Every finding on record at Eagle Health & Rehabilitation

Based on observations, staff interviews, and record review, the facility failed to ensure each resident received food that was prepared in a form designed to meet individual needs for two residents (R) (R4 and R20) of six residents who required a pureed diet. Specifically, the facility failed to ensure that the consistency of the pureed diet was appropriate to meet the needs of the residents. Findings included: Review of the IDDSI (International Dysphagia Diet Standardization Initiative) dated 2019 read in part: Level 4 Pureed - Have a smooth with no lumps .not sticky .do not require chewing .Food characteristic to AVOID .tough or fibrous foods .food with skins or outer shell, food with husks, bone or gristle .stringy food .visible lumps. Examples of food to AVOID .steak .peas .corn .meat with gristle .lumps in pureed food. Review of the lunch menu for the week of 4/22/2025 through 4/24/2025 included: 4/22/2025 Beef stew, white rice, green peas, and frosted spice cake. 4/23/2025 BBQ ribs, baked beans, corn, and double chocolate chip cookies. 4/24/2025 Ethica fried chicken, roasted sweet potatoes, Key [NAME] vegetable blend, dinner roll, and bread pudding. 1. R4 was admitted to the facility on [DATE], and diagnoses included unspecified dementia, hemiplegia and hemiparesis, diverticulitis, gastro-esophageal reflux disease (GERD), cognitive communication deficit, Alzheimer's disease, dysphagia oropharyngeal phase, and dysphagia oral phase. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively impaired and staff identified the resident had short and long-term memory problems, no memory recall, and was severely impaired; never or rarely made decisions. The resident was dependent on staff during meals. She had a mechanically altered diet that required a change in the texture of food or liquids. Review of the care plan, which was reviewed by facility staff on 3/21/2025, identified the resident needed assistance using utensils and bringing food and liquids to her mouth. The interventions included assisting the resident with meals. Further review of the care plan, which was reviewed by facility staff on 3/21/2025, identified the resident was at risk for altered nutrition related to use of daily diuretics, risk of weight fluctuations, edentulous, and history of dysphagia. Interventions included staff was to observe for worsening swallowing and/or chewing problems; staff was to provide diet as prescribed; the resident required total assistance with feeding; and the resident was on a pureed diet. Review of the current physician orders included: Puree 4 for the diagnosis of dysphagia, oropharyngeal phase. The order was entered on 5/15/2024. Review of the annual nutrition assessment dated [DATE] included the diet order of Puree 4. Review of the nutritional screen dated 3/12/2025 included the diet order of Puree 4. Review of R4's meal tickets from 4/22/2025 to 4/24/2025 identified the resident received a pureed diet. During an observation and interview on 4/22/2025 at 12:33 pm, Certified Medication Aide (CMA) HH was feeding R4 her lunch. The CMA stated the meal was beef stew, rice, and mixed vegetables of peas and carrots. She stated the food was not smooth, but was moderately smooth. She stated the resident was supposed to have a pureed diet, which was smoother. CMA HH stated she was able to feed the resident the consistency and give her drinks in between bites of food. The beef stew appeared stringy, the rice looked like mini tapioca pudding beads, and there was the skin from the peas, and the carrots were in small chunks. CMA HH returned the plate to the kitchen and returned at 12:48 pm with another plate. The consistency was not pureed. CMA HH stated it was smoother, to help the resident swallow more easily, but it still was not the consistency of the dessert, which was pudding consistency. During an observation and interview on 4/23/2025 at 12:16 pm, Registered Nurse, MDS (RN/MDS) Coordinator AA sat down to assist R4. She stated the resident's meal consisted of corn, which had a husk, and the BBQ meat was stringy; neither of the two items was smooth or pudding consistency. 2. R20 was admitted to the facility on [DATE] with diagnoses that included dementia and dysphagia, oropharyngeal phase. Review of the quarterly MDS dated [DATE] included the resident's Brief Interview for Mental Status (BIMS) score was seven out of 15, indicating the resident was severely cognitively impaired. The resident was dependent on staff during meals. She had a mechanically altered diet that required a change in the texture of food or liquids. Review of the care plan, which was reviewed by facility staff on 2/24/2025, identified the resident needed assistance using utensils and bringing food and liquids to her mouth. The interventions included assisting the resident with meals. Further review of the care plan, which was reviewed by facility staff on 3/21/2025, identified the resident was at risk for altered nutrition. Interventions included the resident required total assistance with meals; staff was to provide the diet as prescribed; and the resident was on a pureed diet. Review of the current physician orders included: Puree 4 for the diagnosis of infection and inflammatory reaction due to an indwelling urethral catheter. The order was entered on 10/3/2024. Review of R20's meal tickets from 4/22/2025 to 4/24/2025 identified the resident received a pureed diet. During an observation on 4/22/2025 at 12:59 pm, R20 was in her room being assisted with her meal by CNA II. She stated the resident was supposed to have a pureed diet and provided the meal ticket that identified Puree-4. CNA II stated the resident had to have foods softened, and this was not a pudding or mashed potato consistency. She stated the dessert was a pureed consistency. CNA II stated the food should not have stringy pieces in the meat, the rice was not mashed potato consistency, and it was supposed to be pureed. She stated this was not smooth, the peas and carrots should be smooth, and there were pea skins and little chunks of peas and carrots being served. She further stated the rice was ground and not like the dessert, which was a pudding consistency. During an interview on 4/23/2025 at 1:29 pm, CNA BB stated she assisted R20 at about 12:30 pm for the lunch meal. She stated the resident was on a pureed diet, which should be smooth and not lumpy. She stated the meal was not smooth, and she saw the husks from the corn in the food. During an observation and interview on 4/24/2025 at 12:55 pm, R20 was in her room, and her meal was on a tray on her bedside table. CNA BB was assisting the resident, and she stated the lunch meal looked different today, it's thicker and smoother than yesterday and the day before; there are no lumps. During an interview on 4/23/2025 at 12:26 pm, Registered Dietitian (RD) EE stated they followed the IDDSI. She stated they used the spoon test, which included the placement of the pureed product on a spoon and flicking it. She stated they wanted it to come off easily and not leave a lot of residual on the spoon. She stated that as long as it met the test, then it was okay. RD EE stated she could not supply a copy of the IDDSI and stated, You can search it. She stated, I can only give you a copy of the policy. A copy of the policy was requested. The RD left the building at approximately 12:45 pm and did not provide a copy of the policy, as requested. An email was sent to the Administrator to request a copy of the policy for alternate diet textures, which was not received by the time of the exit. During an interview on 4/23/2025 at 1:08 pm, the RN/MDS AA stated she was in the dining room daily to assist and to make sure there was a nurse in the dining room. She stated she and the Assistant Director of Nursing (ADON) took turns in the front or the back of the dining room. She further stated the pureed diets today were different, and it was normally pretty smooth. During an interview on 4/23/2025 at approximately 3:00 pm, the Nursing Home Administrator (NHA) GG stated they did not have a policy for food that was mechanically altered. He stated it was because they followed the IDDSI. NHA GG stated they had not had a negative outcome with the food not being smooth. During an interview on 4/24/2025 at 1:02 pm, with the Dietary Manager (DM) FF and the RD EE present, DM FF stated that on the first day (of the survey), the pureed food was not right. She stated the cook did not puree the food long enough. She stated she felt the meal was smooth enough on the second day because the cook followed protocol, with the spoon test. DM FF stated she could not disagree that the meat was stringy both days, the rice was not smooth, and the vegetables were not smooth enough. She stated it was important to ensure the food was the proper consistency for the safety of the residents. She further stated they did not want the residents to choke, and to make sure they ate properly and comfortably. RD EE would not describe the food. She stated she glanced at it and it was supposed to be smooth, and that it should not have had lumps or clumps.

Based on observations, staff interviews, and record review, the facility failed to provide special eating equipment and utensils and assistance for one of one resident (R) (6) reviewed for the use of adaptive equipment. Specifically, the facility failed to identify the correct position of a plate guard and who was responsible for the correct position of the plate guard on the resident's plate during meals. Findings included; R6 was admitted to the facility on [DATE] with diagnoses that included spastic hemiplegic cerebral palsy, lack of coordination, severe intellectual disabilities, and general weakness. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], which contained a Brief Interview for Mental Status (BIMS) assessment that the staff completed, identified that the resident had long and short-term memory problems and was severely cognitively impaired and never or rarely made decisions. The resident required setup and/or clean-up assistance with meals, in which a helper set up and/or cleaned up; and the helper assisted only prior to or following the activity. The resident's height was 66 inches (5 feet 6 inches), and weight was 185 pounds. There were no therapies during the assessment period. Review of the care plan, which was reviewed by facility staff on 2/11/2025, identified the resident had a self-care deficit and required assistance with Activities of Daily Living (ADLs), which included the resident needing assistance using utensils and bringing food and liquids to her mouth, as evidenced by an assistive device for meals. The care plan did not identify the assistive device for the problem. The interventions included that the staff were to assist the resident with meals. The interventions did not identify what equipment was needed and did not provide instructions on how or where to position the plate guard on the plate, or who was responsible for ensuring the plate guard was placed properly on the plate. Review of the significant Nutritional Change assessment dated [DATE], identified the use of a plate guard. The assessment did not provide instructions regarding how or where to position the plate guard, the plate, or who was responsible for ensuring the plate guard was placed properly on the plate. Review of the Nutrition Screen completed by the Dietary Manager dated 1/21/2025, revealed the use of a plate guard. The screen did not provide instructions regarding how or where to position the plate guard, the plate, or who was responsible for ensuring the plate guard was placed properly on the plate. Review of the Occupational Therapy (OT) Discharge Summary dated 4/6/2017 read in part: Pt [patient] is discharged from OT services secondary to pt's treatment plan completed, staff have been consistently securing a plate guard in place during meals, with pt independent during feeding task with minimal to no spillage noted. The summary did not provide instructions regarding how or where to position the plate guard, the plate, or who was responsible for ensuring the plate guard was placed properly on the plate. During an observation on 4/22/2025 at 12:44 pm, R6 was sitting in the dining room at a table with her lunch meal. The plate had a plate guard set from 9:00 to 2:00 (positions on a clock), and the bottom half of the plate was open. The resident had food debris on the table and her clothing that came from her spilling food from the unguarded portion of the plate. No staff were assisting or queuing the resident while she ate. During an observation on 4/23/2025 at 12:12 pm, R6 was sitting in the dining room at a table with her lunch meal. The plate had a plate guard on from 6:00 to 12:00 (positions on a clock), which left the right side of the plate open. R6 was eating independently without staff assistance or queuing. Continued observation revealed R6 ate less than half of the serving of corn, and there was corn in between the plate and the plate guard. During an interview on 4/23/2025 at 1:08 pm, Registered Nurse/MDS (RN/MDS) Coordinator AA stated she was in the dining room daily to assist and to make sure there was a nurse in the dining room. She stated she and the Assistant Director of Nursing (ADON) took turns in the front or the back dining room. She identified R6 as the only resident with a plate guard of which she was aware. She said she was not sure where it was supposed to be positioned. RN/MDS AA stated she did not know if R6 had an order for the plate guard or if it had a specific location (how/where to place on the plate) or who was supposed to put the plate guard on the plate. During an interview on 4/24/2025 at 2:40 pm, Certified Nurse Aide (CNA) BB helped in the dining room as needed. She stated the plate guard should have been in position when they (staff) served the tray; she reiterated that it should be on. CNA BB stated that if the plate guard was not on the plate, she would ask the Dietary Department for the plate guard. CNA BB stated they used to have a chart to show staff how to put the plate guard on. CNA BB stated Resident 6 used a plate guard, and she would put the plate guard on in the 3:00-9:00 position, which left the top of the plate open, because the resident was right-handed. She stated the lunch ticket did not include the position of the plate guard, and the plan of care did not say anything about the position. CNA BB stated it was important to have the plate guard in the right position, so the food did not go outside the plate and helped keep the food on the resident's fork and spoon. During an interview on 4/24/2025 at 4:38 pm, Director of Rehabilitation/Physical Therapist Assistant (DOR/PTA) CC stated she had been in her current position since 12/30/2024. She explained the process when a resident required a plate guard with the following steps: Notification from dietary, nursing, or a therapist (it was a team effort) would occur; if a device was needed, then they sent a referral to OT (Occupational Therapy) or ST (Speech Therapy). She stated that the majority of the referrals went to OT because they provided assistance with feeding. DOR/PTA CC was not sure where the use of a plate guard would be found in the electronic medical record. She was unsure who placed the plate guard on the plate. She stated they did not have a policy for the use of assistive devices for meals. DOR /PTA CC stated R6's plate guard position should have been open at the top. She stated it was also dependent on whether the resident was right or left-handed. DOR/PTA CC stated R6 was right-handed, so the plate guard should be placed at 12:00-6:00 (position on a clock) on the left side of the plate because she is right-handed. DOR/PTA CC stated that if recommended, they would provide education to the staff on where the opening should be. She stated she was unable to find information about the position or who was responsible for placing the plate guard on the plate in the electronic medical record. She reviewed the care plan and was unable to locate the use of the plate guard. She stated she thought it needed to be on the care plan. DOR/PTA CC further stated it was important to know the position of the plate guard and who was responsible for its placement, so when she ate, food did not fall off the plate. The plate guard was used due to visual impairment. During an interview on 4/24/2025 at 4:44 pm, Director of Nursing (DON) DD stated she did not know who was responsible for placing the plate guard on the plate. She stated that during her observations, the plate guard was already on the plate. DON DD stated the plate guard was not listed on the care plan and should have been. She stated the Registered Dietitian told her an order was not needed for a plate guard to be used. DON DD stated it was important to know the correct position to place the plate guard in order to keep the food on the plate, so the resident was able to get the food to her mouth. During an interview on 4/24/2025 at 5:38 pm, Nursing Home Administrator (NHA) GG provided a copy of the plan of care for the physical functioning portion, which included the history of the use of the plate guard beginning on 3/7/2018. The documentation did not include information regarding the positioning of the plate guard.

Based on staff interviews, record review, and facility document review, and review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, the facility failed to ensure allegations of sexual abuse for three of three residents (R) (R1, R3, and R4) reviewed for abuse prohibition were reported to the state survey agency (SSA) no later than two hours after the allegations were made. Findings included: Review of the facility's policy titled, Abuse Prohibition-Reporting and Investigating, dated 12/27/2024, revealed the Guidelines section included, Any person hearing a complaint of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation must immediately tell the Administrator, the Director of Nursing, the Social Services Director, any specific department leader, or the nurse in charge. Any person identifying any signs and symptoms of abuse as listed in the Abuse Prohibition policy related to a specific patient is responsible to immediately inform the Administrator, the Director of Nursing, the Social Services Director, any specific department leader, or the nurse in charge. All allegations of abuse or allegations involving serious bodily injury must be reported immediately, but no later than 2 hours. The Administrator or designee will notify the Complaint Investigation Intake and Referral Unit and the legal representative and/or responsible party of the incident and the pending investigation. 1. Review of a handwritten witness statement by Scheduling Coordinator (SC) 5, with a corrected date of 4/22/2024, revealed SC5 was traveling a hallway when R5 called her into a living room area. The statement revealed that R5 stated that R2 was masturbating as the resident was rubbing up and down on R1's leg. The statement indicated that when SC5 got into the living room, R2 had their hand in their pants. Per the statement, the staff member took the resident to the nurses' station and reported the incident to a charge nurse. Review of R2's Nurses Note, dated 4/22/2024 at 11:30 am, indicated Licensed Practical Nurse (LPN) 4 documented that another resident observed R2 masturbating while rubbing R1's leg while in a day room with several residents present. The note indicated that the resident who observed the incident got the attention of a staff member, who also witnessed the incident. The note indicated R2 was redirected and taken to their room. During an interview on 4/03/2025 at 4:07 pm, LPN4 stated that she was notified of the incident with R2 and documented the incident in nursing notes. Per LPN4, she also notified the Administrator of the incident. Review of a Facility Incident Report Form, dated 4/30/2024, indicated R2 was observed touching another resident on the leg in a potentially unwanted manner. Further review of the report revealed the number was Not available at this time and no other agencies [were] involved. During an interview on 4/4/2025 at 12:43 pm, the Administrator stated he found out about the incident on 4/30/2024 while reviewing R2's chart for something unrelated. He stated he saw the note that LPN 4 had written. According to the Administrator, staff did not tell him about the incident. Per the Administrator, after speaking with LPN4 and SC5, each staff member thought the other was going to report the incident. During an interview on 4/5/2025 at 3:11 pm, the Administrator stated he reported the incident to the SSA on 4/30/2025. 2. Review of the Concern Manager Grievance Intake Form, dated 1/16/2025 and written by the Healthcare Navigator for Skilled Nursing Services (HNSNS), indicated that at approximately 12:00 pm, she observed R3 and R2 alone in a community room. The form indicated R3 was in distress and calling out for assistance. The form revealed that when the HNSNS went in to speak to R3, the resident was pointing to their genital area. Review of the Facility Incident Report Form, dated 1/16/2025, indicated R3 expressed to staff that R2 touched them without permission. According to the report form, the time of the incident was 2:50 pm, not approximately 12:00 pm as documented on the Concern Manager Grievance Intake Form. Review of an email from the SSA to the facility Administrator, dated 1/16/2025 at 4:50 pm, revealed the SSA had received the facility's incident report. During an interview on 4/4/2025 at 11:37 am, the HNSNS stated she reported the incident to a nurse on duty. She stated the Administrator was not in the building, so she called him to inform him about the incident. The HNSNS stated the Administrator asked LPN13 to interview R3 and write a statement. During an interview on 4/05/2025 at 11:00 am, the HNSNS stated she did not see anything happen with R3, but knew that something was not right because of how upset the resident was, which was not their normal behavior. She stated she took the resident to Certified Nursing Assistant (CNA) 9, and CNA 9 told her she needed to report it to the Administrator right away, so she called him. She stated the Administrator thanked her for letting him know, but did not give her any instructions. During an interview on 4/4/2025 at 11:39 am, LPN 13 stated that the HNSNS witnessed the incident and removed R2, then told the Administrator. She stated the Administrator and Director of Nursing (DON) were not in the building at that time, and the Administrator called her and told her to start conducting interviews. A follow-up interview on 4/5/2025 at 11:25 am, LPN 13 revealed that the Administrator had notified her of the incident via phone, but she did not remember what time she had spoken with the Administrator. During an interview on 4/5/2025 at 11:49 am, the SC revealed she was present when LPN 13 was interviewing R3, noting the resident stated that they were being touched while in the living room. She stated the incident occurred between 12:00 pm and 12:15 pm. During an interview on 4/5/2025 at 2:48 pm, the DON stated she and the Administrator were at training, and she was not involved with the associated investigation. She stated staff should report any suspected abuse to the supervisor immediately, and they had two hours from the time it was observed or reported to report the incident to the SSA. During an interview on 4/5/2025 at 3:25 pm, the Administrator stated he received a call from the HNSNS at lunchtime. Per the Administrator, the HNSNS reported that she saw R3 and R2 in the living room, and R3 was upset. He stated R3 was in distress for some reason, and the HNSNS removed R2 from the area. He stated nothing immediately struck him as suspicious because the resident got upset at times for reasons like the television being too loud. The Administrator stated he had asked a nurse to talk to R3. He stated that when LPN13 spoke with the resident, they called him back, and he reported the allegation to the SSA. He stated he considered the event to have occurred when R3 communicated to LPN13 that something had happened. The Administrator also stated that he documented in the report the time that the incident was reported to him. 3. Review of a handwritten witness statement by LPN14, dated 2/13/2025, indicated that at 11:35 am, she observed R2 rubbing between R4's thighs. The statement indicated that the Director of Nursing (DON) and the physician were notified. Review of a Facility Incident Report Form, dated 2/13/2025, indicated staff observed R2 touching R4 in a potentially unwanted manner. Further review of the report indicated the incident occurred on 2/13/2025 at 1:00 pm. The report did not have the date and time the SSA was notified of the allegation. However, an email from the SSA to the facility administrator dated 2/14/2025 at 2:40 pm indicated the SSA received the facility's incident report. During an interview on 4/4/2025 at 2:39 pm, LPN14 stated she walked into a television room to check on the residents and saw that R2 had their hand rubbing another resident's inner, upper thigh. LPN14 stated she reported to the DON right after it happened. During an interview on 4/5/2025 at 2:48 pm, the DON stated LPN14 met her in the hallway and reported that R2 was touching R4 inappropriately. She stated she had notified the Administrator by telephone call immediately. The DON stated staff should report any suspected abuse to the supervisor immediately, noting they had two hours from the time it was observed or reported to report the incident to the SSA. During an interview on 4/5/2025 at 3:52 pm, the Administrator stated LPN14 identified R2 in the living room rubbing R4's thighs. He stated the nurse notified the DON and the physician. He stated he thought it was the DON that called him at 12:37 pm to notify him. He further stated that once he was notified, he contacted his clinical consultant to see if it should be reported. He stated he had asked the DON to get more information, and she had LPN14 document a detailed statement. He stated he found out later that the incident needed to be investigated and reported. He stated he documented that the incident occurred at 1:00 pm on the incident form because he was trying to do the report while he was mobile. He agreed that the witness statement indicated the event happened at 11:35 am. The Administrator confirmed that once he was notified of an allegation, he had two hours to report to the SSA.

Based on observation, staff interview, record review, review of the facility's policy titled, Abuse Prohibition, the facility failed to protect the residents' right to be free from sexual abuse by another resident for two of three residents (R) (R1 and R4) reviewed for abuse prohibition. Specifically, the facility failed to develop or implement interventions to address R2's sexual behavior to protect R1 and R4 from sexual abuse. Findings included: Review of the facility's policy titled, Abuse Prohibition, dated 12/27/2024, revealed the Intent section included, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Guideline section included, . Identification of patients whose behavior is abusive to other patients. If a patient is identified in one of the following categories, a thorough assessment will be completed to include any identified situations or factors that trigger abusive behavior. Patients who have displayed or attempted to display abusive behavior toward other patients. ii. From the assessment, intervention strategies will be developed on the care plan or behavior management plan to prevent occurrences including monitoring for factors that trigger abusive behavior for this patient. iii. The care plan, including interventions, will be evaluated on a regular basis and revised as necessary. The Prevention section included, The center will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur. This will include an analysis of . The deployment of staff on each shift in sufficient numbers to meet the needs of the patients, and assure that the staff assigned has knowledge of the individual patients' care needs. 1. Review of R2's Face Sheet indicated the facility admitted the resident on 8/4/2023, and diagnoses included acute kidney failure, essential primary hypertension, moderate protein-calorie malnutrition, adult failure to thrive, muscle weakness, difficulty walking, lack of coordination, and unsteadiness. Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/5/2024, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not have any behaviors during the seven-day look-back assessment period. Review of R2's Care Plan included care area/problem, with an onset date of 4/30/2024, that indicated the resident had inappropriate sexual behaviors of touching themself in public areas. Interventions instructed staff to administer medications for a clearly defined goal aimed at a specific target for which the drug was effective, assess patterns of behavior with a behavior monitoring tool, communicate face to face with simple descriptive statements, identify self with each contact, involve the person in activities based on their preferences and cognitive functioning, maintain a tolerant, calm manner, make sure the resident had adequate personal space and safe space to move about, provide privacy appropriate to maintain self-esteem, reward and reinforce positive behaviors, and to talk with the person, not at the person. There was no documented evidence that the facility developed/implemented a care plan for R2's potential for sexual abuse and/or sexually inappropriate behaviors toward other residents, with interventions to protect other residents from further potential sexual abuse. Review of R2's Nurses Note, dated 2/28/2024, indicated a day shift certified nursing assistant (CNA) stated she was attempting to assist R2 with getting changed into a clean incontinence brief, when the resident started rubbing the CNA's leg and became aroused, making the CNA uncomfortable. Review of a facility's 24-Hour Report log dated 4/1/2024 indicated that, during the night shift, R2 displayed inappropriate sexual behavior toward staff. Review of R2's 2's April 2024 electronic medication administration record (eMAR) revealed that medroxyprogesterone acetate (a medication used to decrease testosterone production, which may decrease sexual urges) 5 milligrams (mg) one tablet by mouth one time a day was ordered on 4/1/2024 for sexual dysfunction not due to a substance or known psychological condition. The eMAR revealed that staff documented the medication was administered to R2 beginning 4/2/2024 and was administered daily in the month of April 2024. Review of R2's Behavior Monitoring from 4/1/2024 through 4/30/2024 revealed the facility was monitoring the resident for inappropriate sexual behaviors daily. According to the monitoring: -R2 had two episodes of inappropriate sexual behaviors during the day shift on 4/6/2024, where the resident was redirected with no change. -R2 had two episodes of inappropriate sexual behaviors during the day shift on 4/7/2024, where the resident was redirected with a positive outcome. -R2 had two episodes of inappropriate sexual behaviors during the night shift on 4/7/2024, where the resident was redirected with no change. -R2 had two episodes of inappropriate sexual behaviors during the night shift on 4/11/2024, where the resident was redirected with no change. Review of a Social Note dated 4/15/2024 indicated a referral for psychiatric services was made. Review of R2's Nurses Note, dated 4/22/2024 at 11:30 am, indicated Licensed Practical Nurse (LPN) 4 documented that another resident observed R2 masturbating while rubbing R1's leg while in a day room with several residents present. The note indicated that the resident who observed the incident got the attention of a staff member, who also witnessed the incident. The note indicated R2 was redirected and taken to their room. Review of a Nurse Practitioner (NP) Progress Note dated 4/25/2024 indicated nursing staff and other residents reported R2 was masturbating in multiple common areas. The note indicated the resident started medroxyprogesterone on 4/1/2024, with a plan for as-needed Ativan and scheduled Seroquel with a new diagnosis of dementia with behavioral disturbances. The note revealed that R2's behavior typically started occurring at 3:00 pm, and the plan was to schedule Seroquel 25 mg at 3:00 pm. Review of a Psychiatric Diagnostic Evaluation dated 5/2/2024 revealed R2 received a psychiatric evaluation with medication and monitoring recommendations and a follow-up in one to three months. Review of a Behavior Health Evaluation document dated 5/7/2024 revealed R2 received a psychological services evaluation. Observation of R2's Resident's Consolidated Order revealed a physician's order dated 10/26/2024 for medroxyprogesterone 150 mg per milliliter (mg/mL) intramuscular (IM) every month on the 26th at bedtime. Review of R2's November 2024 eMAR revealed the end date for the order for medroxyprogesterone 5 mg by mouth was 11/14/2024. Review of R2's November 2024 and December 2024 eMAR indicated the diagnosis for the use of medroxyprogesterone was sexual dysfunction not due to a substance or known physiological condition; however, there was no documented evidence that staff administered medroxyprogesterone in November 2024 or December 2024. Review of a Patient Education note, dated 1/28/2025, indicated a social services director, accompanied by a CNA, spoke with R2 regarding inappropriate sexual behaviors. The note revealed R2 was educated that there was nothing wrong with exposing their privates in the privacy of their room; however, a public place, such as the living room and dining area, was not the place to expose themself. The note revealed R2 stated, I can not say I didn't do that, but I promise I will not do it again. The note revealed that the social service director expressed to the resident that if anyone felt they were being approached or harassed inappropriately as a result of the resident's actions, it would warrant calling the police. Per the note, the social service director conversed with a nurse who noted that the resident was placed on medication for inappropriate sexual behavior. Review of R2's clinical record revealed a document dated Every 15-minute Check Sheet dated 2/13/2025 to 2/16/2025, documenting no behaviors. Observation on 4/3/2025 at 2:29 pm revealed R2 sat in a wheelchair in their room. No inappropriate behaviors were observed. Observation on 4/4/2025 at 10:55 am revealed R2 sat in a wheelchair in the hallway outside their room. The resident provided non-sensical answers to questions that were posed. No inappropriate behaviors were observed. Observation on 4/5/2025 at 11:56 am revealed R2 sat in a wheelchair by the nurses' station. During the observation, no other residents were in the area, and no inappropriate behaviors were observed. 2. Review of R1's Face Sheet indicated the facility admitted the resident on 2/11/2022, and diagnoses included diagnoses of Rett's syndrome (a genetic brain disorder), idiopathic scoliosis (curve of the spine from an unknown cause), and cognitive communication deficit. Review of R1's annual MDS, with an ARD of 2/6/2024, revealed R1 had severe impairment in cognitive skills for daily decision-making per a staff assessment of mental status (SAMS). Review of R1's Care Plan included a care area/problem dated 2/10/2025 of limited mobility as evidenced by decreased range of motion and contractures. Review of a handwritten note included with the facility's investigation revealed that a social visit was completed with Resident 1 on 5/8/2024, 5/23/2024, and 6/4/2024, and the resident displayed no signs of distress. Observation of R1 on 4/3/2025 at 2:27 pm revealed the resident was in a geriatric chair in a living room with other residents. The resident's eyes were closed, and the resident did not respond when spoken to. Observation of R1 on 4/4/2025 at 10:48 am revealed the resident sat in a geriatric chair in a living area with other residents. R1 opened their eyes when their name was vocalized, but did not answer any questions. Observation of R1 on 4/5/2025 at 11:27 am revealed the resident sat in a geriatric in a living area. The resident was not able to answer any questions. 3. Review of R4's Face Sheet revealed the facility admitted the resident on 12/06/2024, and diagnoses included need for assistance with personal care, cognitive communication deficit, muscle weakness, and Alzheimer's disease. Review of R4's admission MDS, with an ARD of 12/12/2024, revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. Per the MDS, R4 understood others and was usually understood (difficulty communicating some words or finishing thoughts, but was able if prompted or given time). Review of R4's Care Plan revealed a care area/problem dated 1/3/2025 that indicated the resident had cognitive impairment as evidenced by short- and long-term memory problems, severely impaired decision making, and poor decision making/need for cues. Review of the facility's investigation summary report dated 5/7/2024 indicated a resident of the facility reported to a staff member that they observed R2 with their hand down their pants in the facility's living room, apparently masturbating while rubbing the leg of R1. The report revealed the staff member proceeded immediately to the living room and found R2 had their hand down their pants and was sitting next to R1, but did not see the resident rubbing R1's leg. Further review of the report revealed that interviews with other residents and staff revealed R2 had been observed touching himself in his room and in shared areas, but had not been observed touching other residents. Review of a handwritten witness statement by Scheduling Coordinator (SC) 5, with a corrected date of 4/22/2024, revealed SC5 was traveling a hallway when R5 called her into a living room area. The statement revealed that R5 stated that R2 was masturbating as the resident was rubbing up and down on R1's leg. The statement indicated that when SC5 got into the living room, R2 had their hand in their pants. Per the statement, the staff member took the resident to the nurses' station and reported the incident to a charge nurse. Review of a facility investigation summary report dated 2/20/2025 revealed that on 2/13/2025, a staff member observed R2 rubbing R4's upper, inner thigh while the residents were in a living room. The report revealed that staff separated the residents. Further review revealed that staff assessed both residents for signs of distress, including skin assessments, and there were no concerns. The Administrator notified local law enforcement. The investigation documented that resident-to-resident abuse was unsubstantiated. During an interview on 4/3/2025 at 4:14 pm, SC5 stated R5 summoned her and told her that R2 had their hand in their pants, masturbating while touching R1. She stated she went into the living room and saw R2 sitting next to R1 with their hand in their pants, but she did not see R2 touching R1. She stated she immediately removed R2 from the living area and took them to their room. During an interview on 4/4/2025 at 2:39 pm, LPN14 stated she walked into a television room to check on the residents and saw that R2 had their hand rubbing the other resident's inner upper thigh. She stated she separated the residents, assessed R4 physically and mentally, notified the physician, and received an order for Paxil for R2. She stated R2 was also placed on every 15-minute checks. She stated staff continued to monitor R2 if the resident was out of their room and tried to keep the resident by the nurses' station, noting if R2 was in the television room, she checked on them every 15 minutes and kept R2 at a distance from other residents. During a phone interview on 4/5/2025 at 9:58 am, CNA11 stated she had witnessed R2 touching a female resident's feet while the resident slept on the couch, and she reported the incident to a charge nurse. She stated she had not been told to do anything specific for R2, but when she saw the resident in a public place, she kept her eyes on the resident and kept a distance between R2 and other residents. During a phone interview on 4/5/2025 at 10:07 am, CNA12 stated she had witnessed R2 moaning while their hands were in their pants, but it was not in public. She stated the facility told her that when the resident was not in their room, they were to be monitored. During an interview on 4/5/2025 at 11:11 am, Certified Medication Aide (CMA)8 stated he had seen R2 with their hands in their pants in their room, but not in public. He stated he was told that R2 should not be alone with other residents. He stated he watched R2 whenever they were out of their room. During an interview on 4/5/2025 at 11:18 am, CNA10 stated she had seen R2 touching another resident's feet and told them to stop, but then saw the resident do it again, so she moved R2 away from any other residents in the common areas. She stated the facility had told her not to isolate R2, but to keep them several feet away from other residents, noting the resident had to be in an area in their line of sight. During an interview on 4/5/2025 at 11:30 am, CNA 9 stated she had never witnessed an actual incident, but the facility told her to keep an eye on R2 frequently when the resident was out of bed and in a common area. She stated that staff made sure that R2 was not close to another resident and was kept at a safe distance away. During an interview on 4/5/2025 at 1:53 pm, the Social Service Assistant (SSA) stated she did not witness any of the incidents involving R2. She stated she conducted post-incident resident interviews, referred the residents for psychiatric services, and did well checks afterwards. She stated that the facility discussed all the incidents during a morning meeting. The SSA stated staff should monitor R2 and redirect them, and those interventions should be care-planned. During an interview on 4/5/2025 at 2:48 pm, the DON stated LPN14 met her in the hallway and said R2 was touching R4 inappropriately. She stated she called the Administrator to let him know, then went to determine what interventions they could put in place. She further stated she wanted to send R2 out for stabilization, but the PCP spoke with the psychiatric nurse practitioner, and they decided to start Paxil, so she put the resident on every-15-minute checks. The DON stated that staff had been instructed to separate R2 from other residents if the resident was close to them and that staff knew they should keep an eye on R2 whenever the resident was in a common area. In a continued interview, the DON stated she was aware that R2 did not receive the medroxyprogesterone injection in November 2024 but thought that the December 2024 dose was administered. During an interview on 4/5/2025 at 3:11 pm, the Administrator stated another resident alerted a staff member and told them what they witnessed. Per the Administrator, the staff member saw R2 with their hands down their pants, but the resident was not touching R1. The Administrator stated R1 was not a reliable historian, noting the facility conducted a head-to-toe assessment of R1 and assessed for any changes in behavior. The Administrator stated the facility initiated a behavior assessment, updated R2's care plan, and R2 was seen by psychiatric services on 5/3/2024. The Administrator stated that the primary care provider (PCP) conducted a medication review and gave new orders, and the facility was monitoring behaviors. He stated that social services also spoke with R2 about appropriate places in the facility for masturbating. Further, the Administrator stated they instructed staff to observe R2 when in public places to prevent a recurrence. During the continued interview, the Administrator stated LPN14 identified R2 in the living room rubbing R4's thighs. He stated LPN14 redirected R2 out of the room, assessed R4 for physical and mental distress, notified the DON and the physician, and placed R2 on every 15-minute checks for 72 hours. He stated R2's care plan was reviewed, and they assessed environmental factors, but no new interventions were initiated that he was able to see. He stated was unaware that R2's medroxyprogesterone was not administered in November or December of 2024. Per the Administrator, R2 was able to be up and about and could go wherever they wanted, but when R2 was mobile, they tried to make frequent observations, especially in common areas. He stated they could not tell the resident that they could not go to a common area, but they monitored the resident, including where they were and what they were doing, and redirected if needed. During an interview on 4/6/2025 at 10:45 am, the Medical Director (MD) stated R2 was started on medroxyprogesterone due to having inappropriate behaviors with the staff. He stated he was aware that the IM medroxyprogesterone was not administered in November 2024. He stated he believed that the symptoms were well controlled, and he did not want the medication given too close to the next dose. The MD stated he was not aware that the resident did not get the dose in December of 2024. He stated he spoke with the psychiatric NP, and they decided together that the IM medroxyprogesterone was not completely effective, and the resident needed something more, so they added Paxil.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Food Preparation and Distribution and Storage Areas, the facility failed to store and prepare food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure meal temperatures were documented and failed to ensure dented cans were removed from the dry storage area and were not available for use. This failure had the potential to affect 37 of 39 residents who received meals from the kitchen. Findings included: A review of the Food Preparation and Distribution policy, dated 10/11/2022, revealed It is the intent of the center to prepare and distribute food in a manner that minimizes the risk of food borne illness and promotes safe food handling practices. The policy also revealed, Tray line: A temperature monitoring log should be maintained throughout meal service. Temperatures should be monitored frequently throughout meal service to ensure food quality and safety. A review of facility documents titled Hot/Cold Temperature Log from 01/01/2023 through 02/28/2023 revealed incomplete or missing meal temperature documentation for 40 of 59 days. The missing or incomplete information included: - The meal temperature documentation was missing for 01/11/2023, 01/28/2023, 01/31/2023, 02/03/2023, 02/04/2023, 02/06/2023, 02/08/2023, 02/11/2023, 02/12/2023, 02/13/2023, 02/19/2023, 02/24/2023, 02/25/2023, and 02/26/2023. - The breakfast temperature logs were missing for 02/01/2023. - The lunch temperature logs were missing for 01/27/2023 and 02/17/2023. - The breakfast and lunch logs were missing for 01/14/2023, 01/17/2023, 02/15/2023, 02/16/2023, and 02/23/2023. - The dinner temperature logs were missing for 01/06/2023, 01/07/2023, 01/08/2023, 01/09/2023, 01/10/2023, 01/12/2023, 01/13/2023, 01/18/2023, 01/20/2023, 01/22/2023, 01/24/2023, 01/29/2023, 01/30/2023, 02/02/2023, 02/05/2023, 02/07/2023, 02/09/2023, 02/10/2023, 02/20/2023, and 02/21/2023. Interview on 02/28/2023 at 11:58 a.m. with Dietary Cook #8 stated food temperatures should be taken and recorded for every meal and should be documented. She stated temperature logs were important for food safety and resident food satisfaction. Interview on 02/28/2023 at 12:10 p.m. with Certified Dietary Manager (CDM) stated meal temperature logs should be filled out daily at each meal. He stated his former assistant CDM was checking the logs, and he should have been checking them behind her. He stated most of the dates in the log should be complete, but a few could be missing. He was unaware of how many mealtime temperature documentations were missing from the logs. Interview on 03/01/2023 at 12:06 p.m. with the Director of Nursing (DON) stated she expected temperatures to be recorded during mealtimes per policy and procedure. She stated tracking of meal temperatures were important for food safety and food served at unsafe temperatures could cause bacterial growth and develop food born illnesses. Interview on 02/28/2023 at 2:12 p.m. with the Administrator stated meal temperatures should be logged and filled out at every meal. A review of the facility policy titled, Storage Areas, dated 12/04/2021, revealed It is the intent of this center to store food in a manner that maintains quality and safety. The policy also revealed, Dry Storage. Dented cans should be stored separately in a clearly labeled area. Interview on 02/27/2023 at 9:19 a.m. with the Certified Dietary Manager (CDM) stated dented cans were stored in an outside closet where the emergency food was stored. He stated canned goods were screened for dents and if discovered, should be pulled and the intact cans would get placed onto the rack. He stated he would use cans with minor dents first and cans with major dents would be thrown out right away. Observations on 02/27/2023 at 9:34 a.m. of the dry storage area during the initial kitchen tour on revealed three dented cans of tomato soup, each weighing three pounds. Interview on 02/28/2023 at 11:58 a.m. with Dietary Cook #8 revealed she assisted with putting orders away and dented cans were to be removed to the dented can rack. She stated dented cans could introduce bacteria into the food. Interview on 03/01/2023 at 12:06 p.m. with DON revealed she expected dented cans to be removed as the dent could impact the food's integrity. Interview on 02/28/2023 at 2:12 p.m. with Administrator stated canned goods should be checked upon arrival. He stated cans should be screened and returned if unsafe for use. He stated no dented cans should be in the kitchen.

Based on staff interviews and record review the facility failed to ensure 1 of 5 residents (R) (#30) was free from unnecessary medications. Specifically, the facility failed to discontinue buspirone (an anxiety medication) for R#30 as ordered by the resident's physician on 01/25/2023. As of 02/28/2023, the facility continued to administer the medication to the resident. Findings included: Interview on 03/01/2023 at 2:53 p.m. with the Director of Nursing (DON) revealed the facility had no policy related to unnecessary medications or following physician orders. Review of R#30's Face Sheet revealed the resident was admitted to the facility with a diagnosis including unspecified dementia with anxiety. Review of the most recent admission Minimum Data Set (MDS), for R#30 dated 11/10/2022, revealed R#30 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. Review of the electronic medication administration record (eMAR) indicated R#30 was started on buspirone (anti-anxiety medication) 10 milligram (mg) tablet, once daily by mouth on 01/09/2023. Review of a Psychiatric Diagnostic Evaluation note, dated 01/18/2023, revealed a recommendation to discontinue buspirone 10 mg every day for anxiety due to increased risk of serotonin syndrome (a potentially life-threatening drug reaction that results from too much serotonin in the body). Further review revealed the resident's physician acknowledged the recommendation on 01/25/2023 and documented to discontinue the buspirone. Review of the eMAR for January 2023 and February 2023 revealed R#30 received buspirone 10 mg tablet once daily at 9:00 a.m. every day from 01/25/2023 through 02/28/2023. Interview on 03/01/2023 at 11:11 a.m. with the Pharmacy Consultant revealed she wrote a recommendation in January 2023 related to the buspirone for R#30, and the physician responded. However, in doing a pharmacy review on 02/10/2023, she saw the R#30 was still receiving the buspirone and wrote a clarification note to see if the medication could be discontinued. She stated she had not received a response as of this date (03/01/2023). Interview on 03/01/2023 at 9:26 a.m., the DON stated she did not know why the order was not carried out; it could have been an oversight. She further stated she expected if a physician ordered a medication to be discontinued, it should have been stopped. Follow-up interview with the DON on 03/01/2023 at 10:07 a.m., she stated the nurse who reviewed the 01/25/2023 orders did not document the buspirone order onto a physician's order. She stated she did not know why the order was not entered. She further stated the nurse who reviewed the order was no longer working in the facility and there was no contact information for the nurse. Interview on 03/01/2023 at 2:23 p.m. with the Administrator revealed he would expect the physician's orders to be followed, and the resident would not receive any unnecessary medication.

Based on staff interviews and record review the facility failed to ensure laboratory testing was performed timely and as ordered by the physician for 1 (Resident #35) of 5 residents (R) (#35). Findings included: During an interview with the Administrator on 03/01/2023 at 2:23 p.m., he stated there were no policies related to laboratory testing. Review of the Face Sheet for R#35 revealed the resident was admitted with diagnoses including bipolar disorder and iron deficiency anemia. Review of the physician's orders Summary Report for R#35 revealed an order dated 08/17/2022 for a complete blood count (CBC) every six months. Further review revealed orders, dated 08/15/2022, to start ferrous sulfate (iron) 325 milligrams, one tablet by mouth twice daily for anemia and valproic acid 250 mg by mouth three times daily for bipolar disorder. In addition, R#35 had a physician order dated 08/19/2022 to obtain a valproic acid level every three months related to bipolar disorder. Review of a Note to Attending Physician/Prescriber, for R#35 dated 10/11/2022, revealed the pharmacist had conducted a medication review related to the ferrous sulfate medication and recommended checking the resident's iron level, ferritin (a blood test that helps determine how much iron your body stores), and total iron binding calcium (TIBC is a blood test to see how much iron you have in your blood) to determine the continued need for medication therapy. The physician signed the response on 10/17/2022. However, there was no documented evidence that the laboratory tests were obtained at that time. Review of the pharmacy Past Due Lab [laboratory] Orders, dated 12/09/2022, revealed R#35 had a CBC due 11/30/2022. Review of the pharmacy Past Due Lab [laboratory] Orders, for R#35 dated 01/13/2023, revealed R#35 had a valproic acid level due 11/30/2022. There was no documented evidence the facility had obtained the laboratory test for the resident. Review of a Note to Attending Physician/Prescriber, dated 01/13/2023, revealed the pharmacist made another recommendation for laboratory tests (iron, ferritin, and TIBC) to be performed related to R#35 receiving ferrous sulfate for anemia. The physician signed the note on 01/26/2023 and a nurse noted the order on 01/30/2023. Review of R#35's laboratory results, dated 01/31/2023, revealed the resident's total iron level was low at 55 micrograms per deciliter (ug/dL) (normal range is 65-175ug/dL), total iron-binding capacity (TIBC) was within normal limits at 326 ug/dL (normal range is 240-450 ug/dL), transferrin saturation was low at 17 percent (%) (normal range is 20-50% and a low percentage indicates iron deficiency), transferrin was normal at 233 milligrams per deciliter (mg/dL) (normal range is 202-362), and ferritin was normal at 36 nanograms per deciliter ng/dL (normal range is 24-366). Interview on 03/01/2023 at 9:17 a.m. with the Director of Nursing (DON) revealed she normally printed pharmacy recommendations and put them in a physician book. The physician then reviewed and agreed or disagreed with the recommendations. According to the DON, the nurses and the DON should have seen the physician's comments. She stated if there were any new orders, the staff should have noted the orders and the recommendations and orders should have been given to medical records staff to be scanned into the electronic health record. The DON stated the facility obtained R#35's iron levels on 01/31/2023. However, during a follow-up interview with the DON on 03/01/2023 at 10:45 a.m., she stated she was unable to locate a valproic acid level completed for R#35. Interview on 03/01/2023 at 11:11 a.m. with the Pharmacy Consultant revealed it was important to monitor the valproic acid levels for toxicity and therapeutic range. She stated for R#35, the monitoring was more for toxicity. The Pharmacy Consultant further revealed she left a list of overdue laboratory tests at the facility each month following pharmacy reviews. She further stated that generally, when she asked the facility about why laboratory tests were not being done, the facility stated they had a plan in place, but laboratory tests were still late. Interview on 03/01/2023 at 2:23 p.m. with the Administrator, he stated he expected physician orders to be followed, and resident laboratory testing to be completed as ordered.

Based on staff interviews and record reviews, the facility failed to ensure Level 1 Preadmission Screening and Resident Reviews (PASARR) were accurate to ensure provision of the appropriate level of services for 2 of 3 residents (#8 and #35) whose PASARRs were reviewed. This failure had the potential to increase the risk for a resident with a mental illness diagnosis from not receiving specialized services. Findings included: Review of a Face Sheet indicated R#8 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and schizophrenia. Review of the Nurses Note, dated 03/28/2022, revealed R#8 was admitted to the facility on this date. The note indicated R#8 had a history of schizophrenia. Review of the Care Plan, with an onset date of 03/30/2022, revealed R#8 was taking a psychotropic drug related to schizophrenia. The most recent admission Minimum Data Set (MDS), dated [DATE], for R#8 was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status. Per the MDS, R#8 had a diagnosis of schizophrenia. A review of a Preadmission Screening/Resident Review (PASRR) Level I Assessment (Form: DMA-613), dated 03/24/2022, revealed R#8 did not have a diagnosis of schizophrenia and did not have any diagnoses of a serious mental illness. Interview on 03/01/2023 at 8:06 a.m. the Administrator stated the facility did not have any written policies related to PASARR. 43648 Review of the Face Sheet indicated for R#35 was admitted to the facility on [DATE] with a diagnosis that included bipolar disorder. The most recent admission Minimum Data Set (MDS) dated [DATE] for R#35 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The R#35 had an active diagnosis of bipolar disorder. Review of the Care Plan, dated 02/15/2023, indicated R#35 had a PASARR diagnosis and had received services. The goal of the Care Plan was for the resident to demonstrate positive coping skills. The intervention was to observe the resident and provide psychosocial support as needed. The Care Plan did not address the resident's diagnosis of bipolar disorder. Review of a PASRR Level I Application (DMA-613) Resident Identification Screening Instrument, dated 05/02/2022, indicated the resident did not have a diagnosis of bipolar disorder and did not have any diagnoses of a serious mental illness. Interview on 03/01/2023 at 8:23 a.m., the Social Services Coordinator (SSC) stated admission PASARRs were put in the system by the Business Office Manager (BM). The SSC added she would make sure they were accurate. If they were not accurate, they should be resubmitted with the accurate information. Interview on 03/01/2023 at 12:07 p.m., the Director of Nursing (DON) stated admission PASARRs were reviewed by Social Services to ensure they were accurate. The applicable diagnoses that were listed in the medical record should be noted on the PASARR. If it was not correct it should be resubmitted with the correct information. Interview on 03/01/2023 at 2:12 p.m., the Administrator stated the current diagnoses should be on the PASARR. He added if there was a discrepancy, then the PASARR needed to be updated and resubmitted.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Patient's Plan of Care, the facility failed to follow residents' individualized care plans directing staff to apply barrier cream after an incontinence episode for 2 of 3 residents (#24 and #31) who received incontinence care. This failure had the potential for residents to not receive treatment and/or care according to their needs and may cause adverse consequences. Findings included: The facility's policy titled, Patient's Plan of Care, with a review date of 12/04/2021, indicated, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. A review of R#24's Face Sheet revealed the facility admitted R#24 with a diagnosis of anoxic brain injury. The care plan revised on 11/22/2022 indicated R#24 was at risk for skin breakdown. Interventions included using barrier cream after each incontinent episode to protect the resident's skin. Observation on 03/01/2023 at 9:40 a.m., Certified Nursing Assistant (CNA) #2 removed R#24's brief and removed a bowel movement using a disposable wipe. After cleaning up the bowel movement, the CNA#2 placed a clean brief on the resident without applying a moisture barrier on the resident's skin. Interview on 03/01/2023 at 9:55 a.m., CNA#2 acknowledged she had not applied any moisture barrier, although she said she typically placed barrier cream on a resident after she bathed a resident if the resident's skin was red. CNA#2 stated she had not put any barrier cream on R#24 because she had no barrier cream with her in the room but added that barrier cream was kept on the cart in the hall. She stated she had been helping with R#24. Interview on 03/01/2023 at 10:00 a.m., CNA#3 stated barrier cream was used for any resident who wore briefs and had a risk of skin breakdown. Interview on 03/01/2023 at 10:50 a.m. with Licensed Practical Nurse (LPN) #1 stated interventions to prevent skin breakdown included applying a moisture barrier after each incontinent episode. The LPN#1 stated R#24 was at risk for skin breakdown due to incontinence and would need moisture barrier applied after incontinence care. The LPN#1 stated if the care plan directed staff to apply moisture barrier the expectation would be for staff to follow the care plan. Interview on 03/01/2023 at 12:17 p.m. with CNA#5 stated she was assigned to care for R#24 for the shift. The CNA#5 stated that when she provided incontinence care for R#24, she did not routinely apply barrier cream after an incontinence episode. Interview on 03/01/2023 at 12:19 p.m. with Director of Nursing (DON) stated she expected staff to use barrier cream after incontinence episodes and expected staff to follow the care plan for the residents. Interview on 03/10/2023 at 2:30 p.m. the Administrator stated he expected staff to follow the care plans for the residents. The facility's policy titled, Patient's Plan of Care, with a review date of 12/04/2021, indicated, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the patient's medical, physical, mental and psychosocial needs. A review of a Face Sheet revealed the facility admitted R#31 with hemiplegia (limited movement) following a stroke affecting the left non-dominant side, heart failure, and chronic obstructive pulmonary disease. A review of R#31's care plan, with a revision date of 01/25/2023, revealed the resident was at risk of developing further skin breakdown. Interventions included applying a barrier cream after incontinence episodes. An observation was made on 03/01/2023 at 9:00 a.m. with the Clinical Care Coordinator (CCC) providing wound care. The resident's brief was wet and soiled. The CCC removed the resident's bowel movement using a disposable wipe without applying barrier cream to the resident's skin. Interview on 03/01/2023 at 10:50 a.m. with Licensed Practical Nurse (LPN) #1 The LPN#1 stated interventions to prevent skin breakdown included applying a moisture barrier after each incontinence episode. The LPN#1 stated R#31 was at risk for skin breakdown due to incontinence and would need moisture barrier applied after incontinence care. The LPN#1 stated if the care plan directed staff to apply moisture barrier, the expectation would be for staff to follow the care plan. Interview on 03/01/2023 at 12:54 p.m. with the CCC stated there had been no reason she had not applied moisture barrier to R#31's skin, but would have applied the barrier if the resident's skin had been red. The CCC stated the care plan should be followed. Interview on 03/01/2023 at 12:19 p.m. with the DON stated she expected staff to use the barrier cream after incontinence episodes and expected staff to follow the care plan for the residents. Interview on 03/10/2023 at 2:30 p.m. with Administrator stated he expected staff to follow the care plans for the residents.

Based on observations, staff interviews, and record review, the facility failed to ensure activities of daily living (ADLs) care were provided to maintain good grooming related to facial hair for 1 of 3 residents (R) (#22) reviewed for ADL care. Findings included: Multiple requests were made for a policy that addressed the intent for shaving for residents. On 03/01/2023 at 10:00 a.m. The Administrator presented a shaving procedure guide that only explained how to shave a resident. A review of the Face Sheet for R#22 revealed the facility admitted the resident with a diagnosis that included hemiparesis (lack of movement) on the dominant right side following a stroke. A review of the most recent quarterly Minimum Data Set (MDS), for R#22 dated 02/10/2023, indicated had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The MDS indicated the resident had no behaviors or rejection of care. The MDS indicated R#22 required extensive assistance with personal hygiene and had impairment in functional range of motion on one side of the upper extremities and one side of the lower extremities. The Care Plan, last revised on 02/27/2023, indicated the resident had a self-care deficit related to decreased range of motion and hemiplegia. Interventions included assisting R#22 with ADLs as needed. The care plan did not indicate R#22 refused care. Observation on 02/27/2023 at 9:35 a.m. R#22 was lying in bed. The resident was observed with chin hair that was approximately one to two inches long. The resident stated staff had to assist with the removal of the chin hair and the resident added they would like for the hair to be removed. R#22 was unable to recall the last time a shave had been received. Observations on 02/28/2023 and 03/01/2023 revealed R#22's chin hair was still present. Interview on 03/01/2023 at 11:02 a.m. with Licensed Practical Nurse (LPN) #1 stated the Certified Nursing Assistant (CNA) #6, who was also the scheduler, usually shaved residents. She stated the CNAs on the hall also shaved residents. Interview on 03/01/2023 at 11:06 a.m. with Certified Nursing Assistant (CNA) #3 stated the CNAs on the hall were responsible for shaving residents and shaving should be done daily if needed. The CNA stated she was assigned to care for R#22 on 03/01/2023 but had not given the resident a bath yet and added this was the first day she had worked with the resident this week. The CNA #3 observed R#22 and agreed the resident should have been shaved. CNA #3 stated R#22 had not refused care with her. On 03/01/2023 at 11:15 a.m. LPN #1 observed R#22 and agreed the resident needed to be shaved. At the time of the observation, R#22 stated day shift staff never thought about shaving them. Interview on 03/01/2023 at 11:39 a.m. CNA #6 acknowledged she shaved most of the residents and stated she had tried to shave R#22, but the resident refused. She stated she had reported the refusals, but could not name anyone she had told. The CAN #6 stated she had not documented the refusals. Interview on 03/01/2023 at 12:19 p.m. with Director of Nursing (DON) stated if a resident refused care, she expected the staff member to ask again, then get another staff member to try. The CNA was to then report the refusal to the nurse and if the refusal continued, the nurse should document the refusal. The DON stated that R#22 refused care at times, but she expected the refusals to be documented by the nurse. Interview on 03/01/2023 at 2:30 p.m. with Administrator stated he expected staff to follow the standard of practice for ADL care as outlined in Lippincott's manual (manual for nursing services). He added he expected the residents to be clean shaven and well groomed.

Based on observations, staff interviews, record review, and a review of the facility's policy titled, Perineal care, the facility failed to provide proper incontinent care by not thoroughly removing urine from the resident's skin for 2 of 3 residents (R) (#24 and #31) reviewed for incontinent care. Findings included: The facility's policy titled, Perineal care, with a review date of 12/30/2022, indicated perineal care was to ensure adequate skin care, control odor, prevent skin damage, preserve dignity, and prevent urinary tract infections to the extent possible. Review of the most recent quarterly Minimum Data Sheet (MDS), for R#24 dated 12/20/2022, indicated R#24 was sometimes understood and rarely/never understood others. The staff assessed the resident as having short-term and long-term memory impairment. The resident was dependent on staff for all activities of daily living. The MDS indicated R#24 was always incontinent of bowel and bladder. Observation on 03/01/2023 at 9:40 a.m. Certified Nursing Assistant (CNA) #2 removed R#24's brief and the CNA placed a clean brief on the resident without wiping the urine from the resident's perineal area. On 03/01/2023 at 9:45 AM, CNA #2 was interviewed. She acknowledged she had only removed the bowel movement from the resident and had not removed the urine from the resident's skin. CNA #2 stated she had forgotten to wipe the resident's skin and added there were no more disposable wipes in the room. Interview on 03/01/2023 at 12:19 p.m. with Director of Nursing (DON) stated incontinent care should be provided according to facility policy and that procedures outlined in the Lippincott Manual of Nursing Practice should be followed as well. She added this included wiping the urine off of the resident and cleaning around the urethra. Interview on 03/10/2023 at 2:30 p.m. with Administrator stated he expected staff to follow the standard of practice for activities of daily living care as outlined in the Lippincott manual. Review of the most recent admission Minimum Data Set (MDS), for R#31 dated 10/03/2022, indicated the resident scored 4 on the Brief Interview for Mental Status (BIMS), which indicated R#31 was severely cognitively impaired. The MDS indicated R#31 required extensive assistance for activities of daily living and was always incontinent of bowel and bladder. Observation on 03/01/2023 at 9:00 a.m. with the Clinical Care Coordinator (CCC) providing wound care. Resident #31 had soiled their brief and been incontinent of bowel and bladder. The CCC placed a clean brief on R#31 without cleaning the urine from the resident's perineal area. The CCC was interviewed on 03/01/2023 at 12:54 PM. The CCC stated she forgot to wipe down the middle of the resident's perineum and stated she knew she should have cleaned the urine completely from R#31's body. The Director of Nursing (DON) was interviewed on 03/01/2023 at 12:19 PM. The DON stated incontinent care should be provided according to facility policy and that procedures outlined in the Lippincott Manual of Nursing Practice should be followed as well. She added this included wiping the urine off of the resident and cleaning around the urethra. Interview on 03/10/2023 at 2:30 p.m. with Administrator stated he expected staff to follow the standard of practice for activities of daily living care as outlined in the Lippincott manual.

Based on observations, record review, and staff interviews, the facility failed to develop a care plan to address the behavioral needs of one resident (R) (#31) who removes his clothing. The sample size was 22 residents. Findings include: Observations on 8/15/21 at 1:40 p.m. and 8/16/21 at 10:44 a.m. revealed R#31 was observed with no pants on and brief exposed. During an interview on 8/17/21 at 2:10 p.m., Licensed Practical Nurse (LPN) AA stated that R#31 requires extensive assistance with care needs and does have some behaviors such as crawling on the floor and taking off his clothes at times, which is why staff usually dress the resident early. Interview on 8/17/21 at 2:20 p.m. with Certified Nursing Assistant (CNA) CC revealed that she works with R#31 frequently and he does require assistance with dressing. CNA CC stated that the resident does have pajamas to wear to bed and they are usually on him when she comes in in the mornings. Continued interview revealed that the resident will sometimes crawl around on the floor on the mat at the bedside and remove his clothing. Interview on 8/17/21 at 3:45 p.m. with Training Nursing Assistant (TNA) BB revealed that she usually works with R#31 on the evening shift and before putting resident in the bed for the night she generally changes his adult brief and puts on his pajamas before bed. She stated that sometimes the resident will take his pants off himself or ask for them to be removed. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#31 did not complete the Brief Interview of Mental Status (BIMS) Assessment and was rarely/never understood. Review of the care plan for R#31 revised 7/20/2021 revealed no problem or interventions to address the behavior that the resident removes his clothing. Interview with Administrator on 8/18/21 at 1:03 p.m. revealed she has been employed with facility since July 2020 and usually make rounds on the halls at least twice daily. After first arriving to facility, she observed R#31 uncovered with brief exposed and was told by staff that the resident removing his clothes was a behavior of the resident. She stated she spoke with the care plan team in reference to the behavior but failed to follow up to ensure that a care plan was developed. Behaviors of residents are discussed during Patient at Risk (PAR), care plan, and clinical meetings. During the meetings, appropriate disciplines should address the issue and implement appropriate interventions for the resident's care needs.

Based on observations and staff interviews, the facility failed to maintain a clean environment related to dirt buildup in six shared resident bathrooms (A14, A18, A19, A20, A30, and A34) of 33 rooms. Findings include: Observations of room A19 shared bathroom on 8/15/21 at 1:20 p.m. and 8/16/21 at 8:45 a.m. revealed brown/black stains in the base of the toilet and a large black stain on the floor around the bottom of the toilet. Observations of room A20 shared bathroom on 8/15/21 at 1:30 p.m. and 8/16/21 at 9:06 a.m. revealed a brown ring around the inside base of the toilet. Grime and buildup were noted to the base of toilet on the floor. Observations on 8/15/21 starting at 2:00 p.m. and 8/16/21 starting at 1:23 p.m. revealed the following: In the shared bathroom of room A14, dust buildup was observed in the vent in bathroom and missing wall tile by the toilet paper holder. In the shared bathroom of room A18, dark colored buildup was observed inside the toilet and dust on the vent in the bathroom. In the shared bathroom of room A30, dust buildup was observed on the bathroom vent. In the shared bathroom of room A34(empty), a dark ring build up was observed in the toilet, dirt buildup on floor in the bathroom, and a missing tile behind the toilet. During observation and interview on 8/16/21 at 3:50 p.m., environmental concerns identified during the survey were confirmed with the Administrator and Maintenance Supervisor. Further interview with Administrator on 8/16/21 at 4:23 p.m. revealed that the facility currently does not have a Housekeeping Supervisor in place. Housekeeping is overseen by herself and maintenance.

Based on observations, record review, and resident/staff interviews, the facility failed to ensure the right of one resident (R) (#1) to maintain personal property within her possession. The sample size was 22 residents. Findings include: Review of the clinical record for R#1 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include [CONDITION(S)], anxiety disorder, and depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#1 possessed adequate hearing, impaired vision, clear speech, was understood and understandable. The Brief Interview for Mental Status (BIMS) score was documented at 12, indicating moderate cognitive impairment. During an interview on 8/15/21 at 5:01 p.m. in her room, R#1 stated she was moved from B-Hall to the A-Hall and her belongings have not been moved into her new room. During an interview with the Social Services Director (SSD) on 8/18/21 at 12:42 p.m., she stated residents were moved from the B-Hall to the A-Hall. During that move, the managers were assigned groups of residents to facilitate the moves. She stated R#1 was moved on 7/7/21 but all her belongings were not moved with her. She stated R#1 asked specifically for a shelf to be moved to her new room which staff moved for her. She stated all the residents' belongings should have gone with them when they were moved. She did not know why all belongings for R#1 were not taken with her. Observation of R#1's old room (B-15) with the SSD on 8/18/21 at 12:51 p.m. revealed a dresser with clothes piled on top and coins, jewelry, and remote control strewn on the floor in front of it. The SSD stated that was inappropriate and she would gather R#1's belongings and take them to her current room. During an observation of R#1's old room (B-15) with the Administrator on 8/18/21 at 1:10 p.m., she stated she did not know why all belongings for R#1 were not moved to her new room.

Based on observations, staff interviews, record review, and the facility policies Storage Area and Cleaning and Sanitizing, the facility failed to ensure that food items were being prepared in a clean sanitary environment free of dirt, debris, and pests, food was stored in a manner to prevent food contamination, refrigerator vents were clean, food items are labeled and dated, and all expired food items were discarded. This had the potential to effect 34 of 41 residents receiving an oral diet. Findings include: Record review of policy titled Storage Area dated 2020 documented: It is the intent of this center to store food in a manner that maintains quality and safety . 1(a). Guidelines -items will be covered sealed, labeled, and dated appropriately 7(c). Refrigerator-Food will be properly stored to prevent cross contamination. 7(d) FDA, Food Safety Guide.Gov website, and internal tools may be used as a reference for proper dating. Record review of policy tiled Cleaning and Sanitizing dated 2020 documented: It is the intent of the center to clean and sanitize utensils, dishware, pots, and pans, workspace, and equipment to minimize the risk of food borne illnesses. Guidelines (1). Cleaning schedules will be implemented and maintained for all areas of the kitchen. An observation on [DATE] at 10:47 a.m. of refrigerator #1 with the Dietary Manager (DM) revealed a box of lettuce opened and not properly sealed. A closer observation of the lettuce revealed that positioned directly above was a refrigerator vent covered with thick sticky dark brown substances. The DM wiped the vent with a white hand towel and identified the dark brown substances as dirt and confirmed that the open box of lettuce was being exposed to the dirt from the vent. An observation on [DATE] at 10:48 a.m. of refrigerator #2 with the DM revealed a pan of cooked hamburger meat dated [DATE] and expiration date of [DATE]. The DM confirmed that the hamburger meat should had been discarded within three days and that the dates documented were correct and exceed the three-day time frame. An open package of [MEDICATION(S)] stored in a zip lock bag dated [DATE] with a discard date of [DATE]. Further observation revealed a vent in the refrigerator which was covered with thick sticky dark brown substances. The DM confirmed that the substances was dirt. An observation on [DATE] at 10:49 a.m. of refrigerator of #3 with DM revealed five packages of bread dated [DATE] with an expiration date of [DATE], one package of turkey breast open with an expiration date of [DATE], four prep zip locked bag meals containing four turkey breast sandwiches dated [DATE]. The DM identified and confirmed the five bag items as lunches for the facility's four [CONDITION(S)] residents that should had been discarded. An observation on [DATE] at 10:52 a.m. of freezer #1 with the DM revealed five packages of bread dated [DATE] with an expiration date [DATE], one bag of French fries open from the top dated [DATE]. Further observation of revealed French fries' crumbs on the floor of the freezer. The DM confirmed the crumbs as French fries. An observation on [DATE] at 10:53 a.m. of kitchen floor tile revealed thick yellow color substances coating the tiles underneath vegetable/meat sink and in front of refrigerator #3, and underneath the preparation table #1 and preparation table #2, and on the tile underneath the steam table. There were also dark brown, dark yellowish, greasy substances on the floor along with debris, and dead roaches between the stove and preparation table #1. An observation on [DATE] at 10:55 a.m. with the DM of four open food seasoning containers (lid of seasoning was not sealed properly exposing the content to the environment) stored on a bottom shelf of a cart next to the preparation table. The floor tile was stained with dark thick yellowish substances and a dead roach was lying on the floor next to the cart. Further observation revealed a roach crawling directly across from the seasoning. The DM confirmed that the seasoning lids should have been closed and that a dead roach and a crawling roach was directly across from the opening seasoning, Observation on [DATE] at 11:23 a.m. in the kitchen dishwashing area with DM revealed three roaches crawling in the kitchen area and dish washer area. Further observation revealed dark brown speckle substances with debris lying on top of the surfaces of the dish washer equipment. Observation with the DM on [DATE] at 11:27 a.m. of the space between a preparation table #1 and the stove revealed thick dark brown and black hard speckle substances. The DM identified the substances as grease built up with roach waste. During the observation, a roach was observed crawling from the space and under the steam table. Observation of the steam table wells revealed lunch food items in the trays of each well. The DM confirmed the insects as being a roach and confirmed its movement and location underneath the steam table. The Dietary Aide/Cook (DA) BB was observed using the preparation table to prep food items. Preparation table #2 is positioned directly across from the steam table. Observation on [DATE] at 11:36 a.m. of the kitchen tiles with DA AA and BB revealed dead roaches in front of the preparation table #2. Both DA AA and BB identified the insect as a roach. DA AA stated that earlier she had stepped on the dead roach to kill it. Both DA AA and BB confirmed having to step on crawling roaches often to kill them in the kitchen. DA BB was using preparation table #2 at the time to prep food items for lunch. Interview with the DM at the time of the observation on [DATE] at 12:03 p.m. revealed that he was aware of the problem with roach infestation in the kitchen and had sent a prior email to the Administrator and the facility Register Dietician sometimes last [DATE]. The DM stated that he was employed in August of 2020 and the roach problem was identified back in [DATE]. He stated that pest control has been out to the facility at least monthly to spray the kitchen. He feels that the problems have not been completely resolved. The DM stated that he has not spoken with the Maintenance Supervisor (MS) about the roach problem each time the roaches were identified in the kitchen area. Further interview with the DM revealed that dietary staff have cleaning assignment which included mopping the floors during the shifts. The DM stated that his expectation is for all food items to be properly labeled and stored in a sanitary manner, floors to be mopped and free from dirt, debris, and grease stains. He further stated that dietary staff have been in-serviced on cleaning which includes wiping the fan vents in the refrigerator. Interview on [DATE] at 12:05 p.m., DA AA confirmed being trained on cleaning which included mopping and cleaning fan vents in the refrigerator, food storage and labeling, and discarding of expired food items. Further interview revealed that the roach problem in the kitchen has existed since the last DM left a year ago, she stated that she often has to step on the roaches to prevent them from crawling. DA AA stated that the pesticide is not really working. She further stated that it appears to be more roaches in the dishwashing area. Interview on [DATE] at 12:07 p.m., DA BB confirmed receiving training on cleaning which included mopping and cleaning fan vents in the refrigerator, food storage and labeling, and discarding of expired food items. DA BB revealed that the roach problem in the kitchen has existed for at least a year. She feels there are more roaches crawling in the morning times once they open the kitchen. Interview with the Administrator on [DATE] at 12:24 p.m. revealed that her expectations are for the kitchen to be always maintained in a clean sanitary condition. She further stated that the facility has a cleaning contract for deep cleaning of all tiles in all areas of the facility. This includes deep cleaning of the kitchen tiles. She was unaware of the condition of the kitchen tiles. The Administrator confirmed that she has not been in the kitchen to observe the tiles and the cleanliness of the kitchen area. Further interview revealed that she was aware of the roach problems and that the Pest Control Company HH has been servicing the facility for several months. The Administrator stated that the roaches have only been identified in the kitchen. She stated that there have been no resident complaints of roaches in residents' rooms or resident's common area. There were no adverse resident outcomes identified as a result of the conditions on the kitchen area.

Based on observation, record review, review of the facility policy titled Open Tracheal Suctioning via [MEDICAL CONDITION] instructions, review of the Respiratory Therapy Services Agreement with the contracted Respiratory Therapy Services company, and staff interviews, the facility failed to ensure that there were adequate open suction catheters available to suction seven [MEDICAL CONDITION] and ventilator dependent residents. Findings include: Review of the Respiratory Therapy Services Agreement (effective date 7/8/2011) revealed that the contracted Respiratory Therapy Services company shall keep and maintain at all times all equipment and supplies in accordance with industry standards. Review of the Open Tracheal Suctioning via [MEDICAL CONDITION] instructions (Lippincott, (YEAR)), staff should open the suction catheter kit, don sterile gloves provide suctioning and discard the suction catheter and gloves. An interview with Respiratory Therapist (RT) Manager JJ on 8/13/19 at 1:55 p.m. revealed that he became the new RT Manager for the Ventilator Unit (VU) approximately 1 and ½ weeks ago. Continued interview revealed that there were no available disposable suctioning catheters in the RT office on the VU when he arrived. He stated at that time that two of the RTs who worked on the VU told him that they had to reuse disposable suctioning catheters because the previous RT Manager had not ordered enough to provide suctioning for the residents who resided on the VU. Further interview with RT Manager JJ revealed that reuse of disposable suctioning catheters promoted increased infections in ventilator dependent residents. RT Manager JJ stated that the RTs had his number at the Respiratory Therapy Services Company and could have called for needed supplies. Further interview revealed that he was not aware of any ventilator dependent residents who developed any infections related to the reuse of the disposable suctioning catheters. Interview with RT GG on 8/13/19 at 2:20 p.m. revealed that she had to reuse a closed suction catheter on one resident because there were no disposable suction catheters available. She stated that she did not reuse the suctioning catheter on different residents. Continued interview revealed that she could not remember the date of the event or who the residents was. Further interview revealed that she notified Registered Nursing (RN) staff who worked on the VU and she thought that the RN notified administrative staff. She stated at that time that she did email RT Manager JJ who was working at the main Respiratory Therapy Services office at that time. An interview with RN/Vent Unit Nursing Manager on 8/14/19 at 2:10 p.m. revealed that the RTs ordered their own supplies but, nursing also ordered disposable suctioning catheters and [MEDICAL CONDITION] care kits that were kept in the supply room on the VU. Continued interview revealed that she was not aware that disposable suctioning catheters were not available for the RTs to use and that they could obtain them if needed from nursing. Further interview revealed that if nursing did not have any supplies available, she could call the supply company used by the facility and a courier would be sent with the needed supplies within several hours. An interview with RT FF via phone on 8/15/19 at 8:38 a.m. revealed that she had to reuse the same disposable suctioning catheter on a resident on multiple occasions sometime in (MONTH) and (MONTH) 2019 because the previous RT Manager had not ordered enough. She stated that she did not reuse the disposable suctioning catheter on different residents. Continued interview revealed that she had to use VU nursing staff's supplies at times when the suctioning catheters were unavailable in the RT office. Further interview revealed that she had complained to the Administrator and previous Director of Nursing (DON) but could not remember dates. She finally emailed RT Manager JJ and received the needed disposable suctioning catheters. An interview with RN CC on 8/19/19 at 10:00 a.m. revealed that she worked on the VU. RN CC stated that one night a RT told her that there were no disposable suctioning catheters available. Continued interview revealed that she and the RT checked the RT office and located the drawer labeled for suction catheters and it was empty. RN CC stated that there were disposable suctioning catheters in the supply closet on the VU and she provided those to the RT. Further interview with RN CC revealed that she asked about the lack of disposable suctioning catheters in the RT office to the previous RT Manager AA the next morning and RT Manager AA went to the RT office and came back with a disposable suctioning catheter. RN CC stated at that time that she asked RT Manager AA where the suction catheters were kept and RT Manager AA told her that it was none of her business and that the RTs knew where they were kept. A clarification interview with RT GG via phone on 8/19/19 at 10:56 a.m. revealed that when she reused the disposable suctioning catheter, she cleansed the inside of the catheter after use with normal saline. She stated at that time that she did not clean the outside of the catheter because it had an outside sleeve that she lowered over the catheter after use. Further interview revealed that she stored the suctioning catheter in the packet that it came in. On 8/19/19 at 2:10 p.m. observation of the RT office on the VU revealed that there were 63 Closed Suction catheters and 4 boxes of Disposable Suction Catheter kits. Observation of the supply closet on the VU revealed a large box of approximately 15-20 disposable suction kits. A clarification interview with RT FF via phone on 8/19/19 at 2:46 p.m. revealed that she cleansed the suctioning catheter on the inside and outside with normal saline after use and stored it in the packet it came in. Continued interview revealed that the ventilator dependent residents had the attached closed suction catheters for suctioning; however, the single use catheter could not be used for deep suctioning when needed due to the lack of availibility. RT FF stated that the disposable suctioning catheters were best when deep suctioning was needed. Review of the facility's Infection Control Log revealed that there were four (4) healthcare acquired infections on the VU in 4/2019; none (0) in 5/2019; three (3) in 6/2019; and none (0) in 6/2019. The facility failed to ensure that there were adequate disposable open suction catheters available to suction residents.

Based on observation, record review, review of the facility policy titled Skilled Inpatient Services: Reporting and Investigating Abuse Procedural Guidelines (updated 2/2019), and resident and staff interview, the facility failed to report to the State Survey Agency (SSA) within two hours and thoroughly investigate an allegation of psychological abuse for one (1) resident (R) (R#1) from a sample of four (4) residents. Findings include: Review of the facility's policy titled Skilled Inpatient Services: Reporting and Investigating Abuse Procedural Guidelines (updated 2/2019) revealed once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient property the incident will be reported within two hours. The Administrator or designee will take immediate action to prevent further potential violations .When there is substantial evidence that abuse occurred, the suspected employee will be suspended without pay pending investigation .or at the discretion of the Administrative staff, an employee's assignment may be changed .The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit (State Agency) within two hours upon awareness of the allegation of abuse. The local Police Department will be contacted within two hours if there is reasonable cause to believe abuse or suspicion of a crime has occurred .The initial report of incident will be telephoned or faxed within 24 hours of discovery to the Complaint Investigation Intake and Referral Unit Interviews will be conducted of all pertinent parties and written signed statements from any involved parties will be obtained if possible. Statements will be gathered from the suspect, person making accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have some information. Record review revealed that R#1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that R#1 has a Brief Interview for Mental Status Score (BIMS) of 15, indicating that she was cognitively intact. Continued review revealed that she did not exhibit any negative moods or behaviors; was totally dependent on staff for activities of daily living (ADLs); received oxygen therapy, suctioning, [MEDICAL CONDITION] care and ventilator/respirator care; and received Respiratory Therapy daily in the last 7 days. Review of the care plan dated 1/22/19 revealed that the resident had manipulative behaviors and refused care at times including pressure sore treatments and care by the Respiratory Therapist (7/5/18) with appropriate interventions. Review of the Nurses Note dated 7/2/19 revealed that Respiratory Therapist (RT) Manager AA had provided cough assist therapy (utilizing a machine that clears secretions from the lungs by giving air during inspiration to help expand the lungs) to R#1 at 4:00 p.m. R#1's heart rate increased into the 130s beats per minute (bpm) (normal between 60 and 100) and lingered above 110 bpm. Continued review revealed that the RT informed R#1 of the need for her heart rate to be less than 100 bpm for continued therapy. R#1 told the RT that 110 bpm was acceptable. The RT then informed the resident that a heart rate of less than 100 bpm was required and therapy was held. Review of the Nurses Note dated 7/10/19 documented by Respiratory Therapist (RT) Manager AA revealed that at approximately 2:39 p.m. R#1 requested cough assist therapy; however, her heart rate remained too high (110 beats per minute) to provide. Continued review revealed that the Attending Physician, who was on the Vent Unit at the time, was notified and approved the cough assist therapy while she was in the facility to monitor the resident's heart rate. The cough assist therapy was provided to R#1 by RT Manager AA at that time. Review of the Attending Physician's Progress Note dated 7/10/19 revealed that R#1 had complained to her of difficulty controlling her need to cough with the Respiratory Therapists. Continued review revealed that because she had been [MEDICAL CONDITION] (rapid heart rate), the RT was unable to provide cough assist therapy. However, R#1 stated she was [MEDICAL CONDITION] because she needed to cough. Further review revealed that the Attending Physician agreed to allow the cough assist therapy in the [MEDICAL CONDITION] setting while she was in the building to monitor the resident's heart rate and that the RT and R#1 agreed. There was no indication that R#1 notified the Attending Physician that she was afraid or had been abused by RT Manager A[NAME] Review of the Report of Resident Grievance/Compliments dated 7/10/19 at 4:10 p.m. revealed that R#1 stated to the Social Services Director (SSD) that she did not trust Respiratory Therapist (RT) Manager AA with her care. She stated that she believed that RT Manager AA wanted her out of the facility and had her as needed (PRN) cough assist order changed to twice per shift and the cough assist pressure changed. Continued review revealed that RT Manager AA was always in the room when the physician visited and R#1 felt that RT Manager AA did this to intimidate her. Further review revealed that R#1 complained that RT Manager AA did not suction her properly on purpose and came in her room during her personal care time. R#1 stated that she felt RT Manager AA was dangerous. Review of the Actions Taken section of the Report of Resident Grievance/Compliments revealed that the Administrator met with the resident on 7/10/19 to discuss her concerns. Continued review revealed that R#1 voiced her concern that RT Manager AA was preventing her from utilizing the cough machine the way R#1 felt she needed. Review of the Patient Review Form dated 7/11/19 revealed that the Administrator met with R#1 who stated that RT Manager AA talked down to her. The Administrator met with RT Manager AA about the way she spoke to R#1. The contracted Respiratory Services was contacted and agreed to provide customer service training to RT Manager A[NAME] Review of the Nurses Note dated 7/13/19 and documented by Registered Nurse (RN) BB revealed that R#1 was observed with labored breathing/congestion. RN BB asked the resident if she needed the RT but, R#1 stated that she did not want her in here. Review of the Nurses Note dated 7/14/19 and documented by RN CC revealed that at 9:15 a.m., R#1 complained that RT Manager AA was psychologically abusing me. Licensed Practical Nurse (LPN) EE spoke with R#1 who agreed to have RT Manager AA provide her respiratory care with another care giver present that day since there was not another RT in the building. R#1 stated that she preferred that RT Manager AA not provide her care again after 7/14/19. Continued review revealed that R#1 stated that she was afraid RT Manager AA was going to do something bad to her. Review of the Patient Review Form dated 7/15/19 revealed that the Administrator followed up with R#1 about having RT Manager AA and another care giver present during care. RT Manager AA agreed to provide the cough assist therapy when R#1's heart rate was above 100 bpm but below 130 bpm. Review of the Patient Review Form dated 7/18/19 revealed that the Administrator met with R#1 who stated that there were no issues over the previous weekend. Review of the Patient Review Form dated 7/26/19 revealed that the Administrator met with R#1 who stated that she no longer needed two people in the room when RT Manager AA was providing care for her. Review of the Nurses Note dated 7/29/19 revealed that the Pulmonologist assessed R#1. R#1 requested that the pressure for her cough assist therapy be increased. The Pulmonologist educated R#1 on the risks which included pneumothorax or death and R#1 signed the Informed Care Decision on 7/29/19 that she was aware of and accepted the risks. Review of the written and signed statement by the RN/Vent Unit Manger dated 7/29/19 at 8:10 a.m. revealed that R#1 had no concerns. Continued review revealed that R#1 had been delaying her respiratory treatments such as suctioning and had her preference as to who could suction her or provide cough assist therapy. Review of the Nurses Note dated 7/30/19 and documented by RT Manager AA revealed that at 5:15 p.m., RT Manager AA responded to the high pressure alarm for R#1. Cough assist therapy was provided without results in the presence of another RT and a certified nursing assistant (CNA). The resident's heart rate increased to 128 bpm. Continued review revealed that R#1 requested that the RN suction her although two RTs were present. Further review revealed that R#1 was in no distress when the RTs left her room. Review of the Nurses Note dated 7/30/19 and documented by RT FF revealed that when she arrived for work at 7:00 p.m., RT Manager AA told her that R#1 was waiting for her. R#1's vent was alarming at that time. When she entered the resident's room, RT Manager AA was plugging in the cough assist machine for RT FF to use. Continued review revealed that R#1 was crying and begged RT FF not to let RT Manager AA kill her. R#1 also stated to RT FF that RT Manger AA did not do the cough assist therapy correctly and that she did not want RT Manager AA in her room. Review of the Concern Manager Grievance Intake Form dated 7/30/19 revealed that R#1 told staff that RT Manager AA was attempting to provide cough assist therapy because the resident was super congested but RT Manager AA was ineffective. R#1 stated that RT Manager AA was only flipping it (cough assist machine) every 3 seconds but that was not enough to get anything (secretions) out and she refused to do it any longer. The nurse attempted suction but was unsuccessful. Further review revealed that R#1 stated that she had to wait another hour for the next shift staff to help her. The resident stated that she did not want RT Manager AA in her room anymore, that she did not feel safe around her, and she was an ineffective RT. On 7/30/19, the SSA was notified of R#1's allegation of abuse by RT Manager A[NAME] On 8/13/19 at 12:12 p.m. R#1 was lying in her bed watching television. She was pleasant and did not appear afraid or depressed. She stated at that time that the incident with RT Manager AA has been resolved and she's been fired. R#1 stated that she no longer wanted to discuss the incident. Interview with CNA HH and CNA II on 8/13/19 at 1:25 p.m. revealed that they worked on the Vent Unit and provided care for R#1. Continued interview revealed that they had not observed RT Manager AA abuse any residents. CNA HH stated at that time that RT Manager AA was professional and went by the book. Further interview revealed that the facility did not interview them about their observations or request them to provide written and signed statements. Interview with RN BB on 8/14/19 at 9:20 a.m. revealed that the facility did not request her to provide a written and signed statement about her observations. Interview with the Regional Vice President on 8/19/19 at 3:10 p.m. revealed that RT Manager AA's last day at the facility was on 7/30/19. Although R#1 alleged that RT Manager AA was psychologically abusing her and that she was afraid RT Manager AA was going to do something bad to her on 7/14/19, there was no indication that the facility reported to the SSA within two hours about the resident's allegation of psychological abuse. The facility did not report the resident's allegation of psychological abuse until 16 days later on 7/30/19. There was no indication that the facility suspended RT Manager AA on 7/14/19 in order to protect R#1 from further abuse. There was no indication that the facility thoroughly investigated the resident's allegation of psychological abuse by RT Manager AA to include interviews and written statements from RT Manager AA, CNAs who may have been present during RT Manager AA's provision of care for R#1, other nursing staff and RTs who worked on the Vent Unit, as well as cognitively intact residents on the Vent Unit who also received care from RT Manager A[NAME]

Based on observation, record review and staff interview, the facility failed to ensure that pressure sore treatments were provided as ordered by the Physician for three residents (R) (R#1, #2 and #4) with existing pressure sores from a sample of four residents reviewed. Findings include: 1. Record review for R#1 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that R#1 was severely cognitively impaired; was non-ambulatory; required total assistance of two staff for bed mobility, personal hygiene, bathing and toileting; was always incontinent of bowel and bladder; and had two Stage III pressure sores. Review of the Admission MDS dated [DATE] revealed that R#1 was admitted to the facility with two Stage III pressure sores. Review of the care plan for R#1 revised 3/13/19 to address her new left lateral foot pressure sore revealed an intervention to treat the pressure sores as ordered by the Physician. Review of the medical record for R#1 revealed that she was admitted with a Stage III pressure sore on her left hip that measured 0.5 centimeters (cms.) x 0.4 cms. x 0.1 cms. with slough in the wound bed and a Stage III pressure sore on her sacrum that measured 5.2 cms. x 4.1 cms. x 0.2 cms. with slough in the wound bed. The Physician ordered staff to cleanse the pressure sores with wound cleanser, blot dry and apply Di-Dak-Sol (a broad spectrum, topical antimicrobial) soaked gauze and a dry dressing every day. Review of the electronic Med in eTAR and eTAR (treatment records) revealed that treatments were provided as ordered 1/15/19 to 3/23/19. However, there was no indication that licensed/registered nursing staff provided treatments to the sacrum or left hip on 3/24/19, 3/25/19 or 3/26/19. On 3/27/19, the Physician Ordered staff to cleanse the sacral pressure sore with wound cleanser, blot dry, pack with Calcium Alginate with silver (an antimicrobial) and cover with a dry dressing every other day. Review of the treatment records revealed that treatments were provided as ordered 3/27/19 to 5/24/19. However, there was no indication that the sacral pressure sore was treated as ordered on [DATE], 5/28/19 or 5/30/19. On 6/4/19, the sacral pressure sore had healed and the Physician Ordered staff to cleanse the area with normal saline, pat dry and apply a [MEDICATION NAME] dressing as protection every Monday and Thursday. Review of the 6/2019 treatment records revealed that treatment was provided as ordered. Review of the medical record for R#1 revealed that a Stage III pressure sore on her right lateral foot was identified on 3/13/19. The pressure sore measured 1.4 cms. x 1.5 cms. x 0.2 cms. and had slough in the wound bed. The Physician was notified and ordered staff to cleanse the wound with normal saline, blot dry and apply Medi-honey (used for moderately exuding wounds) and a dry dressing every other day. Review of the treatment records revealed that treatments were provided as ordered for 3/13/19 to 5/24/19. However, there was no indication that licensed/registered nursing staff provided treatment as ordered on [DATE] or 5/28/19. On 5/29/19, the Physician ordered staff to cleanse the right lateral foot pressure sore with normal saline, blot dry, apply a foam non-adhesive pad, cover with 4 x 4 gauze and wrap with rolled gauze. However, there was no indication that licensed/registered nursing staff provided treatment as ordered on [DATE]. Review of the 6/2019 treatment records revealed that treatment was provided as ordered to the right lateral foot pressure sore. Review of the Weekly Wound Report for 6/5/19 revealed that the pressure sore on the right lateral foot was unstageable and measured 2 cms. x 2.3 cms. x 0.1 cms. with light exudate. Review of the treatment records for 3/2019-5/2019 revealed that the pressure sore on the resident's left hip was treated as ordered every day with Di-Dak-Sol from 3/27/19 to 5/14/19 except for 4/7/19. On 5/15/19, the Physician Ordered staff to cleanse the left hip pressure sore with normal saline, pat dry and pack the wound with Mesalt dressing (draws exudate, debris and [MEDICAL CONDITION] out of wound), cover with 4 x 4 gauze and composite dressing every day. Review of the 5/2019 treatment record revealed that there was no indication that licensed/registered nursing staff provided treatment as ordered to the left hip pressure sore on 5/26/19, 5/27/19 or 5/28/19. On 5/29/19, the Physician Ordered staff to cleanse the left hip pressure sore with normal saline, pat dry and pack the wound with Di-Dak-Sol soaked gauze and cover with a composite dressing every day. However, review of the 5/2019 and 6/2019 treatment records revealed that there was no indication that licensed/registered nursing staff provided treatment as ordered to the left hip on 5/29/19, 5/30/19, 5/31/19 or 6/1/19 (7 days between 5/26/19 and 6/1/19). Review of the Wound Report revealed that pressure sore assessments including staging, measurements and description were done weekly except for 5/7/19 and 5/14/19. Continued review of the Wound Report revealed that on 5/21/19 the Stage III pressure sore on the left hip measured 2 cms. x 1.5 cms. x 1.8 cms. and had heavy exudate. On 5/30/19, the Stage III pressure sore measured 2 cms. x 1.5 cms. x 2 cms. and had heavy exudate. On 6/4/19, the pressure sore on the left hip was debrided by the Physical Therapist. Review of the Wound Report for 6/5/19 revealed that after debridement, the left hip pressure sore measured 2 cms. x 1.5 cms. x 3.9 cms., had foul odor and heavy exudate. The Physician was notified and ordered an x-ray and wound culture. The x-ray was negative for osteomyilitis and the culture dated 6/8/19 showed extended spectrum beta-lactamases (ESBL) producer and Proteus mirabilis. The Physician was notified and ordered [MEDICATION NAME] (an antibiotic) IM (intramuscular) for 5 days. On 6/11/19, R#1 was sent to the emergency room (ER) for pneumonia. Review of the Hospital Wound Consultation dated 6/13/19 revealed that the Stage IV left hip pressure sore measured 2 cms. x 2 cms. x 3 cms. and had 90% granulation and 10% slough deep in the wound bed. The Stage III right lateral foot pressure sore measured 2.1 cms. x 3 cms. x 0.1 cms. and had 100% granulation with some hyper-granulation tissue in the wound bed. Continued review of the Wound Consultation revealed that all wounds had good granulation and no evidence of necrosis. Record review revealed that on 6/15/19, R#1 returned to the facility. Observation on 6/17/19 at 1:25 p.m. revealed that R#1 was lying on her right side on her specialty pressure relieving mattress. She was clean and without odors. Treatment Nurse AA provided treatment to the pressure sores on the resident's left hip and right lateral foot as ordered by the Physician using appropriate infection control. The Stage IV pressure sore on the resident's left hip measured 1.3 cms. x 1 cm. x 3.9 cms. The wound bed had granulation tissue and did not have an odor. The right lateral foot pressure sore measured 2 cms. x 2.1 cms. with hyper-granulation tissue and did not have an odor. 2. Record review for R#2 revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge MDS dated [DATE] revealed that she was severely cognitively impaired; requires total assistance from staff for all activities of daily living (ADLs); and was admitted with one Stage II pressure sore. Review of the resident's care plan revealed that she had an actual pressure sore with appropriate interventions. review of the resident's medical record revealed [REDACTED]. x 5.5 cms. The Physician was notified and ordered staff to cleanse the pressure sore, pat dry, apply [MEDICATION NAME], cover with 4 x 4 gauze and then composite dressing every day. However, review of the treatment records revealed that there was no indication that licensed/registered nursing staff provided treatment as ordered on [DATE] and 6/1/19. Continued review of the medical record for R#2 revealed that she had a positive sputum culture for [MEDICAL CONDITION] (MRSA) on 6/2/19. The Physician was notified and ordered Bactrim DS twice a day for 4 days. On 6/4/19, the resident was sent to the emergency room for fever. Review of the medical record revealed that the resident returned to the facility on [DATE]. Her coccyx pressure sore had deteriorated to unstageable and measured 12.5 cms. x 11.5 cms. x 3.5 cms. The Physician was notified and ordered staff to cleanse the pressure sore with normal saline, pat dry, pack with Di-Dak-Sol soaked gauze, cover with 4 x 4 gauze and composite dressing. Review of the 6/2019 treatment records revealed that there was no indication that licensed/registered nursing staff had provided treatments as ordered on [DATE], 6/11/19 or 6/12/19. Observation on 6/13/19 at 11:10 a.m., of LPN/Treatment Nurse AA provided treatment as ordered to the coccyx pressure sore using appropriate infection control revealed that the pressure sore had approximately 40% slough and no odor. 3. Record review for R#4 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 13, indicating that he had some confusion. Continued review revealed that he had verbal behaviors towards others (threatening, screaming and cursing) that occurred 4-6 days of the last 7 days; he rejected care 1-3 days of the last 7 days; required extensive assistance of two staff for bed mobility; was non-ambulatory; had two Stage III pressure sores. Review of the resident's care plan dated 10/25/18 revealed that he had existing pressure sores but refused treatments at times with appropriate interventions. Review of the medical record for R#4 revealed that he was admitted with a Stage II pressure sore on his right gluteal that measured 8.1 cms. x 3 cms. x 0.1 cms. that later healed; a Stage III pressure sore on his right hip that measured 0.2 cms. x 0.3 cms. x 3 cms.; and a Stage II pressure sore on his left medial knee that measured 2.3 cms. x 1.5 cms. x 0.1 cms. that later healed. Continued review of the medical record revealed that the resident was assessed and treated monthly by the Wound Care Physician since 4/2019. Review of the treatment records for R#4 revealed a physician's orders [REDACTED]. Treatment was provided as ordered 3/1/19- 3/20/19 except on 3/2/19. On 3/21/19, the Physician ordered staff to cleanse the pressure sore and apply Alginate every day. Review of the treatment records revealed that there was no indication that licensed/registered nursing staff treated the pressure sore as ordered on [DATE], 5/11/19, 5/13/19, 5/15/19, 5/24/19, 5/31/19, 6/2/19 or 6/12/19. There was no indication in the resident's medical record that he refused treatments on those days. Review of the Weekly Wound Report revealed that the Stage III pressure sore on the resident's right hip measured 0.4 cms. x 0.5 cms. x 1.3 cms. with small amount drainage and no odor. Review of the Staffing Schedules from 5/1/19 revealed that there was no treatment nurse available to provide treatments on 5/4/19 (Sunday), 5/8/19 (Wednesday), 5/9/19 (Thursday), 5/11/19 (Saturday), 5/17/19 (Friday), 5/18/19 (Saturday), 5/19/19 (Sunday), 5/23/19 (Thursday), 5/24/19 (Friday), 5/25/19 (Saturday), 5/26/19 (Sunday), 5/27/19 (Monday), 5/28/19 (Tuesday), 6/1/19 (Saturday), 6/2/19 (Sunday) and 6/9/19 (Sunday). Interview with Licensed Practical Nurse (LPN)/Treatment Nurse AA on 6/12/19 at 1:55 p.m. revealed that the previous treatment nurse had resigned on 4/22/19 and that she was supposed to be the designated treatment nurse at that time. Continued interview revealed that the facility has had nurses call out and she would have to work as a medication nurse on those days. LPN AA stated that she was not providing treatments today because a nurse had called out. Further interview revealed that when she was pulled to provide medications, the other floor nurses were responsible for providing treatments to the residents in their care. LPN AA stated that she performed the weekly pressure sore assessments for all the residents. Interview with Registered Nurse (RN) BB on 6/13/19 at 9:24 a.m. revealed that she usually worked on the weekends on the Ventilator Unit and that the RN supervisor provided treatments on the weekend. Continued interview revealed that if the Treatment Nurse was pulled to work the medication cart during the week, the nurses knew to refer to the daily assignment sheet to see if they were responsible for providing treatments to the residents in their care. Further interview revealed that on the weekdays she did work, there have been times when she did not have time to provide treatments and she asked the 7:00 p.m. to 7:00 a.m. shift nurse to provide them. RN BB stated at that time that sometimes she was not able to document in the computer that she had provided a treatment for [REDACTED]. Interview with LPN CC on 6/13/19 at 9:36 a.m. revealed that she had to provide wound treatments all the time because the treatment nurse had to work the medication cart. Continued interview revealed that she stayed over on her shift and provided wound treatments or asked 7:00 p.m. to 7:00 a.m. shift nurse to provide treatments. Further interview revealed that she had to provide treatments yesterday (Wednesday 6/12/19) because the treatment nurse had been pulled to work the medication cart. Interview with the Administrator on 6/13/19 at 3:40 p.m. revealed that he was aware that the treatment nurse had been pulled to work the medication cart at times. Continued interview revealed that there were two LPN positions open and that the facility was actively recruiting nurses to fill those positions. He stated at that time that the facility had also used agency nurses when needed.

Based on record review and resident and staff interview, the facility failed to ensure that licensed/registered nursing staff reordered an as needed (PRN) pain medication timely prior to running out of the medication for one resident (R) (R A) from a sample of four residents reviewed. Findings include: Record review for RA revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed he had a Brief Interview for Mental Status (BIMS) score of 13, indicating that he was cognitively intact. Continued review revealed that he had verbal behaviors towards others (threatening, screaming and cursing) that occurred 4-6 days of the last 7 days; he rejected care 1-3 days of the last 7 days; required extensive assistance of two staff for bed mobility; was non-ambulatory; had two Stage III pressure sores; had occasional pain; and received an opioid (a narcotic) daily. Interview with RA on 6/14/19 at 9:25 a.m. revealed that he did not receive his pain medication about two weeks ago because the facility had run out of the medication. review of the resident's medical record revealed [REDACTED]. Review of the electronic Nurses' Note dated 5/22/19 at 3:45 p.m. revealed that the resident was out of his [MEDICATION NAME] 10 mg to be administered every six hours PRN. Continued review revealed that at 2:00 a.m., the nurse notified the Physician who ordered a one time dose of two tablets of [MEDICATION NAME] 5 mg. The nurse documented that the order did not cover the additional dosages that the resident may have required later that day. The pharmacy was notified but, was unable to send a courier with the medication at that time. The Nurse Practitioner was notified and ordered enough [MEDICATION NAME] 5 mg, two tablets every four hours PRN to cover the additional doses. Further review of the Nurses' Note revealed that the nurse had to wait to receive a needed code from pharmacy to retrieve the [MEDICATION NAME] from the electronic medication cart. Review of the 5/2019 electronic PRN Medication Administration Record [REDACTED]. There was no indication that RA had requested his PRN Diclofen Sodium 75 mg on 5/22/19. Interview with the Director of Nursing (DON) on 6/18/19 at 9:15 a.m. revealed that the nurses were unable to retrieve the [MEDICATION NAME] from the electronic medication cart on 5/22/19 because they did not have a code. He stated that he corrected the issue that day and ensured that all licensed/registered nursing staff had their own codes to retrieve medications from the electronic medication cart. Continued interview revealed that the nurses had failed to reorder the resident's [MEDICATION NAME] timely so that RA would not run out of his medication. Further interview revealed that the nurse was responsible for reordering medications 3-5 days prior to the last dose of medication in the medication cart, especially narcotics which required notification of the physician and a hard copy prescription.

Based on interview and record review, the facility failed to develop a baseline care plan for one resident, Resident (R)#1, of five sampled residents. The baseline care plan did not include the minimum healthcare information necessary to properly care for the resident including services for transmission based precautions, Foley catheter care, gastrostomy tube ([DEVICE]) care and peripherally inserted central catheter (PICC) care. Findings include: Record review revealed that the resident was admitted to the facility on [DATE] then transferred on November 27, 2017 to an acute care hospital at the request of the family. Review of the immediate (base) care plan, not dated, revealed there was no care planning to address the resident's ongoing infection with [MEDICAL CONDITION] (c. diff), Foley catheter, PICC line or gastrostomy tube as noted on R#1's discharge instructions dated November 16, 2017 from her prior facility. Review of the R#1's 'Admission Assessment, dated November 16, 2017, listed that resident was admitted with [DIAGNOSES REDACTED], a Foley catheter and a PICC line. Interview with the Wound Care Nurse, Licensed Practical Nurse (LPN) GG on 12/18/2017 at 12:30 p.m. who confirmed that resident's infection with [DIAGNOSES REDACTED] was on-going at the time off admission and that transmission based precautions were implemented on admission. LPN GG also confirmed that resident had a PICC line present in her right arm, a Foley catheter, and a [DEVICE], all present on admission. Interview with the of Director Nursing (DON) on 12/18/2017 at 4:35 p.m. who confirmed that resident was admitted with [DIAGNOSES REDACTED], a PICC line, a Foley catheter and a [DEVICE]. Review of the resident's base line care plan with the DON who agreed that R#1's care plan did not provide adequate information for addressing the resident's immediate needs and that Acute Care Plans should have been added for PICC line care, Foley catheter care, [DEVICE], and transmission based precautions to the residen't care plan. Post survey interview with the Infection Control nurse, LPN NN on 12/20/2017 at 10:35 a.m. revealed that R#1 was discussed in the morning meeting the day after R#1 was admitted . LPN NN stated that Infection Control policies are available at the nurse's stations, and staff are trained on the implementation of infection control measures. LPN NN further stated that R#1's medications and discharge planning from her previous facility was reviewed on admission and all transmission based precautions were implemented on admission.