Every finding on record at Bayshore Pointe Nursing and Rehab Center

Based on observations, interview and record review, the facility failed to protect the resident's right to be treated with dignity related to unauthorized video recording in the resident's room for two residents (#8 and #9) out of two residents reviewed and failed to ensure timely incontinence care for one resident (#7) out of seven residents observed. Findings included: 1. During a facility tour on 4/11/2026 at 9:40 a.m. an observation was made of room [ROOM NUMBER] with a warning notice posted on the door reading, NOTICE, THIS AREA IS UNDER 24-HOUR VIDEO SURVEILLANCE. An interview was conducted with the private caregiver of Resident #9. She stated the family installed the video surveillance to monitor Resident #9's care 24-hours a day. She stated the camera was positioned to face Resident #9's bed. She stated it was not meant for the roommate, Resident #8. Record review of Resident #8's medical record revealed there was no consent signed related to being in a room that was under video surveillance 24-hours a day.Review of Resident #8 and #9's care plans revealed there were no plans of care related to the operations of the camera and the intent to ensure the protection of both residents' right to privacy.An interview was conducted with Staff A, Registered Nurse (RN)/Weekend Supervisor on 4/11/2026 at 12:46 p.m. Staff A stated the camera in room [ROOM NUMBER] was for Resident #9 and it had been there for a couple months. She stated the resident was monitored by the family 24-hours a day from their home. She stated she did not know how many family members had access to the surveillance. Staff A stated the camera recorded visual only, and there was no audio. Staff A said, I don't think it records the care of the other resident, but I also cannot speak of how wide the camera view is.On 4/11/2026 at 12:50 p.m. an interview was conducted with Resident #8. She stated she did not know if the camera in the room was recording her. She said, Oh God, I hope not. I try to be careful especially when walking to the bathroom. Resident #8 stated no one had spoken to her about the video surveillance. She said she did not sign a consent to be in a room with on-going video surveillance. The resident stated she did not know anything about the operations of the camera and whether the other resident's family members could hear her or not. Resident #8 confirmed no one at the facility had discussed this with her. She said, I don't know if they can hear me. I truly hope not. That's invading my privacy.On 4/11/2026 at 1:16 p.m. an interview was conducted with the Regional Nurse Consultant (RNC), the [NAME] President of Operations (VPO), and the Nursing Home Administrator, (NHA). The NHA said she was sorry she missed to have Resident #8 sign the consent form. She stated the previous roommates of Resident #9 had signed consents. She stated she believed the admission staff had spoken to the resident, but she may have forgotten. The NHA confirmed the consent was not documented. Regarding the 24-hour video surveillance of a resident's room, The NHA said, I know, trust me, we do not want the cameras we are trying to find Resident #9 a private room. She said she has had some problems with the family because the CNAs (Certified Nursing Assistants) are supposed to turn the camera away during care. She stated the family complains the CNAs do not turn the camera back to position to face Resident #9. The NHA stated she could not speak of the peripheral view of the camera. She stated she does not know how far the camera can see around the room. The NHA stated the agreement with Resident #9's family was for the camera to be on video only. The NHA said, I believe what the family says. I can't confirm if they do not turn on the audio. The NHA stated she could not guarantee Resident #8 was not recorded. Regarding the facility not having control of what the family sees or hears in a room that is dually occupied, the RNC said, I agree, we will fix that. We will speak to the resident.Review of the admission record for Resident #8 revealed the resident was admitted to the facility on [DATE] with a primary diagnosis of wedge compression fracture. Review of a minimum data set (MDS) dated [DATE] revealed Resident #8 had a brief interview for mental status (BIMS) score of 15 out of 15 indicating intact cognition.Review of the admission record for Resident #9 revealed the resident was readmitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease. Review of a minimum data set (MDS) dated [DATE] revealed Resident #9 had a brief interview for mental status (BIMS) score of 00 out of 15 indicating impaired cognition.Review of a facility policy titled, Use of Video Monitoring/Camera in Resident Room, Revised 9/11/2025, revealed a purpose: HIPAA (Health Insurance Portability and Accountability Act) and state statutory and/or common law privacy protections establish broad privacy rights. The presence of a video camera in a resident's room could potentially violate the privacy rights of other residents of the Center. If a video camera also records audio, the unauthorized recording of another person may violate the state's wiretapping law and could result in criminal penalties. Because the Center values transparency and accountability, and considers the health, safety, and privacy of its residents to be the top priority, the Center appreciates and will attempt to honor any request to allow a non-concealed, stationary, video-only camera in a resident's room, subject to certain conditions being met.Authorization and consent: If the resident shares a room with another resident, the resident's roommate or the roommate's authorized representative must consent to the installation and use of a video camera prior to its installation by signing the attached Private Video Camera Notice Consent and Authorization of Roommate and/or Responsible Party Form SHCO20002.10B. If the roommate and/or the roommate's authorized representative refuses to sign the Roommate Authorization and Consent Form, then the Center will make a reasonable attempt to accommodate the resident who wants to install a video camera by offering to move such resident to another shared room or by offering such resident a private room, both are subject to availability. If the resident elects to move to a private room, the resident will be responsible for paying the private room rate. If a shared room is not available at the time, the Center will offer to move the resident at such time as a shared room becomes available.2. On 4/11/2026 at 10:02 a.m. Resident #7, was heard yelling from her room saying, Somebody help me. Resident #7 was observed emotionally agitated, showing anger and physical frowning of the face. She asked, Are you here to help me? The resident stated she was upset because she was waiting to be toileted. She said two staff members had responded to her calls and they said to wait. She said, it had been 2 hours. The resident stated the weekends are bad because no one answers call lights. She stated she had to call the Receptionist, twice, because the CNA never came back. Resident #7 said, I have to go now or I will soil myself. I hate that.On 4/11/2026 at 10:04 a.m. an interview was conducted with Staff B, RN. She confirmed Resident #7 had been calling for help. She said the resident said she had to go to the bathroom, about 30 minutes or so prior. Staff B, RN said she told one of the CNAs who went to the room, and she saw her walking out. She stated she assumed the CNA, (Staff C) had provided care at the time. An observation was made of Staff D, CNA on 4/11/2026 at 10.06 a.m. responding to Resident #7 after the surveyor intervention. Resident #7 could be heard from the hallway crying and saying, Oh! No!, I waited too long, I'm soiled now, I didn't want this. Staff D, CNA said to the resident, I apologize. I have 25 patients. I was taking care of other people. Staff D proceeded to assist Resident #7.On 4/11/2026 at 10:08 a.m., an interview was conducted with Staff D, CNA. She said the resident notified her she needed to go to the bathroom, about 30-45 minutes earlier. She said she was taking care of other residents. She stated she had asked the other CNA (Staff C) for help, but the other CNA was busy too. Staff D, CNA said, I apologize. I should have asked someone else for help.On 4/11/2026 at 10:12 a.m., an interview with Staff E, RN observed in the same hallway revealed the expectation was for the CNAs to get to the resident right away. He stated he would normally help CNAs if they let him know a resident needed care. He stated, No, she shouldn't be waiting that long to be toileted. He stated no one notified him Resident #7 needed help.On 4/11/2026 at 10.15 a.m. a follow -up interview was conducted with Staff A, RN. She said she heard from the Receptionist that [Resident #7] had called twice asking to be changed and the receptionist told her someone would help her. Staff A said the receptionist said the resident was calling downstairs for help, as she needed to be assisted to the bathroom. She said the resident told the Receptionist she had waited for help for may be 20 minutes or so. Staff A said she had just been notified and went to the room and found the CNA (Staff D) assisting the resident. Staff A, RN said the CNAs and nurses should have responded to the resident. She said, It's not acceptable for the resident to wait and end up soiling themselves. She stated anyone can toilet the resident.On 4/11/2026 at 10.28 a.m. an interview was conducted with the Receptionist. She confirmed Resident #7 called twice for help. She said the first time she called she was trying to get someone to toilet her. She said this was approximately 9:15 a.m. She stated the resident called the second time and said she had been waiting over 2 hours to be toileted. The receptionist said she paged the nurse. She stated once she pages the nurse, she would not know if they responded to the resident or not. The Receptionist said the resident called again and said no one had come. She said this was close to 10 a.m. She said she paged the nurse again. She stated she was not sure if anyone had responded.An interview with the NHA on 4/11/2026 at 1:20 p.m. revealed she looked at the cameras, and it showed staff were in and out of the room. She said they attended to her. The NHA stated she thought someone changed her at 7a.m. and again when she called the first time. The NHA stated their expectation was for residents to be attended to in a timely manner. Review of the admission record revealed Resident #7 was admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy. Review of a minimum data set (MDS) dated [DATE] revealed Resident #7's cognition was not documented. Resident #7 presented to be alert and oriented during the interview. Section GG revealed the resident utilized a wheelchair for ambulation and was dependent on staff for toileting/hygiene.Review of a care plan for Resident #7 revealed a focus for incontinent of bowel/bladder initiated on 2/17/2026. The goal showed attempts to have fewer episodes of incontinence will be provided through next review. Attempts to improve level of function will be provided through next review date. Interventions included assist with toileting as needed and Peri care after each incontinent episode. A review of the same care plan revealed an ADL (activities of daily living) self-care performance related to decreased activity tolerance. The interventions revealed the resident was dependent on staff for toilet use.Review of a facility policy titled, Resident Dignity & Personal Privacy, effective 4/2024, revealed a purpose: The center provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Procedure: 1. Care for residents in a manner that maintains dignity and individuality:Assist the resident with grooming; groom appropriately and to resident's desire.

Based on observations, interviews and record reviews, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) assessments were updated to include current diagnoses for eight residents (#28, #1, #46, #33, #57, #47, #40, and #506) out of 22 sampled residents. Findings included: 1. During an observation on 09/09/24 at 10:31 a.m. Resident #28 was in her room lying in bed under a blanket. During an attempt to interview Resident #28, she was not able to answer questions regarding her care or stay. Review of Resident #28's Admission Record showed Resident #28 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease with a date of 06/17/2022. Other diagnoses include unspecified dementia, generalized anxiety disorder and major depressive disorder. Review of the Level I PASSR, dated 06/24/2024 showed in Section II: Other Indications for PASRR Screen Decision-Making, questions 1 through 7 were marked No. A level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease). Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 37999 2. Review of Resident #1's Admission Record revealed the resident was admitted on [DATE] and 4/26/23. The record showed the resident's primary diagnosis was unspecified severity unspecified dementia with other behavioral disturbance (onset 5/31/23) and included diagnoses of cognitive communication deficit, psychotic disorder with delusions due to known physiological condition, and moderate recurrent major depressive disorder. Review of Resident #1's Level I PASRR, dated 6/11/24, included the mental illness (MI) or suspected MI (SMI) of depressive disorder and psychotic disorder. The PASRR did not reveal the resident had a primary diagnosis of dementia and that a Level II PASARR evaluation was required. An interview was conducted with the Director of Nursing (DON) on 9/11/24 at 4:12 p.m. The DON reviewed Resident #1's PASRR and stated the PASRR would need to be updated due to the primary diagnosis of dementia. The DON reported the resident was part of the full house audit of PASRR's in June (2024). 3. Review of Resident #46's Level I PASRR, dated 6/11/24, revealed the resident had no MI or SMI per documented history. Review of Resident #46's Quarterly Minimum Data Set (MDS), dated [DATE], showed the resident had an additional active diagnosis with International Classification of Diseases (ICD) code of F48.2. Review of the website, https://www.aapc.com/codes/icd-10-codes, the ICD code of F48.2 was for Pseudobulbar Affect, listed as a mental, behavioral, and neurodevelopmental disorder. During an interview on 9/11/24 at 3:57 p.m., the DON stated since the facility's Quality Assurance and Performance Improvement (QAPI), started on 6/5/24; if residents come in with depression or anxiety, the facility updates the PASRR. The DON stated the audits continue and she is looking back at PASRRs. The DON reviewed Resident #46's PASRR and diagnoses and stated it should have been updated as the resident was involved in the June audit. 4. Review of Resident #33's Level I PASRR, dated 6/24/24, revealed the resident had mental illness diagnoses of depressive disorder and unspecified psychosis not due to a substance or known physiological condition. The PASRR revealed a Level II PASRR evaluation was not required. The PASRR did not include the resident's diagnosis of anxiety. Review of Resident #33's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was admitted on [DATE]. The Section I - Active Diagnoses revealed the resident had diagnoses of dementia, anxiety disorder, depression, and psychotic disorder. 5. Review of Resident #57's Level I PASRR, dated 6/22/22, revealed the resident did not have any MI or SMI and did have a primary diagnosis of dementia. The PASRR showed a Level II evaluation was not required. Review of Resident #57's Admission MDS, dated [DATE], showed the resident was admitted on [DATE]. Section I - Active Diagnoses revealed the resident had diagnoses of non-Alzheimer's dementia, anxiety, and depression. 50570 6. A review of Resident #47's Admission Record revealed an admitted [DATE]. Further review of Resident #47's Admission Record revealed diagnoses to include: major depressive disorder (onset date of 7/9/24), and adjustment disorder with mixed anxiety and depressed mood (onset date of 5/6/24). A review of Resident #47's active physician orders, as of 9/11/24, revealed medication to include: Bupropion HCI (hydrochloride) ER (extended release) (XL) Oral Tablet Extended Release 24 Hour, 150 mg (milligrams) for depression. Start date 8/1/23. A review of Resident #47's current care plan revealed a focus to include the following, [Resident name] {is at risk for} a mood problem r/t [related to] Depression. Further review of the current care plan revealed another focus to include the following, [Resident name] uses Psychotropic Medication Therapy r/t depression. Goals related to the Psychotropic Medication Therapy care plan include the following, Resident will have decreased risk of discomfort or adverse reactions related to psychotropic therapy through the review date. A review of Resident #47's Quarterly MDS, Section I - Active Diagnoses, dated 7/24/24, revealed the following under Psychiatric/Mood Disorder: Depression. Further review of the Quarterly MDS, Section I - Active Diagnoses revealed the following, Additional active diagnoses . ADJUSTMENT DISORDER WITH MIXED ANXIETY AND DEPRESSED MOOD. A review of Resident #47's Level I PASRR, dated 6/17/24, revealed no documentation of the diagnosis of depression. A review of Resident #47's electronic medical record revealed no evidence of an updated Level 1 PASRR, to include the qualifying mental health diagnosis of depression. On 9/10/24 at 4:53 p.m. an interview with the Regional Registered Nurse (RN) who revealed there is a QAPI for PASRRs. She stated they educated staff on reviewing what's coming in from the hospital and making sure the qualifying diagnoses, to include mental illness or intellectual disability, are present on the PASSR. The Regional RN stated another part of the education was making sure the PASRRs are fully completed. She stated they instructed staff on resubmitting them, if needed. The Regional RN stated on 6/21/24 a whole facility audit was conducted. She stated, Multiple residents' PASRRs were reviewed and updated. The Regional RN revealed there is no PASRR policy. A review of the QAPI plan related to PASRRs revealed the following objective, At the end of this presentation the staff will be able to: Review PASRR prior to admission and change of condition to ensure it reflect the resident accurately. On 9/11/24 at 3:57 p.m. an interview with the Director of Nursing (DON) revealed there was a whole house audit for PASRRs on 6/5/24. She stated this was conducted because the hospital would send PASRRs but would not include updated diagnoses. The DON stated if the resident acquired depression or anxiety, and the diagnoses are not on the original PASRR, then it should be updated. She stated, The audit continues. The DON stated she does a weekly audit and, Look back. She stated she goes by the Order listing, and looks back a week, therefore, within a week she tries to catch PASRRs that needed an update. She stated if the resident has a new diagnoses or medication, she expected the PASRR to be updated. A review of Resident #47's recent PASRR with the DON revealed she confirmed the PASRR should have been updated with the diagnosis of depression. She confirmed the diagnosis for depression was added on 7/9/24. 48441 7. A record review of Resident #40's Admission Record showed an admitted [DATE] with diagnoses to include adjustment disorder with mixed anxiety and depressed mood. A review of Resident #40's Level I PASRR, dated 02/27/2024, Section I: PASRR Screen Decision-Making showed no areas checked in Section A. for Mental Illness (MI) or suspected MI. A review of Resident #40's current physician orders showed an order dated 3/13/2024 for a referral to [vendor name] for psychology services due to depression. 8. A record review of Resident #506's Admission Record showed an admitted [DATE] with diagnoses to include major depressive disorder, bipolar disorder, and generalized anxiety disorder. A review of Resident #506's Level I PASRR, dated 8/22/2024, Section I: PASRR Screen Decision-Making showed areas checked in Section A. for Mental Illness (MI) or suspected MI with bipolar not checked. A review of Resident #506's current physician orders show an order dated 8/27/2024 to monitor for side effects adverse reactions related to use of psychoactive medications. An order for Diazepam tablet 5 milligrams to give one tablet by mouth every day and evening shift for anxiety dated 9/5/2024; and an order for Sertraline HCL tablet 100 milligrams to give 200 milligrams by mouth one time a day for depression. A review of Resident #506's care plan, dated 8/26/2024, revealed a Focus area of psychotropic medication therapy related to anxiety, depression, bipolar with a goal to reduce the use of psychotropic medication will be provided to resident over the next 6 months. Interventions included to observe for side effects and adverse reactions of psychotropic medications, observe ongoing signs and symptoms of depression and consult with pharmacy to provide dosage reduction when clinically appropriate.

Based on observations, record reviews, and interviews the facility failed to provide enteral nutrition per physician orders for three residents (#52, #101, and #14) out of six residents with gastrostomy tubes. Findings included: 1. On 9/9/24 at 10:13 a.m. Resident #52 was observed lying in bed with no response to verbal stimulus. The resident appeared to be cachectic, and lips were dry and flaky. The observation did not reveal any bottle of enteral nutrition hanging from the nutrition pole. On 9/9/24 at 12:31 p.m. Resident #52 was observed lying in bed, with no bottle of enteral nutrition hanging from the nutrition pole located next to the resident's bed. On 9/9/24 at 2:59 p.m. Resident #52 was observed lying in bed, with no bottle of enteral nutrition hanging from the nutrition pole next to the resident's bed. Review of Resident #52's September 2024 Medication Administration Record (MAR) revealed the following orders: - Start date 9/5/24: Enteral Feed Order every day for nutrition management (brand name of enteral nutrition) 1.5, stop enteral feed @ 2pm with a total volume of 1000 mLs (milliliters). This order was held on 9/4/24 and discontinued on 9/10/24 at 2:16 p.m. The MAR revealed on 9/8/24 at 6 p.m. (1800) the enteral nutrition was administered and on 9/9/24 at 2 p.m. the enteral nutrition order was administered. The MAR did not have documentation showing whether the nutrition was stopped at 2 p.m. or started at 6 p.m. - Start date 9/4/24: Enteral Feed Order every day (brand name of enteral nutrition) 1.5 at 50 mL/hr (hour) at 6 p.m. The order was held on 9/4/24 and discontinued on 9/10/24 at 2:17 p.m. The MAR revealed on 9/8/24 at 6 p.m. (1800) the enteral nutrition was administered and on 9/9/24 at 2 p.m. the enteral nutrition was administered. The MAR did not have documentation showing whether the nutrition was stopped at 2 p.m. or started at 6 p.m. - Start date 9/4/24: Enteral Feed Order every 4 hours for nutrition management flush peg tube with 150 mL H2O (water) (total volume 900 mL every 24 hours (Q24hr). The order showed the hydration was held on 9/4/24 and discontinued on 9/10/24 at 2:17 p.m. The MAR documentation revealed the resident received hydration on 9/8/24 at 8 p.m., 9/9 at 0000 (midnight), 9/9 at 4:00 a.m., 9/9/24 at 8:00 a.m., and 9/9/24 at 12:00 p.m. (noon). The hydration was documented during the time Resident #52 was to be receiving nutrition. Review of Resident #52's progress notes, dated 9/9/24, did not include an explanation as to why the resident was not observed receiving nutrition on 9/9/24 from 10:13 a.m. to 12:31 p.m. On 9/10/24 at 9:13 a.m. Resident #52 was observed lying in bed with enteral nutrition running at 50 mL/hr and the pump showed 622 mLs had been delivered. According to the rate of 50 mL/hr and physician order for nutrition to be started at 6 p.m. (15 hours prior to the observation) the resident should have received 900 mLs (15 hours x 50 mL/hr = 900 mLs). An interview was conducted with Staff D, Licensed Practical Nurse (LPN) on 9/10/24 at 10:27 a.m. The staff member stated Resident #52's enteral feed order was for the nutrition to come down at 2 p.m. and up at 6 p.m. The staff member stated Staff G, Certified Nursing Assistant (CNA) informed her, right before lunch on 9/9/24, that the nutrition for the resident was not running; so she had reconnected it. Staff D reported taking the nutrition down around 2 p.m. (on 9/9/24), that it had been running overnight, and according to the machine when it was taken down 550 mLs had been delivered. The staff member stated someone must have reset the machine (pump). Staff D reported there was a bottle of nutrition hanging for Resident #52 (on 9/9/24) at noonish The staff member stated her normal routine before getting started for the day was to check on the resident, and it (the nutrition) gets shut down during care. On 9/10/24 at 10:36 a.m. Resident #52 was observed with Staff D. The observation revealed the (brand name nutrition) bottle was dated 9/9/24 at 5:35 p.m. and the nutrition pump showed 655 mLs of nutrition had been delivered. The staff member stated, We are doing the best we can with what we got. An interview was conducted with Staff D,LPN, Staff F, Licensed Practical Nurse/Unit Manager, (LPN/UM), and Director of Nursing (DON) on 9/10/24 at 11:53 a.m. Staff D stated there had been an oversight yesterday regarding Resident #52's tube feeding. Staff D reported the physician and family member had been notified and confirmed it was an oversight. Review of Resident #52's progress notes revealed: - Effective 9/10/24 at 10:45 a.m. Staff D documented: Residents family and MD aware that due to care being given, resident missed an hour of Gtube feeding. Resident had no signs/symptoms (s/s) of distress and feeding was applied at 6 p.m. on 9/9/24 as ordered. Resident's gtube was patent and flushed as ordered. - Effective 9/10/24 at 10:57 a.m. Staff D documented: Nurse Practitioner (NP) aware and no new orders given, will continue (cont) plan of care. - Effective 9/10/24 at 11:38 a.m. the Dietician documented Rt (resident) had 2 hours of extra down time on 9/9/24 due to care. Will make up by incorporating 100 mL bolus at 4 p.m. on 9/10/24, in middle of regular down time. - The DON documented a late entry Situation, Background, Assessment and Review (SBAR), effective 9/10/24 at 1:15 p.m. revealed an other change in condition. The SBAR revealed nursing observations, evaluation, and recommendations are: Enteral feed was turned off at 10 a.m. order in (electronic record) is to turn feeding pump off at 2 p.m. Resident assessed and noted without distress, MD made aware, no new orders (NNO), Registered Dietician (RD) notified and ordered (brand name liquid nutrition) 1.5 100 mL bolus one time to be administered, labs ordered results within normal limits (WNL). Review of the Nutrition Comprehensive Evaluation/Risk Screen, effective 9/10/24 at 1:39 p.m. revealed Resident #52's most recent weight was 90.6 pounds (#) and a body mass index of 16.0. The resident's diet was nothing by mouth (NPO). The evaluation showed the current enteral nutrition was 50 mL/hr x 20 hours for total volume of 1000 mL's, flush q 4 hrs with 150 mL's of water (total volume 900 mL's, total 1660 mL's plus med flushes. The summary showed TF (tube feeding) regiment not meeting needs . Rt may be at risk for malnutrition due to (d/t) advanced age, medical diagnosis/history (dx/hx). The nutrition summary revealed the recommendation was (brand name of liquid nutrition) at 60 mL/hr x 20 hours, up at 6 p.m. until 1200 mL total volume reached. Review of Resident #52's MAR revealed the resident's enteral nutrition had been increased on 9/10/24: -Enteral Feed Order in the evening (brand name of liquid nutrition) 1.5 at 60 mL/hr x 20 hours. Up 6 p.m. until 1200 mL total volume reached. Started on 9/11/24 at 6:00 p.m. On 9/11/24 at 8:49 a.m. an observation revealed a bottle of enteral nutrition hanging for Resident #52. The 1000 mL bottle was dated 9/10/24 at 6:00 p.m. and the pump showed 60 mL/hr was being delivered. The pump revealed 23 mL volume had been delivered and the bottle contained approximately the original amount of 1000 mL's. The observation showed Resident #52's head of bed was raised approximately 30 degrees, and the resident was positioned almost flat as the resident laid in a loose fetal position. According to the time the bottle was hung and the observation showed a total of 14.75 hours at 60mL/hr = 885 mLs should have been delivered and the bottle should have contained approximately 115 mL's. The resident's lips continued to be dry and flaky. Review of Resident #52's MAR revealed two orders related to the raising of the head of bed: -Enteral Feed Order every shift, elevate head of bed 30-45 degrees at all times during feeding and at least 30-60 minutes after feeding is stopped. The order was to start on 9/9/24 at 3:00 p.m. -Enteral Feed Order every shift, elevate head of bed (HOB) at least 45 degrees at all times. The order was started on 9/9/24 at 3:00 p.m. An interview was conducted with Staff G, CNA on 9/11/24 at 9:08 a.m. Staff G reported Resident #52 did not have a bottle of nutrition hanging on Monday (9/9/24) and does not know what degree the resident's head of bed should be raised to during nutrition. On 9/11/24 at 9:45 a.m. Staff D, LPN was interviewed. The staff member reported not hanging any nutrition on 9/11/24 for the resident. Staff D observed the bottle of nutrition and the pump reading and confirmed the amount of nutrition that should have been delivered had not and thinking 500 mL's should have been delivered. Staff D stated she had notified the Unit Manager (Staff F) and the Director of Nursing (DON). The staff member confirmed Resident #52's head of bed should have been raised to 45 degrees and it was not. An interview was conducted with Staff F, LPN/UM on 9/11/24 at 9:45 a.m. The staff member stated Resident #52's tube feeding was turned off for care around noon (on 9/9/24), care was given, and the nutrition was turned back on. Staff F stated the facility realized the next day an error was made (9/10/24) so they contacted the physician who gave no new orders and had reached out to the nutritionist and was given an order for a 100 mL bolus. Staff F confirmed if the facility shut off the nutrition on 9/9/24 for care the bottle of nutrition would have been hanging. The staff member stated the resident had an agency nurse last night and the facility had started education regarding to not zero out the pump until the total volume had been delivered. Review of the time sheet, dated 9/10/24 for the agency nurse, who the facility revealed worked with Resident #52 showed an in-time of 11 p.m. and out time of 7:20 a.m. The observation of Resident #52's nutrition on 9/11/24 at 8:49 a.m. revealed a delivered volume of 23 mLs, per the physician order of 60 mLs per hour the resident should have received 89 mLs during the 1 hour and 29 minutes between the time the agency nurse left and the observation. The observation, previously noted on 9/11/24 at 8:49 a.m., showed Resident #52 was receiving 60 mL/hr of liquid nutrition and the pump showed 23 mLs of volume had been delivered. The pump had been running 1 hr and 29 minutes after the agency nurse clocked out of the facility. The volume that should have been delivered between the time the agency nurse clocked out and the observation would be 89 mLs. (60 mL/hr x 1 hour 29 minutes = 89 mLs) An interview was conducted with the Director of Nursing (DON) on 9/11/24 at 11:32 a.m. The DON stated the investigation into the incident involving Resident #52 revealed the Staff Development Coordinator (SDC) disconnected the feeding at 10 a.m. because the pump was beeping and said the volume of 1000 mLs had been delivered. The DON stated the issue was with taking the nutrition up and down. The DON confirmed 800 mLs would have been delivered between 6 p.m. (time nutrition was to be connected to resident) and 10:00 a.m. (time reported SDC had disconnected the nutrition). An interview was conducted with the SDC on 9/11/24 at 12:58 p.m. The SDC reported asking Staff D if they wanted Resident #52's nutrition disconnected. The SDC reported Staff D, LPN was told they disconnected the nutrition. The staff member stated she didn't think the bottle (nutrition) was empty, but disconnected because the pump was beeping, and it said it was complete. Review of Resident #52's Admission Record showed the resident was admitted on [DATE] and 9/3/24. The record included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pneumonitis due to inhalation of food and vomit, unspecified severe protein-calorie malnutrition, unspecified Alzheimer's disease, and gastronomy status. Review of Resident #52's care plan included the following: -Resident requires a feeding tube related to (r/t) dysphagia, NPO (nothing by mouth), severe protein malnutrition, initiated 7/10/24. The interventions included: Keep HOB elevated during and after tube feeds (min 45 degrees) (and) NPO as ordered. -Resident is at risk for decreased nutritional status & dehydration r/t advanced age, limited mobility, need for enteral nutrition to meet needs, NPO status, (and) impaired skin integrity. The interventions included Diet: NPO, Encourage PO fluids, initiated 9/4/24, observe PO intakes, initiated 9/4/24, Provide food preferences & substitutions, initiated 7/11/24 and revised 9/4/24. Review of Resident #52's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15. The Functional Abilities and Goals showed the resident was dependent on eating and hygiene. The resident's Swallowing/Nutritional status showed the resident had a feeding tube, received 51% or more of total calories and 501 cubic centimeters (cc)/day or more from the artificial route. 48441 2. On 9/09/24 at 10:16 a.m. Resident #101 was observed sitting in her wheelchair in her room. Behind the resident was an enteral feeding pump attached to an IV (intravenous) pole and currently no infusion of enteral feedings were observed for the resident. On 9/11/24 at 11:38 a.m., an observation was made of Resident #101 in the common area. No enteral feedings were observed. On 9/11/24 at 3:40 p.m. an observation was made of Resident #101 in the common area. In Resident #101's room was a container of Jevity 1.5 labeled 2:00 p.m. [photographic evidence obtained] A review of Resident 101's current physician orders showed an order dated 8/27/2024 for enteral feed order one time a day Jevity 1.5 @ 50 milliliters /hour (ml/hr) for twenty hours for a total of 1000 ml, down at 10:00 a.m., and up at 2:00 p.m. An enteral feed order to flush 150 ml of water (H2O) every six hours. On 9/11/24 at 3:48 p.m. an interview was conducted with Staff K, Registered Nurse (RN). Staff K, RN stated she was waiting for the oncoming staff to get the resident in her room and once the resident was in her room, she would connect the tube feedings to start. Staff K, RN was aware of the delay in the start of the resident's enteral feedings but stated she is back tomorrow so she will make sure the resident gets the full amount of the feedings stating she never calls out. On 9/11/24 at 5:45 p.m. an observation was made of Resident #101 sitting in her wheelchair in her room with family. The enteral feedings were not connected to the resident. 50570 3. On 9/9/24 at 11:28 a.m. an observation of Resident #14 revealed Staff E, LPN and Staff F, LPN/Unit Manager (UM) entered the room to observe the resident. Resident #14 had feces on his face, arms, and bed linens. Observations revealed Staff E, LPN put on PPE to assist with cleaning and changing the resident. Staff F, LPN/UM left the room to retrieve clean linens. Prior to the staff closing the door, to provide privacy while changing the resident, an observation revealed a pole and pump for the tube feeding, however, there was no formula hanging, (Photographic Evidence Obtained). At the time of the observation, Staff E, LPN stated the resident has a gastrostomy (G-tube) tube. On 9/9/24 at 2:39 p.m. an observation of Resident #14 revealed a bottle of Glucerna 1.5 was hanging and running at 72 milliliters per hour (ml/hr). An observation of the bottle of Glucerna 1.5 revealed it was started at 2:00 p.m. The resident's head of bed appeared to be at a 45-degree angle. (Photographic Evidence Obtained) A review of Resident #14's Admission Record revealed an original admitted [DATE] and an admitted [DATE]. Further review of the Admission Record revealed diagnoses to include: dysphagia following cerebral infarction, unspecified dementia, severe, with mood disturbance, chronic kidney disease, unspecified, aphasia, diaphragmatic hernia with obstruction, without gangrene, eosinophilic colitis, Ileus, unspecified, gastrostomy status, hyperosmolality and hypernatremia, dysphagia, and oropharyngeal phase. A review of Resident #14's care plan revealed the following under focus, [Resident name] has a PEG [percutaneous endoscopic gastrostomy] tube r/t [related to] Dysphagia Date Initiated: 11/18/2020 Created on: 11/18/2020 Created by: [Staff member] Revision on: 01/23/2022 Revision by: [Staff member]. A review of Resident #14's progress notes revealed a Nurses Progress Note, on 9/9/24, to include the following, In bed awake and alert non-verbal with confusion, abdomen with (+) bs [positive bowel sounds]. incontinent of bowel, suprapubic cath [catheter]/nephrostomy tube intact draining amber urine in mod. [moderate] amount, g-tube patent, placement verified no residual noted, tolerating Jevity 1.5 via pump at 72cc [cubic centimeters also known as mL]/hr . A review of Resident #14's Active Orders was conducted on 9/9/24 and 9/10/24. A review of Enteral Feed orders, on 9/9/24 and 9/10/24, revealed no documentation regarding the recommended rate of the Enteral Feed. A review of Resident #14's miscellaneous documents revealed a hospital 3008 form. Based on record review, Resident #14 was hospitalized from 8/28/24 to 9/4/24. A review of the hospital 3008 form revealed a different enteral feeding regimen compared to the order the resident had at the facility. The recommendation from the hospital included the following, Jevity 1.2 @ [at] 65ml/hr - water, fluids @65mL/q4h [every four hours]. On 9/11/24 at 9:59 a.m. an interview with Staff E, LPN revealed she goes by doctor's orders for the tube feeding order. She stated changes would also be in the doctor's orders. She stated in the event of a change to a tube feeding order, The RN [Registered Nurse] might also communicate it to you. She stated if she doesn't see an order, then she calls the doctor herself. Staff E, LPN stated she will also verify orders with the doctor. She stated if the resident was in the hospital and came back to the facility with a different enteral feeding order, then she would communicate with the Registered Dietitian (RD). Staff E, LPN stated in the event the facility did not have the same formula as the resident was receiving in the hospital, then she would call the doctor and RD to see if the formula could be switched. On 9/11/24 at 12:46 p.m. an observation of Resident #14 revealed he was laying down in bed. The head of the bed appeared to be at a 45-degree angle. At the time of the observation, the tube feeding was on and the formula, Jevity 1.5, was running at 72 ml/hr. (Photographic Evidence Obtained) A second review of Resident #14's progress notes, conducted on 9/11/24, revealed a, Nurses Progress Note, on 9/11/24, to include the following, Resident returned from [Local Hospital] via wheelchair, awake and alert, non-verbal, skin d/w [dry/warm] to touch afebrile, resp. [respiratory] unlabored lungs sound clear, g-tube patent flushing without difficulty Jevity 1.2 restarted per flushing without difficulty, no residual noted, placement verified, suprapubic cath patent draining mod. amount of clear yellow urine, no distress noted, nephrostomy tube out. On 9/11/24 at 1:36 p.m. an interview with Staff F, LPN/UM revealed she had a verbal order from the facility RD for Jevity 1.5 72ml x 20/hr and indicated, May start upon return. She stated herself and Staff E, LPN got the verbal order from the facility RD, which is how Staff E, LPN knew the rate for the enteral feed. A review of current orders for Resident #14 was conducted with the LPN/UM. She confirmed there was no rate specified for the enteral feeding. An observation at approximately 1:46 p.m. revealed the LPN/UM added the rate for the enteral feeding. Regarding the proposed change to the enteral feeding from the hospital, the UM/LPN stated she doesn't recall seeing that. The UM/LPN stated documents from the hospital, to include new orders, are reviewed in morning meetings. A review of progress notes, conducted with the UM/LPN, revealed there was no evidence of documentation regarding the recommendations on the 3008 form from the hospital and why the formula wasn't being provided on 9/9/24 at the time of the initial observation. A review of Resident #14's Medication/Treatment Administration Record (MAR/TAR) for September 2024 revealed the following: Enteral Feed Order in the morning for enteral for 1 Day Jevity 1.5, Start Date 9/11/24, Discontinue (D/C) Date 9/11/24. Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440ml is delivered @ 72ml/hr, Start Date 9/11/24. Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440ml is delivered, Start Date 9/12/24, D/C Date 9/11/24. Enteral Feed Order everyday related to DYSPHAGIA FOLLOWING CEREBRAL INFARCTION (I69.391);APHASIA (R47.01) Jevity 1.5 @ 72 ml/hr for a total of 1440ml, Start Date 6/07/2024, D/C Date 9/03/24. A review of Resident #14's Discontinued Orders revealed the following, Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440ml is delivered. An observation of the discontinued order revealed it was revised on 9/11/24. A review of Resident #14's Active Orders revealed the following, Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440 ml is delivered @ 72ml/hr. An observation of the active order revealed it was revised on 9/11/24. On 9/11/24 at 4:38 p.m. an interview with the Director of Nursing (DON) revealed she spoke with Staff E, LPN who said she has worked with Resident #14 for three years. The DON stated Staff E, LPN said she knows the order by memory and gave Resident #14 the rate he normally has. The DON stated she reviewed the hospital paperwork and didn't see the recommendation from the hospital of Jevity 1.2 @ 65 ml/hr. She stated the RD may have reviewed the paperwork, but confirmed there's no documentation that it was reviewed by the RD. On 9/12/24 at 9:44 a.m. an interview with the DON and Staff N, Nurse Practitioner (NP) revealed she looked into the orders from the hospital that suggested a new order for the tube feeding. Staff N, NP said she's one of the providers for Resident #14. She confirmed she looked at the hospital records, but didn't agree with the recommendations. Staff N, NP said she did not include that in her note, upon his return from the hospital, that she did not consider the change to the enteral feed. She said Resident #14 had a history of weight loss, but had been stable, therefore, she kept the tube feeding order at the same rate/volume from prior to the hospitalization . A review of the facility's policy titled, Enteral Nutrition, revised 6/2024, revealed the following under procedure: . 7. The nurse obtains a physician's order for placement of an enteral feeding tube. Feeding tube orders include the following information: The product to be used. The rate and/or timing of administration. Total volume to be given per 24-hour period. Total calories provided per 24-hour period. Route of delivery (i.e., NG [nasogastric], gastrostomy, ileostomy, etc.) Method of administration (i.e., pump, gravity drip, bolus) Volume of water given as water flush, and before and after medications. . 9. The nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician . 20. The nurse contacts the physician to discuss and receive orders when complications from or intolerance to enteral feeding and/or inadequate progress towards goals is identified.

Based on observations, record reviews, and interviews the facility failed to provide nursing and related services to assure two residents (#52 and #14) attained and maintained the highest practicable physical, mental, and psychosocial well-being related to 1) not managing the correct administration of enteral nutrition for two residents (#52 and #14) of six residents with gastrostomy tubes and 2) not ensuring certified nursing assistants were applying an orthotic device for one resident (#52) of six sampled residents, and failed to ensure administration and documentation of a physician ordered medication were without error for one resident (#52) of five residents observed for medication administration. Findings included: 1. Review of the Facility Assessment, effective 8/1/24, revealed the type of care the facility's resident population required and provided included: Mobility and fall/fall with injury prevention with specific care and practices of transfers, ambulation, restorative nursing, contracture prevention/ care; supporting resident independence and doing as much of these activities by himself/ herself. The assessment showed the pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs included: ADL ability, transfer and mobility, medical and mental needs are all taken into consideration when scheduling staff - to ensure each resident's needs are met. The staff training/education and competencies portion of the assessment revealed center has an SDC that completes various forms of education that includes but not limited to lectures, videos, observations. Competencies are completed by SDC or designee to ensure compliance. At orientation competency are completed as well, then minimally annually, or as needed. Review of the Director of Nursing Job Description, 2/20/18 revealed, Responsible for the overall direction, coordination and evaluation of nursing care and services provided to the residents. The essential duties and responsibilities included the following: - Ensures nursing staff is providing quality and appropriate resident/ patient care that meets or exceeds company and regulatory standards. - Schedules and performs resident/ patient rounds to monitor and evaluate the quality and appropriateness of nursing care. - Maintains administrative authority, responsibility and accountability for the proper charting and documentation of care and of medications and treatments. - Responsible for overseeing the infection control surveillance, outbreak control, staff education on infection prevention/ control, staff skills checks/ demonstration competencies, process measures, resident/ employee health (i.e. Vaccinations, TB skin tests) you coordinate with central supply doesn't need to ensure facility management and availability of supplies for staff. Review of the Licensed Practical Nurse (LPN) Job Description, revised 9/25/07, revealed A licensed practical nurse (LPN) provides care and treatment in accordance with physician orders. Works in a team environment and will scope of practice as defined by state. The LPN works under the direction of physicians and registered nurses (RNs). The duties and responsibilities of an LPN included the following: - Administers and documents medications and treatments. - Supervises LPNs and certified nursing assistance with appropriate supervisory LPN training. - Documents observations and care and compliance with standards of care in company policy. - Completes required forms and documents in accordance with company policy and state and/or federal regulations. On 9/9/24 at 10:13 a.m. Resident #52 was observed lying in bed with no response to verbal stimulus. The resident appeared to be cachectic, and lips were dry and flaky. The observation did not reveal any bottle of enteral nutrition hanging from the nutrition pole. On 9/9/24 at 2:50 p.m., Resident #52 was not wearing a splint on either hand and what appeared to be a splint continued to be in the personal belonging bag on top of the dresser. On 9/9/24 at 12:31 p.m. Resident #52 was observed lying in bed, with no bottle of enteral nutrition hanging from the nutrition pole located next to the resident's bed. Resident #52 was observed not wearing a splint on either hand. The observation revealed a splint appeared to be inside a plastic personal belonging bag on top of the bedside dresser. Review of Resident #52's Order Summary Report, active as of 9/12/24, showed the resident was to wear Left (L) hand grip splint at all times, as tolerated. Remove for skin check and hygiene to be removed or deferred by patient. On 9/9/24 at 2:59 p.m. Resident #52 was observed lying in bed, with no bottle of enteral nutrition hanging from the nutrition pole next to the resident's bed. Review of Resident #52's September 2024 Medication Administration Record (MAR) revealed the following orders: - Start date 9/5/24: Enteral Feed Order every day for nutrition management (brand name of enteral nutrition) 1.5, stop enteral feed @ 2pm with a total volume of 1000 mLs (milliliters). This order was held on 9/4/24 and discontinued on 9/10/24 at 2:16 p.m. The MAR revealed on 9/8/24 at 6 p.m. (1800) the enteral nutrition was administered and on 9/9/24 at 2 p.m. the enteral nutrition order was administered. The MAR did not have documentation showing whether the nutrition was stopped at 2 p.m. or started at 6 p.m. - Start date 9/4/24: Enteral Feed Order every day (brand name of enteral nutrition) 1.5 at 50 mL/hr (hour) at 6 p.m. The order was held on 9/4/24 and discontinued on 9/10/24 at 2:17 p.m. The MAR revealed on 9/8/24 at 6 p.m. (1800) the enteral nutrition was administered and on 9/9/24 at 2 p.m. the enteral nutrition was administered. The MAR did not have documentation showing whether the nutrition was stopped at 2 p.m. or started at 6 p.m. - Start date 9/4/24: Enteral Feed Order every 4 hours for nutrition management flush peg tube with 150 mL H2O (water) (total volume 900 mL every 24 hours (Q24hr). The order showed the hydration was held on 9/4/24 and discontinued on 9/10/24 at 2:17 p.m. The MAR documentation revealed the resident received hydration on 9/8/24 at 8 p.m., 9/9 at 0000 (midnight), 9/9 at 4:00 a.m., 9/9/24 at 8:00 a.m., and 9/9/24 at 12:00 p.m. (noon). The hydration was documented during the time Resident #52 was to be receiving nutrition. Review of Resident #52's September Medication and Treatment Administration Records (MAR/TAR) did not show nursing staff documented whether or not the resident's left hand grip splint had been applied. Review of Resident #52's CNA Tasks revealed the application of the resident's Left hand grip splint was not included in the documentation. On 9/10/24 at 9:13 a.m. Resident #52 was observed lying in bed with enteral nutrition running at 50 mL/hr and the pump showed 622 mLs had been delivered. According to the rate of 50 mL/hr and physician order for nutrition to be started at 6 p.m. (15 hours prior to the observation) the resident should have received 900 mLs (15 hours x 50 mL/hr = 900 mLs). An interview was conducted with Staff D, Licensed Practical Nurse (LPN) on 9/10/24 at 10:27 a.m. The staff member stated Resident #52's enteral feed order was for the nutrition to come down at 2 p.m. and up at 6 p.m. The staff member stated Staff G, Certified Nursing Assistant (CNA) informed her, right before lunch on 9/9/24, that the nutrition for the resident was not running; so she had reconnected it. Staff D reported taking the nutrition down around 2 p.m. (on 9/9/24), that it had been running overnight, and according to the machine when it was taken down 550 mLs had been delivered. The staff member stated someone must have reset the machine (pump). Staff D reported there was a bottle of nutrition hanging for Resident #52 (on 9/9/24) at noonish The staff member stated her normal routine before getting started for the day was to check on the resident, and it (the nutrition) gets shut down during care. The staff member reviewed the orders and stated the resident wore a left hand splint. Resident #52 was observed in conjunction with Staff D. The resident was lying in bed and the staff member confirmed the resident was not wearing a hand splint. On 9/10/24 at 10:36 a.m. Resident #52 was observed with Staff D. The observation revealed the (brand name nutrition) bottle was dated 9/9/24 at 5:35 p.m. and the nutrition pump showed 655 mLs of nutrition had been delivered. Resident #52 was observed lying in bed and the staff member confirmed the resident was not wearing a hand splint. The staff member stated, We are doing the best we can with what we got. An interview was conducted with Staff D,LPN, Staff F, Licensed Practical Nurse/Unit Manager, (LPN/UM), and Director of Nursing (DON) on 9/10/24 at 11:53 a.m. Staff D stated there had been an oversight yesterday regarding Resident #52's tube feeding. Staff D reported the physician and family member had been notified and confirmed it was an oversight. The DON stated the nutritionist had added a 100 mL bolus of liquid nutrition today and education had been started (due to the oversight). Review of Resident #52's progress notes revealed: - Effective 9/10/24 at 10:45 a.m. Staff D documented: Residents family and MD aware that due to care being given, resident missed an hour of Gtube feeding. Resident had no signs/symptoms (s/s) of distress and feeding was applied at 6 p.m. on 9/9/24 as ordered. Resident's gtube was patent and flushed as ordered. - Effective 9/10/24 at 10:57 a.m. Staff D documented: Nurse Practitioner (NP) aware and no new orders given, will continue (cont) plan of care. - Effective 9/10/24 at 11:38 a.m. the Dietician documented Rt (resident) had 2 hours of extra down time on 9/9/24 due to care. Will make up by incorporating 100 mL bolus at 4 p.m. on 9/10/24, in middle of regular down time. - The DON documented a late entry Situation, Background, Assessment and Review (SBAR), effective 9/10/24 at 1:15 p.m. revealed an other change in condition. The SBAR revealed nursing observations, evaluation, and recommendations are: Enteral feed was turned off at 10 a.m. order in (electronic record) is to turn feeding pump off at 2 p.m. Resident assessed and noted without distress, MD made aware, no new orders (NNO), Registered Dietician (RD) notified and ordered (brand name liquid nutrition) 1.5 100 mL bolus one time to be administered, labs ordered results within normal limits (WNL). Review of Resident #52's MAR revealed the resident's enteral nutrition had been increased on 9/10/24 and the water flushes had been decreased: -Enteral Feed Order in the evening (brand name of liquid nutrition) 1.5 at 60 mL/hr x 20 hours. Up 6 p.m. until 1200 mL total volume reached. Started on 9/11/24 at 6:00 p.m. - Enteral Feed Order every 6 hours flush with 200 mL's water (H2O) for total 800 mL's of water, to start on 9/10/24 at 6:00 p.m. Review of the Nutrition Comprehensive Evaluation/Risk Screen, effective 9/10/24 at 1:39 p.m. revealed Resident #52's most recent weight was 90.6 pounds (#) and a body mass index of 16.0. The resident's diet was nothing by mouth (NPO). The evaluation showed the current enteral nutrition was 50 mL/hr x 20 hours for total volume of 1000 mL's, flush q 4 hrs with 150 mL's of water (total volume 900 mL's, total 1660 mL's plus med flushes. The summary showed TF (tube feeding) regiment not meeting needs . Rt may be at risk for malnutrition due to (d/t) advanced age, medical diagnosis/history (dx/hx). The nutrition summary revealed the recommendation was (brand name of liquid nutrition) at 60 mL/hr x 20 hours, up at 6 p.m. until 1200 mL total volume reached. An interview was conducted with the Director of Rehab (DOR) on 9/10/24 at 4:20 p.m. The DOR stated Resident #52 had a left grip splint. The DOR stated the resident came from a different facility with the splint and it had been carried over. The DOR reported nursing and restorative apply splints. The DOR confirmed seeing the resident wearing the splint and usually staff will let therapy know if the resident consistently refuses it. On 9/11/24 at 8:49 a.m. an observation revealed a bottle of enteral nutrition hanging for Resident #52. The 1000 mL bottle was dated 9/10/24 at 6:00 p.m. and the pump showed 60 mL/hr was being delivered. The pump revealed 23 mL volume had been delivered and the bottle contained approximately the original amount of 1000 mL's. The observation showed Resident #52's head of bed was raised approximately 30 degrees, and the resident was positioned almost flat as the resident laid in a loose fetal position. According to the time the bottle was hung and the observation showed a total of 14.75 hours at 60mL/hr = 885 mLs should have been delivered and the bottle should have contained approximately 115 mL's. The resident's lips continued to be dry and flaky. An interview was conducted with Staff G, CNA on 9/11/24 at 9:08 a.m. Staff G reported Resident #52 did not have a bottle of nutrition hanging on Monday (9/9/24) and does not know what degree the resident's head of bed should be raised to during nutrition. The CNA confirmed being assigned to care for Resident #52. The staff member reported not putting splints on the resident and the restorative aide applies the splints. Staff G stated they went to the laundry and he had to get them. On 9/11/24 at 9:45 a.m. Staff D, LPN was interviewed. The staff member reported not hanging any nutrition on 9/11/24 for the resident. Staff D observed the bottle of nutrition and the pump reading and confirmed the amount of nutrition that should have been delivered had not and thinking 500 mL's should have been delivered. Staff D stated she had notified the Unit Manager (Staff F) and the Director of Nursing (DON). The staff member confirmed Resident #52's head of bed should have been raised to 45 degrees and it was not. Review of Resident #52's MAR revealed two orders related to the raising of the head of bed: -Enteral Feed Order every shift, elevate head of bed 30-45 degrees at all times during feeding and at least 30-60 minutes after feeding is stopped. The order was to start on 9/9/24 at 3:00 p.m. -Enteral Feed Order every shift, elevate head of bed (HOB) at least 45 degrees at all times. The order was started on 9/9/24 at 3:00 p.m. An interview was conducted with Staff F, LPN/UM on 9/11/24 at 9:45 a.m. The staff member stated Resident #52's tube feeding was turned off for care around noon (on 9/9/24), care was given, and the nutrition was turned back on. Staff F stated the facility realized the next day an error was made (9/10/24) so they contacted the physician who gave no new orders and had reached out to the nutritionist and was given an order for a 100 mL bolus. Staff F confirmed if the facility shut off the nutrition on 9/9/24 for care the bottle of nutrition would have been hanging. The staff member stated the resident had an agency nurse last night and the facility had started education regarding to not zero out the pump until the total volume had been delivered. Review of the time sheet, dated 9/10/24 for the agency nurse, who the facility revealed worked with Resident #52 showed an in-time of 11 p.m. and out time of 7:20 a.m. The observation of Resident #52's nutrition on 9/11/24 at 8:49 a.m. revealed a delivered volume of 23 mLs, per the physician order of 60 mLs per hour the resident should have received 89 mLs during the 1 hour and 29 minutes between the time the agency nurse left and the observation. An interview was conducted with the Director of Nursing (DON) on 9/11/24 at 11:32 a.m. The DON stated the investigation into the incident involving Resident #52 revealed the Staff Development Coordinator (SDC) disconnected the feeding at 10 a.m. because the pump was beeping and said the volume of 1000 mLs had been delivered. The DON stated the issue was with taking the nutrition up and down. The DON confirmed 800 mLs would have been delivered between 6 p.m. (time nutrition was to be connected to resident) and 10:00 a.m. (time reported SDC had disconnected the nutrition). An interview was conducted with the SDC on 9/11/24 at 12:58 p.m. The SDC reported asking Staff D if they wanted Resident #52's nutrition disconnected. The SDC reported Staff D, LPN was told they disconnected the nutrition. The staff member stated she didn't think the bottle (nutrition) was empty, but disconnected because the pump was beeping, and it said it was complete. An interview was conducted with Staff I, Restorative Nursing Assistant (RNA) on 9/11/24 at 1:48 p.m. Staff I reported the splints were off this morning and she found the splints in a personal property bag on top of the bedside dresser. The staff member reported applying the splints would have been up to the assigned CNA. A review of the splint assistance CNA documentation showed on 9/10/24 at 12:27 p.m. staff spent 5 minutes applying the splints. Review of Resident #52's Admission Record showed the resident was admitted on [DATE] and 9/3/24. The record included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, pneumonitis due to inhalation of food and vomit, unspecified severe protein-calorie malnutrition, unspecified Alzheimer's disease, gastronomy status, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other reduced mobility, and unspecified site unspecified osteoarthritis. Review of Resident #52's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severe cognitive impairment. The Functional Abilities and Goals showed the resident was dependent on eating and hygiene. The resident's Swallowing/Nutritional status showed the resident had a feeding tube, received 51% or more of total calories and 501 cubic centimeters (cc)/day or more from the artificial route. The Functional Abilities and Goals assessment showed the resident had ROM impairment on both sides of the upper and lower extremities. Review of Resident #52's care plan included the following: -Resident requires a feeding tube related to (r/t) dysphagia, NPO (nothing by mouth), severe protein malnutrition, initiated 7/10/24. The interventions included: Keep HOB elevated during and after tube feeds (min 45 degrees) (and) NPO as ordered. -Resident is at risk for decreased nutritional status & dehydration r/t advanced age, limited mobility, need for enteral nutrition to meet needs, NPO status, (and) impaired skin integrity. The interventions included Diet: NPO, Encourage PO fluids, initiated 9/4/24, observe PO intakes, initiated 9/4/24, Provide food preferences & substitutions, initiated 7/11/24 and revised 9/4/24. -Resident required a Splint/Brace Nursing Restorative Program created on 7/24/24, initiated and revised on 7/31/24 by the Director of Nursing (DON). The goal was for the resident to maintain current level of function by next review date. The interventions revealed the resident: - to wear Right (R) resting hand splint when in bed as tolerated. Patient to wear left grip splint at all times as tolerated. Remove for skin checks and hygiene to be removed or deferred by resident, initiated and created by DON on 7/24/24. - Splint/Brace - Patient to utilize L hand grip splint at all times as tolerated, removed to skin checks and hygiene. To be removed or deferred by patient created on 7/31/24 and system generated revision on 9/3/24. Review of the physician order summary did not reveal a physician order for the observed or care planned Right hand splint. An interview was conducted with the DON on 9/12/24 at 1:07 p.m. The DON stated primarily restorative (applies splints) but an aide can do it, whether restorative is there or not. She reported tasks (are) for restorative and CNAs so they can see it on the Plan of Care (POC) and staff are aware by the first (portion) of shift if there is restorative or not. The facility reported on 9/12/24 at 3:22 p.m. they did not have a policy for splints/braces or restorative program. An interview was conducted on 9/12/24 at 10:26 a.m. with the SDC. The SDC reported being at the facility since January (2024) and staff haven't had any GTube competency other than orientation. The SDC provided a list of nurses who have been in orientation since January, it did not include Staff D. 50570 2. On 9/9/24 at 11:28 a.m. an observation of Resident #14 revealed Staff E, LPN and Staff F, LPN/Unit Manager (UM) entered the room to observe the resident. Resident #14 had feces on his face, arms, and bed linens. Observations revealed Staff E, LPN put on PPE to assist with cleaning and changing the resident. Staff F, LPN/UM left the room to retrieve clean linens. Prior to the staff closing the door, to provide privacy while changing the resident, an observation revealed a pole and pump for the tube feeding, however, there was no formula hanging, (Photographic Evidence Obtained). At the time of the observation, Staff E, LPN stated the resident has a gastrostomy (G-tube) tube. On 9/9/24 at 2:39 p.m. an observation of Resident #14 revealed a bottle of Glucerna 1.5 was hanging and running at 72 milliliters per hour (ml/hr). An observation of the bottle of Glucerna 1.5 revealed it was started at 2:00 p.m. The resident's head of bed appeared to be at a 45-degree angle. (Photographic Evidence Obtained) A review of Resident #14's Admission Record revealed an original admitted [DATE] and an admitted [DATE]. Further review of the Admission Record revealed diagnoses to include: dysphagia following cerebral infarction, unspecified dementia, severe, with mood disturbance, chronic kidney disease, unspecified, aphasia, diaphragmatic hernia with obstruction, without gangrene, eosinophilic colitis, Ileus, unspecified, gastrostomy status, hyperosmolality and hypernatremia, dysphagia, and oropharyngeal phase. A review of Resident #14's care plan revealed the following under focus, [Resident name] has a PEG [percutaneous endoscopic gastrostomy] tube r/t [related to] Dysphagia Date Initiated: 11/18/2020 Created on: 11/18/2020 Created by: [Staff member] Revision on: 01/23/2022 Revision by: [Staff member]. A review of Resident #14's progress notes revealed a Nurses Progress Note, on 9/9/24, to include the following, In bed awake and alert non-verbal with confusion, abdomen with (+) bs [positive bowel sounds]. incontinent of bowel, suprapubic cath [catheter]/nephrostomy tube intact draining amber urine in mod. [moderate] amount, g-tube patent, placement verified no residual noted, tolerating Jevity 1.5 via pump at 72cc [cubic centimeters also known as mL]/hr . A review of Resident #14's Active Orders was conducted on 9/9/24 and 9/10/24. A review of Enteral Feed orders, on 9/9/24 and 9/10/24, revealed no documentation regarding the recommended rate of the Enteral Feed. A review of Resident #14's miscellaneous documents revealed a hospital 3008 form. Based on record review, Resident #14 was hospitalized from 8/28/24 to 9/4/24. A review of the hospital 3008 form revealed a different enteral feeding regimen compared to the order the resident had at the facility. The recommendation from the hospital included the following, Jevity 1.2 @ [at] 65ml/hr - water, fluids @65mL/q4h [every four hours]. On 9/11/24 at 9:59 a.m. an interview with Staff E, LPN revealed she goes by doctor's orders for the tube feeding order. She stated changes would also be in the doctor's orders. She stated in the event of a change to a tube feeding order, The RN [Registered Nurse] might also communicate it to you. She stated that if she doesn't see an order, then she calls the doctor herself. Staff E, LPN stated she will also verify orders with the doctor. She stated if the resident was in the hospital and came back to the facility with a different enteral feeding order, then she would communicate with the Registered Dietitian (RD). Staff E, LPN stated in the event the facility did not have the same formula as the resident was receiving in the hospital, then she would call the doctor and RD to see if the formula could be switched. On 9/11/24 at 12:46 p.m. an observation of Resident #14 revealed he was laying down in bed. The head of the bed appeared to be at a 45-degree angle. At the time of the observation, the tube feeding was on and the formula, Jevity 1.5, was running at 72 ml/hr. (Photographic Evidence Obtained) A second review of Resident #14's progress notes, conducted on 9/11/24, revealed a Nurses Progress Note, on 9/11/24, to include the following, Resident returned from [Local Hospital] via wheelchair, awake and alert, non-verbal, skin d/w [dry/warm] to touch afebrile, resp. [respiratory] unlabored lungs sound clear, g-tube patent flushing without difficulty Jevity 1.2 restarted per flushing without difficulty, no residual noted, placement verified, suprapubic cath patent draining mod. amount of clear yellow urine, no distress noted, nephrostomy tube out. On 9/11/24 at 1:36 p.m. an interview with Staff F, LPN/UM revealed she had a verbal order from the facility RD for Jevity 1.5 72ml x 20/hr and indicated, May start upon return. She stated herself and Staff E, LPN got the verbal order from the facility RD, which is how Staff E, LPN knew the rate for the enteral feed. A review of current orders for Resident #14 was conducted with the LPN/UM. She confirmed there was no rate specified for the enteral feeding. An observation at approximately 1:46 p.m. revealed the LPN/UM added the rate for the enteral feeding. Regarding the proposed change to the enteral feeding from the hospital, the UM/LPN stated she doesn't recall seeing that. The UM/LPN stated documents from the hospital, to include new orders, are reviewed in morning meetings. A review of progress notes, conducted with the UM/LPN, revealed there was no evidence of documentation regarding the recommendations on the 3008 form from the hospital and why the formula wasn't being provided on 9/9/24 at the time of the initial observation. A review of Resident #14's Medication/Treatment Administration Record (MAR/TAR) for September 2024 revealed the following: Enteral Feed Order in the morning for enteral for 1 Day Jevity 1.5, Start Date 9/11/24, Discontinue (D/C) Date 9/11/24. Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440ml is delivered @ 72ml/hr, Start Date 9/11/24. Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440ml is delivered, Start Date 9/12/24, D/C Date 9/11/24. Enteral Feed Order everyday related to DYSPHAGIA FOLLOWING CEREBRAL INFARCTION (I69.391);APHASIA (R47.01) Jevity 1.5 @ 72 ml/hr for a total of 1440ml, Start Date 6/07/2024, D/C Date 9/03/24. A review of Resident #14's Discontinued Orders revealed the following, Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440ml is delivered. An observation of the discontinued order revealed it was revised on 9/11/24. A review of Resident #14's Active Orders revealed the following, Enteral Feed Order in the morning for enteral for 1 Day until total amount of 1440 ml is delivered @ 72ml/hr. An observation of the active order revealed it was revised on 9/11/24. On 9/11/24 at 4:38 p.m. an interview with the Director of Nursing (DON) revealed she spoke with Staff E, LPN who said she has worked with Resident #14 for three years. The DON stated Staff E, LPN said she knows the order by memory and gave Resident #14 the rate he normally has. The DON stated she reviewed the hospital paperwork and didn't see the recommendation from the hospital of Jevity 1.2 @ 65 ml/hr. She stated the RD may have reviewed the paperwork, but confirmed there's no documentation that it was reviewed by the RD. On 9/12/24 at 9:44 a.m. an interview with the DON and Staff N, Nurse Practitioner (NP) revealed she looked into the orders from the hospital that suggested a new order for the tube feeding. Staff N, NP said she's one of the providers for Resident #14. She confirmed she looked at the hospital records, but didn't agree with the recommendations. Staff N, NP said she did not include that in her note, upon his return from the hospital, that she did not consider the change to the enteral feed. She said Resident #14 had a history of weight loss, but had been stable, therefore, she kept the tube feeding order at the same rate/volume from prior to the hospitalization . A review of the facility's policy titled, Enteral Nutrition, revised 6/2024, revealed the following under procedure: . 7. The nurse obtains a physician's order for placement of an enteral feeding tube. Feeding tube orders include the following information: The product to be used. The rate and/or timing of administration. Total volume to be given per 24-hour period. Total calories provided per 24-hour period. Route of delivery (i.e., NG [nasogastric], gastrostomy, ileostomy, etc.) Method of administration (i.e., pump, gravity drip, bolus) Volume of water given as water flush, and before and after medications. . 9. The nurse administers the enteral feeding regimen according to formula, system type, and method of delivery ordered by the physician . 20. The nurse contacts the physician to discuss and receive orders when complications from or intolerance to enteral feeding and/or inadequate progress towards goals is identified. 48441 3. On 9/12/2024 at 8:40 a.m. an observation was conducted with the DON during medication administration with Staff D, LPN for Resident #52. Staff D, LPN dispensed the following medication: -Aspirin 81 mg one tablet - Esomeprazole magnesium 40 mg one packet - Ferrous 325 mg one tablet - Acidophilus one capsule - Vit C 500 mg one tablet - MVI one tablet - D3 2000 IU (international unit) one tablet - Folic acid one mg one tablet. All medication to be administered via gastrostomy tube. A review of the medication administration reconciliation, revealed Amlodipine 5 mg was documented as given but not witnessed during actual medication administration for Resident # 52. On 9/12/2024 at 10:07 a.m. an interview was conducted with Staff D, LPN regarding the Amlodipine 5 mg medication. Staff D, LPN stated she gave the medication. A review of the medication administration showed Amlodipine 5 mg administered at 10:03 a.m. Initially, Staff D, LPN stated she pulled one medication out of the medication cart for Resident #52 which was identified as Folic Acid one mg. Staff D, LPN then stated the night nurse gave the Amlodipine prior to her leaving her shift. Staff D, LPN stated the night nurse was in the resident's room and gave the medication but it was charted under Staff D because she was out of the room in the hallway and had the chart opened under her (Staff D) name. Staff D, LPN stated she had the record opened and asked the night shift nurse if she gave it. Staff D, LPN was unaware of the resident's blood pressure parameters. Staff D, LPN reviewed the vital signs for Resident #52 and stated, Now that I can remember, I did not give that. Staff D, LPN stated she will contact the nurse practitioner down the hallway and inform her the medication was not given. Staff D found the nurse practitioner and informed her the medication, Amlodipine, was charted as given but was not given and will strike out the medication as given. On 9/12/2024 at 10:25 a.m. an interview was conducted with the DON. The DON pulled the medication administration for the resident and saw Amlodipine was given but then there was a strike through the documentation. The DON was aware of the low blood pressures documented on three separate entries prior to the Amlodipine alleged administration. The DON stated Staff D's, documentation and account of the administration of the Amlodipine was not adding up. The DON stated she will have Resident #52 monitored for repeat vital signs and to ensure tube feedings were running according to physician order [TRUNCATED]

Based on observations, interviews and record review, the facility did not ensure: 1. food was properly stored to include labeling and dating, 2. food was handled appropriately to include glove use; and 3. clean kitchen and beverage items were free from possible contamination, in accordance with professional standards for food service in one of one kitchen. Findings included: On 9/9/24 at 9:19 a.m. a tour of the facility's kitchen was conducted with the Certified Dietary Manager (CDM). An observation at 9:21 a.m. revealed a vent that had multiple droplets of water, from what appeared to be condensation. The vent was directly over a rack of items to include plastic jugs and other cookware/kitchen items, (Photographic Evidence Obtained). During the observation, it appeared a few droplets of water fell on one of the jugs/rack. The CDM confirmed the items on the rack are clean. Further observations during the kitchen tour revealed one of three refrigerators, identified as Unit One, contained a large plastic jar of pickles. The jar of pickles had an opened date labeled July 2024, however, there was no expiration date observed. The CDM stated they were fine to use, and they go through them quickly. She discarded the jar of pickles after reviewing the jar and not being able to find an expiration date. She stated whoever is assigned to clean that unit is expected to check/review the items to make sure they are properly labeled and dated. Further observations during the kitchen tour revealed in one refrigerator, identified as Unit Two, a box of nectar thick apple juice and two bottles of thickened water that were not labeled properly, (Photographic Evidence Obtained). The box of nectar thick apple juice did not have a received date labeled. The two bottles of thickened water appeared to be open, but there was no label or date to indicate when they were opened. The CDM stated she checks Unit Two every day and confirmed the beverages should have been labeled and dated. On 9/11/24 at 11:52 a.m. an observation of Staff O, Dietary Aide revealed she wore the same pair of gloves in multiple areas of the kitchen to include touching multiple surfaces, adjusting her glasses, touching her face, reaching into her pockets for a highlighter, and using the highlighter on a paper ticket. Further observation of Staff O, Dietary Aide revealed she began prepping multiple resident lunch trays to include placing dessert and beverages with the same gloves. On 9/11/24 at 11:58 a.m. an observation of Staff P, Dietary Aide revealed he was getting ready for the tray line to start. He was observed standing by the area with utensils and trays. Staff P, Dietary Aide took his cellphone out and proceeded to use it. Staff P was finished using his phone and then put on gloves and touched utensils and trays on the tray line without performing hand hygiene. On 9/11/24 at 12:05 p.m. an observation of the ceiling vent revealed it had small beads of condensation. (Photographic Evidence Obtained) The CDM stated maintenance is responsible for maintaining and cleaning the ceiling tiles/vents. She stated she thinks it's on maintenance's monthly schedule to clean the vents/tiles. On 9/11/24 at 12:12 p.m. an interview with the CDM revealed cellphones should not be used in the kitchen. She stated she is okay with staff listening to music, but the phone should be away. The CDM stated if staff are caught with a cellphone, the consequence would be disciplinary action. She stated staff know they should not be using their cell phones. On 9/12/24 at 10:56 a.m. an interview with the Director of Maintenance revealed the air conditioning company was coming today to attempt to stop the condensation. He said the air conditioning unit is two years old. He stated the hot and cold temperatures are most likely causing a buildup of moisture. On 9/12/24 at 12:25 p.m. an interview with the CDM regarding the water droplets on the vent revealed whenever dietary staff observe the condensation, they cleaned it, or maintenance cleaned it off. She stated the condensation is a result of the humidity. A review of the facility's policy titled, Food Storage Principles, revised 8/2023 revealed the following under procedure: . 3. Label each package, box, can, etc. with date of receipt, and when the item was stored after preparation. a. Discard foods that have exceeded their expiration date. b. Discard leftover foods that have not been used within 72 hours of preparation. 5. Label opened Food items with Date Opened. A review of the facility's policy titled, Handwashing and Glove Usage in Food Service, revealed the following, When Food Handlers must wash their hands: . After touching hair, face, or body . After touching clothing or aprons . After touching anything else such as dirty equipment, work surfaces or cloths.

Based on observations, interviews, and record review, the facility failed to maintain an effective infection control program, related to not ensuring staff were donning personal protective equipment (PPE) before entering the rooms of residents with contact precaution signage on the door, for one (#7) of five residents sampled on transmission-based precautions. The facility did not offer hand hygiene to residents prior to lunch service for two (9/09 and 9/11/2024) out of two days observed on the second floor and third floor main dining. The facility did not ensure appropriate contact isolation was initiated for one resident (#84) while awaiting Clostridium difficile (CDiff) results, and the facility did not ensure appropriate hand hygiene during medication administration for one resident (#87) out of five residents observed. Findings included: 1. On 9/09/24 at 12:14 p.m. an observation was made of residents either self-propelling themselves or assisted via wheelchair into the second-floor main dining area. Eleven residents were observed. Initial hydration was offered with soup followed by main entre. Hand hygiene was not offered to the residents. On 9/11/24 at 11:50 a.m., an observation was made of residents in the second-floor main dining area awaiting lunch service. Staff were bringing residents in while other staff members were providing hydration options. Hand hygiene was not offered to the residents. On 9/10/24 at 2:03 p.m. an observation was made outside Resident #84's room. A sign was posted for Enhanced Barrier Precaution. A review of Resident #84's physician orders showed an order, dated 9/09/24 at 4:30 p.m., for c-diff (Clostridium Difficile) toxin for diarrhea. A physician order, dated 8/28/24, for Enhanced Barrier Precaution secondary to a diagnosis of candida aureus. On 9/10/24 at 2:10 p.m. an interview was conducted with Staff B, Registered Nurse/Unit Manager. Staff B, RN/UM stated she was not aware of Resident #84 having loose stools and stated she will call the primary physician to have the order discontinued. A review of the lab results showed the specimen was collected on 9/10/24 at 6:00 a.m., received at 2:48 p.m. and results negative were reported at 5:16 p.m. On 9/12/24 11:20 a.m. an interview was conducted with the Director of Infection and Control. The Director of Infection and Control provided a bowel audit of Resident #84 for the past two weeks. The Director of Infection and Control stated, Resident #84 did have some loose stools documented but not enough consistently to warrant a C -diff order; however, with this current order for this resident, the order for C. diff would warrant proper signage for contact Isolation until the results are reported. On 9/11/24 at 8:48 a.m. on observation was made of Staff D, Licensed Practical Nurse (LPN) during medication administration for Resident #87. Staff D, LPN was observed using her ungloved finger to pull a tablet from the medication card stock and pick up a loose pill that fell on top of the medication cart. Both medications were provided to the resident. 51097 2. An observation of the lunch meal service on 09/09/24 at 12:44 p.m. was conducted in the 3rd floor dining/activities room and outside of Resident #87's room. On 09/09/24 at 12:45 p.m. Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM) was observed serving Resident #20 a lunch tray. Staff E did not offer Resident #20 hand hygiene prior to eating. An additional observation was conducted on 09/09/24 at 1:00 p.m. outside of the 3rd floor dining/activities room and Resident #20 was eating ice cream with her fingers. An observation was conducted on 09/09/24 at 12:55 p.m. outside of Resident #87's room. Resident #87 was observed at her bedside sitting in a chair with tray table in front of her. Staff E, LPN/UM entered the room and placed Resident #87's lunch tray on her table. Staff E, LPN/UM did not offer Resident #87 hand hygiene prior to eating. 50570 3. On 9/9/24 at 11:05 a.m. an observation of Resident #7's door revealed a contact precaution sign with PPE hanging on the door. Staff E, LPN/UM was observed in the hall checking on residents assigned to her. She stated the contact precaution order included residents who have extended-spectrum beta-lactamases (ESBL), a suprapubic catheter, or a gastrostomy tube (G-tube). An interview with Staff E, LPN/UM revealed the contact precaution signage is for Resident #7. She stated PPE does not need to be put on if the individual is not providing direct care or touching the resident. On 9/9/24 at 3:49 p.m. an observation of Resident #7's door revealed contact precaution signage with PPE hanging from the door, (Photographic Evidence Obtained). Further observation of Resident #7, from the hallway, revealed the Social Services Assistant was assisting her by adjusting the wedge on the right side of the bed. It appeared the Social Services Assistant was attempting to assist Resident #7 with positioning. Further observation of the interaction between the Social Services Assistant and Resident #7, revealed she was close to the resident's face when speaking to her. Further observations revealed the Social Services Assistant was touching the resident's bedside table and standing between the beds, where the privacy screen was. Throughout the observation, the Social Services Assistant was not wearing PPE, to include gloves and a gown. On 9/9/24 at 3:58 p.m. an interview with the Social Services Assistant revealed she was in Resident #7's room and confirmed the resident was on contact precautions. She stated she had to put on PPE if she was doing care. The contact precaution signage was reviewed with the Social Services Assistant, which indicated to apply gloves and gown prior to entry. She stated she should have been dressed in PPE. The Social Services Assistant confirmed she was moving Resident #7's bed wedges. A review of Resident #7's Admission Record revealed an original admitted [DATE] and an admitted [DATE]. Diagnoses included urinary tract infection, site not specified; onset Date 8/10/23; classified upon admission; retention of urine, unspecified; onset Date 9/7/22; classified during stay. A review of Resident #7's Active Orders revealed the following, Precaution: Enhanced Barrier (Urinary Catheter HX [history] of VRE [Vancomycin-resistant Enterococci]/ESBL) every shift for Urinary catheter care and Hx of VRE and ESBL in urine Indefinitely, with an order date of 8/22/24 and start date of 8/28/24. A review of Resident #7's progress notes revealed a note on 8/7/24 titled, ABT [Antibiotic] Stewardship] which included the following, . Notification to Resident Representative: Placed on contact isolation due to ESBL . Further review of progress notes revealed an ABT Stewardship note on 8/20/24, which did not contain any information related to transmission-based precaution recommendations. Further review of Resident #7's progress notes revealed an ABT Stewardship note on 9/3/24, which did not contain any information related to transmission-based precaution recommendations. A review of Resident #7's progress notes from 8/8/24 to current, revealed no information regarding transmission-based precaution recommendations. A review of Resident #7's Medication/Treatment Administration Record (MAR/TAR) for August 2024 revealed the following order, Contact Precautions every shift for ESBL Urine until 8/10/24 23:59, with a start date of 8/7/24. A review of Resident #7's MAR/TAR for September 2024 revealed the following order, Precaution: Enhanced Barrier (Urinary Catheter HX of VRE/ESBL) every shift for Urinary catheter care and Hx of VRE and ESBL in urine indefinitely, with a start date of 8/28/24. A review of Resident #7's current care plan revealed the following under focus, [Resident #7] has a Superpubic Catheter: r/t [related to] Neurogenic Bladder, with an initiated date of 6/19/15, created on 4/01/2015, and revised on 6/26/24. Interventions under that specific focus revealed the following, Precaution: Enhanced Barrier (Urinary Catheter), with an initiated/created date of 4/1/24 and revised on 4/24/24. Further review of Resident #7's current care plan revealed the following under focus, [Resident #7] is at increased risk for infection r/t Personal Hx/Colonization of VRE/ESBL in the urine, with an initiated/created date of 4/23/24. Interventions under that specific focus revealed the following, Precaution: Enhanced Barrier (VRE/ESBL), with a date initiated/created on 4/23/24. Further review of Resident #7's current care plan revealed the following under focus, [RESIDENT PREFERRED NAME] has an infection UTI with ESBL, with a date initiated/created on 8/22/24. Interventions under that specific focus include the following, Isolation precautions as ordered Contact ESBL urine, with a date initiated/created/revised on 8/22/24. On 9/10/24 at 9:23 a.m. an observation of Resident #7's door revealed a contact precaution sign with PPE hanging on the door. (Photographic Evidence Obtained) On 9/10/24 at 2:08 p.m. an observation of Resident #7's door revealed an enhanced barrier precaution (EBP) sign. (Photographic Evidence Obtained)

Based on observations, interviews and record review, the facility did not ensure timely identification of a facility acquired pressure ulcer for one resident (#67) out of two residents sampled. Findings included: On 9/10/2024 at 2:39 p.m. an observation was made of Resident # 67 in his wheelchair with a dressing to his left foot labeled 9/09/2024. Across the hallway from Resident #67 was Staff J, Registered Nurse (RN)/wound nurse. Staff J stated dressings are changed in the evening shift. Staff J, RN stated Resident #67's wound had a foul smell a few days ago and confirmed an order for a culture of the wound was given by the wound therapy physician, but results were still pending. On 9/12/2024 at 12:14 p.m. an interview was conducted with the Dietician Technician Registered (DTR) The DTR stated she reviews all new admits, tube feedings and change of condition reports prompted by a report she runs. The DTR stated a change of condition report on 8/20/2024 prompted her to look into Resident #67 for a pressure ulcer. Since the discovery of his pressure area, the DTR stated orders were placed to increase Resident #67's dietary supplemental intake to optimize skin healing. A review of Resident # 67's Admission Record showed an admitted [DATE]. Diagnoses included unsteadiness on feet, repeated falls, altered mental status and pressure ulcer of left buttock, unspecified staging. On 9/12/2024 at 1:00 p.m. an interview was conducted with Staff B, RN/Unit Manager (UM). Staff B stated Resident #67 arrived at the facility with a pressure area to his left buttocks and a consult was placed for the wound therapy physician. Staff B, RN/UM stated the wound physician communicated after the consult that he did not need to follow this wound and gave orders for topical medication and to re-consult if needed. Staff B, RN/UM stated Resident #67, upon admission, would refuse to get out of bed stating the resident's family member was notified of the resident's refusal at times. Staff B, RN/UM stated on 8/15/2024, Resident 67's assigned nurse asked her to look at Resident #67's left heel. Staff B, RN/UM assessed the black necrotic heel findings immediately to his physician and notified his family. A consult was placed for the wound therapy physician for evaluation. Staff B, RN/UM stated the resident has an order for skin checks to be done weekly. Staff B, RN/UM stated the last skin check was dated 8/05/2024 and confirmed the evaluation for the next skin check was greater than a week. Staff B, RN/UM could not elaborate on the 8/05/2024 skin check assessment with one check mark stating no skin concerns. She stated she would have filled out a more extensive skin assessment. Staff B, RN/UM stated the resident now has a specially ordered pillow to off-load pressure on his heels as well. Staff B, RN/UM stated before the discovery of his necrotic heel, the resident should have had his heels off loaded by a pillow. A review of Resident #67's physician orders showed orders for the following: arterial ultrasound of left lower extremity dated 8/28/2024, fortified foods with meals for nutritional support dated 8/8/2024, House Stock protein supplement one time a day for wound healing give 30 milliliters orally every day dated 8/19/2024, Med Pass 2.0/ Ready Care one time a day dated 8/20/24 enhanced barrier precaution for wound dated 8/26/2024, vascular consult dated 9/6/2024, weekly skin checks every day shift every Monday dated 8/4/2024, Santyl external ointment 250 units per gram apply to left heel topically as needed for pressure wound cleanse left heel with sterile saline, pat dry, apply nickel thick Santyl to wound bed and calcium alginate, wrap with [gauze wrap] and secure with tape dated 9/4/2024, vitamin C tablet 500 milligram one tablet by mouth one time a day for wound healing dated 8/19/2024, zinc oral tablet 50 milligrams give one tablet by mouth one day for wound healing and Cipro 250 milligrams to give one tablet by mouth two times a day for wound infection for 10 days dated 9/10/2024. On 9/11/2024 at 5:47 p.m. an interview was conducted the Director of Infection and Control (IP). The lab results for Resident 67's wound culture from this morning's results were confirmed with the Director of IP. She confirmed the positive findings and antibiotic coverage was warranted. On 9/12/2024 at 1:00 p.m., an interview was conducted with Staff B, RN/UM regarding the Vascular consult order dated 9/06/2024. Staff B, RN/UM stated she and any of the nurses taking care of the resident can arrange for the consult. Staff B, RN/UM stated she has not had the time to make any arrangements. Staff B stated it is a process to find a vascular surgeon and then deal with the insurance company for approval. A review of the initial wound therapy physician consult notes, dated 8/20/2024, showed an unstageable due to necrosis of the left heel full thickness. The etiology of the wound is pressure related and measuring (L x W x D) 4.0cm (centimeters) x 5.0 cm x 0.1 cm for a total surface area of 20.00 cm squared, moderate serous exudate, 90% thick adherent black necrotic tissue (eschar) and 10% slough. On 8/26/2024 the Wound Evaluation & Management Summary showed under the Focused Wound Exam that Resident #67 had a Stage 4 Pressure Wound of the left heel full thickness for the duration of greater than 11 days and the resident underwent a sharp debridement of the left heel. On 8/30/2024, wound therapy physician progress notes under the section Investigations: Recommended and /or Reviewed: a recommendation for vascular surgery referral for further evaluation and recommendations was documented by the wound therapy physician. Review of the Wound Evaluation & Management Summary, dated 9/06/2024, showed the wound under additional wound detail a notation of odor concerning for infection and re-educated nursing staff on dressings and cultures were obtained with a recommendation to start empiric antibiotic consider Bactrim DS 800/160 milligrams twice a day for 10 days or other course per PCP (primary care physician) preference and to adjust per culture and sensitivity results. Vascular surgery referral continued to be a request per the wound therapy physician. On 9/12/2024 at 4:00 p.m. an interview was conducted with the Director of Nursing (DON) regarding the acquired pressure ulcer to Resident #67's left heel. The DON stated skin checks are to be done weekly and confirmed the time frame from one skin check to the next skin check for Resident #67 was longer than seven days. The DON stated the skin check for the week of 8/05/2024 may have been vague but if there were no concerns for his skin checking NO would have not prompted the nurse to further document. The DON stated the order for the vascular consult really should have defaulted to a cardiology consult and not vascular but could not state why the order was not completed. The DON stated the cardiology consult would have determined if a vascular consult was truly warranted. The DON stated she was aware of Resident #67's positive culture after a discussion with the IP and orders have been placed for an antibiotic. The facility did not provide a policy and/or procedure for skin checks or assessments prior by the last date of survey.

Based on observations, interviews and record review the facility did not ensure the physician was promptly notified of a positive lab result for an infection for one resident (#101) out of eight residents sampled. Findings included: On 9/11/2024 at 11:38 a.m. an observation was made of Resident #101 sitting in her wheelchair (WC) with her catheter bag hanging underneath the WC in a privacy bag with a portion of the indwelling tubing touching the ground. An observation was made of a rusty colored, heavy sediment in the tubing. On 9/11/2024 at 5:45 p.m. an observation was made of Resident #101 in her room sitting in her WC. An observation of the urine in the indwelling tubing revealed a darker rusty color than previously observed. A review of Resident #101's Admission Record showed an admitted [DATE]. The resident's diagnoses included acute kidney failure unspecified, malignant neoplasm of bladder, elevated white blood cell count unspecified, urinary tract infection, retention of urine unspecified, and unspecified dementia unspecified severity without behavioral, psychotic mood or anxiety disturbances. A review of Resident #101's Minimum Data Set (MDS), dated [DATE], Section C-Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) of 00, severe cognitive impairment. A review of Resident #101's current physician orders showed: *Diagnosis for Indwelling Catheter: obstructive uropathy, *Change drainage bag w/catheter change as needed *Change drainage bag w/catheter change every night shift every 28 days(s) *Secure catheter tubing using anchoring device to prevent movement and urethral traction every shift. A review of Resident #101's lab results for a Urinalysis with Microscopy Only (No Reflex)/Urine PCR (polymerase chain reaction) obtained on 9/05/2024 and resulted on 9/06/2024 showed a positive culture for Escherichia Coli and Enterococcus Faecalis. A review of Resident #101's care plan, dated 9/07/2024, showed the following Focus areas: *[Resident #101] has an indwelling catheter related to bladder cancer. The goal was to have decreased risk of signs and symptoms of a urinary tract infection (UTI) and other complications related to catheter through next review. Interventions included to ensure proper positioning of drainage tube at all times, keep drainage bag below waist level at all times observe for signs and symptoms of infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increase pulse, increase temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change and eating patterns. *[Resident #101] has an infection abnormal UA (urinalysis), date initiated 9/05/2024. No identifiable goals were documented for this focus area. Interventions included to observe for symptoms of weakness, dehydration, fever, nausea and vomiting and blood in stool and observe for signs and symptoms of delirium including changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. On 9/11/2024 at 4:40 p.m. an interview was conducted with Staff B, RN/UM. Staff B stated once a lab order is received the order will be acknowledged by the nurse. From there, the evening shift nurse will fill out a requisition for the lab(s) the following morning. The lab will come in early in the morning to collect the specimen. If a lab was ordered as a STAT (immediate), the lab would come in at any time to collect. Staff B stated, They are available 24/7. Staff B, RN/UM stated the lab results are available in the resident's electronic medical records for anyone to see. Staff B, RN/UM stated cultures may take a few days for sensitivity. A review of the lab results for Resident #101's urine culture, dated 9/06/2024, was conducted with Staff B, RN/UM. Staff B stated the results were incomplete because it takes three days to get the final results for a culture and sensitivity and the positive results reviewed were the PCR and not the final culture and sensitivity. 0n 9/11/24 5:23 p.m. an interview was conducted with the Director of Nursing (DON). The DON confirmed the lab has a process to report lab results through their electronic chart. The DON stated the ordering physician started Resident #101 on Keflex 500 milligrams for three days based on the UA (urinalysis). The DON reviewed the lab results from 9/06/2024 and confirmed it showed positive culture findings. The DON stated the staff should have notified the doctor, changed out the indwelling catheter, and placed the resident on isolation if warranted. On 9/11/2024 at 5:47 p.m. an interview was conducted with the Director of Infection Prevention and Control (IP). The Director of IP confirmed the positive culture findings for Resident #101. The Director of IP stated the order for the Keflex would not cover the organism currently detected in the culture results. A review of the MedlinePlus website located at https://medlineplus.gov/lab-tests/pcr-tests/#:~:text=PCR%20(polymerase%20chain%20reaction)%20tests,abnormal%20cells%20in%20a%20sample showed a PCR shows the efficiency, faster and highly accurate way to diagnose certain infectious diseases. An additional review of Resident #101's physician orders, dated 9/12/2024, included midline placement and Invanz injection solution reconstituted one gram one a day for ESBL (extended spectrum beta-lactamase) for 7 days. The facility did not provide policy and procedures for collection and reporting of labs.

Based on observations, interviews, and record review, the facility failed to ensure two resident rooms (203 and 207) were maintained in a sanitary manner in one hall (Hall 200) of two halls observed. Findings included: On 09/09/24 at 10:35 a.m. a tour of Hall 200 was conducted. room [ROOM NUMBER] was observed with brown and yellow stains on the walls and ceilings. The floor was observed with a slimy yellow substance in the corner. A white foam cup was observed on the floor next to the slimy yellow substance. Small flying insects were observed above the wall and on the resident's cup. The floors were observed with dirt and debris. The privacy curtain was observed with brown stains. The resident stated she reported to staff this morning that her room was not cleaned over the weekend. Additionally, room [ROOM NUMBER] on 09/09/24 10:44 a.m., was observed with lose bathroom tiles and stained ceiling tiles. A family member stated the room had been like that since the resident moved in. On 09/10/24 at 2:20 p.m. room [ROOM NUMBER] was observed with the same concerns related to the stained floors, walls, ceiling and privacy curtain. On 09/10/24 at 3:02 p.m. room [ROOM NUMBER] was observed with the same concerns as observed the day before. On 09/10/24 at 2:53 p.m. an observation was made of Staff C, Housekeeping Aide cleaning rooms in Hall 200. An interview with Staff C was attempted. She stated she did not speak English. Staff C could not answer any questions. On 09/12/24 at 10:30 a.m., a second interview was attempted with Staff C, Housekeeping Aide. While utilizing a language translation on her phone, Staff C stated the brown stains on the walls and ceiling were from a soda accident. She stated she did not know how long the soda stain had been there. She said, It has been a long time. Staff C stated she saw the stains on the walls before. She stated she would notify her supervisor. On 09/12/24 at 10:45 a.m. an interview was conducted with the Housekeeping Manager. She stated from what she had observed, the stains on the walls and ceilings could have been soda. She said, We had cleaned it before. It might be stained again. I don't know how long it has been there. She stated a maintenance staff member cleaned a similar spillage 4 to 5 months prior. She stated resident rooms should be cleaned daily. She stated she did not know why the rooms had stains on the floors. The Housekeeping Manager stated the housekeeper should clean the rooms daily and if there was a problem, they should let her know. The Housekeeping Manager said, It does not look good. We will clean it. On 09/12/24 at 10:56 a.m. an interview was conducted with the Director of Maintenance (DOM). He stated he was not aware there were stains on the walls and ceilings in rooms [ROOM NUMBERS]. He said, They may have notified someone else and not me. Staff should put in a work order if a room has repair needs. I will take care of it. He reviewed the photographic evidence and stated it was not homelike. On 09/12/24 at 12:04 p.m. an interview was conducted with the Nursing Home Administrator (NHA). The NHA reviewed the photographic evidence and stated they clean all resident's rooms daily. She stated some residents were non-compliant. She said, They do not allow us to clean. The resident in room [ROOM NUMBER] can be non-compliant. She spills soda in her room. staff will clean it up if she allows them. The NHA stated the building was showing wear and tear. She stated the room had a water leak that was repaired recently. She stated it should be painted over. She stated the guardian angel should have reported the stained walls and ceilings over and over until the issue was resolved. Review of a facility policy titled, 5-Step Daily Patient Room Cleaning,dated 1/1/2000, showed the purpose is to show housekeeping employees the proper cleaning method to sanitize a patient's room or any area in a healthcare facility. (3.) Spot clean walls. Vertical surfaces . must be spot cleaned daily. (4.) The entire floor must be dust mopped. (5.) The most important area of a patient's room to disinfect is the floor. This is where most airborne bacteria will settle so it needs to be sanitized daily. (Photographic Evidence Obtained)

Based on observations, record reviews, and interviews the facility failed to provide appropriate assistance for a resident (#52) of six residents sampled for limited range of motion (ROM) related to the application of physician ordered orthotic devices. Findings included: On 9/9/24 at 12:31 p.m., Resident #52 was observed lying in bed, and not wearing a splint on either hand. The observation revealed a splint appeared to be inside a plastic personal belonging bag on top of the bedside dresser. On 9/9/24 at 2:50 p.m. Resident #52 was not wearing a splint on either hand, and what appeared to be a splint continued to be in the personal belonging bag on top of the dresser. An interview was conducted with Staff D, Licensed Practical Nurse (LPN) on 9/10/24 at 10:27 a.m. The staff member reviewed the orders and stated the resident wore a left hand splint. On 9/10/24 at 10:36 a.m. Resident #52 was observed in conjunction with Staff D, LPN. The resident was lying in bed and the staff member confirmed the resident was not wearing a hand splint. On 9/11/24 at 8:49 a.m. Resident #52 was observed lying in bed wearing bilateral hand splints. An interview was conducted with the Director of Rehab (DOR) on 9/10/24 at 4:20 p.m. The DOR stated Resident #52 had a left grip splint. The DOR stated the resident came from a different facility with the splint and it had been carried over. The DOR reported nursing and restorative apply splints. The DOR confirmed seeing the resident wearing the splint and usually staff will let therapy know if the resident consistently refuses it. An interview was conducted with Staff G, Certified Nursing Assistant (CNA) on 9/11/24 at 9:08 a.m. The CNA confirmed being assigned to care for Resident #52. The staff member reported not putting splints on the resident and the restorative aide applies the splints. Staff G stated they went to the laundry and he had to get them. An interview was conducted with Staff I, Restorative Nursing Assistant (RNA) on 9/11/24 at 1:48 p.m. Staff I reported the splints were off this morning and she found the splints in a personal property bag on top of the bedside dresser. The staff member reported applying the splints would have been up to the assigned CNA. Review of Resident #52's Admission Record showed the resident was admitted on [DATE] and 9/3/24 with diagnoses including unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other reduced mobility, and unspecified site unspecified osteoarthritis. Review of Resident #52's Order Summary Report, active as of 9/12/24, showed the resident was to wear Left (L) hand grip splint at all times, as tolerated. Remove for skin check and hygiene to be removed or deferred by patient. Review of Resident #52's September Medication and Treatment Administration Records (MAR/TAR) did not show nursing staff documented whether or not the resident's left hand grip splint had been applied. Review of Resident #52's CNA Tasks revealed the application of the resident's Left hand grip splint was not included in the documentation. Review of Resident #52's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed the resident had a 00 Brief Interview for Mental Status (BIMS) score out of 15, indicating severe cognitive impairment. The Functional Abilities and Goals assessment showed the resident had ROM impairment on both sides of the upper and lower extremities. Review of Resident #52's care plan showed the resident required a Splint/Brace Nursing Restorative Program created on 7/24/24, initiated and revised on 7/31/24 by the Director of Nursing (DON). The goal was for the resident to maintain current level of function by next review date. The interventions revealed the resident: - to wear Right (R) resting hand splint when in bed as tolerated. Patient to wear left grip splint at all times as tolerated. Remove for skin checks and hygiene to be removed or deferred by resident, initiated and created by DON on 7/24/24. - Splint/Brace - Patient to utilize L hand grip splint at all times as tolerated, removed to skin checks and hygiene. To be removed or deferred by patient created on 7/31/24 and system generated revision on 9/3/24. Review of the physician order summary did not reveal a physician order for the observed or care planned Right hand splint. An interview was conducted with the DON on 9/12/24 at 1:07 p.m. The DON stated primarily restorative (applies splints) but an aide can do it, whether restorative is there or not. She reported tasks (are) for restorative and CNAs so they can see it on the Plan of Care (POC) and staff are aware by the first (portion) of shift if there is restorative or not. The facility reported on 9/12/24 at 3:22 p.m. they did not have a policy for splints/braces or restorative program. (Photographic evidence was obtained)

Based on interviews, observations, and record review the facility did not ensure a post dialysis assessment was completed for one resident (#40) out of one sampled resident. Findings included: On 9/10/2024 at 2:20 p.m. an observation was made of a certified nursing assistant (CNA) exiting Resident #40's room. The CNA stated the resident returned from dialysis, post vital signs were done and the resident was resting. On 9/10/2024 at 2:25 p.m. an interview was conducted with Staff B, Registered Nurse/Unit Manager (RN/UM). Staff B provided the dialysis communication binder for Resident #40. The communication sheet for today's dialysis was in the binder with pre- vital signs and assessment complete and the dialysis center information was complete. A review of the Dialysis Communication sheet did not have an area for the facility's post assessment of the dialysis site or vital signs. Staff B, RN/UM stated post dialysis information such as vital signs and assessments are placed in the resident's electronic chart. In Resident #40's Dialysis Communication binder, no further post dialysis communication sheets were present. Upon request, Staff B, RN/UM provided the post dialysis communication sheets for Resident #40 for the month of September and the last week of August. Staff B stated the sheets will be scanned into the resident's electronic chart. Staff B, RN/UM stated post dialysis assessments are completed in the electronic chart by the receiving nurse and it includes vital signs and assessment of dialysis access. A record review of Resident #40's medical record revealed no past dialysis communication sheets scanned into the electronic chart except for March 28, 2024. A review of the electronic chart on 9/10/24 showed an entry for Post Dialysis Assessment in which the receiving nurse placed a note in the chart of her assessment upon Resident #40's return from dialysis. A review of the electronic chart entries did not have assessments post dialysis documented in the chart throughout the month of July through 9/9/24. A record review of Resident #40's Admission Record shows an admitted [DATE] with diagnoses of cardiomyopathy, chronic kidney disease stage IV and dependence on renal dialysis. A review of Resident #40's current physician orders revealed: dialysis days: Tue (Tuesday), Sat (Saturday) Dialysis Center: [Name of Dialysis Center and address]. Chair time: 10am. pick up time: 8:45am. Transport company: [Name of company and phone number] every day shift every Tue, Thu, Sat (start date of 4/6/24); apply dry dressing to dialysis site (right chest dialysis port) as needed for bleeding /leakage, if excess, document and notify MD (physician); dialysis vitals post dialysis in the evening every Tuesday and Saturday for monitoring (start date of 6/1/25); and monitor dialysis site to right chest for signs and symptoms of infection, drainage or bleeding every shift, if present document and notify provider every shift; and complete dialysis communication sheet prior to dialysis in the morning every Tue, Sat (start date of 7/6/24). A review of Resident #40's care plan revealed a Focus Area as, [Resident #40] is receiving Dialysis Therapy hemo r/t [related to] End Stage Renal Failure, initiated on 4/2/24. The goal showed, Resident will have decreased risk of complications, r/t dialysis through the review date. Interventions included to observe access site prior to leaving and upon return to facility from dialysis, observe for s/s (signs and symptoms) hypovolemia or hypervolemia. Observe for shortness of breath, edema, chest pain, elevated B/P (blood pressure), nausea, vomiting, decreased output, fluid volume, bleeding, infection, alteration in skin integrity, effect of dialysis on medication therapy, and send dialysis communication form with resident and be sure to retrieve information from resident on return. On 9/10/2024 at 3:00 p.m. an interview was conducted with the Director of Nursing. The DON stated there is an order for every shift for the assessment of dialysis site. The DON confirmed the assessment post dialysis upon arrival was not well-documented. A review of the facility's policy titled: Dialysis, revised 6/2024, showed under Resident Access, Section B Catheters . Monitor site for bleeding, signs and symptoms of infection-if bleeding present - apply pressure and notify physician. If signs and symptoms of infection present notify physician. Further review of the facility's revealed it was silent of information regarding post assessment of the dialysis access/port.

Based on observations, interviews and record review, the facility did not ensure medications were stored safely, securely, and inaccessible to unauthorized staff, residents, and visitors for four residents (#74, #86, #18 and #9) of 53 residents sampled. Findings included: 1. On 09/09/24 during a facility tour at 10:51 a.m. an oval shaped peach colored tablet, imprinted U-S 250 was observed on the floor besides a floor mat in Resident #86's room. During the facility tour conducted on 09/09/24 at 10:52 a.m. an oval shaped peach colored tablet was observed in the hallway between Resident #74's and Resident #50's rooms. On 09/09/24 at 11:36 a.m. a round, yellow colored tablet was observed on the floor in Resident #18's room. On 09/09/24 at 10:53 a.m. an interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A observed the three tablets on the floor. She said, I crushed Resident #86's medications. I don't know why there is a whole tablet on the floor. She stated the loose tablets must have been from previous shifts. On 09/12/24 at 10:35 a.m. a follow-up interview was conducted with Staff A, LPN. She stated she reviewed the tablets found on the floor and identified them. She stated the tablet observed between Resident #74's and Resident #50's rooms belonged to Resident #74. She stated it was Eliquis 5 mg (milligram). She stated Resident #74 takes his medications crushed. She stated the tablet should not have been outside the room. She stated she did not know what happened. Staff A, LPN stated the tablet observed in Resident 86's room was Divalproex Sodium 250 mg. She stated this resident's medications should be crushed. Staff A, LPN stated Resident #86 did not receive medications whole. Staff A, LPN stated the tablet in Resident #18's room was Zofran (Ondansetron) 4 mg. She stated the resident took his meds whole. Staff A, LPN said, Nurses should supervise the resident. The nurse should stay with resident. Review of the Admission Record showed Resident #74 was admitted to the facility on [DATE] with a primary diagnosis of non-traumatic intracerebral hemorrhage. Review of the September 2024 physician orders for Resident #74 showed the resident was prescribed Eliquis oral tablet 5mg (Apixaban), give 1 tablet by mouth every 12 hours for CVA (cerebrovascular accident). Review of the Admission Record showed Resident #86 was readmitted to the facility on [DATE] with a primary diagnosis of Parkinson's disease without dyskinesia. Review of the September 2024 physician orders for Resident #86 showed the resident was prescribed Divalproex Sodium oral tablet delayed release 250mg, give 1 tablet by mouth two times a day for mood. Review of the Admission Record showed Resident #18 was readmitted to the facility on [DATE] with a primary diagnosis of unspecified dementia. Review of the September 2024 physician orders for Resident #18 showed the resident was prescribed Ondansetron HCI tablet 4mg Give 1 tablet by mouth every 6 hours as needed for nausea and vomiting. An interview was conducted with Staff B, Registered Nurse/Unit Manager (RN/UM). She stated the nurses should supervise the residents during medication intake. She stated the nurse should stay with the resident to make sure the resident takes the medication. She said, Medications should not be on the floor. On 09/10/24 at 12:14 p.m. an interview was conducted with the Director of Nursing (DON). She stated she was notified of the loose tablets found on the floor. She stated all staff should look for tablets on the floor and notify the nurse if any observations were made. The DON said, Medications should not be on the floors. The nurse should make sure they swallow before they walk away. 51097 2. An observation and interview with Resident #9 on 09/11/24 at 10:10 a.m. revealed unsecured medications on Resident #9's bedside furniture including Neosporin and sore throat spray. She stated she uses it from time to time. A review of Resident #9's most recent Quarterly Minimum Data Set, dated dated [DATE], in Section C-Cognitive Patterns, showed a Brief Interview for Mental Status score of 15 indicating she is cognitively intact. A review of Resident #9's September 2024 physician orders revealed there was no order for throat spray or Neosporin and was silent for an order of self-administration of medication. A review of Resident #9 active care plans revealed no care plan indicating self-administration of medication was in place. An interview was conducted with Staff E, LPN on 09/11/24 at 10:20 a.m. She said if she found medications at the bedside, she would tell the resident we need an order from the doctor to have that medication. If it was a medication such as sore throat spray, or Neosporin, she would call the doctor for an order and would store the medication on her medication cart for the resident. Staff E, LPN said she would report it to the manager and DON. Staff E stated she is not sure if there is a policy if residents can give themselves medications or have them, but they should not have them at their bedside. An interview with the DON was conducted on 09/12/24 at 9:44 a.m. She stated, The residents are not allowed to have medications at their bedside without an assessment. If the residents want to have it, we can store it for them in their room in a bag or a box. We can also store it in our medication room or in the medication cart. The DON said if staff were to find a medication at the bedside, they would report it to her or a supervisor; the resident would need an evaluation to administer the medication themselves and they would need to contact the doctor for an order. A review of policy titled, Self-Administration of Medication, updated on 06/28/2024, revealed the following: Policy: The resident has right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. A resident may only self-administer medications after the Interdisciplinary team (IDT) has determined which medications may be self-administered .The nurse will obtain a physician's order for each resident conducting self-administration of medications. Storage of self-administered medications will comply with state and federal requirements for medication storage. A review of policy titled, Storage and Expiration Dating of Medications and Biologicals, revised on 08/01/2024, revealed the following: Policy: Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and facility administration. Facility should store bedside medications or biologicals in a locked compartment within the resident's room.

Based on observations, interviews and record review the facility failed to ensure dental services were provided for one resident (#77) of one sampled resident. Findings included: On 09/09/24 at10:37 a.m. an observation and interview was conducted with Resident #77. Resident #77 was observed with missing teeth. She said, I am missing teeth, I do not eat very well. The bread is hard. On 09/10/24 at 9:09 a.m. an observation and interview was conducted with Resident #77. She stated she was served a sausage patty and it was dry and not chewable. On 09/10/24 at 4:00 p.m. an interview was conducted with Resident #77. She stated she asked to see a dentist. She said, Some doctor came to see me a long time ago. He said somebody will be back on a Monday. I don't know when this was. They never came back. Resident #77 stated she would like to see a dentist. Review of the Admission Record showed Resident #77 was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of endometrium. Review of the September 2024 physician orders for Resident #77 showed the resident received a regular texture, regular consistency, fortified foods with meals for nutrition. Review of Resident #77's care plan, dated 05/30/24, showed the resident is at risk for oral/ dental health problems related to advanced age, cancer, and receiving chemotherapy. The goal showed Resident #77 will be able to eat and drink free of pain through the next review date. Interventions included coordinate arrangements for dental care, transportation as needed/as ordered. Monitor for signs/symptoms of oral/dental problems including pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, and lesions. Provide mouth care as per ADL (Activities of Daly Living) personal hygiene. During an observation and interview on 09/11/24 at 8:45 a.m. Resident #77 was observed in her room. She stated she does not know what was served for dinner the night before. She said, It was hard to chew. It happens all the time. Especially morning breakfast. The sausage is like rubber or tires. I can't eat that. On 09/11/24 at 10:52 a.m. an interview was conducted with the Social Services Director (SSD). The SSD stated Resident #77 refuses dental services. She said, On 09/14/23 she had an appointment. They tried to come and see her, and they said she refused. The SSD reviewed the resident's electronic medical record (EMR) and confirmed there were no documented refusals. The review confirmed all social services notes did not show dental appointments were scheduled or refused. Review of an external provider's document provided by the SSD titled, Oral Assessment (Schedule L), conducted on 09/14/23 , showed Resident #77 was assessed for dental services. The note showed, Pt [patient] has 3 teeth and 3 root tips on the upper and 10 lower. Pt states she has discomfort on remaining tips and requested to see [sic] by a dentist. The patient needs a follow-up with a dentist at earliest possible convenience. Review of an external provider's document titled, Notice of Declined Dental Services, dated 11/08/23, showed Resident #77 had declined participation in this provider's dental services program. On 09/11/24 at 11:10 a.m. an interview was conducted with the Assistant SSD. She stated Resident #77 was sent up to see the dentist a while ago. She said, They wanted to have her go and get dental work done but at the time she was going through chemotherapy. She said she did not want to go at the time. I did not document. Review of the record confirmed there was no documented follow -up with Resident #77 since September 2023. The Assistant SSD stated the facility had an external provider who came to the facility. She stated they give the provider the names of residents who need dental services, and the provider schedules the appointment. The Assistant SSD stated social services coordinated the services and scheduled any follow -up appointments. She stated they had not scheduled any appointments for Resident #77. Review of a facility policy titled, Dental Services, dated 08/2023, showed, the center provides each resident with access to dental services. Residents will be referred to a dentist based on assessed need. The center will obtain services of a qualified dental provider. Basic services will be provided in house. Center staff will assess dental status through the interdisciplinary resident assessment process and daily provision of care. The physician, resident and family/responsible party may request dental services at any time. Social services designee will be responsible for coordinating dental services in the center.

Based on interviews and record review the facility failed to ensure medications were administered as ordered for one resident (#3) out of two residents reviewed for medication administration. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include encounter for surgical aftercare following surgery on the digestive system, and obesity. A review of a Physician Order Summary report, date range 07/26/23 - 07/31/23, revealed the following orders: Levothyroxine Sodium oral tablet 75 MCG (Micrograms) Give 1 tablet by mouth in the morning for low thyroid with start date: 7/27/23. Enoxaparin Sodium injection (Lovenox) solution prefilled syringe 100 mg/ml (Milligram/Milliliter). Inject 1 application subcutaneously two times a day for DVT (Deep Vein Thrombosis) for 14 days with a start date: 7/28/23. A review of the Medication Administration Record (MAR) for Resident #3 showed the resident did not receive her injection 1 out 8 ordered administration times. Medication administration of Sodium injection (Lovenox) solution prefilled syringe 100 mg/ml was missed as follows: 07/29/23 Prior (p.m.) Lovenox injection was not administered. A review of MAR showed on 7/29/23, the resident did not receive her Levothyroxine Sodium oral tablet 75 MCG (microgram). Give 1 tablet by mouth in the morning for low thyroid. The record did not indicate why the medications were not administered as ordered. On 9/7/23 at 2:05 p.m. an interview was conducted with the Regional Director of Clinical Services (RDCS). She stated Upon means upon rising or morning dose and Prior means prior to bedtime or evening dose. She stated the times were adopted for their liberalized medication pass. On 9/8/23 at 2:45 p.m. a follow -up interview was conducted with the RDCS. She reviewed Resident #3's MAR a stated there was no good reason why the resident did not receive her injections. She said, I'm looking at this and there was no good reason. We will educate immediately. The least would be to document why the medications were missed. There is no good explanation. On 09/8/23 at 11:13 a.m., an interview was conducted with the Director of Nursing (DON). She stated the resident's should receive medications as ordered. The DON stated the nurse should notify the physician of any missed doses. The DON stated if medications were not administered for one reason or another, it would be documented. A review of a facility policy titled, Medication Pass Guideline, dated 04/25/27, revealed the following: Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. To systematically distribute medications to residents in accordance with state and federal guidelines. Fundamental Information: Physician orders--Medications are administered in accordance with written orders of the attending physician. Documentation: Record the name, dose, route, and time of medication on the Medication Administration Record. Initial the record after the medication is administered to the resident. Record the reason for not administering if not administered.

Based on interviews, and record review the facility failed to ensure appropriate placement was arranged prior to discharge for one resident (#5) out of two residents sampled for discharge. Findings included: A review of a Nursing Home Transfer Discharge Notice showed a 30-day notice was issued on 08/10/23 to Resident #5/Resident Representative. A certified mail receipt showed the notice was received by Resident #5's Representative on 8/11/23. The notice indicated the reason for discharge was, Your needs could not be met in this facility. A brief explanation documented on the form showed the explanation to support this action was, Behavioral and aggression towards staff and other residents. A review of an Admission Record showed Resident #5 was admitted to the facility on [DATE] and was discharged on [DATE]. The record showed diagnoses to include, unspecified dementia with agitation, anxiety disorder, mood disorder, and delirium due to known physiological condition. A review of a Physician Order Summary Report showed an order dated 09/27/20 as, Admit to skilled care. I certify post hospital SNF services are required to be given on an inpatient basis because of resident's need for skilled nursing or rehab care on a continuing basis for conditions which required inpatient admission prior to transfer to SNF. A review of a document titled, Interdisciplinary Discharge Summary, dated 08/31/23, showed Resident #5 was transferred to an ALF (Assisted Living Facility). The reason for discharge was noted as family chosen facility The nursing services summary was noted incomplete. A care plan for Resident #5, initiated on 08/20/21, revealed the following: Focus area: Resident #5 has potential to demonstrate physical and/or verbally abusive behaviors related to dementia, poor impulse control. Resident will hoard items and go through roommates belongings. Resident yells at staff at times. Goal: Resident will demonstrate affective coping skills through the review date. Interventions included: Anticipate resident's needs food, thirst, toileting needs , comfort level, body positioning; Give as many choices as possible and care activities; Identify triggers and what de-escalate behavior; Administer medications as ordered; Modify environment and monitor danger to self and others. Focus area: Resident has impaired cognitive function/impaired thought process, impaired safety, and communications deficits related to the progression of dementia. Interventions included: Communicate with family care givers regarding resident's capabilities and needs; Cue, reorient and supervise as needed; Engage resident in simple, structured activities; Keep routine consistent and try to provide consistent care as much as possible. Focus area: Discharge plan (initiated on 10/09/20) Resident in need of long-term care due to the level of care required. Goal: Resident will be able to verbalize/communicate required assistance post discharge and the services required to meet needs before discharge. Interventions included: (11/18/20) Apply for benefits for coverage of skilled nursing; Encourage family to bring in items from home to provide resident with familiar objects to encourage adjustment and ease transition; Observe resident for any adjustments issues related to long term care placement and refer for psychological/psychiatric services as needed. A review of a Physician note, dated 08/28/23, showed the following: Patient seen today for follow -up visit. She is sitting up in her wheelchair, . She currently does not appear to be in distress and denies any medical concerns. No concerns per nursing staff at the time of visit. Patient moving to ALF this week. Patient will benefit from hospital bed for repositioning assistance due to dementia, wheelchair dependency and deformity of neck. A review of a Psychiatry note, dated 7/13/23, showed, The patient is a long-term resident . She is very particular to share her room with roommates. The patient was seen as a follow -up. Patient is in private room and no incidents have been reported. As per the collected information and interview, it appears that the patient is stable with psych therapy at this time. The patient appears calm and in good mood. No distress. Appetite and sleep is adequate. As patient is doing well, no medication changes are need. A review of a Psychiatry note, dated 06/12/23, showed [Resident #5] had a history of dementia, delirium and anxiety, cognitive communication disorder. Alert with confusion and forgetfulness. Able to make needs known. Her speech is clear . Patient started on Trileptal on 05/05/22 due to poor impulse control, hoarding and tearfulness with positive results. She is very particular to share her room with roommates. Patient is being seen today 6/12/22 per request via telehealth according to staff, the patient reports her new roommate hit her back. No injuries were reported. Residents were transferred to another room . Assessed the patient sitting up. Reports feeling good at this time, patient is unable to recall incident due to dementia. No signs of psychosocial distress were noted. A review of progress notes for Resident #5, dated 9/1/23 9:50 a.m. showed The resident was discharged to [name of facility], via wheelchair, via [name of company] transportation. In no distress, escorted by [family member]. A review of and IDT note for Resident #5, dated 06/13/23, showed Resident out of bed in wheelchair, self-propels in room and in hallways. Resident went to room [ROOM NUMBER] B side of room, and it was reported by roommate that this resident hit roommate two times on the right shoulder blade and propelled self out of room. Skin check completed on this resident and there were no abnormal findings. A review of a nurses' progress notes for Resident #5, dated 06/12/23, showed Reported that this resident hit her roommate on the back. 'I didn't hit her' reported to Social Worker, DON (Director of nursing), and resident's family member. A review of a nursing progress note, dated 06/5/23, showed Spoke with Resident's [family member] to review information from last week's care plan. [Family member] stated she was very pleased with the care Resident #5 was receiving. A Care plan meeting note held via IDT (inter Disciplinary Team), dated 05/31/23, showed Neither resident nor family were in attendance. Per social services resident continues with potential for hoarding and wandering behavior, poor impulse control and physically/verbally abusive behavior but has not displayed any behaviors within the last quarter. She continues to receive psychoactive medications w/o (without) adverse effect. A review of care plan meeting notes dated 5/31/23, 3/28/23 and 3/1/23, showed Resident #5 Has not displayed any behaviors lately. Family expressed appreciation for care received and stated, 'I love everyone here, it's great.' On 09/07/23 at 12.56 p.m., an interview was conducted with Staff A, Certified Nursing Assistant. She said, Resident #5 was awesome, she was never angry. She did not look happy when she left. The [family member] was not happy either. It is not what they wanted. She did not want a roommate. We tried different people. I miss her. Staff A stated she heard the resident was in an altercation with another resident who was in her room. Staff A stated the resident was normally confused and thought people were in her house or stealing her things. Staff A said, She could not handle roommates. Everyone knew that. It was sad how she left. On 09/07/23 at 1:00 p.m. an interview was conducted with Staff B, CNA. He stated, She [Resident #5] was very pleasant. She roamed the facility. She did not bother anyone. I never heard she wanted to leave. Staff B stated the family member would visit quite often and she appeared happy with the placement. On 09/07/23 at 1.03 p.m., an interview was conducted with Staff C, CNA. She stated she remembers the resident. Staff C said, She was sweet, ambulated up and down halls all day. She liked to sing. I did not know she was leaving. I reported to work after a couple days off and found she was gone. I heard she went to an ALF. On 09/07/23 at 1:14 p.m., an interview was conducted with Staff D, CNA. She said, I remember her she spoke Spanish, she liked to dance, she didn't like cold food, she dressed up all the time, she was kind of a Diva, she was funny had no issues. Staff D stated she never heard the resident had hit another resident. She said, Not that I recall. She liked her space. I don't know why she left. I don't remember hearing she was leaving. I came in after a day off and heard she went to an ALF. Her [family member] visited quite often. She would calm her down if she was upset. She liked it here. Staff loved her too. On 09/07/23 at 1:45 p.m., an interview was conducted with the Social Services Director (SSD). The SSD stated Resident #5 transferred to an ALF per family request. He said, I came in on the tail end of it and helped facilitate her transfer. I set up her paperwork and she left. I did not get to know her. My understanding was that the [family member] was trying to get her to an ALF. The other SSD who no longer works at the facility handled this case. The SSD stated he was made to understand the resident's family member was taking her to the other facility of her own choice. The SSD stated a typical discharge planning process starts on admission. It involves getting with family, finding out if they have community services, schedule follow -up, get orders to the facility home health care, arrange transportation and start discharge planning. He stated if a resident was a long-term resident, they would review plan to remain at the facility during care plan meetings and address any needs or update changes. The SSD said, I was not here when the planning started. I did not hear about the incident with another resident until much later. Just caught the end of it. My assistant was here. On 09/07/23 at 2:16 p.m. an interview was conducted with the Assistant Social Services Director (ASSD). She stated she knew Resident #5 quite well. She stated every time she got a roommate, there was an issue. The ASSD stated there was one roommate whom she would try and dress and feed. She wanted to take care of her. Another roommate was alert, she would remove her clothes from her side and move them to her own side and yell at her. she would get upset with housekeeping for touching her stuff. She did not want people in her room. This was an on-going thing. The SSD said, I remember my supervisor talking about her. She had a roommate who reported she was in her wheelchair and was facing the window and she apparently hit her twice. She yelled at her and then rolled herself out of the room. We reported the incident. Her care plan was updated related to potential to be aggressive. The issue of her not liking roommates was part of the discussion during meetings. I spoke with the [family member] about it. I forgot to put a note in. I dropped the ball on that. The SSD stated the resident was transferred because, We could not put another person in the room with her. We had to find another placement for her because we could not really meet her needs. The ASSD confirmed the discharge was a facility-initiated discharge because they could not meet her needs. The ASSD stated the option to offer Resident #5 a private room even if she was to self-pay was never discussed. The ASSD said, No, I don't know to my knowledge why this was not offered. We did not offer her a private room. It was never discussed in care plan meetings. On 09/07/23 at 2:36 p.m., an interview was conducted with the [NAME] President(VP) and the Regional Director of Clinical Services (RDCS). She stated they had received a letter from Resident #5's family member. The RDCS said, It was appalling to read her experience She stated they had gotten a 30-day notice to find a place because she could not be cared for here. The [family member] apparently found a secured unit. The problem was the NHA was new. She was depending on the Director of Nursing (DON) at the time. They did not follow protocol. They did not run the discharge through the VP per policy. The VP and I did not find out until yesterday. The resident is in a worse situation. She is in a room with 4 people. The RDCS stated they were working on readmitting the resident. The VP said, We can meet her needs. This was not a family-initiated discharge. It was facility initiated. It was not conducted per our policy, and we intend to fix that as soon as possible. On 09/8/23 at 09:39 a.m., a follow -up interview was conducted with the SSD and the ASSD. The SSD stated the NOMNC (Notice of Medicare Non-Coverage), and transfer discharge notices were not issued. The SSD said, From what I heard, the [family member] initiated the transfer. I have become aware this week that this was a Facility initiated discharge. It should have been handled differently. On 09/08/23 at 11:35 a.m., an interview was conducted with the Nursing Home Administrator. She stated the facility was working on a discharge plan according to the previous leadership. She said, They were working on finding placement for her. I never spoke to the family member. On 6/12/23 she had an incident. Another resident was admitted to the same room as her. The census was high. We used her room in error. We should not have put another resident in the room. The new resident said [Resident #5] hit her on the back. We removed the new admission. We reported the incident to law enforcement and [state agency]. They did not accept. The NHA said, I failed. I should not have listened to the DON without fact-finding. I should have looked into it. I did not know the resident's [family member] was trying to get in touch with me. It hurts that she feels the facility failed them. It is not our standard of operation. We will do better. A review of a facility policy titled, Pre and Post Discharge Plan of Care, effective 10/24/22, revealed the following: Policy Pre-discharge Planning will be coordinated by the Social Services Development for the development of post-discharge plan of care. Discharge planning process: The center must develop and implement an effective discharge planning process that focuses on the resident's discharge goals and preparing the residents to be active partners in post-discharge care, effective transition of the resident from SNF [Skilled Nursing Facility] to post-SNF care, and the reduction of factors leading to preventable readmissions. Fundamental Information The Social Service Director or designee coordinates discharge plans through the pre-planning discharge process with the assistance of the IDT [Interdisciplinary Team] members. The post-discharge plan of care is required for the following types of transfer or discharge: 1-discharge due to the fact that the resident's health has improved significantly enough they no longer require services by the center; 2-if there was a pre-determined plan for discharge upon admission for the resident to return home or to a less restrictive environment; 3-discharge is necessary when a resident's welfare or needs can no longer be met by the center; 4-discharge is necessary when the safety of other individuals in the center would be endangered otherwise should the resident not be transferred. I. The center's discharge planning process will- 1. Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. 2. Include regular reevaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. 3. Involve the IDT in the on-going process of developing the discharge plan. 4. Consider caregiver/support person availability and the resident's or caregiver's/support person's capacity and capability to perform required care, as part of the identification of discharge needs. 5. Involve the resident and resident representative in the development of the discharge plan and inform the resident and the resident representative of the final plan. 6. Address the resident's goals of care and treatment preferences. .9. Document complete on a timely basis based on the resident's needs and include in the clinical record .

Based on observations, interviews, and record review the facility failed to ensure pain was managed in a timely manner for one resident (#3) out of three sampled residents. The facility failed to provide Resident #3 Physician ordered pain medication for nineteen hours, as she yelled and cried during the night shift, while waiting for the pharmacy to fill the pain medication order. Findings included: 1) On 07/10/2023 at 10:11 a.m. Resident #3 was observed leaving her bedroom with a therapist. Her Home Companion was present and confirmed the resident had received a pain medication an hour earlier. The Companion stated she has been with Resident #3 since April 2023, and spends five days a week with her. She added, I followed her over from the hospital when she was admitted to the nursing home. She said she knew Resident #3 was having pain when she arrived, but it was close to the end of her shift. She said the nurse came in and was informed of the pain. The Companion said another companion came in shortly after it was the end of her shift. A review of the Admission Record revealed Resident #3 was admitted to the facility 06/16/23 at 6:30 p.m. with a diagnosis to include fracture of other parts of pelvis, subsequent encounter for fracture with routine healing, encounter for other orthopedic after care, unspecified fracture of sacrum, presence of right artificial hip and right knee joint. A review of the hospital Discharge Summary, dated 06/16/2023, revealed the following: Discharge medication: Continue: Oxycodone (Oxycodone 10 milligram (mg) oral tablet) 10 mg=1 tab(s), oral (PO), every (q) 4 hours (hr.) (interval), as needed (PRN): Pain. Hospital Course: admitted from: emergency department. Chief Complaint: Ground Level Fall (GLF), pelvic fracture. Found to have a pelvic fracture and therefore for further evaluation and treatment. Pelvic fracture S2 & S3, compression fx of T5, L4, L5: Orthopedic consulted. Will also consult pain management for pain control. CT Thoracic (T)/Lumbar (L) spine: acute sacral fracture S1, S2; age indeterminate moderate compression. A review of Physician orders revealed the following: Oxycodone Hydrochloride oral tablet 5 mg Give I tablet by mouth every 4 hours as needed for acute pain start date 06/17/2023 10:03 a.m. A review of Nursing Progress Notes dated, 06/17/2023 06:41, Note Text: Resident was admitted on [DATE], report said around 6:30 p.m. (1830). Resident has been yelling and crying out all shift, keeping her roommate awake for majority of the night. Writer explained to Resident that her pain medication script will be sent to pharmacy to be filled. Behaviors continued the entire shift. A review of the Medication Administration Record (MAR) reflected the first dose of Oxycodone was administered on 06/17/2023 at 2:10 p.m. for a pain level of 9 (score of 0 means no pain, and 10 means the worst pain you have ever felt). This indicated Resident #3 was not administered a pain medication for over nineteen hours after her admission. On 07/11/2023 at 11:40 a.m. a phone interview was conducted with the facility Orthopedic Consultant he said he was aware of Resident #3 and the surgical procedure. He said the bilateral screw placement was to prevent a spinal fracture. He said if it was not performed, she could be paralyzed. The Orthopedic Consultant stated, it's a painful procedure and indicated post-operatively it's still going to hurt. He said he was unaware her Oxycodone was not received timely. He stated, that's not ideal. He went on to say they have my phone number on file; they should have notified me. I would have called in script right away. On 07/11/2023 at 1:36 p.m. an interview was conducted with the Nursing Home Administrator who indicated she was unaware Resident #3 was not provided her pain medication until 06/17/2023 at 2:10 p.m. as documentation reflected and the resident was in pain all night. On 07/11/2023 at 2:59 p.m. an interview was conducted with the Regional Clinical Director she confirmed when Resident #3 was admitted her pain medication was not administered for almost 24 hours. The Regional Clinical Director stated, She did not come with a script. I spoke to the nurse who said she tried to call the Physician. He did not call her back until the next morning. She said they don't need to wait for the attending Physician to call back. They could have called the Medical Director. The Regional Director said the nurse is a new nurse and we started education on pain management. On 07/11/2023 at 3:35 p.m. Resident #3 was observed lying in bed on her right hip she smiled and waved her hand in a gesture to approach on the right side of the bed. She appeared thin and frail and said she was having pain. She asked, Can you move my leg, it hurts like that. Resident #3's Home Companion was present and stated, She needs to stay on her side. The Companion stated out loud, You can have another pain pill in 20 minutes. On 07/12/2023 at 10:47 a.m. a phone interview was conducted with the facility Medical Director he stated he was unaware Resident #3's narcotic was delayed for nineteen-hours. He confirmed he knew about Resident #3 and the surgical procedure that was performed he stated, That should not have ever happened the patient should not have suffered through this. We have mechanisms in place for emergency authorization for that. They have access to a Physician on call, if there is no script, we will call it in right way. That should never have happened. The Medical Director said, They need to educate the nurses, all of their problems are solvable. Educating the nurses that are not aware on how to get a hard script, again I think it is more of an education. A review of the facility policy titled Pain Evaluation Chapter: Neurologic Revised: 08/23/2016 revealed the following: PURPOSE: The assessment includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor residents to pain management interventions. It also attempts to target the site of pain. FUNDAMENTAL INFORMATION: Pain refers to any type of physical pain, or discomfort in any part of the body. Pain may be localized to one area or may be more generalized. It may be acute or chronic, continuous, or intermittent (comes and goes), or occur at rest or with movement. The pain experience is very subjective; pain is whatever the resident says it is. Procedure: 3. Observe resident for indicators of pain. Indicators include moaning, crying, and other vocalizations. 6. Assess on 0-10 scale (Wong_Baker). 7. Ask the resident and observe to determine the location of pain. 8. Contact the physician or orders.

Based on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice identified during a complaint survey conducted on 07/11/2023. The facility was cited during the complaint survey for F697. On 09/07/2023 through 07/08/2023 a revisit survey was conducted, and the facility was recited at F697. The facility had developed a Plan of Correction with a completion date by 08/11/2023. The facility had not comprehensively implemented the Plan of Correction for the identified quality deficiencies. Findings included: On 09/07/23 at 10:15 a.m., Resident #6 was observed sitting in her room in a wheelchair next to her bed. She stated she had a lot of pain in her right shoulder due to a stroke. She stated the nurse gave her Tylenol for the pain, but it only works for the first two hours. She stated the nurse gave her the medicine at the correct times, but she is in pain again after two hours. On 09/08/23 at 9:48 a.m., the resident was observed sitting on the side of her bed. A Physical Therapist was in the room setting Resident #6 up for therapy. The resident stated she was in pain, and it hurts all the time in her right arm and right shoulder. She stated she gets Tylenol, but it only works for two hours, and she has to wait another 2 to 4 hours in pain before she can get another pill. Resident #6 stated maybe if she had a sling to put the right arm in, it wouldn't hurt so bad. A review of the admission Record revealed Resident #6 was admitted on [DATE] with a diagnosis to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the Minimum Data Set (MDS), dated [DATE], Section C: Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of the Order Summary Report, with active orders as of 09/08/23, revealed the following orders for pain: 06/06/23- Pain Evaluation- Document pain level and non-pharmacological interventions. 06/10/23- Tylenol Oral Tablet 325 MG (Acetaminophen)- Give 2 tablet by mouth every 6 hours as needed for pain. A review of the Progress Notes revealed the following: 08/04/23 10:06 a.m.- Placed a call to the doctor on call in reference to the resident requesting Tylenol every 4 hours instead of every 6 hours. Message left with answering services. Awaiting medical doctor return call. A review of the care plan revealed the following focus area: Chronic pain, initiated on 06/06/23, and included the following intervention: discuss with resident the need to request pain medications before pain becomes severe. On 09/08/23 at 9:50 a.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN). Staff E stated she received report from the night nurse that she gave Resident #6 pain medication on her shift. Staff E, LPN, stated the nurse aide also told her Resident #6 was in pain earlier this shift but she had not made it to her room yet to give the resident pain medication. She stated if she would have known Resident #6 was in a lot of pain since yesterday, she would have reported this to pain management. On 09/08/23 at 12:36 p.m., the Interim Director of Nursing (DON) stated Resident #6 never mentioned a concern about pain to the Nurse Practitioner and she never mentioned being in pain to any staff member. The Interim DON stated she got an order for scheduled Tylenol for pain this morning and Pain Management will be seeing the resident. She confirmed there was no follow up note related to Resident #6 requesting Tylenol every 4 hours instead of every 6 hours. The Interim DON stated when she completed the audits related to pain, she focused on residents with scheduled pain medications versus residents with orders for as needed (PRN) medications. A review of the facility policy titled Pain Evaluation Chapter: Neurologic Revised: 08/23/2016 revealed the following: PURPOSE: The assessment includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor residents to pain management interventions. It also attempts to target the site of pain. FUNDAMENTAL INFORMATION: Pain refers to any type of physical pain, or discomfort in any part of the body. Pain may be localized to one area or may be more generalized. It may be acute or chronic, continuous, or intermittent (comes and goes), or occur at rest or with movement. The pain experience is very subjective; pain is whatever the resident says it is. PROCEDURE: 3. Observe resident for indicators of pain. Indicators include moaning, crying, and other vocalizations. 6. Assess on 0-10 scale (Wong-Baker). 7. Ask the resident and observe to determine the location of pain. 8. Contact the physician for orders. A review of the facility policy titled Quality Assurance and Performance Improvement- QAPI Chapter: Center Administration Revised: 08/30/2022 revealed the following: POLICY Each center maintains a Quality Assessment and Assurance QA&A Committee, which is responsible for developing the Quality Assessment and Performance Improvement (QAPI) plans. The committee develops, implements, monitors, and maintains appropriate date-driven programs that focuses on indicators of the outcomes of care and quality of life; plans of action to address quality issues identified internally or by regulatory agencies. Centers must present evidence of their ongoing QAPI program implementation and compliance with the requirements. e) Corrective actions address potential gaps in system processes, and are reevaluated for effectiveness; and f) Clear expectations are set around safety, quality, rights, choice, and respect. Purpose: The center develops a plan that describes the process for conducting QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of the residents, through continuous attention to quality of care, quality of life and resident safety.

Based on observations, interviews, and record review the facility failed to assist dependent residents with Activities of Daily Living (ADL's) by 1) not providing showers as scheduled for two residents (#1 and #6) of three residents sampled, and 2) not providing transfer assistance as requested for one resident (#7) out of three residents sampled. Findings Included: 1) A review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] and discharged on [DATE] with a primary diagnosis of wedge compression fracture of unspecified lumbar vertebra, subsequent encounter for fracture with routine healing. Further diagnoses included: collapsed vertebra, syncope and collapse, history of falling, muscle weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, repeated falls, fall on same level from slipping, tripping, and stumbling with subsequent striking against object. A review of the Minimum Data Set (MDS), dated [DATE], Section C: Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) summary score of 15. A score of 15 indicates the resident was cognitively intact. A review of Section G: Functional Status revealed help limited to one person for transfer. Section GG: Self Care revealed shower bathe/self-performance: substantial/maximal assistance. A review of Resident #1's Bathing documentation, dated January 2023 and February 2023, revealed showers were scheduled on Tuesday/Thursday/Saturday on the 3-11 shift. The documentation review reflected Resident #1 was provided showers on 1/12/23, 1/19/23, 1/21/23, 1/24/23, 1/26/23, 2/2/23, 2/4/23, and 2/7/23. Resident #1 received eight of the fourteen scheduled showers during her stay at the facility. On 7/10/2023 at 10:45 a.m. Resident #6 was receptive to an interview and smiled when approached. She appeared comfortable sitting in her wheelchair with her right leg elevated on three pillows. A sign was posted in the resident's room indicating her shower days were on Monday, Wednesday, and Friday. When asked about the sign she stated, Those are the days the facility provides showers, she laughed out loud and stated, I've never had three showers in one week. I get maybe one a week. She said she would be happy with two showers a week. Her hair was oily in appearance. Resident #6 said, I need help with my showers, my right leg doesn't work. It hasn't since I had a stroke, it's been like that for a few years now. Resident #6 said her last shower was, last Wednesday, or maybe Monday. She stated The aide did not help me. She stood behind the chair and talked on her phone the whole time. I need help I can't reach certain areas. Resident #6 reached with her right arm to the left side of her torso, she stated, I can't reach that far. A review of Resident #6's Admission Record revealed she was admitted to the facility on [DATE] with a diagnoses including Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side, localized swelling, mass and lump, lower limb bilateral. A review of the MDS, dated [DATE] revealed a BIMS total score of 15, indicating intact cognition. A review of the Resident #6's Bathing documentation, dated July 2023, revealed Showers/Bathing scheduled on Monday-Wednesday-Friday, evening shift. The review of the documentation reflected Resident #6 was provided showers on 7/5/23 and 7/8/23. There was no shower documented for 7/3/23. On 7/11/2023 at 4:30 p.m. the Nursing Home Administrator (NHA) stated she was unaware showers were not being performed as scheduled, she confirmed showers should be provided and documented as planned for the resident. 2) Resident #7 is a [AGE] year-old male resident admitted to the facility on [DATE] from an acute care hospital with diagnoses including but are not limited to, chronic kidney disease stage 3, dementia without behavioral disturbances, weakness, cognitive communication deficit, and muscle weakness. On 7/10/23 at 10:20 a.m. Resident #7 called out to the surveyor, Hey I need help in here! I need to get in my bed, I've been sitting here a long time! The resident rolled his eyes and turned on his call light. On 7/10/23 at 10:25 a.m. Resident #7's assigned Certified Nursing Assistant (CNA), Staff A, went into the resident's room, turned off the call light and walked out of the room. On 7/10/23 at 10:30 a.m. Resident #7 was reinterviewed, and he said, The girl came in, but she didn't say anything to me. I want something to eat, and I want to get in bed! I'm older than you and everyone here and I can't get any help around here! An interview was conducted on 7/10/23 at 10:38 am. with Staff D, CNA she said, When I went into the room for the call light, he [Resident #7] wanted to go back to bed but I just got him up and made his bed and I think he is going to therapy, and I just came out of another room. The CNA was informed the resident requested to get in bed again and wanted a snack. The CNA said He just had breakfast. I'm not sure if we have any snacks. The CNA asked the Unit Manager if the resident could have a snack and she obtained the snack and brought it to Resident #7 and immediately walked back out of his room. On 7/10/23 at 10:41 a.m. Resident #7 was observed still sitting in his wheelchair next to his bed and eating his snack. On 7/10/23 at 10:56 a.m. Resident #7 was observed still sitting in his wheelchair next to his bed and he yelled out Hey I need some help! Staff B, Registered Occupational Therapist (OTR) went into the resident's room and put the resident's call light on and went to talk with the nurse. On 7/10/23 at 10:58 a.m. Staff B, OTR checked back in with Resident #7 and said, I am still looking for your CNA. The resident was yelling, I need to get back in bed! Staff B, OTR stated I'm not sure how you transfer let me find out. Staff B, OTR called out to other staff from the resident's doorway. Staff B, OTR left the resident's doorway and walked over to another staff member and was overheard talking to the other staff member, I'm trying to find a CNA to transfer him. On 7/10/23 at 11:07 a.m. Resident #7 was observed to be lying in his bed covered with a sheet watching television. An interview was conducted with Staff B, OTR on 7/10/23 at 11:07 a.m. she said [Staff C, CNA] helped transfer [Resident #7] she's awesome. But I was asking around because [Resident #7] isn't my patient and I wasn't sure how he transferred. A review of Resident #7's Admission Minimum Data Set (MDS) Section C, Cognitive Patterns, dated 6/28/23, revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment. A review of Resident #7's care plan revised on 7/5/2023 revealed his ADL (Activities of Daily Living) Self Care Performance care plan had a goal of Resident will maintain current level of function through the review date. Interventions included but are not limited to Transfers: Hoyer x2 person assist. 39866

Based on observations, interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice identified during a complaint survey conducted on 07/11/2023. The facility was cited during the complaint survey for F697. On 09/07/2023 through 07/08/2023 a revisit survey was conducted, and the facility was recited at F697. The facility had developed a Plan of Correction with a completion date by 08/11/2023. The facility had not comprehensively implemented the Plan of Correction for the identified quality deficiencies. Findings included: On 09/07/23 at 10:15 a.m., Resident #6 was observed sitting in her room in a wheelchair next to her bed. She stated she had a lot of pain in her right shoulder due to a stroke. She stated the nurse gave her Tylenol for the pain, but it only works for the first two hours. She stated the nurse gave her the medicine at the correct times, but she is in pain again after two hours. On 09/08/23 at 9:48 a.m., the resident was observed sitting on the side of her bed. A Physical Therapist was in the room setting Resident #6 up for therapy. The resident stated she was in pain, and it hurts all the time in her right arm and right shoulder. She stated she gets Tylenol, but it only works for two hours, and she has to wait another 2 to 4 hours in pain before she can get another pill. Resident #6 stated maybe if she had a sling to put the right arm in, it wouldn't hurt so bad. A review of the Admission Record revealed Resident #6 was admitted on [DATE] with a diagnosis to include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A review of the Minimum Data Set (MDS), dated [DATE], Section C: Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of the Order Summary Report, with active orders as of 09/08/23, revealed the following orders for pain: 06/06/23- Pain Evaluation- Document pain level and non-pharmacological interventions. 06/10/23- Tylenol Oral Tablet 325 MG (Acetaminophen)- Give 2 tablet by mouth every 6 hours as needed for pain. A review of the Progress Notes revealed the following: 08/04/23 10:06 a.m.- Placed a call to the doctor on call in reference to the resident requesting Tylenol every 4 hours instead of every 6 hours. Message left with answering services. Awaiting medical doctor return call. A review of the care plan revealed the following focus area: Chronic pain, initiated on 06/06/23, and included the following intervention: discuss with resident the need to request pain medications before pain becomes severe. On 09/08/23 at 9:50 a.m., an interview was conducted with Staff E, Licensed Practical Nurse (LPN). Staff E stated she received report from the night nurse that she gave Resident #6 pain medication on her shift. Staff E, LPN, stated the nurse aide also told her Resident #6 was in pain earlier this shift but she had not made it to her room yet to give the resident pain medication. She stated if she would have known Resident #6 was in a lot of pain since yesterday, she would have reported this to pain management. On 09/08/23 at 12:36 p.m., the Interim Director of Nursing (DON) stated Resident #6 never mentioned a concern about pain to the Nurse Practitioner and she never mentioned being in pain to any staff member. The Interim DON stated she got an order for scheduled Tylenol for pain this morning and Pain Management will be seeing the resident. She confirmed there was no follow up note related to Resident #6 requesting Tylenol every 4 hours instead of every 6 hours. The Interim DON stated when she completed the audits related to pain, she focused on residents with scheduled pain medications versus residents with orders for as needed (PRN) medications. A review of the facility policy titled Pain Evaluation Chapter: Neurologic Revised: 08/23/2016 revealed the following: PURPOSE: The assessment includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor residents to pain management interventions. It also attempts to target the site of pain. FUNDAMENTAL INFORMATION: Pain refers to any type of physical pain, or discomfort in any part of the body. Pain may be localized to one area or may be more generalized. It may be acute or chronic, continuous, or intermittent (comes and goes), or occur at rest or with movement. The pain experience is very subjective; pain is whatever the resident says it is. PROCEDURE: 3. Observe resident for indicators of pain. Indicators include moaning, crying, and other vocalizations. 6. Assess on 0-10 scale (Wong_Baker). 7. Ask the resident and observe to determine the location of pain. 8. Contact the physician for orders. A review of the facility policy titled Quality Assurance and Performance Improvement- QAPI Chapter: Center Administration Revised: 08/30/2022 revealed the following: POLICY Each center maintains a Quality Assessment and Assurance QA&A Committee, which is responsible for developing the Quality Assessment and Performance Improvement (QAPI) plans. The committee develops, implements, monitors, and maintains appropriate date-driven programs that focuses on indicators of the outcomes of care and quality of life; plans of action to address quality issues identified internally or by regulatory agencies. Centers must present evidence of their ongoing QAPI program implementation and compliance with the requirements. e) Corrective actions address potential gaps in system processes, and are reevaluated for effectiveness; and f) Clear expectations are set around safety, quality, rights, choice, and respect. Purpose: The center develops a plan that describes the process for conducting QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of the residents, through continuous attention to quality of care, quality of life and resident safety.

Based on observations, record review, video surveillance review and interviews, the facility failed to protect one resident (#58) from physical abuse by two direct care staff members (Staff E and Staff F) of one resident sampled. Resident #58 was a victim of physical abuse as evidence by bruising on the resident's left wrist and a scratch to the resident's face resulting from Staff E physically pushing the resident, who fell to the ground with the resident's wheelchair toppling on him and leaving the scene without attempting to assist the resident. Findings included: A review of the medical record for Resident #58 revealed an occurrence note dated 03/21/22 at 21:57 (9:57 p.m.) documenting the following: This writer [Staff G, Registered Nurse], walked toward the elevator when I heard the yelling. Observed resident [#58] half sitting on the floor with wheelchair on the side in front of the elevator. I was trying to get in my apartment and two girls tries to hit me. Upon the assessment, resident has small scratch below his left nose and above lip. Small bruise on left wrist. Resident complains of right lower extremity, knee, and ankle pain. Helped resident back to wheelchair with other nurse. Notified on call through telehealth. Unable to contact family and left message for daughter to call facility. Tylenol 650 given for pain, effective noted. An Event/Interview Statement dated 03/21/22 from Resident #58 revealed, I was trying to get into the apartment and these two black girls beat me up. An Event/Interview Statement dated 03/22/22 from Resident #58 revealed, I was drinking last night. These two girls helped me off the floor because I kept falling down. A handwritten statement from Staff F, Certified Nursing Assistant (CNA) dated 03/21/22 revealed the following: On 03/21/22, I was in the elevator and resident [#58] tried to enter the elevator and the nurse and I told him he couldn't come on the elevator. The resident became combative and got out of his chair and walked onto the elevator. The nurse and I tried to redirect the resident back into his wheelchair and then he became combative again and fell out of his wheelchair after trying to get up again. Another handwritten statement from Staff F, CNA, dated 03/22/22 at 3:21 p.m., revealed answers to questions with more of a description of what occurred. The statement showed: What occurred(?) I was getting on the elevator to take my break. He tried to get on the elevator. I pushed him back using the wheelchair arms. He got out of the chair and became combative he got in the nurse's face saying, I'll kill you. Did you come out of the elevator to assist him back in his chair (from the elevator)(?) No I was behind the nurse. He stumbled over his chair and fell . Did the nurse make contact with him? Yes she grabbed his arm to get him off the elevator. When he fell what did you do? The nurse on the elevator told the other nurse on the floor that he had fallen and we went down the elevator. A handwritten statement by Staff E, Licensed Practical Nurse (LPN), revealed the following: Resident (#58) tried getting on the elevator with this writer along with another staff member. When tried to redirect resident, he became verbally abusive and stood up to come on the elevator. This writer attempted to escort resident off elevator when he became combative and yelling I will kill you. Along with another staff member, resident was attempted to be put back in wheelchair when resident pulled his arm away losing his balance and fell over his wheelchair. With the help of nurse present and the mechanical lift, resident was placed back in wheelchair. An Event/Interview Statement dated 03/21/22 from Staff G, Registered Nurse (RN) revealed: I heard some yelling. I went over to the elevator and saw the resident sitting on the floor with the wheelchair overturned. I told the resident to wait until I could find someone to help him up. I walked to find someone and then I found the other nurse coming up the elevator. She then helped me assist him back to his wheelchair. A review of the Admission Record revealed Resident #58 was readmitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C- Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #58 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderately impaired cognition. Section G- Functional Status of the same MDS indicated the resident needed the following assistance: B. Transfer- limited assistance with one-person physical assist, C. Walk in the room- activity only occurred once or twice, D. Walk in corridor- activity only occurred once or twice, E. Locomotion on unit- Supervision with one-person physical assist, F. Locomotion off unit- Supervision with one-person physical assist. Resident 58's active care plan showed: Focus - (Resident #58) uses [CONDITION(S)] medications r/t (related to) depression, anxiety, and [CONDITION(S)] and [CONDITION(S)] disorder, initiated 2/23/22. Interventions included monitor occurrence of target behavior symptoms, monitor specific target behaviors: possible risk and causal/contributing factors for behavior, desired outcomes, ongoing efficacy of individualized/nonpharmacological approaches and potential for adverse consequences. Focus - (Resident #58) has potential to demonstrate physical behaviors. Resident will sometimes wander into rooms. I can make sexually inappropriate comments to staff at times. I will disrobe and pack personal belongings, initiated on 2/15/21. Interventions included be firm with resident when making sexually inappropriate comments. A review of the 3/10/22 mental health services visit notes Resident #58's medications were reviewed and according to staff Resident #58 was unstable with mood disturbances, making inappropriate sexual comments and having delusions. Regular follow up is needed to assess for the need of Gradual Dose Reductions (GDR). Psychiatric medications are being used when behavioral and supportive interventions are not enough to improve patient's status. Behavioral approach, meetings, care giver education will serve as nonmedicinal and preventive interventions. On 06/22/22 at 10:50 a.m., the Social Services Director (SSD) reported she received a call from the Director of Nursing (DON) on April 21st that said (Resident #58) reported two African American females had beat him up in his apartment. She then called the nurse, (Staff G, RN) to get more information. The DON reported to her that (Staff G, RN) called her and stated (Resident #58) reported two African American females beat him up. She asked Staff G, RN, if anyone met that description because she did not know who it was, and he could not tell them. The resident has had some increased confusion, so they didn't know what was going on. Resident #58 has an extensive psych history. He knows he was at a nursing home and knows his family. When his medications were not working and he was not stable, he starts seeing things, so they got psych to come in. The SSD called the State Agency that evening and notified law enforcement. Law enforcement did not come out at this time and said to revert over to State Agency. The next morning when they (State Agency) came into the facility, they reviewed the camera. The Administrator at that time reviewed the camera system and found video of the allegation occurring. In reviewing the video, he (Resident #58) was trying to get on the elevator with (Staff E, LPN) and (Staff F, CNA). The incident happened on the third floor. They observed the resident sitting in the wheelchair and self-propelled to get onto the elevator. After both staff were observed getting in the elevator, the resident starting wheeling into the elevator. Staff F, CNA put her hand on the wheelchair armrest to push him back into the hallway. She could be seen trying to redirect him. Resident #58 then started swatting at her hand. Staff F, CNA steps back into the elevator and he again propelled toward the elevator. He then stood up and walked into the elevator. Staff E, LPN was in the corner of the elevator and you couldn't see her on the video. When Resident #58 walked into the elevator you could see a reflection of hand motions. The resident stumbled back to the unlocked wheelchair and went to grab the arms of the wheelchair. It looked like he was about to sit. Staff E, LPN then pushed him and he fell down. Resident #58 fell back and the wheelchair flipped on top of him. Neither of the staff members got off the elevator to check on the resident. He was just sitting on the floor. Staff G, RN came around the corner to access him and observed his cheek and arm bleeding. Staff G, RN reported she heard some arguing. She removed the wheelchair from on top of Resident #58 and because he was on the floor, she couldn't pick him up. She paged someone to assist her. Staff E, LPN and Staff F, CNA had gone on break. Staff E, LPN came back up about seven minutes later. She stepped over the resident and walked past him and did not assist him off the floor. Staff E, LPN, Staff G, RN, and another CNA came to help (place Resident back in wheelchair). The SSD reported she called State Agency again due to the video showing everything that happened and law enforcement. An officer and State Agency came out and viewed the video. The officer and State Agency spoke with the resident. He told State Agency nothing happened. Resident #58 stated he was trying not to get the girls in trouble and started crying. Originally, the resident said he was drunk and had just come home from the bar. The SSD contacted the family and told them the two staff members involved would never be at the facility again. Staff F, CNA was terminated and they were going to take actions against both staff members. The state attorney's office was involved with Staff E, LPN. The SSD got a statement from Staff F, CNA and she later admitted the nurse hit the resident in the elevator and she was scared to report this because she didn't know what the nurse was going to do to her. She was afraid of the nurse. Staff E, LPN was terminated. She was employed at the facility through an agency. Staff E, LPN, and Staff F, CNA were reported to the board of nursing on 03/22/22. Another State Agency came out and took a copy of the video. The outside agencies were not really focused on Staff F, CNA because she did not actually put her hands on Resident #58. The SSD later received a letter that Staff E, LPN's license was suspended, and the state attorney general was pursuing charges to arrest her. She was arrested May 12th or 13th. They received a letter that they would have a zoom call to bring formal charges. The court case is in September (2022). Staff E, LPN did not have a lot of alert and oriented residents on her assignment. They did skin assessments for bruises and injuries on the residents. All staff members were reeducated related to abuse. Staff F, CNA had just started working at the facility at the end of February (2022). She had only been an employee for two weeks. Abuse training was covered in orientation. For agency staff, they have a packet and there was information about abuse and neglect in the packet. Staff E, LPN had one incident of child abuse in 2011 or 2012. Staff F, CNA background screening was clear. She stated Mental Health Services saw Resident #58 after the incident and had been following him prior to the incident. He has been fine since the incident. Both staff initially stated the resident fell trying to get into the wheelchair. A Health Care Provider Complaint Form dated 03/22/22 for Staff F, CNA, indicated on 03/21/22 Resident #58 was attempting to get onto the elevator. Staff F, CNA and Staff E, LPN, attempted to get on the elevator. The CNA pushed the resident back to prevent him from getting on the elevator. The resident stood up and attempted to enter the elevator. Both staff pushed the resident knocking the resident over the wheelchair onto the floor. A Health Care Provider Complaint Form dated 03/22/22 for Staff E, LPN, indicated on 03/21/22 Resident #58 was attempting to get on the elevator. Staff E, LPN physically assaulted the resident scratching his face and knocked him over the wheelchair. A review of the Agency Personnel/Contractors Checklist dated 01/27/22 for Staff E, Licensed Practical Nurse (LPN), revealed Abuse Prohibition was reviewed with agency personnel/contractors on his or her first visit to the facility and prior to contact with residents. After reviewing all information on the checklist, it was signed by the agency person/contractor and the facility representative to verify that the orientation had been completed. The completed checklist was returned to the facility's Staff Development Coordinator or facility designee. The orientation materials are retained by the agency person/contractor for future reference. Staff E, LPN signed the form on 01/27/22. The Employee Education Record for Staff F, CNA revealed she was hired on 03/08/22 and completed education related to Abuse & Neglect- Preventing, Recognizing, and Reporting Abuse. A review of the 3/24/22 mental health service visit notes Resident #58's medications were reviewed and according to staff Resident #58 continues with mood disturbances, reporting verbalize abuse to staff. A review of the medical record revealed a Certificate of Professional Initiating Involuntary Examination form dated 3/25/22 showing Resident #58 was Baker Acted due to agitation and being a threat to staff and other residents. Patient refused to take psychotropics and had become increasingly impulsive and a danger to others. On 06/22/22 at 12:27 p.m., the survey team viewed the video surveillance with the SSD. Resident #58 was observed seated in his wheelchair near the elevator for about 5 minutes. Staff F, CNA and Staff E, LPN walked up to the elevator. When the elevator door opened, the nurse said something to the resident, and the two staff got on the elevator. The resident attempted to get on the elevator. The CNA was observed pushing the wheelchair back into the hallway. Resident #58 started hitting at her and stood up from the wheelchair and walked into the elevator. You could see hand motions reflected on the elevator door which appeared to be some tussling, but we could not see what was going on. Resident #58 was observed walking out of the elevator and Staff E, LPN was observed pushing the resident, he fell to the floor, and the wheelchair flipped on the top of him. The two staff left on the elevator and did not attempt to help the resident. The resident was sitting on the floor. Staff G, RN came up to assess the resident and left. Minutes later Staff E, LPN came back to the unit and walked past the resident as he was still on the floor. She did not stop. She glanced at resident and kept walking. Staff E, LPN later came back and helped Staff G, RN lift the resident with a mechanical lift. Staff G, RN was observed rubbing something on the resident's arm and face. Staff G, RN was unavailable for interview. On 06/23/22 at 10:53 a.m., Resident #58 was observed sitting in his wheelchair in the hallway near the nursing station on the third floor. He appeared very calm. When asked how he was doing, he stated he was ok and smiled. He stated staff were treating him okay. The policy provided by the facility titled, Abuse & Neglect Prohibition, revised 05/23/2017 revealed the following: Policy Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, exploitation, and misappropriation of property. Definitions Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.