Every finding on record at Manor House Care Center

Based on observations, record review, staff interviews, and the facility policy, the facility failed to keep a urinary catheter bag off the floor for 1 of 2 residents reviewed for urinary catheters (Resident #42). The facility reported a census of 43 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS indicated resident dependent with toileting hygiene and used an indwelling catheter. The MDS revealed medical diagnoses for renal insufficiency and neurogenic bladder. The MDS indicated the resident took a diuretic. The Care Plan revealed a focus area dated 3/5/26 for use of an indwelling catheter related to comfort for end of life and fluid overload. The interventions dated 3/5/26 indicated to ensure dignity bag remained in place, monitor tubing for kinks and leaks, and ensure tubing remains off the floor. The Electronic Medical Record (EMR) revealed the following Physician Orders dated 3/5/26:16 Fr (french) 5 cc (milliliters) Foley Catheter with Foley drainage bag due to hospice level of care and to promote skin integrity. Change foley catheter every 30 days.Change Foley drainage bag every 2 weeksDuring an interview on 6/22/26 at 11:35 AM, Resident #42 stated she had a urinary catheter since being in hospice and retaining fluid. During an observation on 6/22/26 at 11:35 AM, Resident #42 catheter bag hung on the side of the trash can and touched the floor. The trash can had trash in it. During an observation on 6/23/26 at 1:44 PM, Resident #42 sat in her recliner and her catheter bag hung on the trash can and touched the floor. During an observation on 6/24/26 at 4:30 PM, Resident #42 sat in the recliner and her catheter bag hooked to the trash can and touched the floor.During an observation on 6/25/26 at 7:50 AM, Resident #42 sat in the recliner and the catheter bag hooked to the side of the trash can and touched the floor. During an observation on 6/25/26 at 9:14 AM, Resident #42 sat in her recliner and the catheter bag hooked on the recliner and touched the ground. During an interview on 6/25/26 at 9:36 AM, Staff A, Certified Nurse Aide (CNA) queried if the urinary catheter bag can touch the floor and Staff A confirmed the catheter bag cannot touch the floor. Staff A asked where she placed the catheter bag and Staff A stated they hooked it to the trash can so it hung higher. During an interview on 6/25/26 at 9:55 AM, Staff B, CNA asked if the urinary catheter bag can touch the floor and Staff B confirmed the catheter bag should be off the floor. Staff B asked if they ever seen Resident #42 catheter bag on the floor and Staff B stated they had. During an interview on 6/25/26 at 10:52 AM, the MDS Coordinator confirmed the catheter bag should not touch the ground and needed to be placed in a dignity bag because it was an infection control concern. During an interview on 6/25/26 at 12:23 PM, Staff C, Licensed Practical Nurse, LPN asked if a catheter bag can touch the floor and Staff C no, not unless the bag was placed in a dignity bag. Staff C asked if the catheter bag would touch the floor when hooked to the side of the trash can and Staff C confirmed it would and the reason it should touch the ground was to protect the valve on the catheter bag. During an interview on 6/25/26 at 12:31 PM, the Director of Nursing (DON) queried on a urinary catheter bag touching the ground and the DON stated that the catheter bag should not touch the ground for infection control. The DON queried if she noticed the catheter bag touching the ground today prior to observing catheter cares and the DON confirmed she saw the catheter bag touching the floor. The Facility Catheter Care: Indwelling Catheter Policy dated 12/2023 revealed Validate drainage bag is off the floor and in a dignity bag

Based on clinical record review, policy review, and staff interview, the facility failed to ensure medical records were complete and accurate for 1 of 3 discharged residents reviewed(Resident #46). The facility reported a census of 43 residents.Findings included: The Minimum Data Set(MDS) assessment tool, dated 3/31/26, listed diagnoses for Resident #46 which included anxiety disorder, mild intellectual disabilities, and dysphagia(difficulty swallowing). The MDS listed her Brief interview for Mental Status(BIMS) score as 9 out of 15, indicating moderately impaired cognition. The MDS assessment tool, dated 4/20/26, documented death in facility. A 4/20/26 10:39 a.m. Orders-Administration Note stated the resident passed away.A 4/20/26 11:54 a.m. Incident Report stated the resident sat at the dining room table and ate bite sized pieces of pancakes. The resident reached for her chest and started gasping for air. Four nurses performed the Heimlich maneuver with no return(of food debris). Staff suctioned the resident and obtained a scant amount of residual. The ambulance arrived at this time. The resident's clinical record lacked further information regarding the resident's condition and if the resident left the building with the ambulance crew. The record lacked documentation regarding whether the resident passed away at the facility or at the hospital. The record did not contain any follow up information other than the above. The record lacked documentation as to a follow up call to the hospital regarding what occurred with the resident.On 6/25/26 at 9:35 a.m., the Administrator stated she had no additional documentation regarding the above incident. The undated, untitled facility policy related to medical records stated resident records would include treatments and services. On 6/25/26 at 12:22 p.m., the Director of Nurses(DON) stated documentation should reflect a clear picture of what occurred with a residnet. She stated there should be a paper trail for backup.

Based on clinical record review, policy review, and staff interviews, the facility failed to offer a Covid-19 booster to 1 of 5 residents reviewed for immunizations(Resident #9). The facility reported a census of 43 residents. Findings included: The Minimum Data Set(MDS) assessment tool, dated 6/16/26, listed diagnoses for Resident #9 which included Alzheimer's disease, non-Alzheimer's dementia, and a history of falling. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 2 out of 15, indicating severely impaired cognition. The resident's admission Record listed an admission date of 3/9/26.The resident's Immunization Details report documented the resident received a Moderna Bivalent booster(a booster immunization for Covid-19) on 1/5/23. The resident's clinical record lacked documentation of a more recent booster offered or a declination. The facility policy Infection Control Manual Vaccination and Screening, dated 10/25, stated the primary Covid-19 vaccine required a 2-step vaccine series. The policy stated the Centers for Disease Control and Prevention)CDC recommended a booster 6 months after the primary series and future vaccinations based on CDC recommendations.The CDC guidance Staying Up to Date with COVID-19 Vaccines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.htmlz on 6/24/26 at 11:28 a.m. stated the CDC recommended a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making. The guidance stated protection from the Covid-19 vaccine decreased with time.On 6/24/26 at 2:32 p.m., the Infection Preventionist(IP) stated she was not aware residents should receive the booster until today. She stated moving forward, she would add this to the vaccine form.

Based on record review, facility policy review and staff interview, the facility failed to ensure the signed binding arbitration agreements met requirements for 1 of 2 residents (Resident #42) sampled with an admission prior to 8/1/2024. The facility reported a census of 43 residents. Findings include: Review of the Minimum Data Set (MDS) Assessment for Resident #42, dated 4/28/26, revealed an admission date of 11/9/2022 and Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of an intact cognition. Review of the resident signed admission Agreement, dated 11/9/22, revealed a section of the agreement, titled Arbitration and Limitation of Liability, and revealed the following requirements were missing from the language of the binding arbitration agreement: 1.The document lacked an option for declination of the binding arbitration agreement as a condition of admission to, or as a requirement to continue to receive care at the facility. 2.The document failed to explicitly grant the resident or his/her representative the right to rescind the agreement within 30 calendar days of signing it. 3.The document failed to state that neither the resident or his/her representative was required to sign the binding arbitration agreement as a condition of admission to, or as a requirement to continue to, receive care at the facility. 4.The document failed to include language that allowed the resident or anyone else (e.g., resident's representative) to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 6/25/2026 at 10:11 AM, during an interview, the Adminstrator reported that Resident #42 signed the admission Agreement and Binding Arbitration prior to the current owner taking over the facility. She reported the current owner took over the facility 8/1/24 and changed the admission Agreement and Binding Arbitration Agreement to meet Federal regulatory standards. The Administrator reported they did not update the admission Agreement and Binding Arbitration agreement for Resident #42 when they updated the forms. Review of the facility policy, titled Voluntary Arbitration Agreement, revealed, in part, The Arbitration Agreement is voluntary and does not need to be signed in order for the Patient to be admitted to the Center or to continue to receive care at the Center .The Arbitration Agreement may be revoked in writing by certified mail at any time within sixty days after signing or within sixty days after your discharge from Center. Revocation will not affect the care the Patient receives . Nothing in this Agreement prohibits or discourages the Patient from communicating with any federal, state or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees and representatives of the long-term care ombudsman.

Based on Quality Assurance and Performance Improvement(QAPI) Committee Meeting Attendance Records, policy review, and staff interview, the facility failed to conduct meetings at least quarterly with the minimum required members. The facility reported a census of 43 residents.Findings included: Review of QAPI Committee Meeting Attendance Records revealed a 12/9/25 meeting held with the Director of Nursing(DON) present. Review of subsequent meeting attendance sheets for the period of 12/9/25 to 6/25/26 revealed the DON was not present for the following meetings:1/20/26 2/17/26 3/31/26 4/20/26 5/26/26 The facility QAPI Policy, revised 10/2023, stated the QAPI team developed and implemented appropriate plans of action to correct identified quality of care, quality of life, or safety problems. The policy stated that QAPI members must meet at least quarterly.On 6/25/26 at 1:59 p.m., the Provisional Administrator stated she expected the DON or interim DON to attend QAPI meetings.

Based on observation, record review, resident and staff interview and policy review, the facility failed to notify the resident's provider of a change of condition that required physician intervention, and failed to consistently document the status of a resident for 1 of 3 residents reviewed (Resident #145). The facility staff failed to notify the provider of the blood in Resident #145's catheter for 3 days that required an intervention in a hospital. The facility reported a census of 44 residents. Findings include: The admission Minimum Data Set (MDS) dated [DATE] for Resident #145 revealed a diagnosis of Benign Prostatic Hyperplasia (BPH) (a prostate enlargement that can cause urination difficulty) with lower urinary tract symptoms and identified an indwelling catheter that required moderate assistance of staff. The MDS documented the diagnosis of embolism with thrombosis of arteries of the lower extremities, and the prescribed use of blood thinners. Resident #145's brief interview for mental status (BIMS) score was 15 revealed an intact cognition. Urology Progress Note dated 5/14/25 documented the resident had removal of a blood clot, and placement of a graft (piece of artificial or natural tissue to repair or replace the damaged blood vessel) on 4/22/25 to the left lower extremity. The Care Plan revealed that Resident #145 received anticoagulation therapy for a thrombosis (blood clot) of the left lower extremity. The Care Plan directed staff to monitor for signs and symptoms of bleeding, bruising, headaches, bloody stool, and hematuria (blood in the urine). During an interview on 5/12/25 at 11:32 PM, Resident #145 stated there had been blood in his catheter for 3 days. During an observation on 5/12/25 at 11:32 PM, Resident #145 had a moderate amount of dark red bloody urine in the catheter bag. The Physician admission Order dated 5/2/25 for Resident #145 documented the following orders; 1. An 18 French urinary catheter and drainage bag. 2. Eliquis 5 milligram (mg) two times a day. 3. Document on how resident is doing, feeling, sleeping, etc. One time a day for admission Protocol for 5 days. (start date 5/3/25 5:00AM) scheduled time as 5:00AM 4. Document on how resident is doing, feeling etc. two times a day for 5 days (start date 5/2/25) scheduled times for 1:00PM and 9:00PM The Medication Administration Record (MAR) dated May 2025 for Resident #145 revealed Eliquis (blood thinner) 5 mg was administered 2 times a day signed by nursing staff. The admission Note dated 5/2/25 revealed Resident #145 was admitted from the hospital post removal of blood clots and the Foley catheter contained amber colored urine. A Skilled Note dated 5/3/25 at 10:00PM documented Resident#145 had a Foley catheter in place, but failed to document any description or presence of urine in the catheter bag. Upon review of the Clinical Record the date of 5/4/25 did not contain a documentation of a skilled nursing service note. A Skilled Note dated 5/5/25 at 1:00PM documented Resident #145 had a Foley catheter in place, but lacked description of the urine, or if there was any urine present in the Foley bag. The Progress Note skilled assessment dated [DATE] for Resident #145 revealed the Foley catheter was in place yet lacked assessment of urine color in the bag. A Skilled Note dated 5/6/25 at 5:07PM included the following documentation; Foley catheter remains in place. The documentation lacked presence or absence of urine in the catheter, and also failed to describe any characteristics of any urine. The Provider date of service 5/7/25 revealed Resident #145 did have a Foley catheter in place, continue Eliquis 5 mg two times daily. Provider requested referral for the resident to Urology to evaluate and treat the urinary retention, as resident had seen a Urologist in the past. The Progress Note dated 5/8/25 for Resident #145 was alert, Foley catheter remains in place and lacked assessment of urine color in the bag. The Progress Note dated 5/9/25 for Resident #145 revealed Staff D, Licensed Practical Nurse (LPN) documented notable reddish tinged urine in the catheter bag and tubing and a blood clot. The Progress Note dated 5/10/25 for Resident #145 revealed cranberry colored urine, the staff encouraged fluids and resident denied pain. The Progress Note dated 5/11/25 revealed Resident #145 had notable reddish tinged urine in the catheter tubing with blood clots, signed by Staff E, Registered Nurse (RN). At 5 AM a follow up documentation of 1,200 millimeters (ml) of Dark Beer in color, red hue, and a large amount of air in the collection bag. The Progress Note dated 5/11/25 at 1:48 PM revealed Resident #145 noted to have dark red urine noted in the drainage bag, substantial amount, will continue to monitor and push fluids documented by Staff A, LPN. The Progress Note dated 5/11/25 at 8:29 PM revealed Resident #145 had notable reddish tinged urine in the catheter tubing with blood clots, signed by Staff E, RN. The Progress Note communication with physician dated 5/12/25 at 7:53 AM revealed the Infection Preventionist (IP) Nurse was informed of the blood in Resident #145's drainage bag, assessed and found bright red blood in the tubing and drainage bag, notified the provider and received an order to obtain a urine for testing for culture and sensitivity. The family was updated and notified in process of scheduling an appointment with Urology. At 8:04 AM, a call was placed and message left for the Urologist. A Progress Note dated 5/12/25 at 10:45 AM revealed Resident #145's catheter bag was noted to have a large amount of reddish tinged urine, changed the catheter and obtained a urine (UA) sample and results returned at 12 PM as large amount of blood. The provider was notified. Urology nurse returned call informing staff that this resident was last evaluated in 2021 and would have to be evaluated as a new patient. Resident #145's provider was notified and received an order to transport to the local Emergency Department for evaluation. A document titled emergency room Note dated 5/12/25 for Resident #145 that revealed: 1. the chief complaint of blood in urine 2. On Eliquis due to recent arterial occlusion of the left lower extremity that required thrombectomy and stent placement. 3. Urinary catheter due to a post-surgical urinary retention. 4. Patient stated he had some small pieces of blood in the catheter in the past, but never quite like this. 5. Denies pain. 6. Blood Pressure 108/64 with heart rate of 85. 7. Hemoglobin 10.8 low (13 - 17) and Hematocrit 33.6 Low (normal 39 - 51). 8. The Protime (blood clotting test)11.3 (8.8 - 12). 9. [NAME] blood in urine. 10. ER doctor discussed the case with the Urology (a surgical specialty that deals with the urinary system), exchanged the catheter and bleeding continued. 11. Transferred resident #145 to a higher level of care facility. A document titled Super Triage Transfer Note dated 5/12/25 that revealed: 1. [NAME] blood from Resident #145's catheter. 2. Blood Pressure 108/64 and Pulse 85. 3. Admit and Urology notified for further evaluation and treatment. A document titled Inpatient Consult Urology dated 5/13/25 revealed: 1. Management of gross hematuria stopped Plavix and Eliquis. 2. 20 French silicone Foley catheter draining cherry red urine and a removal of a 60cc clot. 3. Urinalysis with WBC >100 (normal 0-5/HPF) and RBC >100 (normal 0-2/HPF) and Bacteria Few (normal 0/HPF) 4. Procedure for a 22 French 3-way Foley catheter placement. 5. CBI (Continuous Bladder Irrigation) started on a fast drip. 6. Admit to the hospital to urology and started on Ceftriaxone for urinary tract infection (UTI). A document titled Urology Progress Note dated 5/14/25 revealed: 1. Wean the CBI unless clots. 2. Continue Ceftriaxone antibiotic and consider adding Keflex at discharge. 3. Cystoscopy (scope of the bladder) in 4-6 weeks. During an interview on 5/14/25 at 10:11 AM, The Advanced Registered Nurse Practitioner (ARNP) stated Resident #145 was a new resident she had assessed on 5/7/25 and was notified on 5/12/25 that he had hematuria and the staff reported as it was a large amount. The ARNP stated there was an on-call physician on the weekend who was not notified of the blood in the urine. The ARNP stated she would expect the nursing staff to call, depending on the situation as they could use good nursing judgement, but if there was large amount of blood, she would want to know if the person was on blood thinners and had blood in their urine. During an interview on 5/14/25 at10:31 AM, The Infection Preventionist (IP) stated she was notified on 5/12/25 of the blood in Resident #145's urine. She stated the nursing staff are to notify the on-call nurse and then call the doctor to receive an order to flush the Foley catheter, if the flush returns with no blood it's good, but if returns with blood then they are to call the doctor back. The IP stated she was not notified over the weekend and she would expect that the nursing staff would have called the on-call nurse and it was The MDS coordinator. She stated she had no clue how long Resident #145 had blood in his urine until she read the 24-hour report later in the day on 5/12/25. During an interview on 5/14/25 at 11:09 AM, The MDS coordinator stated she was the on-call nurse the weekend of 5/9/25 - 5/11/25 and did not receive a call about Resident #145. The MDS Coordinator stated she worked a 10 AM to 10 PM shift on Saturday 5/10/25 on one end of the building and Staff A, LPN was the nurse providing care for Resident #145 who did not inform her the resident was having blood in his urine or she would have told the nurse to call the on-call provider to receive an intervention. The MDS Coordinator stated she was unaware of the blood in Resident #145's urine until Monday 5/12/25. During an interview on 5/14/25 at 11:49 AM, Staff A, LPN stated she had worked Friday evening 5/9/25 and provided care for Resident #145. Staff A stated the Certified Nursing Assistant (CNA) informed her when emptied the catheter bag and it had a blood clot, and on assessment Staff A stated she did not see a clot but the urine was cranberry in color. On 5/10/25 the urine was getting darker red and on 5/11/25 the urine was darker yet. I didn't notice clots. Staff A stated she mentioned it to the MDS Coordinator on Saturday 5/10/25. Staff A stated she was not concerned on Saturday as Resident #145 said he had blood in the urine in the past. Staff A stated on Sunday 5/11/25 she became more concerned as Resident #145 was on Eliquis and had reported to the oncoming nurse Staff E, RN and documented on the report sheet. Staff A stated when the urine in a catheter bag is mixed with blood, the nurses monitor and check the catheter if it is intact and if it was all blood the nurse would follow up with the provider. Staff A stated the nurses have been shown how to flush a catheter, if there was a lot of clots and would need an order for the flush. During an interview on 5/14/25 at 12:09 PM, Staff B, Registered Nurse (RN) stated the nurse would need to obtain an order to flush a catheter and if the incident was on a weekend, the nurse would call the on-call provider to notify and obtain an order. Staff B stated if a resident with a catheter would be on a blood thinner and had cranberry blood in urine, nursing would hold the blood thinner and notify the provider. During an interview on 5/15/25 at 10:50 AM, Staff E, RN stated he had worked 5/9/25, 5/10/25 and 5/11/25, 6PM to 6AM each day and had provided care for Resident #145 during that time. Staff E stated Resident #145 had blood in the urine, that had started the previous week, progressively became worse over the weekend. Staff E stated one of the CNA's had informed him that the blood was worse, was really dark when the catheter bag was drained at 4 AM on 5/11/25. Staff E stated that Resident #145 was feeling fine therefore waited till the morning on 5/12/25 to notify the day nurse. When asked when would have notified the provider, Staff E stated, depends on how severe the blood. Staff E stated he did not reach out to the on-call nurse and did not report it to the physician but did report Resident #145's condition to the oncoming day shift. A policy titled Notification of Change revealed the facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when: a. An accident involving the resident which results in injury and has the potential for requiring physician intervention. b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). d. A decision to transfer or discharge the resident from the facility as specified in §483.12(a).

2. The Quarterly Minimum Data Set (MDS) quarterly assessment, dated 2/11/25, identified the resident had diagnoses of hypertension (high blood pressure), edema (fluid retention), lymphedema (tissue swelling in the body's lymphatic system), and chronic obstructive pulmonary disease. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which suggested an intact cognition. An Order Entry, dated 3/15/2023, included a physician order for a general, 2 gram sodium diet (low salt diet). Review of Nursing-Daily Evaluation Non-Skilled notes, dated 5/7, 5/8, 5/9, 5/10, 5/11, 5/12, and 5/13/25, included documentation the nurse assessed Resident #20 had 2 plus edema (a moderate degree of swelling characterized by a visible indentation that takes up to 15 seconds to rebound). On 05/12/25 at 10:27 AM, Resident #20 reported she was supposed to be on a low sodium (salt) diet due to ongoing issues with lymphedema/edema (medical condition exacerbated by excess sodium intake). Resident #20 explained concerns that most of the food served was prepackaged and high in sodium. Resident #20 reported she had spoken with the head of the kitchen about her concerns. She reported the facility's dietician, at one time, offered low sodium canned soup. On 05/13/25 at 4:12 PM, Resident # 20 Reported she had not been receiving the low sodium menu options for all meals. For lunch today, she had the option between ham and bean soup and meatballs with sauce (both options not meeting the resident's low sodium requirements). Based on observation, clinical record review, staff interviews, resident interviews, and the facility policy, the facility failed to provide a mechanical/ground texture meat to residents prescribed a mechanical soft or ground meat texture diet for 9 of 9 residents; and failed to provide the prescribe diet for 2 of 2 residents prescribed a 2 gram sodium diet ( Resident #20 and Resident #42) during a meal observation. The facility reported a census of 45 residents. Findings include: 1. The Facility Order Listing Report for Dietary Diet dated 5/12/25 at 1:20 PM revealed 7 residents prescribed a mechanical soft diet; 2 residents prescribed a ground meat only diet; and 2 residents (Resident #20 and Resident #42) prescribed a 2 gram sodium diet. The Facility Menu for Week 1 revealed a mechanical soft diet main course was 6 ground honey garlic meatballs, potato casserole, broccoli, frosted peach cake, and milk. The alternate menu for the mechanical soft diet was ham and bean soup, cornbread, and cottage cheese. The Facility Menu for Week 1 revealed the 2 gram sodium diet main course was 6 plain meatballs, baked potato/margarine, broccoli, angel food cake, and milk. The alternate menu was a 3 ounce pork chop, bread, and cottage cheese. During an observation on 5/13/25 at 11:33 AM Staff C, Dietary [NAME] took the final temperatures for the food items being served for lunch. The items included broccoli, whole meatballs, potato casserole, ham and bean soup, pureed broccoli, pureed potato casserole, pureed meatballs, mashed potatoes, and cottage cheese. The lunch service on 5/13/25 did not provide ground texture meat for the residents, angel food cake or a pork chop. During an interview on 5/13/25 at 12:52 PM, Staff C queried on what prescribed diets the residents had and she stated mechanical soft and pureed. Staff C asked if any of the residents prescribed low sodium diets and Staff C stated no. Staff C showed the Dietary Diet Report and Staff C stated she was told Resident #20 and #42 could have anything they ordered. During an interview on 5/13/25 at 12:56 PM, the Dietary Manager confirmed the diet report indicated 2 residents on a low sodium diet. During an interview on 5/13/25 at 12:57 PM, Staff C queried on the meatballs served during lunch for the residents on a mechanical soft diet and Staff C stated the residents could cut up the meatballs just like they did with meatloaf and the ham balls. During an interview on 5/13/25 at 12:57 PM, the Dietary Manager stated the facility should of ground the meatballs because they were purchased pre-shaped. The Dietary Manager confirmed the sauce mixed in with the meatballs prior to service. During an interview on 5/13/25 at 1:04 PM, the Dietary Manager reviewed the 2 gram sodium diet for 5/13/25 lunch menu and stated the residents with the low sodium diet should of been given the option for meatballs without sauce, baked potato, broccoli or cottage cheese. The Dietary Manager stated Resident #20 and Resident #42 couldn't have the soup, but could of ate a pork chop for the alternate. The Dietary Manager confirmed pork chops were not prepared for lunch. During an interview on 5/13/25 at 1:44 PM, the Registered Dietician (RD) queried on low sodium diets and the RD stated yes, the facility had a few residents on them and the RD checked the residents diet cards and all the diet cards were correct. The RD confirmed the facility needed to follow the menu spreadsheet and the menu spreadsheet indicated the meatballs needed ground for the mechanical diets. During an interview on 5/13/25 at 4:08 PM, the RD confirmed the old Dietary Manager did not print out the low sodium diets for Resident #20 or Resident #42. The RD provided the menu options for supper Resident #20 and Resident #42 given at lunch today and the confirmed the menu options were not for the 2 gram sodium diet. The RD stated the new Dietary Manager printed off the correct menu options cards for the 5 week cycle for the residents with the 2 gram sodium diets. The RD stated they could of served the meatballs plain. During an interview on 5/15/25 at 10:40 AM, the Administrator stated not serving the prescribed diets was unacceptable. The Facility Guideline and Procedure Manual for Diet Orders dated 2020 revealed the following information: a. Diet orders were clearly communicated, using the designated diet order communication form, to Dining Services. In some cases, the Electronic Medical Record (EMR) used will generate a diet order communication which was used in lieu of a paper form. b. Once the diet order was confirmed, it was recorded on the Medication Administration Record (MAR) and the nurse completes the designated diet order communication from and forwards it to Dining Services c. All diet order communication forms received by Dining Services were confirmed for accuracy by the Dining Services Manager or designee and kept on file in a systematic way in the dining department The Facility Guideline and Procedure Manual for Resident Nutritional Care dated 2020 revealed the following information: a. The RD reviewed responsibilities of the Dining Services Department in implementing and delivering nutritional care and provide appropriate guidelines as indicated by observations of dining services.

Based on observation, clinical record review, and staff interviews, the facility failed to ensure the Care Plan reflected edema (swelling) for 1 of 2 resident's reviewed for edema (Resident #30). The facility reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated 4/1/25, listed diagnoses for Resident #30 which included morbid obesity, high blood pressure, muscle weakness, and osteoarthritis (inflammation of the bone and joints). The MDS listed the resident's Brief Interview of Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The facility Care Plan Policy, dated 7/2023, stated the facility would complete a Comprehensive Care Plan after the comprehensive assessment of the resident. Provider Encounter Notes on 1/8/25, 2/5/25, 3/4/25, and 3/26/25 stated the resident had bilateral (referred to both sides) lower 1+ edema (swelling where an indentation or pit remained after applied pressure to the area with severity measured on a 1-4 scale with a 1+ grade indicating a barely visible indentation and a 4+ grade indicating a deep indentation which took a considerable time to fade). A 4/30/25 provider Encounter Note stated the resident had 2-3+ lower extremity edema. A 5/7/25 3:28PM Physician Visit Note, written by the Infection Preventionist, listed an order for Occupational Therapy (OT) to evaluate and treat for lymphedema (a chronic condition characterized by swelling caused by an accumulation of fluid in the body's tissues). The Care Plan did not address the resident's edema or include interventions to manage the condition. On 5/13/25 at 1:01 p.m., the resident sat in her wheelchair and had wraps on her bilateral legs. The resident stated she had a lot of edema. On 5/15/25 at 8:24 a.m. the Director of Nursing(DON) stated the Care Plan should reflect edema.

Based on clinical record review, resident and staff interview, the facility failed to consistently evidence of including residents in care conference meetings on a quarterly basis for 1 of 1 residents reviewed for Care Conferences (Resident #6). The facility reported a census of 45. Findings include: The Minimum Data Set (MDS) Annual assessment, dated 3/13/25, and Quarterly MDS, 4/14/25, revealed Resident #6 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The facility documentation lacked evidence facility staff invited the resident to participate in a care conference with the Care Plan revision on 3/31/25. On 05/13/25 at 1:48 PM, Resident #6 reported she did want to be included in Care Plan meetings, but had not been included in a long time. She reported she would have liked to get a copy of the Care Plan, but had not received a copy of her current plan. On 05/13/25 at 2:02 PM, the Social Worker reported they usually just touch base with Resident #6 and see if she wants the team to meet with her. The Social Worker explained if Resident # 6 did not want to meet with the team, then everyone would meet with her individually. The staff meet quarterly to do Care Plan meetings. The Social Worker reported the MDS Coordinator would make a note quarterly if the resident didn't want to participate in the meeting. On 05/13/25 at 2:26 PM, the MDS Coordinator reported being responsible for completing all of the MDS assessments on the residents. For care planning, if the resident didn't want to meet, she would go in to talk with the resident to see if they had any concerns, see how things were going, how food was, and ask if there was anything they would like to be done differently. The MDS Coordinator that she did create notes in the residents' clinical record regarding the care conferences and whether or not the residents participated or refused. The MDS Coordinator could not remember if she had put a note in for Resident #6. The MDS Coordinator reported she always sends out care conference letters, and probably one of the Resident's sisters would have gotten the letter. On 05/14/25 at 2:47 PM, during an interview, the Director of Nursing (DON) reported she had already identified a concern with the facility not having a good documentation system related to the care planning process to show resident participation, who attended the meeting, and what was discussed. On 5/15/25 at 8:56 AM, in a email response, the Administrator reported they did not have a policy addressing care conferences. On 5/15/25 at 12:49 PM, the Administrator reported an inability to find any evidence of Resident #6 being invited to last care conference associated with the last care plan revision, dated 3/31/25.

Based on clinical record review, observation, staff interview and policy review, the facility failed to ensure nursing staff followed wound care orders for 1 of 1 residents (Resident #6) with a wound care observation. The facility census was 45. Findings include: The Minimum Data Set (MDS) quarterly assessment, dated 4/14/25, identified the resident had diagnoses of congestive heart failure, hypertension, and diabetes mellitus. The resident was dependent on staff for transfers, toilet use and lower body dressing. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which suggested an intact cognition. A Communication with Physician note, dated 4/25/25, included documentation of wound culture results of the left lower leg wound with moderate growth of Staphylococcus Aureus (an infectious organism). (facility) Advanced Registered Nurse Practitioner (ARNP) updated. New orders received to start Bactrim DS (antibiotic) 1 tab every 12 hours for 7 days. Verbal order via (facility) ARNP to discontinue the Doxycycline (antibiotic). The Medication Administration Record Report, dated May 2025, included an order to apply Calcium Alginate to the left lower leg wound and then cover with foam dressing with Medi Honey applied to the foam dressing and a start date of 5/3/25 and discontinue date of 5/4/25. An Order Entry report, dated 5/7/25, included an order to apply Collagen Particles to the left leg wound and then cover with a Silicone foam border dressing one time a day. On 05/13/25 09:48 AM, Staff A, Licensed Practical Nurse (LPN), entered the room of Resident #6 with wound care supplies including a silicone dressing, collagen particles, saline wound cleanser, 4 by 4 gauze pads, 2 cotton tip swabs and plastic wrap. During the course of the observation, Staff A removed a foam wound dressing dated 5/12/25 from the resident's left lower leg. The surveyor observed a small square cut dressing still covering the wound bed. Staff A reported the small square cut dressing covering the wound bed was a Collagen Pad. Staff A explained that they had the option to cover the wound with either a Collagen Pad or Collagen Particles. Staff A cleansed the wound with Saline wound cleanser, applied the collagen particles to the wound bed area with cotton tip swabs, and covered the wound with the silicon foam border dressing. On 05/14/25 at 10:06 AM, the ARNP reported Resident #6 had three open areas on the left lower leg (all located in the same area, just below the left knee). The ARNP explained that she ordered the Collagen Particles, because it would be too difficult to cut a collagen sheet or pad to the right size. The ARNP reported that collagen should only cover the wound bed, and not cover unaffected skin areas. The ARNP explained the collagen would result in moisture to the spots where it was applied and cause a risk for non-wound bed skin to become part of the wound. The ARNP reported she most recently assessed the resident's wound today. On 05/14/25 at 10:42 AM, during an interview, Staff B, RN, confirmed she performed wound care on Resident #6 on 5/12/25. Staff B reported she applied a Collagen Pad to the wound. She reported she cut the collagen to size to cover the entire wound area. When asked to show what Staff B used, Staff B pulled a Calcium Alginate wound dressing package out of cart and reported that was what she used on 5/12/25. Staff B reported she did not know if there was any difference between the Calcium Alginate and Collagen Particles (2 different types of wound care). Review of the policy, titled Physician Orders/Transcription of Orders, dated 7/2023, identified that staff should follow and carry out active orders as written/transcribed.

Based on clinical record review, observations, staff interviews, and the facility policy, the facility failed to notify the physician after a resident lost over 13 pounds in a month for 1 of 1 residents reviewed for nutrition (Resident #13). The facility reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 scored a 1 out of 15 on the (BIMS) exam, which indicated cognition severely impaired. The MDS indicated the resident needed supervision or touching assistance with eating. The MDS indicated a loss of 5% or more in the last month or loss of 10% or more in the last months. The MDS revealed resident received a mechanically altered diet- require change in texture of food or liquids (example- pureed, thickened liquids). The MDS revealed diagnoses for unspecified dementia, unspecified severity, without behavioral disturbance/psychotic disturbance/mood disturbance/anxiety; and malnutrition (protein, calorie), risk of malnutrition. The Care Plan revealed a focus area revised on 4/4/25 for resident has the potential risk for altered nutritional status due to preference to skip meals at times, advanced age, dementia, dysphagia-oropharyngeal phase, and difficulty chewing due to not always wearing dentures at meals. (May refuse to eat if in the dining room when prefers to eat in room. Has upper and lower dentures but does not wear the lower ones and has a few of her own lower teeth.), and advanced age. The interventions dated 10/22/24 indicated for staff to monitor and record intake of meals, and notify MD/RD (Medical Doctor/Registered Dietician) of significant weight change. The interventions dated 4/4/25 revealed supplements as recommended. The Review of the Electronic Medical Record (EMR) revealed the following Physician Orders: a. Mighty Shake- one time a day for extra supplementation dated 3/7/25 b. General diet, Mechanical Soft texture, Regular Fluid consistency dated 6/5/24 The Review of the Weight Summary revealed the following weights: a. 4/1/25 at 8:00 AM- 148.8 pounds b. 5/1/25 at 6:00 AM- 135.6 pounds On 04/01/2025, the resident weighed 148.8 lbs. On 05/01/2025, the resident weighed 135.6 pounds which is a -8.87 % Loss. Observation on 5/13/25 at 12:11 PM, revealed Resident #13 served her lunch meal which included whole meatballs, potato casserole, and broccoli. Staff cut up the meatballs after they placed the plate in front of her. Staff sat at the table next to her while she ate and assisted as needed. Resident #13 was supposed to receive ground meatballs per her prescribed diet. During an interview on 5/13/25 at 1:53 PM, the Registered Dietician (RD), queried on Resident #13 and the RD stated Resident #13 lost a lot of weight and Resident #13 was on the RD list to see this week. The RD stated Resident #13 lost 8.9% this month and had a weight loss of 17.1% in the last 6 months. When RD questioned about the process with residents with weight loss, the RD stated every week she looked at the Interdisciplinary team (IDT) report. The RD asked how often residents were weighed when they had a weight loss and the RD stated some residents were monthly, daily, or weekly and it depended on the physician. The RD asked who notified the provider of weight loss and the RD stated she didn't know. The RD stated she sent her recommendations to the facility for the doctor and the RD didn't know who informed the doctor. During an interview on 5/13/25 at 4:12 PM, the RD queried if the nurses ever notified her of resident's weight losses and the RD said no, and the RD didn't know if the assumption was the RD just checked the weights when she came to the facility. The RD stated the facility had her personal number and stated the facility should notify her of significant weight losses. During an interview on 5/14/25 at 8:21 AM the Staff B, Registered Nurse (RN) stated the Licensed Practical Nurse (LPN)/Infection Preventionist (IP) usually spoke to the provider about weights. During an interview on 5/14/25 at 9:45 AM, the , LPN/IP queried on weighing the residents and the LPN/IP Nurse stated the facility weighed the residents every month and if a big difference in the weights, the dietician reviewed them. The LPN/IP Nurse stated she put all the weights in the computer and the facility reweighed the resident if she noticed a big difference. The IP/Nurse asked about Resident #13 weight and the LPN/IP Nurse stated Resident #13 had a big weight loss. The LPN/IP queried if she notified the RD or the provider of the weight loss and she stated no. The LPN/IP asked her reasoning of not notifying the provider or RD and she stated Resident #13 had always been one to eat what Resident #13 wanted and asked to go back to her room. The LPN/IP stated she didn't see Resident #13 had any signs of dehydration and recently had a head cold and UTI (Urinary Tract Infection) and so the LPN/IP didn't think twice about telling the provider. The LPN/IP Nurse queried on what she did with other residents with weight losses and the LPN/IP stated she always let the RD take care of it and the RD came at least monthly to the facility. The Dietary Progress Note dated 5/14/25 at 4:57 AM, (late entry) revealed visited with Resident (Res) and her daughter yesterday before supper. Res. not able to answer questions but was pleasant during visit. Res. daughter reported that res. has been sick and was hallucinating recently seeing angels and res. spouse which was not normal for res, and also sleeping for about two weeks and just not really eating. Res. daughter indicated that is when res. was tested for Urinary Tract Infection (UTI) and had a UTI. Res. received antibiotics then and previous to that related to boil on inner thigh. Antibiotics may also have affected appetite. Res. has triggered for a significant (sig) weight (wt.) loss of 8.9% in the past month and 17.1% in the past six months at current weight of 135.6#. Per Medication Administration Record (MAR) res. did not have supplement from 4/18-4/23 and also on 4/19. Per MAR from 5/1-5/13, res. accepting 100% of Mighty shake supplement 4 oz/day. Res. being treated for UTI during that time and noted to not eat breakfast on 4/22, only sips of liquids on 4/20, and res. hitting at staff on 4/19 which is not typical of resident. Per record res. came out to the dining room again on 4/24. Previously recommended increase in Mighty shake to twice a day (BID), will recommend again and daughter OK with this. Will start extra margarine on potatoes and vegetables to add flavor and calories. Res. normally eats cheerios at breakfast as part of Mechanical soft diet but daughter willing to try super cereal to see if res. will accept. Notified Dietary Manager (DM) to try this. Based on recent UTI and decreased fluid intakes since last review, will recommend UTI-Stat once daily as a prophylactic. Res. daughter agreeable and wrote down name of product to review with her daughter who is a nurse. Daughter reports res. likes sweets. Sig. wt. loss also related to decrease in oral intakes from 63-96% in March and now 13-88% but mainly 13% at most meals this month. Res. may benefit for weekly weights to monitor progress. BMI (Body Mass Index) still in normal status at 21.6. Will continue to follow and if res. continues to lose weight may need to recommend Benecalorie to add more calories and protein. During an interview on 5/14/25 at 10:01 AM, the Advanced Registered Nurse Practitioner (ARNP) queried on Resident #13 weight loss of 13 pounds in the month of April and the ARNP stated she was unaware of the weight loss. The ARNP stated she received a sheet with recommendations from the dietician and sometimes someone would mention to her, if a resident had a weight loss. The ARNP asked if she should of been notified of the weight loss for Resident #13 and she stated yes. The ARNP asked what she considered timely from notifying her of a resident's weight loss and she stated by the end of the nurse's shift on the day they noted the weight loss. During an interview on 5/15/25 at 10:22 AM, the Director of Nursing (DON), stated even if Resident #13 weight loss was unavoidable, the provider should of been notified. The DON stated even if the provider didn't want to intervene, they needed to be aware of the weight loss. The Facility Weight Management Guidelines Policy dated 6/23 revealed: a. Unavoidable weight loss - unavoidable weight loss occurred when the patient did not maintain acceptable parameters of nutritional status even though: 1. The patient's clinical condition and nutritional risk factors were evaluated 2. Interventions that were consistent with patient needs, goals and recognized standards of practice were defined and implemented 3. The impact of the interventions was monitored and evaluated b. The RD completed a nutrition assessment upon admission, quarterly, with significant changes, and as needed. RD reviewed weight. RD will review weight changes and make recommendations as necessary. The Facility Notification for Change of Condition dated 6/23 revealed: a. The facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there was: 1. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration health, mental, or psychosocial status in either life-threatening conditions or clinical complications)

Based on observation, clinical record review, and staff interviews, the facility failed to obtain Occupational Therapy(OT) services in a timely manner for 1 of 3 residents reviewed for specialized rehabilitative services(Resident #30). The resident reported a census of 45 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 4/1/25, listed diagnoses for Resident #30 which included morbid obesity, muscle weakness, and osteoarthritis(inflammation of the bone and joints). The MDS listed the resident's Brief Interview of Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Provider Encounter Notes on 1/8/25, 2/5/25, 3/4/25, and 3/26/25 stated the resident had bilateral(referred to both sides) lower 1+ edema(swelling where an indentation or pit remained after applied pressure to the area with severity measured on a 1-4 scale with a 1+ grade indicating a barely visible indentation and a 4+ grade indicating a deep indentation which took a considerable time to fade). A 4/30/25 provider Encounter Note stated the resident had 2-3+ lower extremity edema. A 5/7/25 Physician Visit Note, written by the the Infection Preventionist, listed an order for OT to evaluate and treat for lymphedema(a chronic condition characterized by swelling caused by an accumulation of fluid in the body's tissues). The note stated the nurse called the hospital therapy department but there was no answer and the nurse would call again in the morning. The facility lacked documentation of the completion of a follow-up call to set up the therapy services from 5/7/25 to 5/14/25. On 5/13/25 at 1:01 p.m., the resident sat in her wheelchair and had wraps on her bilateral legs. The resident stated she had a of of edema. On 5/14/25 at 9:35 a.m., the Infection Preventionist stated the follow-up for the resident's OT evaluation slipped through the cracks. She stated after she called(on 5/7/25), she did not call again. On 5/15/25 at 8:24 a.m. the Director of Nursing (DON) stated if a provider ordered OT for lymphedema, the facility should set this up immediately. She said that this service was important to residents with lymphedema. On 5/15/25 at 8:56 a.m., via email, the Administrator stated the facility did not have a policy for Rehabilitative Services.

Based on clinical record review, observation, staff interview and policy review, the facility failed to ensure nursing staff followed infection prevention and control policies to help prevent the development and transmission of communicable diseases and infections for 1 of 1 sampled residents (Resident #6) with an observation of wound care. The facility reported a census of 45. Findings include: The Minimum Data Set (MDS) quarterly assessment, dated 4/14/25, identified the resident had diagnoses of congestive heart failure, hypertension, and diabetes mellitus. The resident was dependent on staff for transfers, toilet use and lower body dressing. The resident had a Brief Interview for Mental Status (BIMS) score of 15, which suggested an intact cognition. A Communication with Physician note, dated 4/25/25, included documentation of wound culture results of the left lower leg wound with moderate growth of Staphylococcus Aureus (an infectious organism). (facility) Advanced Registered Nurse Practitioner (ARNP) updated. New orders received to start Bactrim DS (antibiotic) 1 tab every 12 hours for 7 days. Verbal order via (facility) ARNP to discontinue the Doxycycline (antibiotic). An Order Entry report, dated 5/7/25, included an order to apply collagen particles to the left leg wound and then cover with a silicone foam border dressing one time a day. On 05/13/25 09:48 AM, Staff A, Licensed Practical Nurse (LPN), entered the room of Resident #6 with wound care supplies including a silicone dressing, collagen particles, saline wound cleanser, 4 by 4 gauze pads, 2 cotton tip swabs and plastic wrap. Staff A, was not wearing a gown. Staff A washed her hands, gloved, used parchment paper to set up a clean barrier on the resident's dresser, and placed wound supplies on the barrier. Staff A removed a foam wound dressing dated 5/12/25 from the resident's left lower leg. The surveyor observed a small square cut dressing still covering the wound bed. Staff A picked this dressing off with her thumb and index finger and came into contact with bloody drainage on square cut dressing. The surveyor observed that both of the removed dressings, the foam border dressing and small square cut dressing, had reddish brown drainage. Staff A put the removed soiled dressings in the open trash can in the shared bathroom (shared by 2 other residents, Resident #32 and Resident #37). Staff A also removed her gloves and dropped them into the bathroom trash can. Staff A donned gloves without performing any type of hand hygiene (applying an alcohol-based hand rub or hand-washing), applied the Saline wound cleanser directly to the wound bed and used 4x4 gauze to pat the area dry. Staff A put the used 4x4 gauze in the open trash in the bathroom (same trash can), removed her gloves, and dropped them into the same trash can. Staff A then washed her hands, gloved, and measured the wound area without touching the wound. Staff A opened the collagen particles, applied the collagen to the wound bed area with cotton tip swabs, put the swabs back in the used collagen package, and placed the collagen particles package on the clean barrier. Staff A opened and applied the silicone foam dressing and dated the dressing. Staff A placed the collagen particles package and empty foam dressing package in the bathroom trash can. Staff A removed her gloves and put them in the same bathroom trash can. Staff A washed hands and exited the room. Staff A left the trash with the infectious material from the resident's wound care in the resident's bathroom. On 5/14/25 at 09:51 AM, during an interview, LPN/Infection Preventionist reported that staff received training on the facility's policies related to infection control upon hire and at least annually. LPN/Infection Preventionist reported staff should put soiled wound dressings in a red bag, tie up the bag and put the bag in a special container in the soiled utility room. On 05/14/25 at 10:42 AM, during an interview, Staff B, RN, confirmed she performed wound care on Resident #6 on 5/12/25. Staff B reported she put soiled wound dressing in a red bag and took the bag to a container in soiled holding. On 05/14/25 at 2:44 PM, the LPN/Infection Preventionist reported that Resident #6 should be on enhanced barrier precautions (EBP) due to the resident's staphylococcus aureus infection in the left lower leg. She reported the expectation that staff should wear a gown and gloves for wound care. On 05/14/25 at 2:47 PM, the Director of Nursing (DON) reported Resident #6 should be on EBP and staff should be wearing a gown and gloves for wound care. On 5/15/25 at 7:56 AM, Staff A, LPN, explained that a resident should be placed on EBP if they have an infection, open wound or catheter, and that EBP included a gown, gloves, mask and face shield. Review of the policy, titled Infection Prevention and Control Program Guidelines, dated 9/2022, revealed the following: a. Identified staff would follow standard precautions on all residents regardless of suspected or confirmed presence of infectious agent, and they included, but were not limited to hand hygiene, gloves, gown, mask, eye protection or face shield, and safe handling of equipment or items that were likely contaminated with infectious bodily fluids. b. Identified staff would use EBP including targeted gown and glove use during high contact resident care activities to reduce transmission of staphylococcus aureus, including during wound care.

Based on record review, policy review, and staff interviews, the facility failed to offer the pneumococcal vaccine at recommended times to 4 out of 5 residents reviewed for pneumococcal vaccinations (Resident #11, #13, #16, #22). The facility reported a census of 39 residents. Findings include: 1. Resident #11's Immunization record stated the resident received the PCV23 (a type of pneumococcal vaccine) on 10/28/10 and the PCV13(a type of pneumococcal vaccine) on 1/27/17. The record stated the resident was [AGE] years old. 2. Resident #13's Immunization record stated the resident received the PCV23 pneumococcal vaccine on 1/23/08 and the PCV13 vaccine on 7/23/15. The record stated the resident was [AGE] years old. 3. Resident #16's Immunization record stated the resident received PCV13 vaccine on 4/20/15 and the PCV23 pneumococcal vaccine on 5/23/16. The record stated the resident was [AGE] years old. 4. Resident #22's Immunization record stated she resident received PCV23 pneumococcal vaccine on 9/6/07 and the PCV13 on 9/21/15. The record stated the resident was [AGE] years old. The facility lacked documentation of additional pneumococcal vaccinations offered to the above residents. The Centers for Disease Control and Prevention(CDC) Adult Immunization Schedule Notes, retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-schedule-notes.html#note-pneumo on 7/18/24 contained the following guidance: For adults [AGE] year or older who: a. previously received both PCV13 and PPSV23(PCV23) but no PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose PCV20(a type of pneumococcal vaccine) or 1 dose PPSV23. If PCV20 was selected, administer at least 5 years after the last pneumococcal vaccine dose. If PPSV23 was selected, refer to CDC dosing schedule. b. previously received both PCV13 and PPSV23, and PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. On 7/18/24 at 9:40 a.m., the Infection Preventionist stated she utilized current CDC guidance for pneumococcal vaccines. She stated she ensured new residents were up to date on their vaccines but did not offer updated vaccines to residents who were already in the facility. The facility policy Influenza and Pneumococcal Pneumonia Vaccines, updated 8/29/22, stated pneumococcal vaccines would be offered to eligible residents per the recommendations of the CDC.

Based on clinical record review, policy review, and staff interviews, the facility failed to intervene when several days elapsed without a bowel movement (BM) for 1 of 2 residents reviewed for a change in condition (Resident #4). The facility reported a census of 39 residents. Findings: The Quarterly Minimum Data Set (MDS) assessment tool, dated 6/18/24, listed diagnoses for Resident #4 which included schizophrenia, mild intellectual disabilities, and pressure ulcer. The MDS listed a Brief Interview for Mental Status(BIMs) score as 10 out of 15, indicating moderately impaired cognition. 5/6/24 Care Plan entries stated the resident received antipsychotic medication and directed staff to monitor for adverse reactions to antipsychotics including digestive issues and constipation. 7/1/24 Care Plan entries stated the resident received antidepressant medication and directed staff to monitor for adverse reactions to antidepressant therapy including constipation and fecal impaction. The resident's Bowel Movement record lacked documentation the resident had a BM on the following days: 7/1/24 7/2/24 7/3/24 7/4/24 7/5/24 7/6/24 7/7/24 7/8/24 The record stated the resident had an extra large bowel movement on 7/9/24. The July 2024 Medication Administration Record(MAR) revealed the following: The resident received a bisacodyl suppository(used for constipation) on 7/5/24 at 5:12 a.m. and stated it was ineffective. The resident received Milk of Magnesia (MOM-used to treat constipation) 30 milliliters(ml) on 7/7/24 at 11:54 a.m. and stated it was ineffective. The resident received a rectal enema (for constipation) on 7/7/24 at 8:36 p.m. The resident received magnesium citrate (for constipation) 296 mls on 7/8/24 at 5:25 p.m. The MAR lacked documentation of pharmaceutical interventions carried out prior to 7/5/24. Nursing Progress Notes revealed the following: The notes did not address the resident's bowel movements from 7/1/24-7/5/24 at 5:12 a.m. A 7/5/24 5:12 a.m. Orders-Administration Note stated the resident received a bisacodyl suppository. A 7/5/24 10:29 p.m. Orders -Administration Note stated the suppository was ineffective. 7/6/24 Progress Notes lacked documentation related to the resident's lack of a bowel movement and lacked additional interventions provided to assist the resident in having a bowel movement. A 7/7/24 11:54 a.m. Orders-Administration Note stated the resident received MOM. A 7/7/24 7:20 p.m. Communication with Physician note stated the facility notified the on call provider and received an order for an enema. A 7/7/24 8:36 p.m. Order-Administration Note stated the MOM was ineffective. A 7/8/24 11:53 a.m. Communication with Physician note stated the facility updated the provider the resident did not have a bowel movement for eight days and the provider ordered an abdominal x-ray and magnesium citrate. A 7/10/24 encounter note stated the resident had a 7/8/24 abdominal x-ray which found a non-obstructive small bowel gas pattern with above average colonic stool burden. The progress notes lacked documentation of physician notification of the resident's lack of bowel movement from 7/1/24-7/7/24 and lacked documentation of additional assessments and interventions carried out related to the lack of a bowel movement during the time period of 7/1/24-7/7/24. On 7/17/24 at 3:03 p.m. via phone, Staff A Licensed Practical Nurse(LPN) stated they usually administered MOM by day three without a bowel movement and if that was not effective the night shift should administer a suppository. On 7/17/24 at 3:53 p.m. via phone, Staff B Registered Nurse(RN) stated she worked nights and she documented if a resident went two days without a bowel movement and the next day shift was supposed to follow up. She stated after 48 hours staff should administer MOM and after 72 hours they should administer a suppository. On 7/18/24 at approximately 8:00 a.m. the Director of Nursing(DON) stated all bowel movements were documented on the Bowel Movement record and stated they would not be documented anywhere else. On 7/18/24 at 9:01 a.m. the DON stated they usually administered MOM on the second day with no bowel movement and on the third day they administered a suppository. She stated she did hear about Resident #4 going multiple days without a bowel movement and encouraged the staff to reach out to the doctor. On 7/18/24 at 10:13 a.m., via phone Staff C Physician's Assistant (PA) stated if staff used a prn(as needed) medication on day three(without a BM) and it was ineffective and they tried a second medication and it was ineffective, they should contact her. On 7/18/24 at 11:05 a.m. the DON provided a Day Log for 7/4/24 which had documentation that the resident received MOM. The log did not state when the resident received the MOM, who administered it, or if it was effective. The DON stated it was not clear from the document if the MOM was effective. She stated she had no other documentation related to the resident's lack of bowel movement. The undated [facility name] Bowel Protocol policy directed staff to administer MOM or per doctor's orders after day three of no bowel movement and to administer a suppository or per doctor's orders after day 4 of no bowel movement.

Based on record review, staff interviews, and policy review the facility failed to ensure residents were free from neglect when 24 of 24 residents (Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14) did not receive their scheduled medications including, narcotics, insulin, antibiotics, blood pressure, psychotropic, respiratory and blood thinner medications on 7/4/2022 by Staff A, Licensed Practical Nurse (LPN) who was their nurse from 2:00 PM to 6:00 AM on 7/5/22. The facility reported a census of 51 residents. Findings include: Record review of a document created by the facility titled, Medications Documented as Administered by Staff A on 7/4/2022, documented the following 24 residents failed to receive the following medications on 7/4/22 while Staff A was working. 1. Resident #104 Flomax 0.4 mg Levemir 100 unit/ml 35 units Metformin HCI 500 mg Metoprolol Tartrate 50 mg Cephalexin Capsule 250 mg Citalopram Hydrobromide Tablet 20 mg Colace Capsule 100 mg 2. Resident #105 Donepezil 5 mg Mirtazapine 7.5 mg Simvastatin 20 mg Atenolol 12.5 mg 3. Resident #106 Docusate Sodium 100 mg Famotidine 20 mg Magox 400 Mighty Shake (supplement) Hydrocodone-Acetaminophen 7.5-325 mg Hydrocodone-Acetaminophen 7.5-325 mg 4. Resident #107 Senna 8.6 mg Baclofen 10 mg 5. Resident #108 Carbidopa-Levodopa 25-100 mg (1.5 tablet) NovoLOG 10 units Ascorbic Acid 500 mg Ferrous Sulfate 325 mg Gabapentin Capsule 300 mg Insulin Glargine 30 units Pravastatin Sodium 40 mg Combigan Solution 0.2-0.5% 1 drop right eye Tylenol 325 mg 6. Resident #109 Acetaminophen 650 ER Atenolol 25 mg 7. Resident #110 Mirtazapine 30 mg 8. Resident #111 Carbidopa-Levodopa 25-100 mg (2 tablets) Sennosides-Docusate Sodium 8.6-50 mg Venlafaxine 37.5 mg Clonazepam 1 mg Seroquel 25 mg Seroquel 50 mg Carbidopa-Levodopa 25-100 mg (2 tablets) 9. Resident #112Cholecalciferol 1000 Pravastatin 20 mg Metoprolol Tartrate 25 mg Refresh Optive PF Solution 0.5-0.9% 1 drop both eyes Senna Tablet 8.5 mg Latanoprost 1 drop both eyes Nifedipine ER 90 mg Preservision AREDS 2 Tablet Acetaminophen 650 mg ER Brimonidine Tartrate-Timolol 1 drop both eyes Lidocaine Cream 4% right neck Lidocaine Patch 4% 10. Resident #54 Cymbalta 30 mg Donepezil 10 mg Memantine 10 mg (1700) Cholestyramine 4 gram Potassium Chloride liquid 20 meq/15 ml Eye supplement 2 Capsule Saline Nasal Spray 11. Resident #39 Cranberry Tablet 450 mg Docusate Sodium Capsule 100 mg Pentoxlfyline ER Tablet ER 400 mg Prostat 300cc Risperidone Tablet 0.25 mg Mirtazapine 7.5 mg Rocklatan Solution 0.02-0.005% 1 drop both eyes Brimonidine Tartrate Solution 0.15% drop both eyes 12. Resident #14 Mighty Shake 4 oz. (supplement) 13. Resident #22 Eliquis 2.5 mg Namenda 10 mg Ocuvite-Lutein Seroquel tablet 50 mg Buspirone HCI 7.5 mg Refresh Solution 1 drop both eyes 14. Resident #113 Acetaminophen 650 mg ER Senna 8.6 mg 15. Resident #20 Colace 100 mg Acetaminophen 650 ER Calcium - Vit D - Vit K (supplement) Atorvastatin Calcium Tablet 40 mg Zyprexa 10 mg 16. Resident #15 Arginaid Extra Liquid 120cc Metformin HCI ER 500 mg Oxycabazepine 150 mg Eliquis 5 mg Lidocaine Patch 4% (2000) Acetaminophen tablet 650mg 17. Resident #5 Carvedilol 12.5 mg Gabapentin capsule 200 mg Hydralazine HCI tablet 50 mg Ensure Clear 120cc (supplement) Hydralazine HCI tablet 50 mg Acetaminophen tablet 500mg 18. Resident #31 Acetaminophen Sennosides-Docusate Sodium 8.6-50 mg 19. Resident #17 Metoprolol Tartrate 50 mg Haloperidol Tablet 0.5 mg Acetaminophen Tablet 500 mg Fentanyl Patch 25 mcg/hr 20. Resident #114 Acetaminophen 650 mg ER Gabapentin Capsule 300 mg Nexium 20 mg Sennosides-Docusate Sodium 8.6-50 mg Irbesartan 300 mg Melatonin tablet 5 mg Calcium Carbonate-Vitamin D 600-400 mg Lacri-Lube Ophathalmic Ointment to right lower eye lid 21. Resident #18 Budesonide Suspension 0.5 mg/2ml 1 via inhale orally Amlodipine Besylate 5 mg Metoprolol Succinate ER 50 mg Simvastatin 20 mg Ipratropium-albuterol solution 0.5-2.5 (3) mg/ml 22. Resident #115 Pro-Stat (supplement) Quetiapine Fumarate Tablet 25 mg Trazodone HCI 50 mg Tylenol tablet 650 mg Eliquis 5 mg Namenda 10 mg 23. Resident #13 Ocuvite Eye + Multi tablet Acetaminophen ER 650 mg Arginaid Extra Liquid 4 oz. Eliquis Tablet 2.5mg Lexapro 5 mg Acetaminophen ER 650 mg 25. Resident #14 Refresh Tears Solution Muro 128 Ointment 5% Refresh Tears Solution Record review of an undated document created by the facility titled, Timeline, instructed Staff A's whereabouts during her shift and what she did on 7/4/22 at 2:20 PM to 7/5/22 at 6:00 AM. Through review of the timeline Staff A did not pass medications to residents. Record review of a document submitted to the [state redacted] Board of Nursing regarding Staff A, by the facility instructed the following: On 7/5/2022 the Administrator received a concern from a night shift employee that Staff A that worked for a local staffing agency was asleep in the recliner during her 2:00 PM to 6:00 AM shift on 7/4/22. After watching the camera footage, Staff A was asleep from 1:48 AM to 3:40 AM. No other nurse was on duty as this time. During investigation, it was identified that Staff A did not complete her medication administrations that she signed off in the Medication Administration Record (MAR) for multiple residents on 7/4/22. It can be seen in the video cameras that within a 15-minute period, Staff A removed the medications which should have been given on her shift for all assigned residents. She removed the medication cards a few at a time, took out the doses scheduled for her shift, and disposed of them. Some of the medications were put into a medical disposable glove and discarded in the trash. It is unclear via the camera if all medications were thrown in the garbage or if medications could have been kept on her person and stolen. The view is blocked by the laptop on the nurse's cart. Staff A also would have taken out her own trash and disposed of it which is not within sight of the camera. The Administrator also documented she talked to Staff A on 7/5/22 at 6:00 PM via phone that she threw away one resident's medications. During an interview on 7/12/23 at 3:44 PM with the facilities Administrator revealed she received an anonymous note under her door on 7/5/2022 informing her Staff A was sleeping on 7/4/22. She revealed she started to watch the facilities cameras and found there was times she was sitting in the recliner and may have been sleeping. She informed she watched the medication pass and typed up a timeline (Timeline document) of events of exactly what she did to tray an narrow it down. She then revealed she complied a list of residents that did not receive their medications as ordered (Medications Documented as Administered by Staff A on 7/4/2022). She then informed 24 residents did not receive their medications as ordered on 7/4/22. She revealed Staff A was an agency employee that was terminated immediately after this event, but was at the facility for approximately a year and went through all of the facilities normal orientation training. She informed Staff A was well orientated to the facility. She then informed she is unsure of the reason why Staff A did not provide medications to the residents, she informed Staff A worked two (2) prior days that week and they watched the cameras to see if she provided medications on those days and she did, so unsure of why this occurred, this is not what the facility expects of it's employees. During an interview on 7/13/23 at 9:48 AM with the Director of Nursing (DON) revealed she would of expected Staff A to pass medications to all residents as they were ordered. She revealed Staff A was well trained and worked at the facility for about a year, she informed she does not know why she did not pass the medications as she was not trained that way. Record review of the facilites policy titled, Abuse Prevention, Training, and Investigations, last revised on 12/30/20 revealed the facility followed their policy and procedure regarding the neglect that occured for the 24 resident on 7/4/22. The person in charge of the facility shall immediately: a) Separate the alleged perpetrator, if known, from the victim and maintain this separation without exception, pending completion of the investigation; b) Assess the victim for injury requiring immediate medical assistance and provide or arrange for needed care and treatment; c) Implement precautions to preserve physical evidence that might be present at the site and/or on the victim or alleged perpetrator; d) Interview the victim, if possible, for his/her statement related to the occurrence; e) Interview the alleged perpetrator, if known and on-site, to obtain a statement of his/her knowledge and involvement; f) If appropriate due to the seriousness of the allegation, relieve the alleged perpetrator of further work duties and place the person in an unpaid, suspended work status pending further investigation; g) Unless the resident /tenant directs otherwise, notify the victim's responsible party of injuries incurred; h) Notify the victim's attending physician if the allegation could impact the resident's physical or mental well-being: i) Notify the local Police if there is a reasonable suspicion that a crime has Occurred. j) Document all of the above.

Based on record review, staff interviews, and policy review the facility failed to ensure 24 of 24 residents (Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14) were provided with professional standards of nursing care on 7/4/2022 from 2:00 PM to 6:00 AM, by Staff A, Licensed Practical Nurse (LPN) who documented medications were given, but during review of video footage and a facility timeline was found to dispense and dispose of resident medications instead of administering the medications to residents. The facility reported a census of 51 residents. Findings include: Record review of a document created by the facility titled, Medications Documented as Administered by Staff A on 7/4/2022, documented the following 24 residents failed to receive medications on 7/4/22 while Staff A was working: Resident #104, #105, #106, #107, #108, #109, #110, #111, #112, #54, #39, #14, #22, #113, #20, #15, #5, #31, #17, #114, #18, #115, #13, and #14. Record review of an undated document created by the facility titled, Timeline, instructed Staff A's whereabouts during her shift and what she did on 7/4/22 at 2:20 PM to 7/5/22 at 6:00 AM. Through review of the timeline Staff A did not pass medications to residents. Record review of a document submitted to the [state redacted] Board of Nursing regarding Staff A by the facility instructed the following: On 7/5/2022 the Administrator received a concern from a night shift employee that Staff A that worked for a local staffing agency was asleep in the recliner during her 2:00 PM to 6:00 AM shift on 7/4/22. After watching the camera footage, Staff A was asleep from 1:48 AM to 3:40 AM. No other nurse was on duty as this time. During investigation, it was identified that Staff A did not complete her medication administrations that she signed off in the Medication Administration Record (MAR) for multiple residents on 7/4/22. It can be seen in the video cameras that within a 15-minute period, Staff A removed the medications which should have been given on her shift for all assigned residents. She removed the medication cards a few at a time, took out the doses scheduled for her shift, and disposed of them. Some of the medications were put into a medical disposable glove and discarded in the trash. It is unclear via the camera if all medications were thrown in the garbage or if medications could have been kept on her person and stolen. The view is blocked by the laptop on the nurse's cart. Staff A also would have taken out her own trash and disposed of it which is not within sight of the camera. The Administrator also documented she talked to Staff A on 7/5/22 at 6:00 PM via phone that she threw away one resident's medications. During an interview on 7/12/23 at 3:44 PM with the facilities Administrator revealed she received an anonymous note under her door on 7/5/2022 informing her Staff A was sleeping on 7/4/22. She revealed she started to watch the facilities cameras and found there was times she was sitting in the recliner and may have been sleeping. She informed she watched the medication pass and typed up a timeline (Timeline document) of events of exactly what she did to tray an narrow it down. She then revealed she complied a list of residents that did not receive their medications as ordered (Medications Documented as Administered by Staff A on 7/4/2022). She then informed 24 residents did not receive their medications as ordered on 7/4/22. She revealed Staff A was an agency employee that was terminated immediately after this event, but was at the facility for approximately a year and went through all of the facilities normal orientation training. She informed Staff A was well orientated to the facility. She then informed she is unsure of the reason why Staff A did not provide medications to the residents, she informed Staff A worked two (2) prior days that week and they watched the cameras to see if she provided medications on those days and she did, so unsure of why this occurred, this is not what the facility expects of it's employees. During an interview on 7/13/23 at 9:48 AM with the Director of Nursing (DON) revealed she would of expected Staff A to pass medications to all residents as they were ordered. She revealed Staff A was well trained and worked at the facility for about a year, she informed she does not know why she did not pass the medications as she was not trained that way. Record review of the facilites policy titled, Abuse Prevention, Training, and Investigations, last revised on 12/30/20 revealed the facility followed their policy and procedure by completeing the following: The facility has a comprehensive system of practices and procedures designed to a) prevent occurrences of mistreatment, abuse, neglect, and/or misappropriation of resident property, b) monitor, identify and investigate injuries of unknown source and any allegations of suspected abuse, and c) insure that reasonable suspicions are reported to the appropriate law enforcement and regulatory oversight agencies.

Based on clinical record review, facility policy, and staff interview the facility failed to ensure resubmission of the Preadmission Screening and Resident Review (PASARR) following change in medical diagnoses for one of one residents reviewed for PASARR (Resident #39). The facility reported a census of 51 residents. Findings include: The Annual Minimum Data Set (MDS) assessment for Resident #39 dated 4/4/23 revealed the resident scored 11 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was moderately cognitively impaired. The MDS included a psychotic disorder diagnosis for the resident. The MDS documented that the resident had taken in the last seven days the following medication types; antipsychotic, and antidepressant. On 4/22/22 a diagnosis of PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION had been added to the resident's medical diagnoses. The Care Plan, target date 4/11/23, revealed, Resident #39 has a psychosocial well-being problem r/t (related to) Depression and Mood. One of the interventions documented, Observe/document/report PRN (as needed) any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (Extrapyramidal side effects) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. The Level 1 Form Pre-Admission Screening and Resident Review, review date of 03/28/23, documented the resident had no known or suspected mental health diagnosis. An order dated 4/12/23 documented as follows; Mirtazapine (antidepressant) 15 milligrams by mouth daily at bedtime related to psychotic disorder with delusions due to known physiological condition. The Medication Administration Record dated 7/1/2023 to 7/31/23 documented the following medication entry; Seroquel 50 milligrams by mouth daily for mood distrubance with the start date of 7/12/23. On 7/13/23 9:48 AM the Administrator was queried in which instances a level one assessment would be resubmitted, and explained this would occur if the nurses communicated a significant change or medication change. Diagnoses for Resident #39 and the Level 1 PASARR form were reviewed with the Administrator, who confirmed it should have been resubmitted. Any further PASARR for this resident was requested from the Administrator. On 07/13/23 at 9:48 AM, the Administrator explained there was no other PASARR in the record. The Administrator advised a Level 1 PASARR was submitted to on 7/12/23. The Administrator explained there was a process which the facility had not yet initiated. This process would include any time there was a new diagnosis follow up would occur to see if there was need for a new PASARR. Policy provided by the facility titiled; Change of Status PASRR Level I Submissions, dated 04/2019 documented the following; Anytime a resident with mental illnes or intellectual disabilty or related condition experiences changes which affect his/her placement or service decision the nursing home staff must contact Ascend to report that change (via a new Level I).

Based on observation, interview and document review, the facility failed to follow professional standards during the medication pass. The nurse failed to follow professional standards by not priming an insulin pen before selecting the dose of insulin for 1 out of 1 resident reviewed, (Resident #24). The facility reported a census of 49 residents. Findings include: During an observation on 2/16/22 at 10:33 AM, Staff A, Registered Nurse (RN) prepared an insulin pen for Resident #24. The Staff A did not prime the pen before selecting the dose of insulin to be administered. The Nurse Consultant observed surveyor and RN at the time the RN prepared the Insulin Pen. During interview on 2/16/22 at 10:45 AM, the Nurse Consultant agreed the RN did not prime the insulin pen. The Nurse Consultant reported not having a facility policy/procedure for insulin pen usage. The Nurse Consultant provided a document titled Insulin Pen Injections downloaded on 2/16/22 at 11:16 AM from site file:///C:/Users/sackerman/AppData/Local/Microsoft/Windows/Temporary Internet [NAME]/Content.Outlook/CF5J4M4U?Insulin Pen Injections.html. Procedural Details from this document, How do I use an insulin pen? steps 7 & 8 revealed how to prime the insulin pen, remove air bubbles by turning the knob to the 2 units indicator, point the pen upward and push the knob all the way to visualize a drop of insulin, repeat step until a drop is seen.

Based on observation, staff interview, and policy review, the facility failed to provide incontinence cares in accordance with accepted standards of practice for 1 of 1 sampled (Resident #36) and failed to transport linen in a manner to prevent the spread of infection. The facility reported a census of 50. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE], documented Resident #36 had diagnses of [MEDICAL CONDITION] and generalized muscle weakness. The MDS identified Resident #36 required extensive assist of two staff for transfers and toilet use. Resident #36 had bowel and bladder incontinence. Resident #36 had severe cognitive impairments. During an observation on 10/22/19 at 11:41 a.m., revealed Staff A (Nurse Aide) and Staff B (Nurse Aide) and Staff B (Nurse Aide) washed hands and donned gloves while resident was lying in bed. Staff A provided anterior perineal care. Staff A and Staff B removed gloves and sanitized hands. Staff A rolled Resident #36 on her left side and provided posterior perineal care. Staff A removed her gloves, applied a clean brief, and pulled up Resident #36's pants. Staff B removed her gloves. Staff A and Staff B transferred Resident #36 to the wheelchair. Staff A gathered all the trash and removed from room. Staff B pushed resident to the dining room. Staff A and B failed to sanitize or wash hands after removing gloves and before touching Resident #36. During an interview on 10/24/19 at 8:26 AM, the Director of Nursing stated her expectation for staff to wash or sanitize hands after providing cares. Review of the corporate policy and procedure titled Handwashing with revised date 5/17, documented hands will be washed with either soap and water or alcohol-based hand rubs before and after providing direct resident care, before and after using disposable gloves. 2. During an observation on 10/21/19 at 1:32 p.m., Staff L (Housekeeper) transported clean linens and medical equipment from the hallway near the conference room to the linen closet on North Hall. The cart had an open front and back, exposing the linens during the transport. The sides of the cart had drapes which flew up during transport of the cart, exposing the sides as well. After Staff L stopped at the linen closet on North Hall, she transported the cart to the Center Hall. During an observation on 10/23/19 at 7:05 a.m., Staff K (Housekeeper) transported washcloths on a cart from the Main Dining Room down the hall. The washcloths had a towel covering a portion of them. The washcloths had an exposed area measuring 5 inches. During an interview on 10/24/19 at 8:30 a.m., the Nurse Consultant stated they did not have a policy for the transport of linen but they followed the standard of practice. During an interview on 10/24/19 at 9:00 a.m., the Administrator stated they were going to come up with a plan to ensure linen carts had covers. 3. During an observation on 10/22/2019 at 7:21 a.m., Staff M (Housekeeper) pushed a cart to the main dining room that contained clean table linens. The three tiered cart had linens on the second shelf exposed during transport.

Based on clinical record review, facility policy and staff interviews a facility staff failed to prevent resident abuse/degradation for three of six residents reviewed. On [DATE] Staff B witnessed Staff A take a picture of Resident #2 and told Staff A not to post the photo on any social media site. Staff B did not report what she had seen until questioned by the Administrator weeks later. Staff A took another photo on [DATE] near the time of Resident#6's death and reference to the resident passing soon. Staff A took a picture of Resident #4 with an unknown date and made insulting comments. Staff A's failed to display respect for residents and failed to maintain resident's dignity. A reasonable person would feel offended/mortified and hurt by Staff A's actions; and Staff B's failure to notify the Administrator could have possibly prevented Staff A from taking Resident #6's picture since this occurred two weeks later. A reasonable person would value and cherish the time near Resident #6's death and would not insult/or degrade someone in this manner. The facility reported a census of 53 residents. Findings include: On [DATE] at 3:15 p.m., the Administrator received a report from a non-facility person claiming he had received pictures of residents (Residents #2, #4 and #6) taken by Staff A. The Administrator asked for the pictures and texts messages which showed Staff A had taken pictures of Residents #2, #6 and #4. The Administrator notified the Department of Inspections and Appeals on [DATE] at 12:08 p.m., and started an investigation (on [DATE]). Staff B informed the Administrator she had been aware that Staff A had taken a picture of Resident #2 two weeks prior but did not report this to anyone. On [DATE] at 3:15 p.m., the Administrator received a report from a non-facility person claiming he had received pictures of residents (Residents #2, #4 and #6) taken by Staff A. The Administrator asked for the pictures and texts messages which showed Staff A had taken pictures of Residents #2, #6 and #4. The Administrator notified the Department of Inspections and Appeals on [DATE] at 12:08 p.m., and started an investigation (on [DATE]). Staff B informed the Administrator she was aware Staff A had taken a picture of Resident #2 about two weeks prior but did not report this to anyone. On [DATE] at 2:30 a.m. Staff A, LPN shared a photo of Resident #2 that had been enhanced with a cat face on a social media site to a non-facility member. The resident had been unaware that the staff had taken a photo, until she showed the enhanced photo. The resident then became slightly agitated per Staff B, LPN. The quarterly Minimum Data Sets ((MDS) dated [DATE] documented Resident #2 with a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The MDS indicated the resident required limited assistance of one staff for ambulation and locomotion and extensive assistance of one staff for other activities of daily living. The MDS documented the resident with active [DIAGNOSES REDACTED]. The resident's care plan instructed staff the resident utilized an alarm in bed/chair to alert staff that the resident required assistance. The resident enjoyed music activities, would attend activities as an observer. The care plan indicated the resident required staff assistance for transfers, ambulating, toileting and meals. On [DATE] at 12:36 p.m. Staff B, LPN stated she had worked with Staff A on the ,[DATE] p.m. shift. She stated that she had seen Staff A with her cell phone on one occasion when not on break. Staff B stated that she had observed Staff A, LPN take a photo of a resident (Resident #2) with her cell phone and then added ears and whiskers onto the photo so that it appeared as a cat face. Staff B stated that she had explained to Staff A that taking photos of resident had been against the facility policy and she should not place the photo on any social media. Staff B stated she though Staff A had deleted the photo. Staff B stated that Staff A did show the photo to Resident #2 and the resident became a little agitated, pushed the phone away and said; oh that is ridiculous. She stated that was the only photo that she had observed Staff A taken of a resident. On [DATE] at 4:35 p.m. Staff B stated that she had notified the facility Administrator of the incident when she came back for her next shift at the facility two weeks later after the incident. 2. The quarterly Minimum Data Sets ((MDS) dated [DATE] documented Resident #6 with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The assessment revealed Resident #6 had the ability The MDS indicated the resident required total assistance of two staff for ambulation and locomotion and extensive assistance of one staff for other activities of daily living. The MDS documented the resident with active [DIAGNOSES REDACTED]. The resident's care plan identified an admission date of [DATE] with the resident receiving Hospice services. The care plan instructed staff the resident required extensive assistance with two staff members for transfers and personal cares. The care plan indicated the resident required oxygen therapy per nasal cannula per physician order. On [DATE] at 2:46 a.m. Staff A had taken a photo of Resident #6 and posted the photo with a caption of He/She's probably going to go any minute on a social media site. Record review identified Resident #6 expired approximately 3 (three) hours later on [DATE] at 4: 56 am. Resident #6's body had been sent to the funeral home at 6:15 a.m. 3. The quarterly Minimum Data Sets ((MDS) dated [DATE] documented Resident #4 with a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated the resident had been independent for ambulation and locomotion. The MDS indicated the resident required limited to no assistance of staff for other activities of daily living. The MDS documented the resident with active [DIAGNOSES REDACTED]. The resident's care plan instructed staff the resident required assistance with activities of daily living related to disease process, hypertension, [MEDICAL CONDITION], [MEDICATION NAME] degeneration, impaired balance and [MEDICAL CONDITION]. On an unknown date at 1:08 P.M. Staff A had posted a photo of Resident #4, in which the resident appeared to be sleeping. The photos had comments on it; such as In the AL; I'll explain in a minute and Crazy mother***** (Expletive) and had been using a messaging site with an outside person. During investigation of the above issues, on [DATE] several of the night shift (10 p-6a) staff noted that Staff A had been on her phone quite often during the shift as follows: On [DATE] at 9:30 a.m. Staff I , CNA stated she had worked with Staff A on the night shift. Staff I stated Staff A had her cell phone out all the time either talking or playing on it. Staff I stated she had never seen Staff A take photos of residents with the cell phone. Staff I stated the nurse would check on the residents one time during the night, pass medications at 4:00 a.m. if needed and get their paperwork done. She stated that was the only times they saw the nurses at night. On [DATE] at 1:53 p.m. Staff C, CNA stated she had worked the ,[DATE] p.m. or ,[DATE]p.m. shift with Staff A. Staff C stated that Staff A had been observed on her cell phone a lot during the shift. She stated it was more so on the night shift. Staff C stated she had not seen Staff A take resident photos with her cell phone. On [DATE] at 2:15 p.m. Staff D, CNA stated she worked with Staff A on the evening shift. She stated she did see Staff A on her cell phone behind the nurse's desk but not on the floor (in resident areas). On [DATE] at 3:35 p.m. Staff E, CNA stated she worked with Staff A on the ,[DATE] p.m. shift. Staff E stated she had seen Staff A on her cell phone almost every shift she worked with her. Staff E stated she had never seen Staff A take photos of residents. On [DATE] at 3:54 p.m. Staff F, CNA stated that she had worked with Staff A a few times. She stated she did see Staff A on her cell phone quite a lot at the end of her (Staff F's) shift around 10 p.m. Staff F stated she video chatted a lot. She stated she had not seen Staff A take any photos of the residents. On [DATE] at 10:30 a.m. Staff G, CNA stated she did work with Staff A on the night shift (11p-7a). She stated Staff A had her cell phone out every night off and on. Staff F stated she had never seen Staff A take photos of residents with her cell phone. On [DATE] at 9:55 a.m. Staff H, CNA stated she worked with Staff A on the overnight shift. Staff H stated she had seen Staff H with her cell phone out most of the time unless she had been passing medications. Staff H stated she had not seen Staff A take any photos of residents with the cell phone. Staff A's personnel file identified she had been hired to work at the facility as a temporary (agency) nurse and completed Mandatory Reporter training for Dependent Adult Abuse through a staffing agency which she worked for known as GrapeTree Medical Staffing, Inc. on [DATE]. The Abuse Prevention, Training, and Investigations policy revealed the facility had a comprehensive system of practices and procedures designed to prevent occurrence of mistreatment, abuse, neglect and/or misappropriation of resident property ; b) monitor, identify any allegations of suspected abuse; and c) insure that reasonable suspicions are reported to the appropriate agencies. The abuse policy screen revealed an employee is defined as any individual who is paid by either by the health care facility or any entity ( i.e. temporary agency, private duty, Medicare/Medicaid or independent contractors) to provide direct or indirect treatment or services to residents in the facility. The abuse policy training section revealed at the time of hire and annually thereafter, employees and contractors will receive information that explains their obligation as Mandatory Reports under the federal Elder Justice Act. The training (section b) revealed staff would be trained to make a special effort to promote the rights of each resident personal privacy of his/her own physical body and his/her personal space including accommodations and personal care. The policy stated that Abuse training includes prohibiting the use of any equipment (e.g., cameras, smart phones, and other electronic equipment) to take, keep, or distribute photographs and recordings of residents that are demeaning or humiliating. Item 13 of the Abuse policy for prevention revealed reminders of the Mandatory reporter requirements are routinely reviewed at staff meetings, including a) who is a mandatory reporter, b) what are reportable types of alleged abuse, and c) procedures for filing reports. The abuse policy for protection revealed employees are required to report allegations of abuse immediately and without hesitation directly to the person in charge.