Every finding on record at Claiborne Health and Rehabilitation Center

Based on facility policy review, medical record review, and interviews, the facility failed to obtain consent for administration of a psychotropic medication for 1 resident (Resident #3) of 5 sampled residents reviewed for unnecessary medications.The findings include: Review of the undated facility policy titled, Use of Psychotropic medications, revealed .The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use .written consent form, narrative note . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses including Anxiety, Dementia, and Depression. Review of the Physician's Order for Resident #3 dated 7/27/2025, revealed an order for Lorazepam Oral (by mouth) Concentrate 2 mg/ml (milliliters) give 1 ml by mouth every 4 hours as needed.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 0 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #3 received an antianxiety medication during the 7 day look back period. Review of a Psychiatric Periodic Evaluation Progress Note for Resident #3 dated 9/19/2025, revealed .Anxiety .seen today in follow up for ongoing management .hospice more recently initiated lorazepam [a medication used to treat Anxiety] for anxiety and agitation .Ativan [a medication used to treat Anxiety] 2 mg [milligram] every 4 hours as needed .Review of Medication Administration Record (MAR) for Resident #3 dated 11/01/2025 through 11/20/2025, revealed the resident had received 3 doses of Ativan 2 mg.During an observation on 11/17/2025 at 11:59 AM in Resident #3's room, revealed resident was lying in bed watching tv. Further observation revealed Resident #3 showed no signs of Anxiety, distress, or any adverse effects to medications. During an interview on 11/20/2025 at 10:05 AM, Registered Nurse (RN) MDS Coordinator confirmed there was no consent for the use of Ativan for Resident #3.

Based on medical record review and interviews, the facility failed to develop a comprehensive care plan for 2 residents (Residents #9 and #10) of 21 residents reviewed for care planning.The findings include: Review of the medical record revealed Resident #9 admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Depression, and Anxiety. Review of the Pre-admission Screening and Resident Review (PASRR) dated 6/5/2025, revealed Resident #9 had a PASRR Level II outcome related to a serious mental illness. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Comprehensive Care plan revised 10/15/2025, revealed Resident #9's PASRR Level II condition and outcome was not addressed on the comprehensive care plan. During a medical record review and interview on 11/19/2025 at 10:24 AM, Registered Nurse (RN) MDS Coordinator reviewed the comprehensive care plan dated 10/15/2025 and the PASRR level II dated 6/5/2025 for Resident #9. The RN MDS Coordinator confirmed the comprehensive care plan for Resident #9 did not reflect the resident's PASRR level II outcome status. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included Depression, Anxiety, and Schizoaffective Disorder. Review of a PASRR dated 11/5/2021, revealed Resident #10 had a PASRR Level II (2) Outcome related to a serious mental illness. Review of the comprehensive care plan dated 2/6/2024, revealed Resident #10's PASRR level II condition and outcome was not addressed on the comprehensive care plan. Review of an annual MDS assessment dated [DATE], revealed Resident #10 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During a medical record review and interview on 11/19/2025 at 3:50 PM, RN MDS Coordinator reviewed the comprehensive care plan dated 2/6/2024 and the PASRR level II dated 11/5/2021 for Resident #10. The RN MDS Coordinator confirmed the comprehensive care plan for Resident #10 did not reflect the resident's PASRR level II outcome status.

Based on facility policy review, medical record review, observations, and interviews, the facility staff failed to offer hand hygiene prior to serving resident meal trays for 1 resident (Resident #74) of 16 residents observed for meal tray distribution. The findings include:Review of the facility's policy titled, Hand Hygiene, revised 1/2020, revealed All staff will perform proper hand hygiene procedures to prevent the spread of infection.before and after eating.using proper technique consistent with accepted standards of practice .Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Hypertensive Heart Disease, Type 2 Diabetes, and Chronic Kidney Disease.Review of a quarterly [NAME] Data Set (MDS) assessment dated [DATE], revealed Resident #74 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident required set up or clean up assistance from staff with eating. The resident required supervision or touching assistance from staff with personal hygiene. Review of the Comprehensive Care Plan for Resident #74 revised 10/15/2025, revealed the resident had activities of daily living self-care deficit where resident required assistance with eating and personal hygiene.During an observation on 11/17/2025 at 11:59 AM, Certified Nurse Assistance (CNA) F delivered the lunch meal tray to Resident #74. CNA F set up tray for Resident #74 and failed to offer hand hygiene to the resident.During an interview on 11/17/2025 at 12:03 PM, CNA F confirmed she had not provided hand hygiene for Resident #74 before serving his lunch tray.During an interview on 11/19/2025 at 10:38 AM, Director of Nursing (DON) confirmed it was her expectation that hand hygiene be offered to residents prior to meal trays being served.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 2 residents (Residents #9 and #10) of 21 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual dated 10/2025, revealed .Health-related Quality of Life .residents covered by Level II [2] PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Depression, and Anxiety. Review of the Pre-admission Screening and Resident Review (PASRR) assessment dated [DATE], revealed Resident #9 had a PASRR Level II Outcome related to a serious mental illness (Bipolar, Depression, and Anxiety). Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had active diagnosis of Bipolar, Depression, and Anxiety. Continued review revealed the resident was not coded for a Level II PASRR condition. Review of the Psychiatric Periodic Evaluation noted dated 11/14/2025 revealed .history of bipolar disorder, generalized anxiety disorder, and dementia, seen today in follow-up for ongoing management .presentation is consistent with early mood elevation in the context of bipolar disorder . During a medical record review interview on 11/19/2025 at 10:24 AM, Registered Nurse (RN) MDS Coordinator confirmed Resident #9 had a Level II PASRR. The RN MDS Coordinator further confirmed the revealed the Level 2 PASSR was not on the Minimum Data Set or the Care Plan. Further interview revealed she was responsible for all PASRRs and MDS assessments for the building, and she reviewed the Psych provider notes for new diagnoses and other pertinent information for MDS assessments. She stated she was unaware that the Care Plan should have information about Level 2 PASRRs. During a medical record review and interview on 11/19/2025 at 10:24 AM, Registered Nurse (RN) MDS Coordinator reviewed the significant change MDS assessment dated [DATE] and the Level II PASRR dated 6/5/2025 for Resident #9. The RN MDS Coordinator confirmed the significant change MDS assessment for Resident #9 was inaccurate and did not reflect the resident's PASRR Level II outcome status. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE]. Diagnoses included Anxiety, Depression, and Schizoaffective Disorder. Review of a PASRR dated 11/5/2021, revealed Resident #10 had a PASRR Level II outcome related to a serious mental illness (Schizoaffective Disorder, Depression, and Anxiety). Review of an annual MDS assessment dated [DATE], revealed Resident #10 scored 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident had active diagnosis of Anxiety, Depression, and Schizophrenia. Continued review revealed the resident was not coded for a PASRR Level II condition. During a medical record review and interview on 11/19/2025 at 3:50 PM, RN MDS Coordinator reviewed the annual MDS assessment dated [DATE] and the Level II PASRR dated 11/5/2021 for Resident #10. The RN MDS Coordinator confirmed the annual MDS assessment for Resident #10 was inaccurate and did not reflect Resident #10's PASRR Level II outcome status.

Based on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse timely for 1 resident (Resident #83) of 3 reviewed for abuse.The findings include:Review of the facility's policy titled, Abuse, Neglect, and Exploitation. Revised 2/2023, revealed .Investigation of Alleged Abuse, Neglect, and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for investigations. 2. Exercising caution in handling evidence that could be used in a criminal investigation. 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. 6. Providing complete and thorough documentation of the investigation. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Dementia, Heart Failure, and Mixed Receptive Expressive Language Disorder. Review of the discharge Minimum Data Set assessment dated [DATE], revealed Resident #83 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment.Review of a facility investigation summary revealed on 11/12/2025 the Administrator (ADM) was notified of alleged allegations, and an investigation was initiated. Immediate investigation began including interviews with all relevant staff members and review of available video recordings during the identified time frame. This investigation and the associated interviews included both facility and healthcare system leadership, to ensure a complete and unbiased review. During the investigation a delay in reporting was identified. The review of interviews with facility staff and leadership identified that the facility staff had prior knowledge of the daughters reported concern with the first identified information being known on 11/3/2025. The facility investigation for allegation of sexual abuse did not begin until 11/12/2025. Review of a Grievance Decision Report dated 11/12/2025, revealed .Reportedly on 11/01/2025-11/02/2025 .Officer [named officer] called [Social Worker-SW] on 11/12/2025 and advised that an allegation had been made to police department concerning [Resident #83]. The allegation was that [Resident #83] was allegedly sexually abused while in our facility by a male .Review of the facility investigation revealed .on 11/12/2025 at 4:15 PM, Social Worker .was notified by the [Local] police department that a report had been filed with APS [Adult Protective Services] by the resident's daughter .The police department relayed that a report had been filed .alleging that [Resident #83] was sexually assaulted prior to her discharge on [DATE] [11/3/2025] .An investigation was immediately initiated .During the investigation a delay in reporting was identified .The review of interviews with facility staff and leadership identified that the facility staff had prior knowledge of the daughter's reported concern with the first identified information being known on 11/3/2025 .The investigation revealed there was a failure to report this timely .Review of a statement dated 11/17/2025, revealed .FNP [Family Nurse Practitioner] stated she was informed on 11/3/2025 that the family wanted to discharge .[Social Worker] told me [FNP], 'The family said the patient told them that someone put something inside her vagina' .They [Family] didn't think that it [sexual assault] happened. 'It was in her mind and real to her' . Continued review of the FNP statement revealed the FNP did not report the allegation of sexual abuse.During an interview on 11/19/2025 at 8:45 AM, Certified Nurse Assistant (CNA) G stated on 11/1/2025 or 11/2/2025, Resident #83's daughter had stopped her while she was finishing up with her shift and stated her mother said she had a vaginal exam and was wondering if that was true. CNA G stopped what she was doing and went and informed her nurse RN H since there was no management in the building to report to. CNA G stated she did not hear anything else about it until a couple weeks later when she was being questioned by management. CNA G further stated she did not notify anyone else of the alleged allegations. During an interview on 11/19/2025 at 9:33 AM, Registered Nurse (RN) H stated on 11/1/2025 or 11/2/2025, CNA G informed her at the nurse's station around end of shift that Resident #83's daughter was asking if her mom had a vaginal exam. RN H went and talked to the daughter who stated she thought her mom had a bad dream and was confused but just wanted to make sure. RN H further stated she thought CNA G notified the Director of Nursing (DON) of the allegation. RN H stated she did not hear anything else about incident until a couple weeks later.During an interview on 11/20/2025 at 8:30 AM, the SW stated she became aware of the allegations on 11/3/2025, when Resident #83's daughter came to her office to discuss Resident #83's discharge stating they wanted the resident discharged that day. The SW stated she asked if she could wait until the next day and the resident's daughter stated, .no, because momma thinks someone sexually touched her .momma thinks it real, and we just want to take her home . The SW confirmed she did not notify administration of the allegation because the family blew it off and the resident's daughter stated she did not want to file a complaint. The SW stated she became aware an allegation of sexual assault against Resident #83 had been reported to the local police department. It was at this time the SW notified the Administrator. During an interview on 11/20/2025 at 9:07 AM, the RN MDS Coordinator stated on 11/3/2025, Resident #83's daughters came into the MDS and SW office stating they wanted to take their mother home because she thought someone had touched her inappropriately while she was sleeping. The resident's daughters stated the resident was scared and they want to take her home. RN MDS Coordinator further stated family said she might have been dreaming. RN MDS Coordinator stated at some point the Assistant Director of Nursing (ADON) came into the office and was informed of the dream Resident #83 had. The RN MDS Coordinator stated she did not hear anything else until the police department notified the facility of the allegation of sexual assault. During an interview on 11/20/2025 at 10:26 AM, the Administrator (ADM) confirmed facility staff became aware of the allegation of sexual assault for Resident #83 on 11/3/2025 but failed to report the allegation to the facility's Abuse Coordinator. The ADM confirmed the facility did not initiate an investigation until 11/12/2025 (9 days after the allegation was reported to facility staff).

Based on facility policy review, medical record review, facility investigation, observation, and interviews, the facility staff failed to ensure an allegation of sexual abuse was reported within 2 hours as required for 1 resident (Resident #83) of 3 residents reviewed for abuse. The findings include: Review of the undated facility policy titled Abuse, Neglect, and Exploitation revealed, .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes .Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Dementia, Heart Failure, and Mixed Receptive Expressive Language Disorder. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #83 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment.Review of a Grievance Decision Report dated 11/12/2025, revealed .Reportedly on 11/01/2025-11/02/2025 .Officer [named officer] called [Social Worker-SW] on 11/12/2025 and advised that an allegation had been made to police department concerning [Resident #83]. The allegation was that [Resident #83] was allegedly sexually abused while in our facility by a male .Review of the facility investigation revealed .on 11/12/2025 at 4:15 PM, Social Worker .was notified by the [Local] police department that a report had been filed with APS [Adult Protective Services] by the resident's daughter .The police department relayed that a report had been filed .alleging that [Resident #83] was sexually assaulted prior to her discharge on [DATE] [11/3/2025] .An investigation was immediately initiated .During the investigation a delay in reporting was identified .The review of interviews with facility staff and leadership identified that the facility staff had prior knowledge of the daughter's reported concern with the first identified information being known on 11/3/2025 .The investigation revealed there was a failure to report this timely .Review of a statement dated 11/17/2025, revealed .FNP [Family Nurse Practitioner] stated she was informed on 11/3/2025 that the family wanted to discharge .[Social Worker] told me [FNP], 'The family said the patient told them that someone put something inside her vagina' .They [Family] didn't think that it [sexual assault] happened. 'It was in her mind and real to her' . Continued review of the FNP statement revealed the FNP did not report the allegation of sexual abuse.During an interview on 11/19/2025 at 8:45 AM, Certified Nurse Assistant (CNA) G stated on 11/1/2025 or 11/2/2025, Resident #83's daughter had stopped her while she was finishing up with her shift and stated her mother said she had a vaginal exam and was wondering if that was true. CNA G stopped what she was doing and went and informed her nurse RN H since there was no management in the building to report to. CNA G stated she did not hear anything else about it until a couple weeks later when she was being questioned by management. CNA G further stated she did not notify anyone else of the alleged allegations. During an interview on 11/19/2025 at 9:33 AM, Registered Nurse (RN) H stated on 11/1/2025 or 11/2/2025, CNA G informed her at the nurse's station around end of shift that Resident #83's daughter was asking if her mom had a vaginal exam. RN H went and talked to the daughter who stated she thought her mom had a bad dream and was confused but just wanted to make sure. RN H further stated she thought CNA G notified the Director of Nursing (DON) of the allegation. RN H stated she did not hear anything else about incident until a couple weeks later.During an interview on 11/20/2025 at 8:30 AM, SW stated she became aware of the allegations on 11/3/2025, when Resident #83's daughter came to her office to discuss Resident #83's discharge stating they wanted the resident discharged that day. The SW stated she asked if she could wait until the next day and the resident's daughter stated, .no, because momma thinks someone sexually touched her .momma thinks it real, and we just want to take her home . The SW confirmed she did not notify administration of the allegation because the family blew it off and the resident's daughter stated she did not want to file a complaint. The SW stated she became aware an allegation of sexual assault against Resident #83 had been reported to the local police department. It was at this time the SW notified the Administrator. During an interview on 11/20/2025 at 9:07 AM, the RN MDS Coordinator stated on 11/3/2025, Resident #83's daughters came into the MDS and SW office stating they wanted to take their mother home because she thought someone had touched her inappropriately while she was sleeping. The resident's daughters stated the resident was scared and they want to take her home. RN MDS Coordinator further stated family said she might have been dreaming. RN MDS Coordinator stated at some point the Assistant Director of Nursing (ADON) came into the office and was informed of the dream Resident #83 had. The RN MDS Coordinator stated she did not hear anything else until the police department notified the facility of the allegation of sexual assault. During an interview on 11/20/2025 at 10:26 AM, the Administrator (ADM) stated she was not aware of the alleged of sexual assault for Resident #83 which reportedly occurred 11/2/2025 until the police notified the facility on 11/12/2025. The Administrator confirmed facility staff had knowledge of the allegation of sexual assault prior to receiving notification from the local police department on 11/12/2025.

Based on facility policy review, medical record review, video surveillance footage review, facility documentation review, and interview, the facility failed to ensure residents were free from physical restraints for 1 resident (Resident #15) of 24 resident reviewed for restraints.The findings include:Review of the facility's policy titled, Restraint Free Environment, revised 1/2020, revealed .Each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience .A physical restraint is defined as any manual method or physical or mechanical device, material .attached or adjacent [next to] the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to .Tucking in a sheet tightly .so that a resident's freedom of movement is restricted .The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms .Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Reduced Mobility, Adult Failure to Thrive, Dementia, and Anxiety.Review of a comprehensive care plan for Resident #15 dated 4/12/2023, revealed .Alert and confused resident often resists participation in activities .need assistance to be up, dressed, and escorted to and from activities in appropriate chair .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Continued review revealed Resident #15 was dependent on staff for personal hygiene and required substantial/maximal assistance with bed mobility and transfers. Further review revealed no documentation the resident had restraints during the 7 day look back period.Review of video surveillance footage dated 3/31/2025 revealed the following:10:19 AM (44 seconds) - Resident #15 was sitting in a geri-chair with her back to nurses' station and facing the day room. Resident #15's legs were loosely covered with a dark colored blanket.10:22 AM (03 seconds) - The alleged perpetrator (AP) Certified Nursing Assistant (CNA) A entered the nurse's station.10:22 AM (46 seconds) - Resident #15's legs remained covered with a dark colored blanket. The resident was restlessly moving her head, hands, and feet.10:27 AM (34 seconds) - CNA A (AP) adjusted the pillow behind the resident's head and obtained vital signs. Resident #15 continued to restlessly move her head, hands, and feet.10:34 AM (35 seconds)-11:00 AM - Resident #15 threw her pillow in the floor multiple times. The resident remained covered with a colored blanket. Resident #15 continued to restlessly move her head, hands, and feet.11:01 AM (37 seconds) - CNA A (AP) approached Resident #15 and secured the pillow behind the resident's head to the geri-chair with a sheet.11:06 AM (52 seconds) - CNA A (AP) approached Resident #15 and removed the dark colored blanket which was covering the resident's legs. CNA A folded a sheet and proceeded to wrap the sheet around Resident #15's lower legs (knees to ankles) twice, then covered the resident's legs and feet with the dark colored blanket. CNA A tucked each side of the blanket under the resident's legs.11:09 AM-11:40 AM - Resident #15's legs remained covered with the dark colored blanket. The resident continued to restlessly move her head, hands, and feet. An unknown CNA placed a second blanket over Resident #15's legs at 11:40 AM.11:47 AM - Resident #15's toes were visible. The resident continued to restlessly move her feet.12:19 PM (04 seconds) - Video ended. Resident #15 remained in the geri-chair with her legs covered with a blanket. The resident continued to restlessly move her feet when the video ended. It was unknown how long the sheet remained wrapped around Resident #15's lower legs.Review of an Order Summary Report for 1/1/2025-11/30/2025 for Resident #15 revealed no orders for use of restraints.Review of a written witness statement for Registered Nurse (RN) E dated 4/2/2025 revealed .Today we were discussing how a particular resident [Resident #15] was fidgeting/restless. [CNA A] then stated that on either Monday [3/31/2025] or Tuesday [4/1/2025] she took a sheet and tied this resident [Resident #15] legs to her geri-chair and then covered her legs with a sheet .Review of a written witness statement for Licensed Practical Nurse (LPN) D dated 4/2/2025, revealed .On 4/2/25 overheard [CNA A] discussing [Resident #15] about her always being fidgety and about tying her legs down to the chair to prevent her from slinging them out of chair an [and] possible falling out of chair .Review of a written witness statement for CNA B dated 4/2/2025, revealed .We were talking about [Resident #15] moving all the time. [CNA A] said 'well I tied her [Resident #15's] feet down to the chair and covered them up with a sheet. That way she couldn't move around' .Review of facility documentation of an interview with CNA A dated 4/3/2025 at 7:55 AM, revealed CNA A .explained that she took a sheet and folded it, then wrapped it around [Resident #15's] bilateral [both] lower extremities [legs] (from knee covering feet). Then demonstrated how sheet [she-CNA A] folded the sheet around [Resident #15's] legs, then crisscrossed in the back and brought up and tucked. [CNA A] expressed that 'its common occurrence, we all do it.' After the sheet, [CNA A] placed the resident's blanket to cover body including feet, because resident will begin yelling 'cover my feet, cover my feet' if they are not covered. We do this when we are short, which gives us a few minutes of not responding to her throwing her blanket in floor'. [CNA A] explains that the resident is yelling constantly, all day long. [CNA A] denies tying sheet to geri-chair. 'We all tuck a blanket' when a resident is in danger of falling or getting out of Geri chair. [CNA A] explained that she did not think anything about it, it was not intentional to restrain the resident. She felt that the resident [Resident #15] was not restrained because she could still move her legs. She was asked to explain what a restraint is: [CNA A] replied; restraint is when the resident cannot move at all .'Tied to wheelchair' or 'tie the sheet to the bottom of the bed' .During an interview on 11/18/2025 at 3:43 PM, RN E stated .We [staff] were at the nurse's station .CNA A made a comment she had taken a sheet and wrapped or tied [Resident #15's] legs to the geri-chair .She [Resident #15] was always very restless .got up in geri-chair daily .rocked in the chair .lifting her legs . RN E stated [CNA A] said she did it [wrapped or tied Resident #15's legs] because she [Resident #15] was fidgeting in the chair .During an interview on 11/18/2025 at 4:15 PM, LPN D stated staff were .sitting at the nurse's station .she [CNA A] was laughing about it [using a sheet to secure Resident #15's legs] .I look at the RN [RN E] who was there and told her I felt it needed to be reported .She [CNA A] said the day before the resident [Resident #15] had been squirming around in her chair . LPN D stated CNA A described it as .a really tight swaddle where [Resident #15] couldn't move .During an interview on 11/18/2025 at 4:30 PM, CNA B stated Resident #15 was sitting in a geri-chair and moved around a lot. CNA B stated CNA A .said something about she had restrained her [Resident #15's] feet and covered them up .During an interview on 11/19/2025 at 7:38 AM, the Human Resources (HR) Manager stated he reviewed video surveillance of the incident with security which showed CNA A securing Resident #15's legs with a blanket/towel. The HR Manager stated the video showed the resident moved both legs from side to side but could not move one leg without the other. The HR Manager stated CNA A was interviewed and reported she did not consider it bounding, just tucked. The HR Manager stated .If you look at the video it was more than a tuck .During an interview on 11/19/2025 at 2:15 PM, the Administrator stated the surveillance video showed CNA A wrapping and tucking Resident #15's lower legs with a sheet and covered her legs with a blanket. The Administrator stated Resident #15 was able to move her feet and wiggle her toes. The Administrator reported CNA A stated she wanted to make sure the resident was comfortable because she was constantly moving her legs and she didn't want her to fall. The Administrator stated Resident #15's legs were .wrapped . and the ends of the sheet were tucked in .it wasn't tied .it was tucked .During review of video surveillance and interview on 11/20/2025 at 11:20 AM, the Quality and Regulation Manager was asked if she considered wrapping Resident #15's legs with sheets a restraint. The Quality and Regulation Manager replied .No . because the resident's movement of her legs and feet were unchanged. The Quality and Regulation Manager was asked if she would consider wrapping resident legs with sheets a restraint for a resident who moved their legs independent of each other. The Quality and Regulation Manager replied .Yes . When asked if she would want her legs to be wrapped such as Resident #15's legs were wrapped the Quality and Regulation Manager replied .No .During a telephone interview on 11/20/2025 at 11:43 AM, CNA A stated Resident #15 liked to kick her blankets off and throw them on the floor and stated the resident had kicked her blanket off several times. CNA A stated it was like playing a game with a toddler. CNA A reported another resident had tried to pick the blanket up and stated .I was afraid the other resident was going to fall .I took a sheet and wrapped it around the bottom part of the legs [Resident #15's legs] to keep her from kicking it [blanket] off, so no one else fell over it. I had saw other people tuck the blanket under her legs. I had folded it [sheet] and placed it over her legs and tucked under . CNA A stated she did not consider her actions a restraint.

Based on medical record review, observation, and interview the facility failed to ensure call lights were in reach for 2 residents (Resident #15 and #58) of 61 residents observed.The findings include:Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Reduced Mobility, Adult Failure to Thrive, Dementia, and Anxiety.Review of a comprehensive plan for Resident #15's dated 4/11/2023, revealed a care plan for Activities of Daily Living (ADL) deficit related to diagnosis of Dementia. Interventions included .Keep call light in reach while in room .Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had severe cognitive impairment. Continued review revealed Resident #15 was dependent on staff for ADLs, bed mobility, and transfers.Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Need for Assistance with Personal Care, and Dementia.Review of a quarterly MDS assessment dated [DATE], revealed Resident #58 scored 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Continued review revealed Resident #58 required substantial/maximal assistance with showering/bathing and transfer from bed to chair.During an observation of Resident #15's room on 11/17/2025 at 12:00 PM, revealed Resident #15 was lying in bed. Further observation revealed the resident's call light was clipped to the call light cord and was hanging on the wall behind the resident's bed, and out of the resident's reach.During an observation of Resident #58's room on 11/17/2025 at 12:10 PM, revealed Resident #58 was lying in bed. Further observation revealed the resident's call light was looped, hanging on the wall behind the resident's bed, and out of the resident's reach.During an observation of Resident #15's room on 11/17/2025 at 2:54 PM, revealed Resident #15 was lying in bed. Further observation revealed the resident's call light was clipped to the call light cord and was hanging on the wall behind the resident's bed, and out of the resident's reach.During an observation of Resident #58's room on 11/17/2025 at 3:00 PM, revealed Resident #58 was lying in bed. Further observation revealed the resident's call light was looped, hanging on the wall behind the resident's bed, and out of the resident's reach.During an observation of Resident #58's room and interview on 11/17/2025 at 3:10 PM, with the Director of Nursing (DON), revealed Resident #58 was lying in bed. Further observation revealed the resident's call light was hanging on the wall behind the resident's bed. The DON confirmed Resident #58's call light was out of the resident's reach.During an observation of Resident #15's room and interview on 11/17/2025 at 3:13 PM, with the DON, revealed Resident #15 was lying in bed. Further observation revealed the resident's call light was clipped to the call light cord and was hanging on the wall behind the resident's bed. The DON confirmed Resident #15's call light was out of the resident's reach.

Based on medical record review and interview, the facility failed to refer 2 residents (Residents #7 and #15), of 5 residents reviewed for PASRR, to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASRR), after the residents were identified with possible serious mental disorders. The findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness and Dysphagia. Review of a PASSR dated 7/21/2016 showed Resident #7 had diagnoses of Depressive Disorder and Anxiety. Record review showed Resident #7 had diagnoses of Mood Disorder added on 1/31/2020 and Delusional Disorder added on 7/17/2020. Resident #15 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia and Muscle Weakness. Review of a PASSR dated 2/13/2020 showed Resident #15 had a diagnosis of Anxiety Disorder. Record review showed Resident #15 had a diagnosis of Bipolar Disorder added on 10/8/2021. During an interview on 8/8/2023 at 1:19 PM, the Minimum Data Set (MDS) Coordinator stated PASSR should be resubmitted when there was a change in status or new mental health diagnoses were added. The MDS Coordinator confirmed the PASSR's for Resident #7 and Resident #15 should have been resubmitted after the new mental health diagnoses of Delusional Disorder on 7/17/2020, and Bipolar Disorder on 10/8/2021.

Based on medical record review and interview the facility failed to revise a care plan to include a change of code status for 1 resident (Resident #65) of 24 reviewed for code status and care plan. The findings include: Resident #65 was admitted to the facility on [DATE], with diagnoses including Encounter for other Orthopedic Aftercare, Weakness, Alcohol Abuse, and Unsheltered Homelessness. Review of Resident #65's POST form dated [DATE], showed .DNR [Do Not Resuscitate] .Limited Additional Interventions .no artificial nutrition by tube .Discussed with patient . The form was signed by Resident #65 on [DATE]. Review of Resident # 65's comprehensive care plan dated [DATE] revealed resident had documented to be a Do Not Resuscitate, Staff will not initiated CPR (Cardiopulmonary Rescuscitation) in the event that resident is found without a pulse or respirations. Review of Resident #65's POST form dated [DATE], showed .CPR-FULL CODE [all life saving measures to be attempted] .Full Treatment .no artificial nutrition by tube .Discussed with patient .The Basis for the order is .Patients Preferences . The form was signed by Resident #65 on [DATE]. Review of Resident #65's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Review of the active Physician's Orders dated [DATE] showed .CPR-FULL CODE .Signed Date: [DATE] 14:08 [2:08 PM] . During an interview on [DATE] at 2:00 PM, Registered Nurse (RN #1) stated when the resident was admitted it was his wish to be a Do Not Resuscitate (DNR). RN #1 stated the resident did not fully understand what a DNR was and after speaking with his son, his wish changed to be a Full Code. During an interview on [DATE] at 2:17 PM, the Director of Nursing (DON) stated Resident #65's wishes were to have full treatment if his heart were to have stopped at the facility, the resident did not have a cardiovascular event while at the facility. The DON confirmed the facility failed to revise Resident #65's care plan to reflect his updated code status wish to have full treatment.

Based on facility policy review, medical record review, observation and interview, the facility failed to maintain a Physician's Order in the resident's chart for an indwelling urinary catheter for 1 resident (Resident #41) of 3 residents reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Indwelling Urinary Catheter: Care and Maintenance, revised 4/2021, showed .guidelines for the maintenance .of indwelling urinary catheters .catheters will be .indicated per physician order . Resident #41 was admitted to the facility on [DATE] with diagnoses including Obstructive Uropathy (a structural problem preventing the normal flow of urine) and Difficulty Walking. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed severe cognitive impairment for Resident #41. The resident required extensive assistance of 2 staff with bed mobility and toilet use. The resident had an indwelling urinary catheter related to a history of obstructive uropathy. Observation of Resident #41 on 8/7/2023 at 10:19 AM showed the resident had an indwelling urinary catheter. Review of current physician orders for Resident #41 showed no order to maintain an indwelling urinary catheter. During an interview on 8/9/2023 at 9:35 AM, the DON stated it was her expectation that the policy and physician's orders were followed for residents with indwelling catheters. The DON confirmed there was no order in Resident #41's chart for an indwelling urinary catheter.

Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to ensure allegations of abuse were reported timely to the facility's Administrator and to the state survey agency for 4 residents (#1, #2, #3, and #4) of 8 residents reviewed for abuse on 1 of 4 nursing units. The findings included: Review of facility policy titled Reporting Allegations of Abuse/Neglect/Exploitation, last reviewed 6/2018, revealed .policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations . Medical Record Review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 3/15 (severely cognitive impaired) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident exhibited physical and verbal behaviors directed toward others and required total care for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #1's care plan dated 11/16/18 revealed the resident was care planned for episodes of combativeness during care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #2 was assessed as severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident required total assistance for bed mobility, toilet use, dressing, and personal hygiene. Medical record review of Resident #2's care plan dated 9/19/18 revealed the resident would smack at staff during care received for Activities of Daily Living (ADL). Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed Resident #3 was severely cognitive impaired and required extensive assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #3's care plan dated 10/17/18 revealed the resident was care planned for resistance to care during ADLs and smacks and yells out when care was provided. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed Resident #4 was severely cognitive impaired and was unable to complete the BIMS. Further review revealed the resident had episode of physical behavioral directed toward others. Continued review revealed the resident required total assistance for bed mobility, transfer, toilet use, and personal hygiene. Medical record review of Resident #4's care plan revealed the resident was at risk for episodes of [MEDICAL CONDITION] and changes in behaviors and moods. Review of a facility investigation dated 12/14/18 revealed Certified Nursing Assistant (CNA) #1 notified Licensed Practical Nurse (LPN) #1 the morning of 12/14/18 of an allegation of abuse, which occurred on the day shift of 12/13/18 (prior day). Further review revealed CNA #1 alleged she witnessed CNA #2 abuse 4 residents during care. Continued review revealed CNA #1 alleged CNA #2 held her hands over the mouth of Resident #2 and #4 and hit Resident #1 in the head with a pillow because he called the CNAs the B word. Further review revealed CNA #1 stated, during ADL care for Resident #3, CNA #2 was holding the resident's hands tightly because the resident was trying to put her hands in the incontinent episode and when Resident #3 started to cry CNA #2 put her hand over the resident's mouth and told her to be quiet. Continued review revealed CNA #1 stated she was afraid to report the incidents, but after she thought about it over night she reported the incidents to LPN #1. Further review revealed CNA #2 denied the incidents, but she was terminated on 12/18/18 due to .recent investigation has determined that on Thursday, (MONTH) 13th while performing her CNA assignments (CNA #2) provided care and assistance which did not meet an acceptable standard of care . Continued review revealed . a recent investigation determined (CNA #1) observed a number of inappropriate interactions demonstrated by a fell ow coworker (CNA#2). Standard practices were not followed as there was a delay in reporting these events . Interview with CNA #1 on 1/7/19 at 1:30 PM, in the Director of Nursing's (DON) office, confirmed the CNA was aware she was required to report any allegation of abuse immediately. Telephone interview with CNA #2 on 1/7/19 at 1:45 PM revealed the CNA denied the abuse occurred. Interview with the Administrator on 1/7/19 at 3:15 PM, in the Administrator's office, confirmed CNA #1 was aware she should have reported the allegation of abuse immediately, but failed to do so.

Based on medical record review and interview, the facility failed to complete an accurate assessment for 1 resident (Resident #50) of 32 residents reviewed. The findings included: Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #50 received an anticoagulant (a blood thinning medication used to treat, prevent, and reduce the risk of blood clots). Medical record review of the electronic physician's orders [REDACTED].#50 was prescribed an anticoagulant. Interview with the MDS nurse on 03/07/18 at 9:50 AM, in the conference room, confirmed Resident #50 did not receive an anticoagulant and the MDS assessment dated [DATE] was inaccurate.

Based on medial record and interview, the facility failed to follow the comprehensive care plan for 1 resident (Resident #44), of 4 residents reviewed for constipation, of 32 residents reviewed. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Further review revealed the resident was always incontinent of bowel and required extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene. Continued review revealed the resident was total dependence for toilet use. Medical record review of Resident #44's care plan dated 10/12/16 revealed .presence of constipation .Monitor/document bowel sounds (decreased or absent bowel sounds may indicate constipation) and frequency of BM (bowel movement): provide laxative of choice per facility protocol (to include suppository (a medication inserted into the rectum used to treat constipation), enema (injection of fluid into the bowel to stimulate stool evacuation), MOM (Milk of Magnesium to treat constipation), [MEDICATION NAME] (stimulate laxative), [MEDICATION NAME] (stool softener), and Prune juice if no BM for more than 48 hrs (hours) . Medical record review of Resident #44's daily Bowel Program flow sheets (a documentation tool for tracking daily bowel habits and medications administered for bowels) dated 9/1/17 to 3/6/18 revealed the following: September (YEAR) - 10 consecutive days, from 9/10/17-9/19/17, without documentation of a BM and no stool softener or laxative intervention. October (YEAR) - 7 consecutive days, from 9/28/17-10/4/17, without documentation of a BM and with no stool softener or laxative intervention, resulting in Resident #44 requiring disimpaction (manual removal of hard stool from the rectal cavity) on 10/22/17. November (YEAR) - 5 consecutive days, from 11/11/17 - 11/15/17, without documentation of a BM and 2 [MEDICATION NAME] (stimulant laxative) given on 11/15/17; and 7 consecutive days, from 11/22/17-11/28/17, without documentation of a BM and no stool softener or laxative intervention until documentation of 3 [MEDICATION NAME] on 11/29/17. December (YEAR) - 11 consecutive days, from 12/28/17 - 1/7/18, without documentation of a BM and no stool softener or laxative intervention. January (YEAR) - 9 consecutive days, from 1/18/18-1/26/18, without documentation of a BM and no stool softener or laxative intervention. February (YEAR) - 9 consecutive days, from 2/3/18-2/11/18, and an additional 6 days, from 2/16/18-2/21/18, without documentation of a BM and no stool softener or laxative intervention, which resulted in Resident #44 requiring disimpaction on 2/22/18. March (YEAR) - 8 consecutive days, from 2/26/18-3/5/18, without documentation of a BM and no stool softener or laxative intervention. Telephone interview with Resident #44's Physician on 3/7/18 at 1:50 PM, confirmed he had standing orders in place to address constipation. The physician stated he had a standing order for laxative of choice, which would include [MEDICATION NAME] 100 MG (milligram) or [MEDICATION NAME] 17 GM (gram). Further interview confirmed [MEDICATION NAME] and [MEDICATION NAME] had not actually been documented on the routine orders for Resident #44 and the nurses would have had to contact him for further orders. Interview with the Director of Nursing (DON) on 3/8/18 at 10:45 AM, in the conference room, confirmed the facility failed to follow Resident #44's plan of care for bowel management. Refer to F690.

Based on medical record review and interview, the facility failed to implement a bowel protocol for 1 resident (Resident #44) of 4 residents reviewed for constipation. The findings included: Medical record review revealed Resident #44 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely cognitively impaired. Further review revealed the resident was always incontinent of bowel and required extensive assist with bed mobility, transfer, dressing, eating, and personal hygiene. Continued review revealed the resident was total dependence for toilet use. Medical record review of Resident #44's Physician orders [REDACTED]. Medical record review of the Physician's Routine Orders dated 6/1/16 revealed, .laxative of choice . Continued review revealed no administration instructions to include what medication, dosage, frequency, and route. Medical record review of Resident #44's care plan dated 10/12/16 revealed .presence of constipation as defined by 2 or fewer bowel movements during look back period .Monitor/document bowel sounds and frequency of BM (bowel movement): provide laxative of choice per facility protocol if no BM for more than 48 hrs (hours) . Medical record review of the facility's Bowel Program sheet, undated, revealed the following bowel management interventions: suppository (medication inserted into the rectum used to treat constipation), enema (injection of fluid into the lower bowel by way of the rectum to stimulate stool evacuation), Milk of Magnesia (MOM) (medication used to treat constipation), [MEDICATION NAME] (stimulant laxative), [MEDICATION NAME] (stool softener), and prune juice. Continued review revealed no administration instructions to include type of suppository and/or enema to administer. Further review revealed no administration instructions to include dosage, frequency, and/or route for the MOM, [MEDICATION NAME], and [MEDICATION NAME]. Medical record review of Resident #44's daily Bowel Program flow sheets (a documentation tool for tracking daily bowel habits and medications administered for bowels) dated 9/1/17 - 3/6/18 revealed the following: September (YEAR) - 10 consecutive days, from 9/10/17-9/19/17, without documentation of a BM and no stool softener or laxative intervention. October (YEAR) - 7 consecutive days, from 9/28/17-10/4/17, without documentation of a BM and with no stool softener or laxative intervention, resulting in Resident #44 requiring disimpaction (manual removal of hard stool from the rectal cavity) on 10/22/17. November (YEAR) - 5 consecutive days, from 11/11/17 - 11/15/17, without documentation of a BM and 2 [MEDICATION NAME] (stimulant laxative) given on 11/15/17; and 7 consecutive days, from 11/22/17-11/28/17, without documentation of a BM and no stool softener or laxative intervention until documentation of 3 [MEDICATION NAME] on 11/29/17. December (YEAR) - 11 consecutive days, from 12/28/17 - 1/7/18, without documentation of a BM and no stool softener or laxative intervention. January (YEAR) - 9 consecutive days, from 1/18/18-1/26/18, without documentation of a BM and no stool softener or laxative intervention. February (YEAR) - 9 consecutive days, from 2/3/18-2/11/18, and an additional 6 days, from 2/16/18-2/21/18, without documentation of a BM and no stool softener or laxative intervention, which resulted in Resident #44 requiring disimpaction on 2/22/18. March (YEAR) - 8 consecutive days, from 2/26/18-3/5/18, without documentation of a BM and no stool softener or laxative intervention. Medical record review of a nurse's Progress Note dated 10/22/17 by Licensed Practical Nurse (LPN) #4 revealed .patient has noted BM but unable to pass due to impaction. Patient states it is hurting me get it out. Nurse at this time does impaction removal noted very dry hard stool . Medical record review of a nurse's Progress Note dated 2/22/18 by LPN #1 revealed .Resident refused all AM meds (medications) x (times) 3 attempts. Kicking, punching, and cursing at staff for no apparent reason. Impaction removed at approximately 1 PM. Blood noted in stool related to anal tearing from stool being so large and hard . Interview with LPN #1 on 3/7/18 at 11:00 AM, in the unit one medication storage room, confirmed she had manually removed a very large hard stool from Resident #44 on 2/22/18. Continued interview confirmed the resident had a small tear to the rectum due to the size of the bowel movement. Further interview revealed the Certified Nurse Assistants (CNAs) had informed her it was normal for Resident #44 to have hard stool requiring staff assistance for removal. Further interview revealed LPN #1 had no knowledge of a facility bowel protocol or any standing orders to treat constipation. Interview with CNA #1 on 3/7/18 at 11:14 AM, at the unit 1 nurse's station, revealed she was one of the regular care givers for Resident #44. Further interview confirmed Resident #44 did have constipation and required manual assistance from staff to remove the stool. Interview with Registered Nurse (RN) #1, Unit 1 Manager, on 3/7/18 at 12:19 PM, at the unit 1 nurse's station, revealed the nurse was not aware of any standing orders from Resident #44's Physician for constipation, but there was a facility bowel protocol the nurses followed. Further interview revealed the protocol was if no BM in 2 days a stool softener would be administered, if no BM in 3 days a laxative would be administered, if no results, an enema would be administered, and if no results from the enema the Physician would be notified for further orders. Interview with RN #2, Unit 2 Manager, on 3/7/18 at 12:25 PM, at the unit 1 nurse's station, revealed the nurse stated the facility currently had no bowel management protocol. Interview with Resident #44's Physician by phone on 3/7/18 at 1:50 PM, revealed he had standing orders in place to address constipation. Further interview confirmed he had a standing order of laxative of choice which would include [MEDICATION NAME] 100 MG (milligram) or [MEDICATION NAME] 17 GM (gram). Medical record review of Resident #44's Physician orders [REDACTED]. Interview with Resident #44's Physician on 3/7/18 at 3:00 PM, in the conference room, revealed after 7 consecutive days without a BM, Resident #44 would require a laxative. Continued interview confirmed Resident #44 had no order to administer a laxative after 7 days without a BM. Further interview confirmed Resident #44 had the potential for pain and discomfort from constipation. Interview with LPN #3 by phone on 3/7/18 at 6:15 PM, confirmed the LPN had to manually remove stool from Resident #44's rectum. Continued interview confirmed she had no knowledge of physician standing orders to address constipation. Further interview confirmed if a resident had not had a BM in 2 days, night shift would administer MOM or [MEDICATION NAME]; if no results, day shift would administer an enema, and if no results the Physician would be notified. Continued interview confirmed the LPN was not aware of a facility bowel protocol. Interview with RN #3, Night Shift Supervisor, on 3/7/18 at 6:37 PM, at the unit 1 nurse's station, revealed the facility followed the bowel program sheet for the bowel protocol. Continued interview revealed if a resident had not had a BM in 3 days a suppository would be administered, if no results from the suppository, an enema would be administered, if no results from the enema, MOM would be administered. Further interview revealed the bowel program sheet was not clear on when to administer medications or what dosage was to be administered. Interview with LPN #4 on 3/8/18 at 8:34 AM, in the conference room, confirmed on 10/21/17, Resident #44 had hard visible stool in her rectum and was unable to push the stool out without the nurse's assistance. Further interview confirmed LPN #4 was not aware of a facility bowel protocol. Interview with RN #1 on 3/8/18 at 9:23 AM, in the conference room, revealed the facility's bowel protocol sheet did not have administration instructions to include dosage, frequency, and route. Further interview revealed there were no standing orders on the resident charts for nurses to review. Interview with the Director of Nursing (DON) on 3/8/18 at 10:45 AM, in the conference room, confirmed nursing staff were to follow the facility's bowel protocol. Continued interview confirmed the nursing staff had not followed the facility's bowel protocol.

Based on medical record review, review of facility in-service, observation, and interview, the facility failed to implement [MEDICAL CONDITION] (a tube inserted in the neck to allow air to enter the lungs) suctioning equipment to care for 1 resident (Resident #34) of 1 reviewed for a [MEDICAL CONDITION], of 32 residents reviewed. The findings included: Medical record review revealed Resident #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility in-service (education) dated 2/7/18 revealed .In Service on Oxygen and Suction Equipment .All tubing (Nebulizer (a breathing machine used to administer inhaled medications into the lungs), Oxygen, Suction) will be changed once per week and dated .All suction cans will be changed when soiled and replaced with a new one, and dated . Observation with Registered Nurse (RN #1) on 3/6/18 at 7:22 AM in the resident's room, revealed a suction canister (un-dated), on Resident #34's end table, with secretions approximately 1/4 full, and the suction tubing was dated 2/19/18. Interview with RN #1 on 3/6/18 at 7:30 AM, at the unit 1 nurse's station, confirmed the suction tubing was out dated and should be changed every 7 days. The facility failed to implement the facility inservice education.

Based on the facility policy, observation, and interview, the facility failed to dispose of left overs in 1 of 3 refrigerator/coolers by the use by date (UBD), failed to properly store pans and failed to ensure kitchen equipment and non-food contact surfaces were clean and maintained in a sanitary manner, affecting 62 of 74 residents. The findings included: Review of the facility policy Infection Control Sanitation and Storage dated/revised 1/2010 revealed .Any prepared refrigerated foods that are to be used for leftovers are to be covered and dated. And discarded after the (3) third day and not to be used .provide clean .storage and work areas .General Responsibilities: the highest level of sanitation in the areas of food, equipment, work surfaces .maintaining a safe and sanitary work area .equipment cleanliness .Pots and pan are to be air dried . Observation with the Certified Dietary Manager (CDM) on 2/6/17 at 10:00 AM in the kitchen, revealed: a). A can opener with debris on the blade. b). A Commercial mixer with dried debris on the beater shaft and outside rim. Observation with the CDM on 2/6/17 at 10:10 AM, in the kitchen, revealed the following pans stored wet and available for use: a). 2 of 11 four inch 1/2 steamtable pans b). 1 of 12 four inch 1/4 steamtable pans c). 1 of 6 two inch full steamtable pans d). 1 of 6 two inch full steamtable pans with dried debris on the inside of the pan. Observation with the CDM on 2/6/17 at 10:15 AM, in the kitchen, revealed the hood vents with dusty debris. Observation with the CDM on 2/6/17 at 10:20 AM, of the walk-in cooler, in the kitchen revealed these items stored after the UBD and available for resident consumption: a). One 4 inch 1/8 pan ½ full of chopped chicken b). One 2 pound container full of refried beans c). One 4 inch 1/8 pan full of taco meat d). One 6 inch 1/8 pan full of rice e). One 4 inch ¼ pan full cream of chicken soup f). One 1 quart container ¼ full of ketchup g). One 4 inch 1/6 pan 1/3 full of pasta salad. Observation with the CDM on 2/7/17 at 1:45 PM, in the second floor nourishment room revealed an ice maker with a white plastic shield (to guard the ice from falling out of the bin) with a build-up of black debris. Interview with the CDM on 2/6/17 at 10:30 AM, in the dry stock room confirmed the facility failed to properly dispose of left overs in 1 of 3 refrigerator/coolers, failed to properly store pans, and failed to maintain food and non-food contact surfaces in a sanitary manner. Interview with the CDM on 2/7/17 at 1:50 PM, in the second floor nourishment room confirmed the facility failed to maintain the ice machine in a sanitary manner.

Based on medical record review and interview, the facility failed to follow physician orders [REDACTED].#27) of 5 residents reviewed for unnecessary medication of 35 sampled residents. The findings included: Medical record review revealed Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Medical record review of Resident #27's Care Plan dated 11/23/16 revealed .The resident uses [MEDICAL CONDITION] Medications .[MEDICATION NAME] .Administer [MEDICAL CONDITION] medications as ordered by physician .monitor for side effects and effectiveness q (every) shift . Medical record review of a Psychiatric Consult dated 1/13/17 revealed .suggest .1. D/C (discontinue) [MEDICATION NAME] to eval (evaluate) for need . Medical record review of Physician order [REDACTED].[MEDICATION NAME] (antidepressant medication) Tablet 10mg (milligram) Give 1 tablet by mouth one time a day related to Anxiety Disorder . Medical record review of Physicians Orders dated 1/17/17 revealed .TO (telephone order) .D/C [MEDICATION NAME] . Medical record review of the Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) #1 on 2/7/17 at 1:35PM, at the 2nd floor Nurses station confirmed [MEDICATION NAME] had been discontinued on 1/17/17 but Resident #27 continued to receive the medication until 1/30/17, 13 days after the medication was discontinued.

Based on facility policy review, review of a Journal of Wound, Ostomy and Continence Nursing, medical record review, observation, and interview, the facility failed to ensure infection control standards were maintained during a pressure ulcer dressing change for 1 resident (#26) of 3 residents reviewed for pressure ulcers of 32 sampled residents. The findings included: Review of facility policy Nursing Home Skin Care Policy, undated, revealed .to use clean technique in performing dressing changes .Universal precautions are utilized . Review of Journal of Wound, Ostomy and Continence Nursing (March/April 2012), Clean vs. (versus) Sterile Dressing Techniques for Management of Chronic Wounds: A Fact Sheet revealed .clean technique .involves strategies used in patient care to reduce the number of microorganisms .involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves .preventing direct contamination of materials and supplies . Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed Resident #26 .1 unstageable - deep tissue: suspected deep tissue injury in evolution . Medical record review of a physician telephone order dated 12/15/15 revealed .pack wound .Dakins Solution (a dilute solution containing sodium hypochlorite and boric acid, used as an antiseptic in the treatment of [REDACTED].½ strength wet to dry. Cover /c (with) dry gauze wrap /c Kerlix/Conform. Secure /c tape .change BID (twice a day) . Medical record review of Nurse's Treatment Notes dated 1/29/16 revealed .DTI (deep tissue injury) to left heel measures 6.5 cm (centimeters) L (Length) x 6.0 cm W (Width) x 0 cm d (Depth) .75% black soft eschar (a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection, or excoriating skin disease) /c 25% soft yellow slough .(no) odor noted moderate serous discharge . Observation on 2/3/16 at 10:46 AM, in the resident's room, revealed the Wound Care Nurse obtained gauze, packs of 4x4's, Dakins Solution poured on to a 4x4, a drape, and tape, and walked into the resident room and placed the items on the bedside table. Continued observation at 10:49 AM, revealed the Wound Care Nurse dropped the old removed wet to dry dressing on the clean work field, then picked the dressing up and threw it away in a garbage bag at the end of Resident #26's bed. Further observation revealed the Wound Care Nurse turned to the bedside table, opened two clean 4x4 packages, and pulled one 4x4 out with the dirty gloves used to remove the old dressing. Continued observation revealed the Wound Care Nurse sprayed Resident #26's left foot with saline which ran onto a drape under the foot. Certified Nursing Assistant (CNA) #1 dropped Resident #26's foot into the contaminated saline water on the drape under Resident #26's foot. Further observation revealed the Wound Care Nurse opened additional clean 4x4 packages, pat dried Resident #26's foot, took the gloves off, and walked to the treatment cart outside Resident #26's room, without washing the hands, to collect more clean 4x4's. Continued observation revealed the Wound Care Nurse placed the clean 4x4's on the bedside table work field, placed new clean gloves on without washing the hands, squeezed out excess Dakins Solution from a 4x4, placed it on the resident's left heel, and began wrapping Resident #26's foot with Kerlix. Further observation revealed, while wrapping Resident #26's foot, the Wound Care Nurse dropped the Kerlix into the contaminated saline water on the drape under Resident #26's foot, picked the Kerlix up, continued wrapping resident's foot with the contaminated Kerlix, and secured it with tape. Interview with the Wound Care Nurse on 2/3/16 at 10:57 AM, in the hallway outside Resident #26's room, confirmed she failed to ensure infection control standards were followed during the dressing change.

Based on facility policy review, medical record review, observation, and interview, the facility failed to respect resident privacy for 1 resident (#26) of 32 residents reviewed. The findings included: Review of facility policy Resident's Rights Under Federal Law, revised 1/14, revealed .has the right to personal privacy and confidentiality of his or her personal and clinical records . Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #26 was severely cognitively impaired. Observation of Resident #26 on 2/3/16 at 10:46 AM, in the resident's room, revealed Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 completing a dressing change for a pressure ulcer. Continued observation revealed CNA #2 pushed open the resident's door without knocking and began talking in a loud voice .(CNA #1) are you in here? CNA #2 continued to walk forward to the end of the resident's bed and spoke with CNA #1 about another resident while the treatment was in process for Resident #26. Interview with CNA #2 on 2/3/16 at 11:03 AM in the 100 Hall (First Floor) hallway, confirmed .I didn't wait for a response. I just walked in while the treatment was going on . and began discussing another resident in the presence of Resident #26 while a treatment was taking place. Interview with the Administrator on 2/3/16 at 1:30 PM, in the Administrator's office, confirmed .expect the staff to knock on the resident's door and wait for a response to enter .