Every finding on record at Mansfield Nursing Center

Based on record review and interview, the facility failed to ensure 1 (#1) out of 2 residents reviewed for unnecessary medications completed a consent for a psychotropic medication.Findings:Review of Resident #1's medical record revealed an admit date of 12/19/2022 with the following diagnoses, including in part: dementia in other diseases classified elsewhere mild with agitation and insomnia unspecified. Review of Resident #1's physician orders revealed an order dated 06/11/2026 for Dextromethorphan-Bupropion oral tablet extended release 45-105 milligrams give 1 tablet by mouth one time a day for target behavior: agitation related to dementia in other diseases classified elsewhere mild with agitation. Review of Resident #1's June 2026 medication administration record revealed Dextromethorphan-Bupropion extended oral tablet was administered beginning on 06/11/2026. Review of Resident #1's medical record revealed a psychotropic consent for Dextromethorphan-Bupropion was signed by the resident representative on 06/12/2026. During an interview on 08/05/2026 at 10:40 a.m. S1 Director of Nursing acknowledged Resident #1's psychotropic consent for Dextromethorphan-Bupropion was signed by the resident representative after the first dose was administered. S1 Director of Nursing confirmed the consent should have been signed prior to administration.

Based on record reviews and interviews the facility failed to immediately notify 1 (#2) of 3 (#1, #2, and #3) sample resident's physician and/or the DON (Director of Nursing) of the significant change in a resident's physical condition. The facility failed to notify the physician and/or the DON when resident #2 had a change in condition including severe shortness of breath and an oxygen saturation level of 60%.Findings:Review of the facility's Physician Notification policy (undated) revealed in part:Policy Interpretation and Implementation. In general, the Charge Nurse will notify the resident's attending physician:Immediately, if the resident's condition is deemed an emergency. In addition, emergency services personnel may be contacted at the discretion of the licensed nurse on duty.If staff is unable to contact the resident's physician, the medical director will be notified. If the Medical Director is the resident's physician or if staff is unable to contact the Medical Director, the Administrator and/or the DON (Director of Nursing) will be notified.Call the doctor, immediate when Pulse Ox, 90% or less.Review of resident #2's progress notes dated 02/23/2026 revealed in part: S2 LPN (License Practical Nurse) documented at 7:30 a.m. during med pass observed resident #2 with labored breathing, upon assessment resident #2 oxygen saturation was 60% on room air, applied oxygen by way of nasal cannula at 2 liters per minute, oxygen saturation came up to 90%, notified MD at 8:00 a.m. left message at doctor's office. At 8:20 a.m. received orders to send to emergency room for evaluation and treatment related to use of accessory muscles with oxygen saturation remaining at 90-91% with oxygen by way of nasal cannula, EMS (emergency medical service) called arrived at 9:10 a.m.During an interview on 05/07/2026 at 9:45 a.m. S2 LPN reported on 02/23/2026 at 7:30 a.m. she observed resident #2 had labored breathing when she was performing med pass, she reported she assessed resident #2's oxygen saturation level and it was 60% on room air, and the resident was using her accessory muscles to breathe. S2 LPN reported resident #2 was started on oxygen at 2 liters by nasal cannula and resident #2's oxygen saturation level increased to 90% and was monitored. S2 LPN reported resident #2's physician office was called 02/23/2026 at 8:00 a.m. and a message was left with the office nurse. S2 LPN reported around 8:30 a.m. she received a phone call from the office nurse and instructed to send resident #2 out to the emergency room.During an interview on 05/07/2026 at 11:15 a.m. S1 DON reported she was not notified about resident #2's change in condition until EMS was at the facility. S1 DON reported she should have been notified of resident #2's change in condition. S1 DON reported based on a nurse's assessment if there is an emergency, a nurse can send a resident out without a physician's order.

Based on record review, observations, and interviews the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and help prevent the development and transmission of infection for 3 (#10, #13, #79) of 3 (#10, #13, #79) sampled residents requiring EBP (enhanced barrier precautions). The facility failed to:1. Post clear signage outside Resident #10, #13 and #79's room indicating the type of precautions, required personal protective equipment and high contact resident care activities that require the use of gown and gloves,2. Have gowns, gloves and alcohol-based hand rub available outside the room for Resident #10, #13 and #79 and 3. Obtain an order for EBP for Resident #79. Findings:Review of Enhanced Barrier Precautions policy dated January 2025, revealed in part: Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organisms (MDRO) as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Policy Explanation and Compliance Guidelines:45. c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 46. Enhanced Barrier Precautionsa. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices:i. Wounds and /or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes,.) even if the resident is not known to be infected or colonized with a MDRO. 47. Implementation of Enhanced Barrier Precautionsa. Gowns and gloves will be available outside of the resident's room. b. Alcohol-based hand rub will be available.c. A trash can will be positioned inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. 48. High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygiene Resident #10Review of Resident #10's medical record revealed an admit date of 12/02/2024 with diagnoses which include in part acute kidney failure, benign prostatic hyperplasia, liver cell carcinoma, viral hepatitis C without hepatic coma, adult failure to thrive, and chronic obstructive pulmonary disease. Review of Resident #10's Physician orders revealed in part:07/31/2025 cleanse stage 2 to sacrum with wound cleanser and gauze, pat dry and apply foam dressing to area every 3 days and prn soiled or dislodged. 10/09/2024 Urinary Catheter care every shift12/02/2024 Enhanced Barrier Precautions related to Foley catheter. Review of Resident #10's quarterly Minimum Data Set report dated 06/09/2025 revealed in part Resident #10 had a Brief Interview for Mental Status score of 15 indicating intact cognition.Observation on 08/11/2025 at 8:30 a.m. of Resident #10's room failed to reveal EBP were in place. Observation on 08/11/2025 at 9:00 a.m. revealed Resident #10 lying in bed, Foley catheter in place. Further observation failed to reveal EBP signage posted and gowns, gloves and alcohol-based hand rub readily available outside Resident #10's room. Observation on 08/11/2025 at 9:30 a.m. revealed S10 CNA (Certified Nurse Aid) and S11 Student CNA using gloves as the only PPE while providing activities of daily living care for Resident #10. Observation on 08/12/2025 at 8:30 a.m. failed to reveal EBP in place.During an interview on 08/12/2025 at 9:15 a.m. Resident #10 reported staff have not been wearing a gown during baths or turning, only gloves. Resident #13Review of Resident #13's medical record revealed in part an admit date of 06/27/2025, a readmit date of 07/15/2025 with diagnosis which include in part: longstanding persistent atrial fibrillation, anxiety disorder, pain, acquired absence of right leg above knee, and burn of third degree of left lower leg. Review of Resident #13's physician orders revealed in part:08/05/2025 cleanse wound to left lower leg shin with wound cleanser, part dry, apply collagen to wound bed and cover every day07/31/2025 cleanse wound to left lower leg back with wound cleanser and gauze, pat dry, apply collagen to wound bed and cover with dry dressing every day and as needed dislodgement or soiled dressing.07/17/2025 clean stump daily with soap and water, pat dry, do not cover with dressings, leave open to air. Staples to be removed in one month with general surgery clinic.06/30/2025 Enhanced barrier precaution related to wounds Review of Resident #13's quarterly MDS dated [DATE] revealed in part Resident #13 had a Brief Interview for Mental Status score of 11 indicating moderate cognitive impairment.Observation on 08/11/2025 at 9:00 a.m. Resident #13 sitting up in his wheelchair, right above knee amputee noted. Further observation failed to reveal enhanced barrier precautions were in place. Observation on 08/12/2025 at 8:30 a.m. of Resident #13's room failed to reveal enhanced barrier precautions in place.Observation on 08/12/2025 at 9:20 a.m. failed to reveal enhanced barrier precautions in place.During an interview on 08/12/2025 at 11:55 a.m. Resident #13 reported the staff wear gloves when they provide care but no one wears a gown. Resident #79Review of Resident #79's medical record revealed in part an admit date of 08/07/2025 with diagnoses which include in part nontraumatic intracerebral hemorrhage-intraventricular, aneurysm of unspecified site, obstructive hydrocephalus, convulsions, hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side.Review of Resident #79's physician orders revealed in part:08/08/2025 Monitor surgical incision to left upper quadrant of abdomen for s/s (signs/symptoms) of status change until resolved (sealed with topical adhesive)08/08/2025 Monitor 5 staples behind left ear for s/s of status change until resolved08/08/2025 Monitor 7 staples to top of scalp for s/s of status change until resolvedFurther review failed to reveal an order for Enhanced barrier precautions. Observation on 08/11/2025 at 9:10 a.m. Resident #79 lying in bed, staples noted to scalp and behind left ear. Resident #79 indicated she also had a place on her abdomen. Further observation of Resident #79's room failed to reveal EBPs were in place. Observation on 08/11/2025 at 10:15 a.m. revealed S10 CNA providing ADL (activities of daily living) care to Resident #79 using gloves only for PPE.Observation on 08/12/2025 at 8:30 a.m. Resident #79's room failed to reveal enhanced barrier precautions in place.During an interview on 08/12/2025 at 9:00 a.m. S13 Infection Control verified Resident #10, #13 and #79 did not have EBP signage in place or PPE's readily available outside each resident's room and should have. Observation on 08/13/2025 at 9:00 a.m. Resident #79's room failed to reveal enhanced barrier precautions in place. During an interview on 08/12/2025 at 11:30 a.m. S14 CNA reported if a resident is on a precaution there would be signs posted outside the door and a PPE cart outside the room. S14 CNA reported Resident #10 has a catheter and wound, Resident #13 has a wound on his stump and Resident #79 has a surgery wound and staples and they should all be on EBP. S14 CNA verified Resident #10, #13, and #79 did not have EBP signage posted or PPE's outside the resident's room and should have.During an interview on 08/12/2025 at 11:40 a.m. S12 PTA (Physical Therapy Assistant) reported if a resident is on any kind of precaution there would be a sign outside the door indicating the type of precaution and confirmed there was not posted signage for resident #79 and she was not aware of the EBP related to Resident #79's wounds.During an interview on 08/12/2025 at 11:47 a.m. S9 LPN (Licensed Practical Nurse) verified Resident #10 had a catheter and wound, Resident #10 has a catheter and wound, Resident #13 had a wound on his stump and Resident #79 had a surgery wound and staples and they should all be on EBP. S9 LPN verified the Resident #10, #13, and #79 failed to have EBP signage or PPEs available outside the room prior to this morning and should have. Observation on 08/13/2025 at 9:00 a.m. failed to reveal enhanced barrier precautions in place for Resident #79. During an interview on 08/13/2025 at 9:10 a.m. S13 Infection Control confirmed Resident #79 should have an order and EBP in place and did not.

Based on record review, observation, and interviews, the facility failed to accommodate the needs of 1(#8) of 20 sampled residents. The facility failed to ensure the resident was reassessed for the use assist rails.Review of Resident #8's medical record revealed Resident #8 was admitted [DATE], with a readmission date of 07/28/2025. Resident #8's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left-non dominate side and lack of coordination. Review of Resident #8's Quarterly MDS (Minimum Data Set) dated 06/08/2025 revealed Resident #8 had a BIMS (Brief Interview of Mental Status) score of 13/15, indicating intact cognition. Resident #8 had limited range of motion for both upper and lower extremities on one side. An observation on 08/11/2025 at 9:47 a.m. Resident #8's resting in bed, which did not have assist rails.During an interview on 08/11/2025 at 9:47 a.m. Resident #8 reported while she was away at the hospital, the facility removed her bed rails. Resident #8 reported she and her RP (Responsible Party) had requested to have Resident #8's assist rails back. During an interview on 08/13/2025 at 10:35 a.m. S5 CNA (Certified Nursing Assistant) reported Resident #8 used bed rails to turn and aid in mobility. S5 CNA further reported Resident #8 has requested bed rails to be placed placed back on. During an interview on 08/13/2025 at 10:40 a.m. S4 LPN (Licensed Practical Nurse) reported Resident #8 used bed rails for turning assistance during care and had requested bed rails to be returned. During an interview on 08/13/2025 at 10:45 a.m. S6 LPN/MDS nurse reported bed rail assessment should be completed quarterly, upon change in status, return from discharge, admission, or sooner if necessary. During an interview on 08/13/2025 at 10:50 a.m. S7 LPN/MDS reported residents have the right to have assist rails.

Based on record reviews and interviews, the facility failed to: provide to the resident and/or the resident's responsible party (RP) written notice which specified the reason for transfer, effective date, location and statement of the resident's appeal rights, and duration of the bed hold policy for 1 (#74) of 2 (#74, #76) residents reviewed for transfer/discharge, and notify the State's Long Term Care Ombudsman of discharges in writing for 2 (#74, #76) of 2 (#74, #76) residents reviewed for discharge requirements. Findings: Review of the facility's Bed Hold Prior to Transfer undated policy revealed in part: Policy:Prior to transferring a resident to the hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and/or the resident representative regarding bed hold.Policy Explanation and Compliance Guidelines:Notice before Transfer1. The following information will be given to the resident and/or resident representative.a. The duration of the state bed-hold, if any, during which the resident is permitted to return and resume residence in the nursing facilityb. The reserve bed payment policy in the state plan, if anyc. The facility policy regarding behold periods to include permitting residents to return2. The facility will provide the receiving provider the following:a. Contact information of the practitioner responsible for the care of the residentb. Resident representative information including contact informationc. Advance Directive informationd. All special instructions or precautions for ongoing care, as appropriatee. All other necessary information, including a copy of the resident's discharge summary, as applicable, and any other documentation to ensure a safe and effective transition of care.Resident #74 Review of Resident #74's medical record revealed an admit date of 03/11/2021 with diagnoses of, but not limited to Alzheimer's disease, major depressive disorder, and anxiety. Review of Resident #74's medical record revealed Resident #74 was sent to local ED (Emergency Department) on 06/20/2025 for evaluation. Further review of Resident #74's medical record failed to reveal a written notice of transfer/discharge had been provided at the time of transfer. The facility failed to provide documented evidence the State's Long-Term Care Ombudsman had been notified of Resident #74's discharge in writing as required. Resident #76Review of resident #76's medical record revealed an initial admit date of 06/17/2025, with diagnoses of, but not limited to chronic obstructive pulmonary disease major depressive disorder, chronic respiratory failure, and atrial fibrillation. Further review of Resident #76's medical record revealed Resident #76 was discharged home on [DATE].The facility failed to provide documented evidence the State's Long-Term Care Ombudsman had been notified of Resident #76's discharge in writing as required. During an interview on 08/13/2025 at 10:15 a.m., S2DON (Director of Nursing) reported nursing does not provide a written notice of bed hold to the resident or resident's RP at the time of discharge and or transfer and was not aware one needed to be sent with the resident. During an interview on 08/13/2025 at 10:30 a.m., S3Social Services reported a written notice of bed hold was not being provided to residents or residents' RPs at the time of transfer. During an interview on 08/13/2025 at 2:00 p.m. S1Administrator and S3Social Services confirmed the State's Long-Term Care Ombudsman had not been notified of Resident #74's transfer or Resident #76's discharge in writing as required.

Based on observations, record reviews, and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice and followed facility's policies for 2 (# 60, #77) of 2 (#60, #77) residents reviewed for respiratory care. The facility failed to ensure: 1.) Oxygen cannula and tubing was changed per facility policy (Resident #60), 2.) Respiratory mask was stored per facility policy (Resident #77), and 3.) An oxygen in use sign was placed on the outside of the resident's room entrance door per facility policy (Resident #77). Findings:Review of the facility's Respiratory Equipment-Infection Control Guidelines policy procedures dated June 2024 revealed, in part: Oxygen Concentrators: 1. Oxygen cannula or mask and tubing should be dated when put in use and changed at least weekly or whenever contamination is suspected. Medication Nebulizers/Continuous Aerosol Machines/CPAP (Continuous Positive Airway Pressure) /BIPAP (Bilevel Positive Airway Pressure): 3. Equipment, administration sets, and tubing must be covered with plastic or clean towel when not in use. Review of the facility's undated Oxygen Administration procedure revealed, in part: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps: 2. Place an “Oxygen in Use” sign on the outside of the room entrance door. Resident #60 Review of Resident #60’s medical record revealed in part, Resident #60 was readmitted to the facility on [DATE] with diagnoses including, but not limited to chronic respiratory failure with hypoxia and shortness of breath. Review of Resident #60’s active physician orders revealed in part, an order dated 05/06/2025 oxygen at 2L (liters) via NC (nasal cannula) PRN (as needed) SOB (shortness of breath)/O2 (oxygen) saturation less than 95% and an order dated 06/11/2025 change and date O2 tubing every week on Friday during day shift. An observation on 08/11/2025 at 8:28 a.m. revealed Resident’s #60’s oxygen tubing dated 08/02/2025. During an interview on 08/11/2025 at 10:05 a.m. S4LPN (Licensed Practical Nurse) reported Resident’s #60’s oxygen tubing was dated 08/02/2025. S4LPN further reported oxygen tubing should be changed weekly and was not. Resident #77 Review of Resident #77’s medical record revealed in part, Resident #77 was admitted to the facility on [DATE] with diagnoses including, but not limited to COPD (Chronic Obstructive Pulmonary Disease). Review of Resident #77’s active physician orders revealed in part, an order dated 07/23/2025 Ipratropium-albuterol solution 0.5-2.5 (3)mg (milligrams)/3ml (milliliter) inhale 1 vial orally 3 times a day and an order dated 07/28/2025 oxygen at 2L. An observation on 08/11/2025 at 8:50 a.m. revealed Resident #77 lying in bed with oxygen at 2L per nasal cannula in place. Observation on 08/11/2025 at 8:50 a.m. failed to reveal an oxygen in use sign on outside of Resident #77's room entrance door. An observation on 08/11/2025 at 11:00 a.m. revealed Resident #77's respiratory mask was stored uncontained on Resident #77’s bedside table. An observation on 08/11/2025 at 11:00 a.m. failed to reveal an oxygen in use sign on outside of Resident #77's room entrance door. During an interview on 08/11/2025 at 11:14 a.m. S9LPN confirmed nebulizer masks should been stored in a plastic bag when not in use and was not.

Based on record review, observation, and interviews the facility failed to ensure the Controlled Drug Record was maintained and reconciled for 1 (Cart A) of 1 (Cart A) medication cart reviewed. Review of the facility's Medications - Controlled Substances Policy (undated) revealed in part:1. General Protocols:a. Controlled substances are stored in a separate compartment of an automated dispensing system or other locked storage unit with access limited to approved personnel. d. All controlled substances (Schedule II, III, IV, and V) are accounted for in one of the following ways:ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided.iii. All specially compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy.h. The Controlled Drug Record/Narcotic Count form may serve the dual purpose of recording both narcotic disposition and patient administrationi. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR (Medication Administration Record) is the source for documenting any patient-specific narcotic dispensed from the pharmacy. Review of Resident #41's physician orders included an order dated 04/30/2025 Ativan (Lorazepam) oral tablet 0.5 mg (Milligram); give one-half tablet by mouth two times a day.During a review of Medication Cart A on 08/12/2025 at 3:50 p.m. with S4 LPN (Licensed Practical Nurse) an observation of Resident #41's Controlled Drug Record revealed an inaccurate remaining dose count for Lorazepam 0.5 mg oral tablet. Further review of Resident #41's Controlled Drug Record revealed the last dose of Resident #41's Lorazepam was administered 08/11/2025 at 8:00 p.m. with a remaining count of 48 doses. Review of Resident #41's Lorazepam blister pill packet revealed 47 doses remaining for administration. During an interview on 08/12/2025 at 3:50 p.m. S4 LPN reported she failed to complete the Controlled Drug Record for 08/12/2025 8:00 a.m. dose of Resident #41's Lorazepam. S4 LPN acknowledged there was a discrepancy in the dose count of Resident #41's Lorazepam blister pack.During an interview on 08/12/2025 at 3:55 p.m. S2 DON (Director of Nursing) reported narcotics should be documented with two different methods, the MAR and hard copy for [NAME] verification.

Based on record reviews and interview, the facility failed to protect the resident's right to be free from abuse of misappropriation of property and exploitation by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. S2 CNA (Certified Nursing Assistant) transferred money from Resident #1's bank account via [NAME] (bank to bank transfer) to her personal bank account. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 03/17/2025, thus it was determined to be a Past Noncompliance Citation. Findings: Review of Facility's Abuse Prevention and Investigation (undated) Policy and Procedures revealed: Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, and misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone. Policy Interpretation and Implementation: 1.The facility defines resident abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .This includes abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Exploitation is defined as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion. Review of Resident #1's medical record revealed an admitted [DATE] and a discharge date of [DATE] with the following diagnoses, including in part: type 2 diabetes mellitus with hyperglycemia, hypertensive heart disease without heart failure, unspecified sequelae of cerebral infarction and major depressive disorder/recurrent/unspecified. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 14 indicating cognitively intact. Review of Resident #1's Care Plan (no date) revealed: Requesting undesignated staff to obtain money through personal bank account; educate resident on maintaining personal information and not providing to others including undesignated staff, if approached by resident in regard to purchases notify business office and redirect resident to business office, redirect and educate resident on personal funds and safety regards to personal information and safety of, staff to notify administrator with any voiced concerns by resident related to funds and redirect resident to business office at time of occurrence. Review of the facility's internal investigation report dated 02/17/2025 revealed in a statement from S2 CNA that S2 CNA's mother, S3 CNA who also worked at the facility, offered Resident #1 S2 CNA's [NAME] account after Resident #1 asked S3 CNA if she had a [NAME] account so that Resident #1 could transfer money via [NAME] to S2 CNA's bank account and S2 CNA would give the money to Resident #1. S2 CNA acknowledged money was transferred from Resident #1's bank account to her bank account. S2 CNA withdrew the money and gave it to S3 CNA to give the money to Resident #1. As part of the internal investigation, in an interview with Resident #1, she denied asking S2 CNA or S3 CNA to use their [NAME] account in order to get money out of her bank account. Attempted to contact S2 CNA on 03/17/2025 at 12:36 p.m. was unsuccessful and the call went straight to voicemail. Attempted to contact S3 CNA on 03/17/2025 at 12:36 p.m. was unsuccessful. Phone number was not in service. Unable to contact Resident #1's aunt due to no contact information available. During an interview on 03/17/2025 at 12:30 p.m. S1 Administrator reported on 02/17/2025 Resident #1 reported to him that S2 CNA had taken her money. S1 Administrator further reported Resident #1 and her aunt had gone to the bank the Saturday before (02/15/2025) and discovered her money was gone. S1 Administrator reported he immediately began an investigation and suspended S2 CNA and S3 CNA. S1 Administrator reported S3 CNA told him Resident #1 asked if she had a [NAME] account and she told her no but S2 CNA did. S1 Administrator further reported S2 CNA told him she did bring the money to Resident #1 and she did not take it. S1 Administrator reported Resident #1's bank provided him a partial bank statement which showed on January 29th a withdrawal of $250.00 to the [NAME] account of S2 CNA. He indicated he told S2 CNA he saw this withdrawal which didn't look good for her. S1 Administrator verified the police were notified and a police report was filed. S1 Administrator further reported Resident #1 was cognitively intact. S1 Administrator confirmed S2 CNA acknowledged Resident #1's money was transferred to her account. S1 Administrator acknowledged the bank statement of Resident #1 confirmed a transaction of $250.00 was transferred to S2 CNA's account on 01/29/2025. Further interview with S1 Administrator at this time revealed the money was never found. The facility was waiting on the police department. S1Administrator indicated they would pay Resident #1's money back if the police department investigation didn't yield any outcome. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility has implemented the following actions to correct the deficient practice: 1. S2 CNA and S3 CNA were immediately suspended and then terminated. 2. An in-service was conducted on 02/17/2025 on resident abuse policy and reporting - staff within the facility is not under any circumstances to deal with resident finances, for any reason. If a resident asks you to, get Director of Nursing/Administrator/Nurse/Social Services/Business Office Manager. No exceptions. This can be a form of resident abuse. 3. All residents had the potential to be affected. Residents were interviewed and no other residents were affected. Abuse/Safety Questionnaires were conducted on 02/17/2025, 02/28/2025, 03/05/2025, 03/06/2025, and 03/13/2025 to include the following questions: Do you feel safe in your environment? Have you felt abused by another resident or by staff? Do you have any concerns related to your safety? Has any staff member every asked you for money or bank account information (outside of billing purposes if applicable)? Are you aware of your resident rights? 4. Audits/Findings of resident abuse and reporting - Administrator or designee will monitor resident abuse and reporting by interviewing 8 residents per week x 8 weeks then randomly to ensure compliance. Audit reports will be submitted to the Administrator and QAPI (Quality Assurance and Performance Improvement) committee for QA and new interventions will be implemented as needed. Completed weekly beginning 02/17/2025 through 03/13/2025 and ongoing. 5. Date of completion 03/13/2025.

Based on observations and interview the facility failed to ensure the most recent survey results were posted in a place readily accessible to the residents, family members or anyone to review. Findings: Observation on 08/12/2024 at 10:00 a.m. failed to reveal the most recent survey results were posted in a place that was readily accessible for review. Observation on 08/12/2024 at 10:00 a.m. with S1 Administrator revealed the most recent survey results were not posted in a place that was readily available for review. During an interview on 08/12/2024 at 11:45 a.m. S1 Administrator confirmed the most recent survey results should have been posted for residents, family and anyone to review.

45317 Based on record reviews, observations, and interviews, the facility failed to ensure the correct use and the maintenance of bed rails by ensuring residents were assessed for the risk of entrapment from bed rails, obtaining a written order from the physician for bed rails and an informed consent from resident or resident representative prior to installation for 4 (#8, #10, #13, #37) out of 7 (#5, #8, #10, #13, #34, #37, #39) residents reviewed for accidents. Findings: Resident #8 Review of Resident #8's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to functional quadriplegia and history of falling. Review of Resident #8's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 9 indicating moderately impaired cognition and a functional status requiring total dependence with two person for bed mobility and transfer. Review of Resident #8's medical record on 08/13/2024 at 11:00 a.m. failed to reveal a physician's order for bed rails, a risk assessment for entrapment from bed rails, and a signed consent for bed rails. An observation on 08/12/2024 at 9:15 a.m. revealed Resident #8 lying in bed with eyes closed. Resident #8's bed had bed rails in place bilaterally at the HOB (head of bed) in a raised position. An observation on 08/13/2024 at 10:54 a.m. revealed Resident #8 lying in bed with HOB elevated. Resident #8's bed had bed rails in place bilaterally at the HOB in a raised position. An observation on 08/14/2024 at 7:33 a.m. revealed Resident #8 sitting up in bed with HOB elevated eating breakfast. Resident #8's bed had bed rails in place bilaterally at the HOB in a raised position. During an interview on 08/14/2024 at 7:35 a.m. S3 LPN (Licensed Practical Nurse) confirmed Resident #8 did have bed rails in use. During an interview on 08/14/2024 at 11:05 a.m. S4 CNA (Certified Nursing Assistant) confirmed Resident #8 did have bed rails in use. During an interview on 08/14/2024 at 12:15 p.m. S2 DON (Director of Nursing) confirmed Resident #8 did not have an assessment for entrapment of bed rails, a physician's order for bed rails or a signed consent from resident or resident representative prior to installation of bed rails. Resident #10 Review of Resident #10's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to muscle wasting and atrophy not elsewhere classified right upper arm, generalized muscle weakness, malignant neoplasm of unspecified kidney except renal pelvis. Review of Resident #10's Annual MDS assessment dated [DATE] revealed a BIMS score of 5 indicating severely impaired cognition and functional status requiring total dependence with two person for transfers and one person for bed mobility. Review of Resident #10's medical record on 08/13/2024 at 11:30 a.m. failed to reveal a physician's order for bed rails, a risk assessment for entrapment from bed rails, and a signed consent for bed rails. An observation on 08/12/2024 at 8:50 a.m. revealed Resident #10 lying in bed. Resident #10's bed had bed rails in place bilaterally at the HOB (head of bed) in a raised position. An observation on 08/14/2024 at 7:30 a.m. revealed Resident #10 sitting up in bed eating breakfast. Resident #10's bed had bed rails in place bilaterally at the HOB (head of bed) in a raised position. During an interview on 08/14/2024 at 7:35 a.m. S3 LPN confirmed Resident #10 did have bed rails in use. During an interview on 08/14/2024 at 10:50 a.m. S4 CNA confirmed Resident #10 did have bed rails in use. During an interview on 08/14/2024 at 12:15 p.m. S2 DON confirmed Resident #10 did not have an assessment for entrapment of bed rails, a physician's order for bed rails or a signed consent from resident or resident representative prior to installation of bed rails. Resident #13 Review of Resident #13's medical record revealed an admitted [DATE] with the following diagnoses including, but not limited to unspecified lack of coordination, muscle and wasting atrophy/not elsewhere classified/left upper arm, muscle and wasting atrophy/not elsewhere classified/right upper arm, unspecified abnormalities of gait and mobility, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cognitive communication deficit, morbid (severe) obesity due to excess calories, heart failure/unspecified, and muscle weakness (generalized). Review of Resident #13's MDS assessment dated [DATE] revealed a functional status requiring total dependence with two person for bed mobility, transfer and toilet use. Review of Resident #13's medical record failed to reveal a physician's order for bed rails and a signed consent for bed rails prior to installation. Observation on 08/12/2024 at 9:00 a.m. revealed Resident #13 sitting up in bed with padded bed rails raised. During an interview on 08/12/2024 at 9:00 a.m. Resident #13 reported she has to be put on a lift to get out of bed because she is unable to get out of bed by herself. Observation on 08/13/2024 at 10:00 a.m. revealed Resident #13 lying in bed with padded bed rails raised. Observation on 08/14/2024 at 9:50 a.m. revealed Resident #13 sitting up in bed with padded bed rails raised. During an interview on 08/14/2024 at 3:15 p.m. S2 DON acknowledged Resident #13 did not a have a consent or physician's order for bed rails. Resident #37 Review of Resident #37's medical record revealed an admitted [DATE] with the following diagnoses, including but not limited to unspecified lack of coordination, muscle weakness (generalized), abnormal posture, cognitive communication deficit, need for assistance with personal care, functional quadriplegia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and history of falling. Review of Resident #37's medical record failed to reveal a physician's order for bed rails and a signed consent for bed rails prior to installation. Observation on 08/12/24 at 12:44 p.m. revealed Resident #37 lying in bed with bed rails raised. Observation on 08/12/2024 at 2:15 p.m. revealed Resident #37 lying in bed asleep with bed rails raised. Observation on 08/13/2024 at 9:00 a.m. revealed Resident #37 lying in bed with bed rails raised. Observation on 08/14/2024 at 10:30 a.m. revealed Resident #37 lying in bed asleep with bed rails raised. During an interview on 08/14/2024 at 12:55 p.m. Resident #37 reported he cannot turn side to side or use bed rails and that the staff use the Hoyer lift to get him out of bed. During an interview on 08/14/2024 at 3:15 p.m. S2 DON acknowledged Resident #37 did not a have a consent or physician's order for bed rails.

Based on record reviews and interview, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 2 (#13, #39) out of 5 (#13, #14, #37, #39, #60) residents reviewed for unnecessary medications. The facility failed to monitor Resident #13 for side effects while receiving an antidepressant and Resident #39 for side effects while receiving antidepressant and antianxiety medications. Findings: Resident #13 Review of Resident #13's medical records revealed an admitted [DATE] with the following diagnoses, including but not limited to unspecified lack of coordination, abnormalities of gait and mobility, cognitive communication deficit, other specified depressive episodes and muscle weakness (generalized). Review of Resident #13's comprehensive care plan revealed at risk for adverse reactions and or side effects related to daily use of antidepressant medication - assess for adverse side effects/document and report, and monitor for extrapyramidal symptoms and document. Review of Resident #13's physician's orders revealed an order dated 07/24/2024 for Escitalopram Oxalate tab 10 mg (milligram) give 1 tablet orally one time a day related to other specified depressive episodes. Review of Resident #13's August 2024 Medication Administration Record failed to reveal side effects were monitored while receiving antidepressant. Resident #39 Review of Resident #39's medical records revealed an admitted [DATE] with the following diagnoses, including but not limited to cognitive communication deficit, muscle weakness (generalized), unspecified lack of coordination, primary insomnia, generalized anxiety disorder, other specified depressive episodes, and major depressive disorder/recurrent/moderate. Review of Resident #39's physician's orders revealed orders dated: 10/11/2021 for Lorazepam tab 1 mg give 1 tablet orally two times a day related to anxiety disorder 03/11/2021 for Duloxetine HCl (hydrochloride) enteric coated pellets capsule 60 mg give 1 capsule orally two times a day related to major depressive disorder/recurrent/moderate 12/04/2023 for Buspirone HCl tab 10 mg give 1 tablet orally two times a day related to major depressive disorder/recurrent/moderate 03/17/2022 for Divalproex Sodium capsule delayed release sprinkle 125 mg give 2 capsules orally three times a day related to major depressive disorder/recurrent/moderate. Review of Resident #39's August 2024 Medication Administration Record failed to reveal monitoring for side effects from anti-depressant and anti-anxiety medications. During an interview on 08/14/2024 at 4:00 p.m. S2 Director Of Nursing acknowledged Resident #13 and Resident #39 were not monitored for side effects and should have been.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free of unnecessary medications for 1 (#39) out of 5 (#13, #14, #37, #39, #60) residents reviewed for unnecessary medications. The facility failed to monitor Resident #39 for edema while receiving a diuretic. Findings: Review of Resident #39's medical record revealed admitted [DATE] with the following diagnoses including, but not limited to heart failure/unspecified and type 2 diabetes mellitus with diabetic neuropathy/unspecified. Review of Resident #39's physician's orders revealed an order dated 09/09/2021 for Chlorthalidone tab 25 mg (milligram) give 1 tablet orally one time a day related to heart failure. Review of Resident #39's August 2024 Medication Administration Record failed to reveal monitoring for edema. During an interview on 08/14/2024 at 4:00 p.m. S2 Director of Nursing acknowledged Resident #39 was not monitored for edema and should have been.

Based on record review, and interviews, the facility failed to ensure residents were treated with respect and dignity and cared for in a manner that promotes enhancement of his or her quality of life for 3 (#3, #17, #26) of 5 residents attending the survey Resident Council meeting. The facility failed to ensure the residents were treated with dignity and respect during activities and not being scolded or reprimanded by staff causing emotional distress. Findings: During the Survey Resident Council (RC) meeting on 09/25/2023 at 3:00 p.m. Residents #3, #17, and #26 (2 other residents in attendance wished not to be identified or interviewed) reported a week ago Friday all the residents were scolded before Bingo by S7 Activities Director making them feel like little children being scolded. Residents further reported they didn't feel like they could trust S7 Activities Director anymore and were shocked at his actions. Residents reported they feel like they don't have any say and are treated like they are children and it makes them angry and sad and they feel very hurt. During an interview on 09/26/2023 at 1:40 p.m. S7 Activities Director reported the facility had a 'mock survey about 2 weeks ago and the surveyors handpicked residents that could talk to them. S7 Activities Director further reported the residents had voiced complaints to the mock surveyors and they were not true. Residents had reported nothing to do on the weekend and not having a preacher. S7 Activities Director reported he was busy doing other things and had a life. S7 Activities Director reported he would quit if he was asked to work weekends and he and Resident #26 were buddies. Resident #26 Review of Resident #26's Minimum Data Set (MDS) for 07/15/2023 revealed Resident #26 was assessed as requiring Self-performance with set-up assistance with bed mobility, transfers, and all activities of daily living and had a BIMS (Brief Interview Mental Status) score of 14 indicating Resident #26 was cognitively intact. During an interview on 09/26/2023 at 4:30 p.m. Resident #26 reported S7 Activities Director came to us this afternoon at basketball and said he knew what we told the surveyors and he didn't care it still stood. Resident #26 further stated crying, It might not have been so bad but he said he didn't care, HE DIDN'T CARE! And that was hurtful. He said what he told us before still stood. During an interview on 09/27/2023 at 11:50 a.m. Resident #26 reported he felt like he was being scolded and talked down to by S7 Activities Director before the bingo game last week and he didn't like it. Resident #26 reported he felt like he and S7 Activities Director were close friends but now S7 Activities Director won't speak or say hello making resident #26 feel sad. Resident #3 Review of Resident #3's current MDS revealed Resident #3 was assessed as having a BIMS score of 15 indicating Resident #3 was cognitively intact. During an interview on 09/27/2023 at 12:40 p.m. Resident #3 reported before Bingo last week S7 Activities Director was giving it to us and we were just in shock. Resident #3 further reported S7 Activities Director was talking down to us and it made me feel like dirt. Resident #3 reported S7 Activities Director has really been just getting out of hand lately with everybody. S7 Activities Direct told us, we could watch him on the way out of here and say good-by and we would be sorry he left. Like he was trying to make us feel bad for what he did. Resident #3 reported feeling degraded and small. It was hurtful for sure. Resident #17 Review of Resident #17's current MDS revealed Resident #17 was assessed as having a BIMS score of 13 indicating Resident #17 was cognitively intact. During an interview on 09/27/2023 at 1:15 p.m. Resident #17 reported not being able to remember the exact words S7 Activities Director used when he got on them real bad before Bingo, but she was shocked. Resident #17 reported S7 Activities Director told them they could get their own games during the week so they could get them on the weekend and he would not come to the facility to help them. Resident #17 further reported, feeling like an arrow directed right at me in the meeting. He was so angry. You could tell he was angry by the hard tone in his voice. Resident #17 reported, S7 Activities Director scolded residents again during an activity yesterday when S7 Activities Director said, I know what ya'll said to the surveyors and I don't care. Resident #17 reported thinking S7 Activities Director was her personal friend I could talk to, not now. He's been ignoring us especially today and he won't speak. Resident #17 reported the scolding made her feel like a little child and it was hurtful and she didn't like it. During an interview on 9/27/2023 at 2:45 p.m. S1 Administrator, S2 Director of Nursing and S3 Corporate Nurse confirmed S7 Activities Director spoke in an undignified manner to and at least 3 residents. They further indicated S7 Activities Director would be suspended.

Based on record review and interviews the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#13) of 26 sampled residents reviewed, by failing to give medication as ordered by a physician. Finding: Review of the provider's policy for Preventing Medication Errors revealed the following: The facility will ensure its residents are free of any significant medication errors. 5. Compare medication source (bubble pack, vial, etc .) with MAR (medication administration record) to verify resident name, medication name, form, dose, route and time. 18. Correct any discrepancies and report to nurse manager. Review of resident #13's medical record revealed an admitted [DATE] and a diagnosis of but not limited to Dementia, Major Depressive Disorder, Dysphagia, Anxiety Disorder, and Insomnia. Review of resident #13's August 2023 and September 2023 Physician's Orders revealed an order for Klonopin 1mg (milligram) by mouth twice a day, diagnosis anxiety Review of resident #13's Comprehensive Care Plan revealed a problem of Psychotropic Medications usage daily for anxiety/depressive psychotic episodes with an approach of but not limited to give medications as ordered. Review of resident #13 Controlled Substance Record dated 07/30/2023 to 08/14/2023 revealed the following: 1. Klonopin 0.5mg (one tablet) was signed out at 8:00 a.m. 08/05/2023 2. Klonopin 0.5mg (one tablet) was signed out at 8:00 a.m. 08/12/2023 3. Klonopin 0.5mg (one tablet) was signed out at 8:00 a.m. 08/13/2023 4. Klonopin 0.5mg (one tablet) was signed out at 8:00 p.m. 08/14/2023 Further review indicated resident #13 was not administered Klonopin 1mg as ordered by the physician, but was administered Klonopin 0.5mg at 8:00 a.m. on 08/05/2023, 08/12/2023, and 08/13/2023 and at 8:00 p.m. on 08/14/2023. During an interview on 09/26/2023 at 3:00 p.m. S2 DON (Director of Nurses) confirmed resident #13 was not given Klonopin 1mg as ordered by her physician on 08/05/2023, 08/12/2023, 08/13/2023 and 08/14/2023. S2 DON confirmed resident #13 was administered Klonopin 0.5 mg instead of Klonopin 1mg as ordered by the physician. Review of resident #13's September 2023 MAR revealed Klonopin 1mg by mouth twice a day was not given on the following dates: 1. 09/02/2023 8:00 a.m. and 8:00 p.m. doses 2. 09/03/2023 8:00 a.m. and 8:00 p.m. doses 3. 09/04/2023 8:00 a.m. and 8:00 p.m. doses 4. 09/05/2023 8:00 p.m. dose 5. 09/06/2023 8:00 a.m. and 8:00 p.m. doses Review of resident #13's Controlled Substance Records failed to reveal that Klonopin 1mg had been signed out to be administered on 09/01/2023, 09/02/2023, 09/03/2023, 09/04/2023, 09/05/2023 and 09/06/2023. During an interview on 09/26/2023 at 2:45 p.m. S2 DON confirmed resident #13 had not been given Klonopin 1mg as ordered by her physician on 09/01/2023, 09/02/2023, 09/03/2023, 09/04/2023, 09/05/2023 and 09/06/2023. S2 DON confirmed resident #13 was out of Klonopin until 09/07/2023 and was not given Klonopin 1mg as ordered by the physician on 09/01/2023, 09/02/2023, 09/03/2023, 09/04/2023, 09/05/2023 and 09/06/2023.

Based on observations, interviews, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 7 residents were observed during the facility's medication administration by 2 LPN's (Licensed Practical Nurse) on 09/25/2023 through 09/26/2023. A total of 27 opportunities were observed which included 4 errors involving 4 residents (#19, #18, #21, and #7), for a medication error rate of 14.81%. Findings: Review of facility's Medications-Preventing Medication Errors policy (undated) revealed in part: Policy: The facility will ensure its residents are free of any significant medication errors. Mediation error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specification or accepted professional standards or principals. Policy explanation and compliance guidelines: The facility must ensure that it is free of medication errors rates of 5 percent or greater as well as any significant medication errors. Additional requirements 14. Medication will be administered within 60 minutes prior or after scheduled time unless otherwise ordered by physician. 19. Medication error rate is calculated using the following equation: Medication error rate=number of errors observed by the opportunities for errors (doses given plus doses ordered not given) x 100 Resident #19: Observation of medication administration on 09/25/2023 at 9:05 a.m. with S4 LPN (Licensed Practical Nurse) failed to reveal Resident #19 received Miralax powder 17 grams in 8 ounces of water by mouth. During an interview on 09/25/2023 at 9:05 a.m. S4 LPN reported Miralax 17 grams was not available to administer to Resident #19. Review of Resident #19's September 2023 physician orders revealed an order dated 08/2/2022 for Miralax powder; Give 17 grams in 8 ounces of water by mouth daily. Resident #18: Observation of medication administration on 09/25/2023 at 9:18 a.m. with S4 LPN failed to reveal Resident #18 received Hemocyte-F 324/ 106 mg (milligrams) tablet by mouth. During an interview on 09/25/2023 at 9:18 a.m. S4 LPN reported Hemocyte-F 324/ 106 milligrams was not available to administer to Resident #18. Review of Resident #18's September 2023 physician orders revealed an order dated 03/31/2023 for Hemocyte-F 324/ 106 milligrams tablet by mouth every day. Resident #21: Observation of medication administration on 09/25/2023 at 2:31 p.m. with S5 LPN failed to reveal Resident #21 received Bumetanide 1 mg by mouth. During an interview on 09/25/2023 at 2:31 p.m. S5 LPN reported Bumetanide 1mg was not available to administer to Resident #21. Review of Resident #21's September 2023 physician orders revealed an order dated 12/14/2022 for Bumetanide 1mg tablet; Give 1 tablet by mouth daily at 2:00 p.m. During an interview on 09/25/2023 at 2:30 p.m. S2 DON (Director of Nursing) reported medications should be requested prior to completely running out. S2 DON reported Miralax 17 grams and Hemocyte-F 324/ 106 milligrams have not been received from the pharmacy and was not purchased from the local pharmacy. Resident #17 Observation of medication administration on 09/26/2023 at 8:40 a.m. with S5 LPN failed to reveal Resident #17 received Meclizine 25 mg by mouth. Review of Resident #17's September 2023 EMAR (Electronic Medication Administration Record) revealed documentation of administration of Meclizine 25 mg at 8:00 a.m. Review of Resident #17's September 2023 physician orders revealed an order dated 10/03/2022 for Meclizine 25 mg tablet; Give one tab by mouth twice a day. During an interview on 09/26/2023 at 9:15 a.m. S5 LPN reported it must have been an oversight, S5 LPN reported she thought the medication was administered.

Based on record reviews, observations and interviews the facility failed to ensure 1 resident (#52) out of 1 resident reviewed for accommodation of needs and preferences was able to move around room, reach personal items and call light at all times. Findings: Review of Resident #52's diagnoses revealed the following but not limited to hemiplegia following cerebral infraction affecting left dominant side (12/16/2022), muscle weakness (12/16/2022), need for assistance with personal care (12/16/2022), primary generalized (osteo) arthritis (12/16/2022), dysarthria following cerebral infarction (12/16/2022) Review of Resident #52's quarterly MDS (Minimum data sets) dated 08/12/2023 revealed Section C. Cognitive Patterns with a BIMS (Brief interview of Mental Status) score of 14 out of 15 indicating cognitively intact Further review of Section G. Functional Status revealed functional limitation in range of motion with impairment on one side to upper and lower extremity Observation on 09/25/2023 at 1:54 p.m. revealed Resident #52 in room sitting up in motorized wheel chair on the left side of her bed with call light out of reach clipped to the right side of the bed. During an interview on 09/25/2023 at 1:54 p.m. Resident # 52 reported she could not reach call light while up in motorized wheel chair. Resident #52 reported motorized wheel chair can not fit between bed to reach call light or the bookshelf with personal items. During an interview on 09/26/2023 at 10:30 a.m. revealed Resident #52 in room sitting up in motorized wheel chair with call light out of reach. Further observation revealed Resident #52's call light was in between the right side rail and the mattress. During an interview on 09/26/2023 at 10:35 a.m. S6 CNA (Certified Nurse Assistant) reported Resident #52 has been in this bed assignment since she returned to work last Monday. S6 CNA reported Resident #52 prefers her call light on the right side of bed when she is in bed since she has limited use of her left arm. S6 CNA further reported when Resident #52 is up in motorized wheel chair she cannot fit between right side of the bed to get to call light or bookshelf with personal items.

Based on record review and interview the facility failed to ensure residents received treatment and care in accordance with professional standards and comprehensive person centered plan of care for 1 (#1) of 5 sampled residents. The facility failed to provide restorative services according to Resident #1's comprehensive plan of care. Findings: Review of the facility's Restorative Maintenance Policy revealed the following: Goal: To provide the assistance needed to help each resident achieve or maintain his or her highest practical level of functioning: All residents will be assessed on admission and no less than quarterly by a licensed nurse for restorative need. Review of Resident #1's Medical Records revealed an admitted [DATE] with a diagnosis of but not limited to Parkinson's Disease, Type 2 Diabetes, recent history of COVID 19, Rheumatoid Arthritis, Fibromyalgia, Unspecified Dementia with other behavioral disturbances, lack of coordination, and Cognitive Communicative Deficit. Review of Resident #1's Minimum Data Set, dated dated dated [DATE] revealed Resident #1 was assessed to have a BIMS (Brief Interview Mental Status) score of 6 indicating severely impaired cognition. Further review revealed Resident #1 was assessed to require limited one person physical assistance with walking in room, transfers, bed mobility, personal hygiene, dressing and toilet use. Review of Resident #1's Comprehensive Plan of Care revealed the following problems and approaches: Restorative nursing 11/14/2022 Will have improved AROM (active range of motion) to joints as evidenced by the ability to perform BLE (bilateral lower extremities) therapeutic exercise bike times 15 minutes at least 6 days a week Restorative AROM and dressing: to maintain BLE strength using exercise bike - 2/14/2023 Dressing self with limited assist - 2/14/2023 Review of Resident #1's medical record revealed the following physician's orders: 1. 11/14/2022 Restorative - Resident to participate in BLE exercises using exercise bike times15 minutes for maintenance of BLE strength. 2. 11/14/2022 Restorative orders Resident will complete UE/LE (upper/lower extremities) dressing with caregiver with increased precautions for safety awareness. Review of a list of residents residing in the facility who were actively receiving restorative services failed to include Resident #1. During an interview on 3/21/2023 at 1:26 p.m. S3 Restorative Aide reported, Resident #1 was not receiving restorative services. S3 Restorative Aide reported S1 Medicaid/Restorative LPN (licensed practical nurse) provided her with a list of residents to provide restorative services to and Resident #1 was not on the list at this time. During an interview on 3/21/2023 11:25 a.m. S2 PT (Physical Therapist) reported Resident #1 should have been receiving restorative therapy that included occupational therapy needs such as dressing and grooming and arm strengthening. S2 PT further reported S1 Medicaid/Restorative LPN was responsible for resident restorative services. During an interview on 3/21/2023 at 11:30 a.m. S1 Medicaid/Restorative LPN reported Resident #1 was not currently receiving any type of restorative services. S1 Medicaid/Restorative LPN confirmed Resident #1 was not put back on the facilities list of residents requiring restoratives services. S1 Medicaid/Restorative LPN also confirmed Resident #1 should have started restorative services upon completing occupational therapy on 2/18/2023.

Based on record review, observations and interview the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 (#42) of 1(#42) resident reviewed for position and mobility. The facility failed to ensure resident #42 wore a splint on contracted right hand. Findings: Review of resident #42's electronic health record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #42's Minimum Data Set for 8/02/2022 revealed resident #42 was assessed to require total assistance with bed mobility, transfers, and all activities of daily living. Review of resident #42's Comprehensive Care Plan revealed a problem and approaches of: At risk for contractures: resident will not have a decrease in range of motion; Passive range of motion exercises with activities of daily living care every shift to prevent contractures and stiffness to right side upper and lower extremities related to [CONDITION(S)] affecting right dominant side. Review of resident #42's September 2022 Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation 9/12/2022 at 2:20 pm revealed resident #42's contracted right hand without a splint device in place. Observation on 9/13/2022 at 10:15 am with S1 DON (Director of Nursing) revealed resident #42's contracted right hand without a splint device in place. During an interview on 9/13/2022 at 10:15 am S1 DON reported resident #42 should have a splint on her right contracted hand as ordered by the physician.

Based on observations, interviews, and policy reviews, the facility failed to ensure infection control measures were practiced to provide a safe, sanitary environment and prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. The Mechanical Lift was cleaned between use for 2 (#26, #5) of 2 (#26, #5) residents observed for the use of the lift; 2. Staff removed contaminated gloves and sanitized hands before opening the drawers of the resident's bedside table and touching items inside each drawer after performing incontinence care for 1 (#5) of 1 (#5) residents observed for incontinence care. 3. Appropriate PPE (Personal Protective Equipment) was available and utilized by staff while handling soiled linens and laundry in the laundry facility. There were 54 residents in the facility according to the Resident Census and Conditions of Residents report dated 9/12/22. Findings: 1. Observation on 09/12/22 at 10:26 AM revealed S5 CNA (Certified Nursing Assistant) used the mechanical lift assisted by S6 TNA (Temporary Nursing Assistant) to transfer Resident #26 from his bed to his wheelchair. During the transfer they handled the resident's indwelling catheter tubing and drainage bag, linens, the lift hooks, and the operating controls of the mechanical lift. S6 TNA then parked the lift in the hallway and continued to provide care for Resident #26. Further observation on 9/12/22 at 11:10 AM revealed S6 TNA got the same lift from the hallway and used the lift to transfer Resident #5 assisted by S5 CNA. S6 TNA and S5 CNA handled the lift hooks to connect them to the lift pad, and S5 CNA handled the lift controls to transfer Resident #5 from the bed to the wheelchair. S6 TNA then parked the lift in the hallway and proceeded to take the resident to the dining room. During an interview on 9/12/22 at 11:10 AM, S5 CNA confirmed the lift used for Resident #5 was the same lift used to transfer Resident #26. S5 CNA confirmed the lift had not been sanitized between each resident use. S5 CNA further confirmed the lift should have been sanitized between each resident use and before being parked in the hallway where it was available for other staff members to use. Review of the facility's Equipment-Reusable, Cleaning & Disinfecting Policy revealed in part: Blood pressure cuffs, stethoscopes, & reusable digital thermometers, glucometers may be cleaned with alcohol wipes or sani-wipes between resident use .Further review failed to reveal guidelines for sanitizing the mechanical lift. Review of the facility's Equipment & Medical Devices policy revealed in part: All facility equipment, such as Lifts .will be used, cleaned, and maintained according to the manufacturer's instructions .The DON (Director of Nursing) or designee will be responsible to train employees to use the facility's equipment, electronic or mechanical devices, and machinery . Review of the facility's procedure Lifting Machine, Using a Portable revealed no steps or instructions for sanitizing the lift During an interview on 9/13/22 at 9:25 AM S4 Corporate Nurse and S1 DON (Director of Nursing) were asked for the manufacturer's instructions for cleaning and sanitizing the mechanical lift. S4 Corporate Nurse indicated staff were trained to use the purple top disinfectant wipes to sanitize the high touch areas of the lift, such as the lift controls, between each resident use, and on any area visibly soiled. 2. Observation on 9/12/22 at 10:48 AM revealed S5 CNA donned a pair of gloves and provided incontinence care for Resident #5 assisted by S6 TNA. After completing the incontinence care, S5 CNA then proceeded to open both drawers of the resident's bedside table, and touch items inside each drawer with the same contaminated gloves looking for the resident's deodorant. During an interview on 9/12/22 at 11:05 AM S5 CNA confirmed she did not remove her soiled gloves and sanitize her hands before opening the drawers of the resident's bedside table and touching the items inside and should have. Review of the facility's Incontinence Care Procedure revealed no steps regarding changing gloves and/or washing hands prior to handling resident's personal care items and room furnishings. 3. Observation of the Laundry facility on 9/12/22 at 2:21 PM with S7 Laundry Tech revealed S7 Laundry Tech donned a pair of gloves and reached into a soiled laundry barrel, pulled soiled laundry from the barrel and placed it in the washing machine. Further observation revealed S7 Laundry Tech was not wearing any form of protective covering over his clothing, and the front of his shirt was pressed against the side of the soiled laundry barrel while he was reaching down inside the barrel. S7 Laundry Tech then removed his gloves and proceeded to the clean side of the laundry facility where he began folding clean laundry. No fluid resistant PPE (Personal Protective Equipment) gown or protective apron was observed to be in the laundry area at this time. During an interview on 9/12/22 at 2:25 PM S7 Laundry Tech indicated he had been working in the laundry since December of 2021 and had never seen a fluid resistant gown or apron to be used when handling soiled linens. S7 Laundry Tech indicated he should wear a protective gown when handling the soiled linens and did not. A second observation of the laundry facility on 9/13/22 at 9:09 AM with S8 Laundry Tech revealed no fluid resistant PPE gown or protective apron was available for use. During an interview on 9/13/22 at 9:09 AM S8 Laundry Tech confirmed there were no fluid resistant PPE gowns or protective aprons to use when removing soiled laundry from the soiled laundry barrels. When asked how she kept the front of her clothing from being contaminated, she replied she was just really careful and had a cloth gown to use if the laundry was really dirty. S8 Laundry Tech also reported she moved back and forth between the dirty side of the laundry and the clean side in the same unprotected clothing. S8 Laundry Tech produced a thin cloth gown made out of jersey-like material and confirmed it was not fluid resistant and she did not wear it every time she handled soiled laundry. During an interview on 9/13/22 at 9:40 AM S3 IP (Infection Preventionist) reported the laundry facility should have an impermeable (fluid resistant) apron to be used when handling soiled linens and laundry. S3 IP further indicated a cloth gown for PPE was not appropriate for use in the laundry facility. Observation on 9/13/22 at 9:42 AM revealed S8 Laundry Tech delivering laundry to the residents' rooms. During an interview at this time S8 Laundry Tech repeated there were no fluid resistant gowns or aprons in the laundry. A third observation of the laundry facility on 9/13/22 at 9:50 AM with S8 Laundry Tech, S3 IP, and S4 Corporate Nurse revealed no fluid resistant aprons or gowns were available for staff use when handling soiled linens and laundry. S3 IP and S4 Corporate Nurse both observed the thin cloth gowns reportedly used for handling soiled linens and laundry and confirmed they were not appropriate PPE for the laundry area. Review of the facility's Laundry policy revealed in part: It is the policy of this facility to follow infection control methods related to washing clothes .Aligning with principles of standard precautions, staff shall consider all previously worn clothing and used linens as potentially contaminated. The facility's laundry area will provide hand washing facilities and products as well as PPE .Laundry staff will be in-serviced on handling linens and laundry on a regular basis . Review of Laundry Inservice dated 7/20/22 revealed an attached Laundry Staff job description describing the qualifications, responsibilities, and functions related to daily responsibilities. Further review revealed the use of appropriate PPE for handling soiled linens and laundry was not included in the inservice.

Based on observation, record review, and interview, the facility failed to ensure a resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her quality of life for 1 (#42) resident out of a total of 27 sampled residents. The facility failed to ensure resident #42's room was free of flying insects. Findings: Review of resident #42's electronic health record revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #42's Minimum Data Set for 8/2/2022 revealed resident #42 was assessed to require total assistance with bed mobility, transfers, and all activities of daily living and had a BIMS (Brief Interview Mental Status) score of 99 indicating resident #42 was not able to complete the interview. Observation on 9/13/2022 at 10:15am with S1 DON (Director of Nursing) revealed resident #42 lying in bed with black flying insects flying around resident #42's head and face. Further observation revealed resident #42 swatted at the black flying insect with her left hand and held the bedsheet over her mouth. During an interview on 9/13/2022 at 10:15 am resident #42 nodded her head yes when asked are these insects bothering you. Resident #42 nodded her head yes and indicated, Yes, yes, yes again when asked are these insects always in your room? During an interview on 9/13/2022 at 10:20 am S1 DON reported she was not aware of a problem with flying insects in the facility but confirmed there was a problem in resident #42's room and confirmed the flying insects should not have been there.