Every finding on record at Advanced Health Care of Overland Park

Based on observation, record review, and interview, the facility failed to provide Resident (R) 6, R1, R2, and R48 and their representative with a bed hold and notification of transfer when sent to the hospital. The facility failed to ensure the long-term care ombudsman was notified of R1's transfers to the hospital. The facility failed to complete and provide R1, R2, and R48 and their representatives a discharge summary and recapitulation of stay when discharged from the facility. Findings included:- 1. R1 Electronic Medical Record (EMR) documented a Discharge Minimum Data Set (MDS), dated 03/17/2026, documenting a planned discharge to the community with a return not anticipated. R1's Entry MDS, dated 4/17/2026, documented a re-entry to the facility from an acute hospital. R1's Discharge MDS, dated 04/28/2026, documented an unplanned discharge to an acute hospital with a return anticipated. R1's Entry MDS, dated 06/19/2026, documented a re-entry to the facility from an acute hospital. R1's Discharge MDS, dated 04/28/2026, documented an unplanned discharge to an acute hospital with a return anticipated. R1's Entry MDS, dated 05/07/2026, documented a re-entry to the facility from an acute hospital. R1's Discharge MDS, dated 05/18/2026, documented an unplanned discharge to an acute hospital with a return anticipated. R1's Entry MDS, dated 05/24/2026, documented a re-entry to the facility from an acute hospital. R1's Discharge MDS, dated 06/02/2026, documented a planned discharge home with a return not anticipated. R1's Entry MDS, dated 06/12/2026, documented a re-entry to the facility from an acute hospital. On 08/19/2026 at 08:4 AM, the bed hold, written notification of transfer, and LTCO notification were requested from the facility for R1. The facility lacked evidence and was unable to provide the requested bed hold and notice of transfer information regarding R1's transfers to the hospital on [DATE] and 05/18/2026. The facility failed to notify the LTCO when R1 was transferred to the hospital on [DATE] and her discharge home on [DATE]. A Discharge Summary and recapitulation of stay were not provided to R1 or her representative upon her discharge home on [DATE] and 06/02/2026. 2. R2's EMR documented a Discharge MDS, dated 06/08/2026, documenting an unplanned discharge to an acute hospital with a return anticipated. R2's Entry MDS, dated 06/12/2026, documented a re-entry to the facility from an acute hospital. R2's Discharge MDS, dated 06/30/2026, documented an unplanned discharge to an acute hospital with a return not anticipated. R2's Entry MDS, dated 07/13/2026, documented a re-entry to the facility from an acute hospital. R2's Discharge MDS, dated 08/04/2026, documented a planned discharge to home/community with a return not anticipated. R2's Entry MDS, dated 08/13/2026, documented a re-entry to the facility from an acute hospital. On 08/19/2026 at 08:4 AM, the bed hold, written notification of transfer, and LTCO notification were requested from the facility for R2. The facility was unable to provide the requested bed hold and notice of transfer information regarding R2's transfers to the hospital on [DATE] and 06/30/2026. A Discharge Summary and recapitulation of stay were not provided to R2 or her representative upon her discharges home on [DATE] and 08/04/2026. 3. R48's EMR documented an unplanned discharge to an acute hospital with a return anticipated. R48 did not return to the facility after her transfer to the hospital. On 08/19/2026 at 08:4 AM, the bed hold, written notification of transfer, and LTCO notification were requested from the facility for R48. The facility was unable to provide the requested bed hold and notice of transfer information regarding R48's transfer to the hospital on [DATE]. A Discharge Summary and recapitulation of stay was not provided to R48 or her representative upon her discharge from the facility after she did not return to the facility after her hospital stay. On 08/19/2026 at 11:14 AM, Administrative Staff A stated that he was unable to find the bed hold and notice of transfer for R1, R2, and R48. Administrative Staff A stated that nursing had been responsible for completing the bed holds and notice of transfers but that task responsibility had been dropped and was not being completed as they should. Administrative Staff A stated that upon a residents discharge, the discharge summary and recapitulation of stay should have been completed for these residents. Administrative Staff A stated a project improvement plan has been implemented to address and resolve these problems. Administrative Staff A stated that the notices to the ombudsman were mailed monthly but could not state why some of the transfers or discharges had been omitted. The facility's Bed Hold policy dated 01/06/2026 documented: At the time of transfer, or within 24 hours if the transfer is emergent, a facility representative will provide the bed-hold policy acknowledgement form to the patient or patients representative. The facility will hold the patient's bed until admission as an inpatient or after midnight. Payment received during the Bed Hold period is for the purpose of reserving a bed and maintaining the patient's personal effects during the patient's absence and does not represent a payment for the act of readmission at a later date. Patients electing a Bed Hold are guaranteed a bed within the facility. Bed holds will be renewed daily or until revocation. The patient or patients representative may cancel the bed hold at any time. Refunds will not be issued for any days that have already been used. Patients electing not to initiate a Bed Hold will be granted readmission to the next available bed. The facility's Patient Transfer policy dated 12/22/2023 documented: The facility will not transfer or discharge the resident while an appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility will document in the progress notes the danger that failure to transfer or discharge would pose. Residents who are sent emergently to an acute care setting are considered transfers, not discharges. Prior to initiating a transfer or discharge, the facility will document reasonable efforts to meet the resident's needs and prevent transfer or discharge, unless immediate transfer is required for safety or medical necessity. The transfer will be documented in the residents progress notes. The following information will be communicated to the receiving provider via the CCD and/or discharge summary: Contact information of the practitioner responsible for the care of the resident; resident representative information; advance directive information; special instructions or precautions for ongoing care; comprehensive care plan goals; the CCD and/or discharge summary will be provided to the receiving provider prior to or at the time of transfer; prior to transferring a resident the facility will notify the resident/representative of the transfer via the Transfer or Discharge Notice form. The notice will include: the specific reason for the transfer or discharge; the effective date; the specific location; an explanation of the right to appeal; contact information for the Office of the State Long-Term Care Ombudsman; contact information for the Disability Law Center. The notice will be provided at least 30 days prior to the transfer or discharge of the patient unless: the health and/or safety of individuals in the facility would be endangered due to clinical or behavioral status; health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by urgent medical needs; has not resided in the facility for 30 days; a resident who is hospitalized or on a therapeutic leave will be offered a bed hold; the facility will notify the Ombudsman when required. - The Nurse's Note, dated 07/18/2026 at 01:31 PM, documented R6 was admitted to the hospital for pain in the right arm and diarrhea. R6 requested to be transferred to the hospital for further evaluation. R6's clinical record lacked evidence of a bed hold, or a notice of transfer was provided to the resident representative. On 08/18/2026 at 03:00 PM, Consultant GG stated that they were unable to find evidence that a bed hold or a notice of transfer was provided to the resident or representative. Consultant GG further stated that the facility did not do a recapitulation (a concise summary of the resident's stay and course of treatment in the facility)) after she did not return to the facility from the hospital. The facility's Bed Hold undated policy documented that, if a resident required transfer to an acute hospital or went on therapeutic leave, the facility would offer the patient the opportunity to hold a bed while they are discharged from the facility. At the time of transfer, or within 24 hours if the transfer was emergent, a facility representative would provide the bed-hold policy acknowledgement form to the resident or representative.

The facility identified a census of 38 residents. The sample included six residents with three residents reviewed for abuse/neglect. Based on record review and interviews, the facility failed to conduct a complete investigation to rule out abuse and neglect after receiving allegations from representatives for Resident (R) 1 and R2. Findings included:- R1 admitted to the facility on [DATE] and discharged to home on [DATE]. R2 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the facility's notifications to the State Agency (SA) revealed the following: The facility reported intake number 2715968 to the SA on 01/13/26. The intake documented on 01/12/26 at 03:00 PM. The facility received an email from R1's representative that on 01/12/26 between the hours of 02:00 AM and 03:00 AM, R1 put on her call light to request urgent medical assistance, and staff failed to respond in a timely manner. As a result, R1 remained unattended while in acute physical distress and R1 told her representative in the morning when she called. The facility talked to R1 and she did not remember what time she vomited. The facility did not provide a copy of a completed investigation to the State Agency or to the onsite surveyor as requested on 02/26/26. The facility reported intake number 2744352 to the SA on 02/16/26. The intake documented on 01/31/26, R2 had a clogged catheter and staff pushed R2 into the lobby for discharge, so a new admission could have R2's room. R2's representative canceled transportation for his discharge and R2 went to the hospital at his representative's request. The facility did not provide a copy of a completed investigation to the State Agency or to the onsite surveyor as requested on 02/26/26. Upon request for the completed investigations into 2715968 and 2744352, the facility provided only staff witness statements. On 02/26/26 at 01:08 PM, Administrative Nurse D stated R1's representative said the facility neglected R1 when she threw up at night. She stated due to R1's representative's insistence that R1 threw up and staff did not chart on it, she reported the allegation to the SA. Administrative Nurse D stated she reported R2's representative's concerns with his discharge and catheter. On 02/26/26 at 02:16 PM, Administrative Nurse D stated R1's representative emailed her directly and she reported the allegations. She stated she tracked down staff that worked for three days prior to the alleged date to make sure R1 did not throw up on a different night. Administrative Nurse D stated she spoke to R1 and reviewed her chart. She stated she let Administrative Staff A know the investigation was ready to go with the witness statements in a folder. She stated she followed up with a couple of other residents regarding the allegations but did not fill out any documentation. She stated she finished her part of R1's investigation within a couple of days, then let Administrative Staff A know she was finished because she thought the facility only had a certain amount of time for an investigation. Administrative Nurse D stated R2's representative emailed Administrative Staff A with her allegations. She stated she reached out to two nurses who were mentioned in the complaint and got their recollection of events. She stated Administrative Staff A looked at the cameras for R2's discharge. She stated she did not submit the completed investigations for R1 or R2 to the SA. On 02/26/26 at 02:22 PM, Administrative Staff A stated R1's representative reported R1 vomited, and the facility did not clean the vomit up. He stated he checked R1's room and it looked fine and did not smell. He stated R1's representative escalated the concerns later with more complaints. Administrative Staff A stated Administrative Nurse D interviewed staff and he assumed Administrative Nurse D sent the investigation to the SA. He stated he did not send the completed investigation to the SA on R1. He stated the facility had five working days to send the completed investigation to the SA. Administrative Staff A stated he received notification that R2's representative was not happy with catheter care, and she believed he was left in distress in the hallway during discharge. He notified Administrative Nurse D, who reviewed R2's catheter care notes and did not find any issues. Administrative Staff A stated he reviewed the video and R2 was not in distress and was always supervised. He stated he completed a brief note on the video but that was all he did on the investigation. Administrative Staff A stated he did not send the completed investigation on R2 because he thought Administrative Nurse D did that one. The facility's Abuse Policy and Procedure, not dated, directed the Administrator or Director of Nursing (DON) completed an investigation of the incident including a written summary of the findings no later than five working days of the reported occurrence. The summary included interview notes; incident report, and written, signed, and dated statements from the accused witnesses and the person reporting the incident. The policy directed a thorough investigation was critical to developing effective prevention strategies. The facility maintained a written record of all investigations of reported abuse, neglect, mistreatment, misappropriation, exploitation, or deprivation of goods and/or services. The policy directed any investigation and follow-through abided by facility polices and State and Federal laws and regulations.

The facility identified a census of 38 residents. The sample included six residents with three residents reviewed for abuse/neglect. Based on record review and interviews, the facility failed to submit completed investigations within the required five working-day timeframe following reported allegations to the State Agency (SA) for Residents (R) 1 and R2. Findings included:- R1 admitted to the facility on [DATE] and discharged to home on [DATE]. R2 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. Review of the facility's notifications to the State Agency (SA) revealed the following: The facility reported intake number 2715968 to the SA on 01/13/26. The intake documented on 01/12/26 at 03:00 PM. The facility received an email from R1's representative that on 01/12/26 between the hours of 02:00 AM and 03:00 AM, R1 put on her call light to request urgent medical assistance, and staff failed to respond in a timely manner. As a result, R1 remained unattended while in acute physical distress and R1 told her representative in the morning when she called. The facility talked to R1, and she did not remember what time she vomited. The facility did not submit the completed investigation to the State Agency within the required five working days. The facility reported intake number 2744352 to the SA on 02/16/26. The intake documented on 01/31/26, R2 had a clogged catheter and staff pushed R2 into the lobby for discharge, so a new admission could have R2's room. R2's representative canceled transportation for his discharge and R2 went to the hospital at his representative's request. The facility did not submit the completed investigation to the State Agency within the required five working days. On 02/26/26 at 02:16 PM, Administrative Nurse D stated she did not submit the completed investigations for R1 or R2 to the State Agency. On 02/26/26 at 02:22 PM, Administrative Staff A stated Administrative Nurse D interviewed staff and he assumed Administrative Nurse D sent the investigation on R1 to the State Agency. He stated he did not send the completed investigation to the SA on R1. He stated the facility had five working days to send the completed investigation to the SA. Administrative Staff A stated he did not send the completed investigation on R2 because he thought Administrative Nurse D did that one. The facility's Abuse Policy and Procedure, not dated, directed the Administrator or Director of Nursing (DON) completed an investigation of the incident including a written summary of the findings no later than five working days of the reported occurrence. The summary included interview notes; incident report, and written, signed, and dated statements from the accused witnesses and the person reporting the incident. The policy directed a thorough investigation was critical to developing effective prevention strategies. The facility maintained a written record of all investigations of reported abuse, neglect, mistreatment, misappropriation, exploitation, or deprivation of goods and/or services. The policy directed any investigation and follow-through abided by facility polices and State and Federal laws and regulations. The policy did not address the required timeframe to submit completed investigations to the SA.

The facility identified a census of 35 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food-borne illnesses and food safety concerns. Findings included: - On 09/23/24 at 07:27 AM, an observation in the kitchen's dry food storage room revealed one container of pistachios. The container was not labeled and lacked a date. On 09/23/24 at 07:31 AM, an observation in the kitchen's dry food storage room revealed one opened box of puree pasta mix. The box had an opened bag inside that contained the pasta mix. The box and bag lacked a date. On 09/23/24 at 07:33 AM, an observation in the kitchen's dry food storage room revealed one opened box of honey wheat flavoring. The box had an opened bag inside that contained the honey wheat flavoring. The box and bag lacked a date. On 09/23/24 at 07:35 AM, an observation in the kitchen's dry food storage room revealed one opened package of potato pearls mashed potatoes. The package was open to air and lacked a date. On 09/23/24 at 07:37 AM, an observation in the kitchen's dry food storage room revealed two containers of white rice. The container was unlabeled and lacked a date. On 09/23/24 at 07:38 AM, an observation in the kitchen's dry food storage room revealed one opened bottle of browning and seasoning sauce. The bottle lacked a date. On 09/23/24 at 07:39 AM, an observation in the kitchen's dry food storage room revealed one opened package of bran flakes. The package lacked a date. On 09/23/24 at 07:44 AM, an observation on a shelf in the main kitchen area revealed a plastic container of brown powder. The container was not labeled and lacked a date. On 09/23/24 at 07:45 AM, an observation on a shelf in the main kitchen area revealed two opened bags of pie filling mix. The bags lacked a date. On 09/23/24 at 07:46 AM, an observation on a shelf in the main kitchen area revealed three opened bags of yellow cake mix. The bags lacked a date. On 09/23/24 at 07:47 AM, an observation on a shelf in the main kitchen area revealed two opened bags of pretzels. The bags lacked a date. On 09/23/24 at 07:53 AM, an observation in the kitchen's walk-in freezer revealed one opened bag of carrots. The bag lacked a date. On 09/23/24 at 07:54 AM, an observation in the kitchen's walk-in freezer revealed one opened bag of green beans. The bag lacked a date. On 09/23/24 at 07:56 AM, an observation in the kitchen's walk-in freezer revealed one opened bag of hashbrowns. The bag lacked a date. On 09/23/24 at 07:57 AM, an observation in the kitchen's walk-in freezer revealed one resealable bag of steaks. The bag was unlabeled and lacked a date. On 09/25/24 at 02:43 PM, Dietary BB stated food packaging needed to be labeled and dated when opened. Dietary BB stated if something was opened that day, it should be dated with that day's date on it. Dietary BB further stated any bins or containers that contained food should have been labeled and dated accordingly. Dietary BB he was in the process of implementing some of the changes that were recommended during the mock survey; however, he stated he did not have everything ready. The facility's Food Storage policy, with a created date of 01/19/21, documented that food should be dated as it is placed on the shelves if required by state regulation. Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat Time/Temperature Control for Safety (TCS) food should be consumed, sold, or discarded. Plastic containers with tight-fitting covers must be used for storing grain products, sugar, dried vegetables, and lots of bulk foods. All containers must be legible and accurately labeled and dated. Frozen Foods: all foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. The facility failed to maintain sanitary dietary standards related to food storage. This deficient practice placed the residents who received food from the facility kitchen at risk related to food-borne illnesses and food safety concerns.

The facility had a census of 35 residents. The sample included 12 residents with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 09/23/24 at 07:30 AM a walkthrough of the facility's Two Hall revealed an unlocked wound treatment cart. The cart contained multiple bottles of medicated diclofenac (used to treat pain) and nystatin (used to treat fungal infections) ointments with the warning of Keep medication out of reach of children. The cart also contained three purple containers of Sani-Cloth bleach wipes with the Keep out of reach from children warning label. CNA M stated the cart belonged to the nurse but secured it. On 09/24/24 at 07:10 AM an inspection of the facility's One Hall revealed the wound cart was unsecured. The cart contained five bottles of diclofenac, a box of disposable medical scalpels, and five containers of Sani-Cloth bleach wipes. At 07:15 AM Administrative Staff A stated carts should be locked with the items listed and secured the cart. He stated the residents should not have access to the items in the cart. On 09/24/24 at 07:15 AM a Sani-cloth bleach wipes container was on the railing outside Resident (R)76's room. On 09/25/24 at 01:51 PM, Certified Nurse's Aide (CNA) M stated the treatment carts should be always secured. He stated the chemical wipes should be locked up away from the resident. On 09/25/24 at 02:07 PM Licensed Nurse G stated the wound treatment cart should be locked when not in use by the nurses. On 09/23/24 at 03:30 PM Administrative Nurse D stated the treatment cart was to be locked when not in use. She stated that chemical cleaning products should always be locked up. The facility's Accident and Incident policy revised 06/2024 indicated the facility will provide an environment free from potential hazards related to falls, unsafe equipment, chemicals, behaviors, and other assessed or identified factors. The policy indicated the facility will provide ongoing evaluation and supervision to ensure resident safety. The facility failed to ensure a safe environment free from hazardous chemicals and materials for eight cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries.

The facility identified a census of 35 residents. The sample included 12 residents. Based on interview and record review, the facility failed to develop and implement a policy that prohibited and prevented the facility from employing or engaging staff with criminal backgrounds when the facility failed to conduct a background check as required for one employee and the facility policy allowed for 10 days of employment prior to the check. The deficient practice placed all residents at risk for abuse, neglect, misappropriation, or mistreatment. Findings included: - Employee review of Licensed Nurse (LN) H revealed a hire date of 07/03/19. The facility was unable to provide evidence a criminal background check had been completed by the facility for LN H upon request. On 09/25/24 at 11:55 AM Administrative Staff A stated the facility did not have a criminal background check on file for LN H. Administrative Staff A stated he was unable to find LN H's background check after searching through the older files in storage. Administrative Staff A stated LN H was originally hired for home health and hospice when it was owned by the same company as the facility and the background check was done on the home health and hospice end; however, the facility did not complete a background check for LN H when she hired on the work weekends at the facility. Administrative Staff A stated the home health and hospice was no longer owned by the same company as the facility, but he was able to obtain a copy of the background check home health and hospice had completed. Administrative Staff A stated the facility should have completed its own hiring documentation and background checks for employees who worked in their facility. Administrative Staff A stated he placed an order for a new background check to be completed for LN H. The facility's undated Abuse Policy and Procedure policy documented The facility will not knowingly employ any individual who has been found guilty of abuse, neglect, misappropriation of property, or mistreatment in a court of law; has had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of a patient or misappropriation of patient property; or has had a disciplinary action against a professional license issued by a State licensure body as a result of a finding of abuse, neglect, mistreatment of a patient, misappropriation of patient property, exploitation of a patient or deprivation of goods and/or services. The facility will submit criminal background checks, which include sex offender checks within 10 days of employment or per state regulations. The facility failed to develop and implement a policy that prohibited and prevented the facility from employing or engaging staff with criminal backgrounds when the facility failed to conduct a background check as required for one employee and the facility policy allowed for 10 days of employment prior to the check. The deficient practice placed all residents at risk for abuse, neglect, misappropriation, or mistreatment.

The facility identified a census of 35 residents. The sample included 12 residents with three residents reviewed for beneficiary notices review. Based on record review, and interviews, the facility failed to provide Resident (R)82 with a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) CMS -10095 Form upon discharge from Medicare A services. This deficient practice placed the resident at risk for uninformed decisions and inability to exercise her rights. Findings Included: - R82's Discharge Minimum Data Set (MDS) completed 08/30/24 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she was discharged home and was not anticipated to return to the facility. A review of R82's Beneficiary Protection Notification Review completed on 09/24/24 indicated she started Medicare Part A skilled services on 07/08/24. The form designated her last covered day (LCD) as 08/29/24. The form indicated the facility initiated her discharge from skilled with benefit days remaining and she left the facility upon her discharge from services. The facility was unable to provide a completed NOMNC for R82 requested on 09/24/24. On 09/24/24 at 01:23 PM Administrative Nurse D stated the facility did not have the NOMNC for R82. She stated the facility recently identified missing NOMNC documentation and was working to correct the issue. The facility's Notice of Medicare Non-Coverage (NOMNC) policy revised 09/2022 indicated the facility will provide Form 10095 at least two days prior to termination of services. The facility failed to provide R82 with a NOMNC upon discharge from Medicare A services. This deficient practice placed the resident at risk for uninformed decisions and inability to exercise her rights.

The facility identified a census of 35 residents. Based on record reviews, observations, and interviews, the facility failed to follow sanitary infection control standards related to maintaining biliary drains (catheter drain inserted in the liver) and Foley catheters (a tube inserted into the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 9/23/24 at 08:15 AM Resident(R)75 slept in her bed. R75's bed was in the lowest position and her urinary catheter collection bag rested flat on the floor to the right of her bed. On 09/23/24 at 10:18 AM R18 slept in her bed. R18's bed was in the lowest position. R18's tubing for her biliary drain ran over her covers to the right side of her bed. Her drainage collection bag rested on the floor to the right of her bed. On 09/25/24 at 01:51 PM Certified Nurse's Aide (CNA) M stated the medical drains and catheter bags should never touch the floor. He stated they should be positioned below the level of the bladder to ensure proper drainage and prevent urine from flowing back into the resident's body. On 09/25/24 at 02:07 PM Licensed Nurse G stated staff was to check the catheter's placement and positioning each time they entered the room. She stated urinary catheters should be positioned in a privacy bag below the level of the resident's bladder. On 09/25/24 at 03:34 PM Administrative Nurse D stated staff was expected to check the placements of the urinary catheter bags during each interaction with the residents. She stated the catheter tubing and collection bags should be placed below the level of the bladder to allow sufficient drainage and never touch contaminated surfaces. The facility's Indwelling Urinary Catheter Site Care policy revised 07/2023 indicated staff will ensure sanitary placement and storage of the urinary drainage bags. The policy indicated the facility will ensure the drainage bag remained below the level of the resident's bladder, off the floor, and have a privacy bag. The facility failed to follow sanitary infection control standards related to maintaining medical drains and Foley catheters. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 35 residents. The sample included 12 residents with one reviewed for accommodation of needs. Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 75 had her call light to communicate her needs or call for help. This deficient practice placed the resident at risk for unmet care needs. Findings Including: - The Medical Diagnosis section within R75's Electronic Medical Records (EMR) included diagnoses of fracture of her sacrum (bone break of the large triangular bone/area between the two hip bones), fracture of the lumber vertebra (spinal fracture of the lower back), insomnia (difficulty sleeping), and history of repeated falls. R75's Admission Minimum Data Set (MDS) completed 09/20/24 noted a Brief Interview for Mental Status (BIMS) score of 11 indicating mild cognitive impairment. The MDS indicated she required supervision with bed mobility, toileting, transfers, personal hygiene, dressing, and personal hygiene. The MDS noted no falls since her admission. R75's Functional Abilities Care Area Assessment (CAA) completed 09/23/24 indicated she required limited stand-by assistance from staff for her mobility and activities of daily living (ADLs). R75's Falls CAA completed 09/23/24 indicated she was at risk for falls related to weakness, limited mobility, and forgetfulness. R75's Care Plan initiated 09/10/24 indicated she required stand-by assistance with all her ADLs. The plan indicated she was at risk for falls related to her limited mobility, weak gait, urinary catheter, and cognitive impairment. The plan instructed staff to ensure her call light remained within reach. On 9/23/24 at 08:15 AM R75 slept in her bed. R75's bed was in the lowest position and her urinary catheter collection bag rested directly on the floor to the right of her bed. R75's call light rested on the floor on the left side of her bed out of her reach. R75 stated she wasn't sure how her call light or urinary catheter bag got on the floor. She stated she could not safely reach her call light. At 08:20 AM Certified Nurse's Aid (CNA) M entered the room, reattached the catheter bag, and placed the call button back on her bed. CNA M stated the items should never be on the floor. CNA M stated R75's call light should always be within reach. On 09/25/24 at 01:45 PM Licensed Nurse (LN) G stated call lights should either be clipped onto the resident's clothing or on the bed within reach. On 09/26/24 at 03:34 PM Administrative Nurse D stated staff were to ensure call light remained within reach after each encounter. The facility's Call System policy 07/2023 indicated the facility will ensure a working call system. The policy noted the call lights will be placed in a manner to ensure accessibility. The facility failed to ensure R75 had her call light to communicate her needs. This deficient practice placed the residents at risk for unmet care needs.

The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Residents (R)18. This deficient practice placed R16 at risk for decreased psychosocial well-being and other complications. Findings Including: - The Medical Diagnosis section within R18's Electronic Medical Records (EMR) included diagnoses of malignant neoplasm of the pancreas (pancreatic cancer), nausea with vomiting, and gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus). R18's Admission Minimum Data Set (MDS) completed 09/08/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required supervision and/or touch assistance from staff for bathing, toileting, dressing, personal hygiene, bed mobility, and transfers. The MDS indicated she admitted with no pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) or wounds, but the MDS indicated she was at risk. The MDS indicated she had nonsurgical dressings and ointments to prevent skin breakdown. R18's Pressure Ulcer Care Area Assessment (CAA) completed 09/13/24 indicated she was at risk for pressure injuries and skin breakdown due to her immobility. The CAA indicated her skin was intact upon assessment. The assessment indicated she required staff assistance to move sufficiently to relieve pressure. The CAA noted she had incontinence and poor nutrition. The CAA indicated a care plan will be implemented to address her risks. R18's Care Plan initiated on 09/06/24 indicated she was at risk for deficits in her ADL and skin breakdown related to her immobility, urinary incontinence, and biliary (bile) drain. The plan instructed staff to assess her skin weekly, flush her drain as ordered, and always keep her skin clean. The plan indicated staff will need to assist as needed with all her ADLs. The plan indicated staff will assist with showers twice weekly and as needed per patient preference. R18's EMR under Treatment Administration Report (TAR) indicated bathing was signed off as completed on 09/06/23 and 09/11/24. The TAR indicated bathing was not administered on 09/10/24, 09/14/24, 09/18/24, and 09/20/24. The TAR indicated the resident refused bathing on 09/14/24. The TAR noted on 09/20/24 that staff would bathe her the following morning, but this task was not completed. R18's EMR under Progress Notes indicated she was transferred to an acute care facility for emergency treatment related to her worsening cancer symptoms on 09/23/24 at 04:23 PM. On 09/23/24 at 09:01 AM R18 slept in her bed. Her biliary drain collection bag and tubing rested on the floor to the right of her bed. R18 awoke and reported she had felt ill all week. She reported her drainage bag had no specific place to secure it and it often fell on the floor. She stated she only had one bath since her admission to the facility on [DATE]. She stated she refused one shower offered due to her illness, but she was not offered other opportunities. R18's room smelled heavily of urine and body odor. Her hair was greasy and unwashed. Her fingernails were untrimmed and dirty. R18 stated she was supposed to receive a bath on the previous Saturday, 09/21/24, but never received one. On 09/25/24 at 09:45 AM Consultant GG stated when R18 arrived at the hospital from the facility, she had a pressure injury. She stated R18 smelled heavily of urine, feces, and body and R18's hair was unwashed and greasy. On 09/25/24 at 01:51 PM, Certified Nurse's Aide (CNA) M stated the facility followed a bathing schedule and each resident would get a minimum of two baths each week. He stated the bathing documentation would be turned in to nursing for review. He stated any skin impairments or refusals would also be reported to the nurses. He stated that repeated refusals would be reported to the interdisciplinary team to address. On 09/25/24 at 02:07 PM, Licensed Nurse (LN) G stated resident's bathing would be documented in the TAR section of the EMR. She stated that missed bathing or refusals should have been noted in progress notes. On 09/25/24 at 03:34 PM Administrative Nurse D stated staff were expected to document refusals or missed bathing. She stated that R18's bathing would have been noted in the TAR. The facility's Shower/Bath policy revised 07/2023 indicated the residents will be scheduled for bathing twice weekly. The policy indicated staff will ensure appropriate monitoring and documentation for completed, missed, or refused bathing opportunities. The facility failed to provide consistent bathing opportunities for R18. This deficient practice placed her at risk for decreased psychosocial well-being and other complications.

The facility identified a census of 35 residents. The sample included 12 residents with three reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to ensure appropriate Foley catheter (a tube inserted into the bladder to drain urine into a collection bag) care for Resident (R)16 when staff failed to maintain the urine collection bag below R16's bladder to encourage dependent drainage. This deficient practice placed R16 at risk for catheter-related complications including urinary tract infections (UTI). Findings Including: - The Medical Diagnosis section within R16's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), hemiplegia and hemiparesis (weakness and paralysis on one side of the body), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R16's Admission Minimum Data Set (MDS) completed 08/23/24 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS indicated he was dependent on staff assistance for dressing, transfers, personal hygiene, toileting, bed mobility, and bathing. The MDS indicated he had an indwelling urinary catheter. R16's Urinary Incontinence Care Area Assessment (CAA) completed 08/30/24 indicated he had a urinary catheter and was at risk for skin breakdown. The CAA instructed staff to provide peri and catheter care each shift. The CAA indicated a care plan will be created to minimize the risk related to his urinary catheter use. R16's Care Plan initiated on 08/20/24 indicated he was at risk for self-care deficits, skin breakdown, and pressure injuries related to his medical diagnoses. The plan indicated he had an indwelling urinary catheter. The plan instructed staff to provide catheter care each shift and ensure the urine collection bag remained below the level of his bladder. The plan indicated R16 required staff assistance with dressing, personal hygiene, toileting, repositioning, transfers, and bathing. On 09/24/24 at 10:58 AM an inspection of R16's room revealed he was on enhanced barrier precautions (EBP) related to his urinary catheter. EBP signage was posted on the sink close to his bed. R16's bed had a low air-loss mattress set to his weight at 250 pounds (lbs.). R16's urinary catheter collection bag was positioned on the center of his footboard. The collection bag was positioned higher than his bladder due to the bag placement and a large amount of foamy yellow urine pooled in the drainage tubing towards his body. On 09/25/24 at 01:51 PM, Certified Nurse's Aide (CNA) M stated all urinary catheters and medical drains should be positioned below the level of the bladder to allow urine to drain. He stated catheters should be securely placed on the beds and never allowed to make contact with contaminated surfaces. On 09/25/24 at 02:07 PM Licensed Nurse (LN) G stated staff was to check the catheter's placement and positioning each time they entered the room. She stated urinary catheters should be positioned in a privacy bag below the level of the resident's bladder. On 09/25/24 at 03:34 PM Administrative Nurse D stated staff were expected to check the placements of the urinary catheter bags during each interaction with the residents. She stated the catheter tubing and collection bags should be placed below the level of the bladder to allow sufficient drainage. The facility's Indwelling Urinary Catheter Site Care policy revised 07/2023 indicated staff will ensure sanitary placement and storage of the urinary drainage bags. The policy indicated the facility would ensure the drainage bag remained below the level of the resident's bladder, off the floor, and had a privacy bag at all times. The facility failed to ensure appropriate Foley catheter care for R16 when staff failed to maintain the urine collection bag below R16's bladder to encourage dependent drainage. This deficient practice placed R16 at risk for catheter-related complications including UTI.

The facility identified a census of 35 residents. The sample included 12 residents with two reviewed for nutritive diets. Based on observation, record review, and interviews, the facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents (R)75 and R76. This deficient practice placed the residents at risk for impaired nutrition and decreased quality of life. Findings included: - On 09/23/24 at 07:45 AM R75 stated the facility would often serve the food cold in the mornings. She stated staff were available to warm up the food in the microwaves if asked. On 09/23/24 at 08:00 AM R76 stated breakfast often was served cold by the time it reached her room. On 09/23/24 at 12:51 PM, R18 stated the meals were often cold by the time the food was delivered to the rooms. She stated she was told by staff she would have to eat in the cafeteria if she wanted her meals to be served hot. (R18 was sent out to an acute care facility at 04:30 PM on 09/23/24) On 09/24/24 at 08:20 AM R75 received her breakfast tray. A temperature test was completed on her breakfast. The test revealed her scrambled eggs were 90 degrees Fahrenheit, oatmeal was 98 degrees Fahrenheit, and the cherry crumble was 94 degrees. R75 reported the food was cold but she did not want it to be reheated. On 09/23/24 at 08:26 AM R76 received her breakfast tray. A temperature test was completed on her breakfast. The test revealed her scrambled eggs were 92 degrees Fahrenheit, oatmeal was 95 degrees Fahrenheit, and the cherry crumble was 90 degrees. On 09/25/24 at 01:30 PM, Certified Nurse's Aide (CNA) M stated the residents often had concerns with the food being delivered to the room. He stated staff should often test the food temperatures before serving it to the rooms. He stated staff should offer to warm the food up for the residents. He said it sometimes takes longer for the food to be delivered from the kitchen to the rooms which may be why the meals arrived cold. On 09/25/24 at 03:00 PM Dietary Staff BB stated the facility recently had a mock survey and identified concerns with meal service. He stated the facility should be using heaters to keep the food cold and temping test trays to ensure food temperatures were being held. He stated the meal trays would hold temperatures for 15 minutes before they cool down. The facility's Food Service policy 01/2024 indicated the facility would ensure all meals served were safe, nutritious, palatable, and within appropriate temperature ranges. The policy indicated the facility will ensure safe transport of meals between the dining rooms and rooms. The facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for R75 and R76. This deficient practice placed the residents at risk for impaired nutrition and decreased quality of life.

The facility identified a census of 37 residents. The sample included three residents reviewed for misappropriation of property. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from misappropriation of property when his checks were stolen from his room and then cashed. This deficient practice caused R1 to feel anger and frustration as he blamed himself for the misappropriation of his funds while he was a resident in the facility. This failure further placed R1 at risk for further misappropriation of funds and a continued decline in psychosocial well-being. Findings included: - R1 admitted to the facility on [DATE]. R1's Electronic Medical Record (EMR) documented a diagnosis of metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated [DATE], documented R1 had a BIMS of 13 and had forgetfulness. R1's Care Plan, dated [DATE], documented R1 was identified with an alteration in thought process related to short-term and long-term memory deficits. The care plan directed staff not to re-arrange R1's personal belongings in his room, except for safety, and staff encouraged R1 to express concerns or questions as needed. The facility's investigative report, dated [DATE], documented R1's representative reported to Administrative Staff A on [DATE] at 03:20 PM that R1 had multiple checks missing from his checkbook. The bank reported a fraudulent check was cashed for approximately $1,200.00 and a second check was attempted to be cashed but the bank caught it. R1's representative reported a total of eight checks were missing. R1's representative closed the account and took the remaining checks home. Administrative Staff A called the police on [DATE] at 03:24 PM. The facility interviewed R1, and he had no leads on who took the checks. The facility interviewed staff and found no leads. The checks were taken within a 17-day period. The facility reviewed agency staff names and none of those names matched the person to whom the check was written out. The facility's corrective actions include making new residents aware of available lock boxes. Administrative Staff A's notarized Witness Statement dated [DATE] stated he interviewed R1 about who stole the checks. R1 stated that he had no suspects and could not believe any of the staff who cared for him could have done such a thing. Administrative Staff A stated he asked R1 if he had any idea who could have taken the checks and R1 said no. Administrative Staff A first became aware of stolen checks from R1's representative on [DATE] when he was told checks were missing and their bank identified that two checks had been attempted to be cashed. Administrative Staff A stated the bank reported that one check was actually cashed for $1,200.00 and the memo line stated transmission repairs. R1's representative took the checkbook and closed the account. Administrative Staff A stated he spoke with the detective and informed them the facility did not know the person the check was written out to. Upon request, the facility was unable to provide an inventory log of R1's belongings. On [DATE] at 12:16 PM, R1 sat in his bed and ate watermelon. He stated he did not write any checks to anyone, and nobody had asked for any checks. R1 stated he left his checkbook on the table in his room. He stated the facility did not complete an inventory of his stuff on admission and he was not offered a lock box. R1 stated the situation bothered him and he said he blamed himself. He stated it made him mad and it sometimes felt like he was on his own in the facility. On [DATE] at 12:46 PM, Administrative Nurse D stated R1 did not have an inventory log. On [DATE] at 12:47 PM, Certified Nurse Aide (CNA) M stated when a resident was admitted , she readied the room and then helped the resident get situated. She stated she helped the resident unpack and the admissions nurse took it from there. CNA M stated if she found a wallet, checkbook, or money, she gave it to the resident or told them it was in their bag. She stated normally, wallets or money were kept where nobody got into like the top drawer of their bedside table. CNA M stated she was not sure if there was a lock box for residents to use. On [DATE] at 12:55 PM, CNA N stated she did not like to dig through a resident's personal items, but she asked if they had any valuables. She stated they had a checklist where she marked down if they had dentures, hearing aids, or a ring. CNA N stated if a resident had a wallet, checkbook, or cash, she told them to put them somewhere safe. She stated sometimes a resident asked for a lock box, but it was not offered unless they asked for one. On [DATE] at 01:03 PM, CNA O stated she saw R1's checkbook several times and told him to keep it in his zip-up folder. She stated she saw it on his counter and on his bedside table but would tell him to put it away. CNA O stated the admissions nurse did the inventory, not the CNAs. On [DATE] at 01:15 PM, Administrative Nurse E stated if a resident came in with valuables, the facility had cases they could offer to lock the valuables in. She stated the facility did not do a typical inventory unless the resident asked for one, but they did offer to lock up expensive items. On [DATE] at 01:17 PM, Licensed Nurse (LN) G stated when a resident was admitted , the CNA put their clothes up and the floor nurse completed their portion of the admission, but the facility had an admissions nurse. She stated if a resident had valuables, they asked the family if they could take them home. LN G stated if there were valuables, the resident was referred to Administrative Staff A for a lockbox. On [DATE] at 01:21 PM, LN H stated on admission, there was a printout for the resident's inventory which included clothing and belongings. She stated if the resident had cash or a purse, she asked if the family could take it home or ask Administrative Staff A to lock it up. LN H stated she did not normally ask a resident if they had valuables unless it was listed on the checklist, and she was not sure if the facility had lock boxes. On [DATE] at 01:24 PM, Administrative Nurse F stated during a resident's admission to the facility, she went over mealtimes, transportation, therapy times, laundry, and beauty salon. She stated there used to be an inventory in the admissions packet for big items like computers, cell phones, or chargers and she told the resident they could keep it for a running list, or it was placed in the chart. Administrative Nurse F stated the facility did not have enough lockboxes for all the residents. She stated she asked residents on admission if there were any valuables that they wanted to lock up. On [DATE] at 01:42 PM, Administrative Nurse D stated Administrative Staff A notified her that R1's representative reported some checks were missing but was not sure when they went missing. She stated R1's representative thought the last time R1 wrote a check was [DATE]. She stated she never saw any checks in R1's room. Administrative Nurse D stated the facility had security boxes they offered to residents. She stated the facility did not do an inventory when residents were admitted because they were there short-term. Administrative Nurse D stated residents were usually admitted from the hospital and did not have a lot of belongings; the family brought items in. She stated if a resident said they had valuables, the resident was offered a security box. She stated the facility kept residents safe from misappropriation by completing background checks on staff and discussing resident rights with staff. Administrative Nurse D stated R1 was almost always in his room and did not leave his room very often. On [DATE] at 01:59 PM, Administrative Staff A stated R1's representative notified him on [DATE] that one fraudulent check was cashed, and another had been attempted. He stated he called the police and R1's representative believed there were eight checks missing. He stated the facility had safes the residents could use, and Administrative Staff F made residents aware of the lock boxes on admission. Administrative Staff A stated he expected his staff to report if they saw something that could be unsafe. He stated R1 did not want things locked up or want people to mess with his items. Administrative Staff A stated residents chose if they wanted to do an inventory. The facility's Abuse Policy and Procedure, not dated, directed all residents had the right to be free from any form of verbal, sexual, physical, and mental abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services including theft of personal belongings or monies. The policy directed patients were not subjected to abuse by anyone including staff, other patients, consultants or volunteers, contract employees or staff from other agencies, family members or legal guardians, friends, or other individuals. The facility failed to ensure R1 remained free from misappropriation of property when he had checks stolen from his room at the facility which were then cashed for approximately $1,200.00. This deficient practice caused R1 to feel mad and frustrated as he blamed himself for the misappropriation of his funds while he was a resident. This failure further placed R1 at risk for further misappropriation of funds and a decline in psychosocial well-being.

The facility identified a census of 38 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to identify hazards and implement adequate supervision and care to ensure safe smoking for Resident (R) 1. R1 admitted to the facility on [DATE] at approximately 01:00 PM. R1 was alert and oriented to person place time and situation and received oxygen via nasal cannula at six liters per minute (LPM). At 05:15 PM on 12/08/23, Certified Nurse Aide (CNA) M took R1 outside for a cigarette break while R1 wore his oxygen. CNA M locked R1's wheelchair brakes and went back inside. Between 05:26 PM and 05:29 PM, R1 lit his cigarette. Around 05:34 PM R1's nasal cannula ignited. R1 removed the nasal cannula, shook it, and attempted to put out the flame. At approximately 05:35 PM, Licensed Nurse (LN) H approached the facility for her scheduled shift. LN H observed R1 swinging the nasal cannula tubing around and trying to put out the fire. LN H disconnected the tubing from the oxygen cylinder on the back of the wheelchair and turned off the oxygen flow. R1 sustained facial burns and later became hypoxic (insufficient oxygen), which required emergent treatment. The failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Face Sheet tab, recorded diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) with acute exacerbation (worsening of a disease or an increase in its symptoms), pneumonia (inflammation of the lungs), and dependence on supplemental oxygen. R1's Entry Minimum Data Set (MDS) dated [DATE] documented R1 admitted to the facility. R1's Baseline Care Plan initiated 12/08/23 lacked directives related to R1's smoking preference or interventions to address R1's ability to smoke safely. R1's Admission Nursing Observation assessment dated [DATE] documented R1 was alert and oriented to person, place, time, and situation. The assessment inaccurately recorded R1 did not smoke. R1's Inter-Agency Transfer Order dated 12/08/23 documented R1 required continuous oxygen at six LPM at rest and eight LPM with activity via nasal cannula with concentrator, portability, and/or conserving device. R1's Orders in the EMR ordered oxygen per nasal cannula to maintain oxygen saturation (SpO2-the amount of oxygen in the bloodstream) greater than 90 percent (%). Document LPM every shift. Oxygen may be titrated or discontinued as tolerated by R1 while SpO2 maintained over 90 %. The Progress Note dated 12/08/23 at 01:21 PM documented R1 arrived with no signs or symptoms of distress noted. R1 was on six LPM oxygen per nasal cannula continuously and might need to be increased to eight LPM per report from the hospital. The note recorded R1 stated he was unable to sign anything due to fine tremors in his hands. The Progress Note dated 12/08/23 at 06:19 PM documented LN H arrived early and reported R1 was outside trying to smoke with his oxygen on and burned himself. LN H reported she disconnected R1's oxygen tubes and noted when R1 was brought in, R1 had soot all over his face. The Progress Note dated 12/08/23 at 06:35 PM documented LN G was notified by LH H at approximately 05:50 PM that R1 was outside smoking with his oxygen cannula on and six LPM of oxygen flowing. LN H saw flames and immediately shut off the oxygen tank. LN G went outside and observed R1 upright in his wheelchair with soot on his face, hands, and around his nose. LN G cleaned the soot off the R1's hands, nose, and face. R1 had redness to areas of his face, nose and cheeks, as well as singed hair on his mustache and eyebrows. R1 did not have any blisters or wounds observed at that time. Upon return to R1's room, R1's SpO2 was at 91% on six LPM per nasal cannula. LN J notified Consultant GG and awaited call back. R1's cigarettes and lighter were removed from R1's room and placed in the medication cart. The Progress Note dated 12/08/23 at 08:50 PM documented R1 had thick mucus blocking his airway. R1 had an SPO2 of 85% despite supplemental oxygen flowing via nasal cannula at six LPM. The facility sent R1 to the emergency room at 09.04 PM. The Progress Note dated 12/09/23 at 09:00 AM documented R1 admitted to the hospital burn unit. CNA M's Witness Statement dated 12/11/23 documented CNA M entered R1's room and R1's daughter immediately told CNA M to make sure R1 got his smoke breaks. A few hours later, LN G told CNA M to take R1 outside to smoke. CNA M stated that with everything going on, she did not really think about R1's oxygen. CNA M took R1 outside and then came back into the building to get meal trays. LN H's Witness Statement dated 12/11/23 documented LN H pulled up to the building around 05:40 PM and noted R1 outside in his wheelchair. As LN H walked towards R1, LN H saw R1 swinging his oxygen tubing trying to put out a fire. LN H quickly approached R1, disconnected the cannula tubing from the concentrator to stop the oxygen supply, then checked on R1. R1 had black soot around his face, cheeks, and nose. LN H established R1 was out of danger, then went and reported to the admission nurse and LN G. LN G and LN H brought R1 in from outside, cleaned the soot from all over his nose and cheeks, and then LN G took over cares. On 12/13/23 at 12:00 PM Administrative Nurse D stated she expected staff to ask new admission (residents) if they smoke or not, and to assess if the newly admitted resident was safe to smoke or required supervision. On 12/13/23 at 12:19 PM LN I stated she did not ask R1 about smoking. LN I further stated she reviewed the hospital paperwork and did not see any information related to a history of smoking or that R1 did smoke. On 12/13/23 at 02:01 PM CNA M stated that R1's family member wanted to make sure R1 received his smoke breaks. CNA M further stated LN G asked CNA M to take R1 out for a smoke break. CNA M took R1 outside to smoke, asked what time R1 wanted to come back inside and the left R1 outside alone. CNA M revealed she forgot about R1's oxygen being on when she left R1 outside to smoke. The facility's Smoking Policy lacked a date documented residents could not carry smoking materials unless the patient has demonstrated safe smoking habits and practices determined by the assessment for residents who smoke. Residents may smoke in the designated smoking area without staff supervision if the resident has demonstrated safe smoking habits and practice determined by the assessment for residents who smoke. The facility failed to ensure staff identified smoking related hazards and provided adequate care and supervision to avoid preventable smoking related accidents for admitting resident R1. A facility CNA brought R1 outside to smoke with is oxygen on per nasal canula, which caught on fire and caused facial burns to R1, who subsequently admitted to a burn unit. This failure placed R1 in immediate jeopardy. The facility completed the following corrective actions by 12/11/23: The smoking policy was updated, and the facility has changed to a non-smoking facility with smoking residents that were already admitted grandfathered in. The two smoking residents had a safety smoking assessment completed on 12/09/23. The Nurses have received training related to asking the residents about smoking and performing the smoking assessment even though the facility is no longer a smoking facility to assure safety. The facility staff received training related to smoking safety on 12/11/23 The corrective actions were completed prior to the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of J.

The facility identified a census of 30 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals and recording the dish machine temperatures. The facility also failed to ensure the ice machine lid was closed in the nourishment area was closed This deficient practice placed residents at risk for contamination and food borne illness. Findings included: - The initial tour of the facility on 02/23/23 at 07:04 AM the Dietary Staff DD reported the facility had changed chemical sanitization companies in the past two weeks and chemical strips provided by the new company had not been testing within the facility set guidelines. Dietary Staff DD stated the new distributor had been notified. On 02/23/23 at 07:05AM the door of the ice machine in the nourishment was left open with the ice exposed. Review of the Dish Machine Temperature Log from 02/01/23 to 02/27/23 revealed 17 undocumented dish machine water temperature opportunities out of 81 opportunities. Review of the parts per million column (PPM) revealed lack of documentation 16 days out of 27 opportunities. On 02/28/23 at 11:46 AM Dietary Staff BB stated the facility had changed companies that provided the sanitization chemicals and the facility had notified the provider of the problem. On 02/28/23 at 12:24 PM Dietary Staff CC stated the company had reviewed the concern of the chemical test strips the facility had used to check the PPM was for testing fruits and vegetables and not for dish machines. On 02/28/23 at 01:50 PM Licensed Nurse (LN) H stated night was responsible for cleaning the ice machine in the nourishment area. LN H stated it was everyone\s responsibility to close the lid to ice machine when finished getting ice. On 02/28/23 at 02:00 PM Certified Nurse's Aide (CNA) M stated the kitchen was responsible for any maintence of the ice machine. CNA M stated she cleaned the ice chest at the start of each shift. CNA M stated it was everyone's responsibility to ensure the ice machine lid was closed when not in use. The facility's Food handling policy dated 08/06/20 documented sanitization solution must be changed when cloudy, when not with in the recommended concentration or temperature, or at least three times a day. The facility failed to ensure that staff members properly tested the dishwashing sanitization chemicals and recording the dish machine temperatures. The facility also failed to ensure the ice machine lid was closed in the nourishment area was closed. This deficient practice placed residents at risk for contamination and food borne illness.

The facility had a census of 56 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents. Findings Included: - On 02/23/23 at 07:05 AM an initial walkthrough of the facility revealed opened Micro-Kill germicidal cylindrical containers of disinfectant wipes were in the hallway, unsecured, outside of Residents (R)7, R23, R88, R90, and R142's rooms. The disinfectant wipes were also noted outside of unoccupied rooms 104, 105, 108, 114, and 134. The walkthrough revealed 12 total containers of chemical wipes left unsecured. The label of the wipes contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated all chemical products should securely locked up away from resident access. On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated that hazardous chemicals should be secured out of reach from the residents. She stated staff use the wipes to wipes down areas to prevent the spread of infections but should not leave the wipes out for resident to have access. On 2/28/23 at 02:40 PM Administrative Nurse D stated she was not aware that the wipes had been left out but stated that staff used them in the isolation rooms and areas that may be of high contamination risks. She stated that she would educate staff on safety and securing the wipes. The facility failed to secure chemicals in a safe, locked area, and out of reach of the five cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents.

The facility identified a census of 30 residents. The sample included 12 residents with two reviewed for activities of daily living (ADL). Based on observations, record review, and interviews, the facility failed to provide consistent bathing opportunities and the level of assistance required for Resident (R)15. This deficient practice placed R15 at risk for impaired skin integrity, discomfort, and decreased psychosocial well-being. Findings Included: -The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), muscle spasms, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness. A review of R15's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required extensive assistance from one staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated she had no falls since admission. The MDS indicated she used a walker and wheelchair for mobility. A review of R15's Activities of Daily Living Care Area Assessment (CAA) completed 01/12/23 indicated she declined in her ADLs related to her medical diagnoses. The CAA instructed staff to ensure call light devices remained within reach, help and therapy to improve transfers, and continue with supportive care plan. A review of R15's Care Plan revised 01/07/23 indicated she required limited assistance for meals. The plan indicated she required moderate to total assistance for transfers, bed mobility, personal hygiene, dressing, toileting, and bathing. A review of R15's Bathing History report from 01/01/23 through 02/27/23 (47 days reviewed) indicated she received six (1/12, 1/15, 2/2, 2/9, 2/16, 2/23) baths. No refusals were documented. A review of R15's EMR revealed no therapy baths, refusals, or documentation showing why bathing did not occur. On 02/23/23 at 08:02AM R15 sat in her wheelchair at the table in her room. R15 reported the facility had just given her a shower but did not properly dry her hair. R15 had a towel placed over her left shoulder and her hair was damp. R15 reported she was cold from not being fully dried off. She reported since arriving at the facility her bathing had been inconsistent. She stated that she was supposed to be bathed twice a week but had only been given one weekly. She stated that she missed a whole week of bathing a few weeks back. She indicated that she would like to receive bathing twice a week. On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated each resident should be bathed at least twice a week but residents could request to be bathed daily if they wished to be. She stated the unit nurses put out the schedule of which residents were to be bathed and the CNA staff were responsible for completing the bathing. She stated that all baths were to be documented in the Point of Care (EMR) under ADL Care. She stated that if a resident refused the CNA notified the nurse and documented the refusal. On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated the CNA staff were responsible for completing baths and reporting to the nurses if cares were not completed. She stated that R15 received her baths, so she was not sure why they were not documented. On 2/28/23 at 02:40 PM Administrative Nurse D stated that R15 should have received her baths weekly and then during each incontinent episode as part of her plan. She stated that staff should be documenting all bathing and refusals in the EMR. She was not sure why the EMR was missing bathing occurrences. A review of the facility's ADL Charting policy 08/2020 indicated all resident will be provide ADL assistance based on the individualized plan provided. The policy indicated that staff will document all assistance provide and observed the resident throughout the shift for cares needed. The policy indicated staff will document if an activity did not occur. The facility failed to provide consistent bathing opportunities and the required assistance for R15. This deficient practice placed R15 at risk for impaired skin integrity, discomfort, and decreased psychosocial well-being

The facility identified a census of 30 residents. The sample included 12 residents with two residents reviewed for care plan revisions related to accidents. Based on observation, record review, and interviews, the facility failed to revise Residents (R)15 and R33's care plans to reflect interventions implemented for recent falls. This deficient practice placed both residents at risk for uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue and severe sleep disturbance), muscle spasms, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and muscle weakness. A review of R15's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of six indicating severe cognitive impairment. The MDS indicated she required extensive assistance from one staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated she had no falls since admission. The MDS indicated she used a walker and wheelchair for mobility. A review of R15's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 01/12/23 indicated she declined in her ADLs related to her medical diagnoses. The CAA instructed staff to ensure call light devices remained within reach, help and therapy to improve transfers, and continue with supportive care plan. R15's was triggered for Falls CAA on 01/12/23 but no comments were documented. A review of R15's Care Plan revised 01/07/23 indicated she required limited assistance for meals. The plan indicated she required moderate to total assistance for transfers, bed mobility, personal hygiene, dressing, toileting, and bathing. The plan lacked documentation related to her landing strip (fall mat) located on the right side of her bed. A review of R15's Comprehensive Care Plan lasted revised 02/10/23 reflected previous admission care approaches created on 08/11/16. R15's ADL Functional entry indicated she only required limited assistance for ambulation, bed mobility, transfers, and toileting. A review of R15's EMR revealed a Fall Incident note on 01/28/23. The note revealed R15 was found on the floor next to her bed. The note revealed that R15 stated she had slid down her bed and onto the floor. The note revealed a landing strip was added to prevent her from sliding. On 02/23/23 at 08:02AM R15 sat in her wheelchair at the table in her room. R15's bed was in the low position and a landing strip was placed of the right side of her bed. R15 stated she slid out of bed and staff placed the landing strip next to her bed. She stated that she was not sure if staff was supposed to remove the mat when she was out of bed or just leave it on the floor all day. She stated that the landing strip was hard to maneuver around to get to her bed and it often forced her wheelchair backwards when she attempted to go over it. She stated that some staff move it so she could access that side of her room and the sink area. On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated R15 required staff assistance for all her ADLs and was a high fall risk. She stated all staff have access to the care plan in the Point of Care (EMR). She stated that a resident fall intervention should be listed in the care plan. She stated that R15 should have a fall mat and bed in the lowest position. On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated the R15 was a fall risk. She stated R15's fall interventions included a landing strip, frequent checks, call light within reach, and having her bed in the lowest position. She was not sure if the landing strip was to be moved during the day or remain in place while R15 was mobile. On 2/28/23 at 02:40 PM Administrative Nurse D stated R15's care plan should have included her active interventions. She stated the care plan should be based upon the admission assessment and revised each time an event or change occurs with the resident. She stated that all staff have access to the care plans and should be following the provided interventions. A review of the facility's Care Plan policy revised 09/2022 indicated the resident care plans will be continually evaluated to ensure interventions are being followed and effective to maintain the specified goals. The policy noted the plans should be updated to reflect changes, goals, and interventions are identified and effectively treated. The facility failed to revise R15's care plan to reflect implemented fall interventions. This deficient practice both residents at risk for preventable falls and injuries due to uncommunicated care needs. -The Medical Diagnosis section within R33's Electronic Medical Records (EMR) included diagnoses of chronic kidney disease, chronic obstructive pulmonary disorder (COPD - progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), muscle weakness, benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). A review of R33's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of five indicating severe cognitive impairment. The MDS indicated he required extensive assistance from one staff for bed mobility, transfers, dressing, toileting, and bathing. The MDS indicated he had two or more non-injury falls since admission. The MDS indicated he was taking insulin (hormone which regulates blood sugar) medication. The MDS indicated he used a walker and wheelchair for mobility. A review of R33's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 01/26/23 indicated he required limited to extensive assistance from one staff member for his ADLs. The CAA instructed staff to offer and assist in ways that were familiar and safe for R33. The CAA instructed staff to promote independence and provide the least restrictive environment as permitted to enhance his quality of life. R33's Fall CAA completed 01/26/23 indicated that he was at risk for falls related to his medical diagnoses, impaired cognition, and weakness. The CAA noted for staff to ensure he was oriented with his new environment and provide reminders as needed. The CAA instructed that his bed be in the low position, call light within reach, and for staff to anticipate his needs. R33's Cognitive Loss CAA completed 01/26/23 noted that he was at risk for impaired cognition due to his diabetes mellitus diagnosis and hypoglycemia. The CAA instructed staff to monitor for changes in cognition, mood, behavior, and confusion. A review of R33's Care Plan initiated 01/25/23 indicated R33 was at risk for falls related to his fall history, medications, and functional deficits. The plan instructed staff to assist with ambulation and transfers, educate him on fall safety, encourage to call for assistance with his call light, added bolsters (cushioning or pillows used to prevent falls) to his mattress, and monitor him for medication side effects. R33's care plan lacked documentation related to his fall on 01/28/23 or include the increased glucose monitoring intervention put in place after his fall incident. A review of R33's EMR revealed a Fall Incident note on 01/28/23. The note indicated R33 was found on the floor bundled in his blankets. The note indicated R33's blood glucose (blood sugar) was tested . R33's blood glucose was 39 milligram per deciliter (mg/dL). R33 was sent out to an acute care facility for treatment and evaluation and returned five hours later. A review of R33's Physician's Orders revealed an order dated 01/28/22 instructing staff to complete blood glucose checks daily at 12:00AM and 04:00AM related to hypoglycemia (low blood sugar). A review of R33's Blood Glucose history indicated that his levels was checks at 09:45PM on 01/27/23 before his fall incident occurred the morning of 01/28/23. His glucose level was 138mg/dL. On 02/23/23 at 01:23PM R33 sat in his recliner watching television. He wore non-slip shoes. His bed had mattress bolsters in place and was in the low position. His call light was within reach. R33 reported he had fallen several times before coming to the facility but could not remember his recent fall. He stated that he knows he fell but was not feeling well that day. On 02/28/23 at 01:49 PM Certified Nurses Aid (CNA) M stated that R33 was fall risk and has had a fall at the facility. She stated that R33 struggled with remembering and needed reminders to ask for help. On 02/28/23 at 01:49 PM Licensed Nurse (LN) G stated that staff should be following the given physician orders for checking vitals (heart rate, blood pressure, temperatures) as well as blood glucose. She stated that R33 had fallen before and gets his blood glucose checked at bedtime and overnight. On 2/28/23 at 02:40 PM Administrative Nurse D stated R33's care plan should have included active interventions. She stated the care plan should be based upon the admission assessment and revised each time an event or change occurs with the resident. She stated that all staff have access to the care plans and should be following the provided interventions. A review of the facility's Care Plan policy revised 09/2022 indicated the resident care plans will be continually evaluated to ensure interventions are being followed and effective to maintain the specified goals. The policy noted the plans should be updated to reflect changes, goals, and interventions are identified and effectively treated. The facility failed to revise R33's care plan to reflect implemented fall interventions. This deficient practice both residents at risk for preventable falls and injuries due to uncommunicated care needs.

The facility identified a census of 36 residents. The sample included three residents reviewed for abuse. Based on record review and interviews, the facility failed to ensure staff identified a situation of verbal abuse, neglect, and mistreatment as an alleged violation. The facility further failed to ensure staff immediately reported the alleged violation to the facility administrator. Once reported, the facility administrator failed to acknowledge the allegation as abuse and failed to alert the appropriate state agencies as required. On 02/06/22 at approximately 04:30 AM, Certified Nurse Aide (CNA) M entered R1's room while R1 pleaded for help. CNA M called R1 a liar, stated R1 was talking nasty and told R1 you're the devil. CNA M told R1 nobody wanted to hear her. CNA M mocked R1 as R1 cried for assistance, when R1 repeatedly stated she could not hear. CNA M dressed R1, placed her in the wheelchair, but neglected to ensure the call light was within reach for R1 to summon staff assistance. R1's responsible representative alerted the facility to the occurrence on 02/06/22. This failure placed the resident in immediate jeopardy. Findings included: - R1 admitted to facility on 01/28/22 and discharged on [DATE]. The Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status of 15 which indicated intact cognition. R1 had moderate difficulty with hearing and the speaker had to increase volume and speak distinctly. R1 used hearing aides or other hearing appliances. R1 required extensive physical assistance with two staff members for bed mobility, transfers, and toileting; extensive physical assistance with one staff member for dressing; limited physical assistance with one staff member for walking, locomotion, and personal hygiene; and supervision with setup help only with eating. The Communication Care Area Assessment (CAA) dated 02/06/22, documented R1 had minimal difficulty hearing when not in a quiet environment and she had hearing aids. Nursing assisted with hearing aids as needed and staff raised voice volume as needed when addressing resident. R1 generally did not have a problem understanding staff and was able to effectively communicate all wants and needs to staff and family. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 02/06/22, documented R1 required extensive to limited assistance with mobility and ADLs. The Baseline Person Centered Care Plan dated 01/28/22, documented R1 needed assistance with ADLs and wore hearing aids. A recorded message revealed the following interaction between R1 and CNA M on 02/06/22: R1- I'm in trouble, I'm laying here naked and the girl took away my number to call for help and she left me on the bed, naked with no clothes. And I'm in, I can't move, my feet are hanging over the bed, I can't move. Somebody you got to help me, I don't know who to call. Please help me, please. Somebody I'm laying here naked in the bed, all twisted my feet are getting the end of the bed. And she won't do anything, she took my call button away. So I got to get somebody, I don't know who to call. I can't do it, I can't move. Please somebody, I'm laying here, I can't move. She walked out on me with no, nothing, I can't even push a button for help. She was nobody, she walked out on me like this, I'm screaming, please help me somebody. Please, please. I don't know what to do, I don't know. Oh my god, oh my god. Hello? I can't lay like this. [sobbing in background] getting some help. no, I can't lay like this, no, I can't. I can't, I can't go back, I can't go forward, I can't, I can't, I have nothing, but in here with you. CNA M: You calling your family lying. R1: I didn't do anything. CNA M: Calling your family lying. Here, give me that. R1 and CNA M: [unable to discern words] CNA M: You're about to get up, I'm going to put you in your chair. R1: You let me lay here like this. CNA M: You're not going to like this. R1: I can't lay here like this. I can't, I can't lay like this. I didn't do anything. R1 and CMA M-: [unable to discern words] R1: Help me please, I can't lay like this. CNA M: See, that's what you do, you talking nasty then you call and tell lies to your family. Quit lying, you're the devil. R1: I can't lay like this. [unable to discern words] CNA M: You go waking up the whole hall with this foolishness. R1: Where's my thing at? CNA M: 'This is Sunday, don't nobody want to hear that. R1: I can't hear you, I'm sorry. CNA M: I'm sorry, I'm deaf too. R: I'm deaf. CNA M: I'm sure. R1: I can't hear you. CNA M: Okay, yeah R1: I can't lay like this, I'm uncomfortable. In a Progress Note dated 02/06/22 at 07:01 AM, Licensed Nurse (LN) H documented the following: around 04:50 AM, LN H was doing rounds when she heard R1 calling for help. She rushed to R1's room immediately and asked what was wrong. R1stated that she was in pain and needed a pain pill. LN H took an as needed (PRN) pain pill to R1 and R1 was calm. At around 05:50 AM, R1's representative called and stated she heard R1 being abused and harassed and recorded the whole incident. R1's representative narrated that R1 told her the aide who was helping R1 left her naked and uncovered, yelled at R1, and took her call light away. R1's representative stated she was afraid R1 was being abused and she was making arrangements to move her out of the facility. LN H asked R1 about the accusations and R1 did not report any abuse to LN H. In a Progress Note at 04:01 PM LN G documented she, along with two other unidentified nurses, spoke with R1's representative related to the incident with R1 and CMA M overnight. LN G documented Administrative Staff A and Administrative Nurse D were notified of the conversation and advised to contact R1's representative on Monday morning. R1's representative requested R1 move to a room closer to the nurse's station as soon as possible. Upon request, the facility provided the following witness statements: In an undated written statement at 02:30 PM, CNA M wrote R1 complained of pain after dinner and took her gown off. [R1] appeared naked and stated something about sexual misconduct where R1 worked. CNA M wrote she asked R1 not to talk that way as it was [there were] visitors outside her door. CNA M further documented she closed R1's door for privacy. CNA M recorded R1 complained of wanting to be pulled up and the nurse helped CNA M put R1 in her chair. CNA M wrote that she asked R1 why R1 was treating CNA M this way and asked R1 to please not yell and calm down because it was Sunday. CNA M wrote she asked R1 several times not to talk that way. CNA M wrote she stated to R1 please cover up and have some dignity!! CNA M wrote she asked R1 to keep her voice down as R1 kept stating why? CNA M documented she responded to R1 by saying it's Sunday. I have no time for foolishness. CNA M got R1 dressed, put her up in her chair, and R1 calmed down. CNA M documented R1 called R1's representative to complain and CNA M told R1 and/or her representative CNA M was not entertaining R1's foolish and nonsense conversation, and sexual misconduct. CNA M recorded she let R1 and/or R1's representative know that was unacceptable conversation and behavior. In a typed statement dated 02/07/22, Administrative Staff A documented he received a text from LN H who spoke to R1 about an incident involving CNA M at approximately 04:45 AM on 02/06/22. The text stated R1 called her representative to tell her the following: reported that she was left naked, her call light taken away by the aide and that she was yelling at her, her family member admitted recording the whole incident, asked the aide and she denied the accusations. She also stated that she's making arrangements to come get her mom out of there. Patient did not report any abuse. In a typed statement dated 02/07/22, Administrative Staff A documented he received the following statement from CNA N regarding the incident between CNA M and R1: On 02/06/22 around 03:30 AM to 4:15 AM, CNA N walked down to hall one to grab the ice chest but heard someone yelling for help and moaning like they were in pain. CNA N followed the voice down to R1's room and the nurse for the hall happened to be right behind her. CNA N approached R1 who sat in the wheelchair. R1 told CNA N that R1 was left naked in bed and the call light was taken away. R1 was dressed when CNA N walked into her room. R1 did not have her call light on her, it was behind her on the recliner, out of her reach. CNA N pinned R1's call light to R1. R1 complained her back was hurting and CNA N placed a pillow behind R1 in the wheelchair to give her some support. LN H gave R1 a pain pill. In a typed statement dated 02/07/22, Administrative Staff A documented he received reports about an incident regarding a verbal altercation between CNA M and R1. CNA M gave a statement and was immediately placed on the facility's do not return list through the contracting agency. Administrative Staff A received reports from LN H and CNA N then spoke to R1 to make sure she was ok. Administrative Staff A notified R1 that CNA M would not return to the facility. R1 thanked Administrative Staff A for the help. Administrative Staff A called R1's representative and notified her that CNA M was placed on do not return list. In a witness statement obtained on 02/16/22, LN G wrote she came to work for the 06:00 AM shift on 02/06/22 and the night nurse, LN H, was writing an incident report. LN H explained that something happened with the agency CNA overnight and R1's representative had something recorded. LN G encouraged LN H to report to Administrative Staff A and Administrative Nurse D immediately and encouraged CNA M to write a statement. LN G checked on R1. Around lunch, R1's representative arrived and requested to speak with nurse. LN G and two other unidentified nurses went to speak with R1's representative. R1's representative played the recorded interaction between R1 and CNA M. LN G referred R1's representative immediately to Administrative Staff A and Administrative Nurse D. R1's representative requested R1 be relocated to a room closer to the nurses' station. In a witness statement obtained on 02/16/22, Administrative Nurse D documented on 02/06/22 (Sunday) at 12:53 PM, she was notified by a day nurse of a situation that needed addressed by Administrative Staff D and Administrative Staff A on Monday morning. She was notified on 02/06/22 via text by LN H that R1 called and reported she was left naked; her call light was taken away by an aide and yelled at by a CNA. R1's representative also reported she was removing R1 from the facility. LN H stated R1 was not naked and denied any form of abuse. Administrative Nurse D notified the unidentified staffing coordinator and Administrative Staff A of the text and asked the staffing coordinator to take CNA M off the schedule and notify her contracting agency. Administrative Nurse D asked all staff working to write a statement and called Administrative Staff A when the statements were completed. In a witness statement obtained on 02/16/22, Administrative Staff A wrote he was notified Sunday morning, 02/06/22, that LN H and CNA N assisted R1. Administrative Staff A documented LN H and CNA N found R1 upright in a wheelchair, clothed, and complaining of back pain. Administrative Staff A recorded LN H reported R1 denied abuse. Administrative Staff A documented he talked to R1 on Monday, 02/07/22, in the morning and R1 requested to be moved closer to the nurses' station. He told R1 that CNA M had been placed on the do not return list and confirmed R1 would be moved into another room. Administrative Staff A recorded he called R1's representative and notified her CNA M would not be back to the facility and R1 was moving to another room that afternoon. Administrative Staff A recorded he called the corporate office and was instructed to gather the statements. Administrative Staff A documented R1 mentioned she had a verbal altercation with an agency CNA and he immediately notified her that the CNA would not be returning to the facility. On 02/15/22 at 02:58 PM, Administrative Staff A stated the incident with R1 was not treated as an abuse allegation and R1 did not report abuse when interviewed. On 02/16/22 at 11:16 AM, LN M stated on the morning of the incident, she came in at shift change and LN N was frazzled trying to figure out what she should do. LN M stated she knew something happened with R1 and CNA M around 04:00 AM that morning and R1's representative had something recorded. LN M stated she instructed LN N to notify Administrative Staff A and Administrative Nurse D, complete an incident report, and document. She stated she checked on R1 first thing and R1 was pretty shaken. LN M stated R1's representative came into the facility around lunch time and wanted to speak with the nurse. LN M, along with two other nurses as witnesses, spoke to R1's family member. LN M stated R1's family member played the voicemail for LN M. LN M told R1's representative it would be reported immediately to Administrative Staff A. R1's representative wanted to make sure R1 would be safe and was notified CNA M would not be returning to the facility. LN M stated she considered the verbal altercation between CNA M and R1 as abuse. On 02/16/22 at 11:51 AM, Administrative Nurse D stated if abuse was suspected, staff notified administration and if abuse was found after the facility investigation, it was reported appropriately. Administrative Nurse D said if a resident stated they were being verbally abused or staff were being rough, then an investigation was initiated, but if the resident denied abuse, then an investigation was not completed or needed. She stated if the residents' representative alleged abuse, but the resident denied the abuse, then it did not count as an allegation of abuse. Administrative Nurse D stated the incident with R1, and CNA M was reported to her on 02/06/22 at 07:00 AM. She stated the staffing agency was contacted so agency aide CNA M would not return to facility. She stated the nurse that worked during the incident stated she spoke to R1 regarding abuse allegations and R1 denied any abuse. Administrative Nurse D stated if a resident complained of being abused, the facility would investigate. She stated she spoke with R1's family member throughout the week but had not heard the recording. Administrative Nurse D stated the facility's policy directed abuse complaints were investigated only if the residents said they were abused. Administrative Nurse D stated the facility had 24 hours to report once allegations were found to be actual abuse. On 02/16/22 at 12:24 PM, Administrative Staff A stated he was notified early Sunday morning, 02/06//22, about an incident that occurred around 04:30 AM. R1's representative had a recording from around that time. LN H reported to Administrative Staff A that she entered R1's room with CNA N in response to R1 calls for help. R1 was upright in her wheelchair and clothed. He stated LN H asked R1 follow-up questions and asked R1 if she felt abused or neglected. R1 denied feeling abused or neglected. Administrative Staff A stated R1 told him she did not get along with CNA M and that they had a verbal altercation. He informed R1 that CNA M would not return to the facility and R1 requested to move closer to the nurses station. He stated that to his understanding, if a resident or family member alleged abuse then there was a fairly short window of 24 hours to report it. If there was any abuse, he would do an investigation and call the police. Administrative Staff A said R1 had not complained of abuse, and there was no investigation as there was no allegation since R1 denied abuse. He stated R1 said she did not get along with CNA M, CNA M raised her voice at R1, seemed agitated, and not compassionate. Administrative Staff A stated anything had the potential to be verbally abusive. He had not listened to the recording, but stated the resolution was simple as it was an agency aide, she was not allowed back. He stated he had not read the Progress Note by LN H that documented R1's family member alleged abuse and harassment and it was not reported to him as such. On 02/16/22 at 02:00 PM, CNA N stated on 02/06/22 she was working on hall two and heard someone yelling. CNA N and LN H went down to R1's room, R1 sat in her wheelchair, yelling that she was naked in bed. R1 was dressed and did not have call light within reach as it was behind her. CNA N pinned her call light on her CNA N stated if she witnessed abuse, she would report to the nurse, Administrative Nurse D and Administrative Staff A. On 02/16/22 at 02:41 PM, LN H stated she was the nurse on duty on the morning of 02/06/22 and R1's representative called with concerns about R1. R1's representative voiced a concern about R1 being abused. LN H went into R1's room to make sure she had not been abused and had not been naked. LN H stated she reported R1's representative's concerns to Administrative Staff A. The facility's Abuse Policy and Procedure last updated 08/06/20, directed any form of resident abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services was not tolerated and it was the responsibility of all employees to report abuse to the Administrator or Director of Nursing. All residents have the right to be free from any verbal, sexual, physical, and mental abuse, mistreatment, neglect, misappropriation, and deprivation of goods and/or services. Residents were not subjected to abuse by anyone including staff, other residents, consultants or volunteers, contract employees or staff from other agencies serving the residents. Verbal abuse was defined as any use of oral, written, or gestured language that included disparaging and derogatory terms to residents or families or within hearing distance to describe residents regardless of their age, ability to comprehend, or disability. All alleged or suspected violations involving including abuse, neglect, mistreatment, misappropriation, exploitation or deprivation of goods and/or services were promptly reported to the Administrator and/or Director of Nursing. The person observing an incident of resident abuse or suspected abuse must immediately ensure resident safety then immediately report such incidents to their immediate supervision and/or the charge nurse. The supervisor and/or charge nurse contacted the Administrator or Director of Nursing. The Director of Nursing or Administrator ensured the safety of the resident, began the investigation, and if necessary, report information to the police and any other appropriate agency. The facility failed to ensure staff identified a situation of verbal abuse, neglect and mistreatment as alleged abuse. The facility further failed to ensure staff immediately reported the alleged violation of abuse to the facility administrator. Once reported, the facility administrator failed to acknowledge the allegation as abuse and failed to alert the appropriate state agencies as required . This failure placed the resident in immediate jeopardy.

The facility identified a census of 36 residents. The sample included three residents reviewed for abuse. Based on record review and interviews, the facility failed to ensure Resident (R)1 remained free from abuse and neglect when the facility failed to prevent an episode of staff to resident verbal abuse, mistreatment and neglect. On 02/06/22 at approximately 04:30 AM, Certified Nurse Aide (CNA) M entered R1's room while R1 pleaded for help. CNA M called R1 a liar, stated R1 was talking nasty and told R1 you're the devil. CNA M told R1 nobody wanted to hear her. CNA M mocked R1 as R1 cried for assistance, when R1 repeatedly stated she could not hear. CNA M dressed R1, placed her in the wheelchair, but neglected to ensure the call light was within reach for R1 to summon staff assistance. This failure placed the resident in immediate jeopardy. Findings included: - R1 admitted to facility on 01/28/22 and discharged on [DATE]. The Electronic Medical Record (EMR) documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status of 15 which indicated intact cognition. R1 had moderate difficulty with hearing and the speaker had to increase volume and speak distinctly. R1 used hearing aids or other hearing appliances. R1 required extensive physical assistance with two staff members for bed mobility, transfers, and toileting; extensive physical assistance with one staff member for dressing; limited physical assistance with one staff member for walking, locomotion, and personal hygiene; and supervision with setup help only with eating. The Communication Care Area Assessment (CAA) dated 02/06/22, documented R1 had minimal difficulty hearing when not in a quiet environment and she had hearing aids. Nursing assisted with hearing aids as needed and staff raised voice volume as needed when addressing resident. R1 generally did not have a problem understanding staff and was able to effectively communicate all wants and needs to staff and family. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential CAA dated 02/06/22, documented R1 required extensive to limited assistance with mobility and ADLs. The Baseline Person Centered Care Plan dated 01/28/22, documented R1 needed assistance with ADLs and wore hearing aids. A recorded message revealed the following interaction between R1 and CNA M on 02/06/22: R1- I'm in trouble, I'm laying here naked and the girl took away my number to call for help and she left me on the bed, naked with no clothes. And I'm in, I can't move, my feet are hanging over the bed, I can't move. Somebody you got to help me; I don't know who to call. Please help me, please. Somebody I'm laying here naked in the bed; all twisted my feet are getting the end of the bed. And she won't do anything, she took my call button away. So, I got to get somebody, I don't know who to call. I can't do it, I can't move. Please somebody, I'm laying here, I can't move. She walked out on me with no, nothing, I can't even push a button for help. She was nobody, she walked out on me like this, I'm screaming, please help me somebody. Please, please. I don't know what to do, I don't know. Oh my god, oh my god. Hello? I can't lay like this. [sobbing in background] getting some help. no, I can't lay like this, no, I can't. I can't, I can't go back, I can't go forward, I can't, I can't, I have nothing, but in here with you. CNA M: You calling your family lying. R1: I didn't do anything. CNA M: Calling your family lying. Here, give me that. R1 and CNA M: [unable to discern words] CNA M: You're about to get up, I'm going to put you in your chair. R1: You let me lay here like this. CNA M: You're not going to like this. R1: I can't lay here like this. I can't, I can't lay like this. I didn't do anything. R1 and CMA M-: [unable to discern words] R1: Help me please, I can't lay like this. CNA M: See, that's what you do, you talking nasty then you call and tell lies to your family. Quit lying, you're the devil. R1: I can't lay like this. [unable to discern words] CNA M: You go waking up the whole hall with this foolishness. R1: Where's my thing at? CNA M: 'This is Sunday, don't nobody want to hear that. R1: I can't hear you, I'm sorry. CNA M: I'm sorry, I'm deaf too. R: I'm deaf. CNA M: I'm sure. R1: I can't hear you. CNA M: Okay, yeah R1: I can't lay like this, I'm uncomfortable. In a Progress Note dated 02/06/22 at 07:01 AM, Licensed Nurse (LN) H documented the following: around 04:50 AM, LN H was doing rounds when she heard R1 calling for help. She rushed to R1's room immediately and asked what was wrong. R1stated that she was in pain and needed a pain pill. LN H took an as needed (PRN) pain pill to R1 and R1 was calm. At around 05:50 AM, R1's representative called and stated she heard R1 being abused and harassed and recorded the whole incident. R1's representative narrated that R1 told her the aide who was helping R1 left her naked and uncovered, yelled at R1, and took her call light away. R1's representative stated she was afraid R1 was being abused and she was making arrangements to move her out of the facility. LN H asked R1 about the accusations and R1 did not report any abuse to LN H. In a Progress Note at 04:01 PM LN G documented she, along with two other unidentified nurses, spoke with R1's representative related to the incident with R1 and CMA M overnight. LN G documented Administrative Staff A and Administrative Nurse D were notified of the conversation and advised to contact R1's representative on Monday morning. R1's representative requested R1 move to a room closer to the nurse's station as soon as possible. Upon request, the facility provided the following witness statements: In an undated written statement at 02:30 PM, CNA M wrote R1 complained of pain after dinner and took her gown off. [R1] appeared naked and stated something about sexual misconduct where R1 worked. CNA M wrote she asked R1 not to talk that way as it was [there were] visitors outside her door. CNA M further documented she closed R1's door for privacy. CNA M recorded R1 complained of wanting to be pulled up and the nurse helped CNA M put R1 in her chair. CNA M wrote that she asked R1 why R1 was treating CNA M this way and asked R1 to please not yell and calm down because it was Sunday. CNA M wrote she asked R1 several times not to talk that way. CNA M wrote she stated to R1 please cover up and have some dignity!! CNA M wrote she asked R1 to keep her voice down as R1 kept stating why? CNA M documented she responded to R1 by saying it's Sunday. I have no time for foolishness. CNA M got R1 dressed, put her up in her chair, and R1 calmed down. CNA M documented R1 called R1's representative to complain and CNA M told R1 and/or her representative CNA M was not entertaining R1's foolish and nonsense conversation, and sexual misconduct. CNA M recorded she let R1 and/or R1's representative know that was unacceptable conversation and behavior. In a typed statement dated 02/07/22, Administrative Staff A documented he received a text from LN H who spoke to R1 about an incident involving CNA M at approximately 04:45 AM on 02/06/22. The text stated R1 called her representative to tell her the following: reported that she was left naked, her call light taken away by the aide and that she was yelling at her, her family member admitted recording the whole incident, asked the aide and she denied the accusations. She also stated that she's making arrangements to come get her mom out of there. Patient did not report any abuse. In a typed statement dated 02/07/22, Administrative Staff A documented he received the following statement from CNA N regarding the incident between CNA M and R1: On 02/06/22 around 03:30 AM to 4:15 AM, CNA N walked down to hall one to grab the ice chest but heard someone yelling for help and moaning like they were in pain. CNA N followed the voice down to R1's room and the nurse for the hall happened to be right behind her. CNA N approached R1 who sat in the wheelchair. R1 told CNA N that R1 was left naked in bed and the call light was taken away. R1 was dressed when CNA N walked into her room. R1 did not have her call light on her, it was behind her on the recliner, out of her reach. CNA N pinned R1's call light to R1. R1 complained her back was hurting and CNA N placed a pillow behind R1 in the wheelchair to give her some support. LN H gave R1 a pain pill. In a typed statement dated 02/07/22, Administrative Staff A documented he received reports about an incident regarding a verbal altercation between CNA M and R1. CNA M gave a statement and was immediately placed on the facility's do not return list through the contracting agency. Administrative Staff A received reports from LN H and CNA N then spoke to R1 to make sure she was ok. Administrative Staff A notified R1 that CNA M would not return to the facility. R1 thanked Administrative Staff A for the help. Administrative Staff A called R1's representative and notified her that CNA M was placed on do not return list. In a witness statement obtained on 02/16/22, LN G wrote she came to work for the 06:00 AM shift on 02/06/22 and the night nurse, LN H, was writing an incident report. LN H explained that something happened with the agency CNA overnight and R1's representative had something recorded. LN G encouraged LN H to report to Administrative Staff A and Administrative Nurse D immediately and encouraged CNA M to write a statement. LN G checked on R1. Around lunch, R1's representative arrived and requested to speak with nurse. LN G and two other unidentified nurses went to speak with R1's representative. R1's representative played the recorded interaction between R1 and CNA M. LN G referred R1's representative immediately to Administrative Staff A and Administrative Nurse D. R1's representative requested R1 be relocated to a room closer to the nurses' station. In a witness statement obtained on 02/16/22, Administrative Nurse D documented on 02/06/22 (Sunday) at 12:53 PM, she was notified by a day nurse of a situation that needed addressed by Administrative Staff D and Administrative Staff A on Monday morning. She was notified on 02/06/22 via text by LN H that R1 called and reported she was left naked; her call light was taken away by an aide and yelled at by a CNA. R1's representative also reported she was removing R1 from the facility. LN H stated R1 was not naked and denied any form of abuse. Administrative Nurse D notified the unidentified staffing coordinator and Administrative Staff A of the text and asked the staffing coordinator to take CNA M off the schedule and notify her contracting agency. Administrative Nurse D asked all staff working to write a statement and called Administrative Staff A when the statements were completed. In a witness statement obtained on 02/16/22, Administrative Staff A wrote he was notified Sunday morning, 02/06/22, that LN H and CNA N assisted R1. Administrative Staff A documented LN H and CNA N found R1 upright in a wheelchair, clothed, and complaining of back pain. Administrative Staff A recorded LN H reported R1 denied abuse. Administrative Staff A documented he talked to R1 on Monday, 02/07/22, in the morning and R1 requested to be moved closer to the nurses' station. He told R1 that CNA M had been placed on the do not return list and confirmed R1 would be moved into another room. Administrative Staff A recorded he called R1's representative and notified her CNA M would not be back to the facility and R1 was moving to another room that afternoon. Administrative Staff A recorded he called the corporate office and was instructed to gather the statements. Administrative Staff A documented R1 mentioned she had a verbal altercation with an agency CNA and he immediately notified her that the CNA would not be returning to the facility. On 02/15/22 at 02:58 PM, Administrative Staff A stated the incident with R1 was not treated as an abuse allegation and R1 did not report abuse when interviewed. On 02/16/22 at 11:16 AM, LN M stated on the morning of the incident, she came in at shift change and LN N was frazzled trying to figure out what she should do. LN M stated she knew something happened with R1 and CNA M around 04:00 AM that morning and R1's representative had something recorded. LN M stated she instructed LN N to notify Administrative Staff A and Administrative Nurse D, complete an incident report, and document. She stated she checked on R1 first thing and R1 was pretty shaken. LN M stated R1's representative came into the facility around lunch time and wanted to speak with the nurse. LN M, along with two other nurses as witnesses, spoke to R1's family member. LN M stated R1's family member played the voicemail for LN M. LN M told R1's representative it would be reported immediately to Administrative Staff A. R1's representative wanted to make sure R1 would be safe and was notified CNA M would not be returning to the facility. LN M stated she considered the verbal altercation between CNA M and R1 as abuse. On 02/16/22 at 11:51 AM, Administrative Nurse D stated if abuse was suspected, staff notified administration and if abuse was found after the facility investigation, it was reported appropriately. Administrative Nurse D said if a resident stated they were being verbally abused or staff were being rough, then an investigation was initiated, but if the resident denied abuse, then an investigation was not completed or needed. She stated if the residents' representative alleged abuse, but the resident denied the abuse, then it did not count as an allegation of abuse. Administrative Nurse D stated the incident with R1, and CNA M was reported to her on 02/06/22 at 07:00 AM. She stated the staffing agency was contacted so agency aide CNA M would not return to facility. She stated the nurse that worked during the incident stated she spoke to R1 regarding abuse allegations and R1 denied any abuse. Administrative Nurse D stated if a resident complained of being abused, the facility would investigate. She stated she spoke with R1's family member throughout the week but had not heard the recording. Administrative Nurse D stated the facility's policy directed abuse complaints were investigated only if the residents said they were abused. Administrative Nurse D stated the facility had 24 hours to report once allegations were found to be actual abuse. On 02/16/22 at 12:24 PM, Administrative Staff A stated he was notified early Sunday morning, 02/06//22, about an incident that occurred around 04:30 AM. R1's representative had a recording from around that time. LN H reported to Administrative Staff A that she entered R1's room with CNA N in response to R1 calls for help. R1 was upright in her wheelchair and clothed. He stated LN H asked R1 follow-up questions and asked R1 if she felt abused or neglected. R1 denied feeling abused or neglected. Administrative Staff A stated R1 told him she did not get along with CNA M and that they had a verbal altercation. He informed R1 that CNA M would not return to the facility and R1 requested to move closer to the nurse's station. He stated that to his understanding, if a resident or family member alleged abuse then there was a short window of 24 hours to report it. If there was any abuse, he would do an investigation and call the police. Administrative Staff A said R1 had not complained of abuse, and there was no investigation as there was no allegation since R1 denied abuse. He stated R1 said she did not get along with CNA M, CNA M raised her voice at R1, seemed agitated, and not compassionate. Administrative Staff A stated anything had the potential to be verbally abusive. He had not listened to the recording, but stated the resolution was simple as it was an agency aide, she was not allowed back. He stated he had not read the Progress Note by LN H that documented R1's family member alleged abuse and harassment and it was not reported to him as such. On 02/16/22 at 02:00 PM, CNA N stated on 02/06/22 she was working on hall two and heard someone yelling. CNA N and LN H went down to R1's room, R1 sat in her wheelchair, yelling that she was naked in bed. R1 was dressed and did not have call light within reach as it was behind her. CNA N pinned her call light on her CNA N stated if she witnessed abuse, she would report to the nurse, Administrative Nurse D and Administrative Staff A. On 02/16/22 at 02:41 PM, LN H stated she was the nurse on duty on the morning of 02/06/22 and R1's representative called with concerns about R1. R1's representative voiced a concern about R1 being abused. LN H went into R1's room to make sure she had not been abused and had not been naked. LN H stated she reported R1's representative's concerns to Administrative Staff A. The facility's Abuse Policy and Procedure last updated 08/06/20, directed any form of resident abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and/or services was not tolerated and it was the responsibility of all employees to report abuse to the Administrator or Director of Nursing. All residents have the right to be free from any verbal, sexual, physical, and mental abuse, mistreatment, neglect, misappropriation, and deprivation of goods and/or services. Residents were not subjected to abuse by anyone including staff, other residents, consultants or volunteers, contract employees or staff from other agencies serving the residents. Verbal abuse was defined as any use of oral, written, or gestured language that included disparaging and derogatory terms to residents or families or within hearing distance to describe residents regardless of their age, ability to comprehend, or disability. All alleged or suspected violations involving including abuse, neglect, mistreatment, misappropriation, exploitation or deprivation of goods and/or services were promptly reported to the Administrator and/or Director of Nursing. The person observing an incident of resident abuse or suspected abuse must immediately ensure resident safety then immediately report such incidents to their immediate supervision and/or the charge nurse. The supervisor and/or charge nurse contacted the Administrator or Director of Nursing. The Director of Nursing or Administrator ensured the safety of the resident, began the investigation, and if necessary, report information to the police and any other appropriate agency. The facility failed to ensure R1 remained free from abuse and neglect when the facility failed to prevent an episode of staff to resident verbal abuse, mistreatment and neglect. This failure placed the resident in immediate jeopardy.