on 07/19/2023 when Resident #2 was found in feces. She said her shift started at 6:00 a.m. and she began checking on the residents she was assigned to. She said when she walked into Resident #2's room she found her sleeping with feces on Resident #2's body and clothes, the walls, the dresser, the trash can and her wheelchair. She described the feces as hard and dried. On 08/14/2023 at 9:03 a.m., an interview was conducted with S5CNA. She confirmed she worked at the facility on 07/18/2023 from 10:00 p.m. to 6:00 a.m. She said she had been told in report Resident #2 did not need assistance and she only had to check on her. She said the last time she checked on Resident #2 was around 5:00 a.m. and she didn't have feces on her. On 08/14/2023 at 9:35 a.m., an interview was conducted with S3LPN. She confirmed she worked on 7/18/2023 from 10:00 p.m. until 6:00 a.m. and was responsible for Resident #2. She said S5CNA was the CNA responsible for Resident #2. She said she went into Resident #2's room around 4:30 a.m. and called S5CNA into the room because Resident #2 had feces on the floor. She said S5CNA told her she would clean Resident #2. 08/14/2023 at 9:45 a.m., an interview was conducted with S2ADON. He said he arrived to work around 5:45 a.m. on 07/19/2023. He said when he walked into Resident #2's room, there was stool on the floor and bed. He said the feces was dry, hard and smeared. He said S5CNA had already left the facility. He stated he reached S5CNA via telephone. S5CNA yelled and cursed at him over the phone and stated she was not responsible to care for Resident #2. He stated S5CNA was immediately terminated. On 08/14/2023 at 12:10 p.m., an interview was conducted with S1AADM. He confirmed Resident #2 was discovered with feces on her body, clothes, and smeared in her room on the morning of 07/19/2023. He confirmed it was neglect when S5CNA left Resident #2 in feces.

May 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a resident's Hospice company was notified of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a resident's Hospice company was notified of a change in condition for 1 (#8) of 6 (#3, #4, #8, #10, #12, #13) residents reviewed for wounds. The facility failed to ensure Hospice was notified of skin status changes. Findings: Review of the facility's policy for Change in a Resident's Condition or Status revealed, in part, the following: Policy Statement Our facility shall promptly notify the attending physician of changes in the resident's medical condition and/or status. Policy Interpretation and Implementation 2. A Significant Change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing clinical interventions; c. Requires interdisciplinary review and/or revision to the care plan. Review of the facility's policy for Pressure Ulcer/Injury Risk Assessment revealed, in part, the following: Documentation 12. Documentation in medical record addressing MD notification if new skin alteration noted . Reporting 2. Report other information in accordance with facility policy and professional standards of practice. 3. Notify attending MD if new skin alteration noted. Resident #8 Review of Resident #8's Clinical Record revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Adult Failure to thrive, Encephalopathy, End Stage Renal Disease, and Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of Resident #8's MDS, dated [DATE], revealed the resident could not complete the BIMS assessment. The resident required extensive one-person assistance with bed mobility and extensive two plus person assistance with transfers. On 05/24/2023 at 11:56 a.m., an observation was made of S4RN performing a body audit of Resident #8. She confirmed the following wounds were present: Left Great Toe DTI with eschar present; and Right Great Toe DTI. On 05/25/2023 at 9:25 a.m., an observation was made of S4RN obtaining wound measurements of Resident #8's bilateral great toe wounds. S4RN provided the following measurements and confirmed the left great toe had eschar and a foul odor. Left Great Toe: L3.0 x W2.0 cm; and Right Great Toe: L1.5 cm x W2.0 cm. Review of Resident #8's Physician Orders revealed no orders present for wound care to the left great toe DTI. On 05/25/2023 at 11:33 a.m., an interview was conducted with S4RN. She stated the resident was assessed by herself and the Hospice Nurse. She stated the Hospice Nurse was not aware of the resident's bilateral great toe DTIs. On 05/25/2023 at 1:02 p.m., an interview was conducted with Resident #8's Hospice Nurse and the Hospice DON. The Hospice Nurse stated the facility notified her of the bilateral great toe DTIs today (05/25/20023) while she was present in the facility. The Hospice Nurse stated the wounds were not new and looked like they had been there a while. The Hospice DON reviewed Resident #8's record and confirmed there was no documentation regarding notification of the bilateral great toe wounds. The Hospice DON confirmed if Hospice had been notified of the wounds it would have been present in the documentation.

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 F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure services were provided to meet quality profe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure services were provided to meet quality professional standards for 5 (#4, #8, #10, #12, #13) of 6 (#3, #4, #8 #10, #12, #13) residents reviewed for wounds by failing to ensure: 1. Weekly body audits were performed and documented; 2. Weekly wound measurements were obtained and documented; and 3. Accurate documentation of wounds. This deficient practice had the potential to affect a census of 56. Findings: Review of the facility's policy for Pressure Ulcer/Injury Risk Assessment revealed, in part, the following: Purpose The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries. Steps in the Procedure 4. b. Once inspection of skin is completed, document the findings on a facility-approved skin assessment tool. c. If new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alternation in skin. Documentation The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment(s) conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas) if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. 9. Observations of anything unusual exhibited by the resident. 10. The signature and title (or initials) of the person recording the data. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. 12. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan or care, if indicated. 13. Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care, if indicated. Reporting 2. Report other information in accordance with facility policy and professional standards of practice. 3. Notify attending MD if new skin alteration noted. Review of the facility's policy for Wound Care revealed, in part, the following: Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Documentation The following information should be recorded in the resident's medical record: 1. Wound care provided. 2. The date and shift the wound care was provided. 3. The name and title of the individual performing the wound care. 4. Any change in the resident's condition. 5. Assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. 6. How the resident tolerated the procedure. 7. Problems or complaints made by the resident during the procedure. 8. If the resident refused the treatment and why. 9. The signature and title of the person recording the data. Reporting Report other information in accordance with facility policy and professional standards of practice. Resident #4 Review of Resident #4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses; which included, in part, the following; Peripheral Vascular Disease; T2DM; and Acquired Absence of Left Leg Above Knee. Review of Resident #4's most recent MDS, with an ARD of 02/24/2023, indicated resident had a BIMS of 15, which indicated resident had no cognitive impairment. Further review revealed resident required extensive one person physical assist for locomotion, transfers, repositioning and ADLs. Review of Resident #4's Physician Orders revealed, in part, an order written on 01/20/2023 to perform complete body audit with vital signs every Saturday on 6:00 a.m. to 2:00 p.m. shift. Review of Resident #4's MAR/TAR revealed, in part, the following: May 2023 -Complete Body Audit checked off as performed with no documentation of findings on 05/06/2023, 05/13/2023 and 05/20/2023. No indication of performed or not performed on 05/27/2023. Review of Resident #4's Nurses Notes, dated 03/07/2023 through 05/25/2023, revealed, in part, only one nurses note documenting complete body audit results on 03/29/2023. Review of the Resident #4's Wound Care Assessment/Report revealed the resident had no documented Wound Care Assessment or Skin Assessment Reports dated 03/07/2023 through 05/25/2023. Resident #8 Review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses; which included, in part, the following; Adult Failure to Thrive, End Stage Renal Disease, and Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of Resident #8's Significant Change MDS, dated [DATE], revealed the resident could not complete the BIMS assessment. Further review revealed the resident required extensive one person assistance with bed mobility and extensive 2+ person assistance with transfers. Review of Resident #8's Physician Orders revealed, in part, the following: An order written on 03/10/2023 for Pressure Ulcer of Right Great Toe, Unstageable. Cleanse with wound cleanser, pat dry. Paint with betadine and leave open to air every Monday Wednesday Friday and as needed for soilage/dislodgement. An order written on 02/23/2023 to perform complete body audit with vital signs every Thursday on 10:00 p.m. to 6:00 a.m. shift. Review of Resident #8's Care Plan revealed, in part, the following: Pressure Ulcer: Unstageable (DTI) to Right Great Toe: Assess wound healing weekly; Assess changes in skin status that indicate worsening of pressure ulcer and notify the physician; Reassess treatment plan if no healing within 2-4 weeks. Resident is at risk for complications associated with hyper or hypoglycemia r/t DM: Monitor skin for breakdown with attention to feet. Review of Resident #8's MAR/TAR revealed, in part, the following: May 2023 - Complete Body Audit with no indication of performed or not performed on 05/04/2023 and 05/18/2023. April 2023 - Complete Body Audit with no indication of performed or not performed on 04/06/2023. Review of Resident #8's Nurses Notes, dated 04/01/2023 through 05/24/2023, revealed no documentation of complete body audit results. Review of the Resident #8's Wound Care Assessment/Report revealed the resident had no documented Wound Care Assessment or Skin Assessment Reports dated 03/07/2023 through 05/25/2023. On 05/24/2023 at 11:56 a.m., an observation of was conducted of S4RN performing a body audit of Resident #8. The following concerns were identified at that time and confirmed to be present: Left Great Toe DTI - Eschar Present; and Right Great Toe DTI. On 05/25/2023 at 9:25 a.m., an observation was made of Resident #8's bilateral great toe wounds with S4RN. S4RN measured and confirmed the wounds as follows: Left Great Toe - L3.0 x W2.0 cm; and Right Great Toe- L1.5 cm x W2.0 cm. She confirmed the left great toe had eschar and a foul odor. She confirmed the facility was unaware of these wounds. On 05/24/2023 at 3:40 p.m., an interview was conducted with S2ADON and S1DON. S2ADON confirmed the skin assessments were not performed if they were not documented in the progress notes. S2ADON confirmed he was not conducting wound measurements on Resident #8's left great toe DTI. S2ADON stated he did not see the one on the right great toe and was not aware Resident #8 had another DTI on the right great toe. He stated they were only treating the wound on the left great toe. S1DON and S2ADON both confirmed the right great toe DTI was missed. S1DON stated if the skin assessments and complete body audits were being completed as ordered, the right great toe DTI would have been identified earlier. On 05/24/2023 at 3:48 p.m., an observation was made of Resident #8's bilateral great toes with S2ADON. He confirmed the facility had not identified the DTI to the right toe and were only treating one on the left toe. He reviewed and confirmed they were treating the left toe and the Physician's Orders and the TAR were wrong. S2ADON confirmed he was the person who was entered the orders and made a mistake. Resident #10 Review of Resident #10's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses; which included, in part, the following; Obesity due to Excess Calories; Idiopathic Aseptic Necrosis of the Right Femur; Presence of Right Artificial Hip Joint; Pain in Right Hip; Aftercare following Joint Replacement Surgery. Review of Resident #10's MDS, with an ARD of 05/21/2023, indicated resident had a BIMS of 14, which indicated resident had no cognitive impairment. Further review revealed the resident required extensive two plus person physical assist for transfers and limited one-person physical assistance for locomotion, repositioning and ADLs. Review of Resident #10's Physician Orders revealed, in part, an order written on 05/15/2023 to perform complete body audit with vital signs every Monday on 2:00 p.m. to 10:00 p.m. shift. Review of Resident #10's MAR/TAR revealed, in part, the following: May 2023 - Complete Body Audit with no indication of performed or not performed on 05/15/2023 or 05/22/2023. April 2023 - Complete Body Audit checked off as complete on 04/03/2023 with no accompanying notes or documentation of findings attached to the check off. Review of Resident #10's Nurses Notes, dated 03/07/2023 through 05/25/2023, revealed, in part, the only documentation of complete body audit results were entered on 05/10/2023 and 04/06/2023. Review of the Resident #10's Wound Care Assessment/Report revealed the resident had no documented Wound Care Assessment or Skin Assessment Reports dated 03/07/2023 through 05/25/2023. Resident #12 Review of Resident #12's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, the following; Pressure Ulcer of Left Heel - Unstageable; Pressure Ulcer of Right Heel - Stage 4; Cerebral Infarction; Hemiplegia and Hemiparesis; Chronic Pain. Review of Resident #12's MDS, with an ARD of 03/17/2023, indicated resident had a BIMS of Blank, which indicated resident was not able to complete the assessment. Further review revealed resident required extensive two plus person physical assist for locomotion, transfers, repositioning and ADLs. Review of Resident #12's Physician Orders revealed, in part, an order written on 02/20/2023 to perform complete body audit with vital signs every Monday on 2:00 p.m. to 10:00 p.m. shift. Review of Resident #12's MAR/TAR revealed, in part, the following: May 2023 - Complete Body Audit checked off as complete on 05/03/2023, 05/10/2023, 05/17/202 and 05/24/2023 with no accompanying notes or documentation of findings attached to the check off. April 2023 - Complete Body Audit checked off as complete on 04/05/2023, 04/12/2023, 04/19/2023 and 04/26/2023 with no accompanying notes or documentation of findings attached to the check off. March 2023 - Complete Body Audit checked off as complete on 03/01/2023, 03/08/2023, 03/15/2023, 03/22/2023 and 03/29/2023 with no accompanying notes or documentation of findings attached to the check off. Review of Resident #12's Nurses Notes, dated 03/07/2023 through 05/24/2023, revealed, in part, no documentation of complete body audit results were entered. Review of the Resident #8's Wound Care Assessment/Report revealed the resident had no documented Wound Care Assessment or Skin Assessment Reports dated 03/07/2023 through 05/25/2023. Resident #13 Review of Resident #13's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses; which included, in part, the following; Osteomyelitis of Lower Leg; Acquired Absence of Left Leg Below the Knee. Review of Resident #13's MDS, with an ARD of 04/26/2023, indicated resident had a BIMS of 12, which indicated resident was cognitively intact. Further review revealed resident required one-person supervision/set up assist for locomotion, transfers, repositioning and activities of daily living (ADLs). Review of Resident #13's Physician Orders revealed, in part, an order written on 04/19/2023 to perform complete body audit with vital signs every Saturday on 6:00 a.m. to 2:00 p.m. shift. Review of Resident #13's MAR/TAR, dated 04/19/2023 through 05/25/2023, revealed, in part, the following: May 2023 - Complete Body Audit checked off as complete on 05/06/2023, 05/13/2023, 05/20/2023 with no accompanying notes or documentation of findings attached to the check off. April 2023 - Complete Body Audit checked off as complete on 04/22/2023 and 04/29/2023 with no accompanying notes or documentation of findings attached to the check off. Review of Resident #13's Nurses Notes, dated 04/19/2023 through 05/25/2023, revealed, in part, the only documentation of complete body audit results was entered on 05/01/2023. Review of the Resident #13's Wound Care Assessment/Report revealed the resident had no documented Wound Care Assessment or Skin Assessment Reports dated 04/19/2023 through 05/25/2023. On 05/24/2023 at 11:15 a.m., an interview was conducted with S4RN. She stated the floor nurses were responsible for performing weekly body audits of every resident residing in the facility then documenting the findings in the nurses notes. She stated any nurse should have learned in nursing school that simply checking a box on a MAR/TAR was not enough, they needed to describe and document what they found in their nurses notes. On 05/23/2023 at 10:30 a.m., an interview was conducted with S2ADON. He confirmed he was responsible for overseeing the facility's wound care. He confirmed every resident in the building should have a weekly skin assessment/body audit performed with the results documented in their nurses notes. He confirmed nurses should not just check it off on the MAR/TAR; there should be detailed documentation in nurses notes of what was found during that weekly audit/assessment. He confirmed the facility did not currently use the Wound Care Assessment/Report (WAM) tab within the EMR and had not used it in over 6 months. He confirmed there was no paper chart documentation or any other location skin assessment/body audits would be documented other than in the nurses notes section of the EMR. He confirmed Residents #4, #8, #10, #12 and #13 did not have the proper documentation of skin assessments/complete body audits but should. On 05/24/2023 at 2:00 p.m., an interview was conducted with S3NP. He confirmed he was the primary care provider who regularly rounded and cared for residents in the facility. He confirmed he would expect every resident within the facility to receive a complete head to toe body audit weekly. He confirmed there were orders in place to indicate this. He confirmed his expectation for carrying out the order appropriately would be for the weekly skin audits to be documented with details of what was found during the audit, not just a check off on the MAR with no indication of results.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident or representative received education regarding t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident or representative received education regarding the benefits and potential side effects of the influenza vaccination or were given the opportunity to refuse the influenza vaccination for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for vaccines. Findings: Review of Resident #2's Clinical Records revealed he was admitted to the facility on [DATE] with diagnoses which included, in part, the following: Cerebral Infarction, Dysphagia Secondary to CVA, Contractures, Palliative Care, Epilepsy, Seizures, and Right Sided Hemiplegia. Review of Resident #2's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/13/2022, indicated the resident had a Brief Interview of Mental Status (BIMS) of 00, which indicated the resident was severely cognitively impaired. Review of the facility's Influenza/Pneumococcal Immunization Consent Form for Resident #2 revealed: On 11/15/2022 verbal consent was given by Resident #2 and signed by S2ADON and vaccination administered. Review of the Facility's policy on Vaccination of Residents revealed the following, in part: 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccination . 2. Provision of such education shall be documented in the resident's medical record. 3. The resident or the resident's legal representative may refuse vaccines for any reason. On 02/07/2023 at 1:09 p.m., an interview was conducted with the Resident's #2' Responsible Party. He stated he and his sister had medical power of attorney for Resident #2. He stated he was not contacted about giving consent for the Resident to have a flu shot. He stated Resident #2 did not have the mental capacity to grant consent for a flu shot. He stated he would have refused the flu shot for the resident because of his weakened condition. On 02/07/2023 at 3:12 p.m., a phone interview was conducted with Resident #2's hospice nurse. She stated she frequently treated Resident #2. She stated Resident #2's speech was garbled and could not be understood. She stated she did not think Resident #2 could give verbal consent for the flu vaccine due to cognitive impairment. On 02/08/2023 at 10:14 a.m., an interview was conducted with S3MDS. She stated a resident with a BIMS of 00 cannot give informed consent and the Responsible Party should be notified for consent. On 02/08/2023 at 11:13 a.m., an interview was conducted with S2ADON. He confirmed he was responsible for the facility's infection control program. He stated he educated the residents on the benefits and side effects of vaccines. He stated he obtained consents or refusals of vaccinations and placed in the residents' charts. He stated that he called the resident's responsible parties to obtain consent if the resident was not cognitively able to give consent. He stated he received verbal consent from Resident #2 to receive the flu vaccine and administered the vaccine. He stated that he was unaware of Resident #2's cognitive status or BIMS. S2ADON confirmed he should have gotten the Resident's Responsible Party to sign the consent for Resident #2 prior to administering the flu vaccine. On 02/08/2023 at 1:28 p.m. an interview was conducted with S1DON. She stated a resident with a BIMS of 00 could not give consent for any vaccinations and Resident #2's Responsible Party should have been contacted for consent.

Jan 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and d...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity in a manner that promoted the maintenance or enhancement of his or her quality of life. This is evidenced by the closure of facility showers per administration resulting in the inability to receive showers when requested, to include, washing of hair, for 3 (3, 6 and R1) of 8 (1, 2, 3, 4, 5, 6, R1 and R2) residents reviewed for showers. Findings: A review of the facility's policy, Activities of Daily Living (ADLs), Supporting, revealed, in part, the following: Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. 7. The resident's response to interventions will be monitored, evaluated and revised as appropriate. A review of the facility's procedure, Bath, Shower/Tub Level II, revealed, in part, the following: Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. General Guidelines: Bed baths provided if unable to shower or unavailable. Resident 3 Review of Resident 3's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident 3's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/12/2022, indicated the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) of 15, which indicated he was cognitively intact. An interview was conducted on 01/04/2023 at 8:35 a.m. with Resident 3. He stated he hadn't been allowed to take a shower in over a month. He also said the alternative he was offered was to receive a bed bath, however, he felt that the CNAs did not do them well so he never got really clean. He also stated he gave himself a John Wayne bath daily then explained that meant he used a washcloth in his bathroom sink to wipe and clean his private areas so he wouldn't stink. He confirmed the entire situation made him feel nasty. Resident 6 Review of Resident 6's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident 6's most recent MDS, with an ARD of 12/12/2022, indicated the facility assessed the resident to have a BIMS of 11, which indicated she was moderately cognitively impaired. An interview was conducted on 01/03/2022 at 9:13 a.m. with Resident 6 who appeared visibly upset by the topic of the conversation and remained with a frown on her face throughout this interaction. She stated she had not been allowed a proper bath/shower in over a month. She stated she sure did miss getting her shower and confirmed a bed bath did not make her feel clean and refreshed. She said she did not know when they would be allowed to return to shower room but hoped it would be soon. An interview was conducted on 01/04/2023 at 9:57 a.m. with Resident 6. She confirmed she still had not received a proper shower or bath and had not been told by anyone at the facility when she would be able to receive one in the future. She then stated she was waiting anxiously because she did not feel clean without a good shower. She confirmed not being able to receive a shower had affected her well-being because she did not feel like herself. She confirmed it had been 6 weeks since her last shower. Random Resident R1 Review of Random Resident R1's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Random Resident R1's most recent MDS, with an ARD of 12/27/2022, indicated the facility assessed the resident to have a BIMS of 15, which indicated she was cognitively intact. An interview was conducted on 12/29/2022 at 9:30 a.m. with Random Resident R1. She stated she had not been allowed to shower or bathe, aside from using a rag and the sink in her room, since the first week of December. She stated she can only clean up so much with a washcloth and the sink and just didn't feel herself without being able to shower and wash her hair. She stated she had always taken great pride in her long, beautiful hair but it was far from beautiful right now and she did not like feel herself in this condition. She then motioned to her long hair with a frown on her face and stated she knew it smelled because there was no way to wash it in the sink in her room so she had to keep it pulled up in a knot on top of her head and she just couldn't handle it anymore. She stated she had called her daughter the week before Christmas to ask her to come pick her up early for the holiday weekend because she would need to bathe at her house before she would be comfortable going around the rest of their family members because she knew she stunk. She stated her daughter did just as she asked because she understood how embarrassed she was to go around anyone looking and smelling like that. She stated once she was able to fully clean herself at her daughter's house, she finally felt more like a real human being than she had felt since the beginning of December when they shut the showers down. She confirmed she had voiced her concerns and issues with not being allowed to shower and asked the facility to make an exception for her since she was independent but kept being told nothing would change; she would have to continue using the sink in her room until told otherwise. An interview was conducted on 01/04/2023 at 2:25 p.m. with Random Resident R1. She reported having been allowed to finally go to the shower room just after lunch today. She stated it felt great to finally be able to have clean hair again that didn't smell and have to be kept in a ponytail because she wasn't able to wash it and keep it clean. She also stated she felt like she was finally really clean for the first time since Christmas when she had to shower at her daughter's home while on leave from the facility. An interview was conducted on 01/04/2022 at 10:30 a.m. with S4LPN. She stated Random Resident R1 had previously reported to her she just didn't feel clean unless she took an actual bath or shower and was able to wash her hair. She confirmed the resident had mentioned how much it bothered her she was not able to wash her hair. She confirmed they were told the shower room was closed at the beginning of December. An interview was conducted on 01/03/2023 at 1:41 p.m. with S2ADON. He confirmed he made the decision to shut down the communal shower/bath room. He confirmed the communal shower/bath room had been closed since December 3, 2022 and remained closed at this time. An interview was conducted on 01/04/2023 at 9:50 a.m. with S5CNA. She confirmed multiple residents had fussed and voiced concerns about their hygiene since the shower rooms were closed. An interview was conducted on 01/04/2023 at 10:40 a.m. with S3SW. She confirmed she attended as many Resident Council Meetings as she could. She also confirmed the topic of the closed shower/bath room had been brought up by most of the residents in attendance for the December Resident Council Meeting. She stated residents wanted to know when showers would resume and when they could have their hair washed again. An interview was conducted on 01/05/2023 at 11:20 a.m. with S1ADM. She confirmed the facility closed the communal shower/bath room during the first week of December 2022 and it remained closed through January 4, 2022. She confirmed once the shower/bath room was closed no residents would be allowed to use them for any reason. She also confirmed the bathrooms located inside of each resident room only contained a toilet and a sink.

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 F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

Based on record review and interviews, the facility failed to ensure the effectiveness and maintain documentation of required training for all agency staff prior to allowing agency staff to perform re...

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Based on record review and interviews, the facility failed to ensure the effectiveness and maintain documentation of required training for all agency staff prior to allowing agency staff to perform resident care within the facility. An interview was conducted 01/05/2023 at 11:10 a.m. with S9HR. Record review of agency staff training was attempted with her at this time with no records produced. She confirmed she monitored training completion for facility staff but denied ever being in charge of doing so for direct care agency staff. She also confirmed she did not have any documentation of trainings for direct care agency staff. An interview was conducted on 01/05/2023 at 11:15 a.m. with S2ADON. Record review of agency staff training was attempted with him at this time with no records produced. He confirmed he and S10DON worked together to schedule direct care agency staff but neither of them verified required trainings had been completed prior to scheduling or allowing them to provide care to the residents residing in the facility. An interview was conducted on 01/05/2023 at 11:20 a.m. with S1ADM. She confirmed the facility used direct care agency staff on a regular basis. She confirmed the S10DON and S2ADON were in charge of scheduling direct care agency staff. She said she would not expect them to verify completion of required trainings before allowing an agency staff member to provide care to residents within the facility. She then confirmed she would be the person in charge of verifying a staffing agency was fulfilling their role in the contract, in terms of required trainings, education, certification verification, etc. Record review of agency staff training was attempted with her at this time with no records produced. S1ADM confirmed she did not request any paperwork or documentation as proof that direct care agency staff had completed all required education prior to being allowed to enter the facility to work. She stated when a new direct care agency staff member was scheduled, they would report for their shift and receive in-house shadowing with another staff member. She confirmed they received no formal sit down training. She confirmed she was not aware the facility was required to do so for direct care agency staff working within the facility.

Sept 2022 10 deficiencies

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately notify the physician after a cognitively impaired resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately notify the physician after a cognitively impaired resident exited the front door of the facility unsupervised for 1 (#48) of 3 (#25, #48, #54) residents sampled for elopement. Findings: A review of the facility's policy and procedure titled, Wandering and Elopements revealed, in part: 2.c. Inform the charge nurse or Director of Nursing that a resident is attempting to leave or has left the premises. 4.b. contact the attending physician and report findings and conditions of the resident; Review of the clinical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses, which included: Hypoglycemia, Pneumonia, Urinary Tract Infection, Fracture of Sacrum, Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, Diabetes Mellitus 2, Hypertension, History of Falling, Chronic Kidney Disease, Difficulty in Walking, Memory Deficit Following Cerebral Vascular Accident, Dementia in Other Diseases. Review of the MDS with an ARD of 08/31/2022 revealed Resident #48 had a BIMS of 4 which indicated she was severely cognitively impaired requiring limited assistance. Review of Resident #48's Care Plan revealed no care plan noted for wandering behavior. Review of Resident #48's Nurse's Notes revealed the following, in part: 08/11/2022 at 9:33 a.m. - Resident tends to wander, requires verbal cues via staff. 08/12/2022 at 10:07 a.m. - Resident has to be redirected via staff, tends to wander. 08/15/2022 at 1:34 p.m. - Resident is able to feed self, she does wonder and has a risk for falls. 09/17/2022 at 3:51 p.m. - Independent with transfers, mobile per wheelchair, and able to propel self. Resident is also ambulatory and has an unsteady gait and a fall risk. Resident will walk in room or on hallway without assist and easily directed back to room or chair. Resident usually goes out of side patio to go and smoke. Today she went out of door and was on the front porch. Daughter was in facility at this time. Resident stated, A lady let me out the front door. RP agrees with resident having a WanderGuard. 09/18/2022 at 2:32 p.m. - Charting for 10:30 a.m. resident wheeled from front of facility to nursing station per therapist stated, I just want to sit out on the front porch for a while. Informed resident she needed someone to sit out there with her and no staff was available at this time. Resident stated, I don't need nobody to come out there with me, Encouraged resident to go out on enclosed patio for safety precaution. Resident then wheeled to her room. 09/18/2022 at 2:47 p.m. - Charting for 10:50 a.m. Resident wheeled herself up to front door. Another resident had open door for her to go out on front porch earlier. Resident's daughter was called and made aware she was trying to get out and sit on front porch/patio without anyone with her. Informed her that Resident was non complaint and was still trying to go out front door. The daughter called on her cellphone and told her she did not want her to go and sit out on front patio. Resident stated, You think I stupid, of I am not stupid. I can go out there by myself. After several minutes talking with daughter, resident agreed for this nurse to wheel her back to her room. Stated, Ok I'll wait in my room for my daughter to come. A WanderGuard will be placed on Resident #48 on Monday. An interview was conducted on 09/21/22 at 11:38 a.m. with S4ADON. He said he was aware Resident #48 was out on the front patio unsupervised but it was not a concern because she was oriented times three. He stated he was not aware Resident #48 had a BIMS of 4. He said if she had a BIMS of 4, he might need to reconsider letting her out unsupervised. He confirmed he did not notify S3DON or S13NP that Resident #48 was outside unsupervised. An interview was conducted on 09/22/2022 at 1:49 p.m. with S3DON and S1ADM. Both stated they were not aware Resident #48 exited the front door of the facility unsupervised. S3DON stated she would expect S4ADON to inform her and S13NP if Resident #48 left the front door unsupervised.

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#52) of 3(#50, #5...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#52) of 3(#50, #52, #53) residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #52 reported a missing television. Findings: Review of the facility's policy titled Grievances/Complaints, filing revealed the following, in part: Policy: The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Resident #52 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Bipolar Disorder, and Other Specified Disorders of Bladder. Review of Resident #52's Quarterly MDS with an ARD of 09/08/2022 revealed Resident #52 had a BIMS score of 15 which indicated she was cognitively intact. Review of the grievance form dated 10/27/2021 for Resident #52 revealed the following, in part: 2 missing TV's- unknown size. 10/27/2021 Investigation/finding: Administrator verified resident did have television prior to evacuation. Item not present in building. Facility will replace item. 11/26/2021-Television has not been replaced or recovered at this time. Resident updated of status. An interview was conducted on 09/22/2022 at 10:00 a.m. with Resident #52. She said she had evacuated from the facility on 08/30/2021 after a hurricane damaged the facility. She said upon her return to the facility on [DATE], her television was missing from her room. She said she notified S22FADM and filed a grievance regarding her missing television. She said the facility did not replace her television and she eventually replaced it using her own personal funds. She said S22FADM told her the facility would replace the television but never did. An interview was conducted on 09/22/2022 at 10:15 a.m. with Resident #7. She said she had been Resident #52's roommate for 2 years. She said Resident #52 had a television missing from her bedside table upon return to the facility after evacuation. She said Resident #52 notified S22FADM of the missing television. She said Resident #52's television was never replaced as promised by the S22FADM. She said Resident #52 eventually purchased a television with her personal funds. An interview was conducted on 09/22/2022 at 11:00 a.m. with S1ADM. She said she spoke to S22FADM and he reported he was unsure if Resident #52's television had been replaced after she filed a grievance on 10/27/2021. S1ADM confirmed Resident #52's television had not been replaced and should have. She said the grievance had not been resolved timely.

CONCERN (D)

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident's right to be free from verbal an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident's right to be free from verbal and mental abuse by a staff member for 1 (#2,) of 3 (#2, #16, and #50) residents reviewed for abuse. Findings: A review of the facility's policy titled Abuse Prevention Program revealed in part: Policy Statement: Our residents have the right to be free from abuse This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, abuse . Policy Interpretation and Implementation: As part of the resident abuse prevention the Administration will: 1. Protect our residents from abuse by anyone including but not necessarily limited to: facility staff, Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnosis which included, in part: Tremor, Shortness of Breath, Abnormal Weight, Cough, Hypoxemia, Cognitive Communication Deficit, Chronic Obstructive Pulmonary Disease, Wheezing, Bipolar Disorder, Generalized Anxiety, Major Depressive Disorder, and Personal History of Traumatic Brain Injury. Review of the quarterly MDS with an ARD of 08/31/2022 revealed Resident #2 had a BIMS of 11 which indicated she was moderately cognitively impaired and required two person assist for ADL's. An interview was completed with Resident #2 on 09/19/2022 at 10:20 a.m. She said S11CNA was rude, rolled her eyes at me, was mean to me and told me I was biggity. She said the word biggity meant she was a racist and she was not a racist. She said it made her feel like S11CNA hated me and I am a burden. An interview was conducted on 09/21/2022 at 09:34 a.m. with S11CNA. During the interview Resident #2 was in the hallway in her wheelchair and was heard calling out for staff to help pull her up in the wheelchair. S7LPN was observed in the hallway, within 3 feet of the resident, standing with her back turned towards the resident. S7LPN failed to look at the resident or verbally respond to her call for help. S11CNA was observed to be in the hallway, within 4 feet of Resident #2 and failed to respond to her call for help as well. Surveyor asked S11CNA if she would like to postpone the interview in order to provide care to Resident #2. S11CNA rolled her eyes and huffed as she walked away to assist the resident. After S11CNA was observed attempting to pull Resident #2 up in her wheelchair, while out in the hallway, S7LPN instructed the CNA to bring the resident into her room. A few minutes passed and S11CNA exited from Resident #2's room and resumed the interview. Resident #2 was observed to wheel out of her room. S7LPN was heard saying I told you already twice to wait in your room for your medication in a forceful intimidating tone. S7LPN then moved the resident back into her room and was heard saying, come on and let's move her up so we can move on from this. After the staff left the room, Resident #2 wheeled back into her doorway and requested help placing her slippers on her feet. S7LPN was heard saying, You don't need your shoes in the hall, they are fine and I saw you kick them off in a forceful tone. S11CNA walked to help Resident #2 when S7LPN said, I got it because I see what Resident #2 is doing. S7LPN placed Resident #2's shoes back on her feet and Resident #2 was heard telling S7LPN thank you in a very polite tone. S7LPN was noted to keep her back turned away and did not respond to Resident #2. The interview then continued with S11CNA. S11CNA said Resident #2 was very impatient, manipulative and cussed a lot. Surveyor did not ask S11CNA if she called the resident biggity, however, S11CNA quickly stated she did not call Resident #2 biggity. Surveyor asked what the word, biggity, meant, S11CNA stated she did not know but her family used the word. She said she thought it meant smart mouth. She said when Resident #2 had behaviors she walked away and did not go into her room. An interview was conducted on 09/21/2022 at 10:00 a.m. with Resident #2, immediately following the above observation. She said when S7LPN spoke to her in the hall, she made her feel, low down, not worthy, and just really like crap. An interview was conducted on 09/21/2022 at 3:05 p.m. with S2RVPO. The above observation was reviewed with S2RVPO. He confirmed S7LPN was allegedly verbally abusive towards Resident #2. An interview was conducted on 09/23/2022 at 9:25 a.m. with S1ADM. The above observation was reviewed with S1ADM. She confirmed S7LPN was allegedly verbally abusive towards Resident #2. An interview was conducted on 09/23/2022 at 9:30 a.m. with S3DON. The above observation was reviewed with S3DON. She confirmed S7LPN was allegedly verbally abusive towards Resident #2.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure an alleged violation of verbal abuse was reported within 2 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure an alleged violation of verbal abuse was reported within 2 hours to the State Survey Agency for 1 (#F32) of 2 (#F2 and #F32) residents reviewed for abuse. Findings: Review of the facility's policy titled Abuse Investigation and Reporting revealed the following, in part: Reporting: 1. All alleged violations involving abuse will be reported by the facility Administrator, or his/her designee to local, state and federal agencies (as defined by current regulation). 2. Any alleged violation of abuse will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse or has resulted in serious bodily injury. Resident #F32 Review of the medical record for Resident #F32 revealed she was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/08/2022 revealed Resident #F32 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Review of the facility's Investigation Report for Resident #F32 dated 10/12/2022 revealed the following, in part: On 10/12/2022, Resident #F32 reported to S2AIT that S3CNA had cursed at her and that is verbal abuse during the previous overnight shift. Resident #F32 stated S3CNA had told her that she was getting on her everlasting god**** nerves. On 11/09/2022 at 10:09 a.m., an interview was conducted with Resident #F32. She said S3CNA cursed at her but she could not recall the exact date and time. She said when S3CNA assisted her with putting on a brief the CNA told her, you're getting on my everlasting god**** nerves. She said it made her angry and a little sad when S3CNA spoke to her that way. Resident #F32 confirmed she reported the verbal abuse to S2AIT. On 11/09/2022 at 08:51 a.m., an interview was conducted with S2AIT. He confirmed on 10/12/2022 Resident #F32 reported an allegation of verbal abuse by S3CNA. He said Resident #F32 told him S3CNA said you're getting on my everlasting god**** nerves. He said he thought the facility had 24 hours to report the allegation of verbal abuse since there was no serious bodily injury to the resident. On 11/09/2022 at 1:30 p.m., an interview was conducted with S1ADM. She said she was notified on 10/12/2022 at 6:00 p.m. of an allegation of verbal abuse involving Resident #F32 and S3CNA. S1ADM said S2AIT reported to her that S3CNA told Resident #F32 that you're getting on my everlasting god**** nerves. S1ADM confirmed that was considered an allegation of verbal abuse. She confirmed the State Survey Agency was notified of the allegation of verbal abuse on 10/13/2022 at 5:38 p.m. She said she thought she reported the allegation of verbal abuse on 10/12/2022 but could not provide any documentation to support it. She confirmed all allegations of abuse should be reported to the state survey agency within 2 hours. She confirmed the allegation of verbal abuse was not reported within the required time frame.

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

Based on observations, interviews, and record review the facility failed to implement a comprehensive person-centered care plan for each resident as evidenced by failing to ensure a Wanderguard was im...

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Based on observations, interviews, and record review the facility failed to implement a comprehensive person-centered care plan for each resident as evidenced by failing to ensure a Wanderguard was implemented as ordered for 1 (#25) of 2 (#25, #54) residents reviewed. The facility failed to ensure Resident #25 had a Wanderguard in place as ordered by the physician. Review of Resident #25's Face Sheet revealed a diagnosis of Unspecified Dementia without Behavioral Disturbance. Review of Resident #25's Quarterly MDS with an ARD of 07/20/2022 revealed a BIMS score of 04 indicating the resident had severe cognitive impairment. Further review revealed the resident used a wander/elopement alarm daily. Review of Resident #25's Elopement Risk Tool dated/timed 07/16/2022 at 12:39 p.m. revealed the facility assessed the resident as being an elopement risk. Review of Resident #25's September 2022 Physician's Orders revealed the following: 04/03/2022 Wanderguard Q Shift. Review of Resident #25's current Care Plan revealed the following: Resident is at risk for elopement - Wanderguard Q shift. On 09/22/2022 at 10:43 a.m., an observation was made of Resident #25 with S5LPN. S5LPN confirmed Resident #25 did not have a Wanderguard in place. S5LPN confirmed Resident #25 had an order for a Wanderguard. On 09/22/2022 at 11:53 a.m., an interview was conducted with S13NP. S13NP stated Resident #25 had Dementia and would often become confused. S13NP stated the Wanderguard had been ordered for Resident #25 and it should be on him. S13NP stated he was unaware the Wanderguard had been removed. On 09/22/2022 at 12:41 p.m., an interview was conducted with S4ADON. S4ADON confirmed Resident #25 should have a Wanderguard in place. S4ADON stated the Wanderguard kept the resident safe and prevented the resident from exiting the facility doors unassisted. On 09/23/2022 at 8:16 a.m., an interview was conducted with S3DON. S3DON stated she was unaware of Resident #25 not wearing a Wanderguard. S3DON reviewed Resident #25's Physician's Orders and confirmed there was an order for a Wanderguard. S3DON confirmed Resident #25 should have been wearing a Wanderguard.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to ensure all patient care equipment was maintained in sa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to ensure all patient care equipment was maintained in safe operating condition for all call light systems. This deficient practice had the potential to affect any of the 55 residents residing in the facility. Findings: Review of the facility's Policy titled Electrical Safety for Residents revealed, in part: The resident will be protected from injury assisted with the use of electrical devices, including electrocution, burns, and fire. Policy Interpretation and Implementation: 2. Inspect electrical outlets, extension cords, power strips, and electrical devices as part of routine fire safety and maintenance inspections. Review of the clinical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses, which included, in part: End Stage Renal Disease, Anoxic Brain Damage, Contracture Right Wrist, Essential Hypertension, Cognitive Communicative Deficit Review of the Quarterly MDS with an ARD (Assessment Reference Date) of 07/13/2022 revealed Resident #16 had a BIMS of 15, which indicated he was cognitively intact and he required Limited assistance with one person for bed mobility, transfers, ambulation in room, toileting, personal hygiene, and bathing. An interview and observation was conducted on 09/22/2022 at 9:18 a.m. of Resident #16's room. Resident #16 directed surveyor to look in his bathroom at the exposed wires and stated he was afraid of getting shocked. An observation was made of an electrical box with three exposed copper tip wires 4-6 inches in length above the toilet paper dispenser. An interview and observation was conducted on 09/22/2022 at 9:20 a.m. in Resident #16's bathroom. S8MAIN observed an electrical box with three exposed copper tip wires 4-6 inches in length above the toilet paper dispenser. S8MAIN confirmed he was responsible for maintaining the electrical safety and general maintenance of the facility. In addition, he confirmed the exposed wires was not safe and was an electrical safety hazard to Resident #16.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents from occurring for 2 (#48, #54) of 6 (#2, #16, #46, #48, #52, #54) residents reviewed for accidents, as evidenced by: 1) Failing to ensure a cognitively impaired resident (#48) was adequately supervised to prevent unsafe wandering and exiting the facility unsupervised; and 2) Failing to ensure the WanderGuard system was functioning properly for resident (#54). Findings: Resident #48 Review of the clinical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses, which, in part, included: Hypoglycemia, Fracture of Sacrum, Traumatic Subdural Hemorrhage with Loss of Consciousness, Diabetes Mellitus 2, Hypertension, History of Falling, Difficulty in Walking, Memory Deficit following Cerebral Vascular Accident, and Dementia. Review of the MDS with an ARD of 08/31/2022 revealed Resident #48 had a BIMS of 4, which indicated she was severely cognitively impaired, required limited assistance with transfers and was able to independently move around without assistance in the facility. Review of Resident #48's Care Plan, revealed she was not care planned for wandering behavior. Review of Resident #48's Nurse's Notes revealed the following, in part: 08/11/2022 at 9:33 a.m. Resident tends to wander and requires verbal cues via staff. 08/12/2022 at 10:07 a.m. Resident has to be redirected via staff, tends to wander. 08/15/2022 1:34 p.m. Resident is able to feed self, she does wonder and has a risk for falls. 09/17/2022 at 3:51 p.m. Resident is ambulatory and has an unsteady gait and a fall risk. Today she went out of door and was on the front porch. Daughter was in facility at this time. Resident stated, A lady let me out the front door. RP agrees with resident having a WanderGuard. 09/18/2022 at 2:32 p.m. Charting for 10:30 a.m. resident wheeled from outside on the front porch of facility to nursing station per therapist. Resident stated, I just want to sit out on the front porch for a while. Informed resident she needed someone to sit out there with her and no staff was available at this time. Resident stated, I don't need nobody to come out there with me. 09/18/2022 at 2:47 p.m. Charting for 10:50 a.m., resident wheeled herself up to front door. Resident's daughter was called and made aware she was trying to get out and sit on front porch/patio without anyone with her. Informed her that resident was non complaint and was still trying to go out front door. The daughter called the resident on her cellphone and told her she did not want her to go and sit out on front patio. Resident stated, You think I'm stupid, I am not stupid. I can go out there by myself. After several minutes, talking with daughter, resident agreed for this nurse to wheel her back to her room. Stated, Ok I'll wait in my room for my daughter to come. A WanderGuard will be placed on resident on Monday. On 09/19/2022 at 2:00 p.m., Resident #48 was observed wheeling herself to the front area of building. No staff noted at the front door. On 09/19/2022 at 2:15 p.m., Resident #48 was observed wheeling herself back to the nursing station area from the front door area. On 09/20/2022 at 9:00 a.m., surveyor was assisted into the locked building by an assisted living resident. The resident was observed entering a key code then opened the door. Once inside the facility, there were no observed staff present near the door. On 09/20/2022 at 3:15 p.m., Resident #48 was observed resting in bed with no WanderGuard noted. On 09/21/2022 at 7:00 a.m., surveyor was assisted into the locked building by a nursing home resident. The resident was observed entering a key code then opened the door. Once inside the facility, there were no observed staff present near the door. On 09/21/2022 at 8:19 a.m., Resident #48 was observed sitting in the dining room with no WanderGuard noted. On 09/21/2022 at 9:21 a.m., Resident #48 was observed sitting in the doorway of her room with no WanderGuard noted. An interview was conducted on 09/21/2022 at 9:22 a.m. with S5LPN. She explained Resident #48 wandered in the facility and required frequent redirection. An interview was conducted on 09/21/2022 at 9:28 a.m. with S11CNA. She explained Resident #48 was unsafe to be outside alone and needed supervision. She stated the resident self-propelled, wandered all day and it was worse when her daughter was not at the facility visiting. She confirmed on the weekend of 09/17/2022, she observed Resident #48 asking staff if she could go outside but no staff were available to supervise the resident. An interview was conducted on 09/21/2022 at 11:16 a.m. with S6LPN. She confirmed she took care of Resident #48 on 09/17/2022 and 09/18/2022. She said on 09/17/2022, she received a call from S4ADON informing her Resident #48 was found on the front porch unsupervised by the resident's representative. She confirmed she did not know Resident #48 had exited the building unsupervised. She also said on 09/18/2022 at 10:30 a.m., a therapy staff member returned Resident #48 to the nurse's station when she found her outside on the front porch. She confirmed she did not know Resident #48 had exited the building unsupervised. S6LPN stated she could not visualize the front door when she was working on her assigned hall, which made it difficult to supervise Resident #48. She confirmed she notified S4ADON by phone of the incident on 09/18/2022 and was told the facility would place a WanderGuard on Resident #48 on Monday, 09/19/2022 because the WanderGuard bracelets were locked up over the weekend. S6LPN said again on 09/18/2022 at 10:50 a.m. she observed Resident #48 at the front door and brought her back to her room. She confirmed Resident #48 was unsafe to be outside alone and she was not always able to supervise her. An interview was conducted on 09/21/2022 at 11:38 a.m. with S4ADON. He confirmed he was aware Resident #48 was on the front patio unsupervised on 09/17/2022 and 09/18/2022. He further stated, he was not concerned because she was oriented times three, was able to tell you what clothes she wanted to wear each day and what she wanted to eat. Therefore, he did not think she needed supervision outside on the front porch of the facility and did not put any new interventions in place. He confirmed he was not aware Resident #48's BIMS was 4. He then confirmed if she had a BIMS of 4, he might need to reconsider letting her out unsupervised. An interview was conducted on 09/21/2022 at 12:20 p.m. with S10MDS. She confirmed Resident #48's last MDS was completed on 08/31/2022 and her BIMS was a 4. She said her prior MDS assessment dated [DATE] indicated a BIMS of 3. She then confirmed a resident with a BIMS score of 3 to 4 was severely cognitively impaired and should not be outside of the facility unsupervised. An interview was conducted on 09/21/2022 at 1:49 p.m. with S15RT. She said Resident #48 was a fall risk and wandered. She confirmed on 09/18/2022 she observed Resident #48 out on the front porch when she was arriving to work for her shift. She stated she wheeled the resident inside to the nurse's station. She stated the residents nurse was not aware the resident had went outside unsupervised. She explained to Resident #48 it was unsafe for her to be outside unsupervised. On 09/22/2022 at 9:10 a.m., an observation was made of a visitor being assisted into the locked front door of the facility by an assisted living resident. The resident was observed entering a key code then opened the door. Once inside the facility, there were no observed staff present near the door. An interview was conducted on 09/22/2022 at 9:19 a.m. with S12CNA. She said she was agency staff and this was her first time working with Resident #48. She stated she did not know if Resident #48 had wandering behaviors or if she was an elopement risk but could ask a staff member on the assigned hall. An interview was conducted on 09/22/2022 at 9:35 a.m. with S16COTA. She confirmed Resident #48 was impulsive, was not cognitively intact, and was capable of rolling herself around in her wheelchair. An interview was conducted on 09/22/2022 at 10:30 a.m. with S13NP. He stated Resident #48 was cognitively impaired and confirmed it would not be safe for Resident #48 to be outside unsupervised. He stated he had not been made aware of wandering behaviors or elopement attempts on 09/17/2022 or 09/18/2022. He confirmed he should have been made aware in order to assess the resident and/or implement interventions. An interview was conducted on 09/22/2022 at 10:34 a.m. with S14ST. She confirmed Resident #48 had moderate to severe cognitive impairment, required constant redirection and was very impulsive. She said Resident #48 should not be outside on the front porch unsupervised because it was not safe. Resident #54 Review of the clinical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses, which, in part, included: Encephalopathy, Alzheimer's disease, and Cognitive communication deficit. Review of the MDS with an ARD of 09/12/2022 revealed Resident #54 had a BIMS of 2, which indicated she was severely cognitively impaired. Review of the Physician Orders revealed Resident #54's orders included, in part: WanderGuard to left ankle every shift. Review of the Care Plan for Resident #54 revealed the following, in part, Resident #54 was at risk for wandering. Interventions included, in part: Place resident in area where frequent observation is possible, place monitoring device on resident that sounds alarms when resident leaves building, designate staff to account for resident whereabouts throughout the day, alert staff to wandering behavior, and WanderGuard to left ankle every shift. Review of Nurses Note for Resident #54 dated 06/11/2022 revealed a WanderGuard was placed to resident's left ankle related to a diagnosis of Alzheimer's disease and constant wandering. An interview was conducted on 09/22/2022 at 10:40 a.m. with S23CNA. She stated she saw Resident #54 in her wheelchair in the facility's parking lot a few months ago. She stated she and S24CNA brought Resident #54 back inside the facility, and since her shift was completed she left for the day. An interview was conducted on 09/22/2022 at 10:50 a.m. with S4ADON. He stated Resident #54 had a WanderGuard in place. He stated there was never an incident were Resident #54 was found outside of the facility but the WanderGuard was placed because the residents daughter requested it. An interview was conducted on 09/22/2022 at 11:45 a.m. with Resident #54's daughter. She stated several months ago she was notified by S6LPN that a WanderGuard was placed on Resident #54 because she was found in the parking lot in her wheelchair. Following the WanderGuard placement, she stated she was sitting in her car in the facility's parking lot, observed a visitor open the door to go into the facility, and Resident #54 exited the facility while the door was opened. She confirmed the WanderGuard was on Resident #54 but did not work. She stated a CNA assisted Resident #54 back inside. She stated on 09/21/2022 at 3:00 p.m. she visited Resident #54 and the WanderGuard was not on. An interview was conducted on 09/22/2022 at 12:00 p.m. with S6LPN. She stated several months ago she received report that Resident #54 was found in the parking lot in her wheelchair and placed a WanderGuard on Resident #54. On 09/22/2022 at 12:30 p.m. the facility's WanderGuard operation system was tested with S5LPN and S3DON present and revealed the following malfunctions. Resident #54, who was identified as an elopement risk and wore a WanderGuard, was wheeled to the front door to test the system with S5LPN. When Resident #54 was wheeled within one foot of the front door, a warning light flashed on the entry/exit keypad to indicate the WanderGuard was detected. However, the audible alarm did not sound and the doors were able to be opened with the code. The resident was then wheeled back to allow the system to reset. When the resident was again wheeled forward within one foot of the doors, the same malfunction results were observed with a flashing light on the keypad, no audible alarm, and the doors were able to be opened with the code. An interview was conducted on 09/22/2022 at 12:35 p.m. with S3DON. S3DON verified Resident #54's WanderGuard system had failed to activate twice when she approached the front door. She confirmed the WanderGuard system should have audibly alarmed and the entry/exit door should have remained locked even after the code was entered. She further confirmed she was not aware Resident #48 exited the front door of the facility unsupervised and cognitively impaired resident with a BIMS of 4 should not be outside of the facility on the front porch unsupervised. An interview was conducted on 09/22/2022 at 12:36 p.m. with S2RVPO. He confirmed the facility's WanderGuard system was not working properly.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facili...

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Based on observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to properly label respiratory care equipment for 5 (#1, #2, #41, #43, and #51) of 5 residents investigated for respiratory care. Findings: On 09/19/2022 at 1:07 p.m., an observation was made of residents on Hall 2 that required oxygen. The observations revealed the following: Resident #1's filter on her oxygen concentrator was completely covered with a white fluffy substance and the oxygen tubing was not labeled with the date it was last changed. Resident's #2 and #41's nasal cannulas were not labeled with the date it was last changed. Resident's #43 and #51's nasal cannulas were on the floor and not labeled with the date it was last changed. On 09/20/2022 at 9:00 a.m., an observation was made of residents on Hall 2 that required oxygen. The observations revealed the following: Resident #1's filter on her oxygen concentrator was completely covered with a white fluffy substance and the oxygen tubing was not labeled with the date it was last changed. Resident's #2, #41, and #43's nasal cannulas were not labeled with the date it was last changed. Resident #51's nasal cannula was on the floor and not labeled with the date it was last changed. On 09/20/2022 at 12:47 p.m., an observation was made of residents on Hall 2 that required oxygen. The observations revealed the following: Resident #1's filter on her oxygen concentrator was completely covered with a white fluffy substance and the oxygen tubing was not labeled with the date it was last changed. Resident's #2, #41, and #43's nasal cannulas were not labeled with the date it was last changed. Resident #51's nasal cannula was on the floor and not labeled with the date it was last changed. On 09/20/2022 at 12:50 p.m., an interview was conducted with S4ADON. He verified Resident #51's nasal cannula was on the floor and not labeled with the date it was last changed. He verified the nasal cannula's for Residents #1, #2, #41, #43, and #51 were not labeled with the date it was last changed. He verified Resident #1's filter on her oxygen concentrator was covered in a white fluffy substance, and Resident #2's oxygen concentrator did not have a filter. He said oxygen tubing should be changed on the night shift every Sunday. He said it was the responsibility of the nurse to change the nasal cannula and label it with the date it was changed. He confirmed it was the responsibility of the nurse to change the filters on the oxygen concentrator and all oxygen concentrators should have filters on them.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with accepted principles for 1 (Cart 2) of 2 medication carts ...

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Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with accepted principles for 1 (Cart 2) of 2 medication carts and 1 of 1 medication storage refrigerator observed. The facility failed to ensure: a) Expired medications were not available for administration to residents; and b) Medications were labeled properly Findings: Review of facility's policy titled, Administering Medications Policy revealed the following: 10. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. The following observations were made and verified by S4ADON on 09/19/2022 at 12:20 p.m. of the facility's medication storage room refrigerator: One opened vial of Novolin R 100u/ml solution Insulin for Resident #48 with an opened date of 08/10/2022, which was greater than 28 days after opening. One opened vial of Levemir 100u/ml solution Insulin for Resident #32 with no opened dated documented by the nurse to indicate when the vial was opened. One opened vial of Flucelvax Quadrivalent Influenza Vaccine with an expiration date of 06/30/2021. Two unopened vials of Flucelvax Quadrivalent Influenza Vaccines with an expiration date 06/30/2022. Five syringes of Polyvalent Pneumovax Pneumococcal Vaccines with an expiration date 01/2022. One vial of Tuberculin Purified Protein Derivative Tubersol Vaccine with an opened date of 04/26/2022, which was greater than 28 days after opening. On 09/19/2022 at 12:27 p.m., S4ADON said Resident #48's Novolin R Insulin's opened date was greater than 28 days from when it was opened. He said Resident #32's Levemir Insulin should have been labeled with the opened date. He confirmed the Flucelvax Quadrivalent Influenza Vaccine, Polyvalent Pneumovax Pneumococcal Vaccines, and Tuberculin Purified Protein Derivative Tubersol Vaccine were available for use, but expired. He confirmed the expired vaccinations should have been removed from the medication refrigerator. The following observations were made and verified by S3DON on 09/19/2022 at 12:35 p.m. of Cart 2: One opened vial of Novolin R 100u/ml solution Insulin for Resident #47 with an opened date of 07/18/2022, which was greater than 28 days. One opened vial of Novolin R 100u/ml solution Insulin for Resident #50 with an opened date of 07/20/2022, which was greater than 28 days. One opened vial of Novolin R 100u/ml solution Insulin for Resident #48 with an opened date of 08/14/2022, which was greater than 28 days. On 09/19/2022 at 12:40 p.m., an interview was conducted with S3DON. She confirmed when multi-dose vials were opened, the date opened should be recorded on the vial. She further confirmed multi-dose medications expire 28 days after opening or by the manufacturer's expiration date, whichever occurred first.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observations, interview and record review, the facility failed to ensure storage and labeling of food in accordance with professional standards for food service safety. This deficient practic...

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Based on observations, interview and record review, the facility failed to ensure storage and labeling of food in accordance with professional standards for food service safety. This deficient practice was evidenced by the following: 1. Presence of improperly sealed, labeled and dated food items in the dry storage area and walk-in cooler of the facility's kitchen. 2. Presence of improperly stored food items in the walk-in freezer of the facility's kitchen. 3. Presence of expired food past opened label date in the dry storage area and walk-in cooler. S20DM confirmed 56 residents were served food from the facility's kitchen. Findings: Review of the facility's policy titled Food Receiving and Storage revealed, in part: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use bydate). 10. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/ walk-ins will not be overcrowded. 11. The freezer must keep frozen foods solid. Wrappers of frozen foods must stay intact until thawing. 13. Uncooked and raw animal products or fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. 14. e. Other opened containers must be dated and sealed or covered during storage. On 09/19/2022 at 09:00 a.m., an observation was made and confirmed during the initial kitchen tour with S20DM. Thirty boxes observed stacked on kitchen floor area around walk-in cooler and freezer. Walk-in freezer revealed the following: 2 boxes of frozen food on the floor of the freezer, and one package of frozen meat on floor under the shelf. Reddish frozen substance on top of one box of frozen meat stored below shelf. 1 frozen bag of chicken with a reddish crystalized substance coming out of bottom of bag about 1/2 inch in length Dry Storage area revealed the following: 2 packages of spaghetti noodles, opened and undated 4 packages of hot dog buns dated 08/06/2022, expired 2 packages of slider buns dated 08/06/2022, expired Walk-In Cooler revealed the following: 1 package hamburger buns dated with expiration date of 09/18/2022 1 package hamburger buns dated with expiration date of 09/14/2022 1 package of shredded cheese in clear zip-storage bag dated 08/09/2022 1 opened, unsealed, unlabeled or dated sliced ham package 1 sliced ham package with an expiration date of 09/18/2022 1 cheese box opened, undated, not sealed 4 coleslaw dressings, opened, expired on 07/18/2022 1 salad dressing, opened, expired on 07/05/2022 1 mustard dated 06/24/2022, opened and expired 1 container of pickles dated 06/10/2022, opened and expired 1 small mustard dated 07/29/2022, opened and expired 1 orange juice, opened, dated 07/29/2022 opened and expired 2 BBQ sauces dated 07/29/2022, opened and expired 1 jar of mayonnaise dated 07/29/2022, opened and expired 1 jar banana peppers dated 07/22/2022, opened and expired 1 container mayonnaise opened, dated 06/24/2022 opened and expired Low-fat cottage cheese, opened, dated 07/29/2022 and expired 1 pan of sliced tomatoes, covered with clear plastic wrap, undated and unlabeled On 09/19/2022 at 9:30 a.m. an interview was conducted with S20DM. S20DM verified items listed above in the walk in cooler and dry storage areas were improperly stored, or expired, and should have been discarded by the expiration date on the label. S20DM also verified the two boxes observed on the floor of the walk-in freezer should have been stored off the floor and the uncooked chicken noted in the clear zip lock storage bag should have been stored in a drip-proof container below any boxed frozen food items and they were not.

Pines Retirement Center of Baton Rouge

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The Ugly 73 deficiencies on record

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Pines Retirement Center of Baton Rouge

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