Every finding on record at Franklin General Hospital

Based on pharmacy monthly reviews, progress note documentation, policy, and interviews, the facility failed to complete monthly pharmacy reviews and review pharmacist irregularities with action taken along with a rationale for the action, by a provider for 1 of 5 residents (Resident #2). The pharmacist recommended to discontinue Resident #2's order for hydroxyzine (medication used to treat itching), but the facility failed to discontinue the medication. Additionally, the Pharmacist didn't do a monthly medication review on Resident #2 for the month of November 2025. The facility reported a census of 37 residents.Findings include:A Medication Administration Record (MAR) for July 2026 and printed on 7/2/26 directed staff to give Resident #2, 1 tablet of Hydroxyzine oral tablet 10 milligrams (mg) by mouth as needed for pruritus (itchy skin). The medication order carried a start date of 10/27/26. Review of the Pharmacy Monthly Reviews lacked a review of Resident #2's medications in November 2025. The December 2025 Pharmacy Monthly Review, specifically the Nursing Report of Pharmacy Review and the Physician Response portion, documented that staff emailed the individual regarding the incomplete November 2025 review. The December 2025, January 2026, and February 2026 Pharmacy Monthly Reviews all recommended the discontinuation of the as-needed Hydroxyzine. A Progress Note dated 12/1/25 documented a staff member faxed the pharmacy to order Hydroxyzine oral tablet 10 mg because the medication cart lacked the stock, though Resident #2 maintained an active order for itching. The pharmacy returned the call and informed the nurse that Resident #2 required a prior authorization for the medication. The staff member sent the prior authorization request to the clinic and awaited its completion and return. The nurse passed the concern on in the shift report and placed it on the communication board. The nurse notified the nursing staff and social services that staff sent a prior authorization request for the Hydroxyzine to the pharmacy because Resident #2 experienced itching. A Care Conference Note dated 12/22/25 at 1:48 PM documented Resident #2 reported frequent itchy skin and noted Hydroxyzine in use. Review of Resident #2's monthly MARs from October 2025 through July 2026 revealed the order appeared on each month's MAR, and revealed Resident #2 didn't receive the as-needed Hydroxyzine. The Hydroxyzine order still remained as-needed order at the time of the review, and the records lacked further direction regarding the discontinuation of the Hydroxyzine in the monthly reviews or the Gradual Dosage Reduction (GDR) documentation. On 7/2/26 at 11:00 AM, the Director of Nursing (DON) stated staff would've faxed the pharmacy recommendation to the provider and documented the response. She acknowledged the individual didn't complete a monthly review in November 2025 for Resident #2. On 7/2/26 at 11:42 AM, a pharmacy staff member stated she didn't perform the monthly reviews. She also stated she didn't hold access to the electronic record program that the facility utilized to look up records. She stated the specific individual who completed the monthly reviews for the facility remained on vacation, and she planned to reach out to that individual to return the call. The pharmacy didn't return the call. On 7/2/26 at 12:00 PM, the DON stated she placed a call to the clinic but hadn't received a return call, and she had no further information to add. On 7/2/26 at 12:57 PM, the Administrator stated she understood the concerns and had no further questions. The facility didn't maintain a policy that addressed monthly reviews or gradual dosage reductions.

Based on interviews, record review and policy review, the facility failed to timely identify pressure ulcers, consistently document wounds as pressure ulcers with correct staging, correct measuring, and the facility failed to notify the dietitian when a pressure ulcer was identified, for 1 of 2 residents reviewed (Resident #7). The facility reported a census of 37. Findings include:The Minimum Data Set (MDS) assessment tool identified the following descriptions of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue that needs to be removed from the wound for healing to take place; may be used interchangeably with fibrotic or necrotic tissue). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of non-traumatic spinal cord dysfunction, paraplegia (complete paralysis of the lower half of the body), depression, and anxiety. The MDS documented a Stage 2 pressure ulcer (partial-thickness skin loss). The Care Plan dated 3/6/26 documented Resident #7 maintained a risk for impaired skin integrity related to decreased mobility secondary to paraplegia, prolonged time spent in bed, neurogenic bowel and bladder (nerve damage disrupting bladder and bowel tract communication), moisture exposure, and independent manual stool removal. The plan noted that upon admission from a private home, Resident #7 possessed a Stage 2 pressure area on the right buttock and coccyx (tailbone), which resolved. The plan documented an open area on the coccyx on 4/30/26 and recurring blisters on the buttock on 5/27/26, which resolved on 6/1/26. Resident #7 preferred to self-reposition. Interventions included a wound consultation per provider order as needed. A Dietary Progress Note dated 3/5/26 at 1:36 PM documented Resident #7 repeatedly refused Arginaid, which staff added to help promote wound healing and skin integrity. A Dietary Progress Note dated 3/12/26 at 2:43 PM documented an attempt to speak with Resident #7 regarding alternative options to promote wound healing. The Dietitian knocked and walked over to Resident #7, who lay in bed with her head turned and didn't wake up or acknowledge the Dietitian's presence, prompting the Dietitian to plan another attempt later. A Skin assessment dated [DATE] documented a left iliac crest (top ridge of the hip bone) blister measuring 0.5 centimeters (cm) long by 0.5 cm wide. The documentation lacked a depth measurement and identified the blister as unstageable (obscured full-thickness skin loss). A Skin assessment dated [DATE] documented the left iliac crest blister healed. A Skin assessment dated [DATE] documented a right buttock abrasion measuring 0.9 cm long by 1 cm wide by 0.1 cm deep, noting the stage as not applicable. A Nursing Progress Note dated 5/5/26 at 5:17 PM documented an abrasion to the right buttock measuring 1 cm x 1.7 cm with scant bleeding. Staff cleansed the area with wound cleanser, applied skin prep around the wound, and covered it with a Mepilex dressing per Resident #7's request. Staff sent a fax to the physician reporting the findings and requesting orders to change the dressing on bath days and as needed, which the physician approved, prompting an update to the Medication Administration Record (MAR). A Skin assessment dated [DATE] documented a right buttock abrasion measuring 1.0 cm long by 1.7 cm wide by 0.1 cm deep, noting the stage as not applicable. A Skin assessment dated [DATE] documented a right buttock abrasion measuring 7 cm long by 4 cm wide by 0.1 cm deep, noting the stage as not applicable. A Nursing Progress Note dated 5/13/26 at 6:39 PM documented receipt of a return fax from the physician directing the discontinuation of the Mepilex dressing to the buttock wound. A Skin assessment dated [DATE] documented a right buttock abrasion measuring 0.5 cm long by 1.5 cm wide with a depth of 0, noting the stage as not applicable. A Skin assessment dated [DATE] documented a left buttock blister measuring 2 cm long by 2 cm wide and a right buttock blister measuring 2.5 cm long by 0.5 cm wide. The record lacked documentation for the depth and stage of both areas. A Skin assessment dated [DATE] documented the right buttock abrasion healed. A second Skin assessment dated [DATE] documented the left buttock and right buttock blisters healed. A Skin assessment dated [DATE] documented a right rear thigh blister measuring 2.1 cm long by 1 cm wide by 0.1 cm deep and another right rear thigh area measuring 5 cm long by 0.1 cm wide by 0.1 cm deep, noting the stage for both areas as not applicable. A Nursing Progress Note dated 6/1/26 at 11:26 PM documented a fax from the physician regarding an open area on the upper posterior right thigh, instructing staff to check if Resident #7 desired a wound consultation and to monitor the area until healed if declined. A Nursing Progress Note dated 6/2/26 at 10:12 AM documented that staff asked Resident #7 if she desired a wound consultation for her right upper posterior thigh. Resident #7 stated she'd use zinc cream instead, and staff updated the physician. A Nursing Progress Note dated 6/3/26 at 7:50 AM documented that Staff A discussed recurrent blistering and potential open areas on the coccyx, buttocks, and upper thighs with Resident #7. Resident #7 verbalized understanding of the ongoing skin concerns and agreed to a wound therapy consultation. Staff requested a consultation for evaluation and recommendations regarding positioning, pressure relief, turning and repositioning techniques, and wound care management to promote healing and reduce the recurrence of skin breakdown, and sent a fax to the provider requesting the order. A Nursing Progress Note dated 6/3/26 at 5:49 PM documented receipt of a return fax from the Nurse Practitioner (NP) regarding the wound therapy order. The NP directed staff to refer Resident #7 to wound therapy to evaluate and treat pressure injuries to the posterior upper thighs, coccyx, and buttocks, and instructed staff to clean the areas with normal saline, pat dry, and apply Mepilex to open areas until evaluated, while turning Resident #7 every 2 hours. Staff updated Resident #7, who declined the Mepilex covers and refused to let staff clean the areas at that time, stating she wanted to use zinc paste and had been propping her leg up with a blanket. A Nursing Progress Note dated 6/9/26 at 5:10 PM documented that staff notified the provider of current skin assessment findings and wound status, noting no acute concerns and directing a review of the skin assessment logs for completed measurements, descriptions, and healing progress. A Skin assessment dated [DATE] documented normal skin color with an irregular, dry, flaky, peeling skin outline. The record noted that observations of Resident #7 boosting herself in a wheelchair indicated a probable cause of friction to the area, listed a diagnosis of paralysis, and recommended lotion application for the area first noticed on 6/1/26. A second Skin assessment dated [DATE] documented a right upper posterior thigh pressure area measuring 2 cm long by 1.5 cm wide with 0 depth, noting the stage as not applicable. A third Skin assessment dated [DATE] documented a right lower posterior thigh pressure area measuring 7 cm long, but staff didn't measure the depth or length, and noted the stage as not applicable. A Care Conference Progress Note dated 6/10/26 at 1:45 PM documented that the facility conducted the quarterly care conference with Resident #7, the interdisciplinary team participated, and the Dietitian joined via conference call. The team reviewed the plan of care and current medications, discussed recurring right thigh blisters and skin breakdown, and evaluated current interventions including a wound consultation, a pressure-relieving mattress, towel placement on the shower chair, continued lotion application, a turning sheet, and twice-daily Arginaid supplementation. A Skin assessment dated [DATE] documented the left buttock, right buttock, and right rear thigh blisters healed, noting the stage as not applicable and the first noticed date as 2026. The facility printed the aforementioned skin assessments on 7/1/26. A Clinic/Office Physician Preliminary Report Note dated 5/19/26 documented Resident #7 possessed a small Stage 2 pressure area on her right buttock extending through the skin surface. The note indicated the area didn't appear deep, lacked palpability, drainage, or signs of infection, and featured surrounding skin with a darker pink coloration from chronic pressure due to paraplegia. The Physician's Order Sheet dated 6/3/26 at 8:15 AM directed the following interventions:Refer to wound therapy to evaluate and treat pressure injuries to posterior upper thighs, coccyx, and buttocks.Until seen by wound therapy clean areas with normal saline, pat dry, and apply antiseptic to open areas.Turn patient every 2 hours. A response to the orders sent on 6/3/26 at 6:00 PM documented Resident #7 didn't want Mepilex (foam dressing) on skin areas. Resident #7 stated she wanted to use zinc paste and placed a blanket under her thigh to reposition herself, and she declined letting staff clean the areas at that time. A Doctor's Order with a start date of 6/17/26 directed staff to administer Arginaid (nutritional supplement), a supplement supporting wound healing, twice a day. On 7/1/26 at 12:20 PM Staff A, Registered Nurse (RN), stated she should've measured the width and staged the ulcer. The Administrator and Staff A stated they understood that staff should've notified the dietitian. They both acknowledged concerns with following the documentation of a pressure ulcer and the weekly measurements required to note improvement or worsening of an injury. They stated they plan to transfer to a new system that takes pictures of wounds and inputs them directly into the electronic health record. The Administrator and Staff A stated they understood that the documentation didn't reflect the continuance of a pressure ulcer or pressure areas. They acknowledged that staff didn't identify wounds correctly as pressure areas and acknowledged the delay in identifying a pressure area. Staff A stated she completes the wound records when Staff B, Licensed Practical Nurse (LPN), remained unavailable on Tuesdays, and noted she performs rounds with the physician. On 7/1/26 at 12:15 PM the Dietitian stated nobody notified her of Resident #7 developing a new Stage 2 pressure ulcer on 5/19/26. She said she adds Arginaid when staff identify a pressure area. She stated if a resident already receives Arginaid and develops a pressure ulcer, she then reviews additional interventions such as an increase in dietary protein. The Dietitian attempted to find notes on Resident #7 and located the subsequent progress notes. She stated she lacked documentation anywhere indicating that staff notified her of recent pressure ulcers. On 7/1/26 at 2:01 PM the Director of Nursing (DON) stated that registered nurses can stage pressure ulcers, but the process ultimately requires contacting the physician for staging. She stated the facility's nurses must notify the physician when staff identify a pressure area so the physician can assess and stage the area. On 7/1/26 at 2:51 PM Staff B stated she doesn't perform actual wound nurse duties and noted that if residents require a dedicated wound nurse, they must travel to the hospital. Staff B stated she and other nurses don't document wounds as pressure areas, choosing instead to wait until they receive a pressure ulcer diagnosis from the healthcare provider. Staff B expressed a lack of knowledge regarding whether Staff A made pressure assessments before or after the physician's evaluation. Staff B stated she stages wounds based on the paperwork, noting that staff previously utilized paper documentation before transitioning through another system to the current computer network. Staff B said she contacts the primary provider every Tuesday, completes wound measurements, faxes the measurements to the physician, and updates families regarding wound changes. Staff B stated she records the information as a pressure injury upon receiving a formal diagnosis from the physician or when Staff A provides notification. Staff B stated that when she discovers a new wound stems from pressure, she typically notifies the dietitian, and she contacts the providers and dietitian if a wound deteriorates to suggest interventions like Arginaid or Vitamin C. Staff B stated she holds a wound certificate from the National Alliance of Wound Care and Ostomy (NAWCO). The Skin Assessment policy reviewed December 2027 instructed that the prevention of pressure ulcers begins with identifying residents at risk. The policy directed that staff evaluate admitted patients to prevent ulcers from developing and to form an appropriate plan of care for treating individuals with ulcers. The stated goal focused on identifying residents at risk for developing impaired skin integrity, improving the skin condition of patients admitted with ulcers, and preventing further skin breakdown. For the initial assessment, the procedure directed that all residents undergo a risk assessment using the Braden Scale for Predicting Pressure Sore Risk, and mandated that staff measure wounds upon admission and assess patients with ulcers at severe risk. The policy instructed that staff implement necessary interventions based on the Braden score to reduce or eliminate pressure areas. For reassessments, the policy directed that staff observe resident skin during daily care, and instructed certified nursing assistants to utilize the Stop and Watch form to notify a nurse of any skin changes. The procedure required that staff complete a Risk Management file and initiate a skin sheet upon identifying a skin area, which included physician and family notification. The policy mandated weekly monitoring of skin sheets and physician notification of significant changes, alongside Braden completions with each MDS. Upon closure of an area, the policy required filing the skin sheet in the resident chart with an ending entry describing the healed tissue, and verification of physician and dietitian notification to discontinue the treatment plan.

Based on observation, staff interviews, and policy review, the facility failed to date, cover, and label open items were dated, covered and labeled. In addition, the facility failed to ensure staff used proper hand hygiene practices during lunch services while preparing food to serve residents. The facility reported a census of 30 residents. Findings include: On [DATE] at 9:30 AM in the main kitchen with the Dietary Manager (DM), observed the following: a. An open, undated bag of brown sugar. b. An open bag of cereal, with an open date of [DATE], not fully closed. c. 3 open undated bags of cereal. d. An open, undated bag of onion bits. e. Expired, opened container of honey garlic in the refrigerator, expired [DATE]. f. An open, undated bag of frozen chicken patties. g. An open, undated bag of frozen chicken cubes. h. An open, undated bag of frozen fish patties. i. An open, undated bag of frozen corn. j. An open, undated bag of frozen cookie dough pieces. During an interview on [DATE] at 9:50 AM, the DM stated the expected open food items have an open date clearly marked on the product and are securely sealed. If they had expired food, they should throw it out and not use or serve it to the residents. During an interview on [DATE] at 10:00 AM, the Administrator stated they expected a consistent process of ensuring food items once opened are dated and secure, then thrown out by the expiration date. During the lunch service on [DATE] at 11:20 AM, observed Staff D, Dietary staff, serve lunch for residents in the main dining room. Staff D washed their hands, prepared surfaces by getting tongs, scoops, and opening containers of food. Staff D then put a glove on just her left hand. Staff D prepared a cheeseburger by getting a bun out of a bag with her left gloved hand and removed a cheese slice from a stack of cheese with her left gloved hand. Staff D prepared approximately five more cheeseburgers/hamburgers with this same method (removed the bun from the bag with the gloved hand, removed a slice of cheese with her gloved hand). However, Staff D also touched other surfaces with her gloved hand prior to touching the bun and cheese, such as the steam table surface, plates, tongs and bowls. Staff D changed the glove on her left hand 4 times, however in between these times, she touched surfaces with her gloved hand, including the refrigerator, steam table, a bottle of ketchup, bowls and lettuce. Then she touched the bun and cheese, completing the cheeseburgers with the same gloved hand. During an interview on [DATE] at 3:00 PM, the Administrator stated they expected the staff to change gloves after touching a surface area and before touching food again with the same gloved hand. Review of the facility Storage Food/Nonfood/Chemicals policy, revised [DATE], directed to store food appropriately to ensure safety and freshness. Label and date all items when opened for proper rotation. Review of the facility Basic Sanitation Procedures, revised [DATE], documented when preparing foods, use spoons, forks and tongs as much as possible to minimize hand contact. Use plastic gloves as directed, change them as appropriate. When handling food directly change after touching a dirty item.

Based on personnel record review, policy review and staff interview, the facility failed to complete the required Abuse and Criminal History check within the required 30 days of the hire date for 2 of 5 staff reviewed (Staff A, Licensed Practical Nurse LPN, and Staff B, Registered Nurse RN). The facility reported a census of 30 residents. Findings include: 1. Staff A's Personnel File record review listed a hire date of 10/28/24. The record review included the Single Contact License and Background Check (SING) with a completion date of 9/23/24, 35 days prior to hire. 2. Staff B's Personnel File record review listed a hire date of 12/16/24. The record review include a SING completed 11/15/24, 31 days prior to hire. The facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting Policy, revised August 2023 instructed the facility to conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire, in the manner prescribed under 481 Iowa Administrative Code and 58.11(3). During an interview on 5/7/25 at 11:15 AM, Staff C, Manager, acknowledged Staff A and Staff B began employment more than 30 days after the facility completed their background checks.

Based on observations, interviews, and record reviews, the facility failed to have accurate code status directives available to their staff for 4 of 16 residents reviewed (Residents #13, #15, #26 and #27). Resident #15 and #26 didn't have DNR (Do Not Resuscitate in the event of no respirations and no pulse) stickers on the outside of their charts. Resident #13 had a provider's order and an IPOST (Iowa Physician's Orders for Scope of Treatment) indicating them as a DNR. Resident #13 had a heart sticker on the outside of his doorway, indicating he desired to be a full code (have Cardiopulmonary Resuscitation (CPR) performed in the event of no respirations and no pulse). Resident #27 had an order for full code, but didn't have a heart sticker on the outside of his doorway. The facility reported a census of 30 residents. Findings include: 1. Resident #13's IPOST dated [DATE], indicated DNR in the event of his heart stopping and cessation (stop) of breathing. A provider's order dated [DATE], directed Resident #13 didn't want CPR. On [DATE] at 2:18 p.m. observed Resident #13 had a DNR sticker on the outside of his chart. The outside of Resident #13's room door had a heart sticker. 2. An IPOST dated [DATE], listed Resident #27 as a DNR in the event of his heart stopping and cessation of breathing. A provider's order dated [DATE], reflected Resident #27 as a DNR/do not attempt resuscitation. On [DATE] at 2:07 PM, witnessed no DNR sticker on the outside of Resident #27's chart. On [DATE] at 11:02 AM, the Director of Nursing (DON) stated they had several different ways to look at code status for residents. If they are to have CPR performed the outside of their door would have a heart and a heart sticker on their charts. She stated the electronic health record had the code status provider order for either full code or for DNR as would the IPOST which is right inside the hard chart in a red sleeve. The DON said she expected the staff keep all of the areas mentioned up to date. The DON acknowledged the heart sticker outside of Resident #13's door. She stated his code status changed recently when he went on hospice care. She removed the heart sticker off of Resident #13's door at the time. The DON confirmed Resident #27 didn't have a DNR sticker on the outside of their chart, but they should have one. The DON instructed a staff member to apply the DNR sticker. On [DATE] at 11:18 AM, Staff A, Licensed Practical Nurse (LPN), stated to find the code status she would go directly to the electronic health record and check the provider's order. She said she worked at the facility for less than a year, and the code status could change. Staff A stated she felt confident in checking the doctor's (providers) orders. She stated she didn't trust someone to update the stickers. She says she's pretty sure that other nurses check the electronic health record too but couldn't say for sure. She stated she didn't receive education regarding which area to go to find a resident's code status. On [DATE] at 2:03 PM, Staff B, Certified Nurse Aide (CNA), stated she would call her nurse right away if she found a resident not breathing. She stated if someone asked her to look at a code status she thought it was on each residents' door. When asked what is on each resident's door she said she thought it was like a red dot, a yellow dot, and a green dot. She said there is also a red book at the nurses' station that lists all of the residents' code statuses. The DON failed to mention a red book at the nurses' station with resident code status as a place to look for code status. 48003 3. Resident #15's IPOST dated [DATE], listed her as a DNR in the event her heart stopped beating and cessation of breathing. A provider's order dated [DATE], directed Resident #15 did not want CPR. An observation on [DATE] at 2:35 PM, revealed Resident #15's chart didn't have a DNR sticker on the outside. The chart didn't have any stickers on the outside. During an interview on [DATE] at 2:20 PM Staff C, Licensed Practical Nurse, explained she looked a resident's code status sticker on either the outside of the door to the resident's room or on the outside of the chart, During an interview on [DATE] at 2:25 PM, the DON acknowledged the chart needed a sticker on the outside of the chart. 4. Resident #27's IPOST date [DATE], listed her as a Full Code in the event her heart stopped and cessation of breathing. A provider's order dated [DATE], directed Resident #27 did want CPR. An observation on [DATE] at 2:55 PM, witnessed Resident #27's outside of his room by his name didn't have stickers. During an interview on [DATE] at 2:27 PM, the DON acknowledged the outside of Resident #27's room by his name should have a heart sticker due to being a full code.

Based on record review and interview, the facility failed to have the minimal required members at its quarterly QA meeting. The facility reported a census of 30 residents. Findings include: Review of the quarterly QA minutes dated 5/7/24, revealed the Director of Nursing (DON) who is also the Infection Preventionist (IP), did not attend. On 5/22/24 at 10:04 AM, the Licensed Nursing Home Administrator (LNHA), stated they had a clinical nurse sit in for the DON on the 5/7/24 meeting. When asked if the clinical nurse sat in as the IP, the LNHA acknowledged she didn't sit in as the IP. A Quality Assurance and Process Improvement policy dated May 2017, directed the Nursing Facility Quality Assurance and Process Improvement (QAPI) Plan is part of the overall Quality Assessment Program. The staff will appoint a core group of individuals to the performance improvement project (PIP) team. The facility would determine the PIP Team based on opportunity. Individuals directly involved with initial root cause analysis will be encouraged to participate. PIP teams will average 2 5 people. A PIP team will utilize QAPI tools to further investigate opportunity and plan course of action. Managers and Supervisors will provide time for PIP team to meet on a weekly or as needed basis.

Based on clinical record review, facility policy review, staff, and family interview the facility failed to report within the required time frame an allegation of abuse to Iowa Department of Inspection and Appeals and Licensing (DIAL) for 1 of 1 resident reviewed (Resident #22). The facility reported a census of 30 residents. Findings include: Review of the facility intake information reported to DIAL documented the facility reported an allegation of missing money on 4/23/24 at 4:05 PM for Resident #22 after the facility staff learned of the incident on 4/19/24 at 6:33 PM. During an interview on 5/23/24 at 3:20 PM, Staff D, Registered Nurse (RN), reported Resident #22's family reported missing money on 4/19/24. He added that he reported the allegation right away to the Administrator and Director of Nursing. During an interview on 5/22/24 at 10:00 AM, the Administrator reported the facility didn't feel Resident #22 had any missing money so they did an investigation then reported it on 4/23/24. She reported Staff D reported to her on 4/19/23 that the family reported Resident #22 had missing money. The Administrator acknowledged she should have reported it to DIAL within the 24 hours required time frame and not waited until 4/23/24. The Abuse Prevention, Identification, Investigation, and Reporting policy revised August 2023 directed staff must report allegations of abuse within 24 hours of the event that caused the allegation involving neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but didn't result in serious bodily injury.

Based on observation, policy review, and staff interview, staff failed to prepare and serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 36 residents. Findings include: 1. During an observation of the lunch meal on 3/6/23 at 12:15 PM, Staff D, Universal Worker with gloved hands served 5 different residents' lunch trays, and with the same gloves, cleaned spilled fluid off a table with towels, then proceeded to wash her gloved hands. Staff D, with the same gloves on, touched a trashcan lid, a resident's drinking glass, served another resident a cup of coffee, touched a resident's back, and continued with the same gloved hands and touched silverware wrapped in a napkin and gave to a resident. During an interview on 3/8/23 at 1 PM, the Director of Nursing stated expectation was to not wash gloves, discard gloves, and complete hand hygiene. 2. During an observation on 3/8/23 at 10:24 AM, Staff E, Dietary Aide washed hands, applied gloves, and with his gloved hands touched the handle and lid of the food processor, placed 6 scoops of tater tot casserole in the processor, pureed the casserole, and then with his gloved hand touched the pureed food in the processor. Staff E removed gloves, washed hands, applied new gloves, and with gloved hands touched the pan of vegetables, scoop, handle and lid of processor, spatula, and proceeded to place 4 scoops of vegetables in the food processor, pureed the vegetables, and with same gloved hand touched the pureed food in the processor. During an interview immediately after the observation, Staff E stated he touched the pureed food to see if the pureed was okay. Review of facility policy, Food Handling Techniques, effective 8/2021, documented dietary employees will follow sanitary practices when handling food. During an interview on 3/8/23 at 1:15 PM, the Dietary Manager stated expectation was to not touch pureed food with bare or gloved hand, as not a sanitary practice. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.

Based on clinical record review, family interview and staff interview the facility failed to provide bathing assistance twice weekly for 1 of 16 residents reviewed for bathing (Resident #8). The facility reported a census of 40 residents. Findings included: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented the Brief Interview for Mental Status (BIMS) score of 01 which indicated severe cognitive impairment. The MDS showed Resident #8 required extensive assistance of 1-2 persons for assistance with personal hygiene, transfers and dressing. The MDS Diagnosis showed dementia, adult failure to thrive, and polyneuropathy. In an interview on 3/7/23 at 11:48 PM, Resident #8's son reported during a visit on 3/4/22 he noted Resident #8 smelled strongly of urine and her hair appeared uncombed. The Care Plan dated 3/2/23 showed Resident #8 goals included the resident would receive at least one full bath or shower though the next review scheduled for 5/13/23. The Bathing Performance dated 3/08/23 showed Resident #8 received one whirlpool bath on 3/5/23 during the dates of 2/6/23 and 3/23/23. The last column read, the activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity. The facility staff select that answer on the following days which indicated the facility staff did not provide a bath: a. 2/6/23 b. 2/7/23 c. 2/8/23 d. 2/9/23 e. 2/10/23 f. 2/12/23 g. 2/13/23 h. 2/14/23 i. 2/15/23 j. 2/16/23 k. 2/18/23 l. 2/19/23 m. 2/20/23 n. 2/21/23 o. 2/22/23 p. 2/23/23 q. 2/27/23 r. 3/1/23 s. 3/2/23 t. 3/4/23 u. 3/6/23 v. 3/7/23 The Follow Up Bath documentation dated 3/7/23 showed Resident #8 received a whirlpool bath on 3/5/23. The facility staff selected, Not Applicable (NA), for the same dates as listed on the Bath Performance document. In an interview on 3/8/23 at 7:23 AM, Staff A, Certified Nurses Assistant (CNA), reported not applicable on the bath documentation meant the resident did not receive a bath. In an interview on 3/8/23 at 7:24 AM, Staff B, CNA, reported not applicable on the bath documentation meant the resident did not receive a bath. The Resident Care policy last revised in June 2023 documented that all residents will receive a shampoo and bath twice a week. In an interview on 3/8/23 at 2:59 PM, the Director of Nursing (DON), stated that she expected staff to assist Resident #8 twice a week with bathing. The DON explained that she knew Resident #8 received more baths than documented because the bathing room is on the other side of her office and she can hear Resident # 8 be uncooperative. The DON stated, but you know how that goes. If you didn't document then you didn't do it.

Based on clinical record review and staff interview, the facility failed to develop a comprehensive care plan that included the use and monitoring of an anticoagulant (blood thinner medication) for one of three residents reviewed, (Resident #35). The facility reported a census of 36 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE] for Resident #35, included diagnoses of atrial fibrillation (irregular/rapid heart rhythm that can lead to blood clots) and heart failure. The MDS documented the resident received an anticoagulant medication. A Brief Interview for Mental Status (BIMS) score of 15 indicated no cognitive impairment for decision-making. Resident #35's Medication Administration Record dated 3/1/2023 - 3/31/2023, documented a physician's order for Warfarin Sodium (anticoagulant medication), give 3.5 milligrams by mouth in the evening, start date 1/31/23. Review of Resident #35's comprehensive Care Plan with target date 5/1/2023, revealed the care plan lacked documentation/interventions for anticoagulant medication. During an interview on 3/8/23 at 11:16 AM, the Director of Nursing stated expectation for anticoagulant and monitoring for side effects to be included in a resident's care plan.

Based on observation, staff interviews and policy review the facility failed to cover residents personal laundry when transported from the hospital to the nursing facility to return residents personal laundry affecting 34 of 34 residents. The facility reported a census of 34 residents. Observation on 10/11/21 at 2:41 PM Staff C, observed housekeeping operating motorized cart with residents personal laundry on it with no cover. Observation on 10/11/21 at 2:43 PM a facility staff member walked by the uncovered linen cart. Interveiw on 10/11/21 at 2:46 PM with Staff C revealed as long as she has worked at the facility the clothes have never been covered. Staff C revealed the laundry room is approximatly 1000 feet from here and the clothes were not covered throughout the transport. Staff C then revealed she has worked at the facility on and off most of her life and has never covered the residents personal items motorized cart. Review of the facilites policy titled Linen Transportation last approved on 08/2021 documented the following: When transporting linen (with intention of delivery or pickup) on wire carts or blue tripper carts, the facility requires staff to utilize the battery operated lugger bu Ergo-Tug (or similar type machine). The tugger will be used while transporting either soiled or clean linen.

Based on observation, record review and staff interviews, the facility failed to keep medication refrigeration temperatures within the manufacturers recommendations for 2 out of 2 medication refrigerators reviewed. The facility reported a census of 34 residents. Findings include: 1.During a review of the medication storage refrigerator in the North nurses station on 10/12/2021 at 8:15 AM, the displayed temperature registered 37 degrees F (Fahrenheit). A review of the temperature log revealed documented temperatures that fell below 36 degrees F, twenty times in a look back to 7/1/21. There was one shift missing a temperature record for the North refrigerator. A review of the medication inventory of the North refrigerator included the following: a.Liquid Lorazepam (a schedule IV narcotic/sedative) with a manufacturer's box labeling instructing to store between 36 F and 46 F. b.[MEDICATION(S)] (used in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . c.Novolog insulin [MEDICATION(S)] (prefilled insulin delivery system) with manufacturer ' s insert instructions to store the unused [MEDICATION(S)] between 36 F and 46 F. d.Levimer insulin [MEDICATION(S)] with a manufacturer's insert instructions to store the unused [MEDICATION(S)] between 36 F and 46 F. e.[MEDICATION(S)] insulin [MEDICATION(S)] with a manufacturer's insert instructions to store the unused [MEDICATION(S)] between 36 F and 46 F. f.[MEDICATION(S)] insulin [MEDICATION(S)] with manufacturer's insert instructions to store an unused [MEDICATION(S)] between 36 F and 46 F. All inserts include the instructions to not freeze the insulin and do not use the insulin if it has been frozen. The inventoried medications were labeled for four separate residents. 2. During a review of the medication storage refrigerator in the South nurses station on 10/12/21 at 8:40 AM, the displayed temperature reading was 40 degrees F. A review of the temperature log revealed documented temperatures that fell below 36 degrees F one time in a look back to 7/1/21, with one shift missing a temperature record for the South refrigerator. A review of the medication inventory of the South refrigerator included; a. Two Novolog insulin flexpens with a manufacturer's insert instructions to store the unused [MEDICATION(S)] between 36 F and 46 F. b.[MEDICATION(S)] (Duglaglutide) insulin [MEDICATION(S)] with a manufacturer's insert instructions to store the unused [MEDICATION(S)] between 36F and 46 F. c.[MEDICATION(S)] insulin [MEDICATION(S)] with a manufacturer's insert instructions to store an unused [MEDICATION(S)] between 36 F and 46 F. Review of all inserts include the instructions to not freeze the insulin and do not use the insulin if it has been frozen. The inventoried medications were labeled for two seperate residents. In an interview on 10/12/21 at 8:45 AM Staff D revealed the staff lacked knowledge of what temperature parameters she was expected to maintain the refrigerators at and what interventions she should implement if temperatures were out of parameters. Staff D stated the recording document in use lacked guidance and instructions for nurses to follow or implement. In an interview and joint inspection of both North and South medication refrigerators with the MDS Coordinator on 10/12/21 at 12:15 PM, revealed the temperature alarm had been turned off on the North refrigerator and was stored inside the refrigerator, impairing an alarm from being heard. The MDS Coordinator stated the log lacked acceptable storage temperature parameters and instructions for staff to implement should a temperature deviation occur. Stated she expected staff would notify administration and maintenance of temperature concerns and move medications to alternative refrigerated storage. A review of the facility policy titled Refrigerator and Freezer Temperatures, with a last revised date of 04/2021, under section A, instructs all refrigerator temperatures will be kept between 35 - 46 degrees F and low alarms be set. Under section A the policy instructs Quality Assurance will be conducted by the pharmacist and the pharmacy technician to assure temperatures are maintained in the correct range. On 10/14/21 at 7:55 AM in an interview with the DON (Director of Nursing), she stated she was aware of the facility policy discrepancy from the manufacturer's instructions for the low range on the medication refrigerators. Stated she will be in contact with the pharmacist and anticipates the policy will be aligned to match the manufacturer's directions of 36 F to 46 F. The DON stated she has had the thermometers replaced on both medication refrigerators, with the parameters set at 36F to 46 F, the alarms are activated and the units are stored outside the refrigerators for an audible alarm.

Based on observation, record review, staff interview, and facility policy review the facility failed to serve the correct portions of green beans and cheesy tortillas for 2 of 2 residents who received a pureed diet (Resident #22 and #33). The facility reported a census of 34 residents. Findings include: Record review of Resident #22's Order Summary Report dated 10/13/2021, documented the following diet order: General Diet diet, Pureed texture, Regular consistency, related to unspecified dementia. Record review of Resident #33's Order Summary Report dated 10/13/2021, documented the following diet order: General Diet diet, Pureed texture, Regular consistency, having trouble chewing since decline doesn't wear teeth any more. Observation on 10/13/21 at 10:10 AM of Staff A, Lead Cook, pureed two servings of cheesy tortillas. After Staff A completed the task Staff A did not measure the total volume remaing after it was condensed down from pureeing it. Observation on 10/13/21 at 10:13 AM of Staff A pureed two servings of green beans. Staff A again did not measure the total volume after pureeing green beans. Observation on 10/13/21 at 11:24 AM the pureed cheesy tortillas and green beans had blue handled scoops that hold 3 oz. in their containers for serving. Observation on 10/13/21 at 11:58 AM for noon meal Resident #22 received his pureed meal. Staff B, Server, used a full blue scoop (3 oz.) for the cheesy tortillas and a full blue scoop (3 oz.) for the green beans. Observation on 10/13/21 at 12:04 PM Resident #33 received her pureed meal. Staff B used a full blue scoop (3 oz.) for the cheesy tortilla and the rest of the green beans in the container roughly 1/3 of the blue scoop (approximately 1 oz.). Interview on 10/13/21 at 12:08 PM with Staff B revealed she thinks the cook picks the scoop size before he purees and she did not pick the scoop size. Interview on 10/13/21 at 12:15 PM with Staff B revealed about a half of scoop is left of the pureed cheese tortilla and no green beans. Observation on 10/13/21 at 12:20 PM of Resident #22's plate revealed his plate was empty. Observation on 10/13/21 at 12:34 PM of Resident #33's plate revealed his plate was empty. During interview on 10/13/21 at 12:43 PM the Dietary Manager stated since only two residents received a pureed diet Staff B should of given each resident half of each dish to each resident. He revealed the facility does not measure when only two residents receive puree or assign a scoop since each resident would just get half. He then stated there should be no food left. Review of the facilites policies provided titled: Diets - Therapeutic and another policy titled Use of Diet Manul both last revised on 08/2021 provided by the facility when asked for the facilites puree policy lacked instructions for staff puree process.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to utilize proper infection control technique for three of 13 residents observed. (Resident #33, #17 & #18) The facility census was 41 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #33 had [DIAGNOSES REDACTED]. The care plan dated 5/16/19, documented the resident had a current deep tissue injury to her left heel and staff were to complete the current treatment with standard contact precautions. Physician orders [REDACTED]. Observation on 11/24/19 at 10:34 a.m., revealed Staff A, Licensed Practical Nurse, LPN performed a dressing change as ordered. Staff A removed her soiled gloves, turned on the water with her bare hands washed her hands with soap and water, dried her hands and turned the faucet off again with her bare hands, re-contaminating her hands on the soiled sink. Staff A picked up the plastic bag of treatment supplies and left the room and returned the supplies to the medication cart. During interview on 11/25/19 at 3:56 p.m., the Director of Nurses (DON) revealed she expected all facility nurses would perform appropriate hand hygiene. 2. During observation on 11/24/19 at 11:37 a.m., Staff A obtain a blood sample from Resident # 17 and placed the machine back onto the tray on top of the medication cart without first disinfecting it. Staff A stated they only had 1 machine for the north end of the building and she used it for all of the diabetics on that end. During interview on 11/25/19 at 3:56 p.m., the DON expected all nurses to disinfect the glucometer machine after obtaining a blood sugar. A facility policy labeled Diabetic Management: Use of Glucose Monitoring Device revised 12/2018 stated that the device must be cleaned with a purple top wipe, ensuring a two minute wet time, between each use. 3. During observation on 11/24/19 at 1:10 p.m., Staff A washed her hands, applied gloves, and approached Resident #18 in the bathroom to apply a medicated ointment to the rectal area. Observation revealed the resident had fecal material on the rectum. Staff A moistened a washcloth and cleansed the resident's rectal area, disposed of the soiled washcloth, dried her rectal area with a towel and laid the towel on top of the garbage can. Wearing the same soiled gloves, Staff A opened the tube of the medicated ointment and applied the medication to resident's rectal area, followed by a second application of a non-medicated ointment. Staff A touched both tubes of ointments with her soiled gloved hands and returned both tubes into a bag on the back of the sink. Staff A picked up the contaminated bag with the 2 ointments and walked out of the room and placed the bag back into the medication/treatment cart. During interview on 11/25/19 at 3:56 p.m., the DON revealed she expected nurses would perform appropriate hand hygiene with any resident care. A facility policy labeled Hand Hygiene with a revision date of 11/19 stated the purpose was to prevent transmission of infection to patients, visitors, and colleagues by [MEDICATION NAME] effective hand hygiene principles as stated in this policy. The procedure stated to complete handwashing with soap and water by- a. Wet hands under running water b. Apply soap from dispenser and thoroughly distribute over hands. c. Vigorously rub hands together, continuing friction over palms, backs of hands, wrists, and between fingers for 15 seconds. d. Rinse thoroughly under running water. e. Dry hands with a paper towel. Activate lever-operated towel dispensers with forearm f. Use clean, dry paper towel to turn off the faucet.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to separate an alleged perpetrator immediately from all residents including the alleged victim (Resident #1) after the altercation. The facility census was 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The resident required assistance with transfers and ambulation and utilized a walker and wheel chair for locomotion. A BIMS score dated 5/8/18 revealed the resident scored 9, indicating moderately impaired cognition. The Care Plan directed staff to remind the resident of inappropriate comments or behaviors as needed during personal cares, allow resident to voice feeling or concerns, back off and try again later for cares if resident becomes agitated or upset and try different care provider. An incident report completed by the Administrator dated 4/16/18 documented a report of the resident was struck by an employee. The resident stated the aide was belligerent and would not back off about the resident getting out of chair to go to the bathroom. The resident stated a certified nurse aide, (Staff A) pushed on her with a closed hand, making the resident unsteady. The resident stated Staff A later came and poked her repeatedly in the arm. Later in the shift the resident stated Staff A came into room and poked him/her in the cheek and said you deserve to be here. No witness found, no injury noted, DIA and local authority notified. Nurse Notes dated 4/15/18 at 1:30 p.m., revealed Staff C, licensed practical nurse, LPN documented a certified nurse aide, CNA reported the resident got aggressive and hit Staff A in the throat and said she hit all four spouses. The resident called the CNA a dumb [***] . When staff spoke with the resident, the resident reported she did not want to get up to be changed or checked. Staff told the resident they were trying to make sure the coccyx healed properly. At 2:20 p.m., Staff C documented the resident was up in the room as usual, denied discomfort from fall and no injuries. At 2:49 p.m., Staff C documented the resident denied discomfort and no concerns voiced. At 4:58 p.m., Staff C documented the resident's bruise on the right hand had healed. Observation on 5/15/18 at 8:50 a.m., revealed the resident ambulated with a gait belt, wheeled walker and the assistance of one staff. The resident ambulated with a slow and steady gait, had appropriate behavior and the ability to make needs known. During interview on 5/15/18 at 8:50 a.m., the resident said several weeks ago a staff member, whose name she could not recall attempted to get her up from the recliner and hit the resident with a closed fist on the chin. The resident tried to fight against staff to leave her hands off the resident. Staff continued to try to get the resident to stand and there was other staff in the room but that person was the only one who was trying to get the resident up. During interview on 5/15/18 at 1:15 p.m., the Administrator reported on Monday morning, 4/16/18, Staff B, CNA came to her and the Director of Nursing and reported Staff A, CNA became rude and frustrated with the resident. Staff B observed verbal mistreatment. Later that day, Staff A told Staff B, she slugged the resident but the comment was such that Staff B did not understand the situation. Later when Staff B received a text from Staff A, she felt something seemed wrong. They educated Staff B to report bad feelings immediately. Initially when Staff A reported to Staff C, LPN they focused more on Staff A and being hit by the resident. Staff failed to report it as a possible abuse situation. When they were notified on Monday, they started the investigation and notified DIA within 24 hours. Staff A was off for two weeks. The police were notified but did not come out. Staff B received verbal education regarding the abuse policy. All staff was re-educated. The minute Staff B observed inappropriate behavior, she should have called for assistance and notified administration immediately. There was no injury with assessment. The resident said staff poked in the cheek and shoulder, and someone was very argumentative. The resident never said anyone hit her. A few days later the resident worried that she got someone fired. The resident never reported any other mistreatment. On 4/17/18, Staff A returned a call and said it was not a big deal. There was issues the day before because the resident was wet. The resident refused to go to the bathroom, she tried to talk the resident into it and that was when the resident got mad and swung at Staff A. Then the resident agreed to be checked and changed. During interview on 5/15/18 at 11:30 a.m., the Director of Nursing, DON said Staff B, CNA reported on Monday, 4/16/18 there was a verbal altercation with the resident and Staff A, CNA. The resident told the DON that an aide wanted her to go to the bathroom and was belligerent and refused to back off no matter what. The resident said staff had the resident's shirt and tried to get her up. They both cursed. The resident said staff came back and poked her in the arm and cheek you deserve everything that you got here today. The DON did a full assessment and the resident denied pain and had no bruises. The resident described the situation and the staff member but could not recall the name of the staff. The resident said staff did end up checking the resident's brief, and staff abruptly pulled her pants up and down and that made the resident unsteady. That day Staff C, LPN made an entry in the nurse notes after Staff A reported being hit by the resident. Administration educated Staff B regarding the requirement to report abuse immediately. During interview on 5/15/18 at 1:45 p.m., Staff C, LPN reported working the day shift on 4/15/18. Staff A, CNA reported the resident punched her in the throat, called her a [***] , and the resident stated she hit all four of her spouses. Staff C went to the resident and the resident failed to recall the staff member's name but did recall hitting staff. The resident said staff had it coming. The resident never said staff hit her. Staff B, CNA came to Staff C at the end of the shift and said Staff A was mean to the resident and they had a back and forth yelling war. Nobody reported anything physical. Staff C said Staff B reported concerns near the end of the shift and Staff C told Staff B to report it to the second shift nurse. All staff received education regarding the abuse policy. During interview on 5/18/18 at 3:00 p.m., Staff D, registered nurse, RN reported working second shift on Sunday, 4/15/18 from 2:00 p.m. - 10:30 p.m. Staff D replaced Staff C, LPN that day. When Staff D arrived to work she did a narcotic count with Staff C. During the count, Staff B, CNA handed a note and said here's my statement. Neither Staff B or Staff C said anything to Staff D about the incident. Staff D heard about the allegation on Monday when she arrived at work at 2:00 p.m. Staff B told Staff D she got Staff A in trouble and that Staff A wanted Staff B to lie for her. Sunday evening the resident told Staff D she did not like the staff who cared for her that day. Staff D did not think much of it since the resident often made similar comments. During interview on 5/15/18 at 10:30 a.m., Staff B, CNA said on 4/15/18, Staff B and Staff A were providing cares for residents after lunch. They asked the resident to use the rest room and the resident refused. Staff A went to the resident and said 'how about we check you to make sure you are not wet. The resident said no and Staff A said we need to do something. Staff A asked the resident if she knew why she was there and the resident replied it was because she had a stroke. Staff A said that was why they needed to take care of her. Staff A became frustrated and tried to lift the resident up from the chair. Staff A went to the resident's right side and tried to lift her and that was when the resident punched Staff A. Staff B walked out of the bathroom and heard Staff A ask the resident if she was a spouse beater and the resident said yes. Staff A said that was something to be proud of and the resident said yes. Staff A said that was [***] ing ridiculous and tried to raise the lift chair with the remote to get the resident to stand. Staff B grabbed the resident's hand and Staff A had the resident standing up. Staff A ripped the resident's pants down and checked the brief which was dry and she ripped the pants back up and pushed the resident back into his chair. Staff B walked up to the nurse's station and told Staff C she needed to talk to the resident, it was really bad, Staff A was mean and the resident hit Staff A. Staff B went in to speak to the resident and she said the [***] was not allowed back in here. When Staff A returned from break she reported to Staff B that she went into the resident's room and slugged the resident in the arm. When Staff D, RN, second shift arrived, Staff B reported to the nurse that Staff A was mean to the resident and she did not know if Staff C did anything. It was physically and verbally abusive. Staff D told Staff B to tell the DON first thing in the morning. Staff B revealed she should have called them right away. On Monday morning, Staff B went to the DON and Administrator and reported her concerns. During interview on 5/16/18 at 9:30 a.m., Staff A, CNA revealed on 4/15/18, at around 1:30 p.m., Staff B, CNA asked Staff A to assist with taking the resident to the toilet. They went into the resident's and encouraged her to go to the bathroom as the resident sat in the recliner and the resident refused. They asked the resident to walk to the bathroom so they could check her and the resident said no. The resident became upset quickly and started yelling and the resident hit Staff A on the right cheek. Staff A and Staff B eventually did check the residents brief and assisted the resident to sit back down into the recliner. Shortly after that, Staff A went on break and stopped by the resident's room and nudged the resident on the shoulder and asked if she was still mad. The resident called Staff A names and said to get out of the room. When Staff A returned from break she assisted a resident to the bathroom and Staff B entered. Staff A told Staff B she tried to talk to the resident and she slugged the resident in the shoulder trying to make nice, but the resident called Staff A names and so it was a no go. Staff B said Oh my God, you slugged her? Staff A said it was like a pal kind of slug. Staff A indicated she never entered the resident's room the rest of the shift. The facility Abuse Policy included: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint to required to treat the resident's medical symptoms. These procedures include the screening, training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment and misappropriation of property, without fear of recrimination or intimidation. Initial/Immediate Protection During Facility Investigation Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility; and in rare instances (3) separating the employee accused of abuse from the resident alleged to have been abuse, but allowing the employee to care for and have contact with other residents, only if there is a second employee who remains with and accompanies the employee accused of abuse at all times to supervise all contacts and interactions with the residents.

Based on observation, clinical record review and staff interview, the facility failed to ensure one of five residents reviewed had an assessment of a skin issue completed and treatment was started in order to prevent further skin impairment. (Resident #1) The facility census was 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment form dated 2/23/18, indicated Resident #1 had [DIAGNOSES REDACTED]. The Care Plan dated 3/20/18, indicated the resident had skin impairment related to [MEDICAL CONDITION] and patchy skin on the face. Interventions included medications and treatment as ordered and for staff to assist with shaving and monitor skin and notify the nurse as needed. A Treatment Administration Record dated 3/1/18 thru 3/31/18, documented an order for [REDACTED]. Observation on 3/20/18 at 1:30 p.m., revealed the resident with a spotty red, raised, dry peeling rash on his/her face and neck with some scattered blisters present. Staff B, Certified Nurse Aide stated the areas were present the day prior and reported it to the nurse. On 3/21/18 at 1:05 p.m., clinical record review failed to reveal an assessment of the rashy area on the residents face. During interview at the time, the Nurse Lead confirmed the absence of an assessment and/or intervention. The Nurse Lead asked Staff B if she reported the rash to the nurse on 3/20/18 and she confirmed she reported the condition.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff maintained privacy during personal cares for one of five residents reviewed during cares. (Resident #1) The facility census was 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment form dated 2/23/18, indicated Resident #1 had [DIAGNOSES REDACTED]. and required extensive staff assistance with bed mobility, toilet use, personal hygiene and was incontinent of bowel and bladder. During observation on 3/20/18 at 1:40 p.m., Staff A, Certified Nurse Aide, CNA and Staff B, CNA provided perineal care to the resident while positioned in bed without the privacy door closed. Observation revealed the resident's roommate was positioned in an easy chair in view of the resident receiving personal care. During interview on 3/21/18 at 1:55 p.m., Staff B confirmed the privacy door was not shut during personal cares.

Based on observation, review of manufacturers recommendations and staff interview, the facility failed to ensure staff properly sanitized a whirlpool tub between resident use to prevent the spread of infection and failed to sanitize glucometer's according to manufacturer guidelines for one of two residents observed. (Resident #14) The facility census was 50 residents. Findings include: 1. During environmental tour on 6/26/17 at 2:05 p.m., observation revealed Staff A, Certified Nurse Aide in the whirlpool room. At that time the surveyor asked Staff A to demonstrate how they sanitized the whirlpool tub. Staff A stated they used sanitizer from a spray bottle and sprayed the surface of the tub and let it sit for ten minutes, then rinsed it off. The surveyor asked Staff A if they ever allowed the sanitizer to run through the jets of the tub. Staff A replied no because the built-in whirlpool sanitizer did not work so they could not sanitize the jets. At 3:19 p.m., the Assistant Administrator stated staff should have been following manufacturer guidelines to ensure the tub was sanitized properly between resident use. The Assistant Administrator stated they would contact the company to have repairs made to the built-in sanitizer system which sanitized the jets. The Assistant Administrator stated staff would not be using the whirlpool tub until it could be repaired and sanitized properly. On 6/27/17 at 9:05 a.m., the Assistant Administrator provided the surveyor with a policy for sanitizing the whirlpool and stated they had just posted it in the whirlpool room for staff to reference. The Assistant Administrator verified staff had not been sanitizing the whirlpool properly because the disinfectant spray handle had been leaking for the past four to six weeks, and maintenance had now fixed it. 2. During observation on 6/26/17 at 11:37 a.m., Staff D (Licensed Practical Nurse) completed a blood sugar test for Resident #14. Upon completion of the test, Staff D used a Super Sani- wipe to cleanse the glucometer. Staff D failed to follow the directions for disinfecting the glucometer. 3. During observation on 6/27/17 at 8:46 a.m., Staff D completed a blood sugar test for Resident #14. Upon completion of the test, Staff D used a Super Sani-wipe to cleanse the glucometer. Staff D failed to follow the directions for disinfecting the glucometer. Review of the Super Sani-Cloth germicidal disposable wipes container included a directive to unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. During interview on 6/27/17 at 1:10 p.m., the Minimum Data Set nurse stated the expectation of the nurse was to follow the directions and directive on the Sani-wipe container and to keep the glucometer wet for a full two minutes.

Based on clinical record review and staff interview, the facility failed to document non- pharmacological interventions attempted prior to administering [MEDICAL CONDITION] medication for two of eight residents reviewed. (Resident #6 & #11) The facility census was 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The care plan with a target dated 9/7/17, identified a focus area of potential for ineffective coping with interventions that included: a. Allow resident time to voice feelings or concerns b. Current medication as ordered. c. Encourage activities outside of room d. Encourage choices whenever possible e. Encourage resident to do for self as able/tolerates f. Encourage visits from family and friends g. Introduce to other residents h. Monitor for increase in signs/symptoms of depression i. Observe for possible side effects of medication j. Tender, loving, care and reassurance k. visits with Hospice staff, massage therapy, music therapy and volunteers. An Order Summary Report dated 5/27/17, documented an order for [REDACTED]. The Medication Administration Record [REDACTED] a. 5/31/17 at 3:50 a.m. The Medication Administration Record [REDACTED] a. 5/25/17 at 7:32 p.m. Nurse notes lacked documentation staff attempted non-pharmacological interventions to decrease the resident's anxiety, agitation or restlessness prior to administering the [MEDICATION NAME] and [MEDICATION NAME]. During interview on 6/26/17 at 3:30 p.m., the MDS coordinator confirmed the progress notes lacked documentation on any non-pharmacological interventions attempted and stated the expectation of the nursing staff was to document non-pharmacological interventions prior to administering the [MEDICATION NAME] and [MEDICATION NAME], and nurses need more education on attempting other alternative interventions. 2. The MDS assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. The care plan with a target dated 9/7/17, identified a focus area of resident used [MEDICAL CONDITION] medications [MEDICATION NAME], Trazadone and [MEDICATION NAME] with interventions that included: a. Prior to administering as needed medications, try toileting, offering snacks or fluids, repositioning, individual activities, 1-1 with staff or family, or other interventions as situation arises. b. Observe for/record occurrence of target behavior symptoms, example, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. An Order Summary Report dated 5/27/17, documented an order for [REDACTED]. The Medication Administration Record [REDACTED] a. 6/26/17 at 2:58 a.m. The Medication Administration Record [REDACTED] a. 5/2/17 at 10:08 p.m. b. 5/18/17 at 11:02 p.m. c. 5/20/17 at 3:35 p.m. d. 5/24/17 at 4:08 p.m. Nurse notes lacked documentation staff attempted non-pharmacological interventions to decrease the resident's anxiety, agitation or restlessness prior to administering the [MEDICATION NAME]. During interview on 6/27/17 at 2:15 p.m., the administer confirmed the progress notes lacked documentation on any non-pharmacological interventions attempted and stated the expectation of the nursing staff was to document non-pharmacological interventions prior to administering the [MEDICATION NAME] and [MEDICATION NAME], and nurses need more education on attempting other alternative interventions.

Based on observation, clinical record review, and staff interview, the facility failed to ensure 2 of 8 residents reviewed received ongoing restorative exercises. The facility census was 50 residents. (Resident #6 and #7). Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS also documented the resident with limitations in upper and lower extremities on both sides. The MDS assessment reference dated 3/15/17, documented Resident #6 with no upper extremity limitations. The Restorative Nursing Programs documented no days for the program was performed in the last 7 calendar days. A Progress note dated 9/15/16 at 1:26 p.m., stated resident was seen by physical therapy. Patient may perform heel slides, straight leg raise, LAQ, shoulder flexion, bicep curls, Active Range of Motion. Patient my also benefit from Passive range of motion to bilateral upper extremities, bilateral lower extremities as well to active range of motion. The plan of care lacked any focus areas, goals or interventions for the Restorative Program to be performed. Interview on 6/26/17 at 1:30 p.m., Staff B (certified nursing assistant) explained that this resident is not currently on any functional maintenance programs. Interview on 6/27/17 at 1:44 p.m., the facility MDS coordinator confirmed and verified that the clinical record lacked documentation of the AROM or PROM as being completed. 2. The MDS assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. The MDS documented the resident with upper and lower extremity limitations on both sides, and the resident received no Restorative exercises in the 7 day look back period. The MDS assessment reference dated 3/1/17, documented Resident #7 with no limitations to the upper extremity. The plan of care lacked any focus areas, goals or interventions for the resident decline in range of motion to the upper extremities. Progress notes dated 5/26/17 at 9:03 a.m., documented resident uses an EZ stand for transfers. Needs help with activities of daily living, propels self in wheelchair to and from meals, also around facility. Resident does not attend exercise classes or do 1-1, prefers to rest at those times. Progress notes dated 3/3/17 at 7:17 a.m., documented resident transfers with 2 staff, and gait belt for pivot transfers. Also EZ stand as needed. Has assistance with activities of daily living, toileting and transfers. Resident stated Not interested in exercises. Restorative aide encourage if changes mind let the Restorative aide know.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff utilized assistive devices in order to prevent accident injury when transporting seven of eleven residents reviewed and failed to ensure residents medications were properly secured. The facility census was 49 residents. (Resident #2, #5, #6, #7, #9, #10 & # 11) Findings include: 1. On 3/15/11 at 4:10 p.m., observation revealed an unattended and unlocked medication cart in the hallway near room 9 with no staff visible. After approximately one minute, Staff G (Registered Nurse) exited the room. At the time the surveyor asked if he/she had been aware the medication cart was unlocked and unattended. Staff G stated he/she had thought about it after entering the room. 2. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance of one with bed mobility and supervision of one with locomotion on the unit. The plan of care updated 1/7/11, documented a problem of impaired mobility with potential for falls related to impaired balance, states feet are numb, vision impaired and increased restlessness and confusion late afternoon secondary to macular degeneration Interventions included to use a wheel chair for longer distances as needed with staff or family to push. During observation on 3/16/11 at 6:04 p.m., Staff F (certified nurse aide, CNA) pushed the resident in a wheel chair from a table in the dining room to a lounge area near the nurses station. The wheel chair had bilateral foot pedals with leg rests on. The residents feet slid along the floor as the resident attempted to pick them up but the leg rests on the wheel chair were in the way. 3. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance of two for bed mobility and extensive assistance of one with locomotion on the unit. The plan of care updated 2/25/11, documented a problem of impaired mobility-history of falls with potential for more. The problem included an intervention to use a wheel chair per self for short distances or staff/family to push. A consultation report dated 3/8/11, documented a [DIAGNOSES REDACTED]. On 3/16/11 at 3:55 p.m., Staff E (CNA) pushed the resident in a wheel chair from the activity room to his/her room in a wheel chair with no foot pedals. The resident had his/her knees flexed holding both feet up under the wheel chair seat. Surveyor: Griffith, Teresa 4. The MDS assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. The MDS assessment revealed the resident required limited assistance from staff for transfers, walking and locomotion in the wheelchair on the unit. The MDS assessment documented the resident had a history of [REDACTED]. Observation in the facility dining room on 3/16/11 at 11:45 a.m., revealed the resident transported in a wheelchair by Staff A (CNA). The wheel chair had no foot pedals attached to the front of the wheelchair. The resident communicated he/she should probably wheel himself/herself. The resident held their feet in close proximity to the floor while being transported in the chair. 5. The MDS assessment dated [DATE]. documented Resident #5 had [DIAGNOSES REDACTED]. The MDS indicated the resident had moderately impaired cognitive function as well as fluctuating disorganized thinking and fluctuating ability to focus attention. The MDS communicated the resident required 1-2 staff assistance for bed mobility, transfers, ambulation, dressing, eating, toileting, and personal hygiene. The MDS revealed the resident had a history of [REDACTED]. An observation in the facility corridor on 3/16/11 at 4:40 p.m., revealed the resident transported in a wheelchair with no pedals by Staff E (CNA). The resident held his/her feet in close proximity to the floor during the transport process. 6. The MDS assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. The MDS assessment revealed the resident had moderately impaired cognitive function and required extensive assistance for bed mobility, transfers, toilet use and bathing. Observation in the facility dining room on 3/16/11 at 4:50 p.m., revealed the resident transported in a geri chair positioned in an upright position by Staff B (CNA). During forward movement in the geri chair the resident held his/her feet in close proximity to the floor. Observation in the facility dining room on 3/16/11 at 6:25 p.m., revealed Staff C (CNA) push the resident in the geri chair positioned in an upright manner. During transport the resident held his/her feet in close proximity to the floor. Observation in the facility corridor on 3/17/11 at 7:20 a.m., revealed Staff D (certified nursing assistant) transported the resident in the geri chair positioned in an upright manner. During transport the resident's left shoe touched the floor. 7. The MDS assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident had severely impaired cognitive function as well as behaviors that included inattention, disorganized thinking, altered levels of consciousness and psychomotor retardation. The MDS assessment revealed the resident required extensive assistance for bed mobility, transfers, dressing, toilet use and bathing. Nurse notes dated 3/9/11, documented the resident had an abrasion of unknown origin on their left great toe that measured 05. centimeters (cm) by 0.6 cm. with scant amount of bright red bleeding. Observation on 3/16/11 at 5:04 p.m., revealed the resident transported from the dining room in an upright geri chair by Staff E (CNA). The resident's padded open toed foot protectors touched the floor at times during the transport. Staff E communicated to the resident to keep their feet up. Observation on 3/16/11 at 5:50 p.m., revealed the resident as transported in an upright geri chair from the facility dining room to the adjacent area near the nurses station by Staff B (certified nursing assistant). Staff B advised the resident to put their feet up. The resident's padded open toed foot protectors intermittently touched the floor during transport. 8. The MDS assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The MDS assessment revealed the resident required extensive assistance for transfers and locomotion on the unit. The resident's plan of care updated 1/14/11, documented a history of a laminectomy (back surgery) and impaired balance. Observation in the facility dining and corridor area on 3/16/11 at 6:04 p.m., revealed the resident transported by Staff F in a wheelchair with no foot pedals present. The resident's feet were positioned in close proximity to the floor. During interview on 3/18/11 at 10:00 a.m., Staff H ( CNA/rehabilitation aide) stated the expectation for wheelchair pedal usage was when a resident was being pushed in a wheelchair it would be okay to push a resident in a wheelchair without pedals for a short distance if they held their feet up. Staff H verbalized for long distances wheelchair pedals would be placed on the wheelchair when a resident was being pushed. Staff H indicated wheelchair pedals should be used for residents having trouble holding their feet up. Staff H communicated the expectation for transporting a resident in a geri chair would be to put the feet up if the resident's feet are touching or sliding on the floor.