Every finding on record at Greenway Manor

Based on record review and interview, the facility did not ensure 2 of 3 residents (R6 & R32) who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. R6 has a diagnosis of PTSD (Post Traumatic Stress Disorder) and does not have a complete trauma assessment or a care plan addressing triggers, resident specific approaches, or interventions. The facility did not care plan R32's post-traumatic stress disorder and failed to include triggers and interventions to best support R32. This is evidenced by: Example 1: R6 was admitted to the facility on [DATE] with diagnoses that include major depressive disorder and PTSD (Post Traumatic Stress Disorder). R6's most recent MDS (Minimum Data Set) dated 1/16/26 shows R6 has a BIMS (Brief Interview of Mental Status) of 14 out of 15, indicating that R6 is cognitively intact. R6's MDS Section I also indicates that R6 has PTSD. A note for R6, dated 2/9/22 states, Historical Trauma Assessment completed with resident during review of admission paperwork on 2/8/22. Resident described experiencing PTSD, including sensitivity to loud noises. Supportive listening provided. Resident asked staff to be sure to knock prior to entering her room. R6's care plan states, Problem: Resident has health seeking questions related to post traumatic stress disorder .Goal: resident will use effective coping mechanisms to manage post traumatic stress disorder as evidenced by: less seeking of repetitive health issues .Approach: Administer medications .allow resident to practice problem solving techniques .convey an attitude of acceptance toward resident .during acute phase, do not make demands of resident. remove excess stimulation .encourage physical activity to maximal potential .encourage resident to become involved with tension reduction activities: exercise, talking with others .encourage resident to verbalize feelings and fears .maintain a calm environment and approach to the resident .review with resident past effective and ineffective coping mechanisms .teach resident how to identify the problem and options. Explore advantages and disadvantages/consequences of options. (Of note: R6's care plan does not include triggers or resident specific interventions.) On 2/25/26, SW C (Social Worker) provided Surveyors a form, titled, Historical Trauma Assessment that asks residents: 1) What have been the most difficult time/times of your life? 2) Have you ever been through anything life threatening or traumatic? 3) What helped you get through those difficult times? 4) What are some things that you do now to help you manage consequences of having gone through tough times? 5) Are you aware of any particular triggers that may make this worse for you? The form states at the bottom, Care plan notes to address the reported concerns above. Surveyor conducted the following interviews with staff on 2/25/26: *At 8:12 AM, SW C stated that the Historical Trauma Assessment form is used upon admission for all residents, however it was introduced to the facility after R6 had already been admitted and nobody from the facility went back to R6 with the document to gather the information. SW C stated that she wouldn't want to ask her about it and bring that up when asked if she was aware of the details of R6's PTSD. SW C also stated that R6 sees psych and the facility has care planned her behaviors and psychotropic medications. *At 9:32 AM RN E (Registered Nurse) stated she did not know R6 had PTSD, nor did she know of any triggers she has, but stated she (R6) seems to go into slumps of depression. *At 9:41 AM, CNA F (Certified Nursing Assistant) stated that she was not aware that R6 had PTSD nor knew any of her triggers. CNA F stated she believed R6 had attention seeking behaviors. *At 9:57 AM CNA G stated that she was aware that R6 had PTSD as it is on her care plan but did not know what her triggers were or how to address her potential PTSD related behaviors. On 2/25/2026 10:30 AM, DON B (Director of Nursing) stated that the facility tries to get as many behaviors that they will tell them about when care planning. When asked if a document such as their Historical Trauma Assessment be useful for that, DON B stated yes if they (residents) and providers are willing and open to telling them. DON B also stated that she believed if the facility asked R6, she would tell them all the answers to the questions in the Historical Trauma Assessment document. The facility was aware that R6 had a diagnosis of PTSD but did not conduct a complete assessment. On 2/9/22, R6 is noted as not liking loud noises, but her care plan does not detail this dislike. Instead, the care plan talks about seeking health information and does not state what her triggers are and staff was therefore unable to state what R6's triggers were. Example 2: R32 was admitted to the facility on [DATE] with a diagnoses including Parkinson's disease (a progressive neurodegenerative disorder leading to movement related issues like tremors, rigidity, slowness, and postural instability), dementia, major depressive disorder, degenerative disease of nervous system, pain, history of falling, Post-traumatic stress disorder, cognitive communication deficit, degenerative disease of nervous system, restlessness and agitation, adult failure to thrive, reduced mobility, and need for assistance with personal cares. R32's care plan states, 2/24/26.I may have episodes of calling out, swearing or crying related to post traumatic stress disorder. It is important to note survey started 2/23/26. The facility did not include triggers or interventions for R32's post-traumatic stress disorder (PTSD). On 2/25/26 at 8:41 AM, CNA J (Certified Nursing Assistant) indicated she does not know about R32's PTSD diagnosis. CNA J indicated she does know that R32's Parkinson's diagnosis has been very hard on him. On 2/25/26 at 9:51 AM, CNA K indicated she does not know about R32's PTSD diagnosis and possible triggers. On 2/25/26 at 10:27 AM, DON B (Director of Nursing) indicated moving forward the facility will care plan R32's PTSD diagnosis and possible triggers. DON B indicated triggers and interventions should be on the resident's care plan.

Based on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 (R20) of 12 reviewed for ADLs (Activities of Daily Living). Surveyor observed R20 not being shaved on 2/23/26, 2/24/26, and the morning of 2/25/26. R20's care plan, wife, and R20 indicated he needs assistance with personal hygiene and grooming. Evidenced by:The facility policy, Nursing Care, Activities of Daily Living, dated 10/25, states, in part;.A program of activities of daily living is provided to residents to preserve ADL function, promote independence, self-esteem and dignity and achieve maximum level of function.Staff assist is provided as needed to complete tasks. On 2/23/26 at 4:04PM, Surveyor met R20. Surveyor observed R20's face not shaved with long facial hair. R20 indicated he has a razor and staff assist him with shaving and personal cares. R20 was admitted to the facility on [DATE], with a diagnoses including Parkinson's disease (a progressive neurodegenerative disorder leading to movement related issues like tremors, rigidity, slowness, and postural instability), pain, arthritis, and repeated falls. R20's care plan states, I will be groomed appropriate daily and ADL's met.Grooming: 1 assist. On 2/24/26 at 4:00PM, Surveyor observed R20 still needing to be shaved. R20's wife was in his room and indicated he told her that he tried to shave himself. R20's wife indicated he does need to be shaved and that staff usually assist him. At 4:25PM, Surveyor asked Certified Nursing Assistant H (CNA) if he is familiar with working with R20. CNA H indicated R20 does need assistance with personal cares. CNA H indicated he assisted R20 with a tub bath last Wednesday and didn't ask R20 if he would like to be shaved. CNA H indicated he should have asked R20, but did not. CNA H indicated he isn't sure who is responsible for asking residents if they would like to be shaved. CNA H indicated the woman who cuts hair will also assist residents in shaving. Certified Nursing Assistant I (CNA) indicated she is familiar with working down R20's hallway and can check to see if R20 needs assistance with shaving. CNA I indicated residents are assisted with shaving every morning, shower days, and if they request as well. CNA I and Surveyor went by R20 and CNA I showed Surveyor two razors that R20 has. CNA I indicated some residents like to grow a beard in the winter months. Surveyor asked if that is R20's preference. CNA I indicated R20 is pretty laid back. R20's wife indicated that R20 prefers to be clean shaved. On 2/25/26 around 8:30AM, Surveyor observed R20 walking back from breakfast. R20's face was not shaved with long facial hair. On 2/25/26 at 8:41AM, CNA J (Certified Nursing Assistant) indicated staff assist residents with shaving in the morning when they get up, after showers, and as requested. CNA J indicated she was going to shave R20 this morning but couldn't find a razor that worked correctly. CNA J followed up with R20 and then followed back up with Surveyor at 9:47AM. CNA J indicated there was a razor that was working fine in his bedroom, and he was shaved. On 2/25/26 at 9:51AM, CNA K indicated R20 does need assistance with cares and shaving. CNA K indicated R20 has never refused or declined cares for her before. On 2/25/26 at 9:56AM, RN D (Registered Nurse) indicated R20 does need assistance with personal cares. RN D indicated R20 may say he can shave himself, but he needs assistance shaving. RN D indicated if a resident refuses care that is something that should be care planned. On 2/25/26 at 10:27AM, DON B (Director of Nursing) indicated staff should be assisting residents with shaving during morning cares, after showers, and as needed. DON B indicated if residents decline the next shift should offer. DON B indicated R20 will say he can do it himself, but he needs assistance. DON B indicated she is already working with staff on their approach because staff let her know Surveyor was asking about R20 and shaving. DON B indicated if a resident is refusing cares or assistance that is something that should be care planned. The facility did not ensure that all residents receive the necessary services to maintain good grooming and personal hygiene.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 of 4 resident reviewed (R1). On 12/18/2025, the facility became aware of an abuse allegation regarding R1. The facility failed to provide evidence to prevent further abuse to R1 and other residents. The facility did not complete a thorough investigation of the alleged allegation of abuse. Evidenced by: The facility policy, entitled Policy and Procedure for Grievances, Mistreatment Investigations, Mistreatment Prevention and Injuries of Unknown Source, dated 12/18/25, states, in part: . Purpose: To prevent and prohibit mistreatment, abuse, neglect, involuntary seclusion, incidents of unknown source, and misappropriation of property of all residents. To ensure that all residents and family complaints are investigated thoroughly, and appropriate corrective action is promptly taken. Policy: It is the policy of [NAME] manor that all residents will live in a safe, secure environment that is free of any type of mistreatment, abuse, or neglect. All residents shall be free of mental and physical abuse and shall receive considerate care and treatment at all times. Incidents of abuse, caregiver misconduct, and complaints regarding resident's welfare or any suspected violations of resident rights shall be reported immediately. The administrator shall be updated immediately. Mandated reporting shall be done per State Nursing Home Regulations. Procedure: All employees shall be educated as to specific types of abuse and their responsibility to report any and all suspected and observed incidents of abuse. Any incident of misconduct or grounds for suspicion will result in the following:1. First and foremost: Protect the resident. Anyone who witnesses an incident of a resident being physically or mentally mistreated must first and foremost remove the resident from harm. Report to supervisor immediately. Stay with the resident if needed and do not leave Resident with alleged abuser.2. Any individual who witnesses or has any knowledge of an act or suspected act of mistreatment shall notify his/her charge nurse, Director of Nursing, or Administrator immediately.3. Ensure that all residents are kept safe during the investigation.8. Immediately begin a thorough investigation of any misconduct or mistreatment allegations. Thorough internal investigation may include: . Interviewing other residents to determine if they have ever been abused or mistreated, interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; Interviewing staff who worked previous shifts to determine if they were aware of an injury or incident. Mandated Incident Reporting and Where to Report: Alleged violations involving mistreatment, neglect, or abuse, exploitation, including injuries of Unknown source, and misappropriation of resident property, are to be reported as soon as possible (not to exceed 24 hours) to the Division of Quality Assurance (DQA). If the event that causes the allegation involves abuse or results in serious injury, a report of the violation will be made to the NHA (Nursing Home Administrator) and DQA no later than two hours after the allegation is made.Facility also to notify local law enforcement authorities of any situation where there is a potential criminal offense. R1 admitted to the facility on [DATE] and has diagnoses that include severe anemia (dangerously low red blood cell count, causing extreme fatigue, dizziness, shortness of breath, pale skin, fast heart rate, and potentially leading to organ failure or death), major depression disorder, and anxiety disorder. R1's Brief Interview of Mental Status (BIMS) score on 12/22/25 was 15 indicating R1 is cognitively intact. The facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, states, in part: . Summary of Incident: Allegation type Abuse: Hitting, slapping, threats of harm, assault, humiliation. Name - Affected Person: R1.Is date and time when occurred known? NoDate occurred: (blank)Time Occurred: (blank)Is occurred date and time estimated? (blank)Date discovered? 12/18/2025 Brief Summary of Incident: Staff reported hearing rumor that CNA D (certified nursing assistant) was involved in potential sexual misconduct of R1. No law enforcement contacted. CNA D was asked to leave facility and removed from schedule until investigation completed. Report Submitted by DON B (Director of Nursing)Report Submitted Date: 12/18/25b4:54:46PM. The facility's Misconduct Incident Report, dated 12/19/2025, states, in part: . Summary of Incident: Is date and time when occurred known? No Date occurred: (left blank)Time occurred: (left blank)Is occurred date and time estimated? (left blank)Date discovered: 12/18/2025. Briefly Describe the incident.On 12/18/2025, it was reported by staff that they heard a rumor of sexual misconduct regarding CNA D with a male resident on his bath day approximately 3 weeks ago. Explain what steps the entity took upon learning of the incident to protect the affected person and others . CNA D was removed from facility and taken off schedule until investigation completed. Social Services interviewed two male residents regarding their whirlpools. Name-Affected Person: R1. Name-Accused Person: CNA D. Name- Person with information about the incident: CNA G. Name-Person with information about the incident: CNA E. Name-Person with information about the incident: CNA F. Report Submitted by: DON B Report Submitted Date: 12/19/2025 1:46:56 PM The facility's investigation includes: CNA G's facility's statement, dated 12/18/25, states: I, CNA G would like to describe an event from two to three weeks ago. I was assigned to the 300 hall and went to the spa room. Upon entering I saw an aid with a resident standing at a bar to the left (my view) of the entry door. The aid had her hand under a towel in the area of the resident's genital region. The hand/towel had an up/down and a little to the side motion. The motion was repetitive and was still ongoing as I shut the door. If you have any further questions feel free to ask. I deeply regret not coming forward sooner. At the moment of the event, I was in shock and almost disbelief. CNA E's facility statement, dated 12/18/2025, states: I spoke with CNA F regarding concerns raised about incidents on the 100 hall. CNA F reported that CNA G informed her that CNA D gave a resident on the 100 hall a hand job. CNA G did not identify which resident was involved. CNA G also stated that numerous incidents are occurring, but she is afraid to report them because she is an agency employee and did not feel she would be believed. The facility also interviewed CNA D, CNA F, and CNA J. The facility interviewed R1 and R2 (both from same hallway). (Note: The facility failed to interview all residents in house. Interviews were limited to the two male residents on that hallway that could communicate. The facility did not interview staff from different days/shifts. The only staff that were interviewed were the staff the facility was aware of that had knowledge of the allegation. The facility did not document education being provided to staff. ) The facility's Incident 12/18/25 Conclusion states: During staff interviews, investigation and interview of 2 male residents that received whirlpools from CNA D no sexual misconduct was substantiated as described by CNA G. Staff interviewed during the investigation reported as educated by [NAME] on proper procedure on reporting misconduct on an incident. All stated make sure resident is safe then tell the nurse and or management.At this time contracted CNA G contract will be terminated with [Agency staffing name] due to not reporting misconduct in a timely manner per [NAME] policy. Per Orientation Attestation for agency staff declined to sign. At this time, we do not feel the male resident's pyscho-social needs will need to be monitored due to their statements. On 12/23/25 at 1:20 PM, Surveyor interviewed DON B. DON B indicated she had found out about the alleged allegation of abuse on 12/18/25 by HR H (Human resources) and CNA COR C (CNA coordinator) who were informed by CNA E that day. DON B indicated CNA E had been informed of the allegation of sexual abuse between CNA D and R1 by CNA F. CNA F had found out about the allegation from CNA G who witnessed the incident and mistakenly messaged CNA F about the incident. DON B indicated if CNA G would not have mistakenly messaged CNA F the facility would not have found out. Surveyor asked when did the alleged incident occur, and DON B indicated three weeks ago per CNA G's statement. Surveyor asked DON B when the allegation should have been reported to the state. DON B indicated the day it occurred within two hours. Surveyor asked DON B what a thorough investigation includes. DON B indicated the facility interviewed the cnas involved. CNA D was removed from the floor. DON B indicated the facility interviewed the resident (R1) and another resident R2 on that hall. DON B indicated they were the only two residents on that hall that are able to communicate who received whirlpools from CNA D. Surveyor asked DON B if all residents should have been interviewed, and DON B indicated yes. Surveyor asked if all staff should have been interviewed. DON B indicated we only interviewed the cnas with knowledge of alleged incident. Surveyor asked if education was provided on abuse reporting to all staff. DON B indicated education was provided verbally but was not documented. DON B indicated if not documented it was not done. Surveyor asked if skin checks on all residents were completed. DON B indicated skin checks were completed with the residents' weekly skin checks. Surveyor asked if a house sweep of skin assessment had been completed on all residents after the allegation of abuse was reported to the facility. DON B indicated no. On 12/23/25 at 2:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked what his expectation is for reporting an allegation of abuse. NHA A indicated report it to the state within two hours from the time the facility finds out and complete an investigation and submit it to the state in 5 days. Surveyor asked what is included in a thorough investigation. NHA A indicated the facility would interview staff that are aware of what happened, interview a sample of residents depending on the allegation. If general allegation we would interview all residents and if it is a specific allegation, we may not do that. It would be more to specific staff involved, residents and area of facility. Surveyor asked if the facility would provide education to staff. NHA A indicated education would be provided to the staff involved in the investigation. The facility failed to provide evidence to prevent further abuse to R1 and other residents. The facility did not complete a thorough investigation of the alleged allegation of abuse.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 4 residents (R1) reviewed for abuse. An allegation of abuse was reported by staff to the facility on [DATE]. The alleged allegation of abuse had occurred 2 to 3 weeks prior. Evidenced by: The facility policy, entitled Policy and Procedure for Grievances, Mistreatment Investigations, Mistreatment Prevention and Injuries of Unknown Source, dated 12/18/25, states, in part: . Purpose: To prevent and prohibit mistreatment, abuse, neglect, involuntary seclusion, incidents of unknown source, and misappropriation of property of all residents. To ensure that all residents and family complaints are investigated thoroughly, and appropriate corrective action is promptly taken. Policy: It is the policy of [NAME] manor that all residents will live in a safe, secure environment that is free of any type of mistreatment, abuse, or neglect. All residents shall be free of mental and physical abuse and shall receive considerate care and treatment at all times. Incidents of abuse, caregiver misconduct, and complaints regarding resident's welfare or any suspected violations of resident rights shall be reported immediately. The administrator shall be updated immediately. Mandated reporting shall be done per State Nursing Home Regulations. Procedure: All employees shall be educated as to specific types of abuse and their responsibility to report any and all suspected and observed incidents of abuse. Any incident of misconduct or grounds for suspicion will result in the following:1. First and foremost: Protect the resident. Anyone who witnesses an incident of a resident being physically or mentally mistreated must first and foremost remove the resident from harm. Report to supervisor immediately. Stay with the resident if needed and do not leave Resident with alleged abuser.2. Any individual who witnesses or has any knowledge of an act or suspected act of mistreatment shall notify his/her charge nurse, Director of Nursing, or Administrator immediately.3. Ensure that all residents are kept safe during the investigation.8. Immediately begin a thorough investigation of any misconduct or mistreatment allegations. Thorough internal investigation may include: . Interviewing other residents to determine if they have ever been abused or mistreated, interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; Interviewing staff who worked previous shifts to determine if they were aware of an injury or incident. Mandated Incident Reporting and Where to Report: Alleged violations involving mistreatment, neglect, or abuse, exploitation, including injuries of Unknown source, and misappropriation of resident property, are to be reported as soon as possible (not to exceed 24 hours) to the Division of Quality Assurance (DQA). If the event that causes the allegation involves abuse or results in serious injury, a report of the violation will be made to the NHA and DQA no later than two hours after the allegation is made.Facility also to notify local law enforcement authorities of any situation where there is a potential criminal offense. R1 admitted to the facility on [DATE] and has diagnoses that include severe anemia (dangerously low red blood cell count, causing extreme fatigue, dizziness, shortness of breath, pale skin, fast heart rate, and potentially leading to organ failure or death), major depression disorder, and anxiety disorder. R1's Brief Interview of Mental Status (BIMS) score on 12/22/25 was 15 indicating R1 is cognitively intact. The facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, states, in part: . Summary of Incident: Allegation type Abuse: Hitting, slapping, threats of harm, assault, humiliation Name - Affected Person: R1.Is date and time when occurred known? NoDate occurred: (blank)Time Occurred: (blank)Is occurred date and time estimated? (blank)Date discovered? 12/18/2025 Brief Summary of Incident: Staff reported hearing rumor that CNA D (certified nursing assistant) was involved in potential sexual misconduct of R1. No law enforcement contacted. CNA D was asked to leave facility and removed from schedule until investigation completed. Report Submitted by DON B (Director of Nursing)Report Submitted Date: 12/18/25 4:54:46PM. The facility's Misconduct Incident Report, dated 12/19/2025, states, in part: . Summary of Incident: Is date and time when occurred known? No Date occurred: (left blank)Time occurred: (left blank)Is occurred date and time estimated? (left blank)Date discovered: 12/18/2025. Briefly Describe the incident.On 12/18/2025, it was reported by staff that they heard a rumor of sexual misconduct regarding CNA D with a male resident on his bath day approximately 3 weeks ago. Report Submitted by: DON B Report Submitted Date: 12/19/2025 1:46:56 PM CNA G's (certified nursing assistant) facility's statement, dated 12/18/25, states: I, CNA G would like to describe an event from two to three weeks ago. I was assigned to the 300 hall and went to the spa room. Upon entering I saw an aid with a resident standing at a bar to the left (my view) of the entry door. The aid had her hand under a towel in the area of the resident's genital region. The hand/towel had an up/down and a little to the side motion. The motion was repetitive and was still ongoing as I shut the door. If you have any further questions feel free to ask. I deeply regret not coming forward sooner. At the moment of the event, I was in shock and almost disbelief. CNA E's facility statement, dated 12/18/2025, states: I spoke with CNA F regarding concerns raised about incidents on the 100 hall. CNA F reported that CNA G informed her that CNA D gave a resident on the 100 hall a hand job. CNA G did not identify which resident was involved. CNA G also stated that numerous incidents are occurring, but she is afraid to report them because she is an agency employee and did not feel she would be believed. On 12/23/25 at 11:30AM, Surveyor interviewed CNA G who indicated she had opened the spa door three weeks ago approximately and saw R1 standing at the bar. CNA D had her hand wrapped in a towel in R1's genital area going in a back-and-forth rhythmic motion. CNA G indicated she turned away, closed the door and walked away. CNA G indicated she wasn't sure if she should report it or not. CNA G indicated she has past trauma with witnessing sexual assault on a child. Surveyor asked if CNA G did report it, and CNA G indicated no. CNA G indicated the next day she had messaged CNA F on accident thinking it was someone else. CNA G indicated she was messaging to get advice on what to do. She had thought she was messaging someone else for advice. Surveyor asked CNA G if that incident should have been reported at the time and CNA G indicated yes. CNA G indicated the facility called her into the office last Thursday 12/18/25 and informed me that CNA F came forward and reported the message CNA G sent to CNA F asking for advice on an incident that had occurred. CNA G indicated she then gave her statement of the incident on 12/18/25. On 12/23/25 at 1:20 PM, Surveyor interviewed DON B. DON B indicated she had found out about the alleged allegation of abuse on 12/18/25 by HR H (Human resources) and CNA COR C (CNA coordinator) who were informed by CNA E that day. Surveyor asked when did the alleged incident occur, and DON B indicated three weeks ago. Surveyor asked DON B when the allegation should have been reported to the state. DON B indicated that day it occurred within two hours. On 12/23/25 at 2:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked what his expectation is for reporting an allegation of abuse. NHA A indicated report it to the state within two hours from the time the facility finds out and complete an investigation and submit it to the state in 5 days. Staff had knowledge of a potential abuse allegation that was not reported to the NHA timely or to the state within the required time frames.

Based on interview, record review, and policy review, the facility failed to implement the facility's Abuse policy that prohibits staff to resident abuse for 1 of 1 resident (R46) reviewed for abuse in the sample of 14. Specifically, the facility did not protect R46 and other residents during the abuse investigation and failed to conduct a thorough investigation into the allegation of physical abuse as instructed in the facility's Abuse policy. This failure had the potential to negatively impact all 46 residents currently residing at the facility. Findings include: Review of the facility's policy titled, Policy and Procedures for grievances, Mistreatment Investigations, Mistreatment Prevention and Injuries of Unknown Source dated 04/25/24 provided by the Administrator as the facility's Abuse policy indicated, Purpose: To prevent and prohibit mistreatment, abuse .of all residents. To ensure that all residents and family complaints are investigated thoroughly, and appropriate corrective action is promptly taken. Policy: It is the policy of (Facility Name) that all residents will live in a safe, secure environment that is free of any type of mistreatment, abuse .Procedure .3. Ensure that all residents are kept safe during the investigation and the alleged abuser shall not work directly with residents until the outcome of the investigation is determined .5. If the complaint is directed toward a staff member, it is to be handled by Social Services and Administrator/Director of Nursing .8. Immediately begin a thorough investigation of any .mistreatment allegations. Thorough internal investigation may include .Interviewing alleged victim(s) and witness(es); interviewing accused individual(s) .interviewing other residents to determine if they have been abused .Interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused .Document steps taken during the internal investigation .10. Document the investigation, outcome and any corrective action taken if any is needed. Documentation to be filed in the Grievances folder, which is located in the Social Services office. 11. Ensure that the resident filing a complaint is to remain safe during the investigation procedure . Review of R46's Face Sheet, found in the electronic medical record (EMR) revealed R46 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia of the left dominant side, heart failure, chronic obstructive pulmonary disease, dysphasia, and type II diabetes. Review of R46's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/19/24, located in the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R46 was cognitively intact. The MDS indicated that R46 was dependent on staff for mobility of rolling from side to side. The MDS indicated that R46 had no psychosis, no behavioral symptoms, and no behavior of resisting care or medications. Review of the facility's investigative file indicated an email from the Director of Nursing (DON) to the Social Service Director (SSD) dated 06/11/24 at 8:00 AM that indicated, Nurse Manager (NM)1 was informed of 'behaviors' when listening to night shift report .Writer (NM1) immediately went to assess resident at 7:35 AM. Upon entering the room writer asked R46 how her night was. R46 stated that Certified Nursing Assistant (CNA) 1 was rough with her last night. Writer asked R46 to explain how CNA1 was rough. R46 stated that CNA1 was checking her during cares/rounds and pulled the soaker pad to the side causing her to hit the side of her head on the assist bar that is closest to the bathroom side. Writer checked R46's head where she said she had hit it. There are no marks, redness, skin issues, or bruising noted. R46 said that after CNA1 had finished rolling her towards the bathroom and she then rolled her back to the window side by pushing on her hip area. Writer checked R46's legs which were equal in length with no hip rotation noted. Writer asked if R46 was in any pain or discomfort and R46 stated, No. Writer completed a full body skin assessment. There were no bruises, red marks, cuts, scrapes, or skin issues noted . During an interview on 09/30/24 at 1:24 PM, R46 was asked about the incident with CNA1 that occurred four months ago. R46 stated she felt it was abusive. R46 stated this was the first and only time something like this had happened. R46 stated that CNA1 had not been back in the room to provide care. During an interview on 10/02/24 at 11:10 AM with the DON and Human Resources Manager, CNA1's time sheet was reviewed, and it was confirmed that CNA1 worked at the facility on 06/11/24 from 10:00 PM through 06/12/24 at 7:35 AM. The DON and Human Resource Manager confirmed that CNA1 returned to work on R46's hallway the night of 06/11/24 after they were aware of the incident that occurred on 06/10/24 between CNA1 and R46. The DON stated the investigation was not completed prior to CNA1 returning to work on 06/11/24 and that they wanted to complete the abuse investigation prior to placing CNA1 on suspension. Interview on 10/02/24 at 12:00 PM, Nurse Manager (NM) 1 stated that on 06/11/24 in the morning, facility staff became aware of R46's statement that CNA1 treated her roughly based on the night shift nurse report. NM1 stated that she immediately completed R46's full body skin assessment which indicated no skin abnormalities. R46 denied any pain at this time. NM1 stated that she notified the DON of R46's statement. During an interview on 10/02/24 at 12:15 PM, Registered Nurse (RN) 1 stated that she heard from R46 that when CNA1 rolled her over in bed, without a verbal warning, it felt unsafe. R46 told RN1 that she bumped her head on the grab bars during the incident. RN1 stated she reported the incident to the DON and SSD.

Based on interview and document review, the facility failed to ensure that 2 of 6 (Certified Nursing Assistants (CNA5 and CNA8) completed the minimum of 12 hours of inservice training per year. The lack of inservice trainings could have a negative impact for all 46 residents currently residing at the facility. Findings include: Review of CNA5's personnel file indicated CNA5's Date of Hire (DOH) was 08/22/23 and that CNA5 had completed 10.25 hours of training during the past year (August 2023 through August 2024). Review of CNA8's personnel file indicated CNA8's DOH was 07/25/1995 and that CNA8 had completed 8.75 hours of training during the past year. (July 2023 through July 2024). During an interview on 10/03/24 at 3:45 PM, the Director of Nursing (DON) confirmed that the two CNAs' personnel files did not include documentation of 12 hours of inservice training for the past year. The DON stated that the facility did not have a policy regarding CNAs having 12 hours of inservice training per year.

Based on interview, record review, and policy review, the facility failed to thoroughly investigate an allegation of physical abuse for 1 of 1 resident (R46) reviewed for abuse in the sample of 14 residents. This failure had the potential to negatively impact all 46 residents currently residing at the facility. Findings include: Review of the facility's policy titled, Policy and Procedures for grievances, Mistreatment Investigations, Mistreatment Prevention and Injuries of Unknown Source dated 04/25/24 provided by the Administrator as the facility's Abuse policy indicated, Purpose: To prevent and prohibit mistreatment, abuse .of all residents. To ensure that all residents and family complaints are investigate thoroughly and appropriate corrective action is promptly taken . 5. If the complaint is directed toward a staff member, it is to be handled by Social Services and Administrator/Director of Nursing .8. Immediately begin a thorough investigation of any .mistreatment allegations. Thorough internal investigation may include .Interviewing alleged victim(s) and witness(es); interviewing accused individual(s) .interviewing other residents to determine if they have been abused .Interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused .Document steps taken during the internal investigation .9. Assess validity of complaint based on information gathered and gather additional information if needed. Identify whether or not alleged misconduct occurred .10. Document the investigation, outcome and any corrective action taken if any is needed. Documentation to be filed in the Grievances folder, which is located in the Social Services office . Review of R46's Face Sheet, found in the electronic medical record (EMR) tab, revealed R46 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia of the left dominant side, heart failure, chronic obstructive pulmonary disease, dysphasia, and type II diabetes. Review of R46's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/19/24, with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R46 was cognitively intact. The MDS indicated that R46 was dependent for mobility of rolling from side to side, no psychosis, no behavioral symptoms, and no behavior of resisting care or medications. Review of the facility's investigative file indicated a document titled, Date of Concern dated 06/10/24 that revealed, R46 reported Certified Nursing Assistant (CNA) 1 is rough when performing cares. R46 reported Monday 06/10/24 CNA1 rolled R46 to her side and R46 bumped her head on the top rail. R46 stated CNA1 is arrogant offering no apology.Director of Nursing (DON) updated and investigation in progress. Review of the facility's investigative file indicated an email from the DON to the Social Service Director (SSD) dated 06/11/24 at 8:00 AM that indicated, Nurse Manager (NM)1 was informed of 'behaviors' when listening to night shift report .Writer (NM1) immediately went to assess resident at 7:35 AM. Upon entering the room writer asked R46 how her night was. R46 stated that CNA1 was rough with her last night. Writer asked R46 to explain how CNA1 was rough. R46 stated that CNA1 was checking her during cares/rounds and pulled the soaker pad to the side causing her to hit the side of her head on the assist bar that is closest to the bathroom side. Writer checked R46's head where she said she had hit it. There are no marks, redness, skin issues or bruising noted. R46 said that after CNA1 had finished rolling her towards the bathroom and she then rolled her back to the window side by pushing on her hip area. Writer checked R46's legs which were equal in length with no hip rotation noted. Writer asked if R46 was in any pain or discomfort and R46 stated, 'No.' Writer completed a full body skin assessment. There were no bruises, red marks, cuts, scrapes, or skin issues noted . Review of the facility's investigative file indicated a document from the SSD dated 06/13/24 at 2:36 PM which indicated, .Concern resolved on: 06/13/24 Actions/Response to Concern: Investigation completed, and action concluded CNA1 no longer works in this facility. During an interview on 09/30/24 at 11:43 AM, the DON stated she went to R46 to obtain her description of rough and R46 stated rough was moving faster than usual. The DON stated she talked to R46 and that she did not feel the incident was abuse, just that CNA1 was just too fast with her care. During an interview on 09/30/24 at 1:24 PM, R46 was asked about the incident that happened with CNA1 four months ago, R46 stated she felt it was abusive. R46 stated this was the first and only time something like this had happened. R46 stated that CNA1 had not been back to provide her care since the incident. During an interview on 10/03/24 at 11:50 AM, the DON stated as part of the investigative process she interviewed various residents and asked how their night was the night of the incident. The DON stated the residents indicated that CNA1 was too fast and did not explain what she was doing, but the residents did not state that CNA1 had abused them. However, she had no documentation of the residents' interviews. The DON provided no documentation of R46's interview and said that CNA1 would not cooperate with the investigation so she did not have CNA1's statement.

Based on interview, record review, and policy review, the facility failed to report an allegation of staff to resident physical abuse for 1 of 1 resident (R46) reviewed in the sample of 14 residents to the State Agency (SA) immediately, but no later than 2 hours after the allegation was made when the incident involved abuse. This failure had the possibility to negatively impact all 46 residents currently residing at the facility. Findings include: Review of the facility's policy titled, Policy and Procedures for grievances, Mistreatment Investigations, Mistreatment Prevention and Injuries of Unknown Source dated 04/25/24 provided by the Administrator as the facility's Abuse policy indicated, Purpose: To prevent and prohibit mistreatment, abuse .of all residents.Policy: It is the policy of (Facility Name) that all residents will live in a safe, secure environment that is free of any type of mistreatment, abuse . If the event that causes the allegation involves abuse .a report of the violation will be made to the NHA (Nursing Home Administrator) and DQA (Division of Quality Assurance) no later than two hours after the allegation is made. Reports are to be made .via the online reporting system . Review R46's Face Sheet, found in the electronic medical record (EMR) revealed R46 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, hemiplegia of the left dominant side, heart failure, chronic obstructive pulmonary disease, dysphasia, and type II diabetes. Review of R46's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/19/24, located in the EMR under the MDS tab with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R46 was cognitively intact. The MDS indicated that R46 was dependent for mobility of rolling from side to side, no psychosis, no behavioral symptoms, and no behavior of resisting care or medications. Review of the facility's investigative file indicated an email dated 06/11/24 at 8:00 AM from the Director of Nursing (DON) to the Social Service Director (SSD) that stated, Nurse Manager (NM)1 was informed of 'behaviors' when listening to night shift report .Writer (NM1) immediately went to assess resident at 7:35 AM. Upon entering the room writer asked R46 how her night was. R46 stated that Certified Nursing Assistant (CNA) 1 was rough with her last night. Writer asked if R46 explain how CNA1 was being rough. R46 stated that CNA1 was checking her during cares/rounds and pulled the soaker pad to the side causing her to hit the side of her head on the assist bar that is closest to the bathroom side. Writer checked R46's head where she said she had hit it. There are no marks, redness, skin issues or bruising noted. R46 said that after CNA1 had finished rolling her towards the bathroom and she then rolled her back to the window side by pushing on her hip area. Writer checked R46's legs which were equal in length with no hip rotation noted. Writer asked if R46 was in any pain or discomfort and R46 stated, 'No.' Writer completed a full body skin assessment. There were no bruises, red marks, cuts, scrapes, or skin issues noted . Review of R46's EMR Progress note' in the Progress note tab dated 06/12/24 indicated, Late entry 6/11/24. Behavior: CNA1 reported resident demonstrated resistance to care behavior. CNA1 reported resident was pushing back when she was trying to lead her in another direction in an attempt to change her brief. Additionally, resident was calling her names. Review of the facility's investigative file indicated on 06/13/24 at 2:36 PM the SSD documented, .Concern resolved on: 06/13/24 Actions/Response to Concern: Investigation completed, and action concluded CNA1 no longer works in this facility. During an interview on 09/30/24 at 11:23 AM, the SSD was asked why the incident of alleged staff to resident abuse with CNA1 and R46 was not reported to the SA (State Agency). The SSD replied, We addressed it right then, so we did not send a report to the state. R46 said she did not want to file a grievance. SSD stated the incident was not considered abuse and was handled internally. CNA1 was 'let go' so we did not feel it needed to be reported to the SA. SSD stated that the time period to report abuse to the SA was eight hours. During an interview on 10/02/24 at 11:50 AM with the DON and the Human Resources Manager, they stated this incident did not meet our (the facility's) definition of abuse and that the incident was not intentional so that was why the SA was not notified of the abuse allegation.

Based on interview and record review, the facility did not consult with resident's physician or extender when 1 of 3 residents (R1) had a significant change in her medical condition. R1 was receiving an anticoagulant medication and experienced a change in condition when RN C (Registered Nurse) used a Q-tip to remove hard wax from R1's ears. R1's ears began to bleed, and RN C did not contact R1's Medical Doctor (MD) or an on-call MD when R1 had this change in condition. RN H also did not contact R1's MD or an on-call MD regarding uncontrolled bleeding when she became aware. All of this resulted in R1 being sent to the emergency room where she received medical intervention to control bleeding. Evidenced by: Facility policy, entitled Anticoagulant Use Policy, dated 7/20/22, includes in part: when taking warfarin, the international normalized ratio is monitored as ordered to be sure medication is given as therapeutic dose . residents who are taking anticoagulants will have a care plan stating that they are taking the Med and what adverse effects (bleeding) that nursing staff should be monitoring for. signs of adverse bleeding may be bruising without obvious cause, head injury, severe or prolonged headache, hematuria, prolonged bleeding from small cuts, etc. MD should be updated if the above are noted . Facility policy, entitled Resident Change in Condition Policy and Procedure, dated 8/7/22, includes in part: .in the long-term care setting a primary goal of identifying an acute change in condition is to enable staff to evaluate and manage a patient at the facility and avoid transfer to a hospital or emergency room . to achieve this goal the facility staff must recognize an acute change in condition and identify its nature, severity, and cause. Physicians are notified of changes in resident condition. Procedure: if a nurse notices a change in condition she or he should assess the resident to determine the nature, severity, and possible cause of the change. The nurse should determine from the suggested Guidelines for physician notification of clinical problems in facility residence grid if and when the resident's attending physician or on call physician needs to be notified. Abrasion . immediate: accompanied by significant pain or bleeding . non-immediate: if bleeding continues or if associated with evidence of local infection . Injuries and complaints . immediate: abrupt onset of severe pain secondary to fall or injury . hematuria . immediate: gross hematuria with pain . puncture wounds . immediate: deep or open wound . note these are general guidelines which cannot anticipate all circumstances. a nurse should not hesitate to call anytime a situation is unclear or if a physician support is felt to be needed. The National Institute of Health, Drug Information Portal, U.S. National Library of Medicine, last updated 7/25/2022, includes, in part: . TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation . Indications: The only FDA-approved usage for tranexamic acid (TXA) is for heavy menstrual bleeding and short-term prevention in patients with hemophilia. R1's most recent admission to the facility was on 6/11/2021. Her diagnoses include: chronic congestive heart failure, atrial fibrillation, pulmonary hypertension, and longtime anticoagulant therapy. R1's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 3/28/23, indicates R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R1's Comprehensive Care Plan, initiated 3/8/2019, includes in part: problem - potential for uncontrolled bleeding related to longtime anti-coagulant therapy, atrial fibrillation, pulmonary hypertension, and heart failure. Manifested by bleeding, recent bloody nose unable to control and recent hospitalization . approach - nurses assess condition after incidents . administer anticoagulant as ordered . report to MD as needed, assess any bleeding, observe/monitor for bleeding and adverse reactions of warfarin . Update MD if above are noted . nurse aide report any bleeding . goal - no uncontrolled bleed . R1's Physician Orders, January 2023, include in part: start date: 11/09/22 - Warfarin 1 mg by mouth every Tuesday, Thursday, Saturday, Sunday . start date: 11/09/22 -Warfarin 6mg by mouth every Monday, Wednesday, Friday . start date:11/09/22 - Carbamide Peroxide 6.5% . 3 drops two times a day each ear to remove ear wax as needed . R1's Nurse Notes include: 1/6/23 at 1:34 PM Writer was able to remove large hard chunk of cerumen from both ear canals. Wax was visibly blocking outer ear canals. Resident said she did not get ear drops in last night before bed. Writer was able to use Q tip gently to remove hard wax from canal and writer was able to see tympanic membrane without difficulty. Ears cleaned out before lunch. During lunch resident requested cotton balls be placed in outer ear because they were bleeding. Writer updated DON B (Director of Nursing) on bleeding and after lunch writer used warm water in ear flusher to rinse out both outer ears and used dry washcloth to clean outer ears. Writer encouraged resident to leave her ears alone and not put anything in them so they can heal. Will continue to monitor. Signed RN C (Registered Nurse). (It is important to note neither RN C, nor DON B contacted R1's MD when she had a change in condition / bleeding and pain in her ear.) 1/6/23 at 9:38 PM behaviors occurred: No 1/7/23 at 7:15 AM called into patients room at 6:15 AM to assess, as nurse entered room patient is lying in bed on her back, walked around to the right side of her bed and noted copious amounts of wet blood saturated through pillowcase and pillow, onto sheets through onto mattress {sic}, noted a 4 by 4 gauze packed into right ear completely saturated with blood and with large dried blood clot, used a warm wet washcloth to moisten and remove the packing from right ear, noted ear still actively bleeding and placed a cotton ball into the opening of the ear canal. Resident stated, I was supposed to have my ear flushed yesterday after receiving debrox drops to remove the wax and (RN C) dug hard into my ear with several Q-tips just before lunch and kept digging and digging . and then after lunch she flushed my ear with water and it was still bleeding. call place to MD updated on findings from nurse note yesterday 1/6/23 and right ear continues with bleeding and concerns that resident is on 6 milligrams of warfarin daily. order received to transfer resident to local hospital ER for evaluation. 1/7/23 at 7:26 AM call place 911 for ambulance transport and resident's daughter per resident's request to update {sic}. 1/7/23 at 7:36 AM cotton ball nearly saturated with blood again at this time, left cotton ball in place and placed 4 by 4 gauze over her right ear . 1/7/23 at 8:03 AM writer placed hand over resident's left ear to check hearing of right ear and resident reported, not able to hear you as well. 1/7/23 at 8:04 AM prior to leaving facility resident requested to do a formal complaint. message left with SW G (Social Worker) and DON B. 1/7/23 at 1:08 PM R1 returned from ER visit. 1/7/23 at 1:55 PM R1 returned from ER visit for bleeding ear via ambulance. TXA (tranexamic acid) was used in ear to alleviate bleeding. Cotton ball in place to right ear upon return. Assisted off stretcher and into wheelchair. INR checked in ER with result being 2.4. New order to hold warfarin tonight 1/7 and tomorrow 1/8, repeat INR Monday 1/9. Leave cotton balls in the ear and change it once daily (can change cotton ball anytime saturated per MD). (It is important to note according to Drug Information Portal. U.S. National Library of Medicine, TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation.) R1's Nurse Note, 1/7/23 at 2:41 PM, includes, Per nurse to nurse with ER nurse and facility nurse, it was reported that R1's eardrum was not compromised but there was an abrasion present . R1 admits to pain inside my ear. R1's ER Notes, dated 1/7/23, include, in part: . history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear. Patient reports she has been with significant earwax which has been treated with drops although yesterday afternoon (a staff member) used a Q-tip and subsequently was bleeding from the right ear. Patient reports her most recent INR was over 3. Patient reports they were unable to achieve hemostasis at her facility for which she was sent to the Emergency Department . Right external auditory canal with slight oozing of bright red blood. Tympanic membrane is slightly obscured although visualized aspect appears intact. Emergency Department Course - history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear secondary to trauma from a Q-tip. Upon arrival patient is hemodynamically stable and nontoxic. Patient has slight bleeding from the right external auditory canal and visualized aspect of the tympanic membrane appears intact. Gauze soaked in TXA (tranexamic acid) were packed into the right ear. Today your INR was 2.4. Given the bleeding from your ear do not take your Coumadin tonight or tomorrow night. You may resume your Coumadin on Monday if bleeding has stopped. Also recheck your INR Monday. Leave the current cotton balls in the ear and change it once daily. Tomorrow morning it is okay if the ear is bleeding just reapply cotton ball. If there is continued active bleeding on Monday return to the ER for evaluation. On 5/11/23 at 10:38 AM during an interview, CNA E (Certified Nursing Assistant) indicated on 1/6/23 she observed RN C go into R1's room with a handful of Q-tips before lunch. CNA E indicated right after lunch she observed R1's ears to be bleeding. CNA E indicated RN C stated, Oh my God (R1's) ears are bleeding, and took R1 into her room. CNA E then saw RN C return to the hallway with a handful of blood-stained washcloths. CNA E indicated R1 wanted to speak to DON B about this and CNA F and CNA E pushed R1 to DON B's office. In DON B's office R1 stated RN C hurt her ear and was digging and digging in her ear. R1 stated she asked RN C to stop, and she did not stop. CNA E indicated on 1/7/23, R1 was found lying in bed in a pool of blood that saturated the bedding, R1's pajamas, and the pillow. CNA E indicated there was now 4x4 gauze packed in R1's ear that was saturated and had large clots on it. CNA E stated LPN D came in the room and pulled out the 4x4 gauze from R1's right ear and more blood gushed out and at this time R1 stated, I want to file a formal complaint. I thought I did this yesterday. I told her it hurt, and she dug and dug and dug and wouldn't stop. Q-tips don't belong inside the ear. CNA E indicated R1 went to theER on the morning of 1/7/23 and when she came back R1 was saying her ear still hurt and she was very upset. CNA E added at the end of interview, When someone tells me to stop, I stop. My primary residents are family to me. I was upset because R1 was in so much pain. On 5/11/23 at 11:58 AM, LPN D indicated on 1/7/23 at 6:15 AM CNA F called her to come to R1's room due to her lying in an excessive amount of blood. LPN D indicated she observed R1 bleeding from her right ear and 4x4 gauze packed in her ear. LPN D indicated blood clots could be seen on the gauze and on the pillow, the blood had soaked through R1's hair, the sheets, pillowcase, pillow, R1's pajamas, and pooled onto R1's mattress. LPN D indicated she received report in the morning before coming onto the floor and nothing was said about R1 and her ears. LPN D indicated she read through R1's nurse notes from 1/6/23 and noticed R1 was already bleeding then, and her MD was never notified, and no RN assessment was completed. LPN D indicated she called R1's MD and got an order for her to go to ER right away because, I knew she was on Warfarin. I removed the 4x4 to see what was going on and it was still bleeding. I repacked it. I called MD on call. I was embarrassed to report that R1's ears were supposed to be irrigated yesterday. I never dig in anyone's ear with anything. LPN D indicated she reported immediately to DON B because she was the RN on call and when someone tells her to stop, she stops. On 5/11/23 at 12:02 PM during an interview, RN C indicated she was aware R1 was on an anticoagulant. RN C indicated she was also aware R1's ears were bleeding after RN C used a q tip to clean out R1's ears. RN C indicated she did not complete an RN assessment that included the source of the blood, the amount of the blood, the color of the blood, vital signs, and pain level of R1's pain. RN C indicated she placed a cotton ball in R1's ears. RN C indicated she did not recall if R1 had asked her to stop due to pain in her ear. RN C stated, I did not call R1's Medical Doctor to consult with him after the incident and I should have. On 5/10/23 at 12:06 PM, CNA F indicated on 1/6/23 before lunch she saw RN C going in to R1's room with Q-tips to flush R1's ears. She saw R1 coming back from lunch and her ears were bleeding. CNA F indicated R1 was on coumadin at that time and was at a higher risk for uncontrolled bleeding. CNA F indicated RN C probably should have reported the bleeding to R1's MD right away especially with the blood thinner. CNA F indicated she observed RN C carrying blood-stained washcloths from R1's room after lunch. CNA F indicated the next day she found R1 in a pool of blood and it was a mess. CNA F got LPN D right away and there was 4x4 gauze packed in R1's ears that the night shift nurse must have put in there. When LPN D pulled the packing out of ear there was a big clot and blood everywhere. CNA F indicated R1 reported that she had told RN C to stop digging in her ears, but she wouldn't stop. CNA F stated, They didn't say anything about it to us in report that morning. I walked in and was in shock. RN C and RN H knew about it because the nurse put packing in her ears. (It is important to note RN H did not contact R1's MD regarding uncontrolled bleeding, pain, and the injury R1 sustained in her ear.) On 5/10/23 at 1:00 PM during an interview, R1 stated, I was using drops for 5 days and 5th day they were supposed to flush them. RN C took a Q-tip and dug and dug and dug. I told her to stop, and she said we must get that out of there. She kept at it. It bled for a long time and a lot after that. She was only supposed to flush it and not stick anything in there. I don't know if she contacted my doctor. The other nurse came in and put stuff in there. I am on coumadin. They had to change my pillowcase throughout the night because of it. They are supposed to call my doctor if I have bleeding anywhere. I don't let her near me to do anything like that again, but I do take medications from her. On 5/10/23 at 1:27 PM, DON B indicated RN C, RN H, and/or DON B should have notified R1's MD when she was injured, was bleeding with verbal reports of pain, and when bleeding was uncontrolled, and they didn't.

Based on interview and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 3 sampled residents (R1) R1 was receiving an anticoagulant medication and experienced a change in condition when RN C used a Q-tip to remove hard wax from R1's ears and R1's ears began to bleed. RN C (Registered Nurse) did not stop when R1 verbally expressed pain and said Stop, did not complete an RN assessment after an injury was noted, did not contact R1's Medical Doctor (MD) or an on-call MD. RN H, the night shift nurse, did not contact R1's MD or an on-call MD regarding uncontrolled bleeding when she became aware, did not perform an RN assessment, and did not pass on R1's change in condition to the next shift for continued monitoring. All of this resulted in R1 being sent to the emergency room where she received medical intervention to control bleeding. Evidenced by: Facility policy, entitled Anticoagulant Use Policy, dated 7/20/22, includes, in part: when taking warfarin, the international normalized ratio is monitored as ordered to be sure medication is given as therapeutic dose . residents who are taking anticoagulants will have a care plan stating that they are taking the Med and what adverse effects (bleeding) that nursing staff should be monitoring for. signs of adverse bleeding may be bruising without obvious cause, head injury, severe or prolonged headache, hematuria, prolonged bleeding from small cuts, etc. MD should be updated if the above are noted . Facility policy, entitled Resident Change in Condition Policy and Procedure, dated 8/7/22, includes, in part: . in the long-term care setting a primary goal of identifying and acute change in condition is to enable staff to evaluate and manage a patient at the facility and avoid transfer to a hospital or emergency room . to achieve this goal the facility staff must recognize an acute change in condition and identify its nature, severity, and cause. Physicians are notified of changes in resident condition. Procedure: if a nurse notices a change in condition she or he should assess the resident to determine the nature, severity, and possible cause of the change. The nurse should determine from the suggested Guidelines for physician notification of clinical problems in facility residence grid if and when the resident's attending physician or on call physician needs to be notified. Abrasion . immediate: accompanied by significant pain or bleeding . non-immediate: if bleeding continues or if associated with evidence of local infection . Injuries and complaints . immediate: abrupt onset of severe pain secondary to fall or injury . hematuria . immediate: gross hematuria with pain . puncture wounds . immediate: deep or open wound . note these are general guidelines which cannot anticipate all circumstances. a nurse should not hesitate to call anytime a situation is unclear or if a physician support is felt to be needed. The National Institute of Health, Drug Information Portal, U.S. National Library of Medicine, last updated 7/25/2022, includes, in part: . TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation . Indications: The only FDA-approved usage for tranexamic acid (TXA) is for heavy menstrual bleeding and short-term prevention in patients with hemophilia. R1's most recent admission to the facility was on 6/11/21. Her diagnoses include: chronic congestive heart failure, atrial fibrillation, pulmonary hypertension, and longtime anticoagulant therapy. R1's most recent Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 3/28/23, indicates R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R1's Comprehensive Care Plan, initiated 3/8/19, includes, in part: problem- potential for uncontrolled bleeding related to longtime anti-coagulant therapy, atrial fibrillation, pulmonary hypertension, and heart failure. Manifested by bleeding, recent bloody nose unable to control and recent hospitalization . approach- nurses assess condition after incidents . administer anticoagulant as ordered . report to MD as needed, assess any bleeding, observe/monitor for bleeding and adverse reactions of warfarin . Update MD if above are noted . nurse aid report any bleeding . goal- no uncontrolled bleed . R1's Physician Orders, January 2023, include in part: start date: 11/09/22- Warfarin 1 mg by mouth every Tuesday, Thursday, Saturday, Sunday . start date: 11/09/22-Warfarin 6mg by mouth every Monday, Wednesday, Friday . start date:11/09/22- Carbamide Peroxide 6.5% . 3 drops two times a day each ear to remove ear wax as needed . R1's Nurse Notes include: 1/6/23 at 1:34 PM Writer was able to remove large hard chunk of cerumen from both ear canals. Wax was visibly blocking outer ear canals. Resident said she did not get ear drops in last night before bed. Writer was able to use Q-tip gently to remove hard wax from canal and writer was able to see tympanic membrane without difficulty. Ears cleaned out before lunch. During lunch resident requested cotton balls be placed in outer ear because they were bleeding. Writer updated DON B (Director of Nursing) on bleeding and after lunch writer used warm water in ear flusher to rinse out both outer ears and used dry washcloth to clean outer ears. Writer encouraged resident to leave her ears alone and not put anything in them so they can heal. Will continue to monitor. Signed RN C. (It is important to note when R1 was noted to be bleeding from her ears an RN Assessment was not completed, including a description of the amount of blood, the color of blood, and the source of blood.) (It is important to note RN H was the night shift nurse the facility provided no documentation as to R1's condition through the night and RN H did not return call to Surveyor during Survey. The facility failed to provide evidence of RN H completing an RN assessment or updating R1's MD with her uncontrolled bleeding.) 1/7/23 at 7:15 AM called into patients room at 6:15 AM to assess, as nurse entered room patient is lying in bed on her back, walked around to the right side of her bed and noted copious amounts of wet blood saturated through pillowcase and pillow, onto sheets through onto mattress, noted a 4 by 4 gauze packed into right ear completely saturated with blood and with large dried blood clot, used a warm wet washcloth to moisten and remove the packing from right ear, noted ear still actively bleeding and placed a cotton ball into the opening of the ear canal. Call place to MD updated on findings from nurse note yesterday 1/6/23 and right ear continues with bleeding and concerns that resident is on 6 milligrams of warfarin daily. Order received to transfer resident to local hospital ER for evaluation. 1/7/23 at 7:26 AM call placed to 911 for ambulance transport and resident's daughter per resident's request to update. 1/7/23 at 7:36 AM cotton ball nearly saturated with blood again at this time, left cotton ball in place and placed 4 by 4 gauze over her right ear . 1/7/23 at 1:55 PM R1 returned from ER visit for bleeding ear via ambulance. TXA (tranexamic acid) was used in ear to alleviate bleeding. New order to hold warfarin tonight 1/7 and tomorrow 1/8, repeat INR Monday 1/9. Leave cotton balls in the ear and change it once daily (can change cotton ball anytime saturated per MD). (It is important to note according to Drug Information Portal. U.S. National Library of Medicine, TXA or Tranexamic Acid is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation.) 1/7/23 at 2:41 PM Per nurse to nurse with ER nurse and facility nurse, it was reported that R1's eardrum was not compromised but there was an abrasion present . R1 admits to pain inside my ear. R1's ER Notes, dated 1/7/23, include, in part: .history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear. Patient reports she has been with significant earwax which has been treated with drops although yesterday afternoon (a staff member) used a Q-tip and subsequently was bleeding from the right ear. Patient reports her most recent INR was over 3. Patient reports they were unable to achieve hemostasis at her facility for which she was sent to the Emergency Department . Right external auditory canal with slight oozing of bright red blood. Tympanic membrane is slightly obscured although visualized aspect appears intact. Emergency Department Course- history of hyperthyroidism, hypertension, atrial fibrillation, and on Coumadin presenting for bleeding from the right ear secondary to trauma from a Q-tip. Upon arrival patient is hemodynamically stable and nontoxic. Patient has slight bleeding from the right external auditory canal and visualized aspect of the tympanic membrane appears intact. Gauze soaked in TXA (tranexamic acid) were packed into the right ear. Today your INR was 2.4. Given the bleeding from your ear do not take your Coumadin tonight or tomorrow night. You may resume your Coumadin on Monday if bleeding has stopped. Also recheck your INR Monday. Leave the current cotton balls in the ear and change it once daily. Tomorrow morning it is okay if the ear is bleeding just reapply cotton ball. If there is continued active bleeding on Monday return to the ER for evaluation. On 5/11/23 at 10:38 AM, during an interview, CNA E indicated on 1/6/23 she observed RN C go into R1's room with a handful of Q-tips before lunch. CNA E indicated right after lunch she observed R1's ears to be bleeding. CNA E indicated RN C stated, Oh my God (R1's) ears are bleeding, and took R1 into her room. CNA E then saw RN C return to the hallway with a handful of blood-stained washcloths. CNA E indicated R1 wanted to speak to DON B about this and CNA F and CNA E pushed R1 to DON B's office. In DON B's office R1 stated RN C hurt her ear and was digging and digging in her ear. R1 stated she asked RN C to stop, and she did not stop. CNA E indicated on 1/7/23 R1 was found lying in bed in a pool of blood that saturated the bedding, R1's pajamas, and the pillow. CNA E indicated there was now 4x4 gauze packed in R1's ear that was saturated and had large clots on it. CNA E stated LPN D came in the room and pulled out the 4x4 gauze from R1's right ear and more blood gushed out and at this time R1 stated, CNA E indicated R1 went to theER on the morning of 1/7/23 and when she came R1 was saying her ear still hurt and she was very upset. On 5/11/23 at 11:58 AM LPN D indicated on 1/7/23 at 6:15 AM CNA F called her to come to R1's room due to her lying in an excessive amount of blood. LPN D indicated she observed R1 bleeding from her right ear and 4x4 gauze packed in her ear. LPN D indicated blood clots could be seen on the gauze and on the pillow, the blood had soaked through R1's hair, the sheets, pillowcase, pillow, R1's pajamas, and pooled onto R1's mattress. LPN D indicated she received report in the morning before coming onto the floor and nothing was said about R1 and her ears. LPN D indicated she read through R1's nurse notes from 1/6/23 and noticed R1 was already bleeding then, and her MD was never notified, and no RN assessment was completed. LPN D indicated she called R1's MD and got an order for her to go to ER right away because, I knew she was on Warfarin. I removed the 4x4 to see what was going on and it was still bleeding. I repacked it. I called MD on call. LPN D indicated she reported immediately to DON B because she was the RN on call. On 5/11/23 at 12:02 PM during an interview RN C indicated she was aware R1 was on an anticoagulant. RN C indicated she was also aware R1's ears were bleeding after RN C used a q tip to clean out R1's ears. RN C indicated she did not complete an RN assessment that included the source of the blood, the amount of the blood, the color of the blood, vital signs, and pain level of R1' pain. RN C indicated she placed a cotton ball in R1's ears. RN C indicated she did not recall if R1 had asked her to stop due to pain in her ear. RN C stated, I did not call R1's Medical Doctor to consult with him after the incident and I should have. On 5/10/23 at 12:06 PM CNA F indicated on 1/6/23 before lunch she saw RN going in to R1's room with q tips to flush ears. She saw R1 coming back from lunch and her ears were bleeding. CNA F indicated R1 was on coumadin at that time and was at a higher risk for uncontrolled bleeding. CNA F indicated RN C probably should have reported the bleeding to R1's MD right away especially with the blood thinner. CNA F indicated she observed RN C carrying blood-stained washcloths from R1's room after lunch. CNA F indicated the next day she found R1 in a pool of blood and it was a mess. CNA F got LPN D right away and there was 4x4 gauze packed in R1's ears that the night shift nurse must have put in there. When LPN D pulled the packing out of R1's ear there was a big clot and blood everywhere. CNA F indicated R1 reported that she had told RN C to stop digging in her ears, but she wouldn't stop. CNA F stated, They didn't say anything about it to us in report that morning. I walked in and was in shock. RN H knew about it because the nurse put packing in her ears. On 5/10/23 at 1:00 PM during an interview R1 stated, I was using drops for 5 days and 5th day they were supposed to flush them. RN C took a Q-tip and dug and dug and dug. I told her to stop, and she said we must get that out of there. She kept at it. It bled for a long time and a lot after that. She was only supposed to flush it and not stick anything in there. I don't know if she contacted my doctor. The other nurse came in and put stuff in there. I am on coumadin. They had to change my pillowcase throughout the night because of it. They are supposed to call my doctor if I have bleeding anywhere. I don't let her near me to do anything like that again, but I do take medications from her. On 5/10/23 at 1:27 PM DON B (Director of Nursing) indicated RN C should have performed an RN assessment which included R1's pain level, amount of blood, description of blood, and maybe vital signs. DON B indicated RN C should have updated R1's MD on the incident after she became aware of the blood, especially since she is receiving anticoagulant therapy. DON B indicated she did not update R1's MD and did not perform an RN assessment on R1 when she was made aware of the injury by R1, CNA E, and CNA F on 1/6/23. DON B indicated RN H from the night shift should have performed an RN assessment on R1 when she packed the ears with 4x4 gauze but didn't and she should have completed an RN assessment also with information regarding the blood like what color, how much, and where it was coming from. DON B indicated RN C and RN H should have notified R1's MD when she was aware of her bleeding.

Based on observation, interview, and record review, the facility did not ensure that it used feeding assistants consistent with State law, did not use paid feeding assistants only for residents who have no complicated feeding problems, and did not base resident selection for paid feeding assistant use on an Interdisciplinary team assessment and appropriateness for this program reflected in the comprehensive care plan for 1 of 1 of a total of 12 sampled residents (R15). R15 has an altered diet and complicated feeding problems and was being assisted with meals by a Paid Feeding Assistant who had not been provided with in-service/education related to feeding residents since February, 2019. This is evidenced by: The facility does not have a policy regarding Paid Feeding Assistants. The Wisconsin Administrative Code states: (DHS) - Department of Health Services DHS 110-199 - Health DHS 129 - Certification of Programs for Training and Testing Nurse Aides, Medication Aides and Feeding Assistants Subchapter III - Feeding Assistants DHS 129.18 - Feeding assistant training program record retention requirements Subchapter III - Feeding Assistants DHS 129.18 - Feeding assistant training program record retention requirements (1) Feeding assistant training programs shall maintain all of the following records for at least 3 years: (a) All student skill checklists, written examinations, certificates and other relevant training records. (b) Documentation of the training conducted and identification of the instructor who conducted the training. (c) Records of all individuals who have successfully completed the feeding assistant training and competency testing program. (2) Training programs shall maintain the security of the test materials and certificate templates, to ensure disclosure or forgery does not occur. (3) Nursing homes employing feeding assistants shall maintain all of the following personnel and other records for at least 3 years after feeding assistant has competed training: (a) A feeding assistant roster, recording all individuals employed by the facility as feeding assistants who successfully completed the feeding assistant training and competency evaluation, including a written or oral exam and a skill demonstration. (b) A copy of each feeding assistant's training certificate, kept in the person's personnel file. (c) The selected resident's medical record, documenting that no complicated feeding condition exists. (d) The feeding assistant's annual in-service session(s), relating to feeding assistant duties. (e) Annual evaluation documentation, determining a feeding assistant's continued competence in feeding residents. R15 is a [AGE] year old, long-term resident admitted on [DATE] with diagnosis including Dementia, [CONDITION(S)], Actinic [CONDITION(S)], and Calcium Metabolism Disorder, contracture of muscle, Chronic Pain Syndrome, [CONDITION(S)], and abnormal weight loss. R15's Care Plan regarding eating dated 8/25/2020 reads: PROBLEM: Need - Alter food consistency, constipation RELATED TO: Dementia, unable to communicate her needs, [CONDITION(S)], depends on staff with feeding, hx (history) of swallowing impairment. Chewing impairment MANIFESTED BY: not knowing what to do at meals- picking up the glass or utensils, doesn't understand the need to eat, constipation, requiring cuing and takes a long time to eat, chews a long time, hx of holding food in mouth - resident doesn't always open her mouth to be spoon fed. Oral intake usually variable Family's wishes no tube feeding. DIETARY ----- Provide ordered diet, general AS Tolerated Pureed No Tube Feeding, providing pureed foods may have nutritional supplements. Providing 4 oz. nutritional supplement at each meal. Resident is fed by staff, instructions/information provided on the meal table according to guidelines resident's daughter would like staff to follow the best they can- Provide nose cup - thinning the pureed food for resident to drink - seems to work the best. Fluids are enc. Resident receives prune product daily to help with bowel function. Impaired cognitive/alertness interferes with oral intake. Nursing providing 2oz. 2cal supplement bid (two times a day) and recording in the MAR. Ice cream is provided in the afternoon - snack time. It takes longer to feed resident, for she doesn't always want to open her mouth or shy clamps down on the spoon. GOAL: Will tolerate diet consistency (thinned pureed foods, drink from a nose cup), no aspirating pneumonia. Will drink fluids provided at meals. GOAL TIME: Three months. Further record review of R15's chart indicate the facility was aware of complicated feeding concerns for R15. Nursing note on 3/26/21 at 2:18 AM indicates eating ability has decreased, poor appetite, refuses to eat, and difficulty swallowing anorexia noted. Also, a quarterly note documented on 2/3/21 states, Resident continues to remain in fragile nutritional health d/t (due to) poor health status. Continues to be provided with a puree diet with poor intakes. She is fed by staff and only has 25% of most meals consumed. Staff will comment that she will not swallow, however hold food in mouth. She also continues to remain non-verbal . On 2/16/21, R15's record reads, EATING/SWALLOWING: Diet as tolerated, pureed. Feed slowly with sips between small bites. Upright position for eating. Assistive Devices: Use of nose cup. Three times a day every day GOALS: Free of choking episodes. Ease of chewing/swallowing. R15's most recent signed monthly orders on 3/17/21 indicate a diet order Diet as Tolerated Pureed - may have nutritional Supplements [sic]. Other recent diet related orders include in increase in the amount of supplement received on 4/2/21 when the facility updated the provider on R15's slow weight loss and decreased consumption of food but drinking supplement, as well as a telephone order received from provider on 4/13/21 during the recertification survey for Speech Therapy to evaluate and treat. R15's last provider assessment on 3/17/21 notes, Her dementia is very profound, she does not answer questions or speak. Lungs were assessed as clear without rales, rhonchi, or wheezes. On 4/11/21, during the Entrance Conference, NHA A informed Surveyors that the facility did use Paid Feeding Assistants, but none were observed on duty on 4/11/21. On 4/12/21, during the morning meal, Surveyor observed a staff member who was not a CNA (Certified Nursing Assistant) feeding in the dining room. On 4/12/21, at 10:47 AM, Surveyor asked RN E who oversees the facility's Paid Feeding Assistant Program. RN E consulted the facility's Survey Binder for confirmation that DON B (Director of Nursing) oversees the program. Surveyor requested the facility's Paid Feeding Assistant Policy, as well as a list of Paid Feeding Assistants, and documentation of completion of a State approved program, and a list of residents who are allowed to be fed by Paid Feeding Assistants. RN E provided the requested information, and informed Surveyors the facility did not have a Paid Feeding Assistant Policy. On 4/12/21, at 12:17 PM, Surveyor observed Housekeeper/Paid Feeding Assistant F (H/PFA F) feeding R15. Surveyor observed R15's meal to include pureed solids and thin liquids. Surveyor spoke with H/PFA F about feeding residents and H/PFA F indicated she had taken a course on feeding residents several years ago. H/PFA F stated R15 is the only resident she helps and she feeds her every day that she is scheduled to work at breakfast at lunch for the last four or five years. H/PFA F indicated if she had any concerns about R15 while feeding her, she would contact the nurse immediately. On 4/12/21 at 2:15 PM, Surveyor reviewed the list of residents the facility provided that were allowed to be fed by a Paid Feeding Assistant, dated 4/12/21, with Dietary Manager G and inquired who determined which residents were put on the list. Dietary Manager G said, It was created today and reviewed with Nursing. On 4/13/21, at 8:23 AM, Surveyor spoke with Therapy Director H to see if R15 had any Speech Therapy assessments or evaluations in the past. Therapy Director H had no record of R15 ever being seen for Speech Therapy. On 4/13/21, at 8:37 AM, Surveyor spoke with Dietary Manager G regarding R15's feeding needs. Dietary Manager G stated, (R15) won't open her mouth for a spoon, so the only way to get her nutrition is out of a nose cup. She does take thin liquids. On 4/13/21, at 8:38 AM, Surveyor spoke with RN E who said, (R15) has been drinking her food this way. RN E called R15's provider and requested a Speech Therapy order to evaluate and treat. RN E stated she did not recall any coughing or choking episodes by R15 and that H/PFA F is very good with (R15) and knows when she has had enough. On 4/13/21, at 8:39 AM, Surveyor observed H/PFA F feeding R15 pureed food mixed with thin liquids from a nose cup. H/PFA F indicated R15 was doing well and Surveyor observed R15 had been consuming and was continuing to accept food from the cup at that time. On 4/13/21, at 9:41 AM, Surveyor spoke with Dietary Manager G who stated R15 had been taking her food this way for several years and said, There are times if (R15) doesn't want to eat, she either won't even open her mouth or she will just let it run out of her mouth. On 4/13/21, at 9:56 AM, Surveyor spoke with R15's Primary Care Provider who indicated she is very familiar with R15 and has been her provider for years. Provider indicated she did not think R15 was at risk for aspiration, but, I know she doesn't like to open her mouth. Provider indicated she was aware that R15 was fed by a staff member who had been trained in feeding her (R15) and she has not been concerned. Provider stated the facility did call today for a Speech Evaluation order today and thought that was a good plan. Provider indicated she felt like the facility staff was very careful whenever she has been in the facility at mealtimes. The facility has three current employees working in the facility that also have been utilized as Paid Feeding Assistants and have completed the training course - H/PFA F, Activities/Paid Feeding Assistant I, and Activities/Paid Feeding Assistant J. On 4/13/21, at 10:41 AM, Surveyor requested DON B provide Surveyor with additional information on staff members that are currently working in the facility as Paid Feeding Assistants including certificates of completion from feeding assistant program, the last feeding assistant competency evaluation, and any annual in-service/training related to feeding for the three employees, which was received at 11:00 AM with the date of the last training in-service dated 2/12/2019. On 4/13/21, at 1:05 PM, Surveyor interviewed DON B to ask if the last training and skills competency assessments for the Paid Feeding Assistants was in February of 2019, and she stated, Yes, it was. When asked how often it should be completed, DON B said, It should be yearly. I missed it, but I just set up another one. Surveyor asked DON B if R15 had been assessed by the Interdisciplinary Team (IDT) to be appropriate to be fed by a Paid Feeding Assistant, and DON B replied, I don't think so.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use for 3 of 3 Supplemental Residents (R3, R11, & R42) reviewed. R3 did not meet the facility's identified standard of practice for infection surveillance and treatment, McGeer's criteria, according to the symptoms listed on the infection control line log. R11 and R42 are currently receiving prophylactic antibiotics for UTI's (Urinary Tract Infection.) The facility did not provide evidence of a discussion with the physician regarding prophylactic antibiotics not meeting criteria for treatment. The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship for antibiotic use for these residents. This is evidenced by: The Facility Policy entitled 'Antibiotic Stewardship Program,' states in part: STANDARD: To prevent antibiotic resistance, it is important for the nursing home to use the appropriate antibiotic therapy when clinically indicated, and not to use antibiotic therapy when clinically unnecessary . .Protocol: --Infections should be identified using the McGeer Criteria (Stone et al., 2012). --Cultures with sensitivity should be obtained when practical for suspected UTIs --When cultures are complete, MD should be notified to review that the resident is on the correct antibiotic and decide if antibiotic be de-escalated (decreased length of course or less broad antibiotic) (Crnich et al.,2015) . --Prophylactic antibiotics for UTIs should be discouraged. --When antibiotic orders are placed into the electronic charting system by the nurse, a message indicating this goes to the infection preventionist so the order can be reviewed for appropriateness. The facility uses the McGeer's Criteria for its definition of infection and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Surveillance Definitions for Urinary Tract Infections (UTIs): Criteria A. For residents without an indwelling catheter (both criteria 1 and 2 must be present): 1. At least 1 of the following sign or symptom subcriteria: a. Acute dysuria or acute pain .b. Fever or leukocytosis and at least 1 of the following localizing urinary tract subcriteria: I. Acute costovertebral angle pain or tenderness; ii. Suprapubic pain; iii. Gross hematuria; iv. New or marked increase in incontinence; v. New or marked increase in urgency; vi. New or marked increase in frequency. c. In the absence of fever or leukocytosis, then 2 or more of the following localizing urinary tract subcriteria: I. Suprapubic pain; ii. Gross hematuria; iii. New or marked increase in incontinence; iv. New or marked increase in urgency; v. New or marked increase in frequency. 2. One of the following microbiologic subcriteria: a. At least 100,000 cfu/ml (colony forming units/milliliter) of no more than 2 species of microorganisms in a voided urine sample. b. At least 100 cfu/ml of any number of organisms in a specimen collected by in and out catheter. Example 1: R3 was admitted to the facility on [DATE]. Review of the facility's March 2021 Infection Control Log noted the following: -Community or Healthcare Acquired: HAI (Healthcare Acquired Infection); -Onset Date: 3/29; -Symptoms: Increased yelling out; -Infection Type/Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] -Culture Results: met/not met for infection criteria: blank; -Resolved Date/Date returned to work: blank; -Comment/ATB (Antibiotic): [MEDICATION(S)] x 5 days BID (Twice a day). The line list was not completed thoroughly as culture results, met/not met for infection, and resolved date were left blank. R3's urine culture results, with a collection date of 3/30/21 and a Final date of 4/1/21, note >100,000 CFU/ml Escherichia Coli and <10,000 CFU/ml mixed skin microbiota. R3 was started on [MEDICATION(S)] 250 mg twice a day for 5 days without evidence of symptomatology meeting, McGeer Criteria, the facility identified infection control surveillance and treatment criteria. The facility did not have evidence of education being provided to the practitioner/provider regarding starting R3 on an antibiotic. On 3/29/21 at 9:23AM, R3's Nurses Notes, state in part: CALL PLACED TO: attending physician REGARDING: change in condition RESULT: Awaiting return call 10:48 AM CALL RECEIVED FROM: attending physician REGARDING: request for ua (urinalysis) per family d/t (due to) agitation RESULT: new orders received and noted ua with c&s (culture and sensitivity) if indicated CALL PLACED TO: Family (Family Member Name) REGARDING: new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/21 at 8:38PM, R3's Nurses Notes, state in part: CALL PLACED TO: physician on call (Physician Name) REGARDING: UA results- 2+ nitrites, Trace leukocytes, 5-10 WBC, moderate bacteria, occasional epithelia's. RESULT: new orders received and noted- [MEDICATION(S)] 250mg BID x 5 days for UTI. CALL PLACED TO: Family (Family Name) REGARDING: new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Res aware of new orders. On 4/1/21 at 3:53PM, R3's Nurses Notes, state in part: CALL RECEIVED BY: attending physician REGARDING: UA culture and sensitivity RESULT: Reviewed no new orders CALL PLACED TO: Family (Family Name) RESULT: Left message, agreeable with treatment. R3's Physician Telephone Order notes on 3/30/21 [MEDICATION(S)] 250 mg BID x 5 days for UTI. Example 2: R11 admitted to the facility on [DATE]. Review of the facility's Infection Control line log back to Jan of 2021 did not note information on a UTI for R11. Surveyor was provided a list of current residents on antibiotics of which R3 was included. The list notes that R3 is receiving [MEDICATION(S)] - recurrent Urinary Tract Infection - Prophylaxis. Surveyor requested any and all information related to when and why R11 was started on prophylactic antibiotics. A copy of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .History of recurrent UTIs on prophylactic antibiotics use PLAN: Continue [MEDICATION(S)] 250mg daily prophylaxis dosing for history of recurrent UTIs . A copy of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Antibiotics) continue [MEDICATION(S)] at prophylaxis dosing. FU (follow up) 8 mo. to monitor progress. A copy of a urinalysis and culture (of note, no sensitivity is present) with a collection date of 10/6/20 and a final date of 10/8/20 was provided. The urine culture notes 10,000 - 50,000 CFU/ml mixed skin microbiota. There is hand written note on the result that states Abx . (Illegible word) should be continued. R11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation received from the facility showing evidence of: -Review of R11's antibiotic order with a provider/practitioner based on McGeer criteria; -Symptoms R11 was experiencing if they met McGeer's criteria for UTI; -Evidence of a sensitivity completed with the urine culture. Example 3 R42 was admitted to the facility on [DATE]. Review of the facility's Infection Control line log back to Jan of 2021 did not note information regarding a UTI for R42. Surveyor was provided a list of current residents on antibiotics of which R42 was included. The list notes that R42 is receiving [MEDICATION(S)] - Prophylaxis for UTI's. Surveyor requested any and all information related to when and why R42 was started on prophylactic antibiotics. A copy of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] IMPRESSION: .UTI 6/2019 with mental status changes. SIRS (Systemic [CONDITION(S)] Response Syndrome) but resolved with early treatment with oral fluids and [MEDICATION(S)] . A copy of a urinalysis with culture and sensitivity with a collection date of 3/9/20 and a final date of 3/12/20 was provided. The urine culture notes >100,000 CFU/ml Staphylococcus aureus and 50,000 to 100,000 CFU/ml Mixed Bacteria. Possible collection contamination or colonization. There is hand written note on the result that states 3/13/20 Per Dr. (Physician Name), [MEDICATION(S)] 100mg BID x 7 days the [MEDICATION(S)] 100mg dly (daily) at HS (at bedtime) for indefinitely. Let son know this may be what is causing the wt. (weight) loss, d/t (due to) low grade UTI. Sx (Symptoms) are hard to pick up, so she has been placed on long term meds. R42's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation received from the facility showing evidence of: -Review of R42's antibiotic order with a provider/practitioner based on McGeer criteria; -Symptoms R42 was experiencing and if they met McGeer's criteria for UTI. On 4/12/21 at 2:26PM Surveyor interviewed IP L (Infection Preventionist). Surveyor asked what surveillance and treatment standard the facility uses for infection control. IP L stated they use McGeer criteria for determining infections and for surveillance. Surveyor asked IP L what information she could share on the history of R11 being on prophylactic antibiotics for UTI (Urinary Tract Infection). IP L stated they have tried to take her off of the antibiotic, however, family feels it helps with her behaviors and helps with her mentation. We have tried taking her off and then the family wants her put back on it again. Surveyor asked IP L if she had any documentation of the discussions with the son or the physician and she stated she would need to check. Surveyor asked IP L what information she could share regarding the documentation on the line list for R3 from 3/29/21. IP L stated the increased yelling listed is the only symptoms R3 had. We tried to discuss with the son she had no symptoms of a UTI and her dementia was getting worse. She does have a prolapsed bladder and has frequent UTI's but she did not meet criteria. The physician went with the son, who is a nurse, and ordered the antibiotic. Surveyor asked IP L if she had any documentation of the discussions with the son or the physician and she stated she would need to check. Surveyor asked IP L what information she could share on the history R42 being on prophylactic antibiotics for UTI. IP L stated she would have to see what they have. Surveyor asked IP L where documentation should be if residents meet or don't meet criteria for antibiotics. IP L stated there is a place in the nurse's notes to document. Surveyor asked IP L if R3, R11, or R42 met the UTI criteria for antibiotics. IP L agreed they did not. Of note, no further documentation of discussions with the physician or family were received from the facility. On 4/13/21 at 1:54PM Surveyor interviewed DON B. Surveyor asked what the expectation is of staff if a physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B stated for example, with a UTI, in the orders, in the chart (of note, DON B was referencing a section in the electronic health record during this interview), it says what they are supposed to do. If they don't meet for UTI then they have to talk to the doctor and the doctor has to be made aware they don't meet criteria. If the doctor still orders the antibiotic then they should document they informed the physician and they still ordered it. Surveyor asked DON B, for residents who don't meet McGeer's criteria, if she would expect documentation of discussions with the physician to be in the chart. DON B stated, yes.

Based on interview and record review, the facility did not, at admission or the time of discharge provide to resident, family member, or legal representative written notice which specifies the duration of the bed-hold policy or associated costs this has the potenial to affect all 44 residents in the facility. R38 discharged from the facility to the hospital on 1/4/21, R38's family/legal representative was not provided with written notice of the duration of the bed-hold and the associated costs at admission or the time of discharge. R22 was not provided with written notice of the duration of the bed-hold and the associated costs at the time of discharge. R35 was not provided with written notice of the duration of the bed-hold and the associated costs at the time of discharge. The facility does not have a bed-hold policy and per SW C (Social Worker) the facility does not provide residents upon admission or at the time of discharge written notice of the bed-hold policy. This is evidenced by: The facility stated they did not have a Bed-hold Policy, and there is no Bed-hold Policy in their admission packet to be reviewed with residents or family at the time of admission. Upon request, the facility provided Surveyor with a document (generated by their electronic charting system) entitled (Facility Name) Bed-hold Policies, dated 4/13/21 (survey date) which states: 1. All residents have the right to pay bed-hold fee in order to guarentee that their bed will not be given to someone else during an absence, such as a 2. Resident who receive Medicaid can receive up to 15 days of bed-hold per hospitalization . Medicaid will also pay bed hold charge for home visits under certain 3. Medicare will not pay bed-hold charges. If a resident wishes to hold their bed, the resident is responsible for 4. Residents who are paying for there own nursing home costs are also responsible for bed-hold charges. 5. The current bed hold charge for all residents is 75% of their current daily rate. When bed-hold charges are paid, the resident will retain the same bed they occupied prior to their temporary absence. I have read the above bed-hold policies and request to hold my my bed at the current fee. There is a blank for Resident/POA (Power of Attorney) signature and date. (It is important to note, that sentences1, 2 and 3 are incomplete and there are no specific costs (dollar amount) to the resident noted.) Findings: Example 1 R38 was discharge to the hosptial on 1/4/21 and returned on 1/18/21. R38 has cognitive impairment and POA for Health Care. Review of R38's record showed no evidence of a bed-hold notice being given at the time of discharge on 1/4/21. On 4/13/21 at 1:39 PM, Surveyor interviewed SW C (Social Worker) about the facility's bed-hold policy, SW C stated the facility does not have a bed hold policy but always accepts residents back to their room at the facility when they are discharged from the hospital and does not charge residents for bed-hold. SW C stated, we have never denied a resident return to the facility. SW C provided Surveyor with a copy of a document Notice of Discharge or Transfer to Hospital Form for R38 dated 1/4/21, which indicated the reason R38 was being transferred and the hospital R38 was being transferred to, this document had no bed-hold information. Surveyor asked if the facility reviews bed-hold information with residents and families at the time of admission, SW C stated no, and did not know this was supposed to be done and reported there is no bed-hold information in the facility admission packet On 4/13/21 at 2:42 PM, Surveyor interviewed R38's FM K (Family Member) about R38's discharge on 1/4/21 asking if FM K received a written notice of bed-hold for R38. FM K stated she was notified of R38's transfer to the hospital on 1/4/21. FM K could not recall a discussion about a bed-hold, but assumed they kept R38's room for her until she came back, because the facility always had. FM K did not recall bed-hold information being reviewed when R38 was admitted . On 4/13/21 at 2:53 PM, RN D (Registered Nurse) and RN E brought a copy of the document (Facility Name) Bed-hold Policies, dated 4/13/21 (as noted above). RN D explained at the time of discharge to the hospital the nurse goes into the electronic record to print off needed documents for a resident's transfer and these are placed in a folder to be sent to the hospital. The facility was unable to provide Surveyor with a copy of R38's Bed-hold policy that was generated on 1/4/21. RN E indicated the resident signs the Transfer form if they are able, but the bed-hold document is not part of the resident record, it goes to the hospital and it is not reviewed with the resident or family. The facility did not have a thorough bed-hold policy and had no process in place to assure all residents or responsible parties were notified of the facility's bed-hold policy at the time of admission and also at the time of discharge or transfer to the hospital. Example 2 R22 was admitted on [DATE] and due to a change in condition was transferred to the hospital on 2/5/21. R22 returned to the facility after hospital discharge on 2/9/21. Review of R22's record had no evidence of bed hold notification for hospital transfer on 2/5/21. The facility should have provided R22 with written notification of bed hold when transferring to the hospital this was not completed. Example 3 R35 was admitted to the facility on [DATE]. R35 had a change of condition on 2/20/21 and was transferred to the hospital. R35 was discharged from the hospital and returned to the facility on [DATE]. Surveyor reviewed R35's record, and there was no evidence of a bed hold notification for R35's hospital transfer on 2/20/21. The facility should have provided R35 or his responsible party notification of bed hold upon transfer to the hospital, and this was not completed.

Based on interview and record review the facility did not ensure its staff made prompt efforts to resolve a grievance and to keep the resident/resident representative appropriately apprised of progress toward resolution of their grievance for 1 out of 4 Sampled Residents (R1) R1's FM C (Family Member) informed NHA A (Nursing Home Administrator), DON B (Director of Nursing) and SW D (Social Worker) regarding concerns for R1's care. FM C's concerns were not identified to be a grievance and there is no documentation of follow up or a resolution to FM C's concerns regarding R1. This is evidenced by: Facility Policy entitled 'Policy and Procedures for Grievances, Mistreatment Investigations, Mistreatment prevention and Injuries of unknown source,' states in part: Purpose: to prevent and prohibit mistreatment, abuse, neglect, involuntary seclusion, incidents of unknown source, and misappropriation of property of all residents. To ensure that all residents and family complaints are investigated thoroughly and appropriate corrective action is promptly taken.8.d. Resident rights are to be reviewed with the resident and/or responsible party upon admission and yearly. The resident/responsible party is made aware that social services or DON or NHA can be contacted regarding concerns without retribution, that a formal grievance can be written, and that they can contact the ombudsman with complaints. Ombudsman sign is posted in the building . R1 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was responsible for himself up until 12/28/20 when he was deemed incapacitated. On 8/15/20 at 11:57 AM, FM C sent an email to NHA A, that states in part: I would like to speak with you and (DON B) in regards to my dad's care when it comes to his medication Last night I received a call that my dad had missed two doses of the antibiotics he was put on for his infections . This is the third time there's been an issue or mishap with his medication.Now I am genuinely upset and worried .and I want to know each time he's had a med pass error who was the nurse signing off on it and if it was the same nurse this is a serious issue that needs to be addressed. Can either you or (NHA in trainings name) please call me so we can figure this out together? On 8/17/20 at 10:46 AM, NHA A replied to FM C via email, stating I was gone last week and I will be checking on this today and will be calling you. There is no evidence that this concern was transferred to a grievance form and no documentation to show that NHA A followed up with FM C regarding her concerns. On 10/28/20 at 4:37 PM, FM C sent an email to NHA A, DON B and SW D that states in part: I am reaching out to all of you because we need your help to make sure something is changed from today on as to the communication gap between (facility name) and myself when it comes to my dad and his cares and goals.I do not want him feeling like he's a burden or should change his code because it makes nursing staff uncomfortable . There is no evidence of a reply from either NHA A, DON B or SW D regarding her emailed concerns or that a grievance/concern form was ever initiated. On 2/24/21 at 9:00 AM, Surveyor asked for grievance from December 2020 through 2/24/21. SW D indicated there are no grievances during that time period. On 2/24/21 at 12:25 PM, Surveyor interviewed SW D (Social Worker) regarding FM C's concerns regarding R1. SW D indicated she received an email from FM C regarding wanting better communication. SW D indicated FM C was not R1's activated power of attorney but they included her in care conferences. SW D indicated she is unaware of any concerns regarding R1's care. On 2/24/21 at 2:05 PM, Surveyor interviewed CNA E regarding R1. CNA E indicated RN F pulled her aside and indicated she was rough with R1. CNA E indicated she had a student with her, who did all of R1's cares and CNA E never touched R1 other than helping to turn him. On 2/24/21 at 3:45 PM, Surveyor interviewed RN G regarding R1. RN G indicated she heard through report about R1 sitting in stool, and was told it did not happen, as he's on a turning schedule every two hours. RN G indicated she thinks FM C called. On 2/24/21 at 3:50 PM, Surveyor interviewed DON B. DON B indicated she is unaware of R1 having a concern about sitting in stool for 12 hours. On 2/24/21 at 3:54 PM, Surveyor interviewed SW D regarding email correspondence from FM C regarding R1's care/concerns. SW D indicated she read the October email as having a solution and did not write up a grievance concern as it was resolved. Surveyor asked SW D about follow through and documentation regarding a concern and SW D replied NHA A and DON B were aware. Surveyor asked SW D for all grievances from August 2020 to current. On 2/25/21 at 7:50 AM, Surveyor interviewed RN F (Registered Nurse) regarding R1 concerns with staff. RN F indicated staff would check and change R1 every two hours and R1 had many specific medication pass times which meant staff were in there frequently. Surveyor asked RN F if any specific concerns were voiced regarding R1's care, RN F indicated there weren't any that she was aware of. RN F indicated R1 would say he was not checked for twenty-four hours and there was no way he was not checked due to med times and CNA's (Certified Nursing Assistant) checking on him. RN F indicated there was one incident where R1 told FM C he was not check for 24 hours which came through report. RN F indicated she made sure DON B was aware of it and she talked to the CNA's involved to check when they were in there. RN F indicated she is unable to say if this incident was documented or written up as a grievance/concern. RN F indicated she heard about a situation where a CNA was not gentle with cares and knows that DON B is aware of it as RN F did talk to CNA E about the situation such as what cares were done, if she was angry about something etc., and RN F reported it to DON B. RN F indicated she was not asked to write a statement. RN F indicated she is unable to remember when this was but verbally educated CNA E on customer service. RN F indicated R1 reported it to a CNA, who reported it to her. On 2/25/21 at 9:05 AM, Surveyor interviewed DON B regarding R1. DON B indicated she does not remember being told by RN F about any situation with R1. DON B indicated if she would have came to me I would have investigated it and reported it. On 2/25/21 at 1:25 PM, Surveyor interviewed NHA A regarding R1 and FM C's concerns. NHA A indicated he believes he talked with FM C related to her concerns on August 10th. NHA A indicated he would consider the correspondence on 8/10/20 indicating a concern. Surveyor asked NHA A if a concern/grievance form should have been filled out, and NHA A responded can't say if there's any validness to it. Surveyor asked NHA A about 10/28/20 emailed correspondence and NHA A indicated he was not aware of the email from 10/28/20 as he gets a lot of emails. On 2/25/21 at 2:44 PM, Surveyor interviewed FM C (Family Member) regarding her concerns related to R1. FM C indicated her concerns with R1's cares has been going on since August of 2020. FM C indicated she would express concerns to NHA A, DON B or SW D and neither of them followed up with her even after sending emails regarding her concerns. FM C indicated she did not receive a resolution or a plan on how to the facility planed on correcting/addressing the concerns she was voicing to them. FM C indicated she reported care concerns to RN F regarding CNA E and R1 being left in stool. FM C indicated RN F told her there's no way that happened, as she was working that day. FM C indicated the facility has had communication issues and have not been communicating with her as requested. The facility was not able to provide a grievance/concern form, investigation, action/plan to resolve the concerns indicated above or documentation that FM C or R1 were consulted regarding these concerns or that a final acceptable resolution was agreed upon by both parties.

Based on interview and record review the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 out of 4 sampled Residents (R1, R2 & R3). R1's 2020 MARs (Medication Administration Record) for August, September, October, November and December have blanks on them and there is no evidence in R1's Nurses Notes indicating whether R1 did or did not receive his medications/treatments as prescribed. R2 received an incorrect medication/dose when she requested an as needed dose of pain medication. R3 was admitted on [DATE] with an order for a [MEDICATION(S)] 5% patch, which he did not begin to receive until 1/14/21. This is evidenced by: Facility policy titled, Medication Administration, last revised on 5/7/13, which states the standard is that, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The policy also states nurses procedures are, in part, to Indicate on MAR (medication administration record) if medication is not administered as ordered and record reason on MAR Check Electronic Medical Record (MAR). Read each order entirely. Remove medication from drawer. Read label three times - when taking meds out of cart drawer, before pouring, after pouring. If there is a discrepancy between MAR and the label, check physician order before administering medication . Example 1: R1 was admitted on [DATE], with diagnoses that include Malignant Neoplasm of the prostate, hypertension, neuromuscular dysfunction of bladder, Nephrostomy tubes, [CONDITION(S)] of the pelvis and [CONDITION(S)]. On 10/29/20 R1's Significant Change MDS data indicates R1 has a BIMS (Brief interview of Mental Status) of a 15 out of 15, indicating he is cognitively intact. R1's August 2020 signed Physician Orders indicated the following: [MEDICATION(S)] 100 mg (milligram) capsule 1 capsule by mouth twice daily. [MEDICATION(S)] insulin solution per sliding scale four times a day <150 (less than 150) = (equals) zero units, 150 -199 = 2 units, 200-249 = 3 units, 250-299 =5 units, 300 - 349 = 7 units, 350 - 399 = 8 units, >400 (greater than 400) = 9 units and call MD (Medical Doctor). [MEDICATION(S)] 25 mg tablet by mouth three times a day 7:00 AM, 12:00 PM, 6:00 PM and to hold if SBP (systolic blood pressure) is less than 100 and if pulse is less than 60 for hypertension. Polyethylene [MEDICATION(S)] ([MEDICATION(S)]) powder 17 grams by mouth daily 12:00 PM, [MEDICATION(S)] 5 mg tablet by mouth twice a day, Acetaminophen (Tylenol) 500 mg give 2 tablets (1000 mg) by mouth three times daily. Measure Nephrostomy output Right every shift NOC (night shift), AM (day shift), PM (evening shift). Measure Nephrostomy output Left every shift NOC, AM, PM. Measure Supra-pubic catheter output 16fr (French) 10cc (10 cubic centimeters) every shift NOC, AM, PM. R1's August 2020 MAR shows the following dates, times and medications to be without a signature: On 8/6/20 at 11:30 AM, R1's [MEDICATION(S)] insulin (fast acting) sliding scale is blank for initials, blood sugar results, administration site, and the amount that was given. [MEDICATION(S)] [MEDICATION(S)] 25 mg (milligram) tablet to be given three times a day at 7:00 AM, 12:00 PM and 6:00 PM is not signed out for 7:00 AM or 12:00 PM and there is no evidence of a blood pressure being recorded for this medication at either of those times as there blank. R1's [MEDICATION(S)] 5 mg tablet is not signed out at 12:00 PM. Tylenol (acetaminophen) 1000 mg by mouth three times a day is not signed out for 12:00 PM. [MEDICATION(S)] 100 mg capsule by mouth twice a day was not signed out at 12:00 PM. ([MEDICATION(S)]) Polyethylene [MEDICATION(S)] 3350 17 grams per scoop powder by mouth daily 1200 (12:00 PM) is not signed out. Multi-vitamin 1 tablet by mouth daily at 12:00 PM is not signed out. On 8/15/20 R1's ([MEDICATION(S)]) Polyethylene [MEDICATION(S)] 3350 17 grams per scoop powder by mouth daily 1200 (12:00 PM) is not signed out. R1's Multi-vitamin 1 tablet by mouth daily at 12:00 PM is not signed out. On 8/16/20 at (time unknown), R1's [MEDICATION(S)] insulin per sliding scale four times a day 0730 (0730am), 1130 (11:30 am), 1730 (5:30 PM) and 2000 (8 PM), indicates time as dose and it is not signed out. There is no indication if this dose is for 7:30 AM, 11:30 AM, 5:30 PM or 8:00 PM. On 8/30/20 on NOC (night shift) R1's left and right nephrostomy bag output is not signed out as the initials are blank. R1's measuring of his supra-pubic catheter output on NOC shift and keeping R1's SP (supra-pubic) catheter connected to the leg bag is also blank for NOC shift. R1's Nurses notes for 8/6/20, 8/15/20, 8/16/20 and 8/30/20 do not indicate whether these medications were given to R1. There is no evidence on 8/30/20 in R1's Nurses Notes to show that R1's outputs were measured. R1's September 2020 MAR shows the following meds to not be signed out as being given: On 9/4/20 12:00 PM R1's Tylenol (Acetaminophen) 1000 mg by mouth is blank. R1's Nurses notes do not indicate if R1 received his scheduled Acetaminophen or if it was declined or held. On 9/11/20 at 11:30 AM R1's [MEDICATION(S)] insulin (fast acting) sliding scale dose is blank and without a blood sugar reading being documented. At 11:30 AM Scheduled [MEDICATION(S)] Insulin dose of 4 units. At 12:00 PM [MEDICATION(S)] [MEDICATION(S)] 25 mg tablet, [MEDICATION(S)] 5 mg tablet (for inflammation), 12:00 PM dose of Tylenol (Acetaminophen) 1000mg by mouth, 12:00 PM 200 mg dose of [MEDICATION(S)], 12:00 PM 17 gram dose of [MEDICATION(S)] and one Multivitamin tablet. R1's Nurses notes on 9/11/20 has no indication of R1 receiving these medications. R1's October 2020 MAR shows on 10/18/20 at 6:00 PM R1's [MEDICATION(S)] 25 mg tablet and evening shift blood pressure are not signed out as they are blank. No evidence in R1's Nurses Notes that R1 received this medication. R1's November 2020 MAR shows the following meds as not being signed out or indicated as being given: On 11/9/20 AM shift output for Right and Left nephrostomy tubes and supra-pubic catheter is blank. No indication in Nurses Notes that R1's output was measured for day shift on 11/9/20. On 11/15 & 11/17/20 R1's [MEDICATION(S)] 25 mg tablet at 7:00 AM was not signed out and no indication in the Nurses Notes, if it was held or given. R1's December 2020 MAR shows the following: On 12/17/20 on the PM shift R1's nephrostomy site dressings for his left and right nephrostomy tubes are not signed out as being completed. There is no documentation in R1's Nurses Notes to indicate R1's nephrostomy site dressings were changed on 12/17/20. On 12/24/20 R1's AM shift output for R1's left and right Nephrostomy tubes and supra-pubic catheter is blank on R1's MAR and there is no indication in R1's Nurses Notes that his output was measured. On 2/25/21 at 9:05 AM, Surveyor interviewed DON B (Director of Nursing) regarding R1's medications. DON B indicated you would know if a medication was given by it being signed out on the MAR. DON B indicated RN F (Registered Nurse) audits the MARs. DON B indicated if it's not signed out then it wouldn't have been given, as you have to sign it out to show it was completed. DON B indicated she would expect the Physician to be updated if medications were not given. DON B indicated she is unable to say if R1 received the medication as it's not signed out. Example 2 R3 was admitted to the facility on [DATE] with diagnosis including, but not limited to, [CONDITION(S)] disease. R3 was admitted to the facility with an order for a [MEDICATION(S)] 5% patch to be applied to his low back to be place on PM and taken off in the AM. In December 2020, R3's [MEDICATION(S)] patch is marked as either held or not available for 14 of the 17 nights it was ordered in December. Three nights, the [MEDICATION(S)] patch was marked as administered, despite no record of the facility having it available. In December, day shift twice charted held or not available for taking the patch off and 14 times initialed that the patch was off (as it was never applied). In January 2021, R3's [MEDICATION(S)] patch is marked na (not available) on the PM shift and initialed as OFF (emphasis intended) on the day shift from 1/1/21 - 1/13/21. According to the facility Medication Error/Omission Report completed on 1/14/21, the ordered [MEDICATION(S)] %5 patch on PM off AM had not been given since admit and under pharmacy other is marked and the comment states, med was never sent due to confusion in insurance. On 2/24/21 at 1:25 PM, Surveyor spoke with RN G regarding the steps nurses in the facility are expected to take when a medication is not available to be given as ordered. RN G indicated she would check to see if the needed medication was one they had available in their back up medications, and if not, she would call the doctor to see if they can start it when it is available and call the pharmacy to see if they will be able to bring it in that night. RN G stated the pharmacist is located in town and has been known to even bring medications over in the middle of the night if it was needed. RN G also stated if a medication requires Prior Authorization from insurance before it will be dispensed, the pharmacy will call the facility and the facility contacts the provider who takes care of the rest so the medication can be sent. On 2/24/21 at 1:30 PM, Surveyor spoke with RN H who also stated if a medication that was ordered to be given was not available, she would call the pharmacy to make sure it was going to be delivered, check the backup supply, and notify the physician if we don't have it. On 2/24/21 at 1:55 PM, Surveyor spoke with DON B who stated she talked with the pharmacy and with nurses. DON B's follow up to recorded on the Medication Error/Omission report was to instruct the pharmacy to call the facility when insurance will not cover a medication and advised nurses to call pharmacy when a medication is not received, as well as call the provider with a prior authorization is required. Surveyor asked DON B if someone should have followed up on R3's [MEDICATION(S)] patch earlier, and she indicated between the PM shift not having the [MEDICATION(S)] patch available to apply and the day shift not having a [MEDICATION(S)] patch to remove from the resident, someone should have followed up on it sooner. Surveyor reviewed R3's PRN (as needed) pain medication use for evenings through the overnight during his stay at the facility during the hours the [MEDICATION(S)] 5% patch was ordered. Surveyor found R3 used Acetaminophen 500mg Tablet Dose ordered: (2 tablet / 1000mg) 17 times out of the 30 days prior to the unavailable [MEDICATION(S)] 5% patch being followed up on. Starting on 1/14/21, when R3's [MEDICATION(S)] 5% patch was available in the facility, R3 did not require PRN pain medication for the next 7 evenings/overnights, although R3 did again use his PRN pain medication again starting 1/21/21 for four out of the next six nights, along with the [MEDICATION(S)] 5% patch. Example 3 R2 was admitted to the facility on [DATE] with diagnoses including, but not limited to acute [CONDITION(S)], [CONDITION(S)], heart failure, end stage [CONDITION(S)], and cachexia. R2 is also enrolled in hospice. According to the facility Medication Error/Omission report, R2 requested PRN [MEDICATION(S)] at 3:00 AM on 8/12/2020. Instead of receiving her as needed dose of [MEDICATION(S)] 30mg, R2 was given her [MEDICATION(S)] ER 60mg dose which was scheduled for 7:00 AM. On 2/24/21 at 3:15 PM, Surveyor spoke with DON B regarding R2's medication error. DON B stated the nurse making the error realized her mistake and reported it. According to the facility Medication Error/Omission Report, DON B educated that nurse on the five rights of medication administration and the medication administration policy was given to that nurse. Surveyor asked DON B if all nursing staff received a memo or any sort of education related to medication errors and the five rights, and she stated, I don't think so, but I can look. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that its residents were free from significant medication errors for 2 of 4 residents (R1, R3) reviewed for medication errors. R3 was seen by a physician in the facility on 1/8/21, at which time the provider ordered a change to R3's [MEDICATION(S)], a beta blocker (heart medication). R1's previous order was being administered in the morning, but the new [MEDICATION(S)] order was also changed to be given on the PM shift. The facility did not receive the new order from the pharmacy that evening, and the medication was not given from 1/8/21 through 1/13/21. The provider was not updated and the pharmacy was not contacted until 1/14/21. R1 did not receive two doses of [MEDICATION(S)] (antibiotics) upon returning to the facility on [DATE] after being hospitalized for an infection. This is evidenced by: The facility policy titled, Medication Administration, last revised on 5/7/13, which states the standard is that, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms, and help in diagnosis. The policy also states nurses are to Indicate on MAR (medication administration record) if medication is not administered as ordered and record reason on MAR. Example 1 R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to R3's MAR and MD signed monthly orders, R3 was taking [MEDICATION(S)] [MEDICATION(S)] 25 mg tablet - dose ordered: (0.5 tablet / 12.5mg) by mouth daily from 12/15/20 through 1/7/21. (This initial order was scheduled to be given at 8:00 AM from 12/15/20 - 12/30/20 and then scheduled to be given at 9:00 AM from 12/31/20 - 1/7/21.) On 1/8/21, that order was discontinued and changed. On 1/8/21, R3's MAR indicates a new order for [MEDICATION(S)] [MEDICATION(S)] ER 25mg tablet Extended Release 24 hour - dose ordered: (0.5 tablet / 12.5mg) 12.5mg by mouth daily at bedtime. The order was to start on 1/8/21 and scheduled at 8:00 PM. Documentation in the MAR for the new order for [MEDICATION(S)] [MEDICATION(S)] ER 25mg tablet Extended Release 24 hour - dose ordered: (0.5 tablet / 12.5mg) 12.5mg by mouth daily at bedtime is as follows: 1/8/21 - na (not available) 1/9/21 - na 1/10/21 - na 1/11/21 - na 1/12/21 - na 1/13/21 - (CAM) - parenthesis around initials indicate a medication was held/not given There is no reason indicated on the MAR or in nurses' notes why the medication was not administered from 1/8/21 - 1/13/21 as ordered as the policy indicates nurses are expected to do. The omission error was found on 1/14/21 and a facility Medication Error/Omission Report was completed for the error, which indicates the medication was not given and pharmacy saw the time was changed, did not realize it was changed to [MEDICATION(S)] [MEDICATION(S)] from [MEDICATION(S)] [MEDICATION(S)]. On 2/24/21 at 1:25 PM, Surveyor spoke with RN G (Registered Nurse) regarding the steps nurses in the facility are expected to take when a medication is not available to be given as ordered. RN G indicated she would check to see if the needed medication was one they had available in their back up medications, and if not, she would call the doctor to see if they can start it when it is available and call the pharmacy to see if they will be able to bring it in that night even. RN G stated the pharmacist is located in town and has been known to even bring medications over in the middle of the night if it was needed. RN G also stated if a medication requires Prior Authorization from insurance before it will be dispensed, the pharmacy will call the facility and the facility contacts the provider who takes care of the rest so the medication can be sent. RN G and Surveyor observed contingency/back up medication stock in house and noted there was not any back up form of [MEDICATION(S)] available in the facility. On 2/24/21 at 1:30 PM, Surveyor spoke with RN H who also stated if a medication that was ordered to be given was not available, she would call the pharmacy to make sure it was going to be delivered, check the backup supply, and notify the physician if we don't have it. On 2/24/21 at 1:55PM, Surveyor spoke with DON B regarding R3's medication omission from 1/8/21 through 1/13/21. DON B stated it seems what happened was when the order was changed and sent on the day shift, they (day shift) assumed it would be coming over from pharmacy to start that night, but it didn't. Then the nurse on the floor (on PM shift) held it for several days. DON B stated, I don't know why. Surveyor asked DON B if she would expect the nurse to contact the provider or the pharmacy if a medication wasn't available, and she, Yes. I would expect them to call right away. DON B indicated it was concerning that a heart medication was not given for several days. Surveyor asked DON B if the same nurse who had worked the first four nights of the omission error had received any specialized training on medications errors, and DON B stated she would be sure to follow up on that and see she completes the facility's Relias Education training on medication errors if she has not already done so. Surveyor asked if DON B had provided education to all nurses related to this incident. DON B provided Surveyor with a copy of an internal memo sent to all nurses on 1/21/21 (a week after the error was found and corrected) related to orders that require prior authorization indicating they must contact the provider and which states, It is not acceptable to continue to hold a medication without the doctors [sic] consent. Of note, there is no signatures and no evidence all nurses reviewed this memo or completed necessary education to prevent significant medication errors. Surveyor reviewed R3's vital signs, including blood pressure and pulse throughout his stay in the facility and did not observe a significant or concerning change. The facility did not ensure residents were free of significant medication errors. Example 2: R1 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/8/20 at 2:33 PM, R1's Nurses Note states in part: Call placed to: attending Physician. Regarding: dark, blood tinged urine in R (right) nephrostomy bag, 750ml (milliliters) out. Site is red (about 3 inch diameter around site) and tender. Green purulent drainage at site. Result: will receive call from on call Physician. Awaiting return call. On 8/8/20 at 2:46 PM, R1's Nurses Note states in part: Call received by: Physician on call (name). Regarding: Right nephrostomy site. Result: sent to ER (emergency room ) for evaluation. Call placed to: (Family Member C) regarding: new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/12/20 R1 returned from the Hospital after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Secondary discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Hospital Discharge orders state in part: [MEDICATION(S)] [MEDICATION(S)] 250mg tag. Also known as: [MEDICATION(S)]. Take 1 tab by mouth 2 times daily at mealtime for 6 days. Purpose: Infection. R1's August 2020 MAR (Medication Administration Record) states in part: [MEDICATION(S)] [MEDICATION(S)] 250mg (milligram) tablet. Dose Ordered: (1tablet/250mg) by mouth twice a day for 6 days 0800, 1800. First date: 8/12/2020 . For: Infection. R1's MAR is signed out for a total of 14 doses on the MAR. R1's 'Medication Error/Omission Report,' dated 8/15/20, states in part: Date/time of error: 8/13/2 [sic] & 8/14/20. Resident involved (R1) Employee making report (LPN I (Licensed Practical Nurse)). Medication Ordered [MEDICATION(S)] [MEDICATION(S)].Med dose(s) omitted (yes) .Explanation/comment: couldn't find med when looking for it. Signed out inadvertently.Reason given for omission (checked). Explanation/comment: med not in correct place.Dr. (name) notified at 10AM .Date 8/15/20. If error is significant notify M.D. immediately otherwise notify MD next day in office. M.D. Comments: continue giving until all given.Nurse responsible for error: (LPN I). D.O.N Comments: Spoke with (LPN I). LPN I reports she got distracted. Advised (LPN I) to avoid this to always take the med cart to the residents room when passing meds to avoid getting distracted by another resident, staff member, phone call etc. There is no evidence of this Medication error occurring in R1's Nurses Notes. On 2/25/21 at 9:05 AM, Surveyor interviewed DON B regarding R1. DON B indicated that all of R1's doses of [MEDICATION(S)] were sent in one single punch card and not separate cards. DON B indicated she contacted the pharmacy to have them sent over in individual doses after the error occurred. DON B indicated medication audits were completed and all nurses are to take the medication cart with them to Resident rooms. DON B provided performance improvement plan from May and August 2020 along with audits to Surveyor, last medication pass audit was completed on 11/12/2020. (Please note that the Facility has a performance improvement plan from May of 2020 regarding LPN I's medication error rates.)

The facility failed to prevent possible transmission of COVID-19 by failing to: restrict employees with potential symptoms of COVID-19 from work per the Centers for Disease Control and Prevention's (CDC) guidance for return to work for healthcare professionals and screen employees for all the potential symptoms of COVID-19 infection prior to the beginning of their shift. This had the potential to affect all 44 residents residing in the facility at the time of the survey. Findings include: At the time of the survey the facility had one confirmed COVID-19 positive resident and one confirmed COVID-19 positive staff. The confirmed positive resident had expired. 1. According to the CDC Return to Work Criteria for HCP (Health Care Provider) with Suspected or Confirmed COVID-19, Symptomatic HCP with suspected or confirmed COVID-19 (Either strategy is acceptable depending on local circumstances): Symptom-based strategy. Exclude from work until: At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, At least 10 days have passed since symptoms first appeared Test-based strategy. Exclude from work until: Resolution of fever without the use of fever-reducing medications and Improvement in respiratory symptoms (e.g., cough, shortness of breath), and Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of [DIAGNOSES REDACTED]-CoV-2 RNA from at least two consecutive respiratory specimens collected 24 hours apart (total of two negative specimens) . retrieved [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html Review of the facility's Infection Control Log, dated ,[DATE] to ,[DATE], and the corresponding time records, revealed, the following two staff were allowed to return to work after reporting potential symptoms of COVID-19 without meeting the CDC criteria for return to work for healthcare providers: Nursing Assistant (NA2), .Onset date [DATE]. Symptoms: sore throat, cough. (Negative) COVID . Review of NA2's time record revealed, NA2 worked on [DATE], four days after the reported onset of symptoms. NA1, .Onset date [DATE]. Symptoms: sore throat feels warm. Testing for COVID ,[DATE] off work until results. May come back 24 (hours no) fever .(Negative) COVID. Review of NA1's corresponding time record revealed, NA1 worked on [DATE], four days after the reported onset of symptoms. During an interview on [DATE] at 1:13 pm, with the Director of Nursing (DON), when asked if the facility was using the CDC's symptom based or the test based criteria for return to work for healthcare providers, the DON stated that the facility uses the test based criteria. When asked if NA1 and NA2 had two negative COVID-19 tests prior to returning to work per the CDC test based criteria, the DON confirmed that the staff only had one negative test prior to returning to work. The DON also stated the public health department instructed the facility that if symptomatic staff have a negative COVID test they can return to work after ,[DATE] hours. The DON then stated, This is the problem. If CMS (Centers for Medicare and Medicaid), the CDC, Public Health could all agree on something. What are we supposed to do when we are being told different things. During an interview on [DATE] at 1:15 pm, with the Administrator, when asked if the facility required staff to have two negative COVID-19 tests prior to returning to work per the CDC test based criteria, the Administrator stated, We weren't aware and we checked with public health and they thought they (staff) only needed one test too. 2. According to the CDC, Preparing for COVID-19 in Nursing Homes, .Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace . retrieved [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. According to the CDC, Symptoms of Coronavirus, .People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear ,[DATE] days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; Headache; New loss of taste or smell; Sore throat; Congestion or runny nose; Nausea or vomiting; Diarrhea . retrieved [DATE] from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Review of the facility's Infection Prevention Coronavirus (COVID-19) Employee Symptom Evaluation, dated [DATE], revealed the form only screened employees for three potential symptoms of COVID-19: temperature, shortness of breath, and new or worsening cough. The facility's employee screening did not include the following potential symptoms of COVID-19: fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting; or diarrhea. During an interview on [DATE], with the DON, when asked why the facility was not screening employees for all the potential symptoms of COVID-19, the DON stated, We would have no staff if we did all the symptoms. Review of the facility's Coronavirus (COVID-19) Prevention and Outbreak Control Policy and Procedure, dated ,[DATE], revealed, Screening Employees: Facility will actively verify absence of fever and respiratory symptoms when employees report to work-beginning of their shift. Document temperature, absence of shortness of breath and new or change in cough If employee is ill, employee will put on a facemask and self-isolate at home Employees who develop symptoms to COVID-19 (fever, cough, and shortness of breath) will be instructed to not report to work and referred to public health authorities for testing, medical evaluation recommendations and return to work instructions. Employees who develop symptoms on the job will be: Instructed to immediately stop work and provided with a facemask Instructed on self-isolation at home The Infection Preventionist will work with the employee to identify individuals, equipment and locations the employee came in contact with The Infection Preventionist will contact the local health department for recommendations on next steps . The facility policy did not include: all of the potential symptoms of COVID-19 infection and the current CDC guidance for return to work for healthcare professionals.

Based on interview and record review, the facility did not ensure each resident had a Person-Centered Comprehensive Care Plan developed and implemented to address the resident's medical needs for 4 of 17 sampled residents (R10, R96, R31, and R38). R10's care plan did not address R10's risk for bleeding due to being on an anticoagulant medication, or revised after a bleeding incident on 1/31/19. R96's care plan did not address R96's risk for bleeding due to being on an anticoagulant medication. R96 has a history of gastrointestinal hemorrhage. R31's Comprehensive Care Plan and CNA (Certified Nursing Assistant) Assignment Card did not include interventions or goals related to R31's anticoagulant medication use. R38 was prescribed [MEDICATION NAME] (anticoagulant) without a Comprehensive Care Plan developed to monitor for side effects of bleeding or bruising. This is evidenced by: Example 1 R10 was admitted to the facility on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. R10's emergency room Document, dated 1/31/19, states, in part: .brought in by ambulance from local nursing home with a complaint of right nostril bleeding, which started around 5PM this evening. (R10) arrived to the emergency room around 8PM.Patient is on [MEDICATION NAME] for chronic [MEDICAL CONDITION].no difficulty breathing but (R10) has been coughing up egg sized clots intermittently per nursing staff. (R10) has a history of nosebleeds in the past, usually controlled with simple conservative measures. Diagnosis: [REDACTED]. Patient on [MEDICATION NAME] for Chronic [MEDICAL CONDITION] with pro time of 2.2. Large bloody bowel movement, suspect from swallowed blood. R10's CNA Assignment Card, dated 2/20/19, states, in part: 1/24/18 - Problem: Potential for Alteration in: Cardio Respiratory perfusion. Related to:[MEDICAL CONDITION](hypertension), [MEDICAL CONDITION] fib, [MEDICAL CONDITIONS], asthma, anticoagulant therapy. 11/7/2018: Nurse Aide .report increased bruising noted with cares to nurse. (Please note that this is the only area on the CNA Assignment Card, that mentions R10 being on an anticoagulant, and to monitor for bruising. It does not indicate to monitor for bleeding or to report bleeding to nurse, or to monitor/watch R10 for nose bleed(s).) R10's care plan, printed on 2/19/19, states, in part, the following: 1/24/18 Problem: Potential for Alteration in: Cardio Respiratory perfusion. Related to: HTN, [MEDICAL CONDITION] fib, [MEDICAL CONDITION], asthma, anticoagulant therapy. Manifested by: Fatigue, weakness, poor tolerance to extended activity. Approach: 1/24/18 Nurse .Check INR (International Normalized Ratio) as ordered and keep MD (Medical Doctor) updated for changes in dose. Adm (administer) meds as ordered, Observe for effectiveness and adverse s.e (side effects). Goal: 1/24/18 Early interventions to s/s (signs and symptoms) of chest pain/sob (shortness of breath). (Please note there is no indication of what medication side effects the care plan is referring to for R10 and there is no mention of R10 having a history of nose bleeds or that R10 had one recently.) R10's (MONTH) 2019 and (MONTH) 2019 MAR (Medication Administration Record) and TAR (Treatment Administration Record) do not indicate for staff to monitor R10 for bleeding. On 2/19/19 at 4:51 PM, Surveyor interviewed RN C regarding R10's care plan. RN C indicated to Surveyor that R10 is on [MEDICATION NAME] and should have an At Risk for Bleeding Care Plan. RN C indicated at this time that R10 currently does not have an At Risk for Bleeding Care Plan. On 2/20/19 at 10:55 AM, Surveyor interviewed DON B (Director of Nursing) regarding R10. DON B indicated, based on R10's care plan, you would not know that R10 gets nose bleeds or is at risk for or needs monitoring for bleeding. DON B indicated that R10's care plan should have been updated after R10's hospitalization . DON B indicated that the MAR and TAR are part of resident care plans. DON B indicated that she would expect the CNA's Assignment Card for R10 to indicate what symptoms to watch out for (bruising, bleeding etc .). On 2/20/19 at 2:15 PM, Surveyor was informed by SW G (Social Worker) that the facility does not have an anticoagulant policy, just an Anticoagulant Flow Sheet. On 2/20/19 at 2:16 PM, RN C indicated to Surveyor that when a resident is put on [MEDICATION NAME] ([MEDICATION NAME]), they pull out a pink slip (Anticoagulant Flow Sheet) and that they need to make a policy and that they don't have one yet. (Please note that the facility does not have an anticoagulant policy to address what is required/expected of staff in regards to anticoagulant (blood thinner) therapy, such as monitoring of labs, side effects, bleeding potential, other contributing facts or when to seek medical attention.) Example 2 R96 was admitted to the facility on [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. R96's CNA Assignment Card, dated 1/11/19, states, in part: Problem: Potential for Alteration in: Cardio Respiratory perfusion. Related to: End stage [MEDICAL CONDITION]. [MEDICAL CONDITION] ([MEDICAL CONDITIONS]), DM II (diabetes mellitus type 2), post-surgical bypass surgery, [MEDICAL CONDITIONS], ischemic [MEDICAL CONDITION], [DIAGNOSES REDACTED], mitral valve insufficiency. (It is important to note that the CNA Assignment Card does not indicate that R96 is on an anticoagulant, and to monitor for bruising, it does not indicate to monitor for bleeding or to report bleeding to nurse, or to monitor/watch R96 for nose bleed(s).) R96's care plan, printed on 2/19/19, states, in part, the following: 1/11/19 Problem: Potential for Alteration in: Cardio Respiratory perfusion. Related to: End stage [MEDICAL CONDITIONS], DM II, post-surgical bypass surgery, [MEDICAL CONDITIONS], ischemic [MEDICAL CONDITION], [DIAGNOSES REDACTED], mitral valve insufficiency. Manifested by: changing mental status, fatigue, pallor, dyspnea, orthopnea, poor tolerance to activity, SOB (Short of breath), [MEDICAL CONDITION]. Manifested by: Fatigue, pallor, dyspnea, orthopnea, poor tolerance to activity, SOB, increased LE (lower extremity) [MEDICAL CONDITION] to nurse. Anticipate needs. Enc (Encourage) rest periods during the day with LEs(lower extremities) elevated in recliner or in bed. Use of w/c (wheelchair) for mobility long distances with staff assist to propel PRN (as needed) Tubi grips/compression wraps to BLEs (both lower extremities) on in AM (morning), off HS (bedtime) as recommended by therapy. Enc regular exercise as tolerated. Elevate head of bed PRN SOB. (It is important to note that the Comprehensive Care Plan does not indicate that R96 is on an anticoagulant, and to monitor for bruising, it does not indicate to monitor for bleeding or to report bleeding to nurse, or to monitor/watch R96 for nose bleed(s).) R96's (MONTH) 2019 and (MONTH) 2019 MAR and TAR do not indicate for staff to monitor R96 for bleeding. On 2/20/19 at 4:51 PM, Surveyor interviewed RN C regarding R96's care plan. RN C indicated to Surveyor that R96 is on [MEDICATION NAME] and should have an At Risk for Bleeding Care Plan. RN C indicated at this time that R96 currently does not have an At Risk for Bleeding Care Plan. On 2/20/19 at 1:50 PM, Surveyor interviewed DON B regarding R96. DON B indicated when a resident is on anticoagulants it should be on the CNA Assignment Card and the care plan. DON B stated we used to have that on the care plans and DON B was unsure why it was no longer on the care plans. DON B stated she expects staff to monitor for bruising and bleeding and that staff should notify the nurse if a resident is experiencing bruising or bleeding. Surveyor asked DON B for the facility's policy and procedure for anticoagulants. DON B stated they do not have an anticoagulant policy, just an Anticoagulant Flow Sheet. Example 3 R31 was admitted to the facility on [DATE]. R31's most recent Minimum Data Set (MDS), with a target date of 1/17/19, indicates that in the look back period, R31 received anticoagulant medication 7 of 7 days. R31's [DIAGNOSES REDACTED]. R31's Comprehensive Care Plan, initiated 10/23/18, does not include a problem, interventions, or goals related to R31's anticoagulant medication use. R31's CNA Assignment Card, initiated 10/23/18, does not include a problem, interventions, or goals related to R31's anticoagulant medication use. R31's Hospital Discharge Summary, dated 11/9/18, includes, in part: (R31) was recently hospitalized for [REDACTED]. (R31) has had several [MEDICAL CONDITION] emboli throughout the years. (R31) was subsequently found to have a saddle [MEDICAL CONDITION] associated with current [MEDICAL CONDITION] and so was kept a little longer in the hospital . on chronic anticoagulation . Plan: continue current medications . [MEDICATION NAME] 2.5MG (milligrams) daily . R31's Physician Orders, dated 2/1/19-2/28/19, include, in part: Lab/X-ray: INR date 2/4/19 . INR 2/5/19 no finger stick STAT (blood sugar test) . Medications: [MEDICATION NAME] Sodium 4 MG tablet dose by mouth daily 1800 (6:00 PM). First Date: 2/7/19 for [MEDICAL CONDITION] of LE . R31's Physician Note, dated 2/8/19, includes, in part: no bleeding issues . Last INR was high . Medication: [MEDICATION NAME] 2.5 MG tablet by mouth daily for [MEDICAL CONDITIONS]/[MEDICAL CONDITION] . Plan: [MEDICATION NAME] 4 MG daily . On 2/20/19 at 9:15 AM, during an interview, CNA K stated, We don't monitor for much. (R31) is cognitive and tells us if (R31) needs something. We monitor skin if (R31) breaks out and monitored for behaviors, mood, and depression. On 2/20/19 at 10:56 AM, during an interview, DON B indicated that CNAs know what to monitor for regarding a resident's medication use by looking at the resident's Comprehensive Care Plan and the CNA Assignment Card that hangs in residents' bathrooms. DON B reviewed R31's Comprehensive Care Plan and CNA Assignment Card then indicated that they do not include interventions related to bleeding, bruising, or R31's anticoagulant medication use and they should include this. Example 4 R38 was admitted to the facility, on 6/19/16, with [DIAGNOSES REDACTED]. R38 is receiving [MEDICAL TREATMENT] 3 times per week. R38's Annual MDS assessment, on 1/30/19, Section N, notes that R38 is receiving anticoagulants. R38's Physician Orders, signed 2/15/19, includes: [MEDICATION NAME] 7.5 MG daily by mouth at 6:00 PM. Review of R38's Anticoagulation Flow Sheet noted that R38 has been taking [MEDICATION NAME] since 3/20/18. Review of R38's Comprehensive Care Plan, dated 3/20/18, does not address the use of anticoagulant medication or for the need to monitor for bleeding. On 2/20/19 at 2:00 M, Surveyor interviewed RN C about R38 receiving [MEDICATION NAME] and if monitoring for side effects of this medication should be included on R38's care plan, RN C stated it should be and was not.

Based on interview and record review, the facility did not immediately consult with the resident's physician when there is a significant change in the resident's physical, mental or psychosocial status for 1 of 17 residents (R96). The facility did not follow Physician order [REDACTED]. Findings include: R96 was admitted to the facility, on 11/29/18, with a readmission date of [DATE], with [DIAGNOSES REDACTED]. R96's most recent Minimum Data Set (MDS) documents a score of 15 on Brief Interview of Mental Status (BIMS), indicating cognitively intact. R96's Physician order [REDACTED]. Notify physician if weight up 5 lbs (pounds) in 1 week or 2 lbs from day to next. R96's Potential for Altered Renal Function related to: end stage [MEDICAL CONDITIONS] stage IV, DM II (diabetes Mellitus type 2), chronic ischemic [MEDICAL CONDITION], heart failure, hx (history of) GI ([MEDICAL CONDITION]). Manifested by: Critical and changing kidney function lab values, prone to fluid retention with need for diuretic. Variable blood sugars. Approach: Observe labs, VS (vital signs), wt (weight), [MEDICAL CONDITION] The facility did not contact R96's physician on the following dates according to the Physician Orders: 12/6/18: 238.1 12/7/18: 246.9 - Increase of 8.8 lbs or 3.7% (percent) in 1 day 12/8: 251 - Increase of 4.1 lbs or 1.66% in 1 day (or 12.9 lbs and 5.42% in 2 days) 12/14/18: 259.1 12/15/18: 262.0 - Increase of 2.9 lbs or 1.12% in 1 day 12/28/18: 270 12/29/18: 279.8 - Increase of 9.8 lbs or 3.63% in 1 day 1/4/19: 278.9 1/5/19: 285.0 - Increase of 6.1 lbs or 2.19% in 1 day 1/8/19: 284.0 1/9/19: 287 - Increase of 3.0 lbs or 1.06% in 1 day 2/10/19: 255.9 2/11/19: 258.1 - Increase 2.2 lbs or 0.86% in 1 day 2/15/19: 258.5 2/16/19: 264.6 - Increase of 6.1 lbs or 2.36% in 1 day On 12/11/18 at 9:13 AM, R96's Nurses Note states: Call placed to attending physician regarding increase weight and [MEDICAL CONDITION], request for MOM (Milk of Magnesia) for constipation: Awaiting return call. The physician did not call back until 12/13.18. No additional attempts were made to contact the physician before the physician returned the call 2 days later. On 2/20/19 at 1:50 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B if she expects staff to follow Physician Orders. DON B stated, Yes. Surveyor asked DON B if a resident has an order for [REDACTED]. Surveyor asked DON B if a physician does not return a call regarding a weight change, what should staff do. DON B stated staff should call the on-call physician or the Medical Director. DON B agreed that R96's physician should have been notified when weight changes met the Physician's designated parameters and that staff should have followed up with the physician when he did not reply on 12/11.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials including the State Survey Agency for 1 of 15 residents out of a total sample of 17 residents reviewed (R30). The facility did not follow their abuse policy when R30 reported that a staff member on the night shift was rough during care. Evidenced by: On 2/18/19 at 9:49 AM, during an interview, R30 indicated that a staff member on the night shift is sometimes rough during care and grabs R30's arms, causing arms to be sore. R30 also indicated that a girl was rough with R30 through the night of 2/17/19-2/18 /19 and R30 reported it to CNA D (Certified Nursing Assistant) during AM (morning) cares. R30 indicated that this happens about once a week and has reported it each time. On 2/19/19 at 8:21 AM, during an interview, CNA D, indicated that R30 has told CNA D in the past that night shift is rough, but CNA D did not know which night shift staff R30 was referring to. CNA D reported this information to the Unit Nurse immediately upon becoming aware. CNA D stated, I told (RN E) yesterday that R30 said someone was rough with (R30) overnight. On 2/19/19 at 8:53 AM, during an Interview, SW G (Social Worker) was not sure who the facility's Grievance Official is, but thought it could be SW G and would expect staff to report to SW G, DON B (Director of Nursing), or NHA A (Nursing Home Administrator) any concerns that residents voice, especially concerns about their care. SW G did not have any grievances for R30 for the last year. On 2/19/19 at 11:49 AM, during an interview, RN E indicated CNA D came to RN E and said R30 voiced someone was rough with R30 through the night. RN E stated, I didn't see any physical marks on R30. I had several encounters with R30 and R30 never said anything to me. I didn't think much of it. I did not report this to anyone, because I did not see any signs of abuse. RN E indicated that a staff member being rough with a resident could be abuse. On 2/19/19 at 12:03 PM, NHA A indicated that RN E should have reported the allegation to DON B and DON B would be looking into this. NHA A also indicated that he had not reported this allegation to the state. On 2/19/19 at 12:08 PM, during an interview, DON B indicated that, on 2/18/19, CNA J overheard R30 tell Surveyor that a staff member was rough with R30 and reported it to DON B. DON B indicated that she asked a different Surveyor about this conversation and another incident of alleged abuse was told to her at this time. DON B indicated that she did report this to NHA A and she had talked with R30, asking how things were, and R30 did not mention the allegation. DON B indicated that she did not directly ask R30 about a staff member being rough, start a thorough investigation, and had not reported this allegation to the state. DON B also indicated that an allegation of a staff member being rough could be abuse and RN E should have reported this allegation immediately, but RN E thought it was hearsay. Surveyor asked DON B if hearsay of a staff member being rough would raise suspicion enough to investigate. DON B stated, Yes. On 2/19/19 at 12:47 PM, during an interview, DON B indicated that she was going to talk with R30 to try to define what R30 means by the word 'rough' and see what was going on at the time of the alleged incident. DON B indicated that she told a staff member who worked with R30, on 2/17/19-2/18/19 night shift, to remain off while DON B conducted an investigation. DON B also indicated that she was made aware of the allegation around 10 AM on 2/18/19 and did not report this to the state or start an investigation, until now. On 2/20/19 at 12:53 PM, during an interview, DON B indicated that she had started interviews with staff, R30, other residents on the Unit, and she was continuing to investigate. DON B also indicated that an allegation of staff being rough could be abuse and according to the facility's policy and federal regulations this should have been reported to state agency as soon as possible within 24 hours. DON B indicated that through interviewing, she discovered R30's definition of the word 'rough' to be that she was left on the toilet too long. (It is important to note the facility did not report accusation of abuse within 24 hours of becoming aware and it is important to note the new allegation of possible neglect that came from facility investigation initiated two days after abuse allegation was reported to them. The facility provided no evidence that the new allegation was reported to the state agency before Surveyors left the building/survey completion). On 2/20/19 at 1:00 PM, during an interview, NHA A indicated that he was informed about this incident by DON B, on 2/18/19, while she told him of another incident. NHA A indicated that he did not report this allegation to state agency as soon as possible, within 24 hours, according to the facility abuse policy. NHA A also indicated that a report of a staff member being rough with a resident could be abuse. NHA A stated, I did not report it to the state because we interviewed the resident and determined it wasn't abuse, but that she said she was left on toilet too long. (It is important to note the facility did not report accusation of abuse within 24 hours of becoming aware and it is important to note the new allegation of possible neglect that came from facility investigation initiated two days after abuse allegation was reported to them. The facility provided no evidence that the new allegation was reported to the state agency before Surveyors left the building/survey completion).