Every finding on record at Life Care Center of Blount County

Based on facility policy review, medical record review, observation and interviews the facility failed to provide dignity for 1 resident (Resident #90) of 24 residents reviewed for dignity.The findings include:Review of the facility policy titled Activities of Daily Living (ADLs), dated 9/10/2024, revealed .For residents who are unable to carry out activities of daily living receives the necessary services to maintain .grooming .Review of the medical record revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Diabetes, and Dementia.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #90 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and required partial/moderate assistance with personal hygiene.Review of a comprehensive care plan for Resident #90 dated 6/5/2026, revealed .ADL assistance .assist with .ADL's as needed .During an observation/interview on 6/29/2026 at 12:01 PM in Resident #90's room, revealed resident lying in bed with a large amount of facial hair on her upper lip. Resident #90 expressed interest in having the facial hair removed. Review of the facility's bathing schedule revealed Resident #90 was scheduled to receive showers on Wednesday, Saturday and as needed (PRN). Further review revealed Resident #90 received a bed bath on 6/27/2026.During an interview on 6/29/2026 at 11:30 AM, Certified Nurse Assistant (CNA) A stated Resident #90 required assistance with shaving and Resident #90's shower was on Wednesday and Saturday. CNA further stated shaving was to be offered on shower days. During an interview/observation on 6/29/2026 at 11:45 AM, Licensed Practical Nurse (LPN) A stated Resident #90 was to receive showers on Wednesday and Saturday. LPN A stated residents were to have facial hair removed on shower days. LPN A confirmed Resident #90 had a large amount of facial hair and had not been shaved. During an observation and interview on 6/29/2026 at 12:05 PM, in Resident #90's room, the Director of Nursing (DON) stated staff were to offer shaving for male and female residents on shower days and as needed. The DON confirmed Resident #90 had a large amount of facial hair and had not been shaved.

Based on facility policy review, medical record review, observations and interviews the facility failed to honor the bathing preferences of 2 residents (Resident #73 and #106) of 24 residents reviewed. The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), dated 9/10/2024, revealed .the resident will receive assistance as needed to complete activities of daily living (ADL's) .Any change .will be reported to the nurse . Review of the facility policy titled, Resident Rights, dated 9/26/2025, revealed .resident has the right to receive the services .included in care plan .make choices about aspects of his or her life in the facility that are significant to the resident . Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Diabetes, and Muscle Weakness. Review of a comprehensive care plan dated 6/15/2026, revealed Resident #73 had an .ADL [Activities of Daily Living] assistance .to maintain or attain highest level of function .assist with .adl's as needed . Continued review revealed the care plan did not reflect the resident's bathing preference. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #73 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #73 required substantial/maximal assistance with shower. Review of the Kardex (Certified Nurse Assistant (CNA) Care Plan) for Resident #73 revealed, .Bathing .ADL-Bathing-SHOWER-Tuesday and Friday Evening and PRN [as needed]. Review of the facility documentation for Resident #73 titled .ADL-Bathing-SHOWER-Tuesday and Friday evening AND PRN . dated from 6/16/2026 to 7/1/2026 revealed no showers were given. Further review revealed Resident #73 received a bad bath on 6/19/2026. Review of the medical record for Resident #73 revealed no documentation of refusal of showers for Resident #73. During an interview on 6/29/2026 at 12:43 PM, Resident #73 stated he had not received a shower since admission to the facility. Resident #73 further stated he had received bed baths, but his preference was to receive a shower. During an interview on 7/1/2026 at 2:15 PM, Resident #73 stated he still had not received showers since admission but was hoping for one today [7/1/2026]. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety, Muscle Weakness, and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #106 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment and was dependent on staff for showers. Review of a comprehensive care plan dated 4/30/2026, revealed Resident #106 had a .ADL assistance .to maintain or attain highest level of function .assist with mobility and ADLs as needed . Continued review revealed the care plan did not reflect the resident's bathing preference. During an interview on 6/29/2026 at 10:26 AM, in Resident #106's room the Responsible Party stated Resident #106 had not had a shower in over 30 days. The Responsible Party further stated Resident #106 had received bed baths but Resident #106 and the Responsible Party preferred showers. Review of the Kardex for Resident #106 revealed, .Bathing .ADL-Bathing-SHOWER-Wednesday, Saturday and PRN. Review of the facility documentation for Resident #106 titled ADL-Bathing-SHOWER-Wednesday, Saturday, and PRN, dated from 5/27/2026 to 6/27/2026 revealed bed baths were given. Further review revealed Resident #106 received bed baths on 5/30/2026, 6/3/2026, 6/10/2026, 6/13/2026, 6/20/2026, and 6/27/2026. Continued review revealed no showers were provided to Resident #106 per the resident's preference. Review of the medical record for Resident #73 revealed no documentation of refusal of showers for Resident #106. During an interview on 6/29/2026 at 2:00 PM, CNA B stated showers were done twice a week and if the resident refused, the nurse would be informed, and the refusal would be documented. Bed baths were only to be offered if shower were refused. CNA B further stated she would refer to the Kardex for shower days. During an interview on 6/29/2026 at 2:06 PM, the Unit Manager (UM) stated all residents were to be offered a shower and if they refused, the nurse was to be informed and then a bed bath offered. UM further stated it was Resident #106's preference to receive a shower and not a bed bath. The UM manager was unaware of Resident #106 refusing showers. UM confirmed Resident #106 had received bed baths and had not received the showers per the resident preference. During an interview on 6/29/2026 at 8:30 PM, CNA C stated residents received showers twice a week. CNA C further stated residents were to be offered showers first and then a bed bath if refused. CNA C stated if a resident refused a shower she was to report the refusal to the nurse, and any refusals of showers were to be documented in the medical record. During an interview on 7/1/2026 at 10:25 AM, the Director of Nursing (DON) stated residents were to receive a shower twice a week and as needed. The DON further stated showers were to be offered first and if refused the CNA was to report the refusal to the nurse and the refusal documented in the medical record. The DON confirmed Residents #73 and #106 did not have a care plan related to refusal of showers or a preference for bed baths. The DON confirmed Residents #73 and #106 had received bed baths instead of the preferred showers.

Based on facility policy review, observations, and interviews, the facility failed to ensure medications were securely stored in 1 medication cart (Medication Cart 1) of 3 medication carts reviewed. The findings include: Review of the facility policy titled, Medication Storage, dated 11/28/22, revealed .the facility must store all drugs and biologicals in locked compartments .permit only authorized personnel to have access . During an observation and interview on 6/30/2026 at 7:52 PM, revealed Licensed Practical Nurse (LPN) B was standing at a medication cart preparing medications. LPN B left the medication cart and entered residents room, leaving the medication cart unlocked and unattended. LPN B returned to the medication cart and confirmed the mediation cart was left unlocked and unattended. LPN B confirmed she should have locked the medication cart when left unattended. During an interview on 6/30/2026 at 8:01 PM, Registered Nurse (RN) A stated there were no wandering residents in the facility. During the night shift observation on 6/30/2026 from 7:42 PM to 8:50 PM, no wandering residents observed throughout facility. During an interview on 7/1/2026 at 10:53 AM, the Director of Nursing (DON) confirmed medication carts should be locked when left unattended.

Based on facility policy review, medical record review, observations, and interviews the facility failed to develop and/or implement a comprehensive care plan for enhanced barrier precautions (EBP) for 14 residents (Residents #12, #18, #36, #135, #136, #385, #389, #185, #15, #186, #50, #35, #238, and #239) of 14 residents reviewed for EBP, and failed to develop and implement a comprehensive care plan for self administration of medications for 1 resident (Resident #235) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Comprehensive Care Plans and Revisions, dated 9/11/2024, revealed .The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan .to ensure that the care plan is reviewed and revised .by .individuals who have knowledge of the resident .needs .and is involved in developing the care plan .the facility should monitor the resident over time to .identify changes .and update the care plan .to include .additional problem .and interventions . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnosis including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non- Dominant Side, Retention of Urine, and Obstructive and Reflux Uropathy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had an indwelling urinary catheter. Review of a comprehensive care plan for Resident #12 revised 11/6/2024, revealed the care plan was not developed and implemented for EBP for Resident #12. Review of the Physician's Order for Resident #12 dated 12/2/2024, revealed .Enhanced Barrier Precautions [EBP] Diagnosis; [indwelling urinary] Catheter . During an observation on 12/2/2024 at 11:40 AM, revealed Resident #12 had an indwelling urinary catheter. Continued review revealed no EBP signage posted or Personal Protective Equipment (PPE) located in or outside Resident #12's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #12 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside Resident #18's room prior to 12/3/2024. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnosis including Chronic Kidney Disease, Encephalopathy, and Presence of Urogenital Implants. Review of a comprehensive care plan initiated on 6/6/2024 and revised on 9/3/2024, revealed Resident #18 had an indwelling urinary catheter and required EBP. Continued review revealed the EBP was not implemented. Review of a quarterly (MDS) assessment dated [DATE], revealed Resident #18 had an indwelling urinary catheter. Review of the Physician's order for Resident #18 dated 6/7/2024 and revised 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis; [indwelling urinary] Catheter . During an observation on 12/2/2024 at 11:42 AM, revealed Resident #18 had an indwelling urinary catheter. Continued observation revealed no EBP signage posted or PPE available in or outside Resident #18's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #18 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside Resident #18's room prior to 12/3/2024. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnosis including Dysphasia, Hypokalemia, and Calculus of Gallbladder. Review of the Physician's Order for Resident #36 dated 11/17/2024, revealed .Enhanced Barrier Precautions Diagnosis [indwelling urinary] Catheter . Review of a significant change (MDS) assessment dated [DATE], revealed Resident #36 had an indwelling urinary catheter. Review of a comprehensive care plan initiated on 11/18/2024, revealed Resident #36 had an indwelling urinary catheter and required EBP. Continued review revealed the EBP was not implemented. During an observation on 12/2/2024 at 11:48 AM, Resident #36 had an indwelling urinary catheter. Further observation revealed no EBP signage posted or PPE available in or outside Resident #36's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #36 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside Resident' #36s room prior to 12/3/2024. Review of the medical record revealed Resident #135 was admitted to the facility on [DATE] and readmitted [DATE], with diagnosis including Presence of Urogenital Implants, Cyst of Kidney, and Personal History of Pulmonary Embolism. Review of a comprehensive care plan for Resident #135 dated 10/11/2024, revealed the care plan was not developed or implemented for the EBP. Review of a 5-day MDS assessment dated [DATE], revealed Resident #135 had an indwelling urinary catheter. Review of the Physician's Order for Resident #135 dated 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis [indwelling urinary] Catheter . During an observation on 12/2/2024 at 11:55 AM, Resident #135 had an indwelling catheter. Continued observation revealed there was no EBP signage posted or PPE available in or outside Resident #135's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #135 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside Resident #135's room prior to 12/3/2024. Review of the medical record revealed Resident #136 was admitted to the facility on [DATE], with diagnosis including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and End Stage Renal Disease. Review of the Physician's Order for Resident #136 dated 11/25/2024, revealed .Dialysis Resident: Access shunt site for thrill/bruit and bleeding . Review of a 5-day MDS assessment dated [DATE], revealed Resident #136 received Hemodialysis and had 1 or more unhealed pressure ulcers/ injuries. Review of the Physician's Order for Resident #136 dated 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis .wounds .dialysis . Review of a comprehensive care plan initiated on 12/2/2024, revealed Resident #136 had impairment of skin integrity of the left tibial crest and required EBP. Continued review revealed the EBP was not implemented. During an observation on 12/2/2024 at 12:15 PM, revealed there was no EBP signage posted or PPE available in or outside of Resident #136's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #136 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside Resident #136's room prior to 12/3/2024. 50407 Review of the medical record revealed Resident #385 was admitted to the facility on [DATE] with diagnoses including Presence of Internal Device and Graft, Infective Pericarditis, and Abnormality of Gait. Review of the Physician's Orders for Resident #385 dated 11/21/2024, revealed the resident had a Peripherally Inserted Central Catheter (PICC) line [a long, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein near the heart] for intravenous (IV) antibiotic administration. Review of an admission MDS assessment dated [DATE], revealed Resident #385 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident had a PICC line for IV antibiotics and had an active diagnosis of Infective Pericarditis. Review of a comprehensive care plan dated 11/25/2024, revealed Resident #385 had a PICC line for IV antibiotics for an infection. Further review revealed a care plan was not developed or implemented for EBP. During an interview and observation on 12/2/2024 at 10:49 AM, Resident #385 stated he had a PICC line. Continued observation revealed there was no EBP signage posted or PPE available in or outside Resident #385's room. During an observation on 12/3/2024 at 7:45 AM, Resident #385 had a PICC line. Continued observation revealed no EBP signage posted or PPE available in or outside Resident #385's room. During an interview on 12/3/2024 at 2:08 PM, Certified Nursing Assistant (CNA) F stated Resident #385 had a PICC line and was not aware of the EBP requirements for the presence of a PICC line. During an interview on 12/3/2024 at 2:15 PM, LPN G stated Resident #385 had a PICC line and was not aware of the EBP requirements for the presence of a PICC line. Review of the medical record revealed Resident #389 was admitted to the facility on [DATE] with diagnoses including Encounter for Surgical Aftercare following Genitourinary Surgery, Bladder-Neck Obstruction, and Benign Prostatic Hyperplasia (BPH). Review of a comprehensive care plan dated 11/26/2024, revealed Resident #389 had a suprapubic catheter. Further review revealed a care plan was not developed or implemented for EBP. Review of an admission MDS assessment dated [DATE], revealed Resident #389 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had a suprapubic catheter and an active diagnosis of Neurogenic Bladder. Review of the Physician's Orders for Resident #389 dated 12/2/2024, revealed .suprapubic catheter . During an interview and observation on 12/2/2024 at 11:39AM, Resident #389's spouse stated the resident had an indwelling suprapubic catheter. Continued observation revealed no EBP signage posted or PPE available in or outside Resident #389's room. During an observation on 12/3/2024 at 8:05 AM, Resident #389 had a suprapubic catheter. Continued observation revealed no EBP signage posted or PPE available in or outside Resident #389's room. During an interview on 12/3/2024 at 2:08 PM, CNA F stated Resident #389 had a suprapubic catheter and was not aware of the EBP requirments for the presence of a suprapubic catheter. During an interview on 12/3/2024 at 2:15 PM, LPN G stated Resident #389 had a suprapubic catheter and was not aware of the EBP requirments for the presence of a suprapubic catheter. 35460 Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Local Infection of the Skin and Subcutaneous Tissue, Dementia, Diverticulosis, Diabetes Mellitus, Chronic Kidney Disease, and Dysphagia. Review of the comprehensive care plan dated 10/9/2024, revealed Resident #15 had an activities of daily living (ADL) self-care deficit related to general health condition and infection of left hip pressure ulcer. Continued review revealed the care plan was revised on 11/21/2024 with EBP and the use of a feeding tube implemented. Further review revealed the EBP was not implemented. Review of a Physician's Order dated 11/20/2024, revealed Resident #15 had a recent feeding tube placed with enteral feed ordered. Review of a significant change MDS assessment dated [DATE], revealed Resident #15 had a BIMS assessment score of 15 which indicated the resident was cognitively intact. Further review revealed the resident had 2 Pressure Ulcers. During an observation and interview on 12/3/2024 at 9:00 AM, the Treatment Nurse stated there was no EBP signage posted above the PPE storage bin located inside of Resident #15's doorway to identify the type of isolation or PPE to be utilized. Review of the medical record revealed Resident #185 was admitted to the facility on [DATE], with diagnoses including Infection and Inflammation due to Internal Fixation Device of Spine, Bacteremia, and Spinal Stenosis. Review of an admission MDS assessment dated [DATE], revealed Resident #185 had a BIMS assessment score of 14 which indicated the resident was cognitively intact. Further review revealed the resident had a surgical wound with IV medications ordered. Review of an Order Summary Report dated 11/22/2024, revealed .change PICC line transparent dressing weekly . Review of the comprehensive care plan dated 11/23/2024, revealed Resident #185 was to be placed on EBP isolation. Continued review revealed the care plan was not implemented for the EBP. During an observation and interview on 12/2/2024 at 12:45 PM, revealed there was no EBP signage posted or PPE available in or outside of Resident #185's room. The resident stated she had a PICC line in her left arm and the staff did not wear a gown when assisting her with care. Review of the medical record revealed Resident #186 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Presence of Urogenital Implants, and Chronic Kidney Disease. Review of a Physician's Order dated 11/28/2024, revealed Resident #186 had an order for the use of an indwelling urinary catheter with a bedside drainage system. Review of the comprehensive care plan dated 11/28/2024, revealed Resident #186 was to be provided catheter care. Continued review revealed EBP isolation was not developed or implemented on the care plan until 12/3/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #186 had a BIMS assessment score of 3 which indicated the resident was severely cognitively impaired. During observations on 12/2/2024 at 10:30 AM and on 12/3/2024 at 8:00 AM, revealed there was no EBP signage posted or PPE available in or outside of Resident #186's room. 40606 Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Abnormalities of Gait and Mobility, Gastrostomy Status, and Severe Protein Calorie Malnutrition. Review of an admission MDS assessment dated [DATE], revealed Resident #50 had a BIMS score of 14, which indicated the resident was cognitively intact. Resident #50 had a feeding tube present on admission. Review of a comprehensive care plan for Resident #50 dated 11/29/2024, revealed .The resident requires tube feeding r/t [related to] Severe Protein Calorie Malnutrition . Continued review revealed EBP was not developed or implemented for Resident #50. During observations on 12/2/2024 at 8:25 AM and 11:15 AM, revealed no EBP signage posted or PPE available in or outside Resident #50's room. During an observation on 12/3/2024 at 8:30 AM, revealed no EBP signage posted or PPE availabe in or outside Resident #50's room. Review of the medical record revealed Resident #335 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Abnormalities of Gait and Mobility, Morbid Obesity, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of an admission MDS assessment dated [DATE], revealed Resident #335 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #335 required out-patient hemodialysis. Review of the Physician's Orders for Resident #335 revealed .Dialysis patient: Receives dialysis at [dialysis facility name] ON MON-WED-FRI .Start 11/27/2024 .Enhanced Barrier Precautions Diagnosis .wounds .dialysis .Start 12/3/2024 . Review of the comprehensive care plan for #335 dated 11/29/2024, revealed .resident receives hemodialysis r/t [related to] ESRD [End Stage Renal Disease] . Further review revealed the care plan was developed or implemented for EBP. During observations on 12/2/2024 at 8:25 AM and 11:15 AM, revealed no EBP signage posted or PPE available in or outside Resident #335's room. During an observation on 12/3/2024 at 8:30 AM, revealed no EBP signage posted or PPE available in or outside Resident #335's room. During an interview on 12/3/2024 at 10:40 AM, LPN K stated she was not aware of the need to use EBP for Resident #50 or Resident #335 prior to 12/2/2024. LPN K confirmed there was no EBP signage posted or PPE available in or outside Resident #50's and Resident #335's room prior to 12/3/2024. 50480 Review of the medical record revealed Resident #238 was admitted to the facility on [DATE] with diagnoses including Coronary Implant and Graft, Presence of Right Artificial Knee Joint, Dementia, and Chronic Kidney Disease. Review of an admission MDS assessment for Resident #238 dated 9/20/2024, revealed Resident #238 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the facility's document titled Wound Observation Tool, dated 11/14/2024, revealed Resident #238 had an open wound on the left shin. Review of the facility's document titled Wound Observation Tool, dated 11/14/2024, revealed Resident #238 had an open wound on the left heel. Review of the comprehensive care plan dated 12/2/2024, revealed Resident #238 had a pressure ulcer on the left shin and on the left heel. Further review revealed a care plan was not developed or implemented for EBP. During an observation on 12/2/2024 at 10:49 AM, revealed there was no EBP signage posted or PPE available in or outside the Resident #238's room. During an observation on 12/3/2024 at 8:10 AM, revealed there was no EBP signage posted or PPE available in or outside the Resident #238's room. Review of the medical record revealed Resident #239 was admitted to the facility on [DATE] with diagnoses including Heart and Vascular Surgical Aftercare, Cardiac Pacemaker, Indwelling Urinary Catheter, Benign Prostatic Hyperplasia (BPH), and Acute Kidney Failure. Review of an admission MDS assessment dated [DATE], revealed Resident #239 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had an indwelling urinary catheter and an active diagnosis of BPH. Review of the comprehensive care plan revised on 11/19/2024, revealed Resident #239 had an indwelling urinary catheter. Further review revealed a care plan was not developed or implemented for EBP. Review of the Physician's Order for Resident #239 dated 11/22/2024, revealed .Urinary retention .keep catheter [indwelling urinary catheter] . During an observation on 12/2/2024 at 2:05 PM, revealed there was no EBP signage posted or PPE available in or outside Resident #239's room. During an observation on 12/3/2024 at 8:15 AM, revealed there was no EBP signage posted or PPE available in or outside Resident #239's room. Review of the medical record revealed Resident #235 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Cancer, Hearing Loss, and Cognitive Impairment. Review of a 5-day MDS assessment for Resident #235 dated 11/22/2024, revealed Resident #235 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan dated 11/22/2024, revealed Resident #235 was not assessed or care planned for self-medication storage and self-administration. Review of the 11/2024 Medication Administration Record (MAR) for Resident #235 revealed an order dated 11/20/2024 for .Triamcinolone Acetonide Cream 0.1% [percent] .apply to SKIN topically three times a day . The MAR was documented that the medication was administered for 10 days of 11 days scheduled to be administered. Further review of the MAR revealed an order dated 11/21/2024 for .[name brand] Lidocaine External Cream 4 % .Apply to knees topically as needed . The MAR was documented that the medication was administered for 1 day of 10 days available to be administered. Further review of the MAR revealed orders dated 11/21/2024 for .[name brand] Ophthalmic Solution .Instill 2 drop [drops] in both eyes as needed for dry eyes .[name brand] hydrocortisone cream- apply to arms as needed for itching . The MAR was documented that the medications were not administered for 10 days of 10 days available to be administered. During an observation and interview on 12/3/2024 at 4:20 PM, Resident #235 was observed in the room. Further observation revealed a 30-gram tube of Triamcinolone Acetonide Cream 0.1% which was unopened, a 73 milliliter (mL) bottle of name brand Lidocaine External Cream 4% which was almost empty, a 10 mL bottle of name brand Ophthalmic Solution which was half empty, and a 36 mL tube of name brand hydrocortisone 1% cream which was half empty. Resident #235 stated he applied the topical medications himself and administered his own eyedrops. Resident #235 also stated the nurses were aware the medications were in the room and self-administered. During an observation, interview, and record review on 12/3/2024 at 4:30 PM, the Assistant Director of Nursing (ADON) observed the medications in Resident #235's room. The ADON confirmed the medications were available for resident-self administration and confirmed the Triamcinolone Acetonide Cream 0.1% was full, the name brand Lidocaine External Cream 4% was almost empty, name brand Ophthalmic Solution the was half empty, and the name brand hydrocortisone 1% cream was half empty. The ADON stated medication self-administration assessments were recorded on the residents' care plans. The ADON reviewed Resident #235's medical record and confirmed the resident was not care planned for medication self-administration. During an interview on 12/3/2024 at 3:38 PM, the Director of Nursing (DON) confirmed the facility failed to ensure care plans were developed or implemented for Residents #12, #18, #36, #135, #136, #385, #389, #185, #15, #186, #50, #335, #238, and #239 for Enhanced Barrier Precautions and failed to develop a self administration care plan for resident #235. The DON stated .It falls to me to make sure it's done [resident's placed in Enhanced Barrier Precautions] .

Based on facility policy review, refrigerator and freezer temperature log reviews, observations, and interviews, the facility failed to obtain and record twice daily temperatures for 3 of 3 refrigerators, and 2 of 2 freezers in the kitchen per facility policy. The failure had the potential to affect 88 of the 93 residents in the facility. The findings include: Review of the facility policy titled, Food Safety, revised 4/26/2023, revealed .Food is stored and maintained in a clean, safe, and sanitary manner .to minimize contamination and bacterial growth .Cold Food Storage .3. Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log . Review of the facility's documentation titled, Refrigerator/Freezer Temperature Logs, kitchen staff documentation for the month of 11/2024, for 3 refrigerators, and 2 freezers located in the kitchen revealed the following: 1. For the Reach-in Fridge temperature logs dated: 11/17/2024, 11/23/2024, 11/25/2024, the temperatures for the evening or PM shifts were not obtained and documented on the log. On 11/30/2024 the temperatures were not obtained or documented for the morning or AM shift. 2. For the Walk-in Fridge temperature logs dated: 11/17/2024, 11/23/2024, 11/25/2024, the temperatures for the evening or PM shifts were not obtained and documented on the log. On 11/30/2024 the temperatures were not obtained or documented for the morning or AM shift. 3. For the Under-Counter-Fridge temperature logs dated: 11/17/2024, 11/23/2024, 11/25/2024, the temperatures for the evening or PM shifts were not obtained and documented on the log. On 11/30/2024 the temperatures were not obtained or documented for the morning or AM shift. 4. For the Walk-in-Freezer temperature logs dated: 11/17/2024, 11/23/2024, 11/25/2024, the temperatures for the evening or PM shifts were not obtained and documented on the log. On 11/30/2024 the temperatures were not obtained or documented for the morning or AM shift. 5. For the Reach-in-Freezer temperature logs dated: 11/17/2024, 11/23/2024, 11/25/2024, and 11/30/2024 the temperatures for the evening or PM shift were not obtained and documented on the log. On 11/30/2024 the temperatures were not obtained or documented for the morning or AM shift. During an interview on 12/3/2024 at 7:52 AM, the Certified Dietary Manager (CDM) stated it was her expectation for the refrigerators and freezers temperature logs to be completed daily for each shift, AM and PM. The CDM confirmed the kitchen's refrigerator and freezer temperatures were not obtained twice daily, the temperature logs were incomplete, and were not maintained per facility policy.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP) for 14 residents (Residents #12, #18, #36, #135, #136, #385, #389, #15, #185, #186, #50, #335, #238, and #239) of 14 residents reviewed for EBP. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), reviewed 6/3/2024, revealed .The facility should use Enhanced Barrier Precautions (EBP) as an additional .strategy for residents that meet the following criteria .EBP are indicated for residents with any of the following .wounds and/or indwelling medical devices even if the resident is not known to be infected .the facility should develop a process to communicate which residents require the use of EBP .The facility may choose to post signage on the door or wall outside of the resident room indicating the resident is on Enhanced Barrier Precautions .Examples of high-contact resident care activities requiring gown and glove use include .Dressing .bathing/showering .transferring .providing hygiene .changing linens .changing briefs .device care or use: central catheter .feeding tube .tracheotomy tube .wound care . Medical record review revealed Resident #12 was admitted to the facility on [DATE], with diagnosis including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non- Dominant Side, Retention of Urine, and Obstructive and Reflux Uropathy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #12 had an indwelling urinary catheter. Review of the Physician's Order for Resident #12 dated 11/9/2024, revealed .indwelling catheter .as needed for urinary retention . Review of the Physician's Order for Resident #12 dated 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis; [indwelling urinary] Catheter . During an observation on 12/2/2024 at 11:40 AM, Resident #12 had an indwelling urinary catheter. Continued observation revealed there was no EBP signage or Personal Protective Equipment (PPE) available in or outside the resident's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #12 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside the resident's room prior to 12/3/2024. Medical record review revealed Resident #18 was admitted to the facility on [DATE], with diagnosis including Chronic Kidney Disease, Encephalopathy, and Presence of Urogenital Implants. Review of the Physician's Order for Resident #18 dated 6/7/2024 and 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis; [indwelling urinary] Catheter . Review of a quarterly (MDS) assessment dated [DATE], revealed Resident #18 had an indwelling urinary catheter. Review of the Physician's Order for Resident #18 dated 11/17/2024, revealed .change catheter care every shift for obstruction . During an observation on 12/2/2024 at 11:42 AM, Resident #18 had an indwelling urinary catheter. Observation revealed there was no EBP signage or (PPE) available in or outside the resident's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #18 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside the resident's room prior to 12/3/2024. Medical record review revealed Resident #36 was admitted to the facility on [DATE], with diagnosis including Dysphasia, Hypokalemia, and Calculus of Gallbladder. Review of the Physician's Order for Resident #36 dated 11/17/2024, revealed .Enhanced Barrier Precautions Diagnosis Foley Catheter . Review of a significant change (MDS) assessment dated [DATE], revealed Resident #36 had an indwelling catheter. During an observation on 12/2/2024 at 11:48 AM, Resident #36 had an indwelling urinary catheter. Observation revealed there was no EBP signage posted or PPE available in or outside the resident's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #36 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage or PPE available in or outside the resident's room prior to 12/3/2024. Medical record review revealed Resident #135 was admitted to the facility on [DATE] and readmitted [DATE], with diagnosis including Presence of Urogenital Implants, Cyst of Kidney, and Personal History of Pulmonary Embolism. Review of a 5-day scheduled assessment (MDS) assessment dated [DATE], revealed Resident #135 had an indwelling catheter. Review of the Physician's Order for Resident #135 dated 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis Foley Catheter . During an observation on 12/2/2024 at 11:55 AM, Resident #135 had an indwelling catheter. Observation revealed there was no EBP signage posted or PPE available in or outside the resident's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #135 prior to 12/2/2024. Interim Unit Manager A stated there was no EBP signage posted or PPE available in or outside the resident's room prior to 12/3/2024. Medical record review revealed Resident #136 was admitted to the facility on [DATE], with diagnosis including Type 2 Diabetes Mellitus, Chronic Kidney Disease, and End Stage Renal Disease. Review of the Physician's Order for Resident #136 dated 11/25/2024, revealed .Dialysis Resident: Access shunt site for thrill/bruit and bleeding . Review of a 5-day scheduled assessment (MDS) assessment dated [DATE], revealed Resident #136 received Hemodialysis and had 1 or more unhealed pressure ulcers/ injuries. Review of the Physician's Order for Resident #136 dated 12/2/2024, revealed .Enhanced Barrier Precautions Diagnosis .wounds .dialysis . During an observation on 12/2/2024 at 12:15 PM, revealed there was no EBP signage posted or PPE available in or outside of the resident's room. During an interview on 12/3/2024 at 1:45 PM, Interim Unit Manager A stated he was not aware of the need to use EBP for Resident #136 prior to 12/2/2024. Interim Unit Manager A confirmed there was no EBP signage posted or PPE available in or outside the resident's room prior to 12/3/2024. 50407 Review of the medical record revealed Resident #385 was admitted to the facility on [DATE] with diagnoses including Presence of Internal Device and Graft, Infective Pericarditis, and Abnormality of Gait. Review of the Physician's Orders for Resident #385 dated 11/21/2024, revealed the resident had a Peripherally Inserted Central Catheter (PICC) line [a long, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein near the heart] for intravenous (IV) antibiotic administration. Review of an admission (MDS) assessment dated [DATE], revealed Resident #385 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident had a PICC line for IV antibiotics and had an active diagnosis of infective pericarditis. During an interview and observation on 12/2/2024 at 10:49 AM, Resident #385 stated he had a PICC line. Observation revealed no EBP signage posted or PPE available in or outside the resident's room. During an observation on 12/3/2024 at 7:45 AM, Resident #385 had a PICC line. No EBP signage posted or PPE available in or outside the resident's room. During an interview on 12/3/2024 at 2:06 PM, Hospitality Aide (HA) E, further stated she knew when residents were on enhanced barrier precautions when the resident rooms had carts containing gowns. HA E stated she was not aware of the EBP requirements for the presence of a PICC line. During an interview on 12/3/2024 at 2:08 PM, Certified Nursing Assistant (CNA) F stated Resident #385 had a PICC line and she wore gloves to perform the resident's care. The CNA was not aware of the EBP requirements for the presence of a PICC line. During an interview on 12/3/2024 at 2:15 PM, LPN G stated Resident #385 had a PICC line and she wore gloves and a mask to perform the resident's PICC line care. The LPN stated she was not aware of the EBP requirements for the presence of a PICC line. Review of the medical record revealed Resident #389 was admitted to the facility on [DATE] with diagnoses including Encounter for Surgical Aftercare following Genitourinary Surgery, Bladder-Neck Obstruction, and Benign Prostatic Hyperplasia (BPH). Review of an admission MDS assessment dated [DATE], revealed Resident #389 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had a suprapubic catheter and an active diagnosis of Neurogenic Bladder. Review of the Physician's Orders for Resident #389 dated 12/2/2024, revealed .suprapubic catheter . During an interview and observation on 12/2/2024 at 11:39AM, Resident #389's spouse stated the resident had an indwelling suprapubic catheter. Observation revealed no EBP signage posted or PPE available in or outside the resident's room. During an observation on 12/3/2024 at 8:05 AM, Resident #389 had a suprapubic catheter. No EBP signage posted or PPE available in or outside the resident's room. During an interview on 12/3/2024 at 2:06 PM, HA E stated she knew when residents were on EBP when the resident rooms had carts containing gowns. The HA was not aware of the EBP requirments for the presence of a suprapubic catheter care. During an interview on 12/3/2024 at 2:08 PM, CNA F stated Resident #389 had a suprapubic catheter and she wore gloves to perform the resident's catheter care. The CNA stated she was not aware of the EBP requirments for the presence of a suprapubic catheter. During an interview on 12/3/2024 at 2:15 PM, LPN G stated Resident #389 had a suprapubic catheter, and she wore gloves to perform the resident's catheter care. The LPN stated she was not aware of the EBP requirments for the presence of a suprapubic catheter. 35460 Medical record review revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Local Infection of the Skin and Subcutaneous Tissue, Dementia, Diverticulosis, Diabetes Mellitus, Chronic Kidney Disease, and Dysphagia. Review of a Physician's Order dated 11/20/2024, revealed Resident #15 had a recent feeding tube placed with enteral feed ordered. Review of a significant change MDS assessment dated [DATE], revealed Resident #15 had a BIMS assessment score of 15 which indicated the resident was cognitively intact. Further review revealed the resident had 2 Pressure Ulcers. During an observation and interview on 12/3/2024 at 9:00 AM, the Treatment Nurse confirmed there was no EBP signage above the PPE storage bin located inside of Resident #15's doorway. Review of the medical record revealed Resident #185 was admitted to the facility on [DATE], with diagnoses including Infection and Inflammation due to Internal Fixation Device of Spine, Bacteremia, and Spinal Stenosis. Review of an Order Summary Report dated 11/22/2024, revealed .change PICC line transparent dressing weekly . Review of an admission MDS assessment dated [DATE], revealed Resident #185 had a BIMS assessment score of 14 which indicated the resident was cognitively intact. Further review revealed the resident had a surgical wound with IV medications ordered. During an observation and interview on 12/2/2024 at 12:45 PM, with Resident #185 revealed there was no EBP signage posted or PPE available in or outside of Resident #185's room. The resident stated she had a PICC line in her left arm and the staff did not wear a gown when assisting her with care. Review of the medical record revealed Resident #186 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Presence of Urogenital Implants, and Chronic Kidney Disease. Review of a Physician's Order dated 11/28/2024, revealed Resident #186 had an order for the use of an indwelling urinary catheter with a bedside drainage system. Review of an admission MDS assessment dated [DATE], revealed Resident #186 had a BIMS assessment score of 3 which indicated the resident was severely cognitively impaired. During observations on 12/2/2024 at 10:30 AM and on 12/3/2024 at 8:00 AM, revealed there was no EBP signage posted or PPE available in or outside of Resident #186's room. 40606 Review of the medical record revealed Resident #50 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Abnormalities of Gait and Mobility, Gastrostomy Status, and Severe Protein Calorie Malnutrition. Review of an admission MDS assessment dated [DATE], revealed Resident #50 had a BIMS score of 14, which indicated the resident was cognitively intact. Resident #50 required extensive assistance of one or more staff members for toileting, mobility, and ADL care. Further review revealed Resident #50 had a feeding tube present on admission. During an observations on 12/2/2024 at 8:25 AM, and 11:15 AM; revealed no EBP signage posted or PPE available in or outside Resident #50's room. During an observation on 12/3/2024 at 8:30 AM, revealed no EBP signage posted or PPE available in or outside Resident #50's room. Review of the medical record revealed Resident #335 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Abnormalities of Gait and Mobility, Morbid Obesity, End Stage Renal Disease, and Dependence on Renal Dialysis. Review of an admission MDS assessment dated [DATE], revealed Resident #335 had a BIMS score of 15, which indicated the resident was cognitively intact and required out-patient hemodialysis. Review of the Physician's Orders for Resident #335 revealed .Dialysis patient: Receives dialysis at [dialysis facility name] ON MON-WED-FRI .Start 11/27/2024 .Enhanced Barrier Precautions Diagnosis .wounds .dialysis .Start 12/3/2024 . During an observations on 12/2/2024 at 8:25 AM, and 11:15 AM, revealed no EBP signage posted or PPE available in or outside Resident #335's room. During an observation on 12/3/2024 at 8:30 AM, revealed no EBP signage posted or PPE available in or outside Resident #335's room. During an interview on 12/3/2024 at 10:40 AM, LPN K stated she was not aware of the need to use EBP for Resident #50 or Resident #335 prior to 12/2/2024. LPN K confirmed there was no EBP signage posted or PPE available in or outside Resident #50's and Resident #335's room prior to 12/3/2024. 50480 Review of the medical record revealed Resident #238 was admitted to the facility on [DATE] with diagnoses including Coronary Implant and Graft, Presence of Right Artificial Knee Joint, Dementia, and Chronic Kidney Disease. Review of an admission MDS assessment for Resident #238 dated 9/20/2024, revealed Resident #238 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the facility's document titled Wound Observation Tool, dated 11/14/2024, revealed the Resident #238 had an open wound on the left shin. Review of the facility's document titled Wound Observation Tool, dated 11/14/2024, revealed the Resident #238 had an open wound on the left heel. During an observation on 12/1/2024 at 10:49 AM, revealed there was no EBP signage posted or PPE available in or outside the resident's room. During an observation on 12/2/2024 at 8:10 AM, revealed no EBP signage posted or PPE available in or outside the resident's room. Review of the medical record revealed Resident #239 was admitted to the facility on [DATE] with diagnoses including Heart and Vascular Surgical Aftercare, Cardiac Pacemaker, Indwelling Urinary Catheter, Benign Prostatic Hyperplasia (BPH), and Acute Kidney Failure. Review of an admission MDS assessment dated [DATE], revealed Resident #239 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed the resident had an indwelling urinary catheter and an active diagnosis of BPH. Review of the Physician's Order for Resident #239 dated 11/22/2024, revealed .Urinary retention .keep catheter [indwelling urinary catheter] . During an observation on 12/2/2024 at 2:05 PM, revealed there was no EBP signage posted or PPE available in or outside the resident's room. During an observation on 12/3/2024 at 8:15 AM, there was no EBP signage posted or PPE available in or outside the resident's room. During an interview on 12/3/2024 at 3:38 PM, the Director of Nursing (DON) confirmed the facility failed to ensure Residents #12, #18, #36, #135, #136, #385, #389, #15, #185, #186, #50, #335, #238, and #239 were placed in Enhanced Barrier Precautions. The DON stated .It falls to me to make sure it's done [resident's placed in Enhanced Barrier Precautions] . Continued interview with the DON confirmed the facility failed to ensure residents were placed on Enhanced Barrier Precautions until 12/3/2024 after the survey team arrived.

Based on facility policy review, Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, observations, and interviews the facility failed to enter the code for isolation treatment for 1 resident (Resident #236) of 19 residents reviewed for MDS accuracy. The findings include: Review of the facility policy titled, Clostridium (Clostridioides) Difficile (CDI), reviewed 6/4/2024, revealed .The facility will care for residents with suspected and actual Clostridium Difficile in accordance with local, state, and federal guidelines .a system for .identifying .communicable diseases .transmission-based precautions to be followed to prevent spread of infections .isolation should be used . Review of the MDS 3.0 RAI Manual revised 10/4/2024, revealed .Isolation or quarantine .Code only when the resident requires transmission-based precautions .with highly transmissible .pathogens that have been acquired by physical contact . Review of the medical record revealed Resident #236 was admitted to the facility on [DATE] with diagnoses including Clostridium Difficile (C-diff), Chronic Obstructive Pulmonary Disease (COPD), and Rheumatoid Arthritis. Review of the facility's document titled Skilled Nursing Documentation, dated 11/29/2024 revealed the resident was placed into isolation precautions for a C-diff infection. Review of a 5-day MDS assessment dated [DATE], revealed Resident #236 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and had an active diagnosis of C-diff. Further review revealed contact isolation was not captured on the MDS. During an observation on 12/2/2024 at 10:55 AM, Resident #236's door was closed with signage for contact precautions and Personal Protective Equipment (PPE) outside the room. During an interview on 12/2/2024 at 11:00 AM, Unit Manager Licensed Practical Nurse (LPN) L stated Resident #236 admitted from the hospital on 11/27/2024 with an active C-diff infection and was placed into isolation precautions. Unit Manager LPN also stated all the resident's care and services were provided in the room. During an interview on 12/3/2024 at 2:00 PM, Resident #236 stated she went to the hospital for stomach pain and thought she had an ulcer. The resident stated when she returned from the hospital the facility put her in isolation because she had C-diff with diarrhea. During a record review, review of Resident #236's MDS, and interview on 12/4/2024 at 3:00 PM, revealed the MDS Registered Nurse (RN) reviewed the residents record and stated the resident had a diagnosis of a C-diff infection, was placed into isolation precautions, and confirmed the isolation was not included on the 5-day MDS assessment.

Based on facility policy review, medical record, observations and interviews the facility failed to secure medications for 1 resident (Resident #235) of 19 residents reviewed for medication storage. The findings include: Review of the facility's policy titled, Self-Administration of Medication, revised 10/31/2021, revealed Resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications .from a central location .medication cart or medication room .or the resident is able to safely store the medication in a secure are [area] in their room .The interdisciplinary assessment will be completed in the electronic medication record . Review of the medical record revealed Resident #235 was admitted to the facility on [DATE], with diagnoses including Muscle Weakness, Cancer, Hearing Loss, and Cognitive Impairment. Review of the 5-day admission Minimum Data Set (MDS) assessment for Resident #235 dated 11/22/2024, revealed Resident #235 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan dated 11/22/2024, revealed Resident #235 was not assessed or care planned for self-medication storage and self-administration. Review of the 11/2024 Medication Administration Record (MAR) for Resident #235 revealed an order dated 11/20/2024 for .Triamcinolone Acetonide Cream 0.1% [percent] .apply to SKIN topically three times a day . The MAR was documented that the medication was administered for 10 days of 11 days scheduled to be administered. Further review of the MAR revealed an order dated 11/21/2024 for .[name brand] Lidocaine External Cream 4 % .Apply to knees topically as needed . The MAR was documented that the medication was administered for 1 day of 10 days available to be administered. Further review of the MAR revealed orders dated 11/21/2024 for .[name brand] Ophthalmic Solution .Instill 2 drop [drops] in both eyes as needed for dry eyes .[name brand] hydrocortisone cream- apply to arms as needed for itching . The MAR was documented that these medications were not administered for 10 days of 10 days available to be administered. During an observation and interview on 12/3/2024 at 4:20 PM, Resident #235 was observed in the room. Further observation revealed a 30-gram tube of Triamcinolone Acetonide Cream 0.1% which was unopened, a 73 milliliter (mL) bottle of name brand Lidocaine External Cream 4% which was almost empty, a 10 mL bottle of name brand Ophthalmic Solution which was half empty, and a 36 mL tube of name brand hydrocortisone 1% cream which was half empty. Resident #235 stated he applied the topical medications himself and administered his own eyedrops. Resident #235 also stated the nurses were aware the medications were in the room and self-administered. Continued observation revealed Resident #235 did not have a room mate. During multiple observations through out the survey dated 12/4/2024-12/6/2024 at multiple times throughout the day, revealed no residents with wandering behaviors noted on the unit/hall where Resident #235 resided. During an observation, interview, and record review on 12/3/2024 at 4:30 PM, the Assistant Director of Nursing (ADON) observed the medications in Resident #235's room. The ADON confirmed the medications were available for resident-self administration and confirmed the Triamcinolone Acetonide Cream 0.1% was full, the name brand Lidocaine External Cream 4% was almost empty, name brand Ophthalmic Solution the was half empty, and the name brand hydrocortisone 1% cream was half empty. The ADON reviewed Resident #235's medical record and confirmed the resident was not assessed for medication storage and self-administration.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the resident's right to be free from psychosocial abuse for 1 of 13 (Resident #14) sampled residents reviewed for abuse when Resident #15 entered Resident #14's room, pulled the covers off of her, tried to remove her brief, and exposed himself to Resident #14 on 8/21/2023. The facility's failure to protect the resident's right to be free from abuse resulted in actual HARM for Resident #14. The findings include: Review of the facility policy titled, Resident Rights, dated 6/8/2020, revealed .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Review of the facility policy titled, Abuse-Identification of Types, dated 10/4/2022, revealed .Abuse-is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .Willful-is defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Wandering into other's rooms/space .Does not want the contact to occur .Literature indicates that the most prevalent psychosocial outcomes of abuse are depression, anxiety, and posttraumatic disorder . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Dementia with Anxiety, Depression, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 scored a 99 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was unable to complete the interview. Review of an Event Note for Resident #14 dated 8/21/2023, revealed .aide observed another resident [Resident #15] at [Resident #14's] bedside disrobing & [and] pulling at covers, other resident [Resident #15] removed from room immediately. When asked resident [Resident #14] if the other resident [Resident #15] touched her she stated yes he touched her brief .[Doctor O and Doctor P] notified . Review of Doctor (Dr.) O's Progress Note for Resident #14 dated 8/21/2023, revealed .CHIEF COMPLAINT: Evaluation of patient following inappropriate behavior by other resident [Resident #15] .According to social worker, the patient [Resident #14] was asleep while a male patient [Resident #15] entered her room, disrobed, and pulled the cover off of her exposing her own brief. He reportedly touched her brief but it was intact. A hospitality aide was passing by and noticed this and was able to intervene. She [Resident #14] is upset and somewhat tearful following .On examination, she is somewhat withdrawn and tearful .appears unharmed physically .She denies any needs at present, although is clearly anxious about this event . Review of Dr. P's Psychiatry in Longterm Care Summary-Diagnosis-Plan for Resident #14 dated 8/21/2023, revealed .I was asked to see the patient because of an alleged assault by a peer .I asked her about worry and she said yes but she was unable to specify .She looks anxious but she says she's not anxious if someone is with her . Dr. P recommended treatment with an additional antianxiety medication and increased the dosage of her antidepressant. Review of Medication Administration Records for Resident #14 revealed the resident's Zoloft (antidepressant medication) was increased from 12.5 milligrams (mg) daily to 25 mg daily on 8/21/2023. Further review revealed Resident #14 received Hydroxyzine (a medication used to treat anxiety) from 8/21/2023-8/23/2023. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Dementia without Behavioral Disturbance and Abnormalities of Gait and Mobility. Review of the admission MDS assessment dated [DATE], revealed Resident #15 scored a 3 on the BIMS test indicating the resident had severe cognitive impairment. The resident had not exhibited behaviors. Review of a comprehensive care plan dated 8/9/2023, revealed Resident #15 had a care plan for .at risk for complications from potential inappropriate behaviors r/t [related to] dementia . Review of an Event Note for Resident #15 dated 8/21/2023, revealed .aide observed resident [Resident #15] disrobbing [disrobing] and pulling at covers in another residents [Resident #14's] room. family notified @ [at] 1230 [12:30 PM] of residents [resident's] inappropriate behaviors and sent to [named hospital] for behavioral eval. [evaluation] . Dr. O and Dr. P were notified of Resident #15's behaviors. Review of the facility's investigation documentation dated 8/21/2023 at 12:15 PM, revealed .Resident [#15] found standing at Resident [#14] bedside disrobing and pulling her [Resident #14] covers back. Staff immediately removed him [Resident #15] from the room . Resident #14 and Resident #15 were placed on one-to-one supervision until Resident #15 was transferred from the facility. Continued review revealed the following . HOSPITALITY AIDE SAW RESIDENT [#15] IN THE DAY ROOM AS SHE WENT TO THE KITCHEN AT APPROXIMATELY 12:05 PM AND SHE HEARD THE RESIDENT [#14] SAYING 'NO' AS SHE CAME BACK UP THE HALL AT 12:15 pm AND WENT INTO THE ROOM AND IMMEDIATELY TOOK RESIDENT [#15] FROM THE ROOM . Review of Hospitality Aide (HA) K's witness statement dated 8/21/2023 at 12:15 PM, revealed .I walked into [Resident #14's] room and saw [Resident #15] standing beside the bed with his pants and brief pulled down and he [Resident #15] was trying to remove her [Resident #14] brief she was telling him no and trying to keep him from removing the brief. I instantly pulled his pants up and removed him from her room . Review of Social Services Aide (SSA) N's witness statement dated 8/21/2023 at 12:40 PM, revealed .I was asked to sit with [Resident #15] after he was reportedly involved in a situation with another resident [Resident #14] where he displayed inappropriate behavior. After talking with [Resident #15] about what happened, he stated, 'I'm in trouble. I got busted going into another person's room'. Continued review revealed Resident #15 did not offer further information. Review of Licensed Practical Nurse (LPN) L's witness statement dated 8/21/2023 (no time), revealed .Notified by aide that she had observed [Resident #15] standing beside bed with pants and brief on ground and [Resident #14's] blanket down trying to pull off her brief. Went to Resident [Resident #14's] room to assess resident. Resident stated he [Resident #15] touched her brief . Review of LPN M's witness statement dated 8/21/2023 (no time), revealed .I entered [Resident #14's room] after the incident took place to assess [Resident #14] .The resident .very scared and upset . During a telephone interview on 7/8/2024 at 12:00 PM, HA K stated she was coming back from lunch and heard Resident #14 saying, .no .no . HA K stated she saw Resident #15 standing over Resident #14 with his pants down, with his brief on, trying to pull her brief off. HA K stated Resident #15 did not touch Resident #14, as she had intervened and immediately removed Resident #15 from Resident #14's room. During an interview on 7/8/2024 at 1:30 PM, LPN L stated she heard an aide (HA) say, .oh, no . The HA came out and told LPN L Resident #15 was in Resident #14's room with his pants down. During a second telephone interview on 7/9/2024 at 1:34 PM, HA K stated Resident #15's pants and brief were pulled down at the time of the incident. (HA K's first telephone interview stated Resident #15's brief was on when the incident occurred.) During a telephone interview on 7/9/2024 at 3:48 PM, LPN M stated Resident #14 was crying and was trying to pull the blanket up over her after the incident with Resident #15. During a second interview on 7/9/2024 at 4:15 PM, LPN L stated Resident #14 was upset and crying after the incident. During a telephone interview on 7/10/2024 at 10:09 AM, SSA N stated her supervisor had asked her to check on Resident #14 because Resident #15 had gone into Resident #14's room around lunch time. SSA N asked Resident #14 if she was okay. Resident #14 told SSA N, .he [Resident #15] just came in here, he stood over me and tried to pull my blanket off . and tried to take her brief off. Further interview revealed Resident #14 reported Resident #15 had taken his pants off and was trying to climb on top of her. SSA N stated HA K told her Resident #15 was standing next to Resident #14's bed with his pants down. SSA N stated HA K went into Resident #14's room and redirected Resident #15 to his room. During a telephone interview on 7/10/2024 at 1:00 PM, Dr. P stated he recommended administering an antianxiety medication and increasing Resident #14's antidepressant dose after the incident with Resident #15. Dr. P stated .I did this empirically [based on what is experienced or seen] .it wouldn't hurt to give her Hydroxyzine [antianxiety] . When asked if Resident #14's reaction was related to Resident #15 entering her room, removing his brief, and attempting to remove her brief, Dr. P stated .I would say it could be . During a telephone interview on 7/10/2024 at 1:33 PM, Dr. O stated he had spoken with the Director of Nursing (DON) and determined Resident #15 should be transferred due to the incident that had occurred and due to concerns for Resident #14's safety. Dr. O stated, .I think it was a Hypersexual impulse related to Dementia . Dr. O stated he saw Resident #14 after the event.I remember she was anxious above her baseline .she was pretty shook up by it .we looked at her skin for signs of injury and sexual assault .no signs .She was anxious and afraid beyond her baseline . During an interview on 7/10/2023 at 5:02 PM, the Executive Director (ED) stated a staff member observed Resident #15 with his brief off and reaching for a female resident's (Resident #14's) covers. The ED stated the staff member immediately intervened. The ED stated .Obviously, we [the facility] saw the potential for abuse . Resident #15 was transferred out for evaluation and Resident #14 was evaluated by Dr. O and Dr. P.I do acknowledge I saw 100% potential for abuse .

Based on facility policy review, observations, and interviews the facility failed to post accurate nursing staff information to reflect daily staffing levels on 2 of 4 days reviewed for staffing and failed to maintain the posted daily nurse staffing data for a minimum of 18 months. The findings include: Review of the facility policy titled, Staffing, dated 6/12/2024, revealed .The facility maintains adequate staff on each shift to meet residents' needs, posts daily staffing data .The facility must post the following information .Facility name .The current date .The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift .Registered nurses .Licensed practical nurses or licensed vocational nurses .Certified nurse aides .Resident census .Posting requirements .The facility must post the nurse staffing data .on a daily basis at the beginning of each shift .The facility maintains the posted daily nurse staffing data for a minimum of 18 months . During an observation on 7/10/2024 at 5:15 AM, the posted daily staffing data dated 7/9/2024, revealed night shift staff (11:00 PM-7:00 AM) included 1 Registered Nurse (RN), 2 Licensed Practical Nurses (LPNS), and 8.5 Certified Nursing Assistants (CNAs). During observations on 7/10/2024 from 5:20 AM to 7:00 AM, revealed there was 1 RN, 2 LPNs, and 7 CNAs present in the facility. The following staff were observed working on the 200 hallway: CNA A, CNA B, and LPN C. The following staff were observed working on the 100 hallway: CNA D, CNA E, CNA F, and LPN G. The following staff were observed working on the 300 hallway: CNA H, CNA I, and RN J. During an interview on 7/10/2024 at 6:30 AM, CNA E stated 1 CNA had called in for the 7/9/2024 night shift and 1 CNA left at 3:00 AM. During an interview on 7/10/2024 at 6:50 AM, the Director of Nursing (DON) confirmed the 7/9/2024 night shift posting included the hours from 11:00 PM to 7:00 AM. The DON stated 8.5 CNAs were scheduled for the 7/9/2024 night shift and a CNA had called in. The DON confirmed there were 7.5 CNAs working 7/9/2024 night shift and the daily staff posting in the facility entryway had not been updated to reflect the actual number of CNAs working. The DON confirmed the daily staff posting that was posted in the facility entry way every morning included the staffing plan of what staff were scheduled and was not updated throughout the day to reflect staffing changes or call ins. The DON stated there was no designated person responsible for updating the daily staff posting in the facility once it was posted in the morning and .I've never been told I had to update it . During an observation on 7/10/2024 at 8:00 AM, the posted daily staffing data dated 7/10/2024, revealed day shift staff included 1 RN, 7 LPNs, and 10.5 CNAs. During observations on 7/10/2024 from 8:15 AM to 8:45 AM revealed 2 RNs, 6 LPNs, and 10 CNAs present in the facility. The following staff were observed working on the 200 hallway: RN HH, LPN S, LPN T, LPN V, CNA X, CNA Y, and CNA FF. The following staff were observed working on the 100 hallway: LPN V, LPN W, LPN L, CNA BB, CNA Q, and CNA CC. The following staff were observed working on the 300 hallway: RN GG, CNA Z, and CNA AA. The following staff were observed performing restorative therapy services: CNA DD and CNA EE. Observations from 7/7/2024-7/10/2024 revealed the facility posted the daily staffing data on a dry erase board and the facility did not keep a record of the daily staffing data. During an interview on 7/10/2024 at 9:39 AM, the DON confirmed the daily staffing data posted 7/10/2024 was inaccurate, the facility posted staffing data daily on a dry erase board, the facility did not keep a copy of the daily staff posting data, and the data had not been maintained for 18 months.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to report an allegation of abuse to the State Agency when a resident (Resident #15) exposed himself to another resident (Resident #14 of 13 residents reviewed for abuse. The findings include: Review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & [and] Neglect, revised 8/10/2021, revealed .This facility does not condone resident abuse and/or neglect by anyone. This includes, but is not limited to staff members, other residents .family members .or other individuals .The facility must ensure that all alleged violations involving abuse . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations . Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Dementia with Anxiety, Depression, Anemia (low blood count), and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 99 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of an Event Note for Resident #14 dated 8/21/2023, revealed .aide observed another resident [Resident #15] at [Resident #14's] bedside disrobing & [and] pulling at covers. other resident [Resident #15] removed from room immediately. When asked resident [Resident #14] if the other resident [Resident #15] touched her she stated yes he touched her brief .[Doctor O and Doctor P] notified of above . Review of Doctor (Dr.) O's Progress Note for Resident #14 dated 8/21/2023 revealed .CHIEF COMPLAINT: Evaluation of patient following inappropriate behavior by other resident [Resident #15] .According to social worker, the patient [Resident #14] was asleep while a male patient [Resident #15] entered her room, disrobed, and pulled the cover off of her exposing her own brief. He reportedly touched her brief but it was intact. A hospitality aide was passing by and noticed this and was able to intervene. She [Resident #14] is upset and somewhat tearful following .On examination, she is somewhat withdrawn and tearful .appears unharmed physically .She denies any needs at present, although is clearly anxious about this event . Review of Dr. P's Psychiatry in Longterm Care Summary-Diagnosis-Plan for Resident #14 dated 8/21/2023, revealed .I was asked to see the patient because of an alleged assault by a peer .I asked her about worry and she said yes but she was unable to specify .She looks anxious but she says she's not anxious if someone is with her . Dr. P recommended treatment with an additional antianxiety medication and increasing the dosage of her antidepressant. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Digestive System, Dementia without Behavioral Disturbance, and Abnormalities of Gait and Mobility. Review of the Admission MDS assessment dated [DATE] revealed Resident #15 scored a 3 on the BIMS test indicating the resident had severe cognitive impairment. The resident had not exhibited behaviors. Review of an Event Note for Resident #15 dated 8/21/2023, revealed .aide observed resident [Resident #15] disrobbing [disrobing] and pulling at covers in another residents [Resident #14] room. family notified @ [at] 1230 [12:30 PM] of residents inappropriate behaviors and sent to [named hospital] for behavioral eval. [evaluation] . Dr. O and Dr. P were notified of Resident #15's behaviors. Review of the facility's investigation documentation dated 8/21/2023 at 12:15 PM, revealed .Resident [#15] found standing at Resident [#14] bedside disrobing and pulling her [Resident #14] covers back. Staff immediately removed him [Resident #15] from the room . Resident #14 and Resident #15 were placed on one-to-one supervision until Resident #15 was transferred from the facility Continued review revealed the following . HOSPITALITY AIDE SAW RESIDENT [#15] IN THE DAY ROOM AS SHE WENT TO THE KITCHEN AT APPROXIMATELY 12:05 PM AND SHE HEARD THE RESIDENT [#14] SAYING 'NO' AS SHE CAME BACK UP THE HALL AT 12:15 pm AND WENT INTO THE ROOM AND IMMEDIATELY TOOK RESIDENT [#15] FROM THE ROOM . Review of Hospitality Aide (HA) K's witness statement dated 8/21/2023 at 12:15 PM, revealed .I walked into [Resident #14's] room and saw [Resident #15] standing beside the bed with his pants and brief pulled down and he [Resident #15] was trying to remove her [Resident #14] brief she was telling him no and trying to keep him from removing the brief. I instantly pulled his pants up and removed him from her room . Review of Social Services Aide (SSA) N's witness statement dated 8/21/2023 at 12:40 PM, revealed .I was asked to sit with [Resident #15] after he was reportedly involved in a situation with another resident [Resident #14] where he displayed inappropriate behavior. After talking with [Resident #15] about what happened, he stated, 'I'm in trouble. I got busted going into another person's room'. Continued review revealed Resident #15 did not offer further information . Review of Licensed Practical Nurse (LPN) L's witness statement dated 8/21/2023 (no time) revealed .Notified by aide that she had observed [Resident #15] standing beside bed with pants & brief on ground & [Resident #14's] blanket down trying to pull off her brief. Went to residents room [Resident #14] to assess resident. Resident stated he [Resident #15] touched her brief . Review of LPN M's witness statement dated 8/21/2023 (no time) revealed .I entered [Resident #14's room] after the incident took place to assess [Resident #14] .The resident .very scared and upset . During a telephone interview on 7/8/2024 at 12:00 PM, HA K stated she was coming back from lunch and heard Resident #14 saying .no .no . HA K stated she saw Resident #15 standing over Resident #14 with his pants down, with his brief on, trying to pull her brief off. HA K stated Resident #15 did not touch Resident #14, as she had intervened and immediately removed Resident #15 from Resident #14's room. During an interview on 7/8/2024 at 1:30 PM, LPN L stated she heard an aide (HA) say .oh, no . The HA came out and told LPN L Resident #15 was in Resident #14's room with his pants down. Resident #15 was moved to a different location and orders were received to transfer Resident #15 for evaluation. During a second telephone interview on 7/9/2024 at 1:34 PM, HA K stated Resident #15's pants and brief were pulled down at the time of the incident. (HA K's first telephone interview stated Resident #15's brief was on when the incident occurred.) During a telephone interview on 7/9/2024 at 3:48 PM, LPN M stated Resident #14 was crying and was trying to pull the blanket up over her after the incident with Resident #15. During a a second interview on 7/9/2024 at 4:15 PM, LPN L stated Resident #14 was upset and crying a little bit after the incident. During a telephone interview on 7/10/2024 at 10:09 AM, SSA N stated her supervisor had asked her to check on Resident #14 because Resident #15 had gone into Resident #14's room around lunch time. SSA N asked Resident #14 if she was okay. Resident #14 (had severe cognitive impairment) told SSA N .he [Resident #15] just came in here, he stood over me and tried to pull my blanket off . and tried to take her brief off. Further interview revealed Resident #14 reported Resident #15 had taken his pants off and was trying to climb on top of her. SSA N stated HA K told her Resident #15 was standing next to Resident #14's bed with his pants down. SSA N stated HA K went into Resident #14's room and redirected Resident #15 to his room. SSA N stated she was asked to sit at the nurses' station with Resident #15 until an ambulance arrived to transport him to the hospital. Continued interview revealed Resident #15 told SSA N he was in trouble because he had wandered into another resident's room. During an interview on 7/10/2023 at 5:02 PM, the Executive Director (ED) stated a staff member observed Resident #15 with his brief off and reaching for a female resident's (Resident #14's) covers. The ED stated the staff member immediately intervened. The ED stated .Obviously, we saw the potential for abuse . He stated because of the potential for abuse, the facility conducted a full investigation, Resident #15 was transferred out for evaluation, and Resident #14 was evaluated by Dr. O and Dr. P. The ED stated .I'll be honest with you .looking back on this I should have reported this .I do acknowledge I saw 100% potential for abuse .If I could go back to that date, I would have reported it .

Based on review of the Resident Assessment Instrument (RAI) Manual 3.0, medical record review, and interview the facility failed to accurately complete a discharge Minimum Data Set (MDS) assessment for 1 resident (Resident #24) of 3 residents reviewed for falls. The findings include: Review of the RAI Manual 3.0 dated 10/2023, revealed .The MDS is completed on all residents in Medicare or Medicaid certified facilities .Sections A-Q contain the clinical data items used to assess residents in the nursing facility .Assure that the information found in the resident's most current assessment .report changes in the resident's status that may affect the accuracy of this information .J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment .Review nursing home incident reports and medical record .for falls and level of injury . Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including Fracture of the Right Leg, Muscle Weakness, and Lack of Coordination. Review of the comprehensive care plan revised 8/11/2023, for Resident #24 revealed, .Resident is at risk for falls . Review of the Nurse's Notes for Resident #24 dated 8/11/2023, revealed, .Resident observed in floor next to bed on her bottom. Resident was leaning with back against the side of bed . Review of the facility's fall investigation for Resident #24 dated 8/11/2023, revealed, .Resident observed in floor . assisted to the bathroom New Interventions .toileting program . Review of a discharge MDS assessment for Resident #24 dated 8/16/2023, revealed, . Any falls since Admission/Entry or Reentry or Prior Assessment .0 [no] . During an interview on 7/10/2024 at 10:26 AM, the MDS Coordinator Registered Nurse K and the MDS Coordinator Licensed Practical Nurse L confirmed Resident #24 had a fall on 8/11/2023, the fall was not captured on the discharge MDS assessment dated [DATE], and the assessment was inaccurate.

Based on facility policy review, medical record review and interviews the facility failed to provide scheduled showers for 3 dependent residents (Resident #12, #8, and #22) of 10 residents reviewed for Activities of Daily Living (ADLs). The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), revised 2/2024, revealed .The resident will receive assistance as needed to complete activities of daily living (ADLs) .Quality of care is fundamental .the facility must ensure that residents receive treatment .care .in accordance with professional standards of practice .hygiene .bathing .grooming .a resident who is unable to carry out activities of daily living receives .services to maintain good .personal hygiene . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Epilepsy, Vascular Dementia, and Urinary Incontinence. Review of a comprehensive care plan for Resident #12 dated 1/26/2022, revealed the resident was care planned for ADL assistance and required assistance of 1-2 staff for bathing. Review of a quarterly [NAME] Data Set (MDS) assessment dated [DATE], revealed Resident #12 was rarely/never understood which indicated the resident had severe cognitive impairment. Review of the facility ADL documentation for Resident #12 dated 9/1/2023 -9/30/2023, revealed the resident received a shower on 9/8/2023, 9/20/2023, and 9/29/2023. This was a total of 3 showers provided to the resident of 13 scheduled showers during the month of 9/2023. During an interview on 7/10/2024 at 10:21 AM, CNA Q stated she cared for Resident #12 routinely, the resident's shower days were on Monday, Wednesday, and Friday. If the resident did not receive a shower, the resident was provided a bed bath.The CNA also stated when the facility had staff call-ins, she was not always able to document bathing. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Earlobe, Type 2 Diabetes Mellitus, and Age-Related Osteoporosis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident required moderate assistance with activities of daily living. Review of a comprehensive care plan for Resident #8 dated 12/4/2023, revealed the resident was care planned for ADL self-care performance due to limited mobility and .totally dependent on .associates to provide bath/shower . Review of the facility ADL documentation for Resident #8 dated 1/1/2024 - 1/31/2024, revealed the resident received a shower on 1/4/2024, 1/24/2024, and 1/31/2024. This was a total of 3 showers provided to the resident of 15 scheduled showers. Review of the facility ADL documentation for Resident #8 dated 2/1/2024 - 2/29/2024, revealed the resident received a shower on 2/9/2024, 2/13/2024, 2/15/2024, 2/20/2024, 2/27/2024, and 2/29/2024. This was a total of 6 showers provided to the resident of 12 scheduled showers. Review of the facility ADL documentation for Resident #8 dated 3/1/2024 - 3/31/2024, revealed the resident received a shower on 3/9/2024, 3/14/2024, 3/16/2024, and 3/19/2024. This was a total of 4 showers provided to the resident of 13 scheduled showers. During an interview on 7/7/2024 at 2:30 PM, Resident #8 stated a few months ago she had not received scheduled showers. The resident's son reported it to the facility and she started recieving the scheduled showers.The resident also stated when she did not receive a shower staff provided a sponge bath or bed bath. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Dementia, Malignant Neoplasm of the Lung, and Cellulitis. The resident was discharged on [DATE]. Review of a quarterly MDS assessment dated [DATE], revealed Resident #22 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact and was dependent with bathing. Review of a comprehensive care plan for Resident #22 dated 9/1/2023, revealed the resident required ADL assistance. Review of the facility ADL documentation for Resident #22, dated 9/1/2023 - 9/30/2023, revealed the resident received a shower on 9/19/2023 and 9/21/2023. This was a total of 2 showers provided to the resident of 13 scheduled showers. Review of the facility ADL documentation for Resident #22 dated 10/1/2023 - 10/31/2023, revealed Resident #22 received a shower on 10/5/2023. This was a total of 1 shower provided to the resident of 5 scheduled showers. Review of the facility grievance log for 9/2023 and 10/2023 revealed no concerns regarding bathing/showers for Resident #22. During an interview on 7/9/2024 at 10:44 AM, NP II stated she had not observed any unkempt residents. No residents had voiced concerns regarding bathing. During an interview on 7/10/2024 at 4:15 PM, the Director of Nursing (DON) stated it was her expectation for residents to receive 3 scheduled showers per week. Residents are scheduled for showers on Monday, Wednesday, Friday or Tuesday, Thursday, Saturday depending on room number. The DON reviewed Resident #12, #8, and #22's ADL bathing records and confirmed the residents had not received the scheduled showers.

Based on medical record review, facility documentation review, and interview, the facility failed to notify the Abuse Coordinator of an allegation of abuse in a timely manner for 1 Resident (Resident #1) of 7 residents reviewed for abuse. The findings include: Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including encounter for Closed Fracture with Malunion, Osteopenia, Dementia, Depression, Anxiety, Acute Respiratory Failure with Hypoxia, Diabetes, and Cirrhosis. Review of Resident #1's 5-day Minimum Data Set, dated dated dated [DATE] revealed the resident's Brief Interview for Mental Status Score was 7 which indicated the resident was severely cognitively impaired. Review revealed bed mobility activity occurred only once or twice and the resident required 1 staff for physical assistance. Resident #1 required extensive assistance of 1 staff for transfers. Medical record review of Resident #1's care plan dated 12/31/2022 revealed the resident was care planned for falls. The interventions in place were bed in a low position and bilateral floor mats. Medical record review of Resident #1's Nursing note dated 12/31/2022 at 5:00 PM, written by the Nurse Supervisor, revealed .Called to patient room .Pt alert, complaining of pain and complaining that she was hit . Medical record review of a Nursing note dated 12/31/2022 at 6:14 PM, written by Licensed Practical Nurse (LPN) #1 revealed, .Resident reports she was 'thrown in bed' pulled my hair and told 'I don't like you' by staff .Unable to determine which staff member did/said this and unable to determine time this occurred likely due to residents [resident's] dementia dx [diagnosis] . Review of the facility's timeline, undated, revealed, .1/2/2023 .DON [Director of Nursing] called and spoke with daughter [names of 2 of Resident #1's daughters] .Daughters express several concerns and were now able to identify who was rough with the resident during transfers .Facility interviewed resident and associates . Review of the facility's documentation dated 1/2/2023 revealed, .New interventions 2 CNA's [Certified Nurse Assistants] suspended, investigation started . Review of a facility typed document undated revealed, .ED [Executive Director], DON [Director of Nursing], concluded investigation on resident [Resident #1], after conducting investigation (started on 1/2/2023) . During an interview on 1/17/2023 at 2:03 PM, CNA #1 revealed while she was in Resident #1's room providing incontinence care, the resident's family member requested to speak with the Nurse Supervisor. The CNA stated the resident informed her and the Nurse Supervisor the resident's hair was pulled. During an interview on 1/17/2023 at 3:00 PM, LPN #1 stated, .[Resident #1] told me someone threw her in bed, pulled her hair and said someone didn't like her . The LPN revealed while in the resident's room, the resident stated she had been hit on 12/31/2022. During a telephone interview on 1/18/2023 at 9:23 AM, Resident #1's family member confirmed she and Resident #1 informed LPN #1 and the Nurse Supervisor on 12/31/2022 of the resident's complaints of being hit, thrown in bed, hair being pulled, and being told by a staff member he did not like her. The resident's family member stated she informed LPN #1 and RN #2 that Resident #1 was abused by a male staff member on 12/31/2022. During an interview on 1/18/2023 at 3:30 PM, the DON revealed when she was made aware of the allegations of abuse regarding Resident #1, they were not able to determine who the alleged abusers were on 12/31/2022. The DON talked with the resident's family by telephone on Monday 1/2/2023 and the resident's family clarified which staff members had allegedly abused Resident #1. The DON notified the Administrator of the allegation of abuse on 1/2/2023 and initiated an investigation on 1/2/2023. During an interview on 1/19/2023 at 11:55 AM, the Administrator stated, .I was notified of the abuse allegations on 1/2/2022 .The family had reported facility CNAs were rough with her [Resident #1] . Interview revealed the facility failed to notify the Administrator of an allegation of abuse in a timely manner.

Based on facility policy review, review of the facility's glucometer (device used to measure blood glucose levels) Quality Control (QC) Results Log, and interview, the facility failed to ensure glucometer quality control testing was performed daily for glucometers located on 3 of 4 hallways. The findings include: Review of the facility policy Blood Glucose Quality Control Check dated 9/22/2022, showed .Joint Commission Standards .the facility will perform 2 level quality control checks daily .document the results .on the 'Quality Control Record' . Review of glucometer Quality Control Results Logs for the 100, 200, and 300 Halls, dated 9/2022, showed the facility failed to perform glucometer QC tests on the following dates: 100 Hall- 9/1-9/4, 9/6-9/7, 9/9-9/18, and 9/20-9/25/2022. 200 Hall -9/1-9/2, 9/6, 9/8-9/9, 9/11-9/16, and 9/20-9/23/2022. 300 Hall -9/1-9/18 and 9/20-9/25/2022. During an interview on 9/27/2022 at 2:50 PM, Licensed Practical Nurse (LPN) #1 stated the glucometer QC results log for the 100 Hall was incomplete for 9/2022. The LPN stated he worked night shift and the night shift nursing staff was responsible for performing daily QC tests on all glucometers and document the results in the logbook. The LPN stated he has not had an issue with resident blood sugars being inaccurate and did not know why the logbook was incomplete. During an interview on 9/28/2022 at 11:27 AM, the Director of Nursing (DON) stated glucometer QC testing should be completed on every glucometer during the night shift. The DON stated she was not aware of concerns related to glucometers not being accurate .not to my knowledge .none abnormally high or low [blood glucose results] .nobody that we had to send out for any blood sugar issues .no issues with accuracy . The DON confirmed the glucometer QC checks were not completed for glucometers on the 100, 200, and 300 hallways in accordance with the facility policy, .we are supposed to check that every morning . During an interview on 9/28/2022 at 11:43 AM, The Nurse Practitioner (NP) stated she has not had any concerns regarding blood glucose accuracy or issues .no problems with glucometers, no issues with [blood glucose levels]. I would remember that .

Based on review of the facility policy, observation, and interview the facility failed to store food items in a clean, safe, and sanitary manner in 1 walk in cooler, 1 dry storage area, and 1 kitchen with the potential to affect 92 residents in the facility. The findings include: Review of the facility policy, titled Food Safety, undated showed .Pre-packaged food is placed in leak-proof .sanitary .container with a tight-fitting lid .The container is labeled with the name of the contents . Review of the facility policy titled Use by Date Guide, revised [DATE] showed All opened containers of food in the dry storage area should be placed in an enclosed container, labeled, and dated with the open date and use by date. Any unopened cans/packages should be marked with the date received . Observation of the kitchen with the Nutritional Coordinator on [DATE] at 9:30 AM, showed the following: -1 large white bin with a lid which contained a white powdered substance with ¼ of the bin remaining. The bin was unlabeled and had an expiration date of [DATE]. -1 large white bin which contained a brown granular substance. The bin was unlabeled and undated. Observation of the kitchen with the Nutritional Coordinator on [DATE] at 9:40 AM, showed the following: -One 5 pound (lb) bag of grits with ,d+[DATE]th of the bag remaining. The bag was open to air. -One 1.75 lb box of wheat cereal with ½ of the box remaining. The box was open to air and undated. -One 1 lb/12 ounce (oz) container of cream soup base with ¼ of the container remaining. The container was open to air and undated. -One 26 oz bag of corn cereal in a zip lock bag. The bag was undated and unlabeled. -One 13 oz bag of oat cereal in a zip lock bag. The bag was undated and unlabeled. -One 11 oz bag of rice cereal in a zip lock bag, with ½ of the bag remaining. The bag was undated and unlabeled. -One 56 oz bag of bran cereal in a zip lock bag. The bag was undated and unlabeled. Observation of the facility's walk-in cooler on [DATE] at 10:00 AM, with the Nutritional Coordinator showed the following: -One 5 lb bag of grated cheese, in a zip lock bag, unlabeled, and undated. -½ of a cucumber, open to air. -Two ½ onions in plastic wrap, unlabeled, and undated. -One plastic container with an orange creamy cheese substance, unlabeled, and undated. -One metal pan with an oily yellow creamy substance. The pan was unlabeled, undated, and uncovered. -One square covered metal pan which contained 10 chicken breasts in liquid. The pan was undated and unlabeled. -Four 2 oz plastic cups with lids which contained a brown substance. The cups were undated and unlabeled. -Four 2 oz plastic cups with lids which contained a dark brown powder. The cups were unlabeled and undated. During an interview on [DATE] at 10:00 AM, the Nutritional Coordinator stated it is the responsibility of all staff to ensure food items are discarded when expired, dated with the receive date, dated when opened, and are stored in an air-tight container. The Nutritional Coordinator confirmed the food items had not been stored properly and the staff failed to follow the facility's policy. During a telephone interview on [DATE] at 1:00 PM, the Dietary Manager (DM) stated she was responsible for the daily operations of the kitchen. The DM confirmed all food items are to be labeled, dated appropriately, and stored in air-tight containers after opened. Continued interview showed food items were to be discarded when expired. The DM stated there were ongoing issues with food storage at the facility.

Based on review of the facility policy, medical record review, observation, and interview the facility failed to notify the Physician timely after a fall for 1 resident (#189) of 4 residents reviewed for falls. The findings include: Review of the facility policy, titled Fall Management, revised 8/2/2021 showed .The licensed nurse should create an 'event note' and include the following details .Notification of physician and any orders received .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level .A fall without injury is still a fall .when a resident is found on the floor, a fall is considered to have occurred . Medical record review showed Resident #189 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #189's care plan dated 9/17/2021 showed the resident is at risk for falls. Review of an Event Note dated 9/18/2021 at 8:30 PM, showed .notified per CNA [Certified Nursing Assistant] res [resident] on floor .res denies pain, injury. Head to toe assessment completed and no injury noted. assisted back to bed x [times] 3 staff members .notified np [Nurse Practitioner] per communication book . Review of the facility documentation dated 9/19/2021 at 1:00 AM, showed .Resident observed lying on floor beside resident bed .[no] injury noted. noted lying on fall mat .Res .assisted back to bed . Continued review revealed no documentation the Physician had been notified. Review of the NP Communication book dated 9/19/2021 showed .found on floor reports .sliding to floor .[no] injury .* on floor again (2 falls this shift) . Observation and interview of Resident #189 on 9/20/2021 at 11:05 AM, showed the resident lying in bed. The resident stated he had fallen out of bed a couple times a few days ago and had no injuries. During an interview on 9/22/2021 at 12:50 PM, the Director of Nursing (DON) confirmed it is her expectation for Nurses to follow the facility's policy and notify the Physician or NP immediately after a resident's fall.

Based on review of the facility policy, medical record review, facility investigation review, and interview, the facility failed to prevent complications of enteral feeding for 1 resident (Resident #1) of 3 residents reviewed for enteral feedings. The facility provided the resident 2 meal trays, despite the resident being NPO (nothing by mouth). The facility's failure to ensure NPO status was maintained resulted in a rehospitalization and Harm to Resident #1. The findings include: Review of the facility policy titled Feeding Tubes, Gastrostomy [feeding tube placed into the stomach], Jejunostomy [feeding tube placed into the small intestine], Transgastric Jejunal [feeding tube placed into the stomach with 2 ports to access both the stomach and small intestine] dated 5/19/2020, showed .the facility will ensure that staff providing care and services to the resident who has a feeding tube are aware of, competent in, and utilize facility protocols regarding feeding tube . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #1's physician orders dated 3/4/2021, showed .NPO diet .may have ice chips . Continued review of the physician orders showed .TF [tube feeding] [MEDICATION(S)] [calorically dense, fiber-fortified therapeutic nutrition] 1.2 at 75 ml [milliliters]/hr [hour] x [times] 22 hours via pump . Physical (PT), Occupational (OT), and Speech Therapy (ST) were ordered for evaluation and treatment as indicated. Review of the Admissions/Discharges dated 3/4/2021, showed Resident #1 was assigned to room [ROOM NUMBER]. Resident #2 was assigned to room [ROOM NUMBER]. Review of the Care Plan dated 3/5/2021, showed Resident #1 required tube feedings with the goal to maintain adequate nutritional and hydration status and staff to observe and report any abnormal signs and symptoms of aspiration (when food, saliva, liquids or vomit enters the lungs instead of being swallowed into the esophagus and stomach). Review of the Skilled Nursing Documentation dated 3/5/2021, showed .alert and oriented x [times] 3 .Resident [#1] is NPO and takes meds [medications] by PEG [Percutaneous Endoscopic Gastrostomy used for feeding] tube . Review of the Progress Notes dated 3/5/2021 at 9:38 AM, from the Certified Dietary Manager (CDM) showed .admitted on an NPO diet with orders for TF [tube feeding] .resident is alert, oriented and able to make needs known . Review of a facility investigation dated 3/5/2021, showed Resident #1 .was NPO status, received tray c [with] pureed diet for breakfast & [and] lunch due to wrong room in computer .ran into family, upset because resident got a meal breakfast/lunch on 3/5/21 & [and] he ate the meals. Checked with Dietary the name for room [ROOM NUMBER] was not right . Review of the Progress Notes dated 3/6/2021 at 3:03 PM, by LPN #1, showed .Resident [#1] was given 2 trays on 5-5-2021 and ate part of both trays. This was report [ed] to his nurse by his family . Review of the physician's order dated 3/6/2021 at 3:06 PM, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the chest x-ray report dated 3/6/2021 at 6:33 PM, for Resident #1, revealed .Lungs: Bilateral patchy infiltrates [a substance denser than air such blood or food within the lung] . Review of the Progress Notes for Resident #1 dated 3/7/2021 at 6:51 AM, showed .Notified MD [medical doctor] on call .CXR [chest x-ray] shows infiltrates stated pt [patient] is asymptomatic .verbalized to continue monitoring pt . Review of the Skilled Nursing Documentation dated 3/7/2021, showed .PEG tube .may have sparing ice chips . Review of the 5-day Minimum Data Set (MDS) dated [DATE], showed Resident #1 was total dependence for eating and had a feeding tube with coughing or choking during meals or when swallowing medications and complaints of difficulty or pain with swallowing. Review of the Speech Therapy Evaluation and Plan of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .recent PEG insertion and NPO with small amount of ice chips following oral care .extended intubation [tube inserted for artificial oxygen ventilation] for 11 days .resulting in significant voice dysfunction and dysphagia . Resident #1's overall abilities were documented as .swallowing abilities = [equals] Profound/Absent - Little to no attempts to initiate/participate . Clinical impressions included .mod [moderate]-severe oropharyngeal dysphagia and PEG insertion . Review of the Progress Notes for Resident #1 dated 3/8/2021 at 11:31 AM, from LPN #1, showed .Resident up with rehab .O2 [oxygen] sat [saturation] was 68% [percent] [normal value 92%-100%] on room air, placed on 3 liters via NC [nasal cannula]. Rechecked .O2 sat was 85 [%], placed on non re breather on 12 liters, sat came up to 97%. Called 911 for transport to hospital . Resident #1 was hospitalized from 3/8/2021 to 3/11/2021 and returned to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital Discharge Summary for Resident #1 dated 3/11/2021, showed .patient was discharged to rehab facility on 3/4 [3/4/2021] .readmitted on [DATE] for shortness of breath secondary to possible aspiration pneumonia . A [MEDICATION(S)] Swallow Study performed on 3/9/2021 revealed .High risk of Aspiration . Review of the History and Physical for Resident #1 dated 3/12/2021, showed .resident was undergoing PT/OT due to Covid-19 pneumonia and critical care [CONDITION(S)] [loss of control of voluntary movement of body muscles] with severe weakness .developed SOB [shortness of breath] and was diagnosed with aspiration pneumonia . Review of the Admission MDS dated [DATE], showed Resident #1 scored 13 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact, the resident was dependent for eating, and .coughing or choking during meals or when swallowing medication . During an interview conducted on 4/26/2021 at 4:15 PM, LPN #3 stated she was assigned to Resident #1 on day shift on 3/5/2021. She stated she was not aware Resident #1 had received 2 meal trays during her shift. During an interview conducted on 4/26/2021 at 4:55 PM, Speech Therapist (ST) #1 stated Resident #1 .came to us NPO, his O2 dropped low, and went to the hospital. When he came back, we did more swallowing therapies including a FEES [endoscopic evaluation of swallowing to assess areas around the voice box and esophagus] and determined he had functioning capacity .he was in denial about his swallowing issue. He could have ice chips and told me he sometimes drank the ice water. I told him not to . During an interview conducted on 4/26/2021 at 6:50 PM, LPN #1 stated she was assigned to Resident #1 on 3/6/2021 and 3/8/2021. She stated the family approached her on 3/6/2021 and told her Resident #1 had 2 meal trays (breakfast and lunch) given to him on 3/5/2021 .he had tube feedings for 22 hours a day and they were turned off between 10:00 AM and 12:00 noon .I notified the kitchen that he was NPO. I reported it to the Nurse Practitioner and the House Supervisor. Nothing was ordered. I monitored him .when [LPN #2] came in at 3:00 PM, she called the doctor and he got a chest x-ray . LPN #1 stated the kitchen told her the wrong resident name was on the room number and the dietary slip placed on the meal trays. On 3/8/2021 she stated she was alerted Resident #1 became exerted during physical therapy. She stated his oxygen level was very low .68% . She placed him on a nasal cannula, then a facemask, and finally a nonrebreather mask, which increased his oxygen saturation to 97%. She called 911 for transport to the hospital. During an interview conducted on 4/27/2021 at 8:00 AM, the Family Nurse Practitioner (FNP) stated she was told on 3/8/2021, a CNA had brought meal trays into the room despite receiving tube feedings and NPO status. She stated he became hypoxic and was diagnosed with aspiration pneumonia. During an interview conducted on 4/27/2021 at 9:50 AM, and review of the Admissions/Discharges list dated ''3/4'' with Residents #1 and #2 room assignments, the CDM stated .they switched the rooms .and they were put on different halls. [Resident #1] was given [Resident #2] tray, a pureed diet .I found out the next day the 2 residents had switched rooms .we get the information from Admissions, I run a list from the tray cart list and [computer program]. I didn't check it that morning, I usually do, but not that morning . The Admissions/Discharge list dated 3/4 showed Resident #1 was placed in Resident #2's assigned room and Resident #2 was placed in Resident #1's room upon admission which resulted in Resident #1 receiving Resident #2's meal trays before the error was discovered. During an interview conducted on 4/27/2021 at 3:20 PM, with the Administrator, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the Administrator stated .we had a breakdown on the room number .and the CNA didn't check the tray, name, or room number before she took the tray into the room . The ADON stated .we determined 2 trays were given . The Administrator stated .we aren't denying it happened . During a telephone interview conducted on 4/28/201 at 8:05 AM, Resident #1 stated on 3/5/2021 .they gave me a breakfast tray with scrambled eggs .I was only allowed chipped ice. I was hungry, wanted it, and ate it. At lunch they brought me mashed potatoes, dressing, something congealed, and thick iced tea .I got the food and had to go back to the hospital .they talked to my family .I just know I got the trays .they cut it off when my [family] told them about it .

Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to report a fall and implement interventions after a fall for 1 resident (Resident #1) of 4 residents reviewed for accidents. The findings include: Review of the facility's policy titled Fall Management dated 4/15/2019 showed .To promote patient safety .reduce falls by proactively identifying, care planning and monitoring of patient's fall indicators .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level .A fall without injury is still a fall .Unless evidence suggests otherwise, when a resident is found on the floor, a fall is considered to have occurred . Review of the medical record, showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 was moderately cognitively impaired and had a history of [REDACTED]. Further review showed the resident had functional limitations in range of motion on 1 upper extremity, used a wheelchair, and was occasionally incontinent of bowels and bladder. Review of Resident #1's comprehensive care plan 11/19/2020 showed the resident was at risk for falls. Review of the Resident #1's falls incident documentation dated 2/2020 through 4/2020 showed the resident had a fall on 2/16/2020, 2/23/2020, 3/9/2020, and on 4/8/2020 for a total of 4 falls during this time period. During a telephone interview on 4/16/2020 at 1:45 PM Licensed Practical Nurse (LPN) #2 confirmed Resident #1 had a fall the evening of 3/31/2020 and the LPN did not report the fall nor did she fill out an incident report. LPN #2 stated she found Resident #1 on the fall mat in the resident's room and the resident did not have any injuries. LPN #2 stated .she (Resident #1) was sitting on the mat .looked as if she slid off to the floor .should have made an incident report .should have reported it .I observed her on the mat .she didn't get hurt .her vital signs were within normal limits .we frequently assessed her .did not call anyone did not tell anyone .asked her what happened .she said she slid off on the floor . During a telephone interview on 4/16/2020 at 2:47 PM the Administrator and Director of Nursing confirmed staff were expected to report all falls and an incident report should be completed including implementation of interventions to prevent further falls.

Based on review of facility policy, record review, and interview, the facility failed to provide the resident or the resident's representative with a summary of the baseline care plan, including the resident's initial goals, medications, dietary instructions, and any services and treatments that would be provided by the facility, for 8 of 8 residents reviewed for baseline care plan (Resident #43, Resident #213, Resident #60, Resident #40, Resident #56, Resident #57, Resident #113 and Resident #165). This had the potential to affect all residents admitted to the facility. The facility census was 77. Findings include: Review of the facility's policy titled, Baseline Care Plan dated 4/29/2019 revealed, Purpose - To develop a baseline care plan within 48 hours of admission to direct the care team while a comprehensive care plan is developed that incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being .Procedure - 2. Schedule an admission care plan conference with the resident or representative .4. Provide the resident or representative with copies of the baseline care plan and physician orders. 5. Have all care plan conference attendees sign the last page of the Baseline Care Plan form. 1. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #43's Baseline Care Plan in the Electronic Medical Record (EMR) dated 1/31/2020 revealed no documentation that Resident #43 or his representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #43 or his representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #43 or his representative. 2. Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #213's Baseline Care Plan dated 2/14/2020 located in the EMR revealed no documentation that Resident #213 or her representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #213 or her representative. Review of the Progress Notes and Assessments located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #213 or her representative. 3. Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #60's Baseline Care Plan in the EMR dated 2/7/2020 revealed no documentation that Resident #60 or his representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #60 or his representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #60 or his representative. 4. Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #40's Baseline Care Plan in the EMR dated 2/14/2020 revealed no documentation that Resident #40 or his representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #40 or his representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #40 or his representative. 5. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's Baseline Care Plan in the EMR dated 2/5/2020 revealed no documentation that Resident #56 or her representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #56 or her representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #56 or her representative. 6. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #57's Baseline Care Plan in the EMR dated 2/6/2020 revealed no documentation that Resident #57 or her representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #57 or her representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #57 or her representative. 7. Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #113's Baseline Care Plan in the EMR dated 2/21/2020 revealed no documentation that Resident #113 or her representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #113 or her representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #113 or her representative. 8. Resident #165 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #165's aseline Care Planin the EMR dated 2/11/2020 revealed no documentation that Resident #165 or her representative received a copy of the written care plan and summary. The Baseline Care Plan was not signed by Resident #165 or her representative. Review of the Progress Notes and Assessment located in the EMR revealed no documentation that the Baseline Care Plan summary was provided to Resident #165 or her representative. During an interview with Resident #165 on 2/5/2020 at 12:31 PM, in the resident's room, she stated she had not received a copy of her baseline care plan. During an interview with the Director of Nursing (DON) on 2/25/2020 at 1:11 PM, in her office, she stated that a Circle of Service meeting was conducted with residents or their representatives within 72 hours of admission. She stated other disciplines were present, including nursing, social services, dietary, business office and therapy, and they reviewed information from their areas. She stated the resident or representative were offered a copy of the baseline care plan and medication orders, but that information was provided only if the resident requested it. Interview with the Administrator on 2/26/2020 at 11:04 AM, in her office, revealed she was under the impression verbal notification and discussion was all that was required. Interview with the Social Services Director on 2/26/2020 at 1:25 PM, revealed on admission the facility offered a care plan meeting, but not every resident or representative wanted to meet. She stated not everyone attended the care plan meetings and if not, the care plan was discussed in the morning interdisciplinary team meeting. During interview with the Administrator on 2/26/2020 at 2:43 PM, in her office, she stated the Unit Managers were responsible for meeting with the resident or representative to review the baseline care plan and the medications. She stated the Unit Managers were giving copies to the resident or representative and having them sign the copies, however, the facility was unable to provide signed copies for the sampled residents.