Every finding on record at Magnolia Senior Care, LLC

Based on observation, interviews, record review and facility policy review the facility failed to implement comprehensive care plan by not following physician orders related to the application of compression hose, nurses cleaning and changing tubing on suction device and wearing Personal Protective Equipment (PPE) while providing direct care for three (3) of five (5) care observations. Resident #6, Resident #8, and Resident #22.Findings Include:Record review of the facility policy Comprehensive Care Plans revision date of 10/23 revealed, It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet resident's medical, nursing and mental and psychosocial needs, that are identified in the resident's comprehensive care assessment .Resident #6Record review of the Care Plan Report revealed Focus: She has problems with chronic recurring edema to her (B) (bilateral) lower extremities.Intervention.Apply her (B) knee-high compression hose q (every) AM and remove at HS (hour of sleep) per MD orders. On 04/13/26 at 11:20 AM, during an observation and interview, Resident #6 was observed in bed and stated, My legs are swollen and I do not have my compression hoses on yet. My Certified Nursing Assistant (CNA) will come to put them on after lunch. She pulled the bed covers back and the State Agency (SA) observed her legs were swollen and she had red slip free socks on.On 04/13/26 at 2:13 PM, during an interview and observation with Licensed Practical Nurse (LPN) #1 confirmed that Resident #6 did not have compression hose on. She stated they should be put on daily.On 04/16/26 at 2:40 PM in a phone interview with CNA #1stated Resident #6 stated residents went to bingo at 2:00 PM and the resident did not want the compression hose on. The SA informed CNA #1 that Resident #6 did not go to bingo and that LPN #1, and the SA was in an interview and observation with her at 2:13 PM. CNA #1 did not respond.On 04/14/26 at 2:54 PM, in an interview the Director of Nursing (DON) stated the purpose of compression hose is to decrease swelling and increase circulation through the body. She stated her expectations for CNAs to put hose on in the AM after breakfast.Record review of the admission Record revealed an admission date of 10/14/21 with diagnosis of personal history of other venous thrombosis and embolism and localized edema. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/26 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicates the resident is cognitively intact.Record review of the Order Summary Report revealed a physician order dated 8/3/22 Apply bilateral knee-high compression hose every AM (morning) and remove at HS (hour of sleep) every day and night shift for edema.Resident #8Record review of the Care Plan Report revealed Focus: He is at risk for complications related to his use of a feeding tube .Interventions. Observe Enhanced Barrier Precautions when providing care (ie: dressing, bathing, transfers, personal hygiene, changing linen incont (incontinent) care.On 04/15/26 2:32 PM, during an observation of Resident #8 receiving perineal (peri) care revealed CNA#2 provided care without wearing a gown. Resident #8 is on Enhanced Barrier Protection (EBP) due to a percutaneous endoscopic gastrostomy (peg) tube.On 04/15/26 2:46 PM, in an interview with CNA #2, she confirmed she did not wear a gown while providing peri-care. She stated the purpose of the gown to prevent transferring infections to the resident. She stated she placed the resident at risk for infection by not wearing a gown.Record review of Resident #8 admission Record revealed an admit date of 5/18/17 with diagnoses that included hemiplegia and hemiparesis, personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits.Record review of the MDS with an ARD of 4/2/26 revealed a BIMS score of 13 indicating the resident was cognitively intact.On 04/16/26 at 10:48 AM, in an interview the DON stated CNA#2 should have donned (put on) a gown before providing peri care. She stated Resident #8 is on EBP due to the peg tube. She stated staff should wear gowns anytime they are doing high contact care. She stated that peri care is high contact care. She stated her expectation of staff while doing care on residents who are on EBP, is that they give proper and adequate care. She stated CNA #2 placed Resident#8 at higher risk of infection by not wearing a gown.Resident #22Record review of the Care Plan Report revealed .Ensure equipment is cleaned per facility protocol. Ensure equipment is set up and properly working for use. Instruct her to inform staff when she uses the suction machine so that the nurse may document accordingly.On 04/13/26 at 11:28 AM, an interview and observation revealed Resident #22 sitting up in bed watching TV. Resident #22 had suction set up on the bedside table. She stated, I have swollen issues and suction myself. The yankauer is dated 9/15/25, the yanker and tubing were dingy yellow, cloudy.On 04/14/26 10:19 AM in an interview and observation of Resident #22 with LPN #1 confirmed the tubing is dated 9/15/25. She stated Resident #22 son-in- law comes and changes the yankauer and tubing every evening. She stated the coloring of the tube normally looks like that. She stated it comes that way. She confirmed it is the nurse's responsibility to change tubing and yankauer, not the family.On 04/14/26 at 10:26 AM, an interview the Director of Nurses (DON) stated she was not aware of the son-in-law coming and changing the tubing and cleaning the machine. She stated it is the nurse's responsibility to change yankauer weekly and clean the machine on night shift. She stated the family is not supposed to change tubing, yanker or clean it. She stated it should be in a bag to prevent infection and cross contamination. She confirmed it is on the Electronic Medication Administration Record (EMAR,) and nurses are signing off on it. She stated it is not the family's responsibility to change the tubing or clean it. She stated Resident #22 is our resident and our responsibility. She stated, we don't know if the family uses gloves or how they clean the machine or if they are doing it correctly. She stated family doing it could cause the resident to get a respiratory infection.On 04/14/26 at 10:30 AM, in an interview and observation in the room of Resident #22 with the DON, she confirmed the date and discoloration of the tubing. Resident#22 stated my son in law comes every evening and changes the tubing and cleans it. On 04/14/26 at 12:10 PM, in an interview the DON stated they do not have assessment of Resident #22's ability to properly perform self-oral suctioning. She stated they should have completed one to make sure she can suction correctly and safely.On 04/16/26 at 9:28 AM, during a phone interview with Resident #22's son- in- law, he confirmed that he does the care for resident suction machine. He stated he washes the machine and the tubing out daily. He stated he does not change out tubing he only washes it out daily. He stated the facility knows he does it. On 04/16/26 at 10:53 AM, in an interview the DON stated care plans are individualized. She stated it informs the staff of the care residents require and they should follow it. She stated CNA #1, #2, and nurses did not follow care plan.On 04/16/26 at 11:03 AM, in an interview with Registered Nurse (RN)# 1/MDS nurse stated the care plan is used by all staff to give care. She stated she expects staff to use it while providing care. She stated staff can't give adequate care if they do not follow care plan.Record review of Resident #22's admission Record revealed an admission date of 1/27/25 with diagnoses including Myasthenia Gravis and Dysphagia following Cerebrovascular Disease.Record review of the MDS with an ARD of 2/4/26 revealed a BIMS score of 15 indicating the resident is cognitively intact. Record review of Resident #22's Order Summary Report revealed an order dated 11/17/25 Change canker to suction weekly on the PM (night) shift. May change tubing if visibly unable to flush particles. An order dated 9/10/25 revealed Empty suction nightly and rinse with tap water. An additional order dated 1/28/25 revealed Resident may suction self as needed (PRN) due to increased salivation. Resident may use suction independently.Record review of the EMAR for April 2026 revealed nurses' signatures indicating they changed the tubing and cleaned the suction machine.

Based on observation, interviews, record review and facility policy review the facility failed to follow physician orders, as evidenced by not applying compression hose for a resident and not cleaning suction equipment for two (2) of (2) residents reviewed. Resident #6 and #22.Findings Include:Record review of the facility policy Provision of Quality Care dated 2025, revealed, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice.Each resident will be provided with care and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being . Resident #6During an observation and interview on 04/13/2026 at 11:20 AM, Resident #6 was observed in bed and stated, My legs are swollen and I do not have my compression hoses on yet. My Certified Nursing Assistant (CNA) will come to put them on after lunch. She pulled the bed covers back and the State Agency (SA) observed her legs were swollen and she had red slip free socks on.During an interview and observation on 04/13/2026 at 2:13 PM, with Licensed Practical Nurse (LPN) #1 confirmed that Resident #6 did not have compression hose on. She stated they should be put on daily.In a phone interview on 04/16/2026 at 2:40 PM, CNA #1 stated Resident #6 went to bingo at 2:00 PM and the resident did not want the compression hose on. The SA informed CNA #1 that Resident #6 did not go to bingo and that LPN #1, and the SA was in an interview and observation with her at 2:13 PM. CNA #1 did not respond.Record review of the admission Record revealed an admission date of 10/14/21 with diagnosis of personal history of other venous thrombosis and embolism and localized edema. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/26 revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicates the resident is cognitively intact.Record review of the Order Summary Report revealed a physician order dated 8/3/22 Apply bilateral knee-high compression hose every AM (morning) and remove at HS (hour of sleep) every day and night shift for edema.Resident #22During an interview and observation on 04/13/2026 at 11:28 AM, revealed Resident #22 sitting up in bed watching TV. Resident #22 had suction set up on the bedside table. She stated, I have swollen issues and suction myself. The yankauer is dated 9/15/25, the yanker and tubing were dingy yellow, cloudy.During an interview and observation with Resident #22 on 04/14/2026 10:19 AM, LPN #1 confirmed the tubing is dated 9/15/25. She stated Resident #22 son-in- law comes and changes the yankauer and tubing every evening. She stated the coloring of the tube normally looks like that. She stated it comes that way. She confirmed it is the nurse's responsibility to change tubing and yankauer, not the family.During an interview on 04/14/26 at 10:26 AM, the Director of Nurses (DON) stated she was not aware of the son-in-law coming and changing the tubing and cleaning the machine. She stated it is the nurse's responsibility to change yankauer weekly and clean the machine on night shift. She stated the family is not supposed to change tubing, yanker or clean it. She stated it should be in a bag to prevent infection and cross contamination. She confirmed it is on the Electronic Medication Administration Record (EMAR,) and nurses are signing off on it. She stated it is not the family's responsibility to change the tubing or clean it. She stated Resident #22 is our resident and our responsibility. She stated, we don't know if the family uses gloves or how they clean the machine or if they are doing it correctly. She stated family doing it could cause the resident to get a respiratory infection.During an interview and observation on 04/14/26 at 10:30 AM, in the room of Resident #22 with the DON, she confirmed the date and discoloration of the tubing. Resident#22 stated my son in law comes every evening and changes the tubing and cleans it. During an interview on 04/14/26 at 12:10 PM, the DON stated they do not have an assessment of Resident #22's ability to properly perform self-oral suctioning. She stated they should have completed one to make sure she can suction correctly and safely.During a phone interview on 04/16/26 at 9:28 AM, with Resident #22's son- in- law, he confirmed that he does the care for resident suction machine. He stated he washes the machine and the tubing out daily. He stated he does not change out tubing he only washes it out daily. He stated the facility knows he does it. During an interview on 04/16/2026 11:08 AM, Registered Nurse #1 (RN)/MDS stated a nurse is supposed to assess Resident #22 to make sure she can suction herself.Record review of Resident #22's admission Record revealed an admission date of 1/27/25 with diagnoses including Myasthenia Gravis and Dysphagia following Cerebrovascular Disease.Record review of the MDS with an ARD of 2/4/26 revealed a BIMS score of 15 indicating the resident is cognitively intact. Record review of Resident #22's Order Summary Report revealed an order dated 11/17/25 Change canker to suction weekly on the PM (night) shift. May change tubing if visibly unable to flush particles. An order dated 9/10/25 revealed Empty suction nightly and rinse with tap water. An additional order dated 1/28/25 revealed Resident may suction self as needed (PRN) due to increased salivation. Resident may use suction independently.Record review of the EMAR for April 2026 revealed nurses' signatures indicating they changed the tubing and cleaned the suction machine.

Based on interview and record review, the facility failed to ensure accurate and complete submission of staffing data through the Payroll-Based Journal (PBJ) system to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) FY (fiscal year) quarters reviewed. This deficient practice had the potential to result in inaccurate public reporting of staffing levels and misrepresentation of the facility's actual staffing, including the omission of contract nursing staff hours. Findings included:Record review of the facility policy titled Payroll Based Journal, dated 2025, revealed It is the policy of this facility to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .During an interview on 04/16/2026 at 11:50 AM, the Licensed Nursing Home Administrator (LNHA) stated he is responsible for compiling and submitting PBJ data to the CMS portal. He stated employee staffing data is received from the corporate office through a software generated file and used for PBJ submission. He stated contract nursing staffing data is received separately from vendors and manually entered into the PBJ system. The LNHA stated he was not aware of any errors in the PBJ data submitted for the first quarter and provided documentation supporting the submitted data. Upon further investigation, the LNHA stated the data transmitted from the corporate software system was not accurately submitted to the CMS PBJ system. He confirmed contract nursing staffing data for 10/25/2025, 11/22/2025, 12/06/2025, 12/19/2025, 12/27/2025, and 12/28/2025 was not included in the PBJ submission.Record review of PBJ submission documentation confirmed contract nursing staffing hours for the identified dates were not included in the data submitted to CMS.Record review of the PBJ Staffing Data Report for FY (Fiscal Year) Quarter 1 2026 (October 1-December 31) revealed This staffing Data Report identifies areas of concern that will be triggered.Excessively Low Weekend Staffing.During an interview on 04/14/2026 at 1:15 PM, the LNHA confirmed the facility utilized contract nursing staff.During an interview on 04/16/2026 at 11:00 AM, the Director of Nursing (DON) stated she and the Staffing Coordinator are responsible for staffing. She stated staffing is based on resident acuity and the facility assessment. She stated Unit Supervisors may adjust schedules to maintain coverage. She confirmed the current schedule supports a census of 55 residents and call outs are managed without staffing issues.Record review of staffing schedules and daily staffing sheets revealed no staffing shortages or concerns.

Based on observations, interviews, record reviews and facility policy review the facility failed to prevent the possibility of spreading infection as evidenced by not wearing proper personal protective equipment (PPE) and not adhering to Enhanced Barrier Precautions (EBP) during high contact care, not performing hand hygiene prior to care and not protecting a yankeaer from bacteria, changing tubing, and cleaning a suction device for three (3) of five (5) care observations. Resident# 8, Resident #22 and Resident #49.Findings include:Record review of the facility policy Hand Hygiene Policy dated 2025 revealed, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors . Before performing residents care procedures.Record review of the facility policy Enhanced Barrier Precautions dated 2025 revealed it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. EBP refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities.Resident #8On 04/15/2026 at 2:32 PM, during an observation Resident #8 received peri care from Certified Nursing Assistant (CNA) #2. Resident #8 had a percutaneous endoscopic tube (peg) tube and was on EBP. Resident #8 had a bowel movement. CNA did not have a gown on as she was performing perineal (peri) care.On 04/15/2026 at 2:46 PM, in an interview with CNA #2 she confirmed she did not have a gown on while providing peri care. She stated the purpose of the gown to prevent transferring infections to the resident. She stated she placed resident at risk for infection by not wearing a gown.On 04/16/2026 10:48 AM, in an interview with the Director of Nursing (DON) stated CNA#2 should have donned (put on) a gown before doing peri care. She stated Resident #8 is on EBP due to the peg tube. She stated staff should wear gowns anytime they are doing high contact care. She stated her expectation of staff while doing care on residents who are on EBP, is that they give proper care and adequate care. Peri care is high contact care. She stated CNA #2 placed the resident at higher risk for infection by not wearing a gown.Record review of Resident #8 admission Record revealed an admit date of Hemiplegia and Hemiparesis' following unspecified Cerebrovascular Disease affecting left non-dominant side, Personal History of Transient Ischemic attack (TIA) and Cerebral Infarction without residual deficits and Dysphagia unspecified.Record review of Resident #8 Minimum Data Set (MDS) Assessment Reference Date 4/2/26 with a Brief Interview of Mental (BIMS) score of 13, which indicates cognitively intact. Section GG reveals he is dependent on hygiene.Resident #22On 04/13/2026 at approximately 11:28 AM in an interview and observation of Resident #22 sitting up in bed watching TV. Resident #22 has suction set up on the bedside table. Resident #22 picks up canker and uses tip of canker to turn it on and then placed canker in her mouth to suction. The canker was on the bed exposed to bacteria. There was no covering or shield to protect it from bacteria. After suction she uses the tip to turn it off and places it on her bed not enclosed in a zip lock bag. During the interview and observation Resident #22 uses canker to suction three times each time using the tip to turn suction on and off. The canker is dated 9/15/25, the canker and tubing are dingy yellow, cloudy.On 04/13/26 at 2:30 PM, during an observation of Resident #22 suctioning herself revealed she used same technique that she had used the previous time.On 04/13/26 at 2:52 PM, during an observation of Resident #22 suctioning herself and placing the yankeaer on bed. She continued to use the of exposed canker to turn it on and off as she used it.On 04/14/2026 10:19 AM in an interview and observation of Resident #22 with LPN #1 confirmed the tubing is dated 9/15/25. She stated Resident #22 son-in- law comes and changes the yankauer and tubing every evening. She stated the coloring of the tube normally looks like that. She stated it comes that way. She confirmed it is the nurse's responsibility to change tubing and yankauer, not the family.On 04/14/26 at 10:26 AM, an interview the Director of Nurses (DON) stated she was not aware of the son-in-law coming and changing the tubing and cleaning the machine. She stated it is the nurse's responsibility to change yankauer weekly and clean the machine on night shift. She stated the family is not supposed to change tubing, yanker or clean it. She stated it should be in a bag to prevent infection and cross contamination. She confirmed it is on the Electronic Medication Administration Record (EMAR,) and nurses are signing off on it. She stated it is not the family's responsibility to change the tubing or clean it. She stated Resident #22 is our resident and our responsibility. She stated, we don't know if the family uses gloves or how they clean the machine or if they are doing it correctly. She stated family doing it could cause the resident to get a respiratory infection.On 04/14/26 at 10:30 AM, in an interview and observation in the room of Resident #22 with the DON, she confirmed the date and discoloration of the tubing. Resident#22 stated my son in law comes every evening and changes the tubing and cleans it. On 04/16/26 at 9:28 AM, during a phone interview with Resident #22's son- in- law, he confirmed that he does the care for resident suction machine. He stated he washes the machine and the tubing out daily. He stated he does not change out tubing he only washes it out daily. He stated the facility knows he does it. Record review of Resident #22's admission Record revealed an admission date of 1/27/25 with diagnoses including Myasthenia Gravis and Dysphagia following Cerebrovascular Disease.Record review of the MDS with an ARD of 2/4/26 revealed a BIMS score of 15 indicating the resident is cognitively intact. Record review of Resident #22's Order Summary Report revealed an order dated 11/17/25 Change canker to suction weekly on the PM (night) shift. May change tubing if visibly unable to flush particles. An order dated 9/10/25 revealed Empty suction nightly and rinse with tap water. An additional order dated 1/28/25 revealed Resident may suction self as needed (PRN) due to increased salivation. Resident may use suction independently.Record review of the EMAR for April 2026 revealed nurses' signatures indicating they changed the tubing and cleaned the suction machine.Resident #49On 04/15/2026 at 2:10 PM, during an observation of CNA #2 revealed she entered Resident #49's room and pulled gloves from the box and donned (put on) them. CNA#2 assisted the resident to the bed, removed his pants and shoes. She then removed her gloves and exited the room. On 04/15/2026 at 2:23 PM, CNA #2 returned to Resident #49's room and put on gloves. She retrieved peri wipes out of the drawer with gloves on. She provided peri care for Resident #49. She did not perform hand hygiene prior to either of the care observations. On 04/15/2026 at 2:43 PM, in an interview with CNA #2 she confirmed that she did not wash or sanitize her hands either time she entered the room to provide care to Resident #49. She stated I sanitized my hands in the hallway before entering the room. She stated Resident #49 could get infection from her not performing hand hygiene.On 04/16/2026 at 10:43 AM, in interview with the Director of Nursing (DON) confirmed CNA #2 should have washed her hands before and after care and that she should have changed gloves after opening the drawer to get peri wipes. She stated CNA #2 placed the resident at increase for infection.Record review of Resident #49 admission Record revealed an admission date of 3/17/2017 with diagnoses that included Parkinson disease with dyskinesia, with fluctuations and urinary tract infection.Record review of Resident #49's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/10/26 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. Section GG revealed Resident #49 is dependent on hygiene.On 04/16/2026 12:16 PM, in an interview with RN #2/ Infection Preventionist (IP) nurse stated that CNA #2 should have performed hand hygiene upon entry before starting peri care on Resident #8. She stated Resident #8 could get an infection by CNA #2 giving care without a gown in place. She stated the resident is on EBP due to a peg tube. She stated Resident #22 yankeaer should have been in a bag to prevent contamination tubing should have been changed and device should have been cleaned by nurse. She stated Resident #22's yankeaer should have been placed in a bag to prevent cross contamination. She stated that Resident #22 was put at risk for a mouth or bacterial infection or bacterial infection. She stated Residents #8, #22 and #49 were all placed on higher risk for infection.

Based on observations, interviews, record review and facility policy review the facility failed to honor residents' rights as evidenced by posting of personal signage in the resident's room for one (1) of (14) residents reviewed. Resident #6.Findings Include: Record review of the facility's Resident Rights Policy dated 2025 revealed the facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the facility's responsibility to provide proper care to residents.On 04/13/2026 at 11:20 AM, during an observation and interview revealed Resident #6 was in bed. Observed signage on the wall Please put on compression hose daily even when resident is in bed. They are to be removed every night at bedtime Resident #6 stated, my legs are swollen, I do not have my compression hoses on yet. My Certified Nursing Assistant (CNA) will come to put them on after lunch. Resident #6 pulled her bed covers back and her legs were swollen. She had red slip free socks on. She stated the facility put that sign on the wall and stated, I guess it is to remind them to do it, but they still don't.On 04/13/2026 at 2:13 PM, during an interview and observation with Licensed Practical Nurse #1 (LPN) of the h on the signage on the wall. She stated the signage on the wall is to notify the CNAs to put on the compression hose. She confirmed the CNAs have a Kardex and the task pops up daily to remind them. She confirmed that Resident #6 did not have them on. She stated they should be on daily.On 04/14/26 at 2:54 PM, in an interview with Director of Nursing (DON) stated the signage posted in the room is a dignity issue. She stated it should not be on the wall. She stated CNAs should have placed compression hose on in the morning. She stated the reminder for the CNA shows up in task. She stated that it is their reminder. She stated the purpose of compression hose is to decrease swelling and increase circulation through the body. She stated her expectations for CNAs to put hose on in the morning after breakfast.On 04/16/2026 at 2:40 PM, in a phone interview with CNA #1 stated Resident #6 went to bingo at 2:00 PM and did not want them on. The State Agency (SA) informed CNA #1 that Resident #6 did not go to bingo, that LPN #1 and the SA was in an interview and observation with her at 2:13 PM. CNA #1 did not respond.Record review of the admission Record revealed Resident #6 was admitted to the facility on 10 /14/21 with diagnoses that included personal history of other venous thrombosis and embolism and localized edema. Record review of Resident #6 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/26/26 revealed a Brief Interview for Mental Status (BIMS) of 13 which indicated the resident was cognitively intact.Record review of the Order Summary Report revealed apply bilateral knee-high compression hose every AM and remove at sleep every day and night shift for edema.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure a resident was free from accident hazards, causing harm, when Resident #1 was dropped from a lift. Resident #2 had the possibility of an accident hazard when staff transferred the resident using one person assistance, instead of the assessed two (2) person assistance for (2) of four (4) resident sampled for accidents and hazards. Resident #1 and Resident #2. Findings include: A review of the facility, Lift Program Policy,, undated, revealed, Policy: It is the policy of the facility to help lift residents who are unable to be lifted manually, promote comfort and to maintain good body alignment while the resident is being moved .Procedure 1. The portable lift requires (2) trained person to perform the procedure each time it is used . Resident #1 Record review of a facility reported investigation (FRI) revealed on 2/2/25, Resident # 1 sustained a fall with injury. At around 5 AM the Director of Nursing (DON) was informed by the Licensed Practical Nurse (LPN) on duty that a Certified Nursing Assistant (CNA) had dropped a resident from the lift while attempting to transfer her to a wheelchair. The resident suffered a laceration to the back of the head and was rushed to the hospital. Record review of a CT (Computed Tomography Scan) Head without Contrast dated 2/2/2025, from the local hospital revealed EXAM: CT HEAD .HISTORY: fall, ams (altered mental status) scalp contusion . On 2/10/25 at 7:21 AM, during an interview, CNA #2, who is currently working the 11-7 shift and is frequently assigned to Resident # 1, revealed that staff are trained to use two people at all times when using any lift in the building. Additionally, she explained that, for as long as she can remember, Resident #1 requires a manual two-person assist when transferring out of bed, and that the use of a lift is not necessary. On 2/10/25 at 9:34 AM, in an interview with the Minimum Data Set (MDS) Nurse, she revealed the only reason a CNA should use a lift for Resident #1 is if she has fallen on the floor. On 2/10/25 at 12:49 PM, the Director of Nursing (DON) confirmed that CNA #1 dropped Resident #1 during an attempted lift transfer of Resident #1 from the bed to her chair. She stated that all CNAs are required to follow the plan of care listed on the Kardex, which specifies the assistance each resident needs and includes directions on the proper way to transfer residents. On 2/10/25 at 1:12 PM, in a final interview the DON, clarified that Resident #1 suffered a laceration to her head as result of the improper transfer by CNA #1. A record review of the Admission Record revealed the facility admitted the resident on 1/16/2019 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Cognitive Communication Deficit. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/24 reveals a Brief Interview for Mental Status (BIMS) of 01 indicating the resident could not participate in the interview. Resident #2 On 2/10/25 at 12:17 PM, the SA observed CNA #3 exiting Resident #2's room alone after transferring the resident from his wheelchair to the bed. On 2/10/25 at 12:19 PM, on Resident #2 confirmed in an interview that CNA #3 had just brought him back to his room. He revealed that the CNA transferred him from his chair to his bed alone, meaning no one assisted him. On 2/10/25 at 12:26 PM, in an interview with CNA #3, the State Agency (SA) asked what type of transfer assistance is required for Resident #2. CNA #3 confidently responded that his Kardex instructs him to provide a manual assist with two people, but that only applies when it's two females. He stated that because he is a man, he does not need any additional help and can transfer the resident without assistance. A record review of the Admission Record reveals the facility admitted the resident on 8/9/22 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Nontraumatic Intracerebral Hemorrhage in Hemisphere Subcortical. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/24 reveals a BIMS of 15 indicating the resident was cognitively intact.

Based on facility policy review, interviews, and record reviews, the facility failed to ensure Certified Nursing Assistants (CNAs) followed the comprehensive plan of care for manual assistance for two (2) of four (4) sampled residents. Resident #1 and Resident #2. Findings include: A record review of the facility policy on Comprehensive Care Plans, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that include measurable objectives and time frames to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the residents comprehensive assessment. Resident #1 A record review of the Comprehensive Care Plan, with a target date of 3/3/2025 revealed, Focus: She requires limited to extensive assist with some of her daily care .Interventions .Provide Extensive Assist of Two With Her Manual Transfers . Record review of the the Visual/Bedside Kardex Report with a printed date of 2/10/2025 revealed . Transferring .Provide extensive assist of two with her manual transfers . Record review of a facility reported investigation (FRI) revealed on 2/2/25, Resident # 1 sustained a fall with injury. At around 5 AM the Director of Nursing (DON) was informed by the Licensed Practical Nurse (LPN) on duty that a Certified Nursing Assistant (CNA) had dropped a resident from the lift while attempting to transfer her to a wheelchair. The resident suffered a laceration to the back of the head and was rushed to the hospital. During an interview on 2/10/25 at 7:21 AM, CNA #2, who is currently working the 11-7 shift and is frequently assigned to Resident # 1, revealed that staff are trained to use two people at all times when using any lift in the building. Additionally, she explained that, for as long as she can remember, Resident #1 requires a manual two-person assist when transferring out of bed, and that the use of a lift is not necessary. During an interview at 9:34 AM, on 2/10/25, the Minimum Data Set (MDS) Nurse she explained that the purpose of the care plan is to inform staff of the residents' needs, so they know how to care for them. The MDS Nurse confirmed that when the care plan is not followed it can put residents at risk for harm. She stated that all staff must follow the care plan and not deviate from it. If staff believe changes are needed regarding lift or transfer status, they should notify her before deviating from it. A record review of the Admission Record revealed the facility admitted the resident on 1/16/2019 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Cognitive Communication Deficit. A record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/24 reveals a Brief Interview for Mental Status (BIMS) of 01 indicating the resident could not participate in the interview. Resident #2 A record review of the Comprehensive Care Plan with a revision date of 2/7/24 revealed Focus: He is at risk for falls .Interventions: Two Person Assist With All Manual Transfers. On 2/10/25 at 12:17 PM, the State Agency (SA) observed CNA #3 exiting Resident #2's room alone after transferring the resident from his wheelchair to the bed. During an interview on 2/10/25 at 12:19 PM, Resident #2 confirmed that CNA #3 had just brought him back to his room. He revealed that CNA #3 transferred him from his chair to his bed alone, meaning no one assisted him. On 2/10/25 at 12:26 PM, in an interview with CNA #3, the State Agency (SA) asked what type of transfer assistance is required for Resident #2. CNA #3 confidently responded that his Kardex instructs him to provide a manual assist with two people, but that only applies when it's two females. He stated that because he is a man, he does not need any additional help and can transfer the resident without assistance. On 2/10/25 at 12:49 PM, the Director of Nursing (DON) confirmed that CNA #1 dropped Resident #1 during an attempted lift transfer of Resident #1 from the bed to her chair. She stated that all CNAs are required to follow the plan of care listed on the Kardex, which specifies the assistance each resident needs and includes directions on the proper way to transfer residents. A record review of the Admission Record revealed the facility admitted the resident on 8/9/22 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side and Nontraumatic Intracerebral Hemorrhage in Hemisphere Subcortical. A record review of the quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/21/24 revealed a BIMS of 15 indicating Resident #2 was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure dietary staff supported and respected a resident's right to make choices about his or her meal preferences for one (1) of (14) sampled residents. Resident #46. Findings Include: A review of the facility policy titled, Residents Rights, (undated), revealed, . Freedom to Choose . We will accommodate as much as possible individuals needs and preferences in daily routines and activities. Self-determination and reasonable accommodations of individual choices are an important part of residents' rights . On 12/15/24 at 12:25 PM, during an interview with Resident #46, he mentioned that sometimes he likes the food, but he does not have alternative options available and would sometimes prefer to choose different foods instead of eating what is provided to him. He also noted that he is unaware of what is on the menu because there is not one in his room, and the staff do not inform him of the daily menu choices. On 12/16/24 at 10:19 AM, in a follow-up interview with Resident #46, he revealed that no one has come into his room to ask about his menu options today. He added that no one ever comes for that purpose and feels that he must eat what is brought to him. He stated that he would like to have different options available but has not been made aware that he has a choice. On 12/16/24 at 10:30 AM, in an interview with the Dietary Manager, she revealed that the menus are posted in the halls and the dining area. She stated that, at this point, no one from her team retrieves meal choices from residents who are unable to leave their rooms. From her understanding, it is the Certified Nurse Aides (CNA's) responsibility to do so. On 12/16/24 at 10:55 AM, in an interview with the Activities Director, she said she thinks it is the dietary aide who goes out to ask residents their food preferences if they are not able to leave the room to view menus. On 12/16/24 at 11:06 AM, in an interview with CNA #1, she revealed that she has worked in the facility for the last twenty years and has occasionally cared for Resident #46 during her shifts. She acknowledged that he is unable to leave his room to view the menu. While she indicated that it is not her assigned task to ask bed-bound residents about their lunch preferences, she said that if they ask her while she is in their room, she will check the menu for them and report back on their options. On 12/17/24 at 8:15 AM, in an interview with the Director of Nursing (DON), she revealed the facility does not currently have a way of ensuring that residents residents who are unable to walk out of their rooms are able to see the menu. She acknowledged that residents should have access to the menus to ensure they can make choices about their food preferences, as this aligns with resident rights and acknowledges that this is their home. A record review of the Admission Record revealed the facility admitted the Resident #46 on 3/18/24, with diagnoses that included Weakness, Unsteadiness on feet, and Muscle Wasting and Atrophy, not Elsewhere Classified, Multiple Sites. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed to include a resident's diagnosis of Dementia, to provide information related to treatment and appropriate interventions for one (1) of 14 care plans reviewed. Resident #9 Findings Include: A review of the facility's policy titles, Comprehensive Care Plans, dated 10/23, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment . A record review of Resident #9's Comprehensive Care Plan reveled it does not have a focus, with goals and interventions related to a Dementia diagnosis. On 12/18/24 at 11:22 AM, during an interview with Registered Nurse (RN) #1/ Minimum Data Set (MDS) Nurse , she stated care plans are updated with new physician orders, new diagnoses, and falls. She stated Resident #9's diagnosis of Dementia should have been in the comprehensive care plan, if the resident is taking medication for the diagnosis. RN #1 stated the care plan is used by all staff to ensure residents received appropriate care. On 12/18/24 at 11:38 AM, in an interview with the Director of Nursing (DON), she confirmed a diagnosis of Dementia should have been included in Resident' #9's care plan, to ensure that staff know how to provide care. The DON stated the care plans are used by all staff providing direct care to residents and her expectations is that all care plans should be individualized and kept up to date. A record review of Resident #9 Admission Record revealed Resident #9 was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance or Anxiety, with an onset date of 6/1/23. A record review of Resident #9's Order Summary Report, with active orders as of 12/18/24, revealed an order to give 1 (one) tablet of Aricept 10 mg (milligrams) by mouth to be given at bedtime related to Unspecified Dementia. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for one (1) of nine (9) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. Resident #39 Findings include: A record review of facility's policy, Care and Treatment of Feeding Tubes, dated 04/2017, revealed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location .: a. Tube placement will be verified before beginning a feeding . During an observation on 06/14/23 at 10:35 AM, Certified Nurse Aide (CNA) #1 was observed providing catheter care to Resident #39. Prior to exiting the resident's room, the CNA turned the resident's feeding pump back on, as the feeding pump was on hold prior to entering the room. On 06/14/23 at 11:48 AM, in an interview, CNA #1 stated that she should not have turned the resident's feeding pump on, as only the nurses are responsible for managing a resident's feeding pump. On 06/14/23 at 12:50 PM, in an interview, the Director of Nursing (DON) stated CNA #1 should not have turned the feeding pump on that was on hold, as the operation of feeding pumps are beyond the scope of practice of a CNA. A record review of the Admission Record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses that included Dysphagia, Oropharyngeal Phase and Partial Intestinal Obstruction. A record review of the Order Summary Report, revealed a physician order dated 04/04/23, for Enteral Nutrition VIA PUMP-ISOSOURCE 1.5 at 60 ml (milliliters) PER HOUR CONTINOUSLY VIA PUMP PER PEG-TUBE (percutaneous endoscopic gastrostomy tube).

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for two (2) of sixteen (16) sampled residents. Resident #15 and #39 Findings include: Review of the facility's policy, Infection Control Policy, dated 07/2017 revealed, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . 2. The objectives of our infection control policies and practices are to: .a. Prevent, detect, investigate, and control infections in the facility . Review of the facility's, Hand Hygiene Policy, dated May 2019 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations with the facility .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table Hand Hygiene Table .After handling contaminated objects .After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site . Resident #15 An observation of incontinent care on 06/14/23 at 11:35 AM, revealed Certified Nursing Assistant (CNA) #3 and License Practical Nurse (LPN) #1 failed to perform hand hygiene prior to gloving and providing perineal care to Resident #15. CNA #3 also used gloves that had been contaminated with stool to apply a clean brief and incontinent pad under the resident. In an interview on 06/14/23 at 11:38 AM, with CNA #3 confirmed she failed to perform hand hygiene prior to providing care to Resident #15 and failed to remove her contaminated gloves and perform hand hygiene prior to applying a clean brief and incontinent pad. During an interview on 06/14/23, at 12:04 PM, with LPN #1, she confirmed she failed to perform hand hygiene prior to assisting with care of Resident #15. LPN #1 also confirmed CNA #3 failed to perform hand hygiene and apply clean gloves after contaminating her gloves with stool before applying a new brief and incontinent pad. LPN #1 confirmed that not performing hand hygiene could cause the resident to get an infection. .On 06/14/23 at 1:14 PM, in an interview with the Director of Nursing (DON), she also confirmed LPN #1 and CNA #3 should have performed hand hygiene prior to providing care. The DON also confirmed CNA #3 failed to follow infection control guidelines by not removing her gloves and performing hand hygiene after her gloves became contaminated with body excretions prior to applying a clean brief and incontinent pad. Record review of the Admission Record for Resident #15 revealed, the facility admitted the resident on 08/24/2017, with diagnoses that included Urinary Tract infection, Alzheimer's Disease, Anxiety, and Kidney Failure. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 04/03/23 revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated Resident #15 had severe cognitive impairment. Further review of the MDS revealed the resident required two (2) person extensive assistance with hygiene care and was frequently incontinent. Resident #39 On 06/14/23 at 10:35 AM, during an observation of catheter/perineal care with CNA #1 revealed as CNA #1 was performing foley catheter and perineal care Resident #39 had a bowel movement during the care. While performing care, CNA #1 wiped stool off her glove and applied hand sanitizer to her gloves and proceeded to apply a clean brief and pants on the resident. During an interview on 06/14/23 at 11:54 AM, CNA #1 stated she should have removed her gloves and performed hand hygiene when her gloves became contaminated with the resident's stool, prior to applying a clean brief and pants on the resident. She stated her actions could cause the resident to an infection. On 06/14/23 at 12:50 PM, in an interview with the Director of Nursing (DON), she stated CNA #1 should have removed gloves and not used hand sanitizer to clean gloves. She stated CNA #1 should have removed her soiled gloves, performed hand hygiene, and applied clean gloves before applying the resident's brief and pants. She stated the CNA's actions could cause the resident to get an infection. Review of the Admission Record for Resident #39 revealed, the facility admitted the resident on 04/04/23 with diagnoses including Pressure Ulcer of Sacral Area, Stage 3, Dysphagia, Oropharyngeal Phase and Partial Intestinal Obstruction. Review of the Order Summary Report revealed a physician's order, dated 05/29/23, for FOLEY CATH CARE WITH SOAP AND WATER QDay (every day) and PRN (as needed) FOR PRESSURE ULCER. 41680

Based on observation, interviews, record review and facility policy review the facility failed to provide appropriate and sufficient care to prevent the possibility of Urinary Tract Infections (UTIs) for one (1) of four (4) incontinence care observations. Resident #15. Findings Include: Review of the facility's Perineal Care (peri-care) for Female policy, revised 4/2017, revealed, .The purpose of this procedure is to provide appropriate care according to current standards of practice . Procedure .8. Washes genital area, moving from front to back, while using a clean area of the washcloth or wipe for each stroke. 9. Using a clean washcloth or wipe, rinse soap from genital area, moving from front to back, while using a clean area of the washcloth or wipe for each stroke . On 06/14/23 at 11:35 AM, during an observation of incontinent care on Resident #15, with Certified Nurse Aide (CNA) #3 and Licensed Practical Nurse (LPN #1) revealed CNA #3 cleansed the genital area using a circular motion, instead of cleaning from front to back. In an interview on 06/14/23 at 11:38 AM, with CNA #3, she confirmed she cleaned the center of the genital area of Resident #15 using a circular motion. CNA #3 said she knew how to cleanse the resident's genital area, but she was nervous and could not think straight at that moment. CNA #3 also stated that not cleaning the resident properly could cause the resident to get an infection and she confirmed that she had been trained to wipe the center of the genital area from front to back. In an interview on 06/14/23 at 12:04 PM, with LPN #1, she confirmed that CNA #3 failed to cleanse the genital area from front to back, and instead had used a circular motion when cleaning the middle of the genital area. LPN #1 said that CNAs are trained to wipe one side of the genital area from front to back, wipe the other side of the genital area from front to back, and then wipe the center of the genital area from front to back. LPN #1 stated the resident could acquire an infection if the resident did not receive appropriate incontinence care. In an interview on 06/14/23 at 1:14 PM, with the Director of Nursing (DON), she confirmed CNA #3 could have caused the resident to develop an infection by not cleansing the genital area appropriately and that CNAs had received training on incontinence care. Record review of the Admission Record revealed the facility admitted Resident #15 on 07/26/2021 with a diagnosis of Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/23, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated she had severe cognitive impairment. Further review revealed Resident #15 required extensive assistance with personal hygiene and was frequently incontinent.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide privacy during wound care for one (1) of four (4) resident care observations, Resident #10. Findings include: Review of the facility's Resident Rights policy, not dated, revealed a resident is entitled to privacy in accommodations, personal care, visits and meetings of family and resident groups. A review of the facility's Clean Dressing Change policy, dated 4/2017, revealed to screen for privacy during the care. An observation, on 01/08/20 at 10:40 AM, revealed sacral wound care was provided for Resident #10 by Registered Nurse (RN) #2/Wound Care Nurse, and assisted by RN #1. RN #2 closed the door and pulled the curtain between the beds. Resident #10's bed was located next to the outside window. RN #2 did not close the blinds to the window. RN #1 did not close the blinds or say anything about the blinds being open during the care. Resident # 10 was in bed lying on her right side with her back facing the window with the open blinds. The window was located across from the front door of the facility. Resident #10's back and buttocks were facing the window during the whole wound care observation. An interview, on 01/08/20 at 10:55 AM, with RN #2/Wound Care Nurse, confirmed the window blinds were open, and she should have closed the blinds for privacy. She said any reasonable person would expect the blinds to be closed during care. An observation of Resident #10's room, on 01/08/20 at 2:05 PM, from the front door of the facility, one could see inside Resident #10's room and people was walking about in this area who could see into Resident #10's room at any time with the window blinds open. An interview, on 01/09/20 at 12:26 PM, revealed the Director of Nursing (DON) said the facility policy was to provide privacy during care and that would include closing the blinds.

Based on observations, staff interview, record review and facility policy review, the facility failed to revise the Comprehensive Care Plan related to the Focus for Resident #10's behaviors. This concern was identified for one (1) of 16 resident care plans reviewed. Findings include: Review of the facility's Reviewing and Revising the Care Plan policy, dated 2/2017, revealed the care plan would be updated with the new or modified interventions, and the care plan will be modified as needed by the Minimum Data Set (MDS) Coordinator or other designated staff member. A review of the Care Plan for Resident # 10 revealed a Focus related to Resident #10's behaviors for verbally aggressive, rummaging through other's belongings, refusing care and episodes of wandering into other rooms. A review of the Behavior Monitoring on Resident #10's Medication Administration Record [REDACTED]. A review of the Quarterly Minimum Data Set (MDS) Section E, with an Assessment Reference Dates (ARD) of 10/11/19 and 12/27/19, revealed no behaviors were exhibited. An observation, on 1/7/2020 at 10:30 AM, revealed Resident #10 was in a Geri-chair, quiet and her eyes were closed. An interview, on 1/8/2020 at 10:45 AM, revealed RN #1 said Resident # 10 no longer walked and needed a lift to get up to the wheel chair. An observation, on 1/08/20 at 11:13 AM, revealed Resident #10 was in her room lying in bed with her eyes closed. Resident #10 was not observed at anytime with behaviors toward staff or wandering. An interview, on 1/08/20 at 3:16 PM, revealed the Director of Nursing said Resident # 10 had a significant change after a hospital return, and the resident no longer wanders or had issues with behaviors towards staff. An interview, on 1/09/20 at 11:03 AM, revealed Licensed Practical Nurse (LPN) #1/MDS Nurse stated that he was notified through physician orders [REDACTED]. He confirmed Resident # 10 no longer wandered or had behaviors towards staff, but the problem was still current on the care plan. LPN #1 said he usually waited with residents with a history of behaviors before he removed a problem. He said he could probably resolve Resident #10's behavior problems because she no longer wandered or acted out towards staff. LPN #1 said the importance to revise the care plan was to show the staff current resident status and current information for the resident on the care plan.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident received oxygen as ordered, for one (1) of three (3) residents observed with oxygen, Resident #10. Findings include: Review of the facility's policy titled, Oxygen Concentrator, with a revision date of 04/2017, revealed oxygen would be administered for the treatment of [REDACTED]. Record review of Resident #10's physician's orders [REDACTED]. Record review of Resident #10's current Medication Administration Report (MAR) revealed a checkmark for the date of 01/02/18, indicating oxygen was administered. On 01/02/18 at 11:27 AM, Resident #10 was observed sitting up in a recliner at the bedside without an oxygen cannula in her nose. The Oxygen concentrator was not running. Observation and interview on 01/02/18 at 03:15 PM, revealed Resident #10 lying in bed without oxygen and Certified Nurses Assistant (CNA) #1 was leaving Resident #10's room. CNA #1 stated Resident #10 normally used oxygen all the time. Interview on 01/03/18 at 02:55 PM, with Licensed Practical Nurse (LPN) #1, revealed Resident #10 used oxygen at all times, but would occasionally remove the oxygen tubing herself when shaking, related to her [DIAGNOSES REDACTED].#1 said the CNA's did not administer oxygen, but if the oxygen tubing was off, the CNA's should have let the nurse know. Review of Resident #10's face sheet revealed a [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow the comprehensive care plan related to oxygen administration for Resident #10 for one (1) of three (3) resident care plans reviewed for oxygen. Findings include: Review of the facility's Comprehensive Care Plan policy, with a revision date of 2/2017, revealed the care plan would describe the services to be provided to maintain the highest practicable physical, mental and psychosocial well being of the resident. Record review of Resident #10's comprehensive care plan revealed she was at risk for respiratory distress related to her [DIAGNOSES REDACTED]. One (1) of the approaches listed was to administer the oxygen as ordered by the physician. The care plan did not address the resident removing the oxygen cannula. Record review of Resident #10's physician's orders [REDACTED]. On 01/02/18 at 11:27 AM, Resident #10 was observed sitting up in a recliner at the bedside without the oxygen cannula in her nose. Resident #10's breathing appeared relaxed and calm. The Oxygen concentrator was not running. Observation and interview on 01/02/18 at 03:15 PM, revealed Resident #10 lying in bed without oxygen via the nasal cannula. Certified Nurses Assistant (CNA) #1 was observed leaving Resident # 10's room. Certified Nursing Assistant (CNA) #1 said the resident normally used oxygen all the time. Interview on 01/03/18 at 02:55 PM, with Licensed Practical Nurse (LPN) #1, revealed Resident #10 did use oxygen at all time; but, would occasionally remove the oxygen tubing when shaking related to her diagnosis (Dx) of Parkinson. She said the CNA's do not administer oxygen but if the oxygen tubing was off, the CNA's should have let the nurse know. Interview on 01/03/18 at 03:09 PM, with Minimum Data Set (MDS)/Care Plan Nurse, confirmed the care plan instructed to run Oxygen as ordered and did not address the resident removing the oxygen tubing. The MDS Nurse said he received the information to adjust a care plan by the nurse telling him, the stand up meeting, or during resident assessment. The MDS Nurse stated, This is the first I've heard of it. He said he would have to add to Resident #10's care plan.

MS # Based on staff interview, record review and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for Resident #3, related to a [DIAGNOSES REDACTED].#4 after a recent fall, for two (2) of 12 MDS's reviewed. Findings include: Review of the facility's Conducting an Accurate Resident Assessment policy, dated 02/17, noted, The purpose of this policy is to assure that all residents receive an accurate assessment of relevant care areas. The appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. Resident #3: Review of the Diagnosis/History, for Resident #3, revealed a [DIAGNOSES REDACTED]. The MDS dated [DATE], revealed Unchecked on [MEDICAL CONDITION] as an active [DIAGNOSES REDACTED]. Resident #3 was admitted to the facility on [DATE], and readmitted again on 02/03/17, with [DIAGNOSES REDACTED]. The most recent MDS with an Assessment Reference (ARD) date of 02/10/17, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated full cognitive ability. Resident #4: Review of the Accidents and Incidents, for the last 120 days, revealed that Resident #4 had a fall on 10/10/16, that required an emergency room visit, and a hospital stay. Resident #4 sustained a Laceration to the left temporal artery that could not be controlled with pressure applied to the forehead. Resident #4 returned to the facility on [DATE], with Sutures to laceration to right side of head. Review of Resident #4's MDS with an ARD of 10/21/16, under Section J, revealed No fall during month before admission/reentry. The MDS documented a BIMS score of 3, which indicated severe cognitive impairment. Resident #4 was admitted to the facility on [DATE], and again on 10/14/16, with diagnoses, which included Lack of Coordination and Pain. Interview with the MDS Nurse, on 02/22/17 at 12:40 PM, confirmed that the MDSs for Resident #3 and Resident #4 were not coded correctly and stated that she was taught that if the [DIAGNOSES REDACTED]. The MDS Nurse stated that she usually gathered her information from the progress notes, medications and the [DIAGNOSES REDACTED].#4 had a fall.

Based on observation, record review and staff interview, the facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for Resident #1. This affected one (1) of 15 records reviewed for PASRR. Findings include: Review of the Division of Medicaid Pre-Admission Screening Instruction Manual, dated 01/13, revealed all persons requiring nursing facility level of care must have a Pre-Admission Screening completed for admission to a Medicaid certified nursing facility. Medicaid certified Nursing Facilities must comply with federal PASRR requirements regardless of resident payer source. Resident #1 A review of the Face Sheet for Resident #1 revealed this resident was initially admitted to the facility on [DATE]. Review of the nurses' notes for 05/12/15, revealed Resident #1 was admitted to the (name of hospital) by the wound care physician due to right hip wound infection. A review of the nurses' notes revealed Resident #1 was readmitted to the facility on [DATE]. Review of the Social Service notes dated 05/27/15, revealed Resident was being discharged to the hospital due to exhausting her 15 day bed hold. Review of the MDS assessments completed for Resident #1 revealed discharge return not anticipated Minimum Data Set (MDS) assessment with an Assessment Reference Date of 05/27/15, and an admission MDS assessment with an ARD of 07/09/15. Review of the face sheet for Resident #1 revealed she was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A PASRR was not on the chart for Resident #1. A copy of the PASRR was requested from the Social Services Director (SSD). Interview on 10/17/16 at 3:35 PM, with the SSD revealed the only PASRR she could find was from Resident #1's original admitted d 03/27/13. The SSD further revealed Resident #1 went out to the hospital and was gone for a couple of months and readmitted to the facility. SSD stated, I'm sorry, we'll do better. It wasn't done. A further interview on 10/18/16 at 4:45 PM, revealed the SSD was responsible for completing the PASRR. She stated that is a no no not to complete a PASRR as far as Medicaid is concerned. The SSD further stated it fell through the cracks. The SSD presented a copy of the Medicaid Pre-Admission Screening Instruction Manual that is used for completing PASRR. An interview on 10/18/16 at 4:50 PM, with the Administrator, revealed that all he could find was a memorandum, dated 10/24/11, regarding PASRR information. The Administrator stated we operate by the regulations. Review of the Face Sheet revealed the facility readmitted Resident #1 on 07/02/15, with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/25/16, revealed Resident #1 scored 2 on the Brief Interview for Mental Status (BIMS) per staff interview which indicated severely impaired cognition.

Based on observation, record review, interview and policy review, the facility failed to provide a comfortable sound environment free of distracting noises during meals and activities in the dining room next to the kitchen. This affected residents attending activities and during meal times in the dining room next to the kitchen for one (1) of three (3) days of the survey. Findings include: A review of the facility's Maintaining a Safe, Clean, Comfortable and Homelike Environment policy, not dated, documented as follows: This facility will accommodate to the extent possible, a personalized homelike environment that recognizes the individuality ad autonomy of each resident. A review of the facility's Resident Council Report, dated 07/29/16, documented as follows: The council has concerns about the noise level in the dining room during bingo; it is difficult for them to hear what is being called out. During a group meeting on 10/17/16 at 9:15 AM, four (4) of five (5) alert and oriented residents said there was so much noise in the dining room (adjacent to the kitchen) during meals that it was hard to carry on conversations. The residents also said there was so much noise sometimes during activities they could not hear the numbers being called for bingo. During a scheduled activity on 10/17/16 at 10:10 AM, 12 residents were observed attending an activity conducted in the dining room next the kitchen. A telephone was observed on the wall in the dining room and when the phone rings an overhead page announces the phone call. The sounds of dishwashing were audible from the kitchen next to the activity/dining room. During an observation of the lunch meal on 10/17/16 at 12:05 PM, 24 residents were observed eating lunch in the dining room next to the kitchen. The clatter of dishes rattling, clinking of pots and pans and dietary staff talking above the kitchen noises was audible in the dining room. A half door was observed open from the kitchen to the dining area. During an activity of Bingo on 10/17/16 at 2:20 PM, the door to the kitchen was observed closed. Noises of pots/pans clinking together and clatter of dishes/utensils and voices from dietary staff were audible during the activity. 24 residents were present for the activity. During the evening meal on 10/17/16 at 5:30 PM, 17 residents were observed eating in the dining room next to the kitchen. The clatter of dishes and dietary staff conversations were audible in the dining room. During an interview on 10/17/16 at 5:32 PM, Licensed Practical Nurse (LPN) #1, responsible for the MDS (Minimum Data Set), said the dining room was noisy and sounded like dishwashing was going on with dishes and pots and pans being scraped and washed. He said the noises would make him feel bad if he had been in a restaurant. LPN #1 affirmed that residents were still eating in the dining room at the time of the interview. During an interview on 10/17/16 at 5:35 PM, across the hallway from the dining area, the Administrator acknowledged the dining room was too noisy and residents were still eating at the time of the interview. The Administrator said he didn't realize the dining room was so noisy. During an interview on 10/18/16 at 9:10 AM, the Social Services Designee (SSD) said noise carries in the dining room and seems loud. The SSD said loud noises might fluster residents and cause agitation in Dementia residents. The SSD said loud noises might trigger behaviors in residents with a history of behaviors.

Based on observation, staff interview, and facility policy review, the facility failed to store food and clean equipment to prevent contamination one (1) of three (3) kitchen tours with potential for forborne illness for all residents. Findings include: A review of the facility policy entitled Storage of Canned and Dry Food with a revision date of 10/08, revealed procedures included: The first in, first out method was to be used to rotate food and opened packages were to be labeled with the name of the product, date opened, and use by date. A review of the facility policy entitled Storage of Frozen Food with a revision date of 10/08, revealed Ensure the quality and safety of frozen food through accepted storage practices and included a procedure that opened boxes with liners should be closed and sealed tightly with packing tape. A review of the facility policy entitled Sanitary Condition of the Food Service Department, dated 09/04, revealed the dietary manager was to develop a master cleaning schedule that included what was to be cleaned, who was to clean it, when it should be cleaned, and how it should be cleaned. The dietary manager was to supervise the daily cleaning and monitor the completion of all cleaning tasks. On 12/15/15 at 9:00 AM, the following concerns were observed on the initial tour of the kitchen with Dietary Staff #1: In the pantry there was a plastic bin on the pantry shelf that contained one large bowl of croutons and one large bowl of bacon bits both covered in plastic wrap but unlabeled. There were two (2) jars of 13 jars of peanut butter that had expired on 11/29/14. In the walk-in freezer there was a package of flour tortillas containing approximately 10 tortillas that were pulled halfway from the package leaving them uncovered and exposed. The package was on top of a 55 gallon drum that contained bags of ice. There was an opened box of frozen pre-portioned cookies and an opened box of beef patties with box tops open. The food in the boxes were stored in the box liners but the liners were open leaving cookies uncovered and exposed and beef patties uncovered and exposed. Observation in the kitchen revealed the mounted manual can opener had a thick and sticky dark brown build up on the blade and cogwheel, and on the surface above and below the blade and cogwheel. An interview on 12/15/15 at 9:10 AM with Dietary Staff #1 revealed that normally when new food supply comes in it is stocked and old supplies are placed in front. An interview on 12/15/2015 at 9:20 AM with Dietary Staff #1 confirmed 2 jars of peanut butter were expired. Dietary Staff #1 stated she would throw them out and they had just been overlooked. Dietary Staff #1 confirmed tortillas in freezer were half in and half out of packaging and stated they should not be there. Dietary Staff #1 stated there had been a party and the tortillas must have been left like that. Dietary Staff #1 confirmed the open box of cookies and beef patties and stated the food were not supposed to be exposed. The liners were supposed to be sealed and the box tops closed after portions to be used were removed. Dietary Staff #1 confirmed the croutons and bacon bits were unlabeled and undated and stated they were not supposed to be stored in the bin in the pantry. Dietary Staff #1 stated the croutons and bacon bits were used when the facility had salad bar days. Dietary Staff #1 stated there had not been a salad bar day since last week. Dietary Staff #1 stated the croutons and bacon bits should have been labeled and dated. An interview on 12/15/2015 at 9:25 AM with Dietary Staff #2 revealed she was supposed to have cleaned the can opener. Dietary Staff #2 confirmed there was a build-up of thick brown sticky substance on the can opener and stated it was important to clean the can opener because not cleaning it could cause forborne illness. An interview on 12/15/2015 at 9:28 AM with Dietary Staff #1 revealed the facility had a cleaning schedule and staff was supposed to clean according to the schedule. The can opener was an item that was to be cleaned after every use and whoever used it was to clean it. The last time she could confirm the can opener had been cleaned was last week. An interview on 12/16/2015 at 9:35 AM with the Dietary Manager revealed that expired foods were to be removed when they expired. The Dietary Manager stated frozen foods were supposed to be kept in original boxes and if boxes were opened the liner was to be sealed after portions removed and the boxes closed. The Dietary Manager stated the can opener should be cleaned after each use and at the end of each day it should be put in the dishwasher. The Dietary Manager stated there was a verbal cleaning schedule and staff did not sign off when they completed tasks. The Dietary Manager stated she would check behind staff to make sure tasks were completed; however, she had been out over the last week and had not checked behind staff.

Based on record review, staff interview, and facility policy review, the facility failed to report to the State agency an incident involving Resident #1 and a Certified Nurses Aide (CNA), which resulted in resident falling forward out of wheelchair and sustaining a hematoma to the forehead for one (1) of four (4) incidents reviewed. Findings include: A review of the facility's policy entitled "Reporting of Incidents to State Agencies", dated 07/2014, revealed "Policy: It is the policy of this facility that reportable incidents are done so in a timely manner to the proper authorities. Definition: An incident that is an unexpected occurrence or accident resulting in death, life threatening or serious physical injury to a resident or the abuse of a resident." A review of "Resident Incident Report", dated 9/5/14 at 9:45 AM, revealed "While CNA was attempting to propel resident from the nursing (station) to her room, resident fell forward onto the floor." During an interview with the Director of Nursing (DON) on 1/8/15 at 4:30 PM, the DON stated she did not report the incident to the State Agency because the incident was witnessed and they were able to determine the cause of the incident and there was no major injury to the resident. A review of Resident #1's Face Sheet revealed the facility admitted the resident on 3/21/13 with [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/14 revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to prevent neglect of Resident #1 as evidenced by the resident fell out of a wheelchair while being propelled by a Certified Nurses Aide (CNA) and sustained a hematoma to the forehead for one (1) of four (4) incidents reviewed. Findings include: A review of a facility policy entitled Abuse Policy and Procedure, dated 07/2014, revealed "'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." A review of an Incident Investigation dated 9/5/2014 at 9:45 AM revealed "Narrative of investigation: Resident has dx (diagnosis) of late [MEDICAL CONDITION](stroke) and Muscular Disuse Atrophy with confusion noted. Resident requires total care with bathing, dressing, and grooming. Resident propels per wheelchair with staff assist. While CNA was attempting to propel resident from the nursing station to her room, resident feet rolled under the wheelchair which caused resident to fall forward hitting her head on the floor. Resident has hematoma to the forehead. Staff in-service on making sure that all wheelchair has leg rest and residents feet are properly in place on footrest before propelling wheelchair. Staff also instructed to make sure that enablers such as lap buddy, posey vest, etc are properly in place while resident are up in wheelchair. Continue current plan of care. This investigation was signed by the Director of Nursing (DON). A review of Departmental Notes for Nursing dated 9/5/2014 at 11:18 AM revealed "At approximately 0945A CNA was attempting to propel resident via wheelchair from nursing station when resident tilted forward and fell on to the floor. Resident's feet rolled under the wheelchair while CNA attempted to propel her which caused her to fall out of the wheelchair. Resident was assisted off floor x 3 staff members using the lift. Upon assessment, resident was observed with quarter sized hematoma to mid forehead. Resident is able to move upper and lower extremities without S/S (signs/symptoms) of pain or discomfort noted. Neuro checks initiated and remains in progress. Prior to fall, resident was sitting at nursing station with lap buddy in place, which she tends to remove at times. Wheelchair did not have leg rest in place. Floor was dry and resident had on shoes. Staff instructed to make sure that leg rests are in place at all times and that her feet are properly positioned on the footrest. Staff also instructed to make sure that lap buddy is properly in place at all times. Nurse Practitioner (NP) notified and informed of resident's fall and finding of hematoma. NP stated, 'I will be there in a couple of hours to check her out and then determine if she needs to go to the hospital or not.' Cold compresses applied to resident's forehead." This was signed by Licensed Practical Nurse (LPN) #3. During an interview with the DON on 1/8/15 at 4:30 PM, the DON stated she reviewed the video from the incident but could not remember if the lap buddy or wheelchair leg rests were in place. She stated that CNA #2 was called in to review the video and was written up with a warning at that time. The DON stated CNA #2 was terminated for not following facility policy a couple of weeks after this incident. The DON stated, at the time, she did not think there was any abuse or neglect after reviewing the video. A copy of the video was not made available for review. An attempt was made to contact CNA #2 on 1/9/15 at 1:10 PM. A voice message was left but no return call was received. During an interview with LPN #3 on 1/9/15 at 1:30 PM, LPN #3 stated she was on duty at the time of the incident and witnessed the fall. LPN #3 stated the lap buddy and leg rests were on wheelchair. She stated, "I just saw (Resident #1) going forward." She stated the Nurse Practitioner ordered facial x-rays in the facility which were negative. LPN #3 stated neurological checks were performed on Resident #1 and resident had no nausea/vomiting, headache. Record review of the nurses notes revealed the resident was not sent for treatment at the local hospital. A review of Resident #1's Face Sheet revealed the facility admitted the resident on 3/21/13 with [DIAGNOSES REDACTED]. A review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/21/14 revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment.