Every finding on record at Mabee Health Care Center

Based on observation, interview, and record review, the facility failed to post daily information that included the facility name, census, and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 3 days (02/24/2026, 02/25/2026, 02/26/2026) of 3 days observed during survey for staff posting. The facility failed to post the daily staffing information for 02/24/2026, 02/25/2026, and 02/25/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.During an observation and record review on 02/24/2026, 2/25/2026 and 02/26/2026 revealed the facility's daily nursing posting was located behind closed doors at the nurses' station and failed to indicate the actual hours worked for each direct care staffing, the facility name, the total number and actual hours worked by the staff, and resident census. The posting was just a schedule that staff signed upon arrival to work and was in a binder.During an interview on 02/26/26 at 4:22 PM the DON and Administrator stated they were not aware that total hours and the census needed to be on the posting. The DON and Administrator also stated they were unaware that it had to be posted and visible for residents and the public. The DON stated the names and title by each member of staff were to be signed when they arrived at work, on the floor. The DON stated they were not aware the posting had to indicate the number of hours, the facility name and census.During an interview on 2/26/2026 at 4:30PM the Administrator stated they did not have a policy for daily staffing and just follow the regulations.

Based on record review and interview, the facility failed to ensure notices to residents were provided when changes in coverage were made to services covered by Medicare/Medicaid for 3 of 3 residents (Resident #9, Resident #47, and Resident #48) reviewed for resident rights.The facility failed to ensure Resident #9, Resident #47 and Resident #48 was given a Notice of Medicare NON-Coverage CMS form 10123 (NOMNC resident who is not covered on a Medicare Part A skilled nursing stay) and Beneficiary Notice CMS form 10055 (Notice of Medicare Non-Coverage) that inform them how to appeal when residents are discharged from skilled Medicare part A services prior to covered days being exhausted.This failure could place residents, or their representatives, at risk of not being fully informed about services covered by Medicare Part A and not being aware of changes to provided services.Findings include: Resident #9Record review of Resident #9's face sheet dated 02/25/2026, revealed she was admitted to the facility on [DATE] with diagnoses of displaced fracture of right radial styloid process, subsequent encounter for closed fracture with routine healing (fracture in wrist where bone breaks and shifts out of alignment, subsequent encounter refers to the medical and supportive care provided after the surgery to help ensure proper recovery, prevent complications, and restore mobility and function),cardiomyopathy (a group of diseases affecting the heart muscle), muscle weakness (a reduced capacity to generate force), abnormalities of gait and mobility (deviations from a typical efficient walking pattern. Resident #9 remained in the facility as private pay. Discharge from Medicare A date was 12/13/2025 to private pay, length of stay was 62 days.Record review of the CMS form 200052 SNF Beneficiary Protection Notification Review on 2/25/2026 revealed form CMS 10055 and NOMNC was not provided to Resident #9. During an interview on 2/26/2026 at 3:55 pm with the DON, she said Resident #9 was not issued a NOMNC. She said she gave Resident #9 and the Responsible Party a verbal notification. Resident #9 was staying at the facility long term. The DON stated she did not know about the NOMNC form and when she was supposed to give it. She stated they did not have an MDS person in the facility and she completed what was needed at the facility level. The DON stated she was responsible for providing the NOMNC and Beneficiary Notices but did not know she needed to issue the NOMNC. The DON stated the risk of not issuing the forms was residents and the responsible party not being fully informed of their rights. Resident #47Record review of Resident #47's face sheet dated 2/25/26, revealed he was admitted to the facility on [DATE] with diagnoses of fracture of left femur(bone in the thigh), pain, orthopedic aftercare (post discharge phase of recovery following orthopedic surgery). Resident #47 was discharged on 8/28/26. Length of stay was 18 days.Record review of Resident #47's discharge MDS dated [DATE] revealed Resident #47 had a planned discharge to home under care of organized home health service organization. Section C of MDS indicated Resident #47 did not have disorganized thinking. A BIMS was not completed.Record review of the CMS form 200052 SNF Beneficiary Protection Notification Review on 2/25/2026 revealed Resident #47 was not provided with a NOMNC. Resident #48Record review of Resident #48's face sheet dated 02/25/26, revealed she was admitted to the facility on [DATE] with diagnoses of encounter for orthopedic aftercare (post discharge phase of recovery following orthopedic surgery), displaced intertrochanteric fracture or left femur (hip fracture), pain, muscle weakness, unsteadiness on feet. Resident #48 was discharged on 9/18/2025. Length of stay was 19 days.Record review of Resident #48's discharge MDS dated [DATE] revealed Resident #48 had a planned discharge home/community. Resident #48's BIMS score was 15, indicating no cognitive impairment. Record review of the CMS form 200052 SNF Beneficiary Protection Notification Review on 2/25/2026 revealed Resident #48 was not provided with a NOMNC.During an interview on 2/26/2026 at 4:32 pm with the Administrator, she stated the team members responsible for the beneficiary notices was the DON. She said the residents on the Beneficiary Notification Review were not given a NOMNC nor the CMS 10055. She said if the resident received a NOMNC, then they had a chance to appeal the discharge if they do not agree. The Administrator stated they did not have a policy for this and just followed the regulations. She stated the risk of not completing these forms could result in residents not knowing their rights.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for Resident #20, Resident #31 and Resident #46 in that: The facility failed to ensure that the hot water temperatures in the sinks for 3 resident rooms did not exceed the maximum of 110 degrees Fahrenheit (F).The findings included: Record review of Resident 46's face sheet dated 02/26/2026 indicated she was admitted to facility on 02/10/2026 with diagnoses of muscle weakness and muscle spasms. She was [AGE] years of age. Record review of Resident #31's admission record dated 02/26/2026 indicated he was admitted to facility on 01/05/2023 with diagnoses of Alzheimer's disease and muscle weakness. He was [AGE] years of age. Record review of Resident #31's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Record review of Resident #20's admission record dated 02/26/2026 indicated he was admitted to facility on 08/12/2021 with diagnoses of heart failure and muscle weakness. He was [AGE] years of age. Record review of Resident #20's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Interview on 02/24/2026 at 4:30pm the Maintenance Assistant Director was made aware of the water temperatures observed in multiple resident rooms in both of the cottages. The Director said he believed the normal hot water temperature was supposed to be about 120 degrees Fahrenheit (F). The Director said the temperature was controlled at the mixing valves and that they did not checked the water temperature in the resident rooms. The Director brought his thermometer and checked the temperature in one of the resident rooms that had been noted to have water temperature if 118.5 degrees F. The Director's thermometer revealed the water temperature was 119 degrees F. The Director said he was still in the process of learning about safe water temperature levels and that he would adjust the temperature. The Director said they would see that the temperature was turned down as soon as possible. (Note: Water temperature was re-checked and noted to be at 105 degrees F). Observation and interview on 02/24/2026 at 11:05 AM the water temperature in the restroom sink was 122 degrees F in Resident #46's room. Resident #46 said she had not noticed if the water was too hot in her restroom. Observation and interview on 02/24/2026 at 11:12 AM the water temperature in the restroom sink was 120 degrees F in Resident #31's room. Resident #31 said he had noted that the hot water at the faucet in his restroom was pretty hot about a week ago. Resident #31 said that he had never burned his hands because he would adjust the temperature at the faucet. Observation and interview on 02/24/2026 at 11:22 AM the water temperature in the restroom sink was 118 degrees F in Resident #20's room. Resident #20 said he had noted that the hot water at the faucet in his restroom was hot couple of weeks ago. Resident #20 said that he had never burned his hands because he would adjust the temperature at the faucet. Interview on 02/26/2026 at 4:00 PM the Administrator said that the expectation was for the maintenance staff to spot check the water temperatures and monitor the temperatures with the mixing valves. The Administrator said if the hot water was too hot then it could possibly lead to a resident getting burned. The Administrator said they would be keeping a temperature log from now on. The Administrator said they did not have a policy on monitoring hot water. The Administrator said they went based on the regulations. The Administrator said they had not had any residents burned due to the hot water.

Based on observation, interview, and record review the facility failed to ensure each room was designed or equipped to assure full visual privacy for 3 (Rooms C-8, S-8 and S-18) of 4 dual occupancy rooms reviewed for privacy in the facility. The facility failed to ensure that dual occupancy rooms were provided with ceiling suspended curtains, which extended around the bed, to provide total visual privacy. This failure could lead to a lack of privacy for residents, allow residents' private medical treatment to be observed by roommates or others, and lead to a decline in psychosocial well-being. Findings included: Observation on 02/24/2026 at 2:35 PM of resident rooms C-8, S-8 and S-18 revealed that each room had dual occupancy with an A and B bed in each. The rooms had a single ceiling to floor curtain that divided the center of the room but stopped approximately 24 inches from the wall. A beds had a side curtain each but they each had a gap of approximately 30 inches and were unable to allow beds to have total visual privacy. Interview on 02/25/2026 at 4:02 PM the Administrator said if there was no full visual privacy in the resident rooms then there was a possibility of the residents being exposed during resident care. The Administrator said that they did not have a policy on full visual privacy curtains.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 2 (Resident #2 and Resident #8) of 10 residents reviewed for unnecessary medications.The facility failed to ensure Resident #2's PRN Lorazepam (medication generally prescribed to treat symptoms of anxiety) was discontinued after 14 days or documented a rationale for the continued provision of the medication.The facility failed to ensure Resident #8's PRN Lorazepam was discontinued after 14 days or documented a rationale for the continued provision of the medication.This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: Resident #2Record review of Resident #2's face-sheet dated 02/25/26 revealed [AGE] year-old female with admission date 08/31/2023.Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. Section I-Active Diagnoses noted Resident #2 had Psychiatric/Mood disorder, anxiety disorder. Section N- Medications noted Resident #2 was taking an antianxiety medication.Record review of Resident #2's care plan dated 09/29/23 revealed Resident #2 had anxiety and used antianxiety medications. Interventions included for staff to administer Lorazepam per hospice order, to assess effectiveness of antianxiety medication, and assess mood changes.Record review of Resident #2's Prescription Order of Lorazepam 2mg/mL, amount 0.5 ML (1MG) oral (by mouth) every 1 hour as needed for anxiety and duration of hospice start date, 09/29/25, and Open Ended end date. Resident #8Review of Resident #8's electronic face sheet 2/26/2026 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (term used to describe a group of symptoms that negatively affect memory, thinking, and social abilities), depression unspecified, Parkinsons disease with dyskinesia, with fluctuations (involuntary movements and inconsistent medication effects), pain unspecified.Review of Resident #8's quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive impairment. Review of Section I:Active Diagnosis noted Resident #8 had a diagnosis of depression. Review of Section N: Medications revealed Resident #8 was receiving anti-anxiety medications.Review of Resident #8's Comprehensive Care Plan last revised 01/22/2026, revealed: Problem: Anxiety, agitation with use of antianxiety. Approach: Administer medication per MD orders, monitor for any side effects.Review of Resident #8's electronic Physician's Orders dated 2/25/2026 revealed: lorazepam 0.5mg tablet; 1 tab; oral; Special Instructions: May administer 1 tab Every 4 Hours, start date 10/16/2025 with no stop date.Review of Resident #8's February 2026 MAR revealed 11 doses of Lorazepam were administered.Review of Resident #8's physician progress note dated 1/15/2026 revealed no evidence of a documented rationale to order PRN Lorazepam for more than 14 days. In an interview on 02/26/2026 at 3:49 PM with the DON, she stated psychotropic medications were to be prescribed for 14 days or have a documented reason on continued use. The DON stated she oversees the antipsychotic medications and the pharmacy recommendations. She stated she had not received a DRR on this medication from the pharmacist. She stated the rationale was that the medications were prescribed by hospice. She stated there was no policy for psychotropic medications, but the facility followed the regulations.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident of 1 (Scharbauer Cottage) of 2 medication cabinets located in the medication room reviewed for controlled substances and for storage of medications.The facility failed to ensure LVN C signed the Controlled Drugs-Audit Record form after counting and verifying that all controlled substances in the medication cabinet had been accounted for with the off- going nurse at the change of shift on 02/25/26.The failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances. The findings include:In a record review and interview on 02/25/26 at 9:40 AM with LVN C, revealed the Controlled Drug-Count Record was not signed on 02/25/26, 6AM-2PM shift for the Nurse On. The Controlled Drug-Count Record for 02/25/26 2PM-10PM shift was signed on Nurse On, and another signature noted for 02/25/26 10PM-6AM shift under Nurse Off. LVN C stated she forgot to sign under 02/25/26 Nurse On for 6AM-2PM shift and signed under 02/25/26 2PM-10PM and 10PM-6AM shifts. She stated it was a mistake and that was not acceptable. She stated nurses were expected to sign under the change of shift time with the 2 nurses coming onto, and leaving, their shift. She stated she worked double shifts, but she was still to sign the Controlled Drug-Count during the shift change. She stated the potential risks of signing ahead of time included inaccurate and possible unavailability of medications for residents. She stated nurses were responsible for Accurate Controlled Drug-Count documentation, and the DON monitored but was not sure how often.In an interview on 02/26/26 at 10:30 AM with LVN A, she stated the Controlled Drug-Count Record form after counting and verifying that all controlled substances in the medication cart had been accounted for only during the change of shift. She stated this was to have both nurses, on-going and off-going nurses, confirm the count of the Controlled medications in the medication cabinet. She stated the nurses doing the count were responsible for signing the Count Record only when doing the count. She stated the ADON monitored the Audit Records daily for accuracy, and the DON was responsible for monitoring the records but was unsure how often. She stated the potential risks of signing ahead of time or not signing could risks residents for inaccurate medication count and availability.In an interview on 02/26/26 at 3:52 PM with the DON, she stated nurses were expected to sign the Controlled Drug-Count Record form during the change of shift and when both on-going and off-going nurse were confirming count. She stated it was only acceptable for nurses to sign the Controlled Drug-Count Record during the change of shift. She stated as the DON, she was responsible for monitoring the Audit Record forms, which was done on a quarterly basis. The DON stated she did not believe there was a risk to residents if nurses sign ahead of time or inaccurately on the Controlled Drug-Count Record. She stated there was no policy regarding Controlled Medications or the Audit forms.

Based on observation, interview and record review, the facility failed to maintain an Infection Control program designed to help prevent the development and transmission of disease and infection to include hand washing and enhanced precautions for 1 resident (Residents #34) of 5 reviewed for infection control in that:The facility failed to place an Enhanced Barrier Precautions sign outside of Resident #34's door on 02/24/26.This failure could affect the residents who reside at the facility, by placing them at risk for cross-contamination and the spread of infection.The findings were: Record review of Resident #34's face sheet dated 02/25/26 revealed a [AGE] year-old female with admission date 02/02/20 and re-admission date 02/20/26.Record review of Resident #34's Comprehensive MDS dated [DATE] noted there was no BIMS score since Resident #34 was rarely/never understood. Section K-Swallowing/Nutritional status noted Resident #34 had a feeding tube while a resident.In an observation on 02/24/26 at 10:19 AM, Resident #34 was observed in her room, resting in bed with the feeding tube actively infusing 70 ml/hour. There was no EBP sign outside of the room. The enteral feeding was labeled Jevity 1.2 and dated 02/24/26. There were disposable gloves and gowns observed at Resident #34's bedside. Resident #34 was observed waking up but could not answer the surveyor's questions.In an interview on 02/26/26 at 9:25 with LVN A, she stated PPE supplies were located in residents' rooms, in their closets. She stated there were no signs or postings about enhanced barrier precautions (EBP), she stated it was located in the residents' closets. She stated the purpose of staff using PPE was to protect the resident from exposure to bacteria that could potentially cause illness. She stated the potential risks of not having signs outside of resident rooms included staff or visitors to exposing the resident and other residents in the facility since they would not know.In an interview on 02/26/26 at 3:50 PM with the DON, she stated the EBP signs made staff aware of the precautions and PPE was needed to care for the resident. She stated all staff were trained and were aware of which residents required PPE. She stated there was no policy for postings, but the facility followed regulations. She stated there was no potential risk to residents if the EBP postings were not located outside residents' rooms.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's four of four kitchens. The facility failed to ensure milk was not used or discarded by the use by date in 2 of 4 kitchens. The rehabilitation kitchen drawer had an accumulation of food debris in the drawers. The juice reservoirs under the juice dispensers of 2 of 4 kitchens were not clean and beginning to have white mold growing in the bottom. The rehabilitation kitchen refrigerator had fruits that were fuzzy with mold. Food was unlabeled in 2 of 4 kitchens. The handwashing sinks did not have trash cans that did not require staff to touch them in order to prevent re-contamination of hands in 2 of 4 hands. Dishes were stored face up in 1 of 4 kitchens. Hand hygiene was not performed when indicated by staff in 1 of 4 kitchens. Dirty rags were not kept separate from clean rags in 1 of 4 kitchens. These failures could affect residents who received meals prepared from the kitchens at risk for food borne illness and cross contamination. Findings included: Observation of the facility's main kitchen (Younger Unit) on [DATE] at 9:33 a.m. revealed a half-used gallon of milk that had a best by date of [DATE]. [NAME] D stated Oh that's expired milk, took the milk and dumped it down the sink. Observation of the rehabilitation kitchen on [DATE] at 10:05 a.m. revealed: - a drawer of individual serving saltine crackers that had a multitude of crumbs - the refrigerator had a container of unlabeled, unlabeled container of berries that was fuzzy with grey mold. - the reservoir beneath the juice containers had some grey circular mold flecks beginning to grow through it. Observation of the [NAME] Cottage kitchen on [DATE] at 10:30 a.m. revealed: One of two handwashing sinks blocked by an empty milk crate. The other handwashing sink had a flip-lid trash can for paper towels. Interview on [DATE] at 10:45 a.m. Universal Aide E was asked about the flip-top trash can and said there was a foot-pedal type trash can by the blocked hand-washing sink. Universal Aide E asked why that was an issue. The surveyor washed their hands slowly throwing out the paper towel pushing the flip-lid down to dispose of the paper towel. Universal Aide E said Oh, that's cross contamination! Observation of the [NAME] Cottage Kitchen on [DATE] at 10:49 a.m. revealed: -The juice dispenser reservoir had an accumulation of juice and was beginning to have white spots of mold in it. -The resident refrigerator unlabeled (no resident name on it) with a best-by date of [DATE] -The facility refrigerator had a gallon of milk with a best by date of [DATE]. -The hand washing sink trash can had a flip top lid and no paper towels available. -Serving platters and coffee carafes were stored face up (open to air contamination) -In the second refrigerator was a bowl of unlabeled, undated peaches and a bag of shredded cheese. -Universal Aide F rinsed some dirty dishes, took off gloves and did not perform hand hygiene. The aide left to get a resident some iced-tea. - Under the sink was a stack of clean rags folded neatly. Immediately next to it was a stack of used rags (visible stains) touching the clean rags. In an interview on [DATE] at 1:37 p.m. Aide F stated she worked at the facility for 3 years and always worked at the cottages. Aide F stated she worked in the kitchen and was responsible for cooking breakfast and serving lunch. Aide F stated everyone was responsible for making sure the kitchen was clean and there was no set cleaning schedule and the aides got to it if they could. Aide F stated [NAME] Cottage did not have a dedicated cook like [NAME] Cottage did, but they would lose an aide if they did dedicate someone to the kitchen full time. Aide F stated the cook, or the coordinator was responsible for checking to see that foods were not expired and that things were labeled. Aide F said all dishes were supposed to be stored face down. Aide F said she did not know when the peaches were put in the bowl since she did not see them, but they made after [DATE]. Aide F stated they were trained to wash their hands or perform hand hygiene before and after all resident care or when they changed their gloves. She stated the surveyor probably caught her at a busy time and she did not perform hand hygiene. Interview on [DATE] at 2:35 p.m. the Administrator, with the DON present, stated housekeeping was responsible for cleaning out the drawers in the rehabilitation kitchen but the aides or the ADON were responsible for ensuring the reservoir was empty and clean. The DON stated there was no policy it was just to follow regulation and she did not remember the last in-service but there was an all-skills fair on [DATE] that all staff had to go to that covered hand hygiene and food handling. The DON added they facility also used a computer-based computer program that also covered hand-hygiene. The DON and Administrator stated they were mad because they made sure all the hand washing sinks in the cottages had a foot pedal trash can for handwashing.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #6, #14, and #22) reviewed for care plans in that: Resident #6 did not have a care plan in place for fall risk. Resident #14 did not have a care plan in place for dehydration or hand rolls. Resident #22 did not have a comprehensive care plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #6's Resident Face Sheet, dated 12/5/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unspecified dementia, and Diabetes Mellitus with Diabetic Neuropathy (nerve damage causing people to not feel their extremities). Review of Resident #6's Quarterly MDS Assessment, dated 10/23/24 revealed: She had a mental status of 3 of 15 (indicating severe cognitive impairment) with signs of delirium to include disorganized thinking that fluctuated. She needed substantial assistance for transferring to chair to bed. She took the following high-risk medications: anti-anxiety, anti-depressant, opioid. Review of Resident #6's Significant Change MDS, dated [DATE], revealed the Care Area Assessment triggered area: Falls. In the column indicating if it was care planned the facility documented they care planned for falls. Review of Resident #6's electronic record, including the care plan revealed no care plan for falls. Review of Resident #14's Resident Face Sheet, dated 12/5/24, revealed he was a [AGE] year-old male admitted to the facility 10/21/20 with diagnoses including stroke and paralysis of both sides. Review of Resident #14's Significant Change MDS Assessment, dated 11/5/24 revealed: Cognitive statuswas unable to be assessed. Range of Motion impairment was noted of the upper and lower extremities on both sides. He was completely dependent for all ADL's. Review of Resident #14's Care Plan and electronic record revealed no care plan for dehydration and the hand rolls. Observation on 12/3/24 at 3:27 PM revealed Resident #14 was in bed, the head of his bed was raised, he had an air mattress and was hooked to a feeding tube. His hands were severely contracted (curled in and unable to be straightened) and he had hand rolls (rolled up dry wash cloths in them to absorb sweat and keep the contracture from getting worse). Observation on 12/5/24 at 9:48 AM revealed Resident #14 was in bed with the hand rolls in place. Interview on 12/5/24 at 9:52 AM LVN A stated the first thing she did in the morning was make sure Resident #14's hands were clean, and the hand rolls were in place. Review of Resident #22's Face Sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, high blood pressure, high cholesterol, gastroesophageal reflux disease, pain, edema (swelling to the lower extremities), and history of blood clots. Review of Resident #22's Quarterly MDS, dated [DATE] revealed: She scored 2 of 15 on a mental status exam indicating severe cognitive impairment. She displayed wandering behaviors 1 to 3 days during the look back period. She required moderate assistance to total dependence for all ADL's. She had active diagnoses of Alzheimer's disease, dementia, coronary artery disease, high blood pressure, high cholesterol, stroke, and anxiety disorder. She had 2 or more falls without injury reported since the last assessment. She was at risk of developing pressure ulcers. She received an antipsychotic medication and a diuretic medication. She was on hospice services. Review of Resident #22's medication orders, dated 12/05/24, revealed the following orders: Alprazolam 0.25mg give 1 tablet by mouth every 4 hours as needed for anxiety/agitation (Order Date 8/23/24) Amantadine HCl 100mg give 1 capsule by mouth daily (Order Date 8/5/24) Amlodipine 10mg give 1 tablet by mouth daily (Order Date 8/5/24) Furosemide 20mg give 1 tablet by mouth daily as needed for edema (Order Date 8/5/24) Polyethylene glycol 17 grams/dose give 17 grams mixed in 8 ounces of beverage of choice by mouth daily (Order Date 8/5/24) Quetiapine 25mg give 1 tablet by mouth twice daily (Order Date 8/27/24) Levothyroxine 100mcg give 1 tablet by mouth daily (Order Date 8/5/24) Acetaminophen 325mg give 2 tablets by mouth every 6 hours as needed for pain (Order Date 8/8/24) Vitamin D3 25mcg give 1 tablet by mouth daily (Order Date 8/8/24) Review of Resident #22's electronic health record revealed no comprehensive care plan in place. In an interview on 12/05/24 06:03 PM with the Administrator and the DON, the DON stated that Resident #22 was admitted in August 2024 and had a full care plan in the old system that should have transferred into the new system. The Administrator stated that some things did not transfer from the old EMR system, and it was being addressed as it was discovered. The DON stated that Resident #6 should have had a care plan for falls due to her history of falls. The DON stated that an audit had been done in November 2024 for all residents with recent falls to ensure that care plans were in place and Resident #6 was overlooked because she had not had any recent falls. The DON stated that Resident #14 should have had a care plan or intervention under his skin care plan regarding his hand contractures and hand rolls/pads. The DON stated that the ADON for LTC was responsible for starting and maintaining care plans for all residents. (The ADON was not present for an interview at the time of survey.) The DON stated that she expected care plans to be done within the required time frame and that care plans reflected the needs and wants of each resident. She stated that she expected any special needs, such as AFO's, low bed and mats next bed to be addressed in care plans. The DON stated that the purpose of the care plan was to outline needs so that anyone who looked at any resident's care plan would know how to take care of the resident. The DON stated that CAAs did not automatically trigger a care plan in the EMR system and that the care plan had to be built based on assessment and knowledge of each resident. She stated that the nurses had a whole library of care area templates to choose from when creating a care plan. The DON stated the nurses did some training on how to do care plans in the new system. The Administrator stated that she expected care plans to be completed in the correct time frame and so that anyone who looked at the care plan should be able to understand the care of the resident. The Administrator stated that the care plan should have a clear view of what tasks/care nurses were responsible for, what tasks/care CNAs were responsible for, dietary or nutritional needs, and any special situations present for the resident. The Administrator stated that DON audited care plans especially since changing to the new EMR on 10/01/24. The Administrator stated that Resident #22 had been stable with no falls, no infections, and no new diagnoses, so there had been no reason to audit her care plan. DON stated that if a resident falls or had an infection, she looked at the resident's care plan to make sure it was current and updated it if needed. The Administrator stated that the DON looked at the entire care plan during her audits. The DON stated the facility held weekly IDT meeting to discuss every resident - weight, skin, falls, about all changes. The Administrator and the DON both stated that all resident information was supposed to transition into the new EMR system, and some things did not, which they believe was the reason for the failure. The DON stated that the facility did not have a policy regarding care plans. 45411

Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included locked secured medications, the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (Rehab hall and secured unit medication carts), 1 of 2 medication rooms (Secured unit medication room) and to maintain locked medication cabinets for 4 of 60 rooms (Residents #9, #10, #28, #94) reviewed for medication storage. The medication cart used for the secured unit had an insulin pen that had been opened and placed into use but had no open date on it. The medication cart used for the rehab hall had 2 insulin vials that had been opened and placed into use but had no open dates on them. The secured unit medication room had opened Tuberculin (TB) vial that had expired. (Tuberculin is used to test for Tuberculosis in the body, Tuberculosis is a contagious infection caused by bacteria that mainly affects the lungs). The medication cabinets for 4 of 60 rooms (Residents #9, #10, #28, #94) were unlocked and unsupervised. The failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications and could place residents at risk for drug diversion or accidental ingestion. Findings include: INSULIN AND EXPIRED TB During an observation and interview on 12/04/24 at 02:38 PM revealed the medication room in the secure unit was inspected with LVN A present. There was a small refrigerator that contained a vial of Tuberculin that had an open date of 10/30/24 and the box indicated to discard 30 days after opening. LVN A said she was not aware the TB solution had already expired. LVN A said as far as she knew it was each nurse's responsibility to remove any expired medications from the refrigerator. LVN A said if someone received a test with that expired TB solution it could lead to false readings. During an observation and interview on 12/04/24 at 05:39 PM revealed the medication cart in the rehab hall was inspected with LVN B present. Inside the cart were 2 insulin vials that had been opened and placed into use and had no open date written on them. The insulin boxes and vials indicated Discard unused portion 28 days after first opening, Use within 28 days after initial use. LVN B said she had not opened the insulin vials and had no idea who had done that. LVN B said whenever she opened an insulin vial she dated them and as far as she knew every nurse was responsible for dating the insulin when they opened it. LVN B said if an expired insulin was administered to a resident it might not be as effective and lower the resident's blood sugar. During an observation and interview on 12/05/24 at 11:04 AM revealed the medication cart in the secure unit was inspected with LVN A present. Inside the cart was an insulin pen that had been opened and placed into use but had no open date written on it. The insulin pen indicated that it was good for 28 days after being opened. LVN A said she was not aware of the insulin pen not being dated. LVN A said she would always date the insulin pens when she opened them so that they would know when to dispose of them. LVN A said if the insulin pens were not dated and if used after 28 days it could lead to resident's sugar not being lowered and the insulin could have lost its potency. During an interview on 12/05/24 at 05:32 PM the DON was made aware of the opened and undated insulin medications and also the expired TB vial in the medication room. The DON said it was expected for the nursing staff to date the insulin and TB medications when they were opened. The DON said the nursing staff was supposed to date it because those medications were usually good for only 30 days. The DON said they did random audits of the medication rooms and medications carts but not at all times. The DON said if staff administered expired insulin or TB test that could lead to not being as effective. The DON said the failure occurred because the nursing staff did not date the insulins or removed the expired TB from the medication room. During an interview on 12/05/24 at 05:48 PM the Administrator was made aware of the opened and undated insulin medications and also the expired TB vial in the medication room. The Administrator said she expected for the nursing staff to have applied standard nursing practices such as following nursing guidelines they were taught in nursing school. The Administrator said if the staff administered an expired medication it may or may have a negative outcome. The Administrator said the failure because the nurses that open the insulins failed to date the vials and pen and they also failed to remove the expired TB vial from the medication room. During an interview on 12/05/24 at 06:02 PM the DON said they did not have a specific policy or any current training in regard to dating medication when opened. UNLOCKED MEDICATION CABINETS Review of Resident #9's Resident Face Sheet, dated 12/5/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, hypertension (high blood pressure), hypothyroidism (low thyroid levels), Arthritis, Anxiety, Allergies, incontinence, constipation, and dermatitis. Review of Resident #9's Quarterly MDS Assessment, dated 10/11/24, revealed: She had long and short-term memory impairment with moderately impaired decision-making skills. She showed signs of delirium that included disorganized thinking that fluctuated. Triggered medications included an anti-anxiety and a diuretic. Review of Resident #9's Care Plan, last revised 9/25/24, revealed: Problem: History of elevated Blood pressure and needs medication to keep it controlled. Goal: Blood pressures within normal range for resident Approaches included: Administer antihypertensive medication as ordered. Problem: Pain. Will not show decline in mobility due to pain not controlled. Goal: Remain comfortable as disease progresses. Approaches included: Administer pain medications as ordered. Takes acetaminophen twice a day routinely. Problem: Psychosocial Wellbeing, Depression: Chronic. Goal: Depression will not increase as evidenced by participation in activities, leaving room, and absence of crying and making statements that she is depressed. Approaches included: Assess effectiveness of anti-depressant medication therapy. Review of Resident #9's Continuity of Care Document, dated 12/5/24, revealed ordered medications: Benazepril 40 mg tablet, once a day for Hypertension. Citalopram 10 mg, once a day for anxiety Donepezil 10mg , once a day for dementia Hydrochlorothiazide 12.5mg capsule once a day for hypertension. Observation on 12/3/24 at 3:51 p.m. revealed Resident #9's resident room open, the medication cabinet in her room was closed but did not lock. Resident #9 was out of her room. Inside the cabinet were cards of: Memantine 28 mg Benazepril 40 mg Hydrochlorothiazide 12.5mg capsules Citalopram 10mg Donepezil 10mg tablets And a box of Albuterol Sulfate. Interview on 12/4/24 at 12:50 p.m. LVN A stated she never checked the door to the medication cabinets, she put the key in, and the doors unlocked. LVN A was shown Resident #9's cabinet and stated Oh goodness. LVN A said she switched to the cabinet the medications were currently in because the other cabinet in the room required to be slammed and she (LVN A) did not want to scare Resident #9 like that. LVN A stated she guessed as the charge nurse she was responsible for monitoring the doors. LVN A said there were 4 nurses who passed medications: herself, another day shift nurse, and two night shift nurses. LVN A stated she never checked the cabinets to see if they locked before now; she just assumed they would lock. LVN A stated, It's like the gun cabinet; you can bet I will be double checking now. LVN A stated she never received an in-service about checking to make sure the cabinets were [NAME]. LVN A added Why would we? It's a lock; it's supposed to lock. Review of Resident #10's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 6/18/20 with diagnoses including Alzheimer's disease, generalized anxiety disorder, protein-calorie malnutrition, constipation, pain, nausea, and diarrhea. Review of Resident #10's Annual MDS assessment dated [DATE] revealed: She had long and short-term memory impairment with severely impaired decision-making skills. She showed signs of delirium that included continuous inattention. Review of Resident #10's Continuity of Care Document, dated 12/5/24, revealed the following orders: Lactulose 10grams/15ml give 30ml by mouth three times a day as needed for constipation (Order Date 10/26/23) Lactulose 10grams/15ml give 30ml three times a day for constipation (Order Date 12/5/24) Observation on 12/03/24 at 4:00 pm revealed Resident #10's door open and the built-in medication cabinet in Resident #10's room was unlocked. One 32-ounce bottle of Lactulose (liquid laxative) was observed in the unlocked medication cabinet. Resident #10 was not in the room at the time of the observation. Review of Resident #28's Resident Face Sheet, dated 12/5/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including Pseudomonas (having the pneumonia virus), anemia (low iron), pressure ulcer of the left hip (bed sore), tachycardia (unstable heart rhythm), altered mental status, dementia, pain, allergies, arthritis, hypertension (high blood pressure), hyperlipidemia (high cholesterol), Diabetes. Review of Resident #28's 11/17/24 Admission MDS, dated [DATE], revealed: He had long and short-term memory problems with severely impaired cognitive ability. He showed signs of delirium including inattention and disorganized thinking that were continuously present. Triggered medications included anti-anxiety, and opioid medication. Review of Resident #28's Care Plan, initiated 11/26/24, revealed: Category: Pain: Chronic pain due to arthritis and general aches and pains. Goal: Will voice or show relieve or reduction in pain within one hour after receiving intervention for pain. Approaches included: Administer scheduled ibuprofen and monitor effects. Category: Hyper/Hypoglycemia (high and low blood sugar) Goal: Will remain free of complications from hyper or hypoglycemia Approaches included: Administer Metformin as ordered, hold if Capillary Blood Glucose is below 140. Review of Resident #28's Continuity of Care Document, dated 12/5/24, revealed orders for: Diclofenac Sodium 1% gel Four times a day Ibuprofen 600 mg tablets every 6 hours Hyoscyamine sulfate 0.125 mg tablet every 4 hours as needed Metformin 500 mg once a day hold for blood glucose level less than 140. Vitamin B1 100mg tablet once a day Loratadine 10mg once a day Observation of Resident #28's room on 12/4/24 at 11:20 AM revealed Resident #28 in bed asleep. Resident #28's door was open. The medication cabinet in Resident #28's room came open. In Resident #28's medicine cabinet were: 2 boxes of Diclofenac Sodium 1% gel Four times a day Ibuprofen 600 mg tablets every 6 hours Hyoscyamine sulfate 0.125 mg tablet every 4 hours as needed Metformin 500 mg once a day hold for blood glucose level less than 140. Vitamin B1 100mg tablet once a day Loratadine 10mg once a day Review of Resident #94's Resident Face Sheet, dated 12/5/24, revealed she was an 81-year-femaled admitted to the facility on [DATE] with diagnoses including hypokalemia (low potassium), hypertension (high blood pressure), hyperlipidemia (high cholesterol), hypothyroidism (low thyroid), hypo-somality (sleeps too much), edema (swelling, usually to lower extremities), allergies, and respiratory failure (difficulty breathing). Review of Resident #94's Care plan, updated 10/16/24, revealed: Problem: Nutritional Status: At risk in nutrition/hydration due to needs for assist with meal intake, risk for weight changes due to edema and diuretic use. Goal: Will encourage at least 75% of meal and offer fluids regularly Approaches included: Administer sodium and diuretic medication daily as ordered. Problem: Sleep: Difficulty with insomnia. Goal: Will be able to sleep 6 - 8 hours at night. Approaches included: Assess effectiveness of medication therapy Melatonin. Review of Resident #94's Continuity of Care Document, dated 12/5/24, revealed orders: Fexofenadine 180 mg -pseudoephedrine 240mg once a day Amlodipine 10mg once a day Digoxin 0.125mg once a day. Furosemide 20mg twice a day Gabapentin 100mg 2 capsules three times a day Levothyroxine 100 mcg tablet once daily Melatonin 3 mg tablet at bedtime Montelukast sodium 10mg once day Potassium Chloride 20 meq tablet, 5 tablets to equal 100 meq three times a day. Simvastatin 20 mg at bedtime Sodium Chloride 1,000 2 tablets twice a day Rivaroxaban 20mg at bedtime Observation on 12/04/24 on 12:01 PM revealed Resident #94 in the dining room. The door to the room was open the medication cabinet in her room was completely open with the work ledge down. All medications were easily accessible to people passing by. Medications included: Montelukast sodium -10 mg Vitamin D-1 Amlodipine desolate 10mg Levothyroxine 10mg in am Digoxin 0.125 mg Furosemide 20 mg bid Gabapentin 100mg Rivaroxaban 20 mg Simvastatin 20 mg Sodium chloride 1,000 mg Potassium 20 meq Iron tab ferrous sulfate 65 mg Melatonin 3 mg Fexofenadine 180 mg -pseudoephedrine 240mg Interview and observation on 12/4/24 at 12:35 PM, LVN C said she did not have trouble keeping cabinets locked. She said only the nurses had keys. LVN C was shown Resident #94's cabinet. LVN C said she just did not lock it behind her because she was in a rush. LVN C explained she gave Resident #94 their meds, closed the door and forgot to lock the cabinet because she was busy taking Resident #94 to the dining room. LVN C was shown Resident #28's medicine cabinet that was unlocked. LVN C stated the cabinets were supposed to be locked. LVN C stated they closed and should lock automatically. LVN C said she covered all medications on that cottage (20 rooms) and no one had orders to self-medicate. LVN C attempted to show that the cabinet closed automatically and admitted the cabinet did not lock automatically and she had to push the door closed and lock the door with the key. Interview on 12/4/24 at 1:18 p.m. the DON and Administrator were informed of the cabinets that were unlocked and unattended. The DON stated she had never found a medication cabinet unlocked when she had the occasion to have the medication keys. The DON said she did not know why they would be unlocked, and it was brand new information to her. The Administrator added the Maintenance Department did not check the cabinet doors in the rooms to ensure they locked. The DON said she would rather nursing staff did that because of the medication. The DON said the nurses must not be pushing hard enough on the doors. The DON said there was no in-services on locking the cabinets because there did not need to be one until now. The Administrator and DON both said there was no policy about unlocked medication cabinets when a policy was asked for.

Based on observation and interview the facility failed treat each resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of five residents (Residents #31, #32) and two unsampled residents (Residents #3 and #10) reviewed for treatment with respect and dignity. CNA E was on her cell phone and tapped her fingers on Resident # 32's wheelchair arm. CNAF stood while feeding Resident #31 and #10. This failure placed residents at risk of feeling embarrassed, infantilized, dehumanized, or stigmatized due to their need for assisted dining. Findings included: Review of Resident #31's Face Sheet, dated 11/15/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included diabetes, weight loss. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed (an 11/9/23 quarterly MDS assessment was in progress): He had long- and short-term memory loss and had severely impaired decision-making skills (indicating he was not interview-able). He needed extensive assistance from staff for ADLs. Review of Resident #32's Face Sheet, dated 11/15/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive disease affecting the resident's memory and ability to perform basic functions), psychotic disorder with hallucinations due to known physiological conditions (they see or hear things that are not there). Review of Resident #32's Annual MDS Assessment, dated 9/27/23, revealed: She had short- and long-term memory impairment with severely impaired decision-making skills (indicating she was not interviewable). She was totally dependent on staff for all ADLs. Observation on 11/15/23 at 11:39 AM revealed CNA E stood while trying to feed Resident #3 but then walked around and crouched to talk to unidentified Resident #6. At 11:45 AM CNA E sat next to Resident #32, CNA E took her cell phone out of her pocket and tapped her fingers on Resident #32's wheelchair arms in a sequential fashion. Observation on 11/16/23 at 9:42 AM revealed CNA F stood while feeding Resident #31. CNA F turned and fed unsampled resident #10 while standing. Interview on 11/16/23 at 09:45 AM LVN G stated her expectation for staff while feeding residents was, they needed to speak and visit with the residents. LVN G said she did not prefer them standing except for Resident #3 who you could sometimes sneak in a bite if you said, here trying this, give her a bite and walk away. LVN G said some staff had to stand while feeding Resident #32 because she was so tall the staff had to support her head. LVN G said cell phone use depended on the aide. LVN G stated she did not agree with staff texting but did not mind staff playing music on their phones. LVN G said she monitored by looking over the window into the dining room from the nurses' station. LVN G said she would wait and get the aides by themselves because she did not like being called out in front of someone else. Interview 11/16/23 04:34 PM the DON stated the expectation for staff feeding dependent residents was for them to do it. The DON said she expected staff to sit with residents and feed the residents at the resident's speed and the staff did not need to be on their phone. The DON said standing was ok in certain circumstances. The DON elaborated that there was one resident who would gaze up so to make eye contact, the staff would have to stand to feed the resident. The DON said the computer training program had trained on resident rights in the last year but did not know if it specifically covered feeding or being on the phone. Interview on 11/16/23 at 05:15 PM the DON said the last in person in-service on cell phone use was done prior to the last annual survey.

45411 Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 3 of 9 residents (Residents #19, #31 and #32) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #19, Resident #31 and Resident #32 developed pressure ulcers. These failures placed residents at risk of having assessments that do not reflect significant changes in their conditions and need for additional care/treatment. The findings included: Review of Resident #19's Face Sheet, dated 11/16/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including pulmonary embolism, acute kidney failure, dementia, chronic obstructive pulmonary disease, heart failure, high blood pressure, anemia, and depression. Review of Resident #19's most recent MDS Assessment, dated 10/11/23 revealed: He scored a 3 on his mental status exam, indicating severe cognitive impairment. He required substantial to maximal assistance with all ADLs and used a wheelchair for mobility. He had no documented pressure ulcers at the time of the assessment. Review of Resident #19's Physician's Orders for November 2023 revealed the following orders: Apply medi-honey to buttocks, cover with foam border dressing every day and PRN (start date 10/22/23) Multivitamin 1 tablet by mouth every day (start date 11/15/23) Push Powder in 8oz beverage of choice to aid in wound healing twice a day (start date 11/13/23) Vitamin C 500mg 1 by mouth twice a day (start date 11/15/23) Air mattress every shift (start date 11/13/23) Turn every 2 hours (start date 9/23/23) Right buttocks wound care: clean with normal saline/wound cleanser, pat dry, apply Santyl to eschar, cover with padded dressing every day and PRN (start date 11/13/23) Review of Resident #19's Care Plan, most recent revision date 11/14/23, revealed: Care Plan Description: Pressure Ulcer, Stage 2 (start date 10/30/23) Goal: Ulcer will heal Interventions: Repositioning - two person assist to avoid skin friction/shearing; Refer to dietician for evaluation of current nutritional status, provide supplemental nutritional support; Perform wound care as ordered; Mechanical lift to avoid skin friction/shearing; Full skin evaluation with bath/shower; Float heals off the bed; encourage good nutritional intake; Provide pressure reducing surfaces on bed and chair; Assess wound healing weekly; Assess skin daily with routine care; Administer pain medication prior to initiating treatment Review of Resident #31's Face Sheet, dated 11/15/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included diabetes, weight loss , kidney disease disorders of the skin of subcutaneous tissue, and skin cancer. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed (an 11/9/23 quarterly MDS assessment was in progress): He had long- and short-term memory loss and had severely impaired decision-making skills (indicating he was not interview-able). He needed extensive assistance from staff for ADLs. There were no identified skin issues. Review of Resident #31's November 2023 Physician's Orders, printed 11/15/23, revealed: Order dated 10/5/23 Cleanse Stage II to left inner buttock with wound cleanser, apply hydrocolloid dressing and change every three days and as needed if soiled until healed. Review of Resident #31's Care Plan, dated 5/23/23, revealed: Resident #31 had a history of pressure ulcer and skin issues., he moves his heels against bed sheets frequently, at high risk for further break down. The goal was Remain free from skin break down. Identified interventions included: perform wound care as ordered, asses changes in skin status that indicate worsening of pressure ulcer and notify the physician, keep skin clean and dry, provide pressure reducing surfaces on bed and chair, repositioning assist to avoid friction/shearing/contact with other body part or objects, monitor for signs of infection or spreading, provide incontinent care as needed, apply moisture barrier to peri area as indicated, turn and reposition every two hours, keep heels off bed, may have heel boots to relieve pressure, stage II area to left inner buttock apply treatment as ordered, monitor skin weekly if area is not improving notify hospice/doctor, administer vitamins per dietary consultant recommendations to promote healing. Review of Resident #32's Face Sheet, dated 11/15/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, psychotic disorder with hallucinations due to known physiological conditions, and stage III of the sacral region (tail bone). Review of Resident #32's Annual MDS Assessment, dated 9/27/23, revealed: She had short- and long-term memory impairment with severely impaired decision-making skills (indicating she was not interviewable). She was totally dependent on staff for all ADLs. She had no identified pressure injuries. Review of Resident #32's Care Plan for Pressure Ulcer, Stage 2 to Coccyx, started 10/2/23, revealed: Care Plan Goal: Area will remail free of infection with interventions including perform wound care as ordered, assess changes in skin status that indicate worsening of pressure ulcer and notify the physician, reposition every two hours off back as much as possible, encourage nutritional intake provide protein supplement if intake less than 50%, and administer vitamins per dietary consultant recommendations. Review of Resident #32's Physician's Orders for November 2023 revealed: Cleanse Stage II to coccyx and right side of coccyx with wound cleanser, pat dry and apply hydrocolloid dressing every three days and as needed if soiled, dated 10/2/23. In an interview on 11/16/23 at 5:04 PM, the MDS Coordinator stated that a Significant Change MDS was required when a resident had 2 or more changes in their care, significant weight loss, and when a resident started on or went off hospice. She stated that a significant change assessment could be done with only 1 change if the IDT (Interdisciplinary Team) agreed. She stated that the IDT's decision-making process was normally based on the severity of the diagnosis. When asked if the development of new pressure ulcer required a significant change assessment, she stated that she thought it still required a change in level of care for 2 care areas, but she would have to look at the CMS (Centers for Medicare and Medicaid Services) resident assessment tool to be certain. The MDS Coordinator logged onto the CMS RAI (Resident Assessment Instrument) guide during the interview to double check and she stated that, according to the tool, Resident #19, Resident #31, and Resident #32 all should have had significant change assessments done when they developed pressure ulcers. She stated that she was not notified by the nursing staff that those residents had new pressure ulcers. The MDS Coordinator stated that she was made aware of changes with the residents primarily by the ADONs via email. She stated that skin issues were not addressed during the morning meeting unless a new skin tear or bruise was identified. In an interview on 11/16/23 at 5:33 PM, ADON A stated that she was not aware that the MDS Coordinator needed to be notified when a resident developed a pressure ulcer. She stated that when a CNA charted a new skin issue it alerted the nurse to follow up, and the way the nurse charted should alert her (MDS Coordinator). ADON A stated that when she was informed of a new pressure ulcer by staff, she would send a text message to the DON and the Administrator to let them know. She stated that the weekend RN did skin checks for the residents, but she was not aware if they notified the MDS Coordinator of their findings. In an interview on 11/16/23 at 5:58 PM, the DON and Administrator were informed that significant change MDS assessments had not been completed for Residents #19, #31, and #32. Neither was able to offer any further information regarding why the significant change assessments were not done. The facility did not have a policy regarding resident assessment per the DON.

45411 Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 9 residents (Residents #17, #19, and #32) reviewed for care plans in that: Resident #17 did not have a care plan in place for fall risk. Resident #19 did not have a care plan in place for skin integrity risk, bipolar disorder, or psychotropic medication use. Resident #32 did not have a care plan in place for an indwelling catheter. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #17's Face Sheet, dated 11/16/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Lewy Body dementia, high blood pressure, generalized osteoarthritis, and pain. Review of Resident #17's Annual MDS Assessment, dated 4/20/23, revealed: Fall risk CAA triggered and to be added to care plan. Review of Resident #17's Care Plan, most recent revision date 10/25/23, revealed no fall risk care plan. Review of Resident #17's Quarterly MDS Assessment, dated 11/2/23, revealed: He had short-term and long-term memory loss, and severely impaired decision-making skills (indicating he was not interviewable). He had behavioral symptoms not directed towards others which occurred less than daily. He required maximum assistance and was dependent on staff for all ADLs except for eating. He used a wheelchair for mobility. He had no reported falls in the previous 6 months. He received antipsychotic medication, antidepressant medication, opioid medication, and antiplatelet medication. Review of Resident #17's Physician's Orders for November 2023 revealed: Quetiapine 12.5mg by mouth every night - give 1/2 of 25mg tablet (start date 5/9/32) Tylenol with codeine #3, 1 tablet by mouth three times a day as needed for breakthrough pain (2/16/19) Cymbalta 60mg 1 capsule by mouth daily (start date 5/16/17) Metoprolol succinate ER 50mg 1 tablet by mouth daily (start date 2/15/22) Memantine 10mg tablet by mouth twice a day (start date 10/20/17) Carbidopa-Levodopa 25-250mg 1 tablet by mouth four times a day before meals and at bedtime (start date 6/23/17) Neurontin 600mg 1 by mouth every evening (start date 2/16/19) Trazodone 50mg 1 tablet by mouth at bedtime (start date 11/4/19) Neurontin 300mg 1 by mouth every morning and noon (start date 4/2/19) MS Contin ER 15mg tablet give 1 by mouth every 12 hours, hold for lethargy (start date 2/9/23) Review of Resident #19's Face Sheet, dated 11/16/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including pulmonary embolism, acute kidney failure, dementia, chronic obstructive pulmonary disease, heart failure, high blood pressure, anemia, and depression. Review of Resident #19's most recent MDS Assessment, dated 10/11/23 revealed: He scored a 3 on his mental status exam, indicating severe cognitive impairment. He required substantial to maximal assistance with all ADLs and used a wheelchair for mobility. He had no documented pressure ulcers at the time of the assessment (10/11/23). He was taking an antipsychotic medication and a hypnotic medication. Review of Resident #19's Physician's Orders for November 2023 revealed the following orders: Temazepam 15mg give 1 by mouth at bedtime PRN (start date 9/15/23) Quetiapine fumarate 25mg give two (50mg) by mouth daily (start date 9/15/23) Offload heels while in bed every shift (start date 11/13/23) Air mattress every shift (start date 11/13/23) Monitor right heel every shift and PRN for openings and report to ADON (start date 11/13/23) Monitor left heel every shift and PRN for openings and report to ADON (start date 11/13/23) Turn every 2 hours (start date 9/23/23) Review of Resident #19's Care Plan, most recent revision date 11/14/23, revealed no care plan for skin integrity, bipolar disorder , or his use of psychotropic medication. Review of Resident #32's Face Sheet, dated 11/15/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, psychotic disorder with hallucinations due to known physiological conditions, neurogenic disorder of the bladder, and stage III pressure ulcer of the sacral region (tail bone). Review of Resident #32's Annual MDS Assessment, dated 9/27/23, revealed: She had short- and long-term memory impairment with severely impaired decision-making skills (indicating she was not interviewable). She was totally dependent on staff for all ADLs. She had an indwelling catheter. Review of Resident #32's Care Plan, most recent revision date 11/2/23, revealed no care plan for indwelling catheter use. Review of Resident #32's Physician's Orders for November 2023 revealed: Foley catheter care every shift (start date 9/21/22) Foley output every shift (start date 9/21/22) Continue foley catheter 20 French change every month and as needed (start date 12/27/22) In an interview on 11/16/23 at 5:04 PM, the MDS Coordinator stated that she was responsible for creating care plans for the skilled residents and the ADONs were responsible for creating care plans for the rest of the residents. She stated that if a CAA was triggered during an assessment, a care plan should automatically be created. She stated that she was not aware if the new system generated care plans based on the MDS or if the care plans had to be done manually. In an interview on 11/16/23 at 5:33 PM ADON A stated that she was responsible for care plans for all the rehab and long-term care residents. She stated that she would expect a care plan to address admitting diagnosis and other pertinent diagnoses, psychotropic medication, pain and pain medication, pressure ulcers, consent for psychotropic medication, code status, dietary changes, antibiotics, lab work, fall risk, catheter care. When asked if a pressure ulcer care plan would override a skin integrity care plan, she stated she would have both because if the sore heals the resident would still be at risk. She stated that any type of preventative care, air mattress, moon boots things like that should be care planned. ADON A stated that she had to manually add everything into the computer program when something needed to be care planned. She stated that if a CAA triggered, she would add it on the care plan. She stated she did not have an answer as to why there were no care plans for Resident #17 for fall risk, Resident #19 for skin integrity, depression, or psychotropic medication use, or Resident #32 for her catheter. In an interview on 11/16/23 at 5:58 PM the DON stated that all resident care plans had been redone recently and she was not surprised that some were missed. She stated that she would not expect a skin integrity care plan and a pressure ulcer care plan for the same resident because it was apples to apples and apples to oranges even though they would have different interventions. She stated that psychotropic medications, depression, catheters, and fall risk would require care plans. On review of care plans with surveyor, she acknowledged that Residents #17, #19, and #32 were missing care plans. The DON stated that the facility did not have a policy regarding care plans.

Based on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #18) reviewed for indwelling catheters. The facility failed to ensure Resident #18's indwelling catheter was secured to prevent pulling or tugging. The facility failed to ensure CNA B performed urinary catheter care for Resident #18 during incontinent care. These failures could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Record review of Resident #18's face sheet dated 11/15/2023 indicated he was admitted to the facility on [DATE] with diagnoses of retention of urine and Alzheimer's disease. He was [AGE] years of age. Record review of Resident #18's physician order report for the month of November 2023 indicated in part: Foley catheter care (Q = every) shift. Start date 03/29/2017. Record review of Resident #18's care plan dated 04/18/2023 indicated in part: Care plan description - urinary catheter : Indwelling due to urinary retention. Care plan goal: will reduce the risk of infection. Interventions; Assess color, clarity and character of urine, assess for acute behavioral changes that may indicate UTI. Catheter care every shift. Monitor catheter tubing for kinks or twists in tubing. Record review of Resident #18's MDS dated [DATE] indicated in part: Cognitive skills for daily decision making = Severely impaired-never/rarely made decisions. Appliances: indwelling catheter. Bowel continence = Always incontinent. During an observation on 11/14/23 at 09:50 AM Resident #18 was in bed resting and had a urinary catheter which hung on the side of the bed. The urinary catheter tube was not secured to the resident's leg. The resident was not able to state if the catheter had caused him any discomfort due to his cognitive status. During and observation and interview on 11/14/23 beginning at 11:45 AM CNA B and CNA C performed incontinent and urinary catheter care for Resident #18. CNA B put some gloves on and undid the resident's brief and performed catheter care. CNA B took some wipes and wiped the resident's penis with front to back motions. CNA B did not cleanse the catheter tubing that entered the resident's penis. Both CNAs then turned the resident on his side and CNA B wiped the resident's bottom as he had a bowel movement. CNA B then disposed of the soiled brief and pad, removed her gloves and fastened a new brief to the resident. Both CNAs then dressed the resident and got him out of bed with the use of the mechanical lift. CNAs B and CNA C said they had never seen the catheter secured to his leg. During an interview on 11/15/23 at 01:52 PM ADON A said she recalled Resident #18 having his catheter anchored to his leg at times but did not know why he no longer had it. The ADON said the reason it was anchored to his leg was to prevent the catheter from tugging or injury to his urethra. During an interview on 11/16/23 at 10:02 AM LVN D said she did not recall Resident #18 having his catheter anchored as she did not believe the resident would pull on the catheter and staff were careful not to pull on it when they assisted the resident. The LVN said that but now the resident did have his catheter secured to prevent any issues. During an interview on 11/16/23 at 02:58 PM CNA B said she had gotten nervous and forgot to cleanse the catheter tubing during the incontinent care she performed for Resident #18. CNA B said she had been trained on how to properly perform catheter care but again she got nervous during the procedure and forgot to wipe the catheter tubing. During an interview on 11/16/23 at 03:47 PM ADON A said she expected for staff to clean from the meatus up to the catheter tube and from dirty to clean during catheter care. The ADON was made aware of the observation of the catheter care performed by CNA B. The ADON said if the catheter care was not done correctly it could lead to infections. The ADON said she believed the failure occurred because the CNA got nervous and forgot her steps. The ADON said they had just initiated the catheter leg strap this morning 11/16/23 to prevent tugging and pulling on Resident #18's penis. The ADON said the CNAs received in-services and computer training on how to perform catheter care. During an interview on 11/16/23 at 04:14 PM the DON was made aware of an observation of Resident #18's urinary catheter not being secured to his leg. The DON said if a resident was mobile then it would be good to have a leg strap that secured the catheter to prevent it from being tugged. The DON said if the catheter was not secured it could become dislodged. The DON said the staff received training such as in-services and computer training regarding catheter care. The DON said Resident #18 now had a leg strap in place. The DON was made aware of an observation of Resident #18's urinary catheter care. The DON said it was her expectation for the staff to clean the meatus around the penis and then wipe the catheter tubing as well. The DON said if the care was not cone correctly it could lead to an infection. The DON said the failure probably occurred because the CNA got nervous and forgot the steps. The DON said she would do rounds to monitor staff and conducted in-services to include computer training regarding catheter care. During an interview on 11/16/23 at 04:15 PM the Administrator was made aware of an observation of Resident #18's urinary catheter not being secured to his leg and the catheter care performed by the CNA. The Administrator said she was not a nurse and agreed with the DON's answers regarding the catheter not being secured and the catheter care performed by the CNA. Record review of the document provided by the facility on 11/16/23 and titled Catheter and perineal care and dated 2022 indicated in part: Following proper perineal and catheter care procedures can prevent contamination that can lead to urinary tract infections. This course discusses how to perform perineal care and catheter care. It also discusses how to empty a catheter drainage bag. Male catheter care: Using your non-dominant hand retract the foreskin if it is not already retracted. Hold the penis just below the head and use two fingers of the same to grasp the catheter to grasp the catheter to secure it. Remove the excess water from a cloth, apply soap and wash around the meatus using a circular motion and use a clean area of the washcloth with each stroke. Set the used washcloth on the disposable pad on the table. Take another washcloth from the basin and remove excess water. Apply soap to the cloth . Cleanse the catheter working your way down from the meatus about 4 inches or farther if needed. Avoid tugging the catheter Set the used cloth on the disposable pad on the table and get a clean cloth, then remove excess water and rinse the meatus in the same manner used to cleanse it. Use a clean area of the washcloth for each stroke. Set the used cloth on the waterproof pad on the table. Take the last washcloth and remove excess water. Rinse the catheter from the insertion site downward at least 4 inches. Return the foreskin to its natural position and gently pat with a dry towel. Follow post procedure instructions. Replace the catheter in the leg strap. Secure the catheter to the individual's leg using a leg strap to prevent pulling or tugging. The catheter and tubing must be free from kinks to allow the urine to drain safely. Review of the online the CDC website - According to the CDC website document, dated 2012, indicated in part: Indwelling Urinary Catheter Insertion and Maintenance. Catheter securement devices act as an anchor to prevent tugging and pulling which can cause irritation and inflammation. When catheters are not secured in male patients, the tugging and pulling can cause pressure sores on the penis tip. Properly secure catheters to prevent movement and urethral traction. Reference. https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf Review of the online the CDC website - According to the CDC website document, dated 06/06/2019, indicated in part: Guideline For Prevention Of Catheter-Associated Urinary Tract Infections 2009. Proper Techniques for Urinary Catheter Insertion. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. Reference. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf

Based on interview and record review, the facility failed to ensure the residents have the right to formulate an advanced directive for 4 of 11 residents (Resident #16, #17, #23, and #86) reviewed for advance directives, in that: The facility failed to obtain a valid Out-of-Hospital Do Not Resuscitate (OOHDNR) form for Residents #16, #17, #23 and #86. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having cardiopulmonary resuscitation (CPR) performed against their wishes. The findings were: Record review of the facility's undated document titled Admission Agreement revealed a document titled Resident/family consent for cardiopulmonary resuscitation. There was no OOH-DNR document or explanations on how to obtain one found in the agreement. Review of the Resident/Family Consent for Cardio-Pulmonary Resuscitation form , undated, revealed: This Care Center requests that a written signature of the Elder be obtained in advance regarding the desire for cardiopulmonary (CPR) in the event of an extreme emergency. CPR is the initiation of life saving measures for an individual who has had the sudden cessation of cardia and/or respiratory function. These procedures include the artificial respiration (oxygen) and chest compressions. These procedures will artificially enable the heart to keep pumping as well as aerate the lungs. If the Elder is mentally or physically unable to make this decision and the physician documents this, then a Responsible Party can be assigned as durable Power of Attorney for Health Care. Please note that CPR constitutes an extraordinary measure that can be a life saving procedure. Possible effects of these procedures may be some forms of brain damage due to the absence of oxygen reaching the brain. Other side effects can be damage to internal organs or broken ribs. Often these procedures are successful and will allow the patient life saving time until they can make it to the hospital. We ask that you mark ONE of the decisions below, accompanied by your signature and date. If you have further questions, please contact your attending physician. This statement will remain in effect as long as the resident remains a resident of this facility or until we receive a written and signed notice of revocation from you. (box) I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration, and certain medications for the relief of pain be administered to maintain the resident's comfort. (box) I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency. Resident #16 Review of Resident #16's Face Sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated he was a DNR. Review of Resident #16's Quarterly MDS Assessment, dated [DATE], revealed Resident #16 had: -long- and short-term memory loss and had moderately impaired decision-making skills. - needed assistance of one staff for ADLs, except locomotion and eating which he needed supervision. - used a walker. - was frequently incontinent of bladder and occasionally incontinent of bowel. - was on scheduled pain medication and reported not experiencing any pain; - had two or more falls with no injury; - triggered medications included insulin injections for 7 of 7 days; an antidepressant for 7 of 7 days; and was an anticoagulant for 7 of 7 days. Review of Resident #16's Advanced Directive care plan started [DATE] documented: Need: Resident has the following Advanced Directives on record : Do Not Resuscitate (DNR) *Date of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Identified Approaches included: discuss advanced Directives with the resident and/or appointed health care representative. An Advanced directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and/or appointed health care representative to provide copies to the facility and any updated Advanced Directives. For DNR Status verify presence of pink DNR on resident's chart, certify presence of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission paperwork completed on [DATE] documented the Responsible Party signed the Resident/Family Consent for Cardiopulmonary Resuscitation. Review of Resident #16's admission paperwork showed his primary physician signed the Certificate of Incapacity (facility form) on [DATE]. Interview on [DATE] at 11:55 AM, LVN F stated Resident #16's DNR paperwork should be at the front of chart. She flipped through chart for OOHDNR and was unable to find one. She stated she would ask ADON H if the OOH was not filed yet because they were way behind on the filing. She stated she and the other charge nurse worked with the family forever to get them to make up their mind for the OOHDNR. Interview on [DATE] at 12:04 PM, LVN H stated the family wanted a copy of the OOHDNR and they didn't put it back in the clinical record. She said ADON H was looking for it. Follow-up interview on [DATE] at 9:10 AM, LVN H stated the facility was unable to find Resident #16's OOHDNR so they started a new one yesterday ([DATE]). Interview on [DATE] at 9:29 AM, LVN H stated she and the evening nurse worked months to get the family to accept that Resident #16 was declining and sign the OOHDNR. She stated they convinced the family to go to the social worker. She said she was told the family signed the OOHDNR in the wrong place and the actual OOHDNR was in a folder. LVN H said the OOHDNR did her no good in a folder because if she had to send Resident #16 out she would have been standing there with the Resident/Family Consent for Cardio Pulmonary Resuscitation while the Emergency Medication Technicians waiting on her trying to explain Resident #16 had a OOHDNR. She stated without the OOHDNR the EMTs would not be able to respect Resident #16 wishes. Interview on [DATE] at 10:42 AM, ADON H stated she had more problems with getting the OOHDNR than anything. She said in Resident #16's case the Responsible Party signed the form in the wrong place. ADON H stated she did not know why the social worker did not catch the error. Resident #17 Review of Resident #17's Face Sheet, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Her Face Sheet indicated she was a DNR. Review of Resident #17's Care Plan dated [DATE] revealed, in part, Elder has a terminal illness with a prognosis of six months or less; place copy of advanced directive on the chart, For DNR status: verify presence of PINK DNR on resident's chart, verify presence of physicians order for DNR, place resident's name on DNR lists hanging in the facility common places. Review of Resident #17's Quarterly MDS assessment, dated [DATE], revealed: Her cognitive status was not assessed. She had no symptoms of [CONDITION(S)]. She sometimes understood others and sometimes was understood. She had unclear speech. She had physical behaviors 1 to 3 out of 7 days. She had verbal behaviors 1 to 3 out of 7 days. She had other behaviors 4 to 6 out of 7 days. She required extensive assistance with most ADLs, was totally dependent for bathing, and required limited assistance with eating. She used a wheelchair for locomotion. She was always incontinent of bowel and bladder. She had a condition or chronic disease that might result in a life expectancy of less than 6 months. She received antianxiety medication 7 out of 7 days. Review of Resident #17's clinical record revealed no OOHDNR. Resident #23 Review of Resident #23's Face Sheet, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His Face Sheet indicated he was a DNR. Review of Resident #23's Care Plan dated [DATE], revealed, in part, DNR; For DNR status: verify presence of PINK DNR on resident's chart, verify presence of physicians order for DNR, place resident's name on DNR lists hanging in the facility common places. Review of Resident #23's Quarterly MDS assessment, dated [DATE], revealed: He scored a 3 out of 15 on his mental status exam (indicating severe cognitive impairment). He exhibited physical behavioral symptoms directed at others 1 to 3 of 7 days. He refused care 1 to 3 of 7 days. He had wandering behavior 4 to 6 of 7 days. He required extensive assistance with dressing, toileting, and personal hygiene. He required one person assistance for all other ADLs. He used a rolling walker to ambulate. He was frequently incontinent of bladder and always incontinent of bowel. He received antianxiety medication 7 of 7 days. Review of Resident #23's clinical record revealed no OOHDNR. Resident #86 Review of Resident #86's Face Sheet, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet identified she was on hospice and was a DNR. Review of Resident #86's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #86's Admission MDS assessment, dated [DATE], revealed Cognitive ability was not assessed. She was totally dependent on one or two staff for all ADL's. She used a wheelchair. She had a catheter. Pain was not assessed. She was identified as having less than 6 months to live. Triggering medications included an antipsychotic for 7 of 7 days, an antianxiety medication for 6 of 7 days, an antidepressant for 7 of 7 days, and antibiotic for 7 of 7 days. Review of Resident #86 care plan documented a care plan for a DNR that included approaches that included Date of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on [DATE] at 12:58 p.m., ADON H looked through Resident #86's clinical record and confirmed she did not have an OOHDNR. She stated Resident #86 was admitted to the facility two weeks ago. ADON H stated the Hospice company stated they would get one so she guessed Resident #86 was a full code on hospice for about a year prior to her admission. Interview on [DATE] at 12:13 p.m., the Administrator said the facility used the Resident/Family Consent for Cardiopulmonary Resuscitation in place of a DNR. She stated the form covered the facility for what happened in the facility but would not cover the facility if they needed to send a resident to the emergency room or something. Interview on [DATE] at 12:27 p.m., LVN F said she was not comfortable with the Family Consent for Cardio-Pulmonary Resuscitation. She said in the event of finding a resident not breathing she would send the resident out to the ER. She said she worked with a family for two months to sign a OOHDNR because she was not comfortable with that form. LVN F said as a nurse she would not accept the consent form in place of an OOHDNR. She said she did not know the facility's policy for DNRs and had not received any in-services about it because we know as a nurse. Interview on [DATE] at 12:58 p.m., ADON H stated the family consent was what the facility used. She said as a nurse working the floor, if that was all the resident had they had to send the resident to the emergency room and treat them as a full code. She said unless the resident signed the OOHDNR on admission, they facility would have to send out the OOHDNR to be signed by the doctor. ADON H stated she did not know how long the process took because she did not keep up with it. ADON H stated surveyor would have to ask the DON what the policy was and how long the process should take. She said the social worker was responsible for keeping up with the OOHDNR but the facility was between social workers right now and had a designee. She said they had been without one for at least six months. Interview on [DATE] at 1:41 p.m., the SSD stated she was designated to be the SSD until the facility found a full-time social worker. She stated she did a lot of OOHDNR on the rehab side of the facility but had not been doing much on the long-term side unless the facility brought it to her attention. The SSD said she did not check to see if a resident's code status was consistent through all the lists and records. She stated one doctor came about once a week and that was when he would sign the OOHDNR. She said there was not an initial timeframe for how long it took to get it signed, it just depended on the doctor. She said the facility had a cheat sheet for who was what code status, and she went by the in-house list. The SSD said she would not have any idea how many residents an OOHDRN had signed because she did not check them. She said the only list she checked was on the rehab side. Interview on [DATE] at 2:36 PM, the DON said the facility went through on admission and asked family what their advanced directive was at that time. She said as a nurse working the floor, she would be comfortable accepting the Family Consent form in place of an OOHDNR. The DON stated the facility had not trained nurses on OOHDNRs. She said the nurses had multiple places to check for code status including the crash cart, the pink or yellow sheet at the front of the resident's file, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the consent was only in-house and an OOHDNR would go with the EMT. She said if it came down to brass tacks the EMTs would have to perform CPR on the resident. The DON said the facility had no policy on DNR/CPR. She said she had not in-serviced the nurses because as nurses they all know. The DON said she checked approximately a month ago to make sure the code lists were consistently documented

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests, and the physical, mental, and psychosocial well-being of 5 of 6 residents reviewed for activities. (Residents #7, #19, #20, #23, and #86). Residents on the Younger Unit were not provided with activities that matched the cognitive or psychosocial level for Residents #7, #19, #20, #23, and #86. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: Resident #7 Review of Resident #7's Face Sheet dated 10/05/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly MDS assessment, dated 6/20/22, revealed: She scored a 0 out of 15 on her mental status exam (indicating severe cognitive impairment). She exhibited wandering behaviors 4 to 6 of 7 days. She needed extensive to total assistance for all ADLs but was able to feed herself with only setup assistance. She was always incontinent of bowel and bladder. She used a wheelchair for locomotion. She received antipsychotic medication 7 of 7 days. She received antianxiety medication 7 of 7 days. She received antidepressant medication 7 of 7 days. Activities were not addressed. Resident #19 Review of Resident #19's Face Sheet, dated 10/5/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet indicated she was Roman Catholic. Review of Resident #19's Quarterly MDS assessment, dated 8/17/22, revealed: Cognitive abilities/Mental Status Exam was not assessed. She showed no signs of [CONDITION(S)]. She needed supervision of staff for transfers, walking and eating. She needed assistance of one staff for all other ADLs. She was frequently incontinent of bladder and continent of bowel. She had no pain and no falls. Trigger medications was an antidepressant for 7 of 7 days. Review of Resident #19's Annual MDS assessment, dated 5/17/22, revealed: She had long- and short-term memory impairment with modified independent decision-making skills. It was very important to the resident to listen to her preferred music, to do things with groups of people, to do her favorite activities, to go outside, and to participate in religious activities. Resident #20 Review of Resident #20's Face Sheet, dated 10/5/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Quarterly MDS Assessment, dated 8/17/22, revealed: She scored a 5 of 15 on her mental status exam (indicating severe cognitive impairment). She needed assistance of one staff for all ADLs. She used a wheelchair. She was frequently incontinent of bowel and bladder. She had no pain and no falls. Triggering medications included an antidepressant for 7 of 7 days and an anxiety for 7 of 7 days. Review of Resident #20's Annual MDS Assessment, dated 7/7/22, revealed it was very important for her to listen to her preferred music, to do her favorite activities, and participate in religious practices. Resident #23 Review of Resident #23's Face Sheet, dated 10/05/22, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Quarterly MDS assessment, dated 8/22/22, revealed: He scored a 3 out of 15 on his mental status exam (indicating severe cognitive impairment). He exhibited physical behavioral symptoms directed at others 1 to 3 of 7 days. He refused care 1 to 3 of 7 days. He had wandering behavior 4 to 6 of 7 days. He required extensive assistance with dressing, toileting, and personal hygiene. He required one person assistance for all other ADLs. He used a rolling walker to ambulate. He was frequently incontinent of bladder and always incontinent of bowel. He received antianxiety medication 7 of 7 days. Activities were not addressed. Resident #86 Review of Resident #86's Face Sheet, dated 10/5/22, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #86's Admission MDS assessment, dated 9/27/22, revealed Cognitive ability was not assessed. She was totally dependent on one or two staff for all ADL's. She used a wheelchair. She had a catheter. Pain was not assessed. She was identified as having less than 6 months to live. Triggering medications included an antipsychotic for 7 of 7 days, an antianxiety medication for 6 of 7 days, an antidepressant for 7 of 7 days, and antibiotic for 7 of 7 days. Observations on the Younger Unit 10/3/22 at 10:51 a.m. through 12:35 p.m., showed no activities occurred. The noon meal was observed from 11:43 a.m. - 12:35 p.m., the staff were observed passing food but there were no other resident interaction, there was no music playing and there was nothing to do. At 12:00 p.m. the residents who were able to eat independently were getting restless and were playing with the cloth items in reach (clothes protector, napkins) by folding them; the independently mobile residents began to try to wander off and the dependent residents had increase hand wringing or other repetitive motions. At 12:11 p.m. Resident #26 (non-sampled) started yelling out can we go now, when staff tried to correct her she responded well, lets go!. Resident #8 (not sampled) pushed herself backwards with her feet repetitively trying to tip her wheelchair over. At 12:19 p.m. Resident #7 (not sampled) started sorting her silverware and licking her butterknife. Staff snatched it out of her hands telling her she could not have the butterknife but could have the fork and spoon. When Resident #7's table mate was served lunch, she immediately started to reach over to grab it. Observation on the Younger Unit on 10/5/22 between 9:08 a.m. and 10:48 a.m., showed no activates occurring on the unit. After the morning meal, residents were parked in front of the television and left to sit there. Observation of the [NAME] unit during the same time revealed the residents were getting manicures outside). Observation on 10/5/22 between 12:44 p.m. and 2:00 p.m. showed no activities on the Younger Unit. Interview on 10/05/22 at 1:35 PM, LVN F stated there were no scheduled activities for the Younger Unit. She stated sometimes they had eating popcorn as a group activity and there was bible study on Thursday nights, but generally there was nothing else offered. She stated the staff normally parked the residents in front of the television and left them. LVN F stated the residents on the Younger Unit were viewed as though they weren't missing out by not having activities due to their cognitive statuses. She stated she believed the lack of activities was due to budget and the facility not having enough staff. Interview on 10/05/22 at 2:53 PM, the DON stated the Younger Unit had an activity calendar. She stated there was a staffing issue right now and the facility was trying to fill the scheduling holes right now. She said the CNA Coordinator was usually responsible for doing activities on the Younger Unit but was working the floor as a CNA that week. The Administrator said the unit did a lot of music and memory activities and the residents liked it. They both said the activities did not get done every day. The DON stated the facility had a Chaplain that did a bible study with the residents and if he was unavailable, then Resident #23 used to be a minister and he would do it. The Administrator stated that the CNAs would do circles with the residents which was when the staff would sit around and talk with the residents about an event. The Administrator added visitors would come and do impromptu stuff with the residents like play music. The Administrator and DON agreed it had not been a good week for Activities on the Younger Unit due to staffing. The DON stated the residents would sometimes play with baby dolls and on the weekends, they did a movie with a projector with movie type of snacks. The DON said when the CNA Coordinator could be at the facility during the day activities would usually get done, but she was currently working on the rehab unit . Observation and interview on 10/05/22 at 3:10 PM, revealed CNA G playing music and interacting with 9 residents in the dining room. CNA G stated they had music and dancing every day around 3PM when they could. She stated that the residents liked music and didn't like having to leave the unit or go outside because they got anxious. She stated she was a neighborhood coordinator but had been working in the kitchen and on the floor because facility had been short staffed. Interview on 10/05/22 at 4:04 PM, the Activity Director stated she believed there were activities happening on the Younger Unit but there were not as many as there could have been because the campus had large scale outdoor activities planned for the week and the residents on Younger Unit would not have enjoyed attending them. She stated that each unit was supposed to have a neighborhood coordinator that was responsible for planning activities for each unit, but that currently there was not enough staff to accommodate it. The Activity Director stated the neighborhood coordinator for the Younger Unit was working in the kitchen and as direct care due to staff shortages. She stated she would have to look at the activity calendar for the Younger Unit to see what changes could be made in the future. She stated that she was unaware there were not activities for the residents in the mornings in the Younger Unit. Interview on 10/05/22 at 6:00 PM, the DON stated the facility did not have a policy regarding activities. She stated all staff received training online related to activities for residents with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 8 (Resident #2, #189, #191 and #195) reviewed for infection control in that: a) Resident # 189's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. b) Resident # 191's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. c) Resident # 195's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. d) CNA A wiped Resident #2's vaginal area with back to front motion and then applied her brief while wearing soiled gloves. This failure could place residents at risk of respiratory infections, cross contamination and spread of infections. Findings included: INCONTINENT CARE: Record review of Resident #2's admission record dated 05/12/22 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #2's MDS dated [DATE] indicated in part: Cognitive Patterns - Cognitive skills of daily decision making = moderately impaired- decisions poor; cues/supervision required. Bladder and Bowel: Urinary Continence =. e. Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #2's care plan dated 10/04/22 indicated in part: Problem/Need: Incontinent of bowel and bladder. Goal and target date: Will be clean, dry and comfortable in between incontinent episodes over the next 90 days. Approaches: Administer peri-care after each incontinent episode. During an observation on 10/03/22 at 11:29 AM, CNA A performed incontinent care for Resident #2. CNA A took some wet wipes and wiped the residents vaginal area a couple of times with a back to front wiping motion. The resident was turned on her right side and the CNA proceeded to clean the residents rectum. The resident had a bowel movement also. While still wearing the same gloves CNA A proceeded to apply the new brief on the resident. During an interview on 10/05/2022 at 12:48 PM, CNA A said the way to wipe the resident's peri-area was with a front to back motion. CNA A said during incontinent care with Resident #2 she had become very nervous and wiped in the wrong direction which was back to front. CNA A said she knew she was supposed to change her gloves prior to applying the clean brief. CNA A said she was so nervous she forgot to change them prior to applying the new brief on the resident. CNA A said wiping from back to front could lead to UTI's and not changing her gloves could lead to cross contamination. CNA A said she received training on those tasks regularly. During a telephone interview on 10/05/22 at 09:46 AM, the nurse aide instructor said she did skills training with skills with the CNAs such as how to wash their hands, glove changing and discuss how to wipe the residents during incontinent care. The instructor said they monitored the CNAs by conducting in-services. The instructor said she was responsible for training the staff on incontinent care and infection control procedures. The instructor said when CNAs performed incontinent care they were supposed to wipe away from the urethra and to wipe from front to back. The instructor said if the staff wiped from back to front that could lead to a risk of infections such as a UTIs. The instructor said staff were trained to change their gloves after they performed the incontinent care and when going from dirty to clean. The instructor said the staff were supposed to don new gloves to place the new brief on the resident to prevent cross contamination. The nurse aide instructor said she believed the failure occurred because the nurse aide got nervous and forgot her steps. During an interview on 10/05/22 at 04:56 PM, the Administrator and DON said the nurse aide instructor would do in-services with CNAs regarding incontinent care and that the DON would also do trainings. The DON said the aides were supposed to wipe from front to back so the residents would not get UTIs. The DON said the aides were supposed to change their gloves when going from dirty to clean to prevent cross contamination. The DON and Administrator said they believed the failure occurred because the CNA got nervous and forgot the correct steps. NASAL CANNULA TUBING: Record review of Resident # 189's face sheet revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was [AGE] years of age. Record review of Resident #189's care plan dated 10/01/2022 indicated, in part: Interventions: oxygen 1 Liter per minute via nasal cannula, as needed. Record review of Resident #189's medication profile dated 10/01/2022 indicated in part: Oxygen via nasal cannula at 1 liter per minute, as needed. Record review of Resident #191's face sheet revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #191's medication profile dated 09/28/2022 indicated in part: Oxygen 1 liter per minute via nasal cannula, as needed. Record review of Resident # 195's face sheet revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #195's care plan dated 09/30/2022 indicated, in part: Interventions: oxygen via nasal cannula, as needed, 2 liters per minute for [CONDITION(S)]. Record review of Resident #189's medication profile dated 09/30/2022 indicated in part: Oxygen 2 liters per minute via nasal cannula, as needed. During an observation on 10/3/22, 10/4/22 and 10/5/22 Resident #195's oxygen tubing was not in plastic bag when not in use. During an interview and observation on 10/05/2022 at 09:55 AM, Resident #195's oxygen tubing revealed the cannula and tubing hanging on the recliner and nebulizer mask on bedside table while not being used. Resident #195 was in the wheelchair, oxygen tank attached to wheelchair and oxygen tubing and cannula hanging on oxygen tank. There were no plastic bags to store oxygen tubing, cannula and mask while not in use. CNA E stated that oxygen tubing is supposed to be in a clear plastic bag when not in use. CNA E stated she would get plastic bags to bag them all up. During an observation on 10/3/22, 10/4/22 and 10/5/22 Resident #189's oxygen tubing was not in a plastic bag when not in use. During an interview on 10/05/2022 at 09:40AM, revealed Resident #189's oxygen tubing and cannula lying on an unmade bed. The wheelchair in the resident's room revealed the oxygen tubing and cannula in the wheelchair seat while not in use. No plastic bags to store the oxygen tubing and cannula were observed while they were not in use. During observations on 10/3/22, 10/4/22 and 10/5/22 Resident #191's oxygen tubing was not stored in plastic bag when not in use. During an interview and observation on 10/05/22 at 09:45AM, Resident #191's oxygen tubing and cannula was hanging from oxygen concentrator and not in use. There was no plastic bag in the room to store oxygen tubing and cannula and mask while they were not in use. During an interview on 10/05/2022 at 10:08 AM, LVN D stated that all residents with oxygen should have plastic bags for the oxygen tubing when not in use. LVN D stated when residents are admitted to the facility with oxygen ordered, staff should place a plastic bag in the room for storing the oxygen tubing when it is not being used. LVN D stated that she will get bags for the residents now. During an interview on 10/05/2022 at 11:30 AM, the DON stated the facility had no policies for oxygen tubing storage and she was aware of Residents #189, #191, and #195 not having storage bags for oxygen tubing this morning but stated it has been fixed now. Record review of the facility's document titled Infection control-personal protective equipment and dated 3/15/2020 indicated in part: Facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors and other staff. Gloves: wear gloves when direct contact with blood, body fluids, mucous membrane, non-intact skin, or potentially contaminated surfaces or equipment is anticipated.

Based on observations, interviews and record review the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #1 was digitally dis-impacted on 1/19/22. LVN A attempted to use a facial massager in a glove to dis-impact Resident #1 instead. The facility was determined to be in an Immediate Jeopardy situation between the dates of 1/19/22 - 1/21/22. The deficient practice was determined to be Past Non-Compliance at an Immediate Jeopardy level due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice could place other residents in need of fecal dis-impaction at risk bowel perforation, surgery, infection, bleeding, or laceration causing potential discomfort, pain and/or injury. Findings included: Review of Resident #1's Face Sheet dated 1/25/22 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS assessment dated [DATE] documented: She scored a 4 of 15 on her mental status exam indicating severe cognitive impairment but showed no signs of [CONDITION(S)]. She showed physical behaviors directed towards others, verbal behaviors directed towards others and rejection of care 1 - 3 days a week. She needed extensive assistance of two or more staff for transfers and toileting. She was frequently incontinent of bladder and occasionally incontinent of bowel. Dehydration was not checked. Triggering medications included an antidepressant medication for 7 of 7 days. Review of Resident #1's electronic care plan, reviewed 1/25/22, showed no care plan for constipation. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10 milligram suppository 1 per rectum every day as needed. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Senna 2 tabs by mouth every night/ hold for loose stools. Begun 7/10/18 Discontinued 1/19/22. Senna 2 tabs by mouth twice a day/ hold for loose stools/diarrhea. Dated 1/19/22. [MEDICATION(S)] powder 17 grams mixed with 8 ounces of beverage of choice by mouth every day hold for diarrhea. Dated 5/21/18. Review of Nursing Notes for Resident #1 dated 1/19/22 at 9:47 PM revealed: 1. resident is constipated. New order to disimpact. Small amount of hard stool disimpacted. 2. change Senna as order to two by mouth twice a day. 3. [MEDICATION(S)] 10 milligrams one per rectum everyday constipation completed by LVN A. Interview and observation on 1/25/22 at 9:08 a.m. the DON stated the facility made a self-report on 1/21/22 where a nurse inserted an object into a resident #1's rectum. The DON took the object out of her drawer. The object was ½ inch wide and was a green, flat, hard plastic. The DON stated she asked LVN A was anyone in nursing school ever taught how to use a foreign object to dis-impact someone since you could not feel anything. The DON stated the disimpaction was reported to her between 10 and 10:30 a.m. on 1/21/22 the LVN Awas terminated by 11:10 a.m. that day. The DON said LVN A alluded to using a rectal thermometer and the DON stated the facility did not use rectal thermometers. The DON stated LVN A said the only thing she used the handle for was to see how far the impaction went. The DON stated the expectation for dis-impacting stool was for the nurse to use a lubricated finger for a dis-impaction. The DON stated LVN A did put the object in a glove. The DON explained Resident #1 had issues with constipation prior to this incident. She said Resident #1 had regular bowel movements since then with no pain, bleeding, or anything to indicate there was any injury. The DON stated Resident #1 did not remember the incident, but wasn't happy at the moment. The DON stated, I get she wasn't trying to hurt the resident, but it wasn't prudent nursing. Interview on 1/25/22 at 11:00 a.m. CNA D revealed she just completed Nurse Aide training . CNA D described Resident #1 as a 2-person transfer with a mechanical lift, who needed incontinent care, and said her cognition was about a 5 on a scale of 1 - 10. She said Resident #1 would screaming during care. CNA D stated Resident #1 could recognize what people did to her. CNA D stated she was present for the incident. CNA D explained on 1/19/22 herself, CNA B and CNA C were in the bathroom with Resident #1 on the toilet. CNA D stated we got LVN A and told LVN A that Resident #1 was constipated for a couple of days. CNA D said LVN A told them that Resident #1 was already on [MEDICATION(S)] and a couple of little tablets for constipation. CNA D said she returned to the bathroom and Resident #1 was bent over on the toilet when LVN A came into the bathroom with a glove and something in it, but CNA D was unable to see what was in the glove. CNA D said the glove was dry and there was no lubricant on it. CNA D made an up-and-down stabbing motion and stated, it was not [LVN A's] finger, it was wider than a finger. CNA D stated Resident #1 screamed, it sounded like pain, and Resident #1 screamed get that thing out of my bottom. She said LVN A explained to Resident #1 she was trying to help. CNA D said, I'm a new CNA and I know that didn't look right. CNA D said when LVN A was done she put the object to the side on the counter and tried to block the view with her body . CNA D stated the object looked like a discount store face massager. CNA D said she was confused about what LVN A was using because it didn't seem right, and she (CNA D) felt bad for Resident #1, but LVN A was the nurse. CNA D stated Resident #1 had a change of attitude and acted scared but that she (CNA D) did not see any bruising . Interview on 1/25/22 at 3:20 p.m., CNA B said the incident happened at about 9:30 p.m. She said she and CNA C were working Resident #1's hall and had CNA D as a trainee. CNA B said they went into the room and Resident #1 said she felt like she had rocks shoved up her butt. CNA B said CNA C got LVN A. She said Resident #1 was on the toilet leaned over. CNA B stated LVN A came in and had a glove in her hand and checked Resident #1, then LVN A squatted where she could see Resident #1's bottom. CNA B stated LVN A checked Resident #1, CNA B demonstrated by making a stabbing, up and down motion with her hand to show how LVN A checked Resident #1. CNA B said Resident #1 made a different kind of scream and the glove LVN A held slipped. CNA B said it looked like LVN A held a soup spoon with a metal ball in the center. CNA B said Resident #1 yelled quit, quit, I won't get on the toilet until tomorrow and LVN A said she was trying to help the resident. CNA B said this took approximately 5 minutes , and the other aides got Resident #1 up off the toilet, put her pants on and helped her to bed. She said LVN A walked to the sink, took the massager out of the glove , put it on the counter, washed her hands and put it in her pocket. CNA B said LVN A moved too quickly for her to take a picture of it. CNA B remembered she told CNA C that she had seen nurses dis-impact residents before and it was not done on a toilet, it was done in bed. CNA B said she texted her boss (CNA House Manager) that she wanted to talk to ADON E on 1/20/22 and sent a picture of a similar face massager (CNA B showed the phone that verified the texts setting up a meeting with ADON E and a picture of the massager were sent beginning at 9:31 a.m. on 1/20/22). CNA B said she told ADON E and ADON E said that LVN A had dis-impacted people before and was a good nurse. CNA B said she told ADON E she knew it was not LVN A's finger because LVN A's fingers were not green, and she knew it was not right. CNA B said she told ADON E that Resident #1 said stop. Interview on 1/25/22 at 4:06 p.m. CNA C said Resident #1 had problems with constipation on 1/19/22 and was impacted really bad. CNA C stated Resident #1 had not been able to have a bowel movement for 2 or 3 days. CNA C said earlier that evening LVN A gave Resident #1 a suppository. She said she told LVN A that Resident #1 was trying to dig herself out because Resident #1 said it felt like she had a rock inside. CNA C said the aides were rubbing Resident #1's tummy to relieve the pain. CNA C said LVN A said she could not dig out Resident #1 without calling the doctor. CNA C told LVN A Resident #1 was in pain, and asked if she was going to call the doctor and LVN A told CNA C she did not want to use her finger. CNA A C asked how else was LVN A going to help Resident #1. CNA C said when LVN A came into the bathroom she had a thing in a glove, but she (CNA C) could not see it. CNA C said the glove was dry and earlier CNA C saw her pull a green thing out of her bag. CNA C said LVN A crouched behind Resident #1 while she was on the commode and moved her hand up and down for probably 5 minutes (CNA C made an up and down stabbing motion). CNA C said Resident #1 was screaming saying please stop, you're killing me; and LVN A told Resident #1 'I'm trying to help you' ; and Resident #1 said 'just leave it in there, don't touch me' and tried to push LVN A away. CNA C said she thought it took maybe 5 minutes, but she was concentrating on comforting Resident #1. CNA C demonstrated LVNA's actions by making up-and-down stabbing motions. CNA C said when the glove came off, she saw it. CNA C said it was not done professionally, and it was painful by the way Resident #1 screamed. CNA C said she had never seen anything like that before. CNA C said she told LVN A to use her finger and lube and LVN C did not want to use her finger. CNA C said she saw no blood and Resident #1 had been the same since the incident. Interview on 1/25/22 at 4:38 p.m. ADON E said CNA B approached her on 1/20/22 and told her that LVN A checked Resident #1 with something green. ADON E said and LVN A said it was a soft tipped rubber glove. ADON E said she thought CNA B meant a soft glove and finger because that was how it was done. ADON E said LVN A said she gave Resident #1 a suppository and changed her medications. ADON E said LVN A had never been dishonest with her and repeated she (LVN A) only used a soft tip glove and never thought she would use anything else. ADON E said she thought some of the gloves were a teal-green or that LVN A used a finger condom or something. ADON E stated the facility did not have finger condoms. ADON E admitted CNA B brought a picture later of the object but she did not fathom it because that's just not something you do. Interview on 1/26/22 at 9:33 a.m. Resident #1's physician said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician said she was informed of an incident last week when a device was used to dis-impact the resident. She said she did not remember giving a verbal order over the phone but was on-call for the hospital and it was hard to remember. She said, I probably did give the order. The physician said if she gave the order to dis-impact, her expectation was the nurse write the order, use a lubricated, gloved finger to dis-impact and call the physician if it was not successful. She said she did not think she needed to specify this in the order. The physician said the consequences of using a foreign object were perforation, object could lodge itself in there, ER visit, surgery, infection, bleeding, or laceration. The physician said she had not assessed Resident #1 since the incident. Observation on 1/26/22 at 10:24 a.m . of the object used to dis-impact Resident #1 showed the face massager used was 6 inches in length total. The handle was curved and three inches in length. It was ½ inch wide at the handle. It was ¼ inch thick. Surveyor attempted to call LVN A on 1/26/22 at 11:08 a.m. and she said she would not answer any questions. Review of the facility investigation summary documented the facility took the following statements dated 1/21/22: CNA B at 10:15 a.m. CNA B came to DON's office and wanted to speak to DON . Administrator was in office as well. CNA B started crying and begun to describe what she saw. CNA B said it was light green and described it, that it looked like a face massager. CNA B sent (texted) DON a picture of what she thought it was. CNA B said that it was round on one end with a silver ball in the middle of it. CNA B stated that the patient was having some constipation and that the nurse (LVN A) came in with this item and put it in the patient's (Resident #1's) butt. CNA B was very distraught and said she had never seen anybody do something like that before. This occurred about 9:30 p.m. on 1/19/22. CNA B also stated that when the nurse was asked what she used, she (LVN A) would not tell them (the aides). CNA B said LVN A stated she did not have to answer to them. LVN A at 11:10 a.m. DON called LVN A and informed her that an allegation had been made against her. DON asked her if she had used an object to insert into a resident's rectum. She said that she had. DON asked (LVN A) to come to the facility immediately and bring the item. LVN A agreed. LVN A came to the facility and was asked to come into the DON's office. The Administrator and Employee F were also present. DON asked LVN A what item she used. LVN A produced a light green facial massager that was long with a rounded end with a silver ball in the middle of the round end. LVN A stated that she (LVN A) had used it to feel where the stool was in the patient's rectum. LVN A stated that she used the handle end of the item and that she put it in a glove. She stated that her intention was to help her (Resident #1) and not trying to harm her (Resident #1) in any way. DON asked LVN A if she had ever learned in nursing school that it was ok to put foreign objects into the patient's rectum that were not meant to be used in that way. LVN A said no. LVN A stated this occurred about 9:30 p.m. on 1/19/22. LVN A had the facial massager in her possession. LVN A was brought in (the DON's office) and DON told her that this was not considered prudent nursing and that DON was going to terminate her employment immediately and this issue would be reported to the state as abuse/neglect . CNA C 1/21/22 afternoon (no time specified) This occurred Wednesday night (1/19/22). Resident #1 had the light on, and she was sitting on the side of the bed saying she had to go to the bathroom. So, CNA C went and got CNA D to help transfer (Resident #1) to the toilet. Resident #1 complained that it hurt, feels like a rock. CNA B came in because Resident #1 was screaming. CNA B told CNA C to tell LVN A that Resident #1 was very constipated. CNA C told LVN A. CNA C went back to Resident #1's room and Resident #1 was trying to dis-impact herself. LVN A said she could not help Resident #1, that LVN had already given Resident #1 a suppository. LVN A said she had to have a doctor's permission to dis-impact Resident #1. LVN A came to Resident #1's room and (had) something in a glove. The object looked like a face massager, light green with a silver circle on one end. It was round on one end. LVN A was telling Resident #1 that she was trying help her. CNA C could see LVN A's hand moving and trying to dig it out with this thing. CNA C asked LVN A why are you using that thing on Resident #1. LVN A said, because I don't want to use my finger. CNA C said she had been a CNA for [AGE] years and had helped a lot of nurses with this situation and CNA C had always seen the nurse use lubricant and their finger. CNA C had never seen a nurse use an object to dig someone out. Two little turds came out. LVN A left the room. No blood was in the toilet. CNA C asked LVN A what she used and LVN A said it helped a little. Thursday: LVN A approached CNA C and CNA B in the dining room and said, really, you were crying because you thought I was going to kill Resident #1? LVN A wouldn't let us (CNA C and CNA B) talk. CNA B said, tell me what you used, you know what you did. LVN A said, I don't have to tell you anything. CNA C told LVN A she had been a CNA for a long time and have never seen a nurse do that. LVN A said, I don't have to explain myself to you. Review of ADON E's statement dated 1/21/22 documented: the CNA coordinator received a call from CNA B and she stated LVN A had used something to check Resident #1 for impaction - looked green and long ADON E told CNA B she would talk to LVN A as she would not be in to work until later - LVN A said she used something like from what I understood may be a glove tip she talked about glove soft tip or I thought it could have been an applicator for a suppository. LVN A did not report to work until 6 p.m. This morning I called DON to report to her - I did not know if/what was used but have never known LVN A to do anything like that. Interview on 2/8/22 at 1:05 p.m. the Administrator/Abuse Coordinator and DON stated they presented the incident to the QA Committee. The DON stated fecal disimpaction was an exception and should have been in the nurse's notes. Observation on 2/8/22 from 1:24 p.m. - 2:06 p.m. revealed additional signage with the Administrator's picture, phone number, and reminder of the necessity to report abuse immediately posted at all the entrances of the different nursing units (5) and public bathrooms. Interview on 2/8/22 at 2:53 p.m. the DON stated the staff all knew what to do regarding reporting were completed. She stated all nursing staff completed one-on-one in servicing to include not sticking foreign objects up a residents' rectum. Interview on 2/9/22 at 4:17 p.m. the Administrator was notified the facility was in an Immediate Jeopardy situation between the dates of 1/19/22 - 1/21/22 due to the nurse's failure to follow basic nursing principles. She was informed the facility was back in compliance on 1/21/22. The Administrator stated, I'm a social worker and I know it's not ok to insert anything into a resident's rectum. She had nothing to add to the information. She was emailed the IJ template outlining the facility failure at that time. Interview on 2/9/22 at 4:37 p.m. LVN G said she had been in-serviced on how to disimpact a resident the previous week. She stated she was told to glove up, lubricate the finger, and to 'pick at the edge' of a resident's impaction. LVN G stated using an instrument was invasive and the unit she worked on used other methods like prune juice, pushing fluids or giving laxatives if they were ordered. She stated she did not like to do it because it caused the resident pain. Interview on 2/9/22 at 4:53 p.m. LVN H (who worked on Resident #1's unit) stated she was in-serviced on disimpacting a resident. She said first she would feel the resident's abdomen to see if it was hard or soft or to see if you could feel where the disimpaction was. She stated first the nurse was to try Milk of Magnesia or another [MEDICATION(S)] or suppository and give it time to work. She was able to pantomime the motions and actions needed to dis-impact a resident. Interview on 2/9/22 at 4:58 p.m. LVN I said she tried to not let a resident get a fecal impaction. She stated she would first try a stool softener, then prune juice and increase fluids. She said to assess for fecal impaction you would get the resident's vital signs, first assess the bowel by feeling the abdomen for firmness and then call the doctor and see what he or she wanted LVN I to do. She said if she got an order she would have an assistant with her and lay the resident on the resident's side. She said she would then glove up, lubricate her finger and feel around the rectal area. She said she would little by little try to pick at the stool close to the rectal area. She stated she had an in-service with the DON about one week ago to not use foreign objects in any orifice. Review of the Daily Agenda Minutes documented the facility reviewed all incidents, accidents, allegations of abuse, and identification of any training needs by unit. On 1/31/22 additional computer trainings were added as an requirements and additions to the facility's computerized bulletin boards were made. Review of the QA Meeting sign-in sheet dated 1/27/22 documented all department heads were present and the 1/19/22 incident was discussed. Review of the Abuse Prohibition Postings (undated) documented: We ALWAYS report abuse! If you see, suspect, or hear that any of our residents have been abused or neglected you must IMMEDIATELY report that information to your Administrator (who is your Abuse Prohibition Coordinator). Do not wait until the next shift. Do not wait until Monday morning. Do not wait until lunch is over. Report to the Administrator immediately. Your Administrator is [Administrator's Name, Administrator's picture, and Administrator's cell phone number]. Review of the one-on-one in-service completed by the DON on 1/31/22 documented the DON completed in-servicing on abuse to include that inserting anything into a resident's rectum was not acceptable. Review of the LVN's Job Description, revised August 2015 documented: Responsibilities and Duties: Direct management of resident's care through planning for nursing interventions. Administration of medications and treatments with documentation. Detects and corrects potential accident situations . The facility did not have a policy or written practice/standard of care for fecal impaction.

Based on observation, interview and record review, the facility failed to implement their abuse and neglect policies to prohibit and prevent abuse for 1 of 6 residents (Resident #1) reviewed for abuse. 1. CNA B, CNA C, and CNA D failed to immediately report an allegation of abuse until approximately 15 hours after the incident involving Resident #1 occurred. 2. ADON E failed to follow the facility's policy and report CNA B's allegation allegation of abuse and protect Resident #1 by allowing LVN A to work an additional shift with Resident #1. This failure could place residents at risk for abuse and psychosocial harm. Findings include: Review of the facility's policy and procedure for Abuse dated 10/5/2010 documented: It is the policy of the facility to promote an atmosphere of heightened awareness in the prevention of abuse and/or neglect of its residents. The facility's policy holds a no tolerance stand for any type of abuse - physical, verbal, emotional, exploitation or misappropriation of resident property. All reports of resident Abuse, Neglect, and Injuries of Unknown Origin will be investigated. This policy provides for a systematic program of Abuse Prevention, which includes, but is not limited to identification of potential types of abuse; investigations of all reports of abuse; protection of a resident's person. Abuse is defined as willful infection of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Procedure: Prevention and Identification: Physical: watching for unexplained bruising, bumps or skin tears or any injuries of unknown origin. Listening to resident, staff, and family complaints. Emotional: watching for signs of withdrawal. Looking for signs of fear in the resident. Listening to resident, staff, and family complaints. Investigation: All reported allegations of resident abuse, mistreatment, neglect, or injury of unknown source will be investigated by the Administrator or his/her designee. A. Identify and interview all witnesses of alleged abuse or neglect in any form. B. Interview the resident (as medically appropriate). C. Identify and interview accused perpetrator and immediately suspend them from their duties and the facility pending the outcome of the investigation. D. The resident will be protected from interrogation by the accused or anyone not conducting the investigation. Protecting - All resident and their property are the facility's #1 priority. Steps will be taken to protect residents from harm during an investigation. Interview and observation on 1/25/22 at 9:08 a.m. the DON stated the facility made a self-report on 1/21/22 where a nurse (LVN A)inserted an object into a resident's rectum. The DON took the object out of her drawer. The object was ½ inch wide and was a green, flat, hard plastic. The DON stated she asked LVN A was anyone in nursing school ever taught how to use a foreign object to dis-impact someone since you could not feel anything. The DON stated it was reported to her between 10 and 10:30 a.m. on 1/21/22 the nurse was terminated by 11:10 a.m. that day. The DON said LVN A alluded to using a rectal thermometer and the DON stated the facility did not use rectal thermometers. The DON stated LVN A said the only thing she used the handle of a facial massager for was to see how far the impaction went and did not think she did anything wrong. The DON stated the expectation was a nurse to use a lubricated finger for a dis-impaction. The DON stated LVN A did put the object in a glove. The DON stated the incident happened on 1/19/22 and it was not reported to her until 1/21/22 by CNA B. The DON explained Resident #1 had issues with constipation prior to this incident. She said Resident #1 had regular bowel movements since then with no pain, bleeding, or anything to indicate there was any injury. The DON stated Resident #1 did not remember the incident, but wasn't happy at the moment. The DON stated there were three CNAs who witnessed the event, and they confronted the LVN who told them she did not answer to the aides. The DON stated, I get she wasn't trying to hurt the resident, but it wasn't prudent nursing. The DON stated she did not know why it took 2 days for the aides to tell her it occurred because the staff were trained if they were uncomfortable with something to report it. Review of Resident #1's Face Sheet dated 1/25/22 documented she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly MDS assessment dated [DATE] documented: She scored a 4 of 15 on her mental status exam indicating severe cognitive impairment but showed no signs of [CONDITION(S)]. She showed physical behaviors directed towards others, verbal behaviors directed towards others and rejection of care 1 - 3 days a week. She needed extensive assistance of two or more staff for transfers and toileting. She was frequently incontinent of bladder and occasionally incontinent of bowel. Dehydration was not indicated. Review of Resident #1's electronic care plan showed no care plan for constipation. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10 milligram suppository 1 per rectum every day as needed. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Senna 2 tabs by mouth every night/ hold for loose stools. Begun 7/10/18 Discontinued 1/19/22. Senna 2 tabs by mouth twice a day/ hold for loose stools/diarrhea. Dated 1/19/22. [MEDICATION(S)] powder 17 grams mixed with 8 ounces of beverage of choice by mouth every day hold for diarrhea. Dated 5/21/18. Review of Nursing Notes for Resident #1 dated 1/19/22 at 9:47 PM revealed: 1. resident was constipated. New order to disimpact. Small amount of hard stool disimpacted. 2. change Senna as order to two by mouth twice a day. 3. [MEDICATION(S)] 10 milligrams one per rectum everyday Constipation by LVN A Interview on 1/25/22 at 11:00 a.m. CNA D revealed she just completed training. CNA D described Resident #1 as a 2-person transfer with a mechanical lift, who needed incontinent care, and said her cognition was about a 5 on a scale of 1 - 10 . She said Resident #1 would screaming during care. CNA D stated Resident #1 could recognize what people did to her. CNA D stated she was present for the incident . CNA D explained on 1/19/22 herself, CNA B and CNA C were in the bathroom with Resident #1 on the toilet. CNA D stated we got LVN A and told LVN A that Resident #1 was constipated for a couple of days. CNA D said LVN A told them that Resident #1 was already on [MEDICATION(S)] and a couple of little tablets for constipation. CNA D said she returned to the bathroom and Resident #1 was bent over on the toilet when LVN A came into the bathroom with a glove and something in it, but CNA D was unable to see what was in the glove. CNA D said the glove was dry and there was no lubricant on it. CNA D made an up-and-down stabbing motion and stated, it was not [LVN A's] finger, it was wider than a finger while making an up-and-down stabbing motion. CNA D stated Resident #1 screamed, it sounded like pain, and Resident #1 screamed get that thing out of my bottom; she said LVN A explained to Resident #1 she was trying to help. CNA D said, I'm a new CNA and I know that didn't look right. CNA D said when LVN A was done she put the object to the side on the counter and tried to block the view with her body. CNA D stated the object looked like a discount store face massager. CNA D said she was confused about what LVN A was using because it didn't seem right, and she (CNA D) felt bad for Resident #1, but LVN A was the nurse. CNA D stated Resident #1 had a change of attitude and acted scared but that she (CNA D) did not see any bruising. Interview on 1/25/22 at 3:20 p.m. CNA B said the incident happened at about 9:30 p.m . on 1/19/22. She said she and CNA C were working Resident #1's that hall and had CNA D as a trainee. CNA B said they went into the room and Resident #1 said she felt like she had rocks shoved up her butt. CNA B said CNA C got LVN A. CNA B stated LVN A came in and had a glove in her hand and checked Resident #1, then LVN A squatted where she could see Resident #1's bottom. CNA B stated LVN A checked Resident #1 (for impaction), and used the green thing to go up Resident #1's bottom while CNA B made a stabbing, up and down motion with her hand. CNA B said Resident #1 made a different kind of scream and the glove LVN A held slipped. CNA B said it looked like LVN A held a soup spoon with a metal ball in the center. CNA B said Resident #1 yelled quit, quit, I won't get on the toilet until tomorrow and LVN A said she was trying to help the resident. CNA B said this took approximately 5 minutes, and the other aides got Resident #1 up, put her pants on and helped her to bed. She said LVN A walked to the sink, took the massager out, put it on the counter, washed her hands and put it in her pocket. CNA B said LVN A moved too quickly for her to take a picture of it. CNA B remembered she told CNA C that she had seen nurses dis-impact residents before and it was not done on a toilet, it was done in bed. CNA B said she texted her boss that she wanted to talk to ADON E on 1/20/22 and sent a picture of the face massager (CNA B showed the phone that verified the texts setting up a meeting with ADON E and a picture of the massager were sent beginning at 9:31 a.m. on 1/20/22). CNA B said she told ADON E and ADON E said that LVN A had dis-impacted people before and was a good nurse. CNA B said she told ADON E she knew it was not LVN A's finger because LVN A's fingers were not green, and she knew it was not right. CNA B said she told ADON E that Resident #1 said stop. CNA B said ADON E told CNA B she would talk to LVN A on 1/20/22. CNA B said when she started her shift 1/20/22, LVN A was not there so she thought ADON E suspended her and was doing an investigation - but LVN A came in at 6 p.m. CNA B said LVN A confronted her and told CNA B that LVN A had an order from the doctor and got the face massager out of her bag. CNA B said she told LVN A that doctor did not give orders to stick something up someone's rectum. CNA B said she tried to stay away from LVN A. Interview on 1/25/22 at 4:06 p.m. CNA C said Resident #1 had problems with constipation on 1/19/22 and was impacted really bad. CNA C stated Resident #1 had not been able to have a bowel movement for 2 or 3 days. CNA C said earlier that evening LVN A gave Resident #1 a suppository. She said she told LVN A that Resident #1 was trying to dig herself out because Resident #1 said it felt like she had a rock inside. CNA C said the aides were rubbing Resident #1's tummy to relieve the pain. CNA C said LVN A said she could not dig out Resident #1 without calling the doctor, so CNA C asked LVN A Resident #1 was in pain, was she going to call the doctor and LVN A told CNA C she did not want to use her finger and CNA A C asked how else was LVN A going to help. CNA C said when LVN A came into the bathroom she had a thing in a glove, but she (CNA C) could not see it. CNA C said the glove was dry and earlier CNA C saw her pull a green thing out of her bag. CNA C said LVN A crouched behind Resident #1 and moved her hand up and down for probably 5 minutes (CNA C made an up and down stabbing motion). CNA C said Resident #1 was screaming saying please stop, you're killing me; and LVN A told Resident #1 'I'm trying to help you'; and Resident #1 said 'just leave it in there, don't touch me' and tried to push LVN A away. CNA C said she thought it took maybe 5 minutes, but she was concentrating on comforting Resident #1. CNA C showed LVN made up-and-down stabbing motions. CNA C said when the glove came off, she saw it (the facial massager). CNA C said she thought it was abuse because it was not done professionally, and it was painful by the way Resident #1 screamed. CNA C said she had never seen anything like that before. CNA C said she told LVN A to use her finger and lube and LVN C did not want to use her finger. CNA C admitted she did not report it and knew she should have. CNA C said she thought more would have been done if both her and CNA B went to ADON E. CNA C said she saw no blood and Resident #1 had been the same since the incident. Interview on 1/25/22 at 4:38 p.m. ADON E said CNA B approached her on 1/20/22 and told her that LVN A checked Resident #1 with something green. ADON E said she called LVN A immediately and told her (LVN A) the accusation and LVN A said it was a soft tipped rubber glove. ADON E said she thought CNA B meant a soft glove and finger because that was how it was done. ADON E said LVN A said she gave Resident #1 a suppository and changed her medications. ADON E said LVN A had never been dishonest with her and repeated she (LVN A) only used a soft tip glove and never thought she would use anything else. ADON E said she thought some of the gloves were a teal-green or that LVN A used a finger condom or something. ADON E stated the facility did not have finger condoms. ADON E admitted CNA B brought a picture later of the object off the Internet but she did not fathom it because that's just not something you do. ADON E admitted she did not report the allegation to anyone because LVN A assured her (ADON E) nothing had happened. ADON E said she thought it might have been a 'tit for tat' sort of thing and she did not ask any of the other staff if anything had happened. ADON E admitted she should have reported the incident to the DON and Administrator right away. ADON E said she texted the DON about the incident at 9:55 a.m. on 1/21/22 and told her she needed to visit with her. Interview on 1/26/22 at 9:33 a.m. Resident #1's physician said Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician said she was informed of an incident last week when a device was used to dis-impact the resident. She said she did not remember giving a verbal order over the phone but was on-call for the hospital and it was hard to remember. She said, I probably did give the order. The physician said if she gave the order to dis-impact, her expectation was the nurse write the order, call the physician if it was not successful and use a lubricated, gloved finger. She said she did not think she needed to specify this in the order. The physician said the consequences of using a foreign object were perforation, the object could lodge itself in there (in the rectum), ER visit, surgery, infection, bleeding, or laceration. The physician said she had not assessed Resident #1 since the incident. Observation on 1/26/22 at 10:24 a.m. showed the face massager used was 6 inches in length total. The handle was curved and three inches in length. It was ½ inch wide at the handle. It was ¼ inch thick. Attempted interview with LVN A on 1/26/22 at 11:08 a.m. and she said I don't want to answer any questions, I will let my attorney talk. Interview on 1/26/22 at 1:21 p.m. the DON said she thought the aides did not report the abuse because LVN A was so ugly to them. She said it was posted all over the facility to call the DON/Administrator, never mind the chain of command for anything like this. The DON said she did not think CNA B communicated very well with ADON E because she needed to be calmed down to tell what happened. The DON said she did not know why CNA C did not report, the DON guessed CNA C thought someone else would do it. The DON said CNA D was too new as a CNA to know. Review of the facility investigation summary documented the facility took the following statements dated 1/21/22: CNA B at 10:15 a.m. CNA B came to DON's office and wanted to speak to DON. Administrator was in office as well. CNA B started crying and begun to describe what she saw. CNA B said it was light green and described it , that it looked like a face massager. CNA B sent (texted) DON a picture of what she thought it was. CNA B said that it was round on one end with a silver ball in the middle of it. CNA B stated that the patient was having some constipation and that the nurse (LVN A) came in with this item and put it in the patient's (Resident #1's) butt. CNA B was very distraught and said she had never seen anybody do something like that before. This occurred about 9:30 p.m. on 1/19/22. CNA B also stated that when the nurse was asked what she used, she (LVN A) would not tell them (the aides). CNA B said LVN A stated she did not have to answer to them. LVN A at 11:10 a.m. DON called LVN A and informed her that an allegation had been made against her. DON asked her if she had used an object to insert into a resident's rectum. She said that she had. DON asked (LVN A) to come to the facility immediately and bring the item. LVN A agreed. LVN A came to the facility and was asked to come into the DON's office. The Administrator and employee F were also present. DON asked LVN A what item she used. LVN A produced a light green facial massager that was long with a rounded end with a silver ball in the middle of the round end. LVN A stated that she (LVN A) had used it to feel where the stool was in the patient's rectum. LVN A stated that she used the handle end of the item and that she put it in a glove. She stated that her intention was to help her (Resident #1) and not trying to harm her (Resident #1) in any way. DON asked LVN A if she had ever learned in nursing school that it was ok to put foreign objects into the patient's rectum that were not meant to be used in that way. LVN A said no. LVN A stated this occurred about 9:30 p.m. on 1/19/22. LVN A had the facial massager in her possession. LVN A was brought in (the DON's office) and DON told her that this was not considered prudent nursing and that DON was going to terminate her employment immediately and this issue would be reported to the state as abuse/neglect. CNA C 1/21/22 afternoon (no time specified) This occurred Wednesday night (1/19/22). Resident #1 had the light on, and she was sitting on the side of the bed saying she had to go to the bathroom. So, CNA C went and got CNA D to help transfer (Resident #1) to the toilet. Resident #1 complained that it hurt, feels like a rock. CNA B came in because Resident #1 was screaming. CNA B told CNA C to tell LVN A that Resident #1 was very constipated. CNA C told LVN A. CNA C went back to Resident #1's room and Resident #1 was trying to dis-impact herself. LVN A said she could not help Resident #1, that LVN had already given Resident #1 a suppository. LVN A said she had to have a doctor's permission to dis-impact Resident #1. LVN A came to Resident #1's room and (had) something in a glove. The object looked like a face massager, light green with a silver circle on one end. It was round on one end. LVN A was telling Resident #1 that she was trying help her. CNA C could see LVN A's hand moving and trying to dig it out with this thing. CNA C asked LVN A why are you using that thing on Resident #1. LVN A said, because I don't want to use my finger. CNA C said she had been a CNA for [AGE] years and had helped a lot of nurses with this situation and CNA C had always seen the nurse use lubricant and their finger. CNA C had never seen a nurse use an object to dig someone out. Two little turds came out. LVN A left the room. No blood was in the toilet. CNA C asked LVN A what she used and LVN A said it helped a little. Thursday: LVN A approached CNA C and CNA B in the dining room and said, really, you were crying because you thought I was going to kill Resident #1? LVN A wouldn't let us (CNA C and CNA B) talk. CNA B said, tell me what you used, you know what you did. LVN A said, I don't have to tell you anything. CNA C told LVN A she had been a CNA for a long time and have never seen a nurse do that. LVN A said, I don't have to explain myself to you. Review of ADON E's statement dated 1/21/22 documented: the CNA coordinator received a call from CNA B and she stated LVN A had used something to check Resident #1 for impaction - looked green and long ADON E told CNA B she would talk to LVN A as she would not be in to work until later - LVN A said she used something like from what I understood may be a glove tip she talked about glove soft tip or I thought it could have been an applicator for a suppository. LVN A did not report to work until 6 p.m. This morning I called DON to report to her - I did not know if/what was used but have never known LVN A to do anything like that. Review of the In-service dated 1/9/22 documented: please notify Administrator (phone number) and DON (phone number) for the following: Administrator - potential abuse of any kind. CNA B, CNA D, and ADON E signed the in-service.

Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rates of five percent or greater. There were 2 errors in 27 opportunities resulting in a 7.41% error rate by 2 of 4 staff members observed (LVN E and LVN A), administering medications to 2 of 10 residents. (Resident #262 and # 34) LVN E failed to administer Resident #262's [MEDICATION(S)] as ordered by physician every 6 hours. LVN A failed to administer Resident # 34's [MEDICATION(S)] as ordered by physician. These deficient practices placed residents at risk for receiving less than therapeutic benefits from medications. Findings Include: Record review of Resident # 262's electronic face sheet revealed an [AGE] year-old female admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident # 262 quarterly MDS, dated [DATE], revealed BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating no cognitive impairment. Medication received during the last 7 days; Antidepressant 7 days; Anticoagulant 7 days; Diuretic 7 days; opioid 7 days. Record review of Resident #262's physicians orders dated 3/19/2020 revealed, [MEDICATION(S)] HCL 50 MG 1 tablet every 6 hours. During observation of medication pass on 8/24/2021 at 3:23 PM, LVN administered Resident #262 with [MEDICATION(S)] 50 MG 1 tablet whole with water. Record review of Resident #262's Individual Patient's Narcotics Record revealed that on 8/24/2021 Resident received [MEDICATION(S)] 50mg at 4:20 AM, 11:00 AM, 3:23 PM, 11:00 PM. Record review of Resident #34's electronic face sheet revealed an [AGE] year-old female admitted on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident # [AGE] yearly MDS, dated [DATE], revealed BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating no cognitive impairment. Record review of Resident #34's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <110 or HR <60. Record review of Resident #34's eMAR revealed that LVN A did not administer Resident #34 [MEDICATION(S)] on the evening of 8/24/2021 scheduled for 7:00 PM. During Oobservation and interview of mediation pass on 8/24/2021 at 7:00PM with LVN A, LVN A took Resident #34's blood pressure before administering medication. Resident #34's was 108/66 with a pulse of 81. LVN A stated that she was going to hold the [MEDICATION(S)] because of Resident 34's blood pressure was in the parameters to hold medication, and that she was going to hold the [MEDICATION(S)] because she knows the patient and the [MEDICATION(S)] would make her blood pressure drop more. During interview with DON on 08/27/21 10:22 AM, DON stated that the facility does not have a policy for administration for medication. DON stated that nurses use the standard nursing practice. Staff have electronic training they complete, and if DON observes issues with administration of medications, she will provide in-services. DON stated that her expectation is licensed nurses are to follow the standard practice they learned in nursing school. DON stated that she could not speak to what led to the failure of the Medication error in LVN A withholding the [MEDICATION(S)], that there was not a reason to hold the medication. DON stated that a blood thinner would not be a medication that a nurse could hold with their own nursing judgement. DON stated that the cause of the failure of LVN E giving [MEDICATION(S)] before the 6 hours period is that nurses are used to giving medications either an hour before or hour after the scheduled times. (Twice per day 7:00 Am and 7:00 PM; Four times per day 4:00 AM, 10:00 AM, 4:00 PM 10:00 PM) giving before the hour/before and hour after.