Every finding on record at Chatuge Regional Nursing Home

Based on observations, record review, staff interview, and facility policy review, the facility failed to evaluate a resident's physical and cognitive ability to safely self- administer medication for one (Resident (R) 27) of six residents during medication administration observations out of a total sample size of 21 residents. This failure resulted in the resident administering the incorrect amount of medication.Findings include:Review of the facility's policy titled, Self-Administration of Medications, dated May 2020, revealed, . 1. The facility and Interdisciplinary Care Team should assess and determine resident eligibility to self-administer medications by: a. Evaluating resident's functionality and health condition, b. Educate the resident to ensure the resident is able to state the name, dose, strength, frequency and purpose for use of his/her medications, c. Educate the resident to ensure he or she understands the possible side effects of medications and that he or she should notify the facility staff if any of these events are experienced, d. Educate the resident to correctly administer, inject or apply his or her medications . 3. Facility should ensure that the orders for self-administration of medications list the specific medication(s) that the resident may self-administer . 6. Facility should document in the resident's care plan whether the resident or the facility staff is responsible for the storage of the resident's medications . j. Facility staff should document the self-administration of medications and self-storage of medications in the resident's care plan.Review of R27's Clinical/Charting Snapshot located under the Charting section of the electronic medical record (EMR) revealed R27 was admitted to the facility on [DATE] with diagnoses including allergy, unspecified, and chronic obstructive pulmonary disease (COPD).Review of R27's undated Physician Orders located under the Charting section of the EMR, reflected an order written on 7/1/2025 for Flonase 0.05 [milligrams] mg [per] actuation spray one spray to each nostril via nasal inhalation twice daily for allergies. The orders did not indicate that R27 was able to self-administer the medication.Review of R27's Plan of Care, last reviewed 10/14/2025, under Care Plan located in the Charting section of the EMR, revealed no problem statement or interventions for the self-administration of medication(s).Review of a Self-Medication Report as of 12/4/2025 at 1:49 PM located under Reports under the Clinical Reporting section in the EMR revealed no Self-Medication Assessment for R27.During an observation on 12/2/2025 at 8:35 am, R27 self-administered two sprays of Flonase spray into each nostril. Registered Nurse (RN) 1 handed R27 the medication bottle to self-administer. R27 cleared her nostrils by gently blowing her nose. R27 shook the medication bottle, closed her left nostril with a finger, inserted the nozzle tip into the right nostril. R27 inhaled through her nose while pressing down on the nozzle to spray. R27 administered two sprays to the right nostril and repeated the process for the left nostril.During an interview on 12/2/2025 at 8:49 am, RN1 indicated R27 could self-administer the nasal spray; she [RN1] had to monitor R27 during medication administration. RN1 could not confirm if R27 was assessed for self-administration of medications and did not know how to verify.During an interview on 12/4/2025 at 2:10 pm, the Assistant Director of Nursing (ADON) stated residents were assessed for self-medication administration if the residents requested. The ADON indicated R27 was not assessed to self-administer the nasal spray. The ADON said that there was a form located under the assessments section in the EMR to complete when the resident was assessed. The ADON said after the resident was assessed, a physician's order must be obtained and then it was care planned. The ADON confirmed that R27 was not assessed for medication self-administration, there was not a physician's order, and it was not care planned.

Based on observations, family member and staff interviews, record review, and facility policy review, the facility failed to ensure the call button to activate the emergency call light was accessible for two (Resident (R) 3 and 87) of 21 residents in the sample. This failure placed the residents at risk for accident, injury, or unmet needs related to an inability to call for staff assistance.Findings include:Review of the policy titled, Call Light System Policy and Procedure dated June 2024, revealed, Staff should verify the call light is within reach prior to leaving the resident alone in their room.1. Review of R3's Record of Admission, located in the Resident tab in the Snapshot of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including paraplegia, weakness, and vascular dementia. Review of R54's Care Plan, dated 7/1/2023 and found in the Resident tab under Care Plans in the EMR revealed, [R3] was at risk for fall [sic] or injury from fall related to impaired mobility. The interventions for this included, call light within reach, with prompt response to her requests.Review of R3's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/9/2025 and located in the Resident table of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment. The MDS also indicated R3 had lower extremity impairment and was dependent on staff to complete toileting hygiene, bathing, dressing, personal hygiene, and transfers. During an observation on 12/1/2025 at 1:17 pm, R3's call button was observed hanging on the side rail, out of reach of the resident. During an observation on 12/3/2025 at 7:44 am, R3's call button was observed dangling through the right handrail out of reach of the resident. During an interview on 12/3/2025 at 10:15 am with Certified Nurse Aide (CNA) 1, she confirmed call buttons should always be within the resident's reach, adding it allows the residents to get a hold of the staff if they need anything. During an interview on 12/3/2025 at 10:55 am with the Wound Care Registered Nurse (WC), she confirmed R3's call button was not within her reach when WC entered R3's room to provide wound care. 2. Review of R87's Clinical/Charting Snapshot located under the Charting section of the EMR revealed R87 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, unspecified; vascular dementia, mild; functional quadriplegia; and current pathological fracture, left humerus (upper arm).Review of R87's Plan of Care, initiated 1/13/2023 under Care Plan located in the Charting section of the EMR, revealed, [R87] requires assistance with activities of daily living [ADLs] . Reduced range of motion [ROM] to Left hand/fingers and shoulder . The interventions included: Place call light within reach. Another area, [R87] is at risk for falls . included an intervention: Instruct on use of call light and place within reach when in room.During an observation and interview on 12/1/2025 at 11:15 am, R87 was in bed, family member (FM) 1 at bedside. The button to activate the call light was hanging across the left handrail of the bed not within reach of R87. R87 demonstrated the inability to reach the call button to activate the call light. During an interview, FM1 indicated the call light button was often outside of R87's reach. During an observation and interview on 12/1/2025 at 11:28 am, Licensed Practical Nurse (LPN) 1 said that R87 had a fracture of the left shoulder, had functional limitations, and required the call button near the right hand to activate the call light. LPN1 observed the call button hanging across the left handrail of the bed and placed the call light on R87's chest near the right hand within reach.During observations on 12/3/2025 from 9:15 am to 10:04 am and at 10:23 am, R87 was lying asleep in bed. R87's call button was dangling over the left handrail near the floor, not within reach. During an interview on 12/4/2025 at 12:10 pm, the Director of Nursing (DON) stated the call light should be accessible to every resident. The DON said that it is the nurse's and nursing assistant's responsibility to ensure the call button is within reach during rounds.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure written notices for bed holds and transfers were provided to residents and/or resident representatives and that the Ombudsman was notified when residents transferred to the hospital for four of 21 sampled residents (Resident (R)1, R7, R83, and R94) reviewed for hospitalization. These failures had the potential to cause confusion for residents and their representatives regarding the reason for their hospitalization, their ability to return to the facility, and their ability to appeal the discharge.Findings include:Review of the policy titled, Bed Hold and Returns, dated October 2024, revealed, Prior to transfers and therapeutic leaves, the residents or resident representative will be informed in writing of the bed-hold and return policy . Prior to a transfer, written information will be given to the resident and the resident representatives that explain in detail: a. The rights and limitations of the residents regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan [Medicaid Residents]; c. The facility per diem rate required to hold a bed [non- Medicaid], or to hold a bed beyond the state bed-hold period [Medicaid residents]; and the details of the transfer.Review of the facility policy titled, Resident Transfer and Discharge Rights Policy and Procedure, revised September 2024, revealed, .3. The resident and/or representative [sponsor] will be notified in writing of the following information: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is being transferred or discharged ; . 4. Office of the State Long-Term Care Ombudsman will be notified of the transfer/discharge. 1. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/2025, located in the electronic medical record (EMR) under the Charting/MDS tab, revealed an admission date of 3/13/2023 with diagnoses which included pneumonia, Alzheimer's disease, and atrial fibrillation. A Brief Interview for Mental Status (BIMS) score of six out of 15, indicated R1 was severely cognitively impaired.Review of R1's Nurse Progress Note, dated 8/15/2025 and located in the EMR under the Charting/Progress Notes tab revealed, Resident has been laying in bed all morning. Resident states, I'm too weak to get out of bed. MD [Medical Doctor] gave order. Send resident down to ER [emergency room] for eval [evaluation] and treatment . All transport paperwork sent with resident.Review of R1's Nurse Progress Note, dated 8/18/2015, located in the EMR under the Charting/Progress Note tab, revealed, resident returned to facility around 1420 [2:20 pm] . Review of R1's Nursing Home Transfer and Discharge Notice, dated 8/15/2025, provided by the facility, revealed blank sections that included Location to which resident is transferred or discharged , Notice given to, and Current Ombudsman Contact Information.Review of R1's EMR revealed no bed hold notice or documentation that a bed hold notice was provided.During an interview on 12/2/2025 at 9:17 am, R1 was sitting in a wheelchair at her bedside. R1 stated her (family member) took care of her paperwork. R1 stated she was in the hospital recently.During an interview on 12/2/2025 at 9:55 am, the Director of Nursing (DON) was asked if R1's responsible party was provided with a written notice for the bed hold and transfer when R1 was sent to the hospital in August 2025. The DON provided the Nursing Home Transfer and Discharge Notice, dated 8/15/2025, stating that R1's family member was mailed a copy. The DON was asked why there was no date or note documenting that the transfer notice was mailed. The DON stated sometimes she uploads the transfer notice before the notice was dated and documented as to when the notice was mailed.During a follow up interview on 12/4/2025 at 9:14 am, the DON confirmed the transfer form did not include the transfer location, documentation that a written notice was provided, and that the ombudsman was notified. The DON stated the Business Office Manager (BOM) handled the bed hold notices and ombudsman notifications.During an interview on 12/4/2025 at 9:20 am, the BOM was asked if R1's responsible party was provided with a written bed hold notice for R1's transfer to the hospital in August 2025 and if the ombudsman was notified of the transfer. The BOM stated R1 was an automatic bed hold as she was Medicaid. The BOM stated she was not sure what would happen if residents exceeded their allotted bed hold days. The BOM stated the Social Service Director (SSD) notified the ombudsman but that she would look into it since the SSD was on vacation.During a follow up interview on 12/4/2025 at 10:04 am, the BOM confirmed no bed hold notice was provided to R1's responsible party. The BOM provided a blank Nursing Home Bed Hold form for Medicaid residents, and confirmed the form did not include the daily per diem bed hold rate. The BOM confirmed she was unable to find documentation that the ombudsman was notified of R1's 08/15/2025 transfer to the hospital.2. Review of R7's Record of Admission, located in the Resident tab in the Snapshot of the EMR, revealed she was admitted to the facility on [DATE].Review of a Physician Order, dated 11/20/2025 and located under the Resident tab under Physician Orders in the EMR, revealed, send to ER for evaluation of left hip and leg following ground level fall.Review of a Nursing Home Transfer and Discharge Notice, dated 11/10/2025 and located in the Residents tab and in the Connections tab, revealed R7 was sent to the emergency department on 11/10/2025. In the area Notice given to: there was no date for Local long-term care Ombudsman Review. A review of R7's EMR revealed no bed hold notice for the hospital transfer on 11/10/2025.During an interview on 12/4/2025 at 10:00 am, the BOM revealed the SSD called the family and the Ombudsman the day after a resident discharged to the hospital; however, the SSD did not document this anywhere. The BOM confirmed there was no way to know if the Ombudsman was notified of the resident's transfer. The BOM also confirmed there was no bed hold notice for R7's 11/10/2025 transfer. 3. Review of R83's Clinical/Charting Snapshot under the Resident tab of the EMR indicated he was initially admitted to the facility on [DATE] with diagnoses that included bipolar disorder, chronic kidney disease, and functional quadriplegia.Review of R83's discharge MDS with an ARD of 10/8/2025, located in the EMR under the Charting/MDS tab, indicated the resident was discharged to the hospital.Review of R83's Notice of Transfer or Discharge, dated 10/8/2025 and found in the EMR's Documents tab, revealed no information regarding bed hold or indication that the facility provided a written bed hold notice to the resident or resident representative.4. Review of R94's Clinical/Charting Snapshot under the Resident tab of the EMR indicated he was initially admitted to the facility on [DATE] with diagnoses that included stage three kidney disease and diabetes.Review of R94's discharge MDS with an ARD of 9/15/2025, located in the EMR under the Charting/MDS tab, indicated the resident was discharged to the hospital.Review of R94's Notice of Transfer or Discharge, dated 9/15/2025 and found in the EMR's Documents tab, revealed no information regarding a bed hold or indication that the facility provided a written bed hold notice to the resident or resident representative.During an interview on 12/3/2025 at 1:45 pm, the Administrator stated that he was aware the bed hold notifications were not being provided to the residents or the residents' representatives.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan directing interventions for positioning and feeding for two (Resident (R) 3 and R57) of a total sample of 21 residents. This failure placed the residents at risk for unmet care needs.Findings include:Review of the policy titled, Care Plan Meetings, dated September 2024, revealed Each resident will have an individualized plan of care in place . The Comprehensive Care Plan will be resident centered having the individual resident as the locus of control. The Comprehensive Care Plan will be resident centered having individual resident as a unitary being.1. Review of R3's Record of Admission, located in the Resident tab in the Snapshot of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with paraplegia, weakness, and vascular dementia. Review of R54's Care Plan, dated 8/23/2023 and found in the Resident tab under Care Plans in the EMR revealed, Actual pressure ulcers and [R3] is at risk for complication of infection or worsening and is at risk for new pressure ulcers due to [R3] prefers lying on her back and has been resistive to turning and repositioning at times. An intervention was wedge while in bed, positioning with pillow . Review of R3's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/9/2025 and located in the Resident tab under MDS of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment. The MDS indicated R3 had lower extremity impairment and was dependent on staff to complete toileting hygiene, bathing, dressing, personal hygiene, and transfers. The MDS also indicated R3 had one unhealed stage four pressure injury and had a pressure reducing device for her chair and bed.During an observation on 12/1/2025 at 1:17 PM, R3 was observed lying on her back without pillows or a wedge to offload the coccyx area. During a wound care observation on 12/3/2025 at 7:44 am, R3 was observed lying on her back without a pillow or wedge to offload the coccyx area prior to the start of treatment.During an interview on 12/3/2025 at 11:58 am, Licensed Practical Nurse (LPN) 3 confirmed that a wedge was not in use during R3's wound care and that there was no wedge in the room. LPN3 stated if the coccyx was not offloaded the wound could worsen.During an interview on 12/3/2025 at 10:55 am, the Wound Care Registered Nurse (WC) confirmed R3 did not have a wedge or pillows to offload the coccyx area when she entered the resident's room to provide wound care with LPN3. During an interview on 12/4/2025 at 12:08 pm, the Director or Nursing (DON) stated if a resident refused care or to allow the staff to implement interventions, it should be in the care plan. She added the care plan guides staff on how to care for the residents.2. Review of R57's quarterly MDS with an ARD of 10/7/2025, located in the EMR under the Charting/MDS tab, revealed an admission date of 6/25/2025 and diagnoses which included cerebral palsy, dysphagia (difficulty swallowing), and gastro esophageal reflux disease (GERD - stomach acid flows into the esophagus causing heartburn). R57 was dependent on staff for eating, received a mechanically altered diet, and was severely cognitively impaired.Review of R57's diet order, dated 7/1/2025, located in the EMR under the Charting/Physician Order tab revealed, Puree and Nectar thick liquids *No caffeine [Soda, Tea, or Coffee], no straws, coated spoon, no metal utensils, hard cup for fluids, milk, water, orange juice, or apple juice, and no bread.Review of R57's SLP [Speech-Language Pathologist] Evaluation and Plan of Treatment, dated 10/3/2025 and provided by the facility, revealed, . [Patient] often hyperextends his head/neck during meal consumption and requires tactile stim [stimulation]/hold to the posterior of his head to bring him forward and to assist him in maintaining a forward stance to decrease risk for aspiration. Review of R57's Care Plan, dated 11/19/2025, located in the EMR under the Charting/Care Plan tab revealed, Nutrition: Risk for altered nutritional status due to dx [diagnoses] of Cerebral palsy, anemia, needs altered diet . Dependent on staff for meals. Interventions included: Provide set up and feed meals, Monitor tolerance to diet texture and ability to swallow during meals, and Allow extra time to eat as needed. The care plan did not include staff standing and holding the back of R57's head while feeding him.Review of R57's undated Kardex (computerized system of communication), located in the EMR under the Charting/Kardex tab, revealed nothing about standing or holding the back of R57's head while feeding him.On 12/1/2025 at 12:59 pm, R57 was observed sitting in his specialized wheelchair in the dining room for lunch. Certified Nurse Aide (CNA) 5 was noted to be feeding R57 a pureed diet. While spoon feeding R57, CNA5 stood next to R57, holding the back of his head. R57 ate 100 percent.During an interview on 12/4/2025 at 9:55 am, Physical Therapist Assistant (PTA) stated the speech therapist was involved with R57 and evaluated him on 10/3/2025, and a pureed diet with thickened liquids was recommended due to swallowing issues. PTA was asked if it was safe for a CNA to stand while feeding R57 in his wheelchair, and PTA stated, No because R57 could choke. PTA stated the speech therapist was unavailable to interview.During an interview on 12/4/2025 at 12:28 pm, the DON was asked about her expectations of CNAs feeding R57. The DON stated, safety first, but [R57] is hard to feed while sitting down because [R57] bites down on the spoon. The DON stated normally staff sit, but if staff do stand, R57 should be evaluated by speech therapy, and it should be care planned to stand if that is their recommendation. During an interview on 12/4/2025 at 3:03 pm, CNA5 stated the Speech Therapist told her to stand while feeding R57 and hold the back of his head because R57 throws his head back. CNA5 stated she tried sitting to feed R57, but R57 bites the spoon. CNA5 stated she was not sure if it was on the Kardex, but the speech therapist's instructions should be on the Kardex.

Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure clinical criteria were met prior to prescribing and administering an antibiotic for a urinary tract infection (UTI) for two (Resident (R) 5 and R34) of six residents reviewed for unnecessary medications. This failure had the potential to cause antibiotic resistance, increased risk of Clostridioides difficile (C. diff) infection, and adverse drug reactions.Findings include:Review of the facility policy titled, Surveillance for Infections, dated September 2017, revealed, . 2. The criteria for such infections are based on the current standard definitions of infections, . 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible, e. Bacteriuria WITH corresponding signs and symptoms of UTI; and f. Other positive cultures, and McGeer Criteria for UTI [Without indwelling urinary catheter] UTI should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture result. 1. Review of R5's comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/2025, located in the electronic medical record (EMR) under the Charting/MDS tab, revealed an admission date of 5/22/2025. R5 had a Brief Interview for Mental Status BIMS score of 15 out of 15, indicating R5 was cognitively intact. R5 took an antibiotic and had a diagnosis of urinary tract infection in the past 30 days.Review of R5's Nurses Progress Note, dated 10/10/2025, located in the EMR under the Charting/Progress Note tab, revealed, Resident very confused this shift, such as not being sure where she is. Resident voicing discomfort upon urination of pain and pressure. Resident has HX [history] of frequent UTIs with common symptoms of discomfort and the increase of confusion. Medical Doctor [MD] 2 called and gives new order to obtain Cath [catheter] U/A [urinary analysis] with reflex C&S [culture and sensitivity] . Review of R5's October 2025 Medication Administration Record (MAR), located in the EMR under the Charting/Physician Orders, revealed, 10/12/2025 Macrobid 100 mg [milligram] capsule . give 1 by mouth twice daily for 10 days for UTI, stop date:10/13/2025.Review of R5's Urine Culture, completed date 10/13/2025, located in the EMR under the Connections/Resident Results tab, revealed R5 was resistant to seven out of the 17 antibiotics. The results revealed a resistance to Macrobid. Review of R5's October 2025 MAR, located in the EMR under the Charting/Physician Orders tab, revealed 10/13/2025 cefuroxime axetil 500 mg tablet . 500 mg by mouth twice daily for UTI, stop date: 10/19/25. Review of R5's MD [physician] Progress Note, dated 10/21/2025 and located in the EMR under the Charting/Progress Notes tab revealed, Follow up of altered mental status, unspecified. Last visit, nurse [name] called reporting increased confusion. UA was ordered. UA showed proteinuria, hematuria. Cx [culture] ABN [abnormal]. Patient was on Macrobid to which there is resistance. Order was given 10/13 to replace Macrobid with cefuroxime 500mg po [oral] bid [twice daily] x [times] 5 d [days]. Pt [patient] is confused at today's visit.Review of R5's Urine Culture, ordered 10/24/2025 as a follow-up to antibiotic completion, located in the EMR under the Connections/Resident Results tab, revealed growth greater than 100,000 of [bacteria name]. No symptoms of a UTI were documented in the EMR.Review of R5's October 2025 and November 2025 MAR, located in the EMR under the Charting/Physician Orders tab, revealed 10/27/2025 Macrobid 100 mg capsule . 1 capsule by mouth twice daily for Urinary Tract Infection, discontinued 11/6/2025. The MAR indicated R5 was administered all doses although R5 showed resistance to Macrobid in the 10/13/2025 urine culture.Review of R5's Communication note, dated 11/25/2025 at 2:51 am, located in the EMR under the Charting/Progress Notes tab revealed, Patient has had increased confusion this HS [bedtime]. She thought she was in Florida and phoned her [family member] to tell her. I spoke with her [family member] over the phone, and she was concerned she was getting another UTI. She stated that [R5] always becomes disoriented when she has one. UTI STAT [the facility's protocol to encourage/push fluids] will start in the AM [morning]. Work sheet for UTI STAT (right away) filled out and placed on clipboard. Left message with unit manager about [family member] wanting UA [urinary analysis] done.Review of R5's Nurses Progress note, dated 11/25/2025 at 9:58 am, located in the EMR under the Charting/Progress Note tab revealed, [MD2] into facility this morning, due to resident increased confusion and HX of frequent UTIs, new order given to obtain cath U/A with C&SReview of R5's urine culture results, completion date 11/28/2025, located in the EMR under the Connections/Resident Results tab revealed > [greater than] 100,000 cfu/ml [colony-forming units per milliliter]-[bacteria name]. R5 was resistant to seven of the 17 antibiotics with an additional antibiotic showed intermediate.Review of R5's Order, dated 11/28/2025, located in the EMR under the Charting/Physician Orders tab, revealed, cefuroxime axetil 500 mg tablet . by mouth twice daily for Urinary Tract Infection, stop date 12/5/2025.Review of R5's Weekly Summary, dated 12/1/2025, located in the EMR under the Charting/Progress Notes tab revealed 11/25 Patient had an episode of delirium, so UTI STAT was initiated. MD visited and gave N.O [new order] for UA with C&S, refer to neurologist for delirium .11/28 Cefuroxime 500mg po BID for 7 days . UTI- UA grew out Providencia. Patient is alert and oriented with some confusion at times. She is pleasant and cooperative with care. Review of R5's Care Plan, dated 12/2/2025, located in the EMR under the Charting/Care Plans tab revealed UTI- Resident has an infection. An intervention included Urine: monitor color, odor, c/o [complaint of] urgency, Frequency or burning.Review of R5's Point of Care for toileting, dated 11/3/2025 to 12/3/2025 located in the EMR under the Charting/Point of Care tab revealed R5 was provided incontinent care two to three times daily. No pattern of increased incontinence frequency was found.On 12/2/2025 at 2:43 pm, R5 was awake in bed dressed in a gown and groomed. R5 stated she was on an antibiotic due to a UTI. R5 stated she didn't experience burning or other symptoms. R5 went on to say, Just the test showed a UTI. The doctor ordered the test. R5 stated she did not ask for the UA.During an interview on 12/2/2025 at 4:20 pm, the Infection Preventionist (IP) stated they used McGeer [evidence-based guidelines] for determining UTIs. The physician ordered the most recent UA for R5 due to R5 having increased confusion, which was documented in the progress notes. During an interview on 12/3/2025 at 1:57 pm, the IP stated R5's UTI met McGeer's criteria because of R5's confusion and the bacterial growth greater than 100,000. The IP reviewed a form with McGeer's criteria and reviewed R5's EMR for symptoms. The IP stated because the laboratory results were greater than 100,000, and R5 was having increased incontinence, this met criteria. When the IP was asked what she meant by increased incontinence, the IP stated the Certified Nurse Aide (CNA) reported that right after she provided R5 with incontinent care, the CNA turned to the roommate to provide her with incontinent care. At that time R5 informed the CNA she was urinating again. On 12/3/2025 at 2:13 pm, R5 stated the nurse used a needle (catheter) to collect urine for the UA, and it was unpleasant. R5 stated she had no symptoms and was not sure why a test was done. R5 stated she was just on an antibiotic recently for a UTI.During a follow up interview on 12/4/2025 at 10:50 am, the IP provided the McGeer Criteria for Infection Surveillance Checklist, from a facility binder. It included handwritten notes increased confusion 11/24-11/25- UA ordered and 11/25/2025 recurrence of psychosis [the change symbol] Thanksgiving x 2 freq [frequency] per CNA while still in room /c [with] other resident care. The IP was asked if 11/25/2025 was the only day R5 had increased incontinence. The IP stated, yes. The checklist was marked new or marked increase in incontinence, suprapubic pain, and a handwritten note > [greater] + [plus] Providencia + gram - [negative] rods. The IP confirmed these symptoms were not documented in the progress notes or in the CNA charting but should have been. The IP stated she has told the physicians about antibiotic stewardship, but the physicians still prescribe antibiotics. The IP confirmed she did not document her educational discussions with the physicians.During an interview on 12/4/2025 at 12:35 PM, the Director of Nursing (DON) stated, An altered mental status was not a good reason for a UA. The DON stated one day of increased incontinence did not meet the criteria for a marked increase in incontinence/frequency. The DON stated that physician education on the antibiotic stewardship program should be documented.During a telephone interview on 12/4/2025 at 2:15 pm, MD2 stated he saw R5, and she was experiencing psychotic behavior that could be due to a UTI. MD2 stated he prescribed antibiotics due to R5's behavioral change and the culture. MD2 stated he prescribed antibiotics only when indicated. MD2 stated R5's incontinence was getting worse. MD2 was asked if the facility informed him the increased incontinence was just once. MD2 did not respond about the incontinence but stated that R5 had three cultures, all with growth, in October 2025 and was also seen by the gynecologist for a mass that she refused treatment for which might be contributing to the UTIs.2. Review of R34's quarterly MDS with an ARD of 10/16/2025, located in the EMR under the Charting/MDS tab, revealed an admission date of 2/2/2023. R34 had a BIMS score of 15 out of 15, indicating R34's cognition was intact. R34 took an antibiotic and had diagnoses of heart failure, chronic kidney disease, and Alzheimer's disease.Review of R34's EMR revealed R34 received an antibiotic at least monthly from December 2024 to November 2025 for UTI and UTI prophylaxis, for sinusitis, or for dental procedures.Review of R34's Antibiotic Therapy note, dated 12/3/2024, located in the EMR under the Charting/Progress Notes tab, revealed, Resident on Macrodantin [antibiotic] r/t [related to] prophylactic abt [antibiotic] for hx of UTI. No adverse s/s [signs/symptoms] noted or reported.Review of R34's Weekly Summary note, dated 1/3/2025, located in the EMR under the Charting/Progress Notes tab, revealed, Conts [continues] on PO ABT A/O [alert/oriented] x3 with some periods of confusion . continuously for proph. [prophylatic] measures to prevent UTI. No adverse reactions noted.Review of R34's Weekly Summary note, dated 1/12/2025, located in the EMR under the Charting/Progress Notes tab, revealed, on 1/04, resident's pending urine culture finalized which resulted proteus mirabilis. md notified and gave orders to d/c [discontinue] macrobid due to resistance and start bactrim ds [double strength].Review of R34's Nurses Progress Note, dated 2/17/2025, located in the EMR under the Charting/Progress Note tab revealed, Resident is not her baseline. Resident had c/o [complained] of numbness to right great toe. MD made aware. MD gave order to obtain UA With C&S .Review of R34's Antibiotic Therapy note, dated 2/18/2025, located in the EMR under the Charting/Progress Notes tab, revealed, Patient is currently on [oral antibiotic] for a UTI. Urine showed 2+ bacteria. Patient has been more confused this [bedtime]. She thinks she has to get up to go to work, and she gets confused if it's day or night time. [Oral] fluids have been encouraged. No adverse reactions noted to [antibiotic] therapy.Review of R34's Antibiotic Therapy note, dated 3/4/2025, located in the EMR under the Charting/Progress Notes tab, revealed, Resident on [oral] antibiotic Cipro r/t UTI until 3/9. No adverse s/s noted or reported. No c/o dysuria.Review of R34's EMR revealed no documentation of symptoms, other than confusion.Review of R34's Antibiotic Therapy note, dated 10/1/2025, located in the EMR under the Charting/Progress Notes tab revealed, resident continues on [oral antibiotic] for prophylactic use, no adverse reactions noted, po fluids [increased], resident at nurses station countless times asking for her pain med, resident walking and roaming in room out in hallway or to activities room . Review of R34's Order, dated 10/1/2025, located in the EMR under the Charting/Physician Orders tab revealed Macrodantin 50 mg capsule . *** to be given daily until further notice as prophylactic therapy*** 1 capsule by mouth every day for prophylactic therapy.Review of the EMR revealed no documentation regarding why the prophylactic antibiotic was ordered such as failed treatments or negative outcomes.Review of R34's Care Plan, dated 10/29/2025, located in the EMR under the Charting/Care Plan tab revealed Resident at risk for recurrent UTI's. An intervention included Urine: monitor color, odor, c/o urgency, Frequency or burning.On 12/1/2025 at 1:20 pm, R34 was sitting in a chair in her room dressed and groomed. R34 mentioned a nurse came into her room last night to give her an antibiotic for a UTI but she feels fine.During an interview on 12/3/2025 at 10:55 am, the IP was asked about R34's prophylactic antibiotic and her history of receiving antibiotics for one year. The IP stated she had informed the physician that the prophylactic antibiotic was against McGeer's criteria, but the physician still insisted on prescribing it. The IP stated the physician said R34 was at risk for sepsis due to her frequent UTIs. The IP stated R34's family member also wanted R34 on the antibiotic for prevention. The IP stated she was unsure where documentation was regarding her education of the physicians. During a telephone interview on 12/4/2025 at 2:06 pm, MD1 stated R34's prophylactic antibiotic was very appropriate due to various treatments that had been tried and her frequency of UTIs. MD1 stated he was aware of the facility's antibiotic stewardship program and that he used the lowest dose with the narrowest possible spectrum antibiotic. During a follow-up interview on 12/4/2025 at 2:55 pm, the IP provided a letter from MD1, with a facsimile time stamp of 12/4/2024 at 2:47 pm, that revealed, R34 is a patient under my care at [name of clinic]. R34 was seen on 11/12/2025. Patient suffers from chronic urinary infections that necessitate continued prophylactic treatment. She has failed conservative measures and as a way to maintain her comfort and avoid recurrent serious urinary bacterial infections it is prudent to continue low dose prophylactic antimicrobial therapy. Please feel to contact our clinic if you have any questions or concerns.

Based on observations, staff interviews, record review, facility policy review, and document review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had three errors in 47 opportunities, which resulted in a six percent error rate. This affected three (Resident (R) 27, R42, and R87) out of six residents observed. Medication errors have the potential to result in adverse health outcomes.Findings include:Review of the facility's policy titled, Storage of Medication, dated May 2020, revealed, . III. Expiration Dating . 3. Certain medications or package types, such as . multiple dose injectable vials . require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency . 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating . 6. The nurse will check the expiration date of each medication before administering it . 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining . Review of the American Diabetes Association's Safe Storage of Insulin, dated 2018 and located at: https://diabetes.org/sites/default/files/2023-10/ddrc-storing-insulin-2018.pdf, revealed insulin products contained in vials supplied by the manufacturers (opened or unopened) may be left unrefrigerated for up to 28 days and continue to work.1. Review of R27's undated Physician Orders located under the Charting section of the electronic medical record (EMR), reflected an order written on 7/01/2025 for Flonase 0.05 [milligrams] mg [per] actuation spray, one spray to each nostril via nasal inhalation twice daily for allergies. The order did not indicate that R27 was able to self-administer the medication.During a medication observation on 12/2/2025 at 8:35 am, R27 self-administered two sprays of Flonase spray, an allergy relief nasal spray, into each nostril. Registered Nurse (RN) 1 handed R27 the medication bottle to self-administer, and R27 administered two sprays to the right nostril and repeated the process for the left nostril. During an interview on 12/2/2025 at 8:49 AM, RN1 indicated R27 could self-administer the nasal spray; she [RN1] had to monitor R27 during medication administration. 2. Review of R42's Physician Orders located under the Charting section of the EMR, reflected an order written on 8/18/2502 for Vitamin B12 1000 micrograms (mcg) tablet one tablet sublingually (placed beneath the tongue to dissolve and be absorbed directly into the bloodstream) every day for Vitamin B12 deficiency.During an observation and interview on 12/1/2025 at 11:28 am, Licensed Practical nurse (LPN) 4 prepared medications for R42. LPN4 removed an over-the-counter stock bottle of vitamin B12 1000 mcg tablets from a drawer of the medication cart. LPN4 placed one tablet into a medication cup with the remaining medications. LPN4 administered the medications to R42 by mouth. R42 swallowed the medications whole with water. During an interview, LPN4 said that she did not realize the tablet should be administered under the tongue. LPN4 said that it was her responsibility to ensure that she read and understood the physician orders for medication administration.3. During an observation on 12/1/2025 at 11:28 am, LPN1 was observed drawing a sliding scale insulin (SSI) dose from a vial for R87. LPN1 removed a box of insulin aspart, a rapid-acting insulin, from the top drawer of the medication cart. The box had a handwritten open date of 10/30/25 and end date 11/28/2025. The insulin vial was not dated. LPN1 pulled the plunger back to draw eight units of insulin into a syringe for administration to R87. LPN1 administered the insulin to R87's abdomen, right upper quadrant. During an interview on 12/1/2025 at 11:46 am, LPN1 said that she misread the open and expiration date(s) on the box and thought the open date was 11/30/2025. LPN1 said that the insulin was recently opened. She did not know why there was not a date on the bottle, but it was on the box. LPN1 said that the risk of administering insulin after 28 days was that it would not be as effective.During an interview on 12/4/2025 at 12:10 pm, the Director of Nursing (DON) stated nurses should follow the five medication rights when administering medications to ensure that the right medications were administered to the right person, the right dose, the right route, at the right time. The DON said that the nurses were responsible for checking expiration dates on all medication packaging before administration.

Based on record review, interviews, review of the Administrator Job Description, and review of the policy titled Abuse Reporting and Investigation, the facility Administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident abuse, exploitation, and injury of unknown origin, which were reported to him. The failure of the Administrator to take appropriate action which was reported to him has the likelihood to lead to future allegations of abuse, exploitation, and injury of unknown origin that are not identified, reported, or investigated. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the Immediate Jeopardy's was identified to have existed on 3/22/2024 when the facility failed to protect two residents (R) (R78 and R107) from physical, mental, and verbal abuse. A second Immediate Jeopardy was identified to have existed on 3/22/2024 when Certified Nurse Aide (CNA)1 began a personal relationship with R71. A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024. Findings include: Review of the undated document titled Nursing Home Administration Job Description/Performance Evaluation documented the Administrator of the Nursing Home shall be responsible for the planning, controlling, and directing the overall program and shall be responsible for direct supervision of all departments of the Nursing Home. The Administrator of the Nursing Home is an experienced professional who ensures that the facility meets the age specific needs of adults and geriatrics as well the physical, psychosocial, and cultural needs of the residents. Functions and duties include: Assist with planning, organizing, controlling, and directing a viable program of services at Nursing Home. Manage a program of patient services that allows resident the opportunity for input into the facility's operation and to promote an environment that is conducive to the social, physical, psychological, and cultural health of the patient population. Ensure the facility's physical plan is maintained to OSHA guidelines and standards and that the physical environment remains attractive and pleasant to residents and visitors. Ensure compliance with State and Federal guidelines regarding Nursing Home operations. Monitor in-service training and ensure that it is carried out on an on-going basis and encourage staff development. Attend organizational meetings, board meetings, and represent the Nursing Home in all matters. Review of a policy titled Abuse Reporting and Investigation, last revised March 2017 revealed Implementation: Number 3.c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident; f. and interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; g. Interview staff members on all shifts who have had contact with the resident during the period of the alleged incident; i. interview other residents to whom the accused employee provides care or services; j. and review all events leading up to the alleged incident, and obtain the interviews in writing by the staff member or the administrator/abuse coordinator, notify the ombudsman, suspend the employee pending the progress/findings of the investigation. Number 5. Witness reports will be obtained in writing. Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency. 1. On 7/12/2023, an allegation of exploitation was reported to the Administrator regarding a staff to resident personal relationship between CNA 1 and R71. The Administrator failed to identify this personal relationship as potential exploitation and did not investigate or report this allegation. Cross Refer F602 2. On 3/8/2024, the Administrator was made aware of an injury of unknown origin for R71 and failed to investigate and report this incident. Cross Refer F609 and F610 3. On 3/22/2024, the Administrator became aware of an allegation of employee to resident abuse towards R78, perpetrated by CNA 2. The Administrator did not identify this situation as abuse, did not protect R78 from CNA 2, failed to investigate this allegation, and failed to report the incident accurately. Cross Reference F600 , F609 and F610 4. On 4/22/2024 the facility became aware of an allegation of mental and verbal abuse from CNA 2 to R107 and did not report or investigate the incident. Cross Refer F600, F609, and F610 During an interview on 6/6/2024 at 9:20 am, the Administrator confirmed the incidents listed above were indicative of abuse to the residents, and were either not reported timely, and/or investigated thoroughly. He indicated he had misplaced the documentation related to the incidents.

Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect the resident's right to be free from abuse from by facility staff. Specifically, the facility failed to protect two residents (R) (R78 and R107) of 27 total sampled residents from physical, mental, and verbal abuse from Certified Nursing Assistant (CNA) staff. Due to the vulnerable nature of the nursing home population and the likelihood of resident abuse in the facility, immediate action was required to prevent further events of abuse. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the first Immediate Jeopardy was identified to have existed on 3/22/2024 when the facility failed to protect two residents (R) (R78 and R107) from physical, mental, and verbal abuse. A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024. Findings include: Review of the policy titled Abuse Reporting and Investigation, revised March 2017, revealed Facility will not permit residents to be subjected to abuse by anyone, visitors, other residents, staff members, volunteers, and/or other agency working inside facility. Forms of abuse consist of verbal, sexual, physical, mental, neglect, exploitation/misappropriation of resident property, mistreatment, and injuries of unknown origin. 1. Review of R78's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admitted [DATE] with a diagnosis of dementia. Review of R78's significant change Minimum Data Set (MDS) dated of 3/21/2024 revealed a Brief Interview of Mental Status (BIMS) score of a zero out of 15 which indicated R78 was severely cognitively impaired. Review of the Facility Reported Incident (FRI) dated 3/22/2024, completed by the Administrator/Abuse Coordinator, revealed a report of verbal abuse. The report stated, allegation was reported by another CNA [CNA3] that a staff member [CNA2] spoke harshly to the resident during her shower. The FRI further revealed that Human Resource (HR) staff was interviewed and stated that CNA 3 reported the above incident to her. The HR staff stated CNA 3 submitted a written statement of the incident and it was provided to the administrator. The FRI included an interview with the Director of Nursing (DON) where she stated that she provided verbal training to staff to always be mindful of your tone of voice. Review of CNA 2's personnel file revealed no evidence of abuse training other than a statement on how to report elder abuse under the Elder Justice Act. CNA 2 was suspended with pay for three days. The facility could not provide a facility investigation that determined the outcome of the incident. CNA 2 continued to provide direct care to R78, 16 times since this incident occurred, as recently as 6/5/2024. During an interview on 6/6/2024 at 9:20 am, the Administrator stated he had misplaced all documentation related to this incident. During an interview on 6/6/2024 at 9:55 am, CNA 3 stated she provided a verbal and written statement that CNA 2 was rough with R78 during a shower by throwing the resident into the shower chair. CNA 3 said R78 began gagging and crying. She stated R78 said l am going to vomit. She stated that CNA 2 told the resident if you vomit on me, I am going to punch you. CNA 3 proceeded to say that CNA 2 sprayed water in R78's face. 35690 2. Review of R107's Record of Admission, located under the Clinical tab of the EMR, revealed R107 was admitted to the facility on [DATE] with a diagnosis of Hemiparesis. Review of R107's Discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact. The resident required supervision for lower body and toileting. Review of a Grievance Form dated 4/22/2024 documented that R107 submitted a grievance form to Social Services Director (SSD). The grievance read, SS (social services) received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend. SS spoke with resident who advised when resident asked to get up for bedside toilet the CNA told the resident to use her pull up. Resident advised that the CNA did not get her up, did not take her to the bedside toilet, and kept her in bed all weekend. Resident said she did not get up out of the bed until Monday 4/22/2024. Resident advised that she was given an enema Friday, and it did not feel right to her to be made to use the bathroom on herself. The Investigation portion of the Grievance Form read Spoke with the staff member in charge of resident. She stated that resident asked her to help her get on BSC (bed side commode). Staff member then informed resident that since she just had an enema, they [sic] may not make it to the toilet. Staff member also reported that resident did not go to sleep until after 4:00 am and she voiced she was tired. The Action Taken included no documentation. The investigating employee was the Director of Nursing (DON), dated 4/24/2024 and the Administrator signed the document on 5/1/2024. During an interview on 6/6/2024 at 5:30 pm, the DON revealed she had talked to CNA 2 but did not document anything. The DON confirmed that CNA 2 who was named in the allegation had continued working since the event occurred. During an interview on 6/6/2024 at 7:30 pm, the Administrator revealed he had suspended CNA 2 and has since been terminated. During an interview on 6/8/2024 at 3:15 pm, the Administrator revealed the police had been notified regarding the incident. An attempt to interview CNA 2 was unsuccessful.

Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect one resident (R) (R71) out of a total sample of 27 from exploitation perpetrated by Certified Nurse Aide (CNA)1. Due to the vulnerable nature of the nursing home population, a potential for serious exploitation existed, and the likelihood of CNA 1 exploiting other residents in the facility required immediate action to prevent further events of exploitation. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 7/12/2023 when the facility failed to protect R71 from exploitation by CNA 1. A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024. Findings include: Review of the policy titled Abuse Reporting and Investigation, revised March 2017, indicated the Procedure is the facility will not permit residents to be subjected to abuse by anyone, visitors, other residents, staff members, volunteers, and/or other agency working inside facility. Forms of abuse consist of verbal, sexual, physical, mental, neglect, exploitation/misappropriation of resident property, mistreatment, and injuries of unknown origin. Implementation: Number 8. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admitted [DATE] with a diagnosis of dementia and delusions. Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated R71 was moderately cognitively impaired. Review of an untitled document dated 7/12/2023, written by the Administrator documented CNA 1 was spending time with R71. The document revealed CNA 1 was staying with the resident in the facility until 2:00 am. The document revealed that facility staff observed CNA 1 holding hands with R71 in his room during this time. Further review of the document revealed the Administrator spoke with CNA 1 regarding the relationship with R71 and she denied any involvement. The Administrator discussed concerns that CNA 1 was spending so much time with R71 while other residents assigned to her required assistance, which had to be provided by other CNA's. The Administrator informed CNA 1 that personal relationships between resident and employees crossed professional boundaries and would not be tolerated. ln this document, he indicated he was reassigning CNA 1 to another hall and that she was no longer allowed to cross over to R71's hall. Review of a report filed to the Adult Protective Services (APS), by the Business Office Manager dated 5/30/2024, revealed R71 left Against Medical Advice (AMA). Review of additional information in the report filed to the APS revealed R71 came to the business office to pay his bill and R71 presented three debit cards that were all declined. He stated I don't know who is spending all my money. Review of an untitled document, dated 6/3/2024, written by the Administrator revealed R71 returned from the hospital with his medical record. The medical record revealed that CNA 1 was listed as his emergency contact. The Administrator spoke with the staff member about her being listed as the emergency contact on the hospital medical records for R71. He reiterated to her their prior conversation from 7/12/2023. CNA 1 would not respond to the Administrator during this conversation. CNA 1 then requested a piece of paper from the Administrator and proceeded to write her resignation letter and presented it to the administrator. During an interview on 6/6/2024 at 10:48 pm, the Administrator confirmed he did not thoroughly investigate the allegations of exploitation of R71 by CNA 1 as he felt they were rumors and had no further information to provide.

Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to ensure allegations of abuse, an injury of unknown origin that resulted in a hip fracture, and an allegation of employee to resident exploitation were reported to the State Survey Agency (SSA). Specifically, residents (R) (R71 and R107) were verbally abused by staff; R71 sustained an injury of unknown origin and potential exploitation by facility staff. The failure of the facility to report these incidents has the likelihood to lead to future unreported injuries of unknown origin, exploitation, and mental and verbal abuse against residents. The sample size was 27. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/12/2023 related to the failure to report exploitation by Certified Nursing Aide (CNA) CNA 1 to R71, failed to report an injury of unknown origin for R71, and failed to report employee to resident abuse for R107. A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024. Findings include: Review of the facility policy titled Abuse Reporting and Investigation, revised March 2017, indicated Implementation: Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the State Survey and Certification Agency, the local police department, the Ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. 1. Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admitted [DATE] with a diagnosis of dementia and delusions. Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicated R71 was moderately cognitively impaired. Review of an untitled document dated 7/12/2023, written by the Administrator, summarizes a situation between CNA 1 and R71. CNA 1 would spend time in R71's room while neglecting her other assigned residents and was observed to be holding hands with R71. The Administrator spoke with CNA 1 regarding personal relationships between residents and employees that crossed professional boundaries and would not be tolerated. She denied any involvement with R71. She was reassigned to another hall, informed her that she was no longer allowed to cross over to R71's hall. There was no evidence this incident was reported to the SSA. Review of the Adult Protective Services (APS) report dated 5/30/2024 filed by the Business Office Manager revealed R71 left facility Against Medical Advice (AMA). Review of additional information in the report revealed R71 attempted to pay his bill and R71 presented three debit cards that were all declined. Resident stated, I don't know who is spending all my money. There was no evidence this incident was reported to the SSA. Cross Refer F602. Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024. Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip. This note further revealed R71 was not able to move his leg on that side and knee and foot appeared very swollen. R71 was immediately sent to the emergency room . On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery. There was no evidence that the injury of unknown origin was reported to the SSA. 2. Review of R107's Record of Admission, located under the Clinical tab of the EMR revealed R107 was admitted to the facility on [DATE] with a diagnosis of Hemiparesis. Review of the Discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact. The resident required supervision for lower body and toileting. Review of the Grievance Form dated 4/22/2024 revealed that R107 submitted a grievance form when the facility received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend. When Social Services spoke with R107 he advised that that CNA 2 would not assist him to the bathroom and told him to go in his pull up. He further stated CNA 2 did not get him up all weekend. There was no evidence the incident was reported to the SSA. During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed the exploitation, injury of unknow origin, and verbal abuse were not reported to the SSA. Cross Reference F600.

Based on record review, interviews, and review of the policy titled Abuse Reporting and Investigation, the facility failed to ensure that allegations of abuse, allegations of exploitation, and an injury of unknown origin, were thoroughly investigated for three residents (R) (R78, R71, and R107) reviewed out of a total sample of 27 residents. Specifically, the facility failed to investigate allegations of employee to resident abuse for R78 and R107, perpetrated by Certified Nurse Aide (CNA) 2. In addition, the facility failed to investigate an injury of unknown origin that resulted in a hip fracture and failed to investigate allegations of exploitation for R71 perpetrated by CNA 1. The failure of the Administrator to investigate these incidents have the likelihood to lead to future unreported allegations of abuse and exploitation as well as injuries of unknown origin. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 7/12/2023 when the facility became aware CNA 1 was in a personal relationship with R71 and potentially exploited is money. A Credible Allegation of Compliance was received on 6/7/2024. Based on observations, record review, resident and staff interviews, and review of facility policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed as of 6/8/2024. Findings include: Review of the facility policy titled Abuse Reporting and Investigation, revised March 2017, indicated the Statement Of Purpose is that all reports of resident abuse, neglect, and injuries of unknown source shall be thoroughly and promptly investigated by the facility. Implementation: Number 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator and/or the Director of Nursing (DON), will appoint a member of management to investigate the alleged incident. Number 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state and local laws, within five working days of the reported incident. 1. Review of R71's Record of Admission located under the Clinical tab of the electronic medical record (EMR), revealed an admitted [DATE] with diagnoses of dementia and delusions. Review of R71's quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 11 out of 15 which indicated R71 was moderately cognitively impaired. The Administrator submitted a written document dated 7/12/2023 that documented a suspected situation with CNA 1 and R71 being involved in a relationship with each other. The document continued to indicate that CNA 1 would neglect the other residents on her assignment, while she would be spending time in R71's room. CNA 1 was reassigned to another hall, and she was no longer allowed to go to R71's hall. There was no evidence this incident was thoroughly investigated by the facility. Review of the Adult Protective Services (APS) report dated 5/30/2024 filed by the Business Office Manager revealed R71 left facility Against Medical Advice (AMA). Review of additional information in the report revealed R71 attempted to pay his bill and he presented three debit cards that were all declined. Resident stated, I don't know who is spending all my money. There was no evidence this incident was reported to the SA. Review of the Progress Notes dated 3/8/2024 indicated resident was on a leave of absence (LOA) from the facility 3/5/2024 through 3/7/2024. Upon his return, the resident reported that he had a fall while on LOA and thought he had a broken right leg/hip. This note further revealed R71 was not able to move his leg on that side and knee and foot appeared very swollen. R71 was immediately sent to the emergency room . On 3/12/2024, the resident returned to the facility from the hospital. He had a fractured right femur that had been repaired in surgery. There was no evidence that the injury of unknown origin was investigated by the facility. During an interview with the Administrator on 6/6/2024 at 10:48 pm, he confirmed the above incidents involving R71 were not thoroughly investigated. 3. Review of R78's Record of Admission located under the Clinical tab of the EMR revealed an admitted [DATE] with a diagnosis of dementia. Review of R78's significant change MDS dated of 3/21/2024 revealed a BIMS score of a zero out of 15 which indicated R78 was severely cognitively impaired. Review of the Facility Reported Incident (FRl) dated 3/22/2024, completed by the administrator/abuse coordinator, revealed a report of verbal abuse to R78 by CNA 2. Further review of this FRI revealed no documentation of an investigation. During an interview on 6/6/2024 at 9:20 am, the Administrator revealed he had investigated the issue but misplaced all documentation related to this incident. He was unable to provide or report the outcome of the investigation and confirmed CNA 2 continued to provide care to R78 and other residents. 4. Review of R107's Record of Admission, located under the Clinical tab of the EMR revealed R107 was admitted to the facility on [DATE] with a diagnosis of Hemiparesis. Review of R107's discharge MDS dated [DATE] revealed a BIMS score of 15 out of 15 which indicated R107 was cognitively intact. The resident required supervision for lower body and toileting. Review of the Grievance Form dated 4/22/2024 revealed that R107 submitted a grievance when the facility received a message from resident's granddaughter stating that the resident was not allowed to use the bathroom over the weekend. When Social Services spoke with R107 he advised that that CNA 2 would not assist him to the bathroom and told him to go in his pull up. He further stated she did not get him up all weekend. There was no evidence the incident was investigated by the facility. During an interview on 6/5/2024 at 2:50 pm, the Administrator confirmed there was an allegation of abuse reported by R107 against CNA 2 and the facility did not complete a thorough investigation of the abuse.

Based on record review, interview, and review of the policy titled Grievance Policy, the facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one resident (R) (R107) out of 27 sampled residents. Additionally, the facility failed to have a process in place for residents to file a grievance anonymously. This had the potential to affect all of the residents of the facility. Findings include: Review of the facility's policy titled, Grievance Policy, dated May 2022 revealed the policy of the facility is to assist residents and their family members or advocates in filing grievances when such requests are made. Procedure: Number 1. Any resident, his/her representative, family member, or advocate may file a grievance concerning his/her treatment, medical care, behavior of other residents, staff members, theft of property, etc. without fear of threat or reprisal in any form. Number 3. The Administrator has delegated the responsibility of the grievance investigation to the Social Services department. Number 4. Upon receipt of the grievance the social worker will determine which department head or heads need to investigate the allegations and submit a written report of such findings to the Administrator within five working days of receiving the grievance. Number 6. The resident, or person filing the grievance will be informed of the findings f the investigation and the actions that will be taken to correct any identified problems. Review of a Grievance Form dated 4/22/2024 documented that R107 submitted a grievance form to Social Services Director (SSD). The grievance read, SS (social services) received a message from resident's granddaughter that the resident was not allowed to use the bathroom over the weekend. SS spoke with resident who advised the Certified Nurse Aide (CNA) when resident asked to get up for bedside toilet the CNA told the resident to use her pull up. Resident advised that the CNA did not get her up, did not take her to the bedside toilet, and kept her in bed all weekend. Resident said she did not get up out of the bed until Monday 4/22/2024. Resident advised that she was given an enema Friday, and it did not feel right to her to be made to use the bathroom on herself. The Investigation portion of the Grievance Form read Spoke with the staff member in charge of resident. She stated that resident asked her to help her get on BSC (bed side commode). Staff member then informed resident that since she just had an enema, they [sic] may not make it to the toilet. Staff member also reported that resident did not go to sleep until after 4:00 am and she voiced she was tired. The Action Taken was blank. The Person making the complaint has been informed of results was blank. The investigating employee was the Director of Nursing (DON), dated 4/24/2024 and the Administrator signed the document on 5/1/2024. During an interview on 6/6/2024 at 3:23 pm, the Administrator said the incident, from 4/22/2024, when CNA spoke rudely to R107 was documented on a grievance form and then staff completed education. He said the CNA should always report something like that and then it should be documented on a grievance form. The Administrator said he was typically the grievance coordinator. He said that any grievance should go to the correct department who can address the grievance and then they should follow up with the resident and the family. He said when a grievance comes up in a Resident Council meeting then the Activity Director (AD) should write it on the grievance form and get them to the right department. He confirmed he currently didn't have a grievance form that residents and family members could access and submit anonymously if they chose to. During an interview on 6/7/2024 at 3:35 pm, the Director of Nursing (DON) stated that completing a grievance form was important. She indicated if the grievance involved nursing then she would be involved with the investigation. She stated the SSD will be involved in every grievance. Cross Reference F600.

Based on observations, record review, interviews, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure that informed consents were signed prior to the use of bedrails for four of 27 sampled residents (R) (R1, R45, R72, and R78) reviewed for bed rail use. The failure had the potential for risks of injury, entrapment, and/or death. Findings include: Review of the policy titled Proper Use of Side Rails, revised December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids. General Guidelines: Number 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 1. Review of R1's Face Sheet from the electronic medical record (EMR) Face Sheet report tab showed a facility admitted [DATE]. The residents quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact. Review of the care plan for R1 dated 12/17/2021 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility, turning, and repositioning. Interventions to care include monitor for safety, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly. Review of the 8/22/2020 (first) and 4/10/2024 (most recent) bed rail assessments showed bed rail precautions and alternatives to siderails had been discussed with R1 for the first assessment and the family/resident representative for the most recent. Review of the 12/14/2020 quarterly restorative Interdisciplinary Progress Notes (IPN) written by Registered Nurse (RN) RN3 documented Resident has order for one bed rail but has requested two bed rails with turning and repositioning in bed, risks and benefits of bed rail use discussed with resident and resident wife. However, there wasn't an informed consent signed located in the EMR. During an observation and interview on 6/5/2024 at 10:40 am, R1 was noted to have bilateral upper quarter rails on his bed. When asked if he used them, R1 responded I hate these damn things, they antagonize me. When asked if he had been advised of the risks/benefits of the rails, he stated, No risk/benefits - I hate them damn things. 2. Review of R45's Face Sheet from EMR Face Sheet report tab showed a facility admitted [DATE]. The residents quarterly MDS with an ARD of 3/11/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact. Review of the care plan for R45 dated 12/16/2020 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility, turning and repositioning, and to access his bed controls. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly. Review of the 12/28/2020 (first) and 2/14/2024 (most recent) bed rail assessments for R45 showed siderail precautions and alternatives to siderails had been discussed with family/representative. However, there was no signed consent form found in the EMR. Review of the 12/28/2020 restorative IPN written by RN3 documented resident has bilateral upper bedrails and risks/benefits had been discussed with the resident and wife. However, there was no signed consent form found in the EMR. During an interview and observation on 6/420/24 at 2:14 pm, it was observed that R45 had one upper quarter bed rail on the window side of the bed. When asked if anyone had reviewed the risks and/or benefits of the bed rail, R45 stated, No, not said anything to me. 3. Review of R72's Face Sheet from the EMR Face Sheet report tab showed a facility admitted [DATE]. The residents quarterly MDS with an ARD of 3/19/2024 revealed no BIMS score and the resident was rarely or never understood. Review of the care plan for R72 dated 9/30/2022 documented resident has impaired bed mobility and uses bilateral upper quarter-length side rail to assist with bed mobility and turning and repositioning. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly. Review of the 9/30/2022 (first) and 3/5/2024 (most recent) bed rail assessments for R72 showed siderail precautions and alternatives to siderails had been discussed with family/representative. However, there was no informed consent found with the family and/or representative in the EMR. During an observation on 6/4/2024 at 12:09 pm, R72 was out of the room but the bed had one upper quarter rail in the up position on the window side of the bed. During an observation of R72's bed on 6/7/2024 at 10:54 am, bilateral upper quarter rails now wrapped in pipe insulation padding. Registered Nurse (RN)1 was outside the door and said, The padding was added yesterday because she fell out of bed and hit her cheek on the siderail. When asked if R72 used the rails, RN1 replied Yes - to turn and reposition, that's how she fell out of the bed. 4. Review of R78's Face Sheet from the EMR Face Sheet report tab showed a facility admitted [DATE]. Review of the significant change of status MDS with an ARD of 3/21/2024 revealed a BIMS score could not be obtained and the resident was rarely or never understood. Review of the care plan for R78 dated 2/14/2024 documented resident has impaired bed mobility and uses 1-2 upper quarter-length side rail(s) to assist with bed mobility, turning and repositioning, and bed controls. Interventions to care include monitor for safety while in bed, provide frequent visual checks, assist in turning, repositioning, pulling up in bed as needed, and assess for changes quarterly. Review of the 2/2/2023 (first) and 3/4/2024 (most recent) bed rail assessments for R78 showed siderail precautions and alternatives to siderails had been discussed with family or representative. Review of the 4/20/2023 restorative IPN written by RN4 documented resident demonstrates proper use of upper bilateral quarter length side rails for turning, and repositioning. There was no signed consent form found in the EMR. During an observation of R78's room on 6/4/2024 at 10:15 am, the bed had bilateral upper quarter rails in the up position. During an interview on 6/7/2024 at 7:19 pm, the Director of Nursing (DON) stated the expectation was that the facility would attempt alternatives before side rails were used and that they do assess the resident; that risk/benefits would be advised, and it is documented who is being advised. No signed consents were provided for any of the four residents above by the time of the exit conference.

Based on observations, interviews, and review of the policy Titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure expired medications were removed from one of two medication carts, failed to remove expired phlebotomy supplies for one of two phlebotomy carts, and one of two medication rooms. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The census was 104. Findings include: Review of the undated policy titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles revealed Procedure: C.9. Nursing staff will monitor for expired drugs and cleanliness of medication room/medication carts once weekly. Procedure: D. Facility should ensure that medications and biologicals: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 1. Observation on 6/6/2024 at 9:27 am in the Blue Hall medication room, the following expired items were found: One bottle Pro- Stat (protein) expired 4/2024 One bottle Pro-Stat expired 3/2024 One bottle Co-Q-10 100 milligrams (mg) tabs expired 5/2024 One bottle Zinc Sulfate 220 mg expired 4/2024 One bottle Zinc Sulfate 220 mg expired 3/2024 One box L-Methylfolate Calcium Tablets expired 4/2024 One box L-Methylfolate Calcium Tablets expired 10/2023 Seven boxes of Omeprazole 20 mg tablets expired 5/2024 One box Omeprazole 20 mg tablets expired 12/2023 One box Omeprazole 20 mg tablets expired 2/2024 One box Pink Bismuth anti-diarrheal 30 chewable tablets expired 5/2024 Four boxes of Omeprazole acid reducer 20 mg tablets expired 5/2024 One box Saccharomyces Boulardii (probiotic) 250 mg capsules expired 5/2024 One bottle Iron supplement liquid expired 2/2023 One bottle Centrum Adults expired 2/2024 Interview on 6/6/2024 at 9:27 am, Registered Nurse (RN) 2 verified the expiration dates and, confirmed that the medications were still available for resident use. She stated the expired medications should be given to the Director of Nursing (DON) for destruction. Interview on 6/6/2024 at 9:50 am, Licensed Practical Nurse (LPN) 4 stated the expiration dates should be checked upon receiving the medications from the pharmacy. The LPN stated the night shift nurses were responsible for checking the medication room for expired medications. 2. Observation and interview on 6/6/2024 at 2:07 pm, the phlebotomy cart located at the nurses' station between the pink and green halls revealed one black top vacutainer tube that expired on 6/2/2024; one container (85 tubes) of light blue top vacutainer tubes expired on 12/31/2023. RN 1 verified the expiration dates and confirmed they were still available to be used. 3. Observation on 6/6/2024 at 2:10 pm, the [NAME] Hall medication cart was inspected with LPN 5 and revealed one card of discontinued oxycodone (narcotic pain medication) 15 mg with 78 tablets was on the cart. The LPN stated that discontinued narcotics should be removed from the cart the day they are discontinued. LPN 5 verified the oxycodone medication was discontinued. Interview on 6/6/2024 at 2:20 pm, the DON stated expired medications should not be available for use on medication carts or in the medication room. She stated they should be removed immediately.

Based on observations and resident and staff interviews, the facility failed to ensure that meals were served according to resident preferences and designated meal times for 50 residents on the green and pink halls. Findings include: Interview on 6/4/2024 at 9:30 am, the Registered Dietician (RD) and the Dietary Manager (DM) stated the designated meal times were: Breakfast was to be served at 8:00 am, Lunch to be served at 12:00 pm, and Dinner was to be served at 5:00 pm. Interview on 6/4/2024 at 1:39 pm, R48 stated she had not received her lunch yet. At that moment, a staff member entered the room with her tray. R48 stated the trays should be there at noon or 12:30 pm. Her roommate also did not have a tray and revealed it was supposed to be noon. Interview on 6/4/2024 at 2:08 pm, R45 stated he had not received his lunch tray. The interview ended at 2:25 PM and the lunch tray had still not arrived. During a group interview on 6/6/2024 at 10:00 am with members of the Resident Council (R88, R15, R17, R2, R44, R94 and R8), residents confirmed meal delivery was consistently late. R88 and R15 said dinner was sometimes so late it affected their acid reflux. R17 and R55 expressed concerns about having lunch so late because they were diabetics and received insulin. R17 stated sometimes lunch is served as late as 2:15 pm. Observation on 6/6/2024 at 1:31 pm (an hour and a half after the scheduled time), lunch trays for 24 residents were observed to arrive on the pink hall. Continued observation revealed the last tray on the hall was served at 1:51 pm. Interview on 6/6/2024 at 1:57 pm, Certified Nurse Aide (CNA) 9 revealed room trays always come late. She said she has seen them come as late as 3:00 pm. Interview on 6/6/2024 at 2:00 pm, CNA10 confirmed that room trays always come late. She said they are supposed to make round on their residents between 2:00 pm - 4:00 pm daily and it is difficult when lunch is served so late. Interview on 6/6/2024 at 2:12 pm, CNA 11 said lunch trays always come around this time or later. She said when trays come so late it makes it difficult to complete other work because residents are eating. She said residents frequently complain about how long it takes to get their meals. Interview on 6/7/2024 at 1:30 pm, R45 stated he had not yet received his lunch tray. Observation on 6/7/2024 at 1:45 pm (an hour and 45 minutes after the scheduled time), lunch trays for 26 residents were observed to arrive on the green hall. Continued observation revealed the last tray on the hall was served at 2:19 pm. Observation on 6/7/2024 at 1:50 pm, eight residents were observed on the green hall, sitting outside their rooms, waiting for their lunch. R81 said we always eat lunch late. R52 agreed saying, usually we don't get lunch earlier than 2:00 pm. R52 stated she was hungry since breakfast was served earlier this morning. Observation and interview on 6/7/2024 at 2:15 pm, family members (FM) 1 and FM 2 for R97 were observed giving him a protein shake. FM 2 revealed the lunch trays were always served late and they were not sure why. They said that's too late for lunch, and R97 agreed. Interview on 6/7/2024 at 6:54 pm, the DM said room trays are late because of the lack of communication between nursing and dietary staff. He said having a list of who is coming into the dining room would help with room trays being served earlier. Interview on 6/7/2024 at 7:06 pm, the Director of Nursing (DON) stated the expectation is that meal service would be timely, all day should be timely. Interview on 6/8/2024 at 11:27 am, License Practical Nurse (LPN) 4, the Unit Manager for Pink Hall and LPN 2, the Unit Manager for [NAME] Hall, stated they were not aware that meals were served as late as 2:00 pm at times. They both agreed that receiving meals at 2:00 pm was too late and said serving a meal late impacts other resident care that staff need to complete. A policy for meal service and/or mealtimes was requested. The policy was never provided. 28154

Based on interviews, review of facility's Nursing Home Inspection Report Upon Receipt of Equipment, review of the Food and Drug Administration (FDA) guidelines, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure bed rails were inspected for safety to minimize the risks of possible entrapment or resident injury for 90 resident beds out of 104. This failure had the potential to cause serious injury to all 90 residents in the facility using a bed with bed rails attached. Findings include: Review of the policy titled Proper Use of Side Rails, revised in December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids. General Guidelines: Number 13. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress used). Review of the Nursing Home Inspection Report Upon Receipt of Equipment provided by the facility and completed annually, documented items inspected included electrical and bed function. There was nothing noted regarding the review of the bed rails for secure attachment and/or gaps that the US Department of Health and Human Services: FDA guidelines dated 3/10/2006 that showed the measurements for the bed rails to reduce the chance of resident entrapment when using bed rails. During an interview on 6/7/2024 at 9:55 am, Maintenance Worker (MW) confirmed that they did not perform safety checks on resident beds with side rails. Review of a resident list compiled by Restorative Nurse Aide (RNA) on 6/7/2024 at 8:05 pm revealed that 90 of 104 residents in the facility have one or two side rails on their beds. During an interview on 6/7/2024 at 7:14 pm, the Director of Nursing (DON) stated the expectation was that maintenance would inspect the beds, including bedrails for safety and security.

Based on record review and interviews, the facility failed to assist one resident (R) (R56) in obtaining identification for voting purposes out of total sample of 27 residents reviewed for resident rights. This had the potential for a diminished quality of life and the failure to promote the resident's right to vote. Findings include: Review of R56's Record of Admission, located under the Clinical tab of the electronic medical record (EMR), revealed R56 was admitted to the facility on [DATE]. Review of R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2024 and located under the Clinical tab of the EMR, revealed R56 scored 15 out of 15 on the Brief interview for Mental Status (BIMS), which indicated R56 was cognitively intact. During an interview on 6/4/2024 at 11:42 am, R56 stated he needed assistance getting his license so he could vote. R56 stated when he went to vote last time, he only had a copy of his identification card, and they would not accept the copy, so his vote did not count. He indicated that it was important to him that he vote as he has never missed a vote in his life. R56 said the facility is aware of what he needs but no one has helped him. During an interview on 6/5/2024 at 4:30 pm, the Activities Director (AD) stated he was aware that R56 needed to renew his identification card but confirmed he had not done anything about it. During an interview on 6/6/2024 at 5:15 pm, the AD revealed he had taken R56 to get his identification card. During an interview on 6/7/2024 at 2:00 pm, the Social Services Director (SSD) and the Director of Nursing (DON) verified that the AD would have been responsible for ensuring R56 had his identification card updated.

Based on record review, interviews, and review of the policy titled Resident Transfer and Discharge Rights Policy and Procedure, the facility failed to ensure three of five residents (R1, R72, and R101) and/or their representatives reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and their representatives by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility policy titled Resident Transfer and Discharge Rights Policy and Procedure, revised 6/2024 indicated the policy is to ensure that prior to resident transfer or discharge, whether voluntary or involuntary, resident transfer or discharge is necessary and if so, facility is in compliance with all regulatory requirements. Procedure: Number 6. Written Transfer Notification must include the following: a. Notification must be an advance notice (either 30 days or as soon as practicable, depending on the reason for the transfer/discharge: b. Reason for transfer/discharge c. The effective date of the transfer or discharge d. The location to which the resident was transferred or discharged e. Statement that the resident has a right to appeal the action to the State of Georgia (facility will not discharge or transfer resident when an appeal is pending unless failure to transfer or discharge would endanger the health or safety of the resident or other individuals in the facility f. Name, address, and telephone number of the State Long Term Care Ombudsman. 1. Review of R1's Face Sheet from the electronic medical record (EMR) Face Sheet report tab showed a facility admitted [DATE]. Review of R1's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/2024 showed a Brief Interview for Mental Status (BIMS) of 15, indicative of being cognitively intact. During an interview on 6/5/2024 at 10:37 am, R1 stated he had just come back from the hospital, he thought it was for a urinary tract infection. Review of R1's EMR Progress Notes revealed on 5/13/2024 at 2:17 pm, R1 was experiencing a change in mental status, increased weakness, and slurred speech; the physician was contacted and an order to send to the emergency room (ER) was received; emergency services were called for transport to the ER. Further review of the EMR did not show any documentation of a written notice of transfer provided to R1 or his representative. During an interview on 6/6/2024 at 5:55 pm, the Director of Nursing (DON) revealed she was not aware a transfer notice was required in writing and needed to be given to the resident and/or their representative. She revealed they call the doctor, EMS [Emergency Medical Services], and call the family to let them know. During an interview on 6/7/2024 at 1:50 pm, with the representative of R1 revealed she was with him at a doctor's appointment, and she called and told the nurse his symptoms. When we got back to the facility the doctor was there and gave orders to send him to the hospital. The representative stated she did not receive anything in writing about the transfer. 2. Review of R72's Face Sheet from the EMR Face Sheet from the Report tab showed a facility admitted [DATE]. Review of R72's EMR Progress Note revealed on 5/30/2024 at 6:59 pm the nurse documented a change in mental status, decreased intake, increased sleeping, and a lack of response to stimuli; the physician was notified and an order to send to the ER was received; and R72's representative was notified by phone. Further review of the EMR did not show any documentation of a written notice of transfer provided to R72 or her representative. During a telephone interview on 6/7/2024 at 8:06 pm, the representative for R72 stated he had not been given a written transfer notice, was notified (by phone) and was at the hospital when R72 arrived. 3. Review of R101's Face Sheet from the EMR Reports tab showed a facility admitted [DATE]. Review of R101's Progress Note revealed on 3/15/2024 at 6:47 pm the nurse noted labored breathing and a decrease in his oxygen saturation. The nurse contacted the physician and received an order to send the resident to the ER for evaluation and treatment; the nurse contacted EMS for transport to the hospital. Further review of the EMR did not show any documentation of a written notice of transfer provided to R101 or his representative. During an interview on 6/7/2024 at 7:10 pm, the DON stated she would expect that we follow the regulations. During an interview on 6/7/2024 at 8:10 pm regarding the emergent transfer process, Licensed Practical Nurse (LPN) 6 stated We tell them [resident], and we call the family. When specified if anything in writing was given to the resident or family, LPN 6 stated, No.

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure an annual Minimum Data Set (MDS) assessment was submitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for one resident (R) (R58) reviewed out of a total sample of 27. This failure had the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment. Findings include: Review of the October 2023 RAI Manual page 2-24 showed: The ARD . must be set within 366 days after the ARD of the previous . comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous . Quarterly . (ARD of previous . Quarterly assessment + 92 calendar days). Review of R58's electronic medical record (EMR) Face Sheet from the Face Sheet tab showed a facility admitted [DATE]. Review of the MDS assessments received by Centers for Medicare and Medicaid Services (CMS) showed the last MDS received had an assessment reference date (ARD) of 1/15/2024. The MDS Coordinator (MDSC) provided documentation for R58 of . Final Validation Report dated 5/30/2024 that the ARD of 4/11/2024 annual (comprehensive) MDS was not submitted until 5/30/2024 and, on page 4 of 52, showed Message: Record Submitted Late: The submission date is more than 14 days after V0200C2 on this new comprehensive assessment. During an interview on 6/6/2024 at 10:50 am, the MDSC confirmed R58's assessment was submitted late, stating, The assessment was closed, and the care plan signature was in there, but the last audit was not done to actually close it and I didn't notice it. In a follow-up interview on 6/6/2024 at 6:12 pm, the MDSC stated the facility did not have a policy regarding timely submission of assessments. She stated, We use the RAI Manual and follow that. During an interview on 6/7/2024 at 7:00 pm, the Director of Nursing (DON) stated the expectation is that MDS assessments would be submitted within the RAI guidelines and confirmed the facility did not have a policy and used the RAI Manual.

Based on record review, interviews, and review of the policy titled Care Plan Meetings, the facility failed to ensure that three residents (R) (R56, R44, and R17) of 27 sampled residents had scheduled care plan conferences after each assessment. In addition, the facility failed to ensure updated interventions were included on the comprehensive care plan for one resident (R3). This failure had the potential for residents not to be involved with their care decisions and potential unmet care needs. Findings include: Review of the undated policy titled Care Plan Meetings, revealed the policy is that each resident will have an individualized interdisciplinary care plan in place. The care plan will be ongoing, focusing on each individual resident as a unitary unit. Resident and their representative will play an active role in the development of goals and implementation of the residents Comprehensive care plan. Procedure: Number 5. The resident, resident representative, and IDT team members will sign attendance sheet at each comprehensive care plan meeting and this form will be scanned into the residents EMR. Number 7. The comprehensive care plan will be revised as needed and goals updated as appropriate. 1. Review of R56's Record of Admission, located under the Clinical tab of the electronic medical record (EMR), revealed R56 was admitted to the facility on [DATE] with a diagnosis of hemiparesis. Review of R56's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated R56 was cognitively intact. Review of the Care Plan Attendance Sheet provided by the MDS Coordinator (MDSC) dated 11/8/2023 revealed that R56 and a friend attended. The form did not indicate the type of assessment. This was the only care plan conference that was held since R56's admission. Interview on 6/4/2024 at 11:42 am, R56 said he was never involved in planning his care but would like to be. 2. Review of R44's Record of Admission, located under the Clinical tab of the EMR revealed R44 was admitted to the facility on [DATE] with a diagnosis of dementia and seizure disorder. Review of R44's quarterly MDS with an ARD of 2/26/2024 and located under the Clinical tab of the EMR, revealed a BIMS of 15 which indicated R44 was cognitively intact. Review of the Care Plan Attendance Sheets dated 5/4/2023 and 8/31/2023 revealed that R44 attended. The form indicated the type of assessment was a quarterly assessment. These were the only care plan conferences that were held for R44 since admission. 3. Review of R17's Record of Admission, located under the Clinical tab of the EMR revealed R17 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. Review of R17's significant change MDS with an ARD of 2/16/2024 and located under the Clinical tab of the EMR, revealed a BIMS score of 11 which indicated R17 was moderately impaired. Review of the Care Plan Attendance Sheet dated 2/10/2023 revealed that R17 and two other unknown individuals attended. The form did not indicate the type of assessment. This was the only care plan conference that was held for R17 since admission. During a group interview on 6/6/2024 at 10:00 am, members of the Resident Council (R88, R15, R17, R2, R44, R94 and R8), all seven residents revealed they had never been invited to a care plan conference and did not know that care plan conferences existed. R44 and R17 stated it would be important to them to be involved in planning their care. 30622 4. Review of R3's Record of Admission, located under the Clinical tab of the EMR), revealed R3 was admitted on [DATE] with diagnosis of cerebral palsy. Review of R3's quarterly MDS with an ARD of 3/12/2024 located under the MDS tab revealed the resident did not have a BIMS score. Review of R3's June 2024 Physician Orders, revealed the following order dated 9/21/2023: Bilateral body pillows to be in place under fitted sheet when resident in bed for torso support Resident having no upper body core strength and having gastric feeding tube in place resident needs for support in attempt to keep resident upright and aide in possible prevention of aspiration. Review of the care plan dated 12/23/2020 revealed R3 had impaired bed mobility. Interventions to care include assess for changes quarterly and as needed. The care plan did not address the resident's order for body pillows under the fitted sheet. Observations on 6/5/2024 at 10:34 am, 6/5/2024 at 1:27 pm, 6/5/2024 at 5:14 pm, and 6/6/2024 at 8:30 am, revealed R3 was observed in bed without pillows under the fitted sheet. During an interview on 6/6/2024 at 12:25 pm, MDS Coordinator (MDSC) stated she was currently working on the care plan conference process. She revealed since COVID the facility has not had care plan conferences. She said their new process would start today and they would be starting a Performance Improvement Plan (PIP) on this date. The MDSC said usually when it is time for R56's care conference, they do not invite him, only his responsible party. During an interview on 6/7/2024 at 2:15 pm, R97's Family Members (FM)1 and FM 2 stated they are rarely informed about the status of R97 and were uncertain about the process. The family members indicated they would appreciate a care plan conference, so they would know more about what was going on with R97. During an interview on 6/7/2024 at 3:35 pm, the Director of Nursing (DON) stated she was not aware that care plan conferences were not being conducted until R56 was discussed the day before. She said moving forward care conferences will happen because they are important. Cross Refer F684