Every finding on record at Accura Healthcare of Shenandoah

Based on resident council meetings, Electronic Health Record review, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #1, #2, #12 and #28). The facility reported a census of 40 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/16/25 at 9:33 AM Resident #1 stated it took the staff longer than 15 minutes at least twice a week to answer her call light. Resident #1 stated the staff have told her it took a while to answer the call lights because there just wasn't enough staff. Resident #1 explained it took longer than 15 minutes to answer her call light when she was on the toilet a lot of the time. Resident #1 stated it has happened at least twice in the last 7 days. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/16/25 at 8:13 AM Resident #2 stated it had taken longer than 15 minutes for the staff to answer her light in the last 2 weeks a couple of times. Resident #2 stated she could not remember the exact dates. Resident #2 stated she could read the clock and knew it took longer than 15 minutes3. The Minimum Data Set (MDS) dated [DATE] documented Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/15/25 at 1:57 PM Resident #12 stated it takes forever for someone to answer her call light in the evening, especially when she is on the toilet. Resident #12 stated she has a push button clock that tells the time so she is exactly aware of how long it took the staff to answer the call light. Resident #12 pressed the button on the clock and the clock responded with 2:01 PM. Resident #12 stated it can take up to 45 minutes. Resident #12 stated it takes longer than 15 minutes almost nightly. 4. The Minimum Data Set (MDS) dated [DATE] documented Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/18/25 at 10:59 AM during a resident council meeting Resident #28 laughed and stated it would be nice if it only took 15 minutes to have a call light answered. Resident #28 stated it took longer than 15 minutes frequently to have the call light answered. Resident #28 stated it could take up to 45 minutes to have the call light answered.On 9/18/25 at 10:27 AM during a resident council meeting residents stated they had to call the nurses station with their phones because CNA's would come into the room, shut the call light off and never return. Review of documents titled, Grievance Forms documented on 8/7/25 a resident explained Certified Nurse Assistant (CNA) came into the room, shut off the call light and said they would be back and did not see her again for the rest of the day. On 7/30/25 documented CNA's come into the room turn off call light without addressing the problem. Staff tell the resident they would return but do not return. On 8/26/25 documented during care plan conferences call light wait times were brought up by multiple residents.Review of document titled, Resident Council dated 7/30/25 documented call light delays and response was a current concern that a grievance was filed for.On 9/16/25 at 2:55 PM Staff C, Registered Nurse (RN) stated did not think there was enough staff to provide adequate care to residents. Staff C stated taking residents to the bathroom and answering call lights could be difficult to complete in a timely manner because of the lack of CNA's at the facility. Staff C acknowledged call lights frequently last longer than 15 minutes. On 9/17/25 at 10:24 AM Staff D, MDS Coordinator acknowledged residents had voiced concerns in the resident council about the length of call light times. Staff D stated the residents had complained about the amount of time it takes to answer call lights. Staff D stated the management had talked about a call light audit but does not know where to find it or if it had been started. On 9/17/25 at 1:25 PM the Administrator stated she had heard some reports of call light wait times and wrote up a call light audit. The Administrator stated it had been reported during resident council there were extended call light wait times. The Administrator stated she would have to look at the audits to see if there were any concerning times. The Administrator stated the facility's expectation was call lights would be answered in under 15 minutes. On 9/17/25 at 6:52 PM the DON stated she had seen a grievance from a resident about call lights and asked the situation. The DON stated she spoke to all the staff during an in-service about answering the call light and during 2 huddles. The DON stated she spoke with the staff about leaving the call light on if they have not finished what they had been doing. The DON stated she went back to the resident that filled the grievance and asked if the call lights had gotten better and he had stated yes they have. The DON stated Staff L brought up notes with any concerns from resident council the morning after resident council. The DON acknowledged she did not review the actual minutes from the resident council meetings. The DON stated she did not remember Staff L voicing any concerns with call light from resident council. The DON stated she started a call light audit but did not put anything on a form. The DON explained she would go into a room, turn her stop watch on and time how long it took for the call light to be answered. The DON stated she did not have any call light responses longer than 8 or 10 minutes. The DON stated she did those audits morning and evening both. The DON stated her expectation was that call lights would be answered in less than 15 minutes.On 9/18/25 at 8:11 AM Staff A, Licensed Practical Nurse (LPN) stated the staff do the best they can to answer call lights. Staff A stated she could not remember any call lights specifically lasting longer than 15 minutes. Staff A stated she felt there was not enough staff to provide adequate care for the residents at the facility. Staff A stated all the baths do not get done, meals are served late, in the evening it seems if there was one more CNA the call lights would be answered quicker. On 9/18/25 at 8:33 AM Staff L, Director of Life Enrichment stated there had been hit or miss concerns during resident council meetings about delay in call light times. Staff L stated during resident council meetings residents reported when the call light was answered the CNA would enter the room, tell the resident they would be back later, the CNA would not return and the resident would have to turn the call light on again. Staff L stated during resident council it was reported that by the time the second light was turned on, the second time, the resident had soiled themselves already especially on the overnights. Staff L stated there are several 2 assist residents and he would say there should be more CNA's on the floor to care for the residents. Policy was not provided with regards to call light response.

Based on document review, staff interview and policy review the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 6 of 90 days reviewed (April 1 - June 30, 2025). The facility reported a census of 40 residents.Findings include:Review of the Payroll Based Journal (PBJ) staffing data report for the fiscal year quarter three (April 1st through June 30th, 2025) revealed there was no Registered Nurse (RN) hours for 04/20, 04/26, 05/11, 05/18, 05/31, and 06/21/2025.In an interview on entrance date 9/15/2025 the Administrator confirmed that the facility did not have RN coverage listed on the PBJ. The Administrator confirmed these dates, and revealed that the facility only had one RN at the facility during this time. The Administrator revealed that her expectation would be for 8 hours RN coverage per day. Review of a facility provided document titled, Facility Assessment with a completed date of 7/27/2024 revealed:Federal regulations will require that facilities must provide 3.48 hours per resident day (HPRD) of direct care with 0.55 HPRD from registered nurses (RNs) and 2.45 HPRD from nurse aides (CNAs, NAs, or medication technicians/aides). The remaining 0.48 HPRD can be a combination of nurse staff (RNs, LPNs/LVNs, or nurse aides) to comply with the minimum. Listed below are some tables the facility can utilize to help determine their staffing needs based on the Federal minimum staffing standards, however, if State regulations require a higher standard, then the higher standard should be met. The minimum staffing standard is considered the floor of the standard. Facilities with higher resident acuities and needs may need to adjust their staffing numbers higher than the minimum standard.

Based on observation, staff interviews, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by serving incorrect portion sizes for meals. The facility reported a census of 40 residents.Findings include:Continuous observation of lunch meal on 9/17/25 from 11:30 am to 2:30 pm revealed the following: Staff N, Dietary Cook/Aide placed 3 hot dogs into the blender to be pureed. After completing the process, the pureed food was transferred to a holding steel container without measuring the total volume of pureed food to be divided into 3 serving portions. Staff N continued to puree 3 servings of hot vegetables with 3 buns and prior to transferring the content into a steel container visualized the measurement marks on the blender and stated it was about 12 oz. Staff N completed serving lunch meal and stated she had served all pureed diets servings and had some left in the container. Along with pureed food items she also had mechanical soft diets for 3 residents and she also had left over hot dogs in that container. She stated she didn't know why she ended up having extra food left in the steel containers since she used the 8 oz portion scoops. She further stated she didn't use the volume chart at this facility but she did recall using such a chart to measure volume and divide between needed servings at a previous facility. In an interview with the Dietary Manager on 9/17/25 at 2:30 pm she stated that the cooks didn't use a food volume chart to measure altered food items but she will look into it. She then provided a pureed diet portion sizes/scoops chart and stated the chart will be used to measure the total volume of the food after it is pureed and then divided by the original number of potions. A review of the facility provided policy titled Policy & Procedure Manual, Portion Control dated 2021 documented: Individuals will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. Standardized recipes should be used to avoid waste caused by overproduction. Recipes should be adjusted as needed and the yield and serving size specified on each recipe. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so staff can refer to the proper portions for each diet. Food should be served with ladles, scoops, spoodles, and spoons of standard sizes. Scales should be used as needed to weigh meat portions. Scoops should be leveled off (not overflowing) for the most accurate portion size.a. Portions that are too small result in the individual not receiving the nutrients needed.b. Portions that are too large increase food costs as well as providing the individual more food than needed.Food and nutrition services staff will receive training on proper portion sizes at regular intervals by the director of food and nutrition services. The director of food and nutrition services, registered dietitian nutritionist (RDN) or designee will observe meals on a routine basis to assure quality control of portion sizes

Based on observations, staff interview, and policy review the facility failed to store food in accordance with professional standards. The facility reported a census of 30 residents.Findings include: On 9/15/25 from 11:00 am through 12:00 pm during initial kitchen tour observation revealed dry food storage items not stored properly:a. A box of white rice 25 lbs. half full lined with a blue plastic not sealed, open to air. b. 5 - 20 oz bottles of grape jelly and strawberry jelly expired.c. A box of Pan Asian sesame seed dressing 60 packets/box full expired 2/26/24. d. A box with Garden Wraps 12 inch containing 2 packs expired 10/22/24.e. A box of Catallia Premium Tortillas 8 inch 12 packs of 12/bag manufacturing date 3/17/25, box opened date 4/7/25, no date when to use by. f. A box of baking cocoa powder clear liner unsecured, open to air, labeled opened on 11/20/23. On 9/15/25 at 11:15 am in an interview with the Dietary Manager she revealed she wasn't aware the food items were expired or that the dry food storage area had to be checked for expired items regularly. She proceeded to discard expired food items and those that were not stored properly. A review of the facility provided policy titled Policy & Procedure Manual, Food Storage dated 2021 documented: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing.Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or crosscontamination.Food will be purchased in quantities that can be stored properly; and arranged in food groups for organized storage and inventory.Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages.All containers or storage bags must be legible and accurately labeled and dated.

Based on document review, staff interviews, and facility policy review the facility failed to demonstrate evidence of systematic identification of reporting, investigation, analysis, and prevention of adverse events. The facility failed to demonstrate the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility reported a census of 40 residents.Findings include:Review of facility's provider Centers for Medicare and Medicaid Services (CMS) report revealed repeated deficient practices identified during the facility's annual surveys completed 10/17/2024, 06/29/2023 and current survey:F658F812F880During an interview on 09/18/2025 at 1:16 pm the Administrator acknowledged the facility had repeat deficiencies. The Administrator stated they reviewed progress during monthly and quarterly Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) review meetings. She stated that recently there has been a noted improvement in several areas.A review of the facility provided policy titled Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) dated 5/23/23 documented the following: Purpose: To ensure facilities develop a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety.

Based on Medication Administration Record - Treatment Administration Record (MAR-TAR) review, Electronic Health Record (EHR) review, resident interviews, staff interviews and policy review the facility failed to provide dignity and respect during interactions with a resident and failed to provide medication when a resident requested for 1 of 16 residents reviewed (Resident #1). The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/16/25 at 9:38 AM Resident #1 stated a couple months ago Staff A, Licensed Practical Nurse (LPN) was going to give her a respiratory treatment and Resident #1 questioned Staff A about the amount of times a day the order was for. Resident #1 stated Staff A threw the nebulizer mask down and told her not to call her if she is short of breath because she would not help. Resident #1 stated Staff A also refused to put voltaren gel on her neck. Resident #1 stated she reported the incident to the Director of Nursing (DON) and there was a CNA present at that time. Review of Resident #1's EHR titled, Orders documented a physician's order for DuoNeb solution to inhale one vial twice a day for shortness of breath and diclofenac sodium (voltaren gel) to be applied to the right shoulder topically two times a day for pain.Review of Resident #1's MAR-TAR documented a physician's order for DuoNeb solution to inhale one vial twice a day for shortness of breath and diclofenac sodium (voltaren gel) to be applied to the right shoulder topically two times a day for pain.On 9/16/25 at 11:57 AM Staff B, Certified Nurse Assistant (CNA) stated she used to work the 2:00 PM -10:00 PM shift but she switched about a month ago. Staff B stated she had noticed a couple of times where staff were being short, unkind, and did not provide dignity or respect to the resident. Staff B stated she had reported a couple of the CNA's to the nurse and to the DON but had not gone to the Administrator. Staff B explained she had reported Staff A to the DON. Staff B stated Staff A was very short, rude and very snappy with the residents. Stated the nurse invalidated the residents feelings. Staff B stated Resident #1 told her Staff A refused to apply voltaren gel to the back of her neck and was short to her about a respiratory treatment in the past. Staff B stated she did not remember the dates but did discuss the incidents with the DON.On 9/16/25 at 2:55 PM Staff C, Registered Nurse (RN) stated she did not think there was enough staff to provide adequate care to residents. Staff C stated Resident #1 had complained to her that Staff A told her that she would not give her the voltaren gel that she had requested. On 9/17/25 at 10:24 AM Staff D, MDS Coordinator stated Resident #1 spoke to her about a nurse not providing medications when requested. Staff D explained Resident #1 stated she told Staff A that she did not want the breathing treatment at that moment and Staff A told her that she would not give it to her at all then. Staff D stated she thought there was something written up about it. Staff D acknowledged she reported the incident to the DON. Staff D stated she did not remember the date but the incident happened sometime last month. Staff D stated Resident #1 told her that she did not think that Staff A liked her. On 9/17/25 at 1:25 PM the Administrator stated the facility had reports of staff being short with some residents. The Administrator stated she thought there was a report that a nurse had said something to a resident but did not know if that was related to when the medication was due. The Administrator acknowledged there was corrective action that was being drafted but had not been completed. The Administrator explained the corrective action was for Staff A. The Administrator acknowledged the corrective action was related to Staff A telling Resident #1 if she did not take the breathing treatment at that time she, she did not want to hear she was having trouble breathing later and not applying voltaren cream to Resident #1's neck when requested. On 9/17/25 at 6:52 PM the DON stated she recently overheard Resident #1 talking to a CNA about who she could complain to about medications. The DON stated to the CNA to bring Resident #1 in right now. The DON explained Resident #1 told her Staff A told her if she did not take the breathing treatment now she didn't want to hear about her not taking it later. The DON stated Resident #1 also stated Staff A refused to apply voltaren gel to her back after going to the nurse's station. The DON stated she had just worked on a corrective action related to these incidents. The DON stated Staff E, Office Manager was going to come in and present the corrective action while she was on vacation. The DON acknowledged it is not always an opportune time when residents request medications but the residents have to know all their needs will be met. The DON stated Resident #1 came into her office and she seemed irritated. The DON acknowledged Resident #1 wanted the voltaren gel because she had a pain in her neck. The DON stated she told Resident #1 she would address the situation and Resident #1 seemed to be alright with the resolution. The DON explained she did not feel Resident #1 was provided the dignity and respect she deserved in those incidents.On 9/18/25 at 11:56 AM Staff F, Certified Nurse Assistant (CNA) stated she had not heard of any staff being short or rude to the residents. Staff F stated she watched Staff A not give the voltaren gel to Resident #1 when she requested the gel. Staff F stated she had to repeatedly ask nurse Staff A to put the gel on Resident #1's shoulders and knees. Staff F stated after the 6th time of asking Staff A did apply the voltaren gel to Resident #1. On 9/18/25 at 8:11 AM Staff A, LPN stated had worked at the facility about a year. Staff A stated she had not heard any staff being short with the residents or talking down to them. Staff A stated she had never heard of any staff talk down to the residents. Staff A stated she had not heard of any staff telling residents no to any requested medications. Staff A stated if there was the resident was probably requesting the medication too early. Staff A stated she had not told any residents that she would not give the residents Tylenol, breathing treatment or voltaren gel. Staff A stated she felt the staff treated the residents with dignity and respect at the facility. Review of policy revised 1/30/24 titled, Promoting / Maintaining Resident Dignity documented It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Respond to requests for assistance in a timely manner. Speak respectfully to residents; avoid discussions about residents that may be overheard. Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

Based on resident interview, staff interviews and document review the facility failed to ensure 1 of 1 resident's personal property was protected from loss or theft when Resident #32 reported a missing ring and necklace and no personal inventory sheet was completed upon entry to the facility or updated throughout time living at the facility. The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) dated [DATE] for Resident #32 documented a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. The MDS also documented an admission date of 11/21/22.On 9/15/25 at 3:19 PM Resident #32 explained she had a nice diamond necklace and her engagement ring that were missing since she had entered the facility. Resident #32 stated she had talked to the Administrator about the missing jewelry. Resident #32 stated a couple of nurses came in and looked through the drawers but did not find anything. Resident #32 stated her daughter was more upset than she was. Resident #32 stated she had a feeling someone took it. Resident #32 stated it had been quite a while since she saw the jewelry. Resident #32 opened the drawer in the table next to her chair to reveal a small box inside of another box with jewelry and stated this is where I kept my ring and the missing necklace for special occasions. Resident #32 stated she had brought the item to the facility when she moved into the facility. Resident #32 stated her son told her that she should be able to have the jewelry at the facility when she moved in and that she was not able to bring that much stuff. On 9/17/25 at 11:27 AM Resident 32's daughter and Power of Attorney (POA) stated Resident #32 had her original diamonds from her original wedding ring and had it reconstructed into more of a cocktail ring. Resident 32's daughter and POA stated Resident #32 had the necklace and ring when she entered the facility. Resident 32's daughter and POA stated she had a diamond necklace on a gold chain with 3/4 carat diamond that was a gift from her husband. Resident 32's daughter and POA stated both were missing. Resident 32's daughter and POA stated she talked to the Administrator about it and sent her a picture that she drew of it. Resident 32's daughter and POA stated she also looked through everything at home. Resident 32's daughter and POA stated she was told that the jewelry was not on Resident #32's inventory sheet. Resident 32's daughter and POA stated Resident #32 had worn it at the facility several times. Resident 32's daughter and POA stated Resident #32 was very private and did not want anyone to know the jewelry had come up missing. Resident 32's daughter and POA stated those are family heirlooms. Resident 32's daughter and POA stated she did not take those items home but looked there just in case and did not find them. Observation on 9/17/25 at 12:47 PM revealed an inventory sheet on the back of the door in Resident #32's room. The inventory sheet had 2 items on the sheet from 2024. Observation of Resident #32's room revealed numerous bracelets, earrings and numerous necklaces on a jewelry stand, picture frames, a telephone, a small indoor light lit tree with pumpkin ornaments and sunflowers. Review of document titled, Resident #32's Item Description List documented to write in all clothing items of resident and date when they were brought in. When you take things home please cross item out and initial and date it. Items on list Pink / silver dressy top dated 4/25/24 and 3 sweaters colors rust, white and light blue dated 9/16/25.On 9/17/25 at 10:24 AM Staff D, MDS Coordinator stated inventory was completed upon entrance. Staff D stated Resident #32 was missing a ring. Staff D stated it was brought up in a care conference that she was present at. Staff D stated it was reported to the Administrator and she had talked to Resident #32's daughter. Staff D stated she thought there was a grievance filled out. Staff D acknowledged she did not fill out a grievance form. Staff D stated the care conference was on 8/12/25. Staff D stated she did not know if the ring was found. Staff D stated she filled out a statement or questionnaire about the missing ring. Staff D stated it was not on the residents inventory. Staff D stated Resident #32 thought it was missing and her daughter thought she had taken it home.On 9/17/25 at 6:52 PM the DON stated she knew that Resident #32 reported a necklace and ring missing. The DON stated the room was searched with Resident #32's permission. The DON stated she had spoke with Resident #32's family about the incident to find out if they were taken home. The DON stated the family stated they did not take the items home. The DON stated after this incident the residents if they had anything of value in their room and offered them lock boxes. The DON stated the inventory sheet is part of the admission packet. The DON stated the inventory sheet is then placed on the back of the door so it could be updated. The DON stated it was everyone's responsibility to make sure the inventory sheet was filled out and updated. On 9/17/25 at 12:15 PM the Administrator stated the facility conducted closet audits and sent out letters to families to fill out the inventory sheet on the back of the door. The Administrator stated the staff are supposed to check off what the family had filled out on the inventory sheet to ensure the items match the inventory sheet. The Administrator acknowledged she did have a report of jewelry missing. The Administrator stated it was with Resident #32. The Administrator stated it was reported to a staff member by the daughter and Resident #32 that a ring and a necklace were missing. The Administrator stated she did not think there was any theft involved. The Administrator stated Resident #32 stated she had worn jewelry a couple years ago. The Administrator stated there was an inventory sheet on the back of Resident #32's door that the daughter was responsible to fill out. The Administrator stated that the investigation did not suspect any theft so the item was not replaced. The Administrator stated she did not speak to the family about the incident after the investigation was complete. The Administrator stated it was the facility's opinion the resident did not have the item at the facility. The Administrator acknowledged the initial inventory sheet from when Resident #32 had entered the facility was either not filled out or not completed appropriately. The Administrator stated she was unable to find any other inventory sheet except the sheet where the daughter had added the two items. The Administrator stated it was on the family to fill the inventory sheet out on admission and there was no expectation of staff to ensure that the inventory sheet is filled out. The Administrator stated nursing has been going over the inventory sheet with the family members. The Administrator stated the Admissions Agreement had language for the responsibility of the facility with regards to lost property. On 9/17/25 at 1:25 PM the Administrator stated she did not know if she did a grievance on the ring or if she just did the investigation. The Administrator stated she would have written up a grievance on the ring but she was trying to determine if it was reportable or not. On 9/18/25 at 8:11 AM Staff A, LPN stated one of the staff had mentioned Resident #32 was missing a necklace in the past. Staff A stated Resident #32 did have jewelry because they found a jewelry box in her trash can. Staff A stated one of CNA had found the jewelry in the trash can. Staff A stated there was a box in the cabinet and she told every nurse that came on duty about it. Staff A stated an agency CNA found the box in the trash can. Review of investigation dated 8/13/25 documented the facility had notified Resident #32 daughter the inventory sheet did not have the missing jewelry documented on it. The investigation documented Resident #32's daughter was advised any items brought in the facility need to be added to the inventory sheet so that the facility was aware of what Resident #32 had in the event something was missing. The investigation documented Resident #32's daughter verbalized understanding. Review of document titled, Admissions Packet documented the facility shall not be liable for loss or damage to the resident's property caused by fire, theft, or other casualty, nor for any injuries from the use of the facility by the resident.

Based on Medication Administration Record (MAR) - Treatment Administration record (TAR), Electronic Health Records (EHR) review, resident interviews, staff interviews and policy review the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing the use of insulin for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 9/16/25 at 9:36 AM Resident #1 stated she had not been on insulin since being at that facility. Resident #1 stated she used to be on Ozempic. Review of Resident #1's MDS dated [DATE] documented 1 day insulin injections were received during the last 7 days and no order for insulin.Review of Resident #1's EHR titled, Orders documented no current order for insulin.Review of Resident #1's EHR titled, Orders documented an order for Ozempic subcutaneous solution inject 2 mg subcutaneously discontinued 7/17/25.Review of Resident #7's MAR - TAR for the month of June, July, August and September revealed no orders for insulin.On 9/17/25 at 10:01 AM Staff D, MDS Coordinator / RN stated Resident #1 was on Ozempic and then her insurance would not cover the medication. Staff A stated Ozempic was discontinued. Staff D stated Resident #1 was on Ozempic until 7/17/25. Staff A stated she was told that Ozempic was an insulin. Staff D explained Ozempic was on the insulin medication list when she did the initial training on MDS. On 9/17/25 at 1:48 PM Staff G, Nurse Consultant acknowledged Ozempic was not a type of insulin and would not be identified as insulin on the MDS. Staff G explained Ozempic was not considered an insulin according to the Resident Assessment Instrument (RAI) manual either. Review of policy updated 4/25 titled, Conducting an Accurate Resident Assessment documented the purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. A registered nurse will coordinate the RAI completion process with the appropriate participation of health professionals. The registered nurse is responsible for certifying that the assessment has been completed.

Based on clinical record review, document review and staff interviews, the facility failed to refer a resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who had an identified mental disorder, intellectual disability, or other related condition that was not addressed on PASRR completed prior to admission to the facility, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 resident (Resident #2) reviewed for PASRR requirements. The facility reported a census of 40 residents.Findings include:The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS revealed Resident #2 had a diagnosis of bipolar disorder upon admission to the facility on 7/10/25.Review of the document dated 7/1/25 titled, Notice of PASRR Level 1 Screen Outcome documented no diagnosis of bipolar under the diagnosis of mental health diagnoses portion of the screening. On 9/17/25 at 10:00 AM Staff D, MDS Coordinator stated bipolar disorder should have been identified on the PASRR for Resident #2 upon admission to the facility. Staff D stated a new PASRR would be completed when there were any medication changes. Staff D stated that PASRR was completed at the hospital for Resident #2 prior to admission to the facility. Staff D stated when residents come to the facility from the hospital she tried to review all diagnoses to ensure the appropriate diagnoses are identified Staff D acknowledged Resident #2 did not have the diagnosis of bipolar disorder on her PASARR that was completed 7/1/25. Staff D explained the diagnosis should have been on the PASRR dated 7/1/25.On 9/17/25 1:58 PM Staff G, Nurse Consultant stated it was her expectation that Resident #2 would have the diagnosis of bipolar disorder documented on the PASSR. Staff G stated the missed diagnosis should have been noticed and submitted upon admission to the facility. Staff G acknowledged Resident #2 had a diagnosis of bipolar disorder. Staff G acknowledged Resident #2's PASSAR dated 7/1/25 did not have the diagnosis of bipolar disorder documented under the mental health diagnoses portion. On 9/17/25 at 5:58 PM the DON documented in an email the facility did not have a policy on PASRR completion.

Based on clinical record review, observations, staff interviews, and facility policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #35) requiring the use of oxygen. The facility reported a census of 40 residents.Findings include: The Minimum Data Set (MDS) for Resident #35 dated 8/8/25 documented admission to the facility on 7/24/23. The MDS documented the need for oxygen in the last 14 days.The Care Plan dated 11/24/23 revealed interventions for respiratory abnormalities related to oxygen dependance to change oxygen tubing on concentrator including humidifier bottle on Sunday night shift. The Medication Administration Record (MAR) for the month of September of 2025 documented an order to change oxygen tubing, humidifier, and clean concentrator every Sunday, every night shift for protocol, start date 6/1/25. Documented dates of completion were 9/7, 9/14. During an observation on 9/15/25 at 3:10 pm the oxygen concentrator in Resident #35's room was set to 1L/min with a humidifier bottle containing sterile water at about 1/4 of the bottle full, dated 9/8/25. The tubing connecting the humidifier bottle to the oxygen concentrator was also dated 9/8/25. The tubing from the humidifier bottle connecting the nasal cannula was dated 9/15/25. Observation on 9/17/25 at 9:50 am revealed the same dates on the humidifier bottle and tubing as on the initial observation. In an interview on 9/17/25 at 10:45 am with Staff M, Licensed Practical Nurse (LPN) stated the tubing was scheduled to be changed every Sunday night and all components of the oxygen therapy needed to be changed and labeled with a date and staff initials. In an interview on 9/18/25 at 11:00 am with the facilities Infection Preventionist, she confirmed Sunday overnight staff were supposed to changed oxygen tubing and humidifier sterile water and date it. Facility provided policy titled Respiratory Equipment Cleaning Procedure updated 11/13/24 documented the following: a) O2 tubing, nasal cannula/mask will be changed weekly. O2 tubing will, also, be changedwhen tubing (nasal prong area) is noted lying on the floor.c) Pre-filled Humidifier bottle needs to be replaced weekly & prn (date and initial). RefillableHumidifier receptacle needs to be cleaned weekly.

Based on observations, Medication Administration Record / Treatment Administration Record (MAR/TAR) review, Electronic Health Record (EHR) review, policy review, and staff interviews the facility failed to provide appropriate infection prevention practices when blood glucose sample was obtained and when providing care to a residents on Enhanced Barrier Precautions (EBP) for 2 of 4 residents reviewed (Resident #4 and #8). The facility reported a census of 40 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #4's EHR titled, Orders revealed a physician's order with a start date of 3/26/25 for NovoLog injection solution with siding scale 4 times a day.Review of Resident #4's MAR-TAR documented a physician's order with a start date of 3/26/25 for NovoLog injection solution with siding scale 4 times a day.Observation on 9/16/25 at 7:18 AM of Staff C, Registered Nurse (RN) complete the administration of medications to Resident #4 and obtain a blood glucose sample. Staff C obtained insulin pens, completed hand hygiene, applied gloves, utilized alcohol wipe to cleanse the tip of the insulin pen, Staff C wasted 2 units to ensure patency, dialed up basaglar 35 units, knocked on residents door, placed glucose monitor on plastic container on residents bedside table, no barrier placed on the container, medication handed to resident in medication cup, resident self administered oral medication, left room, removed gloves, obtained breathing treatment from medication cart, applied gloves, completed no hand hygiene, entered room, cleansed 5th digit on Resident #4's left hand, obtained blood sample, 169 blood glucose, area on left thigh cleansed with alcohol wipe, insulin administered, placed nebulizer mask on resident, removed gloves, exited the room, opened medication cart, placed insulin back into medication cart, completed hand hygiene, placed blood glucose machine on the medication cart did not cleanse, left blood glucose machine on the medication cart and moved to the next resident's room. On 9/17/25 at 12:00 PM Staff H, Licensed Practical Nurse (LPN) acknowledged all the residents used the same blood glucose machine. Staff H stated after use on a resident the blood glucose machine was wiped down for 5 or 6 minutes with a moist wipe. Staff H stated the blood glucose machine is then wrapped in a wipe and left to sit. Staff H acknowledged the sanitization wipes that were utilized had directions that documented once item was cleansed it was to remain wet for 2 minutes to be effective in sanitization.On 9/17/25 at 6:52 PM the DON stated she expected there would have been a barrier placed when the glucose machine was brought into the room and the glucose machine should be cleaned once the machine was returned to the medication cart and left moist for 2 minutes according to the cleansing wipes. On 9/18/25 at 8:11 AM Staff A, LPN stated after taking the resident's blood glucose sample she would wipe the blood glucose machine with an alcohol wipe on the outer surface and put the machine back in the drawer. On 9/18/25 at 1:21 PM Staff I, Infection Preventionist stated she would like to see the facility move to have individual blood glucose machines for each resident the required blood glucose monitoring. 2. The Minimum Data Set (MDS) dated [DATE] documented Resident #8 had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. The MDS also identified skin tears as a wound with the application of nonsurgical dressings.Review of Resident #8's EHR titled, Orders revealed a physician's order with a start date of 8/22/25 to cleanse left upper thigh posterior side area, pat dry, apply xeroform and dry dressing with abdominal pad and secure with kerlix, to be changed daily. A physician's order with start date of 8/21/25 to cleanse right posterior mid-thigh skin tear wound, pat dry, apply Vaseline gauze, cover with abdominal pad and secure with kerlix to be changed daily.Review of Resident #8's MAR-TAR documented a physician's order with a start date of 8/22/25 to cleanse left upper thigh posterior side area, pat dry, apply xeroform and dry dressing with abdominal pad and secure with kerlix, to be changed daily. A physician's order with start date of 8/21/25 to cleanse right posterior mid-thigh skin tear wound, pat dry, apply Vaseline gauze, cover with abdominal pad and secure with kerlix, to be changed daily.Observation on 9/18/25 at 9:40 AM revealed EBP supplies on the wall outside of Resident #8's room.Observation on 9/18/25 at 9:41 AM Staff J, Licensed Practical Nurse (LPN) and Staff K, Certified Nurse Assistant (CNA) completed a dressing change on Resident #8. Staff J and Staff K completed hand hygiene, applied gloves, removed the dressing on the right leg with scissors, removed gloves, completed hand hygiene, applied gloves, cleansed area, removed gloves, completed hand hygiene, applied gloves, applied Vaseline gauze to area on right leg calf, applied an abdominal pad with gauze wrapped loosely, removed gloves, completed hand hygiene, applied gloves, removed the dressing on left upper leg with scissors, removed gloves, completed hand hygiene, applied gloves, cleansed the area on left leg back of thigh, removed gloves, completed hand hygiene, applied gloves, applied xeroform to area, removed gloves, completed hand hygiene, applied gloves, wrapped gauze loosely, removed gloves, completed hand hygiene. On 9/18/25 at 9:54 AM Staff K, CNA acknowledged she should have worn a gown into Resident #8's room. Staff K explained the staff are to wear gowns when interacting with the resident and during wound dressing changes. On 9/18/25 at 9:59 AM Staff G, Nursing Consultant stated the facility's expectation was EBP would have been followed with gowns worn during treatment to Resident #8's dressing change.Review of policy updated 5/11/21 titled, Competency for Cleaning of Glucometers documented Staff member would wear gloves to disinfect the glucometer. Staff would wipe away any visible soil with a sanitizing wipe. Alternatively the meter may be disinfected with a sanitizing wipe per manufacturer's recommended cleansing and drying time. Review of policy updated 11/13/24 titled, Enhanced Barrier Precautions documented the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions would be utilized during wound care with any skin opening requiring a dressing change.

Based on clinical record review and staff interview the facility failed to develop care plans to address COVID-19, oxygen therapy and medications in 4 out of 14 sampled residents reviewed for comprehensive care plans (Resident #16, 22, 29 and 35). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 showed the resident returned to the facility from a critical access hospital on 9/6/24. The Medical Diagnosis report for Resident #16 documented diagnoses of COVID-19, heart failure, atrial fibrillation and dementia. Observation on 10/14/24 at 12:28 PM showed Resident #16 received continuous oxygen therapy at 1.5 Liters (L). The Physician Orders for Resident #16 showed oxygen ordered at 2 L continuous and to titrate oxygen to keep blood oxygen saturation above 90%. The Care Plan last reviewed on 8/2/24 for Resident #16 showed the facility failed to develop a care plan for oxygen therapy. 2. The MDS assessment dated [DATE] for Resident #29 documented diagnoses congestive heart failure, fluid overload and pulmonary hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observation on 10/14/24 at 1:17 PM for Resident #29 showed a sign on the door that indicated personal protective equipment (PPE) required to enter the room. The Progress Notes for 10/5/24 at 9:49 AM for Resident #29 showed the facility notified family of COVID-19 positive test results. The Care Plan last reviewed on 8/10/24 for Resident #29 showed the facility failed to develop a care plan for management of COVID-19. In an interview on 10/16/24 at 3:01 PM, the Director of Nursing (DON) reviewed Resident #29's care plan and determined the facility lacked a care plan for oxygen therapy. When asked if COVID-19 should be included on the care plan, the DON stated, It has already been added. The DON and nurse consultant reported the facility lacked a policy for care plan development. 47673 3. The MDS assessment dated [DATE] for Resident #22 documented a BIMS score of 8 indicating moderate cognitive impairment. The MDS also documented a diagnosis of essential (primary) hypertension. Review of Resident #22's Medication Administration Record (MAR) documented a physician's order to give one furosemide 20 mg oral tablet by mouth daily that was started on 8/2/24. Review of Resident #22's Care Plan documented no focus, goals or interventions for diuretic therapy. 4. The MDS assessment dated [DATE] for Resident #35 documented a BIMS score of 13 indicating no cognitive impairment. Review or Resident #35's electronic health record (EHR) documented a diagnosis of Covid-19 on 10/5/24. Review of Resident #35's Care Plan documented no focus, goals or interventions for a diagnosis of Covid-19. On 10/16/24 at 9:56 AM Staff A, MDS Coordinator acknowledged Resident #22 was on furosemide, a diuretic. Staff A stated she developed care plans for the facility. Staff A acknowledged that Resident #22 did not have a care plan associated with the use of a diuretic and should have. Staff A acknowledged Resident #35 did not have a care plan in place associated with a diagnosis of Covid 19 and should have. On 10/16/24 at 10:15 AM the DON acknowledged Resident #22 had an order for furosemide. The DON acknowledged there was no care plan in place related to diuretic therapy for Resident #22. The DON stated the facility's expectation was that use of a diuretic would have been addressed on the care plan. The DON acknowledged Resident #35 did not have a care plan in place associated with a diagnosis of Covid-19 and should have. On 10/16/24 at 1:05 PM the Administrator stated the facility followed standards of care and regulations for care plan development.

Based on facility document review and staff interview the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 7 of 33 days reviewed. The facility reported a census of 19 residents. Findings include: The PBJ Staffing Data Report run date 10/9/24 triggered for failure to have a RN in the facility for 8 consecutive hours on 5/11 and 5/26/24. Review of the last 30 days of nursing schedules revealed no RN coverage on 5/11, 5/26, 9/14, 9/15, 9/28, 9/29, and 10/12/24. On 10/16/24 at 3:09 PM the Administrator acknowledged there was no RN coverage on 5/11, 5/26, 9/14, 9/15, 9/28, 9/29, and 10/12/24. The Administrator stated the facility's expectation was 8 consecutive hours of RN coverage every day.

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food, and failed to keep utensils on a sanitary surface during meal service. The facility identified a census of 41 residents. Findings included: a. The initial kitchen walkthrough on 10/14/24 at 10:05 AM revealed the following: b. The stove top and backsplash showed a thick layer of grease with food splatter and a variety of food debris. c. The oven and stacked oven splattered with food. d. The hood with visible grease buildup. e. A clean dish cart contained a variety of scattered food debris at the bottom of the cart. f. The floor contained an accumulation of food debris and a variety of dried liquid. g. Two stand up freezer units with debris on the bottom of the unit. h. The dishwasher with thick, crusty layers of lime. i. Lime build up on the floor under the dishwasher. j. During the initial kitchen tour the Dietary Manager (DM) reported the inability to join the tour due to filling in as the cook. Observation of lunch service on 10/16/24 at 12:40 PM showed the following: a. Staff B, [NAME] used a knife to cut a sandwich then placed the knife on top of the meal ticket. Staff B later used the knife to cut another sandwich. b. Staff B placed a rubber spatula on an unsanitized counter, used the spatula to scoop butter from the container then spread the butter on bread. c. Staff B placed a food scoop on an unsanitized area of the steam table then later used the scoop to plate food. The Food Safety and Sanitation policy dated 2021 identified the state and or federal survey team as part of the annual survey process will inspect the department. The food and nutrition service department will follow regulations as outlined by official health agencies and organizations with jurisdiction over the facility. The policy also identified food should be protected from contamination. In an interview on 10/16/24 at 2:20 PM, the DM stated, the deep cleaning doesn't get done because there isn't enough time in the day. We have the help that we're supposed to but it's not enough to get everything done.

Based on observations, facility policy review, procedure review and staff interviews, the facility failed to perform proper transmission based precaution techniques, perform appropriate hand hygiene during wound care, and failed to effectively sanitize a glucometer for 2 of 14 residents reviewed (Resident #16, #25). The facility reported a total census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 showed the resident returned to the facility from a critical access hospital on 9/6/24. The Medical Diagnosis report for Resident #16 documented diagnoses of COVID-19, heart failure, atrial fibrillation and dementia. Observation on 10/15/24 at 1:35 PM showed Staff C, Licensed Practical Nurse (LPN) failed to perform hand hygiene, donned gloves and removed the brace from Resident #16's left leg. Staff C removed the dressing from the left heel, examined the wound then asked the Infection Preventionist (IP) if the wound should have a dressing. The IP replied, she wouldn't know. Staff C applied skin prep to the open wound on the left heel then instructed Staff D, Certified Nursing Assistant (CNA) to put the leg down. Staff C failed to place a barrier under Resident #16's heel before Staff D lowered the resident's leg to the bed. Resident #16's heel rested directly on the bed linens. Staff C doffed gloves, failed to perform hand hygiene, opened the door and left the room. Staff C arrived back to the room, removed the dressing from the package, wrote the date on the dressing then donned gloves without performing hand hygiene. Staff C covered the wound with the dressing, failed to remove gloves and perform hand hygiene before she assisted the resident to drink from the water pitcher, used the bed controls and arranged the bedside table. Staff C then doffed gloves, discarded the gloves and exited the room without performing hand hygiene. The Hand Hygiene policy last updated 9/6/24 identified proper hand washing techniques should be used to protect against the spread of infection. The policy documented that cleaning your hands reduces the spread of potentially deadly germs to the resident and reduces the risk of health care provided causation or infection caused by germs acquired from the resident. Hand hygiene may occur multiple times during a single care episode. The policy indicated hand hygiene is required immediately before touching a resident, immediately before putting on gloves and after glove removal, after touching a resident or the resident's immediate environment, and contact with blood, body fluids or contaminated services. In an interview on 10/16/24 at 3:17 PM, the IP reported during Resident #16's wound care observation, she noticed Staff C failed to perform hand hygiene. The IP stated, there were many times hand hygiene should have been done. When asked if hand hygiene should have been performed before, after and in between glove changes, the IP replied, yes. When asked if she noticed additional infection control concerns, the IP replied, the open wound was put down directly on the bed. 47673 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 documented a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. An observation on 10/15/24 at 12:04 PM revealed Staff C donned mask, gown, glove, and face shield. Staff C entered Resident #25's room with medications, administered medications, checked CGM with Resident #25's reader in the room. Resident #25's reader read HI. Staff C left the room, removed the gown, rolled the gown up, and placed it on the hand rail in the hall with a face shield. Staff C obtained the blood glucose machine from the medication cart and returned to the room. Staff C donned the gown inside out and then reapplied correctly with gloves and face shield. Blood sugar of 438 obtained. Staff C returned to the medication cart with the blood sugar machine, placed it on the cart, utilized an alcohol wipe to cleanse the machine, and placed the machine back in the drawer. Staff C kept her gloves, gown, and N95 on while at the cart. Staff C opened the computer, opened the drawer, leaned on the cart, removed gloves, reapplied gloves without any hand hygiene and entered Resident #25's room without a face shield in place. Staff C left Resident #25's room with a gown mask and gloves. Staff C removed gloves, leaned on the medication cart, opened the computer with gown and N95 in place under her chin. Staff C then removed gloves, mask, gown, and hand hygiene was completed. Staff G LPN / IP present making observations during that entire observation. On 10/15/24 at 12:25 PM Staff C stated she had always just wiped the blood glucose monitors down with alcohol wipes before and after each resident and placed them back in the drawer. On 10/15/24 at 12:32 PM Staff G LPN / IP stated hand hygiene would be expected with all gloved changes, prior to and after resident care. Staff G acknowledged that Staff C concerns with doffing PPE and hand hygiene after entering Resident #25's room and when returning to the cart. Staff G stated ideally Staff C would have doffed PPE appropriately with hand hygiene completed appropriately as well. Staff G stated she would have to check with the corporate nurse for the policy on the reuse of gowns. Staff G stated her expectation was the gown would not have been balled up and stuffed in the hand rail. Staff G stated the facility's expectation was the blood glucose machine would have been cleansed by utilization of the sanitizing wipes. Staff G stated the blood glucose machine should have been wiped down with the sanitizing wipe then wrapped with sanitizing wipe and placed in a disposable cup for 3 minutes per the sanitizing wipe wipe instructions. On 10/15/24 at 1:11 PM the DON stated the facility's expectation was the blood glucose machine should have been wiped down with the sanitizing wipe then wrapped with sanitizing wipe and allowed to sit for 3 minutes wrapped per the sanitizing wipe wipe instructions. Observation on 10/15/24 at 11:17 AM revealed Staff E entered a residents room and obtained a sample for blood glucose reading. Staff E exited the room after obtaining blood glucose with the blood glucose monitor. Staff E returned to the medication cart and wiped the blood glucose machine off with alcohol wipe and put in the drawer. On 10/15/24 at 11:23 Staff E stated each cart has a blood glucose machine for each hall. Staff E stated the machine should be wiped with alcohol wipe and placed back in the medication cart. Review of procedure titled Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID -19. PPE must be donned correctly before entering the patient area. PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. Put on a face shield or goggles before entering the room. When exiting doff PPE. Perform hand hygiene after removing and before putting it on again if your workplace is practicing reuse. Review of procedure titled Competency for Finger Stick Blood Glucose updated 5/11/21 documented to cleanse equipment with PDI pad, microkill, or other approved agent and put away.

Based on clinical record review and staff interview, the facility failed to obtain physical signatures or record attempts to obtain physical signatures on notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 and CMS form CMS-10055 for 1 of 3 sampled residents (Residents #38). The facility reported a census of 41 residents. Findings Include: Record review for Resident #38 revealed form CMS 10123-NOMNC with a services end date of 9/24/24. Resident #38's representative gave verbal consent for signature on 9/20/24 however lacked a signature of resident or resident representative. CMS-10055 form lacked a services ending date and reason Medicare may not pay. Resident #38's representative gave verbal consent for signature on 9/20/24 however lacked a signature of resident or resident representative. Review of Resident #38 Progress Notes lacked any documentation on resident representative giving verbal consent and any attempts to obtain physical signatures on CMS 10123-NOMNC and CMS-10055. Review of the Centers (CMS) Medicare Claims Processing Manual Chapter 30 with a revision date of 1/21/22 revealed the following information under ABN options for Delivery other than in-person revealed ABN's should be delivered in-person and prior to the delivery of medical care which is presumed to be non-covered. In circumstances when in-person delivery is not possible, notifiers may deliver an ABN using another method. Examples include: Direct telephone contact; Mail; Secure fax machine; or Internet e-mail. All methods of delivery require adherence to all statutory privacy requirements under HIPAA. The notifier must receive a response from the beneficiary or his/her representative in order to validate delivery. When delivery is not in-person, the notifier must verify that contact was made in his/her records. In order to be considered effective, the beneficiary should not dispute such contact. Telephone contacts should be followed immediately by either a hand-delivered, mailed, emailed, or a faxed notice. The beneficiary should sign and retain the notice and send a copy of this signed notice to the notifier for retention in the patient's record. The notifier must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice. If the beneficiary does not return a signed copy, the notifier should document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself. Review of the CMS NOMNC form instructions for the NOMNC CMS-10123 revealed the signature line: beneficiary/enrollee or the representative must sign this line and the date line: The beneficiary/enrollee or the representative must fill in the date that he or she signs the document. If the document is delivered, but the enrollee or the representative refuses to sign on the delivery date, then annotate the case file to indicate the date that the form was delivered. CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee's medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee's liability starts on the second working day after the provider's mailing date. Interview on 10/18/24 at 03:01 p.m., with the Director of Nursing revealed she was unaware the facility was required to have physical signatures if the facility had obtained verbal consent from the resident's representative. The DON reported the facility does not have a policy for advance beneficiary notices, however the facility followed standard regulations.

Based on clinical record review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of a diuretic for 1 of 5 residents reviewed (Resident #22). The facility reported a census of 41 residents. Finding include: The MDS assessment dated [DATE] for Resident #22 documented a Brief Interview for Mental Status (BIMS) score of 8 indicating moderate cognitive impairment. The MDS also documented a diagnosis of essential (primary) hypertension. Review of Resident #22's MDS dated [DATE] documented no use of diuretic therapy by Resident #22. Review of Resident #22's MAR-TAR documented a physician's order to give one furosemide 20 mg oral tablet by mouth daily that was started on 8/2/24. On 10/16/24 at 9:56 AM Staff A, MDS coordinator acknowledged Resident #22 was on furosemide, a diuretic. Staff A acknowledged that the use of a diuretic should have been documented on the MDS. Staff A acknowledged that Resident #22 started furosemide on 8/2/24. On 10/16/24 at 10:15 AM the DON stated she expected the MDS would reflect the use of a diuretic. The DON acknowledged Resident #22 was on a diuretic since 8/2/24. On 10/16/24 at 1:05 PM the Administrator stated the facility followed standards of care and regulations for MDS assessments.

Based on clinical record review, staff interviews and facility policy review, the facility failed to provide professional standards of care by not obtaining daily weights per physician orders, and allowing a resident to self administer medications without a physician's order for 2 of 14 residents reviewed (Resident #6 and #29). The facility reported a census of 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #29 documented diagnoses Congestive Heart Failure (CHF), fluid overload and pulmonary hypertension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Observation on 10/14/24 at 1:17 PM for Resident #29 showed a sign on the door that indicated personal protective equipment (PPE) required to enter the room. The Progress Notes for 10/5/24 at 9:49 AM for Resident #29 showed the facility notified family of COVID-19 positive test results. Review of signed Physician Orders dated 6/13/23 revealed an order for daily weights, give extra dose of Lasix if weight gain of 5 pounds in one week. The Care Plan for Resident #29 documented altered cardiovascular status related to atrial fibrillation, CHF, fluid overload, and hypertension. The care plan instructed staff to obtain daily weights. Review of Treatment Administration Record (TAR) for October 2024 revealed the facility failed to obtain weights for the following dates: a. 10/5/24 b. 10/6/24 c. 10/7/24 d. 10/8/24 e. 10/9/24 f. 10/10/24 g. 1011/24 h. 10/12/24 i. 10/13/24 j. 10/14/24 The Progress Notes for Resident #29 indicated because of COVID-19 staff failed to weigh the resident daily. Review of Resident #29's medical record revealed the facility failed to clarify the daily weight order with the physician while the resident was infected with COVID-19. In an interview on 10/16/24 at 3:01 PM, the Director of Nursing (DON) revealed staff should have clarified the daily weight order with the physician while the resident had COVID-19, or ask the DON for further instructions. The DON reported the facility does not have a policy regarding professional standards or following physician orders. The DON stated, we follow professional standards and regulations. 47673 2. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Observation on 10/14/24 at 1:15 PM revealed medication in a nebulizer sitting in Resident #6's room. On 10/14/24 at 1:20 PM Staff E, Registered Nurse (RN) stated Resident #6 had a breathing treatment in the morning, afternoon, and evening. Staff E acknowledged that she had left the medication in Resident #6's nebulizer for him to return to lunch and administer himself. Staff E stated she had been leaving the medication in Resident #6's nebulizer in his room for him to self administer since she started. On 10/15/24 at 1:08 PM a continuous observation revealed Staff E removed medication from medication cart and entered Resident #6's room. Staff E emptied a vial of ipratropium / albuterol into Resident #6's nebulizer. Staff E applied nebulizer mask to Resident #6. Staff E left a tablet of gabapentin 100 mg in a medication cup on Resident #6's bedside table. Review of Resident #6's electronic health records (EHR) documented a physician's order for Gabapentin 100 mg TID and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3 ML 1 vial daily. On 10/15/24 a continuous observation from 1:08 PM - 1:21 PM revealed Resident #6 shut off the nebulizer and picked up the medication cup at 1:21 PM and self administered medication with a sip of water. No staff present in the room. Review of Resident #6's EHR documented no self administration assessment. On 10/16/24 at 7:59 AM Staff F, Licensed Practical Nurse (LPN) stated she never left medication in Resident #6's room because the resident could forget to take the medication. Staff F stated there were no self administration assessments at the facility. Staff F stated she would not leave a breathing treatment in the room for a resident to take on their own either. On 10/15/24 at 1:11 PM the Director of Nursing (DON) stated the medication should not have been left in the room with the resident. The DON stated she felt that Resident #6 had been administering his own nebulizer treatments since he had entered the facility. The DON stated she felt that was how the treatments were given to him at the previous facility. The DON acknowledged no self administration assessment. The DON acknowledged medication in the medication cup in Resident #6's room at that time. Review of policy dated 4/16/24 titled Medication Management / Medication Administration documented to explain to the resident the type of medication being administered and after administration return to the medication cart and document the administration of medication.

Based on clinical record review, hospital record review, staff interviews, and facility provided document review the facility failed to follow facility guidance by transferring without a full body lift after a fall for 3 of 3 residents (Resident #1, Resident #2, Resident #3) reviewed. The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 8/2/24 identified a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The MDS documented diagnoses that included: anxiety disorder, depression, heart failure, atrial fibrillation (A-fib), dementia, osteoarthritis, and intervertebral disc degeneration. The resident was frequently incontinent of bladder. Resident #1's functional transfers, and sit to stands were dependent upon staff. The document revealed during the last 5 days of the assessment period the resident received scheduled pain medication and did not receive as needed (PRN) pain medication. The document further revealed that during the previous 7 days of the assessment period the resident received antianxiety, antidepressant, anticoagulant, and diuretic medications. The resident had no falls since the prior assessment. Resident #1's Care Plan printed on 9/14/24 revealed a focus area of risk for falls and had falls while in the facility. The Fall Risk assessment dated [DATE] identified Resident #1 at high risk for falls. The Incident Report dated 9/4/22 at 8:50 PM documented an aide passing by room and heard Resident #1 calling for help. Nurse to room and noted resident sitting on floor beside bed with back resting against bed and legs outstretched with left leg under right leg. Bed in low position and wearing socks. No obvious areas of concern noted, resident is complaining of left leg pain. Was able to move leg out from under other leg. No shortening or rotation noted to bilateral lower extremities. Neuro checks initiated. Assist up by two staff onto bed. No bruising or swelling noted. Resident states she was trying to get up to the bathroom and she was trying to get her phone. A Nurse Note entered by Staff C, Licensed Practical Nurse (LPN) in Resident #1's electronic health record (EHR) dated 9/4/22 at 10:55 PM revealed the resident was found on the floor beside the bed with her back resting against the bed with her legs outstretched with the left leg under the right. The resident was assisted up by 2 staff onto the bed. On 9/5/24 at 2:01 AM Staff C, LPN, entered a Nurse Note indicating a change in condition form was completed and faxed to the physician. On 9/5/24 at 2:33 AM Staff C, LPN, documented in the Nurse's Note the resident was continuing to guard the left lower extremity, no bruising noted. On 9/5/24 at 4:50 AM Staff C, LPN, documented in the Nurse's Note the resident had complaints of left leg pain pointing to the knee and had stated I need an x-ray. The note stated no swelling or bruising, observed. On 9/5/24 at 6:30 AM Staff E, LPN, documented an assessment of Resident #1 found the resident with complaints of pain to the left thigh area and increased swelling. Staff E sent the resident to the hospital. The document hospital X-ray results dated 9/5/24 revealed a displaced oblique fracture of the distal femur of the left leg. On 9/14/24 at 3:44 PM Staff D, CNA, stated when coming in from a break during the evening shift, she heard Resident #1 call out nurse and observed the resident's feet in a weird way on the floor on top of the bedside table bottom brace. The staff notified Staff C, who came and completed vitals and assessment on the floor. Staff C provided a gait belt and instructed the CNA to assist her in getting the resident up. Staff D stated she asked Staff C if the resident should be sent to the hospital due to complaints of pain and the position the left leg was in. Staff D stated the resident complained of pain pointing/touching her left leg prior to getting up and when seated on the edge of the bed. On 9/14/24 at 3:58 PM Staff C stated she was contacted by Staff D indicating that Resident #1 was on the floor. The staff stated the resident was seated on the floor with the left leg under the right leg with no obvious rotation. Staff C stated neuro and vital assessments were completed, and then assisted Staff D with getting the resident off the floor and onto the bed. The staff acknowledged the resident rubbed the left leg and complained of pain. Staff C stated the resident was provided with PRN Tylenol due to complaints of pain. The staff stated neuro checks were completed throughout the night and the resident did appear to sleep at times, but did have complaints of pain. The staff stated she would have called the physician regarding the resident's fall if there had been an obvious injury. On 9/14/24 at 4:26 PM Staff E stated a mechanical dependent full body lift (Hoyer) should be used to get residents off of the floor. On 9/14/24 at 4:33 PM Staff F, CNA, stated Resident #1 had utilized her call light earlier in the evening on 9/4/24 to ask for assistance regarding her cell phone. The staff provided reassurance to the resident on the location of the phone, and the resident settled down. Staff F stated she was at the nurse's station when she heard the resident had fallen. Staff F stated she heard the resident complain of pain in the left leg when checking on the staff to see if assistance was needed. The staff stated a Hoyer should be used for getting residents off of the floor. On 9/14/24 at 4:39 PM Staff G, CNA, stated she came on shift on 9/4/24 at 10:00 PM after Resident #1's fall. The staff stated the resident had called out in pain and she notified Staff C. Staff G stated Staff C provided the resident with Tylenol for pain. The staff stated the resident throughout the night shift complained of leg pain and wanted to go to the hospital. Staff G stated the roommate at one point attempted to get up and provide assistance to Resident #1. Staff G stated if a resident was found on the floor, she would follow the nurse's instructions and get the resident off the floor with assistance. 2. The MDS for Resident #2 dated 7/2/24 identified a BIMS score of 2 which indicated severe cognitive impairment. The MDS documented diagnoses that included: depression, wedge compression fracture unspecified lumbar vertebra, adjustment disorder with mixed anxiety and depressed mood, and spinal stenosis. Resident #2's functional transfers, and sit to stands were partial/moderate assistance upon staff. The document revealed during the last 5 days of the assessment period the resident received scheduled pain medication and did not receive PRN pain medication. The document further revealed that during the previous 7 days of the assessment period the resident received antidepressant medication. The resident had no falls since the prior assessment. The resident had occasional bladder incontinence. Resident #2's Care Plan printed on 9/14/24 revealed a focus area of risk for injury for falls and had falls while in the facility. The interventions for staff to follow prior to 8/24/24 included: non-skid socks or shoes when ambulating, call light within reach, fall risk assessment completed quarterly and with any falls, and having his walker within reach. The Fall Risk assessment dated [DATE] identified Resident #2 at moderate risk for falls. On 8/24/24 at 10:38 PM the Nurse Note revealed the resident had an unwitnessed fall. Following an assessment, the resident was assisted off the floor and ambulated with 2 assist and his walker to the bathroom. The resident had a 1 cm round abrasion to the right elbow and 4 cm round, raised knot on the middle back of his head. On 8/25/24 at 12:10 AM the Nurse Note revealed a change of condition and the resident was sent to the hospital for evaluation. On 8/25/24 at 2:56 AM the Nurse Note revealed the resident returned with no acute injury. The entry further revealed facility fall protocol was resumed with neuro checks and routine monitoring. On 9/14/24 at 1:58 PM observed Staff K assisting Resident #2 from the dining room to his room. The staff utilized a gait belt and front wheeled walker. Resident #2 had a stutter step gait. 3. The MDS for Resident #3 dated 6/11/24 identified a BIMS score of 12 which indicated moderate cognitive impairment. The MDS documented diagnoses that included: peripheral vascular disease, diabetes, cerebrovascular accident, non-Alzheimer's dementia, Parkinson's, depression, systemic Lupus erythematosus, unspecified, and polyneuropathy. The resident was occasionally incontinent of bladder and bowel. Resident #2's completed transfers, ambulation with a walker, dressing and toileting skills with independence. The document revealed during the last 5 days of the assessment period the resident received scheduled pain medication and did not receive PRN pain medication. The document further revealed that during the previous 7 days of the assessment period the resident received antidepressant, diuretic, antiplatelet, and hypoglycemic medications. The resident had no falls since the prior assessment. Resident's Care Plan printed 9/15/24 revealed a focus area addressing moderate risk for falls with interventions for staff to follow prior to 8/23/24 included: education to resident to be backed up to the bed before sitting, fall assessment quarterly and with any falls, and staff were to follow the facility fall protocol. The Fall Risk assessment dated [DATE] revealed a moderate fall risk for falls. The Nurse Note in the EHR dated 8/23/24 at 2:54 PM revealed the resident was found on the floor and was assisted up from the floor by 2 staff. An assessment and fax were sent to the primary care provider. The Nurse Note on 8/30/24 at 5:02 AM revealed the resident had turned on the call light after falling to the floor and sustaining an injury. The resident had a laceration to the left forearm and was taken to the hospital by emergency medical services. The resident required sutures and steri-strips. The Nurse Note on 9/6/24 at 12:03 AM revealed the resident was on the floor with legs in front of her. The resident was assisted up off of the floor by 2 staff. The assessment revealed the resident was slightly out of breath. Neuro checks were initiated and the resident was assisted to bed following the assessment. On 9/15/24 at 10:30 AM observed Resident #3 ambulating without assistance in her room, using furniture as supports as she ambulated. On 9/15/24 at 11:00 AM the Administrator stated the facility did not have specific policies related to falls. The Administrator acknowledged the Education Forms for Staff D dated 9/10/24 and Staff C dated 9/10/24 indicated a policy regarding falls and staff not lifting residents from the floor manually but with a mechanical full body (Hoyer lift). The Administrator stated there was not a policy but the facility had a document titled Safe Resident Handling and Movement Quick Talks that the facility followed that was provided by the facility's workman's compensation provider. The Administrator stated the facility followed standards of practice, and Center for Medicare and Medicaid Services (CMS) guidelines. On 9/15/24 at 11:45 AM Staff I, LPN, MDS Coordinator, concurred the facility did not have a Facility Fall Protocol as referenced in Resident #3's care plan. Staff I stated the CNA's knew not to get residents up from the floor prior to nurse assessments, and the nursing staff knew that Hoyer lifts were required to get residents up from the floor. The facility provided document, Safe Resident Handling and Movement Quick Talks, dated 8/18, revealed a caregiver should never lift a resident. The document further revealed that if a resident cannot be coached on getting up from the floor, the staff should use a mechanical lift or call 911.

Based on observations, record review, facility investigation file review, resident interview, staff interviews, and facility policy review the facility failed to report abuse concerns involving 3 of 6 residents (Resident #2, #4, and #5) reviewed for potential abuse. Staff reported Staff A would pick on Resident #2 to get a rise out of her. He would pick at her wig and annoy her, would hide her cell phone, move her shoes and she did not like it. If she wanted to go to bed before 8:00 PM, he would push her in her wheelchair to the opposite hall and make her self-propel to her room so she couldn't go to bed right when she wanted to. Staff A would run with Resident #2 in her wheelchair down the hall but backwards. Resident #4 stated Staff A had scared the poop out of her one time. While sitting in her wheelchair up by the nurse's station one night, Staff A came up from behind her and tipped her wheelchair backwards all the way to the floor and then raised it back up on all 4 wheels. Resident #4 stated she immediately went to her room after that because she was so scared. She said what if he had lost grip of the wheelchair and she fell to the ground. She indicated he gave her no warning just did it nor did he apologize for scaring her. Staff reported Staff A would hold Resident #5's arms down during cares to stop him from hitting staff members during cares. The facility reported a census of 44 residents. A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/28/23 at 3:00 PM. The facility staff removed the Immediate Jeopardy on 11/29/23 at 3:34 PM through the following actions: -On 11/28/2023, staff education was initiated to ensure staff are competent in the areas identified below. This education will be completed for all staff on 11/28/2023, or prior to their next shift: Resident rights and facility responsibilities -On 11/28/2023, all interview-able residents were interviewed by staff to ensure any abuse-related concerns have been addressed appropriately. No new concerns from residents were brought forward. -On 11/28/2023, all staff were interviewed to ensure any abuse related concerns have been properly addressed. An additional concern was brought forward during these interviews. The facility is following its process related to the allegation, including filing a new facility-initiated self-report. -On 11/29/2023, a resident council was completed by the Executive Director to ensure residents are aware of their options for reporting abuse and any other concerns to facility leadership and/or other available entities. -The facility initiated an ongoing audit on 11/29/2023 to include meeting with all interview-able residents once weekly for 16 weeks to ensure any concerns are addressed appropriately. -The facility initiated an ongoing audit on 11/29/2023 to assess staff understanding of the facility abuse policy, resident aggression, and resident rights. This audit will occur three times weekly for 16 weeks. -Any concerns will be reported to the Administrator immediately and addressed in facility QA. -The facility had attempted to contact the alleged perpetrator since 11/22/23, with no response from the employee. His last date worked was 11/17/2023. He had been suspended since that last day worked on 11/17/2023. On 11/29/23, contact was again attempted to be made with the alleged perpetrator. A voicemail was left that his employment had ended with his last date worked of 11/17/2023. Findings include: 1. The quarterly Minimum Data Set (MDS) with a reference date of 8/28/23 documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 indicating mild cognitive impairment. The MDS indicated she required extensive assistance of two staff for bed mobility; transfers; toilet use and extensive assistance of one staff for dressing and personal hygiene. The MDS documented she utilized a wheelchair for mobility. The following diagnoses were documented for Resident #2: anxiety, heart failure, dementia, depression and atrial fibrillation. The Care Plan focus area with an initiation date of 6/15/23 documented she had self-care deficit related to her restricted mobility, arthritis and anxiety. The Care Plan indicated she required assistance of one staff for bed mobility, transfers, toileting, dressing and ambulation in her room, wheelchair for mobility out of her room. While ambulating she required a gait belt and walker plus one staff member on stand by and one staff on stand by for transfers and toileting. 2. The quarterly MDS with a reference date of 9/12/23 documented Resident #4 had a BIMS score of 11 out of 15 indicating mild cognitive impairment. The MDS documented she required supervision with setup help only for bed mobility, transfers, toilet use, and personal hygiene. Resident #4 utilized a wheelchair and walker. The following diagnoses were listed for Resident #4: acute and chronic respiratory failure with hypoxia, cancer, anemia, heart failure, renal failure, diabetes mellitus, stroke, anxiety, depression, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). The Care Plan focus area with an initiation date of 7/7/21 documented Resident #4 had an activities of daily living (ADL) deficit due to having a stroke, COPD, chronic heart failure, chronic respiratory failure, and lower back pain. The Care Plan documented she was an assistance of one staff with a gait belt and forward wheeled walker for ambulation; assistance of one staff for bathing, bed mobility, and dressing. She could independently complete her personal hygiene, toileting, transfers, and eating. The Care Plan focus area with an initiation date of 7/14/21 documented Resident #4 had actual pain related to osteoarthritis and previous compression fracture to her lower back. Staff were encouraged to assess for signs and symptoms of pain, administer medications as ordered and to notify the physician of any uncontrolled pain. On 11/21/23 at 9:33 AM observed Resident #4 in her wheelchair in her room. When asked how she felt staff were, she stated they are short and it doesn't seem like a friendly atmosphere. She added the 2:00 PM-10:00 PM shift seemed short/pissed off at her but has had no issues with abuse. Resident #4 stated Staff A scared the poop out of her one time. She was sitting in her wheelchair at the nurse's station, one night when he walked up behind her and tipped her wheelchair backwards. He tipped it all the way down to the floor then raised her back up on all four wheels. After this happened she immediately went to her room because she was so scared. She questioned, what if he lost his grip and she fell on the ground. Staff A did not say anything, no warning, he just did it. He also did not apologize either for scaring the her. She did not tell anyone about this incident with Staff A. During a follow-up meeting on 11/29/23 at 1:17 PM she indicated she spoke to the Administrator about this incident with Staff A and felt very comfortable doing so. Resident #4 added she still has nightmares about what happened that night. She initially felt bad talking about it but now she does not because this is her home. She stated Staff A should feel bad for what he did, not her. She believes over time she will not have those nightmares. 3. The quarterly MDS with a reference date of 10/16/23 documented Resident #5 had severely impaired cognitive skills for decision making skills. The MDS documented he exhibited physical behavioral symptoms directed towards others 4-6 days during the review period and verbal behavioral symptoms towards others 1-3 days during the review period. Resident #5 also rejected cares 1-3 days during the review period. The MDS documented he was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #5: Alzheimer's disease, coronary artery disease, hip fracture, anxiety, and depression. The annual MDS with a reference date of 7/18/23 documented Resident #5 required extensive assistance of two staff for bed mobility; transfers; dressing; toilet use and extensive assistance of one staff for personal hygiene. The MDS documented he utilized a wheelchair for mobility. The Care Plan focus area with an initiation date of 9/14/22 documented Resident #5 had ADL self-care performance deficit related to Alzheimer's disease, impaired balance, left femur fracture with partial replacement. The Care Plan documented he required assistance of 2 staff and a gait belt for ambulation, assistance of two staff for toileting, wears a disposable brief and assistance of 1 staff for hygiene. The following Progress Notes documented the following: -On 10/7/23 at 3:45 PM resident was combative with cares this morning, hitting and kicking. -On 10/9/23 at 12:00 AM some hitting at CNA while he was sitting in the wheelchair. -On 10/10/23 at 1:38 AM resident resistant with cares at bed time; hitting, kicking staff. -On 10/31/23 at 12:08 PM resident has been alert today and combative when being transferred or changed. Resident tried to spit on the CNA when transferring. -On 11/16/23 at 7:08 PM resident physically abusive to CNAs while assisting to bed; hitting, cursing and pulled CNA by the hair in to his bed. On 11/17/23 at 10:37 AM the Activity/Social Service Director stated she heard complaints from other CNAs that Staff A picked on residents, and did small things to get them going. She was asked to give examples of what she has heard and she stated there is a resident that wears a wig and Staff A would pull it off as the resident would tell him to give it back. The same resident was lying in bed and Staff A would raise the bed higher than normal to scare her. With Resident #1 he would pick on her, take her stuff, take her glasses away from her just to get a rise out of her. She indicated she took her concern to the previous Director of Nursing (DON), current DON and Administer because these things should not be happening. It was reported that Staff A would sit on the floor in Resident #2's room and make her walk from the bathroom by herself with gait belt on. Another CNA walked in to help Resident #2 before she fell to the ground because Staff A was not doing anything. On 11/17/23 at 12:45 PM Staff F CNA stated she has had other residents voice concerns about Staff A. Resident #4 stated Staff A will not give her snacks and had tipped her chair back with her in it which scared her. She has also witnessed Staff A mess with Resident #2; moved her wig, hide her cell phone, moved her shoes and she did not like that. He would also run with her in her wheelchair, down the hall but pushing the wheelchair backwards. Staff F stated that if Resident #2 wanted to go to bed before 8:00 PM, he would push her in her wheelchair down another hall. Staff F stated the Social Worker/Activity Director asked her how Staff A had been and she told her he seemed rough. On 11/17/23 at 2:18 PM Staff E CNA stated she had witnessed Staff A pick on Resident #2 by taking her down the wrong hall to mess with her. Resident #2 wears a wig, is very protective of it and will not take it off. Staff E had witnessed him touching her wig to annoy and bother her. It really set her off when he took her down the wrong hall. When asked how often this happens she stated it happened quite a bit; Staff A things he is joking but that is not something to joke about especially if it is setting off the residents. Staff E reported she did not witness Staff A holding Resident #5 down but had heard of him doing this. Since she had not witnessed this she just watched to make sure nothing like that is being done. On 11/17/23 at 2:47 PM Staff B CNA stated had witnessed him being rough with Resident #5 while he was having behaviors. Staff A would hold on to him so he does not hit during cares. When asked what she meant by hold on to him she stated he would hold on to his arms way too hard and squeeze them so he does not hit during cares. At times Staff A would stand up while doing this and hold Resident #5's arms in the air or hold him in a bear hug like manner. Staff B reported Staff A also liked to pick on residents and if they asked him to stop he would not. He would pick on Resident #2 by pulling off her wig and would continue to do that even after she told him to stop. Staff A had a rule for Resident #2 that she should could not go to bed before 8:00 PM, but this is not care planned. If she wanted to go to bed before 8:00 PM, he would put her on a different hall and make her wheel herself back to her room. She was on B hall and he would put her on A hall that is directly in front of the nurse's station. He would do this almost every single night he worked if she asked to go to bed. Staff B reported Staff A had tipped Resident #4's wheelchair back while she was in it. This scared her but he kept doing it. She indicated they have reported their concerns to nurses, could not remember their names, but not sure if anything had been done about it. On 11/21/23 at 12:09 PM the MDS Coordinator stated she was not aware of any staff members picking on residents as well as no complaints of Staff A. She denied hearing residents and resident voicing concerns about Staff A. On 11/21/23 at 12:22 PM the DON indicated she was unaware of any resident concerns with Staff A. She added she was not aware of any staff members teasing or taking things away from residents. During a follow-up interview on 12/5/23 at 3:30 PM the DON acknowledged staff should report abuse concerns immediately. Staff should notify the charge nurse and the charge nurse will then notify someone in leadership. Most concerns have to be reported within two hours so if the charge nurse is the issue they must notify the DON or Administrator. There is also a reporting hotline if the staff member is not comfortable reporting to their supervisor. On 11/21/23 at 2:55 PM the MDS Coordinator, Administrator, DON, Office Manager, and Infection Control nurse were made aware of the concerns with Staff A and his treatment towards Resident #2, #4 and #5. They were all taken back by the information that was shared with them and indicated they had never heard of these concerns before. On 11/22/23 at 12:49 PM Staff G CNA was asked how Staff A was as a co-worker and she began to laugh. She indicated she has had issues with him all the time. He had told Resident #2 that she couldn't go to bed at a certain time. One-night Staff G put Resident #2 to bed because she was ready for bed but Staff A went back in and took her out of bed, and placed her in her wheelchair by the nurse's station. She indicated this happened a couple of months ago and when she called him out on it he did not say or do anything. She would take her concerns to the nurses, which was usually the night nurses and had talked to the Activity/Social Service Director about it too. Staff had told her that Staff A was in assisting Resident #2 but he sat on the floor and watched the resident walk to her bed by herself. Staff G indicated Resident #2 used a gait belt to walk. The other staff member had to help Resident #2 so she would not fall. This happened not too long ago. Staff G had witnessed Staff A take Resident #2 to the opposite hall when she wanted to go to bed. She again called him out on this and he just ignored her. Staff G stated this is their home and they can go to bed when they want to. Staff G also reported Staff A put Resident #2 to bed and raised the bed as high as it would go; there is no reason for that. Staff A would not answer Staff G when she questioned him about it. She reported Staff A would hover over Resident #5 while he had behaviors and that is not a good way to calm him down. They are to leave him alone to calm him down. She had taken her concerns to the nurses and it goes nowhere so she had gone to the Social Service Director/Activity Director. The nurses she reported this to, work nights and was usually Staff J Licensed Practical Nurse (LPN). Staff G stated she worked weekends so she does not work with management to report her concerns to. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated on 10/19/22 indicated all allegations of resident abuse and neglect should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator or designated representative. All allegations of resident abuse shall be reported to the State Agency no later than two hours after the allegation is made.

Based on observations, record review, facility investigation file review, resident interview, staff interviews, and facility policy review the facility failed to ensure 4 of 6 residents (Resident #1, #2, #4, and #5) reviewed were free from abuse. Resident #1 stated Staff A crossed her arms and held them while doing something she did not want him doing and she told him to stop. Staff observed a bruise to her right outer forearm after the alleged incident. She indicated she would be frightened if she saw him again but if she does not see him she feels safe. Staff stated Resident #1 seemed really depressed about what happened and she could not understand why he would do that to her. Staff also reported Resident #1 indicated Staff A would pick on her, take her things, put them out of reach and was rough with her when he would change her brief. Staff reported Staff A would pick on Resident #2 to get a rise out of her. He would pick at her wig and annoy her, hide her cell phone, move her shoes and she did not like it. If she wanted to go to bed before 8:00 PM, he would push her in her wheelchair to the opposite hall and make her self-propel to her room so she couldn't go to bed right when she wanted to. Staff A will run with Resident #2 in her wheelchair down the hall but backwards. Resident #4 stated Staff A had scared the poop out of her one time. While sitting in her wheelchair by the nurse's station one night, Staff A came up from behind and tipped her wheelchair backwards all the way to the floor. He then raised it back up on all 4 wheels. Resident #4 stated she immediately went to her room after that because she was so scared. She stated what if he lost grip of the wheelchair and she fell to the ground. She indicated he gave her no warning just did it nor did he apologize for scaring her. Staff reported Staff A would hold Resident #5's arms down during cares to stop him from hitting staff members during cares. The facility reported a census of 44 residents. A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/28/23 at 3:00 PM. The facility staff removed the Immediate Jeopardy on 11/29/23 at 3:34 through the following actions: -On 11/28/2023, staff education was initiated to ensure staff are competent in the areas identified below. This education will be completed for all staff on 11/28/2023, or prior to their next shift: -Resident rights and facility responsibilities: -On 11/28/2023, all interviewable residents were interviewed by staff to ensure any abuse-related concerns have been addressed appropriately. No new concerns from residents were brought forward. -On 11/28/2023, all staff were interviewed to ensure any abuse related concerns have been properly addressed. An additional concern was brought forward during these interviews. The facility is following its process related to the allegation, including filing a new facility- initiated self-report. -On 11/29/2023, a resident council was completed by the Executive Director to ensure residents are aware of their options for reporting abuse and any other concerns to facility leadership and/or other available entities. -The facility initiated an ongoing audit on 11/29/2023 to include meeting with all interviewable residents once weekly for 16 weeks to ensure any concerns are addressed appropriately. -The facility initiated an ongoing audit on 11/29/2023 to assess staff understanding of the facility abuse policy, resident aggression, and resident rights. This audit will occur three times weekly for 16 weeks. -Any concerns will be reported to the administrator immediately and addressed in facility QA. -The facility has attempted to contact the alleged perpetrator since 11/22/23, with no response from the employee. His last date worked was 11/17/2023. He had been suspended since that last day worked on 11/17/2023. On 11/29/23, contact was again attempted to be made with the alleged perpetrator. A voicemail was left that his employment has ended with his last date worked of 11/17/2023. Findings include: 1. The annual Minimum Data Set (MDS) with a reference date of 7/18/23 documented Resident #1 required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use. She also required extensive assistance of one staff for locomotion on and off the unit and personal hygiene and set up help only for eating. The quarterly MDS with a reference date of 10/27/23 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9 out of 15 indicating mild cognitive impairment. She reported feeling down, depressed, hopeless for 2-6 days during the review period. The MDS documented she exhibited physical and verbal behavioral symptoms directed towards others for 1-3 days during the review period. Resident #1 experienced rejection of care for 1-3 days during the review period. The resident was always incontinent of urine and continent of bowel. The following diagnoses were documented for Resident #1: major depressive disorder, dementia, psychotic disorder, personal history of a stroke, macular degeneration, and psychotic disorder with hallucination. The Care Plan focus area with an initiation date of 10/24/17 documented Resident #1 had limited mobility due to a stroke. Staff encouraged to be aware that she can experience dizziness when standing up. The care plan documented she required assistance of one staff while in her wheelchair. The wheelchair is her primary mode of locomotion but she rarely chose to get out of bed. A second care plan focus area with the same initiation date of 10/24/17 documented the resident had activities of daily living (ADL) self-care performance deficit due to her stroke, dementia, psychosis. The care plan documented she required assistance of two staff for bed mobility, assistance of one staff with stand-by assistance for dressing. The Care Plan focus area with an initiation date of 11/15/22 documented Resident #1 exhibited behaviors such as swearing at staff, screaming, throwing trash on the floor, self-isolation, rejection of cares, combative with cares. The care plan documented she had behaviors of making false accusations to staff. Staff were encouraged to approach her in a calm manner and explain what cares are going to be given; document behaviors such as yelling, swearing, combativeness, rejection of care; she moved to a private room with tile floor due to her throwing trash and food on the carpet; her family reported that she has always been a negative person this is not a new problem; she likes to joke around with people; please ensure that two staff go in to her room for all cares; and re-approach when agitated. The following Progress Notes were documented for Resident #1: -On 11/8/23 at 7:40 PM Staff B Certified Nursing Assistant (CNA) told nurse that Resident #1 had a bruise on her right arm and that the resident reported that it was from Staff A holding her down. A 4-centimeter (cm) x 4 cm dark purple bruise noted to resident's right arm. The nurse asked the resident what her bruise was from and she said Staff A had pinched her when he was putting her pants on. Resident #1 stated she was yelling at him and that she had been swinging her arms. The resident stated this happened last night, not this evening. -On 11/9/23 at 1:09 PM the Social Worker went into the resident's room at 11:00 AM on this day to do an interview with her about concerns with a staff member. Resident #1 stated he held both my arms down, squeezed her right arm harder than the left and that he comes in to torment her. The resident stated she was not sure what happened that night other than he came into change her and he's usually rough changing her so she told him no and that's when they started to fight. The Social Worker stated she does not feel safe when Staff A is working; he argues with her, takes her things, when he comes back everything starts up. The resident told the Social Worker that she told Staff A she does not want him in her room anymore. She added he takes her table away from her so she can't reach her water at night and has to go all night without a drink. During the altercation, Resident #1 indicated she told Staff A Ow you're hurting my arm, he wouldn't let go and believed he did it on purpose. Resident #1 stated she was sick it of and was not going to let him mess with her anymore. She reported being afraid to go to sleep because she does not feel safe. The facility investigation file included the following: -A document titled Abuse Investigation documented Resident #1 was able to identify Staff A by name on 11/8/23 when speaking with Certified Nursing Assistants (CNA) and the nurse regarding her bruise. Staff E CNA was caring for Resident #1, when the resident showed Staff E a bruise to her right arm. Resident #1 reported to Staff E, Staff A had taken care of her the night before, held her down on the bed during cares. Resident #1 also told Staff F CNA and the MDS Coordinator that Staff A held her arms down during cares. The Social Worker interviewed Resident #1 the next day and Resident #1 again indicated that Staff A held her arms down during cares and believed he hurt her on purpose. -The investigation documented the resident had a bruise to her right forearm that measured 4 centimeters (CM) x 4 cm. Resident #1 also told Staff B that Staff A held her arms down during cares, causing the bruise to her right forearm. -Staff A was immediately suspended pending investigation and Resident #1 will be care planned to have 2 staff assist her at all times. -Staff A reported while changing Resident #1, the resident was telling him that her brief was too tight so he let her do it herself. Staff A stated the resident started hitting him, screaming that the brief was too tight, so he left the room. Staff A denied grabbing Resident #1's arm or holding her down at any time. He stated that he might have put his arm up to block her form hitting him. -Timeline of Incident: On 11/8/23 at 7:40 PM the Administrator was notified by the MDS Coordinator that Resident #1 sustained a bruise to her right arm. Staff E was providing cares to Resident #1 at approximately 7:30 PM on 11/8/23 at which Resident #1 told her about and showed her a bruise she had on her right arm. The resident stated she told Staff A he was hurting her but he did not stop and later she noticed the bruise on her arm. Staff E asked Staff B to come in to Resident #1's room to look at her arm. The resident showed her the bruise. Staff B asked Resident #1 how she got that bruise and the resident stated Staff A held her arms down onto the bed. Staff B notified the nurse manager, the MDS Coordinator, who was working on the floor at that time of Resident #1's report. The MDS Coordinator spoke to Resident #1 and she again stated that Staff A pinched her as he was putting her pants on. She also stated she yelled at Staff A while swing her arms. No other injuries were found during the head to assessment completed. -Social Service Director interviewed Resident #1 the next day, 11/9/23 at approximately 11:00 A to get additional details of the incident. During this interview Resident #1 reported that Staff A held both her arms down, squeezing her right arm harder. Resident #1 stated he comes in and torments her. She was not sure what happened that night but he came in to change her. She told him no, since he was always rough with her when he changes her and that's when they started to fight. The resident reported that she does not feel safe when Staff A is working. He argues with her and takes her things. She stated when he comes back everything starts up. She also stated that she told him that she does not want him in her room anymore. Resident #1 stated that Staff A takes her table away from her to where she can't reach her water. She told Resident #1 that he was hurting her arm and he did not let go. She thinks he hurt her on purpose. The resident also stated we were both in the fight and that she was not going to let him mess with her anymore; she is sick of it. Resident #1 reported that she is afraid to go to sleep and does not feel safe. He crossed her arms which made it easier for him to squeeze her arm. -Plan of Action: after being notified of Resident #1's allegation, Staff A was immediately suspended pending investigation. The community will continue to follow the current care plan and add that the resident will require assistance of two staff members for cares at all times. On 11/17/23 at 10:58 AM observed Resident #1 lying in bed with her bedside table close by and her call light within reach. When asked if anyone had ever hurt her during cares, she indicated there was one guy. Then she crossed her arms in a bear hug way and pointed to a bruise on her right outer lower arm just above her wrist. It was circular, purple with different healing stages of yellow and light brown. She added it still hurt too. When asked what happened she stated that guy came in and did something she did not want him to do, so he held my arms down. She told him to stop. She added he liked to move her things like her TV and other things in her room. Why would he do that, he could break my things. Resident #1 was asked why that staff member did that to her arm she said because he was doing something she did not want him to do but could not recall what that was. When asked what the name of the guy she indicated she did not know his name but looks like Santa because he is fat. When asked if she had seen him recently she stated she has not seen him in a long time and would be frightened if she saw him again. She felt safer if she does not see him. 2. The quarterly MDS with a reference date of 8/28/23 documented Resident #2 had a BIMS score of 10 out of 15 indicating mild cognitive impairment. The MDS indicated she required extensive assistance of two staff for bed mobility; transfers; toilet use and extensive assistance of one staff for dressing and personal hygiene. The MDS documented she utilized a wheelchair for mobility. The following diagnoses were documented for Resident #2: anxiety, heart failure, dementia, depression and atrial fibrillation. The Care Plan focus area with an initiation date of 6/15/23 documented she had self-care deficit related to her restricted mobility, arthritis and anxiety. The care plan indicated she required assistance of one staff for bed mobility, transfers, toileting, dressing and ambulation in her room, wheelchair for mobility out of her room. While ambulating she required a gait belt and walker plus one staff member on stand by and one staff on stand by for transfers and toileting. On 11/28/23 at 10:30 AM Resident #2 sat in her wheelchair at the nurse's station, staff assisted her to her to her room so a private interview could be completed. Resident #2 was asked how staff were she stated good, they are good. Resident indicated she had no concerns with staff picking on her, touching her wig when they shouldn't, and denied ever being in her bed when it was raised up high. 3. The quarterly MDS with a reference date of 9/12/23 documented Resident #4 had a BIMS score of 11 out of 15 indicating mild cognitive impairment. The MDS documented she required supervision with setup help only for bed mobility, transfers, toilet use, and personal hygiene. Resident #4 utilized a wheelchair and walker. The following diagnoses were listed for Resident #4: acute and chronic respiratory failure with hypoxia, cancer, anemia, heart failure, renal failure, diabetes mellitus, stroke, anxiety, depression, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). The Care Plan focus area with an initiation date of 7/7/21 documented Resident #4 had an activities of daily living (ADL) deficit due to having a stroke, COPD, chronic heart failure, chronic respiratory failure, and lower back pain. The care plan documented she was an assistance of one staff with a gait belt and forward wheeled walker for ambulation; assistance of one staff for bathing, bed mobility, and dressing. She could independently complete her personal hygiene, toileting, transfers, and eating. The Care Plan focus area with an initiation date of 7/14/21 documented Resident #4 had actual pain related to osteoarthritis and previous compression fracture to her lower back. Staff were encouraged to assess for signs and symptoms of pain, administer medications as ordered and to notify the physician of any uncontrolled pain. On 11/21/23 at 9:33 AM observed Resident #4 in her wheelchair in her room. When asked how she felt staff were she stated they are short, and that it just does not seem like a friendly atmosphere. She added the 2:00 PM-10:00 PM shift seemed short/pissed off at her but has had no issues with abuse. Resident #4 stated Staff A scared the poop out of her one time. She was sitting in her wheelchair at the nurse's station, one night when he walked up behind her and tipped her wheelchair backwards. He tipped it all the way down to the floor then raised her back up on all four wheels. After this happened she immediately went to her room because she was so scared. She questioned, what if he lost his grip and she fell on the ground? Staff A did not say anything, no warning, he just did it. He also did not apologize either for scaring the her. She did not tell anyone about this incident with Staff A. During a follow-up meeting on 11/29/23 at 1:17 PM she indicated she spoke to the Administrator about this incident with Staff A and felt very comfortable doing so. Resident #4 added she still has nightmares about what happened that night. She initially felt bad talking about it but now she does not because this is her home. She stated Staff A should feel bad for what he did, not her. She believes over time she will not have those nightmares. 4. The quarterly MDS with a reference date of 10/16/23 documented Resident #5 had severely impaired cognitive skills for decision making skills. The MDS documented he exhibited physical behavioral symptoms directed towards others 4-6 days during the review period and verbal behavioral symptoms towards others 1-3 days during the review period. Resident #5 also rejected cares 1-3 days during the review period. The MDS documented he was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #5: Alzheimer's disease, coronary artery disease, hip fracture, anxiety, and depression. The annual MDS with a reference date of 7/18/23 documented Resident #5 required extensive assistance of two staff for bed mobility; transfers; dressing; toilet use and extensive assistance of one staff for personal hygiene. The MDS documented he utilized a wheelchair for mobility. The Care Plan focus area with an initiation date of 9/14/22 documented Resident #5 had ADL self-care performance deficit related to Alzheimer's disease, impaired balance, left femur fracture with partial replacement. The care plan documented he required assistance of 2 staff and a gait belt for ambulation, assistance of two staff for toileting, wears a disposable brief and assistance of 1 staff for hygiene. The following Progress Notes documented the following: -On 10/7/23 at 3:45 PM resident was combative with cares this morning, hitting and kicking. -On 10/9/23 at 12:00 AM some hitting at CNA while he was sitting in the wheelchair. -On 10/10/23 at 1:38 AM resident resistant with cares at bed time; hitting, kicking staff. -On 10/31/23 at 12:08 PM resident has been alert today and combative when being transferred or changed. Resident tried to spit on the CNA when transferring. -On 11/16/23 at 7:08 PM resident physically abusive to CNAs while assisting to bed; hitting, cursing and pulled CNA by the hair in to his bed. On 11/17/23 at 10:37 AM the Activity/Social Service Director stated Resident #1 told her she does not like Staff A in her room because he picks on her, takes things from her and puts them out of reach and is rough with her when he changes her brief. Resident #1 reported to her that Staff A crossed her arms with her right arm on top and squeezed her arms that way. Resident #1 said Ow that hurts but Staff A did not stop and did not say why he did that to her. When asked how Resident #1 was after this happened she stated the resident was scared if Staff A would be in the building because she could not sleep and was afraid he would come in to her room to torment her or sneak up on her. The Activity/Social Service Director stated she heard complaints from other CNAs that Staff A picked on residents, and did small things to get them going. She was asked to give examples of what she had heard: there is a resident that wears a wig and Staff A would pull it off as the resident would tell him to give it back. The same resident was lying in bed and Staff A would raise the bed higher than normal to scare her. With Resident #1 he would pick on her, take her stuff, take her glasses away from her just to get a rise out of her. She indicated she took her concern to the previous Director of Nursing (DON), current DON and Administer because these things should not be happening. It was reported that Staff A would sit on the floor in Resident #2's room and make her walk from the bathroom by herself with the gait belt on. Another CNA walked in to help Resident #2 before she fell to the ground because Staff A was not doing anything. On 11/17/23 at 12:45 PM Staff F CNA stated Staff A would go in to assist Resident #1 without telling her what he was doing, would just go in and do whatever. If Resident #1 would tell Staff A no or refuse the tasks he would continue on and not walk away which intensified her mood. She had thrown a tray at Staff A before and would yell at him. Resident #1 told her that Staff A pinned her down and continued to change her then pointed to a bruise on her arm. Staff F stated Resident #1 appeared kind of angry about the situation and did not want him back in her room. She has had other residents voice concerns about Staff A. Resident #4 told her Staff A would not give her snacks and had tipped her chair back with her in it which scared her. She had also witnessed Staff A mess with Resident #2; moved her wig, hides her cell phone, moved her shoes and she did not like that. He would also run with her in her wheelchair, down the hall but pushing the wheelchair backwards. Staff F stated that if Resident #2 wanted to go to bed before 8:00 PM, he would push her in her wheelchair down another hall away from her room. On 11/17/23 at 2:18 PM Staff E CNA stated Resident #1 reported to her that she was very sad and depressed. When asked why, Resident #1 stated because Staff A grabbed her arms to hold her down and squeezed hard. Resident #1 indicated she told him to stop because it hurt but he continued to squeeze her harder after that. Staff E stated Resident #1 seemed really depressed it happened and did not understand why Staff A would do that to her. Staff E had witnessed him pick on Resident #2 but taking her down the wrong hall to mess with her. Resident #2 wears a wig, is very protective of it and will not take it off. Staff E had witnessed him touching her wig to annoy and bother her. It really set her off when he took her down the wrong hall. When asked how often this happens she stated it happened quite a bit; Staff A thinks he is joking but that is not something to joke about especially if it is setting off the residents. On 11/17/23 at 2:47 PM Staff B CNA reported Resident #1 told her Staff A held her down on the bed but was unsure why he did that. Staff B stated she knows Staff A is rough with residents; he is stronger than he thinks. She had witnessed him being rough with Resident #5 while he was having behaviors. Staff A would hold on to him so he did not hit during cares. When asked what she meant by hold on to him she stated he would hold on to his arms way too hard and squeeze them so he does not hit during cares. At times Staff A would stand up while doing this and hold Resident #5's arms in the air or hold him in a bear hug like manner. Staff B reported Staff A also liked to pick on residents and if they asked him to stop he would not. He would pick on Resident #2 by pulling off her wig and would continue to do that even after she told him to stop. Staff A had a rule for Resident #2 that she could not go to bed before 8:00 PM, but this is not care planned. If she wanted to go to bed before 8:00 PM, he would put her on a different hall and make her wheel herself back to her room. She was on B hall and he would put her on A hall that is directly in front of the nurse's station. He would do this almost every single night he worked if she asked to go to bed. Staff B reported to her that Staff A had tipped Resident #4's wheelchair back while she was in it. This scared her but he kept doing it. She indicated they have reported their concerns to nurses but not sure if anything had been done about it. On 11/21/23 at 12:09 PM the MDS Coordinator was not aware of any staff members picking on residents as well as no complaints of Staff A. She denied hearing residents and resident voice concerns about Staff A. On 11/21/23 at 12:22 PM the DON indicated she was unaware of any resident concerns with Staff A. She added she was not aware of any staff members teasing or taking things away from residents. During a follow-up interview on 12/5/23 at 3:30 PM she stated all staff are to complete the mandatory reporting training upon hire, complete the refresher course every three years and complete regular training for competencies. The DON was asked to describe what abuse is and she indicated physical, verbal, financial, sexual, inappropriate touching, teasing, taunting, making residents feel scared. Abuse can be from residents, family members and other visitors. She added residents should be treated with respect, kindness, while respecting their rights. The DON stated this is their resident's homes and they should feel comfortable and safe. On 11/22/23 at 12:49 PM Staff G CNA was asked how Staff A was as a co-worker and she began to laugh. She indicated she had issues with him all the time. He has told one resident that she can't go to bed at a certain time, Resident #2. One-night Staff G put Resident #2 to bed because she was ready for bed but Staff A went back in and took her out of bed, placed her in her wheelchair by the nurse's station. She indicated this happened a couple of months ago and when she called him out on it he does not say or do anything. She would take her concerns to the nurses, which was usually the night nurses and had talked to the Activity/Social Service Director about it too. Staff had told her that one day Staff A was in assisting Resident #2 but he sat on the floor and watched the resident walk to her bed by herself. Staff G indicated Resident #2 used a gait belt to walk. The other staff member had to help Resident #2 so she would not fall. This happened not too long ago. Staff G had witnessed Staff A take Resident #2 to the oppose hall when she wanted to go to bed. She again called him out on this and he just ignored her. Staff G stated this is their home and they can go to bed when they want to. Staff G also reported Staff A put Resident #2 to bed and raised the bed as high as it would go; there is no reason for that. Staff A would not answer Staff G when she questioned him about it. She reported Staff A would hover over Resident #5 while he had behaviors and that is not a good way to calm him down. They are to leave him alone to calm him down. On 11/28/23 at 11:34 AM Staff A stated his job duties at the facility included cleaning up residents, providing hygiene, make sure residents are emotionally ok, their meal trays are being passed, they are eating if they chose to do so, check and change them at night, and make sure they are not abused or anything, no bruises or anything. Staff A acknowledged this was his first CNA job. Staff A stated the facility has residents that hit but he himself is a big [NAME] and can take it. When asked what residents had those types of behaviors he stated Resident #1 and #5, along with two other residents. When asked what kind of abuse training he had he indicated just the standard pamphlet the facility gave out to staff and residents, and the facility has signs everywhere. He stated the facility has online courses, nothing more than the monthly online courses. Staff A was asked what he would do if a resident he was caring for would have behaviors he indicated he would come back later and try to provide cares again. He had heard of redirection as a way to handle the behavior but his instincts are to block and he put his arms up in the air. Staff A denied knowing of residents being teased at the facility by any staff members and acknowledged it was unacceptable to tease anyone. When asked if he heard of staff picking on residents he stated there's no point in that, why would you irritate residents, it would just make your job harder. Staff A was asked to talk about the night Resident #1 made the allegation he stated he went into her room to ask if she wanted changed and she told him he should have been in there forever ago. As he was providing cares, she swatted at him and he walked away. He added she can do things on her own but he tried to be extra helpful and make sure her brief was on right. He went back, looked in to see if she was ok. Resident #1 told the nurse she had hit him because her brief was tight. He said he instinctively put his arm up when she swatted at him and walked away to get her to calm down faster. He denied holding her arms down, squeezing her arms. He did state she told him to stop as he assisted with her brief, he walked away after she was hitting him. Staff A denied pushing Resident #1's arms during cares. Staff A stated Resident #1 called him Santa [NAME] because he has a big belly like him. He also denied removing Resident #2's wig to pick on her, he likes her. He would let her self-propel to her room when she is ready for bed. He denied pushing her down the opposite hall, she liked to be at the nurse's station because she is a fall risk. When asked if he ever sat back and watched Resident #2 walk from the bathroom without assistance, he stated when he first started she was a lot more independent, he would hold on to her and corrected her posture if needed. He added she is to always have two people in with her now. Staff A indicated there was no point in sitting back and allow her to walk alone, she would not make it. He would only raise her bed up to adjust her in bed and put it back to the lowest position how she likes it. Staff A was asked if he tipped Resident #4's wheelchair back as she sat in it, he denied this and stated he walked up behind her pretending to scare her but that was it. He stated one time he walked up behind her, tapped on her shoulder and that scared her. Staff A acknowledged Resident #5 would hit a lot and he would just let him do it. He denied using his body to block Resident #5 from hitting staff during cares such as lying on him. Staff A was asked to describe what abuse is to him: either being negligent, physical or emotional abuse, preventing them from going to their rooms and not allowing them to do what they want. When asked if teasing and picking on residents is considered abuse he indicated he would say so. Staff A said it would be considered abuse to hold someone's arms down to the point that it caused pain and left a bruise. When asked if any of the cares he provided to the residents at the facility would be considered abuse he stated he did not think so. Review of a documented titled Freedom from Abuse Notice to Employees Resident/Patient Abuse, Neglect and Mistreatment of Belongings documented among the rights specified in the federal and state laws, each resident and patient has a right to a dignified existence and to be free from verbal, sexual, physical or mental abuse: corporal punishment and involuntary seclusion. Abuse includes, but not limited to: -Verbal Abuse: oral, written, or gestured language, including sarcastic remarks and derogatory statements, directed to residents, family members or significant others. -Physical Abuse: hitting, slapping, pinching, scratching, spitting, holding roughly, jerking, [NAM

Based on observations, resident and staff interviews and clinical record review the facility failed to provide accurate and timely interventions to prevent hospitalization for 1 of 3 residents. Resident #29 had a diagnosis of Congestive Heart Failure (CHF) and required monitoring of Blood Pressures (BP), Heart Rate (HR) and weights. On 6/27/23 the resident was taken to the hospital for exacerbation of CHF with a BP of 181-126 (normal BP 120/80). A review of the chart revealed that her most recent complete set of vitals had been taken on 6/19/23. The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (intact cognitive ability). The MDS documented she required limited assistance with the help of one staff for transfers, walking and toileting. The MDS documented she had diagnoses to include atrial fibrillation (A-fib), pleural effusion and congestive heart failure (CHF). The Care Plan dated 6/14/23 for Resident #29 included a focus area of altered cardiovascular status related to A-fib, CHF, fluid overload and hypertension. The Care Plan directed staff to assist with edema wear, obtain daily weights and to take vitals monthly or on an as-needed basis. The Clinical Census documented the resident received skilled services 6/1/23 to 6/11/23. The Prescription Fax dated 6/7/23 for the resident documented an order if patient has a 5 pound weight gain OR (capitalized and underlined) systolic blood pressure (BP) greater than 100 to give an extra dose of Lasix 40 milligrams (mg) once and then return to normal dosing. The Clinical Physician's Order for the resident, documented an order dated 6/13/23 at 6:00 AM, for a daily weight and to give an extra dose of Lasix (used to stabilize fluid overload) if the resident had a weight gain of 5 pounds in one week and a systolic blood pressure greater than 100. Staff were to notify the physician if/when these conditions occurred. The Progress Note for the resident documented the following: On 6/7/23 at 4:21 PM the facility received a signed fax with an order if the resident has a 5 pound weight gain in one week or systolic BP greater than 100 give an extra dose of Lasix 40 mg once and then return to normal dosing. On 6/12/23 at 3:01 PM received electronically signed fax with clarification: If in one week's time there is a 5 pound weight gain and patient's systolic BP on that day is greater than 200 administer 40 mg of lasix extra dose x 1 and then return to regular dosing schedule. On 6/13/23 at 1:02 AM Correction - if resident systolic BP is greater than 100 not 200. On 6/26/23 at 1:01 PM observed the resident walk back to her room from the dining area and by the time she got to her room she was short of breath and had difficulty talking. On 6/27/23 at 9:07 AM observed the resident up in her recliner in her room and she stated that she was feeling bad and did not want to visit. Review of the facility BP Summary revealed the staff documented a daily BP 6/1/23 through 6/12/23 except for the days of 6/3/23 and 6/5/23. The Summary lacked any other BP after 6/12/23 except for 6/19/23. Review of the facility Weight Summary revealed the staff documented a weight every day except for 6/5, 6/6, 6/18, 6/23 and 6/27/23. The Progress Note dated 6/27/23 at 9:24 AM documented the staff got her out of bed and dressed that morning and the resident complained of shortness of breath and was panting. Staff assessed her vitals with her blood pressure 181/126, heart rate 134 beats per minute, and oxygen saturation 87% (normal oxygen level is >90%). They gave her supplemental oxygen and called for an ambulance. The Progress Notes lack any documentation on 6/26/23. The emergency room Report dated 6/27/23 at 9:40 AM documented Resident #29 admitted to the hospital with diagnosis of diastolic congestive heart failure, atrial fibrillation and was given intravenous (IV) Lasix for diuresis (to remove access fluids). On 6/28/23 at 11:51 AM, Certified Medication Aide (CMA), Staff C, stated she went in to get the resident up for the morning and the resident was panting, and struggling to breath. Staff C paged Registered Nurse (RN), Staff B, to come to the resident's room and assess her. They took her BP, HR and oxygen, and all were outside the normal range. Staff C did not know if the resident was supposed to have daily vital signs completed but if she did, it would have triggered on the electronic chart. On 6/28/23 at 11:53 AM, Registered Nurse (RN), Staff B, stated Staff C had gotten the resident up in the morning and paged for her to come assess her. The resident was panting and her oxygen level was low, which was unusual for her. The Director of Nursing (DON) brought supplemental oxygen and they had to convince the resident to go to the hospital. Staff B stated that she hadn't seen the resident struggle to catch her breath that way before and she was a relatively new resident. She said that the resident was no longer on skilled services and when a resident is on skilled, they are triggered in the electronic charting to conduct vitals every shift (twice daily). On 6/28/23 at 10:55 AM, the facility nurse consultant agreed that skilled assessments should include at least one set of vitals a day. On 6/28/23 at 3:53 PM, the Nurse Practitioner (NP) from the hospital that cared for the resident stated the resident came into the hospital with a perfect storm of A-fib and high blood pressure. She had a high heart rate (HR) and blood pressure (BP) and with the IV medication, those vitals had become more stable. She stated they had been working with her to get this under control since March and had tried different medications. She acknowledged that if they had known about the BP or HR out of the normal ranges they could have tried something before she ended up being hospitalized . On 6/28/23 at 5:19 PM, the Cardiac Nurse Practitioner (CNP) stated she gave the order for weekly weights and blood pressure parameters. She stated a family member had told her on 6/7/23 that the facility had been doing vital signs twice a day and monitoring the weights weekly. That was the last time she had information about the resident's care and assumed that the facility had continued that level of monitoring. She stated that had she known that they were not doing vitals very often, she would have requested it be done twice a day. She stated that she could only make decisions based on the data that she received and if there had been vitals out of the norm she may have made some medication adjustments. She stated she couldn't say for sure if it could have prevented the hospitalization but she can only respond to the information that she got from the staff and family. On 6/29/23 at 10:25 AM, the DON stated the nurses understood the order to mean that if the resident had a 5-pound weight gain, then they would take her BP to see if she had a systolic reading over 100. The DON acknowledged that with the diagnosis of A-fib and fluid overload a more regular assessment with vitals could have tipped them off sooner and the doctor may have tried different medication before having to go to the hospital. On 6/28/23 at 2:20 PM the Administrator stated that they did not have a specific policy for following doctors' orders and staff are expected to follow standards of care.

Based on observation, record review and staff interviews, the facility failed to provide adequate supervision and implement and or revise care plan interventions identified to prevent accidents for 2 of 6 residents reviewed (Residents #3 & #5). The facility reported a current census of 42 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #5 scored 15 on the Brief Interview for Mental Status (BIMS) test revealing no cognitive impairments. The assessment identified the resident had [DIAGNOSES REDACTED]. Resident #5 required one staff to assist with bed mobility, transfers, using the toilet and personal hygiene. Resident #5's care plan documented the following: a). Initiated on 11/5/13, he/she had been planning to return home. The resident had been working with (physical) Therapy approximately 4 times a day. The hand written notes on the care plan documented PT's (Physical Therapy) last visit would be 11/22/13 and then would be discontinued; with the resident starting restorative therapy per PT. b) Initiated on 11/1/13, he/she had ADL (Activities of Daily Living) self-care performance deficit and impaired mobility. The interventions identified the following: assist the resident with the assistance of walker, gait belt and one person assist and the resident had shuffling gait at times. The resident required one staff for personal hygiene and oral care. The resident required one staff for toileting. The resident required extensive assistance of 1-2 persons to move between surfaces. Effective 11/27/13, the resident was not to be left unattended while standing, to get wheelchair or have the resident sit on the toilet or call for help. Review of Patient Progress Notes for Physical Therapy (PT) dated 11/22/13 at 1515 (3:15 PM), determined the resident required verbal cues to lift his/her feet during ambulation. The resident reported ambulation had been difficult that afternoon due to him/her feeling fatigue. The resident reported his/her left lower extremity felt as if it was going to give out on him/her. The PT notes for the same date at 5:53 p.m. assessed the resident had difficulty with sit to stand transfers supports with decision not to allow independence in room. The PT therapist would see the resident one more time and would be discharged to restorative program. A PT (Physical Therapy progress noted dated 11/27/13 at 8:45 a.m., documented Resident #5 ambulated to and from the MDR (main dining room) with standby assist of one (1) with a walker. The resident's gait had been described as slow, short steps, shuffling almost at times especially when complaining of legs tired. The nurse noted dated 11/27/13 at 8:45 a.m. documented the resident ambulated to and from the MDR (main dining room) with standby assist of one (1) with a walker. The resident's gait had been described as slow, short steps, shuffling almost at times especially when complaining of legs tired. Review of the Variance Report dated 11/27/13 at 2115 (9:15 PM) documented that Resident #5 found on the bathroom floor, on his/her back. Staff A, a Certified Nursing Assistant stated, she assisted the resident into the bathroom and up to the sink to brush their teeth. She stated she had to leave the room for an alarm sounding and when she returned, she found the resident on the floor. The resident complained of right shoulder pain, rated it a 7. Ice applied to shoulder and the resident had been able to answer questions. His/her neurological checks were within normal limits (WNL). The resident was sent to the emergency room and admitted to the hospital for pain control and fractured clavicle. The on call physician and the documented contact family member had been notified. The nurse's notes dated 11/29/13 documented Resident #5 returned from the hospital and a new physician's orders [REDACTED]. Observation on 1/22/14 at 2:48 PM revealed the resident ambulating down the hall with the aide of a physical therapist. The resident had a slow gait, almost shuffling then sat in the living room completing a repetition of exercises. During interview on 1/21/14 at 3:00 PM, the resident stated he/she remembers there were 2 nurses in the bathroom when he/she fell . He/she stated they had left the room leaving him/her alone and that is when he/she fell . During interview on 1/22/14 at 2:25 PM, Staff A, stated she had left the resident standing at the sink. She stated she heard an alarm sounding, left the resident for a few minutes and when she returned, she found the resident flat on his/her back. She stated the resident care plan said assistance from surface to surface. She stated she should have stayed with the resident. She stated she called for a nurse to come by the phone because she did not have a walkie talkie with her. During interview on 1/24/14 at 7:40 AM, Staff E, LPN (licensed practical nurse) stated when she entered Resident #5's room, she found the resident on the floor, face down. Staff E reported the resident told her the other staff left the room to check on an alarm and then he/she had fallen. She stated that staff should not have left the resident alone. During interview on 1/23/14 at 9:45 AM, the Resident's Primary Care Physician stated she would have expected the nursing staff to have at least remained close by in the same room. During interview on 1/22/14 at 2:05 PM, Staff B, CNA-CMA stated when a resident requires assistance, they are expected to stay with them. During interview on 1/11/14 at 2:55 PM, Staff D, CNA stated any resident that needs assistance of one they are never to leave the resident alone. 2. Review of the Minimum Data Set (MDS) assessment for Resident #3, dated 12/31/13 revealed pertinent [DIAGNOSES REDACTED]. The same assessment revealed the resident required assistance of two staff for transfers and using the toilet. The assessment revealed the resident frequently incontinent of bowel and bladder and a problem with memory and cognitive skills for daily decision making moderately impaired for decisions poor; cues/supervision required. Review of the Care Plan for Resident #3 (last review date of 1/20/14) identified the resident at high risk for falls related to past falls at home and highly impaired vision. The care plan directed staff to implement the following interventions: Assistance of one for all transfers and ambulation using gait belt and walker. Ensure the resident is wearing appropriate footwear when ambulating. Floor mat alarm beside the bed at bedtime. If restless, bring the resident to the nurses station and place a sensor pad in the chair. Attempt to engage the resident in activity. Bed lowered to its lowest position when in bed. The care plan directed staff to reposition the motion alarm so out to the resident's reach and on at all times when the resident is in the room during the day. During observation and an interview on 1/22/14 at 10:45 AM, found the resident sitting in his/her room in a recliner. The call light was located on the bedside table out of the resident's reach and a motion detector alarm had been observed on the top of the bedside table. The motion detector alarm had not been activated. Staff F, CNA entered and stated the resident does not require alarms during the daytime. During observation on 1/22/14 at 3:10 PM, Resident #3 had been sitting in the commons area in a wheelchair, across from the nurse's station. There was no alarm noted in the wheelchair.