Every finding on record at Good Samaritan Society Scotland

Based on observation, interview, and policy review, the provider failed to ensure medications were not expired and medication and treatment carts were locked for one of one medication storage room that had expired medications, one of one medication carts that was left unlocked and unattended by one of one certified medication aide (CMA) (E), and one of one treatment cart (a cart with prescribed medical supplies) that was left unlocked and unattended by one of one registered nurse (RN) (D). Findings include:1. Observation and interview on 7/14/26 at 12:20 p.m. in the dining room revealed that while CMA E was administering medications to residents, she would leave the medication cart unlocked and unattended. CMA E was observed with her back to the unlocked medication cart on three occasions. When asked whether the medication cart should be locked while not at it, she stated If I'm in the same room, I don't have to.Further observations revealed that CMA E locked the medication cart each time she left it unattended.2. Observation and interview on 7/15/26 at 3:05 p.m. in the medication room revealed there was a box of (10) Fluzone (Influenza Vaccine) High dose 0.5 ml (milliliter) syringes with an expiration date of June 2026. RN J agreed that the vaccines were expired and should not have been in the medication refrigerator where they could potentially be used. RN J stated that RN/clinical care coordinator C was responsible for the destruction or return of expired medications.3. Interview on 7/15/26 at 3:15 p.m. with RN/clinical care coordinator C revealed that she was aware that the expired influenza vaccines were in the refrigerator and she was trying to figure out how to return them to the vendor. She confirmed that the vaccines should not have been in the refrigerator.4. Observations on 7/16/26 at 10:21 a.m., 10:39 a.m., and 10:52 a.m. revealed that RN D had left the treatment cart unlocked and unattended while providing care for residents.5. Interview on 7/16/26 at 10:55 a.m. with RN D revealed that she should have locked the treatment cart while it was unattended.6. Interview on 7/16/26 at 12:45 p.m. with director of nursing (DON) B revealed that she expected the staff to lock the medication and treatment carts when the carts were not in the staff member's line of sight. She agreed that CMA E and RN D should have locked their carts before walking away.7. Review of the provider's 3/30/26 Medications: Acquisition Receiving Dispensing and Storage policy revealed Medications will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas. The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations.

Based on interview, record review, and policy review, the provider failed to provide restorative therapy (a nursing-based program designed to help residents maintain or improve their independence) services for two of twelve sampled residents (9 and 22) who reported their restorative therapy services were not being completed. Findings include: 1. Interview on 7/15/26 at 9:03 a.m. with resident 22 in her room revealed that she was doing exercises on her own because restorative therapies were not being offered regularly. She wanted to keep her strength up so she could continue to remain as independent as possible. She would go to the therapy room to use the Nu Step machine (a seated, recumbent cross-trainer used in senior living centers for low-impact, full-body workouts). If no one was using the Nu Step, she was allowed to use it for her own workout. She stated the restorative aide would often get pulled from the schedule to work on the floor if another staff member called in sick, which meant restorative therapy was not offered on those days.2. Review of resident 22's electronic medical record (EMR) revealed, her revised 5/5/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated, The resident has a need for restorative interventions to maintain transfer and ambulation ability. Resident will maintain current level of mobility IND [independent] with ambulation in room through review date. Nursing Rehab #1: Transfers pulleys or restorative/Omnicycle 10-15 minutes 6x/week (six times per week) to maintain ability to transfer. Nursing Rehab #2: Walking and NuStep L3 [level 3] 15 minutes 6x/week to maintain ability to ambulate IND with FWW [front wheel walker] or stepper in res. [resident] room. Nursing Rehab #5: Active range of motion [flexible movements designed to keep joints active, reduce stiffness, and improve mobility] UE [upper extremities] and LE [lower extremities] exercises with wts [weights] per her discretion 6x/week 15 min/day goal to maintain IND transfers.Resident 22's restorative therapy documentation revealed, for the month of June nursing rehab #1 was completed two times, nursing rehab #2 was completed three times, and nursing rehab #5 was completed two times. For 7/1/26 through 7/15/26 nursing rehab #1 was completed two times, nursing rehab #2 was completed two times, and nursing rehab #5 was completed two times. 3. Interview on 7/15/26 at 3:52 p.m. with resident 9 revealed she had difficulty breathing and mobility was important to her. She used her manual wheelchair to get to and from the dining room. Exercise was hit or miss depending on the staff available for the day.4. Review of resident 9's EMR revealed her revised 5/4/26 care plan indicated, The resident has a need for restorative interventions due to activity intolerance E/B (evidenced by) [the] need for frequent rest breaks. Nursing Rehab #1 Active range of motion: bilateral legs: seated leg weight exercises: 3 lb (pound) leg weights, marching, kicking, side-to-side; 10 reps [repetitions] of 10 each. 1x/day, 6 days/week. Nursing Rehab #1: Passive range of motion [moving a joint with and outside force-like a therapist, a machine, or your other hand-while your muscles stay completely relaxed]: bilateral legs: Omnicycle set to 50 rpm [revolutions per minute]: goal of 15 minutes per day, 6 days per week.Resident 9's restorative therapy documentation indicated that for June 2026 active range of motion was completed four times. Passive range of motion was completed four times. For 7/1/26 through 7/15/26, active range of motion was completed seven times. Passive range of motion was completed seven times. 5. Interview on 7/16/26 at 11:47 a.m. with director of nursing (DON) B revealed that about a year and a half ago the resident census was low so the scheduled CNAs were tasked with providing restorative therapies to the residents with their other regular duties. Recently the resident census increased and a restorative aide was scheduled to provide restorative services to the residents. Two weeks ago, one of the scheduled CNAs was in an accident and could not work, so the scheduled restorative aide had to help complete the resident's basic care needs tasks instead of providing restorative services to the residents. She agreed restorative therapy was not being completed regularly. 6. Interview on 7/16/26 at 1:00 p.m. with administrator A revealed she knew there was an issue with restorative therapy getting completed regularly. She expected the staff to follow the resident's care plan for restorative therapy to be completed for all residents. The staff had tried different schedules to accommodate restorative therapy being completed. She agreed restorative therapy was not being done consistently. 7. Review of the provider's 9/30/25 revised Restorative-Identifying Decline in Activities of Daily Living policy revealed, Purpose: To identify declines in ADL [activities of daily living]. To consider interventions to avoid ADL decline. Guidelines: Residents with the potential for ADL decline can be identified through early detection. The following can help you recognize areas that may contribute to ADL decline: 1. Newly admitted residents without therapy orders: a. Residents admitted from home or from hospital and without a qualifying Medicare stay or orders for therapy need to be evaluated for therapy or restorative interventions.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff monitored the nutrition, hydration, and weight status as ordered by the physician for one of one sampled resident (43) who did not have drinking water available and had documented weight fluctuations.Findings include:1. Observation and interview on 7/14/26 at 4:08 p.m. with resident 43 in his room revealed that he was sitting up in his bed, his water cup was empty, and the resident pointed at his water cup. When asked if he needed water, the resident nodded yes. The resident's call light was within reach, but he did not use it.2.Observation on 7/16/26 from 10:35 a.m. to 11:53 a.m. revealed resident 43 could be heard in the hallway yelling from his bedroom for help to the bathroom, and his water cup was empty. His water cup was still empty at 11:53 a.m. 3. Review of resident 43's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. His 7/11/26 Brief Interview for Mental Status (BIMS) assessment score was 99, which indicated he was unable to complete the assessment. His medical diagnoses included multiple pelvic fractures, unspecified intellectual disabilities, schizophrenia (a brain disorder characterized by delusions, hallucinations, and disorganized thinking), and an encounter for autism screening. There was a 7/8/26 physician's order for the resident to be weighed daily for the first 14 days after admission. There was a 7/8/26 physician's order for the staff to record the amount of food and fluid the resident ate and drank three times per day.4. Resident 43's documented weight on 7/9/26 was 145 pounds. On 7/10/26, his weight was 155 pounds. On 7/11/26, he weighed 154 pounds. On 7/12/26, he weighed 144.5 pounds. There was no documentation stating that the resident was re-weighed after those weights.5. Resident 43's Amount eaten by Mouth documentation indicated that on 7/9/26, two meals were documented as 25%-50% and 50%-75%, on 7/14/26, only one meal was documented as 50%-75%, and on 7/15/26, only one meal was documented as 25%-50%. An oral intake was documented only once on 7/14/26 (480 milliliters (mL)) and once on 7/15/26 (100 mL).6. Interview on 7/16/26 at 10:42 a.m. with certified nursing assistant (CNA) I revealed the CNAs were responsible for obtaining the resident's weights. She reported that the nurses monitor the resident's weight changes and would tell the CNAs if a re-weigh was needed.She stated that fresh water was passed in the mornings by the CNAs and was replenished throughout the day when a resident asked for it, or if the staff recognized a resident needed water.8. Interview on 7/16/26 at 10:44 a.m. with registered nurse (RN) D revealed that she thought that the night shift nurse and the dietary manager monitored the resident's weights for changes.9. Interview on 7/16/26 at 10:46 with certified medication aide (CMA) E revealed that she would pass water to the residents between 6:30-7:00 a.m. when she started administering medications to the residents. That was the only scheduled water pass.10. Interview on 7/16/26 at 12:45 p.m. with director of nursing (DON) B revealed that she expected the staff to document the amounts of food eaten and fluids drank by the residents as ordered by their physician. Regarding resident 43's weights, she expected that the resident would have been re-weighed when his weights varied that much. She reported that when a resident was re-weighed, it was done the following day. She expected that there would have been more documentation regarding resident 43's weight changes.She would expect that due to resident 43s communication difficulties, staff would ensure he has water available even if he does not put on his call light to ask for it. 11. Review of the provider's 9/30/25 Weight and Height policy revealed a purpose of To ensure that the resident maintains acceptable parameters of nutritional status regarding weight. To report changes in a resident's clinical condition (significant weight change) to [the] physician and family and/or resident. To monitor weight loss or gain in a resident.The policy's weight procedure stated 7. If weight varies by more than three percent, reweigh resident and document. Report weight to licensed nurse. 8. The licensed nurse should notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. Significant weight change is defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days. 9. The licensed nurse should immediately notify the medical provider regarding any significant weight as defined in step 8.12. A review of the provider's 4/27/26 Nutrition and Hydration-Food and Nutrition policy revealed a purpose of To routinely monitor resident's nutritional status and monitor nutritional risk. Hydration, Offer sufficient fluid intake to maintain proper hydration and health. A goal of 1,500 mls [milliliters] of liquids per day is often recommended.

Based on record review, interview, policy review, and job description review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for four of four recently admitted sampled residents (8, 133, 183, and 184) within 48 hours of their admission to the facility. Findings include: 1. Review of resident 8's electronic medical record (EMR) on 3/24/25 revealed: *He was admitted on [DATE]. *There were no progress notes pertaining to a baseline care plan. *The first progress note pertaining to care planning was titled care plan change and dated 3/11/25. -It included removing 15-minute checks that had been instituted due to a concern for self-harm. *There were no notes indicating a baseline care plan had been provided to the resident. *A progress note indicating initial care plan was entered on 3/20/25 by Minimum Data Set (MDS) Coordinator C, for Assessment Reference Date (ARD) of 3/11/25. Interview with resident 8 on 3/26/25 at 11:42 a.m. revealed: *He was not interviewed by staff about his daily routine or preferences. *He did not know what a care plan was. *He had not received a copy of any care plan. A request was made on 3/25/25 at 2:05 p.m. to Administrator A to review resident 8's baseline care plan. No baseline care plan was provided by time of survey exit on 3/27/25. There was no documentation to support a baseline care plan had been completed within 48 hours of his admission. 49238 2. Interview on 3/27/25 at 8:58 a.m. with resident 133 revealed: *He admitted to the facility on [DATE] after he was hospitalized due to an amputation of his toes on his right foot, and he was no longer safe at his home. *He did not have a power of attorney (POA) and made his own decisions. *He had an allergy to chocolate. *He was supposed to get therapy. *The director did his admission paperwork but he could not remember her name, and he signed those papers. *He did not remember if his medical needs or cares were discussed with him. *He stated he had not received a summary or paper copy of his care plan. Review of resident 133's electronic (EMR) revealed: *He admitted to the facility on [DATE] from the hospital for inability to thrive and right toe amputation. *His admission assessment was not completed inidicated in progress and it was signed by MDS coordinator C. *His brief interview for mental status (BIMS) assessment indicated he refused to the answer the questions. *His comprehensive care plan indicated it was not completed until 3/24/25. 43021 3. Interview on 3/25/25 at 2:28 p.m. with resident 183 and his wife in his room revealed: *He was admitted on [DATE]. *He and his wife could not recall any conversation with staff regarding his plan of care within the first two days of his admission to the facility. *He stated they had not received a summary of his baseline care plan or a list of his medications. -His wife stated his medication list would have been lengthy as he was on many medications. *His wife stated she recalled visiting with administrator A regarding admission paperwork and administrator A had mentioned he would be receiving physical and occupational therapy, but she stated no other services were discussed. Review of resident 183's EMR on 3/25/25 revealed: *He was admitted on [DATE] at 11:00 a.m. *His eight-page 3/12/25 Nursing Admit Re-Admit ([NAME]) Data Collection assessment was signed by registered nurse (RN) J on 3/12/25. -Care planning, including a focus area, goal, and interventions were indicated for: --The six skin/wound areas identified. --His limited activities of daily living (ADL) function. -The sleep pattern section indicated he was experiencing a sleep disturbance [and/]or using any pharmacological . sleep aides and noted the sleep aide supplement/medication he used. --The Care planning for sleep disturbance indicated no focus, goal, or intervention had been identified to address his sleep. *His progress notes for his first 48 hours included: -On 3/12/25 at 1:22 p.m. registered nurse (RN) J noted the Skilled services to be provided included: --Dressing changes and wound assessments. --Diabetes control. --Strengthening with physical therapy and occupational therapy. --Pain control. --Antibiotics for his wounds. -On 3/12/25 at 3:32 p.m. MDS coordinator C noted that his admission orders had been entered into his EMR. *On 3/12/25 at 3:51 p.m. administrator A documented that she had completed his admission agreement with him and his wife and identified his discharge goal as returning home. *On 3/12/25 at 4:04 p.m. RN J noted his oxygen administration orders, chronic low back pain, pain medications, blood sugar checks for his diabetes, and that he was non-weight bearing. *On 3/12/25 at 11:08 p.m. licensed practical nurse (LPN) K noted his right leg had a warming boot in place at all times and that he used a full-body mechanical lift with the assistance of two staff members. *On 3/13/25 at 2:58 p.m. activities director L documented she had completed his: -BIMS assessment, which was scored at 14 indicating he was cognitively intact. -Patient Health Questionnaire (PHQ) indicated he had no mood problems. -Activity preferences. *On 3/13/25 at 3:24 p.m. RN J noted she had received physician orders for side rails on both sides of his bed. *On 3/13/25 at 11:31 p.m. LPN K noted his health status. *There was no progress note regarding any care conference held during his first 48 hours in the facility. *His 3/25/25 care plan indicated his baseline care plan had included focus areas of: -ADL assistance with transferring, toileting, personal hygiene, and bed mobility. -Skin wounds with dressing changes. -Enhanced Barrier Precautions (EBP) related his wounds which included his surgical wound with infection. -Chronic pain/discomfort. -Preferences for independent activity pursuits. *His baseline care plan had not addressed the required areas of his dietary orders, therapy services, and social services. *There was no documentation indicating that the baseline care plan had been reviewed or provided to the resident or his representative. 4. Review of resident 184's EMR revealed: *She was admitted on [DATE] at 2:32 p.m. *Her eight-page 3/20/25 [NAME] Data Collection assessment was signed by RN J on 3/20/25. -The Reason for Admission section indicated: --She had been hospitalized for a cerebrovascular accident (CVA) (stroke) which had affected her changes in mentation [cognitive abilities], increased weakness on right side, [and] urinary retention. --Her skilled care services included physical therapy strengthening, diabetes control, [and] assist with ADL's. -Care planning included one focus area, her impaired vision in her right eye. -The Care planning for indicated no focus, goal, or intervention had been identified to address her: --Increased confusion, disorientation, and forgetfulness. --Need for ADL assistance. --Urinary retention and Foley catheter. *Her progress notes for her first 48 hours included: -On 3/20/25 at 2:32 p.m. administrator A documented her arrival with family members and that the resident was not alert. -Administrator A indicated she had completed the admission agreement with the resident's daughter and noted the discharge goal of returning home. -On 3/20/25 at 4:03 p.m. RN J noted the skilled services to be provided included: --Physical therapy strengthening. --Diabetes control. --Assistance with ADL's. -On 3/20/25 at 5:48 p.m. MDS coordinator C noted that her admission orders had been entered into her EMR and the family members' concerns regarding her not eating, feeling nauseous, and ability to use the call light. -On 3/21/25 at 3:48 a.m. RN M noted she had received physician orders for physical therapy and occupational therapy services for strengthening and the resident's need to be checked on frequently, repositioned routinely, encouraged to drink, and the need for assistance with her cares. -On 3/21/25 between 1:48 p.m. and 6:32 p.m. RN J noted the following: --Resident's elevated temperature of 100.8 F (Fahrenheit) and that she had received physician orders for lab work. --Resident's Foley catheter had been removed. --Antibiotic medication order had been received to treat her UTI (Urinary Tract Infection). --Physician order for dietary supplement three times a day had been received. --Nursing interventions required for the resident's care included: --Monitor for any changes in cognition. --Complete vital signs every shift. --Monitor urine output. --Participation with therapy services. --Frequent repositioning. --Encourage food related to her poor intake and loss of appetite. --Need for one person to assist with her ADLs. *There was no progress note regarding any care conference held during her first 48 hours in the facility. *Her 3/25/25 BIMS assessment was three which indicated her cognition was severely impaired. *Her 3/25/25 care plan indicated her baseline care plan had included focus areas of: -Impaired visual function related to difficulty seeing out of right eye. -ADL assistance with transferring and bed mobility. -Infection of the (urine). -Potential for pain. *Her baseline care plan had not addressed the required areas of dietary orders, therapy services, social services, and her need for extensive to total assistance with ambulation, bathing, dressing, eating, oral care, personal hygiene, and toilet use. *There was no documentation to support the baseline care plan had been reviewed and provided to the resident or her representative. 5. Interview on 3/25/25 2:49 p.m. with RN J revealed she: *Had worked at the facility since 9/24/24. *Worked as a charge nurse on the day shift and was responsible for completing the nursing assessments which included newly admitted residents. *Stated her responsibilities were not so much for the care plan of the residents. *Stated MDS coordinator C or director of nursing (DON) B completed the residents' care plans. Interview on 3/25/25 at 4:12 p.m. with MDS coordinator C revealed: She had worked at the facility for nearly thirty years. *Completing the resident care plans was the responsibility of the interdisciplinary team (IDT) including social services, activities, dietary, and nursing staff. *The baseline care plan was her responsibility. -She stated the charge nurses did not have the time to complete resident care plans. -She used the provider's EMR care planning software to complete the baseline care plan. -Three months ago they had tried to organize the process for the baseline care plan, that fell apart with staff challenges. -She acknowledged completing the baseline care plan and its requirements were an area for improvement. -She agreed that resident baseline care plans had not been completed within 48 hours of their admission and the baseline care plans had not been given to the resident or representative as required. Interview and record review on 3/26/25 at 11:03 a.m. with MDS coordinator C regarding resident 184's baseline care plan revealed: *The electronic care plan that initially had her baseline care plan had been developed into her comprehensive care plan and included: -A focus area initiated on her admission day, 3/20/25, indicated The resident has impaired visual function R/T [related to] CVA [Cerebrovascular Accident] E/B [evidenced by] difficulty seeing out of right eye. -No goal or interventions had been identified for that focus area. -A focus area initiated on 3/22/25 indicated The resident has an ADL self-care performance deficit R/T [related to] non traumatic cerebral hemorrhage E/B [evidenced by] Alzheimer's Dementia, convulsions with two goals initiated on 3/22/25. -Three interventions regarding bed mobility were initiated on 3/21/25. -One intervention regarding transfers was initiated on 3/21/24. -A focus area initiated on 3/21/25 indicated The resident has infection of the (urine) R/T [related to] (having Foley catheter in hospital) E/B [evidenced by] (lab results) with a goal and three interventions initiated on 3/21/25 indicated. -A focus area initiated on 3/21/24 indicated The resident has P/F [potential for] pain. -No goal or interventions had been identified for that focus area. *MDS coordinator C confirmed that not all the required components of the baseline care plan were included within the required 48-hour timeline. *She confirmed the baseline care plan had not been provided to the family or representative as required. *She agreed that the resident's dietary orders, therapy services, and social services were not included in the baseline care plan within the required 48-hour timeline and should have been. *The focus area addressing the resident's dietary orders which included her nutritional problem and unplanned weight loss had been initiated on 3/25/25, five days after her admission. *The focus area addressing the resident's social services which included her psychosocial well-being deficit and discharge plan to return home had been initiated on 3/25/25. *The ADL interventions that addressed her therapy services which indicated PT [physical therapy] and OT [occupational therapy] had been initiated on 3/25/25. *She agreed they were not meeting the requirements for the baseline care plan. Interview and policy review on 3/26/25 at 1:19 p.m. with DON B regarding the baseline care plan revealed: *It was her expectation that the charge nurses completed the required nursing assessments. *Specific assessments included care planning functionality that helped develop the resident's individual care plan. *The required [NAME] Data Collection assessment which was completed on a resident's admission day included: -Section B Physical Exam with care planning features. -Section C Clinical Data with care planning features. -Further assessments have been triggered depending on how the [NAME] Data Collection was completed by the admitting nurse. *She confirmed MDS coordinator C's responsibilities included completing residents' baseline care plans. *She agreed the 12/2/24 Care Plan policy which referred to the baseline care plan was their current policy. *She stated there were different options available to document the baseline care plan was provided to the resident or representative according to the policy. Those included: -A care conference progress note could have been completed. -The baseline care plan could have been printed and the resident and/or representative could have signed that document to acknowledge they had received it. --The provider could have scanned that signed document into the resident's medical record. *She confirmed they were not meeting the requirements for the baseline care plan to be completed within 48 hours of a resident's admission and ensuring the resident or representative had received a summary. -She stated with their staffing challenges sometimes it was the decision between providing care to the resident or complying with the requirement for the baseline care plan. Interview and record review on 3/27/25 at 12:23 p.m. with administrator A regarding the residents' baseline care plan revealed: *She agreed the baseline care plan was required to be developed and completed within 48 hours of a resident's admission. *She agreed that resident 183's and resident 184's baseline care plans were missing the required dietary orders, therapy services, and social services. *She agreed the baseline care plan should have been given to the resident or representative within 48 hours of the resident's admission. -She stated If I was a family member, I'd want that information close to admit. -She stated it was the MDS coordinator's responsibility to provide the baseline care plan to the resident or representative. 6. Review of the provider's 12/2/24 Care Plan policy revealed: *Purpose: To provide guidance to the interdisciplinary team in developing the initial care plan. *Definitions: Baseline care plan - Includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. *Policy: A baseline care plan will be developed upon admission according to federal and state regulations. The location must provide the resident and resident representative with a written summary of the baseline care plan. Use the PN [Progress Note] - Care Conference Note . to document that the meeting occurred with the resident and representative and any significant discussion that occurred. Review of the provider's undated job description for RN, MDS, LTC [Long Term Care] Nurse revealed: *Summary The MDS Nurse uses independent judgment in the planning, organizing, directing, and evaluation of activities of the professional and supportive nursing staff engaged in resident plan of care. Evaluates care provided to each resident and keeps care plans current . *Collaborates with the resident, family or advocate, other inter-disciplinary colleagues, including providers, to assure ongoing care of each resident to provide the best quality of life possible.

Based on record review, interview, policy review, and job description review, the provider failed to ensure staff had administered 2 of 13 sampled residents (3 and 11) medications as ordered by their physicians. *Resident 3 had errors related to a diuretic medication for heart failure and an antiviral medication. *Resident 11 had errors related to two different psychotropic medications (medications that affect mental state). Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *She had a Brief Interview For Mental Status (BIMS) assessment score of 14, indicating she was cognitively intact. *Her diagnoses included congestive heart failure and chronic respiratory failure with hypoxia (inadequate supply of oxygen to the body's tissues). *Her medications included: -Spironolactone 50 mg oral tablet, ordered on 12/18/24, 1 tablet every morning for heart failure. -Tamiflu 30 mg oral capsule, ordered on 2/7/25, 1 capsule twice a day for 12 doses for influenza. *She was hospitalized from 2/2/25 to 2/7/25 for influenza. *Her discharge orders included a prescription for Tamiflu, 30 mg. capsule, twice a day for 12 capsules, last taken 2/6/25 at 9:06 p.m. *The facility staff entered this order into resident 11's MAR as one capsule by mouth at bedtime only. *Resident was given one capsule per day until 2/12/25 when the error was found. *The physician was notified of the error and ordered to stop the medication on 2/13/25. *The resident had not received six total doses of Tamiflu as ordered initially on 2/7/25. 2. Review of the provider's 3/5/25 medication error report #2357 for resident 11 revealed: *The resident's spironolactone dose had been held beginning on 2/3/25 related to a physician's order. *On 2/21/25 there was an order for her to resume the spirinolactone. *The resumption of the medication was missed by the facility staff and identified as a medication error on 3/5/25. *The resident had missed 12 doses of sprinolactone from 2/22/25 to 3/5/25. 3. Review of provider's 3/7/25 medication error report #2358 for resident 11 revealed: *The facility staff had misread the resident's 2/21/25 physician order to renew the spirinolactone and believed they had missed 12 doses resulting in a medication error. *On 3/7/25 the staff identified that medication error report #2357 was not an actual medication error of missed doses, but because of the 3/5/25 error report staff had restarted the resident's spironolactone on 3/6/25. *Facility staff had restarted the spirinolactone without a physician order on 3/6/25. *On 3/7/25 the physician was contacted and clarified that the spirinolactone should had not been resumed on 2/21/25. *The 2/21/25 physician order had been to renew the holding of the spirinolactone for the resident, not to resum. 4. Interview on 3/27/25 at 10:30 a.m. with director of nursing (DON) B regarding resident 11's medication errors above revealed: *On 2/21/25 the physician had marked to renew the hold on the spirinolactone. *The facility staff misread the order as resuming the medication and completed a medication error report that the resident had missed 12 doses. *Then they restarted the medication on 3/6/25 without an order. *On 3/7/25 they clarified the order from the physician and found that the medication was to have remained on hold, not be restarted. *The staff incorrectly transcribed the Tamiflu order as one dose per day instead of two doses per day, causing the resident to miss six doses. 5. Record review of resident 3's EMR revealed: *She had a BIMS score of 3, indicating she had severe cognitive impairment. *Her diagnoses included severe vascular dementia other behavioral disturbance, bipolar disorder, and generalized anxiety order. *She had ongoing episodes of extensively calling out which had been documented to be disturbing to other residents, family members, and staff. *Her medications included: -Cymbalta (duloxetine, an antidepressant medication) for mood, related to bipolar disorder, current episode depressed, major depressive order. -Clozaril, (an antipsychotic medication that treats mental health conditions to help regulate mood.) 6. Review of the provider's 3/13/25 medication error report #2360 for resident 3 revealed: *The resident's 2/27/25 order for Cymbalta had increased her dose on 2/27/25 from 30 mg. daily to 60 mg. daily to start on 2/28/25. *On 3/13/25 a medication aide notified DON B that the blister pack of Cymbalta in the medication cart was labeled for and contained 30 mg. tablets, while the medication administration record showed the dose should have been 60 mg. *The 30 mg. doses were missing from the 3/1/25 to 3/12/25 dates of the blister pack indicating they had been administered *The blister pack with the 60 mg. tablets had been located on the counter of the medication storage room with no tablets missing. *The pharmacy had delivered the 60 mg. dose blister pack initially on 2/27/25 to start on 2/28/25 according to the physician order. *On 3/10/25 the 60 mg. dose card had been sent back to the pharmacy by staff with no doses missing or administered. *On 3/11/25 the pharmacy had returned the 60 mg. dose blister pack back to the facility as the pharmacy had not received an order to discontinue that dose. *After the 3/11/25 pharmacy delivery, the 60 mg. blister pack had been left in the medication storage room and not put in the medication cart. *The resident had missed 13 doses of the increased Cymbalta order from 2/28/25 to 3/12/25. 7. Review of the provider's 3/11/25 medication error report #2359 for resident 3 revealed: *The resident's Clozaril 12.5 mg was to start on 3/10/25 at bedtime. *The resident's MAR was signed off as having the medication given by certified medication aide (CMA) E. *The ordering physician was in the facility and pointed out that the resident could not have received the Clozaril dose as it had not been filled by the pharmacy yet. *That was a medication omission as CMA E had charted that he gave an ordered medication that was not available in the medication cart and had not been reported to the charge nurse that the medication had not available in the cart. 8. Interview with CME on 3/26/25 at 5:20 p.m. revealed: *He had been a certified nurse's aide (CNA) for about ten years and a Certified Medication Aide (CMA) aide for about five years. *He would have known if a resident had a new medication as it would have been included in the nursing report (communication between outgoing and incoming nursing and care staff at the end of shift.) *The first dose of a new medication for a resident should have been given by the nurse, not the CMA. *He had not gotten report on 3/10/25 so he was not aware that the Clozaril was a new medication. *He described that he should have used the five rights (process for medication administration) as right person right medication and all the rest of the things but I must have missed it. *He had received verbal education from the DNS about the process and following it after the 3/11/25 medication error report. 9. Interview on 3/27/25 at 10:30 a.m. with DON B revealed: *The steps for administering the correct dose of Cymbalta had not been followed from 2/28/25 to 3/12/25 resulting in a medication error for resident 3. *The resident's MAR had incorrectly reflected that the resident had been administered Clozaril on 3/10/25 and 3/11/25. -That was also a medication error. *She was doing rounds with the ordering physician on 3/11/25, who indicated that the medication could not have been given yet as it had not been provided by the pharmacy. *She had provided verbal education to CMA E about the five rights of medication administration, the administration of new medication by a nurse only, and ensuring accuracy. *CMA E had received report on 3/10/25 including information that the Clozaril for resident 3 was a new medication. *She had provided verbal education to CMA F, CMA G, CMA H, and CMA I, who had incorrectly administered the 30 mg. dose and had documented that they had administered the 60 mg. doses from 2/28/25 to 3/12/25 for resident 3. 10. Interview on 3/27/25 at 8.37 a.m. with registered nurse (RN) D revealed: *A licensed nurse should have given a new medication to the resident because a CMA was not supposed to give a first dose of a new medication. *The new medication blister pack would have been kept separate from the current medications and placed into the top drawer of the medication cart with a note on it. *That information would have been mentioned in their nursing report to the next shift. *When there was a change in the medication dose the current medication should have been pulled from the medication cart and replaced with the new medication blister pack and a CMA could give that new dose to the resident. Review of provider's undated certified long term care medication assistant job description revealed the medication assistant administers prescribed medications as delegated by a licensed nurse and within their scope of practice as defined by state regulations. Review of the provider's 12/11/19 onboarding manual draft revealed: *All new/refill medications will be delivered to the facility with a paper manifest. *The facility nurse was to match the delivered medications to the manifest. *The manifest required a nursing signature and the date of receipt of the medications. Review of the provider's revised 3/4/25 medication acquisition, receiving, dispensing, and storage policy revealed: *Licensed nursing employees are responsible for checking of all new orders of medications from the physician's orders. *Licensed nurses and medication aides (when allowed by state law) are responsible for reconciling medications received.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, observation, interview, and policy review, the provider failed to protect the resident's right to be free from verbal abuse for one of one sampled resident (1) with cognitive impairment by one of one certified nursing assistants (CNA) (C). Findings include: 1. Review of the provider's 10/21/24 SD DOH FRI revealed: *On 10/18/24 cook D reported to registered nurse (RN) E a verbal exchange between CNA [certified nursing assistant C] and resident [1]. *RN E instructed cook D to write the information on a suggestion/concern form and place it under [the] administrator's door. *The suggestion/concern form was not found until 10/21/24 at approximately 1:30 p.m. *Cook D reported CNA C was raising his voice demanding that [resident 1] shut her mouth and drink her coffee and you can't drink your coffee when you are arguing with me. *Verbal abuse [was] substantiated. *CNA C stated, I could have handled it better, and I am guilty. *CNA C was suspended pending investigation. *Corrective action was given in the form of written reminder. *Education was provided to every staff member on the abuse/neglect policy. *The family and provider were notified. 2. Review of resident 1's EMR revealed: *She was admitted on [DATE]. *Her diagnosis included unspecified dementia, generalized anxiety disorder, rheumatoid arthritis, and cognitive communication deficit. *Her Brief Interview for Mental Status (BIMS) assessment score was 5 which indicated she had severe cognitive impairment. *Trauma assessments completed on 12/20/22 and 8/16/24 indicated a history of anxiety with difficulty breathing after childhood tonsil surgery and after her husband passed away. -There was no documentation that indicated a trauma assessment had been completed after the 10/21/24 incident. *A 10/24/24 progress note indicated a discussion with the medical director regarding the DOH-reported investigation and a plan to correct the incident. -No other progress notes were identified regarding the allegations of abuse on 10/18/24. Review of resident 1's care plan revealed: *She had impaired cognitive function due to dementia, anxiety, and short-term memory impairment. -Interventions for that included: --Monitor/document/report to health care provider any changes in cognitive function specifically changes in .difficulty expressing self. --Cue, reorientate and supervise as needed. *She had a hearing deficit and needed repeated information at times. -Interventions for that included, Speak clearly and slowly. *She had a psychosocial well-being deficit related to dementia, anxiety, voiced past trauma of not being able to breathe, and changes in her routine. -Interventions for that included: --Remove resident to a calm safe environment and allow to vent/share feelings when conflict arises. --Provide assistance/encouragement/support to identify problems that cannot be controlled. --Encourage calming breathing techniques . *Resident has a mood problem R/T [related to] dementia, anxiety .likes consistent routine. -Interventions for that included Provide encouragement/assistance support to maintain as much independence and control as possible. 3. Observations and interview on 1/14/25 between 9:26 a.m. and 12:00 p.m. with resident 1 revealed: *She ate independently in the dining room and used a four-wheeled walker for mobility. *She was pleasant with conversation but when asked about her care she would pause for long periods and then redirect the conversation. -Her answers to questions were inconsistent. -She was unable to recall an incident where staff had shouted at her. *She was observed in church and therapy that day. 4. Interview on 1/14/25 at 11:26 a.m. with activities supervisor (AS) G regarding resident 1 revealed: *Resident 1 frequently engaged in activities, liked to stay busy, attended group activities, and enjoyed playing the piano. *She confirmed that resident 1 occasionally became anxious but had not noticed any changes in her behavior recently. *AS G stated she had never witnessed resident abuse towards any resident and received education on resident abuse every year. -She stated she would go straight to the charge nurse with any concern, after she made sure the resident was safe. She would follow up to make sure a report was filed. 5. Observation and interview on 1/14/25 at 11:46 a.m. with licensed practical nurse (LPN) H and resident 1 revealed: *Resident 1 approached licensed LPN H in the hallway and asked What should I do? Her voice was very anxious. *LPN H told resident 1 it was almost time for lunch and asked if she needed to use the restroom. -Resident 1 started repeating, Please God, Please God, louder and louder as she independently approached her bathroom. As she entered her room, she repeatedly stated Go to the bathroom and then to lunch. Interview on 1/14/25 at 11:49 a.m. with LPN H regarding resident 1 revealed: *Resident 1 was frequently anxious, often thought something was wrong, and could be hard to redirect. *At times resident 1 would scream at the top of her lungs. *LPN H had never witnessed any staff speak unkindly to resident 1. *She had received training on how to deal with residents with difficult behaviors, and resident abuse at a recent all-staff meeting. *She stated if she had witnessed resident abuse, she would first ensure that the resident was safe and then she would find the registered nurse or go directly to the director of nursing. *She knew a report would need to be sent to the DOH. 6. Interview on 1/14/25 at 1:38 p.m. with cook D regarding the above incident revealed: *CNA C was getting very verbal in the dining room with resident 1. *Resident 1 had been trying to get a Styrofoam cup to take her coffee to her room. CNA C did not want her to leave with the coffee. He told her Tough ****, drink the coffee and you can't leave with it. When she approached CNA C, he left the area. *She stated that she was paraphrasing because she could not recall the exact words that had been used. *She stated she didn't do anything right away but had gone home and called the nutrition and food services supervisor (NFSS) F who told her, it was a little bit too late and to talk to the charge nurse in the morning. *She reported her concerns to RN E first thing that morning [10/19/24]. -RN E told her to write a report and slide it under administrator (Admin) A's door. *On 10/21/24 she spoke to NFSS F again about her concerns and they went down to get the report out of Admin A's office and gave it to the social worker to ensure it had been reported. *Cook D received education on reporting abuse when she was hired on 9/3/24 and again after the incident occurred. Interview on 1/14/25 at 1:56 p.m. with NFSS F about the incident that occurred between CNA C and resident 1 revealed she: *Recalled that an incident had occurred with a CNA and a resident in the dining room. *Thought cook D had texted her about the incident the evening it occurred but was not sure. -Was unable to recall any specific information about the incident. *Instructed cook D to report her concerns to the charge nurse. *Thought cook D had been at work and would have reported it to the charge nurse at that time. *Confirmed abuse concerns needed to be reported to the charge nurse and a form needed to be filled out. *Could not recall if she had been questioned about the incident or had spoken to the management team about it. *Had attended an all-staff meeting that included abuse after that incident. Interview on 1/14/25 at 2:30 p.m. with CNA C revealed: *He had been a CNA at that facility for eight years and had received online training every year about resident abuse. *Regarding the incident above, resident 1 was in the dining room trying to take a glass coffee cup out of the dining room. -No other residents were present at that time. *CNA C was frustrated, and It escalated. *He had tried to get her to stop and told her to Shut up. He said, It was a bad decision. *He walked away and told the charge nurse he had been frustrated with resident 1. *He completed his shift on 10/18/24 and was not scheduled to work again until 10/21/24. He was sent home when he went to work that day (10/21/24). -He was allowed to return to work two or three days later and received written information about verbal and mental abuse. Review of the Suggestion or Concern form completed by cook D on 10/18/24 revealed: *As I was preparing to leave for the night [CNA C] was raising his voice demanding that [resident 1] Shut her mouth and drink her coffee. [Resident 1] said something I did not hear in return [CNA C] then said, You can't drink coffee when you are arguing with me. [Resident 1] continued to try to argue. [CNA C] raised his voice again and told her to Shut your mouth and drink your coffee. She went to say something again, and he said, Shut up, I don't care. *Two additional staff were present when the incident occurred. Interview on 1/14/25 at 4:02 p.m. and again on 1/15/25 at 10:24 a.m. with Admin A revealed: *Admin A was on vacation when the above incident occurred and returned to work on 10/22/24. *CNA C had acknowledged that he should have approached it better . *The incident occurred and was observed by cook D on 10/18/24 who reported it to RN E on 10/19/24 around 6:00 a.m. *RN E had instructed cook D to complete a concern form and put it under Admin A's door. *That form was found on 10/21/24, the SD DOH was notified and CNA C was suspended pending an investigation. *CNA C had completed his shift on 10/18/24 and had not worked on 10/19/24, 10/20/24, or 10/21/24. *She confirmed that the incident reporting had not been completed timely. *Individual staff training had been initiated on 10/22/24 with a memo that each staff member was to read and sign. -Admin A expected all staff to follow the guidance in the memo. *An all-staff meeting was held on 10/25/24, that covered the topic of resident abuse and emphasized that there was a two-hour timeline for reporting to the DOH. *She confirmed cook D had reported her concerns to NFSS F. -She expected cook D to have reported those concerns to the charge nurse immediately. No matter what. There is always a charge nurse here. *She thought NFSS F should have known those concerns needed to be reported immediately. *She expected RN E to notify the DOH within two hours, by completing a report, and to notify the director of nursing services, social worker, or administrator of the allegation immediately. *The incident had been addressed at the last Quality Assurance Performance Improvement (QAPI) meeting held on 10/28/24. Review of the provider's 7/22/24 Abuse and Neglect policy revealed: *To ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location. *To ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect exploitation and abuse of residents . *To ensure that residents are not subjected to abuse by anyone, including, but not limited to, vocation employees . *To ensure that all identified incidents of alleged or suspected abuse neglect . are promptly reported and investigated. *The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. *Residents must not be subject to abuse by anyone, including, but not limited to, location employees . *Alleged or suspected violations including any mistreatment, neglect exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. *The charged nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation The charged nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions: a. If this is an allegation of employee to resident abuse, the employee will be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation. Another employee will be assigned to complete the care of the resident. *In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.) *If there is an allegation of abuse, neglect exploitation or mistreatment . then it will be reported immediately, but not later than two hours after the allegation is made.

Based on South Dakota Department of Health (SD DOH) complaint online report, document review, interview, and policy review, the provider failed to report an incident of alleged abuse in the required timeframe to the SD DOH for one of one sampled resident (1). Findings include: Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to report an incident of alleged abuse in the required timeframe to the SD DOH for one of one sampled resident (1). Findings include: 1. Review of the provider's 10/21/24 SD DOH FRI revealed: *On 10/18/24 cook D reported to registered nurse (RN) E a verbal exchange between CNA [certified nursing assistant C] and resident [1]. *RN E instructed cook D to write the information on a suggestion/concern form and place it under [the] administrator's door. *The suggestion/concern form was not found until 10/21/24 at approximately 1:30 p.m. Interview on 1/14/25 at 1:38 p.m. with cook D regarding the above incident revealed: *CNA C was getting very verbal in the dining room with resident 1. *Resident 1 had been trying to get a Styrofoam cup to take her coffee to her room. CNA C did not want her to leave with the coffee. He told her Tough ****, drink the coffee and you can't leave with it. When she approached CNA C, he left the area. *She stated that she was paraphrasing because she could not recall the exact words that had been used. *She stated she didn't do anything right away but had gone home and called the nutrition and food services supervisor (NFSS) F who told her, it was a little bit too late and to talk to the charge nurse in the morning. *She reported her concerns to RN E first thing that morning [10/19/24]. -RN E told her to write a report and slide it under administrator (Admin) A's door. *On 10/21/24 she spoke to NFSS F again about her concerns and they went down to get the report out of Admin A's office and gave it to the social worker to ensure it had been reported. *Cook D received education on reporting abuse when she was hired on 9/3/24 and again after the incident occurred. Interview on 1/14/25 at 1:56 p.m. with NFSS F about the incident that occurred between CNA C and resident 1 revealed she: *Recalled that an incident had occurred with a CNA and a resident in the dining room. *Thought cook D had texted her about the incident the evening it occurred but was not sure. -Was unable to recall any specific information about the incident. *Instructed cook D to report her concerns to the charge nurse. *Thought cook D had been at work and would have reported it to the charge nurse at that time. *Confirmed abuse concerns needed to be reported to the charge nurse and a form needed to be filled out. *Could not recall if she had been questioned about the incident or had spoken to the management team about it. *Had attended an all-staff meeting that included abuse after that incident. Interview on 1/14/25 at 4:02 p.m. and again on 1/15/25 at 10:24 a.m. with Admin A revealed: *Admin A was on vacation when the above incident occurred and returned to work on 10/22/24. *The incident occurred and was observed by cook D on 10/18/24 who reported it to RN E on 10/19/24 around 6:00 a.m. *RN E had instructed cook D to complete a concern form and put it under Admin A's door. *That form was found on 10/21/24, the SD DOH was notified and CNA C was suspended pending an investigation. *CNA C had completed his shift on 10/18/24 and had not worked on 10/19/24, 10/20/24, or 10/21/24. *She confirmed that the incident reporting had not been completed timely. *Individual staff training had been initiated on 10/22/24 with a memo that each staff member was to read and sign. -Admin A expected all staff to follow the guidance in the memo. *An all-staff meeting was held on 10/25/24, that covered the topic of resident abuse and emphasized that there was a two-hour timeline for reporting to the DOH. *She confirmed cook D had reported her concerns to NFSS F. -She expected cook D to have reported those concerns to the charge nurse immediately. -She stated. No matter what. There is always a charge nurse here. *She thought NFSS F should have known those concerns needed to be reported immediately. *She expected RN E to notify the DOH within two hours, by completing a report, and to notify the director of nursing services, social worker, or administrator of the allegation immediately. Review of the provider's 7/22/24 Abuse and Neglect policy revealed: *To ensure that employees are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the location. *To ensure the location has an effective system in place that, regardless of the source, prevents mistreatment, neglect exploitation and abuse of residents . *To ensure that all identified incidents of alleged or suspected abuse neglect . are promptly reported and investigated. *The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. *Alleged or suspected violations including any mistreatment, neglect exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. In the absence of the administrator from the location, the following individuals have the administrative authority of the administrator for purposes of immediate reporting of alleged violations: the director of nursing services or the supervisor of social services. *The charged nurse or licensed nurse will be notified immediately, assess the situation to determine whether any emergency treatment or action is required and complete an initial investigation The charged nurse also will ensure that any potential for further abuse is eliminated by taking one of the following actions: a. If this is an allegation of employee to resident abuse, the employee will be removed from providing direct care to all residents. Additionally, the employee will be placed on suspension pending the results of the internal investigation. Another employee will be assigned to complete the care of the resident. *In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.) *If there is an allegation of abuse, neglect exploitation or mistreatment . then it will be reported immediately, but not later than two hours after the allegation is made.

Based on observation, interview, and policy review, the provider failed to ensure: *A countertop ice machine was free of limescale build-up. *A shower room was kept in sanitary condition, including storage, labeling, and an open package of crackers stored next to resident personal care items. *Beauty shop equipment filters were maintained in clean condition. Findings include: 1. Random observations on 12/5/23 from 3:30 p.m. to 5:00 p.m., 12/6/23 from 9:00 a.m. to 5:00 p.m., and again on 12/7/23 from 9:00 a.m. to 11:00 a.m. revealed: *A countertop ice machine located near the nurse's station that had limescale build-up on the front of the machine and on the ice spout. Interview and cleaning log review on 12/07/23 at 12:46 p.m. with maintenance director J regarding the cleaning of the ice machine revealed: *He was responsible to clean the ice machine. *He followed the manufacturer's instructions for cleaning it. -He stated the instruction included for the ice machine to have been cleaned every two months. *He documented the cleaning in an electronic maintenance tracking system. *The ice machine in the 300 hallway was cleaned on 8/31/23 and 10/31/23. *He confirmed the ice machine had a large amount of limescale build-up on it. Interview on 12/07/23 at 12:49 p.m. with administrator A regarding cleaning of the ice machine revealed she: *Was aware of the limescale build-up on the ice machine in the 300 hallway and she: -Was not certain why there was that much limescale build-up. -Thought the city water was hard water and they had no water softener. *Had checked into ordering parts to replace the areas on the ice machine that had lime build-up. -The cost of the those parts were almost as much as purchasing a new ice machine. *Had not determined if she would replace the parts or order a new ice machine. Review of the manufacturer's instructions for cleaning of the countertop ice machine revealed: *Maintenance and cleaning instruction -A. General --The times and the procedures for maintenance and cleaning are given as guides are not to be construed as absolute or invariable. Cleaning especially will vary depending upon local water and ambient conditions and the ice volume produced. Each ice machine must be maintained individually, in accordance with its particular location requirements. 2. Observation on 12/5/23 at 9:49 a.m. of the shower room on the 300-hall revealed: *There was a yellow basin, that was sitting on the counter by the sink, that contained four cream-colored combs and a yellow electric razor that had a large amount of whiskers inside of the rotating head. -There was no name on the basin, combs, or the razor. *Another yellow basin contained one fingernail clipper, two toenail clippers, one large toenail clipper, tweezers, three pairs treatment scissors, a pink rubber band with hair wrapped in it, and a bracelet. -All the clippers had what appeared to be fingernail dust and nail clippings on them. *A plastic 3-drawer bin and lying on top of it was a partially unlabeled tube of A & D ointment. *A plastic 3-drawer bin that contained the following: -In the top drawer there were new brushes still in plastic wrappers, clean face masks, and an opened unlabeled tube of A & D ointment. -In the second drawer there was a bottle of Suave lotion, a bottle of Bath and Body Works Gingham lotion, and a bottle of [NAME] lotion. --All the lotions were partially used and were not labeled with a resident's name. *A small table with wheels that had what appeared to have been a clean towel on it. -On the clean towel were three combs, three hair picks, tweezers, a toenail clipper, and a partially used unlabeled tube of A & D ointment. Interview on 12/05/23 at 10:23 a.m. with certified nursing assistant (CNA) L regarding bathing revealed: *She was unsure who the yellow electric razor belonged to. -Each male resident should have had their own razor. *Resident personal care supplies should have been labeled with each resident's name and not shared. Interview on 12/5/23 at 2:38 p.m. CNA M revealed she: *Was a temporary agency employee and it was her second-day giving baths. -Had assisted several residents with bathing that morning. *Confirmed the lotions were not labeled with any resident's names. -Was not sure who each lotion belonged to. *Was unsure who the yellow electric razor belonged to. *Was not certain if the combs were dirty or clean. Interview on 12/5/23 at 10:14 a.m. with Minimum Data Set (MDS) coordinator N revealed resident's personal care items should have the resident names on them and should not be shared with other residents. Interview on 12/6/23 at 8:29 a.m. with CNA I regarding the shower room revealed: *She was the primary bath aide. -CNA M was filling in as the secondary bath aide. -She had provided training related to bathing to CNA M on 12/4/23. *She often found crackers in the top drawer of the three-drawer small bin with the disposable razors. -She had thrown the crackers away. *She had thrown quite a few things away if no resident's name were on them. *Did not work on 12/5/23. -Confirmed she found the partially used tube and unlabeled tube of A & D ointment and had removed it. -Confirmed there was an unlabeled partially used tube of A & D ointment on top of the three-drawer bin. *Clean combs were stored in the yellow basins. *The yellow basins had not been on the countertop when she entered the shower room on 12/6/23. *She had not seen the yellow razor and was not aware of a resident who had one that was yellow. *Each resident should have their own razor, with their name or room number written on it. *Resident personal care items should not be shared. Interview on 12/7/23 at 11:35 a.m. with the infection control preventionist (ICP) K regarding the above findings revealed: *She had received a box of personal care items from CNA I on the morning of 12/7/23. -Those items were from the shower room in the 300-hall. -That box contained unlabeled resident personal care products including: --A bottle of Suave lotion, a bottle of Bath and Body Works Gingham lotion, and a bottle of [NAME] lotion, and a tube of A & D ointment. --A yellow electric razor. ---ICP K knew which resident the yellow razor belonged too and he had not had a bath since the previous week. --CNA I had stated, I know this isn't right. -Confirmed the razor should have been labeled with a resident name or room number. Review of the provider's Standard and Transmission-Based Precautions policy revealed included there were no instructions regarding shared resident personal items including lotions, combs, and razors. Review of the provider's Nail Care policy revealed: *Policy/Procedure Fingernails -Clean and return equipment. *Toenails -4. Follow same procedure for cleaning and cutting fingernails as above. *There was no procedure included in the policy regarding the cleaning of the equipment. 3. Observation and interview on 12/5/23 at 2:39 p.m. with the self-employed beautician O revealed: *There was a hooded-style stand-alone hair dryer which had a filter in the back. *The filter: -Was missing two of fifteen panels. -Had a torn area at the top of the filter -Was covered in dust. *She had used that hair dryer for a resident on that day. *She was not responsible for cleaning the beauty shop equipment that the facility provided, including the hooded hair dryer. -She was unsure of who cleaned the facility beauty shop equipment. Observation and interview on 12/7/23 at 12:10 p.m. with ICP K regarding beauty shop equipment revealed: *There was hooded-style stand-alone hair dryer which had a filter in the back. *She was not certain who cleaned the beauty shop equipment. *She agreed the filter of the stand-alone hair dryer had not been cleaned, was torn, and missing panels of the filter. Review of the provider's Barber/Beauty Shops policy revealed: *Purpose -To ensure the barber/beauty shop provides sanitary and safe services for residents. *Procedure -1. All equipment and items used on a resident will be clean and sanitized at the time of use. --b. All equipment will be sanitized between each resident use.

Based on observation, interview, and policy review, the provider failed to ensure two of two wound care dressing changes for two of two sampled residents (6 and 22) had been completed using appropriate infection control practices by one of one licensed practical nurse (LPN) (C). Findings include: 1a. Observation and interview on 3/4/20 at 10:20 a.m. with LPN C during and following resident 22's wound care revealed: *She brought the wound supplies into his room in a plastic tray. *She stated he had opened wounds to his right third finger they were treating with a calcium alginate dressing, covered by foam, and then wrapped with gauze. *After washing her hands she put on gloves and then used a pair of bandage scissors to remove the gauze wrap and dressing from his finger. *When she was done with the potentially contaminated bandage scissors she put them back into the tray with her clean wound supplies. -She then cleaned the wound areas with wound cleaner and gauze. *After the wound cleaning she removed her gloves, sanitized her hands, put on new gloves, and then opened the packages of the calcium alginate dressing and the foam dressing. -She set the calcium alginate dressing and foam dressings on the outsides of their packages and used the potentially contaminated scissors to cut the dressings into the size she wanted to put on the wound. *She then put those cut pieces of calcium alginate onto the opened wounds, followed by the foam dressing, wrapped the finger with a gauze dressing, and then put tape over the gauze to secure it. *She then removed her gloves, washed her hands, and brought the plastic tray of wound supplies back out to the treatment cart. -She set the potentially contaminated scissors on the top of the medication cart. *She indicated the above process was her usual practice. *She had not considered: -The outsides of the dressing packages as unclean or potentially contaminated.-The bandage scissors as potentially contaminated after she had used them to remove the old dressing. *After further discussion she agreed: -The bandage scissors should have been cleaned and disinfected prior to using them to cut the clean dressings that were used directly on the wounds and following use when they would have been potentially contaminated. -The outsides of the packages were potentially contaminated. --She should not have set the clean dressings on those surfaces prior to using them directly on the wounds. -Dressing changes should have been done with proper infection control practices in an attempt to protect the resident from a possible infection. *She was unsure if she had training in the past on dressing change techniques. -She indicated she learned from other nurses and her own experience. b. Observation and interview on 3/4/20 at 11:09 a.m. with LPN C during and following resident 6's wound care revealed: *She brought the wound supplies into the room in a plastic tray. *There were no dressings in place to remove since the resident had just been seen by the practitioner. *After LPN C washed her hands she put on gloves and used wound cleanser and gauze to clean the resident's bilateral buttock wounds. *She removed her gloves, sanitized her hands, opened the package of calcium alginate dressing, and then set the dressing on the outside of the package. -With her bare hands she held the calcium alginate dressing, used scissors to cut pieces for the wound, and then set those pieces back onto the outside of the package. *After the above process she stated she should not have done that and sanitized her hands before putting a pair of gloves on. *She then put the above potentially contaminated cut pieces of calcium alginate dressings on the resident's right buttock wounds. *She cut more pieces of the calcium alginate and put those on the resident's left buttock wounds. *With her same gloves on she grabbed a large roll of Omnifix tape out of the tray, used the scissors to cut pieces of tape, and put that roll back into the plastic tray with the clean dressing supplies. -She used the cut pieces of tape to secure the calcium alginate dressings to the resident's wounds. *After the dressing change we discussed the above process and she confirmed: -The dressing should not have been set on the outside of the package since that could have been potentially contaminated. -She should not have touched the calcium alginate dressing with her bare hands since it was used to directly cover the opened wound. -The roll of tape should not have been touched with potentially contaminated gloves. Interview and policy review on 3/4/20 at 1:19 p.m. and again at 2:23 p.m. with registered nurse/infection control nurse B regarding the above observations revealed:*She confirmed dressing changes should have been completed with appropriate infection control practices to protect the residents from potential infection. *The outside of packages should have been considered potentially contaminated, and the dressings used for wounds should not have been set on them. *The bandage scissors should have been considered potentially contaminated after using them on the old dressing. -They should have been cleaned and disinfected prior to using them for cutting clean wound dressings. *All staff had completed infection control training. *Competencies had not been done to ensure nursing staff were completing dressing changes appropriately. *The policy for dressing changes had not been followed. -That policy included a competency that evaluated staffs' clinical skills related to wound dressing changes. Interview on 3/4/20 at 4:05 p.m. with director of nursing A regarding the above concerns revealed:*She expected staff to have followed their policy for dressing changes. *Dressing changes should have been completed using appropriate infection control practices to protect the residents from potential infection. Review of the provider's revised October 2017 Wound Dressing Change policy revealed:*The purpose was: -To promote wound healing. -To help wound remain free of infection. *The procedure included to: -7. Remove soiled dressing and discard in plastic bag, avoiding contact and thus contamination of other surfaces. Remove gloves and discard in same plastic bag. Perform hand hygiene. -8. Create field with equipment/dressing wrappers. Use sterile technique if required. -9. Open all supplies and pour solution if ordered. -10. Put on gloves. -11. Assess wound and surrounding area to ensure the selection of the appropriately-sized dressing. -14. Remove dressing from inner wrapper, avoiding finger contact with the dressing .

Based on observation, record review, interview, and policy review, the provider failed to ensure eight of eight randomly residents (2, 16, 18, 25, 29, 31, 36, and 42) received the required level of assistance for eating and had a dignified dining experience during two of two lunch meal observations. Findings include: 1a. Review of resident 2's 10/11/18 Minimum Data Set (MDS) assessment revealed she required extensive assistance from one staff member for eating. Review of resident 16's 11/9/18 MDS assessment revealed she required extensive assistance from one staff member for eating. Review of resident 29's 12/11/18 MDS assessment revealed she required extensive assistance from one staff member for eating. Review of resident 42's 1/1/19 MDS assessment revealed he required extensive assistance from one staff member for eating. Observation on 1/15/19 from 12:13 p.m. through 12:42 p.m. revealed: *Residents 2, 16, 29, and 42, shared the same dining table. *There was one staff member seated between residents 29 and 42 and assisting at the table. *Resident 29 was eating independently. *Resident 2 had food in front of her, but she was not eating. -After the seated staff member had gone over to encourage her to eat, she attempted to eat the pot pie. -She struggled getting the food on the fork. -At 12:25 p.m. she was not eating, and no one assisted her. -At 12:28 p.m. she got up and walked out of the dining room without eating any of her food. -No staff attempted to redirect her back to the table. Observation on 1/16/19 from 12:00 noon through 12:43 p.m. of certified nurse aide (CNA) A and the following residents revealed: *Residents 2, 16, 29, and 42 shared the same dining table. *Residents 2, 16, and 42 were seated at the table awaiting their meals and had drinks in front of them. -There were no staff present to assist them with their beverages. *Residents 2, 16, and 42 had their food served. -At 12:13 p.m. as resident 42's food was placed, CNA A came to the table and sat down by him. -She rolled back and forth assisting the three of them. *At 12:17 p.m. she got up from the table and walked over to another table. -Resident 29 was brought to the table. *At 12:19 p.m. CNA A returned to the table, took resident 29's ordered and served her food. *At 12:20 she walked away to wash her hands. *Between 12:20 p.m. and 12:39 p.m. CNA A was up and down, back and forth seven times between the four residents. *At 12:27 p.m. resident 16 left the table. *At 12:32 p.m. CNA A told resident 29 Your ice cream is going to melt. Though she still did not eat, she had not attempted to assist her. -At 12:36 p.m. she left the table to assist a resident at another table. -At 12:39 p.m. she sat back down and cued resident 2 to take a drink. *With a single staff member up and down, wheeling back and forth, it was disruptive and not conducive to a pleasant dining experience for any of the residents. b. Review of residents 18, 25, 31, and 36's Minimum Data Set (MDS) assessments revealed: *On 11/13/18 resident 18 required the extensive assistance of one staff member for eating. *On 12/25/18 resident 25 required the extensive assistance of one staff member for eating. *On 10/18/18 resident 31 required the limited assistance of one staff member for eating. *On 12/4/18 resident 36 required the extensive assistance of one staff member for eating. Observation and interview on 1/15/19 from 12:14 p.m. through 12:29 p.m. of CNA B and the following residents revealed: *Residents 18, 25, 31, and 36 were seated at the same dining table. *CNA B was seated and the only staff assisting at the table. *At 12:14 p.m. resident 18 had two bowls of pureed food in front of her. -Her eyes were half or fully closed at times. -She was taking small bites when she could get food on her spoon and keep her eyes opened. *Between 12:14 p.m. and 12:29 p.m. CNA B provided four verbal cues and stood up or wheeled over to resident 18 three times and continued to assist the others at the table. *There was no observation of resident 18 having been provided extensive assistance of one staff to eat her meal. -At 12:20 p.m. CNA B had shared resident 18 did not allow staff to feed her. *It was very disruptive to the others seated at the table for CNA B to continuously get up or wheel back and forth. Observation on 1/16/19 from 12:15 p.m. through 12:42 p.m. of CNA B and the following residents revealed: *Residents 18, 25, 31, and 36 were seated at the same dining table. *CNA B was the only staff member at the table and sat between residents 25 and 36. *At 12:16 p.m. resident 18 was given two bowls of food. -Lasagna was identified to her in one bowl and the other bowl was not identified for her. -Her sherbert was also placed at her table out of her reach and not identified for her. -She was struggling to get food onto her spoon. *At 12:18 p.m. CNA B got up from sitting between residents 25 and 36 walked around to resident 18 to clean off the glass she had put into her lasagna bowl. -She went back and sat between residents 25 and 36. *At 12:28 p.m. she got up from the table and went to the refrigerator for a glass of milk for resident 18. -She did not identify it was milk in the glass. -She then sat between residents 25 and 36. *At 12:32 p.m. resident 18 continued to eat without staff assistance and only got small amounts of food on her spoon about every other bite. *At 12:42 p.m. she went to the refrigerator and got resident 18 a glass of juice but had not identified it to the resident. -She then sat down between residents 25 and 36. *With a single staff member up and down, wheeling back and forth, it was disruptive and not conducive to a pleasant dining experience for any of the residents. c. Interview on 1/16/19 at 4:18 p.m. with the certified dietary manager revealed: *Extensive assistance of one staff member for eating would have been the staff putting food on the utensil or feeding the resident. *Cueing would not count as extensive assistance. Review of the provider's (MONTH) (YEAR) Food First Philosophy policy revealed: *Purpose: To promote resident satisfaction with the quality of the food and the dining experience as a priority. *It did not define what the dining experience should have been.

Based on observation, interview, record review, and policy review, the provider failed to ensure five of five sampled residents (18, 28, 31, 36, and 42) who were using a u-shaped body pillow had an assessment completed to ensure it was not a restraint. Findings include: 1. Review of resident 18's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Pain. -Anxiety disorder. -Heart failure. Review of resident 18's 11/13/18 Minimum Data Set (MDS) assessment revealed she required the extensive assistance of two staff for bed mobility, transferring, toileting, and dressing. Review of resident 18's 11/16/18 care plan revealed: *She required assistance to reposition every two hours during the day and every four hours during the night. *She needed to have her feet up on pillows. *She needed a pressure reducing mattress and a wheelchair cushion. *There was no indication for the use of a u-shaped pillow. Review of resident 18's 8/11/18 Positioning Assessment and Evaluation -V3 revealed she needed total assistance of two staff for bed mobility and transfers. Review of resident 18's 8/11/18 Mobilization Support Data and Collection Tool -V5 revealed: *She slept in a bed at night. *She was totally dependent on two staff for positioning and turning in bed. Interview on 1/15/19 2:55 p.m. with resident 18's representative revealed: *He had seen her try to climb around the u-shaped body pillow but every time she had gone back to sleep. *He did not think she could get over it. *He did not know what the pillow was for. Interview on 1/16/19 at 11:11 a.m. with certified nursing assistant (CNA) B regarding resident 18 revealed: *The u-shaped body pillow was to keep her from falling out of bed. *If she wanted to get over the pillow she would not be able to. *She used to put her feet out of the bed but could not do that with the pillow there. Interview on 1/16/19 at 11:21 a.m. with licensed practical nurse (LPN) H regarding resident 18 revealed: *The u-shaped body pillow was a barrier to identify the edge of the bed. *She could get out of her bed if she wanted to. Interview on 1/16/19 at 11:22 a.m. with CNA E regarding resident 18 revealed: *The u-shaped body pillow was for repositioning it cradled her. *She could get out of bed with it, because she could move her blanket away when she was hot. -She never tried to get out of bed. Interview on 1/16/19 at 4:34 p.m. with CNA C regarding resident 18 revealed: *The u-shaped body pillow was used for repositioning. *It was for her safety, so she could not roll out of bed. *She could not get out of bed when it was in place. *She had her call light to notify staff if she needed help. Interview on 1/16/19 at 4:47 p.m. with CNA I regarding resident 18 revealed the u-shaped body pillow prevented her from getting out of bed. *He did not think she could get over it. *He did not know what the pillow was for. Interview on 1/16/19 at 4:34 p.m. with CNA C regarding resident 18 revealed: *The u-shaped body pillow was used for repositioning. *It was for her safety, so she could not roll out of bed. *She could not get out of bed when it was in place. *She had her call light to notify staff if she needed help. Interview on 1/16/19 at 4:47 p.m. with CNA I regarding resident 18 revealed the u-shaped body pillow prevented her from getting out of bed. 2. Observation on 1/15/19 at 10:30 a.m. revealed resident 28 had a u-shaped body pillow on his bed along with a regular mattress on it. Review of resident 28's electronic medical record revealed he had: *Been admitted on [DATE] from a hospital, was hospitalized again on 3/22/18, and readmitted on [DATE]. *[DIAGNOSES REDACTED]. *Skin breakdown on his buttocks. *A previous pressure ulcer to his right heel. *No assessment of or for the use of the u-shaped body pillow. Review of resident 28's 3/13/18 care plan revealed: *Focus: The resident at risk for falls. *Goal: Resident will be free of falls through the review date. *Interventions included: -ENVIRONMENTAL: Use body pillow on outside of res (resident) bed for boundary, low to floor bed. -Monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function. Interview on 1/16/19 at 2:00 p.m. with CNA E revealed resident 28 used the u-shaped body pillow for repositioning. Interview on 1/16/19 at 4:50 p.m. with CNA C revealed resident 28: *Used the u-shaped pillow when he was in bed for repositioning and to keep him in bed. *He was able to put his legs out of the bed. *He did attempt to get out of bed without assistance. 3. Observation on 1/16/19 at 11:21 a.m. of resident 31's bed revealed a u-shaped pillow on the bed. Review of resident 31's medical records revealed: *She was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) of six indicating severe cognitive impairment. *Her [DIAGNOSES REDACTED].>-Hypertension. -Heart failure. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Pain in unspecified ankle and joints. -Low back pain. -Rash and other nonspecific skin eruption. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. Interview on 1/17/19 at 10:00 a.m. with the director of nursing (DON) regarding the uses of the u-shaped pillow for resident 31 revealed: *The resident threw her feet over the edge of the bed. *She was not capable of getting from a lying to sitting position in her bed. *If she threw her feet over the edge of the bed she could end up on the floor. *The u-shaped pillow would slow down the process of falling out of bed. 4. Observation on 1/15/19 at 10:37 a.m. and on 1/16/19 at 3:45 p.m. revealed a u-shaped pillow on resident 36's bed. Review of resident 36's medical records revealed: *She was admitted to the facility on [DATE] and had a BIMS of seven indicating severe cognitive impairment. *[DIAGNOSES REDACTED].>-Unspecified [MEDICAL CONDITION]. -Hypertension. -Heart failure. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Pain in unspecified hip, low back pain. -Rash and other nonspecific skin eruption. -Anxiety disorder. -[MEDICAL CONDITION]. -Delusional disorders. -Dementia with behavioral disturbances. Review of resident 36's care plan with a revision date of 10/03/18 revealed: *Intervention: Modify to maximize safety with the use of U Shaped pillow when in bed to assist with location of edge of bed. *Goal: was for the resident to be free of minor injuries. Interview on 1/17/19 at 10:00 a.m. with the DON regarding the use of the u-shaped pillow for resident 36 revealed: *The pillow assisted her in locating the edge of the bed. *She had fallen out of bed a couple of times. *The u-shaped pillow kept her in the middle of the bed. *She might have fallen out of the bed and landed on the u shaped-pillow in the past. 5. Observation on 1/15/19 at 10:29 a.m. and on 1/17/19 at 8:40 a.m. revealed a u-shaped pillow on resident 42's bed. Review of resident 42's medical records revealed: *He was admitted to the facility on [DATE] and had a BIMS of ninety nine indicating he was unable to complete the assessment. *[DIAGNOSES REDACTED].>-Unspecified [MEDICAL CONDITION]. -Chronic ischemic [MEDICAL CONDITION]. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Dementia with behavioral disturbance, -Rash and other nonspecific skin eruption. -Major [MEDICAL CONDITION]. -Personality disorder. Interview on 1/17/19 at 9:03 a.m. with CNA F regarding the use of the u-shaped pillow for resident 42 revealed: *The u-shaped pillow was used to raise his feet off the bed. *The u-shaped pillow was used to keep him in bed. *He had falls in the past, and that was another reason for the pillow. Review of resident 42's care plan with a revision date of 11/09/18 revealed: *Intervention: U shape pillow when in bed for positioning/boundaries. *Goal related to the resident having intact skin. 6. Interview on 1/16/19 at 11:15 a.m. with LPN H regarding the reason for the use of the u-shaped pillows for some of the residents revealed: *It let the residents know where the edge of the bed to prevent them from falling out of the bed. *It was also used for elevating heels and positioning while in the bed. Interview on 1/16/19 3:53 p.m. with registered nurse (RN) G regarding which residents used the u-shaped pillows, what they were used for, and how they were implemented revealed: *Resident 42 used the u-shaped pillow when he was in bed. The u-shaped pillow was used as a boundary barrier and to help prevent pressure injuries. *Residents 31 and 36 used the u-shaped pillow to help with positioning and prevention of pressure injuries. *The care team meetings would meet and approve the use of the u-shaped pillows and when to use them. *If it was overnights or weekends then she would implement the use of the u-shaped pillow and pass the information onto the team. A follow-up interview on 1/16/19 4:10 p.m. with RN G to clarify her criteria on the overnights or weekends when implementing a u-shaped pillow revealed: *If there was an admission on the overnights or weekends and they were at a risk for skin issues she would use the u-shaped pillow to keep heels off the bed or for repositioning. *When a resident was at risk for sliding and getting a pressure ulcer it was used. *Also used if the resident did not have an air mattress. *The resident was assessed to determine if they could remove the pillow, so it would not be a restraint. She said they would not document that assessment anywhere. *The person who would assess the ability of the resident to remove the pillow was an RN, the DON, or the occupational therapist (OT). *The u-shaped pillow would not be considered a restraint if the person would not be able to move in the bed regardless of the pillows presence. In that case the pillow would be used for the repositioning and raising of heels off the bed. *She said because the u-shaped pillow would not be considered a restraint for any of the residents they did not document any kind of assessment for its use. Interview on 1/17/19 at 10:00 a.m. with the DON regarding the use of u-shaped pillows and what would be considered a restraint revealed: *They had used the u-shaped pillows for two decades. *Some residents preferred the u-shaped pillows. *When a resident was using a u-shaped pillow it should have been on their care plan. *The u-shaped pillows were used for positioning, so instead of having three smaller pillows they could have the one u-shaped pillow. *There was not a tool to determine if the u-shaped pillow was a restraint or if the resident could remove it. *The u-shaped pillows were not looked at as a restraint; it was considered a comfortable positioning device. *Some residents had stated the pillow was too bulky or too hot, and they could not move it. *When the resident requested to have the u-shaped pillow removed they would remove it. *They had a policy that stated if the resident had an air overlay or air mattress they required a boundary. Corporate office enforced that policy. *The u-shaped pillow was used as a safety device for boundary. *If a resident needed an air mattress the policy required a boundary, and the resident would have to use the u-shaped pillow. *The interdisciplinary team determined if a piece of equipment was a restraint. *Something would have been a restraint if it restricted movement, and they would also assess the capabilities of the resident. Review of the provider's (MONTH) (YEAR) policy and procedure on Restraints revealed: *Defined a physical restraint as: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily that restricts freedom of movement or normal access to one's own body. *If the device, material or equipment cannot be removed easily by the resident and restricts freedom of movement or normal access to one's own body, then this is a restraint and this procedure must be followed. *Remove easily-The manual method, device material or equipment that can be removed intentionally by the resident in the same manner as it was applied by the employee (side rails are put down and not climbed over, etc.) considering the resident's physical condition and ability to accomplish objective (e.g., transfer to a chair, get to the bathroom on time). *If the device, material or equipment is not a restraint for this resident, then the steps taken to make this decision must be documented in the medical record. *The PN-Psychopharmacological Med/Physical Restraint is a suggested location for documentation. *If the device, material or equipment is not a restraint, it must be reviewed quarterly and with a significant change in condition in conjunction with the care plan to ensure that it continues to not be a restraint for the resident. Review of the provider's (MONTH) (YEAR) Bed Safety-Including Bed Rails/Side Rails/Assist Bars policy and procedure revealed it defined a bolster as a long pillow or cushion used to prevent entrapment between a mattress and assist bars or side rail.

Based on observation, record review, interview, and policy review, the provider failed to ensure 2 of 12 sampled residents' (18 and 29) care plans had been updated with changes related to nutrition and restraints. Findings include: 1. Review of resident 18's 7/2/15 revised care plan revealed her use of a u-shaped body pillow had not been care planned. Refer to F604, finding 1. 2. Review of resident 29's 12/18/18 revised care plan revealed there had been no updates for interventions related to her continued weight loss. Refer to F692, finding 1. 3. Review of the provider's (MONTH) (YEAR) Care Plan policy revealed: *A qualified team of persons would review care plans at least quarterly. *Care plans would also be reviewed, evaluated, and updated when there was a significant change in the resident's condition. *That plan of care would be modified to reflect the care currently required/provided for the resident.

Based on observation, interview, record review and policy review, the provider failed to ensure two of four sampled residents' (28 and 29) had nutrition interventions monitored and assessed. Findings include: 1. Review of resident 29's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Dementia in other diseases classified elsewhere without behavioral disturbance. -[MEDICAL CONDITION]. -Vitamin B12 deficiency. -[MEDICAL CONDITION]. -Type 2 diabetes mellitus without complications. Review of resident 29's following Minimum Data Set (MDS) assessments revealed: *On 12/11/18 her MDS assessment revealed: -Her weight was 105 pounds (lb). and she required extensive assistance of one staff person for eating. -She had a 5% or more weight loss in one month. *On 6/19/18 her MDS assessment revealed: -Her weight was 112 lb, and she required the extensive assistance of one staff person for eating. Review of resident 29's following weights revealed: *On 9/5/18: 110 lb. *On 10/3/18: 108.5 lb. *On 11/6/18: 112 lb. *On 12/5/18: 105 lb. -That was a seven pound weight loss in thirty days and was a 6.25% weight loss. Surveyor: Observation on 1/16/19 from 12:00 noon through 12:43 p.m. of certified nurse aide (CNA) A and the following residents revealed: *At 12:17 p.m. resident 29 was brought to the table. *At 12:19 p.m. CNA A returned to the table, took resident 29's ordered and served her food. -CNA had not attempted to assist her. *At 12:20 CNA A walked away to wash her hands. *At 12:32 p.m. CNA A told resident 29 Your ice cream is going to melt. Though she still was not eating on her own, she had not attempted to assist her. -At 12:36 p.m. CNA A left the table to assist a resident at another table. *Resident 29 had not received extensive assistance from one staff member to eat. Surveyor: Review of resident 29's 1/16/19 care plan revealed: *On 12/17/15 her unplanned weight loss had been identified and had been reviewed on 12/18/18. *On 12/17/18 it was her goal to maintain a weight between 105 and 115 lb with the goal reviewed on 1/8/19. *Interventions included: -Invite resident to food-related activities and offer food, beverages of choice to encourage intake. --Initiated on 12/17/15 and last revised on 11/22/16. -Provide fortified foods high in calories at meals. Super cereal with cream and brown sugar (dislikes oatmeal). Whole milk, cream, extra margarine, extra gravy, sauces, cheese, peanut butter on toast, eggs. High calorie juice. Sugar free hot chocolate made with milk and half and half instead of water. --Initiated on 12/17/15 and revised on 9/17/18. -Scheduled resident specific snack/food intervention #2 (2 peanut butter cup and crackers). --Initiated on 1/24/18 and revised on 11/14/18. *Resident's significant weight loss was identified on 12/5/18. *The last revisions for unplanned weight loss interventions were made on 11/4/18. -There had been no updates to her interventions for an unplanned weight loss since the significant weight loss had been identified on 12/11/18. Interview on 1/16/19 at 3:15 p.m. with the certified dietary manager (CDM) revealed: *Meal intakes were documented for each resident by nursing staff. *Fortified foods were not documented separately. Interview on 1/16/19 at 4:18 p.m. with the CDM regarding resident 29 revealed: *There had been no updates to the interventions for her unplanned weight loss since 11/4/18. *Her 12/5/18 MDS indicated a 5% or more weight loss in thirty days. *There was no way to track the interventions for unplanned weight loss separately. *Extensive assistance of one staff person for eating would have been either putting food on a utensil or feeding the resident; cueing was not extensive assistance. *She stated resident 29 went on hospice due to her weight loss even though the interventions for weight loss had not been evaluated for effectiveness. *CNAs tracked whether a snack was accepted or refused. -She stated there is no way to track the intake regarding the residents' snacks. -Snacks were either accepted or refused. Interview on 1/16/19 on 4:31 p.m. with CNA C about resident 29 revealed: *He assisted her to eat snacks in her room. *When he documented she had accepted her snack she had eaten at least half of it. *If she had not eaten at least half of her snack he documented it as refused. *That was the guideline he had come up with on his own for documenting snacks. Interview on 1/16/19 at 4:50 p.m. with the CDM regarding resident 29 revealed: *The only intervention that had been tracked for weight loss was the nutritional supplement. *The nutritional supplement was not care planned as an intervention for unplanned weight loss. Review of providers (MONTH) (YEAR) Food First Philosophy policy revealed: *Purpose: -To promote resident satisfaction with the quality of the food and the dining experience as a priority. -To promote the food first philosophy with the understanding that resident's thrive better in an environment with familiar meal and snack choices. -To advocate the use of real food before the addition of medical nutritional supplements. *Policy: -Meals and snacks are the foundation of a resident's dining plan with fortified foods and supplements being used only when the resident's clinical condition or resident choice warrant it. Every effort is made to meet the resident's nutritional needs with regular and fortified foods before supplements are ordered. 2. Review of the registered dietician's (RD) progress notes for resident 28 revealed: *11/7/18 at 3:21 p.m.: Weight has remained stable over the last 180 days with current weight at 187# (pounds). He is consuming 48-63% at meals and he is accepting the evening snack. He does have a tendency to fall asleep at meals and requires supervision at meals. He has a wound on his coccyx with (which) is almost healed with 110% granulation. Continuing all nutrition interventions to prevent weight loss. *12/13/18 at 9:32 a.m.: Weight is trending down. He is now 180# with a weight of 192# - 90 days ago. (resident name) is unable to give this recorder information about his likes and dislikes. His spouse (name) was very helpful and she mentioned he likes the strawberry drinks he use to get. (spouse name) mentioned (resident name) food likes and she states he consumes al the snacks her currently receives throughout the day. Interventions: continue fortified foods, fortified cereal, juice at all meals, fruit at all meals, chocolate milk at breakfast, snacks TID (three times daily) and adding sugar free Mighty Shake in the afternoon to prevent further weight decline. *1/14/19 at 10:00 a.m.: Weight has decreased to 180#. He was 183# - 30 days ago and 189# - 180 days ago. Meal consumption ranges from bites to 75% at meals. He is accepting snacks at all 3 intervals throughout the day. Continue to offer snacks TID along with fortified foods, extra fruit at meals and chocolate milk at breakfast. Review of resident 28's weight loss for one month was 1.64%, three months was 2.11%, and six months was 5.26%. Review of his MDS assessments revealed: *Admission 3/19/18 MDS he was independent with eating after set-up. *Quarterly 6/18/18 MDS he required extensive assistance with eating from one staff person. *Quarterly 9/11/18 MDS he required extensive assistance with eating from one staff person. *Quarterly 12/11/18 MDS he was independent with eating after set-up. Review of resident 28's following care plans revealed: *Activities of daily living interventions revised on 4/30/18 included: -EATING: STRENGTH: Independent with eating with set-up of cut meat. *Revised care plan on 3/21/18. -Focus: The resident has altered nutrition R/T (related to) Diabetes, history of UTI (urinary tract infection) &[MEDICAL CONDITION] E/B (evidenced by) Hx (history) pressure ulcers to right heel and coccyx, need for extra calories and protein. -Goal: Resident will consume an average greater than 50% of meals through the review date. -Interventions included: --Provide fortified foods at meals (Super Cereal, sugar free health shake, whole/chocolate milk, juice, extra gravy, margarine, sauces, cheese, peanut butter) and an extra fruit to promote wound healing and increase calories. Review of resident 28's intake documentation for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 2019 revealed: *His intake had been documented at 9:00 a.m. for breakfast, 1:00 p.m. for lunch, and 6:00 p.m. for dinner. *November (YEAR) he ate: -25% or less for breakfast one time and 50% or less four out of thirty times. -25% or less for lunch eighteen times and 50% or less four out of thirty times. -25% or less for dinner ten times and 50% or less seven out of thirty times. *December (YEAR) he ate: -50% or less two out of thirty times. -25% or less for lunch twelve times and 50% or less seven out of thirty times. -25% or less for dinner six times and 50% or less twelve out of thirty times. *January 1, 2019 through (MONTH) 16, 2019 he ate: -50% or less two out of sixteen times. -25% or less for lunch eleven times and 50% or less two out of sixteen times. -25% or less for dinner nine times and 50% or less three out of sixteen times. Interview on 1/16/19 at 4:29 p.m. with the CDM revealed: *The RD had not done an extension for fortified foods. *A list of fortified foods was used, but there were no amounts listed of each type of food. *The list for fortified foods had been developed in (YEAR). *Agreed there were no amounts of food to have been served on the fortified foods list. *Did not known how many calories each of those listed fortified foods contained. Review of the provider's 7/29/16 Fortified Foods list revealed: *It had been reviewed and signed by the RD, CDM, and dietary supervisor. *Focus: Extra items to be added to foods to increase calories. *Goal: Add at least 2 per meal. *Fortified foods included: super cereal, health shake, margarine, gravy, cheese (shredded, slice, sauce, and parmesan), whole milk, chocolate milk, sugar (brown, granulated, and powdered), half and half cream, syrup (chocolate, strawberry, caramel, and butterscotch), whipped topping, sour cream, ranch, Dorothy Lynch, or other salad dressing, ketchup, barbeque sauce, tarter sauces, peanut butter, jelly, and chocolate chips. *No serving amounts for each food had been listed. *No calorie amounts for each food had been listed.

Based on observation, interview, and procedure review, the provider failed to ensure linen had been covered during transport for five of six observations. Findings include: 1. Observations on 1/16/19 from 10:48 a.m. through 11:44 a.m. revealed: *At 10:48 a.m. laundry assistant D transported clean sheets from the laundry room to the clean linen closet uncovered. *At 11:05 a.m. laundry assistant D moved clean personal resident laundry uncovered down the 200 hallway. *At 11:19 a.m. laundry assistant D moved a cart of clean sheets, towels, and residents' personal laundry from the laundry room to the linen closet uncovered. *At 11:20 a.m. laundry assistant D left the linen closet, and laundry was covered with a blue blanket. *At 11:44 a.m. laundry assistant D transported four piles of clean laundry on a small cart; two were covered and two were uncovered. Observation on 1/17/19 at 1:16 p.m. of laundry assistant D revealed she brought out a cart from the laundry room with towels on the top shelf. The towels had not been covered. Interview on 1/17/19 at 3:00 p.m. with the administrator revealed she agreed the linen should have been covered while being transported. Review of the provider's (MONTH) (YEAR) Laundry Room procedure revealed: *Information regarding the maintenance of laundry room environments. *It did not indicate a procedure for laundry transportation. *It referred to the infection control policies for their facilities.

Based on observation, record review, interview, and policy review, the provider failed to ensure an accurate and thorough assessment and management of pain for three of nine sampled residents (3, 5, and 10). Findings include: 1. Observation and interview on 9/21/16 at 9:20 a.m.with resident 5 revealed she was: *Sitting in a wheelchair in the chapel waiting for devotions. *Oriented to person only. *Constantly rubbing her left outer thigh and knee. *Able to state she was in pain, some days more than others. *Unable to rate her pain severity. *Displaying facial grimacing and furrowing of her eyebrows as she rubbed her left thigh and knee. Review of resident 5's 9/21/16 nursing progress notes revealed: *[MEDICATION NAME] 50 milligrams (mg) was documented as administered at 7:34 a.m. for complaints of pain upon arising. *As needed (PRN) administration was documented as effective at 8:35 a.m. as resident with less complaints of pain at breakfast. Was able to eat meal with just cueing and went to beauty shop for hair. Review of resident 5's August 2016 medication administration record (MAR) revealed: *Aleve 220 mg one tablet two times a day related to arthropathy. *[MEDICATION NAME] 325 mg two tablets every four hours PRN as needed for mild pain related to arthopathy. There was documentation the [MEDICATION NAME] had been administered two times and the results had been effective. *[MEDICATION NAME] 50 mg one tablet every six hours PRN related to arthopathy. -There was documentation she had received one dose on twenty-three days. -Twenty-one of those doses were documented effective. -There was documentation on 8/13/16 she had received one dose and the results were effective. Review of resident 5's September 1 through 19, 2016 MAR revealed: *Aleve 220 mg one tablet two times a day. *[MEDICATION NAME] 325 mg two tablets PRN had been documented as administered two times with results documented effective. *[MEDICATION NAME] 50 mg every six hours PRN was documented as: -Administered one dose on fifteen days. -All fifteen doses were documented effective. -There was documentation on five days two doses had been administered with the results being effective. *BenGay PRN for pain in knees. There was no documentation it had been administered. Review of resident 5's 8/10/16 nursing progress notes documented by the Minimum Data Set coordinator revealed: *Nursing staff advised to offer PRN pain medication upon arising and PRN BenGay three times a day to see if this helps resident's pain or affects ambulation prior to seeking an order for [REDACTED]. *Staff are to continue to encourage resident to ambulate and utilize wheelchair as needed. Review of resident 5's 9/14/16 pain assessment by registered nurse (RN) A revealed: *Is the resident at high risk for pain was documented yes. *What non-pharmacological interventions work best for this resident use of wheelchair for locomotion. *Is the current medication regime working no. *If no, recommended changes to this regime PRN [MEDICATION NAME] has been utilized without relieve. Doctor has been faxed. Awaiting orders. *What is the recommended pain management plan Question if a pain patch may be beneficial. Staff will wait to see what doctor orders. Review of resident 5's 8/29/16 revised care plan revealed: *Resident has impaired cognitive function related to [MEDICAL CONDITION]. *The resident has alteration in musculoskeletal status related to pain in left knee. *Resident will remain free from pain or at a level of discomfort acceptable to the resident. *Assist the resident with the use of wheelchair with autolock brakes as recommended. *May use wheelchair as needed with complaints of increased pain. *Heat/cold applications as ordered and as tolerated. *Resident has limited mobility related to [MEDICAL CONDITION] arthritis. Interview on 9/21/16 at 9:45 a.m. with certified nursing assistant E regarding resident 5 revealed she: *Had been having some physical changes the past couple weeks. *Was having more difficulty with transfers and had complained of pain especially in her knees. *Had been using a high-riser on the toilet which had helped with toilet transfers. *Knew the nurses were aware of her pain and thought she was receiving pain medication. Interview on 9/21/16 at 9:50 a.m. with restorative aide D regarding resident 5 revealed she: *Had stopped coming to restorative care about a month ago. *Prior to month ago, she had not been coming to restorative care on a consistent basis. *Usually complained of pain in her knees as the reason she did not want to do restorative care. Interview on 9/21/16 at 10:00 a.m. with RN B regarding resident 5 revealed she: *Knew the resident often had complaints of pain in her knees. *Thought it had been decided in a care team meeting recently they were to try administering the [MEDICATION NAME] at least twice a day to see if that helped her pain. *Agreed the [MEDICATION NAME] usually had not been administered twice a day and on some days not at all. *Felt the staff were having a hard time deciding if the resident was truly having pain or it was a behavior related to her dementia. *Stated the resident had been failing physically the past couple weeks. They had done a computerized tomography (CT) scan and that showed no abnormalities. *Was unable to locate a fax sent to the physician on 9/13/16 regarding the possibility of using a [MEDICATION NAME]. *Knew nothing about a [MEDICATION NAME] being considered for her pain. *Was uncertain why the BenGay topically had not been used on her knees for pain. Interview on 9/21/16 at 11:15 a.m. with physician C regarding resident 5 revealed: *It was difficult to say if she was truly having pain related to her significant dementia. *He did not recall a fax being sent to him on 9/14/16 regarding the suggestion of a [MEDICATION NAME]. *He wondered why the nursing staff would suggest a [MEDICATION NAME] when they had not been administering the [MEDICATION NAME] as much as they could have. *He felt the documentation of relief of pain being obtained after the nursing staff had administered the [MEDICATION NAME] was reason to use the [MEDICATION NAME]. *The addition of adding a [MEDICATION NAME] to an older resident's pain regime increased their risk for falls and increased confusion. *They had recently injected her left knee with cortisone for pain control. *The resident had been seen by an orthopedic physician shortly after they had injected her knee, and the orthopedic physician had also given her a cortisone injection. 2. Review of resident 10's 7/8/16 through 7/9/16 nursing progress notes revealed: *7/8/16: -1:53 p.m. Doctor here to examine resident and her continued pain. Orders noted for [MEDICATION NAME] 50 mg at 8:00 a.m., 12:00 p.m., and 4:00 p.m. for two weeks. -2:01 p.m. The system has identified a possible drug allergy for the following order [MEDICATION NAME] tablet 50 mg. There was no further documentation the allergy had been reviewed with the physician. -6:35 p.m. [MEDICATION NAME] 325 mg two tablets administered for resident's complaint of pain all over. Pain was documented as a 10 on a 1 to 10 pain scale with 1 being minimal pain and 10 being severe pain. PRN administration of the [MEDICATION NAME] was effective. *7/9/16: -4:02 a.m. [MEDICATION NAME] 325 mg two tablets administered for resident's complaint of joint pain at a pain rating of 6. PRN administration of the [MEDICATION NAME] was effective. -12:14 p.m. Resident given first dose of [MEDICATION NAME] at breakfast and complains of a 5 pain rating. No adverse side effects noted. -7:55 p.m. Doctor notified niece here this evening and is very upset [MEDICATION NAME] was ordered for her pain med. Did tell doctor resident had not gone out for supper due to complaints of diarrhea and upset stomach. Doctor stated she has an upset stomach likely due to diarrhea stool. Doctor did give following orders to hold [MEDICATION NAME] until further notice. Interview on 9/21/16 at 11:30 a.m. with physician C regarding resident 10 revealed: *The resident's niece was upset with him for trying to make some changes different from the resident's previous physician who had retired. *He was not aware of the [MEDICATION NAME] allergy when he had prescribed the [MEDICATION NAME]. *He did not recall the nursing staff notifying him of the alert of the drug allergy of [MEDICATION NAME] before they started the first dose. Interview on 9/21/16 at 2:00 p.m. with the director of nursing regarding resident 10 revealed: *The resident's niece had multiple issues with physician C and often voiced she wanted to change physicians, but never followed through. *The resident did not voice any concerns with physician C. *The niece had not informed them of an allergy or sensitivity with [MEDICATION NAME] when she had been admitted to the facility on [DATE]. *The nurse should have called the physician on 7/8/16 when the alert came up regarding the potential [MEDICATION NAME] allergy and had not. The nurse had received disciplinary action for proceeding with the administration of the [MEDICATION NAME]. *She felt the resident's pain was controlled with frequent use of [MEDICATION NAME] after the [MEDICATION NAME] had been discontinued. *She did not know why on 7/8/16 at 6:35 p.m. they had administered PRN [MEDICATION NAME] for a pain rating of 10 instead of administering the [MEDICATION NAME]. *The [MEDICATION NAME] had not likely been delivered yet from the pharmacy, but the [MEDICATION NAME] could have been used from the emergency box. 3. Observation on 9/20/16 at 10:00 a.m. of resident 3 revealed two unidentified certified nursing assistants (CNA) were going to transfer her using an EZ Lift to a commode for toileting. Resident 3: *Sat quietly in her wheelchair when staff entered her room. *She had a flat affect and sad look on her face. *Moved her hand as able and indicated resistance to their care when they attempted to touch her arms and hands. *She responded to the staff presence by watching them while they were in her presence, but did not speak. *When spoken to, she slowly responded to what was said to her. *Appeared to guard her left hand and began making a repetitive sound as they began working with her. *Continued making the repetitive sound similar to the word here from the time they put the sling behind her back, and started moving her until she had been lowered to the commode with the EZ stand lift. -The repetitive sound became faster, and at times louder as the lifting was in process. *When she was ready to be lifted off the commode she resumed making the repetitive sound. -Again, the sound became faster as she was lifted. *She was quiet after the transfer and cares had been completed. Review of resident 3's Minimum Data Set (MDS) assessments revealed: *She had been admitted on [DATE]. *Comprehensive MDS assessments had been completed twice in the past two months. -An annual MDS assessment had been completed on 7/5/16. -A significant change MDS assessment had been completed on 8/30/16. *Both comprehensive MDS assessments indicated: *She was severely cognitively impaired. -She received no scheduled or as needed medications for pain. -There were nonpharmacological approaches to managing her pain. *She had the following indicators of pain daily: -Non-verbal sounds. -Facial expressions. -Protective body movements. Review of resident 3's care area assessments for pain for the above comprehensive MDS assessments revealed: *Nature of the problem: Resident is unable to state if she is having pain or not. Staff have noted non-verbal sounds, vocal complaints, facial grimace and guarding during transfers with sit to stand lift. CNA that is most consistent with care states that res (resident) does not have these signs. PRN (as needed) APAP 650 (Tylenol) suppository no used and PRN APAP 325 mg not used since 12/13/15. *Characteristics of the pain: Yells out with transfers and bath and staff state they think it is more fear of what is going to happen than pain. -They had not explained how they made that determination. *Frequency: Just during the transfer or bath or bath res yells out. *Non-verbal indicators of pain: Facial expression, guarding body position were checked. -Facial grimace and guarding noted by CNA's. *Care plan consideration: Minimize risk of pain and res (resident) ability to let staff know concerns. Review of resident 3's 8/29/16 Pain Assessment in Advanced Dementia (PAINAD) revealed: *She exhibited: -Occasional moaning/groaning or low level speech with a negative or disapproving quality. -Facial expressions sad, frightened, frowning. -Body language that was tense and distressed. *No movement or transfer was the non-pharmacological interventions that worked best for this resident. *Because resident calling out, facial grimace and bracing of body is only noted with repositioning and ambulation, it is difficult to determine if this is due to dementia or pain. Resident has no scheduled pain medication. Review of resident 3's physician's progress notes revealed: *4/15/15; Admission history and physical: She is quite anxious and sort of screams and screeches when she becomes so frightened. *Her problems/[DIAGNOSES REDACTED]. *She had been seen by her physician every 60 days since her admission. *Physician visits on 4/15/16, 4/25/16, 6/10/16, 8/10/16 revealed: -She had dementia with agitation and paranoia. -She received the following medications for those concerns including: --[MEDICATION NAME] 4.6 mg/24 hour for dementia with behavioral disturbance. --[MEDICATION NAME] tablet 12.5 mg two times a day for dementia with behavioral disturbance. -She had 2-4+ [MEDICAL CONDITION] to both legs which had been present at the time of her admission. --She did not receive any pharmacological approaches to addressing this. *6/10/16; She is quite demented and she was so agitated when she came in and paranoid the nursing personnel were not even able to provide daily cares for her. We added some [MEDICATION NAME]es as well as some [MEDICATION NAME] and is significantly improved. She still does not want me to touch her and she tells me to get out of here, but she is much better with the nursing home staff that she sees each and everyday. *There is no documentation the results of the pain assessments had been discussed with the physician. *8/10/16; She is disoriented to time, person and place, She does hit at me when I get too close, By touching her with a stethoscope, that really agitates her even more. Review of resident 3's nursing progress notes following each of the above resident's physician's visits revealed there was no indication the results of any pain assessments had been discussed with the physician. Interview on 9/20/16 at 3:30 p.m. with RN A revealed she: *Confirmed the resident made repetitive sounds daily whenever she was moved, touched, or transferred. *Staff cares of her and transfers occurred several times every day. *Was difficult to assess for pain because she could not tell you if she had pain. *Agreed they did not know if her behaviors were related specifically to dementia or pain. -They had only addressed the dementia. *Her family just wanted her to be comfortable. *Confirmed the [MEDICAL CONDITION] in the resident's legs could also contribute to her discomfort. *Thought the pain assessment was very subjective because it depended on when you saw the resident. -When the physician saw her, she was usually sitting in her chair and very quiet. *Agreed that while they had addressed her behaviors with an antipsychotic medication ([MEDICATION NAME]) and the [MEDICATION NAME], she continued to exhibit behaviors. -The behaviors were less severe than they were before though. *Agreed they had never even tried a pain medication to see if that helped the resident's behaviors during transfers. Interview on 9/20/16 at 5:00 p.m. with the resident's son revealed he: *Did not feel her behaviors were related to pain, but was related to fear. *Thought if she had pain she would show facial grimacing, or readjust her body after they had completed her transfers. *Was not under the impression the behaviors occurred very often. *Denied she had arthritis, but said while she was at home she took a Tylenol every night before bed. -That was for arthritis in her hands and pointed to her hands which had evidence of swollen joints. *Stated the family had gotten clothes for her that either zipped or buttoned up the back, because her left shoulder gave her problems. -She could not lift her arm very high. -She had some arthritis in her shoulder. Interview on 9/21/16 at 8:05 a.m. with the MDS coordinator regarding resident 3 revealed: *She confirmed the information on the above pain assessments had been completed by her. *She agreed pain had never been ruled out as a contributor to her behaviors and agitation. *They had not followed up on their pain assessments by suggesting to the physician they consider addressing the possibility of pain. Interview on 9/21/16 at 12:05 p.m. with physician C regarding resident 3 revealed: *He was unaware of any specific indication of pain. *His treatment would have been directed toward an acute indicator of pain, and she did not have that. *He treated her with the [MEDICATION NAME] and [MEDICATION NAME] because of her dementia, and her behaviors occurred every single day. -He was aware the behaviors were still occurring, but thought they had improved from admission. 4. Review of the provider's July 2016 Pain Management policy revealed: *All residents will receive interdisciplinary consultations on assistance in managing pain. When a resident is identified as being in pain, the social worker, as part of the interdisciplinary team, will assess the psychosocial well-being of the resident. Individualized approaches will be developed to address their resident's pain management needs in a holistic manner. *A pain management plan can include, but not be limited to, a medical regime. The plan should help determine what other methods or alternatives of pain control/relief may be implemented prior to contacting a physician. The interdisciplinary team and nurses must continually communicate with the resident and monitor and evaluate the pain management plan. *Follow prescribed orders for pain, documenting results in the MAR and eAdmin notes as needed.

Based on observation, interview, record review, and policy review, the provider failed to provide preventative maintenance to one of one fan oscillating over clean resident clothing items in one of one laundry room. Findings include: 1. Observation on 9/19/16 at 1:35 p.m. in the clean laundry room revealed an oscillating fan was observed in use on the south wall of the room. *It was in use immediately above a laundry cart containing clean resident clothing. *The blades and frame of the fan were covered in a thick layer of gray colored debris. Observation and interview on 9/20/16 at 9:10 a.m. with the laundry supervisor revealed: *The oscillating fan remained in use immediately above the laundry cart with clean resident clothing. *She verbalized the cleaning of the fan had been completed by maintenance in the past. *She thought the maintenance supervisor did not realize it needed to be done because he was relatively new to the position. *Acknowledged there was significant debris on the fan and it should have been cleaned by maintenance or her department. Interview on 9/20/16 at 4:15 p.m. with the infection control nurse revealed: *She had spoken to the laundry supervisor and felt maintenance was not aware of the presence of this fan. *Acknowledged it did present an infection control concern. Interview on 9/21/16 at 10:30 a.m. with the maintenance supervisor revealed: *He verbalized the fans in the hallway were cleaned every two months and more if needed. *The hallway fans had been cleaned in July with the next cleaning due before the end of September. *He was not aware of the fan in the clean laundry room. *He thought the fans in their respective departments were the responsibility of that particular department. *The fan in the laundry room was cleaned by him late the day before when it had been brought to his attention. Review of the facility cleaning/task checklist revealed: *Clean hallway wall fans was present on the list and last completed 7/13/16. *Fans in the department rooms were not included on the list. Review of the provider's March 2016 Preventative Maintenance Program policy revealed Preventative maintenance also means carrying out manufacturer requirements for cleaning, lubing, replacing small parts, etc.

Based on record review, interview, and policy review, the provider failed to thoroughly investigate two of three reviewed incident reports for one of one sampled resident (1) and one of two random residents (12) to verify no abuse or neglect had occurred. Findings include: 1. Review of resident 12's 9/2/15 incident report revealed: *The incident description had been: -Nurse summoned to room by housekeeping via (by) radio. -Resident laying face down on floor in front of recliner, head turned towards the left. -Legs outstretched towards the door. -Blood observed on the floor from forehead gash and nose bleed. -I forgot I couldn't walk. *The immediate action taken had been: -ROM (range of motion, moving arms and legs). -Resident denies pain to extremities (arms and legs). -Resident was rolled onto back and assisted to her wheelchair with sling lift (mechanical device used to move resident from place to place) x (times) 2. -Icepack applied to forehead. -Skin tear was noted to left knee, kling (soft dressing) applied. -Dr. (doctor) ambulance and family notified. *Her mental status had been oriented to person (knows herself when spoken to). *The predisposing environmental factor section had not applicable checked. *The predisposing physiological (mental) factors section had confused checked. *The predisposing situation factors section had not applicable checked. *No witnesses found had been typed in under the witness section. *There had been no other documentation regarding what had occurred prior to the fall, who had been working with the resident, or when she had last been assisted with any personal care. 2. Review of resident 1's 7/24/15 incident report revealed: *The incident description had been: -This RN (registered nurse) was called to resident's room by (certified nursing assistant (CNA) name). -CNA states resident's roommate was looking for money to go shopping. -Apparently res (resident) roommate took resident's piggybank off of the shelf. -Roommate broke the bank trying to get the money out. -Money was noted on the dresser and on roommate bedside table. *The immediate action taken had been: -(CNA name) picked up all the money and noted there was $14.95. -Money was put into a white foam cup along with the broken bank into the med room. -Will keep it in med (medication) room until social services returns on Monday. -Floor was swept to clean up any broken glass. -Resident's roommate has a history of dementia (unable to think well enough to do normal activities) and Alzheimer's (disease, loss of mental functioning). *There had been no follow-up documentation regarding what social services had done and what had happened with the money after it went into the med room. 3. Interview on 10/28/15 at 2:10 p.m. with the director of nursing (DON) revealed: *They had an internal investigation form they used but per the administrator it was not a part of the resident's medical record. *There had not been a form for resident 1's incident. *There was no additional information on resident 12's form that documented a thorough investigation had been completed. Review of the provider's June 2014 Abuse and Neglect policy revealed: *The investigation team should have reviewed all incidents no later than the next working day following the incident. *They should have determined whether further investigation was needed. *Investigations might have included interviewing staff, residents, or other witnesses to the incident. *If possible they should have gotten signed and dated statements from any witnesses.

Based on observation, interview, and procedure review, the provider failed to offer fortified foods (have added calories and/or protein) to 22 of 22 residents who were to receive them during 1 of 2 observed meals. Findings include: 1. Observation and interview on 10/27/15 at 5:35 p.m. with cook A revealed: *Residents' diet cards with an F written on them were to have received fortified foods. *Foods were fortified by adding butter or gravy to the food. *Whole milk was to have been served. *The food items offered were: -Crispy fish fillet. -Hamburger on a bun. -Oven french fries. -Corn -Dinner roll -Tomato slice on lettuce. -Peach crisp. *She did not serve fortified foods to twenty-two residents who were to have received them. *She stated there was not much she could have added to the food items for that meal. Interview on 10/28/15 at 2:15 p.m. with the dietary manager revealed: *Foods were fortified for residents who needed more calories and/or protein. *Residents' diet cards with an F written on them were to have received fortified foods. *There were twenty-two residents on a list to receive fortified foods. *They: -Fortified foods by adding butter, gravy, sour cream, cream, or whole milk to them. -Served whole milk with meals for residents who were to receive fortified foods. -Did not have a fortified foods menu or recipes for fortified foods. -Used the February 2013 Procedure for Fortified Foods as their fortified foods policy. -Were not following their fortified foods policy. *She expected the cook to have added cheese or butter to the foods or to have served a larger dessert to those residents needing fortified foods. Interview on 10/28/15 at 3:25 p.m. with the registered dietician revealed: *The provider did not have: -A fortified foods menu. -Recipes for fortified food items. *Some meals would not be able to be fortified. *She did not expect to have fortified foods at every meal. Interview on 10/28/15 at 3:50 p.m. with dietary consultant B revealed she stated the provider's: *Fortified foods policy was under review. *Fortified food menus were not effective. *Process was to address that issue on the residents' care plans and to update their diet cards. *Dietary staff could have written their own fortified foods menu. *Diet manual could have been referred to for recipes for fortified foods. Interview on 10/28/15 at 4:28 p.m. with the director of nursing revealed: *Foods were fortified to provide additional calories and/or protein to promote wound healing or weight management. *There were residents with weight loss or facility acquired pressure ulcers (injury to skin usually from pressure and frequently over a bony area). -She had expected fortified foods would have been provided to those residents during meals and at snack times. Review of the provider's February 2013 Fortified Foods procedure revealed: *Fortified foods are used when a resident's calorie and/or protein needs are increased or when a resident is experiencing weight loss. *Fortified foods were menu items and snacks that were enhanced by increasing calories and protein through the addition of nonfat dried milk, extra margarine, peanut butter, and chocolate. *A fortified food menu extension could have been written by either the food vendor or the registered dietician. *There would be recipes for the menu extension.

Based on observation, interview, and record review, the provider failed to maintain control of scheduled (government controlled) medications within one of one medication cart. Findings include: 1. Observation on 10/28/15 at 4:30 p.m. with registered nurse (RN) G and the medication cart revealed: *Resident 13's container of liquid morphine sulfate (controlled medication given for pain) one hundred milligrams (mg) per five milliliters (ml) solution had one drop of fluid in it. -There should have been 6.5 ml left in the container according to the narcotic (scheduled pain medication) record. *Resident 14's container of liquid oxycodone hydrochloride (medication given for pain) one hundred mg per five ml solution had fourteen ml in it. -There should have been twenty-two ml according to the narcotic record. *Resident 15's container of liquid promethazine-codeine syrup (medication given for coughing) had forty ml in it. -There should have been forty-eight ml of syrup in it. Observation of the above medication containers, review of the narcotic records, and interview with the director of nursing (DON) and RN G on 10/28/15 at 5:25 p.m. revealed: *There was no explanation for the above missing scheduled medications. *The DON had not been notified of any missing medications. A copy of the procedure for dealing with missing scheduled medications was requested of the DON. That procedure was not received before the end of the survey.

Based on observation, interview, record review, and procedure review, the provider failed to ensure: *A UAP (unlicensed assistive personnel) had notified and consulted with the licensed nurse prior to administering a PRN (as needed) pain medication for one of one sampled resident (1) having pain. *A physician's order had been obtained to self-administer a nebulizer treatment for one of one sampled resident (6) and one of one randomly observed resident (12). Findings include: 1. Observation and interview on 10/27/15 from 5:10 p.m. through 5:25 p.m. with resident 1 revealed: *She had difficulty speaking due to several past [MEDICAL CONDITION] (blood clots in the brain). *She had winced a few times at the end of the interview. *She grabbed at her right arm with her left while grimacing. *When asked if she was okay she stated no. *When asked if her arm hurt she stated yes. *When asked if she wanted me to get a nurse she stated no, and instead she loudly hollered hey to the certified nursing assistant (CNA) in the hallway. *At 5:20 p.m. CNA D came into the room. *She had asked the resident what she needed. *The resident was having difficulty expressing her pain. *The CNA asked if she needed something to drink. *She stated no. *After a few minutes of struggling with her speech she was asked if she wanted to tell the CNA about her arm. She stated yes. *CNA D then asked if she was in pain and she stated yes. *CNA D asked her what number of pain based on a scale of one to ten with ten being the worst. *She stated her pain was at a 10. *CNA D stated she would go tell the nurse. *At 5:25 p.m. UAP/CNA E went into resident 1's room with medication. *A licensed nurse had not gone into the resident's room to assess her pain prior to the medication being administered. Interview on 10/27/15 at 5:25 p.m. with UAP/CNA E regarding resident 1 revealed she had been told by CNA D the resident was having pain in her arm. CNA D had told her the pain level was at a ten. She had given the resident Tylenol since she had a PRN order for it. She gave the Tylenol instead of something else, because the resident would be getting scheduled pain pills at bedtime. Review of resident 1's medical record revealed UAP/CNA E had documented registered nurse (RN) F had approved the Tylenol given at 5:25 p.m. on 10/27/15. There had been no assessment or documentation completed by RN F regarding resident 1's pain. Resident 1 had four different PRN pain medications that could have been administered. Interview on 10/28/15 at 9:40 a.m. with the director of nursing (DON) regarding resident 1 revealed a licensed nurse should have completed an assessment on her pain. The licensed nurse should have decided which medication to administer. Interview on 10/28/15 at 1:10 p.m. with the DON revealed she had called RN F and asked about resident 1's pain the night before. RN F was not aware of the pain issue from 10/27/15. She had not been consulted by UAP/CNA E. The DON had also called UAP/CNA E regarding the situation. She had not consulted RN F regarding resident 1's pain prior to administering the PRN pain medication. Review of the provider's September 2012 Medication Administration and Scheduling policy revealed: *Medication administration is a nursing task. *Nursing assessment is a function of the registered nurse. *When the center utilizes medication aides, the delegating nurse is accountable for assessing a situation and making the final decision to delegate. *Prior to delegating medication administration, the nurse assesses the resident's nursing care needs. 2. Observation and interview on 10/27/15 at 11:44 a.m. with licensed practical nurse (LPN) C while she was administering a nebulizer (device to administer medicine as a mist into lungs) treatment to resident 12 revealed she: *Took the medication to the room. *Set-up the nebulizer for use and assisted the resident with preparing for the treatment. *Started the nebulizer machine, said she would be back, and left the room. *Returned at 11:59 a.m. and discontinued the nebulizer treatment. *Stated that was her normal procedure for administering a nebulizer treatment. Review of resident 12's complete medical record revealed there was no physician's order for self administration of nebulizer medication. 3. Observation and interview on 10/27/15 at 4:23 p.m. with LPN C while she was administering a nebulizer treatment to resident 6 revealed she: *Took the medication to the room. *Set-up the nebulizer for use and assisted the resident with preparing for the treatment. *Started the nebulizer machine, said she would be back, and left the room. Review of resident 6's complete medical record revealed there was no physician's order for self- administration of nebulizer medication. 4. Interview on 10/28/15 at 4:00 p.m. with the DON and administrator regarding the above two nebulizer administration observations revealed the DON agreed there were no physicians' orders for residents 6 and 12's self-administration of the nebulizer medication. Review of the provider's July 2014 Resident Self-Administration of Medication procedure revealed: *A physician's order must be obtained prior to the resident self-administering medications. *The order must be specific to the medication being self-administered. Review of the provider's July 2015 Self Consumption of Medications procedure revealed: *Self consumption of medications may not begin until the physician has been involved and signed an order for [REDACTED].>*The order must state which medications a resident may self consume.