Every finding on record at Brookridge Cove Rehabilitation and Care Center

Based on facility document review, interviews, record review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet the residents' needs as evidenced by not following the facility assessment staffing guidelines for 15 of 15 shifts reviewed from 01/04/2025 day shift through 03/06/2025 night shift. The findings include: The Facility Assessment indicated the facility acuities affecting licensed nurses included cancer treatments, respiratory treatments, behavioral and mental health, medication management, high risk of intravenous or intramuscular medications and infusions, dialysis care which was contracted with an outside vendor, ostomy care, hospice care also contracted with an outside vendor, respite care, isolation precautions/education/monitoring, wound care, tube feedings/parenteral nutrition and drain/tube management. The Facility Assessment indicated the facility acuities affecting nurse aides indicated assistance provided with dressing 90%, assistance provided with bathing 100%, assistance provided with transfers 90%, assistance provided with eating 95%, assistance provided with toileting 90-95%, assistance provided with mobility 70-75% with varying times and distances, assistance provided with splints/braces 25-30 residents, assistance provided with behavioral symptoms, 50% of the population. The facility assessed their coverage needs to adequately meet the residents' daily needs per shift as: Registered Nurses (RN): - Director Of Nursing (DON): One RN full-time, 5 days a week; Assistant Director of Nursing (ADON): two RNs full-time, 5 days a week; Minimum Data Set (MDS) Coordinator: 5 days a week; Other RN: 5 days a week. Days may vary, to include at least one full-time RN every day. Overall staffing coverage needed for RNs per day equaled eight hours per day. Licensed Nurses and Certified Nursing Assistants (CNAs): The following staff recommendations were indicated for licensed nurses and CNAs: For a census of 95 to 99, day shift required 18, evening shift required 11 to 12, and night shift required 8. For a census of 101 to 103, day shift required 18-19, evening shift required 11 to 12, and night shift required 8. For a census of 106 or greater, day shift required 20 to 21, evening shift required 15, and night shift required 10 to 11. A review of documents titled Time Punch Sheets for January 2025 through March 2025 daily staffing was reviewed from the employee's time clock punch reports starting with the day shift on 01/04/2025 on specific dates through the end of the night shift on 03/06/2025. Using staffing guidelines defined by the facility in their 05/26/2025 Facility Assessment the bedside staff coverage was found lacking coverage by either a partial or complete shift on the following days: 02/01/2025 Day Shift: 1 RN worked 9:03AM-3:00 PM; 2 LPNs; 13 CNAs. Per facility assessment with a census of 106+ Day Shift should have 5-6 LPNs, 15 CNAs. Evening Shift: 2 RNs (1 RN worked 3:00 PM-7:00 PM);1 LPN; 12 CNAs (1 CNA worked 3:00 PM – 7:00 PM). Per facility assessment with a census of 106+ Evening Shift should have 4 LPNs and 11 CNAs. Nights Shift: 1RN; 2 LPN; 7 CNAs. Per facility assessment with a census of 106+ Night Shift should have 2-3 LPNs and 8 CNAs. 02/02/2025 Day Shift:1 RN hours worked 9:00AM-3:00 PM; 2 LPNs; 14 CNAs (1 CNA worked 8:00 AM-3:00 PM.) Per facility assessment with a census of 106+ Day Shift should have 5-6 LPNs and 15 CNAs. Evening Shift:2 RNs, 1RN worked 3:00 PM-7:00 PM; 1 LPN; 12 CNAs (1 CNA worked 3:00 PM – 7:00 PM). Per facility assessment with a census of 106+ Evening Shift should have 4 LPNs and 11 CNAs. Night Shift: 1 RN; 2 LPNs; 7 CNAs. Per facility assessment with a census of 106+ Night Shift should have 2-3 LPNs and 8 CNAs. 02/15/2025 Day Shift- 1 RN worked 9:30AM-3:00 PM; 2 LPNs; 10 CNAs (1 CNA worked 7:00 AM-11:00 AM). Per facility assessment with a census of 106+ Day Shift-should have 5-6 LPNs and 15 CNAs. Evening Shift: 2 RNs (1 RN worked 3:00 PM-6:30 PM); 2 LPNs (1 LPN worked 3:00 PM-7:00 PM); 10 CNAs (1 CNA worked 3:00 PM-7:00 PM). Per facility assessment with a census of 106+ Evening Shift should have 4 LPNs and 11 CNAs. Night Shift: No RNs worked this shift; 2 LPNs; 6 CNAs. Per facility assessment with a census of 106+ Night Shift should have 2-3 LPNs and 8 CNAs. 02/16/2025 Day Shift: 1 RN worked 9:45AM-3:00 PM;1 LPN; 13 CNAs (1 CNA worked 7:00 AM-10:45 AM). Per facility assessment with a census of 106+ Day Shift should have 5-6 LPNs and 15 CNAs. Evening Shift: 2 RNs (1 RN worked 3:00 PM-7:00 PM); 3 LPNs (1 LPN worked 3:00 PM-7:00 PM); 12 CNAs (1 CNA worked 7:00 PM-11:00 PM). Per facility assessment with a census of 106+ Evening Shift should have 4 LPNs and 11 CNAs. Night Shift:1 RN; 2 LPN;6 CNAs. Per facility assessment with a census of 106+ Night Shift-should have 2-3 LPNs and 8 CNAs. 03/01/2025 Day Shift:1 RN worked 9:30AM-3:00 PM; 3 LPNs; 13 CNAs (1 CNA worked 9:00 AM-3:00 PM and another worked 8:00 AM-3:00 PM). Per facility assessment with a census of 106+ Day Shift should have 5-6 LPNs and 15 CNAs. Evening Shift:2 RNs (1 RN worked 3:00 PM-7:00 PM);3 LPNs1 (LPN worked 3:00 PM-9:00 PM); 9 CNAs (2 CNAs worked 3:00 PM-7:00 PM). Per facility assessment with a census of 106+ Evening Shift should have 4 LPNs and 11 CNAs. Night Shift: 1 RN; 2 LPNs; 6 CNAs. Per facility assessment with a census of 106+ Night Shift should have 2-3 LPNs and 8 CNAs. Based on the information listed above, the facility did have RN coverage for eight consecutive hours each day. A review of a document titled, Incident by Incident Type, reviewed for a date range from 01/01/2025 to 03/31/2025, revealed 7-Physical aggression-initiated incidents; 9-Physical aggression received incidents; 9-Injury of known cause incidents; 23-witnessed fall incidents; 73- un-witnessed fall incidents; 4-Falls during staff assist incidents;15- Skin concern incidents; 1-Other incident. A review of a Grievance Log, from 01/01/2025 to 03/31/2025, revealed several grievances, which included residents not being turned, perineal care not being completed, call lights not being answered and clothes not being changed. During an interview on 07/28/2025 at 11:05 AM, Resident #67 stated staff took a long time to answer the call lights, due to not having enough staff. The resident did not specify a specific shift. During an interview on 07/28/2025 at 11:15 AM, Resident #72 stated the facility was short staffed on nights and weekends most of the time, and it took a long time for staff to change my diaper. The resident reported they would get irritated under their brief, due to staying wet for long periods, but did not have any breakdown from it. During an interview on 07/28/2025 at 12:11 PM, Resident #32 stated it took hours for CNAs to change the resident's brief. The resident stated they had called the front desk on their cell phone to have them change their brief. The resident reported the staff recognized their number, and now their calls would not go through. Resident #32 reported there were not enough staff there. Resident #32 revealed they had worn their wet brief for so long, they had to dig the plastic clips that hold the brief out of their skin. During an interview on 07/28/2025 at 11:53 AM, Resident #52 stated it took staff a long time to answer the call light, with the weekdays being the worst, staff stated they were too busy. During a concurrent interview and observation on 07/28/2025 at 1:00 PM, Resident #97 stated they used a urinal and wore a brief. This surveyor observed two half-full urinals sitting on the bedside table which left a strong, foul odor in the room and outside in the hall. The resident stated the facility had been short-staffed, which affected the care they provided. Resident #97 stated it took too long, and being dependent on staff for everything made it hard sometimes. Resident #97 revealed the longest time they had to wait for staff to change their brief was four hours. During an interview on 07/30/2025 at 10:49 AM, Resident #32's family member stated, the facility was always short staffed and always made excuses. Resident #32's family member also indicated facility staff left the resident lying in a urine-soaked bed with a full diaper. Resident #32's family member stated staff changed the brief but left the bed soaking wet. The family member reported they checked that when they first arrived. The family member had mentioned to the nurses how soaked the bed was and was told, if you get the resident up to a chair, we will change the linens. Resident #32's family member stated they spoke to the DON about the resident lying in a dirty brief for two hours on urine soaked linens. The family member revealed staff stated they would change the resident when it was the residents' turn. The family member stated, the facility did not have enough staff during all shifts and the ones [staff] they did have did not care. During an interview on 07/30/2025 at 1:49 PM, CNA #12 stated all residents' positions should be changed every two hours or as needed. She stated she frequently started the shift with residents in a dry brief and soaked bed. The residents that could talk would tell staff they were cold, and needed a blanket, or were dirty due to being left in a soaked bed. CNA #12 stated, The staff during Monday through Friday night shift does not know how to place a diaper on correctly. CNA #12 stated it was harder on the day shift staff to clean all the residents, due to being frequently short staffed. During an interview on 07/30/2025 at 3:06 PM, LPN #9 stated there had been residents with dry briefs on, left with soaking wet bed linens. I see it more than I should. We are short staffed at times. During an interview on 07/30/2025 at 6:24 PM, Resident #111's family member revealed staff always stated they were short staffed or would say other staff were supposed to come in but had not shown up to work, therefore they were not able to get to the residents timely. During an interview on 07/31/2025 at 11:18 AM, CNA #14 revealed there were some halls where the call lights would go off for a long period of time, and some of us staff frequently leave our hall to help the residents on other halls, so there would not be an incident of a resident getting hurt or skin breakdown. CNA #14 stated there were times when the staff would be so busy, due to being short staffed that they would not have time to complete all their required assignments or tasks for that shift. CNA #14 also revealed staff were frequently asked to stay over to cover a call in or to work an extra shift due to being short staffed. During an interview on 07/31/2025 at 11:42 AM, CNA #15 stated there have been a few times baths were not given to the residents, due to not having enough staff. CNA #15 stated, You can only do so much. CNA #15 did not specify which shift but stated that weekends were always low staffed due to employees not wanting to work. CNA #15 revealed the task they had a hard time completing was changing the residents' briefs during the last round. CNA #15 stated they were asked to stay late, work over, or come in early to help due to call ins on a regular basis. During an interview on 07/31/2025 at 2:29 PM, the DON defined direct care staff as staff that provided direct care to the residents, and the staffing matrix was defined as the number of staff used to provide care to the residents. The DON revealed that to determine the staffing levels needed to meet residents needs each day and during emergencies, the Administrator met annually with the DON, the ADONs and the Regional [NAME] President (RVP) to review the halls, the census, and what licensed staff were needed. She reported they would review what type of residents were on the halls, and how they assigned staff to a hall according to the residents' care. The DON revealed there were times staff had talked to her about workload concerns, and she stated she reassured them adjustments would be made. The DON stated the workload was adjusted, time management skills were reviewed, and she made changes to the system. The DON reported in the last six months; the facility had experienced low staffing. She also reported some residents had been wet at shift change but did not have adverse effects from these incidents. During an interview on 07/31/2025 at 4:59 PM, the Administrator verified direct care staff as someone that had a certification or license and took direct care of the residents. The Administrator reported they have had grievances on staff starting their shift with residents that had wet briefs and wet linens from not being changed. He also revealed that they would have to read the actions taken to find out what was done for that grievance. During an interview on 08/01/2025 at 11:15 AM, the Administrator and RVP asked this surveyor what was flagged on the Payroll Based Journal (PBJ). The Administrator stated they were always above the required staffing numbers. The reports provided titled Monthly Reporting Average Direct Care hours, showed the report was from a third-party service and was tallied on an average of staffing for the month not daily or per shift. He mentioned that they had different office personnel that were CNAs that would work the floor instead of in their office when they were short staffed. He stated when they worked the floor and not in their office, they would sign in on the daily staffing log for that shift, with the hours worked. A review of a facility policy titled, Facility Assessment, dated 05/26/2025, indicated they had an average daily census of 105-110. Common diagnoses of the facility's residents included psychiatric/mood Disorders, heart and circulatory system disorders, intellectual disabilities, neurological system disorders, vision and hearing disabilities, musculoskeletal system disorders, cancers, respiratory disorders, metabolic disorders, genitourinary disorders, blood diseases, digestive system disorders, skin conditions and infectious diseases.

Based on observation, interview, and facility policy review, the facility failed to ensure that the dish washing machine vent hood was free of rust; the pest trap was free of rust and dirt; two of three ice machines were maintained in a clean and sanitary condition in one of two kitchens; expired food item was promptly removed / discarded on or before the expiration or use by date, and dietary staff washed their hands before handling clean equipment or food items for two of two meals observed.Based on observation, interview, and facility policy review, the facility failed to ensure a pest trap was free of rust and dirt and kept away from meal preparation areas; two of three ice machines were maintained in a clean and sanitary condition in one of two kitchens; expired food items were promptly removed and discarded on or before the expiration or use by date, and dietary staff washed their hands before handling clean equipment or food items for two of the two meals observed. The findings include: During an observation and concurrent interview on 07/28/25 at 10:10 AM, one box on a shelf under the food preparation counter contained 10 bags of 12 hot dog buns. Another box contained two bags of 12 hot dog buns with a received date of 07/09/2025. All hot dog buns showed a sage discoloration on them. The Dietary Manager (DM) stated there was mold on the hot dog buns. The manufacturer's specification on the box indicated for the hamburger buns and hot dog buns to be kept frozen at 0 degrees Fahrenheit or below. The DM stated the hot dog buns had been out of the freezer since they were received. The facility Dietician verified that the buns were supposed to be kept frozen. Once removed from the freezer, they should be used within seven to 10 days. During an observation and concurrent interview on 07/28/25 at 10:30AM, Dietary Aide (DA) #1 lifted the trash can lid and threw away a tissue. Without washing her hands, she picked up cups by the rim and placed them on the trays to be used in serving beverages to the residents for the supper meal. DA #1 stated she should have washed her hands after touching the trash can. During an observation and interview on 07/28/25 at 11:21 AM, the metal covering of the pest trap on the wall above the food preparation counter was rust colored and loose. The cord attached to the pest trap had a greasy, dusty substance stuck to it. The pest trap cord was hanging down toward a basket containing napkins with utensils meant for the residents to use during their meals. The DM stated that it should not have been there. During an observation and concurrent interview on 07/28/25 at 11:27 PM, Dietary [NAME] (DC) #2 turned on the sink faucet to wash the blender bowl, blade, and lid. After sanitizing the equipment, DC #2 turned off the faucet with her bare hand. Without washing her hands, she then picked up a clean blade and attached it to the blender to puree food items to be served to the residents. DC #2 stated she should have washed her hands after touching dirty objects and before handling clean equipment. During an observation on 07/28/25 at 12:19 PM, the following observations were made in the freezer in the treatment room on 400 hall. a. A box of crackers on top of the freezer had an expiration date of 05/08/25. b. A box of honey buns on top of the freezer had an expiration date of 07/15/25. During an observation and concurrent interview on 07/28/25 at 12:28 PM, the ice machine located by the kitchen door, and the ice machine in the kitchen both had an accumulation of wet black residue at the corners of the panel inside the ice machine and on the area where ice traveled down to the ice collector. There was a wet accumulation of black residue on the inside body of the ice machine that was loose and could have fallen onto the ice. The DM stated she cleaned the ice machine once a week. She also verified that the Certified Nursing Assistants used the ice for the water pitchers in the residents' rooms and the ice machine in the kitchen was used to fill beverages served to the residents at mealtimes. The DM confirmed both ice machines were dirty with black residue. During an observation and concurrent interview on 07/28/25 at 1:17 PM, an opened box of tea was on a rack. The box was not covered or sealed, which exposed it to air, heat and moisture. The DM stated air getting in the bag would cause it to lose freshness. During an observation and concurrent interview on 07/28/25 at 5:13 PM, DC #3 removed gloves from her pocket, pushed a cart towards the food preparation table, contaminating her hands in the process. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items. When DC #3 was ready to place corndogs into the blender to ground. This surveyor immediately stopped DC #3 before the blender could be used. DC #3 stated she should have washed her hands after touching dirty objects and before handling clean equipment. During an observation and concurrent interview on 07/29/25 at 8:10 AM, DC #4 turned on the three- compartment sink faucet and rinsed a spatula. After rinsing the spatula, DC #4 turned off the faucet with her bare hand. Without washing her hands, she then placed gloves on her hands. Then DC #4 removed slices of bread from the bread bag to be used in preparing French toast for breakfast. This surveyor immediately stopped DC #4, who stated she should have washed her hands after touching dirty objects and before handling food items. During an observation and concurrent interview on 07/29/25 at 8:25 AM, DC #5 turned on the two-compartment sink faucet and washed her hands. After washing her hands, she turned off the faucet with her bare hand. Without washing her hands, DC #5 picked up a bowl with her fingers inside the bowl and poured instant oatmeal into the bowl to be prepared and served the residents. DC #5 stated that she should have washed her hands after touching dirty objects and before handling clean equipment. A review of the facility policy titled, Hand washing and glove usage in food service, indicated hands should be washed before starting work, after leaving and returning to the kitchen preparation area and after touching anything else such as dirty equipment and work surfaces. A review of the facility policy titled, [Name brand and model] Ice Machine Technician's Handbook, Indicated under preventative maintenance cleaning that the cleaning procedure can be performed between the bi-annual cleaning and sanitizing cycles and does not require removing the ice from the ice bin.

Based on record review, interviews, and social media observations, the facility failed to ensure a resident's photograph was not posted on social media without permission and was not visible to the public or other residents, to maintain dignity and privacy for one (Resident #70) of one resident observed.The findings include:Record review of a document titled, Division of Aging and Adult Services, dated 03/06/2017, indicated that Adult Protective Services (APS) was Resident #70's custodian.Record review of a document titled, Physician Affidavit, dated 12/03/2018, indicated Resident #70 was mentally and physically impaired and the physician recommended that the resident remain in the protective custody of the Arkansas Department of Human ServicesReview of photos posted on social media under the facility's page revealed photos of Resident #70. Included were photos showing Resident #70 with food stains on the resident's shirt and the resident eating with food on their mouth. During an interview on 07/31/2025 at 9:47 AM, Human Resources indicated that the Activities Department was responsible for displaying any photographs of the residents on the facility's social media. She indicated that permission to display a resident's photograph should be obtained during the admission process.During an interview on 07/31/2025 at 10:10 AM, the Social Services Director (SSD) indicated that even if Resident #70 had given consent to have their photograph taken, if the resident did not look presentable in the photograph, she would expect that the photograph would be deleted. She also indicated if a facility posted a photograph of a resident on social media without consent of the resident that would be against their rights.During an interview on 07/31/2025 at 10:35 AM, the Activities Director (AD) indicated that during admission to the facility the SSD obtained permission from the resident or resident's representative to take and display photographs of the resident during activities. She indicated she could take photographs and display the photographs on the facility's social media page. She also indicated that the Administrator, the Assistant Administrator, and the Director of Nursing may also post photographs to the social media page. She added she was the main staff member to add photographs of residents to social media. She indicated if a photograph was appropriate, she could post it. She reported only family members could join the facility's social media account. She indicated that on 07/31/2025 there were 1,800 followers that would be able to view the photographs posted on the facility's social media page. She reported that even if Resident #70 had given permission for photographs to be taken and a photograph was taken where the resident was not presentable, she would expect that the photograph would be deleted and not displayed.During a telephone interview on 07/31/2025 at 2:48 PM, Resident #70's APS guardian stated the facility cannot have Resident #70's photo displayed. The APS Guardian reported she was not aware that the resident's photographs were on social media or any other public viewable forum. She also indicated that when a resident was under custody of APS, the resident's identifying photo may be taken and posted on the resident's admission record only. She reported that the facility does not have permission to post the resident's photo to any social media or any other public viewable forum. She indicated the facility should have admission paperwork filled out by APS that specifically states permission was not given to post the resident's photo. The APS guardian reported Resident #70 became custody of APS in September of 2016.During an interview on 07/31/2025 at 5:09 PM, the AD verified the photos from the facility's social media page were Resident #70 with food stains on their shirt and the resident eating with food on their mouth. The AD verified that the background in the photograph was the inside of the facility and that she had taken the photographs of Resident #70 and posted the photographs to the facility's social media. She indicated she would not want the facility represented by photos of residents with food on resident's mouths and clothes. AD stated I am pretty sure the resident was able to consent to having photographs taken and posted for public display.During a telephone interview on 08/01/2025 at 12:06 PM, Resident #70's APS guardian reported she had been unable to locate the resident's admission paperwork at the APS office. She reported that the facility should have the admission paperwork which was signed by APS when the resident was taken under custody of APS.During an interview on 08/01/2025 at 12:32 PM, the Administrator reported that the facility had multiple social media accounts. The Administrator stated the AD, assistant administrator, and the administrator all have permission to post photographs of residents on the facility's social media page. He indicated that he was responsible for the social media of the facility. He also indicated the AD posted most photos and the facility would need a photograph release form with permission from the residents, if they were their own responsible person. He verified that the facility social media account was publicly shared. The Administrator stated he did not realize the site had 1,800 followers who would be allowed to view the posted photographs of the residents. He reported he did not know if Resident #70 could provide consent for themselves. He stated APS was the guardian for Resident #70. The Administrator also indicated the facility did not have a policy for social media display and he was not aware of any rules of not posting the photograph of a resident in custody of APS. He described Resident #70 in the photograph that was posted on the facility's social media. He also described Resident #70 as having food on their face and on both sides of Resident #70's mouth. The Administrator indicated Resident #70's photographs should not be posted on social media without signed consent. Review of a facility policy titled, Resident Rights and Responsibilities, indicated every resident will be treated with consideration, respect and full recognition of dignity and individuality. It further indicated every resident has the right to know that photographs and interviews shall not be released without written consent of the resident or responsible party.

Based on observations, record review, interviews, and facility policy review, it was determined the facility failed to ensure that staff performed proper hand hygiene when providing incontinent care for two (Resident #56 and Resident #92) of two residents observed and followed Enhanced Barrier Precautions (EBP) for one (Resident #92) of one resident observed for EBP. The findings include: Resident #56 On 07/30/2025 at 9:40 AM, during an observation of incontinent care for Resident #56 this surveyor observed that Certified Nursing Assistant (CNA) #8 and CNA #7 did not utilize hand sanitizer at any time while providing incontinent care for Resident #56. After removing dirty gloves, CNA #8 and CNA #7 did not sanitize their hands before putting on clean gloves. Both CNA #8 and CNA #7 removed the dirty gloves, placed them in the trash bag and then reached into their scrub top to obtain new gloves without hand sanitizer being utilized. CNA #8 and CNA #7 both participated in the dirty and clean tasks of incontinent care. CNA #8 tucked used wipes between the resident's legs. CNA #8 wiped the resident's skin more than once with the same wipe, multiple times. CNA #7's name tag, bare skin on arms and scrub top were against the resident and the resident's bed linen multiple times during incontinent care. CNA #8 and CNA #7 both obtained clean wipes with dirty gloves. CNA #8 and CNA #7 were putting a clean brief on the resident, and both verbally verified they were finished with peri care. CNA #8 then used clean wipes to show this surveyor that Resident #56 was properly cleaned. The clean wipes had return of stool on the wipe which indicated the stool remained on the resident. Numerous wipes were required to continue cleansing the resident of stool. CNA #7 used the same dirty gloves utilized for perineal care, to close the wipes container, and place that container back with the resident's belongings beside the bed. She then used the same dirty gloves to move the room-separation curtain back. CNA #8 used dirty gloves utilized for perineal care to touch the door and doorknob going outside of the resident's room. She came back into the room, removed the gloves, then washed her hands in the resident's bathroom. During an interview on 07/30/2025 at 10:05 AM, CNA #7 indicated it was important for a CNA to perform proper hand hygiene before, during and after providing incontinent care to protect the resident from cross contamination and infections. She reported hands should also be properly cleaned every time gloves are put on or taken off. She verified she did not perform proper hand hygiene at any time while providing incontinent care to Resident #56. She indicated each wipe should be used for one swipe to cleanse a resident to prevent cross contamination. She reported it was not acceptable to tuck used wipes between a resident's legs because the wipe could be lost or forgotten and cause skin breakdown. She indicated proper incontinent care was necessary to prevent skin breakdowns and infections. During an interview on 07/30/2025 at 2:25 PM, CNA #8 indicated it was important for a CNA to perform proper hand hygiene before and after providing peri care, before and after putting on gloves and each time gloves were changed. She verified she did not perform proper hand hygiene at any time while providing incontinent care to Resident #56. She reported it was important to remove used gloves and perform proper hand hygiene before touching the door, doorknob, or other objects in a resident's room to prevent infection. She indicated each wipe should be used for one swipe to cleanse a resident to prevent cross contamination. She reported dirty wipes should not be tucked between a resident's legs because the wipe could be lost or get stuck and might cause skin breakdown. She indicated proper incontinent care was necessary to prevent discomfort, rash or bed sores. Resident #92 On 07/30/2025 at 10:20 AM, during an observation of incontinent care for Resident #92, CNA #7 washed her hands and put on clean gloves. She did not don a gown. While providing incontinent care of bowel and bladder for Resident #92, CNA #7 reached into her scrub top pocket for clean gloves without using hand sanitizer. CNA #7's skin and clothing touched the resident's skin, clothing and bedding several times during incontinent care. She touched the clean bed linen and resident with dirty gloves, multiple times. CNA #8 donned gloves without hand sanitizer being utilized and did not don a gown. She assisted Resident #92 with removing clothing, then designated herself as the clean side of peri care. Her arms and scrub top touched the resident's skin, clothes, and bedding multiple times. Licensed Practical Nurse (LPN) #6 entered Resident #92's room during incontinent care to provide wound care to the resident's groin. LPN #6 performed proper hand hygiene and donned gloves but did not don a gown when providing wound care. LPN #6's clothing touched the resident's legs and bedding during the wound care. Review of Resident #92's order dated 07/24/2025, revealed that the Stage 3 pressure injury to the right gluteal fold should be cleansed with wound cleanser and patted dry. Collagen powder should then be added to barrier cream and applied to the wound bed. The wound would be left open to air. Review of Resident #92's order dated 07/11/2025 revealed enhanced barrier precautions (EBP), gown and gloves were to be worn during any prolonged contact during personal care, transfers, and wound care During an interview on 07/30/2025 at 1:59 PM, CNA #7 reported EBP was important for the resident, so they did not get an infection. She reported she had not realized the resident had EBP in place and verified she did not wear a gown while providing peri care for Resident #92. CNA #7 also verified there was an EBP sign on Resident #92's door and indicated she should have worn a gown and gloves while providing peri care. CNA #7 verified she had not performed proper hand hygiene before, during and after peri care, or before and after each glove change. During an interview on 07/30/2025 at 2:25 PM, CNA #8 indicated it was important for a CNA to perform proper hand hygiene before and after providing peri care, before and after putting on gloves and each time gloves were changed. She verified she did not perform proper hand hygiene each time she changed gloves while providing incontinent care to Resident #92. She indicated that a CNA should wear a gown and gloves when they provided incontinent care to a resident on EBP. She reported she knew Resident #92 was on EBP because there was a sign on the resident's door indicating EBP. During an interview on 07/30/2025 at 2:15 PM, LPN #6 indicated she had not realized Resident #92 was on EBP. She stated she should have worn a gown when applying topical medication to the resident's wound and verified that she did not. She reported it was important to wear a gown when a resident was on EBP to protect the resident and staff from infection. During an interview on 07/30/2025 at 2:49 PM, the Assistant Director of Nursing (ADON) indicated proper hand hygiene should be performed before gloves are put on and each time before and after gloves are changed. She reported wipes may be used one time while providing peri care and the wipes should be discarded after one swipe to avoid cross contamination. The ADON reported dirty wipes should not be tucked in between a resident's legs while providing incontinent care. She indicated skin breakdown; urinary tract infections and excoriation could result from improper incontinent care. The ADON indicated a CNA would know if a resident was on EBP because there would be a sign indicating that information on the resident's door. She reported CNAs and nurses should wear gowns and gloves when providing incontinent care to a resident on EBP. During an interview on 07/31/2025 at 1:02 PM, the Director of Nursing (DON) reported CNAs should sanitize their hands before starting incontinent care, each time gloves are removed, and at the completion of the care. She indicated that neither a resident's door nor doorknob should be touched with dirty gloves. The DON reported, during incontinent care each wipe should be used one time then thrown away. Dirty wipes should immediately be thrown in the trash and never tucked between a resident's legs. She indicated skin breakdown could be the result of improper incontinent care. The DON reported CNAs should wear gloves and gowns when providing incontinent care to a resident on EBP. She then added that a nurse should wear gloves and a gown when applying a topical medication to an open wound when a resident was on EBP. Review of a policy titled, Peri-care Procedure, indicated hands should be washed when entering a resident's room, before putting on gloves, after removing gloves, and before leaving the resident's room. It is stated be sure to wipe the crack until area is clean. It indicated one wipe for each swipe. Review of a facility policy titled, Handwashing, indicated hands should be washed when entering a resident's room. Review of a facility policy titled, Hand Hygiene, indicated hand hygiene will be performed, using proper technique consistent with accepted standards of practice. Review of a facility policy titled, Enhanced Barrier Precautions, indicated enhanced barrier precautions (EBP) refers to the use of gown and gloves during high-contact resident care activities. High-contact resident care activities included providing hygiene and changing briefs. The policy also indicated the initiation of enhanced barrier precautions will be obtained for residents with a wound and should be used for the duration of the resident's stay or until the wound heals.

Based on observation, interview, and record review, the facility failed to maintain a safe, and homelike environment as evidenced by not ensuring safe wall mounted railings for safety and convenience. The findings are: Review of a policy titled, Accidents, Hazzard Prevention, specified the frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life-threatening injuries. It is important that all facility staff understand the facility's responsibility, as well as their own, to ensure the safest environment possible for residents. On 09/03/2024 at 10:22 AM, on the 200 Hall, standing facing room [ROOM NUMBER], to the immediate right approximately 6 inches, the wall mounted handrail was not anchored, and the bracket was disconnected from the sheetrock. On 09/03/2024 at 12:33 PM, on the 300 Hall, standing facing room [ROOM NUMBER], 5 feet on the left toward the double doors, the wall mounted handrail bracket connected to the handrest was loose. On 09/03/2024 at 1:02 PM, the Administrator stated, Maintenance is not here, he is new and has not had time to inspect the rails. The Administrator indicated that the repairs will be made immediately. Review of the facility's Maintenance Request Form with the Alternate Administrator on 09/04/2024 at 09:00 AM, dated 08/16/2024 through 09/02/2024, revealed no maintenance request for the handrail repairs for the 200 and 300 halls.

Based on observation and interview, the facility failed to ensure 1 of 1 kitchen was in sanitary condition. The findings are: On 04/24/2024 at 09:04 AM, the ice machine had a cloth trimming under the lid. It was wet and had brown and black stains. On 04/24/2024 at 09:05 AM, the Dietary Manager was asked, What's the cloth material on the ice machine? She stated, I don't know what that is. It's been on there since I've been here. I've been here for 2 years. On 04/24/2024 at 09:30 AM, the Administrator stated, We are taking the ice machine out of commission. On 04/24/2024 at 10:22 AM, the Dietary Manager stated, A new ice machine has been ordered. On 04/24/2024 at 11:54 AM, a thick layer of dust and lint was observed on a spice rack on the counter in the kitchen. A lid on top of a blue bin that had coffee in it was dirty. A cart with dessert on it had a grease and dirt built up. On 04/24/2024 at 11:56 AM, the Dietary Manager was asked, Can you tell me what's on the spice rack, and the food cart? She stated, Dust on the spice rack and build up on the food cart. She was asked, How often should it be cleaned, She stated, It should be cleaned weekly.

Based on observation, interview, and record review, the facility failed to ensure an accident/hazard free environment was provided for smokers requiring a smoking apron. The findings are: 1) Resident #13 has diagnoses of Alzheimer's, Stroke with left side paralysis, and Seizure disorder. On the Quarterly Minimum Data Set (MDS) with the assessment reference date (ARD) of April 15, 2024, the resident received a score of 15 (cognition is intact) on the brief interview for mental status (BIMS). a) On 04/23/2024 at 11:45 PM, the Surveyor observed Residents #66, #16, and #13 outside smoking without wearing smoking aprons. b) On 04/24/2024 at 11:50 PM, Residents #66, #16, #13 were outside smoking without wearing a smoking apron. c) On 4/24/2024 at 3:10 PM, Surveyor asked Certified Nursing Assistant (CNA) # 1 what their procedure is when they take smokers out. CNA #1 stated they take them out together and make sure they have their cigarettes, then put their aprons on for the ones who require them. They look at a list where they get the cigarettes to see who needs aprons to prevent them from burning holes in their clothes. They make sure they have their aprons on and supervise them closely. d) On 04/24/2024 at 03:15 PM, CNA # 2 was asked what their procedure is when they take smokers out. CNA #2 stated they take them out together at the same time and make sure they have all their cigarettes then put their aprons on for the ones who require them. They need the aprons to prevent them from burning holes in their clothes. e) On 4/25/2024 at 09:15 AM, the Director of Nursing (DON) stated the Residents are taken out at the same time; CNAs get their cigarettes from the medication room and take them to the designated smoking area outside, then look at the smokers list to see who is supposed to have aprons. The facility was unable to produce a smoking policy.

Based on observation and interview, the facility failed to ensure Resident ' s bedding was clean and in place for 1 (Resident #1) of 1 sampled residents. The findings include: An Admission Record indicated Resident #1 was admitted with diagnoses of Dementia and Multiple sclerosis. A Care Plan indicated that Resident #1 had an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) disease process of MS (Multiple Sclerosis) and needed assistance with his/her ADL's. On 04/22/2024 at 09:17 AM, Resident #1 had a yellowish/brown ring on the pillowcase on the pillow that was used for positioning in the reclining chair. On 4/23/24 at 9:20 AM Resident #1 was observed with a blanket covering that was stained with yellow/brown substance and 1 pillow under the Resident's head had no slip covering. On 04/24/2024 at 09:28 AM, Certified Nursing Assistant (CNA) #3 was observed pushing Resident #1 into his/her room and the Resident was noted to have a pillow under the right arm. The pillowcase had a yellowish- brown ring shaped stain. CNA #3 was asked what she thought the yellowish-brown ring was. CNA #3 stated She may have spilled her coffee. She was asked, how often should Resident #1 have a pillowcase on her pillow? She stated, At all times.

Based on observation, and interview, the facility failed to ensure staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent the potential for food borne illness for residents who received meals from 1 of 2 kitchens; failed to ensure dairy products were maintained at or below a temperature of 41 degrees Fahrenheit; failed to ensure expired food items were promptly removed/discarded by the expiration or use by dates to prevent the potential for food borne illness for residents who received meals from 2 of 2 kitchens. These failed practices had the potential to affect 85 residents who received meals from the Main Kitchen and 11 residents who received meals from the Cottage (total census:107), as documented on the list provided by Dietary Supervisor on [DATE] at 2:27 PM. The findings are 1. On [DATE] at 10:15 AM, Dietary Employee (DE) #1 turned the hand washing sink faucet and washed her hands. She turned off the faucet with her bare hands, contaminating her hands. Without washing her hands, she picked up clean dishes and placed them on a rack with her fingers touching the interior surfaces of the dishes 2. On [DATE] at 10: 25 AM, the following items were in a milk crate on a cart in the walk-in refrigerator: a. 21 cartons of whole milk. b. 25 carons of sugar free Vanilla Mighty Shakes. c. One half gallon of Chocolate Milk. d. One half-gallon of cultured Bulgarian Style Buttermilk. All the dairy products were warm to the touch. The Dietary Supervisor stated, They were left over from breakfast. 3. The Surveyor asked the Dietary Supervisor to check the internal temperature of the milk. The temperatures were as follows: a. Whole Milk - 46 degrees Fahrenheit. b. Mighty Shake - 50 degrees Fahrenheit. The manufacture specification on the carton stated, Store frozen, thaw at low 40 degrees Fahrenheit. Use product within 14 days and keep refrigerated. c. Cultured Bulgarian Style Buttermilk - 53 degrees Fahrenheit. d. Chocolate Milk - 47 degrees Fahrenheit. 4. On [DATE] at 10:34 AM, DE #1 turned on the hand washing sink faucet and washed her hands. She turned off the faucet and without washing her hands, she picked up tomatoes, placed them on the cutting board and diced them. She then picked up the diced tomatoes and placed them in a container to be served to the residents for the lunch meal. 5. On [DATE] at 10:44 AM, one 5-pound container of cottage cheese with an expiration date of [DATE] was stored on a shelf in the walk-in refrigerator. 6. On [DATE] at 11:04 AM, DE #2 turned on the hand washing sink faucet and washed her hands. She turned off the faucet and without washing her hands she picked glasses by their rims and placed them on a tray to be used in serving beverages to the residents for the lunch meal. The Surveyor asked, What should you have done after touching dirty objects and before handling clean objects? She stated, Washed my hands. 7. On [DATE] at 11:57 AM, DE #1 turned on the 3-compartment sink and rinsed the inside of a pan. DE #1 picked up a spray bottle and sprayed inside the pan. Without washing her hands, she pushed the blade down that was attached on the base of the blender and continued to puree chili to be served to the residents on pureed diets. At 11:58 AM, DE #1 placed 7 servings of shredded cheese on top of the chili and pureed. 8. On [DATE] at 12:12 PM, DE #3 removed a bottle of grape jelly, a container of pimento cheese, and a container of peanut butter and placed them on the counter. He picked up a bag of bread from the bread rack and placed it on the counter. He turned on the hand washing sink and washed his hands. He turned off the faucet with his bare hands contaminating his hands. He removed gloves from the glove box and placed them on his hands, contaminating the gloves. At 12:18 PM, he removed a ziplock bag that contained slices of cheese and a ziplock bag that contained slices of ham from the walk-in refrigerator and placed them on the counter and untied the bag of bread. At 12:20 PM, when he was ready to remove slices of bread from the bread bag. The Surveyor immediately stopped him and asked, What should you have done after touching dirty objects and before handling clean objects? He stated, Rewash my hands and put on new gloves. 9. On [DATE] at 4:53 PM, in the Cottage, Certified Nursing Assistant (CNA) #1 turned on the hand washing sink, she washed the blender bowl and the blade with hot water and soap. She placed them in the dish washing machine. She washed her hands and then turned off the faucet with her bare hands. Without washing her hands, she picked up a clean blade from the dish washing machine and attached it to the base of the blender to be used in grounding food items for a resident on a mechanical soft diet. The Surveyor asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 10. On [DATE] at 5:12 PM, in the Cottage, CNA #1 pushed a cart towards the ice machine, contaminating her hands. Without washing her hands, she picked up glasses with her fingers inside the glasses and placed them on the cart to be used in serving beverages to the residents for supper meal. The Surveyor immediately asked, What should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 11. The facility policy titled, Handwashing and Glove Usage in Food Service, provided by the Dietary Supervisor on [DATE] at 2:27 PM documented, .Food handlers must wash their hands: After touching anything else such as dirty equipment, work surfaces or cloths. After leaving and returning to the kitchen/prep area .

Based on observation, interview, and record review, the facility failed to ensure contact information for the State Long-Term Care Ombudsman, the Office of Long Term Care (OLTC) Complaint Department were posted and readily accessible to all 11 residents who resided in the Cottage at the facility. The findings are: 1. On 02/13/23 at 11:00 AM, the Surveyor was unable to locate an Ombudsman or OLTC information poster in the cottage at the facility. 2. On 02/14/23 at 2:30 PM, the Surveyor asked Resident #63, the Resident Council President of the Cottage, if the Cottage had an Ombudsman poster. He answered, I have not seen one. 3. On 02/14/23 at 2:45 PM, the Surveyor asked Resident #59 if she knew where the Ombudsman poster was. She answered, We don't have a poster. 4. On 02/14/23 at 3:00 PM, the Surveyor asked Certified Nursing Assistant (CNA) #5 where the Ombudsman poster was located. CNA #5 stated, When they built the Cottage, we were told there couldn't be anything on the walls, because this is supposed to be more homelike. The Surveyor asked if the Ombudsman poster was in a binder. CNA #5 answered, They have a lot of binders, but I haven't seen one with the Ombudsman's information in it. 5. On 02/15/23 at 1:43 PM, the Surveyor asked the Administrator where the Ombudsman and OLTC Complaint information was located in the Cottage. The Administrator stated, Should be in a white binder. The Surveyor asked where the binder was kept. The Administrator stated, On a table. It's homelike, not a traditional model. It was set up that way and that's the way the training went. The Administrator stated the residents are told when they move in. The Surveyor asked who was the person that informs them. The Administrator stated, Someone should tell them. Whoever does the admission. 6. On 02/15/23 at 2:02 PM, the Surveyor asked Resident #63, the Resident Council President of the Cottage, if the Surveyors could go through the cabinets in the Main Living Area of the Cottage. Resident #63 stated, Yes, that would be fine. The Surveyor located a white binder in the back of the cabinet next to the fireplace titled, Information Binder Ombudsman Information, Resident Rights, Recent Surveys, Workers Comp, on the bottom shelf with 2 other binders on top. Included in the binder was an 8 1/2 inch x 11 inch piece of paper with the Ombudsman poster copied on it and an 8 1/2 inch x 11 inch piece of paper with the Resident Rights poster copied on it. The Surveyor took the binder to Resident #63 in his room and showed him the binder. Resident #63 stated he had not seen that binder before. The Surveyor took the binder to Resident #59 in her room and showed her the binder. Resident #59 stated she had not seen the binder before.

Based on interview, and record review, the facility failed to ensure mail was provided on Saturdays to honor resident rights and prevent potential delays in receipt of mail. This failed practice had the potential to affect all 107 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 02/14/23. The findings are: 1. On 02/15/23 at 10:45 AM, during a Resident Council Meeting, the Surveyor asked Residents #37, #59, #63, #70, and #71 if they received mail on Saturdays. The five residents in attendance stated they do not receive mail on Saturdays. Resident #63 and Resident #37 stated they see mail and packages delivered to the main building on Saturdays, but they don't receive mail on Saturdays. 2. On 02/15/23 at 1:38 PM, the Surveyor asked the Activities Director if she was responsible for passing out the mail to the residents. She replied, Yes, I am responsible for the mail. The Surveyor asked when it is handed out. She replied, When, every day that mail comes. Usually, every day when I am here, I pass it. The Surveyor asked who handles the mail on the weekend when she is not at the facility. She replied, It can be delivered, but since the Business Office Manager (BOM) and me do the mail and checks, then they only [pause] usually no. When I get back Monday, I have a pile from the weekend, and they get their mail. 3. On 02/15/23 at 1:43 PM, the Surveyor asked the Administrator when residents should receive their mail. The Administrator stated, When it comes in. The Surveyor asked who was responsible for obtaining the mail and passing it out to the residents. The Administrator stated, I've taken it to [Activities Director] and [BOM] and I've called staff to come over. The Surveyor asked if he obtains the mail on Saturdays. The Administrator stated, No, I do not check the mail on Saturdays. The Surveyor asked if he was aware of anyone being assigned to deliver mail on Saturdays. The Administrator stated, No, I am not aware. 4. The facility policy regarding Mail provided by the Registered Nurse Consultant on 02/16/23 at 3:01 PM documented, .Mail or other materials will be delivered to the Resident/Elder within 24 hours except when there are no regularly scheduled postal hours .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets and 32 residents who received mechanical soft diets, 59 residents who received regular diets, in the Main Building and the residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight according to a list provided by Dietary Supervisor on 02/14/23 at 2:27 PM. The findings are: 1. The facility menu for the lunch meal provided by the Dietary Supervisor documented the residents who received regular diets and mechanical soft diets were to receive 1/2 cup of Chopped Lettuce with Tomatoes and residents on pureed diets were to receive a #8 scoop of pureed 4 Layer Delight. 2. On 02/13/23 at 12:39 PM, the following observations were made during the noon meal service in the kitchen: a. Dietary Employee (DE) #2 used a tong to portion a pinch of Shredded Lettuce with Diced Tomatoes onto the residents' plates. 3. On 02/13/23 at 1:21 PM, the following observations were made during the noon meal service: a. On 02/13/23 at 12:55 PM, the residents who received meal trays in the Unit were served a pinch of Salad. Licensed Practical Nurse #1 was asked, How much Salad do the residents receive? She stated, That doesn't look like a half cup. It was a pinch. b. Residents on regular diets and residents on mechanical soft diets were served a pinch of Shredded Lettuce with Diced Tomatoes, instead of 1/2 cup as specified on the menu. c. The residents on pureed diets were served Pudding, instead of 4 Layer Delight. d. On 02/13/23 at 1:38 PM, DE #1 and DE #2 were asked, How much Shredded and/or Chopped Lettuce and Tomatoes should the residents have? They both stated, I thought we were supposed to give a pinch of it like garnishing. At 1:46 PM, DE #2 was asked the reason the residents on pureed diets did not receive pureed 4 Layer Delight. She stated, We ran out of 4 Layer Delight, and we gave Pudding to the residents on pureed diets.

Based on observation, record review, and interview, the facility failed to ensure a residents Continuous Positive Airway Pressure (CPAP) mask was properly stored when not in use to prevent potential contamination that could result in respiratory infection and failed to ensure a malfunctioning CPAP machine was reported and replaced in a timely manner consistent with professional standards of practice and to prevent possible respiratory complications for 1 (Resident #34) of 2 (Residents #34 and #507) sampled residents who had Physician Orders for CPAP. The findings are: 1.Resident #34 had a diagnosis of Obstructive Sleep Apnea. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/22 documented the resident was moderately impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS) did not receive oxygen therapy. a. The Clinical Physician Orders in the Facility Computer Software documented, .Apply CPAP at (bedtime) . On Hold 8/15/2022 . CPAP to be cleaned weekly . On Hold . 10/15/2022 . The February 2023 Physician Orders did not contain an order for CPAP usage/care. b. The Care Plan with a revision date of 12/27/22 did not address CPAP usage and/or care. c. On 02/13/23 at 01:11 PM, Resident #34 was lying in bed. A CPAP mask was lying on the bedside table, not in a bag. The mask appeared to have intermittent coating of a white and yellow colored substance throughout the inside of the mask. d. On 02/14/23 at 08:56 AM, Resident #34 was lying in bed. A CPAP mask was lying on the bedside table, not in a bag. The Surveyor asked Resident #34 if the CPAP was used every night. Resident #34 stated No, it doesn't work. The Surveyor asked how long it had not been working. Resident #34 stated, I don't know. e. On 02/15/23 at 10:44 AM, the Surveyor asked the Director of Nursing (DON) if she was aware of Resident #34's CPAP machine not functioning. The DON said she had not heard about that and asked the Treatment Nurse about it, who stated it was on the 24 hour report. f. The 24 Hour Report dated 02/15/23 provided by the Assistant Director of Nursing (ADON) on 02/15/23 at 11:02 AM, documented at the bottom of the page, Notes: [Resident # 34] - CPAP not working correctly, system fault error 001 phone number listed . The ADON said she had called the phone number at the bottom of the form today. They said the CPAP had to be replaced. The Surveyor requested the original 24 hour report that documented the first date the CPAP was not working. g. The 24 Hour Report dated 01/28/23 provided by the ADON on 02/15/23 at 11:40 AM documented at the bottom of the page, .Resident #34] CPAP not working correctly system fault error 001 handwritten with phone number at bottom of the form . h. The February 2023 Treatment Administration Record (TAR) documented, .Apply CPAP at (bedtime) at bedtime - Start Date - 08/15/2022 2000 [8:00 PM] . CPAP to be cleaned weekly - must take apart and clean reservoir. In the morning every Sat [Saturday] - Start Date - 10/15/2022 0700 [7:00 AM] . The TAR was checked off as the CPAP being applied every day starting on 02/01/23 through 02/14/23 and as the CPAP being cleaned on 02/04/23 and 02/11/23. 2. The facility policy titled, Respiratory Care, provided by the Administrator on 02/16/23 at 8:30 AM documented, .Policy. The facility will ensure residents that need respiratory care, including tracheostomy care and suctioning, will be provided consistent with professional standards of care . The policy did not address CPAP usage/care.

Based on observation, interview, and record review, the facility failed to ensure the metal bolts securing toilet seats were cut to a safe length to prevent potential accidents and injury to residents on the Secure Unit for 1 (Resident #96) of 7 (Residents #18, #65, #66, #88, #96, #99 and #100) sampled residents who were able to stand and move on their own. The failed practice had the potential to affect 18 residents on the Secure Unit who were able to stand and move on their own as documented on a list provided by the Registered Nurse (RN) Consultant on 02/17/23. The findings are: 1. Resident #96 had a diagnosis of Alzheimer's Disease. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/20/23 documented the resident scored 3 (0-7 indicates severely cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required extensive physical assistance of one person with transfers and toilet use and was not steady and only able to stabilize with staff assistance when moving from seated to standing position, on and off the toilet and from surface to surface transfer and has had two falls since admission. a. On 02/13/23 at 12:15 PM, Resident #96's family member informed the Surveyor she had concerns regarding the screw sticking up from the toilet bottom since he [Resident #96] has fallen in the bathroom. She stated he does not understand that he should not get up on his own. b. The Care Plan with a revision date of 01/03/23 documented, . is at risk for falls . 10/14/2022-fell in bathroom, he is to wear non-skid socks to bed . c. The 01/01/23 to 01/31/23 and 02/01/23 to 02/13/23 Incident and Accident lists provided by the Administrator on 02/13/23 at 1:13 PM documented, . Fall Un-Witnessed Incidents . [Resident #96] . 2/12/23 7:30 AM . 1/3/23 1:15 AM . 1/13/23 11:15 PM . d. On 02/13/23 at 2:00 PM, the Surveyor accompanied the Maintenance Supervisor to the Secure Unit. The Surveyor entered Resident #96's room and asked the Maintenance Supervisor if he was responsible for repair to the toilets. He stated he was. The Surveyor pointed to the screw sticking approximately 3 inches up from the nut on the screw and asked the Maintenance Supervisor what could happen if a resident fell while in the bathroom. The Maintenance supervisor stated, They could get a scratch, or they could get really hurt. The Surveyor accompanied the Maintenance Supervisor to 7 of the 12 resident occupied rooms on the Secure Unit and found all had screws sticking up approximately 3 inches past the nut. The Maintenance Supervisor stated, I can get them cut down. I never thought of it as a problem. I guess they could get hurt. e. On 02/13/23 at 2:30 PM, the Surveyor asked the Administrator if he was aware of the screws sticking up from the base of the toilets in the Secure Unit. The Administrator stated he was not. The Surveyor asked if the Administrator felt the screws could be a safety issue. He stated, I have done this for [AGE] years and have never had anyone get hurt on a toilet screw. f. The facility policy titled, Accident Hazards Prevention, provided by the Registered Nurse (RN) Consultant on 02/17/23 at 8:39 AM documented, .Resident Environment. The environment will be free from accident hazards as is possible . An effective way for the facility to avoid accidents is to develop a culture of safety and commit to implementing systems that address resident risk and environmental hazards to minimize the likelihood of accidents. A facility with a commitment to safety: .6. Demonstrates a commitment to safety at all levels of the organization .

Based on observation, record review, and interview, the facility failed to ensure bathing services were regularly provided and chin hairs were removed to maintain good hygiene for 1 (Resident #93) of 30 (Residents #5, #10, #14, #16, #17, #18, #31, #35, #37, #42, #44, #50, #58, #59, #63, #65 #66, #70, #71, #83, #88, #93, #96, #96, #97, #99, #100, #104, #157, #457 and #507 sampled residents who required assistance with bathing and/or grooming. This failed practice had the potential to affect 74 residents who required assistance from staff for bathing/showers according to a list provided by the Registered Nurse (RN) Nursing Consultant on 02/16/23 at 4:03 pm. The findings are: 1. Resident #93 had diagnoses of Chronic Kidney Disease, Stage 4 (Severe) Dementia, Moderate with Anxiety, Alzheimer's Disease with Late Onset, Nondisplaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for closed Fracture with Routine Healing and Nondisplaced Lateral Mass Fracture of First Cervical Vertebra. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/22 documented the resident scored 12 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and required limited physical assistance of one person for personal hygiene and bathing. a. The Care Plan with a revision date of 12/27/22 documented, .has an ADL [Activities of Daily Living] ADL self-care performance deficit . Bathing: Requires extensive assistance with bathing . Dressing: Requires extensive assistance with dressing . Personal Hygiene/oral care: She requires extensive assist [assistance] of x [times] 1 staff for personal hygiene and oral care. She frequently refuses nail cares, continue to offer, and encourage, but respect her choice . b. The February 2023 Bathing Self Performance sheet provided by the Director of Nursing (DON) on 02/16/23 at 12:06 pm documented, .Resident Refused . with check mark on 02/08/23 at 23:36 [11:36 pm] and 02/11/23 at 03:34 [3:34 am] . and Not Applicable .with check marks on every day except for 02/08/23 at 23:36 and 02/11/23 at 03:34 . Upon observation of the Bathing Self Performance sheet, the surveyor asked the DON what Not Applicable (n/a) means. She stated, That's not a shower day. c. On 02/13/23 at 12:13 pm, Resident #93 was lying in bed and stated, I have not had a bath or shower since being here, and have not been shaved. I look horrid. She had facial hair on her chin and left upper side of her lip, that was thick and approximately 1/4 long. d. On 02/15/23 at 10:15 am, Resident #93 was in her room sitting in a wheelchair (w/c). She was wearing the same dress she had on two days before. The Surveyor asked if she had been given a shower yet. She stated, No, I haven't had one since I've been moved from that Cottage and look (rubbing her chin hair with her fingers), I need all this hair off my chin. e. On 02/16/23 at 1:50 pm, Resident #93 was in her room sitting in her w/c. She was wearing a different dress, her hair was pulled back in ponytail and her chin hair had been removed. The Surveyor asked if she had her shower. She stated, Yes, I had a shower and I feel so much better. f. On 02/17/23 at 9:16 am, the Surveyor asked Certified Nursing Assistant (CNA) #10, How often are residents supposed to get showers? She stated, Twice a week unless care planned. The Surveyor asked, On the Bathing Self Performance sheet, what does n/a mean? CNA #10 stated, Showers are assigned for certain days by hall and room number. When residents get moved to another room/hall for different reasons, it may show that it is not their designated shower day. I'm on the shower team so the only reason I would check n/a is because it isn't their scheduled day. The Surveyor asked, Can residents get showers when it isn't their scheduled day? CNA #10 stated, Yes. The Surveyor asked, Who shaves the residents? CNA #10 stated, They usually get shaved during showers unless they refuse. The Surveyor asked, Can all CNAs shave residents? CNA #10 stated, Yes. g. On 02/17/23 at 9:35 am, the Surveyor asked CNA #11, How often are residents supposed to get showers? She stated, Twice weekly unless they ask to have more. The Surveyor asked if she was familiar with Resident #93. She stated, Yes. The Surveyor asked how often Resident #93 was scheduled to receive showers. She stated, Twice weekly on the 3-11 [3:00 pm to 11:00 pm] shift. The Surveyor asked, On the Bathing Self Performance sheet, what does n/a mean? CNA #11 stated, You check that when you don't give showers for any reason. The Surveyor asked, Can residents get a shower when it isn't their scheduled day? CNA #11 stated, Yes, we try to get the residents who are scheduled for that day first, but they are worked in. The Surveyor asked, What do you do when a resident complains of not getting a shower? She stated, I try to figure out why she hasn't had one, then give them a shower as soon as I can. h. On 02/17/23 at 9:40 am, the Surveyor asked License Practical Nurse (LPN) #3, How often are residents supposed to get showers/bathing? She stated, Twice a week, but they can have more if they want. The Surveyor asked, What does n/a mean on the bathing sheet? She stated, It means maybe they were not here, maybe they refused, or Hospice did their bathing. The CNAs tell me when a resident refuses a scheduled bath. The Surveyor asked, Who is responsible for shaving faces, and can all CNAs perform it? She stated, Nursing and CNAs are responsible. As long as the CNAs are certified and have been checked off on that. We have a shower team and shaving should be an option at that moment. The Surveyor asked, What would you do if a resident complained that they didn't get a shower? She stated, I would make sure the resident got a shower or bed bath even if I had to give it myself. i. On 02/16/23 at 4:03 pm, the RN Consultant stated, The facility does not have a policy/procedure on showering and facial shaving. j. On 12/22/20 at 11:05 am, during a telephone interview with the DON, the Surveyor asked, Who is responsible for giving the resident showers? The DON stated, The CNAs. The Surveyor asked, Is there a shower team? The DON stated, No team now, we used to have one, but we've had several people quit, so the shower CNAs now have to work the floor. The Surveyor asked, Is the facility short staffed at this time? The DON stated, Yes, we've been short for about 2 weeks now. The Surveyor asked, Who fills in and takes care of the residents since you have been short staffed? The DON stated, The nurses, the DON, the ADON [Assistant Director of Nursing]. Last weekend we had someone come in designated to do showers. The Surveyor asked, When is nailcare performed? The DON stated, With the showers.

Based on interview, and record review, the facility failed to ensure a report of stolen and/or missing items was thoroughly investigated and documented to determine if misappropriation of the resident's property occurred for 1 (Resident #107) of 1 sampled resident whose family had reported items missing. The findings are: 1. Resident #107 had a diagnosis of Alzheimer's Disease with Late Onset. 2. The Letter dated 12/08/22 and an Invoice from Resident #107's family received by the facility for the loss or stolen items while Resident #107 was in the facility was reviewed. The Invoice documented, .Personal Property lost or stollen: Dozens of articles of clothing over a 12-year period with an average purchase price of $25 $1800.00 Two prescription glasses $800.00 Silver Wedding Ring $125.00 Total; Payable upon receipt $2725.00 . 3. Resident #107's Progress Notes contained the following documentation: a.1/17/2022 14:51 [2:51 PM] Social Note Late Entry: Note Text: Resident't [Resident's] [family member] came to get her personal items - He took w/c [wheelchair], photo albums, a jewelry box, 2 corkboards with photos, a box of photos and cards, some jewelry Social Services . b.1/18/2022 10:05 [10:05 AM] DC [Discharge] Summary Note Text: .Disposition of personal belongings: Family picked up W/C and pictures. Donated Clothing to facility . Nursing . c.1/19/2022 14:50 [2:50 PM] Social Note Note Text: Called .funeral home in [City] looking for her wedding band - They will call me back if they find anything. I went through all of her personal belongings twice looking for the ring. Social Services . 4. On 02/15/23 at 8:26 AM, the Surveyor asked the Administrator when incidents are reported to OLTC. The Administrator stated, Within 2 hours of being an allegation of abuse, neglect, misappropriation of property, sexual, verbal, or physical abuse. The Surveyor asked what meets the criteria for misappropriation of property. The Administrator stated, When someone says this is missing, they are not alleging misappropriation. We treat that as a grievance and do that or reconcile that. If they are alleging that a facility employee said they got rid of it, then that is misappropriation. The Surveyor asked if the Administrator had received any notifications by letter of any items being stolen or missing. The Administrator stated, No, I have not received a letter notifying us of anything missing. Typically, if we suspected it and someone stole something or purposefully threw it away, we would report it. 5. On 02/15/23 at 9:08 AM, the Surveyor asked the Social Services Director (SSD) when she reports a resident's lost or stolen belongings. The SSD stated, It depends on how they say it. If they say it has been stolen, then I tell [Administrator]. If they say it is just missing, that is a grievance process and I document how the search was. It depends if they come at me. If it is regarding staff, then [Administrator] is the one that handles it. The Surveyor asked if Resident #107's missing ring was reported to the Administrator. The SSD stated, It should have been on the grievance form. I did a search for it. The Surveyor asked if she had any documentation of the investigation besides the entry in the Progress Notes about calling the funeral home. The SSD stated, I did not feel at that time that it was [paused], I took it that they were not angry, and I looked everywhere. The way it was said that it was missing I did not feel it was reportable. Looking back, it maybe should have been. I should have made better notes and noted the grievance. I have learned from that experience. I will learn from that error. 6. On 02/15/23 at 9:20 AM, the Surveyor asked the Administrator what should be done if it was reported to the SSD that a resident was missing items. The Administrator stated, If it is missing items, then we search for them and complete a grievance. If it is a stolen item, then we do a reportable and start and investigation. The Surveyor asked if it should be documented of what all was done to find the missing or stolen items. The Administrator stated, Yes, it should be documented on the grievance log and documented in the resident's chart. The Surveyor asked if a grievance was completed in January 2022 when Resident #107's family reported her ring missing. The Administrator checked his computer and stated, There is not a grievance listed for [Resident #107] in January last year. 7. On 02/16/23 at 10:12 AM, the Surveyor asked if the BOM received a response from the family regarding the bill. The BOM stated she received a letter and list of items. I opened it, and I showed it to [Administrator]. I submitted the write off after the response from the family came in the mail. [Administrator] and someone at corporate has to sign it and then I do not know after that. The Surveyor asked if she had any other interaction with the family after that point. The BOM stated, No, I gave the letter and invoice to [Administrator] and I do not know what was done after that. On 12/08/22, a letter and invoice from Resident #107 ' s family was received by the facility for the loss items while she was in the facility. 8. On 02/16/23 at 10:17 AM, the Surveyor asked the Administrator if he remembered receiving a letter and invoice from Resident #107's family on 12/08/22. The Administrator stated, Yes, I vaguely remember the letter but not an invoice. The Surveyor asked what steps he took after receiving the letter and invoice. The Administrator stated, We wrote off quite a few accounts in December and I believe [Resident #107] was one of them. We didn't pay it. We didn't do a grievance or anything else like that. The Surveyor asked if a reportable or investigation should have been performed. The Administrator stated, We do not do reportables when someone states an item is missing. The Surveyor showed the Administrator the letter and invoice and asked if a reportable was completed when the resident or family stated the items were stolen. The Administrator stated, Yes, if it is stated it is stolen it should have been a reportable. The Surveyor asked when the letter and invoice were received was an investigation completed. The Administrator stated, No, I do not believe one was done then because one was already done previously by [SSD]. 9. On 02/16/23 at 4:30 PM, the Administrator provided Resident #107's, Resident's Personal Possessions, during her stay at the facility, A list of items signed by a family member or responsible party at or after discharge was not provided. 10. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation & Reporting provided by the Administrator on 02/13/23 at 3:10 PM documented, .The facility will endeavor to protect Resident/Elders from . the misappropriation of Resident/Elder property . 3. Identification and Investigation . The Administrator or Administrator's designee will conduct an immediate investigation of all alleged or actual incidents of abuse, neglect, or misappropriation of property .

Based on observation, interview, and record review, the facility failed to ensure the confidentiality of resident records were kept private by locking the computer screens when not in use. This failed practice had the potential to affect 93 residents who received medication from the medication carts in the facility's main building as documented on a list provided by the Registered Nurse (RN) Consultant on 02/16/23 at 4:03 PM. The findings are: 1. On 02/14/23 at 8:19 AM, during the morning medication pass the Surveyor observed Licensed Practical Nurse (LPN) #4 walk away from the computer with it left open and visible to anyone walking by the computer. LPN #4 walked off the hall then into the medication room. 2. On 02/14/23 at 8:26 AM, the Surveyor asked LPN #4 if she was aware that she had walked away from the computer with the medical record visible during medication pass. She stated, That is when I went to the Medication Room to find those updrafts. The Surveyor asked what could happen if a computer was left open with a resident's information on it visible to anyone. LPN #4 stated, Somebody can see something they aren't supposed to see. The Surveyor asked what would that be called. She stated, HIPPA [Health Insurance Portability and Accountability Act]. 3. On 02/14/23 at 3:30 PM, the Surveyor observed LPN #5 with 3 other staff standing in front of a room on the 300 Hall talking. The Surveyor noted the computer with approximately a dozen residents' names and information in boxes on the screen sitting on the medication cart, approximately 15 feet from the staff talking. The Surveyor watched and waited by the medication cart. LPN#5 returned to the medication cart four minutes later and the Surveyor asked her if she saw an issue. LPN #5 stated, Yes, I left the computer on. I had to go stop a staff from going in a room. The Surveyor asked her about the conversation for the next few minutes following her stopping the staff. LPN #5 stated, No, I should have come back to the computer right away. Sorry, I am new and still getting all this down. The Surveyor asked her what the concern was with leaving the computer on. LPN #5 stated, The information that is left up on the screen. 4. On 02/15/23 at 10:25 AM, the 300 Hall medication cart computer was left opened with a resident ' s medical record visible for anyone to see. There was no nurse in sight. The Social Director walked by and closed out the computer and stated, They have been told to lock out of their computer if they walk away. 5. On 02/15/23 at 10:39 AM, the Surveyor asked LPN #3 if she realized that she had left the computer opened. LPN #3 looked down at the computer and said, I was told that I could just lower the top of the computer and that it would be ok. The Surveyor asked what could happen if the computer was left open and the residents medical record was visible. LPN #3 stated, Someone could read it and a HIPPA violation could happen, and someone could get information. 6. On 02/16/23 at 3:38 PM, the Surveyor asked the Director of Nursing (DON) if the computer should be left open with resident information visible for anyone to see. She stated, No. The Surveyor asked what could happen. The DON stated, HIPPA, their picture, and medical record is open for whoever goes by. 7. The facility policy titled, Confidentiality of Social and Medical Record Information, provided by the RN Consultant on 02/16/23 at 3:01 PM documented, .Privacy and Confidentiality . Residents/Elders' personal and medical records are protected to assure confidentiality . 46868

Based on interview, and record review, the facility failed to ensure residents received an individual Quarterly Financial Record Statement for 2 (Residents #58 and #74) of 13 (Residents #5, #10, #14, #17, #31, #46, #53, #55, #58, #65, #74, #81 and #83) sampled residents who had Trust Funds managed by the facility. This failed practice had the potential to affect 44 residents who had Trust Funds managed by the facility as documented on the Trust Transaction Current Account Balance received from the Business Office Manager (BOM) on 02/15/23. The findings are: 1. Resident #58 had a diagnosis of Diastolic (Congestive) Heart Failure. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS). a. On 02/14/23 at 10:22 AM, the Surveyor asked Resident #58 if the facility managed her money. Resident #58 answered, I get $40.00 per month. The Surveyor asked if she received statements from the facility. Resident #58 answered No. 2. Resident #74 had a diagnosis of Chronic Obstructive Pulmonary Disease. The Significant Change MDS with an ARD of 11/20/22 documented the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. a. On 02/14/23 at 10:05 AM, Resident #74 reported to this Surveyor that the facility holds personal funds for her, but she does not receive quarterly statements from the facility. 3. On 02/15/23 at 10:18 AM, the Surveyor asked the BOM how often statements were provided. The BOM stated, Quarterly. The Surveyor asked the BOM how they were issued. The BOM stated, Through the mail. We do have some that we hand out here. 4. On 02/16/23 at 11:21 AM, the Surveyor requested from the BOM documentation that statements were provided to Resident #58 and Resident #74. The BOM stated, I do not have documentation. I mail them out. The Surveyor asked who they were given to. The BOM stated, If they do not have a responsible party and they are their own person then I give it to them. The Surveyor asked who received Resident #58's statements. The BOM stated, Her [family member]. He is the responsible party. The Surveyor asked of Resident #58 was competent and her own person. The BOM stated, Well, Yes. The Surveyor asked if Resident #58's [family member] was her Power of Attorney (POA). The BOM stated, I will have to look into that. The Surveyor asked if a responsible party was the same as a legal representative. The BOM stated, I think so. The Surveyor asked who received Resident #74's statements. The BOM stated, Her [family member]. She is the responsible party. The Surveyor asked if Resident #74 was competent and her own person. The BOM stated, I believe she is. The Surveyor asked if the resident is competent and their own person should the statements be sent to the responsible party of the resident/elder. The BOM stated, I will have to look into that. 5. On 02/26/23 at 11:40 AM, the Registered Nurse (RN) Consultant informed the Surveyor the facility did not have POA documentation for Resident #58 or Resident #74. 6. On 02/16/23 at 1:50 PM, the Surveyor asked the Administrator who should receive quarterly Trust Fund statements. The Administrator stated, Whoever is listed as the responsible party or to the resident if they are listed as their own person. The Surveyor asked if a responsible party was the same as a legal representative. The Administrator stated, Can be or cannot be. The Surveyor asked when POA's were active. The Administrator stated, When the resident is incapacitated or if the wording on the POA says another reason or situation. The Surveyor asked if a resident is their own person should they be receiving their statements and not the responsible party. The Administrator stated, Yes. Are they not? 7. The facility policy titled, Management of Resident and Elder Trust Accounts, provided by the RN Consultant on 02/16/23 at 3:01 PM documented, .The Resident/Elder's individual financial record is available through quarterly statements .

Based on interview, and record review, the facility failed to ensure a report of stolen items was reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state and federal law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 1 (Resident #107) of 1 sampled resident whose family had reported items missing. The findings are: 1. Resident #107 had a diagnosis of Alzheimer's Disease with Late Onset. 2. The Letter dated 12/08/22 and an Invoice from Resident #107's family received by the facility for the loss or stolen items while Resident #107 was in the facility was reviewed. The Invoice documented, .Personal Property lost or stollen: Dozens of articles of clothing over a 12-year period with an average purchase price of $25 $1800.00 Two prescription glasses $800.00 Silver Wedding Ring $125.00 Total; Payable upon receipt $2725.00 . 3. Resident #107's Progress Notes contained the following documentation: a.1/17/2022 14:51 [2:51 PM] Social Note Late Entry: Note Text: Resident't [Resident's] [family member] came to get her personal items - He took w/c [wheelchair], photo albums, a jewelry box, 2 corkboards with photos, a box of photos and cards, some jewelry Social Services . b.1/18/2022 10:05 [10:05 AM] DC [Discharge] Summary Note Text: .Disposition of personal belongings: Family picked up W/C and pictures. Donated Clothing to facility . Nursing . c.1/19/2022 14:50 [2:50 PM] Social Note Note Text: Called .funeral home in [City] looking for her wedding band - They will call me back if they find anything. I went through all of her personal belonging twice looking for the ring. Social Services . 4. On 02/15/23 at 8:26 AM, the Surveyor asked the Administrator when incidents are reported to OLTC. The Administrator stated, Within 2 hours of being an allegation of abuse, neglect, misappropriation of property, sexual, verbal, or physical abuse. The Surveyor asked what meets the criteria for misappropriation of property. The Administrator stated, When someone says this is missing, they are not allocating misappropriation. We treat that as a grievance and do that or reconcile that. If they are allocating that a facility employee said they got rid of it, then that is misappropriation. The Surveyor asked if the Administrator had received any notifications by letter of any items being stolen or missing. The Administrator stated, No, I have not received a letter notifying us of anything missing. Typically, if we suspected it and someone stole something or purposefully threw it away, we would report it. 5. On 02/15/23 at 9:08 AM, the Surveyor asked the Social Services Director (SSD) when she reports a resident's lost or stolen belongings. The SSD stated, It depends on how they say it. If they say it has been stolen, then I tell [Administrator]. If they say it is just missing, that is a grievance process and I document how the search was. It depends if they come at me. If it is regarding staff, then [Administrator] is the one that handles it. The Surveyor asked if Resident #107's missing ring was reported to the Administrator. The SSD stated, It should have been on the grievance form. I did a search for it. The Surveyor asked if she had any documentation of the investigation besides the entry in the Progress Notes about calling the funeral home. The SSD stated, I did not feel at that time that it was [paused], I took it that they were not angry, and I looked everywhere. The way it was said that it was missing I did not feel it was reportable. Looking back, it maybe should have been. I should have made better notes and noted the grievance. I have learned from that experience. I will learn from that error. 6. On 02/15/23 at 9:20 AM, the Surveyor asked the Administrator what should be done if it was reported to the SSD that a resident was missing items. The Administrator stated, If it is missing items, then we search for them and complete a grievance. If it is a stolen item, then we do a reportable and start and investigation. The Surveyor asked if it should be documented of what all was done to find the missing or stolen items. The Administrator stated, Yes, it should be documented on the grievance log and documented in the resident's chart. The Surveyor asked if a grievance was completed in January 2022 when R107's family reported her ring missing. The Administrator checked his computer and stated, There is not a grievance listed for [Resident #107] in January last year. 7. On 02/16/23 at 10:12 AM, the Surveyor asked if the BOM received a response from the family regarding the bill. The BOM stated she received a letter and list of items. I opened it, and I showed it to [Administrator]. I submitted the write off after the response from the family came in the mail. [Administrator] and someone at corporate has to sign it and then I do not know after that. The Surveyor asked if she had any other interaction with the family after that point. The BOM stated, No, I gave the letter and invoice to [Administrator] and I do not know what was done after that. 8. On 02/16/23 at 10:17 AM, the Surveyor asked the Administrator if he remembered receiving a letter and invoice from Resident #107's family. The Administrator stated, Yes, I vaguely remember the letter but not an invoice. The Surveyor asked what steps he took after receiving the letter and invoice. The Administrator stated, We wrote off quite a few accounts in December and I believe [Resident #107] was one of them. We didn't pay it. We didn't do a grievance or anything else like that. The Surveyor asked if a reportable or investigation should have been performed. The Administrator stated, We do not do reportables when someone states an item is missing. The Surveyor showed the Administrator the letter and invoice and asked if a reportable was completed when the resident or family stated the items were stolen. The Administrator stated, Yes, if it is stated it is stolen it should have been a reportable. The Surveyor asked when the letter and invoice were received was an investigation completed. The Administrator stated, No, I do not believe one was done then because one was already done previously by [SSD]. 9. On 02/16/23 at 4:30 PM, the Administrator provided Resident #107's, Resident's Personal Possessions, during her stay at the facility. A list of items signed by a family member or responsible party at or after discharge was not provided. 10. The facility policy titled, Abuse, Neglect, and Maltreatment Investigation & Reporting, provided by the Administrator on 02/13/23 at 3:10 PM documented, .The facility will endeavor to protect Resident/Elders from . the misappropriation of Resident/Elder property . 4. Reporting: All Others - 24 hour limit: If the events that cause the reasonable suspicion do not include allegations of abuse or serious bodily injury to a resident, the staff person shall report the suspicion no later than 24 hours after forming the suspicion .

Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (Resident #88) of 18 (Residents #2, #17, #21, #26, #31, #34, #35, #42, #53, #55, #74, #88, #93, #94, #96, #97, #257 and #507) sampled residents whose MDS was reviewed. This failed practice had the potential to affect 107 residents who resided in the facility as documented on the Daily Census provided by the Administrator on 02/13/23. The findings are: 1. Resident #88 had diagnoses of Vascular Dementia without Behavioral Disturbance, Psychotic Disorder, and Mood Disorder with Hallucinations. The Quarterly MDS with an Assessment Reference Date (ARD) of 01/27/23 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview of Mental Status (BIMS) and had a Psychiatric Disorder (other than Schizophrenia). 2. The electronic records for Resident #88 contained a (State Designated Professional Associates) document dated 11/05/2021 documented, You recently submitted a Level I application . on the above client. (State Designated Professional Associates) has reviewed this application and has determined this client is a NON-PASRR [Preadmission Screening and Resident Review] client . 3. On 02/14/23 at 3:09 PM, the Surveyor asked MDS Coordinator #1, MDS Coordinator #2 and the MDS Consultant if they were able to locate the PASRR II for Resident #88. MDS Coordinator #1 stated she was a Non-PASRR client. MDS Coordinator #2 stated, Oh, on the Annual it says Bipolar. I do not know why it says that. MDS Coordinator #1 stated, We will have to do a correction and modification for 10/27/22. That explains it. The MDS Consultant stated, I want to make sure there was not a diagnosis code that was resolved. MDS Coordinator #2 stated, No, there is no resolved or struck out diagnosis. It pulled on both the Modification and the original Annual. MDS Coordinator #1 stated, Something somewhere is triggering it. We never have had one pulled like that before. It pulled on her Annual and her Quarterly. It is on all of them except the Admission and the February 2022. MDS Coordinator #2 stated, May is the first one that is wrong. All since then are wrong too. MDS Coordinator #1 stated, We will get those corrected now. The Surveyor asked them who was responsible for ensuring the MDS accuracy. MDS Coordinator #1 stated, I have to close them out, but when I sign off on them an RN [Registered Nurse], I am signing that they are completed, but not completely accurate. The Surveyor asked how often the MDSs were reviewed. MDS Coordinator #1 stated, I do not think there is any RN that (paused) I don't believe there is a review done. The MDS Consultant stated, You are not signing for accuracy. MDS Coordinator #2 stated, I am the one that completed and did the May. 4. On 02/16/23 at 4:03 PM, the RN Consultant informed the Surveyor the facility did not have a policy regarding MDS assessments.