Every finding on record at Asbury Health and Rehabilitation Center

Based on observations, record review, and resident, staff and Medical Director interviews, the facility failed to provide safe transfers using a mechanical lift. Resident #79 was dependent on staff and required the use of a mechanical lift for transfers. On 8/30/25 Nursing Assistant (NA) #1 transferred the resident twice. Resident #79 complained of left leg pain with notable swelling to her left leg and knee. X-rays obtained in the facility indicated Resident #79 had a fracture of the left distal femur (lower thigh bone near the knee joint) and she was transferred to the emergency department (ED) for further evaluation. An x-ray and computed tomography (CT) scan obtained in the ED revealed Resident #79 had an acute comminuted (broken in multiple pieces) mildly displaced (misaligned) and impacted (the broken ends of the bone jam together) fracture of the left distal femur. Resident #79 was admitted to the hospital and surgery was performed on 9/02/25 to repair the fracture. The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #79).The findings included: Resident #79 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, quadriplegia, vitamin D deficiency and essential hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact, always incontinent of bowel and bladder, dependent on staff for activities of daily living (ADL) including toileting hygiene, bathing, and transfers. Resident #79 was coded for having upper and lower extremity impairment on both sides and used a motorized wheelchair with set up assistance. The MDS further revealed Resident #79's speech was unclear but usually understood. The care plan dated 8/16/25 indicated Resident #79 had limited physical mobility due to a diagnosis of multiple sclerosis, utilized a powered wheelchair for mobility and required 2-person assistance and the use of a mechanical lift for all transfers. An interview conducted with NA #1 on 9/24/25 at 9:16 AM revealed she was working on the 400-hall and assigned to Resident #79 during first shift (7:00 AM to 3:00 PM) on 8/30/25. She stated Resident #79 was dependent on staff for all care, was non-ambulatory and was transferred with the mechanical lift. She stated Resident #79 made no attempts to get up on her own and she was not aware of any recent falls or incidents. NA #1 revealed on 8/30/25 at approximately 7:00 AM Resident #79 was in bed and she assisted her with morning care. She indicated at approximately 7:30 AM NA #2 assisted her with transferring Resident #79 from the bed to her motorized wheelchair using the mechanical lift and Resident #79 drove herself to the dining room for breakfast. She indicated at approximately 11:00 AM she and NA #2 used the mechanical lift to transfer Resident #79 to the bed to provide incontinent care and then back into the wheelchair. NA #1 revealed at approximately 11:30 AM Resident #79 went to lunch in the dining room with her Responsible Party and was with her RP until she went to Bingo around 1:30 PM. She stated Resident #79 remained in Bingo until after her shift ended at 3:00 PM and she did not provide any care for Resident #79 after 11:30 AM. NA #1 revealed she was not aware of any staff training or safety interventions that were put in place regarding Resident #79 using the motorized wheelchair. An interview with NA #2 on 9/24/25 at 11:20 AM revealed she was working on the 400-hall during first shift on 8/30/25 but was not assigned to Resident #79. She stated Resident #79 was dependent on staff for care and was unable to roll in bed or get up without assistance. NA #2 revealed that Resident #79 was transferred using the mechanical lift and required the assistance of two people. She stated on 8/30/25 NA #1 did not ask for her assistance with transferring Resident #79 at any time during her shift, nor did she assist with any of Resident #79's care. She stated at approximately 1:15 PM the RP requested for Resident #79 to lay down before Bingo, so she went with Nurse #2 to assist with the transfer. NA #2 revealed when they went to Resident #79's room the Activities Director arrived a few minutes later to take her to Bingo so they did not transfer her, and she remained in her motorized wheelchair. A follow-up interview was conducted with NA #1 on 9/25/25 at 12:03 PM. She stated on 8/30/25 at approximately 7:30 AM she transferred Resident #79 from the bed into the wheelchair using the mechanical lift without the assistance of another staff member. She revealed at approximately 11:00 AM she transferred Resident #79 from the wheelchair to the bed to provide incontinent care and then transferred her from the bed back to the wheelchair using the mechanical lift without the assistance of a second person. She stated no incidents or injuries to Resident #79 occurred during the transfers nor did she complain of any pain or discomfort. NA #1 indicated she should have requested a second person assist her with the transfers however she felt comfortable transferring Resident #79 using the lift alone and did not request assistance from any other staff members. A phone interview with the Activities Director on 9/24/25 at 10:14 PM revealed on 8/30/25 at approximately 1:30 PM she went to Resident #79's room to take her to Bingo. She stated NA #2 and Nurse #2 were in Resident #79's room and were going to transfer her into bed however Resident #79 remained in her motorized wheelchair. The Activity Director stated she walked beside Resident #79 as she drove her motorized wheelchair to Bingo and at approximately 3:00 PM she walked beside Resident #79 as she drove her motorized wheelchair back to her room. The Activity Coordinator indicated Resident #79 had no incidents while at Bingo nor did she have any complaints of pain. An interview conducted with NA #3 on 9/18/25 at 12:32 PM indicated she was working on the 400-hall and assigned to Resident #79 during second shift (3:00 PM to 11:00 PM) on 8/30/25. She stated at approximately 3:00 PM Resident #79 complained of leg pain but she did not recall which leg she reported having pain. NA #3 revealed she notified Nurse #3, and she assessed Resident #79 and administered pain medication. She stated Resident #79's private caregiver arrived around 4:30 PM and assisted her with eating dinner. NA #3 indicated at approximately 7:00 PM she and Nurse #3 transferred Resident #79 into bed, assisted her with incontinence care and an x-ray was obtained. She revealed the x-ray technician instructed them not to transfer Resident #79 out of bed until the x-ray results came back. NA #3 indicated her shift ended at 11:00 PM prior to the x-ray results returning. A phone interview was conducted with the Private Caregiver on 9/23/24 at 4:17 PM. She indicated she was a licensed occupational therapy assistant and had been working with Resident #79 for approximately 4 years. She revealed 5 to 6 days a week she arrived around 4:30 PM, assisted Resident #79 with range of motion (ROM) exercises and if able would assist Resident #79 to a standing position for 2 to 3 minutes to bear weight on her legs. The Private Caregiver stated she also assisted Resident #79 with eating dinner and getting ready for bed but did not assist with incontinent care or transfers. She indicated 8/30/25 she was starting ROM exercises at approximately 5:00 PM when Resident #79 started yelling out in pain and reported her left leg was painful with movement. She stated Resident #79's left leg was notably swollen but there was no bruising or redness. She revealed Resident #79 was cognitively intact but was forgetful and her ability to communicate and recall events varied from day to day. The Private Caregiver stated she asked Resident #79 if there was an incident that caused injury to her leg, but she was unable to say what or if anything had occurred. The Private Caregiver indicated she immediately notified Nurse #3. She revealed after assessing Resident #79, Nurse #3 notified the on-call provider and received an order to obtain an x-ray in the facility and to apply ice to Resident #79's left leg. The Private Caregiver stated she left the facility prior to the x-ray being obtained and was notified by the family that Resident #79 had a left femur fracture and was admitted to the hospital for surgery. She indicated she worked with Resident #79 on the evening of 8/29/25 and during ROM exercises she reported no pain or discomfort. A nurse's note dated 8/30/25 at 5:41 PM written by Nurse #3 revealed at approximately 3:00 PM Resident #79 reported leg pain and as needed pain medication was administered. At approximately 5:10 PM the private caregiver reported Resident #79 was complaining of left leg pain and upon assessment her left leg was noted to be swollen and painful to touch. The on-call provider was notified and gave an order for an x-ray to be obtained in the facility and to apply ice, on for 10 minutes and off for 10 minutes for 72 hours. The RP was notified of change in condition and order to obtain an x-ray. During a phone interview with Nurse #3 on 9/29/25 at 12:39 PM she indicated she was assigned to Resident #79 on 2nd shift 8/30/25. She stated at approximately 3:00 PM NA #3 informed her that Resident #79 was complaining of leg pain. She indicated she assessed Resident #79 and she reported having pain in her leg and was pointing to her right leg. Nurse #3 revealed she assessed Resident #79's right leg but there was no visible injury, and she administered acetaminophen. She stated at approximately 5:00 PM Resident #79's private caregiver reported to her that Resident #79 was complaining of left leg pain and that it was swollen. Nurse #3 revealed she assessed Resident #79 and noted her left was visibly swollen and painful to touch. She indicated the on-call provider was notified and gave an order to obtain an x-ray in the facility and apply ice to the left leg. Nurse #3 revealed Resident #79 denied any incidents had occurred causing injury to her leg. Nurse #3 indicated at approximately 7:00 PM NA #3 assisted her with transferring Resident #79 into bed so the x-ray could be obtained, and they were instructed by the x-ray technician not to transfer Resident #79 again until the x-ray results returned. Nurse #3 revealed Resident #79 had continued complaints of pain after the x-ray and additional orders were obtained by the on-call provider for a pain-relieving topical cream and ibuprofen. She stated the x-ray results returned indicating a left femur fracture and Resident #79 was transferred to the ED for further evaluation. A review of Resident #79's physician orders and medication administration record (MAR) revealed the following: 11/30/23 acetaminophen 500 milligrams (mg) give 2 tablets by mouth every 24 hours as needed for pain. The MAR indicated it was administered on 8/30/25 at 4:00 PM and pain level was 4 (1-10). 8/30/25 obtain x-ray of the left femur and knee. 8/30/25 ibuprofen 600 mg tablets give 1 tablet by mouth every 6 hours as needed for left leg pain for 3 Days. The MAR indicated it was administered on 8/30/25 at 9:45 PM and pain level was 4. 8/30/25 menthol topical analgesic gel 4% apply topically to the thigh down to knee every 6 hours as needed for left leg pain. The MAR revealed it was applied on 8/30/25 at 9:46 PM. 8/30/25 acetaminophen 500 milligrams (mg) give 2 tablets by mouth every 8 hours as needed for left leg pain. The MAR revealed it was administered on 8/30/25 at 9:51 PM and pain level was 4. The radiology x-ray results report dated 8/31/25 at 12:05 AM revealed Resident #79 had a non-displaced fracture of the left distal femur (lower thigh bone near the knee joint). The report further noted diffuse osteopenia (weakening of the bone) and swelling in the left leg. A nurse's note dated 8/31/25 at 5:49 AM revealed Resident #79's x-ray results indicated a left femur fracture. The on-call provider was notified and ordered for Resident #79 to be transferred to the ED for further evaluation. The RP (Responsible Party) was notified and at 1:15 AM Resident #79 was transferred by emergency medical services to the ED for further evaluation. The initial allegation report submitted by the facility on 8/31/25 at 8:43 AM revealed Resident #79 had an injury of unknown source reported left leg pain and mild swelling was noted. An x-ray was obtained in the facility and then Resident #79 was transferred to the hospital for further evaluation. Resident #79 was cognitively intact and denied a fall, trauma or other wrongdoing occurred. The 5-day investigation report dated 9/05/25 completed by the Director of Nursing revealed Resident #79 and nursing staff were interviewed and denied any trauma or falls occurring that would have caused injury it was determined the left femur fracture was likely due to her medical diagnoses including vitamin D deficiency and osteopenia noted in the x-ray results, both of which increased her risk of fractures. The ED report and hospital records from 8/31/25 through 9/07/25 revealed Resident #79 was evaluated in the ED on 8/31/25 due to an x-ray obtained in the facility indicating a left femur fracture with no reported falls, trauma or cause of injury. Resident #79 was assessed with no signs of head trauma, or abdominal bruising but did have a deformity of the left lower leg. X-ray and computed tomography (CT) scans obtained in the ED revealed Resident #79 had an acute comminuted, mildly displaced and impacted left distal femur fracture with moderate fluid in the knee joint and marked osteopenia (reduced bone density) but no suspicious bone lesions noted. The orthopedic consultation note indicated Resident #79 had a left lower extremity injury sustained from a ground level fall and was noted to be non-ambulatory at baseline. The RP reported Resident #79 was able to stand at times for a few minutes with assistance. Operative versus non-operative treatments were discussed, the RP desired to proceed with surgical repair to prevent non-weight bearing status long term and to manage pain, and Resident #79 was admitted to the hospital. Resident #79 was discharged back to the facility on 9/7/25 with orders for occupational therapy and a follow-up appointment scheduled with the orthopedic surgeon on 10/16/25. An interview was conducted with Resident #79 on 9/22/25 at 2:05 PM. Resident #79 stated she fractured her left leg when she fell going to the bathroom but was unable to recall any other details related to the incident. Resident #79 indicated she was transferred with the mechanical lift and at times only one NA assisted but was unable to recall a specific date this occurred or the name of the NA involved. A phone interview conducted with the Medical Director on 9/25/25 at 8:41 PM revealed that a comminuted, displaced and impacted fracture, as described in Resident #79's ED x-ray and CT scan results, would not have been caused by her engaging in ROM exercises or standing with assistance to bear weight for a few minutes. The Medical Director indicated that the type of fracture Resident #79 sustained was likely caused by a fall or trauma and not pathological in nature. The Medical Director stated that Resident #79's cognition was better some days than others, but she was cognitively intact with no diagnosed cognitive impairment however her memory and ability to recall events varied from day to day. During a phone interview with the DON on 9/29/25 at 7:38 AM indicated she was notified at approximately 7:00 AM on 8/31/25 that Resident #79 was transferred to the hospital due to an x-ray obtained in the facility indicating a left femur fracture. She stated statements were obtained from staff that worked on 8/30/25 and there were no reports of any incidents or accidents occurring that may have caused the fracture. She stated an initial allegation report was submitted due to Resident #79 having an injury of unknown source. The DON revealed after reviewing the x-ray obtained in the facility which noted diffuse osteopenia and interviews with staff not indicating an incident occurred to cause injury, she determined the source of the injury was due to Resident #79's diagnoses which increased her risk of fractures. The DON indicated that there were concerns related to Resident #79 safely operating the motorized wheelchair and incidents of her running into things and getting stuck in her bathroom. She revealed the family was resistant to her transitioning to a manual chair and there were on-going discussions as to what interventions would be implemented prior to her discharge to the hospital on 8/31/25. She stated on 9/07/25 after Resident #79 returned to the facility the family was requesting more information as to how the fracture occurred. She indicated NA #1 reported NA #2 assisted with transferring Resident #79 the morning of 8/30/25 however NA #2 really would not say that she did or did not assist with the transfer. The DON revealed she did not investigate the inconsistent statements from NA #1 and NA #2 but that it was suspected that NA #1 transferred Resident #79 using the mechanical lift alone. She stated even if NA #1 transferred Resident #79 alone, she denied an incident occurred resulting in injury and the cause of Resident #79's fracture remained inconclusive. The DON stated that staff should have a second person assisting when using the mechanical lift to transfer a resident for safety. An interview conducted with the Administrator on 9/25/25 at 11:23 AM revealed she was notified on 8/31/25 at approximately 7:00 AM that Resident #79 was transferred to the hospital due to a femur fracture. She stated the cause of the injury was unknown and the DON initiated an investigation to determine if an incident or accident had occurred. The Administrator indicated the inconsistent statements given by NA #1 and NA #2 should have been investigated further and that transferring a resident using the mechanical lift without a second person was not safe. The Administrator indicated Resident #79 also had several incidents involving the motorized wheelchair and there was question if she had run into something while driving her chair that caused the injury. The Administrator revealed the cause of Resident #79's leg fracture was still unknown.

Based on observations, record review and staff interviews, the facility failed to promote a dignified dining experience for 2 of 3 residents who required assistance with meals (Resident #17 and Resident #92). Nurse Aide #5 was observed standing at a table beside Resident #17 and across the table from Resident #92 while providing the residents with assistance with eating. A reasonable person expects to be treated with dignity and would not want staff to stand over them while assisting them with eating. Findings included:a. Resident #17 was admitted to the facility on [DATE]. A review the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was assessed as severely cognitively impaired. The assessment indicated Resident #17 required substantial assistance from staff for eating and was on a mechanically altered diet. b. Resident #92 was readmitted to the facility on [DATE]. A review of the admission MDS dated [DATE] revealed Resident #92 was assessed as having unclear speech and severe cognitive impairment. The assessment indicated Resident #92 required substantial assistance from staff for eating. During a continuous lunch meal observation on 9/22/25 from 11:45 AM to 11:50 AM, Resident #17 was observed sitting at a table in the resident dining room and Nurse Aide (NA) #5 was observed standing beside Resident #17, leaning over and assisting Resident #17 with eating. Resident #92 was observed sitting across the table from Resident #17 in the resident dining room. NA #5 leaned across the table and assisted Resident #92 with eating while standing. NA #5 continued to assist Resident #92 and Resident #17 with eating at varying intervals as the residents sat across from each other. There were empty chairs at the table. During a telephone interview on 9/25/25 at 2:27 PM, NA #5 indicated the Resident #17 needed assistance with eating and he would help set her up for meals by covering her clothing. He stated he often stood when providing feeding assistance to residents. NA #5 stated when he assisted in feeding two residents, he typically would sit down in between them on the same side of the table. He stated another Nurse Aide walked away from the table and he reached over to continue feeding Resident #92, while standing next to Resident #17. NA #5 indicated both residents needed total assistance with eating and he didn't think about sitting down while assisting Resident #17 and Resident #92 with eating their meals. An interview with the Assistant Director of Nursing (ADON) on 9/25/25 at 3:07 PM revealed all staff received training in feeding assistance. She stated NA #5 was from a staffing agency, and he would not have received the training from the facility. The ADON had the expectation that all nursing staff would provide dignity in dining and if someone from nursing management had observed a staff member assisting a resident with eating while standing up, it would have been immediately corrected. An interview with the Administrator on 9/25/25 at 3:09 PM revealed she expected all residents to have a dignified dining experience and that facility staff would not assist residents with eating while standing and reaching across the table. She stated she would work with the staffing agency to ensure all staff would have training on feeding assistance and dignified dining to include sitting while assisting residents with their meals.

Based on record review, and staff and Medical Director interviews, the facility failed to implement their abuse policy and procedure in the areas of reporting to Adult Protective Services (APS) and thoroughly investigating an injury of unknown source for a dependent resident who sustained an acute comminuted (broken in multiple pieces), mildly displaced (misaligned) and impacted (the ends of the broken bone jam together) left femur (thigh bone) fracture for 1 of 3 residents reviewed for accidents (Resident #79).The findings included:A review of the facility's abuse, neglect and exploitation policy and procedure dated 4/29/24 indicated the following: -The facility will have written procedures to assist staff in identifying the different types of abuse. Possible indicators of abuse include but are not limited to: Physical injury of a resident, of unknown source. -An immediate investigation is warranted when suspicion or reports of abuse, neglect or exploitation occur. The procedures for investigations include:1. Identifying staff responsible for the investigation.2. Exercising caution in handling evidence that could be used in criminal investigation (e.g., not tampering or destroying evidence).3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.5. Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent and cause.6. Providing complete and thorough documentation of the investigation.-The facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes1.Reporting immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #79 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 was cognitively intact and dependent on staff for assistance with activities of daily living (ADL). The x-ray report dated 8/31/25 revealed Resident #79 had a non-displaced fracture of the left distal (lower) femur. The emergency department (ED) report dated 8/31/25 revealed Resident #79 was evaluated due to an x-ray obtained at the facility indicating a left femur fracture with no reports of a fall or trauma and the source of injury was unknown. X-rays and a computed tomography (CT) scan obtained in the ED confirmed Resident #79 had an acute comminuted mildly displaced and impacted left femur fracture. A review of the initial allegation report dated 8/31/25 indicated Resident #79 had a left femur fracture and the source of the injury was unknown and was reported to the state survey agency however no report was made to APS. The 5-day investigation report dated 9/05/25 completed by the Director of Nursing (DON) revealed Resident #79 and nursing staff were interviewed and denied any trauma or falls occurring that would have caused injury it was determined the left femur fracture was likely due to her medical diagnoses including vitamin D deficiency and osteopenia noted in the x-ray results, both of which increased her risk of fractures. A phone interview conducted with the Medical Director on 9/25/25 at 8:41 PM revealed that a comminuted, displaced and impacted fracture, as described in Resident #79's ED x-ray and CT scan results, was likely caused by a fall or trauma and was not pathological in nature. The Medical Director stated that Resident #79's cognition was better some days than others, but she was cognitively intact with no diagnosed cognitive impairment however her memory and ability to recall events varied from day to day. A phone interview with the DON on 9/29/25 at 7:38 AM indicated she was notified at approximately 7:00 AM on 8/31/25 that Resident #79 was transferred to the hospital due to an x-ray obtained in the facility indicating a left femur fracture. The DON stated an initial allegation report was submitted to the state survey agency on 8/31/25 within 2 hours of becoming aware of the injury of unknown source but was not reported to APS because she was unaware that was required. She stated statements were obtained from staff that worked on 8/30/25 and there were no reports of any incidents or accidents that may have caused the fracture and Resident #79 also denied a fall or incident had occurred. The DON revealed she did not review Resident #79's hospital records nor did she consult with the Medical Director for further information regarding the fracture. She stated she determined that Resident #79's fracture was pathological due to no reports of an incident or accident occurring and based on the x-ray obtained at the facility noting diffuse osteopenia. She stated on 9/07/25 after Resident #79 returned to the facility the family was requesting more information as to how the fracture occurred. The DON indicated she re-interviewed staff to obtain more details but did not document the interviews or obtain updated written statements. She revealed when interviewing NA #1 she reported NA #2 assisted with transferring Resident #79 the morning of 8/30/25, but when she interviewed NA #2 she really would not say that she did or did not assist with the transfer. She stated it was suspected that NA #1 transferred Resident #79 using the mechanical lift alone however she did not investigate further since NA #1 reported that no accident or incident occurred resulting in injury. The DON revealed that the cause of Resident #79's fracture remained unknown. An interview conducted with the Administrator on 9/25/25 at 11:23 AM revealed she was notified on 8/31/25 at approximately 7:00 AM that Resident #79 was transferred to the hospital due to a femur fracture and the cause of the injury was unknown. She indicated the DON submitted an initial allegation report within two hours to the state survey agency but did not report to APS. The Administrator indicated she was unsure that a report to APS was warranted since they did not suspect abuse as the source of the injury. She stated the DON initiated an investigation obtaining statements from staff and there were no reports of an incident or accident that would have caused the injury and based on the x-ray obtained in the facility noting osteopenia the fracture was determined to be pathological. The Administrator indicated due to Resident #79's family requesting more information regarding what may have occurred the DON re-interviewed staff and it was suspected NA #1 transferred Resident #79 using the mechanical lift without a second person however it was not investigated further since NA #1 reported no incidents or accidents occurred during the transfers. She revealed there were also safety concerns related to Resident #79 operating the motorized wheelchair but also no reports of an incident or accident. The Administrator revealed the investigation into the source of Resident #79's injury should have been more thorough including reviewing the hospital records, consulting with the Medical Director and taking a deeper look at any safety concerns related to the mechanical lift transfers and the motorized wheelchair to determine if they contributed to Resident #79's injury.

Based on record reviews, observations, and resident and staff interviews, the facility failed to store lidded containers of prescription topical medicated cream and medicated powder in a secure locked storage area for 2 of 3 residents observed with medicated cream and medicated powder at the bedside and bathroom (Resident #69 and Resident #21).The findings included: 1.Resident #69 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis or weakness on one side of the body) and weakness. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #69 cognitively intact requiring limited assistance of one staff member for most activities of daily living (ADL). Resident #69 was assessed as having no skin conditions during the assessment period. On 09/22/25 at 2:25 PM Resident #69 was observed to have a lidded container of prescription topical medicated steroid cream that treats inflammation, redness and itching on her bedside dresser. Resident #69 stated, The nurses put it on my back because of dry skin. Resident #69 explained she had the cream while being a resident in the facility and that it was prescribed to her a couple of months back. The interview revealed the medicated cream was typically left on the bedside dresser and not placed in the medication cabinet. During an observation of Resident #69's room on 09/25/25 at 8:50 AM the lidded container of prescription topical medicated cream that treats inflammation, redness and itching remained on her bedside table. An interview and observation were conducted on 09/25/25 at 9:10 AM with the Assistant Director of Nursing (ADON). The interview revealed she was not aware of any medication on Resident #69's bedside dresser. She explained that no residents in the facility were allowed to keep medications at the bedside and that was why there was a locked medication cabinet in each resident room. The ADON was observed to go into Resident #69's room and pick up the lidded container of prescription topical medicated cream and place it into the resident's locked medication cabinet. On 09/25/25 at 11:50 AM an interview was conducted with Nurse #1. During the interview she stated she was not aware Resident #69 had the lidded container of prescription topical medicated cream on her bedside dresser and when she went into the room this morning to administer medications, she noticed it in the medication cabinet and asked the ADON why it was in there. She stated the ADON explained the surveyor had identified it on the resident's bedside dresser and brought it to her attention, so she placed it into the locked cabinet. The Director of Nursing (DON) was unable to be interviewed during the survey due to being on leave. On 09/25/25 at 12:22 PM an interview was conducted with the Administrator. She stated she expected the nurses to be observant of medication at bedside and if they saw any medication at the bedside to immediately remove it. 2.Resident #21 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus and protein calorie malnutrition. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact requiring supervision to substantial assistance from one staff member for most activities of daily living (ADL). Resident #21 was assessed as needing ointment medications for his skin. A review of Resident #21's physician's orders revealed an order dated 4/5/25 for miconazole nitrate powder 2% (a medicated powder to treat fungal skin infections) to be applied to the affected area topically, two times daily for rash and irritation. Further review of Resident #21's physician's order 8/26/25 for nystatin external ointment 100,000 unit/gram (a medicated cream to treat fungal skin infections) to be applied to the abdomen topically every day and night shift for 10 days, starting 8/26/25 to 9/5/25. On 9/23/25 at 12:12 PM Resident #21 was observed to have a tube of nystatin ointment and a container of miconazole powder on the counter in the bathroom both labeled with prescription labels for Resident #21. During an observation of Resident #21's room, conducted in conjunction with an interview with Resident #21, on 9/25/25 at 9:13 AM the tube of nystatin ointment and the container of miconazole powder were present on his bathroom counter. Resident #21 stated he liked those medications kept in there so when he needed them, he could use them. A telephone interview with Nurse Aide (NA) #6 on 9/30/25 at 10:42 AM revealed Resident #21 liked to apply the cream medication as well as the powder medication by himself. She stated she had not witnessed him applying the medication as he was independent with a lot of his ADL. NA #6 stated she had seen the two medications laying out on his bathroom counter for a while. She stated she generally understood all medications should be stored in the locked medication cabinets in each resident room. An interview with Nurse #5 on 9/25/25 at 10:40 AM revealed the facility typically kept all prescription medications including creams and powders in each resident's locked medication cabinet in their room. She stated Resident #21 used the cream and powder left on the counter in his bathroom and he did not like staff members touching or moving his belongings. Nurse #5 stated the tube of nystatin ointment and the container of miconazole powder were present on his bathroom counter and had been removed from Resident #21's bathroom and placed in the medication cabinet in his room a few minutes earlier by nursing management. An interview was conducted on 9/25/25 at 11:18 AM with the Assistant Director of Nursing (ADON). She was made aware of Resident #21's tube of nystatin ointment and the container of miconazole powder that were present on his bathroom counter. She explained no residents in the facility were allowed to keep medications at the bedside and she would expect the medicated cream and powder to go in Resident #21's locked medication cabinet. The ADON explained once the medication order was completed, any medication should be sent back to the pharmacy. The Director of Nursing (DON) was unable to be interviewed during the survey. An interview with the Administrator on 9/25/25 at 12:23 PM revealed the medicated cream and powder were immediately removed from Resident #21's room earlier in the morning on 9/25/25. She stated she all prescribed medications were to be stored in each resident's locked medication cabinet. On 9/25/25 at 2:57 PM an interview was conducted with Physician Assistant #1. He stated he was not familiar with Resident #21 but generally all medications that are prescribed by a provider should be locked in the medication cabinet. Physician Assistant #1 stated the medications were labeled with directions and there could be a risk present if the medication was used incorrectly.

Based on observations and staff interviews, the facility failed to ensure scoops were stored without the potential for cross-contamination, discard outdated prepared food items stored for use and utilize a facial hair covering while in the food preparation area. These practices occurred in the reach-in coolers (reach-in coolers # 4 and #5) and food preparation area in 1 of 2 kitchens (Kitchen #2) and the food preparation service line (Household #4) in 1 of 2 Households and had the potential to affect food served to residents.The findings included: a. An initial tour of kitchen #2 occurred on 9/22/25 at 10:08 AM with the Dietary Manager (DM).-Scoops were left in the sugar and food starch bins with the handles touching the sugar and food starch in the food preparation area.-Items in reach in cooler #5 and reach in cooler #4 that were past the use by date included: -one plastic preparation container of pureed brussels sprouts with a use by date of 9/20/25. -one plastic preparation container of chicken gravy with a use by date of 9/21/25. b. The following concern was identified in the food preparation service line in Household #4 on 9/25/25 at 11:45 AM:An observation of the meal service on 9/25/25 at 11:53 AM revealed the DM taking temperatures of the food to be served to residents without a facial hair cover. The DM had facial hair about a quarter of an inch in length on the lower portion of his face. An interview with the DM on 9/25/25 at 3:54 PM was conducted. He explained the facility had updated their labeling system for the kitchen items. The DM stated the labeling system was supposed to reflect a seven-day timeline instead of a four-day timeline per the facility policy. He stated he controlled the timeline in the labeling system and had updated it to reflect the seven-day period since the kitchen tour. The DM expected the staff to look at the labels and either re-label the food items or throw them away. He stated he expected kitchen staff to utilize the scoop hooks in the sugar and food starch bins. The DM explained he had not worn a facial hair covering before but would implement their use. An interview with the Administrator on 9/25/25 at 4:26 PM was conducted. She stated she expected the scoops in the food bins to be stored properly and food left past the use by date needed to be thrown out. The Administrator stated she expected facial coverings to be used when staff members had facial hair.

Based on observations, record review, and staff interviews, the facility failed to have systems in place to ensure Nurse #1 received the most recent training provided by the facility for blood glucose monitors. In addition, Nurse #1 failed to demonstrate competency in following the manufacturer's instructions for the cleaning and disinfection of a shared blood glucose meter between two residents. Nurse #1 stated she knew she was supposed to use the disinfectant wipes to disinfect the blood glucose meters between residents but had just gotten nervous and forgotten. The interview with Nurse #1 further revealed she did not know the wet time, or dry time for cleaning/disinfecting the glucometer using the disinfectant wipe. The deficient practice occurred for 1 of 3 nursing staff reviewed for competent nursing staff (Nurse #1). Immediate Jeopardy began on 10/10/24 when Nurse #1 failed to demonstrate competency through her failure to disinfect a shared glucometer per manufacturer's instructions. Immediate jeopardy was removed on 10/15/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. The findings included: This tag is cross referred to: F880 Based on observation, record review and staff interviews, the facility staff failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 4 residents whose blood sugar levels were checked (Resident #95, Resident #207). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were no residents with a bloodborne pathogen in the facility at the time of the investigation. On 10/10/24 at 9:17 AM an interview was conducted with Nurse #1. She stated the facility had a skills day in 2023 and she remembered receiving training then about glucometers but since then she had not received any training on glucometers, or disinfecting glucometers. She stated she worked at the facility on a as needed (PRN) basis working one or two days during the week or month and may have just missed training if the facility had conducted one. A glucometer skills check dated October 2023 revealed Nurse #1 received education on glucometer care and disinfecting. Review of facility documents revealed Nurse #1 attended the annual skills fair in December 2023 and received education on bloodborne pathogens including the modes of transmission and recognizing potential sources of exposure. The training also included decontamination and disinfection of glucometers using disinfectant wipes. A review of Blood Glucose Monitors and Control Test training attendance log, from a training conducted on 05/05/24, revealed Nurse #1 did not receive the education. An interview was conducted on 10/10/24 at 10:24 AM with the Director of Nursing (DON). The DON stated the Infection Preventionist was constantly providing training and education for staff however Nurse #1 worked on a PRN basis in the facility, and he felt that was why she hadn't received the most recent education regarding glucometers. The interview revealed the IP and SDC always attempted to ensure the PRN staff were receiving education however sometimes staff got overlooked. An interview was conducted on 10/10/24 at 9:22 AM with the Infection Preventionist. During the interview, the Infection Preventionist stated she had completed a glucometer training course on 05/05/24 for all staff. She stated after reviewing the in-service sheets she had realized Nurse #1 did not receive the training that was conducted. She stated Nurse #1 was, just missed because she was an as needed (PRN) staff member. The Staff Development Coordinator (SDC) was not available for an interview. An interview on 10/10/24 at 2:26 PM with the Administrator revealed the in-service conducted in May 2024 was supposed to be for all staff and Nurse #1 should have received the education. She stated looking back at the education log for Nurse #1 the facility should have ensured she received an updated in-service because Infection Control was a priority for the facility. The Administrator was notified of immediate jeopardy on 10/10/24 at 3:10 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. A nurse in one of the households, during observation, was found to be non-compliant in following the facility's protocol (and the manufacturer's guidelines) on disinfecting glucometers between resident use. The nurse failed to follow the processes she had been educated on in past trainings, indicating a need to routinely monitor the staff's compliance with the glucometer disinfection policy so that either additional training can be provided, or the deficient practice can be addressed from a performance standpoint. Attendance compliance with important in-service education also needs to be routinely audited, as this nurse missed the last training that was provided on glucometer disinfection. All nursing staff that could do a blood glucose monitoring were identified by pulling a log from Human Resources of all applicable nursing staff. This was completed on October 10th, 2024, by the Director of Nursing and the Director of Human Resources. All residents residing in household two that could have been affected by the deficient practice were seen by the medical provider, with orders received as necessary by the practitioner's assessment. This was completed on October 11th, 2024, by the medical provider on duty. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The nurse found to be non-compliant with the glucometer disinfection process was re-educated with return demonstration immediately, as were all nurses in the building at the time of the observation of non-compliance. This was completed on October 10th, 2024, by the Infection Preventionist, Director of Nursing, and Nursing Supervisor. All nursing staff that do (or could) perform glucose monitoring will be in-serviced on the glucometer disinfection process before being allowed to work. All education will be completed on or before October 14th, 2024, by the Director of Nursing, Assistant Director of Nursing, Infection Preventionist, or Nursing Supervisor. All staff members will also have a skills validation performed to ensure that they can perform the disinfection appropriately. Any staff that do not receive the education and skills validation by the October 14th, 2024, date will not be allowed to work until they are compliant with the educational training. This compliance will be monitored by the Assistant Director of Nursing/Staff Development Coordinator and/or the Infection Preventionist nurse. All new hires for the nursing team that do (or could) perform glucose monitoring will be educated at hire (with a skills competency performed) on the glucose monitor disinfection process. This will be completed by the Assistant Director of Nursing/Staff Development Coordinator, or designee, before the new hire is allowed to take an assignment. All staff will be educated with a skills competency performed on the glucose disinfection process on an annual basis. This will occur annually at the December annual skills fair (or at an annual time determined by nursing leadership). Staff members found to be non-compliant with the annual training will not be allowed to return to work until compliance with education is reached. This will be completed annually by the Director of Nursing, Assistant Director of Nursing/Staff Development Coordinator, or designee. Alleged immediate jeopardy removal date: October 15th, 2024 A validation of IJ removal plan was conducted on 10/16/24. The facility had compiled a list of nursing staff that were responsible for blood glucose monitoring. All staff were educated on the glucometer disinfection process before being allowed to work. The facility provided an immediate in-service for Nurse #1 with a return demonstration provided. All staff members responsible for blood glucose monitoring also completed a skills validation with return demonstration to the Director of Nursing. Audits of any newly hired staff were reviewed to ensure they had received education on glucose monitor disinfection. An observation was conducted of glucose disinfection while onsite, the staff member cleaned the glucometer according to manufacturer instructions. Nursing staff interviews revealed they had received education on the disinfection of glucometers. The IJ removal date of 10/15/2024 was validated.

Based on observations, record review and staff interviews, the facility staff failed to follow the manufacturer's instructions for cleaning and disinfection of a shared blood glucose meter between resident usage for 2 of 4 residents whose blood sugar levels were checked (Resident #95, Resident #207). Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood borne infections. There were no residents with a bloodborne pathogen in the facility at the time of the investigation. Immediate Jeopardy began on 10/10/24 when Nurse #1 was observed performing blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's instructions. Immediate jeopardy was removed on 10/15/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring systems are in place. Findings included: The blood glucose meter manufacturer's instructions for cleaning and disinfecting dated 04/2023 indicated the blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. A list of Environmental Protection Agency (EPA) wipes were recommended on the cleaning instructions. Additional instructions were to read the manufacturer's instructions for the use of the wipes. Review of the facility policy Glucometer Disinfection revised in May 2024 read, in part, to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The procedure for disinfecting glucometers included: a. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single use lancet, blood glucose testing strips, disinfecting wipes. b. Wash hands c. Explain the procedure to the resident. d. Provide privacy. e. Put on gloves. f. Obtain capillary blood glucose sampling according to the facility policy. g. Remove and discard gloves, perform hand hygiene prior to exiting room. h. Reapply gloves if there is visible contamination of the device or if the resident is HIV or Hepatitis B or C positive. i. Retrieve (2) disinfectant wipes from container. j. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use a second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturers' instructions. Allow the glucometer to dry air. l. Discards disinfect wipes in waste receptacles. m. Perform hand hygiene. The wipes container which was located at the nurses station read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for two minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. A continuous observation of Nurse #1 was conducted from 10/10/24 at 8:54 AM through 9:17 AM and revealed the following: On 10/10/24 at 8:54 AM Nurse #1 gathered necessary supplies, removed the glucometer from the top of the cart and went into Resident #95's room and obtained his blood sugar. She exited the room at 9:04 AM and returned to the cart in the hall. Nurse #1 was observed placing the glucometer immediately back into the unlabeled black bag on the cart and move to the next room. No disinfecting wipes were observed on the medication cart. Nurse #1 did not disinfect the glucometer during the observation. At 9:06 AM Nurse 1 gathered necessary supplies, removed the same glucometer from the top of the cart and went into Resident #207's room and obtained her blood sugar. She exited the room at 9:10 AM and returned to the cart in the hall. Nurse #1 was observed placing the glucometer immediately back into the unlabeled black bag on the cart and move to the next resident room. Nurse #1 did not disinfect the glucometer during the observation. At 9:13 AM of Nurse #1 necessary supplies, removed the same glucometer from the top of the cart and went into Resident #49's room. The surveyor stopped Nurse #1 and asked her to return to the hallway. An interview and observation occurred with Nurse #1 on 10/10/24 at 9:17 AM. Nurse #1 revealed she had worked in the facility for 9 years as an as needed (PRN) nurse and she knew she was supposed to disinfect the glucometer after each use. Nurse #1 was observed cleaning the glucometer with an alcohol swab. At 9:17 AM Nurse #1 re-entered Resident #49s room to obtain his blood sugar. The surveyor stopped Nurse #1 for the second time. Nurse #1 exited Resident #49's room and entered the hallway. Nurse #1 stated she knew she was supposed to use the disinfectant wipes but had just gotten nervous and forgotten. She stated she did not know the wet time, or dry time for cleaning the glucometer using the disinfectant wipe. The interview revealed she typically cleaned the glucometer in between residents and had been instructed to do so in the past. An interview on 10/10/24 at 9:22 AM with the Infection Preventionist (IP) revealed each resident household had 2 glucometers to use because not all residents admitted into the facility had their own glucometer. She stated the facility was very strict on disinfecting glucometers in between use of each resident and had just provided education on glucometer cleaning and disinfecting in May 2024. The IP stated the nurses should be using the disinfectant wipes after each use of the glucometer with a wet contact time of 2 minutes using two wipes and wiping the entire surface of the glucometer. After that, the nurses are to lay the glucometer on a towel and let it dry for a duration of 2 minutes. The IP stated she had contacted the Center for Disease Control and Prevention (CDC) to ensure it was okay to use the glucometer on multiple residents. She was told the practice was acceptable if the glucometer was disinfected per the manufacturer's instructions in between each resident use. The IP indicated Nurse #1 had not received the recent training on disinfecting glucometers in May 2024. She stated Nurse #1 should have known the policy on cleaning the glucometers and followed it. The interview further revealed the use of an alcohol swab to disinfect the glucometer was not an acceptable practice. The IP stated the negative outcome that could occur from not disinfecting the glucometer between resident use included the spread of bloodborne pathogens. She stated there were no current residents in the facility with a bloodborne pathogen. The IP stated the facility did not have dedicated glucometers to each individual resident because the staff had been provided with education and training on how to disinfect the glucometers per manufacturer's instructions. She stated Nurse #1 had not been included in the recent education. The interview revealed the household observed had a total of two glucometers and Nurse #1 should have been utilizing both. An interview was conducted on 10/10/24 at 10:24 AM with the Director of Nursing (DON). The DON stated that the disinfecting contact time for the blood glucose meter should be two minutes. He stated the staff had been trained and he did not know why Nurse #1 didn't follow policy. The DON stated he had worked in the facility since August 2024 and the process of using a glucometer for multiple residents had not been an issue because the facility had provided education to the staff. An interview on 10/10/24 at 2:26 PM with the Administrator revealed that blood glucose meters should be disinfected according to the manufacturer's instructions. The Administrator was notified of immediate jeopardy on 10/10/24 at 3:10 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. A nurse (Nurse #1) in one of the households, during observation, was found to be non-compliant in following the facility's protocol (and the manufacturer's guidelines) on disinfecting glucometers between resident use. All residents residing in the building that receive blood glucose monitoring at the time of the observation of non-compliance were identified, especially those that resided in the same household where the non-compliance occurred. These residents were identified immediately after notification of the deficient practice observation, on October 10, 2024, by the Infection Preventionist and MDS nurse. All residents residing in household two that could have been affected by the deficient practice were seen by the medical provider, with orders received as necessary by the practitioner's assessment. This was completed on October 11, 2024, by the medical provider on duty. All glucometers (12 in total) that are presently in the clinical spaces in the building were disinfected immediately, per policy and manufacturer's recommendations. The brand of wipes used are [NAME] Disposable Germicidal Surface wipes. This disinfection is completed by using one wipe to wipe away any visibly soiled areas of the glucometer. Using a second wipe, the glucometer is wiped down again to disinfect, followed by two minutes of air-dry time. This was completed on October 10, 2024, by the nursing supervisor and nurses on duty All diagnoses of residents in the building were reviewed to ensure that no one currently has an active diagnosis of a bloodborne pathogen. This was completed on October 10, 2024, by the Infection Preventionist and Administrator. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The policy and procedure for glucometer disinfection was reviewed and compared to manufacturer recommendations. This was completed on October 10, 2024, by the Infection Preventionist and Administrator. The nurse found to be non-compliant with the glucometer disinfection process was re-educated with return demonstration immediately, as were all nurses in the building at the time of the observation of non-compliance. This was completed on October 10, 2024, by the Infection Preventionist, Director of Nursing, and Nursing Supervisor. All nursing staff that do (or could) perform glucose monitoring will be in-serviced on the glucometer disinfection process before being allowed to work. All education will be completed on or before October 14, 2024, by the Director of Nursing, Assistant Director of Nursing, Infection Preventionist, or Nursing Supervisor. All staff members will also have a skills validation performed to ensure that they can perform the disinfection appropriately. Any staff that do not receive the education and skills validation by October 14, 2024, date will not be allowed to work until they are compliant with the educational training. This compliance will be monitored by the Assistant Director of Nursing/Staff Development Coordinator and/or the Infection Preventionist nurse. The [NAME] County Communicable Disease branch was notified of the infection control breach. An update was also provided to the division on the plan in place for correction. Communication was also provided to the residents affected by the deficient practice and/or their responsible parties. Communication to the local health department and the residents/responsible parties completed on October 11, 2024, by the Executive Director (health department communication) and the Assistant Director of Nursing/Staff Development Coordinator (resident and responsible party notifications). Immediate jeopardy removal date of October 15, 2024. A validation of IJ removal plan was conducted on 10/16/24. The facility had compiled a list of nursing staff that were responsible for blood glucose monitoring. All staff were educated on the glucometer disinfection process before being allowed to work. The facility provided an immediate in-service for Nurse #1 with a return demonstration provided. All staff members responsible for blood glucose monitoring also completed a skills validation with return demonstration to the Director of Nursing. Audits of any newly hired staff were reviewed to ensure they had received education on glucose monitor disinfection. An observation was conducted of glucose disinfection while onsite, the staff member cleaned the glucometer according to manufacturer instructions. Nursing staff interviews revealed they had received education on the disinfection of glucometers. The IJ removal date of 10/15/2024 was validated.

Based on record review, observations and staff interviews, the facility failed to label and date leftover food items stored for use in the dry goods storage area and walk-in cooler and failed to ensure residents' leftover food items stored in nourishment room refrigerators were labeled and dated for 2 of 6 common area refrigerators (400 and 300 Hall nourishment rooms). These practices had the potential to affect food served to residents. The findings included: 1. An initial tour of the dry good storage area and walk-in cooler occurred on 10/7/24 at 11:30 AM with the Executive Chef. The dry goods storage and walk in refrigerator were in the basement and served all neighborhoods in the facility. The following concerns were identified: -a bag of bowtie pasta opened 4/4/24 with a use by date of 7/4/24 stored in the dry good storage area -a metal pan of pork butt prepared 9/29/24 with a use by date of 10/3/24 stored in the walk-in cooler An interview with the Executive Chef on 10/7/24 at 11:35 AM revealed staff went through the walk-in cooler, walk-in freezer, and dry goods storage on Mondays to clean out any food items past the use by date and they had not been to the storage area yet that day. 2. A tour of the resident common area refrigerators occurred on 10/9/24 at 12:35 PM. The following concerns were identified: a. Items in the 400-hall resident refrigerator opened and not labeled with a date or room number were a 46fl oz. bottle of vegetable juice and a half of an ice cream sheet cake in freezer. b. Items in the 300-hall resident refrigerator labeled 305 but with no date or name included two cartons of pre-hardboiled eggs which had a strong, foul odor, eight pears in carboard cartons, six apples in bags, six frozen meals, and a 16fl oz. container of coffee ice cream. A 16oz. carton of heavy whipping cream was stored past the expiration date. An interview with the Dietary Manager (DM) on 10/9/24 at 3:29 PM revealed the items in the resident common area refrigerators needed to be labeled with the name of the resident and their room number. She explained there was no timeline for the use by date and the facility went by the expiration date on the item. The DM stated dietary supervisors checked the refrigerators each morning to ensure there were no items in the refrigerators out of date. An interview with the Administrator on 10/10/24 at 2:36 PM revealed she had the expectation that stored food should be properly labeled and dated in the facility's refrigerators and storage rooms. The Administrator stated that food left in the resident refrigerators should be thrown out if they were past the expiration date.

Based on record review and staff and resident interviews the facility failed to invite a resident to participate in the planning of the resident's care for 1 of 4 residents reviewed for participation in care plan meetings (Resident # 9). The findings included: Resident #9 was readmitted to the facility on [DATE]. Review of the electronic medical record for Resident #9 revealed a form dated 7/13/2024, addressed to the family member of Resident #9, notifying them that a care plan meeting needed to be scheduled. Resident #9's most recent minimum data set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact with daily decision making and had adequate hearing. Review of the most recent care plan revealed it had been updated in the electronic medical record on 8/27/2024, however there was no indication that there had been any involvement from Resident #9 or family members. Review of the medical record included no evidence that Resident #9 was invited to participate in care plan meetings or evidence of refusing to participate. An interview with Resident #9 completed on 10/8/2024 at 9:54 AM revealed he had not been involved in a care plan meeting and was not aware of what a care plan meeting was. On 10/9/2024 at 2:25 PM an interview with MDS Coordinator #1 revealed care plan meetings were set up by the Social Worker (SW) using the MDS assessment calendar to make sure the care plan meeting dates were aligned with the most recent MDS assessment. The SW would give a list of residents to the receptionist that needed a care plan meeting. The receptionist would then mail out the care plan meeting invitation to the resident's family. Upon receiving the care plan letter the family would call the SW to set up a time to meet. MDS Coordinator #1 stated all residents, especially ones that were cognitively intact, must be invited to the care plan meetings. On 10/9/2024 at 3:17 PM an interview was completed with SW. The SW explained when Resident #9's care plan meeting was scheduled the family member would be called and care discussed because the resident usually did not want to attend due to difficulty hearing. An additional interview was conducted on 10/10/2024 at 8:44 AM with the facility SW. During the interview the SW reported she usually scheduled care plan meetings on days when Resident #9 could attend. The SW further explained that all residents needed to be invited to the care plan meetings and there should be documentation in the resident electronic medical records if he or she refused to participate. An interview was conducted on 10/10/2024 at 10:54 AM with the Director of Nursing (DON). During the interview the DON reported all residents should be involved in care plan meetings and if the residents chose not to be involved then that should have been documented. The DON went on to say, regardless of cognition the resident needs to be invited. On 10/10/2024 at 2:23 PM and interview was completed with the Administrator where she revealed she expected residents, regardless of cognition, have to be invited to the care plan meetings and if the resident did not want to attend then it needed to be documented in the resident's electronic medical record.

Based on staff interviews and record review, the facility failed to have a Centers for Medicare and Medicaid Services (CMS)-10123 Notice of Medicare Non-Coverage letter (NOMNC) signed prior to discharge from Medicare part A services with benefit days remaining to 1 of 3 residents reviewed for SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (Resident #307). Findings included: Resident #307 was admitted to the facility under part A Medicare services on 6/19/24. A review of the medical record revealed a NOMNC letter was not signed either physically or verbally by Resident #307 or their responsible party, but was signed by Social Worker #1, with the following statement Notice waived. Last covered date is 7/2/24 and discharge from the facility on 7/3/24. An interview was conducted with Social Worker #1 on 10/10/24 at 11:25 AM revealed she tried to have all the NOMNC forms signed either verbally or in writing but didn't have Resident #307's form signed. She stated Resident #307 wanted to speak to her husband about leaving early as her discharge was near a holiday. Resident #307 discharged a day early due to the holiday. She stated because Resident #307 left early, she signed the notice as waived and did not acquire a signature from Resident #307. An interview was conducted with the Administrator on 10/10/24 at 2:26 PM revealed she had the expectation that if a resident could physically sign the NOMNC form, it should be signed but if not a verbal signature from a resident or someone to sign or their behalf was appropriate.

Based on record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date (ARD), which was the last day of the assessment period for 1 of 4 residents reviewed for resident assessment (Resident #8). Findings included: Resident #8 was admitted to the facility on [DATE]. A review of Resident #8's electronic medical record revealed an annual MDS assessment with an ARD of 9/11/2024 that was open and not signed completed as of 10/09/2024. An interview with MDS Coordinator #1 on 10/09/2024 at 2:59 PM revealed the annual MDS assessment had not been completed and signed within 14 days of the ARD. MDS Coordinator #1 went on to say the assessment had been missed and was being worked on. The MDS Coordinator #1 further explained she and MDS Coordinator #2 had been looking over the assessment schedule to ensure nothing else had been overlooked. On 10/10/2024 at 10:48 AM an interview was completed with the Director of Nursing (DON). During the interview the DON stated the annual MDS assessment for Resident #8 should have been completed within 14 days of the ARD date. The DON went on to say his expectation was that all MDS assessments needed to be completed in the appropriate timeframe. During an interview with the Administrator on 10/10/2024 at 2:23 PM she stated she expected all MDS assessments to be completed in a timely manner.

Based on observations and staff interviews, the facility failed to remove expired medications available for use from the refrigerator of a medication storage room in 1 of 3 medication rooms reviewed for medication storage (Windsor medication room). Findings included: On 10/10/24 at 11:25AM during an observation of the Windsor medication room with Nurse #2 the observation yielded 81 unopened acetaminophen suppositories 650 milligram (mg) with an expiration date of 04/24 (April/2024). On 10/10/24 at 11:28 AM an interview was conducted with Nurse #2. During the interview she stated the refrigerator was checked daily by the nursing staff. She stated she was responsible for checking the medication room refrigerator for the household and had just missed the expiration date by mistake. Nurse #2 stated the mediation had not been used in some time and that was probably why it was missed. The interview revealed the medication was available for nurses to obtain from the room and should have been discarded if it was past the date listed on the packaging. An interview was conducted with the Director of Nursing (DON) on 10/10/24 at 12:35 PM. The DON was informed of the findings in the medication storage room and the DON stated the facility staff had looked in both rooms a couple of days prior and had not found the expired medication. He stated the facility went by the expiration date listed on the packaging of the medication and the expired medications should have been discarded. An interview was conducted with the Administrator on 10/10/24 at 2:26 PM she stated the medication should have been discarded. She stated she expected nursing staff to check the expiration dates daily.

Based on observations, record review, and staff interviews, the facility failed to discard expired food items in the 2 of 2 freezers, 1 of 4 refrigerators, 1 of 1 dry storage room of satellite kitchen #1 and satellite kitchen #2 used to prepare resident meals. This practice had the potential to affect food served to residents. The findings included: An observation on [DATE] during a tour of freezers and refrigerators of satellite kitchen #1 and #2 and the dry storage room with the Culinary Chef and Assistant Culinary Chef, the following concerns were identified: a) One bin of ,d+[DATE] grayish fuzz on turnip vegetables in the freezer of satellite kitchen #2 b) One container of cottage cheese with expiration date of [DATE] in freezer of satellite kitchen #2 c) Two packages of dessert mix gelatin with no expiration date or made date in dry storage room d) One large package of marshmallows with expiration date of [DATE] in dry storage room e) Six loaves of unfrozen bread and 4 hot dog rolls with no label or expiration date in dry storage room f) No expiration date or label on 18 raw eggs in satellite kitchen #1 refrigerator g) One opened carton liter of liquid eggs was unlabeled in kitchen #1 refrigerator h) One unlabeled opened package of grated cheese in satellite kitchen #1 refrigerator i) Unlabeled and opened sliced Swiss cheese in satellite kitchen #1 refrigerator j) Unlabeled repackaged plastic bags of 6 frozen raw burgers in satellite kitchen #1 freezer k) 2 Unlabeled repackaged plastic bags of 6 count frozen salmon servings in satellite kitchen #1 freezer. During an interview on [DATE] at 10:38 AM Cook #1 indicated she transfers frozen foods to a smaller bag and placed in the smaller freezers in kitchen #1 in preparation for daily use and sometimes forgets to place labels on food that have been opened such as grated cheese, Swiss cheese, repackaged frozen raw burgers and repackaged frozen salmon found in satellite kitchen #1 freezer and refrigerator. She further indicated she was not the only dietary staff who worked in the kitchen and placed food in the freezer or refrigerator. An interview with the Culinary Chef on [DATE] at 11:14 AM revealed all dietary staff were responsible for labeling foods and discarding expired foods on a daily and weekly basis. He further revealed although there was a posted guidance sheet on shelf life of perishable and non-perishable foods served to residents, the food categories were vague, and he was unable to determine true expiration dates of certain foods that were opened. He was also unable to determine the expiration dates of foods removed from original box or packaging whose expiration dates were located on original boxes that may have already been discarded. An interview on [DATE] at 11:25 AM the Culinary Director indicated she expected dietary staff to identify and discard expired food items on a regular basis. She further indicated she will research and obtain a user-friendly shelf life/ expiration sheet from manufacturers to educate dietary staff on when to discard foods served to residents. An interview with the Administrator on [DATE] at 4:18 PM indicated she was not aware of the expired foods and that his expectation was for foods to be checked for expiration dates on a regular basis and discarded if expired.

Based on record review, resident interviews and staff interviews the facility failed to resolve group grievances that were brought to resident council meetings for 4 consecutive months (February, March, April, and May 2023). The findings included: A review of Resident Council meeting minutes from February 2023 through May 2023 was completed. Each month's meeting minutes had a culinary/dietary section that identified the concerns related to residents frequently missing food items from meal trays, such as ordering dessert and not receiving it or ordering soup with cheese and not receiving the cheese. On 3/30/23 meeting minutes identified the previous month's concern of missing food items as improved. 4/25/23 meeting minutes identified the concern of missing food menu items as on-going. May 2023 (no date) meeting minutes identified the concern of missing food menu items as improved but on-going. During interviews with residents #28 and #20 who attended the Resident Council meeting on 6/6/23 at 1:30 PM revealed the occurrence of missing food items continued weekly and the transition from the use of paper ticket menus to computer tablet menus was not a good idea due to the computer tablets not recording menu selections at times. They further revealed the concern had been voiced during resident council meetings and nothing seemed to change. Resident #28 added that her shake was missing from her tray on 6/5/23 and it was order on her menu. During an interview on 6/7/23 at 12:16 PM the Life Enrichment Director indicated her standard practice for submitting grievances voiced in Resident Council meetings was to document the grievances on the meeting minutes form and provide the administrator with the form. She further indicated she also encouraged residents to reinforce their concerns by talking directly to dietary staff. She stated Resident Council attendees complained they're selected menu items did not arrive on their food trays during moths (Feb, March, April & May 2023). She provided the Director of Nursing (DON) with the meeting minutes for her to review the grievances/ concerns. She further stated she was not provided with a resolution or update from the DON to provide to residents regarding why the items were missing or what was being done to resolve their concerns. During an interview on 6/7/23 at 11:25 AM the Culinary Director revealed they implemented use of computer tablets for the servers to take resident menu orders about two months ago to enhance the dining process. They were also experiencing dietary staff turnover and there may have been a breakdown in communication in the team process between servers and nurse aides who build resident trays. Therefore, some food items may get missed. During an interview on 6/7/23 at 10:30 AM the Director of Nursing (DON) revealed they began using computer tablets to take resident meal orders in May 2023 and heard feedback from residents that the paper menus were preferred due to staff making errors when adding menu items to the tablet. She further revealed the reasons for missing food items may have been the combination of nursing staff and server error as well as high turnover in dietary. She also stated tray audits were being performed on a regular basis and she was not aware missing food items continued to be a concern. During an interview on 6/7/23 at 3:10 PM the Administrator indicated she was unaware of the concerns expressed in Resident Council meetings and planned to discuss the trend.

Based on record review and resident and staff interviews the facility failed to develop comprehensive care plans in the areas of anticoagulant (blood thinning) medication (Resident #63 and Resident #79) and communication (Resident #4). This deficient practice was for 3 of 5 residents whose comprehensive care plans were reviewed. Findings included: 1. Resident #63 was admitted to the facility on [DATE] with a diagnosis of atrial fibrillation. A review of Resident #63's medical record revealed a physician's order dated 04/17/2023 for Apixaban (an anticoagulant medication) 2.5 milligrams (mg) twice daily for atrial fibrillation. A review of the admission Minimum Data Set (MDS) assessment for Resident #63 dated 04/23/2023 revealed she was cognitively intact. She received anticoagulant medication on 7 of 7 look-back days of the assessment. A review of Resident #63's May and June 2023 Medication Administration Record revealed she received Apixaban twice daily as prescribed. A review of Resident #63's comprehensive care plan last revised on 5/2/23 did not reveal any care plan focus area or interventions related to receiving an anticoagulant medication. On 06/06/2023 at 2:16 PM an interview with Resident #63 indicated she could not remember the names of her medication. She did not know if she was taking a blood thinner. On 06/08/2023 at 10:13 AM an interview with MDS Nurse #1 and MDS Nurse #2 indicated Resident 63#'s care plan should address anticoagulant medication so staff caring for her would be aware she was receiving it. On 06/08/2023 at 10:54 AM an interview with the Director of Nursing (DON) indicated anticoagulant medication was a high-risk medication. She stated it should be addressed in Resident #63's comprehensive care plan so all staff caring for her would be aware she was at risk for side effects like bleeding or bruising. 2. Resident #79 was admitted to the facility on [DATE] with Covid 19 and pneumonia. Additional diagnoses included deep vein thrombosis (blood clot in lower leg) and pulmonary emboli (blood clot in the lungs). A review of Resident #79's medical record revealed a physician's order dated 2/17/2023 for Apixaban (an anticoagulant medication) 5 milligrams (mg) twice daily for deep vein thrombosis and pulmonary emboli. A review of the quarterly MDS assessment dated [DATE] for Resident #79 revealed he was cognitively intact. He received anticoagulant medication on 7 of 7 look back days of the assessment. A review of Resident #79's medical record revealed a physician's order dated 2/17/2023 for Apixaban (an anticoagulant medication) 5 milligrams (mg) twice daily for deep vein thrombosis and pulmonary emboli. A review of Resident #79's May and June 2023 Medication Administration record revealed he received Apixaban twice daily as prescribed. A review of Resident #79's comprehensive care plan dated 04/24/2023 did not reveal any care plan focus area or interventions related to receiving an anticoagulant medication. On 06/06/2023 at 2:40 PM an interview with Resident #79 indicated he was currently receiving anticoagulant medication. He stated he had not experienced any usual bleeding or bruising. On 06/08/2012 at 10:19 AM an interview with MDS Nurse #1 and MDS Nurse #2 indicated Resident #79's care plan should address anticoagulant medication. MDS Nurse #2 stated receiving anticoagulant medication put Resident #79 at risk for side effects like bleeding and bruising. On 06/08/2023 at 10:54 AM an interview with the Director of Nursing (DON) indicated anticoagulant medication was a high-risk medication. She stated it should be addressed in Resident #79's comprehensive care plan so all staff caring for her would be aware she was at risk for side effects like bleeding or bruising. 45358 3. Resident #4 was admitted to the facility on [DATE] with diagnosis inclusive of congestive heart failure, anemia, hypertension, atrial fibrillation, chronic obstructive pulmonary disease, and dysphagia. A review of the admission Minimum Data Set assessment for Resident #4 dated 3/16/23 revealed she had moderate cognitive impairment. Section B was coded as clear speech, makes self-understood verbally and had the ability to understand others verbally. The MDS question regarding the resident's need or want for an interpreter to communicate with a doctor or health care provider was answered no. A review of an admission progress notes dated 3/10/23 indicated Resident #4 was alert and unable to speak English. A revised care plan dated 5/5/23 did not address a communication plan for Resident #4 who did not speak English. A review of a nursing progress note dated 3/13/23 revealed Resident #4's English was poor, and she was not able to communicate her needs. During an interview on 6/6/23 at 4:33 PM Social Worker #2 revealed she was responsible for assessing for and adding the language barrier/ communication to the Care Plan for Resident #4. She further revealed she did realize that she did not add the problem to the Care Plan. During an interview on 6/7/23 at 3:22 PM the Administrator indicated she expected the Care Plan to include the problem area, goal and intervention related to the communication deficit for Resident #4 and all residents.

Based on observations, staff interviews, and record reviews the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor the interventions the committee put in place following the Focused Infection Control Survey conducted on [DATE]. The deficiency was in the area of Food Procurement, Store/Prepare/Serve. This deficiency was cited again on the annual recertification survey on [DATE]. The continued failure of the facility during two consecutive recertification surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812 - Based on observations, record review, and staff interviews, the facility failed to discard expired food items in the 2 of 2 freezers, 1 of 4 refrigerators, 1 of 1 dry storage room of satellite kitchen #1 and satellite kitchen #2 used to prepare resident meals. This practice had the potential to affect food served to residents. During the Focused Infection Control Survey conducted on [DATE] the facility failed to perform hand hygiene before contacting clean dishes and failed to sanitize a soiled dish towel before reuse. An interview with the Administrator on [DATE] at 4:18 PM indicated she was not aware of the expired foods and that her expectation was for foods to be checked for expiration dates on a regular basis and discarded if expired.

Based on record review, observations, resident, family and staff interviews the facility failed to provide communication to a resident in a language that she could understand for 1 of 1 non-English speaking residents (Resident #4) reviewed for resident rights. Findings included: A review of the language line service agreement revealed services were set up on 2/21/2012. The language line was a telephone service that provided language translation for staff to communicate with residents who were not fluent in English. Resident #4 was admitted to the facility on [DATE] with diagnoses inclusive of congestive heart failure, anemia, hypertension, atrial fibrillation, chronic obstructive pulmonary disease, and dysphagia. A review of an admission progress notes dated 3/10/23 indicated Resident #4 was alert and unable to speak English. A review of a nursing progress note dated 3/13/23 revealed Resident #4's English was poor, and she was not able to communicate her needs. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had moderate cognitive impairment. The MDS question regarding the resident's need or want for an interpreter to communicate with a doctor or health care provider was answered no. A revised care plan dated 5/5/23 did not address a communication plan for Resident #4 who did not speak English. During an interview on 6/6/23 at 12:31 PM Resident #4's family member indicated the resident spoke Greek and did not speak English. During an interview on 6/6/23 at 4:33 PM Social Worker #2 revealed she used a communication booklet to complete the Brief Interview Mental Status (BIMS) assessment but did not notify nursing staff or document in the medical record (Care Plan or MDS) that Resident #4 had a language barrier. She further revealed she had not used the language line telephone service to communicate with the Resident. She stated she should have care planned the language barrier when she completed her initial care plan on 3/16/23. During an interview on 6/6/23 at 4:57 PM Nurse Aide (NA) #1 indicated she was assigned to Resident #4 at times and that the Resident communicated her needs by pointing to the bathroom or stating choice English words such as food, chair, or pain. Otherwise, she was unable to communicate her needs or understand what the NA was saying. She further indicated she was not instructed to use a communication board or language line to communicate with the Resident. An observation and interview on 6/7/23 at 2:28 PM with Resident #4 who was in her room and spoke limited English and there were no alternate forms of communication (communication board, directions, or instructions/ interpreter phone line) to assist with translating her native Greek language. Resident #4 attempted to participate in the interview by verbalizing a series of random English words to understand the Surveyor's conversation and was unsuccessful. During an interview on 6/7/23 at 12:16 PM the Life Enrichment Director (Activities Director) indicated she handled all resident activities to include resident participation and refusals. She also indicated she was never instructed to use a communication board or language line when communicating with Resident #4. During an interview on 6/7/23 at 3:22 PM the Administrator indicated she expected the need for interpreter services to be added to resident charts upon admission and that she was unaware the information was not captured on the MDS and Care Plan for Resident #4. She further indicated she sent out a reminder to staff regarding how to access the language line after the issue was identified during survey and that the information was located in the Director of Nursing Office.

Based on record review, observation and staff interviews, the facility failed to accurately code the admission Minimum Data Set (MDS) assessment in communicatio for 1 of 1 resident reviewed for MDS accuracy (Resident #4). The findings included: Resident #4 was admitted to the facility on [DATE]. A review of an admission progress notes dated 3/10/23 indicated Resident #4 was alert and unable to speak English. A review of a nursing progress note dated 3/13/23 revealed Resident #4's English was poor, and she was not able to communicate her needs. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had moderate cognitive impairment. Section B was coded as clear speech, makes self-understood verbally and had the ability to understand others verbally. The MDS question regarding the resident's need or want for an interpreter to communicate with a doctor or health care provider was answered no. During an interview on 6/6/23 at 12:31 PM Resident #4's family member indicated the resident spoke Greek and did not speak English. During an interview on 6/6/23 at 4:33 PM Social Worker #2 revealed she used a communication booklet to complete the Brief Interview Mental Status (BIMS) assessment but did not notify nursing staff or document in the medical record (MDS section B) that Resident #4 had a language barrier. She further revealed she had not used the language line telephone service to communicate with the Resident. She stated she was responsible for coding section B of the MDS for Resident #4 and did not code it accurately. During an interview on 6/7/23 at 3:22 PM the Administrator indicated she expected the MDS to be coded accurately and timely for Resident #4 and all residents.

Based on record review, observations, family interview and staff interviews, the facility failed to obtain and honor a resident's dietary preferences for 1 of 1 resident (Resident #4) reviewed for accommodation of needs. Findings included: Resident #4 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 had moderate cognitive impairment. A review of an admission progress notes dated 3/10/23 indicated Resident #4 was alert and unable to speak English. A review of admission orders dated 3/10/23 indicated Resident #4 was to receive a pureed diet. A review of nutrition assessment dated [DATE] and completed by the dietitian, indicated Resident #4 was on a pureed diet with dietary supplement, and food preferences for breakfast, lunch and dinner indicated select menu prior to service. During an observation on 6/6/23 at 12:31 PM Resident #4 was sitting in the dining room with her family and eating lunch. Her meal ticket indicated she was on a pureed diet and should have received pureed chicken and pinto beans. Instead, she received pureed beef, rice, and sweet potatoes. During the observation, Resident #4's family reported she preferred chicken, not beef. No dessert was checked off on the menu and according to her family, she usually got dessert and they were surprised it was not selected or received. Resident #4 did not eat the pureed beef. On 6/6/23 at 12:31 PM Resident #4's family member explained Resident #4 did not speak English and staff filled out meal menus without input from the responsible party/ family. The family further indicated they were not contacted about Resident food preferences and that the Resident enjoyed pureed cookies and spaghetti. During an interview on 6/7/23 at 2:38 PM the Kitchen Ambassador revealed she was responsible for assisting residents (400, 500 and 600 halls) with completing their menus and serving meals from the unit kitchen/ dining room. She further revealed she completed pureed menus for Resident #4 and did not seek assistance or input from the Resident because she did not speak English and was not instructed to contact the family for input. During an interview on 6/6/23 at 3:30 PM the Dietician revealed she usually contacted the family about food preferences if a resident was unable to communicate and added the preferences to the care plan. If no preferences were identified, pureed meals were prepared and chosen by the cook. Although pureed menu tickets were completed and menu items selected by the resident or family members, residents on a pureed diet may not receive what they ordered. She further revealed she did not have a conversation with Resident #4's family about dietary preferences and she was aware the Resident did not speak much English. During an interview on 6/7/23 at 3:22 PM the Administrator indicated she expected food preferences to be discussed with residents/ family members during the dietary admission assessments. She further indicated she was unaware the Resident #4's preferences were not offered or discussed with the family.

Based on record review, observations, staff and resident interviews, the facility failed to honor 1 of 21 resident's rights to maintain dignity by providing showers on the toilet, not providing incontinence care and failed to honor the resident's right to refuse care resulting in the resident feeling belittled, embarrassed and undignified (Resident #43). The findings included: 1. Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's admission/5-day Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact for daily decision making, had no behaviors for refusal of care, required extensive assistance of 2 staff for bathing and toileting and was frequently incontinent of bowel and bladder. The MDS further revealed it was very important for Resident #43 to have his preferences honored regarding showering. a. Interview on 2/14/21 at 12:51 PM with Resident #43 revealed he had concerns about not having a choice of showering. He further stated that staff just came in and gave him a shower when they felt like he needed one. Resident #43 indicated there had been at least three occasions when he had been given a shower on the toilet. He further stated, How would it make you feel if you are sitting on the toilet and the staff just come in and turn on the water and start showering you? Resident #43 revealed it made him feel belittled and embarrassed and became tearful and started to cry. Resident #43 stated that he had a bowel movement during one of the showers. Observation of Resident #43's room on 2/14/21 at 12:51 PM revealed a private bathroom with a walk-in shower, shower chair, toilet and sink. Further observation revealed a shower nozzle with an extended cord. Interview with Nurse Aide (NA) #4 on 2/16/22 at 2:10 PM revealed she gave Resident #43 showers on the toilet because she felt like Resident #43 would slide from the plastic shower chairs. NA #4 stated there were times when the Resident would have a bowel movement while sitting on the toilet. She further indicated that Resident #43 was not the only resident that she showered on the toilet. NA #4 stated Resident #43 had not shared any concerns with her about receiving showers on the toilet. Interview with Nurse Supervisor #1 on 2/16/22 at 3:24 PM stated residents were given showers on shower chairs, and some were being provided showers on the toilet. She further indicated she was unaware of the showers being given on the toilet until she was informed by NA #4 today (2/16/22). Nurse Supervisor #1 indicated the shower chair was the normal process, but she understood the NA's rationale if the resident was incontinent and having incontinent episodes on the floor. Interview with Resident #43 on 2/17/22 at 8:54 AM revealed he was showered again yesterday (2/16/22) on the toilet. He further revealed he had told the staff at least three times he did not like having showers on the toilet. Resident #43 stated it made him feel degraded and undignified. NA #6 was interviewed on 2/17/22 at 10:27 AM. She revealed she had given Resident #43 his shower on the toilet yesterday (2/16/22) around 5PM. She revealed she transferred him to the toilet with a mechanical lift as he was not safe on the regular shower chair. She stated she was afraid he would fall. She further revealed Resident #43 had not verbalized any concerns with being showered on the toilet. Interview with Nurse #2 on 2/17/22 at 10:57 AM revealed she was aware that NA #4 gave showers on the toilet as it was easier for her if the resident had an incontinent episode. She further stated Resident #43 had not shared any concerns with her regarding not wanting to be showered on the toilet. In an interview with the Administrator in Training (AIT) on 2/17/22 at 11:42 AM revealed she had spoken to NA #4 about Resident #43's concern of being showered on the toilet. The AIT revealed NA #4 bathed Resident #43 on the toilet because it was cemented to the floor. Due to the toilet being affixed to the floor it was safer. b. An interview and observation on 2/15/22 at 3:28 PM with Resident #43 revealed he had concerns about the staff providing incontinence care. Resident #43 indicated he was upset because he soiled himself at the Medical Doctor's (MD's) office today (2/15/22). He further indicated that staff was with him during his appointment but did not take him to the bathroom. Resident #43 stated he had to urinate in his brief. Resident #43 indicated he was not provided incontinence care for at least four hours. Resident stated it was an uncomfortable feeling to be left soiled for four hours and became tearful. Interview with Nurse Supervisor #1 on 2/16/22 at 2:00 PM revealed during Resident #43's appointment yesterday (2/15/21) he was not taken to the bathroom. She revealed NA #5 attended the appointment with Resident #43 and had not taken him to the bathroom. She further revealed Resident #43 was incontinent, and his brief was soiled at the appointment. In an interview with NA #4 on 2/16/22 at 2:10 PM revealed Resident #43 liked to be clean. She further revealed there was an incident yesterday with NA #5 during the MD's appointment. She stated that Resident #43 had not been taken to the bathroom at the appointment. She further indicated that the resident was brought back to the facility around 12:00 PM, however NA # 5 did not tell her until around 2:00 PM that Resident #43 needed to be changed. She stated that his pants were soiled and wet, and she assisted Resident #43 with incontinence care around 3:00 PM. Interview with NA #5 on 2/17/22 at 10:33 AM revealed she went to the MD's appointment with Resident #43. She stated that the Resident #43 required two people to assist him with incontinence care. He had an incontinent episode at the MD's office, and because Resident #43 could not assist with transferring and repositioning, she was unable to provide the incontinence care. She stated that she also did not have incontinence supplies with her. She further revealed that Resident #43 had been wet for about an hour before they returned to the facility around noon. When she returned to the facility, she gave the paperwork to Nurse #2 and let her know she needed help changing Resident #43. She stated that Nurse #2 told her it was lunch time, and she needed to wait until lunch was finished so she could find assistance. When Resident #43 finished his lunch, she assisted him with cleaning his face, and she removed the lunch tray. She stated a little while later NA #4 came into the room and started asking her what she was doing in there. She further stated she had been waiting for help to provide Resident #43 incontinence care, but no one had come to help her. She stated that the staff at the facility assisted Resident #43 with incontinence care. Interview with Nurse #2 on 2/17/22 revealed at 10:57 AM revealed the day of Resident #43's appointment a contracted staff went with him. Upon return NA #5 came to the nurse's station window and stated that Resident #43 needed to go to the bathroom. Nurse #2 told NA #5 to go find another NA to help assist her with Resident #43 incontinence care because she busy trying to send someone out to the emergency room . She stated that the staff usually toileted residents before appointments and that once they return from MD's appointments it was the facilities responsibility to assist with care needs. c. Review of facility grievance dated 1/4/22 revealed Resident #43 reported to Social Worker #1 that staff shaved him against his will. The grievance continued that Resident #43 had asked staff at least three times to stop. The facility investigation and response were as followed, NA #3 was asked to shave Resident #43 by the nurse as requested by the Power of Attorney (POA), the facility spoke with the (POA) and it was decided Resident #43 would go to the salon to be shaven. Interview on 2/16/22 at 11:05 AM with the Social Worker #1 revealed she received a call from Resident # 43's Power Of Attorney (POA) regarding the shaving incident. The Social Worker further revealed she went and spoke with Resident #43, and he told her that he wanted to go to the barber shop. NA #3 shaved him although he had asked her not to at least twice. The Social Worker revealed she spoke to Nurse #2 and was told that Resident #43 wanted to go to the barber shop and did not want the NA# 3 to shave him. The Social Worker indicated she spoken to NA #3 and was told that Resident #43 had not asked her to stop shaving him until later when she was almost finished. Interview on 2/16/22 at 11:19 AM with NA #3 revealed she had been asked by Nurse #2 to shave Resident #43. NA #3 further revealed that Resident #43 was upset because he was going to go to the beauty shop, and she shaved him. Resident #43 did request for her to stop, but she had already shaved the left and the right side of his face, and only had the middle section and under his chin left. She further indicated that she could not leave him like that way, so she finished shaving him. Interview with Resident #43 on 2/16/22 at 11:40 AM revealed he filed a grievance with the facility because the NA shaved his facial hair, and he asked her to stop at least three times. He stated that although he requested for her to stop, she continued. Interview with Nurse #2 on 2/17/22 at 10:57 AM revealed the POA had called and wanted Resident #43 shaved. Nurse #2 stated she asked NA #3 to shave him. She further revealed NA #3 came out of the room and told her Resident #43 was upset because he did not want her to shave him and that he wanted someone else to do it. She stated that the POA was called and put on speaker phone to help calm Resident #43 down, but he was not satisfied. She further revealed she was not aware Resident #43 had requested for the NA to stop, and if he did, she should have stopped and reported it to the nurse. Interview with the Administrator in Training (AIT) on 2/17/22 at 10:10 AM revealed she was aware of the concern with Resident #43 shaving. She further revealed it was not confirmed at the time of the investigation if NA #3 was asked to stop by Resident #43. She stated that if Resident #43 had requested for NA #3 to stop she should have.