Every finding on record at Diversicare of Amory

Based on observation, interview, record review, and facility policy review, the facility failed to implement infection control practices to prevent the spread of infection for four (4) of four (4) days of survey, which included not performing hand hygiene between residents during meal service (4/13/26 and 4/14/26), not maintaining aseptic technique during medication administration (4/15/26), and not ensuring biohazard waste was securely stored (4/16/26). Findings Include: Review of the facility's Policies and Practices - Infection Control dated 11/01/17 revealed, The center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . Meal Observation On 4/13/26 from 12:30 PM to 12:40 PM, during an observation of A-Wing lunch meal tray pass, staff did not perform hand hygiene between residents. Certified Nursing Assistant (CNA) #1 pushed the dietary cart down A-Wing and delivered trays and set up meals in room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] without sanitizing her hands between residents. CNA #2 removed a tray from the cart, entered room [ROOM NUMBER], and exited without performing hand hygiene. She then removed another tray, entered room [ROOM NUMBER], moved the television remote with her hand, and placed the tray on the bedside table. CNA #2 exited the room, retrieved another tray, and entered room [ROOM NUMBER] to feed the resident. No hand hygiene was observed during the lunch meal tray pass. On 4/13/26 at 12:45 PM, during an interview, Certified Nursing Assistant (CNA) #1 confirmed she passed lunch meal trays without washing or sanitizing her hands between residents. She explained she was nervous and forgot to perform hand hygiene. She acknowledged she was expected to wash her hands prior to passing meal trays and sanitize her hands between residents. She confirmed failure to perform hand hygiene between residents could result in the spread of germs, contamination, and infection. On 4/13/26 at 12:55 PM, during an interview, CNA #2 explained staff passed out and set up trays for residents who could feed themselves first, then delivered trays to residents who required assistance with feeding. She reported staff washed their hands prior to handing trays out and confirmed she did not perform hand hygiene between residents while passing trays. She explained she was aware she was expected to perform hand hygiene between residents but forgot. She acknowledged failure to perform hand hygiene between residents could result in the spread of germs and possible infection. On 4/14/26 from 11:45 AM to 11:55 AM, during an observation of A-Wing lunch meal tray pass, staff did not perform hand hygiene between residents. Certified Nursing Assistant (CNA) #3 entered room [ROOM NUMBER] with a lunch tray and exited without using hand sanitizer. She then delivered trays to residents in room [ROOM NUMBER] and room [ROOM NUMBER] without performing hand hygiene between residents. During the same observation, CNA #4 removed a meal tray from the cart and delivered it to room [ROOM NUMBER], exited the room, and returned to the cart to retrieve another tray. While in the hallway next to the cart, an unsampled resident propelled herself down the hall, spoke with CNA #4, and shook her hand. CNA #4 then retrieved another tray from the cart and delivered it to room [ROOM NUMBER] without performing hand hygiene between resident rooms or after contact with the unsampled resident. An interview on 04/14/26 at 11:58 AM with CNA #3, revealed that she washed her hands when she left the kitchen to hand out trays and they were clean. She revealed that she wasn't aware of the need to wash hands or use hand sanitizer while passing out trays in between residents. She agreed that this could cause the spread of germs. An interview on 04/14/26 at 12:03 PM with CNA #4, revealed that she should have washed her hands after contact with the unsampled resident who came down the hall and touched her hand. She revealed that she was supposed to wash hands or use hand sanitizer between residents and by not washing her hands, she risked the spreading of germs which could cause possible infection. On 4/15/26 at 12:28 PM, during an interview, Registered Nurse (RN) #5, Infection Preventionist, explained staff were expected to wash their hands or use hand sanitizer between residents while passing meal trays. She explained staff should deliver a tray, set it up for the resident, and perform hand hygiene prior to entering another resident room. She reported meal trays were typically delivered first to residents who could feed themselves, followed by those who required assistance. She confirmed staff were aware of the expectation to perform hand hygiene between residents. She explained failure to perform hand hygiene between residents could result in cross contamination, spread of germs, and increased risk of residents becoming ill. Medication Administration On 4/15/26 at 8:45 AM, during an observation of medication administration, Registered Nurse (RN) #4 administered Resident #23's morning medications through his Percutaneous Endoscopic Gastrostomy (PEG) tube. RN #4 pushed the medication cart into Resident #23's semi-private room. She washed her hands, applied a gown and gloves and assisted RN #5/Infection Preventionist to reposition the resident in the bed. Using the same gloves, RN #4, returned to the medication cart, retrieved the measuring tape, and then measured the PEG tube to ensure proper placement. RN #4 then walked back to the medication cart and prepared his medications without changing gloves. She pulled Resident #23's medications out of the medication cart and placed each tablet in the palm of her gloved hand prior to placing them into the individual medication packets. RN #4 then crushed the medications, changed her gloves and administered them by PEG tube. On 4/15/26 at 9:20 AM, during an interview, RN #4 confirmed she pushed the medication cart into Resident #23's room prior to administering medications. She confirmed she did not change gloves after resident contact and handled medications with the same gloves. She explained she should have changed gloves after resident contact and prior to medication preparation to prevent contamination. She acknowledged placing medications in the palm of her gloved hand could contaminate the medications and place the resident at risk for infection. She also confirmed the medication cart should have remained in the hallway during medication administration to prevent cross contamination. On 4/15/26 at 9:30 AM, during an interview, the Assistant Director of Nursing (ADON) confirmed medication carts should not be taken into resident rooms during medication pass due to risk of cross contamination. She also confirmed staff were expected to perform hand hygiene after resident contact and prior to handling medications. The ADON also confirmed that she was on A-Hall during the lunch meal tray pass the day before (4/14/26) and witnessed staff not performing hand hygiene between residents. On 4/15/26 at 10:25 AM, during an interview, RN #5/Infection Preventionist, confirmed medication carts should remain outside resident rooms during medication administration. She confirmed RN #4 failure to change gloves after resident contact and prior to medication administration could result in cross contamination and infection. A record review of the admission Record revealed the facility admitted Resident #23 on 3/30/26 with diagnoses including Dysphagia. A record review of Resident #23's Medication Administration Record (MAR) revealed medications were administered via PEG tube on 4/15/26 during the AM, and documentation included verification of enteral tube placement by measurement prior to administration. Biohazard Waste Review of the facility's policy titled, Regulated (Biohazard) Medical Waste, undated, revealed, It is the policy of this facility to ensure that regulated medical waste is managed, handled, stored, and transported as per Federal, State and local guidelines and regulations. On 4/16/26 at 12:20 PM, during an observation and interview, unsecured biohazard waste was observed in two red barrels located outside of the locked biohazard room. One barrel contained used gowns, gloves, and a sharps container with used needles. The lid was not locked and contents were accessible. The Maintenance Supervisor confirmed biohazardous waste should not be stored outside of the building at any time. On 4/16/26 at 12:30 PM, during an observation, the door to the outdoor biohazard room was shut and locked; however, the key was stored above the door frame and was accessible. On 4/16/26 at 12:40 PM, during an interview, the Administrator confirmed medical waste should be stored in a locked area and that storing used gowns, gloves, and needles in an unsecured outside barrel was not proper. She also confirmed the key to the biohazard room should be secured and not stored above the door frame.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to dignity for one (1) of six (6) residents observed for dining, Resident #4.Findings include:A review of the facility's policy, Residents' Rights in Nursing Centers, undated, revealed, .Resident's rights are part of the federal Nursing Home Reform Law.The law requires nursing centers to 'promote and protect the rights of each resident' and places a strong emphasis on individual dignity.Specific Rights.The Right to Dignity, Respect, and Freedom, including the right to: Be treated with the fullest measure of consideration, respect, and dignity.On 4/14/26 at 2:10 PM, during an observation, Registered Nurse (RN) #1 fed Resident #4 fortified pudding in the common television area with other residents present. RN #1 remained standing beside the resident while feeding and did not sit at eye level throughout the feeding.On 4/14/26 at 2:30 PM, during an interview, RN #1 acknowledged she did not sit while feeding Resident #4 and reported she forgot she was expected to sit while feeding residents.On 4/14/26 at 3:00 PM, during an interview, the Assistant Director of Nursing (ADON) confirmed staff were expected to sit while feeding residents to promote dignity during meals.A record review of the admission Record revealed the facility admitted Resident #4 on 1/13/26 with diagnoses including Dementia.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/19/26 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to Activities of Daily Living (ADLs) (Resident #108 and #102) and wound care (Resident #3) for three (3) of 23 sampled residents. Findings Include: Review of the facility's policy Care Plans dated October 2021 revealed, Care plans will be developed and implemented for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines Resident #108 A record review of the Clinical Care Plan Detail revealed Resident #108 had a Focus of I have a Self Care Deficit. with Interventions/Tasks including Nail, hair, and oral care daily and as needed. On 4/13/26 at 11:40 AM and 4/14/26 at 9:00 AM, during observations and interviews, Resident #108 had long nails, approximately 3/4 inch from the top of the nailbed. There was also a brown substance noted underneath the nails. He stated he preferred his fingernails to be kept short and he wanted them trimmed. During an interview on 4/14/26 at 12:20 PM, the Director of Nursing (DON) acknowledged he observed Resident #108's fingernails and confirmed they were long, jagged, and dirty. Record review of the admission Record revealed the facility originally admitted Resident #108 on 1/20/26 with the most recent admission date of 10/9/25. Diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date of 1/15/25, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact. RESIDENT #102 A record review of the Care Plan Report revealed Resident #102 had a Focus of I have a Self Care Deficit. The Goal was listed as My ADL needs will be met in a comfortable and caring manner. and the Interventions included toilet hygiene with substantial/maximum assistance support. On 4/14/26 at 8:30 AM, during an observation and interview, Resident #102 reported she had requested a bedpan at approximately 8:00 AM and staff had not returned to assist her. She reported feeling uncomfortable with a full bladder. On 4/14/26 at 9:04 AM, during interview, CNA #1 stated she was going to assist Resident #102, which was approximately one (1) hour and four (4) minutes after Resident #102 had requested toileting assistance. On 4/14/26 at 9:15 AM, during an interview, the DON stated that CNA #1 should have assisted Resident #102 at the time of her request. A record review of the admission Record revealed the facility admitted Resident #102 on 1/27/22, with a most recent admission date of 3/31/26, and she had diagnoses including Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 4/7/26 revealed Resident #102 had a BIMS score of fourteen (14), which indicated she was cognitively intact. A review of Section GG revealed she required partial to moderate assistance for toilet transfers and substantial to maximal assistance with toileting hygiene. Resident #3 Record review of Resident #3's Care Plan Report revealed a focus area for I have non-pressure impaired skin integrity of the right posterior leg related to cellulitis wound and I have non-pressure impaired skin integrity related to wound to the right heel with goal of My affected area will heal without complications. The interventions listed included treatments as ordered. An interview with the Minimum Data Set (MDS) Registered Nurse on 4/15/26 at 10:53 AM revealed the purpose of the care plan was to provide an individualized plan of care with information on how to treat and provide care for each resident. She acknowledged that wound care was part of the care plan and the intervention to provide treatments as ordered was not followed. During an interview on 4/15/26 at 2:10 PM, the Director of Nursing stated his expectation was for each staff member to follow the care plan and to provide treatments as ordered. He confirmed the facility failed to follow the developed care plan for wound treatments as ordered for Resident #3. A record review of the Order Review revealed Resident #3 had Physician's Orders, dated 2/25/26, for Dakins solution to the right heel wound topically every day shift for wound infection and for the right heel to be packed moist-to-dry with one-quarter (1/4) strength Dakins solution daily and as needed. A record review also revealed a Physician's Order, dated 3/5/26, to the right lateral lower leg to be cleaned with one-quarter (1/4) strength Dakins solution every day shift for cellulitis wound. A record review further revealed a Physician's Order, dated 2/25/26 and discontinued on 3/5/26, for treatment to the right posterior lower leg every Monday, Wednesday, and Friday. A record review of the Treatment Administration Record (TAR) for March 2026 revealed Resident #3 had a Physician's Order, dated 2/25/26, for Dakins solution to the right heel wound topically every day shift for wound infection. There was no documentation the treatment was performed on 3/4/26, 3/14/26, 3/15/26, 3/23/26, 3/25/26, 3/27/26, or 3/30/26 for a total of seven (7) missed treatments. A record review also revealed a Physician's Order, dated 2/25/26, for the right heel to be packed moist-to-dry with one-quarter (1/4) strength Dakins solution daily and as needed. There was no documentation the treatment was performed on 3/4/26, 3/14/26, 3/15/26, 3/23/26, 3/25/26, 3/27/26, or 3/30/26 for a total of seven (7) missed treatments. A record review further revealed a Physician's Order, dated 3/5/26, to the right lateral lower leg to be cleaned with one-quarter (1/4) strength Dakins solution every day shift for cellulitis wound. There was no documentation the treatment was completed on 3/14/26, 3/15/26, 3/23/26, 3/25/26, 3/27/26, or 3/30/26 for a total of six (6) missed treatments. A record review also revealed a Physician's Order, dated 2/25/26 and discontinued on 3/5/26, for treatment to the right posterior lower leg every Monday, Wednesday, and Friday. There was no documentation indicating the treatment was performed on 3/4/26 for a total of one (1) missed treatment. A record review of the Treatment Administration Record (TAR) for April 2026 revealed Resident #3 had a Physician's Order, dated 2/25/26, for the right heel to be packed moist-to-dry with one-quarter (1/4) strength Dakins solution daily and as needed. There was no documentation the treatment was performed on 4/9/26 for a total of one (1) missed treatment. A record review of the admission Record revealed the facility admitted Resident #3 on 12/26/25 with diagnoses including Cellulitis of Right Lower Limb, Acute Osteomyelitis of Right Ankle and Foot, and Type 2 Diabetes Mellitus. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/26 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were securely stored and administered in a manner that prevented them from being left unattended at the bedside for two (2) of twenty-three (23) sampled residents, Residents #35 and #44. Findings include: A review of the facility's policy, Medication Administration Guide, undated, revealed, Other best practice for medication administration includes: . observing that the resident/patient swallow medications administered. Do not leave medications at the bedside. A review of the facility's policy, Medication Storage, dated 4/2023, revealed, .Medications are accessible ONLY to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Resident #35 On 4/14/26 at 8:45 AM, during an observation and interview, Resident #35 was in her room and placed four (4) medication tablets from a medication cup into her hand and swallowed them. She reported the nurse left these medications, along with others she had already taken, at her bedside several minutes earlier. On 4/14/26 at 8:54 AM, during an interview, Licensed Practical Nurse (LPN) #1 acknowledged she left medications at Resident #35's bedside. She reported she had received in-service training on medication administration and was aware it was not safe to leave medications unattended. She explained she should have remained with the resident until the medications were taken. On 4/14/26 at 2:15 PM, during an interview, the Director of Nursing (DON) explained his expectation was for nurses to administer medications safely and follow medication administration guidelines. He confirmed this included observing the resident take the medication and not leaving medications unattended at the bedside. He confirmed the facility did not ensure the resident received medications safely by not remaining with the resident during administration. A record review of the Medication Administration Competency Audit - Oral Meds for LPN #1 revealed the action observes resident swallow medications was marked as met. A record review of the admission Record revealed the facility admitted Resident #35 on 11/27/12 with diagnoses including Primary Generalized Osteoarthritis. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/26 revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. Resident #44 On 4/13/26 at 10:56 AM, during an observation and interview, Resident #44 had a prescription bottle of Nystatin powder with a prescription label affixed to the bottle at the bedside. On 4/14/26 at 3:30 PM, during an observation and interview, the Interim Director of Nursing (DON) confirmed the bottle of Nystatin powder was on Resident #44's bedside table. Further review showed the prescription label belonged to the resident's roommate, Resident #92, and was not from the facility pharmacy. The Interim DON removed the medication from the room and informed Resident #44 he would consult the nurse practitioner regarding obtaining a prescription if needed. On 4/14/26 at 3:45 PM, during an interview, the Interim DON explained prescription medications should not be left at the bedside, especially medications from an unknown source. He explained the presence of medication not prescribed to the resident created a risk for medication errors or unintended use. A record review of the admission Record revealed the facility admitted Resident #44 on 7/28/25 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/26 revealed Resident #44 had a BIMS score of fifteen (15), which indicated the resident was cognitively intact. A record review of the Order Summary Report with Active Orders As Of: 4/15/26 revealed Resident #44 did not have an active physician's order for Nystatin powder.

Based on observation, interview, and record review, the facility failed to provide services to prevent possible complications for one (1) of one (1) resident reviewed with an indwelling urinary catheter, Resident #11. Findings include:A review of the facility's document, Standards of Practice, on company letterhead revealed, The expectation set forth.is that nurses comply with current standards of practice in terms of following the physician's orders on replacement of foley (type of indwelling catheter) catheters On 4/16/26 at 11:25 AM, during an observation and interview, Resident #11 reported he had a suprapubic catheter in place due to bladder cancer and had the catheter for a long time. He reported he could not remember the last time the catheter had been changed.On 4/16/26 at 11:30 AM, during an interview, Registered Nurse (RN) #3 explained that catheters were to be changed monthly unless otherwise specified in physician orders. She explained catheter change orders were located on the Treatment Administration Record (TAR) and the treatment nurse was responsible to complete them. She confirmed Resident #11 had an order for catheter changes every thirty (30) days.On 4/16/26 at 11:45 AM, during an interview, the Director of Nursing (DON) confirmed Resident #11 had an order for the suprapubic catheter to be changed every thirty (30) days on the 26th of each month. He reviewed the TAR and confirmed there was no documentation the catheter was changed in March 2026. He explained the catheter should be changed as ordered to help prevent infection.A record review of the admission Record revealed the facility admitted Resident #11 on 11/24/25 with diagnoses including Malignant Neoplasm of Bladder and Weakness.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/26 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.A record review of the Order Summary Report revealed Resident #11 had a Physician's Order, dated 1/26/26, to Change out suprapubic catheter q (every) 30 days on 26th of the month.A record review of the Treatment Administration Record (TAR) dated 3/1/26 - 3/31/26 revealed there was no documentation indicating Resident #11's suprapubic catheter was changed on 3/26/26.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure necessary care and services were provided to promote healing and prevent complications of a non-pressure wound, including failure to complete wound treatments as ordered and ensure accurate documentation of care for one (1) of two (2) residents reviewed for wounds, Resident #3. Findings include:A review of the facility's Skin Care Guideline, dated July 2018, revealed, Purpose: To provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruptions in skin integrity .A review of the facility's Standards of Practice, undated, revealed, Core Principles of Documentation Purpose: Facilitates interdisciplinary communications, provides a legal record of care.The 'Golden Rule': If it is not documented, it is considered not done.Best Practices Timeliness: Document as soon after the event as possible to avoid losing details.Legal Protections: Documentation acts as a key defense, ensuring care is aligned with established standards.On 4/13/26 at 12:15 PM, during an interview, Resident #3 reported he had diabetic wounds to his leg and foot and that dressings were scheduled to be changed daily. He reported the treatments had not been completed on several occasions. During the same observation, Resident #3 had a dressing and boot in place to the lower right leg.On 4/16/26 at 10:20 AM, during an interview, Licensed Practical Nurse (LPN) #2 reported she worked at the facility and at the wound clinic where Resident #3 received care. She explained she worked twelve (12)-hour shifts on weekends and occasionally worked evening shifts at the facility. She reported Resident #3 preferred for her to complete his wound treatments and she would provide the treatment even when not assigned to the resident. She acknowledged she did not document care on those occasions. She explained for multiple dates in March 2026 she could not recall with certainty whether treatments were completed due to lack of documentation. She reported she was not assigned to Resident #3 on 3/4/26 during the 5:30 PM to 11:00 PM shift and was unsure if treatment was completed. She reported on 3/14/26 she may have completed the treatment but would have reported it to the assigned nurse as she was not working on that hall. She reported on 3/15/26 she worked in the memory care unit and did not leave that area and did not complete the treatment. She reported she did not work on 3/25/26 or 3/27/26. She reported on 3/23/26 and 3/30/26 during the 7:00 PM to 11:00 PM shift she likely completed the treatment prior to the resident's wound clinic appointments. She acknowledged without documentation she could not confirm when care was provided. She confirmed accurate documentation was a standard of nursing practice and she had been in-serviced on completing and documenting treatments but failed to do so.On 4/16/26 at 11:15 AM, during an interview, the Director of Nursing (DON) confirmed if care was not documented it was not considered completed. He acknowledged some missed documentation could reflect documentation issues rather than omitted care; however, he confirmed there were multiple dates where ordered treatments were not completed. He explained failure to complete wound care as ordered could lead to worsening of the wounds. He confirmed staff were expected to complete ordered treatments and accurately document care and acknowledged the facility failed to follow these standards for Resident #3.A record review of the Order Review revealed Resident #3 had Physician's Orders, dated 2/25/26, for Dakins solution to the right heel wound topically every day shift for wound infection and for the right heel to be packed moist-to-dry with one-quarter (1/4) strength Dakins solution daily and as needed. A record review also revealed a Physician's Order, dated 3/5/26, to the right lateral lower leg to be cleaned with one-quarter (1/4) strength Dakins solution every day shift for cellulitis wound. A record review further revealed a Physician's Order, dated 2/25/26 and discontinued on 3/5/26, for treatment to the right posterior lower leg every Monday, Wednesday, and Friday.A record review of the Treatment Administration Record (TAR) for March 2026 revealed Resident #3 had a Physician's Order, dated 2/25/26, for Dakins solution to the right heel wound topically every day shift for wound infection. There was no documentation the treatment was performed on 3/4/26, 3/14/26, 3/15/26, 3/23/26, 3/25/26, 3/27/26, or 3/30/26 for a total of seven (7) missed treatments. A record review also revealed a Physician's Order, dated 2/25/26, for the right heel to be packed moist-to-dry with one-quarter (1/4) strength Dakins solution daily and as needed. There was no documentation the treatment was performed on 3/4/26, 3/14/26, 3/15/26, 3/23/26, 3/25/26, 3/27/26, or 3/30/26 for a total of seven (7) missed treatments. A record review further revealed a Physician's Order, dated 3/5/26, to the right lateral lower leg to be cleaned with one-quarter (1/4) strength Dakins solution every day shift for cellulitis wound. There was no documentation the treatment was completed on 3/14/26, 3/15/26, 3/23/26, 3/25/26, 3/27/26, or 3/30/26 for a total of six (6) missed treatments. A record review also revealed a Physician's Order, dated 2/25/26 and discontinued on 3/5/26, for treatment to the right posterior lower leg every Monday, Wednesday, and Friday. There was no documentation indicating the treatment was performed on 3/4/26 for a total of one (1) missed treatment.A record review of the Treatment Administration Record (TAR) for April 2026 revealed Resident #3 had a Physician's Order, dated 2/25/26, for the right heel to be packed moist-to-dry with one-quarter (1/4) strength Dakins solution daily and as needed. There was no documentation the treatment was performed on 4/9/26 for a total of one (1) missed treatment.A record review of the admission Record revealed the facility admitted Resident #3 on 12/26/25 with diagnoses including Cellulitis of Right Lower Limb, Acute Osteomyelitis of Right Ankle and Foot, and Type 2 Diabetes Mellitus.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/2/26 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) services resulting in unmet care needs for two (2) of 4 residents reviewed for ADL care, Resident #108 and Resident #102. Findings include: Review of the facility's policy titled ADL's, dated August 2021, revealed, .Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. Resident #108 On 4/13/26 at 11:40 AM and 4/14/26 at 9:00 AM, during observations and interviews, Resident #108 stated he preferred his fingernails to be kept short and he wanted them trimmed. His fingernails were noted to be long (approximately 3/4 inch from the tip of nailbed) and jagged with a brown substance under each nail. During an interview on 4/14/26 at 12:20 PM, the Director of Nursing (DON) acknowledged he observed Resident #108's fingernails and confirmed they were long, jagged, and dirty. He revealed it was his expectation that each resident received the activity of daily living (ADL) care which included nail care daily and as needed to maintain nails at a length that was safe and preferred by the resident. He confirmed the facility failed to provide nail care for a dependent resident. Record review of the admission Record revealed the facility originally admitted Resident #108 on 1/20/25 with the most recent admission date of 10/9/25. Diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date of 1/15/26, revealed Resident #108 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated he was cognitively intact. Resident #102 On 4/14/26 at 8:30 AM, during an observation and interview, Resident #102 was lying in bed and reported she was unable to get up without assistance and had requested a bedpan at approximately 8:00 AM. She reported staff had not returned and that she was told assistance would be provided after meal trays were passed. She indicated her breakfast tray had been delivered and removed, and she had still not received assistance. She reported feeling uncomfortable with a full bladder. On 4/14/26 at 8:34 AM, during an observation, Resident #102 activated the call light. At 8:42 AM, Certified Nursing Assistant (CNA) #1 entered the room and exited without providing toileting assistance. On 4/14/26 at 8:44 AM, during an interview, Resident #102 explained CNA #1 told her she would return with a bedpan. On 4/14/26 at 9:04 AM, during interview, CNA #1 was in the hallway and reported she was going to assist Resident #102. This occurred approximately one (1) hour and four (4) minutes after the initial request for toileting assistance. On 4/14/26 at 9:06 AM, during an interview, Registered Nurse (RN) #3 explained that when a resident requests assistance, including toileting during meal tray pass, CNAs are expected to stop and assist the resident while other staff continue tray distribution. RN #3 confirmed delayed toileting could result in the resident holding urine, increasing the risk for urinary retention and urinary tract infection. On 4/14/26 at 9:15 AM, during an interview, the DON explained CNA #1 should have stopped and assisted Resident #102 at the time of request. He confirmed delaying toileting could result in incontinence, urinary retention, and increased infection risk, and emphasized the importance of meeting needs promptly, especially for a new resident. On 4/14/26 at 2:30 PM, during an interview, the Assistant Director of Nursing (ADON) confirmed awareness of the incident and reported CNA #1 should have delegated tray passing or notified the nurse if unable to assist immediately. The ADON explained the delay in toileting could lead to urinary retention, infection, or attempts to self-transfer, increasing fall risk. A record review of the admission Record revealed the facility admitted Resident #102 on 1/27/22, with a most recent admission date of 3/31/26, and she had diagnoses including Cerebral Infarction. A record review of the Quarterly MDS with an ARD of 4/7/26 revealed Resident #102 had a BIMS score of fourteen (14), which indicated she was cognitively intact. A review of Section GG revealed she required partial to moderate assistance for toilet transfers and substantial to maximal assistance with toileting hygiene.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to a safe, clean, and homelike environment for one (1) of twenty-three (23) sampled residents, Resident #124.Findings include:A review of the facility's Residents' Rights and Quality of Life Policy, dated 3/13/2020, revealed, .It is the policy of (Proper Name of Facility) that all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center.Procedure.to receive services in a center environment that is safe, clean, and comfortable.On 4/13/26 at 11:31 AM, during an observation, Resident #124's wall behind the headboard of her bed had a large area of missing paint measuring approximately four (4) feet by four (4) feet. In some areas, the top layer of sheetrock was visible.On 4/15/26 at 8:50 AM, during an observation and interview, the Maintenance Supervisor reported the damaged wall behind Resident #124's bed was an ongoing issue. He explained staff and family had been educated not to push the bed against the wall; however, the condition continued to occur. He reported staff completed daily rounds to identify maintenance concerns, but this issue had not been reported. He confirmed the condition did not provide a home-like environment and should have already been corrected.A record review of the Work Orders from 2/18/26 through 4/15/26 revealed there were no work orders to repair Resident #124's wall.On 4/16/26 at 11:27 AM, during an interview, the Administrator confirmed residents were expected to live in a home-like environment and that a large area of missing paint on the wall did not meet that expectation and should have already been corrected.A record review of the admission Record revealed the facility admitted Resident #124 on 2/14/24 with diagnoses including Moderate Protein-Calorie Malnutrition.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/31/26 revealed Resident #124 had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident's cognition was moderately impaired.

Based on resident and staff interviews facility policy review, and record review, the facility failed to protect the resident's right to be treated with dignity and respect for one (1) of ten (10) residents sampled. Resident #1 Findings include:Resident #1Record review of facility policy titled, Your Resident Rights and Protections Under State and Federal Law dated 2022, revealed, A nursing home must care for you in a manner and environment that promotes the maintenance and enhancement of your quality of life. Dignity and Respect. You have the right to be treated with consideration and respect in full recognition of your dignity and individuality.During an interview on 2/4/26 at 12:00 PM, Resident #1 stated she had a staff member to be rude and disrespectful to her. She stated that person was always rushing and did not perform her care in a gentle manner. Attempted to contact Certified Nursing Assistant (CNA) #1 by phone on 2/5/26 at 11:15 AM, 11:29 AM and 3:50 PM. Message left, but call was not returned. During interviews on 2/5/26 at 10:30 AM and 2:20 PM, the Administrator revealed CNA #1 did not provide gentle care and was rude and disrespectful to Resident #1. She acknowledged that each resident had the right to be treated with dignity and respect and this was not honored for this resident. She confirmed the facility failed to honor Resident #1's right to be treated with dignity and respect. Record review of Customer Concern Log for Resident #1 dated 12/17/25, revealed, Resident reports CNA is 'too rough' and has a bad attitude. Record review of Customer Concern/Grievance Communication Form dated 12/17/25, revealed Resident #1 submitted a grievance. Summary Statement of the resident or family member concern: CNA is too rough with me. I always use good manners and say please and thank you, but she has a bad attitude and doesn't stop. Record review of CNA #1's Progressive Discipline Form, dated 12/16/25, revealed Continued poor work quality/productivity as evidenced by repeated concerns voices via both staff and residents that have been previously addressed and continue.Record review of Certified Nursing Assistant #1's Progressive Discipline Form, dated 12/18/25, revealed, On 12/16/25 it was reported to center leadership by coworkers and resident's family members concerns around continued poor work performance including but not limited to not getting patients out of bed timely, being too rough with handling of patients while providing care, and not being on the hallway at assigned times. After investigating the incidents reported on 12/16/25, the decision has been made to terminate your employment with (proper name of facility) effective 12/18/25. Record review of CNA #1's User Learning revealed Abuse, Neglect, and Exploitation training and Compliance Training was completed on 8/31/25.Record review of Team Member Orientation Guide Receipt and Acknowledgment Form dated 6/25/24 revealed training on Patient/Resident Rights was completed. Record review of admission Record revealed the facility admitted Resident #1 on 7/27/23, with diagnoses that included Cerebral Infarction.Record review of Resident #1's Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated a moderate cognitive impairment.

Based on staff interviews and record review, the facility failed to ensure that newly hired licensed nurses and certified nurse assistants (CNAs) received skills competency checkoffs before providing resident care for three (3) of three (3) new hires reviewed. Findings include: Review of a form presented by the Administrator titled, “We Are Knowledgeable and Competent,” revealed the expectation that new hire licensed practical charge nurses (LPN) complete a three-week skills checkoff process, to be signed by both the Administrator and the LPN charge nurse upon successful completion. On 8/21/25 at 8:48 AM during a phone interview conducted as part of the complaint investigation, Graduate Practical Nurse (GPN) # 1 stated she had graduated nursing school and began employment at the facility on 7/15/25. She reported that no staff had checked her off on any skills and she had not been provided with a skills checkoff form. She explained that she had not been assigned a specific preceptor and stated, “If I had questions, I just asked whoever was around.” She further reported she felt overwhelmed with charting, admission paperwork, and incident reporting because the staff she shadowed during her first days of employment had not reviewed these processes with her. On 8/21/25 at 11:16 AM during an interview conducted as part of the complaint investigation, the Clinical Educator (CE) confirmed she was on vacation when GPN #1 began employment on 7/15/25. The CE stated that when she returned on 7/18/25, GPN #1 was on the medication cart by herself and each time she passed her in the hall, she was alone. She confirmed she had not performed any skills checkoffs with GPN #1 and was unsure if the former Director of Nursing (DON) had. She further stated, “She should not have been on the medication cart alone. She could have hurt someone.” After reviewing the skills checkoff forms for Certified Nurse Assistant (CNA) #2 and CNA #3, the CE confirmed the forms were not signed by staff or trainers and she could not verify that the competencies had been completed. The CE explained it was very difficult to complete her educator responsibilities because she was frequently pulled to work the medication cart. She reported she had been in the educator role since March 2025 and had never obtained completed new hire skills checkoffs. She also stated she only learned of the “We Are Knowledgeable and Competent” LPN skills checkoff form one week prior during a meeting. Review of the “Z Slider Lift Skills Checklist” for CNA #2, dated 7/15/25, revealed the form was not signed as completed. The “Peri-Care Audit Tool” was not signed or dated by CNA #2, and the “Shaving, Nail, and Foot Care Audits” were checked as skills met but contained no staff or trainer name. Review of the “Z Slider Lift Skills Checklist” for CNA #3, dated 7/29/25, revealed the form was not signed as completed and no staff name was identified. The “Peri-Care Audit Tool” was not signed or dated by CNA #3, and the “Shaving, Nail, and Foot Care Audits” were checked as skills met but contained no staff or trainer name. On 8/21/25 at 12:00 PM during an interview, the Administrator stated the previous DON would have started GPN #1 on 7/15/25. She confirmed the facility was unable to locate any skills review forms for GPN #1. The Administrator acknowledged that all new hires should have skills checkoffs to ensure they are competent in their skills, and that failing to do so could result in residents not receiving care or receiving the wrong care.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that a resident was free from verbal abuse when one (1) of seven (7) residents reviewed for abuse was subjected to verbal threats by a staff member. (Resident #1) Findings include: Review of the facility policy titled, “Abuse, Neglect, Misappropriation, Exploitation Policy,” dated January 2019, revealed the purpose: “To prohibit and prevent abuse . in accordance with Federal and State laws.” The policy defined verbal abuse as: “May be considered a form of mental abuse. Verbal abuse includes written or gestured communication, or sounds to residents within hearing distance, regardless of age, ability to comprehend, or disability.” The policy further defined mental abuse as: “The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .” Resident #1 Record review of a facility-reported investigation dated 6/8/25 at 7:00 PM related to allegations of threats revealed Resident #1 reported that Certified Nurse Assistant (CNA) #1 had taken the smokers out and shut the door in front of him. Resident #1 stated that when he reached the smoking area, he and CNA #1 exchanged words, and she told him she would slap him. He reported that when he replied she should not do that, she asked what he would do about it. He stated he told her he would call the police, and CNA #1 then stated she would put him in the morgue. Resident #1 also reported that he kept accusing her of slamming the door until she became angry and admitted she saw him before closing it. On 8/20/25 at 12:12 PM during an interview, Resident #1 recalled the incident in June. He stated CNA #1 knew he was behind her and slammed the door in his face. He reported he knocked on the door, but CNA #1 would not answer, and he had to ask someone else to open it. Resident #1 stated that when he confronted CNA #1 about shutting the door, she denied it, became upset, and they argued and cursed each other. Resident #1 confirmed that CNA #1 told him she would slap him, and when he threatened to call the police, she stated she would put him in the morgue. Review of the “admission Record” revealed Resident #1 was admitted on [DATE] with a diagnosis of abnormalities of gait and mobility. Review of the Quarterly Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 8/4/25 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident# 6 Record review of an interview with Resident #6 conducted as part of the facility’s investigation revealed he heard CNA #1 threaten to slap Resident #1 and say she would put him in the morgue. He stated Resident #1 accused CNA #1 of slamming the door in his face. At first, CNA #1 denied it, but later admitted it. On 8/21/25 at 11:00 AM during an observation and interview, Resident #6 confirmed he heard CNA #1 threaten to slap Resident #1 and said she would put him in the morgue. He reported Resident #1 accused her of slamming the door in his face and that the two argued and cursed at each other. Record review of the “admission Record” revealed Resident #6 was admitted on [DATE] with a diagnosis of centrilobular emphysema. Record review of the Quarterly MDS for Resident #6 with an ARD of 7/28/25, Section C, revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #7 Record review of an interview with Resident #7 conducted as part of the facility’s investigation revealed, “I heard an argument between Resident #1 and CNA #1. I heard Resident #1 say CNA #1 let the door close in front of him before he could get to it. She got upset and they argued.” Record review of the “admission Record” revealed Resident #7 was admitted on [DATE] with a diagnosis of major depressive disorder. Record review of the Quarterly MDS for Resident #7 with an ARD of 6/3/25, Section C, revealed a BIMS score of 14, indicating the resident was cognitively intact. On 8/21/25 at 8:25 AM during an interview, the Administrator confirmed she substantiated the allegation of verbal abuse because CNA #1 had received previous training on abuse prevention and the investigation determined that another cognitively intact resident corroborated hearing CNA #1 curse at Resident #1. The Administrator stated CNA #1 denied saying she would put the resident in the morgue but admitted she cursed at him after he cursed at her. The Administrator confirmed CNA #1 acted in an unprofessional manner and that this conduct constituted verbal abuse which could lead to fear or psychosocial harm. On 8/21/25 at 8:35 AM during a phone interview, CNA #1 denied cursing Resident #1 or saying she would put him in the morgue. She confirmed she had received training on the definition of verbal abuse and de-escalation of potentially abusive situations. She stated she did not know why residents were reporting she had said this, but acknowledged she knew cursing at a resident is considered verbal abuse. She again denied closing the door on Resident #1 and stated he continued to accuse her of doing so.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by: 1) not having procedures in place to monitor and test the water source for Legionella's Disease which had the potential to affect all residents in the facility; 2) storing of respiratory equipment on the floor for Resident #82, and 3) not using required Enhanced Barrier Precautions (EBP) Resident #11 and Resident #157 for three (3) of 23 sampled residents. Findings include: Record review of facility policy titled, Infection Control Guide, dated 2022, revealed, .In order to accomplish the primary goal of infection control, which includes preventing or reducing the risk of healthcare associated infections, an epidemiology plan needs to be designed to include the following oversight operations and responsibilities: . cleaning and disinfecting equipment . prevention of infections .Enhanced Barrier Precautions recommendations is to consider expanding the use of PPE (Personal Protective Equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug resistant organism) to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, from nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infections or colonization . Record review of facility policy titled, Policies and Practices - Infection Control, dated 11/1/17, revealed, This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of our infection control policies and practices are to: a. prevent, identify, detect, investigate, report and control infections in the center; b. maintain a safe, sanitary, and comfortable environment for team members, residents, volunteers, visitors, and the general public . Record review of facility policy titled, Legionnaires' Disease: Detection, Response, Prevention with revision date of 2/2/17, revealed, The Center will utilize sound clinical and infection control practices to quickly identify and treat any potential Legionnaires related illnesses. This water management program will consist of the following . decide where 'control measures' should be applied and set limits, such as, temperature levels, disinfectant levels, acceptable ranges, etc., establish ways to intervene when control limits are not met (corrective actions), verify that your program is running as designed and is effective, document and communicate all activities of your Water Management Program. During an interview with Maintenance #1 on 2/13/25 at 10:15 AM, he revealed that they changed shower heads in the facility monthly, flushed unused water sources, and flushed eye wash stations to prevent Legionella. He stated he did not keep logs on the measures he had in place, and he did not monitor them to ensure the measures used were effective. An interview with the Administrator on 2/13/25 at 10:30 AM revealed Legionella and other water borne illnesses were serious and could cause major health complications. She stated the water system should be checked and monitored to ensure the residents were safe from any potential illness and to ensure this and thinks the water should be tested to be certain the measures in place were effective. She confirmed that the facility failed to have documented monitoring of the preventative measures testing to ensure they maintain the water system safely. Resident #11 During an interview on 2/11/25 at 9:30 AM, Resident #11 stated she had a sore on her bottom and her feet and she was receiving treatment on them. An observation on 2/12/25 at 2:45 PM of wound care provided by Licensed Practical Nurse (LPN) #1 and assisted by Certified Nursing Assistant (CNA) #7 revealed revealed neither staff member donned a gown prior to beginning the care. During an interview on 2/12/25 at 2:47 PM with CNA #7 she stated she had been in-serviced on EBP but was nervous and forgot to put the gown on. LPN#1 revealed that this was his second day back after not working at the facility for over a year, and when he previously worked at the facility, EBP were not used. He stated he had been instructed on this new process, but did not have a good understanding of what was required. An interview with the Administrator on 2/12/25 at 2:55 PM, revealed EBP were required to reduce the spread of infection and should be used during care on a resident with a chronic wound. She confirmed the facility failed to use EBPs during wound care for this resident. During an interview on 2/12/25 at 3:15 PM, the Director of Nursing (DON) revealed EBP were required to reduce the likelihood of the spread of infection to a vulnerable resident with a wound. She confirmed the facility failed to ensure EBP was used as required for a resident receiving pressure wound care, which increased the risk of an infection to the resident. Record review of Resident #11's Admission Record revealed the facility admitted the resident on 4/28/21 with medical diagnoses that included Protein Calorie Malnutrition, Polyneuropathy, History of Falling, and Chronic Pain. Record review of Resident #11's Significant Change in Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) or 1/15/25 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. Resident #82 During the initial tour on 2/10/25 at 11:05 AM, Resident #82's respiratory treatment nebulizer was noted on the floor next to the resident's bed. The tubing and mask were in a bag on top of the nebulizer. The resident stated he had lung issues and received treatments several times a day. He stated that he had asked staff about this being on the floor, but nothing was done differently. An observation on 2/11/25 at 9:05 AM revealed the respiratory nebulizer on the floor by the resident's bed with tubing and mask lying on the floor next to nebulizer. During an observation and interview on 2/11/25 at 1:30 PM, Resident #82 stated he had been at a doctor's appointment and received breathing treatment and pain medicine when he returned. Observation of nebulizer, tubing, and mask still on floor by bed. During an observation in Resident #82's room and interview on 2/11/25 at 3:10 PM, the Director of Nursing (DON) verified that the resident's respiratory nebulizer, tubing, and mask were on the floor and was unacceptable. She stated this was a concern for infection control and the resident could breathe bacteria into his lungs and become sick. She confirmed the nebulizer should be off the floor and the tubing and mask should be stored in a bag to ensure they remained clean. She confirmed the facility failed to ensure a resident's respiratory equipment was clean and stored properly to assist in the prevention of a respiratory infection. Record review of Resident #82's Order Summary Report revealed an order dated 1/28/25 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg (milligrams)/3 ml (milliliters) inhale orally three times a day for COPD (Chronic Obstructive Pulmonary Disease). Record review of Resident #82's Admission Record revealed the facility most recently admitted the resident on 1/23/25 with medical diagnoses that included Wedge Compression Fracture of Fourth and Fifth Lumbar Vertebra, Malignant Neoplasm of Bronchus or Lung, Emphysema, and Chronic Obstructive Pulmonary Disease. Record review of Resident #82's admission MDS with an ARD of 1/30/25 revealed a BIMS of 12 which indicated the resident had a moderate cognitive impairment. Resident #157 During a medication administration observation for Resident #157 on 2/11/25 at 2:50 PM revealed, Registered Nurse (RN)#1 administered intravenous (IV) antibiotics via a Peripherally Inserted Central Catheter (PICC) to the right upper arm, with no observation of staff wearing a gown as part of EBP. A continued observation revealed no signage was visible to alert staff that the resident was on EBP. In an interview with RN #1 on 2/11/25 at 2:55 PM, she confirmed she forgot to wear a gown for EBP and confirmed she knew that EBP should have been used because the resident has a PICC line. She then revealed EBP is used for all residents with indwelling devices to add a layer of protection to reduce the risk of spreading infection. She also confirmed there was no signage on the door or in the residents' room alerting staff that EBP should be used. In an interview with CNA #1 on 2/11/25 at 3:00 PM, she confirmed she was assigned to Resident # 157 and then revealed she was not aware that the resident was on EBP. She confirmed she had not been using the precautions. She stated she knew the resident had a PICC line, but there was no sign on the door, so she did not think he was on any precautions. Record review of the Order Summary Report for Resident #157 revealed Cefazoline Fosamil 600 mg (milligrams) intravenously three times a day for septic discitis of the lumbar region until 3/10/25 with a start date of 2/5/25. In an interview with the Director of Nursing (DON) on 2/13/25 8:13 AM, she confirmed that RN #1 should have used EBP to protect the residents from increased risk of transfer of bacteria. She also confirmed that an EBP sign should have been on the door to alert staff that the resident was on EBP. Review of the Admission Record revealed the facility admitted Resident # 157 on 2/5/25 with a diagnosis that included Discitis of the Lumbar Region. Record review of Resident #157s Section C of the Admission MDS with an ARD of 2/12/25 revealed the BIMS score was 15, indicating the resident was cognitively intact. 47157

Based on observations, staff and resident interviews, record review, and facility policy review, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 10/19/23. This was for deficiencies re-cited during a recertification and complaint survey on 2/13/25. The re-cited deficiencies included F 584, F 656, F 677, F 684, F 761, and F 880. The continued failure of the facility during two state surveys indicates a pattern of the facility to sustain an effective QAPI program. This was for six (6) of 18 deficient practice citations. Findings Include: This citation is cross-referenced to: F 584, F 656, F 677, F 684, F 761, and F 880 Review of the facility policy titled Quality Assurance and Performance Improvement dated February 2017 revealed, Purpose: QAPI is a data driven, proactive approach to improving the quality of life, care, and services in our centers. The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor the effectiveness of our interventions. QAPI is consistent with our Services Standard: We continually strive to improve personal and company performance . During the recertification and complaint survey on 10/19/23 the facility was cited F 561, F 584, F 656, F 677, F 684, F 761, F 812, F 880. During the recertification and complaint survey on 2/13/25 the facility was cited F 550, F 576, F 584, F 604, F 623, F 641, F 655, F 656, F 677, F 684, F 698, F 755, F 758, F 761, F 806, F 867, and F 880. During an interview on 2/13/25 at 10:18 AM, the Administrator (ADM) revealed our EMBRACE rounds, which are checklist sheets assigned to all supervisory staff. She stated the goal of the program is to go out and catch the issues found and ensure they are corrected. She confirmed she feels like the staff finds deficient practices when they do the Embrace rounds, then stated, but the follow-up is not strong as it should be to ensure the problems are corrected. She also stated the facility had had a lot of turnover in staff including the Infection Control Nurse/ Educator resulting in the Embrace audits halting from November 2024 and restarted in January 2025. Furthermore, she revealed the facility recently hired a new Infection Control Nurse/ Educator on 2/11/25, and she hopes that that will help with addressing issues. During an interview with the Director of Nursing (DON) on 2/13/25 at 11:30 AM, she confirmed the facility had a lot of staff turnover the past few months, she then stated when the facility finds issues they audit and monitor the concerns for awhile, and then it just gets pushed to the side and there is no follow-up.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for three (3) of 23 residents reviewed for Activities of Daily Living (ADL) care. Resident #62, #74 and #253. Findings include: Review of the facility policy titled, ADL's (activities of daily living), dated August 2021, revealed, Policy: Ensure ADLs are provided in accordance with accepted standards of practice. ADLs-(hygiene-grooming) . Resident #62 An observation and interview on 2/11/25 at 11:00 AM, revealed Resident #62's fingernails to be approximately 1/2 (one-half) inch long past the tips of the fingers, dirty in appearance with a dark brown substance under the nail beds. Resident #62 stated he would like to have them trimmed and confirmed he did not like them long. An observation on 2/12/25 at 1:30 PM, with Certified Nurse Assistant (CNA)#3 confirmed that Resident #62's nails were very long and dirty with a dried dark brown substance under the nail beds. She stated it appeared that the resident had not had nail care in a very long time. In an interview with the Director of Nursing (DON) on 2/12/25 at 2:09 PM, she revealed that if the residents were not getting personal hygiene it could lead to the spread of bacteria and skin concerns. She confirmed that Resident #62's nails should have already been cleaned and trimmed. Review of the Admission Record revealed the facility admitted Resident #62 on 8/23/23 with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction. Record review of Resident #62's Section C of the Annual Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. Section: GG0130- I.) Personal hygiene-was coded setup or clean-up assistance. Resident #253 An observation on 2/10/25 at 10:10 AM, revealed Resident #253's fingernail beds to have a dark brown substance underneath them, and they were jagged in appearance. His facial hair was also observed to be unkept. An observation on 2/11/25 at 1:30 PM, revealed Resident# 253 to have a brown substance under his fingernail beds, and the fingernails remained jagged in appearance. An observation of Resident #253 on 2/11/25 at 1:53 PM, with CNA #2 confirmed the resident's nails were jagged and had a brown substance under the nail beds. In an interview with the Certified Occupational Therapist (COTA) on 2/11/25 at 1:55 PM, she stated that she has Resident #253 on caseload for upper body therapy and confirmed his fingernails were dirty last week and his facial hair was also unkept. In an interview with the DON on 2/11/25 at 2:05 PM, she confirmed that Resident #253 should have had nail care and that staff failing to provide personal hygiene care for any resident could lead to skin concerns and spread of bacteria. Review of the Admission Record revealed the facility admitted Resident # 253 on 1/29/25 with a diagnosis of Traumatic Subdural Hemorrhage. Record review of Resident #253's Section C of the Admission MDS dated [DATE] revealed the BIMS score was 9, indicating the resident was moderately cognitively impaired. Section: GG0130- I.) Personal hygiene-was coded partial/moderate assistance. Resident #74 An observation on 2/10/25 at 10:45 AM, revealed Resident #74 sitting in his wheelchair in the hallway with long gray hairs extending from both of his ears, approximately one-half (1/2) inch in length. His fingernails on both hands measured approximately one-fourth (1/4) inch in length and jagged with a brown substance underneath. An interview with the Memory Care Unit Coordinator on 2/10/25 at 1:29 PM, confirmed Resident #74 had long, jagged nails. She revealed the aides were responsible for cutting, cleaning, and filling them with showers. She revealed the resident could scratch himself and cause a skin injury. She stated the barber was responsible for trimming the resident's ear hair and explained he trimmed it when he had time but had not been there recently. Record review revealed the facility admitted Resident #74 on 11/30/23 with a medical diagnosis that included Cerebral Infarction. 47874

Based on observation, resident and staff interviews, and facility policy review, the facility failed to provide a safe, clean environment as evidenced by an unsanitary toilet in room C-7, resident wheelchair (Resident #60), overbed tables, and wall in disrepair affecting three (3) residents in the seventy-three resident occupied rooms observed. Resident #48, Resident #60 and Resident #99 Findings Include: Review of the facility policy titled, Resident Rights and Quality of Life Policy, dated 3/13/20, revealed, A patient or resident has the right: . to receive services in a center environment that is safe, clean, and comfortable . Review of the facility policy titled, Resident/Patient Room Cleaning, last reviewed 2/1/2025, revealed Policy: Room Cleaning: Rooms are to be regularly cleaned and disinfected with a particular focus on disinfecting high-touch surfaces such as light switches, bed rails, doorknobs, call lights, etc. Nursing staff provides the initial cleanup of blood and bodily fluids . Environmental services staff follow by disinfecting surfaces contaminated with a small, residual amount of feces, blood, or other bodily fluids . Resident #48 An observation on 2/10/25 at 11:45 AM, revealed two (2) overbed tables in Resident #48's room. One overbed table was situated to the left of the bed, and the other overbed table was situated to the right of the bed. Both overbed tables had a thick red and black rust like appearance to the metal base of the overbed tables. The edges of both overbed tables were tattered and torn with edging missing. During an observation and interview on 2/11/25 at 3:30 PM, the Director of Nursing (DON) confirmed both overbed tables in Resident #48's room had thick rust on the metal frames, and the tabletops had torn and jagged edging and needed to be replaced. She stated, These certainly need to be replaced. A record review of Resident #48's Admission Record revealed the facility admitted the resident on 4/19/2019 with diagnoses that included Unspecified Dementia, Peripheral Vascular Disease, Contracture of the Right Hand, and Contracture of the Left Hand. Resident #60 An observation and interview on 2/10/25 at 10:45 AM, revealed Resident #60 sitting in a wheelchair with the left armrest vinyl tattered and torn. Resident #60 revealed that she has been in this wheelchair for three weeks, and the armrest was torn when they gave it to her. A dark-gray thick substance was noted on the frame and the spokes of the wheels. During an interview on 2/11/25 at 3:10 PM, Certified Nursing Assistant (CNA) #5 revealed the night shift CNAs are responsible for cleaning the wheelchairs. She revealed that we let the Maintenance Director know about any equipment or furniture in a resident's room that needs to be replaced or repaired and admitted that she had not told anyone about the wheelchair armrest. During an interview and observation on 2/11/25 at 3:20 PM, the DON confirmed that Resident #60's wheelchair armrest was torn and tattered and could cause a skin tear. She revealed that the night shift staff is responsible for ensuring that the wheelchairs are clean and confirmed that the wheelchair had a gray substance on the frame and needed to be cleaned. Record review of Resident #60's Admission Record revealed the facility admitted the resident on 6/28/2023. Record review of Resident #60's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/27/24, revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. C-7 Bathroom An observation 2/10/25 at 10:45 AM, of the bathroom in room C-7 revealed a raised toilet seat that had a large dark brown dried substance on the back of the toilet seat rim, and a smeared dark brown substance was also on the metal bar at the top of the back of the raised toilet seat. An observation of the bathroom of room C-7 with CNA #3 on 2/11/25 at 1:25 PM, she confirmed there was a large dried dark brown substance on the back of the toilet seat rim and a smeared dark brown substance on the metal bar at the top of the back of the raised toilet seat that appeared to be stool. She stated concerns about the toilet not being clean is that it is not sanitary and could lead to the spread of infection. She then stated the nursing staff are responsible for cleaning the toilets or any equipment or surface that is contaminated with bodily secretions. An interview with the DON on 2/11/25 at 2:05 PM, she confirmed that nursing staff are responsible for cleaning equipment that is soiled with bodily fluids. She stated concerns from not sanitizing the toilet is an infection control concern and sanitation issue and could lead to infections. In an interview with Housekeeper #2 on 2/12/25 at 2:00 PM, she revealed housekeeping should notify their supervisor and nursing staff if they find a room that has surfaces or equipment soiled with bodily fluids. She then stated that the housekeeping staff clean the contaminated surfaces after nursing has cleaned the surfaces. Resident #99 During the initial tour on 2/10/25 at 11:40 AM, an observation revealed a large section of paint, measuring approximately two feet wide by one and a half feet high, missing from the wall behind Resident #99's headboard. The resident's overbed table was observed to have rust on the entire metal frame. During an interview, Resident #99 stated he would like to have the paint repaired and the table replaced. During an observation of Resident #99's room with the DON and interview on 2/11/25 at 3:25 PM, the DON confirmed the wall needed repair. She stated the maintenance department is responsible for the repair of damaged walls and it was the staff's responsibility to report these concerns so they could be addressed. She stated it was also the staff's responsibility to ensure the residents' equipment was in good repair, and this overbed table did not meet that standard. She confirmed each resident should have a room that is clean, comfortable and homelike and the facility failed to provide this for Resident #99. An interview on 2/12/25 at 8:50 AM, with the Administrator confirmed that the maintenance staff was responsible for painting and repairing damage. She stated the paint concern had been noted on the room rounds previously but had not been repaired. She confirmed each resident has the right to a safe, comfortable, home-like environment and the facility failed to provide this for Resident #99. Record review of Resident #99's Admission Record revealed the facility admitted the resident on 1/23/25 with medical diagnoses that included Traumatic Subdural Hemorrhage, Dysphagia, and Epilepsy. Record review of Resident #99's Admission MDS with an ARD of 1/30/25 revealed a Brief Interview for BIMS score of 9 which indicated the resident had a moderate cognitive impairment. 47157 41878

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for residents with personal hygiene needs (Resident #62, #74, #253), taking an antiplatelet medication (Resident #25), storage of respiratory equipment (Resident #82), and failed to implement a care plan for a resident on Enhanced Barrier Precautions (EBP) (Resident #11), Thromboembolic Deterrent (TED) (Resident #253), and receiving dialysis (Resident #8) for six (6) of 23 sampled residents. Residents #8, #11, #62, #74, #82, and #253 Findings Include Record review of facility policy titled, Care Plans with effective date of October 2021, revealed, Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #8 A record review of Resident #8's care plan revealed the resident has an alteration in Kidney Function, evidenced by now requiring Hemodialysis. Interventions include obtaining pre- and post-dialysis vital signs every day and a written communication form with a review of weights and any changes in condition between the dialysis provider and center. A record review of Resident #8's Admission Record revealed the facility admitted the resident on 07/25/2012 with medical diagnoses of Chronic Kidney Disease, Stage 5, and Dependence on Renal Dialysis. A record review of Resident #8's Order Review History Report for 01/01/2025-01/31/2025 revealed a physician order for dialysis at the proper name dialysis center on Monday, Wednesday and Friday .Obtain pre- and post-dialysis vital signs one time a day every Monday Wednesday and Friday. An interview with Resident #8 on 2/11/25 at 8:54 AM confirmed that she is on dialysis and goes to the dialysis center on Monday, Wednesday, and Friday. She stated that don't always check her vital signs before and after. In an interview on 2/13/25 at 8:35 AM, the Director of Nurses (DON) confirmed she could not find any vital sign documentation for Resident #8's dialysis communication for January. She revealed that those records would have been sent with the resident on her dialysis appointments and returned afterward. The communication records were to have vital signs and pertinent information for Resident #8, and because the communication records were not being done, the resident's dialysis care plan was not followed. An interview on 2/13/25 at 9:10 AM with Licensed Practical Nurse (LPN) Medical Records confirmed that the last communication record sent to the dialysis was on 12/11/24. A record review of the Dialysis Communication Record dated 12/11/2024 revealed a completed communication record between the facility and the dialysis center with nurse signatures. This review revealed there were no complete communication records for 01/2025. Record review of the MDS Section C with an Assessment Reference Date (ARD) of 1/13/25 revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. Resident #11 Record review of Resident #11's care plan revealed a care plan for a pressure ulcer on left heel with intervention to administer treatments as ordered. Another care plan for stage one pressure wound to right heel with intervention for treatments as ordered. Resident had a care plan for an unstageable pressure ulcer to the sacrum with an intervention to administer treatments as ordered. Another care plan was for an infection related to wound infection with intervention administer antibiotics and treatment as ordered. An observation of Resident #11's pressure wound care completed by Licensed Practical Nurse (LPN) #1 and assisted by CNA #7 on 2/12/25 at 2:45 PM, revealed EBP was not followed when gowns were not worn during all of the wound care. An interview on 2/12/25 at 3:15 PM with the Director of Nursing (DON) revealed the care plan was developed and specified administer treatments as ordered for wound care. She stated enhanced barrier precautions (EBP) was part of the wound care guidelines and it was not listed as a separate intervention since it was included as an expected step in the wound care process. She confirmed that since enhanced barrier precautions were not properly used, the care plan for treatments as ordered was not followed. During an interview on 2/13/25 at 9:30 AM, MDS Coordinator #2 revealed this resident had a wound care plan developed to administer treatments as ordered and this automatically included the use of EBP. She stated the care plan was not followed as required. Record review of Resident #11's Admission Record revealed the facility admitted the resident on 4/28/21. Diagnoses included Protein Calorie Malnutrition and Polyneuropathy. Record review of Resident #11's Significant Change in Status MDS with ARD of 1/15/25 revealed a BIMS score of 9 which indicated the resident had a moderate impairment cognitively. Resident #62 Review of a care plan for Resident #62 titled, Nursing Kardex, revealed no interventions related to personal hygiene. On 2/11/25 at 1:30 PM, observation with Certified Nurse Assistant (CNA)#3 revealed that Resident #62's nails were long with a dark brown substance under them. She confirmed the residents nails needed clipping and cleaning. On 2/11/25 at 2:09 PM, in an interview with the DON she revealed after review of the Kardex care plan for Resident #62 that there was not a care plan developed regarding personal hygiene. In an interview with MDS Nurse on 2/12/25 at 2:40 PM, she revealed the purpose of the care plan is to let the staff know the type of care and services the resident requires and confirmed that the care plan is not thoroughly developed, the resident may not get the services they need. Review of the Admission Record revealed the facility admitted Resident #62 on 8/23/23 with a diagnosis of Hemiplegia and Hemiparesis following a Cerebral Infarction. Record review of Resident #62's Section C of the MDS dated [DATE] revealed the BIMS score was 13, indicating the resident was cognitively intact. Section: GG0130- I.) Personal hygiene-was coded setup or clean-up assistance. Resident #253 Review of a care plan for Resident #253 titled, Nursing Kardex, initiated on 1/31/25, revealed, Interventions: TED hose - apply every am (morning) and remove every pm (night) due to orthostatic blood pressures. Record review of a physician's order dated 1/30/25 for Resident #253 revealed, TED- (thromboembolic deterrent) hose - apply every am (morning) and remove every pm (night) due to orthostatic blood pressure. On 2/11/25 at 2:05 PM, during an interview with the DON she confirmed after review of the care plan related to the use of the TED hose for Resident #253 the care plan was not being implemented when staff did not apply the hose as ordered. In an observation with LPN #3 on 2/11/25 at 2:10 PM, of Resident # 253 she confirmed the resident was not wearing TED hose. An interview Physical Therapy Assistant (PTA) on 2/12/25 at 2:08 PM she revealed she has seen Resident # 253 several times over the past two weeks for physical therapy of the lower body and confirmed she had not seen the resident wearing TED hose until today. In an interview with the MDS Nurse on 2/12/25 at 2:40 PM, she revealed the purpose of the care plan is to let the staff know of the type of care and services the residents requires. Review of the Admission Record revealed the facility admitted Resident # 253 on 1/29/25 with a diagnosis of Traumatic Subdural Hemorrhage. Record review of Resident #253's Section C of the MDS dated [DATE] revealed the BIMS score was 9, indicating the resident was severely cognitively impaired. Section: GG0130- H.) putting on/taking off socks and shoes was coded as dependent (helper does all the effort). Resident #74 Record review of Resident #74's Care Plans revealed a care plan for Activities of Daily Living (ADL's) was not developed. On 2/10/25 at 10:45 AM, an observation revealed Resident #74 had visible gray hairs extending from both ears that were approximately one-half (1/2) inch in length. This observation also revealed the resident's fingernails were approximately one-fourth (1/4) inch in length, jagged and had a brown substance under the nail beds. On 2/10/25 at 1:29 PM, an interview with the Memory Care Unit Coordinator confirmed Resident #74 needed his nails trimmed and cleaned and had long ear hair. An interview with the MDS Nurse on 2/12/25 at 9:20 AM, confirmed Resident #74 did not have an ADL care plan. She revealed the purpose of having the care plan was so that staff knew how to care for the residents. Record review of the Admission Record revealed the facility admitted Resident #74 on 11/30/23 with a medical diagnosis that included Cerebral Infarction. Resident #82 Record review of Resident #82's care plan revealed a care plan for storage of respiratory equipment was not developed for the staff to follow. On 2/10/25 at 11:05 AM, during the initial tour Resident #82's respiratory treatment nebulizer was observed on the floor next to the resident's bed. The tubing and mask were in a bag on top of the nebulizer. The resident stated he had lung issues and received treatments several times a day. An interview with the Director of Nursing (DON) on 2/11/25 at 3:10 PM, revealed a care plan provided staff with information on the daily care and preferences for each resident. She confirmed the facility failed to develop a care plan for proper storage of respiratory equipment. During an interview on 2/12/25 at 9:10 AM, Minimum Data Set (MDS) Coordinator #1 revealed a care plan guides the needed care and preferences for each resident and she was responsible for developing the care plans. She confirmed the facility failed to develop a care plan for the proper storage of Resident #82's respiratory nebulizer equipment. Record review of Resident #82's Admission Record revealed the facility most recently admitted the resident on 1/23/25 with medical diagnoses that included Wedge Compression Fracture of Fourth and Fifth Lumbar Vertebra, Malignant Neoplasm of Bronchus or Lung, Emphysema, and Chronic Obstructive Pulmonary Disease. Record review of Resident #82's admission MDS with an ARD of 1/30/25 revealed a BIMS of 12 which indicated the resident had a moderate cognitive impairment. 41878 47157 47874

Based staff interview, record review, and facility policy review the facility failed to store controlled drugs in a locked permanently affixed compartment for storage as evidenced by an unopened box of Lorazepam Concentrate 30 milliliters sitting on a shelf in the refrigerator among other non-narcotic medications for one (1) of three (3) narcotics refrigerator storage observed. Findings include: Review of the facility policy titled, Medication Storage, last reviewed 4/23, revealed, .Procedure .Controlled medications---stored in a separately locked, permanently affixed compartment designated for that purpose . An observation of the A hall medication room refrigerator narcotic box with Licensed Practical Nurse (LPN) #1 on 2/12/25 at 8:35 AM, revealed an unopened box of Lorazepam Concentrate 30 milliliters sitting on a shelf in the refrigerator among other non-narcotic medications not in a secure affixed box. LPN #1 confirmed the Lorazepam was not stored appropriately and should have been in the secured lock box in the refrigerator. In an interview with the Director of Nursing (DON) on 2/13/25 at 8:00 AM, she confirmed the Lorazepam Concentrate that was stored unsecured should have been in the affixed lock box in the refrigerator. She stated the secure lock box was full, and she believed that is why it was just placed on the refrigerator shelf. She then stated staff should have informed her of the problem. Furthermore, she also revealed that improper storage of narcotics could lead to missing narcotics and possible diversion.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for treating skin concerns (Resident #303) and application of TED (thromboembolic deterrent) compression hose for two (2) of 23 sampled residents. Resident #253 and #303 Findings include: Review of the facility policy titled Skin Care Guideline unrevised, revealed under, Purpose: To provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. A review of a statement on facility letterhead titled, Standards of Practice, revealed, The expectation set forth by (Proper Name) management is that nurses comply with current standards of practice in terms of following physician's orders. This includes following orders for application of medical devices such as TED hose. Resident #253 Record review of a physician's order dated 1/30/25 for Resident #253 revealed, TED hose - apply every am (morning) and remove every pm (night) due to orthostatic blood pressures. An observation on 2/10/25 at 10:10 AM, revealed Resident #253 lying in the bed with regular socks on his feet. An observation on 2/11/25 at 1:30 PM revealed no TED hose on Resident #253's legs and none in the resident's room. An observation of Resident # 253 on 2/11/25 at 1:53 PM with Certified Nurse Assistant (CNA) #2 revealed she was unaware of any TED hose and had not seen them on the resident. In an observation and interview with Licensed Practical Nurse (LPN) #3 on 2/11/25 at 2:10 PM, she revealed after review of Resident # 253's physician's orders, she confirmed the resident had an order for TED hose. An observation of Resident # 253 at this time with LPN #3 she confirmed the resident was not wearing TED hose and that if the resident did not wear the hose as ordered it could lead to increased episodes of orthostatic hypotension. An interview Physical Therapy Assistant (PTA) on 2/12/25 at 2:08 PM she revealed she has seen Resident # 253 several times over the past two weeks for physical therapy of the lower body and confirmed she had not seen the resident wearing TED hose until today. Review of the Admission Record revealed the facility admitted Resident # 253 on 1/29/25 with a diagnosis of Traumatic Subdural Hemorrhage. Record review of Resident #253's Section C of the MDS dated [DATE] revealed the BIMS score was 9, indicating the resident was moderately cognitively impaired. Section: GG0130- H.) putting on/taking off socks and shoes was coded as dependent (helper does all the effort). Resident #303 An observation on 2/10/25 at 10:50 AM, revealed Resident #303 sitting in a recliner in the activity room. Two beige foam dressings observed on his left elbow with a moderate amount of brown drainage the size of 2 quarters. There was no date on the bandage. Record review of Resident #303's Order Summary Report revealed there were no orders for any skin concerns. An observation of Resident #303 on 2/13/25 at 8:56 AM, revealed two brown foam bandages observed to the left elbow with no date. An observation and interview with Registered Nurse (RN) #3 on 2/13/25 at 9:02 AM, after removal of the two dressings on Resident #303's left arm revealed, a skin tear to the left upper arm above the elbow with intact skin and a skin tear to the elbow with no intact skin that was circular in appearance. A moderate amount of whitish drainage was present. RN #3 revealed she was not aware that the resident had skin tears. She revealed the resident did have a fall after admission and could have gotten a skin tear then. She confirmed the resident did not have an order for treatment and explained she had no idea how long the bandage had been there. RN #3 confirmed Resident #303 could get an infection or a delay in healing due to lack of treatment and monitoring. Record review of the Progress Notes dated 2/1/25 for Resident #303 revealed, Resident rolled out of bed and hit head on garbage can and cut above eyebrow, skin tear on left hand and left elbow. Also revealed, The areas were cleaned and steri strips put on them. An interview with Registered Nurse (RN) #1 on 2/13/25 at 11:02 AM, revealed without proper monitoring and treatment of Resident #303's skin tears, they could worsen and deteriorate and become infected. Record review of the Admission Record revealed the facility admitted Resident #303 on 1/30/25 with a diagnosis that included Acute Kidney Injury. 47874

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from physical restraints as evidenced by restricting a resident's voluntary movement by body contact for one (1) of 23 sampled residents. Resident #88 Findings Include: Review of the facility policy titled Residents' Rights Summary unrevised, revealed under, Examples of Violations: . 12. Restraining a resident without a physician's order for the convenience of staff, or as a disciplinary measure. An observation on the Memory Care Unit on 2/11/25 at 3:49 PM revealed Resident #88 sitting in a wheelchair in the activity room and Certified Nurse Aide (CNA) #4 was standing in front of the resident with her right knee in between the residents' legs. The resident was anxious and asked the aide to take her to the bathroom. The resident tried to stand up from the wheelchair several times but was stopped. CNA #4 replied, No, you've got to stay right here while touching the resident's leg and instructing her to sit down because she had just went to the bathroom. The resident continued rocking forward in her wheelchair. An observation and interview with the Memory Care Unit Coordinator on 2/11/25 at 4:01 PM confirmed CNA #4 was standing over Resident #88 and restricting her from voluntarily standing up. She revealed CNA #4 was doing that to keep the resident from getting out of the chair and falling. She stated that the resident had just been toileted and was frequently asking to go to the bathroom. The Memory Care Coordinator revealed the resident was on a toileting program and should be toileted every two (2) hours and when needed. An interview with the Administrator (ADM) on 2/11/25 at 4:08 PM confirmed the aide's actions were not how the facility should be handling the residents. She stated that she had been made aware of the incident witnessed between CNA #4 and Resident #88. She revealed the resident's request to go to the bathroom could be a behavior or a urinary tract infection. An interview with the Director of Nursing (DON) on 2/11/25 at 4:13 PM confirmed that CNA #4's action was restraining Resident #88 from standing up from the wheelchair. An interview with CNA #4 on 2/11/25 at 4:18 PM revealed she was trying to prevent Resident #88 from getting up and falling. She explained the resident was a fall risk and always asking to go to the bathroom because she wanted to go and stay in her room. An interview with the Nurse Practitioner (NP) on 2/12/25 at 10:08 AM revealed Resident #88 had declined over the past three (3) months with an increase in behavior and restlessness. She explained that the resident had been up walking but recently required a wheelchair because she was unsteady. She revealed frequent bathroom requests had started around the same time and the resident was currently on an antibiotic for a urinary tract infection (UTI) which could be increasing her behavior. An interview with Registered Nurse (RN) #3 on 2/13/25 at 8:38 AM revealed the Memory Care Unit had a fall risk area where the residents that were at risk stayed, so they were overseen closely by the staff. She revealed the aides were to watch over the residents and oversee but never prevent a resident from getting up. Record review of CNA #4 Education Transcript revealed she was trained on preventing falls (8/15/24), dementia care (8/16/24), and dementia with challenging behaviors (1/21/25). Record review of the Admission Record revealed the facility admitted Resident #88 on 3/19/24 with a diagnosis that included Alzheimer's Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/24 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3, which indicated Resident #88 was severely cognitively impaired.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents had the right to participate in smoking during rainy or inclement weather for two (2) of four (4) survey days. Resident #60, 65, A, and B. Findings include: Review of the facility policy titled, Resident Rights & Quality of Life Policy with an effective date of 3/13/20, revealed, It is the policy of proper name that all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center .A patient or resident has the right: To be fully informed of his or her rights and all rules and regulations governing patient and resident conduct and responsibilities during the stay in the center. Review of Proper name Smoke Schedule undated, revealed ** Staff members are not allowed to take residents out to smoke during inclement weather, such as: Rain, Sleet, Snow, [NAME], Storms, Heat index of 100+ and freezing temp of 32 degrees and below. ** In an interview on 2/12/25 at 8:35 AM, Resident #60 revealed that she wanted to go out and smoke, but they won't take anyone because it is raining outside. She stated she would really like to have a cigarette, plus we didn't get to go out yesterday and smoke all day because it was raining. During an interview on 2/12/25 at 8:45, Certified Nurse Aide (CNA) #8, with Resident #60 present, confirmed that the residents aren't allowed to go out today and smoke because it is raining. She revealed they aren't allowed to go out if it's raining, snowing, bad weather, or cold. During an observation and interview on 2/12/25 at 11:05 AM, Resident #60 was sitting in her doorway in her wheelchair and stated that she really wanted to go out and smoke, but we still can't because it's still raining. In an interview on 2/12/25 at 11:15 AM, Central Supply revealed that the person that is assigned to take the smokers out at 11 AM is the Minimum Data Set (MDS) #1, but she probably won't do it because it's raining. She then confirmed that the residents don't go out to smoke if it's raining, so they did not get to go yesterday either. An observation and interview on 2/12/25 at 11:25 AM revealed several residents sitting by the smoking door waiting for the 11 AM smoke break. Resident A and Resident #60 both revealed they hoped they would let them, especially since they missed yesterday because it rained all day. An observation and interview on 2/12/25 at 11:30 AM, MDS #1 arrived at the door to the smoking area with the residents still waiting and stated that they do not usually take them out to smoke when it's raining or inclement weather. An interview on 2/12/25 at 11:35 AM with Resident A, B and #65. Resident A stated, I don't understand why we can't come out to smoke, because we have a pavilion to sit under and it helps my nerves. Resident B revealed he wishes they would let them go out and smoke regardless of the weather when it is their smoke break time. Resident #65 stated, I didn't get a cigarette all day yesterday because it was raining. During an interview on 2/12/25 at 2:35 PM with the Admission Liaison she revealed it is her responsibility to complete admission paperwork with the residents and their families. She stated that the admission paperwork does not address smoking. She revealed that if they ask, she does tell them that they allow smoking, but they do not sign anything. An interview on 2/12/25 at 3:37 PM, the Administrator (ADM) confirmed that the residents do not have to sign anything regarding smoking rules. She revealed that they discuss smoking rules during the 72-hour report after admitting the residents and confirmed that she understands that residents have their rights. Record review of Resident #60's Admission Record revealed the facility admitted the resident on 6/28/2023 with diagnoses that included Major Depressive Disorder, and Nicotine Dependence, Cigarettes. Record review of Resident #60's MDS with an Assessment Reference Date (ARD) of 11/27/24 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. A record review of Resident #65's Admission Record revealed the facility admitted the resident on 10/14/2023 with diagnoses that included Heart Failure, Major Depressive Disorder, and Nicotine Dependence on Cigarettes. A record review of Resident #65's MDS with an ARD of 12/9/24 revealed, under section C, a BIMS score of 15, which indicated that Resident #65 is cognitively intact. Record review of Resident A's Admission Record revealed the facility admitted the resident on 1/9/2025 with diagnoses that included Displaced Trimalleolar Fracture of the Left Lower Leg, Encounter for Closed Fracture with Routine Healing, Weakness, and Bipolar Disorder. A record review of Resident A's MDS with an ARD of 1/16/25 revealed, under section C, a BIMS score of 15, which indicated the resident is cognitively intact. A record review of Resident B's Admission Record revealed the facility admitted the resident on 11/27/2023 with diagnoses that included Anxiety Disorder and Major Depressive Disorder. A record review of Resident B's MDS with an ARD of 11/14/24 revealed, under section C, a BIMS score of 13, which indicated that the resident is cognitively intact.

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on record review, staff interview and policy/procedure review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well being for three (3) of eight (8) residents reviewed (Resident #1, Resident #2 and Resident #3) as evidenced on 11/24/12 by a Licensed Practical Nurse (LPN) that allowed a Certified Nurse Aide (CNA) to perform a treatment and service outside of their scope and practice. The CNA was allowed to perform a venipuncture and draw lab on Resident #1. On 12/2/12, the same LPN allowed the same CNA to crush and give medications to Resident #2 and crush and give medication to Resident #3. Resident #3 did not have an order to crush medications. It was determined that Substandard Quality of Care and Immediate Jeopardy were identified on 12/18/12 at 12:18 p.m. to begin on 11/24/12. The IJ and SQC were removed on 12/19/12. The facility provided a credible Allegation of Compliance (AOC) on 12/20/12 at 4:30 p.m. Based on verification of the facility's corrective actions that were verified by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 12/19/12. from a " J " Level deficiency to a "D" level, which constituted no actual harm with potential for more than minimal harm. The corrective actions were also verified by the state surveyor to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Resident #1 Record review of Resident #1 revealed an admission date of [DATE]. Her diagnosis (dx) since admission have included: Unspecified Hemorrhage of Gastrointestinal Tract; Urinary Tract Infection; Constipation; Restless Legs Syndrome; [MEDICAL CONDITION]; Joint Pain; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; Diabetes without Complications; and, [MEDICAL CONDITION] Fibrillation. Review of the most recent Minimum Data Set (MDS), for a quarterly assessment with an Assessment Reference Date (ARD) of 10/16/12, revealed that her Brief Interview for Mental Status (BIMS) score to be a 15, meaning she was cognitively independent and able to make her own decisions. Review of Resident #1's MD (physician) orders on 11/24/12 revealed, "Need Gastrointestinal (GI) referral for possible GI bleed", "Obtain Complete Blood Count (CBC), Complete Metabolic Profile (CMP), [MEDICATION NAME] Time (PT), aptt send to (local hospital) lab, notify Medical Doctor (MD) with results". There were no times on either of these orders. Review of Resident #1's MD order on 11/24/12 at 1:41 p.m., revealed "[MEDICATION NAME] (150 milligrams) (MG). By mouth two times a day (BID) Everyday". Review of Resident #1's MD order on 11/24/12 revealed "[MEDICATION NAME], 325 (65 Fe) MG, By mouth BID Two times a day Everyday". There was no time on this MD order. Review of Resident #1's Nurses note for 11/24/12 revealed at 12:18 p.m., "Change of Condition. Family concerned with resident weakness. ASSESSMENT: 99/59, 71, 98.0, 94 O2 sat. with oxygen (O2) on at two (2) liters per minute (LPM), resident appeared weak, stated just feeling bad all over, skin around eyes seem dark, face pale, resident has been passing blood in stool for a couple of months, MD aware, but noted she is concerned that the loss of the blood may be her problem in feeling so bad. Skin is warm and dry to touch, grips as strong and equal as usual. RESPONSE: called MD, waiting for response, responsible party (RP) aware. AUTHOR: (LPN #1)" Nurse ' s note at 1:47 p.m., revealed "blood obtain for CBC, CMP, PT, APTT sent to (local hospital) lab, waiting for results. Will notify (MD) when receive results". Review of Resident #1's lab results revealed that the lab ordered is present on the chart and dated for 11/24/12. Resident #2 Record review of Resident #2 revealed an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Hypopotassemia; and, Senile Dementia. Review of the most recent MDS for a significant change in status assessment with an ARD of 11/7/12, revealed that her BIMS score was 03, meaning she never/rarely made decisions and was severely impaired. Review of Resident #2's MD orders for December 2012 revealed the following medications ordered: [MEDICATION NAME] 25MG 1 tablet daily, [MEDICATION NAME] 320 MG 1 tablet daily, [MEDICATION NAME] HCI 40mg 1 tablet daily. There is also an order [REDACTED]. APPLESAUCE-Complex". Review of Resident #2's December 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #3 Record review of Resident #3 revealed an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Unspecified site, Anxiety, Unspecified [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION]. Review of the most recent MDS for a quarterly assessment with an ARD of 11/12/12, revealed her BIMS score was 03, meaning she never/rarely made decisions and was severely impaired. Review of Resident #3's MD orders for December 2012 revealed the following medications ordered: [MEDICATION NAME] 10 MG 1 tablet daily, [MEDICATION NAME] HCL 50 MG 1 tablet at bedtime (HS) Everyday, [MEDICATION NAME] HCL 20 MG 1 tablet daily, [MEDICATION NAME] 120MG 1 tablet daily, [MEDICATION NAME] 0.25MG 1 tablet BID, [MEDICATION NAME] 5- 500MG 1 tablet BID, [MEDICATION NAME] 20 MG 1 tablet daily, [MEDICATION NAME] 10MG 1 tablet daily, K-Dur 10 MEQ 1 tablet daily, Multivitamin/Mineral 1 tablet daily and [MEDICATION NAME] 10MG 1 tablet BID. Review of Resident #3's MD telephone orders for December 2012 revealed a new order dated 12/18/12, stating, "May crush meds as needed." Review of Residents #3's MD telephone orders for December 2012 revealed new orders dating 12/19/12 stating, "Multivitamin & Mineral(Multiple Vitamins w/Minerals), 30ml, by mouth once daily everyday", "Potassium Chloride(Potassium Chloride), 10 MEQ, by mouth once daily everyday" the word "Liquid" with "D/C tabs" handwritten in. an order for [REDACTED]. Review of Resident #3's MAR for December 2012 revealed that LPN #1 initialed that she administered the 9:00 a.m. medications on 12/2/12. Review of Resident #3's nurse ' s note dated 12/18/12 at 4:57 p.m. revealed, "Dr notified of resident need to crush meds. Order received may crush meds as needed. RP aware." Review of Resident #3's Nurse ' s note dated 12/19/12 at 10:02 a.m., revealed "new order obtained for Potassium to be changed to liquid form along with Multi Vitamin/with minerals be changed to liquid for easier swallowing. Responsible Party (RP) aware. Meds ordered." Review of CNA #1's written statement dated 12/3/12 during the facility investigation revealed, "I, (name of CNA #1) drawed blood on Resident #1 on A-hall. LPN #1 was the nurse at the time. I told her that I was a licensed Phlebotomist and had been at the hospital before I came to (name of facility). She said that I could draw the blood for her on Resident #1 on Saturday Nov. 24th, after dinner trays". "I, (name of CNA #1), on Sunday [DATE]nd as well helped give Resident #3, her medication with LPN #1 in the AM. Because Resident #3 was really not wanting to take her medication". Review of LPN #1's written statement dated 12/3/12, during the facility investigation revealed: "I had gotten behind so CNA #1 offered to help so I pulled (Resident #3's name) meds and crush and mixed in applesauce and she went in to give meds, Resident accepted and was fine. My supervisor ask me not to let her help anymore because I would get in trouble so she didn't pass anymore medications. We had a order for some blood work on a resident on A-hall. CNA#1 said, "I'm a phlebotomist I can go draw the blood". Later my supervisor said that was not what she was here for. The resident was fine, the blood was obtained from her right AC on the first attempt." Interview with the facility's administrator on 12/18/12 at 11:30 a.m., revealed "CNA #1 was hired here as a CNA. We do not allow CNAs to draw blood. It's outside their scope of practice. She was not hired as a phlebotomist. We do not have a position for a phlebotomist. RN's and (intravenous) IV certified LPN's draw blood and we contract with (name of local lab service) lab services. We do not use CNAs to give medications, only Nurses can do that." Interview with CNA #1 on 12/18/12 at 1:24 p.m., revealed "I'm a certified pharmacy tech, phlebotomist, CNA. I started at (name of facility) in November this year. I was hired as a CNA. They knew my certification but I was hired at the time as a CNA. They were going to check to see if I could draw blood on weekends. No one ever told me I could though. I drew lab on Resident #1 on a Saturday or Sunday in November or December. I drew a purple tube, yellow tube and blue tube. LPN #1 was my supervisor that day. She told me what lab to draw. I had worked prior in a hospital so I knew what tubes to use. When she called out the lab I knew what color tubes I needed. I stuck her (Resident #1) right (antecubital) AC. It was 1 stick. She tolerated it fine. I gave medication to (Resident #3's name). It was the next weekend after drawing blood on Resident #1. LPN #1 was the LPN that day. Resident #3 was refusing to let LPN #1 give her the meds. I was with LPN #1 at that time. We both were coaxing her to take the meds. It was crushed up and was in pudding, applesauce or something like that. I had the spoon and said, " (Resident #3's name), please open your mouth, " and she did, so I gave her the spoonful. LPN #1 was right there with me. I do not have a nursing license. I've never been trained to give others medication. I don't know what medications were in the cup. It wasn't (name of Resident #2). I don't even know who she is. I don't know what room Resident #3 was in." Interview with CNA #1 on 12/18/12 at 3:20 p.m., revealed "LPN #1 asked me if I could go draw the blood on Resident #1. She knew I could draw blood. I told her ' yes ' because she is the nurse, so I did. When I got through drawing the blood, I labeled the tubes and gave them back to LPN #1. She gave me all the equipment to draw the blood. I even took the blood to the hospital lab per LPN#1's request. I told LPN #1 I would try to give the medicine since she couldn't get her (Resident #3) to take the medicine. Then I took the medicine cup and spoon from LPN #1 and spooned it into Resident #3's mouth. She took the medication easily." Interview with the DNS, RN #1, on 12/18/12 at 4:30 p.m. revealed, "We didn't see Resident #3's name in CNA #1's or LPN #1's written statements. I didn't see it. I investigated Resident #2 because that's who was reported to me. It's my fault that Resident #3 wasn't investigated. We'll do the investigation on her now." Interview with the administrator (ADM) on 12/18/12 at 4:45 p.m. revealed, "We will have an emergency Quality Assurance (QA&A) meeting tonight about Resident #3 getting the meds." Interview with CNA #1 on 12/19/12 at 2:15 p.m. revealed, "She (LPN #1) pulled the medication and put them in a bag to crush and I crushed them because she told me to. I had gone to the med cart to get a cup. She was preparing medicines. We were talking about different pill crushers. She handed me a bag of pills. She said Resident #3 was a pill crusher. I took that as I needed to crush the pills so I crushed the pills. She mixed the meds in the applesauce. I went back into Resident #3's room and LPN #1 followed me. Resident #3 said "NO, I don't want to take those". LPN #1 couldn't get her to take her medicine. I said " Please, (name of Resident #3)". I said to LPN #1 "let me try, she don't like you". So I got the cup from LPN #1. There was a spoon in it and Resident #3 opened her mouth and I gave them to her. It was in the morning. It was after breakfast, it was on Sunday. LPN #1 didn't tell me what medications she pulled for Resident #3." Interview with CNA #2 on 12/19/12 at 2:44 p.m. revealed, "CNA #1 was splitting hall on A hall and A north. That morning I went down to room [ROOM NUMBER] and when I came out I saw CNA #1 at the med cart with LPN #1. I slowed down to see what they were doing. I saw CNA #1 crushing pills and then mix the pills with applesauce. I saw her go into A North 27, Resident #2's room. I didn't see her give any meds, just crush them. I didn't see LPN #1 go into the room, just CNA #1. I went up to the nurse ' s desk and told CNA #3 "this girl is passing meds". RN #5 walked by then and I said "RN #5, your CNA split is crushing pills and passing meds". RN #5 went to A north and I went to the dining room. When the 3-11 nurse, LPN #2, came in, I told (her). I told LPN #2 cause I didn't think RN #5 was doing anything about it. I know LPN #2 and knew she would take care of it. Later on LPN #2 told me she called RN #1, the Director of Nurse (DNS)." Interview with CNA #3 on 12/19/12 at 3:00 p.m. revealed, "I never saw CNA #1 crush meds, walk into a resident rooms with meds or do a venipuncture (VP). I did see her at the med cart. She was walking away from it. I didn't see LPN #1 at all." Interview with LPN #2 on 12/19/12 at 5:40 p.m. revealed, "On Sunday 12/2/12 after 3:00 p.m., I was at A north desk. CNA #2 walked up to the desk. CNA #2 said "She's (CNA #1) been giving meds." I didn't want to over react. I just said, " You've got to be kidding" and CNA #2 said ' no. ' I asked who she's been giving meds to. CNA #2 said, "I'm not sure; it was down the hall on the left. I'm not sure but I think it was (nickname for Resident #2). She then said, "You know she drew blood on somebody?" I said ' no. ' I asked, ' who ' and CNA #2 said, ' a patient on A hall. ' CNA #3 walked up and CNA #2 said, "Ask CNA #3". I ask CNA #3 about CNA #1 drawing blood and giving meds and she confirmed what CNA #2 said. At this time it also came up that CNA #1 took some supplies from the facility home to do wound care on a family member. I waited for CNA #2 and CNA #3 to leave, only a few minutes later then I went into the med room and called RN #1, the DNS. I told her exactly what CNA #2 and CNA #3 told me. RN #1asked for CNA #1 and LPN #1's phone numbers. CNA #2 did tell me that someone told RN #5 and RN #5 went down and told LPN #1 that she shouldn't let CNA #1 do that cause she would get into trouble. When I was talking to RN #1, RN #5 came to the desk. She must have overheard part of our conversation cause when I hung up she said that she had been so busy that morning, she was passing meds but she did stop and go talk to LPN #1 when she was told what was going on. She also said, "I need to call RN #1 also." RN #5 never said what she talked to LPN #1 about. I reported Resident #2 to RN #1 because CNA #2 said to me, "I'm not sure who it is but I think it's (Resident #2's nickname)." Interview with RN #5 on 12/19/12 at 8:00 p.m. revealed, "On 11/24/12, I think it was a Saturday, sometime during the day, LPN #1 said that Resident #1's family wanted blood drawn. She asked if I would do a VP if she got the order. I told her sure, just let me know. The day went on, then the next day near the end of the shift, I mentioned to LPN #1, I saw Resident #1's lab on the fax machine. I asked if she had gotten the order for the lab. I just thought she had never gotten up with the doctor. I asked her who drew it for her. She said CNA #1 drew it. I asked her why she let CNA #1 draw that blood cause she's an aide. I told LPN #1 she needed to call RN #1 or RN #2 and let them know what she did. I told myself to remember to call RN #1 when I got home. I got busy and I honestly forgot to call RN #1. I never thought about it again. I went to work the next weekend. I was on the med cart both days. I just didn't think about it. On Sunday, before lunch on 12/2/12, I overheard CNA #2 say the aide on A north is helping give medicine. My back was to them, I didn't see who all she was talking to. I looked up and asked CNA #2 "what did you say?" and she said the aide on A North is helping give meds. I locked my med cart and went to find LPN #1 and asked her, "You're not letting one of the aides give medicines, are you? " She said, "Well, yeah I did. I let CNA #1 give meds crushed up to Resident #3". I told her she had probably gotten herself in trouble and CNA #1, too. She said she wouldn't do it again. I called RN #1 after I got home. I did not go and assess Resident #3 to see if she was ok. I verbally disciplined LPN #1. I didn't write her up. She never told me why she let CNA #1 give the meds. When I told RN #1, she suspended us and started an investigation." Interview with CNA #2 on 12/20/12 at 8:00 a.m. revealed, "I came out of A North 31 going towards the Nurse's station. The med cart was between room [ROOM NUMBER] and room [ROOM NUMBER]. LPN #1 was on the left in front of room [ROOM NUMBER]'s door. CNA #1 was on the right side of the cart closer to room A27. When I came out of A31 that's where they were standing. I slowed down being nosy. CNA #1 was crushing pills. I was between room A29 and A27. I saw CNA #1 go into room A27. She had a small medicine cup with a wood spoon in it. Resident #2's roommate wasn't in there. Resident #2 was sitting in her recliner. I went past the room. I never saw where LPN #1 went. I never turned around when I passed the rooms." Interview with RN#1, the Director of Nursing, on 12/20/12 at 2:00 p.m. revealed, "On 12/2/12, it was 7:30 p.m., I got a call from LPN #2 and she reported that day shift CNAs, CNA #2 and CNA #3 reported to her that CNA #1 gave a resident meds. The resident was Resident #2, then 2 hours later, LPN #3 called to make sure I had been told about a lab draw that had happened the weekend of 11/24/12. She was told that CNA #1 performed the lab draw. I didn't ask her who told her. On Monday, 12/3/12, I went to the ADM and told him what happened. We suspended CNA #1, LPN #1 and RN #5, immediately. I began my investigation. I began in-services immediately on blood draws, med administration and the MS Board of Nursing guidelines on delegation of duties, reporting alleged violations, abuse and neglect. When LPN #2 said Resident #2's name, I ran with it. I didn't read their written statements so I never knew about Resident #3 until 12/18/12. When I heard about Resident #3, we did a complete physical assessment, called her MD, contacted her RP and had an emergency QA&A meeting. The MD changed her potassium Chloride to liquid form. I did an investigation on her as well." Interview with RN #2 on 12/27/12 at 4:30 p.m. revealed, "If the MD doesn't specify an exact time for meds to be given, a med ordered daily will be given at 9 a.m., if the med is ordered BID, it is given at 9 a.m. and 5 p.m. These are the times unless the MD specifies exact times." Review of the facility's policy/procedure for "MEDICATION ADMINISTRATION" dated 2007, revealed, "POLICY: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication." "PROCEDURES: Medication Preparation: #5 If it is safe to do so, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing or is tube-fed, using the following guidelines and with a specific order from prescriber. a. The need for crushing medications is indicated on the resident's orders and the MAR indicated [REDACTED]." "Medication Administration: #5. The person who prepares the dose for administration is the person who administers the dose." Review of the "Mississippi Board of Nursing Statement of Delegation" revised 04/06/2000 states, "Tasks Not Appropriate for Delegation to Auxiliary Workers/Unlicensed Personnel Including, but not limited to: 7. medication administration". ALLEGATION OF COMPLIANCE "On 12/2/12 at 7:30 p.m., Registered Nurse #1 was notified by Licensed Practical Nurse #2 that Licensed Practical Nurse #1 had allowed Certified Nurse Aide #1 to give crushed medication to Resident #2 on 12/2/12. Certified Nursing Aide #2 interviewed on 12/3/12 indicated she observed Certified Nurse Aide #1 receive medications from Licensed Practical Nurse #1 in a medicine cup. Certified Nurse Aide #1 then poured the medications into a small plastic bag and crush them with the pill crusher on the medication cart. She then poured them back into the medicine cup and mixed them in applesauce. Certified Nurse Aide #1 was then observed by Certified Nurse Aide #2 walking into room [ROOM NUMBER] with the medicine cup. Certified Nurse Aide #2 was approximately three to five feet from the open door to room [ROOM NUMBER]. Resident #3 resides in room [ROOM NUMBER] which is the adjoining room to room [ROOM NUMBER] separated by a 12 inch wall. On 12/3/12 Registered Nurse #1reviewed the Medication Administration Record for Resident #2's 12/2/12 morning medication pass; all three medications were initialed as administered by License Practical Nurse #1. On 12/2/12 at approximately 8:45 p.m., Registered Nurse #1 was notified by Licensed Practical Nurse #3 that Licensed Practical Nurse #1 had allowed Certified Nurse Aide #1 to draw blood on Resident #1 on 11/24/12. On 12/3/12 at 10:00 a.m., Registered Nurse #1 began an investigation into these incidents. On 12/3/12 at approximately 10:00 a.m., Registered Nurse #5, (the weekend Registered Nurse Supervisor), Licensed Practical Nurse #1, and Certified Nurse Aide #1 were suspended pending full investigation and subsequently employment was terminated for all three on 12/10/12. On 12/3/12 at 1:48 p.m., State Department of Health, Licensing and Certification was notified of an "unusual occurrence" concerning these incidents. On 12/3/12 at 1:57 p.m., the Mississippi State Attorney General was notified. Approximately 3:30 p.m. on 12/3/12, Registered Nurse #1 was contacted by the State Board of Nursing because the MS State Attorney General's Office had contacted them regarding this incident. State Board of Nursing was given the name, address, phone numbers, social security numbers and license numbers of both Licensed Practical Nurse #1 and Registered Nurse #2. On 12/3/12, immediate in-service education was initiated at 10:30 a.m. on: Living Center Policy and Procedures for blood draws; medication administration; including the crushing of medication; the MS Board of Nursing Guidelines on delegation; the regulations on reporting abuse and neglect; and adhering to the Register Nurse, Licensed Practical Nurse, and Certified Nurse Aide facility job descriptions. All licensed nurse and certified nurse aides were in-serviced prior to working the floor. Beginning on 12/3/12, all facility staff were in-serviced on reporting abuse and neglect. At approximately 10:00 a.m., Resident #3, Resident #1 and Resident #2 had a physical assessment with no negative findings. On 12/3/12 both Physician and Responsible Party for Resident #1 were contacted and notified by Registered Nurse #3 that Resident #1 had a venipuncture performed by Certified Nurse Aide #1. On 12/3/12, Physician and Responsible Party for Resident #2 was contacted and notified by Registered Nurse #3 that medications had been administered by Certified Nurse Aide #1 for possible labs and follow up care. On 12/18/12 at approximately 4:30 p.m., further investigation of the written statements by Licensed Practical Nurse #1 and Certified Nurse Aide #2 revealed that Resident #2 may not be the only resident affected by the deficient practice. It was discovered Resident #3 may also have been affected by the deficient practice on 12/18/12. On 12/18/12, Registered Nurse #1 reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/18/12 at 5:00 p.m., Registered Nurse #3 completed a physical assessment of Resident #3 in which no negative findings were identified. Registered Nurse #1 completed a Medical Record review of documentation from 12/2/12 to present with no negative findings identified. On 12/18/12 at 5:30 p.m., Registered Nurse #3 notified the Medical Director for facility and physician's office for Resident #3 of medication administration by Certified Nurse Aide #1. On 12/18/12 at 4:45 p.m., Licensed Practical Nurse #2 notified Responsible Party for Resident #3 of medication administration by Certified Nurse Aide #1 on 12/2/12. All residents receiving medications have the potential to be affected. All interviewable residents were interviewed related to the staff member administering their medications by the Registered Nurse #1, this was initiated 12/3/12 and completed on 12/4/12 and revealed no further incidents. All residents with orders for lab draws have the potential to be affected. All interviewable residents were interviewed by Registered Nurse #1 beginning 12/3/12 and ending 12/4/12. All other residents had lab draws done per policy and procedures by a licensed nurse and no other residents were affected. Beginning 12/2/12, Registered Nurse #1 or designee will review lab logs five times per week for two weeks, then weekly for two months. A special Quality Assurance and Assessment meeting took place on 12/4/12 at 2:30 p.m. with: the Medical Director; Executive Director; Registered Nurse #1; Registered Nurse #2; business Office Manager; and the Social Service Director to analyze and identify opportunities for quality improvement related to these incidents. Beginning 12/3/12, monitoring tools were put in place to include that the Director of Clinical Education or designee will complete the observation of monitoring medication passes five times per week for four weeks, then monthly for three months. Thus far, no medication errors have been identified. On 12/3/12, Registered Nurse Unit Managers or designees will perform observations of one Certified Nurse Aide providing care daily for five days a week for two weeks, then weekly for four weeks to assure care provisions falls within the scope of practice for Certified Nurse Aides. Beginning 12/3/12, Registered Nurse #1 or designee will review lab draws reports five times a week for two weeks then weekly for the next two months for continuity of care. On 12/18/12 at 8:00 p.m., a special Quality Assurance and Assessment meeting took place with: the Medical Director; Director of Operations; Executive Director; Registered Nurse #1; Registered Nurse #2; Registered Nurse #3; Registered Nurse #4; and the Director of Clinical Education to analyze and identify opportunities related to the incident of identifying Resident #3. Recommended in-service on proper techniques of conducting a thorough investigation was completed on 12/19/12., by the Director of Operations, to the Executive Director and Registered Nurse #1." Verification of the facility's corrective actions were: 1. Random staff interviews with Certified Nurses Aides, Licensed Practical Nurses and Registered Nurses. Staff interviewed stated there have been recent in-services on job descriptions, abuse/neglect and exploitation of residents and reporting abuse/neglect. Nurses were additionally inserviced on medication administration. 2. Review of the facility's Quality Assurance and Assessment meetings held on 12/4/12 and 12/18/12. Both meetings included the "Problem, Task(s), Person Assigned and Follow up" plan regarding a Certified Nurses Aide performing venipunctures for lab, Certified Nurses Aides administering medications to residents and conducting a thorough investigation. 3. Review of monitoring tools put in place for the observation of medication passes scheduled at five times per week for four weeks then monthly for three months. 4. Review and verification of employee signatures on recent in-services on Abuse/Neglect, Exploitation of Residents and reporting abuse/neglect. Based on verification of the facility's corrective actions that were verified by staff interviews and in-service, the Immediate Jeopardy (IJ) and SQC were removed and the scope and severity was lowered on 12/19/12 from a " J " Level deficiency to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

483.20(k)(3)(i) SERVICES PROVIDED MEET PROFESSIONAL STANDARDS The services provided or arranged by the facility must meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on Record review, Staff interview and Policy/Procedure review, the facility failed to provide services that met professional standards of quality as required by the Mississippi State Board of Nursing regulatory requirements for three (3) of eight (8) residents reviewed (Resident #1, Resident #2, Resident #3) as evidenced on 11/24/12 by a Licensed Practical Nurse (LPN) that allowed a Certified Nurse Aide (CNA) to perform a treatment and service outside of their scope and practice as follows: The CNA was allowed to perform a venipuncture and draw lab on Resident #1; crush and give medications to Resident #2; and, crush and give medications to Resident #3, when Resident #3 did not have a crush medication order. It was determined that Immediate Jeopardy was on 12/18/12 at 12:18 p.m. to begin on 11/24/12. The IJ was removed on 12/19/12. The facility provided a credible Allegation of Compliance (AOC) on 12/20/12 at 4:30 p.m. Based on verification of the facility's corrective actions that were verified by surveyor through staff interviews and documented in-services, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered from a " J " on 12/19/12. to a "D" level, which constituted no actual harm with potential for more than minimal harm. The corrective actions were also verified by the state surveyor to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Cross Refer to F-309 related to the facility's failure to provide the necessary care and services to attain and maintain the highest practicable physical, mental and psychosocial well being for Resident #1, Resident #2 and Resident #3 as evidenced on 11/24/12 by a Licensed Practical Nurse (LPN) that allowed a Certified Nurse Aide (CNA) to perform a venipuncture and draw lab on Resident #1. On 12/2/12, this LPN also allowed the CNA to crush and administer medications to Resident #2 and crush and administer medication to Resident #3. Resident #3 did not have a crush medication order. Review of the "Mississippi Board of Nursing Statement of Delegation" revised 04/06/2000 states, "Tasks Not Appropriate for Delegation to Auxiliary Workers/Unlicensed Personnel Including, but not limited to: 7. medication administration". ALLEGATION OF COMPLIANCE "On 12/2/12 at 7:30 p.m., Registered Nurse #1 was notified by Licensed Practical Nurse #2 that Licensed Practical Nurse #1 had allowed Certified Nurse Aide #1 to give crushed medication to Resident #2 on 12/2/12. Certified Nursing Aide #2 interviewed on 12/3/12 indicated she observed Certified Nurse Aide #1 receive medications from Licensed Practical Nurse #1 in a medicine cup. Certified Nurse Aide #1 then poured the medications into a small plastic bag and crush them with the pill crusher on the medication cart. She then poured them back into the medicine cup and mixed them in applesauce. Certified Nurse Aide #1 was then observed by Certified Nurse Aide #2 walking into room [ROOM NUMBER] with the medicine cup. Certified Nurse Aide #2 was approximately three to five feet from the open door to room [ROOM NUMBER]. Resident #3 resides in room [ROOM NUMBER] which is the adjoining room to room [ROOM NUMBER] separated by a 12 inch wall. On 12/3/12 Registered Nurse #1reviewed the Medication Administration Record for Resident #2's 12/2/12 morning medication pass; all three medications were initialed as administered by License Practical Nurse #1. On 12/2/12 at approximately 8:45 p.m., Registered Nurse #1 was notified by Licensed Practical Nurse #3 that Licensed Practical Nurse #1 had allowed Certified Nurse Aide #1 to draw blood on Resident #1 on 11/24/12. On 12/3/12 at 10:00 a.m., Registered Nurse #1 began an investigation into these incidents. On 12/3/12 at approximately 10:00 a.m., Registered Nurse #5, (the weekend Registered Nurse Supervisor), Licensed Practical Nurse #1, and Certified Nurse Aide #1 were suspended pending full investigation and subsequently employment was terminated for all three on 12/10/12. On 12/3/12 at 1:48 p.m., State Department of Health, Licensing and Certification was notified of an "unusual occurrence" concerning these incidents. On 12/3/12 at 1:57 p.m., the Mississippi State Attorney General was notified. Approximately 3:30 p.m. on 12/3/12, Registered Nurse #1 was contacted by the State Board of Nursing because the MS State Attorney General's Office had contacted them regarding this incident. State Board of Nursing was given the name, address, phone numbers, social security numbers and license numbers of both Licensed Practical Nurse #1 and Registered Nurse #2. On 12/3/12, immediate in-service education was initiated at 10:30 a.m. on: Living Center Policy and Procedures for blood draws; medication administration; including the crushing of medication; the MS Board of Nursing Guidelines on delegation; the regulations on reporting abuse and neglect; and adhering to the Register Nurse, Licensed Practical Nurse, and Certified Nurse Aide facility job descriptions. All licensed nurse and certified nurse aides were in-serviced prior to working the floor. Beginning on 12/3/12, all facility staff were in-serviced on reporting abuse and neglect. At approximately 10:00 a.m., Resident #3, Resident #1 and Resident #2 had a physical assessment with no negative findings. On 12/3/12 both Physician and Responsible Party for Resident #1 were contacted and notified by Registered Nurse #3 that Resident #1 had a venipuncture performed by Certified Nurse Aide #1. On 12/3/12, Physician and Responsible Party for Resident #2 was contacted and notified by Registered Nurse #3 that medications had been administered by Certified Nurse Aide #1 for possible labs and follow up care. On 12/18/12 at approximately 4:30 p.m., further investigation of the written statements by Licensed Practical Nurse #1 and Certified Nurse Aide #2 revealed that Resident #2 may not be the only resident affected by the deficient practice. It was discovered Resident #3 may also have been affected by the deficient practice on 12/18/12 . On 12/18/12, Registered Nurse #1 reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 12/18/12 at 5:00 p.m., Registered Nurse #3 completed a physical assessment of Resident #3 in which no negative findings were identified. Registered Nurse #1 completed a Medical Record review of documentation from 12/2/12 to present with no negative findings identified. On 12/18/12 at 5:30 p.m., Registered Nurse #3 notified the Medical Director for facility and physician's office for Resident #3 of medication administration by Certified Nurse Aide #1. On 12/18/12 at 4:45 p.m., Licensed Practical Nurse #2 notified Responsible Party for Resident #3 of medication administration by Certified Nurse Aide #1 on 12/2/12. All residents receiving medications have the potential to be affected. All interviewable residents were interviewed related to the staff member administering their medications by the Registered Nurse #1, this was initiated 12/3/12 and completed on 12/4/12 and revealed no further incidents. All residents with orders for lab draws have the potential to be affected. All interviewable residents were interviewed by Registered Nurse #1 beginning 12/3/12 and ending 12/4/12. All other residents had lab draws done per policy and procedures by a licensed nurse and no other residents were affected. Beginning 12/2/12, Registered Nurse #1 or designee will review lab logs five times per week for two weeks, then weekly for two months. A special Quality Assurance and Assessment meeting took place on 12/4/12 at 2:30 p.m. with: the Medical Director; Executive Director; Registered Nurse #1; Registered Nurse #2; business Office Manager; and the Social Service Director to analyze and identify opportunities for quality improvement related to these incidents. Beginning 12/3/12, monitoring tools were put in place to include that the Director of Clinical Education or designee will complete the observation of monitoring medication passes five times per week for four weeks, then monthly for three months. Thus far, no medication errors have been identified. On 12/3/12, Registered Nurse Unit Managers or designees will perform observations of one Certified Nurse Aide providing care daily for five days a week for two weeks, then weekly for four weeks to assure care provisions falls within the scope of practice for Certified Nurse Aides. Beginning 12/3/12, Registered Nurse #1 or designee will review lab draws reports five times a week for two weeks then weekly for the next two months for continuity of care. On 12/18/12 at 8:00 p.m., a special Quality Assurance and Assessment meeting took place with: the Medical Director; Director of Operations; Executive Director; Registered Nurse #1; Registered Nurse #2; Registered Nurse #3; Registered Nurse #4; and the Director of Clinical Education to analyze and identify opportunities related to the incident of identifying Resident #3. Recommended in-service on proper techniques of conducting a thorough investigation was completed on 12/19/12., by the Director of Operations, to the Executive Director and Registered Nurse #1." Verification of the facility's corrective actions were conducted on 12/18/12 beginning at 12:18 p.m. and ended on 12/20/12 at 4:30p.m. were: 1. Random staff interviews with Certified Nurses Aides, Licensed Practical Nurses and Registered Nurses. Staff interviewed stated there have been recent in-services on job descriptions, abuse/neglect and exploitation of residents and reporting abuse/neglect. Nurses were additionally in-serviced on medication administration. 2. Review of the facility's Quality Assurance and Assessment meetings held on 12/4/12 and 12/18/12. Both meetings included the "Problem, Task(s), Person Assigned and Follow up" plan regarding a Certified Nurses Aide performing venipunctures for lab, Certified Nurses Aides administering medications to residents and conducting a thorough investigation. 3. Review of monitoring tools put in place for the observation of medication passes scheduled at five times per week for four weeks then monthly for three months. 4. Review and verification of employee signatures on recent in-services on Abuse/Neglect, Exploitation of Residents and reporting abuse/neglect. Based on verification of the facility's corrective actions that were verified by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 12/19/12 from a " J " Level Deficiency to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

CI MS #9956 Based on observation, record review, policy review, Pest Control Company Representative interview, Resident interview and facility staff interview, the facility failed to ensure that the pest control program was effective as evidenced by one (1) of three (3) residents, Resident #1. Resident #1 had 10 fire ant bites to the right upper arm. Findings Include: Resident #1 Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 was receiving hospice care. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/11 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of one (1) which indicated severe cognitive impairment. Section K0500 revealed that Resident #1 had a feeding tube. Review of Resident #1's physician's orders [REDACTED]." Review of Resident #1's "Progress Notes" dated "Late Entry 12/21/11 16:00 (4:00 p.m.)" revealed "Change of Condition. Situation: Notified of resident having skin cincern (concern) to the right upper arm. Resident is lying in bed. Several small pink areas noted to the right upper arm. No drainage or open areas noted. MD notified with no new orders noted. Just to observe arm." Interview on 12/29/11 at 9:15 a.m. with the Director of Nursing (DON) confirmed that during the night of 12/21/11 ants were discovered in Resident #1's bed. The DON stated that the Treatment Nurse "notified me pass lunch that there were pus filled areas on the right upper arm, small pus filled. Looked like ant bites- we knew ants had bitten her (Resident #1). Doctor was here and went and looked with no new treatment. " The DON was not sure how the ants had gotten into Resident #1's bed. The DON stated that Resident #1 was a "tube feeder" and maybe that was what drew the ants to Resident #1. Observation and interview of Resident #1 on 12/29/11 at 10:40 a.m. revealed small dark areas on the right upper arm. At this time the Treatment Nurse confirmed the small dark areas noted on Resident #1's right upper arm were the remains of the ant bites. A feeding of [MEDICATION NAME] 1.5 was infusing at 55 cc (cubic centimeters) per gastrostomy tube. Resident #1 state, when asked what happened to the right upper arm, "ants". Review of facility document "Hall Report for 3-11 Supervisor" dated 12/20/11 revealed "Ants noted in (name) Resident #1's room and on bed. Moved resident to 25 A temporarily till we can get rid of ants." Review of a facility document "Time Line" (not dated) revealed that the ants were noted in Resident #1's bed on 12/20/11 at 9:30 p.m. Staff removed Resident #1 from her bed to another room. "Ants were removed from the residents room on 12/20/11 after immediate protection of the resident. The physician and RP notified the morning of 12/21/11." On 12/29/11 at 4:30 p.m. the "Time Line" was reviewed/confirmed with the Director of Nursing (DON). Review of a facility document "Verification of Investigation" dated of occurrence 12/21/11 at 8:00 a.m. revealed "Staff discovered that ants were in resident's (Resident #1) bed. Resident was immediately removed from bed and placed in different room. Body audit performed with no negative findings at time of event. The resident's right upper arm initially had some redness and then on 12/22/11 resident was noted to have pin point pustules to her right upper arm. Resident Interview summary: "I don't know, I knew ants were in my bed, but I did not know they bit me, they don't hurt." Immediate resident protection initiated- 1) Resident (Resident #1) was immediately removed from bed and placed in different room. 2) Resident assessed with [REDACTED]. 3) Treatment nurse evaluated resident's arm on 12/22/11. 10 pustules had formed but no drainage, itching or pain. MD (medical doctor) also examined resident on 12/22/11 with no new orders. 4) Treatment orders were obtained on 12/23/11 when redness on right arm became more pronounced." Review of Resident #1's "Wound Evaluation Flow Sheet" dated 12/21/11 revealed: 12/21/11 "Several small areas of redness were noted to the right upper arm. No open area noted at present." 12/22/11 "Slight redness cont (continue) The areas of redness has small puss like centers appr (approximately) 10 areas." 12/23/11 "Cont redness c (with) areas slightly increased size. Placed warm compress. Cont denies pain/itching at present. Cont c appro (approximately) 6 (six) pus filled areas". (Note the facility submitted documentation which has conflicting dates regarding the date of Resident #1's ant incident.) Interview on 12/29/11 at 11:40 a.m. with Certified Nursing Assistant (CNA) # 2 revealed that "pulled cover back. My last round was pass nine (9) p.m. It was late. Her gown was wet, took gown off. Ants on (her) stomach, in her hair, bed, nice amount of ants. Not just around the tube, they were on her chest. She (Resident #1) did not say anything." Interview on 12/29/11 at 11:00 a.m. with CNA #1 revealed that CNA #2 had requested assistance in Resident #1's bedroom after the discovery of ants in Resident #1's bed and on Resident #1. Interview on 12/29/11 at 12:20 p.m. with the Pest Control Company Representative #1 revealed that initially on 12/21/11 Resident #1's bedroom was treated for [REDACTED]. Treatment in the C Hall Dining Room was initiated on 12/26/11. Observation on 12/29/11 at 12:50 p.m. in the C Hall Dining Room with the Maintenance Director and the Pest Control Representative in attendance revealed four (4) live ants near the door and one (1) dead ant behind the base board. The Pest Control Company Representative #1 stated that on 12/28/11 a chemical had been sprayed behind the base plank in the C Hall Dining Room and the ants observed at that time were fire ants. Observation of the facility continued, which revealed fire ants in the A Hall Dining Room. The DON provided a document not titled and not dated that revealed "The Golden Living Center of Amory abides by Federal Guidelines regarding pest control. Employees should be aware of the presence of items that may attract pests into the facility and tend to or report them to the supervisor, such as uncovered food items, spills that are not cleaned promptly, unclean equipment, etc." The facility had no pest control policies to provide.

CI MS #9956 Based on observation, record review, policy review, Pest Control Company Representative interview, Resident interview and facility staff interview, the facility failed to ensure that one (1) of three (3) residents, Resident #1, was free of fire ant bites. This was evidenced by Resident #1 having sustained 10 fire ant bites on the right upper arm. Findings Include: Resident #1 Review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 was receiving hospice care. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/11 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of one (1) which indicated severe cognitive impairment. Section K0500 revealed that Resident #1 had a feeding tube. Review of Resident #1's physician's orders [REDACTED]." Review of Resident #1's "Progress Notes" dated "Late Entry 12/21/11 16:00 (4:00 p.m.)" revealed "Change of Condition. Situation: Notified of resident having skin cincern (concern) to the right upper arm. Resident is lying in bed. Several small pink areas noted to the right upper arm. No drainage or open areas noted. MD notified with no new orders noted. Just to observe arm." Interview on 12/29/11 at 9:15 a.m. with the Director of Nursing (DON) revealed that during the night of 12/21/11 ants were discovered in Resident #1's bed. The DON stated that the Treatment Nurse "notified me pass lunch that there were pus filled areas on the right upper arm, small pus filled. Looked like ant bites- we knew ants had bitten her (Resident #1). Doctor was here and went and looked with no new treatment." The DON was not sure how the ants had gotten into Resident #1's bed. The DON stated that Resident #1 was a "tube feeder" and maybe that was what drew the ants to Resident #1. Observation and interview of Resident #1 on 12/29/11 at 10:40 a.m. revealed small dark areas on her right upper arm. At this time the Treatment Nurse confirmed the small dark areas noted on Resident #1's right upper arm were the remains of the ant bites. A feeding of Jevity 1.5 was infusing at 55 cc (cubic centimeters) per gastrostomy tube. Resident #1 state, when asked what happened to the right upper arm, "ants". Review of facility document "Hall Report for 3-11 Supervisor" dated 12/20/11 revealed "Ants noted in (name) Resident #1's room and on bed. Moved resident to 25 A temporarily till we can get rid of ants." Review of a facility document "Time Line" (not dated) revealed that the ants were noted in Resident #1's bed on 12/20/11 at 9:30 p.m. Staff removed Resident #1 from her bed to another room. "Ants were removed from the residents room on 12/20/11 after immediate protection of the resident. The physician and RP notified the morning of 12/21/11." On 12/29/11 at 4:30 p.m. the "Time Line" was reviewed/confirmed with the Director of Nursing (DON). Review of a facility document "Verification of Investigation" dated of occurrence 12/21/11 at 8:00 a.m. revealed "Staff discovered that ants were in resident's (Resident #1) bed. Resident was immediately removed from bed and placed in different room. Body audit performed with no negative findings at time of event. The resident's right upper arm initially had some redness and then on 12/22/11 resident was noted to have pin point pustules to her right upper arm. Resident Interview summary: "I don't know, I knew ants were in my bed, but I did not know they bit me, they don't hurt." Immediate resident protection initiated- 1) Resident (Resident #1) was immediately removed from bed and placed in different room. 2) Resident assessed with [REDACTED]. 3) Treatment nurse evaluated resident's arm on 12/22/11. 10 pustules had formed but no drainage, itching or pain. MD (medical doctor) also examined resident on 12/22/11 with no new orders. 4) Treatment orders were obtained on 12/23/11 when redness on right arm became more pronounced." Review of Resident #1's "Wound Evaluation Flow Sheet" dated 12/21/11 revealed: 12/21/11 "Several small areas of redness were noted to the right upper arm. No open area noted at present." 12/22/11 "Slight redness cont (continue) The areas of redness has small puss like centers appr (approximately) 10 areas." 12/23/11 "Cont redness c (with) areas slightly increased size. Placed warm compress. Cont denies pain/itching at present. Cont c appro (approximately) 6 (six) pus filled areas". (Note the facility submitted documentation which has conflicting dates regarding the date of Resident #1's ant incident.) Interview on 12/29/11 at 11:40 a.m. with Certified Nursing Assistant (CNA) # 2 revealed that "pulled cover back. My last round was pass nine (9) p.m. It was late. Her gown was wet, took gown off. Ants on (her) stomach, in her hair, bed, nice amount of ants. Not just around the tube, they were on her chest. She (Resident #1) did not say anything." Interview on 12/29/11 at 11:00 a.m. with CNA #1 revealed that CNA #2 had requested assistance in Resident #1's bedroom after the discovery of ants in Resident #1's bed and on Resident #1. Interview on 12/29/11 at 12:20 p.m. with the Pest Control Company Representative #1 revealed that initially on 12/21/11 Resident #1's bedroom was treated for [REDACTED]. Treatment in the C Hall Dining Room was initiated on 12/26/11. Observation on 12/29/11 at 12:50 p.m. in the C Hall Dining Room with the Maintenance Director and the Pest Control Representative in attendance revealed four (4) live ants near the door and one (1) dead ant behind the base board. The Pest Control Company Representative #1 stated that on 12/28/11 a chemical had been sprayed behind the base plank in the C Hall Dining Room and the ants observed at that time were fire ants. Observation of the facility continued, which revealed fire ants in the A Hall Dining Room. The DON provided a document not titled and not dated that revealed "The Golden Living Center of Amory abides by Federal Guidelines regarding pest control. Employees should be aware of the presence of items that may attract pests into the facility and tend to or report them to the supervisor, such as uncovered food items, spills that are not cleaned promptly, unclean equipment, etc." The facility had no pest control policies to provide.