Every finding on record at Hammond-Henry District HSP

Based on interview and record review, the facility failed to protect a resident from misappropriation of property for one of three residents (R1) reviewed for misappropriation of property in a sample of three. Findings include:The facility's Long Term Care Abuse and Neglect Procedures, revised 10/8/2025, documents, It is the policy of this hospital that all residents will be free from abuse, neglect, exploitation, mistreatment, including injuries of unknown source, involuntary seclusion, and/or misappropriation of property. This form documents that misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. This form documents that if an allegation is made that involves an employee, that employee will immediately be suspended pending the result of the review. The facility's Final Report Misappropriation of Property/Theft, dated 6/12/26, documents that V8 (Environmental Services Staff) found R1's credit card on 6/6/26 in the hallway of the hospital. V8 was off on Monday, so the card was given to V3 (Plant Services Manager) on Tuesday morning. This form documents that due to not recognizing the name on the card, it was taken to lost and found, where V9 (Supervisor) thought it was a long-term care resident. On Wednesday, June 10, 2026, R1 stated that 5 unauthorized transaction attempts were made on his credit card on 6/5/26-6/9/26. This form documents that R1 went into the hospital on Thursday but did not take his wallet. This form documents on 6/5/26 at 10:16am, V4, Housekeeper, was seen entering R1's room to clean. At 11:36am V4 was seen walking towards the area where the card was found. V4 was seen grabbing into her side pocket on her pants as she walked around a pillar. V4 sat down in the chair and appeared to bend down. V4 then immediately got up and went back down the hallway toward maintenance/laundry. On 6/12/26 at 1:30pm, V4 was notified that R1's credit card was compromised and that videos of her in the spot where the card was found. V4 stated that she found the credit card on the floor of the resident's room. V4 stated that she took it, carried it to the hospital's main hallway, and left it on the floor so that someone could find it and return it to the owner. V4 was immediately terminated. V1 provided V4's work schedule, which was 6/5/26, 6/6/26, and 6/7/26, indicating that V4 worked 6/6/26 and 6/7/26 after R1's credit card was found. On 6/27/26 at 9:10am, V1, Administrator, stated that R1's credit card was found in the main hospital area on 6/6/26 by V8, but V8 did not turn it in until 6/9/26. V1 stated that after reviewing the video surveillance, V4 was seen entering R1's room, then walking around to the area where R1's card was found. V1 stated that it appeared V4 took something out of her pocket and sat down in the chair. V1 stated that V4 then immediately got up and walked back where she came from. V1 stated that V4 was terminated. V1 stated that V8 was unsure as to what to do with the credit card, because her direct supervisor was off, so she held on to it till they next day, when they worked together. V1 verified that the allegation of theft investigation was not initiated until 6/9/26, three days after the credit card was found. On 6/27/26 at 11:50am, R1 stated that V1 brought his credit card to him and told him it was found in the hallway of the hospital. R1 stated that he was not in the area where the card was found. R1 also stated that he did not take his wallet with him when he went into the hospital. R1 stated that he called the credit card company, and there were five attempted charges on two different days. R1 stated that one was at an apparel shop, and the others were from Amazon. R1 verified that all the orders were declined by the company. R1 stated that he cancelled the card. R1 also stated that V4 had to really dig for the card because he had it hidden at the bottom and back of his nightstand drawer. R1 stated that he hasn't used the card for over a month. On 6/27/26 at 1:00pm, V7, Human Resources, stated that V4 was terminated on 6/11/26.

Based on observation, interview and record review the facility failed to have a policy and system in place to account for controlled medications. This applies to all 36 residents of the facility.The findings include:The facility's 4/7/26 Centers for Medicaid and Medicare (CMS) form 671 documents the census as 36.On 4/7/26 at 10:35 AM, the facility was observed to have 2 medication carts, one for the long hall, and one for the short hall. Each cart had a narcotic count book and a locked narcotic box inside each cart.The short hallway narcotic book had a shift change narcotic count sheet with the AM shift (12-hour day shift) and PM shift (12- hour night shift) signing on and off their shift. The sheet had a column for added or removed medications and sheets with a total for the sheet counts at the beginning and end of each shift. The short hallway counts sheet shows no AM shift signatures for the beginning or end of the shift, and no signature of the beginning of 4/7/26 with the number of sheets and medications. The long hallway had an additional signature sheet labeled Pharmacy lock box count. On 4/8/26 at 2:00 PM, V9 (Registered Nurse/RN) said one nurse on the unit works 12 hours on the long hallway, and the second nurse works 8 hours taking the short hallway. She said when the 12-hour nurse comes in, they count both carts so the night nurse can go home. And since she was working the short hall, she did not count her cart, she reviewed it when she arrived. She did not sign the count book, and was not familiar with the count sheet, and the adding and subtracting of controlled medications and sheets.On 4/8/26 at 2:10 PM, V3 (RN) said she arrives at 6:00 AM for the 12-hour shift and counts both carts with the night nurse and signs for the narcotic count. She said both nurses sign on the front sheet when the count is correct. She shows this surveyor the Pharmacy lock box count sheet as the all over count accuracy. V3 said the sheet shows the count is accurate and the convenience box usage and storage. The narcotic count sheet showed the count at the end of the night shift 4/8/26 as 16 total medications and sheets for the short hallway cart. The count of sheets and cards was 15. V3 was unable to state why the count was different. No documentation of a sheet removed, or medication removed was noted on the record. V9 was asked if she removed any medications, and she said yes, but did not know to subtract the sheet and medication from the count. V3 and V9 both said there was no way to know what medications were added or removed based on the current documentation process. On 4/8/26 at 2:10 PM, V1 (Administrator) said when night shift is leaving, they count with the day shift, and they both sign the count when it is accurate. The sheets should be signed every day. She said the pharmacy lock box sheet is only for the locked boxes and not for the overall medication counts. V1 said when a controlled medication is removed for any reason, it would be subtracted off the count sheet for the shift. There is no signature or resident name or medication listed. If medication was removed there would be no way of knowing, who did it, or what was taken out. She said the shift nurse would have to ask other nurses if they wanted to know.On 4/9/26 12:15 PM, V1 stated there was no policy regarding the control medication or counting of narcotics.

Based on observation, interview, and record review, the facility failed to perform perineal care for 1 of 1 residents (R18) reviewed for ADL's (Activities of daily living) in the sample of 23.The findings include:R18's electronic face sheet dated 4/9/26 showed R18 has diagnoses including but not limited to anxiety disorder, dementia without behaviors, chronic kidney disease, & rheumatoid arthritis.R18's facility assessment dated [DATE] showed R18 has severe cognitive impairment, is always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for personal hygiene R18's care plan dated 1/26/24 showed, The resident has bladder incontinence .clean peri-area with each incontinent episode .check every 2 hours and as required for incontinence. Wash, rinse, and dry the perineum . On 4/7/26 at 10:48AM, V4 and V5 (Certified Nursing Assistants/CNAs) provided incontinence care to R18. R18's incontinence brief was saturated with urine when removed by V5. V5 cleansed R18's buttocks but did not cleanse R18's groin and genital area that was covered by her soiled incontinence brief. V4 and V5 then applied a clean incontinence brief and clothing for R18 and took her to the lunch room. V5 stated she did provide complete incontinence care to R18.On 4/8/26 at 9:53AM, V6 and V7 (CNAs) provided incontinence care to R18. V6 removed R18's incontinence brief that was saturated with urine and had a strong ammonia type odor. V6 cleansed R18's buttocks but did not provide any cares to R18's groin and genital area. V7 stated they try to go a little quicker with R18 sometimes because she does not like to be washed up.On 4/9/26 at 10:04AM, V1 (Administrator) stated, When a resident has an incontinent episode, staff should be providing complete incontinence care which consists of cleansing a resident's genital area as well as the perineal area. This is done to prevent UTIs (urinary tract infections) and skin irritation. For female residents, they should be cleansing vaginal area every time a resident is incontinent.The facility's policy titled, Performing Perineal Care dated 5/15/24 showed, 1. If performing perineal care for (female patient): gently retract labia from thigh with nondominant hand, then use gently downward strokes with washcloth to cleanse vaginal area, use separate section of washcloth or new washcloth for each stroke .

Based on interview and record review the facility failed to perform weekly pressure ulcer wound assessments and implement pressure ulcer interventions. This applies to 2 of 2 residents (R13, R26) reviewed for pressure injuries in the sample of 23.The findings include: 1. R13's admission Record (Face Sheet) showed an original admission date of 2/17/22 with diagnoses including, but not limited to, Type II diabetes, heart failure, and obesity. R13's In-house Patient Status Change (Hospital Discharge summary) from 2/8/26 showed he had been in the hospital for stroke like symptoms (R13 was in the hospital for less than 24 hours and returned on 2/8/26 at 4:17 PM.) and he also had a pressure ulcer to his right heel and buttocks. The note showed he was only oriented to person. On 4/9/26 at 11:00 AM, a record of all wound assessments for R13's right heel wounds and buttock wounds was requested. The facility provided wound assessments for the right heel as follows: 1) 2/8/26 Progress Note from 4:53 PM showed the wound was measured and it was blue tinted area with the appearance of a bruise. The note did not indicate any treatment or interventions had been initiated. 2) 2/12/26 Wound Care nurse's note from 2:00 PM showed measurements were taken and the resident's wound would be addressed by the podiatrist. 3) 2/20/26 (8 days after last assessment) Podiatrist note showed R13's heel was a pressure ulcer, the skin was intact and was approximately 6 centimeters (cm) in diameter. The note showed the wound was non-blanching, reddened, and bruised. 4) The next provided assessment was a podiatrist note on 4/3/26 (nearly 6 weeks later); however, the note did not mention the right heel wound. R13's February 2026 Treatment Administration Record (TAR) showed skin prep spray.Apply to right heel topically every day and night shift for wound healing. The TAR also showed Pressure relieving boot to the right foot every day and night shift for wound healing. These treatments/interventions were not started until the evening of 2/10/26 (2 days after his return from the hospital.) R13's 2/8/26 Progress Note from 4:33 PM showed .New order for referral to [homecare] for wound care to right heel and buttocks. (The note showed no assessment of the buttock wound.) The initial assessment provided by the facility for a wound involving R13's buttocks was not completed until 3/28/26. The 3/28/26 progress note from 11:24 AM showed, Resident with shearing and open area to left buttock measuring approximately 1.6 cm x 2 cm x 0.5 cm. R13's care plan showed no mention of interventions specific to R13's heel or buttock wounds. At 9:33 AM, V1 (Administrator) stated wound assessments should be completed weekly. V1 said the purpose of wound assessments is to track the progression or decline in wound status. V1 said the wound assessments are an objective measure of wound status. V1 said a wound assessment should include wound size, wound bed description, drainage description, and type of wound. V1 said the purpose of a care plan is so any staff member could reference the document and understand how to care for the residents. V1 said R13's wounds have healed. V1 said staff would have done a full body skin assessment and it was possible the buttock wound was no longer present; however, the staff should have indicated this in a progress note. V1 said the purpose of wound treatments and interventions, like R13's boot, is to promote healing. V1 said, if R13 had no treatment orders and/or interventions upon return from the hospital, nursing staff should have contacted the provider for orders. The facility's Wound Management and Pressure Ulcer Prevention policy (reviewed 2/7/25) showed, 1. Assessment: a. Upon admission to Acute Care and Long Term Care a risk assessment using the Braden Scale Pressure Ulcer Risk Assessment Tool will be completed. b. Upon arrival to the Emergency Department a skin risk assessment is completed. c. The nursing staff identifies the patient's level of risk (low risk/moderate risk/high risk) and implements Standard Pressure Injury Prevention Interventions to minimize their potential for pressure injury. d. Document any skin anomaly on assessment using standardized points of measurement. e. Photos may be taken with patient consent, with two patient identifiers and tape measure in the picture. (The policy does not mention routine, weekly assessments.) 2. R26's electronic face sheet dated 4/9/26 showed R26 has diagnoses including but not limited to urinary tract infection, peripheral vascular disease, chronic kidney disease stage 3, and hypertension. R26's facility assessment dated [DATE] showed R26 has no cognitive impairment and has no pressure injuries. R26's physician's orders dated 2/24/26 showed, Hydrofera blue to great toe right foot and offload right heel with pressure relief (boot) continuously. R26's care plan dated 7/5/24 showed, The resident has potential for pressure injury related to impaired mobility .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. R26's care plan dated 9/17/25 showed, The resident has a chronic non pressure ulcer of the left foot, right heel related to PVD (peripheral vascular disease) .Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R26's podiatrist note dated 2/20/26 showed, There is a large wound on the posterior aspect of the right heel that is difficult to assess in this situation, unstageable at this point and measures approximately 4 cm in diameter. Assessment: pressure ulcer of left heel, unstageable. R26's podiatrist note dated 4/3/26 showed, The wound on the posterior aspect of the right heel measures approximately 2 cm in diameter. On 4/8/26 at 2:11 PM, R26 stated, I have had the wound on my heel off and on for a long time, I came here because of wounds. The nurse that is working usually does my treatments on my foot; it just depends on who is working. I started wearing the heel boot about a month ago because my foot kept rubbing on the sheets, so they gave me a boot to wear. I don't remember them measuring it or anything when they do the dressing changes. On 4/9/26 at 9:33 AM, V1 (Administrator) stated, R26 has had her wounds on and off for a long time. The current treatment for her is offloading. I do not see any weekly assessments in her medical record showing there were any wound assessments other than the 2 visits from the podiatrist on 2/20/26 and 4/3/26. I understand this would be a concern because we are not tracking the progress of the wound and determining whether the current treatment is working or not.

Based on observation, interview, and record review, the facility failed to supervise a resident (R10) when providing toileting assistance. This applies to 1 of 1 residents reviewed for safety and supervision in the sample of 23.The findings include:R10's electronic face sheet dated 4/9/26 showed R10 has diagnoses including but not limited to chronic kidney disease, heart failure, and hypertension. R10's facility assessment dated [DATE] showed R10 has mild cognitive impairment and is dependent on staff for toileting assistance. R10's care plan dated 2/23/24 showed, (R10) has had an actual fall with no injury on 10/25/23 and 2/22/24 and a fall with minor injury on 12/20/23 related to poor balance, unsteady gait .tab alarms added, and to be used while on the toilet. R10's care plan dated 10/1/25 showed, The resident is high risk for fall related to gait/balance problems .follow facility fall protocol. R10's fall risk assessment dated [DATE] showed R10 is a high fall risk. On 4/8/26 at 10:14 AM, V8 (Certified Nursing Assistant/CNA) assisted R10 to sit on the toilet and then left the room to return to her hall she was working. Surveyor conducted continuous observations from 10:14 AM-10:35 AM and no staff entered R10's bathroom to check on her. Surveyor entered R10's bathroom and R10 was sleeping on the toilet. Surveyor had to shake R10's shoulders to wake her up. R10 stated, I've been done for awhile now but nobody came back. At 10:36 AM, Surveyor notified V1 (Administrator) that R10 needed assistance to get off the toilet. V7 (CNA) came and assisted R10 off the toilet and stated neither he or his partner on the hall knew that R10 was on the toilet by herself. On 4/9/26 at 9:33 AM, V1 stated, (R10) is supposed to have a tab alarm in bed, bed in lowest position, floor mats on floor, tabs alarm on when on toilet (initiated 10/25/23). No recent falls for quite some time. She makes her needs known when we ask her. It depends on her day/time of day with her memory and if she can recall instructions or anything we have told her. She does use her call light but she must have forgotten she had one in the bathroom. The CNA who put her on the toilet should have communicated with the aides working that hall that she put R10 on the toilet. Someone should have been checking on her intermittently at least since she is a fall risk. The facility's undated policy titled, Fall Prevention showed, All patient/residents admitted to (facility) will be assessed for fall risk. Fall prevention interventions will be implemented for patients, based on their risk level all long term care residents will be considered high risk for falling.

Based on observation, interview, and record review, the facility failed to ensure a resident's (R31's) urinary catheter drainage bag was kept off the floor. This applies to 1 of 1 residents reviewed for catheters in the sample of 23.The findings include:R31's electronic face sheet dated 4/9/26 showed R31 has diagnoses including but not limited to fracture of right lower leg, urinary retention, hypertension, and fall. R31's facility assessment dated [DATE] showed R31 has no cognitive impairment and has an indwelling catheter R31's care plan dated 4/7/26 showed, (R31) has Indwelling Catheter: Neurogenic bladder. On 4/7/26 at 10:23 AM, R31 was sitting up in his reclining chair in his room. R31's urinary catheter drainage bag was hanging on the side of the recliner, with the bottom of the bag and drainage tube sitting on the floor. R31 stated he has a history of urinary tract infections and his last one was in December 2025. R31 stated staff put a bag over his drainage bag sometimes but they must not be using one anymore because he hasn't seen it lately. On 4/8/26 at 9:22 AM, R31's catheter bag was hanging on the side of his recliner with a privacy bag over it. R31 stated, I told them you were asking about it and looking at it so they put the bag over it. I think they put it on earlier this morning but I can't remember for sure. On 4/9/26 at 9:33 AM, V1 (Administrator) stated, Catheter bags should be placed below the level of the bladder and should not be touching the floor for infection control purposes. If the bag is touching the floor, it could potentially introduce bacteria into catheter bag and lead to a urinary tract infection. The facility's undated policy titled, Indwelling Urinary Catheters showed, iii. collection bags should always be kept below the level of the bladder but should never touch the floor or garbage can .

Based on observation, interview and record review the facility failed to ensure pureed diets were prepared in manner to meet the resident needs for 5 of 5 residents (R10, R14, R27, R34, R36) on puree diets in the sample of 23.The findings include:The facility presented a list of residents with puree diet orders including R10, R14, R27, R34, and R36. On 4/7/26 at 12:00 PM, V11 (Cook) set up the noon meal, including puree foods for altered diets. The pureed foods included chicken and cauliflower. While placing the pureed items on a plate, both foods were running over the plate and had no thickness to them and had a soup consistency. V11 stated they should have been thicker; they are too thin. On 4/7/26 at 12:42 PM, R27 was served her pureed diet including mashed potatoes, chicken, and cauliflower. The chicken and cauliflower were in a puddle on the plate running together. R27 feeds herself; however, the food was running off the spoon onto her clothing protector, approximately half the food making it into her mouth.On 4/7/26 at 12:47 PM, V10 (Dietary Manager) said the pureed consistency can vary, but it should be like baby food.On 4/8/26 at 12:01 PM, V12 (Cook) said the puree food should be at a pudding consistency and should not be dripping off of the spoon. She said if the puree food is too thin the resident could aspirate, and we do not want that to happen.The facility's 1/29/25 policy for pureed foods documents the objective to ensure that each resident on a pureed diet will receive food that is prepared in a manner that will increase acceptance by enhancing intake and tolerance and also provide for consistency in preparation. Procedure: 4. Blend mixture to a baby food or mashed potato consistency.

Based on observation, record review, and interview the facility failed to protect a resident from abuse/mistreatment-specifically, V3/Certified Nursing Assistant-CNA was physically rough when providing incontinence care for one resident (R1) of three residents, reviewed for abuse, in a total sample of three residents. This failure resulted in V3 being physically abusive to R1 which caused R1 to clench her teeth, grimace, moan, cry, cover her face, and attempt to take a protective/defensive position.This failure resulted in an Immediate Jeopardy.While the immediacy was removed on 10/8/25, the facility remained out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include:The Facility abuse policy, entitled LTC Abuse & Neglect Procedures, reviewed 5/3/2021, documents: Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.R1's Electronic Medical Record/EMR document: R1 is not cognitively intact and has a diagnosis of Alzheimer's Disease, Osteoarthritis, Anxiety Disorder, Hypothyroidism, Hemorrhoids, Lyme's Disease, Restlessness and Agitation, Hypertension, Hyperlipidemia, and Depression. On 10/1/25, at 12:30 a.m., a video recording (taken in R1's room) shows during incontinence care: V6/CNA and V3 provided cares; V3 pressed and held R1's hand down on R1's chest; adjusted R1's legs roughly; pressed R1's hand into R1's chest a second time-pushing down twice and R1 stated, I didn't do anything.; V3 roughly adjusted R1's legs again and R1 reached toward V3 and V3 pressed R1's hand back to R1's chest; V3 wiped R1's perineal area forcefully causing R1 to grimace and moan to which V3 responded Sorry, this is what your daughter wanted.; V3 finished incontinence care and pulled on R1's incontinence brief three times firmly enough that R1's body jerked upwards in bed while R1 continued grimacing.On 10/1/25, at 2:13 a.m., a video recording (taken in R1's room) shows: V3 and V6 providing cares; R1's shirt was wet; V3 firmly/roughly pulled R1's shirt off; R1 started crying while covering R1's face with R1's hand; V3 tied the gown and then without lifting R1's head, pulled it over R1's head which caused R1's head to tilt upwards and R1 grimaced.V6's statement to the facility, on 10/2/25, It wasn't just that resident, it was all of them. She was harsh and rough with people. She would snatch them and treated all of the residents like this.On 10/3/25, at 8:30 a.m., V2/Director of Nursing confirmed, in the 10/1/25 video recording which was taken in R1's room, V3 was abusive to R1 and V3's employment was terminated.On 10/7/25, at 9:30 am, V6 stated, during R1's cares, on 10/1/25: (V3) was Horribly rough and mean; overly aggressive, harsh, and unkind; way too hard; Resident (R1) was defensive and in protection mode.; I tried to reassure (R1), but (R1) was stressed with (V3) and that is the reason (R1) was combative because of the harsh treatment. Before we (V3) and (V6) went into the room, (V3) told me to keep my mouth shut and follow her lead. When asked if she felt V3 was abusive, V6 replied, Yes, (V3) was way out of line; and No, I did not report it because as agency, it was my word against hers (V3).The Immediate Jeopardy was identified to have begun on 10/1/25, at 12:30 a.m., when V3 was abusive to R1 during cares. On 10/07/25 at 3:35 p.m. V1/Chief Nursing Officer, V2/Director of Nursing-DON, V15/Risk Manager, and V16/Chief Executive Officer were notified of the Immediate Jeopardy.On 10/08/25 at 10:56 AM the facility submitted the abatement plan.On 10/08/25 at 1:48PM a phone conversation was had with the Facility concerning the submitted abatement plan.On 10/08/25 at 3:16PM the Facility submitted a revised abatement plan.On 10/08/25 at 4:22PM the Regional Office requested a revision to the abatement plan.On 10/08/25 at 5:04PM the Facility submitted a revised abatement plan.On 10/09/25 at 8:37AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 9:11AM the Facility submitted a revised abatement plan.On 10/09/25 at 10:31AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 11AM the Facility submitted a revised abatement plan, and the abatement plan was accepted.On 10/09/25 the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.On 10/2/25, V3's employment, with the facility, was terminated.2.10/2/25 at 1150 V2/DON and V15/Risk Manager performed visual assessment of resident (R1) for signs of physical and emotional abuse, no physical marks noted and patient's emotional status unchanged.3.On 10/8/25 V1/Chief Nursing Officer-CNO, V2, and V15 reviewed LTC/Long Term Care Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.4.V2 reviewed the LTC Abuse and Neglect Procedures Policy and Behavior Standards with the V18/Assistant Director of Nursing-ADON and then all staff on shift on 10/08/25 day shift was educated.5.Staff not working day shift 10/8/25 were called by V18 and V2 and the LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, were reviewed.6.Remainder of staff not working or reached by phone on 10/8/25 will be required to receive education on LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, prior to working next shift by the V2 or V18 and will be tracked on sign-in sheet.7.Long Term Care Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift, completed on October 8th, 2025.8.On 10/8/25 an Emergency QAPI/Quality Assurance Performance Improvement discussion was held with V1/Chief Nursing Officer, V2, V17/Social Services Director-SSD, V20/ Medical Director and V15 to review the resident audit findings performed and review investigation. On-going audit plan was created. Five residents a month will be interviewed by Social Services or V2 or designee about cares received and any concerns regarding cares. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality assurance meetings.

Based on observation, record review, and interview the facility failed to report an allegation of abuse to the abuse coordinator and the State Agency for 2 residents (R1 and R2) of three residents, reviewed for abuse, in a total sample of three residents. These failures resulted in V3/Certified Nursing Assistant-CNA continuing to be abusive to R1 which caused R1 to clench her teeth, grimace, moan, cry, cover her face, and take a defensive/protective posture.This failure resulted in an Immediate Jeopardy.While the immediacy was removed on 10/08/25, the facility remained out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring.Findings include:The facility policy, entitled LTC Abuse & Neglect Procedures, Last Periotic Review 5/3/2021, documents: a. All incidents and allegations will be reported immediately. d. The Nurse Manager will ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after any allegation made if the events that cause the allegation involve abuse or cause serious bodily injury 24 hours if the allegations do not involve abuse or do not result in serious bodily injury, to administrator of the facility and to other officials (including to the State Survey Agency.R1's Electronic Medical Record/EMR document: R1 is not cognitively intact and has a diagnosis of Alzheimer's Disease, Osteoarthritis, Anxiety Disorder, Hypothyroidism, Hemorrhoids, Lyme's Disease, Restlessness and Agitation, Hypertension, Hyperlipidemia, and Depression.R2's EMR documents R2 is cognitively intact with a Brief Interview for Mental Status as 14/15 and has a diagnosis to include: Polyneuropathy, Unspecified Dementia, Chronic Obstructive Pulmonary Disease, Urinary Tract Infection, Iron Deficient Anemia, Hypertension, Chronic Kidney Disease Stage 3, Hypercholesterolemia, Hypothyroidism, Generalized Osteoarthritis, Presence of Cardiac Pacemaker, and Weakness.Facility Document entitled Corrective/Disciplinary Action, dated 02/24/25, documents: It was previously verbally discussed with (V3) that a resident reported she was being rough during a transfer. Concerns were brought forth that she is being rough during rounds and changing.Facility Document entitled Corrective/Disciplinary Action, dated 07/23/25, document: It was reported to Manager on 7/24/2025 that a R2 stated that (V3) was rough during cares; (V3) was rough doing peri care. V3 has violated behavioral standards through these actions. 7/24/25 at 6:26 p.m.- (V8/Registered Nurse) notified (V2/Director of Nursing) that resident (R2) reported that (V3) was rough with her last night and hurt her; (V8) stated, Resident said (V3) pulled her clothes off roughly. R2 said she told (V3) that she was slipping off the toilet and tried to grab the bar. (V3) told her she was fine and didn't need to hold the bar. (R2) said (V3) grabbed her roughly.; (R2) stated (V3) started to undress her and pulled the shirt and jacket off at the same time over the head instead of separately. Resident reported she thought it was going to make a spot on her head bleed. Resident reported she was almost shaking. Resident said, seems like she doesn't like me, I don't like her. Resident reports some nights she is nice. Some nights she is ferocious. Resident stated she didn't know if she could sleep that night but stated she did. Resident stated (V3) has a horrible attitude and I don't know what her problem is. I don't know if it's just me. Resident reports one time she pushed her through the privacy curtain without opening it and the resident hit her on the door.Email communication sent from V4/CNA, witness to 7/24/25 incident, to V2: (V3) and I went into (R1's room) during first rounds to check and change the resident. I grabbed the blue cushion to use and (V3) asked why I was grabbing it to use. I said that we had to use it or at least attempt to use it. (V3) then said, No we don't. and I just nicely mentioned that (R1's daughter would like us to use it or attempt to. I mentioned that (R1's daughter) can see if we are using it or attempting to use it through the camera. (V3) shook her head and said that the daughter was an idiot for coming into the facility with poison ivy on her arms and contaminating everybody, loudly. I said that I was going to stop talking because we were on camera. She said she didn't give a sh*t, I said Well I do. After the conversation was over, she was also somewhat very rough with resident when it came time to do peri care on her.On 10/1/25, at 12:30 a.m., a video recording (taken in R1's room) shows during incontinence care: V6/CNA and V3 provided cares; V3 pressed and held R1's hand down on R1's chest; adjusted R1's legs roughly; pressed R1's hand into R1's chest a second time-pushing down twice and R1 stated, I didn't do anything.; V3 roughly adjusted R1's legs again and R1 reached toward V3 and V3 pressed R1's hand back to R1's chest; V3 wiped R1's perineal area forcefully causing R1 to grimace and moan to which V3 responded Sorry, this is what your daughter wanted.; V3 finished incontinence care and pulled on R1's incontinence brief three times firmly enough that R1's body jerked upwards in bed while R1 continued grimacing.On 10/1/25, at 2:13 a.m., video recording, taken in R1's room, shows: V3 and V6 providing cares; R1's shirt was wet; V3 firmly/roughly pulls R1's shirt off; R1 started crying while covering R1's face with R1's hand; V3 tied the gown and then without lifting R1's head, pulled it over R1's head which caused R1's head to tilt upwards and R1 grimaced.On 10/3/25, V2 confirmed: the 7/24/25 abuse allegation was not reported to the State Agency; the 10/1/25 video recording shows V3 was abusive to R1; V6 did not report V3 abuse of R1; and V3's employment was terminated.On 10/7/25, at 9:30 am, V6 stated, during R1's cares, on 10/1/25: (V3) was Horribly rough and mean; overly aggressive, harsh, and unkind; way too hard; Resident (R1) was defensive and in protection mode.; I tried to reassure (R1), but (R1) was stressed with (V3) and that is the reason (R1) was combative because of the harsh treatment. Before we (V3) and (V6) went into the room, (V3) told me to keep my mouth shut and follow her lead. When asked if she felt V3 was abusive, V6 replied, Yes, (V3) was way out of line; and No, I did not report it because as agency, it was my word against hers (V3).The Immediate Jeopardy was determined to have begun on 7/24/25, when the facility failed to report abuse allegations, to the State Agency. On 10/07/25 at 3:43 p.m. V1/Chief Nursing Officer, V2/Director of Nursing-DON, V15/Risk Manager, and V16/Chief Executive Officer were notified of the Immediate Jeopardy.On 10/08/25 at 10:56 AM the facility submitted the abatement plan. On 10/08/25 at 1:48PM a phone conversation was had with the Facility concerning the submitted abatement plan.On 10/08/25 at 3:16PM the Facility submitted a revised abatement plan. On 10/08/25 at 4:22PM the Regional Office requested a revision to the abatement plan.On 10/08/25 at 5:04PM the Facility submitted a revised abatement plan.On 10/09/25 at 8:37AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 9:11AM the Facility submitted a revised abatement plan.On 10/09/25 at 10:31AM the Regional Office requested a revision to the abatement plan.On 10/09/25 at 11AM the Facility submitted a revised abatement plan, and the abatement plan was accepted. On 10/09/25, the surveyor confirmed through observation, interview, and record review, that the facility took the following actions to remove the Immediate Jeopardy: 1.On 10/2/25, V3's employment, with the facility, was terminated.2.10/8/25 V2 and V18/Assistant Director of Nursing-ADON performed education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.3. V15/Risk Manager reviewed with V2 (designated abuse coordinator) on 10/8/25 policy Abuse and Neglect Procedures specifically for reporting and escalating abuse allegations immediately for review and reporting.4. 10/8/25 V1/Chief Nursing Officer, V2, and V15, reviewed LTC Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.5. V2 reviewed with the V18 the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information. V2 and V18 then educated all staff on shift on 10/8/25 day shift of the above stated policy.6. Staff not working day shift 10/8/25 were called by V18 and V2 and the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.7. Remainder of staff not working or reached by phone on 10/8/25 will be required to receive education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information. prior to working next shift by V2 or V18 and will be tracked on sign-in sheet.8. LTC Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift, completed on October 8th, 2025.9. 10/8/25 An Emergency QAPI/Quality Assurance and Performance Improvement discussion was held with V1, V2, V17/Social Services, V20/Medical Director and V15 to review the resident audit findings performed and reviewed investigation. On-going audit plan was created, to include monitoring of any concerns/complaints to ensure appropriate follow-up to include reporting of any abuse per policy. five residents a month will be interviewed by Social Services or V2/designee about cares received and any concerns regarding staff. These audit findings will be reviewed by V17 and the V2 and reported monthly by the V2 on the QAPI scorecard and at the quarterly Quality assurance meeting.10. V15 will monitor all incidents of patient injury and meet monthly with V2 to review for trends for further review.

Based on observation, interview, and record review, the facility failed to ensure staff change gloves during incontinence care for one resident (R1) of three residents, reviewed for incontinence care, in a total sample of three.Findings include:The video recording, taken in R1's room, on 10/1/25, at 12:30 a.m., shows V3/Certified Nursing Assistant-CNA (employment terminated and unavailable for interview) providing incontinence care (with the assistance of V6/CNA) to R1. Without changing gloves, V3: lowered the bed; pulled down the blankets; pulled out the pillow from underneath R1's buttocks; checked for incontinence; rolled up the reusable incontinence pad from under the resident; rolled R1 to her left side; removed the pillow from between R1's legs; lifted R1's legs and set them on a blue holder; went to R1's closet, reached in, pulled out a clean incontinence brief; walked into R1's bathroom and immediately walked out and went to R1's bed; touched the end of the bed; lowered the head of the bed; placed a clean incontinence brief on R1's bed; walked back to the bathroom; came back out; placed wipes on the bedside table; walked back to the bathroom. walked back to the bedside table with a spray; grabbed the incontinence wipe and threw it on the bed; lifted R1's legs to adjust them; grabbed the wipe and cleaned R1's perineal area; threw the dirty wipe down; grabbed a clean wipe; wiped R1's perineal area; threw the wipe away; grabbed a clean wipe; grabbed paper towels and dried R1's perineal area; adjusted R1's legs and rolled resident over; removed soiled incontinence brief; grabbed a couple clean wipes and wiped R1's buttocks several times; discarded dirty wipe; grabbed a clean wipe; dried R1's buttocks again; discarded dirty wipe; grabbed paper towels and dried R1's buttocks; discarded the paper towels; adjusted the incontinence pad; grabbed the new incontinent brief; tucked the brief under R1; placed the new incontinence brief on R1; removed blue foam pad from under R1's legs and repositions R1; adjusted pillows, blankets, and bed alarm; threw gloves in the trash; pulled out the old trash bag; put a new trash bag in the trash can and then V3 left R1's room. On 10/9/25, at 11:05 a.m., V2/Director of Nursing would not confirm V3 should have changed gloves, from soiled body site to a clean body site, but rather the expectation is to perform hand hygiene for five minutes between dirty to clean surfaces. Per the Center for Disease Control/CDC, glove changes should occur when: If gloves become soiled with blood or body fluids after a task; If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs; If moving from care on one patient to another patient; and If they look dirty or have blood or body fluids on them after completing a task.

Facility Failure resulted in two deficient practices. A. Based on observation, interview and record review the facility failed to monitor the active infections of the unit. This failure has the potential to affect 34 resident who currently reside in the facility. B. The facility failed to perform perineal care in a way to prevent possible cross contamination for one resident (R1) of three reviewed for perineal care. Findings Include: A. The Facility's Departmental Responsibilities for Infection Control Policy document The Infection Control Practitioner (ICP) performs most aspects of the Infection Control Program decided upon by the Infection Control Committee. Time is devoted to surveillance and implementing procedures of reporting infections, staff education, employee health assisting in the development of policies and procedures, resolving problems related to infection control by assuring that isolation practices are working well and doing paperwork. The Facility's undated Antibiotic Stewardship Program documents The ASP (Antibiotic Stewardship Program) team will review infections and monitor antibiotic usage patterns on a regular basis and address an issue regarding antibiotic use if identified. ASP activities reflect the scope and complexity of the services provided (at the facility) Such activities include: observation of trends, retrospective review of antimicrobial use and susceptibility, monthly monitoring of antibiotic days of therapy per 100 patient days, monthly monitoring of defined daily dose of levofloxacin per 100 patient days. On 01/02/2024 at 10:00 AM V3 (Registered Nurse/Assistant Director of Nursing) stated that the facility pharmacy monitors the use of some of the antibiotics and will send memos. V3 stated there was no monitoring of infections per each resident, what the antibiotic was ordered for, what the symptoms were, when the symptoms began, what antibiotic the resident was on and when the symptoms were resolved for each resident. V3 also stated that there was no tracking and trending of where the infections were at in the facility or if there were an increase in any certain type of infections. On 01/02/24 at 1:30 PM V2 (Registered Nurse/Director of Nursing) confirmed that there was no active infection control monitoring for the facility itself for infections and/or antibiotic use. Pharmacy does antibiotic reports for QA (Quality Assurance) reports but nothing on an ongoing basis that I am aware of. Throughout the survey, V14 (Registered Nurse/Infection Preventionist) was not available for interview. The facility's room roster listed 34 residents who currently reside in the facility. B. The facility's undated Hand Hygiene policy all employees will use effective hand hygiene. Hand washing is considered the single most important procedure for preventing the spread of microorganisms that may lead to infection. Hand Hygiene is to be completed at each of the 5 moments, but not limited to, according to the World health Organization, regardless of whether gloves are used or not. Hand Hygiene can occur via hand washing with soap and water or use of alcohol-based hand rub. 1. Before touching a patient 2. before clean/aseptic procedure 3. after body fluid exposure risk 4. after touching a patient 5. after touching patient surroundings. The facility's undated Hand Hygiene policy states that Gloves are to be discard/changed after use on a contaminated body site before moving to a clean body site. On 01/03/24 at 10:15 AM both V2 (Registered Nurse/Director of Nursing) and V3 (Registered Nurse/Assistant Director of Nursing) that the video dated 11/27/24 at 12:07 AM starts as V6 (CNA) is on R1's right side with a towel/drape of some sort on the bedside table with wipes already laid out in a row. V15 (CNA) is on R1's left side and positioning and calming R1. When the video started both V6 (CNA) and V15 (CNA) were already in place with gloves on. V6 (CNA) unfastened the front of R1's incontinent brief and tucked it between her legs. V6 then removed her gloves and performed hand hygiene with hand sanitizer and regloved. V7 (LPN) can then be seen walking into the room with gloves already on and reached into her shirt pocket and removed a tube of cream. V7 opened the tube with her left hand and squeezed some cream into her left hand and applied the cream to R1's front perineal area. V7 (LPN) then puts the tube of cream back into her pocket and moves to the other side of the bed and reaches back into her shirt pocket and removes the tube of cream and opens it with her left hand and squeezes some onto her left hand and applies it to R1's buttocks. V7 then recaps the tube of cream and puts in back in her pocket and the video then stops before the rest of the incontinent care by the CNAs can be observed. On 01/02/24 at 10:15 AM both V2 (Registered Nurse/Director of Nursing) and V3 (Registered Nurse/Assistant Director of Nursing) both confirm that V7 should not have reached into her shirt pocket with gloved hands to retrieve the tube of cream and both V2 and V3 stated that V7 (LPN) should have applied R1's cream to her front perineal area then removed her gloves and performed hand hygiene of some sort and regloved prior to applying the cream to R1's buttocks. On 01/03/24 at 10:30 AM both V2 (Registered Nurse/Director of Nursing) and V3 (Registered Nurse/Assistant Director of Nursing) confirmed that the video dated 12/23/24 at 6:28 PM shows V6 (Certified Nurse Aid) and V9 (Certified Nurse Aid) enter R1's room and perform hand hygiene with hand sanitizer and then donned gloves. V9 (CNA) had her towel/drape on the bedside table with the wipes already pulled out of the package and lined up on the assumed clean towel/drape. V6 comforted R1 while V9 (CNA) used a wipe and wiped R1's left groin, threw it away, used another clean wipe for R1's right groin, threw it away and then used another clean wipe while cleaning R1's pessary area (vaginal slit area) and then threw it away. V9 then changed gloves without any hand hygiene. V10 (Registered Nurse) can then be seen entering the room, performing hand hygiene with hand sanitizer and then donned gloves. V10 opened a tube of cream that she had laid on the bed and could be seen obviously touching the tip of the tube while squeezing some cream onto her fingers and left the tube open and in her left hand. V10 (RN) then applied some cream to R1's groin area, squeezed more cream onto the same fingers and hand while obviously touching the tip of the tube and applied more to R1's perineal area. V10 (RN) then moved to the other side of the bed and V6 (CNA) rolled R1 so that V10 could squeeze more cream onto the same glove and same finger/hand and apply it to R1's buttocks. V9 (CNA) then removed R1's incontinent brief and incontinent pad and removed her gloves and performed hand hygiene and completed R1's care without any further cross contamination of R1 or the environment. On 01/03/24 at 10:30 AM both V2 (RN/DON) and V3 (RN/ADON) confirmed that when V9 (CNA) changed her gloves after she had wiped R1's front perineal area that she should have performed hand hygiene of some sort. Both V2 and V3 confirmed that V10 (RN) should not have touched the tip of tube of cream with her fingers at any time and that once V10 applied the cream to R1's front perineal area she should have removed her gloves, performed hand hygiene and donned new gloves before applying the cream to R1's buttocks. On 01/03/24 at 11:00 AM both V2 (Registered Nurse/Director of Nursing) and V3 (Registered Nurse/Assistant Director of Nursing) confirmed that the video dated 12/31/24 at 12:18 AM shows V6 (Certified Nurse Aide), V7 (Licensed Practical Nurse) and V8 (Certified Nurse Aid) all enter R1's room and don gloves. V6 (CNA) and V8 (CNA) position R1, V6 unfastened the front of R1's incontinent brief and pushed it in between R1's legs and then without changing gloves or hand hygiene, turned to the bedside table and pulled wipes out of the wipe package. V6 stated she did not have enough wipes to perform incontinent care at that time so V8 left the bedside with her original set of gloves on and went to the bathroom door and opened it and went inside. A couple seconds later V8 returned to the bedside with a new package of wipes that V6 then opened and put a couple on a towel on the bedside table. V6 then used her gloved hands to open R1's bedside drawers but did not state out loud what she was looking for. V6 then used her right hand to wipe the top of R1's pubic area and threw it away. V6 used another wipe and wipe on R1's left groin area, pulled the wipe out, flipped it inside out and wiped R1's right groin and threw it away. V6 then used a new wipe to cleanse R1's urethra. V6 then took her gloves off and put new ones on without performing any hand hygiene. V7 (LPN) then reached into her shirt pocket with her gloved hand and pulled out a tube of cream. V7 opened the tube with her gloved left hand and squirted some cream on her left fingers while obviously touching the tip of the tube before resealing it and putting it back into her shirt pocket. V7 then applied the cream to R1's right and left groin areas. R1 was rolled to the side and V6 (CNA) wiped her with a wipe and then stated, I need to dry her and wiped her with another type of cloth. V7 then pulled the tube of cream out of her shirt pocket and opened it with her right hand and squeezed some cream on her right fingers while obviously touching the tip of the tube and then closed it and dropped it back in her pocket and then applied to the cream to R1's buttocks. V6 (CNA) then pulled out the incontinent pad and rolled up incontinent brief with her gloved hand and then used the same gloved hand to get the new incontinent pads and briefs and apply those to R1. On 01/03/24 at 11:00 AM both V2 (RN/DON) and V3 (RN/ADON) both confirmed that after V6 unfastened R1's incontinent brief and pushed it between her legs that V6 (CNA) should not have touched the wipe package or the drawers. Both V2 and V3 stated that V8 (CNA) should not have kept her gloves on when she left the bedside to get more wipes out of the bathroom. Both confirmed that V8 should have removed her gloves, performed hand hygiene of some sort, obtained the wipes and gave them to V6 (CNA) then V8 (CNA) should have performed hand hygiene and regloved. Both V2 and V3 confirmed that V7 (LPN) should not have reached into her pocket with a gloved hand and that V7 shouldn't have touched the tip of the tube. Both V2 and V3 verified that V7 (LPN) should have removed her gloves, performed hand hygiene and regloved before she put the cream on R1's buttocks. V2 (RN/DON) and V3 (RN/ADON) both confirmed that V6 (CNA) should have removed her gloves and performed hand hygiene after she removed the soiled incontinent pad and incontinent brief before she applied the clean incontinent pad and incontinent brief.

Based on observation, interview and record review the facility failed to perform hand hygiene before starting incontinence care and throughout incontinence care for one resident (R24) of three residents reviewed for urinary incontinence care in a total sample of 14. Findings Include: The Facility's undated Hand Hygiene policy and procedure documents that handwashing is to occur when a. hands are visibily soiled b. before eating c. after use of the bathroom d. when there is significant build-up of alcohol based hand rub e. caring for a patient on enteric isolation. The Facility's undated Hand Hygiene policy documents Gloves are to be discarded/changed after use on a contaminated body site before moving to a clean body site. On 9/25/24 at 2:40 PM V7 (Certified Nurse Aid) and V8 (Certified Nurse Aid) had gloves on and transferred R24 with a mechanical lift from the toilet to the bed. V7 and V8 both undressed and rolled R 24 while preparing her for incontinence care. V7 used warm wipes to wash R24's front perineal area and then assisted V8 to turn R24 to her side. V7 then changed gloves without washing hands or performing any sort of hand hygiene and washed R24 buttocks. V7 and V8 then rolled R24 back on her back, pulled up her pants, adjusted her shirt and pillow all without changing gloves, removing gloves or doing any sort of hand hygiene. On 9/25/24 at 3:30 PM V7 (Certified Nurse Aid) confirmed that she had not done any hand hygiene during incontinence care and that she should have every time she changed her gloves to prevent cross contamination of R24 clothes and bed.

Based on observation, record review and interview, the facility failed to ensure a controlled substance medication was reconciled at the time of medication administration for one of ten residents (R21) reviewed for controlled medication in the sample of 24. Findings include: The facility's Medication Administration policy (undated) documents Objective/ Purpose: To provide safe, consistent method to administer medications. Controlled Substances: Controlled substances are to be signed out on controlled substance sign out sheet and charted as they are given. On 8/22/23 at 2:00 PM V6 (Registered Nurse) completed a controlled substance count. During this count, R21's Controlled Substances Proof of Use form for Lorazepam 1 milligram (controlled substance medication) documented the count of remaining pills should be 28. At this time the actual count that V6 had of R21's Lorazepam was 27. V6 then stated I gave (R21) a dose at 12:15 PM today. I usually sign them out as given, right when I administer the medication. That's what we are supposed to do. I am not sure why I didn't with this one. The sign-out sheet should say 27.

Based on interview and record review, the facility failed to ensure an end of life care plan includes Hospice services that identify specific resident needs and individualized interventions and ensure Hospice plans of care were kept updated in the resident's record for three of three residents (R1, R6, R8) reviewed for Hospice in the sample of 24. Findings include: The facility's Interdisciplinary Plan of Care policy (undated) documents, All Long Term Care residents will have a comprehensive interdisciplinary care plan developed with quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment. This policy also documents, All staff will be familiar with each resident's plan of care and are responsible for implementation of plan of care. Care plans will be continuously evaluated by each discipline and modified as indicated. The facility's Hospice Programs (undated) policy documents, Policy: Staff members will follow the policies/procedures of Hospice agency depending upon the admitting. Procedure: Communicate with hospice staff members regarding admissions of hospice patient. Follow the plan of treatment which has been initiated. The facility's (undated) Hospice Nursing Facility Hospice Service Agreement documents, C. Hospice will furnish a copy of each Hospice patient's Plan of Care to the facility at the times of the resident's admission into the Hospice program. The Plan of Care will be furnished to the facility in the form of Physician orders. K. Facility acknowledges and agrees that when facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by Hospice and delineated in the Hospice patient's Plan of Care. Facility personnel may administer the therapies where permitted by State law and as specified by the Facility. 1. R1's current Hospice Plan of Care, dated 6/21/23, documents that R1 was admitted to hospice services on 2/2/23 with the diagnosis of senile degeneration of brain. The Plan of care also documents that R1's current benefit period is 5/3-7/31/23. R1's Physician's orders, dated 8/1-8/31/23, have no documentation of an order for R1 to receive hospice services. R1's facility care plan, dated 2/6/23, documents, R1 was recently admitted to hospice services. R1's care plan is not revised to include person centered interventions to address end of life care. On 08/24/23 at 10:54 AM, V3 (Minimum Data Set Coordinator/Infection Preventionist) confirmed that R1 is receiving hospice care, however R1's care plan does not document her hospice diagnosis nor interventions to address end of life care. 38396 2. R6's Hospice Plan of Care, dated 6/19/23, documents that R6 is a hospice patient with the diagnosis of Coronary Artery disease. The Plan of care also documents that R6's benefit period is 3/31/23-6/28/23. R6's facility care plan, dated 1/31/23, documents, (R6) has a terminal prognosis related to failing health. R6's care plan is not specific to Hospice services or what Hospice cares R6 is receiving. 3. R8's Hospice Plan of Care, dated 6/20/23, documents that R8 is a hospice patient with the diagnosis of Parkinson's disease. The Plan of care also documents that R8's benefit period is 5/26/23-7/24/23. R8's facility care plan, dated 5/25/22, documents, (R6) has a terminal prognosis related to end stage disease. R8's care plan is not specific to Hospice services or what Hospice cares R8 should receive. On 8/23/23 at 12:35 PM V2 (Registered Nurse) stated We didn't have the updated Care Plan from Hospice in the building until today. They (Hospice services) said they have volunteers who bring them and the last delivery there was an (unknown) issue. Hospice just came in today and brought the updated Hospice care plans for (R1, R6 and R8).

Based on record review and interview, the facility failed to notify the Ombudsman of a resident (R13) transfer to the hospital. This failure had the potential to affect all 36 residents residing in the facility. Findings: R13's Nursing note, dated 7/4 at 6:34 p.m., documents, R13 sent to ED (Emergency Department) for evaluation and treatment after resident became lethargic, had emesis and was not able to take her evening medications. T (temperature) 101.4 attempted to give Tylenol but was unable to get her to open her mouth. R13's ED Report, dated 7/4/23, documents, Diagnosis/Problems: Pyelonephritis; altered mental status, elevated troponin. Disposition: admitted in patient to our hospital. R13's MDS (Minimum Data Set) log, dated 8/24/23, documents that R13 had a discharge return anticipated on 7/4/23. R13's current medical record has no documentation of the Ombudsman being notified of R13's discharge to the hospital on 7/4/23. On 08/24/23 10:34 AM, V1 (Director of Nursing) stated, The ombudsman is not being notified of any residents when they are discharged to the hospital. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents form 672, dated and signed by V3 (Minimum Data Set Coordinator) on 8/21/23, documents that 36 residents reside in the facility.

Based on interview and record review, the facility failed to administer medications per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Facility Medication Administration- Paper MAR/Medication Administration Record, no date, documents All medications will be given safely according to physician instructions. Procedure: Check MAR with physician orders. Check medications with MAR assuring the five rights are met: right time, right dose, right route, right patient, right medication. R1's initial and final medication error faxed to state agency on 4/12/22 documents On 4/12/22 (V3) Consulting Pharmacist and (V4) Manager discovered an administration error had occurred for (R1). On 4/4/22 (R1) received a new order for [MEDICATION(S)] (medication for overactive bladder) XL 10mg (milligrams) every night and to discontinue [MEDICATION(S)] 5mg BID (twice a day). On 4/7/22 the monthly medication change over happened and the two cards for (R1's) [MEDICATION(S)] were not removed form the box of new meds from pharmacy. Resulting in (R1) receiving [MEDICATION(S)] 5mg BID on 4/7, 4/8, 4/9, 4/10, 4/11 and 4/12 (am) along with the [MEDICATION(S)] 10mg XL at night. R1's Note to Attending Physician, dated/signed 4/4/22 by R1's physician, documents [MEDICATION(S)] XL 10 mg at bedtime in an attempt to reduce R1's falls and drowsiness. R1's Paper MAR, dated April 4, 2022, has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician Order Sheet/POS and paper MAR for April 2022 has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/22 at 11:36am, V5 RN/Registered Nurse stated I took (R1's) order 4/4/22. I transcribed it to (R1's) MAR for the [MEDICATION(S)] 10mg at bedtime. I discontinued her prior order for [MEDICATION(S)] 5mg BID. I pulled her 5mg tablets from the medication cart. Medication change over happened on April 7th where I took all the medications delivered by pharmacy on the 4th and put in my medication cart. In those medications (R1) had both [MEDICATION(S)] 5mg and 10mg which was put into the medication cart. We dispense medication by the day of the month, so today is the 19th I would punch out the number 19 on the medication card, that is how we know the medication has been given, and for tracking purposes besides the MAR. The 5mg BID [MEDICATION(S)] that was given on April 7th, 8th, 9th, 10th, 11th, and once on the 12th is not marked on the April MAR because it was discontinued off the MAR April 4th, but we know (R1) was given the [MEDICATION(S)] 5mg BID and [MEDICATION(S)] 10mg daily because they were punched out of the medication cards on those days. The medication cards are marked as AM/morning, noon, PM/night, HS/hour of sleep, and other specific times so we know when to give the medications without needing to look at the MAR. I did not look at the MAR very well when giving (R1) her medications. I give the medications and then go back and mark them off the MAR when medication pass is done. I do not sign out and look at the MAR when giving medications because I know what they take, I have worked here for two years, and I work full time four days a week from 7:30am until 4pm. Multiple nurses gave the [MEDICATION(S)] 20mg when it was supposed to be 10mg. On 4/19/22 at 12:05pm, V3 Consultant Pharmacist stated I come to the home once a month and look over medications. I had a pharmacy recommendation that was signed for (R1) to change her [MEDICATION(S)] from 5mg BID to 10mg XR daily to help with her falls. I asked (V4/RN Manager) to check the medication cart to make sure (R1's) 5mg medication was pulled and (R1) was only getting 10mg of the [MEDICATION(S)]. (V4) told me both medications (5mg and 10mg) were in the medication cart and had been administered to (R1). (R1) was getting 20mg instead of the 10mg daily. This happened at the time of medication turn over (April 7th) where they need to exchange out the medication cards being used for new medication cards for the new month. They get medications a month at a time to keep in their carts. The new medications were delivered on April 4th, and the new order for (R1) was received on April 4th, so the nurses needed to make sure the medications put in the cart matched the orders. On 4/19/22 at 12:30pm, V4 RN Manager stated On 4/4/22 a new order was written for (R1) to get [MEDICATION(S)] 10mg daily at bedtime. The old order for 5mg's BID was discontinued off (R1s) April MAR and the new order for 10mg's was transcribed onto (R1s) April MAR on 4/4/22. V5 RN took the order, made the changes on (R1's) MAR (paper), and took the 5mg [MEDICATION(S)] medication out of the medication cart. Medication change over for the month was on April 7th. On April 7th, (V5) took (R1's) medication delivered from pharmacy and put the medications in the medication cart. In those medications was (R1's) [MEDICATION(S)] 5mg and 10mg tablets. (V5) needed to take the 5mg [MEDICATION(S)] out of those medications but she did not so (R1) got too much [MEDICATION(S)] until it was discovered on April 12th when I was asked by (V3) to look at (R1's) medications in the medication cart when both the 5mg and 10mg [MEDICATION(S)] tablets were in the cart being administered to (R1). I know she was getting both of them because the medication cards are numbered 1-31 for the days of the month, and the staff push out the medication on the day they are delivered so we know the medications are given on that day. On 4/19/22 at 1:01pm, V2 RN DON/Director of Nursing stated (R1's) original order was for [MEDICATION(S)] 5mg BID but was changed to [MEDICATION(S)] 10mg XR for her at bedtime for the sake of drowsiness and falls as a medication review of her falls. The order was received on April 4th, medication change over happens on the 7th, the cards were pulled from the medication cart on the 4th but not from the new medications which contained both the 5mg and 10mg [MEDICATION(S)]. It appears the nurses were not following their MAR when administering medications.

Based on observation, interview and record review, the facility failed to assess, monitor and document wound care for a abdomen and thigh burn for one resident (R1) of three residents reviewed for accidents. Findings include: Facility Policy/Wound Management Pressure Injury Prevention (undated) documents: When a pressure injury or wound is present: - Nursing staff should perform a skin assessment every shift - Follow a Physician's wound care orders or nursing wound skin care protocol - Measure any suspected pressure area or existing wound using standardized points of measurement during each assessment Current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Facility Incident Report/Summary (undated) indicates that on March 18, 2022 at 4:00pm, R1 was drinking coffee in the dining room prior to dinner when R1 spilled the coffee on her abdomen and right thigh. This report indicates redness was immediately noted to the affected areas and at bedtime blisters started to form. This report indicates that on March 21, 2022 V2, DON (Director of Nursing) spoke with R1 regarding the incident and noted the burn areas to Have redness and a few blisters. The report as of April 1, 2022 indicates the blisters to R1's abdomen remain intact with one scab to right thigh. Physician's Assistant (PA) Note dated 3/22/22 indicates, Staff reports (R1) recently spilled hot coffee on abdomen and thigh. Skin: Blisters with mild [CONDITION(S)] (redness) to abdomen, dressed with bandages; continue wound care for [CONDITION(S)]. Nurse Note dated 4/5/22 at 9:34am indicates blister to (R1's) abdomen opened and drainage noted, open area measuring 4.7cm (centimeters) wide X 2.2cm length. Nurse Note indicates Physician notified and treatment order received to apply a topical antibiotic/antimicrobial cream two times per day for 10 days to the affected areas. On 4/5/22 at 2:00pm, R1 had an open partial thickness, oval shaped wound on lower abdomen. Wound borders were irregular in shape and reddened. Wound bed was 75% covered in greenish/yellow slough with yellow/gray drainage noted on the dressing covering the wound. R1 had an irregular shaped brown/red scab along the top of her right thigh with diffuse red/dark pink skin along the edge of the wound spreading out toward her inner, medial thigh. Nurse Note dated 4/6/22 at 11:09am indicates R1's abdominal wound bed is covered with 95% slough, peri wound is red and minimal serosainguinous fluid on old bandage. R1's Medical record contained no monitoring, treatment or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation on 4/5/22 and 4/6/22 did not include assessment of scabbed area on R1's right thigh that was also caused from the hot coffee burn on 3/18/22. On 4/5/22 at 2:10pm V6, Charge RN (Registered Nurse) stated that no treatment orders were obtained/documented (for R1). We just monitor, and the monitoring is not documented. We just got report from nurse to nurse to monitor. V6 stated that R1 was seen by the Physician's Assistant last week and just wrote to keep a treatment on the blister. V6 stated that the treatment wasn't specified and no one called to clarify. On 4/6//22 at 9:00am V2, DON (Director of Nursing) stated that the scab on R1's right leg should have been measured and all areas assessed and monitored until healed.

Based on observation, interview and record review, the facility failed to prevent a second degree burn from hot coffee for one resident (R1) of three residents reviewed for accidents. Findings include: Current Physician Order Sheet indicates R1 is [AGE] years old with diagnoses that include Dementia. Current Comprehensive Assessment (dated 3/21/22) indicates R1 has moderate cognitive impairments. Facility Incident Report/Summary (undated) indicates that on March 18, 2022 at 4:00pm, R1 was drinking coffee in the dining room prior to dinner when R1 spilled the coffee on her abdomen and right thigh. The report indicates redness was immediately noted to the affected areas and at bedtime blisters started to form. The report indicates that on March 21, 2022 V2, DON (Director of Nursing) spoke with R1 regarding the incident and noted the burn areas to, have redness and a few blisters and that R1 stated she dropped the cup of coffee. The report indicates staff gave R1 a cup of coffee - per R1's request - in a green mug without a lid. Report indicates staff were educated to always provide cups to R1 with a spouted lid due to shakiness and potential to spill hot/cold liquids on self. The report indicates that the coffee that burned R1 was made in a (single serving style) coffee maker. The report as of April 1, 2022 indicates the blisters to R1's abdomen remain intact with one scab to right thigh. On 4/5/22 at 10:25am V5, Dietary Manager stated that the coffee that burned R1 came from a (single-serving style coffee maker) - not from the coffee dispenser in the resident dining room. V5 stated that coffee in the dining room dispenser is temped every morning. The coffee that was given to R1 was made from a coffee maker that is not part of the dietary department, It belongs to nursing and we don't have anything to do with that. On 4/5/22 at 2:00pm, R1 had an open partial thickness, oval shaped wound on lower abdomen. The wound borders were irregular in shape and reddened. The wound bed was 75% covered in greenish/yellow slough with yellow/gray drainage noted on the dressing covering the wound. R1 had an irregular shaped brown/red scab along the top of her right thigh with diffuse red/dark pink skin along the edge of the wound spreading out toward her inner thigh. On 4/6/22 at 1:00pm V7, Physician, stated that if a burn has blistering it is a second degree partial thickness wound. V7 stated that he ordered a topical antibiotic treatment when the blister popped and the wound was open. V7 stated that he did not want to order oral antibiotics as R1 was just recovering from an intestinal infection. On 4/5/22 at 2:10pm V6, Charge RN (Registered Nurse) stated, (R1) is shakey with her one good hand at times and would spill her juice on her clothes. V6 stated that R1 is unable to use her other arm and they had just started testing different style cups with lids (prior to the coffee spill), to reduce the spilling. R1's Nutrition Note dated 3/24/22 at 10:30am indicates Nutrition Diagnosis: Self-feeding difficulty; Intervention: sippy cup. R1's Care Plan was reviewed and no care plan had been developed - before or after being burned with hot coffee - to address the problem or implement interventions related to R1 spilling liquids while drinking.

Based on interview, observation and record review, the facility failed to label and date opened food items in the kitchen and ensure that kitchen equipment was clean. These failures have the potential to affect all 37 residents residing in the facility. Findings include: The facility's Storage of Food policy (undated) documents the following: When a new food item is opened, it is to be labeled and dated. The label is to indicate product name, date opened and use by date. The facility's Equipment Cleaning Nutrition Services Department policy (undated) documents, Daily cleaning and sanitizing of surfaces is part of daily tasks. This policy also documents, Outcome: Equipment will be cleaned and maintained in good working order. On 12/13/21 at 10:30am, there were five, 56 ounce opened cans of a dark brown oily substance sitting on the floor, between the stove and the steam kettle. Inside the door to the dish room, there were two large pans of a dark brown oil, sitting on the floor. V3, Dietary Manager, stated that the five 56 ounce cans were liquid that was drained out of the kettle steamer, the two large pans were oil drained from the deep fryer the previous night. V3 stated that all of the containers should have been disposed of at the time they were drained out of the equipment, not left sitting on the floor. At this same time, the grill had grease and debris on it, and what appeared to be dried eggs running down the side of the grill. V4, Cook, stated that the grill will not be cleaned until after dinner. V4 verified that the substance on the side of the grill was eggs that were cooked for breakfast. At this time, there were two opened bags of shredded cheese that did not have an open date. V3 verified that everything is to have an open date on it. There were four containers of opened dry cereal that were undated. The facility Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Service/CMS 672) form, dated 12/13/21, documents there are 37 residents residing in the facility.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent the elopement of a resident, for one of three residents (R1) reviewed for elopement. Findings include: R1 was admitted to the facility from home on 9/24/21 with diagnoses of Dementia. On 10/27/21 main entrance/exit doors were noted to be adjacent to the dining room. These doors exited directly into an indoor hallway of the main hospital. A wander alarm keypad was noted near the main doors within the unit and only alarmed if a resident with an alarm bracelet was nearby the doors. Entrance/exit to the unit is not dependent on keying in a code, access into and out of the unit is accessible without staff assistance. The keypad is only used to deactivate the alarm. On 10/27/21 R1 was observed at times walking in the hallway, in R1's room and at scheduled activities. R1 was able to ambulate without difficulty and without any assistance. Social Service Note dated 9/24/21 at 2:43pm indicates Therapy and nursing state wander alert bracelet to be placed on resident due to dementia and memory loss. Nursing Note dated 9/24/21 at 3:07pm indicates R1 wears a wander alert bracelet on for safety due to forgetfulness. Current Comprehensive Assessment indicates R1 is independent in mobility/ambulation and does not require any assistive mobility devices. On 10/27/21 V2, Nursing Supervisor stated that on admission R1's family indicated that R1 wanders. V2 also stated that R1's family works in the hospital attached to the facility unit and R1 often is looking for her (R1's family) because R1 knows she (R1's family) works there. Elopement Risk assessment dated [DATE] indicates R1 scored 10 and on 9/30/21 scored 26. Assessment Form indicates that a score of 10 or greater is determined to be an elopement risk. Nursing Notes indicate wandering and exit-seeking behavior occurred on the following dates: 9/25/21 at 5:53pm - R1 trying to leave unit, wants to get to the hospital to find daughter. 10/4/21 at 1:37pm - R1 tried twice to leave out of the front doors; first time turned around when alarm activated and second time tried to enter the code into the keypad to stop the alarm. Also tried to exit through a side door. 10/4/21 at 9:25pm - R1 tried to exit from the unit at least 6 times in the evening. 10/8/21 at 11:34pm - Staff had a lot of trouble keeping track of R1 during the night; walks all over the unit and several times could not be found, then located in other resident's rooms/bathrooms. Nursing Note dated 10/19/21 at 7:55pm indicates that shortly after 6pm it was observed that R1 was missing. Staff did a room to room search, however R1 was not located. Note indicates at that time search was widened to outside areas of the unit including searching in the hospital adjacent to the facility unit. Note indicates shortly after the search was widened, V4, LPN (Licensed Practical Nurse) received a call from Radiology stating R1 was in their department. On 10/27/21 at 3:20pm V3, CNA (Certified Nurse Assistant) stated that at 6pm on 10/19/21 she was just starting her shift and sat down at the computer in the nursing station nearest the dining room and main entrance/exit doors. V3 stated that while she was logging into the computer the alarm at the main doors went off. V3 stated that she saw R1 walking nearby the doors and trigger the alarm. V3 stated that she continued to stay at the computer, believing she had enough time to log her entrance time into the computer. V3 stated that while she was at the computer she saw R1 walk past her and believed R1 was going down to her room. V3 stated that shortly after that she turned off the alarm at the front door and a short while after that V9, Activities asked her if she had seen R1 and that R1 was not in her room. V3 stated that V4, LPN was nearby and was immediately told that R1 was missing. V3 stated that room to room and outside area searches were done. V3 stated that R1 was found in the X-ray department of the hospital. V3 stated that R1 must have looped around and went back through the dining room and out the main doors (while the alarm was still activated) into the hospital while she (V3) was at the computer, instead of going down to her room. V3 stated it was change of shift and there were no other staff nearby at the time.V3 stated that she delayed turning off the alarm and should have turned off the alarm right away and redirected R1 away from the door. Incident Investigation Report dated 10/22/21 indicates the time R1 was off the unit was 10 to 15 minutes and that R1 was found not far from the facility unit in an adjacent hospital department. Elopement Debriefing dated 10/20/21 documents: When the (wander alert alarm) goes off at a door, it is absolutely required for a staff member to identify the resident, assure the resident has returned to a safe placement on the unit and is directed appropriately. The alarm should never be turned off without those three steps completed.