Every finding on record at Harmony Manor Skilled Nursing Facility

Based on interview, personnel record review, and document review, the facility failed to ensure annual behavioral health care training was completed for 1 of 18 sampled employees (Employee #7). This deficient practice had the potential to prevent residents with behavioral health care needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being.Findings include:Employee #7Employee #7 was hired as a Certified Nursing Assistant (CNA) on 06/17/2019.Employee #7's personnel record documented annual behavioral health care training completed on 04/11/2025, however lacked documented evidence of behavioral health care training completed in 2026.On 04/22/2026 at 1:45 PM, the Human Resources (HR) Director verbalized dementia care training (behavioral health care training) was to be completed annually for all staff on or before the date of last completion. The HR Director verbalized Employee #7 was assigned behavioral health care training for 2026; however, Employee #7 had not yet completed the assigned training. The HR Director confirmed Employee #7 did work in the memory care unit of the facility and did have contact with residents diagnosed with dementia and Alzheimer's disease.The facility policy titled, Requirements for Staff Training in Alzheimer and Dementia Care, reviewed 11/07/2025, documented all staff employed by the facility with direct contact with resident with dementia must complete continuing education related to dementia for every year after the first year of employment.The Facility Assessment, updated 03/2026, documented staff would receive ongoing annual training in dementia care.

Based on observation, interview, record review, and document review, the facility failed to ensure a care plan was developed with interventions to assist a resident to maintain continence after the previously continent resident began to experience occasional incontinence for 1 of 12 sampled residents (Resident #24). This deficient practice had the potential to result in staff not offering the resident services or assistance to maintain continence resulting in the resident experiencing worsening urinary incontinence.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis, unspecified and polyneuropathy, unspecified.On 04/20/2026 at 2:15 PM, the resident verbalized the resident had recently started experiencing occasional urinary incontinence but was still able to get to the bathroom once the resident realized they were urinating. The resident verbalized the resident could not recall any staff prompting the resident to go to the bathroom to urinate at timed intervals.A Minimum Data Set 3.0 (MDS) Assessment, dated 07/07/2025, documented the resident was always continent of bladder.An MDS Assessment, dated 04/06/2026, documented the resident was occasionally incontinent of bladder.The Care Plan for Resident #24 did not include a focused care area with interventions related to the resident's recent issue of urinary incontinence.On 04/22/2026 at 8:31 AM, the Director of Nursing (DON) verbalized the resident had become increasingly incontinent of urine over the last several months and the DON believed the incontinence was due to the resident's diagnosis of multiple sclerosis. The DON verbalized the facility could try to offer the resident assistance with a toileting schedule. The DON confirmed the resident's care plan did not include a care area or interventions related to the resident's concerns related to new onset urinary incontinence. The DON verbalized the facility did not have a policy for a bladder training or retraining program.A facility policy titled Resident Assessment Process, documented the purpose of developing a Care Plan was to establish a course of action (specific interventions) to be completed by staff knowledgeable about the resident's needs, develop care goals and approaches to carry out the how and when of resident care.

Based on observation, interview, record review, and document review, the facility failed to ensure a previously continent resident received assistance or interventions to ensure the resident maintained or improved the resident's level of urinary continence when the resident began to experience occasional incontinence for 1 of 12 sampled residents (Resident #24). This deficient practice had the potential to result in a resident's incontinence worsening due to a lack of interventions or assistance to maintain or improve the resident's continence.Findings include:Resident #24Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including multiple sclerosis, unspecified and polyneuropathy, unspecified.On 04/20/2026 at 2:15 PM, the resident verbalized the resident had recently started experiencing occasional urinary incontinence but was still able to get to the bathroom once the resident realized they were urinating. The resident verbalized the resident could not recall any staff prompting the resident to go to the bathroom to urinate at timed intervals.A Minimum Data Set 3.0 (MDS) Assessment, dated 07/07/2025, documented the resident was always continent of bladder.An MDS Assessment, dated 04/06/2026, documented the resident was occasionally incontinent of bladder.The Care Plan for Resident #24 did not include a focused care area with interventions related to the resident's recent issue of urinary incontinence.On 04/22/2026 at 8:24 AM, the Certified Nursing Assistant (CNA) for Resident #24 verbalized the resident had begun experiencing incontinence several months prior. The CNA verbalized the CNA was not aware of a bladder training or retraining program for the resident. The CNA verbalized an example of bladder training could include taking the resident to the bathroom at timed intervals, such as every two hours.On 04/22/2026 at 8:31 AM, the Director of Nursing (DON) verbalized the resident had become increasingly incontinent of urine over the last several months and the DON believed the incontinence was due to the resident's diagnosis of multiple sclerosis. The DON verbalized the facility could try to offer the resident assistance with a toileting schedule. The DON confirmed the resident's Care Plan did not include a care area or interventions related to the resident's concerns related to new onset urinary incontinence. The DON verbalized the facility did not have a policy for a bladder training or retraining program.

Based on interview, document review, and personnel record review, the facility failed to ensure a nurse aide performance review was completed at least once every 12 months and areas of weakness were identified and addressed for 1 of 2 sampled Certified Nursing Assistants (CNAs) employed at the facility greater than one year (Employee #8). This deficient practice had the potential to affect the care provided to all residents in the facility.Findings include:Employee #8Employee #8 was hired as a CNA on 10/21/2024.Employee #8's personnel record lacked documented evidence of a nurse aide performance evaluation.On 04/22/2026 at 1:55 PM, the Human Resources (HR) Director verbalized CNA performance evaluations were completed by the facility every year on October 1st to review the year prior. The HR Director explained because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility.The Facility Assessment, updated 03/2026, documented areas of weakness as determined in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.

Based on interview and document review, the facility failed to ensure the Facility Assessment accurately reflected current staffing needs for the facility. This deficient practice had the potential to deprive residents of necessary care and services required to meet each individual's needs and preferences.Findings include:The Facility Assessment, updated 03/26/2026, documented the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner (memory care unit). Consistent staffing would be prioritized in the memory care unit. Staffing levels would not be adjusted for low census/low acuity so residents' needs would be met even in times of call in and other circumstances of staff shortages.The April 2026 staffing schedule documented Quail Corner and Harmony Manor would share a licensed nurse during night shift on 04/04, 04/05, 04/06, 04/07, 04/12, 04/13, 04/14, 04/18, 04/19, 04/20, and 04/26 of 2026.On 04/24/2026 at 9:27 AM, the Director of Nursing (DON) explained on Saturday, Sunday, Monday and Tuesday nights, both Quail Corner and Harmony Manor shared a licensed nurse during night shift. The DON explained on those days, the nurse would be responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated Quail Corner and Harmony Manor required a licensed nurse in each unit during night shift. The DON explained the Facility Assessment needed to be updated to reflect the staff scheduling.

Based on observation, staff interview, and document review, the facility failed to ensure the staff maintained sanitary floor drains. This deficient practice had the potential to result in development and transmission of infection.Findings include:On 04/20/2026 at approximately 10:45AM a kitchen floor drain was observed to have a buildup of debris and grime. On 04/20/2026 at approximately 10:50 AM, the Kitchen Manager confirmed the kitchen floor drain had buildup of grime and acknowledged the potential spread of contamination. The Kitchen Manager explained the cleaning of the floor was the responsibility of the Maintenance Department.On 04/23/2026 at approximately 9:15 AM, the Maintenance Manager confirmed the kitchen floor drain had not been recently cleaned, was not sanitary and acknowledged the potential spread of contamination.The facility's policy titled, Maintenance of Strict Sanitary Conditions, dated 07/12/2022 and reviewed 07/08/2024, documented maintenance of strict sanitary conditions was of paramount importance in the Dietary and Nutrition Departments to eliminate food contamination and prevent growth of disease producing organisms, to ensure maximum level of cleanliness and sanitation in the department.

Based on interview, record review, and document review, the facility failed to ensure a resident with a progressive, neurodegenerative disease was screened for a pneumococcal (PNA) vaccine for 1 of 5 residents reviewed for vaccine compliance (Resident #32). This deficient practice had the potential to result in a resident with a chronic illness not receiving a vaccine with the potential to prevent the resident from developing a severe illness leading to increased disability or death. Findings include: Resident #32 Resident #32 was admitted to the facility on [DATE], with diagnoses including Hallervorden-[NAME] Disease (a rare, inherited, and progressive neurodegenerative disorder) and other specified extrapyramidal and movement disorders. The clinical record for Resident #32 lacked documentation the resident had received or been offered a PNA vaccine. On 04/21/2026 at 3:27 PM, the Infection Preventionist (IP) verbalized the resident had not been screened to determine whether the resident wanted to receive a PNA vaccine because of the resident's young age. The IP confirmed the resident had a chronic, degenerative condition causing the resident to have trouble with swallowing placing the resident at an increased risk for PNA. On 04/21/2026 at 4:14 PM, the IP verbalized the IP had discussed offering the resident a PNA vaccine with the facility's Medical Director and the Medical Director had informed the IP the resident should have been offered a PNA vaccine. The facility policy titled Standing Orders for Administering Vaccines at Humboldt General Hospital, revised 01/01/2026, documented all residents admitted to the facility would be screened to determine whether they were current on adult immunizations. Pneumococcal immunization of all residents would be determined on admission. If the resident was not sure of their status, the attending physician would be contacted for an assessment before receiving the immunization.

Based on clinical record review, interview and document review, the facility failed to ensure an incident of resident-to-resident physical abuse was reported to the State Agency (SA) for 1 of 12 sampled residents (Resident #10). This deficient practice had the potential to result in lack of investigation of alleged incidents of abuse by the facility and/or the SA, placing residents at risk for further abuse.Findings include:Resident #10Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified and episodic tension-type headache, not intractable.A nursing progress note dated 11/01/2025, documented Resident #10 was seen by a Certified Nursing Assistant (CNA) slapping another resident. The other resident slapped Resident #10 back. The on-call manager was called with the information. Per the on-call manager, continue to keep residents apart and if the residents were together, staff were to keep the residents in eye sight.A Physician Progress Note dated 11/14/2025, documented Resident #10 was involved in a behavioral disturbance approximately one week prior when Resident #10 began to have words with another resident. A heated exchange led to physical aggression between the two residents and each of the residents was physically striking the other.On 04/22/2026 at 1:22 PM, a Licensed Practical Nurse (LPN) verbalized staff received training annually related to abuse and neglect. If staff observed an incident suspicious for abuse or an allegation of abuse was reported to a staff member, staff were to report the incident/allegation to the Director of Nursing (DON) immediately.On 04/22/2026 at 3:19 PM, the DON denied the facility had anyone designated as the facility's Abuse Coordinator and verbalized the DON was responsible for reporting of incidents and/or allegations of abuse, neglect and exploitation of residents to the SA. Reportable incidents were those resulting in major injuries to a resident and any abuse. The DON explained the DON was ultimately responsible for investigating allegations and/or suspicion of abuse.On 04/23/2026 at 11:19 AM, the DON provided copies of the nursing progress note and physician progress note documenting Resident #10 and another resident were slapping/striking each other. The DON verbalized the DON would probably not consider the incident resident-to-resident abuse as it was mutual combat. If a resident slapped another resident because the resident was confused, it was not a reportable incident. The DON verbalized the DON did not know if either resident involved was assessed for pain, injury or mental anguish following the incident as the DON was unable to locate any documentation of an assessment and explained the DON was not the DON at the time.On 04/23/2026 at 11:38 AM, the Minimum Data Set 3.0 (MDS) Coordinator verbalized there were several categories of abuse including sexual, physical and exploitation. Physical abuse was an altercation between multiple residents or between a resident and staff member or visitor and included hitting and slapping. If an allegation of abuse was reported or staff observed an incident suspicious for abuse the facility would need to investigate the incident, assess the resident/s for injuries, talk to the residents, talk to staff, notify the resident's power of attorney, and ensure the resident/s were safe. The MDS Coordinator confirmed the MDS Coordinator was the facility's DON in November 2025. The MDS Coordinator reviewed the nursing progress note dated 11/01/2025 and denied having been made aware of Resident #10 and another resident slapping each other. The MDS Coordinator confirmed the MDS Coordinator should have been notified at the time of the incident and denied the incident was reported to the SA.The facility policy titled Freedom from Abuse/Abuse Prohibition, revised 01/19/2026, documented residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse included hitting, slapping, punching, biting and kicking. Any covered individual (owner, operator, employee, manager, agent, or contractor of the facility) identifying signs of possible abuse would immediately report the signs to the charge nurse. The charge nurse would notify the DON or, in his/her absence, the Chief Nursing Officer and/or the Director of Risk Management. Suspected abuse was to be reported to the SA within two hours after the alleged abuse occurred if it resulted in serious bodily injury or within 24 hours if the events causing the allegation did not involve abuse and did not result in serious bodily injury.

Based on clinical record review, interview and document review, the facility failed to provide documented evidence a fall resulting in pain, swelling, and a skin tear, with an age-indeterminate fracture identified on post-fall imaging was thoroughly investigated to determine if the incident was a result of neglect for 1 of 12 sampled residents (Resident #10). This deficient practice had the potential to result in physical and/or psychosocial harm to residents due to incidents with the potential to indicate neglect not being thoroughly investigated and documented to ensure appropriate protections were in place to prevent future neglect.Findings include:Resident #10Resident #10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified and episodic tension-type headache, not intractable.A final Facility Reported Incident (FRI) report submitted by the facility on 03/03/2026, documented the report was related to an incident involving Resident #10 and the incident type was neglect. On 02/25/2026 at 5:25 PM Resident #10 was last seen sitting at the dining room table. A Certified Nursing Assistant (CNA) was at the sink in the dining room with the CNA's back turned to the resident. The CNA heard Resident #10 hit the floor. When the CNA turned around it appeared the resident had attempted to get up and lost footing or got tangled up in the chair in which the resident was sitting. Resident #10 had verbal complaints of pain during the initial assessment, sustained a three-centimeter skin tear to the left elbow, bruising to the left knee and swelling to the left ankle. On 02/26/2026, an x-ray of the resident's left ankle was completed. Results of the x-ray included soft tissue swelling of the ankle, age-indeterminate fracture fragments at the lateral malleolus tip, lateral talus, and extensor digitorum Brevis origin.On 04/22/2026 at 3:19 PM, the Director of Nursing (DON) denied the facility had anyone designated as the facility's Abuse Coordinator and verbalized the DON was responsible for reporting incidents and/or allegations of abuse, neglect and exploitation of residents to the State Agency (SA). Reportable incidents were those resulting in major injuries to a resident and any abuse. The DON explained the DON was ultimately responsible for investigating allegations and/or suspicion of abuse and neglect. An investigation would include talking to staff, talking to the resident/s, getting the provider involved and talking to the resident's family if needed to gather as many facts as possible.The DON confirmed the DON was familiar with Resident #10's fall in the dining room on 02/25/2026, as documented in the FRI. The DON explained the incident was different from other falls and was reported due to the ankle fracture identified in the x-ray. The investigation included speaking with the nurse on duty at the time of the fall and reviewing notes in the resident's clinical record. The DON denied the DON had documentation of the facility's investigation of the incident including any observations made and interviews conducted with residents and/or staff.The facility policy titled Freedom From Abuse/Abuse Prohibition, revised 01/19/2026, documented residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Neglect was defined as indifference or disregard for resident care, comfort or safety resulting in, or may have resulted in, physical harm, pain, mental anguish or emotional distress. When a direct care provider was suspected of abusing, neglecting or mistreating a resident the Chief Nursing Officer, Long-Term Care Supervisor, Chief Risk Officer, or the designated nursing supervisor could relieve the individual of his/her duty until the investigation was complete. Each situation would be assessed, and actions would be taken to prevent further potential abuse while the investigation was in progress.FRI 2791829

Based on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely for 2 of 18 sampled employees (Employee #16 and #17). This deficient practice had the potential to place all residents at risk for abuse and neglect.Findings include:Employee #16Employee #16 was hired as a Cook, with a start date of 11/19/2025.Employee #16's personnel record documented elder abuse prevention training completed on 11/28/2025, 9 days late.Employee #17Employee #17 was hired as a Dietary Aide, with a start date of 12/15/2025.Employee #17's personnel record documented elder abuse prevention training completed on 12/31/2025, 16 days late.On 04/22/2026 at 1:45 PM, the Human Resources (HR) Director verbalized all staff were required to take initial elder abuse prevention training upon hire. The HR Director confirmed Employees #16 and #17 completed initial elder abuse prevention training late.The facility policy titled, Freedom from Abuse/Abuse Prohibition, revised 01/19/2026, documented employees would receive orientation upon hire to include training on abuse prohibition practices such as appropriate interventions, reporting, signs of burnout, frustration and stress, and what constitutes abuse, neglect and misappropriation of resident property.

Based on observation, interview, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) donned gloves, according to the facility's policy, prior to removal and placement of transdermal patches. This deficient practice had the potential to transfer bacteria, germs, and residual medication between residents. Findings include: On 02/05/2025 at 8:30 AM, during the morning medication pass, an LPN removed a transdermal patch from a resident's chest. The LPN was not wearing gloves during the removal of the patch and did not perform hand hygiene after removing the patch. On 02/05/2025 at 8:31 AM, the LPN placed a new transdermal patch on the resident's right arm. The LPN was not wearing gloves. On 02/05/2025 at 8:37 AM, the LPN confirmed the LPN was not wearing gloves during the removal and placement of transdermal patches while completing the morning medication pass. The LPN verbalized the LPN should have been wearing gloves since the removed patch had been in contact with the resident's skin and to prevent potential transfer of medication from the patches to the LPN's hands. On 02/06/2025 at 10:05 AM, the Infection Preventionist/Registered Nurse (IP/RN) confirmed nursing staff were expected to perform hand hygiene and wear gloves when removing transdermal patches and when administering topical or transdermal medications to residents. The IP/RN verbalized hand hygiene was required to be performed prior to donning and after doffing gloves. The facility policy titled Transdermal Patch Application, revised 05/19/2024, documented staff were to perform hand hygiene and put on gloves prior to the removal of previously applied transdermal patches and application of new patches. The facility policy titled Hand Hygiene, reviewed 08/13/2024, documented hand hygiene was the single most important strategy to reduce the risk of transmitting organisms from one person to another or from one site to another on the same resident. All staff were to perform hand hygiene before each patient encounter including before donning gloves, after contact with a resident's intact skin, and when moving from a contaminated body site to a clean body site during resident care.

Based on interview, personnel record review, and document review, the facility failed to employ a trained Activity Coordinator. This deficient practice had the potential to affect resident safety and satisfaction for the entire facility census. Findings include: The personnel roster provided to the State Agency lacked documentation of an Activity Coordinator. On 02/03/2025 at 1:10 PM, the Infection Preventionist/Registered Nurse verbalized the facility did not have a certified Activity Coordinator. An Activity Aide was acting in the Activity Coordinator role and working to complete the required credentials. On 02/06/2025 at 10:35 AM, the Resident Care Coordinator verbalized the previous Activity Coordinator stopped working at the facility around the end of September 2024, and the Activity Aide took on the Activity Coordinator role as soon as the Activity Coordinator left. The Resident Care Coordinator explained since the Activity Coordinator left, the facility had received an elevated number of complaints regarding the activities program. On 02/06/2025 at 11:21 AM, the Human Resources (HR) Manager verbalized the previous Activity Coordinator moved to a new position on 09/09/2024. As a result, the facility hired a Certified Activity Consultant and would be working with the facility remotely. The HR Manager verbalized responsibilities of the Activity Coordinator included attending care plan conferences, organizing and maintaining a safe environment, transporting residents to local appointments, and compiling the monthly program calendar. The HR Manager believed the Activity Consultant acted as the Activity Coordinator; however, the HR Manager verbalized the Consultant had not signed the Activity Coordinator position description, was unsure how the consultant would be aware of the expectations without a signed position description, was unsure whether the Consultant fulfilled the job duties of the Activity Coordinator and confirmed it would be difficult to perform those responsibilities while working remotely. The HR Manager confirmed the Agreement for Activity Consultant referred to the Activity Coordinator as a separate person to receive guidance from the Consultant. The HR Manager also verbalized the Activity Aide was not the Activity Coordinator. An Agreement for Activity Consultant dated 09/06/2024, documented the Activity Consultant would provide the Activity Coordinator with information regarding existing community resources, literature and services which would enhance activity programming. An unsigned facility position description titled, Activity Coordinator, revised 02/16/2024, documented the Activity Coordinator was responsible for all aspects of the activities program including the development and implementation of recreation programs, assessment of resident abilities and needs, compilation of a social program calendar, and transportation of residents to local appointments. The position description lacked language to include the role and responsibilities of a certified Activity Consultant to direct the facility's activities program during the period a new Activity Coordinator was obtaining certification. The Activity Aide and Activity Consultant's personnel records lacked a signed position description for Activity Coordinator. On 02/06/2025 at 12:15 PM, the Activity Consultant explained the Consultant was responsible for reviewing the activity calendar, updating resident care plans, and training and certifying employees for the Activity Coordinator position. The Consultant verbalized the Activity Aide had not completed the required training to be in the Activity Coordinator position and had only begun the training in January 2025, despite being in the role since September 2024. Additionally, the Activities Aide did not have two years of experience in an activities program as required to be a qualified Activity Coordinator. The Consultant verbalized neither the Consultant nor the Activity Aide were the facility's Activity Coordinator and confirmed the Activity Coordinator position remained vacant. An Education Reimbursement Request form dated 11/05/2024, documented the Activity Aide needed the certification to hold the Activity Coordinator position.

Based on observation, interview, and document review, the facility failed to ensure resident information was not visible on an unattended computer screen. This deficient practice had the potential for unauthorized access to residents' protected health information. Findings include: On 02/05/2025 at 7:49 AM, a Licensed Practical Nurse (LPN) was preparing medications for a resident. The LPN was utilizing a stationary (desktop) computer next to the facility's medication dispensing system. The computer and medication dispensing system were in a common area, near the nurses' station, and the computer screen was facing the hallway. The LPN verbalized one of the medications was required to be cut in half and the half tablet not being used was to be discarded in the medication storage room. The LPN took the half tablet, walked away from the computer and entered the medication storage room to dispose of the half tablet. The computer screen was left on and unlocked; resident information was visible on the screen. On 02/05/2025 at 8:05 AM, the LPN began preparing medication for a resident. One of the resident's medications required the tablet to be cut in half. The LPN cut the tablet in half, walked away from the computer and entered the medication storage room to dispose of the half tablet. The computer screen was left on and unlocked; resident information was visible on the screen. On 02/05/2025 at 8:36 AM, the LPN verbalized the LPN usually minimized the window on the computer screen prior to walking away from the workstation. The LPN acknowledged the computer screen was left on and unlocked, with resident information visible, while the LPN went into the medication storage room. The LPN verbalized protected resident health information should always be hidden from view prior to staff walking away from a workstation. On 02/06/2025 at 10:05 AM, the Infection Preventionist/Registered Nurse (IP/RN) verbalized private health information should not be visible when staff walked away from a workstation. The IP/RN explained if a computer screen was left on and unlocked without staff present, residents' private health information was not protected. The IP/RN verbalized private health information was anything showing on the screen when a resident's chart was open. The facility policy titled Workstation Use, reviewed 04/04/2024, documented the facility ensured the security of all electronic protected health information by structuring the access to electronic information through workstations. A workstation was an electronic computing device such as a laptop or desktop computer. Employees found to leave any computer workstation unattended after logging in would be subject to the facility's disciplinary process for suspected breach of patient protected health information.

Based on interview, clinical record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #10). This deficient practice had the potential for the care plan to omit current needs, services, and monitoring for residents. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including depression, hypertension, hyperlipidemia, and type two diabetes mellitus. A Physician Progress Note dated 10/14/2024, documented Resident #10 had a diagnosis of depression. The resident was not receiving any medication for depression and the physician recommended follow-up with behavioral health if the resident showed any overt signs of depression. A quarterly MDS assessment dated [DATE], Section I - Active Diagnoses, included instructions to check all that apply. Diagnoses of hypertension, hyperlipidemia, and diabetes mellitus were checked with an X. Item I5800 - Depression lacked a checkmark, X, or any other indication the resident had the diagnosis. Section Z, item Z0400, included a signature indicating the facility's MDS Coordinator completed Section I of the MDS assessment. On 02/05/2025 at 1:52 PM, a Licensed Practical Nurse (LPN) confirmed Resident #10 had a diagnosis of depression. The LPN explained Resident #10 was not currently taking any medication for depression and staff were monitoring the resident for any changes in behavior such as being tearful or not wanting to get out of bed. The LPN verbalized Resident #10 had some days when the resident did not want to get out of bed and had to be encouraged by staff to get up. If the resident exhibited any signs or symptoms of depression or changes in behavior, staff would notify the physician. On 02/06/2025 at 11:34 AM, the MDS Coordinator verbalized residents' diagnoses were recorded in section I of the MDS assessment. The MDS Coordinator explained the MDS Coordinator included diagnoses in section I of the assessment based on physician notes completed in the 60 days prior to the assessment date. The MDS Coordinator verbalized Resident #10 had a diagnosis of depression, and the resident had been gradually reduced off of psychiatric medications. The MDS Coordinator reviewed the Physician Progress Note dated 10/14/2024, and confirmed the note documented Resident #10 had a diagnosis of depression. The MDS Coordinator confirmed the MDS assessment dated [DATE], did not document the resident's diagnosis of depression and was inaccurate. The facility policy titled Resident Assessment Process, reviewed 01/14/2025, documented it was the responsibility of each member of the Interdisciplinary Team (IDT) to document all information gathered into the resident's clinical record during the lookback period, so it was a comprehensive, accurate, standardized, and reproducible assessment of the resident's status. The information was then entered into the MDS. Each person completing a section of the MDS attested to its accuracy by electronically affixing a signature to the section. The comprehensive care plan must address all care issues relevant to the individual.

Based on interview and document review, the facility failed to ensure Minimum Data Set 3.0 (MDS) assessments were encoded and transmitted timely for November 2024. The deficient practice had the potential to impact resident care by delaying the development and implementation of resident care plans. Findings include: The MDS Submission Report for November 2024, documented 2 of 15 (13.3%) MDS assessments were encoded and transmitted late. On 02/06/2025 at 9:36 AM, the MDS Coordinator verbalized the MDS Coordinator was responsible for completing and submitting the MDS assessments for the facility and confirmed two MDS assessments were completed late for November 2024. The facility policy titled Resident Assessment Process, reviewed 01/14/2025, documented the MDS completion, locking, submission, and transmission of the assessment would be according to the timelines outlines in the Resident Assessment Instrument (RAI) Manual.

Based on observation and interview, the facility failed to ensure current nursing hours were posted for the facility. This deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the number of nursing staff on duty. Findings include: On 02/04/2025 at 4:42 PM, the nursing staff posting for the memory care unit of the facility was dated 01/23/2025. The unlocked unit of the facility lacked a nursing staff posting. On 02/05/2025 at 11:18 AM, the nursing staff posting for the memory care unit of the facility was dated 01/23/2025. The unlocked unit of the facility lacked a nursing staff posting. On 02/05/2025 at 3:40 PM, the Infection Preventionist/Registered Nurse verbalized nurse staffing hours were to be updated daily at shift change in the facility, for both units to ensure there was enough staff and to inform resident families of facility staffing. On 02/06/2025 at 9:01 AM, the nursing staff posting for both the unlocked and memory care units of the facility were dated 02/05/2025. On 02/06/2025 at 9:06 AM, a Certified Nursing Assistant (CNA) verbalized nurse staffing hours were updated every morning. The CNA confirmed the nurse staffing postings were not updated to reflect the current date.

Based on interview and document review, the facility failed to ensure Monthly Medication Reviews (MMR) were completed monthly for 4 of 5 residents reviewed for unnecessary medications (Resident #11, #14, #30, and #12). Findings include: On 04/03/2024 at 3:12 PM, the Director of Nursing (DON) verbalized all psychotropic medications were reviewed monthly by the consulting Pharmacist for appropriateness and recommendations for dose reduction. The DON confirmed monthly was defined as no later than the first Monday of the month for the proceeding month of use. The following residents lacked an MMR completed within thirty (30) days of the prior MMR for June 2023, completed 07/12/2023 and September 2023, completed 10/03/2023, and November 2023, completed 12/23/2023: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including benign prostatic hyperplasia without urinary obstruction, congestive heart failure, shoulder pain, bilateral, atrial fibrillation, controlled, essential (primary) hypertension, gastro-esophageal reflux disease, depression, hyperlipidemia, depression, glaucoma, hypothyroidism, chronic low back pain, right knee pain, left knee pain, osteoarthritis of multiple joints, and chronic pain. Resident #14 Resident #14 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including syncope, bladder spasms, chronic obstructive pulmonary disease without exacerbation, oxygen dependent, anemia, chronic leg pain, right shoulder pain and chronic pain. 43310 Resident #30 Resident #30 was admitted to the facility on [DATE], with diagnoses including chronic neck pain, sciatic pain, hip pain, right, chronic anticoagulation, history of deep vein thrombosis (DVT) of lower extremity, major depressive disorder, neurocognitive disorder, and post-traumatic stress disorder. 46301 Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including depression, type 2 diabetes mellitus, hypothyroidism, hypertension, and kidney disease, chronic stage III. On 04/03/2024 at 4:10 PM, the DON confirmed the MMRs were not completed within thirty (30) days of the prior MMR for June 2023, completed 07/12/2023 and September 2023, completed 10/03/2023, and November 2023, completed 12/23/2023 for Resident #11, #14, #30, and #12. The DON explained there was no policy related to Monthly Medication Reviews.

Based on observation, interview, clinical record review, and document review the facility failed to ensure 1 of 12 residents (Resident #10) had an active order for the use and monitoring of a urinary catheter and failed to ensure the resident urinary drainage bag was maintained at a safe and appropriate level. The failure to maintain the urine collection bag at the appropriate level could have resulted in urine flowing back into the residents bladder, placing the resident at increased risk for infection. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including history of cerebral vascular accident (CVA) with residual deficit, left sided weakness, type II diabetes mellitus, complicated urinary tract infection (UTI), frequent urinary tract infections, voiding dysfunction, urinary retention with incomplete bladder emptying. On 04/01/2024 at 2:54 PM, Resident #10 was lying in bed, a urinary collection bag was covered with a dignity bag, and the bag was lying on the floor. On 04/03/2024 at 4:09 PM, the Minimum Data Set (MDS) Coordinator/Registered Nurse (RN) Confirmed Resident #10's clinical record did not include an order for the use and monitoring of a urinary catheter. The MDS RN explained when Resident #10 was readmitted from an acute care stay on 03/26/2024, the facility failed to ensure the order was entered into the resident's clinical record. Resident #10's Urinary Catheter Flow Sheet, utilized to monitor and document observations of the resident's urinary catheter, lacked documented evidence the catheter was monitored from 03/22/2024 - 04/04/2024. The flow sheet was repopulated on 04/04/2024 at 11:30 AM. On 04/04/2024 at 9:00 AM, Resident #10 was lying in bed in preparation for wound care. The resident's urinary drainage bag was not visible and appeared to be in the resident's bed beneath the blankets. On 04/04/2024 at 9:57 AM, a Certified Nursing Assistant (CNA) located Resident #10's urinary drainage bag lying next to the resident, in the residents bed. The CNA verbalized it was important to keep urinary drainage bags below the level of a resident's bladder and confirmed Resident #10's urinary drainage bag was not below the resident's bladder when lying next to the resident in the resident's bed. On 04/04/2024 at 10:00 AM, the Director of Nursing (DON) verbalized the expectation was urinary drainage bags would not be left lying next to residents and would be kept below the level of a resident's bladder. The DON confirmed Resident #10's urinary drainage bag should have been hooked to the side of the resident's bed to allow urine to flow to gravity. On 04/04/2024 at 11:03 AM, the DON verbalized the facility did not have a policy related to the care of urinary catheters. The DON verbalized [NAME] online was the facility's Standard of Practice (SOP). On 04/04/2024 at 11:30 AM, the DON explained when the Resident #10 returned to the facility following an acute care stay, the facility failed to re-enter the resident's urinary catheter orders. The failure to enter the orders led to the monitoring flow sheet not being populated. The monitoring flow sheet triggered staff to monitor and document observations of the urinary catheter and collection bag. The DON confirmed not entering the orders led to the lack of monitoring and documenting observations of Resident #10's urinary catheter and drainage bag. A [NAME] online document titled Indwelling Urinary Catheter (Foley) Care and Management, dated 12/10/2023, printed by the facility on 04/04/2024, documented to monitor for intake and output, changes in urinary output, including volume and color. Keep the drainage bag below the level of the bladder to prevent backflow of urine into the bladder. Backflow of urine into the bladder increased the risk for catheter associated urinary tract infections (CAUTI).

Based on interview, clinical record review, and document review, the facility failed to ensure a resident on a psychotropic medication had a gradual dose reduction (GDR) for 2 of 12 sampled residents (Resident #28 and #12). Findings include: Resident #28 was admitted to the facility on [DATE], with diagnoses including atypical psychosis, schizophrenia, auditory hallucinations, and depression. Resident #28's orders were as follows: - Depakote extended release 750 milligrams (mg) = 3 tablets, by mouth, every night before bedtime, with original start date of 11/01/2022, for atypical psychosis, schizophrenia, and history of auditory hallucinations. - olanzapine 15 mg = 3 tablets, by mouth, every night at bedtime, with original start date of 11/01/2022, for atypical psychosis, schizophrenia, and history of auditory hallucinations. The Monthly Medication Review dated April 2023, documented the Pharmacist's recommendation to try a GDR for sertraline and Depakote. The Psychiatric Nurse Practitioner Note dated 04/17/2023, documented the provider did not recommend a GDR attempt at this time due to the stability of resident's behavior. On 04/03/2024 at 4:10 PM, the Minimum Data Set (MDS) Coordinator verbalized there was not a GDR recommendation for olanzapine and there was not a second GDR attempt for Depakote within the first year of use of Resident #28's two antipsychotic medications. 46301 Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses including depression, type 2 diabetes mellitus, hypothyroidism, hypertension, and kidney disease, chronic stage III. Resident #12's order was as followed: -citalopram 20 mg oral tablet, one tablet, by mouth, daily, start date of 09/16/2022, for depression. The Psychiatric Nurse Practitioner Note dated 04/03/2023, documented the provider did not recommend a GDR attempt at this time due to the stability of resident's behavior. On 04/03/2024 at 4:10 PM, the MDS Coordinator verbalized there was not a second GDR attempt for citalopram within the first year of use of Resident #12's antidepressant medication. The facility policy titled Psychotropic Medication Use In Long Term Care, reviewed 12/29/2023, documented within the first year a resident was admitted on psychopharmacological medication or after the facility had initiated such medication, dose reduction should be attempted twice in two separate quarters with at least one month in between attempts.

Based on observation, clinical record review, document review, and interview, the facility failed to ensure a care plan was developed and implemented related to a resident's hearing deficit and the use of a hearing device for 1 of 12 sampled residents. Findings include: Resident #11 Resident #11 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including ceruminosis, vertigo, and head injury. A Physician Office Clinic Note dated 02/07/2024, documented the resident was severely hard of hearing and even with his hearing aids in place, the resident could not hear what was being said. On 04/01/2024 at 4:37 PM, Resident #11 verbalized the resident could not hear very well and had hearing aids. The resident verbalized the hearing aids did not work very well when the resident placed them in the resident's ear. On 04/02/2024 at 11:25 AM, the Certified Nursing Assistant (CNA) assisted Resident #11 place the resident's hearing aids in the resident's ears and verbalized the hearing aids did not work well. The CNA verbalized previously the resident had another pair which worked better but lost one of them and was using a cheaper pair of hearing aids now which did not work as well. On 04/02/2024 at 11:32 AM, the CNA verbalized sometimes the CNAs had to use a white board to communicate with Resident #11. Resident #11's Care Plan dated 03/25/2024, lacked documented evidence of a care plan for a hearing deficit and the use of hearing devices. On 04/04/2024 at 9:26 AM, the CNA verbalized assisting the resident with the resident's hearing aids and confirmed if the resident did not have the hearing aids in use, the resident could not hear. The CNA verbalized the current devices were hit and miss for working and had been cleaned. On 04/04/2024 at 9:53, the Resident Advocate (RA) confirmed the facility was aware of the current issue with the resident's hearing devices not working properly and the resident's hearing deficit. The RA verbalized the facility lacked transportation for the resident to travel to an appointment for the resident to receive a hearing test and new hearing devices. On 04/04/2024 at 10:40 AM, the Minimum Data Set Coordinator confirmed Resident #11's Comprehensive Care Plan lacked care planning for the resident's hearing deficit and use of hearing aids and verbalized Resident #11 should have a care plan with a communication focus area to address the resident's hearing deficit. The facility's policy titled Care Plan Development Process, reviewed 11/03/2023, documented the care plan guided the care and treatment provided to each resident. The care plan was individualized and addressed the resident's medical, nutritional, psychological, physical, functional, social, educational, and spiritual needs, and the severity of the resident's condition, impairments, disability or disease as indicated.