Every finding on record at Liberty Commons Nursing & Rehabilitation Center of

Based on observations, manufacturer instructions, and staff interviews, the facility failed to date open multi-dose vials of insulin on the 300 hall medication cart, failed to date multi-dose vials of semaglutide (glucagon-like peptide-1 (GLP-1) receptor agonist medication used for managing type 2 diabetes and promoting weight loss) on the 100 hall and 300 hall medication carts, and failed to discard expired a bottle of proton pump inhibitor tablets on the 300 hall medication cart. The failure to date multi dose vials of medication or dispose of expired medication was discovered in 2 of 3 medication carts reviewed for medication storage (100 hall and 300 hall medication carts).Findings Included: 1. On 1/6/26 at 8:05 AM, an observation of the 100-hall medication cart with Nurse #2 revealed one (1) open and undated multi-dose vial of semaglutide. Review of the manufacturer's instructions indicated to discard semaglutide multi-dose pen 56 days after opening. On 1/6/26 at 8:10 AM, during an interview, Nurse #2 indicated the nurses who worked on the medication carts were responsible for discarding open and undated multi-dose vials. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medication vials. The nurse stated she had not checked the date of opening on semaglutide vial in her medication administration cart at the beginning of her shift. Nurse #2 stated she had not administered open and undated medication during her shift. 2. On 1/6/26 at 8:45 AM, an observation of the 300-hall medication cart with Nurse #3 revealed one (1) open and undated insulin glargine pen and one (1) open and undated semaglutide pen. A review of the manufacturer's instructions indicated to discard insulin glargine multi-dose insulin pens 28 days after opening and semaglutide multi-dose pens 56 days after opening. In the second drawer of the medication cart there was one container of half-empty omeprazole (proton pump inhibitor that treats excess stomach acid) 40 milligram tablets that expired on 1/11/25. On 1/6/26 at 8:50 AM, during an interview, Nurse #3 indicated that the nurses who worked on the medication carts were responsible for discarding open and undated or expired multi-dose vials. She mentioned that per training/competency, every nurse should put the date of opening on multi-dose medication vials. Nurse #3 stated that she had not checked the date of opening on insulin glargine, semaglutide multi-dose vials or the expiration date of the omeprazole in her medication administration cart at the beginning of her shift. The nurse stated she had not administered expired medication during her shift. On 1/7/26 at 11:35 AM, during an interview, the Director of Nursing indicated that the nurses were responsible for checking the date of opening, and the expiration dates of the medications at the beginning of the shift. On 1/7/26 at 11:50 AM, during an interview, the Administrator expected no expired medications to be left in the medication carts.

Based on record review and staff and detective interviews, the facility failed to protect the resident's right to be free from misappropriation of resident's property, when Resident # 123's responsible party (RP) observed a payment to a staff member on the resident's bank statement. On 3/10/25 the resident's RP observed a payment of $372.94 on the resident's bank statement to an unknown account related to the admission Director. This occurred for 1 of 1 resident reviewed for misappropriation of property (Resident #123).Findings included:Resident #123 was admitted to the facility on [DATE].Review of Resident #123's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as moderately cognitively impaired.Review of the initial allegation report regarding misappropriation of resident's property dated 3/13/25 revealed the facility was made aware of the incident on 3/13/25 at 11:30 AM. The report details read in part Family member observed payment to a staff member on the resident's bank statement. The accused staff was suspended until the completion of the investigation to minimize the risk for misappropriation of resident property. The local Law enforcement was notified on 3/13/25. The initial allegation report was completed by the Director of Nursing (DON) on 3/13/25. Review of the investigation report dated 3/20/25, revealed the incident was investigated under misappropriation of resident's property. The incident occurred on 3/10/25 and the facility was made aware of the incident on 3/13/25 at 11:30 AM. The allegation details were Resident #123's family member observed a payment to a staff member on the resident's bank statement. The accused staff was suspended pending investigation. All alert and oriented residents were interviewed by facility leadership team on 3/1/3/25 regarding any concerns with misappropriation of resident property. The allegation details included that all residents who are not able to be interviewed will have assessments completed to identify any signs of potential misappropriation of resident property. The allegation was not substantiated. County Department of Social Services (DSS) and Law enforcement were notified on 3/13/25.Review of the addendum to original 5-day investigation report dated 3/25/25 stated that due to updated related new information from law enforcement this allegation was substantiated. The Local law enforcement had charged the accused staff member related to the allegation. The accused staff was terminated on 3/13/25. During an interview on 1/8/26, at 11:00 AM, the admission Coordinator reported that she had been serving as the Business Office Assistant (BOA) at the time of the incident. She stated that she was assisting the Business Office Manager during that period. She further indicated that, during her tenure as BOA, she had never reviewed nor had access to any resident's financial data. The admission Coordinator stated that she received a call from Resident #123's family member (date unknown) and the family member informed her that an employee's name appeared on Resident #123's bank statement. The admission Coordinator stated that she immediately notified the previous Business Office Manager (BOM) and transferred the call to the BOM. She further stated that the Business Office Consultant visited the facility the following day, conducted checks, and initiated education and training for all Business and admission staff. The training addressed the following points: 1) Resident bank statements must not be taken from residents or family members. 2) Any personal or financial information must be blacked out. 3) All documents must be stored in a locked cabinet in the BOM's office. Additionally, the Business Office Consultant completed a chart audit for new admissions. The admission Coordinator reported that she did not have access to these cabinets.During a telephone interview on 1/7/26 at 1:35 PM, the previous Business Office Manager (BOM) indicated that she had received a phone call from Resident #123's family member (date unknown) who stated that they noticed a charge of approximately $300 on the resident's bank account, which included the admission Director's name. The family member emailed the bank statement to the BOM, who then provided it to the Administrator and the Director of Nursing (DON). The previous BOM stated that the Administrator called the admission Director to his office, and the allegation was investigated. The admission Director was suspended during the investigation and never returned to the facility. The previous BOM indicated that the admission Director had been handling a private-pay resident admission and was reviewing the resident's bank statements. He had requested copies of bank statements from the resident's family member. The BOM stated that she had not seen these statements and confirmed that they were not in the resident's financial folder. She further indicated that she had been on vacation during Resident #123's admission and upon her return, was not given any of the financial documents. The BOM stated that the facility conducted an internal audit following the incident. A keypad lock was installed on the BOM's office door, and cabinets storing sensitive financial and personal information were fitted with double locks. Only the Administrator and BOM had access to that room. The BOM stated that the Business Office Consultant audited all residents' financial records, and no concerns were reported. BOM indicated she called all residents' representatives, notified them of the incident and asked them to check their bank statements for any concerns. No concerns were reported to her. She stated that she received education on the following: 1) Not requesting residents' financial statements, 2) Proper procedures for securing financial records and 3) Abuse, neglect, and misappropriation prevention. The BOM indicated that Resident #123 was a private-pay resident admitted in February 2025, and the bank charge occurred in March 2025. She stated that the resident's bank reimbursed the money to the resident's account, which was confirmed to her by Resident #123's family member who initially reported the incident.During a telephone interview on 1/7/26 at 11:30 the previous Director of Nursing (DON) stated that the Business Office Manager (BOM) informed her of the incident immediately after receiving the call from the resident's representative. The previous DON indicated that she was unsure of the exact date. The BOM had received a call from Resident #123's family member, who reported that while reviewing the resident's bank statement, they found a payment to a credit card in the name of the admission Director. The employee's name was written on the bank statement, and the family member recognized it. The Administrator was also informed, and the employee was suspended during the investigation. During the investigation, the accused employee produced a letter from the credit card company indicating that no monetary transaction had occurred. The Administrator reported the incident to local law enforcement and the Department of Social Services (DSS). Local law enforcement also initiated an investigation into the allegation. The DON stated that all alert and oriented residents were interviewed regarding any misappropriation of property, and no concerns were reported. Representatives of residents who were not alert and oriented were also notified, and no concerns were reported. The DON stated that she educated all facility staff on abuse, neglect, and misappropriation of property. The Corporate Consultant also trained the Business and Administrative staff, and efforts were made to ensure that financial records were kept secure. The DON stated that the staff member was not allowed to return to the facility. After the five-day report was filed, law enforcement informed the Administrator that the accused staff member (admission Director) had been charged with fraudulent activity. An addendum to the five-day investigation report was sent to the State, and the allegation was substantiated.During a telephone interview on 1/7/26 at 12:35 PM, the previous Administrator stated that he had served as the facility's Administrator from early February to May 2025. He indicated that he was informed by the Business Office Manager (BOM) and Director of Nursing (DON) that the admission Director at that time had taken money from a resident's account and transferred it to his own account. The resident's family member had reported the incident to the facility. The resident's family member was the resident's RP and was managing resident's finances. The resident did not have any access to her bank. The initial allegation report and the five-day investigation report were completed and submitted to the State. The allegation was initially unsubstantiated because the facility was unable to prove it. The Administrator stated that, after the investigation, the detective (law enforcement officer) had reported to him that the letter from the credit card company, which the admission Director (accused employee) had provided, was fraudulent. The employee was subsequently charged with fraud and elderly abuse. An addendum to the five-day investigation report was submitted to the State, and the allegation was substantiated. The Administrator confirmed that the accused employee was suspended immediately upon the allegation and later terminated. The Administrator stated that this incident of misappropriation of a resident's property could have been prevented at the Business Office. At the time of the incident, the BOM was on vacation, and the previous Health Information Management (HIM) staff was assisting the admission Director and covering Business Office duties. The resident was newly admitted and had provided a bank statement for verification of funds during admission. The HIM staff placed this information in a file, which the admission Director later accessed. The Administrator stated that this process was corrected, and neither the Business Office nor the admission Office now keeps bank statements in residents' files. Staff are prohibited from taking any financial documentation from residents or their representatives. Physical security of records was also improved by installing double locks on the room, ensuring that only Business Office staff could access financial records. The Administrator indicated that audits for all residents were completed to ensure there was no misappropriation of funds. Residents' representatives were notified, and no concerns were reported. Background checks for new employees were rerun, and no issues were found. The background check for the accused staff member was also rerun and remained clean even after the incident. Business Office Consultants audited all residents' records, and no concerns were reported. admission and Business Office staff were educated on procedures for safeguarding residents' records. The Administrator stated that, during the investigation, the resident's family member informed him that the resident's bank had reimbursed approximately $300 back into the resident's account. The Administrator also indicated that, during the investigation, the accused admission Director emailed him a letter from his credit card company claiming that no financial transactions had occurred between the resident's bank and the employee's credit card account. This document was provided to the investigating police officer and was later determined to be fraudulent.During a telephone interview on 1/7/26 at 1:45 PM, the previous Health Information Management (HIM) staff stated that she had been working as a medical records staff member and assisting with Admissions and the Business Office. She reported that she became aware that a resident's family member had reported missing funds from the resident's account. The admission Director was identified as the cause for the misappropriation of the resident's funds and he was suspended during the investigation and later terminated. The incident was reported to the State and law enforcement. The previous HIM staff stated that, at the time of the incident, she was assisting the admission Director, who was newly hired in January 2025, with new admissions. She indicated that she was reviewing referrals and completing admission paperwork for the facility. The HIM staff further stated that it was not facility policy to collect bank statements. Newly admitted residents' families would bring bank statements for verification of funds, and these were returned to the families. The BOM reviewed direct deposits and credit receipts. The HIM staff member indicated that, during Resident #123's admission, the bank statement was kept by the admission Director. She stated that Corporate Consultants visited the facility and investigated the entire incident. Education was provided by the Business Office Consultants to all administrative staff, policies were reviewed, and new locks and filing cabinets with locks were installed to prevent similar incidents in the future. She indicated that she had also provided a written statement during the investigation.During a telephone interview on 1/5/26 at 12:54 PM, the Law Enforcement Detective stated that the police department had received a report from the facility regarding an incident of misappropriation of property. He indicated that an employee had transferred funds from a resident's personal bank account to pay his credit card bills. The Detective reported that the incident was filed on 3/13/25, and a case number was opened. He further stated that the employee, by virtue of his position, used the resident's bank information to make payments to his credit card account. The resident's family member had also filed a report after noticing suspicious activity in the resident's bank statement. The Detective stated that the employee provided a fraudulent letter from the bank claiming that the charges were false. When the letter was verified with the bank, the bank confirmed that the document was fake. The Detective further stated that the accused employee had already been terminated by the facility when he met with the Administrator. The employee had used the resident's bank account details to make a payment of $372.96 to his credit card account. The employee was charged with fraud and other related offenses and was currently awaiting court proceedings. The Detective further stated that the family member informed him that the bank reimbursed the withdrawn amount to the resident's account. During an interview on 1/8/26 at 2:07 PM, the Business Office Consultant stated that she became aware of the incident on 3/13/25. She indicated that she audited residents' financial charts and information to ensure that no sensitive financial data was accessible to the employee. She reviewed the last 30 days of financial charts to identify any concerns and found none. She further stated that education was provided to the BOM, HIM, and BOA at that time. She instructed them that no financial records were to be placed in residents' files and that all sensitive records including ACH (Automated clearing house- a system that facilitates electronic money transfer between banks and credit unions) and credit card authorization must be locked in the Business Office cabinets. She emphasized that no financial statements should be collected from families during admission. The Consultant indicated that she continued auditing new admission paperwork to ensure no financial details were included. During these audits, no such information was found. During an interview on 1/8/26 at 2:17 PM, the Administrator indicated that he was hired on 4/24/25, as the facility's Administrator. At the time of hire, he was informed of the incident and trained on maintaining residents' financial documents. He stated that the Business Office entrance door had a keypad lock, and the code was only available to the BOM, BOA, the Maintenance Director, and himself. The Business Office also had double-locked cabinets where residents' financial data and records were stored. The keys for these cabinets were held by the BOM and the Administrator, and no other staff had access to these records. The Administrator stated that the facility continuously monitored the financial records for all new admissions, and no concerns were identified. The Corporate Business Consultant completed audits and trained new admission and Business Office staff to ensure such incidents did not recur. He confirmed that no misappropriation incidents occurred after this case and that audits were ongoing. All staff were frequently educated on resident abuse, neglect, and misappropriation. The physical location of financial records was changed to include a double-lock system for added security. The Administrator indicated that the process was revised so that the facility no longer accepts any financial information from families prior to or during admission. He stated that he had reviewed the entire investigation, root cause analysis, and audit tools. Based on these reports, the family was notified of the investigation results and was satisfied with the outcome. He further stated that the local police department worked closely with the facility to provide staff training on misappropriation and fraud, with one such training scheduled for 1/27/26.The facility provided the following corrective action plan with a completion date of 3/28/25:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 03/13/2025, the Business Office Manager (BOM) was made aware by the Responsible Party of Resident #123 that there was an unauthorized charge in the name of the facility Admissions Director on the personal account of the resident. Resident #123 has a Brief Interview for Mental Status, (BIM's) of 9 and is not an active participant in her financial affairs prior to this event. The facility immediately initiated a 24-hr. report for misappropriation after gathering the details from the niece. The accused staff member was suspended pending facility investigation. On 03/13/2025, The facility Administrator contacted law enforcement to notify them of the allegation of resident misappropriation. On 03/13/2025, the Social Services Director (SS) contacted Adult Protective Services to notify them of the allegation of resident misappropriation. On 03/19/2025, the Administrator was made aware by the resident's niece that the resident's funds had been reimbursed by the bank.2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 03/13/2025, current residents with a BIMS 13 or greater that were able to be interviewed were asked if they had any concerns with misappropriation of their funds. This audit was completed on 03/13/2025. The results included: There were no residents who had concerns with any misappropriation of their funds. Additionally, on 03/14/2025 interviews were completed with the responsible party of current residents with a BIMs of 12 or less that were not interviewed to ask:If they have noticed any charges, either for facility personal items or facility services on your account that you weren't aware of or didn't authorize?This audit was completed on 03/14/2025. The results included: There were no responsible parties who had any concerns with misappropriation of their funds.On 03/17/2025, the Business Office Consultant initiated staff interviews with all staff who have access to the Business Office Files and ask staff:If they have access to any resident's financial information including bank accounts or credit cards?If they have ever used a resident's financial information for their personal gain or benefit?If they have ever left financial files open in an area where others may have access to them?If they have witnessed any staff accessing resident financial documents when not authorized to do so?This audit was completed on 03/17/2025. The results included: There were no staff members who answered in a manner that would indicate they have any wrongdoing that would indicate they were involved in misappropriation. There was no corrective action required.On 03/13/2025 - 03/19/2025, the DON initiated random staff interviews and asked staff:If they are aware of anyone involved in misappropriation of resident's funds or money?If they have ever taken money or gifts from a resident?If they witnessed a staff member misappropriate or be involved in misappropriation of resident's funds or money? if so what would you do if you witness misappropriation?If they have received training for abuse and misappropriation?This audit was completed on 03/19/2025. The results included: There were no staff members who were aware of anyone involved in misappropriation of resident's funds or money, that had ever taken money or gifts from a resident, had witnessed a staff member misappropriate or be involved in misappropriation of resident's funds or money, and everyone verbalized having received training for abuse and misappropriation. There was no corrective action required.On 03/17/2025, the Business Office Consultants reviewed the financial files of new admissions admitted in the last 30 days to ensure there were no documents with sensitive account information that should not be in the file. This audit was completed on 03/17/2025. The results were: There was one resident financial file with sensitive account information which was removed from the file and destroyed. This financial file was for the resident involved in this allegation. The files were removed. No further corrective action was required.On 03/19/2025, the Business office Manager (BOM) reviewed the employee file of the new hires from the last 30 days to ensure that a background had been completed and that abuse education was completed at the time of hire. This audit was completed on: 03/26/2025. The results included: The background was completed prior to new hire and the employee did have abuse education completed at the time of new hire.On 03/14/2025 & 03/17/2025, The accused staff presented an email and a bank statement from the bank listed on the resident's personal statement stating that he didn't have an account with the bank in question on the resident's statement.3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 03/13/2025, the DON began educating all facility staff in all departments (including agency) on abuse and misappropriation. This training will include all current facility staff including agency. This training included:Recognizing and reporting abuse including misappropriation of propertyWhat abuse isTypes of abuseHow to report abuseWhat else should I do other than reporting the eventWhat happens after I report abuseHow can I minimize the risk of abuse happeningWhat else can I do to minimize the risk of abuseWhat are some negative results of resident abuseOn 03/13/2025, the BOM Consultant educated the staff who work directly in the Business Office and those who support the Business Office. This training will include all current Business Office staff. This training included:Proper storage of financial statementsStorage of ACH and Credit authorizationsRedacting sensitive informationLocking file cabinet when staff not accessing filesThe need to make the BOM Consultant aware of coverage needs if BOM staff are offAs of 03/19/2025, the DON will ensure that any of the above identified staff will not be allowed to work until the training is completed. The DON or designee will ensure that this education is a part of the general orientation for new hires and for agency staff.4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.The BOM Consultant or designee will monitor Financial Security of the Business Office and all new admission and prospective admissions financial files weekly for 3 weeks and monthly for 2 months to ensure compliance. Additionally, the DON or designee will monitor the abuse/misappropriation process by interviewing 5 random staff weekly x 3 weeks and monthly x 2 months to ensure compliance. Monitoring will start the week of 03/19/2025. Reports will be presented to the monthly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the monthly QA Meeting. The monthly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager.Date of Compliance: 3/28/2025Validation of the corrective action plan was completed on 1/8/26: The validation included staff interviews and a review of the in-service education provided to all staff (including agency staff) in subject of abuse and misappropriation of property. The in-service records confirmed that all staff (Full time, part-time, PRN staff in all departments and agency staff) scheduled to work during the 4-day survey had completed this education. On 3/17/25 in-service education was provided to previous BOM, BOA and previous HIM related to 1) safe keeping of resident's financial records, 2) all financial documents in a locked file, 3) ACH and credit card authorization should be kept in a locked file and 4) making Business Office Consultant aware when BOM was out of office. This training was done by the Business Office Consultant. Review of the in-service records and interviews with staff (current and previous) revealed they had completed the education. An observation was also conducted of the Business Office door keypad and the double lock cabinet that holds residents' files. Interview with the current BOM revealed that only 4 people had the numbers for door keypad. They included the BOM, BOA, Administrator and the Maintenance Director. The keys to the double lock cabinet were with the BOM and Administrator. Staff personal files were reviewed with the Administrator to ensure background checks were completed prior to employment. No concerns were identified. A review of the facility's monitoring tool revealed audits were initiated on 3/17/25 and continued in accordance with the corrective action plan.The facility's completion date of 3/28/25 was validated on 1/8/26.

Based on staff interviews and record review, the facility failed to have accurate advanced directive documentation throughout the medical record for 1 of 6 residents reviewed for advanced directives (Resident #51). The findings included: Resident #51 was initially admitted to the facility on [DATE] and had a reentry date of [DATE]. Her diagnoses included cerebral infarction (a disruption to blood supply that is severe enough and long enough in duration to result in tissue death), Type II diabetes, and chronic kidney disease. The electronic medical record profile indicated Resident #51's code status as a cardiopulmonary resuscitation (CPR)/Full Code. Review of Resident #51's physician orders dated [DATE] revealed her Do Not Resuscitate (DNR) order was discontinued; she was CPR/Full Code status. Review of Resident #51's electronic medical record revealed a signed Advance Directive form dated [DATE] which indicated no code (DNR) status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was moderately cognitively impaired. Review of Resident #51's care plan last reviewed on [DATE], showed a focus area of do not attempt resuscitation. An interview was conducted on [DATE] at 1:51 PM with Nurse #6. She stated when she verified code status, she first checked the banner in the electronic medical record (EMR). She stated she also looked in the medication administration record (MAR), and if she found a discrepancy, she notified the Director of Nursing (DON) and called the physician. An interview was conducted on [DATE] at 3:03 PM with Nurse #7. She stated she spoke to Resident #51 at the time of readmission on [DATE] regarding her code status. She stated Resident #51 told her she wanted to have CPR. Nurse #7 added Resident #51 was readmitted to the facility with a full code order and Nurse #7 was not aware that she needed to fill out a new form that reflected a change to Full Code status. An interview was conducted on [DATE] at 2:08 PM with the DON. She stated a resident's code status was verified when staff checked the banner in a resident's EMR, reviewed the advanced directive document in the EMR, and verified the code status with the physician order. An interview was conducted on [DATE] at 3:26 PM with the Social Worker (SW). She could not explain the discrepancy in Resident #51's code status. She was unable to locate documentation regarding Resident #51's change in code status within the EMR. An interview was conducted on [DATE] at 3:52 PM with the Medical Director. He stated he relied on the documentation to be correct in a resident's chart. The Medical Director added he expected that staff ensured code status documentation was accurate when a resident returned to the facility.

Based on observations, record reviews and staff interviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen (O2) was in use for 2 of 3 residents reviewed for respiratory care (Resident #63 and Resident #24). The findings included: 1. Resident #63 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure, interstitial pulmonary disease (a group of lung disorders that cause inflammation or scarring of the lungs and air sacs), and chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). Review of Resident #63's physician's orders revealed she had an oxygen order dated 4/19/2024 for oxygen supplementation at 4L (liters) continuous via nasal cannula (a device that delivers extra oxygen through a tube and into the nose). Resident #63's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was severely cognitively impaired and was coded for oxygen use. Observations on 9/24/24 at 1:45 PM and 9/25/24 at 10:17 AM revealed Resident #63 was in her room wearing a nasal cannula for supplemental oxygen. There was no signage outside Resident #63's room indicating supplemental oxygen was in use. An interview was conducted on 9/25/24 at 10:20 AM with Nurse #5. She stated Resident #63 was on 4 l NC continuous oxygen (O2) therapy since April 2024. She stated nursing was responsible for putting the O2 sign on a resident's door. She added Resident #63 had moved rooms and staff may not have taken the O2 sign from her door when they moved her into her new room. An interview was conducted on 9/25/24 at 10:52 AM with the Director of Nursing (DON). She stated nursing was responsible for putting O2 signs on a resident's door. 38077 2. Resident #24 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. Review of Resident #24's physician order dated 7/8/24 indicated Oxygen at 3 Liters (L) continuous via nasal cannula. Check every shift for Oxygen supplement. Oxygen saturation levels to be checked every shift. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was assessed as moderately cognitively impaired and was not coded for oxygen use. Resident #24 comprehensive care planned dated 7/15/24 included focus area related to COPD and the need for continuous oxygen therapy for COPD. Intervention included providing oxygen therapy as ordered by the physician. An observations was conducted on 9/24/24 at 10:04 AM as Resident #24 was lying in her bed with supplemental oxygen provided via nasal cannula by an oxygen concentrator placed next to her bed. There was no signage placed on the resident's door or anywhere near the entry to Resident #24's room to indicate oxygen was in use. An observation was conducted on 9/25/24 at 9:32 AM as Resident #24 was lying in her bed with supplemental oxygen provided via nasal cannula by an oxygen concentrator placed next to her bed. There was no signage placed on the resident's door or anywhere near the entry to Resident #24's room to indicate oxygen was in use. During an interview on 9/24/24 at 2:41 PM, Nurse #7 stated Resident #24 had a long history of COPD and was admitted on continuous oxygen. The resident was on 3 L, continuous oxygen via nasal cannula. The resident has no distress, and able to tolerate her supplemental oxygen. During an observation and interview on 9/25/24 at 9:42 AM, the 3 red signages Oxygen in Use were placed on the door of the nursing station. Nurse #8 indicated Resident #24 was 3 L of supplemental oxygen. Nurse #8 stated the oxygen signage should be placed on the resident's room doorway. She was unsure why it was not place near the entrance of the nursing station door. Nurse #8 further stated she was unsure who was responsible for placing the Oxygen in use signage on the resident's rooms entryway. During an interview on 9/25/24 at 11:11 AM, the Director of Nursing (DON), indicated Resident #24 was in a memory unit. The DON further indicated that there was one resident on the unit who removed these signage from the resident's room. The DON stated the nurses was responsible for placing and ensuring the Oxygen in Use signage was on the room entryway /door. DON indicated that she would ensure the signage was placed above the door so that the resident could not reach them.

Based on record review and staff interviews, the facility failed to accurately code the discharge status on the discharge Minimum Data Set (MDS) assessment and oxygen therapy on the admission MDS assessment for 2 of 23 residents reviewed for MDS assessment accuracy. (Resident #97 and Resident #24). Findings included: 1. Resident #97 was admitted to the facility on [DATE]. Review of the physician discharge order dated 7/5/24 revealed Resident #97 was to discharge home on 7/5/24 with home health services related to home bound status. Home health physical therapy and occupation therapy to evaluate and treat. Home health Aide for Activities of Daily living support. Record review of the nurses' notes, dated 7/5/24 revealed Resident #97 was discharged home per his request on 7/5/24. Resident #97 was discharged with home care agency set up, ordered durable medical equipment, and follow up appointment scheduled. The Nurse Practitioner was present at discharge. Record review of the Discharge Minimum Data Set (MDS) assessment, dated 7/5/24, revealed Resident #97 was coded as having been discharged to an acute hospital. On 9/25/24 at 9:35 AM, during an interview, Nurse # 1 indicated Resident #97 was discharged home with his family and home care set up. On 9/25/24 at 9:40 AM, during an interview, MDS Coordinator, indicated the resident had a planned discharge home on 7/5/24. The nurse stated the discharge MDS dated [DATE] for Resident #97 was incorrectly coded as discharge to an acute hospital. 38077 2. Resident #24 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dependence on supplemental oxygen, and chronic respiratory failure with hypoxia. Review of Resident #24's physician order dated 7/8/24 indicated Oxygen at 3 Liters (L) continuous via nasal cannula. Check every shift for Oxygen supplement. Oxygen saturation levels to be checked every shift. Nursing note dated 7/10/24 revealed Resident #24 was on continuous Oxygen at 3 L via nasal cannula. The resident was not in any acute distress. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was assessed as moderately cognitively impaired and was not coded for oxygen use. During an interview on 9/24/24 at 2:41 PM, Nurse #7 stated Resident #24 had a long history of COPD and was admitted on continuous oxygen. The resident was on 3 L, continuous oxygen via nasal cannula. The resident has no distress, and able to tolerate her supplemental oxygen. During an interview on 9/25/24 at 10:38 AM, the MDS Coordinator stated Resident #24 was admitted with oxygen therapy. The MDS Coordinator indicated it was an oversight and MDS was inaccurately marked as not receiving oxygen. On 9/25/24 at 10:10 AM, during an interview, the Director of Nursing (DON) expected the staff to complete MDS data correctly and on time. She continued that it was an error by the MDS nurse and the MDS nurse was in the process of correcting it.

Based on record review, resident interview, family interview, and staff interviews, the facility failed to provide the resident and their representative with a summary of the baseline care plan for 2 of 2 residents reviewed for care plans. (Resident #51 and Resident #248) Findings included: 1. Resident #51 was admitted to the facility on [DATE]. Baseline care plan meeting documentation dated 9/6/24 indicated Resident #51 would prefer discharge to assistant living or if resident did not improve then the resident would continue in the long-term care unit. The durable medical equipment that was needed at discharge and Resident #51's code status was discussed in the meeting. The document indicated the Social Worker (SW) and MDS coordinator attended the meeting. There was no indication that a copy of the baseline care plan was given to the resident's family member. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was assessed as severely cognitively impaired. During an interview on 9/23/24 at 11:48 AM Resident #51 indicated she was recently admitted to the facility. The resident stated she does not recollect having received care plan documentation provided to her or her family member after resident's admission to the facility During an interview on 9/25/24 at 12:05 PM, the Social Worker (SW) stated the baseline/ Admission care plan meeting was usually conducted with the resident and/or resident representative within 72 hours of resident's admission. The SW further stated that the MDS coordinator and therapy staff were present during the care plan meeting. Resident #51's representative and MDS coordinator were present for the baseline care plan meeting. The baseline care plan meeting was held on 9/6/24. The SW stated she had not been providing the residents and their representatives with a summary of the baseline care plan. 2. Resident # 248 was admitted to the facility on [DATE]. Baseline care plan meeting documentation dated 9/20/24 indicated the meeting was attended by resident's representative and family member, SW, therapy staff and MDS coordinator. Document indicated Resident #248's discharge planning and code status were discussed in the meeting. There was no indication that a copy of the baseline care plan was given to the resident's family member. During an interview on 9/23/24 at 2:23 PM, Resident #248's representative indicated that the resident was admitted to the facility few days ago. The resident's representative stated she does not recollect having received care plan documentation provided to her after resident's admission to the facility. During an interview on 9/25/24 at 12:05 PM, the SW stated the resident's baseline care plan meeting was attended by the resident's representative, resident's family member, therapy staff and MDS coordinator. The baseline care plan meeting was held on 9/20/24. The SW stated she had not been providing the residents and their representatives with a summary of the baseline care plan. During an interview on 9/26/24 at 12:04 PM, the Administrator indicated all new admission resident's baseline care plan should be completed with resident and /or resident's representative within 48 hours of admission. A copy of baseline care plan should be provided to the resident and /or attending representative. The Administrator stated the SW was unaware that a copy of the baseline care plane should be provided to the resident and /or resident representative.

Based on record reviews and staff interview, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 17 of the past 45 days reviewed. The findings included: A review of the facility's Daily Schedules for the past 45 days was conducted. The Daily Schedules indicated a Registered Nurse (RN) was not scheduled for at least 8 consecutive hours a day on the following dates: 9/1/21, 9/2/21, 9/6/21, 9/7/21, 9/9/21, 9/10/21, 9/15/21, 9/16/21, 9/20/21, 9/21/21, 9/29/21, 9/30/21, 10/1/21, 10/4/21, 10/5/21, 10/6/21 and 10/7/21 On 10/14/21 at 12:00 PM, during an interview, the Director of Nursing (DON) revealed she was responsible in collaboration with the Administrator to review the Daily Nurse Staffing form prior to posting it. DON indicated she was aware a RN needs to be scheduled 8 consecutive hours a day, however it was hard for the facility to acquire registered nurse to work for the days indicated. DON stated she was a RN, and could assist nurses if needed. During an interview on 10/14/21 at 1:39 PM, Administrator stated he was aware that on some days there were no RN in the facility. Administrator stated the facility had contacted the contract agencies and they were unable to provide RN. Administrator stated he preferred to have RN for 8 hours but on some days could not acquire them. Administrator stated the facility DON was a RN and full-time employee. He further stated the DON does not work on the cart but available when needed. Administrator indicated the facility has been hiring RN and other staffing and this was continuous process.

Based on observations, record review and staff interviews, the facility failed to review and revise the care plan for activities of daily living for two of eighteen sampled residents (Resident #60 and Resident # 46). The findings included: 1. Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #60's cognition was severely impaired. Resident was assessed as needing extensive to total assistance of one-to-two-person physical assist for activities of daily living (ADLs). Eating was assessed as total assistance with one-person physical assist. Review of the care plan dated 8/28/21 revealed Resident #60 was care planned for ADL self-care performance deficit related to dementia and impaired movement. Interventions indicated Resident #60 was independent with eating, and able to feed self with setup help only On 10/11/21 at 1:30 PM during lunch meal observation, Resident # 60 was observed to be assisted with eating by Nurse #3. On 10/12/21 at 8:15 AM during breakfast meal observation, Resident #60 was observed to be assisted with eating by Nursing Assistant (NA) #1. During an interview on 10/12/21 at 10:15 AM, NA #1 stated the resident needed total assistance with ADL care and needed assistance with eating. NA #1 indicated the resident could not feed herself. During an interview on 10/13/21 at 1:07 PM, NA #2 stated the resident needed total assistance with one-person physical assist with ADL care including eating. During an interview on 10/14/21 at 12:58 AM, Nurse #3 stated Resident # 60 was alert and was able to move her upper extremities. Nurse #3 further stated Resident #60 could feed herself, however, does not have the motivation to eat. The resident would leave the tray untouched if placed in front of her. Resident needed encouragement and assistance with eating from staff. During an interview on 10/14/21 at 1:05 PM, the MDS Nurse stated based on the resident's MDS assessment, Resident #60 needed extensive assistance with one-person physical assist for eating. MDS Nurse further stated even though the MDS assessment indicates the resident was extensive assistance with eating, this does not mean Resident #60 could not feed herself. MDS coordinator confirmed she reviews and updates the care plans based on her observation and interviews from the staff assigned to the residents. MDS Nurse stated she does not think the care plan needed to be updated based on her observation. During an interview on 10/14/21 at 1:14 PM the Director of Nursing (DON) stated it was her expectation that the care plans were updated to reflect the actual status of the resident based on the MDS assessment. 2. Resident #46 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the quarterly MDS assessment dated [DATE] revealed Resident #46's cognition was assessed as severely impaired and needed extensive assistance of one-to-two-person physical assist for Activities of Daily Living (ADLs) including eating. Review of the care plan dated 8/14 /21 revealed Resident #46 was care planned for ADL self-care performance deficit related to dementia, confusion, musculoskeletal impairment, and pain. Interventions indicated Resident #46 was independent with eating, and able to feed self with setup help only. On 10/11/14 at 1:25 PM during meal observation, Resident #46 was observed to be assisted with eating by Nursing Assistant (NA) #1. During an interview on 10/11/21 at 1:25 PM, NA #1 stated Resident #46 was totally dependent with one-person physical assist with ADL care and needed assistance with eating. NA #1 stated the resident could not feed herself. During an interview 10/14/21 at 11:13 AM, NA #2 stated the resident needed extensive assistance with eating. NA #2 stated the resident was able to feed herself finger food like a burger cut in quarters or a sandwich cut in bite size pieces, however if utensils were needed to eat, the resident could not feed self. NA #2 indicated Resident #46 was closely monitored during eating due to dysphagia and risk for aspiration. During an interview on 10/14/21 at 12:58 PM, Nurse #3 stated Resident #46 could sometimes feed herself if the food served was finger foods. Resident #46 could not feed herself with utensils due to poor hand coordination, confusion, and hand muscle impairment. Nurse #3 indicated the resident had a high risk for aspiration and needed to be closely monitored. During an interview on 10/14/21 at 01:05 PM, the MDS Nurse stated based on the resident's MDS assessment, Resident #46 needed extensive assistance with one-person physical assist for eating. MDS Nurse further stated even though the MDS assessment indicates the resident was extensive assistance with eating, this does not mean Resident #46 could not feed herself. MDS Nurse confirmed she reviews and updates the care plans based on her observation and interviews with staff assigned to the residents. MDS coordinator stated she does not think the care plan needed to be updated as the resident was able to feed herself. During an interview on 10/14/21 at 1:14 PM the Director of Nursing (DON) stated it was her expectation that the care plans were updated to reflect the actual status of the resident based on the MDS assessment.

Based on observations, record review, and staff interviews the facility failed to honor the food preferences for 1 of 4 resident observed during dining (Resident #23). Findings included. Resident # 23 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, dysphagia, and moderate protein calorie malnutrition. Dietary note dated 7/7/21 revealed Resident #23 was on a soft and [NAME] size texture, thin liquid diet. Gravy or sauce to be provided with meals. The resident disliked tomato soup. Resident's tray card was updated. Review of the quarterly minimum data set (MDS) assessment dated [DATE] for Resident #23 revealed the resident was assessed as cognitive intact, independent with eating and received a mechanically altered diet. A review of the October 2021 physician orders for Resident #23 read in part regular diet, soft & bite sized texture, thin consistency. may have bread and cake textures, may have straws, no tomato soup, may have crackers, may have chicken noodle soup, provide sauce/gravy with meals. During an observation on 10/11/21 at 11:00 AM, the resident's breakfast tray was on the side table. Observations of the food served on the resident's meal tray revealed some ground, brown food, that looked like ground meat, and which was not eaten by the resident. There was no sauce or gravy on the tray. An interview with Resident #23 on 10/11/21 at 11:00 AM revealed she could not eat the meat as it was too dry and would prefer to have some gravy to soften it. An observation of Resident #23 on 10/11/21 01:11 PM revealed the resident was served her lunch meal. Observations of the food served on the resident's meal tray revealed she had been served ground fish, mashed potatoes, chopped zucchini, bite size corn nuggets, 8 fluid ounce (fl. oz.) iced tea, and a can of tomato juice. Resident had not eaten the fish served on her tray. An interview with Resident #23 on 10/11/21 01:13 PM revealed she does not like fish, and it was too dry eat. There was no gravy on her tray. Resident indicated she was not served warm soup which she likes. Resident further indicated she dislikes tomatoes and tomato juice. Resident stated she was not served ice cream. Review of the tray card that was present on Resident #23's lunch meal tray on 10/11/21 revealed she was on a soft/ bite size diet. Fish was identified as a dislike on the tray card. Standing orders on the card read in part ½ Cup ice cream (do not send fat free), 6-ounce soup of the day (no tomato). Tray card also indicated to send gravy for meats. During an interview on 10/11/21 01:16 PM, Nurse aide (NA) #1 indicated she had served Resident #23 her lunch meal. NA #1 stated she did not look at the tray card on resident meal tray prior to serving the resident her meal to see if the resident's meal tray contained any food she dislikes. An observation of Resident #23 on 10/12/21 08 :15 AM revealed the resident was consuming her breakfast. Observation of the food served on the resident's meal tray revealed she was served a bowl of oatmeal, pancakes cut bite size, scrambled eggs, and ground sausage. The tray also contained 8-ounce juice, coffee, and condiments. The resident had not consumed her pancakes and sausage. Resident #23 during an interview on 10/12/21 at 8:17AM, stated it would be nice if the pancakes were served with some syrup. She indicated the pancakes and sausage were too dry for her to eat. Review of the tray card that was present on Resident #23's breakfast meal tray on 10/11/21 revealed standing order: sausage patty with gravy. During an interview on 10/12/21 at 8:22 AM, Nurse #2 stated there must have been an error on the part of kitchen that tray did not contain syrup for the pancakes and gravy for the meats. Nurse #2 indicated the kitchen staff should be checking trays prior to be sent to the residents. During an interview on 10/14/21 at 9:00 AM, Dietary Manager stated all resident's food preferences were taken at admission, quarterly and as needed. Dietary Manager indicated Resident #23's food preferences were recently updated. Dietary Manager indicated there were 3 staff on the tray line to assist with plating of meals according to resident's diet and preferences. Tray accuracy was checked prior to placing the tray in the cart. She stated few of her dietary aides were new and were been trained on the tray line. The Dietary Manager verbalized that her expectations were that employees were reading the tray tickets to ensure resident food preferences were honored and diet served was per orders. During an interview on 10/14/21 at 1:14 PM, the Director of Nursing (DON) indicated the kitchen staff should be checking all meal trays for tray accuracy prior to be placed in the cart. All resident's meal preferences should be honored as long as the food preferences did not conflict with the diet order. DON further stated it was her expectation that the NAs check the trays for accuracy when setting up the tray for residents during meals. During an interview on 10/14/21 01:52 PM, the Administrator indicated the meal trays should be reviewed by staff for accuracy, diet, and preferences. Residents should be served meals based on their preferences. Care should be taken to accommodate the likes and dislikes of the residents.

Based on observations, staff interviews and record review the facility failed to implement its policy on the use of Personal Protective Equipment (PPE) when staff did not don a face shield, gloves, and gown when assisting residents to eat meals while in their rooms for two of four residents (Resident #1 and Resident #2) who resided on the facility's Covid isolation unit and were on Enhanced Droplet Isolation Precautions. The failure occurred during a Covid-19 pandemic. The findings include: 1. Review of an undated facility guidance for PPE (Personal Protective Equipment), read in part, page 1. Mask: Universal use. To be worn at all times by all staff. This includes hallways and nurse's stations. Eye protection: wear upon entering patient's rooms. Wear during patient care activities in therapy, gym and other facility locations. Gloves: wear upon entering room where transmission-based precautions require use. Gloves should always be worn when there is a likelihood that the employee may be exposed to blood or other potentially infectious materials, mucous membranes, non-intact skin or potential contaminated intact skin. Gowns: wear upon entering room where transmission-based precautions require use. a. Resident #1 was originally admitted to the facility on [DATE]. The resident tested positive for Covid-19 on 12/28/20. On 1/5/21 at 5:45 PM, Nursing Assistant (NA) #1 was observed in Resident #1's room, that was located on the Covid unit, assisting the resident to eat her meal. While assisting Resident #1 with her meal, NA #1 was not wearing gloves, gown or face shield. NA#1 was wearing a mask, a uniform blue multi-colored top and blue pants. Enhanced Droplet Isolation Precautions signage was observed posted on Resident #1's door, which specified a face shield, mask, gown and gloves to be worn when entering the resident's room. b. Resident #2 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. The resident tested positive for Covid-19 on 12/21/20. On 1/5/21 at 6:00 PM, NA#1was observed in Resident #2's room, that was located on the Covid unit, assisting the resident to eat his meal. While assisting Resident #2 with his meal, NA#1 was not wearing gloves, gown or face shield. NA#1 was wearing a mask, a uniform blue multi-colored top and blue pants. Enhanced Droplet Isolation Precautions signage was observed posted on Resident #2's door, which specified a face shield, mask, gown and gloves to be worn when entering the resident's room. During an interview on 1/5/21 at 6:10 PM, NA#1 revealed she usually put on a gown when providing care, but she did not when she was going in and out of resident's rooms delivering meal trays and assisting residents with meals. During an interview on 1/5/21 at 6:15 PM, Nurse #1 stated that she was an agency nurse and full PPE should be put on before entering a resident's room and removed when exiting a resident ' s room, and to sanitize hands. During an interview on 1/6/21 at 11:16 AM the Administrator stated all residents on the covid unit tested positive for covid-19 and were on Enhanced Droplet Isolation Precautions. He revealed staff assisting with feeding residents without wearing a gown, mask, gloves and face shield was not okay. During an interview on 1/6/21 at 12:35 PM, the Administrator stated his expectation was that agency staff would be trained on the basics such as personal protective equipment and handwashing before they started work at the facility. He stated the facility staff would reeducate agency staff on enhanced precautions and the agency staff would adhere to enhanced precautions anytime when on the covid unit. The Administrator revealed last night, 1/5/21, was the first night NA#1 worked at the facility and the nurse supervisor was supposed to train her, but she failed to do so before NA#1 began working her shift.

Based on staff interviews and hospital and facility record reviews, the facility failed to implement their Abuse Prohibition policy to investigate and report an allegation of an injury of unknown origin to the Health Care Personnel Registry (HCPR) for 1 of 1 resident (Resident #1) reviewed for an injury of unknown origin. The findings included: The facility ' s Policy and Procedure entitled, Abuse Prohibition was dated [DATE] and last revised ,[DATE]. The Policy read, in part, It is the responsibility of our employees, facility consultants, attending physicians, family member, visitors, etc. to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of an unknown source and theft or misappropriation of resident property, to facility management. The Investigation Guidelines included the following statement: The administrator, or designee, will conduct investigation of any areas of concern. Resident interviews, family interview, and staff interviews may be used to investigate an incident. Investigations will be individualized to determine if abuse, neglect or misappropriation of property has occurred. If abuse is suspected, reports according to state guidelines will be completed. In the following list are some examples of allegations .(r) injuries of unknown origin (typed in capital letters). Under the subheading of Reportable Incidents, the Policy/Procedure noted, Reports of alleged incidents of abuse, neglect, exploitation, involuntary seclusion, and misappropriation of resident ' s property should be reported to the Administrator immediately. Reports must be submitted to the state agency via the Healthcare Personnel Registry (HCPR). Resident #1 was discharged from a hospital to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. Resident #1 ' s admission Minimum Data Set (MDS) assessment was dated [DATE]. The MDS revealed the resident had moderately impaired cognitive skills for daily decision making. She required extensive assistance with one-person physical assistance for bed mobility, transfers, walking in her room, locomotion on the unit, dressing and toileting. She required supervision with setup help only for eating and was independent with personal hygiene with setup help only. Resident #1 utilized a walker and wheelchair for mobility. Section J of the MDS indicated the resident had no falls since her admission. The resident ' s individualized Care Plan (undated) included an area of focus which addressed her increased risk for falls related to confusion, de-conditioning, gait/balance problems, and incontinence. Review of Resident #1 ' s Interdisciplinary Team (IDT) Progress Notes and Assessments was conducted. There was no documentation to indicate the resident had a fall or other incident during her stay in the facility. No bruising of Resident #1 ' s skin was reported in her medical record. A Nurse Practitioner (NP) Progress Note dated [DATE] reported the resident had acute kidney injury (a condition where the kidneys suddenly stop working properly) as evidenced by lab results collected and reported on [DATE]. The NP noted the resident was sent to the hospital Emergency Department (ED) for treatment upon request of her family. The Emergency Medical Service (EMS) Patient Care Record of Resident #1 ' s [DATE] transport to the hospital was reviewed. EMS reported arriving at the facility on [DATE] at 5:13 PM. The resident was transported and care was transferred to the hospital ED on [DATE] at 5:40 PM. Resident #1 ' s ED records and records from her hospital stay were reviewed. These included the following notations: --On [DATE] at 8:59 PM, an Emergency Department to In Patient Handoff Report written by a Registered Nurse (RN) included, Additional Notes: Memory loss noted upon assessment. Old bruise, hematoma noted to left forehead; pt (patient) unable to recall incident. --A consultation note from nephrology (kidney specialists) dated [DATE] at 4:24 PM reported upon physical exam, the resident was reported to have left eye ecchymosis (a discoloration of the skin, typically caused by bruising) noted. --Results of a computerized tomography (CT) scan of Resident #1 ' s head completed on [DATE] indicated she had a Mild left forehead scalp hematoma. No underlying skull fracture. --A nephrology Rounding Note dated [DATE] at 2:03 PM reported a physical exam of her head indicated, L (left) eye ecchymosis. --An MD Progress Note written on [DATE] at 12:49 PM included a Physical Exam which reported Resident #1 had a left frontal scalp hematoma; present on admission. --A nephrology Rounding Note dated [DATE] at 1:58 PM reported the resident had L (left) eye ecchymosis. --An MD Progress Note written on [DATE] at 9:36 AM included a Physical Exam which reported the resident had a left frontal scalp hematoma; present on admission. --A nephrology Rounding Note dated [DATE] at 2:51 PM reported Resident #1 had L (left) eye ecchymosis. A review of the facility ' s Incident Log from [DATE] – [DATE] was conducted. No injuries, bruising, or incidents were reported for Resident #1 during her stay at the facility. Additionally, no incident reports of injuries of unknown origin (including bruises) or falls were reported for any female residents in the facility from [DATE] - [DATE]. A telephone interview was conducted on [DATE] at 2:00 PM with Nurse #3. Nurse #3 was identified by the facility ' s schedule as working with the nurses on Resident #1 ' s hall for orientation from 7:00 AM to 7:00 PM on [DATE] and from 7:00 AM to 7:00 PM on [DATE]. During the interview, the nurse recalled seeing a female resident the morning of [DATE] who had a huge knot with a bruise around it on her head. She recalled the injury was not present when she worked the previous day ([DATE]). Nurse #3 stated she was new to the facility and not yet familiar with the residents. She could not recall the female resident ' s name. She reported the hall nurse (Nurse #4) was with her at the time when she first saw the bruise the morning of [DATE]. She stated the resident was, very confused and couldn ' t tell us what happened. An interview was conducted on [DATE] at 2:42 PM with Nurse #4. Nurse #4 was the hall nurse who was assigned to care for Resident #1 from 7:00 AM – 7:00 PM on [DATE] and [DATE]. During the interview, the nurse recalled caring for this resident. When asked, the nurse stated the resident did not experience any falls or incidents that she was aware of. Upon further inquiry, she did not recall seeing any bumps or bruising on Resident #1 ' s face or head. A telephone interview was conducted on [DATE] at 12:41 PM with NA #6. NA #6 was identified by the facility ' s schedule as having worked on Resident #1 ' s hall from 7:00 AM – 7:00 PM on [DATE] and [DATE]. During the interview, the NA reported she did recall this resident and described her as, really weak and confused. NA #6 recalled staff did have an issue of the resident trying to get up by herself to go to the bathroom. The NA reported she seemed to recall that one day when she came in for her shift the resident had a knot on her forehead. She stated this was the first time she had seen it and staff couldn ' t figure out where it came from. The NA indicated she thought it was Resident #1 who had that bump on the head, but could not be certain of the resident or the date this may have been observed. Upon further inquiry, NA #1 stated she was fairly certain she would have noted such a bruise in the NA progress notes (under alerts/new alerts) for the Resident #1. A telephone interview was conducted on [DATE] at 10:39 AM with NA #7. NA #7 was identified by the nursing schedule as having worked on Resident #1 ' s hall from 7:00 AM – 3:00 PM on [DATE] and from 7:00 AM – 7:00 PM on [DATE]. NA #7 recalled this resident. When asked, the NA recalled Resident #1 did attempt to get out of bed on her own a few times on her shift. She stated, One time I caught her trying to stand up between the wall and bed using the window sill. NA #7 reported one day when she came in to work a weekend shift, She (Resident #1) had a giant knot on her head. The NA stated from what she could remember, she thought the resident had fallen on 3rd shift when she was trying to get out of bed. However, she could not recall for certain if the injury was discussed in report or who may have told her about a fall. Upon further inquiry as to the location of Resident #1 ' s injury, the NA reported she thought it was above the resident ' s left eye. An interview was conducted on [DATE] at 10:47 AM with the facility ' s Administrator. Upon inquiry, the Administrator reported he first became aware of the concern regarding bruising of Resident #1 ' s face during an initial complaint investigation conducted on [DATE] – [DATE]. He stated, That (the injury) didn ' t happen here. He reported it was his understanding the bruising was not noted initially in the resident ' s hospital admission records. When asked who would be responsible for investigating an allegation of Abuse, the Administrator reported it would be both he and the facility ' s Director of Nursing (DON), with the DON investigating the nursing side of it. An interview was conducted on [DATE] at 11:30 AM with the facility ' s DON. During the interview, the DON recalled she first found out about the concern of bruising on Resident #1 ' s face ,[DATE] days after she was discharged from the facility to the hospital. At that time, the resident ' s Responsible Party (RP) called the facility to inquire about the bruising and to find out what had happened to cause it. When asked, the DON stated she could not recall if she herself talked with the RP or if someone else did. The DON reported after the phone call from the RP, she did an informal investigation at the facility. When asked, she stated there was no documentation of the investigation. The DON stated she reviewed Resident #1 ' s records and interviewed nursing staff. She stated no falls or reports of bruising had been reported for the resident while she was in the facility. The DON reported she had access to Resident #1 ' s hospital records. When she reviewed these records, she did not see any reports of bruising until approximately 4 days after the resident was discharged from the facility. Follow-up telephone interviews were conducted with the DON on [DATE] at 1:05 PM and 1:20 PM. A request was made to review the NA progress note charting (under alerts/new alerts) for Resident #1 from [DATE] through [DATE]. The DON reported such notes from the NAs were deleted by the electronic system after 90 days and were no longer available. A follow-up telephone interview was conducted on [DATE] at 1:45 PM with the DON. During the interview, the DON recalled when Resident #1 ' s RP contacted the facility a few days after her discharge from the facility. The RP said the resident had a fall at the facility and was upset he wasn ' t informed of it. The DON confirmed an Initial Report and 5-day Investigation Report were not submitted to the State regarding Resident #1 ' s injury of unknown origin because, We didn ' t see that she had one (injury) before she left. When asked what types of injuries of unknown origin were expected to be reported, she stated examples would include a fracture or a suspicious looking bruise where the cause could not be pinpointed or explained. The DON reported she was not aware Resident #1 ' s hospital records documented the resident had a bruise on her face the day she was discharged from the facility. When asked, the DON also stated she was not aware nursing staff members had observed bruising on Resident #1 ' s face during her stay at the facility.

Based on staff interviews and hospital and facility record reviews, the facility failed to evaluate the potential causes of an injury and implement safety interventions to prevent further injuries for 1 of 1 resident (Resident #1) reviewed for an injury of unknown origin. The findings included: A review of Resident #1 ' s hospital records revealed she was hospitalized from [DATE] to 6/2/20 prior to her facility admission date of [DATE]. Her 6/2/20 hospital Discharge Summary reported her discharge [DIAGNOSES REDACTED]. The resident ' s past medical history included, in part: colon and [MEDICAL CONDITION], cancer of the hypopharynx (throat), malnutrition of moderate degree, and dementia. Upon discharge from the hospital on [DATE], Resident #1 was admitted to the facility for rehabilitation. A Risk Assessment completed on 6/2/20 indicated the resident was at a high risk for falls. A review of the physician ' s admission orders [REDACTED]. physician's order [REDACTED]. Resident #1 ' s medical record included an Informed Consent for Use of Bed Rails dated 6/3/20. The medical need for the use of grab bars was reported to be weakness with a possible benefit of improved mobility for this resident. Potential risks and negative outcomes were described and included, in part: The use of bed rail(s) may involve risks such as .hitting against the rail(s) causing bruising and/or skin tears .Bed rail(s) can present a hazard to certain individuals, particularly those residents with physical limitations or altered mental status, such as dementia or [MEDICAL CONDITION] . Resident #1 ' s admission Minimum Data Set (MDS) assessment was dated 6/9/20. The MDS revealed the resident had moderately impaired cognitive skills for daily decision making. She required extensive assistance with one-person physical assistance for bed mobility, transfers, walking in her room, locomotion on the unit, dressing and toileting. The resident required supervision only for eating and was independent with personal hygiene with setup help. Section G of the MDS also indicated Resident #1 was not steady. The resident was only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around/facing the opposite direction while walking, moving on and off the toilet, and with surface-to-surface transfers. The resident ' s Care Area Assessments (CAAs) included: --Falls (CAA worksheet dated 6/19/20) read, in part: Resident triggered due to balance and unsteadiness .Resident requires extensive assistance with her ambulation and transfers. Resident is ambulatory with assistance using a walker and or wheelchair. Resident has had no falls since admission here to this facility. Resident has poor balance and unsteady gait. Resident is currently on therapy case load. Resident remains at risk for falls and injuries related to falls. The resident ' s individualized Care Plan (undated) included an area of focus related to her increased risk for falls due to confusion, de-conditioning, gait/balance problems, and incontinence. Interventions on the care plan included the following, in part: Anticipate and meet my needs as much as possible; Assist me to bed when I am tired or drowsy; Check on me frequently throughout the shift; Encourage me to use my walker when ambulating; Ensure that call light is within my reach; Keep frequently used objects within my reach as much as possible; Monitor for and document for 72 hours post fall following signs/symptoms: pain, bruising, mental status change, or new onset of confusion, sleepiness, inability to maintain posture, agitation, and report to the Medical Doctor (MD) any of the above signs/symptoms. Resident #1 was discharged from receiving therapy services on 6/24/20. Resident #1 ' s PT Discharge Summary dated 6/24/20 reported Resident #1 required contact guard assistance to ambulate 25-70 feet on a level surface using a rolling walker. Contact guard assistance was required due to the resident ' s unsteadiness. Resident #1 required stand by assistance from staff to safely transfer from sitting to standing, standing to sitting, bed to the wheelchair, and the wheelchair to the bed. PT notes indicated the care provider needed to be close enough to reach the resident if needed when providing stand by assistance. A Nurse Practitioner (NP) Progress Note dated 6/29/20 reported the resident had acute kidney injury (a condition where the kidneys suddenly stop working properly) as evidenced by lab results collected and reported on 6/29/20. The NP noted the resident was sent to the hospital Emergency Department (ED) for treatment upon request of her family. The Emergency Medical Service (EMS) Patient Care Record of Resident #1 ' s 6/29/20 transport to the hospital was reviewed. EMS reported arriving at the facility on 6/29/20 at 5:13 PM. The resident was transported and care was transferred to the hospital ED on 6/29/20 at 5:40 PM. Resident #1 ' s ED records and records from her hospital stay were reviewed. These included the following notations: --On 6/29/20 at 8:59 PM, an Emergency Department to In Patient Handoff Report written by a Registered Nurse (RN) included, Additional Notes: Memory loss noted upon assessment. Old bruise, hematoma noted to left forehead; pt (patient) unable to recall incident. --A consultation note from nephrology (kidney specialists) dated 6/30/20 at 4:24 PM reported the resident had left eye ecchymosis (a discoloration of the skin, typically caused by bruising) noted. --Results of a computerized tomography (CT) scan of Resident #1 ' s head completed on 7/2/20 indicated she had a Mild left forehead scalp hematoma. No underlying skull fracture. --A nephrology Rounding Note dated 7/2/20 at 2:03 PM reported a physical exam of her head indicated, L (left) eye ecchymosis. --An MD Progress Note written on 7/3/20 at 12:49 PM included a Physical Exam which reported Resident #1 had a left frontal scalp hematoma; present on admission. --A nephrology Rounding Note dated 7/3/20 at 1:58 PM reported the resident had L (left) eye ecchymosis. --An MD Progress Note written on 7/4/20 at 9:36 AM reported the resident had a left frontal scalp hematoma; present on admission. She was diagnosed with [REDACTED]. The [MEDICATION NAME] (an anticoagulant) used for [MEDICAL CONDITIONS] [MEDICATION NAME] (prevention) while hospitalized was discontinued. --A nephrology Rounding Note dated 7/4/20 at 2:51 PM reported Resident #1 had L (left) eye ecchymosis. Resident #1 ' s Interdisciplinary Team (IDT) Progress Notes and Assessments at the facility were reviewed. There was no documentation to indicate the resident had any incident or fall during her stay in the facility. No bruising of the skin was reported in Resident #1 ' s medical record. A review of the facility ' s Incident Log from 6/2/20 - 6/29/20 was conducted. No injuries, bruising, or incidents were reported for Resident #1 during her stay at the facility. Additionally, no incident reports of injuries of unknown origin (including bruises) or falls were reported for any female residents in the facility from 6/26/20 - 6/29/20. An interview was conducted on 10/20/20 at 2:30 PM with Nursing Assistant (NA) #1. NA #1 was identified to have worked on Resident #1 ' s hall from 7:00 AM - 3:00 PM on 6/26/20 and 6/29/20. The NA recalled Resident #1 and reported she could reposition herself in bed. She stated the resident loved to slide down on the bed and on her side. The NA reported she did not remember the resident having any bruising or discolorations on her skin. An interview was conducted on 10/21/20 at 10:32 AM with NA #2. NA #2 was identified to have worked on Resident #1 ' s hall from 7:00 AM - 3:00 PM on 6/26/20 and 6/29/20. The NA recalled Resident #1 and reported sometimes she would try to get out of bed by herself and staff would find her with her feet hanging off the bed. However, staff knew they needed to hurry to get into her room quickly because she might try to get up without assistance. While the NA stated she did not recall seeing any bruising on the resident ' s head, she reported it may have been possible for Resident #1 to bump her head on the grab bar as she turned herself or slid down in the bed. An interview was conducted on 10/20/20 at 3:20 PM with NA #3. NA #3 was identified to have worked on Resident #1 ' s hall from 3:00 PM - 11:00 PM on 6/26/20 and 6/29/20. This NA did not recall the resident. A telephone interview was conducted on 10/22/20 at 8:20 PM with Nurse #2. Nurse #2 was identified as the hall nurse who was assigned to care for Resident #1 from 7:00 PM on 6/26/20 to 7:00 AM (on 6/27/20); from 7:00 PM on 6/27/20 to 7:00 AM (on 6/28/20); and, on 7:00 PM on 6/28/20 to 7:00 AM (on 6/29/20). During the interview, the nurse stated he was able to remember the resident but could not recall any details of her stay. The nurse was asked to describe what he would typically do if a resident was observed to have a bruise on his/her skin. He reported he would complete an Incident Report for both a bruise from a known cause and a bruise of unknown origin. If the bruise was on the head, he would initiate neurochecks. Additionally, Nurse #2 reported he would notify the resident ' s Medical Doctor (MD) and Responsible Party (RP). A telephone interview was conducted on 10/23/20 at 11:25 PM with NA #4. NA #4 was assigned to work on Resident #1 ' s hall from 11:00 PM on 6/26/20 - 7:00 AM (on 6/27/20). During the interview, the NA reported she was typically assigned to care for Resident #1 on her shift but stated she vaguely recalled this resident. She stated Resident #1 could roll back and forth in bed by herself but needed a little assistance for other positioning. The NA stated she did have grab bars on her bed and recalled the resident favored the foot of the bed and would tend to scoot down towards it. Upon inquiry, the NA reported Resident #1 did not have an incident or fall on her shift; she did not recall seeing any bruising on the resident. The NA also stated if a resident fell or if she saw a new bruise on a resident, she would immediately alert the hall nurse. A telephone interview was conducted on 10/22/20 at 2:00 PM with Nurse #3. Nurse #3 was identified by the facility ' s schedule as working with the nurses on Resident #1 ' s hall for orientation from 7:00 AM to 7:00 PM on 6/26/20 and from 7:00 AM to 7:00 PM on 6/27/20. During the interview, the nurse recalled seeing a female resident the morning of 6/27/20 who had a huge knot with a bruise around it on her head. She recalled the injury was not present when she worked the previous day (6/26/20). Nurse #3 stated she was new to the facility and not yet familiar with the residents. She could not recall the female resident ' s name. She reported the hall nurse (Nurse #4) was with her at the time when she first saw the bruise the morning of 6/27/20. She stated the resident was, very confused and couldn ' t tell us what happened. An interview was conducted on 10/20/20 at 2:42 PM with Nurse #4. Nurse #4 was the hall nurse who was assigned to care for Resident #1 from 7:00 AM - 7:00 PM on 6/27/20 and 6/28/20. During the interview, the nurse recalled caring for this resident. She reported Resident #1 could use the call light when she wanted staff assistance. Upon inquiry, the nurse stated the resident did not have any bumps, falls, or incidents that she was aware of. She did not recall seeing any bumps or bruising on Resident #1 ' s face or head. A telephone interview was conducted on 10/22/20 at 12:41 PM with NA #6. NA #6 was identified by the facility ' s schedule as having worked on Resident #1 ' s hall from 7:00 AM - 7:00 PM on 6/27/20 and 6/28/20. During the interview, the NA reported she did recall this resident and described her as, really weak and confused. NA #6 recalled staff had an issue of the resident trying to get up by herself to go to the bathroom. The NA reported she seemed to recall that one day when she came in for her shift Resident #1 had a knot on her forehead. She stated this was the first time she had seen it and staff couldn ' t figure out where it came from. The NA indicated she thought it was Resident #1 who had that bump on the head, but could not be certain of the resident or the date this may have been observed. Upon further inquiry, NA #6 stated she was fairly certain she would have noted such a bruise in the NA progress notes (under alerts/new alerts) for Resident #1. A telephone interview was conducted on 10/23/20 at 10:39 AM with NA #7. NA #7 was identified by the facility ' s schedule as having worked on Resident #1 ' s hall from 7:00 AM - 3:00 PM on 6/27/20 and from 7:00 AM - 7:00 PM on 6/28/20. NA #7 recalled this resident. When asked, the NA recalled Resident #1 did attempt to get out of bed on her own a few times on her shift. She stated, One time I caught her trying to stand up between the wall and bed using the window sill. NA #7 reported one day when she came in to work a weekend shift, She (Resident #1) had a giant knot on her head. The NA stated from what she could remember, she thought the resident had fallen on 3rd shift when she was trying to get out of bed. However, she could not recall for certain if the injury was discussed in report or who may have told her about a fall. Upon further inquiry as to the location of Resident #1 ' s injury, the NA reported she thought it was above the resident ' s left eye. A telephone interview was conducted on 10/21/20 at 4:52 PM with NA #8. NA #8 was identified as having worked from 3:00 PM - 7:00 AM on 6/27/20 and 6/28/20. When asked, the NA stated she could not recall this resident. A telephone interview was conducted on 10/22/20 at 1:40 PM with NA #9. NA #9 was identified as having worked on Resident #1 ' s hall from 3:00 PM on 6/28/20 - 7:00 AM (on 6/29/20). Upon inquiry, the NA reported she could not recall this resident or any details of her stay. An interview was conducted on 10/20/20 at 3:07 PM with Nurse #5. Nurse #5 was assigned to care for Resident #1 from 7:00 AM - 7:00 PM on 6/29/20. During the interview, the nurse recalled the resident would try to get out of bed on her own. However, she did not recall the resident having a fall. Nurse #5 confirmed she was the nurse who sent Resident #1 out to the hospital on [DATE]. When asked, the nurse stated she did not do a skin assessment on Resident #1 when she was discharged to the hospital. She did not recall the resident having any bruising on her face or head. However, the nurse stated, I do remember that she tossed and turned in the bed. She did have the grab bars up. Nurse #5 reported the resident had the ability to turn and reposition herself in bed for the duration of her stay at the facility. She also recalled, Sometimes she went to the bathroom by herself and you would catch her coming back. The nurse also reported she thought she had found the resident ' s head at the foot of the bed on one occasion. An interview was conducted on 10/21/20 at 10:47 AM with the facility ' s Administrator. Upon inquiry, the Administrator reported he first became aware of the concern regarding bruising of Resident #1 ' s face during an initial complaint investigation conducted on 9/17/20 - 9/18/20. He stated, That (the injury) didn ' t happen here. He reported it was his understanding the bruising was not noted initially in the resident ' s hospital admission records. An interview was conducted on 10/21/20 at 11:30 AM with the facility ' s Director of Nursing (DON). During the interview, the DON recalled she first found out about the concern of bruising on Resident #1 ' s face 3-4 days after the resident was discharged from the facility to the hospital. At that time, the resident ' s Responsible Party (RP) called the facility to inquire about the bruising and to find out what had happened to cause it. When asked, the DON stated she could not recall if she herself talked with the RP or if someone else did. The DON reported after the phone call from the RP, she did an informal investigation at the facility. When asked, she stated there was no documentation of the investigation. The DON stated she reviewed Resident #1 ' s records and interviewed nursing staff. She stated no falls or reports of bruising had been reported for the resident while she was in the facility. The DON reported she had access to Resident #1 ' s hospital records. When she reviewed these records, she did not see any reports of bruising until approximately 4 days after the resident was discharged from the facility. Follow-up telephone interviews were conducted with the DON on 10/22/20 at 1:05 PM and 1:20 PM. A request was made to review the NA progress note charting (under alerts/new alerts) for Resident #1 from 6/26/20 through 6/29/20. The DON reported such notes from the NAs were deleted by the electronic system after 90 days and were no longer available. A follow-up telephone interview was conducted on 10/26/20 at 1:45 PM with the DON. During the interview, the DON again recalled Resident #1 ' s RP contacted the facility a few days after her discharge from the facility. The RP said the resident had a fall at the facility and was upset he wasn ' t informed of it. When asked, the DON reported she was not aware Resident #1 ' s hospital records documented the resident had a bruise on her face the day she was discharged from the facility. Upon further inquiry, the DON also stated she was not aware nursing staff members had observed bruising on Resident #1 ' s face during her stay at the facility.

Based on observation, staff interviews and review of facility policy and procedure, the facility failed to implement infection control measures when one of two dietary workers was observed wearing a face mask that did not cover their nose or mouth while working in the kitchen (Dietary Manager). This failure occurred during the COVID-19 pandemic. Findings included: The policy titled COVID-19 Policy and Procedure and dated 6/26/2020 stated under 5) d) Universal use of mask. i)Universal use of mask means that all employees will wear a mask while in the facility. Under 19) Dietary Services: Staff should wear a mask when in the facility. On 7/16/2020 at 9:50 AM, the Dietary Manager was observed working in the kitchen with her mask below her chin. When asked if she had received training about wearing a mask she stated yes, she had received in-services. The Dietary Manager indicated she was not wearing her mask over her nose and mouth because it was hot in the kitchen and sometimes hard to breathe. In an interview on 7/16/2020 at 10:20 AM, the Director of Nursing stated the dietary workers in the kitchen get hot and that is why they may pull their masks down.

Based on observations, staff and family interviews, the facility failed to clean a resident's wheelchair for 1 of 3 residents reviewed for environment (Resident #1). Findings included: Resident #1's 5-day Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired. The resident required limited assistance with bed mobility, transfers, walking in corridor, and locomotion. He required extensive assistance with dressing, toilet use and supervision with eating and personal hygiene. Resident #1's room was observed on 1/27/20 at 9:10 AM. The resident's wheelchair was observed in the corner of the room. The blue seat cushion of the wheelchair had a circular area of a dried brown substance covering about 40 percent of the wheelchair's cushion. There were also a few small, brown flakes on top of the brown, dried substance on the cushion of the wheelchair. On 1/27/20 at 10:04 AM environmental services staff member #1 was observed cleaning Resident #3's room and taking the trash out of the resident's room. The environmental service staff member #1 (who was cleaning Resident #1's room at 10:04 AM) was interviewed on 1/27/20 at 10:10 AM. She stated she cleaned residents' rooms throughout her shift. She would go back to each room and take out the trash in the afternoon and clean if needed. The nursing assistant (NA) would tell her if they needed anything cleaned and she would do it. She was unsure who was supposed to wipe down the wheelchairs, but she would do it if the wheelchair needed it. Nursing Assistant #5 was interviewed on 1/27/20 at 10:35 AM. She stated the resident used the toilet and needed more help but now could do it (get to the bathroom) on his own. She stated she checked on the resident this morning. She stated the resident had no concerns. She stated she didn't know when he received bathing/got up in the morning as she was new to this hall. Nurse #1 was interviewed on 1/27/20 at 12:06 PM (assigned the resident on 1/27/20 on day shift). She stated the resident was having diarrhea. If there was something obviously dirty in the resident room, then she would notice it. She hadn't noticed anything obviously dirty in the resident's room. She was unsure who washed the resident's wheelchair. Environmental services staff member #1 was interviewed on 1/27/2020 at 3:58 PM. She stated she wiped the resident's wheelchair down earlier today. The seat of the wheelchair had a brown substance on it. It looked like the resident had an (stool) accident on the cushion part of the wheelchair. She stated she tried to watch out for this and make sure his wheelchair was clean. The business office manager was interviewed on 1/28/20 at 8:48 AM. She stated there was a meeting where the resident's family was upset because the resident's wheelchair was dirty. The family also had concerns about medication for the resident's diarrhea. She thought the meeting was on 1/8/20 or 1/9/20. She stated the resident's family grabbed her to see the dirty wheelchair first (unknown date; suspect this was before the meeting on 1/8/20 or 1/9/20). She stated on the cushion of the wheelchair, there was a spot of a dried, brown substance. The resident's family member also grabbed the administrator to see the wheelchair and the administrator told them that he would have someone clean the wheelchair. Resident #1's family was interviewed on 1/27/2020 at 3:39 PM. He stated the resident's wheelchair had stool on it again on Sunday (1/26/20). Resident #1's family was interviewed again on 1/28/20 at 10:14 AM. He stated the resident's wheelchair had a brown substance on the seat cushion for 6 days. He stated on 1/6/20, he got the administrator and the business office manager and showed them. The administrator got them (the facility) to clean the wheelchair. Then on 1/11/20 through 1/14/20, the resident's wheelchair had a brown substance on the cushion again on each of these days, which looked like feces. He stated he did not file a formal grievance but did tell staff (did not state who he told) about the dirty wheelchair. He stated the staff did not do anything. He stated on Saturday (1/25/20) the resident's wheelchair was clean. However, on Sunday 1/26/20, there was a brown substance that appeared to be feces on the wheelchair seat again. He stated he spoke to the administrator on 1/20/20 about his concerns and nothing was done about his concerns. Nurse #4 was interviewed via phone on 1/28/2020 at 2:13 PM. She stated the resident needed assistance with getting up. The resident gets up on his own without their knowledge. The resident would not tell staff when he was going to get up. She has never known his wheelchair or room to be dirty. The administrator was interviewed on 1/28/2020 at 2:56 PM. He stated there was a time the resident's family came to him because resident's #1 wheelchair was dirty. The wheelchair was soiled but he was unable to say what the substance was. He stated that environmental services staff cleaned the wheelchair. He stated he spot checked the resident's wheelchair for a few days after that and it was fine. The Director of Nursing was interviewed on 1/28/20 at 4:23 PM. She stated she looked at the resident's wheelchair this morning and the wheelchair wasn't dirty. The administrator was interviewed on 1/29/20 at 12:10 AM. The NAs would clean the wheelchairs. If a wheelchair sat overnight and it was cleaned the next day and the resident wasn't using the wheelchair, then that was acceptable. He stated he would expect for the wheelchair to be cleaned before the resident utilized it.

Based on staff and family interviews, the facility failed to file a grievance for a reported missing cell phone for 1 of 3 residents reviewed for misappropriation of property (Resident #1). Findings included: A policy titled: Introductions form (no date) in resident #1's admission packet revealed that if you have filed a complaint with any of the above individuals and have not gotten a satisfactory response, we encourage you to call our corporate hotline. The document included a list of key individuals and their contact information for a complaint, which included the administrator and business office manager's contact information. There were no grievances filed for this resident regarding a missing cell phone. Resident #1 was admitted to the facility on [DATE] with the current [DIAGNOSES REDACTED]. Resident #1's 5-day Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired. The resident required limited assistance with bed mobility, transfers, walking in corridor, and locomotion. He required extensive assistance with dressing, and toilet use. He required supervision with eating and personal hygiene. The social worker was interviewed on 1/28/20 at 8:36 AM. She stated the business office manager and Director of Nursing (DON) dealt with the resident's family regarding everything. Nothing was brought to her attention because the family didn't want her to be involved in the resident's care. The Director of Nursing was interviewed on 1/28/20 at 8:42 AM. She stated the resident hasn't had any missing items. Residents' clothes were usually labeled and there were a lot of residents with cell phones. The resident or family had not reported any missing items. They (the facility) typically don't complete an inventory list of items when residents were admitted . The associate director of nursing (ADON) was interviewed on 1/28/2020 at 4:21 PM. The resident's family had not filed any grievances with her. The business office manager was interviewed on 1/28/20 at 8:48 AM. She stated there was a meeting on 1/8/20 or 1/9/20 (She was unsure of the exact date). They had a meeting because the family wanted the power of attorney to be changed and had concerns about the resident's care. She stated the day the social worker, another staff member, and herself met with the family, they (the family) said Resident #1 was missing a cell phone. She stated she went to the resident's room and looked for the cell phone. She added that she went with the resident's family member to look for the cell phone (date unknown). The cell phone was mentioned again to her and she told the family they could not find the cell phone on 1/8/19 (the day of the meeting). The resident's family lead her to believe that the resident misplaced the cell phone. She didn't file a grievance for the cell phone. She tried to handle the situation and had looked for the cell phone. She told the family she would keep an eye out for it. The resident's family did not want any interaction with the social worker. She stated she probably should have filed a grievance for the cell phone, but she thought the concern was resolved as she never heard anything about the issue after she spoke with the family about it. The resident's family was interviewed on 1/28/20 at 10:14 AM. He stated on 1/4/20, the resident still had a cell phone at the facility as the resident had called him about getting to the bathroom. He stated the resident had a cell phone and a cell phone charger. He noticed the cell phone was missing on 1/7/20 and he told the facility (he didn't say who he told). He stated that nothing was done about the missing cell phone. The Administrator was interviewed on 1/28/2020 at 2:56 PM. He never knew of a cell phone missing for Resident #1. He stated the family could have filed a grievance at any time, which are made available at the facility. If a resident had an issue that wasn't taken care of immediately a grievance would be filed. He stated generally they would write grievance for missing items unless it was found immediately. The Administrator was interviewed on 1/29/2020 at 12:03 PM. He stated the business office manager just told him about the missing cell phone (during the survey). He stated he would expect for a missing item to be searched for and located (if possible). If the item was not able to be located, then he would expect for a further investigation to be completed and the findings to be reported to the family. If the item was money or an item of value, then they would follow up with the police. For a missing cell phone, they would complete a grievance and talk with the family. Depending on what the family wanted to do, they could replace the item. He stated he was the abuse coordinator at the facility.

Based on observations, staff interview, facility record review and review of the manufacturer's medication storage specifications, the facility failed to date medications when opened, failed to discard expired insulin and failed to properly store an unopened insulin pen in 2 of 2 medication carts. (Unit 100 and right side of Unit 300 and Unit 200 and left side of Unit 300). Findings included: The review of manufacturer's storage specifications revealed: [MEDICATION NAME](insulin) once opened should be disposed after 42 days, even if there was insulin left in it. All forms of [MEDICATION NAME] (insulin)are good for up to 28 days once they are opened, after which any unused portions must be discarded. [MEDICATION NAME] (insulin) after opened and not used within 28 days must be discarded. All unopened [MEDICATION NAME] must be stored in a refrigerator and protected from light. Travoprost ophthalmic drops must be discarded 4 weeks after being opened. Review of the in-service training records revealed drug storage training was completed on [DATE] and [DATE]. Record review of medication storage audits revealed audits were completed on [DATE], [DATE], [DATE], [DATE] and [DATE]. a. Observation on [DATE] at 4:35 PM of the medication Cart for Unit 100 and right side of Unit 300 revealed: [MEDICATION NAME] was opened and undated for Resident #1. [MEDICATION NAME] pen for Resident #4 was opened and undated. [MEDICATION NAME] 0.5% Ophthalmic drops for Resident #5 was opened and undated. [MEDICATION NAME] was opened for Resident #6. The date on the label affixed to the [MEDICATION NAME] was [DATE] as opened. As of [DATE], there were more than 28 days after the initial opening of the [MEDICATION NAME]. [MEDICATION NAME] was not opened for Resident #7. Two (2) bottles of [MEDICATION NAME] propionate nasal spray were open and not dated. The resident names were smeared and was difficult to obtain resident names. Travoprost ophthalmic drops for Resident #3 was opened and undated. During an interview with Nurse #5 on [DATE] at 4:50 PM Nurse #5 stated it was the responsibility of the nurse who opened a new bottle of medication and/or insulin to write the date it was opened. Nurse #5 stated she knew unopened insulin pens should be refrigerated and was not sure why the unopened insulin pen was stored in the cart. b. Observation on [DATE] at 4:59PM of the medication Cart for Unit 200 and left side of cart for Unit 300 revealed: [MEDICATION NAME] propionate nasal spray was open and not dated for Resident # 8 Three (3) tubes of [MEDICATION NAME] sodium topical gel was open and undated. [MEDICATION NAME] sodium topical gel was prescribed for Resident # 9, Resident #10 and Resident #11. Interview with Nurse #6 occurred on [DATE] at 5:15 PM. Nurse #6 stated it was the responsibility of the nurse who opened a new medication to document the date the medication was opened. Interview on [DATE] at 5:30 PM with the Director of Nurses (DON) stated nurses get in a hurry and forget to date medications when initially opened. Continued interview with the DON stated her nurses were educated to date medication when initially opened and audits were completed as a result of the last recertification survey ending [DATE].

Based on facility record reviews and staff interviews, the facility failed to post an accurate and complete daily nurse staffing information for 11 of 92 days of staffing information reviewed (11/04/19, 11/8/19, 11/11/19, 11/20/19, 11/28/19, 12/4/19, 12/11/19, 12/28/19, 1/21/20, 1/25/20 and 1/27/20). Findings included: 1a. Review of the 1/27/20 posted nursing staff information on 1/28/20 revealed the resident census was documented as 81 residents for the 3:00 PM to 11:00 PM shift and the 11:00 PM to 7:00 AM shift. Interview on 1/28/20 at 10:00 AM with the Admissions Assistant revealed the resident census on 1/27/20 was 80 during the morning and the census changed to 84 due to 4 admissions on 1/27/2020. The Admission Assistant stated on 1/27/20, 1 resident was admitted at noon, 1 resident was admitted at 3:30 PM, 1 resident was admitted at 5:00 PM, and 1 resident was admitted at 6:15 PM. b. Review of the retained posted nursing staffing records revealed: Staff posting dated 11/4/19 revealed under the columns for the number and hours of registered nurses on duty during the entire day was entered as 0(zero). Review of the payroll report for 11/4/19 revealed one (1) registered nurse worked 8:00 AM to 5:00 PM. No posted staffing forms were retained for 11/8/19, 11/11/19, 11/20/19, 11/28/19, 12/4/19, 12/11/19, 12/28/19 and 1/21/20. The posted staffing form for 1/25/20 was incomplete. There was no documentation under the columns for the census, number of registered nurses or hours on duty for 7 PM -7 AM and there were no hours for licensed staff during the 11 PM-7 AM shifts. Interview on 1/29/20 at 12:08 PM with the Director of Nurses (DON) stated the HR payroll staff completed the daily staff posting for all shifts, but no one had been assigned to make changes or modifications to the information once the information was completed and posted in the morning. The DON stated she was responsible for retention of the posted staffing and staff would place the prior day's staff posting in her mailbox and at the time of the survey there were months of posted staffing in her mailbox that had not been filed.

Based on record review, staff and resident interviews, the facility failed to respond to group grievances regarding dietary concerns that were reported in the monthly resident council meetings for 4 of the 5 months reviewed (May 2019, (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019). Findings included: 1. During a resident council meeting on 10/15/19 at 10:00 AM, the residents in the resident council reported not all grievances were acted on promptly by the facility and there were no explanations given as to the reason the grievances were not resolved. A resident reported the Activities Director (AD) documented the issues and discussed the ongoing concerns during each meeting. Several of the members indicated the AD explained during the meetings that the issues were passed along to the appropriate staff to ensure resolution of the issues. Residents indicated that they felt their concerns expressed in the meeting were not addressed by the dietary staff. The Resident Council minutes dated 5/23/19 revealed residents with food concerns. The residents were assured that their concerns were forwarded to dietary. The minutes did not indicate the type of food concern or include the residents name with the concerns. The Resident Council minutes dated 6/26/19 read in part no new business forward other than personal food concerns. The resident council minutes dated 7/25/29 revealed there were no concerns other than personal food concerns that were forwarded to the dietary. The resident council minutes dated 9/26/19 revealed several residents with personal food concerns that were forwarded to the dietary department. The facility grievance logs from (MONTH) to (MONTH) 2019 revealed no grievances related to Resident Council minutes. An interview was conducted with the Social Worker (SW) on 10/15/19 at 2:22 PM. SW stated she was the grievance officer and receives the grievances. The grievances were forwarded to the appropriate department for interventions to be put in place. SW stated once the interventions were put in place, she follows up to ensure the interventions were appropriate and resolution was reached. Oral and written response was provided to the residents and family members. SW indicated she was responsible only for individual grievance and does not complete any resident council grievances as she does not regularly attend resident council meeting. SW stated the activity director (AD) was responsible for resident council grievances. During an interview on 10/15/19 at 2:17 PM, the AD stated any concerns or grievances that were expressed in the resident council were written and forwarded to the respective departments. The departments were responsible for the interventions and follow up. AD indicated she does not maintain a grievance log for resident council concerns. Related to dietary concerns, AD stated as residents expressed personal dietary concerns in the meeting, these were forwarded to the dietary department via email. AD indicated no grievances were written as they were personal food choices and that the dietary department does address resident's concerns promptly. During an interview on 10/17/19 at 10:29 AM, the Dietary Manager (DM) explained she sometimes receives email from AD or a piece of paper with the resident's name that had dietary requests. DM indicated the dietary department had not received any grievances related to residents' dietary concerns for past few months. DM stated in (MONTH) 2019 she did received an email from AD regarding a resident's request to change meal options, which was addressed by the dietary staff. She further stated she received monthly emails from the AD regarding meal of the month that was discussed with the resident's council minutes. The Dietary manager was unable to provide any documentation that concerns were received and addressed. She was unaware of what the resident council concerns were related to dietary department. During an interview on 10/17/19 at 11:53 AM, the administrator stated group grievances can be stated or written by the residents. Depending on the concern or grievance, these should be forwarded to the appropriate department. The departments were supposed to provide appropriate intervention and provide documentation to the AD for resident council grievances. The resolutions were then given to the members of the Resident Council. Administrated stated he expects that these procedures were followed.

Based on record review, observation and staff interviews the facility failed to provide a dignified feeding experience by standing beside the bed to feed meals to 2 of 2 residents reviewed for dignity. (Resident # 60 and Resident # 42). Findings included: 1.Resident # 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] indicated resident was cognitively impaired and was total dependent with one to two-persons physical assistance with activities of daily living (ADL). Review of Resident # 60's care plan dated 9/18/19 reveals a focus area of feeding regarding needing total assistance with meals. The goal was for staff to assist resident with feeding to promote optimum nutrition and hydration. The interventions included setting up the tray, assisting resident with meals and fluids and reporting to nursing any difficulties related to chewing and swallowing. Record review indicated Resident# 60 was on a cardiac diet, pureed texture with nectar thick liquid. During a continuous observation on 10/14/19 from 8:35 AM to 8:45 AM, Resident # 60 was being assisted with eating while in her bed by Nurse aide (NA). NA was standing beside the resident's bed while assisting the resident with her breakfast tray. A wooden chair was noted in the room, near the wall behind the N[NAME] The observation continued until the resident had completed consuming her meal and the NA brought the tray out of the room to be placed on the tray rack. During an interview on 10/14/19 at 8:50 AM, NA # 4 indicated she wasn't sitting while assisting Resident # 60, but she usually does. The NA stated it was more convenient to feed residents standing up. The NA further stated she should have pulled the chair closer to the bed and should have sat down to feed the resident. During an interview on 10/17/19 at 11:18 AM, the Director of Nursing (DON) stated the residents care needs were listed in the care guide for each resident. The care guides were available on the NA's tablet and used for documenting care provided. The DON indicated during orientation and at least once a year, information regarding assisting resident with meals was reviewed in training. The NA's were provided in-service recently. The DON stated her expectations were for staff to be sitting down during a meal, talking and trying to encourage a resident to eat and not to be standing. 2. Resident # 42 was admitted to facility on 5/20/19 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed with [REDACTED]. The MDS indicated resident was cognitively impaired and was total dependent with one-person physical assistance with activities of daily living (ADL) related to transfer, bed mobility, personal hygiene, dressing, toilet use and bathing. Resident was assessed as needing supervision with set up help only for eating. Review of Resident # 42's care plan dated 8/27/19 reveals a focus area related to ADL self-care performance deficit due to confusion and dementia. The goal was to improve resident's current level of functioning related to ADL's. The interventions included anticipating resident needs. The resident was able to self-feed independently and needed only set up assistance during meals. The food was to be placed in clear bowls on the tray, Record review indicated Resident# 42 was on a regular diet with regular texture and thin liquid. During a continuous observation on 10/16/19 from 8:15 AM to 8:40 AM, Resident# 42 was observed lying in bed. Nurse Aide (NA) # 5 (who was assigned to the resident), brought the resident's meal tray and placed it on the resident's bedside table. The NA assisted the resident with positioning on the bed and setting up the breakfast tray for the resident. NA # 5 was observed feeding the resident while standing beside the resident's bed. A chair was noted in the room, on the opposite side of the resident's bed. The observation continued until the resident had completed consuming her meal and the NA brought the tray out of the room to be placed on the tray rack. During an interview on 10/16/19 at 8:45 AM, NA#5 indicated resident was total dependent with one person physical assist with ADL. NA stated resident was assisted with feeding and needed to be encouraged to consumed meals. NA further stated she should have pulled the chair over and sat down to feed the resident. NA indicated she should not be standing beside the resident during feeding. During an interview on 10/17/19 at 11:18 AM, the Director of Nursing (DON) stated the residents care needs were listed in the care guide for each resident. The care guides were available on the NA's tablet and used for documenting care provided. The DON indicated during orientation and at least once a year, information regarding assisting resident with meals was reviewed in training. The NA's were provided in-service recently. The DON stated her expectations were for staff to be sitting down during a meal, talking and trying to encourage a resident to eat and not to be standing. During an interview on 10/17/19 at 2:26 PM, the Administrator stated his expectation were for staff was to sit and engage the resident appropriately during feeding while following the safety precautions.

Based on staff and family interviews, and record review, the facility failed to document and resolve individual grievances for 1 of 1 resident reviewed for grievances. (Resident # 60). Findings included: Resident # 60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated resident was cognitively impaired and was total dependent with one to two-persons physical assistance with activities of daily living (ADL). Resident # 60's care plan dated 9/18/19 reveals a focus areas of increased risk of falls related to deconditioning, gait problems and unaware to safety needs and actual fall. The goal to minimize falls with no major or minor injuries. The interventions included anticipating resident's needs, assisting resident to bed when tired and frequent monitoring throughout shifts. Resident to be offered to be put to bed after therapy and staff to reinforce safety reminders frequently. The nursing notes dated 9/27/19 revealed resident was noticed on the floor after returning from therapy. Resident # 60 had a small slit over the right eyebrow and steri strip was applied. The resident was sent to emergency room upon family request. Resident returned to facility later at 9:15 PM after evaluation. Facility grievance logs were reviewed from (MONTH) 2019 to (MONTH) 2019. There were no grievances for the month of September. During an interview on 10/14/19 at 1:15 PM, Resident # 60's responsible party (RP) stated on 9/27/19 at 11:30 AM, the family was notified about resident's fall from her wheelchair. RP stated when he arrived at the facility an hour later, he had some concerns related to resident care after the fall and spoke with the social worker (SW) about their concerns. Upon the family's request the resident was sent to the hospital. RP stated he reported his grievance to the SW and did not receive any resolution since 9/27/19. During an interview on 10/15/19 at 2:22 PM, SW stated she was the grievance officer. SW indicated Resident# 60's RP did approach her related to resident's care after the fall. The assigned nurse had provided appropriate treatment and vital signs were checked. SW stated therapy and nursing staff had interventions in place related to the resident's fall. The resident was sent to the hospital upon family request. SW indicated as the resident was sent to the hospital, she assumed the family's concern was resolved and no grievance was filled. She stated she had met with the RP multiple times after the incident and the RP had not expressed any concerns regarding the resolution. She stated she had not filled any grievance related to the resident's family members concern. During a telephone interview on 10/15/19 at 3:32 PM, the resident's RP stated he was informed about the resolution to his grievance 30 minutes ago. RP further stated initially when he had expressed his concerns to the SW on 9/27/19, he had requested for certain documents. RP indicated Resident # 60 had returned to the facility on [DATE] late in the evening when the administrative staff and SW had left the facility for the week. RP stated he had not received the documentation and resolutions related to the incident. RP stated his preference was for the facility be proactive in providing the information he requested before he expressed his concerns with the onsite State surveyors. During an interview on 10/17/19 at 11:53 AM, the administrator stated the individual grievances can be stated or written by the residents, family members or any concerned party. Depending on the concern or grievance these should be forwarded to the department. The departments were supposed to provide appropriate intervention and provide the documentation to the SW. The resolutions were provided orally and in written to the concerned person so that the resolution was to their satisfaction. The administrator indicated he does review the resolutions prior to them been given to responsible party. Administrated stated he expects that these procedures were followed.