Every finding on record at Mapleton Post Acute

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#16) of three residents reviewed for discharge planning out of 18 sample residents. Specifically, the facility failed to: -Ensure the discharge planning was process was documented, including the reason for discharge in Resident #16's electronic medical record (EMR); -Notify Resident #16 and Resident #16's representative, in writing, of the discharge, including the reason for the move, the effective date of discharge, the location where the resident was being discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman; and, -Notify the facility's ombudsman of Resident #16's discharge in writing. Findings include: I. Facility policy and procedure The Discharge Planning Process policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 6/17/25 at 7:27 p.m. It read in pertinent part, The facility's discharge planning process shall provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the facility. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE] and discharged on 6/5/25 to another skilled nursing facility. According to the June 2025 computerized physician orders (CPO), diagnoses included anoxic brain injury (brain is deprived of oxygen, leading to cell damage and potentially severe neurological consequences), alcohol dependence, chronic pancreatitis, and accidental poisoning by other opioids. The 6/3/25 minimum data set (MDS) assessment revealed the resident was cognitively impaired, with a brief interview for mental status (BIMS) score of five out of 15. The MDS assessment revealed there was no active discharge planning occurring for the resident. The MDS assessment revealed the resident did not want to talk about the possibility of leaving the facility and returning to live and receive services in the community. B. Record review The discharge care plan, initiated 3/2/24 and revised 3/4/24. revealed Resident #16 was admitted for long-term care following a hospitalization after a recent unintentional opioid overdose that resulted in a cardiac arrest. The resident reported his representative helped him with cleaning, cooking and shopping but it was decided by the resident and his representative that long term care was needed. The resident and his representative wanted to discuss community referrals and discharge planning on comprehensive assessments only. Interventions included encouraging the family to visit and call regularly, inviting the resident and the requested family to care plan quarterly, and social services providing assistance and support as needed. The 5/2/25 letter to Resident #16's representative revealed the facility was looking for alternative placement for the resident. -The letter did not reveal the reason the resident was being discharged , the effective date of discharge, the location where the resident was being discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman. The 6/2/25 social services assessment revealed Resident #16's discharge plan was for alternate placement at a smoking nursing facility. The 6/2/25 IDT care plan review note revealed Resident #16 and his representative did not participate in the care plan review. The discharge plan was to continue long term care at the current facility. -The 6/2/25 IDT care plan review failed to review the resident needing a facility accommodating smoking, three days before the resident was discharged . -A review of Resident #16's EMR did not reveal documentation to indicate the resident was notified of the discharge in writing, including the reason for the move, the effective date of discharge, the location where the resident was discharged to, a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman. -A review of Resident #16's EMR did not reveal the ombudsman was notified of the resident's discharge in writing (see frequent visitor interview below). C. Frequent visitor interview A frequent visitor, with knowledge of the facility, was interviewed on 6/17/25 at 4:23 p.m. The frequent visitor said she was familiar with Resident #16. She said she was not aware Resident #16 was discharged from the facility. The frequent visitor checked her records during the interview and she said she did not have any documents in writing or in an electronic (e-mail) format from the facility which informed her that Resident #16 was being discharged from the facility. III. Staff interviews The social services director (SSD) was interviewed on 6/17/25 at 5:09 p.m. The SSD said she was responsible for coordinating a resident's discharge. She said discharge planning was reviewed at admission with a care conference, quarterly and as needed with the IDT team and the resident. She said discharge planning was documented in the care conference assessment, discharge planning assessment or as a progress note in the residents EMRs. She said the resident's family or representative participated in their care planning process if the resident wanted them to attend. She said the ombudsman attended discharge planning if a resident requested the ombudsman to attend. The SSD said she was familiar with Resident #16. She said he was admitted for long term care but he was discharged to live closer to his family member. She said his representative was hard to get a hold of by phone and if the representative did not answer his phone, she sent him a letter. She said the letter sent to the representative on 5/2/25 did not include the reason for Resident #16's discharge, the effective date of discharge, the location where the resident was being discharged to or a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman. She said she did not send a letter to the ombudsman informing her of Resident #16's discharge. She said the facility did not provide a letter to the resident or the resident's representative after 5/2/25. The NHA was interviewed on 6/17/25 at 6:15 p.m. The NHA said the IDT team was responsible for discharge planning. She said discharge planning was reviewed at admission, quarterly and as needed. She said discharge planning was documented as a progress note, in the IDT care conference assessment and social services quarterly assessment. She said the resident's family or representative attended the discharge planning care conference. She said Resident #16 was admitted for long-term care but he was discharged to live closer to his family member and at a facility that allowed smoking due to the fact that the current facility was a non-smoking facility. She said a letter was not provided to the resident or the resident's representative that included the reason for the resident's discharge, the effective date of discharge, the location where the resident was being discharged to or a statement of the resident's appeal rights and the name, address and telephone number of the office of the state long term care ombudsman. She said the facility did not send a letter to the ombudsman informing her of Resident #16's discharge.

Based on record review and interviews, the facility failed to inform one (#3) of ten residents reviewed for beneficiary notices and appeal rights out of 18 sample residents of changes in their services covered by Medicare in a timely manner. Specifically, the facility failed to provide a written notification of Medicare Notice of Non-Coverage (NOMNC) letter to Resident #3's representative when the resident's Medicare Part A covered skilled services were ending. Findings include: I. Facility policy and procedure The Medicare Notice of Non-Coverage (NOMNC) policy and procedure was provided by the nursing home administrator (NHA) on 6/17/25 at 7:27 p.m. It revealed in pertinent part, Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact can not be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. II. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (a group of neurological disorders that affect movement, posture and muscle coordination), monoplegia (paralysis or weakness) of lower and upper limb affecting the right dominant side and peripheral vascular disease (circulatory problem where narrowed or blocked blood vessels reduce blood flow to limbs). The 6/8/25 MDS assessment revealed the resident had short-term and long-term memory deficits through staff assessment. B. Resident's representative interview The resident's representative was interviewed on 6/17/25 at 11:05 a.m. The representative said she was not notified that Resident #3's medicare services had ended and said the resident was receiving rehabilitation. She said she did not receive anything in writing that the insurance had changed. -Resident #3 was no longer on skilled therapy services and was receiving restorative nursing services, however, Resident #3's representative believed the resident was still on skilled therapy services. C. Record review Review of Resident #3's electronic medical record (EMR) revealed Resident #3 was discharged from Medicare Part A skilled therapy services on 4/9/25. The NOMNC notice revealed the social services director (SSD) provided verbal notification to the resident's representative on 4/7/25 at 2:25 p.m. that the resident's Medicare Part A skilled therapy services would be ending on 4/9/25. The resident continued to live in the facility. The NOMNC form indicated that if verbal notification via telephone was given, notification must also be provided via mail. -However, the section on the NOMNC for confirmation of a follow-up notice by mail was not completed with a date or the method indicating the route the follow-up notice was sent. -A review of the resident's EMR revealed no documentation to indicate that Resident #3's representative was provided with a written notice that Resident #3's Medicare Part A skilled therapy services were ending, given the estimated cost of services the resident would incur if the representative chose to pay out of pocket to continue skilled therapy services, the reason why the Medicare Part A skilled therapy services were ending and the information the representative needed to appeal the decision, if desired. III. Staff interviews The SSD was interviewed on 6/17/25 at 5:05 p.m. The SSD said she and the director of rehabilitation (DOR) were responsible for notifying the resident or the resident's representative when their Medicare Part A benefits were ending. The SSD said she did not document in the resident's EMR that the resident or the resident's representative were notified. She said the signed NOMNC was uploaded to the resident's EMR which provided evidence that the resident or the resident's representative was informed of the appeal process. She said if the resident's representative was notified by phone, the NOMNC was sent by certified mail and she would document the call in the resident's EMR. She said she determined who signed the NOMNC based on whether or not the resident was alert and oriented or based on the resident's BIMS score. The SSD said she was familiar with Resident #3. She said she did not provide the written NOMNC to the resident's representative in April 2025. The DOR was interviewed on 6/17/25 at 5:56 p.m. The DOR said he or the SSD was responsible for notifying the resident or resident's representative when their Medicare Part A benefits were ending. He said he determined who signed the NOMNC based on who was the responsible party in the resident's EMR. He said if it was not clear on who the responsible party was, he asked the SSD. He said a copy of the written NOMNC was provided to the resident but he did not provide a copy of the NOMNC to the resident's representative. The DOR said he was familiar with Resident #3. He said a copy of the written NOMNC was not provided to the resident's representative in April 2025. The NHA was interviewed on 6/17/25 at 6:33 p.m. The NHA said the SSD and the DOR were responsible for notifying the resident or resident's representative when their Medicare Part A benefits were ending. She said the SSD or the DOR determined who signed the NOMNC based on the resident's cognition and their BIMS score. She said there should be documentation in the resident's EMR that the resident or the resident's representative was notified that the resident's r Medicare Part A benefits were ending in addition to the NOMNC form being added to the resident's EMR. She said a copy of the NOMNC was provided to the resident or resident's representative if they requested a copy. The NHA said she was familiar with Resident #3. She said she did not know a written copy of the NOMNC was supposed to be provided to the resident or the resident's representative. She said she did not know there was no documentation in Resident #13's EMR that the written copy of the NOMNC was delivered.

Based on observation and interviews, the facility failed to ensure all drugs and biological used in the facility were properly stored and labeled in two out of two units. Specifically, the facility failed to: -Ensure medications that were self administered were stored securely at the bedside for Resident #33; -Ensure a medication storage room was securely locked; -Ensure medications that were not administered were not left unsecured at Resident #28's bedside; and, -Ensure medications were not left unattended on medication and treatment carts. Findings include: I. Facility policy and procedure The Medication Access and Storage policy and procedure, reviewed November 2022, was provided by the nursing home administrator (NHA) on 12/5/24 at 11:08 a.m. It read in pertinent part, Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (medication aides) are allowed access to medications. Medication rooms, carts and medication supplies are locked or attended by persons with authorized access. II. Ensure medications that were self administered were stored securely at the bedside for Resident #33 A. Observations and resident interview On 12/3/24 at 9:34 a.m. Resident #33 was observed with one medication card of sevelamer (a medication used to control phosphorus levels in the blood) and two medication cards of calcium acetate (a medication used to treat high phosphorus levels in the blood) unsecured on his bedside table. Resident #33 was interviewed on 12/3/24 at 9:35 a.m. He said the staff evaluated him and he was allowed to self administer his own medications. On 12/3/24 at 1:47 p.m. Resident #33 was observed with sevelamer and calcium acetate (a medication used to treat high phosphorus levels in the blood) medication cards on the bedside table. III. Ensure the medication storage room was securely locked On 12/4/24 at 3:30 p.m. the director of nursing (DON) was observed opening the south side nurses station medication room door by pushing on the door without entering the code on the coded lock on the door. IV. Staff interviews The DON was interviewed on 12/3/24 at 2:00 p.m. The DON said Resident #33 had been evaluated and had a physician's order to be able to self administer his own sevelamer and calcium acetate medications. He said the resident had recently changed rooms and this was a reason why his medications were unsecured on top of his bedside table. He said the medications should not be left out unsecured because other residents could have access to them if they were unsecured. The DON was interviewed on 12/4/24 at 3:15 p.m. The DON said the outer door of the medication storage room should always be locked to prevent unlicensed and unauthorized personnel from being able to access medications in the medication storage room. 48112 IV. Failure to leave medications unattended with residents A. Observations and interview On 12/2/24 at 2:07 p.m. during an interview with Resident #28, a yellow tablet that was cut in half in a medication cup was on the bedside table. Resident #28 said the nurses left the medication at her bedside table. Registered nurse (RN) #2 was interviewed on 12/2/24 at 2:20 p.m. in Resident #28's room. RN #2 said the yellow tablet that was on the bedside table. RN #2 said she did not know what type of medication was left on the resident's bedside table. RN #2 did not remove the medication from the resident's bedside table. B.Record review A review of Resident #28's electronic medical record did not reveal a record that the resident was able to self-administer medications. C. Staff interviews LPN #1 was interviewed on 12/5/24 at 11:04 a.m. LPN #1 said medications should never be left at a resident's bedside. LPN #1 said the only time a medication could be left with a resident was if the resident had an assessment indicating the resident was able to self-administer medications. LPN #1 said she only worked on the North unit and there were no residents on the North unit who could self-administer medications. The DON was interviewed on 12/5/24 at 3:30 p.m. The DON said the only time medications could be left with a resident was if the resident had an assessment indicating the resident was able to self-administer medications. The DON said Resident #28 could not self-administer medications because she did not have the agility to handle medications and because of her disease process. The DON said RN #2 told him on 12/2/24 a medication was left with Resident #38. V. Failure to leave medications unattended at medication carts A. Observations On 12/4/24 from 11:06 a.m., a medication cart on the North unit was observed with triple antibiotic cream on top of the medication cart. There was no nurse within the vicinity of the cart. At 11:23 a.m. LPN #1 and DON were at the medication cart on the North unit and they removed the triple antibiotic cream from the top of the medication cart. On 12/4/24 at 3:00 p.m., a tube of Aspercream (topical pain medication), a bottle of magnesium oxide tablet and a tube of triple antibiotic cream were left on top of a medication cart on the North unit. There was no nurse within the vicinity of the cart. B. Staff interviews LPN #1 was interviewed on 12/5/24 at 11:04 a.m. LPN #1 said medications including over-the-counter medications and creams should never be left unattended on the medication and treatment cart. LPN #1 said it was important not to leave medications unattended because the residents could take the medication and cause harm to themselves. The DON was interviewed on 12/4/24 at 3:30 p.m. The DON said he saw the antibiotic cream on top of the North unit's medication cart on 12/4/24 when he talked with LPN #1. The DON said he told LPN #1 not to leave any medication, creams, or over-the-counter medications on the cart when left unattended. The DON said it was important not to leave medications unattended because residents who can ambulate could easily take the medication and cause harm to themselves.

Based on observations, record review and interviews, the facility failed to provide services for three (#39, #22 and #52) of five residents out of 32 sample residents according to professional standards of practice. Specifically, the facility failed to monitor vital signs prior to the administration of a blood pressure medication for Resident #39, Resident #22 and Resident #52. Findings include: I. Professional reference According to Khashayar, F., [NAME], J. (2023). Beta Blockers. Stat Pearls. National Library of Medicine, was retrieved on 12/9/24 from https://www.ncbi.nlm.nih.gov/books/NBK532906/. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these receptors with beta blocker medications can lead to many adverse effects. Bradycardia (low heart rate) and hypertension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta blockers. According to Bulara, K. G., [NAME], P., [NAME], M. (2024). Amlodipine. Stat Pearls. National Library of Medicine, was retrieved on 12/9/24 from https://www.ncbi.nlm.nih.gov/books/NBK519508/. Since amlodipine is an antihypertensive medication, clinics and patients should regularly measure blood pressure to achieve target levels per the 2017 American College of Cardiology/American Heart Association hypertension guidelines. According to Kiziour, R. J., [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess blood pressure (B/P), heart rate immediately before drug administration. If pulse is 60 beats per minute (bpm) or less or systolic B/P is less than 90 mm Hg (millimeters of mercury) withhold medication and contact physician. According to Kiziour, R. J., [NAME], K. J. (2023). Amlodipine. [NAME] Nursing Drug Handbook. Elsevier. p. 60. Assess B/P. If systolic B/P is less than 90 mm Hg, withhold medication and contact physician. According to Kiziour, R. J., [NAME], K. J. (2023). Amiodarone. [NAME] Nursing Drug Handbook. Elsevier. p. 52. Assess B/P, apical pulse immediately before drug is administered. If the pulse is 60 bpm or less or systolic B/P is less than 90 mm Hg, contact physician. II. Resident #39 A. Resident status Resident #39, age 78, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), the diagnoses included hypertension (high blood pressure), diabetes mellitus (DM) and abdominal aortic aneurysm (a bulge in the aorta). The 10/21/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 13 out of 15. He was independent with eating, toileting, personal hygiene, bed mobility and transfers. B. Observation On 12/4/24 at 9:00 a.m. registered nurse (RN) #1 was dispensing and administering Metoprolol 25 milligrams (mg) to Resident #39. RN #1 did not check the order for blood pressure parameters or review the resident's record for the resident's most recent vital signs prior to administration of the Metoprolol medication to Resident #39. C. Record review The December 2024 CPO documented a physician's order of Metoprolol 25 mg twice a day for hypertension and tachycardia (high pulse rate), ordered on 1/20/24. -The CPO did not document any vital sign parameters for when to hold the Metoprolol medication or when to notify the physician of irregular vital sign results. The December 2024 medication administration record (MAR) and treatment administration record (TAR) documented to check vital signs on the day shift every Wednesday, ordered on 2/14/24. The October 2024, November 2024 and December 2024 vital signs summary revealed Resident #35's blood pressure and pulse were only assessed on 10/2/24, 10/9/24, 10/14/24, 10/23/24, 10/30/24, 11/6/24, 11/13/24, 11/20/24, 11/27/24, 11/30/24 and 12/4/24 and not daily at the time the resident was given the prescribed Metoprolol tablets. III. Resident #22 A. Resident status Resident #22, age 74, was admitted on [DATE]. According to the December 2024 CPO, the diagnoses included congestive heart failure (CHF), atrial fibrillation (irregular heart rate) and right below the knee amputation. The 11/8/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She was dependent on staff for toileting, required substantial/maximal assistance with transfer, partial/moderate assistance with bed mobility and was independent with eating and personal hygiene. B. Observation On 12/4/24 at 9:10 a.m. RN #1 was dispensing and administering Amiodarone (medication that treats irregular and fast heart rhythms) 100 mg tablets, 1.5 tablets for a total of 150 mg to Resident #22. RN #1 did not check the order for blood pressure or pulse parameters or review the resident's record for the resident's most recent vital signs prior to administration of the Amiadarone medication to Resident #22. C. Record review The December 2024 CPO documented a physician's order of Amiodarone (medication used dto treat blood pressure) 100 mg tablets five 1.5 tablets for a total of 150 mg by mouth in the morning for atrial fibrillation, ordered on 9/30/24. -The CPO did not document any vital sign parameters for when to hold the Amiodarone medication or when to notify the physician of irregular vital sign results. The December 2024 MAR and TAR documented to check vital signs on the day shift every Wednesday, ordered on 7/8/24. The October 2024, November 2024 and December 2024 vital signs summary revealed Resident #22's vital signs were only assessed on 10/2/24, 10/9/24, 10/13/24, 1016/24, 10/23/24, 10/27/24, 10/30/24, 11/6/24, 11/13/24, 11/15/24, 11/16/24, 11/17/24, 11/20/24, 11/27/24. 11/29/24, 12/1/24, 12/2/24, 12/3/24, 12/4/24 and not daily when the resident was given the prescribed Amiodarone tablets. IV. Resident #52 A. Resident status Resident #52, age less than 65, was admitted on [DATE]. According to the December 2024 CPO, the diagnoses included hypertension, DM and chronic kidney disease (CKD). The 10/17/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with eating, toileting, personal hygiene, bed mobility and transfers. B. Observation On 12/4/24 at 9:15 a.m. RN #1 was observed dispensing and administering Amlodipine (medication used to treat blood pressure) 10 mg. RN #1 did not check the order for blood pressure or pulse parameters or review the resident's record for the resident's most recent vital signs prior to administration of the Amliodipine medication to Resident #52. C. Record review The December 2024 CPO documented a physician's order of Amliodipine 10 mg in the morning for hypertension, ordered on 4/10/24. -The CPO did not document any vital sign parameters for when to hold the Amliodipine medication or when to notify the physician of irregular vital sign results. The December 2024 MAR and TAR documented to check vital signs on the day shift every Wednesday, ordered on 5/3/24. The December 2024 documented an order to check vital signs every shift for hyperkalemia (high blood potassium), ordered 10/14/24. The November 2024 and December 2024 vital signs summary revealed Resident #52 blood pressure and pulse were only assessed on 11/4/24, 11/6/24, 11/7/24, 11/8/24. 11/13/24, 11/19/24, 11/20/24, 11/21/24, 11/23/24, 11/24/24, 11/25/24, 11/26/24, 11/27/24, 11/28/24, 11/29/24, 11/31/24. 12/3/24 and 12/4/24 and not daily at the time the resident was given the prescribed Amliodipine tablets. V. Staff interviews RN #1 was interviewed on 12/4/24 at 9:20 a.m. RN #1 said the residents who were admitted for rehabilitation had physician's orders to check vital signs every shift. She said the residents that were admitted for long term care had a physician's order to obtain their vitals taken once a week. She said not all blood pressure medications had parameters ordered. She said she checked vitals when there were parameters ordered. She said she did not routinely check vitals if there were not parameters ordered for blood pressure medications. The assistant director of nursing (ADON) was interviewed on 12/4/24 at 9:50 a.m. The ADON said residents had their vital signs checked once a week. She said the residents that had parameters ordered would have their vitals taken more frequently. She said the residents that did not have parameters did not have their vitals taken more frequently because the philosophy of the facility was to make it more homelike. She said part of the nursing assessment before giving a blood pressure medication was to assess making sure they were not dizzy or exhibiting any other signs of low blood pressure. She said part of the nursing assessment included taking vital signs and monitoring those vital signs before the administration of a blood pressure medication.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infection on two out of two units. Specifically, the facility failed to: -Ensure glucometers were sanitized appropriately between uses; and, -Ensure the resident's rooms were cleaned in a sanitary manner. Findings include: I. Ensure glucometers were sanitized appropriately between uses A. Professional reference The Centers for Disease Control and Prevention (CDC). Considerations for Blood Glucose Monitoring and Insulin Administration (8/7/2024), was retrieved on 12/10/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. It read in pertinent part, Unsafe practices during assisted monitoring of blood glucose and insulin administration contribute to the spread of hepatitis B virus, hepatitis C virus, human immunodeficiency virus (HIV) and other infections. Unsafe practices include: using fingerstick devices for more than one person, using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses. B. Facility policy and procedure The Glucometer Disinfection policy and procedure, reviewed on 1/1/24, was provided by the nursing home administrator (NHA) on 12/5/24 9:17 a.m. It read in pertinent part, Glucometers should be cleaned and disinfected before and after each use and according to manufacturer's instructions, regardless of whether they are intended for single resident or multiple resident use. Glucometers should be disinfected with a wipe presaturated with an environmental protection agency (EPA) registered healthcare disinfectant that is effective against human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B virus (HBV). The facility currently uses Medline Micro Kill Bleach Wipes, which have been validated by the glucometer manufacturer. C. Manufacturer recommendations The Medline Evencare G2 Blood Glucose Meter manufacturer cleaning and disinfecting guidelines. undated, were retrieved on 12/10/24 from https://www.medline.com/media/catalog/Docs/MKT/MAN_MPH1540_EvenCare%20G2%20Users%20Guide.pdf. It included the following recommendations in pertinent part, The following products are validated for disinfecting the Evencare G2 meter and lancing device: Dispatch Hospital Cleaner Disinfectant Towels with bleach, Medline Micro-Kill Disinfecting, Deodorizing Cleaning wipes with alcohol, Clorox Healthcare Bleach Germicidal and Disinfectant Wipes, Medline Micro-Kill Bleach Germicidal Bleach Wipes. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. The Medline Micro Kill One disinfectant wipes manufacturer guidelines, undated, was retrieved on 12/10/24 from https://www.medline.com/media/catalog/Docs/MKT/LIT998_CAT_Healthcare%20Disinfectant%20W.pdf. It read in pertinent part, One minute disinfectant time for HIV, HBV and HCV. D. Observations On 12/4/24 at 7:37 a.m licensed practical nurse (LPN) #1 took a glucometer out of Resident #13's labeled bag. She went to Resident #13's room and obtained the resident's blood glucose. She returned to the medication cart and placed the glucometer on top of the medication cart. She returned the glucometer to Resident #13's bag. -LPN #1 did not clean or disinfect the glucometer before or after use. On 12/4/24 at 7:45 a.m. LPN #1 took a new glucometer out of the box. LPN #1 went in to Resident #224's room and obtained the resident's blood glucose. She then returned to the medication cart and placed the glucometer next to the computer. She obtained a new bag and labeled it with Resident #224's name and placed the glucometer into the bag. -LPN #1 did not clean or disinfect the glucometer before or after use. On 12/4/24 at 7:56 a.m. LPN #1 took a glucometer out of Resident #26's labeled bag. She then went into Resident #26's room and obtained the resident's blood glucose. She returned to the medication cart and returned the glucometer back into Resident #26's labeled bag. -LPN #1 did not clean or disinfect the glucometer before or after use. E. Staff interviews LPN #1 was interviewed 12/4/24 at 8:42 a.m. LPN #1 said each resident that needed blood glucose checks had their own designated glucometer. She said the glucometers should be cleaned after every use before they were returned to their labeled bag. She said they used the Medline Micro Kill germicidal wipes, which had a contact disinfection time of one minute. She said she was aware she did not do the appropriate cleaning after using each glucometer. Registered nurse (RN) #1 was interviewed on 12/4/24 at 9:20 a.m. RN #1 said all of the glucometers were cleaned before and after use with the Medline Micro Kill wipes with a disinfection time of one minute. The assistant director of nursing (ADON) was interviewed on 12/4/24 at 9:50 a.m. The ADON said the glucometers were cleaned with the designated Medline Micro Kill with the disinfection time of one minute. She said this needed to be done before and after every use with every resident to kill microorganisms, especially blood borne pathogens (microorganisms that cause disease). She said LPN #1 was a newly graduated nurse and would provide follow up education. II. Ensure the resident's rooms were cleaned appropriately A. Professional reference The Centers for Disease Control and Prevention (CDC), Environment Cleaning Procedures (3/19/24), was retrieved on 12/10/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. Include identified high touch surfaces and items in checklists and other job aids to facilitate completing procedures. Common high touch surfaces include: bedrails, intravenous poles (IV) sink handles, bedside tables, call bells, doorknobs and light switches. B. Manufacturer's recommendations According to [NAME] Bay Lemon Disinfectant manufacturer guidelines, reviewed 2024, retrieved on 12/11/24 from https://s3.amazonaws.com/imperialdade.com/apps/catalog/digital-assets/55877/product-documentation/eb73269ecc51efb6993f5bef4a5e1a1aca22f589.pdf. It read in pertinent part, For use as a one step, general, hospital, medical disinfectant, fungicide, virucide, cleaner, deodorizer. Treated surfaces must remain visibly wet for two minutes to kill SARS CoV 2 or for 10 minutes to kill all organisms listed on the label. According to the [NAME] Bay Non Acid Disinfectant Bathroom Cleaner manufacturer guidelines retrieved on 12/11/24 from https://s3.amazonaws.com/imperialdade.com/apps/catalog/digital-assets/55879/product-documentation/fc5575bf4104f772b21e594fb2a632fdce4be18e.pdf. It read in pertinent part, For use as a one step, general, hospital, medical disinfectant, fungicide, virucide, cleaner, deodorizer. Treated surfaces must remain visibly wet for two minutes to kill SARS CoV 2 or for 10 minutes to kill all organisms listed on the label. D. Observations On 12/5/24 at 9:20 a.m. the housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER] A and B. HSK #1 performed hand hygiene and put on gloves. She lightly sprayed the [NAME] Bay Lemon Disinfectant on the B side of the room, the top of the bedside tables and then sprayed the A side's top of the bedside table. She then sprayed the top of the bathroom vanity, the toilet hand rails, the top of the toilet seat, under the seat and top of the toilet bowl. She then placed the disinfectant bottle on the handrail next to the vanity. She obtained a clean towel and immediately started wiping down B side bedside tables. She disposed of the towel, removed her gloves and performed hand hygiene, obtained a new towel and wiped down the A side bedside tables. -HSK #1 failed to ensure surfaces remained visibly wet for the two minute virucidal and the ten minute total disinfection time specified by the manufacturer's guidelines. HSK #1 cleaned the inside of the toilet bowl with toilet brush, she then wiped down the hand rails on either side of the toilet, wiped the top of the toilet tank, top of the lid, under the lid and then the top of the toilet bowl. She then carried the used towel, picked up other used towels and cleaning supplies at the vanity and went to the housekeeping cart. She then disposed of used towels and placed cleaning supplies back into the housekeeping cart. -HSK #1 failed to change gloves, perform hand hygiene after cleaning the toilet and picking up used towels and before touching a clean disinfectant bottle and the housekeeping cart. -HSK #1 failed to clean high touch surface areas which included light switches, door knobs and call lights. On 12/5/24 at 9:35 a.m. HSK #1 was observed cleaning room [ROOM NUMBER]. HSK #1 performed hand hygiene and put on gloves. She lightly sprayed the book case that was next to the resident's bed, the top of the bedside table and the door knobs on the door into the room and the bathroom. She lightly sprayed the toilet tank, toilet lid, toilet bowl and toilet hand rails. She then immediately wiped down the bookcase and bedside table. She wiped down the door handles on the door from the hallway and to the bathroom. She disposed of used towel. She removed gloves and performed hand hygiene. -HSK #1 failed to ensure surfaces remained visibly wet for the two minute virucidal and the ten minute total disinfection time specified by the manufacturer's guidelines. HSK #1 wiped the toilet hand rails, wall around the hand rail, down the lid, down the top of the toilet bowl, down the sides of the toilet bowl and the toilet tank. She then left the bathroom, picked up the trash, disposed of a used towel on the housekeeping cart and returned cleaning supplies to the cleaning cart. She removed her gloves and performed hand hygiene. -HSK #1 failed to clean the inside of the toilet bowl. She failed to change gloves and perform hand hygiene after cleaning down the toilet bowl and returning up to the toilet tank. She failed to remove her gloves and perform hand hygiene after disposing of used towel and before touching cleaning supplies and the housekeeping cart. E. Staff interviews HSK #1 was interviewed on 12/5/24 at 10:00 a.m. using a staff interpreter. HSK #1 said after cleaning a dirty area gloves must be changed and hand hygiene performed and a new towel before wiping a clean or high area. She said after cleaning the toilet, her gloves must be removed and hand hygiene be performed before touching clean supplies and the housekeeping cart. She said high touch areas including light switches, door knobs and call lights. She said the disinfection time for the cleaning supplies is two to three minutes. The housekeeping supervisor (HSKS) was interviewed on 12/5/24 at 10:05 a.m. The HSKS said gloves must be changed and hand hygiene performed after cleaning or touching a dirty area and before touching a clean area. He said the disinfection time of the cleaners is a three minute contact time.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for two (#128 and #125) of three residents reviewed for discharge planning out of 32 sample residents. Specifically, the facility failed to provide an appropriate discharge planning process for Resident #128 and #125. Findings include: I. Facility policy and procedure The Discharge Planning policy and procedure, not dated, was provided by the nursing home administrator (NHA) on [DATE] at 11:08 a.m. It read in pertinent part, It is the policy of this facility that discharge planning and evaluation will be provided by the social services staff for each resident. The discharge planning process focuses on the resident's discharge goals, the preparation of the resident to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Discharge planning involves the resident, family, or responsible party, IDT (interdisciplinary team), and others involved in the resident's care plan. Monitoring of the discharge planning program is the responsibility of the Social Services staff. The social services staff will ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. The Social Services staff member assigned to the resident regularly evaluates and re-evaluates the resident to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. Referrals for discharge planning may be made by the physician, resident, family or responsible party, or staff member. It is essential to ensure that there is a planned program of continuing care to meet each resident's discharge needs Social Services or designee shall involve the interdisciplinary team (IDT) in the ongoing process of developing the discharge plan. Social Services or designee shall involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. Social Services or designee will document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation will be discussed with the resident or the residents representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. II. Resident #128 A. Resident status Resident #128, over [AGE] years old, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included osteomyelitis left ankle and foot, type 2 diabetes mellitus, and trochanteric bursitis left hip. The [DATE] discharge minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. He required substantial/maximal assistance with showers, and lower body dressing. He required partial/moderate assistance with sit to stand, and transfers. The MDS assessment revealed active discharge planning was occurring for the resident to return to the community and no referrals had been made to the local contact agency because a referral was not wanted. Type of discharge: planned. B. Resident's representative interview Resident #128's representative was interviewed on [DATE] at 7:04 p.m. via email and phone. She said on [DATE] she took Resident #128 for a VA (Veterans Affairs) doctor's appointment to help facilitate him to go to a VA skilled nursing facility (SNF) however Resident #128 was unable to transfer to a car so they had to order an ambulance transport via stretcher. The representative said when they got to the VA doctor's appointment, regarding Resident #128's hip pain from bursitis, Resident #128 started talking gibberish so the VA doctor sent him to the hospital where he died the next day. The representative said the facility's social workers had not helped her with finding a facility placement that was contracted with the VA and that was why she was taking the resident to the VA appointment on [DATE]. The representative said the social services director (SSD) had not offered to help her with getting Resident #128 transferred or discharged to a facility who would accept the resident's VA benefits. The representative said when Resident #128's skilled benefits insurance ran out, the facility offered to help get the resident on Medicaid, but when she asked about using Resident #128's VA benefits no assistance was offered. The representative said the SSD had made no effort to move Resident #128 anywhere. The representative said the facility just told her that the insurance decided to stop paying and Resident #128 would need to get on Medicaid benefits to continue his stay at the facility. The representative said the responsibility of finding a facility that would accept Resident #128's VA benefits were placed totally on her and her sister. The representative said prior to Resident #128's discharge, she and her sister had considered caring for him at home but then realized that they were not prepared or able to care for him. The representative said she told the SSD she would not be able to care for him at home and had asked about getting the resident into a VA facility. She said the SSD did not offer her assistance with finding a VA facility. C. Record review Review of the discharge care plan, initiated [DATE], revealed Resident #128 was admitted to the facility for skilled services following a hospitalization . Prior to the hospitalization , the resident was living with family in the community and the resident and family felt that long-term care may be needed and were considering transition to long-term care. Interventions included reviewing the discharge plan quarterly and as needed, encouraging family/responsible parties to be involved in the facility events, plan of care and encouraging them to discuss feelings/concerns with impending discharge, monitoring for and addressing episodes of anxiety, fear, and distress, evaluating the resident's motivation to return to the community and inviting the resident and requested family to care plan and staff to provide any needed support. -The care plan was not updated to include the family's request for discharge to a VA facility. Review of the social services admission assessment/evaluation, dated [DATE], revealed the prior living arrangements were at home in the community with a family member. The discharge plan was long-term care placement in the current facility. -Review of Resident #128's progress notes revealed there was no documentation of any interdisciplinary team (IDT) meetings or care conference meetings or other discussions in regards to discharge planning. -Review of Resident #128's electronic medical record (EMR) did not reveal documentation which acknowledged the representative's wishes to find VA facility placement for the resident or documentation of referrals sent by the facility to VA facilities. The [DATE] physician note revealed, per social services, Resident #128's family member wanted Resident #128 sent non-emergently to the VA doctor appointment so they could assist with finding a facility placement that was contracted with the VA. The facility was working on coordinating transport. -The physician's note documented the reason for the transfer was so the VA physician could help find placement for the resident in a VA facility, however, there was no documentation in the resident's EMR that the SSD attempted to assist Resident #128's representative to find VA placement, despite the representative's request and reason for the resident's transport to the VA appointment. III. Resident #125 A. Resident status Resident #125, age 69, was discharged on [DATE], and readmitted on [DATE]. According to the [DATE] CPO, diagnoses included congestive heart failure (heart does not pump blood efficiently), acute respiratory failure with hypoxia (lungs cannot adequately oxygenate the blood leading to low oxygen levels), atrial fibrillation (abnormal heart rhythm) and adult failure to thrive (a condition of physical and cognitive decline, decreased functional status, and poor nutritional intake). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with all functional abilities. The MDS assessment revealed no behaviors or rejection of care. B. Resident interview Resident #125 was interviewed on [DATE] at 9:58 a.m. Resident #125 said his discharge plan was to go to a VA facility in a different state either a SNF or an assisted living facility (ALF) but he was not sure if social services was working on that for him. Resident #125 said he wanted to go to another state because it was warm there and he had spent many years as a bus driver in the cold. Resident #125 said he had tried to make the arrangements himself because the facility had not helped him and did not always follow his preferences. The social services assistant (SSA) walked past during the interview and said she thought Resident #125 wanted to discharge to a local ALF. Resident #125 responded that was not his preference and he wanted to go to a VA facility in a different state. C. Record review The [DATE] social services quarterly note revealed Resident #125 was currently in the facility for long-term care but was working with a transition's coordinator (who was not part of the facility) for potential ALF placement. Prior to admission, Resident #125 was living at a homeless shelter. Resident #125 was a veteran of the military forces and social services would continue to provide support as needed. -Review of Resident #125's EMR revealed there was no documentation of any IDT meetings, care conference meetings or other discussions with the resident in regards to discharge planning. The [DATE] physician note revealed Resident #125 wanted to discuss discharge planning with the physician. Resident #125 said he would like to move down to a different state as he had previously lived in the area and did better with the heat. Resident #125 said he had contacts at the VA and said he could easily get housing there. Resident #125 was competent and endorsed that he had bought a plane ticket. The facility had concerns about a potential safe discharge. Resident #125 was his own medical decision maker and was medically stable for discharge at that time. The physician's note documented the facility was to reach out to the resident's VA contacts to ensure a safe discharge for the resident. -However there was no facility or social services follow-up documentation that contact had been made with the VA community where the resident wanted to discharge to in order to ensure a safe discharge location. The [DATE] physician note revealed Resident #125 again asked to discuss with his physician his discharge plans. Resident #125 wanted to make sure that he had clearance for discharge but the resident had not yet been cleared by physical therapy for discharge. According to the physician's note, the facility confirmed that Resident #125 had a place to discharge to. -However, there was no facility or social services follow-up documentation that revealed the discharge location had been contacted. The [DATE] physician note revealed the facility had asked the physician to specifically follow up with the resident regarding discharge planning. Resident #125 was planning to discharge that weekend. He had a flight scheduled for Sunday. The physician was able to clarify Resident #125's discharge plan as there was concerns earlier in the week that Resident #125 was planning to fly to a different state and present to the emergency department. However, the physician's note documented the physician was able to clarify and confirm that Resident #125 had been in contact with the VA in the other state and would present to a VA facility there upon arrival. -However there was no social services discharge planning documentation in the progress notes that indicated the facility had been in contact with or arranged for Resident #125 to discharge to a VA facility in another state. The [DATE] discharge summary revealed Resident #125 had a planned discharge date of [DATE]. Discharge instructions were provided to the resident and he was able to make his needs known. The discharge location was a VA facility in a different state. -However there was no documentation in Resident #125's EMR to indicate the facility had contacted the VA facility in the other state to confirm the resident had been approved for acceptance at the facility or to provide a continuity of care handoff to the facility. The [DATE] discharge note revealed Resident #125 left the facility via ride-share services around 6:10 p.m. Resident #125 had everything ready and said he was flying (name of airline) he had everything in order and the airline ticket was confirmed. Resident #125 made his own decisions. A copy of the discharge and medications list and instructions were handed to the resident, including his medication. Resident #125 took all his belongings with him. -However there was no documentation that the facility had assisted with discharge planning or contacted the VA location to confirm the resident was being accepted at the location. The [DATE] physician note revealed Resident #125 had been discharged from the facility on [DATE] and was supposed to fly to another state where he planned to be admitted to a VA facility. He purchased a plane ticket and went to the airport then fell asleep and missed his flight. He stayed in the airport for multiple days until he finally called 911 for chest and abdominal pain and was taken to a medical center on [DATE]. Resident #125 was discharged back to the facility for ongoing medical management. The [DATE] nurses note revealed Resident #125 was readmitted to the facility from the hospital via emergency medical services (EMS) accompanied by three paramedics via stretcher. Review of the discharge care plan, initiated [DATE] (upon the resident's readmission to the facility), revealed the resident readmitted for long-term care and was working with a transition's coordinator for potential ALF The goal was to find ALF placement in the near future. Interventions included for the discharge care plan to be reviewed quarterly and as needed, encouraging the resident to discuss feelings and concerns with impending discharge and to monitor for and address episodes of anxiety, fear, and distress, establishing a pre-discharge plan with the resident, family/caregivers and evaluating progress and revising the plan as needed, evaluating and discussing with resident/family/caregivers the prognosis for independent or assisted living, identifying, discussing and addressing limitations, risks, benefits and needs for maximum independence, evaluating motivation to return to the community and inviting the resident and the requested family to care plan quarterly and as needed and staff to provide any needed support. -However it was not documented in the care plan that Resident #125 wanted to go to a VA facility in another state. The [DATE] social services admission quarterly note revealed the resident had readmitted to the facility for long-term care and was working with a transition's coordinator for potential ALF placement. The goal was to find ALF placement for the resident in the near future. The resident had mild forgetfulness related to age and was able to make his own decisions. Social services would continue to provide support as needed. -There was no documentation of social services assistance or care conferences to discuss discharge planning since the resident returned to the facility and still desired to discharge to a VA facility in another state. IV. Staff interviews The SSD was interviewed on [DATE] at 1:44 p.m. The SSD said Resident #125 had gone to get on a plane to another state to go to a VA facility. The SSD said she had not contacted the facility or provided any assistance to Resident #125 with transferring there. The SSD said she had recommended an ALF to the resident but had not looked at any for him in the other state. The SSD was interviewed again on [DATE] at 2:00 p.m. The SSD said Resident #128's insurance for skilled benefits would not cover him anymore and the representative had wanted him to go to a VA facility. The SSD said the plan was for him to stay at the current facility but at the last minute the resident representative decided to take him to a VA clinic to facilitate a transfer to a VA facility. The SSD said she helped to coordinate the discharge planning for the representative to do that, but she did not write a care coordination conference note regarding the discharge. -However, there was no documentation in Resident #128's EMR regarding a discharge planning process (see record review above). The SSD was interviewed a third time on [DATE] at 9:59 a.m. The SSD said a referral could have been sent for Resident #128 to go from the current facility to a VA facility but she did not make any referrals. The SSD said it was a last minute decision that the resident's representative did not want him to stay at the facility and go onto Medicaid services. The SSD said, in the five years she had worked in the facility, she had never sent a referral to a VA facility before but she assumed it would be just like any other facility to facility transfer. The SSD said the resident;s representative had met with the business office about Resident #128's insurance ending but had opted to not transition to Medicaid because she wanted the resident to use his VA benefits. The SSD said the resident's representative decided to go to the VA for a medical appointment instead of staying at the facility and transitioning to Medicaid. The NHA was interviewed on [DATE] at 12:28 p.m. The NHA said when a resident was about to be discharged from therapy and the insurance would stop paying, the resident/representative would meet with the business office to discuss financial options, including discussions about Medicaid. The NHA said if the resident/representative did not want to transition to Medicaid, then private pay options would be discussed because the resident would need to have a payor source. The NHA said he was not sure how to work with VA resources and was still learning about that. The NHA said he would find out why, if a resident had VA resources, the social services department did not assist the resident/representative with transferring/exploring/researching the possibility of the resident transferring to a VA facility. The SSD was interviewed on [DATE] at 1:11 p.m. The SSD said she followed up with Resident #125 about his discharge goals (during the survey) and he still wanted to transfer to another state because it was warmer there. She said she researched and found out there were four VA facilities in the other state The SSD said she called all of them and was able to speak with two of the facilities.The SSD said she was working on getting a VA referral faxed over to the VA facilities she had spoken with in the other state.The SSD said she would notify Resident #125 that she had sent the referrals to the facilities in the other state.

Based on observations, record review and interviews, the facility failed to ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion (ROM) and/or prevent further decrease in ROM for one (#42) of two residents reviewed for restorative services out of 32 sample residents. Specifically, the facility failed to ensure Resident #42 was provided with a restorative nursing program to maintain and/or prevent deterioration of her current level of function and mobility. I. Facility policy and procedure The Restorative Nursing Program policy and procedure, reviewed January 2024, was received by the nursing home administrator (NHA) on 12/5/24 at 9:17 a.m. It read in pertinent part, It is the policy of this facility to provide maintenance and restorative services designed to improve residents' abilities to the highest practicable level. Nursing personnel are trained to basic or maintenance nursing care that does not require a qualified therapist or licensed nurse oversight. This training may include, but is not limited to, maintaining proper positioning and body alignment, encouraging and assisting residents, as needed, in turning and position changes, encouraging residents to remain active and assisting with any exercises according to plan of care, promoting independence in activities of daily living (ADL), performing tasks for residents only as needed to ensure completion of tasks, assisting residents in adjustment to their disabilities and use of any assistive devices, assisting residents with range of motion exercises and performing passive range of motion for residents who lack active range of motion ability. II. Resident #42 A. Resident status Resident #42, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease (CKD) and osteoarthritis. The 9/13/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent with toileting and bed mobility, she required partial/moderate assistance with personal hygiene and transfers and was independent with eating. The assessment indicated Resident #42 was not involved in a restorative nursing program during the seven day look back period. B. Observation and resident representative interview On 12/2/24 during a continuous observation, beginning at 11:57 a.m. and ending at 12:15 p.m., the following was observed: At 11:57 a.m., during the lunch meal, the director of rehabilitation (DOR) approached Resident #42 and the resident's representative. Resident #42's representative told the DOR she understood the resident did not qualify for skilled rehabilitation services but she wanted Resident #42 to continue to receive some form of mobility services. The representative told the DOR she wanted Resident #42 to be transferred from her wheelchair and placed in a recliner after lunch so the resident would be in a different position than she had been all morning. Resident #42's representative told the DOR she could only imagine how the resident felt sitting in her wheelchair all morning. Resident #42's representative told the DOR she did not want the resident to become stiff. The DOR told the Resident #42's representative that a a ROM program provided through a restorative nursing program would address what the representative wanted the facility to provide for the resident. However, the DOR told Resident #42's representative that the facility did not currently have a restorative nursing program to provide the services to the resident. Resident #42's representative was interviewed on 12/2/24 at 4:01 p.m. The representative said she and her family had requested some kind of therapy to help her mother walk with a walker to help minimize her falling. She said the family was aware the resident was not going to get better, but they wanted to prevent the resident from getting worse and losing muscle mass. Resident #42's representative said the facility had changed ownership and the current ownership had discontinued the restorative nursing program. She said she and her family had had conversations with the facility regarding the resident being in a restorative nursing program. She said the family had a care conference scheduled in December 2024 and she was going to talk with the facility again about having Resident #42 participate in a restorative nursing program. C. Record review The ADL care plan, initiated 3/20/23 and revised on 5/15/24, documented Resident #42 was at risk for self care performance related to Alzheimer's disease, poor balance, weakness, incontinence, CKD, osteoarthritis and chronic pain. Interventions included therapy evaluation and treatment. The fall care plan, initiated 3/20/23, indicated Resident #42 was at risk for falls due to previous fall with injury, weakness, dementia, poor balance and unsteady gait. Interventions included checking the resident's ROM, continuing therapy services and physical therapy to evaluate and treat as indicated. -A comprehensive review of Resident #42's care plan failed to reveal documentation that the resident was offered a restorative nursing program to help the resident maintain and/or prevent a decline in her functional and mobility levels. -The 9/16/24 quarterly interdisciplinary team (IDT) care plan review failed to reveal documentation of Resident #42's previous involvement in a nursing restorative program or a current personalized restorative nursing program plan. A review of Resident #42's electronic medical record (EMR) revealed restorative nursing program notes from 1/1/24 through 6/30/24. The restorative nursing program notes revealed Resident #42 was provided restorative nursing services for active range of motion (AROM), which included knee extensions, seated marches, hip abduction, ankle pumps, hamstring curls and walking from 1/1/24 through 6/30/24. -There was no further documentation of restorative nursing program services being provided to Resident #42 after 6/30/24. III. Staff interviews. The director of nursing (DON) and the physical therapy assistant (PTA) were interviewed on 12/4/24 at 10:13 a.m. The DON and the PTA said the facility had not had a restorative nursing program since July 2024. The DON and the PTA said the facility discontinued the restorative nursing program due to not having financial support for the program. The DON and the PTA said the facility was looking at restoring the restorative nursing program. The DOR was interviewed on 12/4/24 at 12:00 p.m. The DOR said the facility had to discontinue the restorative nursing program in July 2024 due to certified nurse aide (CNA) staffing issues and the facility needed to use the CNAs who provided the restorative nursing services to help staff the floor. She said the facility was in the process of reorganizing and reinstituting the program. She said she did not have a date when the restorative nursing program might be reinstated. She said she would be overseeing the program once it was available again. She said Resident #42 had been on a restorative nursing program until the facility discontinued the program in July 2024. She said the facility had eight to 10 residents who would benefit from a restorative nursing program.

Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#2) of three residents reviewed for pain management out of five sample residents. The facility failed to ensure Resident #2, with a diagnosis of chronic low back pain, low back compression fractures, spinal stenosis (spaces inside bones get small putting pressure on spinal cord), spinal fusion, history of infection in the back with sepsis (infection of the bloodstream), repeat falls and anxiety, was administered scheduled pain medication as ordered. Resident #2 was interviewed about her pain during the survey, she cried and sobbed, hardly able to speak when she described how she was not administered her pain medication due to it not being available. She reported severe pain to her lower back, legs and nose affecting her ability to sleep and do any day to day activities. Record review revealed the resident did not receive her scheduled Oxycontin on 3/16/24 or 3/17/24 and only received it on 3/18/24 after the missing medication doses were brought to the facility's attention during the survey. The facility documented the medication was pending from the pharmacy. There was no documentation the provider was notified for further orders when the medication was not available. Further record review revealed there were multiple occasions when the resident did not receive her scheduled pain medication. Findings include: I. Facility policy and procedure The Pain Recognition and Management policy, revised April 2023, was received from director of nursing (DON) #2, on 3/19/24 at 10:56 a.m. It read in pertinent part, Pain will be documented in the electronic health record using a scale of one to 10. Monitor pain status every shift. If the pain management program is not effective, contact the physician. Medication received and response will be documented in the electronic medication administration record (MAR). II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic low back pain, low back compression fractures, spinal stenosis, spinal fusion, history of infection in the back with sepsis, repeat falls and anxiety. According to the 2/19/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial maximal assistance from staff with toileting, and partial to moderate assistance with bed mobility, transfers, dressing and personal hygiene. The assessment documented she had pain almost constantly with the worst being a pain level of 10 on a scale of 1-10, with 10 being the worst pain. The pain frequently affected her sleep and constantly affected her ability to perform day to day activities. The assessment further documented the resident was on scheduled and as needed (PRN) pain medication. B. Resident interview Resident #2 was interviewed on 3/18/24 at 1:14 p.m Resident #2 cried and sobbed, hardly able to speak when she described how she had not gotten her scheduled pain medication, Oxycontin, over the weekend. She said her pain was over 10 on a scale of 1-10, with 10 being the worst pain. Resident #2 said the pain was in her lower back, legs and her nose, as she had recently fallen out of bed and fractured her nose. She said the pain affected her sleep, her day to day activity and made her more anxious. She said the provider had come in to see her this morning (3/18/24) after it had been reported she went all weekend without the scheduled Oxycontin. Resident #2 had asked the provider to increase her PRN Oxycodone, until the long acting scheduled, Oxycontin was back in her system. She said the provider agreed. Resident #2 said this was not the first time she experienced a severe increase in her pain due to the facility not having her scheduled pain medication (cross-reference F760 significant medication errors). C. Record review The February 2024 CPO revealed: -On 2/1/24 the resident had orders for Oxycontin 20 mg (milligrams) in the morning and at bedtime for pain. -On 2/19/24, after readmission from the hospital for lumbar (back) incision dehiscence (separation of surgical wound edges due to failure of proper wound healing) the resident had orders for Oxycontin 40 mg in the morning and at bedtime for seven days for pain. The March 2024 CPO revealed: -On 3/8/22, the resident had orders for Oxycontin 10 mg twice daily for pain. -On 3/13/24, the resident had orders for Oxycontin 20 mg twice daily for pain. On 3/16/24 at 7:45 a.m. the nursing progress notes documented the Oxycontin was not given because it was enroute from the pharmacy. On 3/16/24 at 9:14 p.m. the nursing progress notes documented the Oxycontin was not given because it was enroute from the pharmacy. On 3/17/24 at 5:33 a.m. the nursing progress notes documented the Oxycontin was not given because it was on order. On 3/18/24 at 6:17 a.m. the nursing progress notes documented the Oxycontin was not given because it was pending from the pharmacy. On 3/18/24 at 11:34 a.m., after it was brought to the facility's attention, the nursing progress notes documented the physician was notified. -There was no previous documentation of provider notification for further orders when the scheduled Oxycontin was not available. The narcotic count sheet for the Oxycontin was reviewed on 3/18/24 at 10:00 a.m. The count sheet documented the resident did not receive the scheduled Oxycontin 40 mg twice daily as ordered on 2/21/24, 2/23/24, 2/24/24 and 2/26/24. On 3/8/24, when the Oxycontin was reduced to 10 mg twice daily, the resident received 20 mg once daily on 3/8/24, 3/9/24 and 3/10/24 (cross-reference F760). After 3/13/24, when the Oxycontin was increased to 20 mg twice daily, the resident did not receive the Oxycontin on 3/14/24, received one dose on 3/13/24, and no Oxycontin on 3/16/24, 3/17/24 or 3/18/24 until it was brought to the facility's attention. The February 2024 MAR revealed the resident's PRN Oxycodone dose on 2/26/24 when the Oxycontin was not available, was documented as ineffective for pain levels of seven to nine. The March 2024 MAR revealed the PRN Oxycodone doses on 3/14/24, when the Oxycontin was not available, was documented as ineffective for pain levels of nine. The pain care plan, initiated 1/9/24, documented to follow pain scale to medicate as ordered and monitor/document for side effects of pain medication. Observe for constipation, new onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness and falls. Report occurrences to the physician. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion (ROM), withdrawal or resistance to care. -There were no resident centered non-pharmacological interventions on the care plan. III. Staff interviews The nursing home administrator (NHA) was interviewed on 3/18/24 at 12:03 p.m. The NHA said the facility had identified in their quality assurance performance improvement (QAPI) meetings that medications were not given because they were not available. He said the facility had changed pharmacies in March 2024. He said the facility had not identified medications continued to not be available and administered as ordered (cross-reference F867 QAPI). The interim director of nursing (IDON) and the director of nursing from a sister facility (DONSF) were interviewed on 3/18/24 at 12:52 p.m. The IDON said if a medication was unavailable the nurse should obtain the medication from the facility's emergency medication machine and notify the pharmacy. If the medication was still unavailable, the nurse should notify the provider for further orders. The IDON said the facility had changed pharmacies due to multiple issues including timeliness of medication refills. The IDON further said non-pharmacological interventions should be documented in the care plan to assist with pain management. The IDON said the floor nurses were responsible for completing a pain care plan for the residents. However, the licensed nurses should have notified the provider when the medication was not available. The IDON reviewed the narcotic sheet for Oxycontin, the resident CPOs for February 2024 and March 2024. She said there were several missed doses of Oxycontin on the narcotic count sheet, despite the medication being signed off on the MARs as administered. The IDON said she did not know what the problem was or why this had happened. She said the problem seemed to be with the nurses not following up with the pharmacy and the provider. She said she did not think this was an issue with the new pharmacy. The IDON reviewed the nursing progress notes in the resident's record and said there was no documentation the provider was notified. She said the nurses did not notify the provider and should have. The DONSF said she had spoken with the provider and the provider did not know she needed to write a prescription for Oxycontin. The IDON said the resident had just received a dose of the Oxycontin, after it was brought to the facility's attention this morning (3/18/24). The IDON said the nurse did give the resident her Oxycodone during the days she missed the Oxycontin. However, she said this was supposed to be as needed for breakthrough pain. The IDON and DONSF were interviewed again on 3/18/24 at 2:58 p.m. The DONSF said the pharmacy had not received a prescription from the provider for the Oxycontin for Resident #2. She said the nurse should have contacted the pharmacy and the provider when the Oxycontin was not available to be administered.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns were implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care. Findings include: I. Facility policy and procedure The facility QAPI policy was requested from the nursing home administrator (NHA) on 3/19/24 at 10:58 a.m. -The policy was not received by the end of the survey on 3/19/24. II. Cross-reference citations Cross-reference F697:The facility failed to manage residents' pain resulting in actual harm that was isolated. Cross-reference F760: The facility failed to prevent significant medication errors resulting in substandard quality of care, facility wide. III Staff interviews The NHA was interviewed on 3/18/24 at 12:03 p.m. The NHA said the facility had identified in their QAPI meetings that medications were not given because they were not available. He said the facility had changed pharmacies in March 2024. He said the facility had not identified medications continued to not be available and administered as ordered. The interim director of nursing (IDON) and the director of nursing from a sister facility (DONSF) were interviewed together on 3/18/24 at 12:52 p.m. The IDON said she did not know what the problem was or why this had happened. She said the problem seemed to be with the nurses not following up with the pharmacy and the provider. She said she did not think this was an issue with the new pharmacy. The DONSF said she had spoken with the provider and the problem was the provider did not know she needed to write a prescription for the pain medication (cross-reference F697). The NHA was interviewed again on 3/19/24 at 10:38 a.m. The NHA said he was not aware and had not reviewed the continued issues with medications not being administered due to not being available, despite the new pharmacy. The NHA said the QAPI committee had not identified that nurses still were not notifying providers when medications were not available, including significant pain medications. He said he felt the service with the new pharmacy was better but not perfect. The NHA said he had trusted that the DON was following up. He said that DON was no longer with the facility. The NHA said he would review the medication concerns at the next QAPI meeting in March 2024. He said the facility had started a new performance improvement plan yesterday when he was made aware that residents still were not receiving prescribed medications. The medical director (MD) was interviewed on 3/25/24 at 9:59 a.m. He said he remembered the facility had switched pharmacies in January 2024, but did not recall what the specific issues were or if the unavailability of medications had been discussed in the February 2024 QAPI meeting. He said he had not heard concerns regarding providers not knowing they needed to provide prescriptions for controlled substances as a reason for medication not being available. The MD said in the March 2024 QAPI meeting, he reminded the facility that they could call him for a prescription if needed.

Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for five (#2, #3, #4, #5 and #1) of five residents reviewed for medication errors. Specifically, the facility failed to ensure Residents #2, #3, #4, #5 and #1 received medications according to the physician's orders which resulted in significant medications errors. The failure to ensure medications were given according to physician orders affected all five sample residents and was recognized to affect all other residents prescribed medications in the facility. Record review and interviews showed the facility systematically had problems with the pharmacy filling orders and staff ordering medications. Findings include: I. Facility policy The Medication Management and Administration policy, undated, was received from the interim director of nursing (IDON) on 3/18/24 at 1:20 p.m. It read in pertinent part: Every effort must be exhausted to provide a medication to a resident. This includes, but is not limited to: checking the med (medication) cart, checking the med fridge (refrigerator), pull from the 1st (first) dose machine, call pharmacy. Don't wait until you are out of a medication to re-order or notify management. Nursing must notify the provider when a medication is unable to be administered. Nursing must enter a note into (electronic medical record system) that includes: what medication couldn't be given and why, what was done to get it, any new orders received from the provider. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included chronic low back pain, low back compression fractures, spinal stenosis, spinal fusion, history of infection in the back with sepsis, repeat falls and anxiety. According to the 2/19/24 facility assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial maximal assistance from staff with toileting, and partial to moderate assistance with bed mobility, transfers, dressing and personal hygiene. B. Resident interview Resident #2 was interviewed on 3/18/24 at 1:14 p.m. Resident #2 said she did not receive her pain medications over the weekend. Resident #2 said she had missed medications prior to this episode (cross-reference F697 for pain management). C. Record review The 1/9/24 care plan, revised 2/4/24, revealed Resident #2 had acute and chronic pain resulting from compression of her vertebrae, spinal stenosis, and spinal fusion. Pertinent interventions included following a pain scale to medicate as ordered and anticipate the resident's need for pain relief. The 1/9/24 care plan revealed Resident #2 had hypothyroidism. Pertinent interventions included giving thyroid replacement therapy as ordered, and monitoring for side effects and effectiveness. The 2/2/24 care plan revealed Resident #2 was on diuretic therapy. Pertinent interventions included administering medications as ordered. The March 2024 CPO revealed Resident #2 was prescribed the following medications: -Oxycontin 10 mg (milligrams) oral extended release tablets. Resident #2 was prescribed originally 10 mg by mouth twice a day for pain on 2/1/24, but was changed to 20mg twice a day on 3/13/24; and, -Spironolactone 25 mg oral tablet. Give 25 mg by mouth in the morning for hypertension. Started on 2/19/24. Progress notes revealed Resident #2 did not receive the following medications due to the medication being on order: -Oxycontin on 1/8/24 and 3/16/24 to 3/18/24; and, -Spironolactone on 3/10/24 to 3/14/24 and 3/17/24. The oxycontin controlled drug record for Resident #2 revealed the following: -No tablets were marked as administered between 2/22/24 and 2/25/24 and 3/7/24; -Tablets were marked as administered once a day from 3/8/24 to 3/10/24; -No tablets were marked as administered between 3/10/24 and 3/13/24; -No tablets were marked as administered on 3/9/24 nor 3/11/24; and, -Tablets were marked as administered once a day on 3/13/24 and 3/14/24. -However, according to the orders the oxycontin was supposed to be administered twice a day. It was not administered according to the orders or not at all for the days indicated. D. Staff interviews The IDON and the director of nursing from a sister facility (DONSF) were interviewed on 3/18/24 at 12:53 p.m. The DONSF said Resident #2 running out of her Oxycontin due to the nurse and disciplinary action would be taken. The provider had been notified that morning, as the nurses had not notified them at any point over the weekend that Resident #2 was out of this medication (cross-reference F697). III. Resident #3 A. Resident status Resident #3, age 91, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included chronic kidney disease, pulmonary hypertension, gastroesophageal reflux disease and arthritis. The 1/24/24 MDS assessment revealed the resident was mildly cognitively impaired with a BIMS score of 12 out of 15. The resident was mostly dependent and required supervision and assistance with most activities of daily living. B. Record review The 3/1/23 care plan identified Resident #3 had a potential for mood problems resulting from anxiety and depression. Pertinent interventions included administering medications as ordered. The 3/7/23 care plan identified Resident #3 was on palliative care. Pertinent interventions included administering pain medications as ordered. The 3/18/24 care plan identified Resident #3 had a urinary tract infection (UTI). Pertinent interventions included administering medications as ordered. The March 2024 CPO revealed Resident #3 was prescribed the following medications: -Cephalexin 500 mg tablets. Give 500 mg orally three times a day for seven days for UTI. Start date was 3/16/24. -Butrans (buprenorphine) transdermal patch 5 mcg (micrograms)/hour. Apply one patch transdermally every seven days for chronic pain. Started on 1/24/24, discontinued 2/8/24 and restarted on 3/11/24. -Fexofenadine HCl 180 mg tablet. Give one tablet by mouth in the morning for allergic rhinitis and vertigo. Started on 3/4/24. -Lorazepam oral tablet 0.5 mg. Give 0.5 tablet by mouth in the morning related to anxiety disorder. Started on 2/14/24. -Sertraline HCl 100 mg tablet. Give 1.5 tablets by mouth one time a day related to anxiety disorder. Started on 7/24/23. -Oxycodone HCl oral tablet 5 mg. Give 0.5 tablet by mouth two times a day for chronic pain. Started on 2/2/24 and discontinued 3/11/24. -Carvedilol Oral tablet 12.5 mg. Give 0.5 tablet by mouth every morning and at bedtime related to hypertensive heart disease and chronic kidney disease. Started on 2/22/24. The January 2024 MAR revealed Resident #3 had a Butrans transdermal patch applied on 1/4/24 at 6:29 a.m., 1/11/24 at 9:42 a.m. and 1/18/24 at 8:49 a.m. Resident #3's buprenorphine transdermal patch controlled drug record revealed the resident had a patch signed out on 1/15, 1/16, 1/17 and 1/18/24. -The MAR and controlled drug record revealed inconsistencies from when the patch was signed out and administered. In addition, the resident was not administered the patch on 1/22/24, 1/23/24, 1/24/24 and 2/1/24 due to it being on order. Progress notes revealed Resident #3 did not receive the following medications due to the medication being on order: -Butrans on 1/22/24 1/23/24, 1/24/24 and 2/1/24; -Sertraline on 2/1/24, 2/27/24, 3/3/24 and 3/10/24; -Carveditol on 3/10/24; -Oxycodone on 3/10/24; -Cephalexin on 3/17/24; and, -Fexofenadine HCl on 3/17/24 and 3/18/24. C. Staff interviews The IDON, DONSF and nursing home administrator (NHA) were interviewed on 3/19/24 at 11:01 a.m. The IDON assessed the controlled drug log for Resident #3's Butrans patch and said the patches were signed out once a day from 1/15/24 to 1/18/24. The IDON said when signing things out on a narcotic book, it means that it was taken out and administered that day. IV. Resident #4 A. Resident status Resident #4, age 94, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included hypertension, gastroesaphogeal reflux disease (GERD) and hypothyroidism. The 2/9/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was mostly independent and required supervision and assistance with few activities of daily living. B. Record review The March 2024 CPO revealed Resident #4 was prescribed the following medications: -Nexium 20 mg oral packet. Give 20 mg by mouth two times a day for GERD. Started on 1/12/24. -Sertraline HCl 125 mg tablet. Give 125 mg by mouth one time a day for anxiety. Started on 1/6/23. -Fentanyl 50 mcg/hour 72 hour patch. Apply 50 mcg transdermally one time a day every three days for pain. Started 11/22/22. -Levothyroxine sodium 50 mcg oral tablet. Give one tablet by mouth in the morning for hypothyroidism. Started on 1/10/24. -Hydrocodone 5-325 mg tablet. Give one tablet by mouth two times a day related to chronic pain. Started on 3/24/22. -Lasix 20 mg tablet. Give 20 mg by mouth in the morning for edema. Started on 3/7/23. -Eliquis 2.5 mg oral tablet. Give one tablet by mouth two times a day for chronic embolism and thrombosis of veins. Started on 9/11/23. -Metoprolol tartrate 25 mg tablet. Give one tablet by mouth two times a day for hypertension. Started on 10/8/22. -Myrbetriq 25 mg extended release tablet. Give one tablet by mouth in the morning for overactive bladder. Started on 2/8/24. Progress notes revealed Resident #4 did not receive the following medications due to the medication being on order: -Nexium on 1/26/24, 2/20/24, 3/3/24 and 3/10/24; -Hydrocodone on 1/29/24, 3/3/24, 3/4/24 and 3/6/24; -Sertraline on 2/8/24 and 2/20/24; -Myrbetriq on 2/9/24, 2/26/24 and 3/13/24; -Levothyroxine on 2/13/24, 3/4/24 and 3/10/24; -Lasix on 3/10/24; -Eliquis on 3/10/24; -Metoprolol on 3/10/24; and, -Fentanyl patch on 3/11/24. V. Resident #5 A. Resident status Resident #5, age 96, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included hypothyroidism, chronic pain, trigeminal neuralgia (a type of nerve pain) and heart failure. The 12/14/23 MDS assessment revealed the resident was significantly cognitively impaired with a BIMS score of three out of 15. The resident was dependent and required supervision and assistance with most activities of daily living. B. Record review The March 2024 CPO revealed Resident #5 was prescribed the following medications: -Hydrocodone 5-325 mg tablet. Give one tablet by mouth two times a day related to trigeminal neuralgia. Started on 4/27/23. -Metoprolol tartrate 12.5 mg tablet. Give 12.5 mg by mouth two times a day for hypertension. Started on 2/19/24. Progress notes revealed Resident #5 did not receive the following medications due to the medication being on order: -Hydrocodone on 1/17/24, 2/5/24 and 3/5/24; and, -Metoprolol on 3/3/24 and 3/7/24. VI. Resident #1 A. Resident status Resident #1, age 83, was admitted on [DATE] and passed away on 2/3/24. According to the March 2024 CPO, diagnoses included pancreatic cancer, gastritis and gastric ulcer. B. Record review The physician orders 2/1/24 revealed the following: -Morphine sulfate 15 mg extended release tablets. Take one tablet by mouth every twelve hours for pain. -Morphine 20 mg/ml (milliliters) solution. Take 0.25 ml (5 mg) by mouth every four hours as needed for pain. -Lorazepam 2 mg/ml oral concentration. Take 0.25 ml by mouth/under the tongue every six housr as needed for anxiety. -Ondansetron 4 mg tablet. Take one tablet by mouth every eight hours for nausea. The 2/2/24 care plan identified that Resident #1 had occasional nausea and vomiting resulting from pancreatic cancer and gastritis. Pertinent interventions included administering anti-emetics as ordered. The 2/2/24 care plan identified that Resident #1 was on pain medication therapy due to having pancreatic cancer. Pertinent interventions included administering medications as ordered as ordered and reviewing pain medication efficacy. Progress notes from 2/1/24 at 7:09 p.m. revealed Zofran (ondansetron) was on order and not able to be given. Progress notes from 2/1/24 at 7:04 p.m. revealed Resident #1's morphine tablets were on order and not able to be given. The notes indicated liquid morphine was available for use for Resident #1. Progress notes from 2/2/24 at 5:08 a.m. revealed Resident #1's Zofran was on order and not able to be given. The February 2024 MAR revealed the following: Zofran was not administered from the afternoon of 2/2/24 to the morning of 2/3/24 due to the medication being on order; no resident refusals were indicated. Resident #1's liquid morphine controlled drug record revealed the resident was given 0.25mL at 7:15 p.m. on 2/1/24. An additional 0.75mL was administered to Resident #1 at 8:30 p.m. on 2/1/24. -Liquid morphine was not administered from the night of 2/1/24 to the afternoon of 2/2/24. VII. Staff interviews The IDON and DONSF were interviewed on 3/18/24 at 12:53 p.m. The IDON said when a medication was out, the nurses in the facility should check the Pyxis (a secured automated medication dispensing system) to see if the medication was available through those means, alert the resident's physician and have the physician reorder the medication from the pharmacy. The IDON said the facility switched pharmacies at the beginning of March 2024 due to issues with ordering. Per the IDON, the issue with ordering was identified in January 2024. The IDON said the staff had been educated on what to do if medications were out of stock and agency staff were educated through a portal prior to coming in for their shifts. Certified nurse aide with medication authority (CNAMA) #1 was interviewed on 3/18/24 at 1:50 p.m. CNAMA #1 said medications in the facility were not being administered correctly and that sometimes the correct medication was not being given altogether. CNAMA #1 said Naloxone had been given to residents instead of Methadone, among other errors. Licensed nurse practitioner (LPN) #1 was interviewed on 3/18/24 at 3:52 p.m. LPN #1 said whenever a medication was out, she would check the Pyxis, call the pharmacy to get a refill and call the physician to get orders of what to do in the meantime. LPN #1 said that since the facility changed pharmacies the issue of running out of medications had been much better. When these medications ran out, LPN #1 said she notified the physician that the resident missed their dose and the residents were closely monitored in the meantime before their medication was delivered. VIII. Performance improvement plan (PIP) The facility's PIP, dated 1/25/24, was provided by the NHA on 3/18/24 at 2:46 p.m. The PIP identified that the facility failed to have medications available according to policy. The causes identified were a lack of consistent direct staffing and a lack of pharmacy timely delivery of new admission resident's medications. The solutions identified included nurse managers monitoring and auditing medications and contacting the pharmacy and providers for new orders. The PIP also identified that if their pharmacy at the time failed to provide timely medications, the facility would cancel its contract and look for a new pharmacy. -However, even though the facility had implemented a PIP and switched pharmacies, the residents were still missing their medications.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, quality of life and quality of care. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Plan, last revised January 2023, was received on 6/27/23 , from the nursing home administrator. The policy read in pertinent parts, The facility will establish and implement a Quality Assessment and Assurance Committee, develop a written Quality Assurance and Performance Improvement Plan, which will be reviewed and updated annually, and implement Performance Improvement Projects (PIPs) through a data driven and proactive approach. The purpose of the QAPI Plan and processes is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable physical, mental, and social well-being. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F 610 During the recertification on 6/29/22 (Abuse investigations) was cited at a D scope and severity. During the recertification survey on 8/29/19, the facility was cited at a D scope and severity. F 849 During the recertification on 6/29/22 (Hospice services) was cited at a D scope and severity. During the recertification survey on 8/29/19, the facility was cited at a D scope and severity. III. Cross-reference citations F610 Cross-reference F610 Abuse investigations: The facility failed to ensure abuse allegations were investigated timely. F 692 Cross-reference F692 Hydration: The facility failed to ensure residents received adequate hydration. F 686 Cross-reference F686 Pressure injury: The facility failed to ensure residents were free from pressure injury. F 677 Cross-reference F677: The facility failed to ensure activities of daily living were provided for dependent residents. F 689 Cross-reference F689 accident hazard: The facility failed to ensure residents were safe from accident hazards. F 725 Cross-reference F725 nurse staffing: The facility failed to ensure sufficient nurse staffing were provided. IV. Interview The nursing home administrator (NHA) and the corporate executive director ((CED) were interviewed on 6/29/23 at 7:03 p.m. The NHA said he was recently transferred to the facility on e week ago. He has not participated in any QAPI meetings. The corporate executive director said he was familiar with the facility, and had attended some of the QAPI meetings, however, had not been at a meeting since March 2023. The corporate executive director had the minutes book to review. The CED said the committee meets one time a month. The CED said the meeting had an agenda. He said the QAPI committee has sub-committees and the sub-committees also report on their findings. He said resident council, grievances and any happenings in the building were used to identify issues. The CED reviewed the minutes and said hydration issues were not identified. He said that the facility had a nutrition at risk committee and discussed weight loss, however, hydration had not been discussed or identified. The CED said in March 2023 meeting, it was identified there were two pressure injuries in the facility. The wound care team changed and on 4/6/23 a performance improvement plan was put into place in relation to getting orders late from the wound team. Then the facility had new nursing management, and the director of nurses was doing the wound rounds and getting the orders. He said since 4/13/23 there had been no more late orders. He said the system failed as the orders were late and not getting updated. He and the NHA were not aware there continued to be issues with resident pressure injuries. The CED said showers in F677 had not been identified. He said if it was not a grievance then it was not reviewed. He said the system failed from lack of communication. The NHA said the ultimate goal was to get the agency staff out of the building. He said they have a performance improvement plan for reduction of agency. He said it was hard to educate staff when the agency was being used. He said the facility needed to have their own staff to focus on the areas for improvement. The NHA said the facility reports abuse allegations to the appropriate agencies. The CED said as the governing body they need to talk about investigations and what to include in the investigations.

Based on record review and interviews, the facility failed to ensure mandatory submission of direct care staffing based on payroll roll data. Specifically, the facility failed to ensure staffing data entered in the Payroll-Based Journal (PBJ) system was accurate. Findings include: The facility had a change of ownership on 3/1/23. I. Record review The PBJ stuffing report for quarter two (1/31/23 to 3/31/23) showed the following triggered areas: -Excessively low weekend staffing; -No registered nurse (RN) hours; and -Failed to have licensed nursing coverage 24 hours a day. January and February 2023 staffing data was not entered in the PBJ system; the following information was generated from March 2023. II. Interview Nurse consultant #2 was interviewed on 6/29/23 at 5:00 p.m. The nurse consultant said she reached out to the company service center and the PBJ data was not submitted by the previous owner for January and February 2023. She said as the new ownership they submitted the data for March 2023, therefore it triggered.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored in three out of three medication carts. Specifically, the facility failed to ensure medication carts were locked when left unattended. Findings include: I. Facility policy and procedure The Medication Access and Storage policy and procedure, revised on 5/3/23, was provided by the nursing home administrator (NHA) on 6/29/23 at 12:02 p.m. It revealed, in pertinent part, Store all drugs and biologics in locked compartments. Medication supply is accessible only to licensed nursing personnel. Locking/securement of medication and treatment carts when not in immediate use or attendance to prevent the access of unauthorized individuals. II. Observations On 6/26/23 at 12:04 p.m. the south wing back medication cart was observed unlocked and unattended by licensed personnel. Six facility staff members and one resident passed by the unattended and unlocked medication cart. On 6/26/23 at 2:36 p.m. the north wing medication cart was observed unlocked and unattended by nursing staff. On 6/28/23 at 10:45 a.m. the south wing front medication cart was observed unlocked and unattended by nursing staff. Residents were observed near the cart. III. Interviews Licensed practical nurse (LPN) #1 was interviewed on 6/26/23 at 12:10 p.m. She said the medication carts should be locked when left unattended to ensure no one had access to the medications. LPN #1 said she had left the medication cart unlocked while she was administering medications to a resident. LPN #4 was interviewed on 6/26/23 at 2:40 p.m. She said she left the medication cart unlocked and unattended on the north wing. She said that the cart should be locked at all times when it was left unattended. The director of nursing (DON) was interviewed on 6/29/23 at 5:03 p.m. She said the medication carts should be locked when left unattended to prevent someone from accessing the medications.

Based on observations, record review and interviews the facility failed to ensure the medication error rates were less than five percent for two residents (#15 and #11). Specifically, the facility had a medication error rate of 21 percent, which was eight errors out of 38 opportunities for error. Findings include: I. Professional references According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. [NAME] Missouri, pp. 606-607, retrieved on 6/12/23, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy The Medication Administration policy, revised March 2023, received from the nursing home administrator on 6/29/23 at 12:02 p.m. revealed in pertinent part, medication shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written order of the attending physician. Medication must be administered within one hour before or after their prescribed time. The staff administering the medications must record information on the residents MAR (medication administration record) before administering the next residents medications. Should a drug be withheld, refused, or given other than at the scheduled time it should be appropriately documented on the MAR. III. Observations and interviews On 6/28/23 at 12:52 p.m. licensed practical nurses (LPN) #2 was administering medications to Resident #15. The medications ordered were: Insulin Lispro (used to treat diabetes) give five units subcutaneously before meals. LPN #2 administered five units of Insulin to Resident #15's right abdomen. -The insulin was administered after the resident had eaten lunch and not before the meal as the order indicated. At 6:00 p.m. LPN #3 was preparing medications for Resident #11. The medications ordered were: Lactaid 9000 units three tabs (for lactose intolerance) Gabapentin 300 milligrams (mg) (for nerve pain) Natural tears two drops per eye (for dry eyes) Restasis 0.005% 1 drop per eye (for dry eyes) Zoloft 125 mg (antidepressant) Simvastatin 20 mg (for cholesterol) Norco 5-325 mg (pain medication) LPN #3 entered Resident #11's room at 6:02 p.m. He placed the medication cup and the two eye drop vials on the side table next to the resident's recliner. Resident #11 was sitting in bed upon entering the room and requested the LPN look at her skin. LPN #3 left the room to find a certified nurse aide (CNA) leaving the medications on the side table. LPN #3 returned with a CNA at 6:04 p.m. and reviewed residents' skin. Resident #11 remained sitting in bed with medication not in reach when LPN #3 returned to the medication cart at 6:07 p.m. LPN #3 returned to Resident #11's room at 6:09 p.m. and took her blood pressure then exited the room at 6:13 p.m. LPN #3 returned to the medication cart and documented Resident #11 took her medication. The medications remained on the resident's side table. At 6:28 p.m. the medication still remained on the side table. At 6:30 p.m. the director of nursing (DON) and the assistant director of nursing (ADON) were alerted about Resident #11's medication being on the side table. The DON asked the resident to take her medications and the resident responded with I will take them at bed time. The DON offered to remove medications and have them brought back to her later and the resident responded with I will just take them now.The DON then administered the medications. -LPN #3 failed to ensure the medication was administered as charted and not left on the resident's side table. IV. Staff interviews LPN #2 was interviewed on 6/28/23 at 1:40 p.m. She said Resident #15 had already eaten lunch but still had to administer her insulin. She said the order indicated for insulin to be administered before meals but the medication administration record indicated that it could be given between 11:00 a.m. and 2:00 p.m. LPN #2 said insulin was a high risk medication as it helps regulate a resident's glucose levels. The DON was interviewed on 6/28/23 at 6:35 p.m. She said medication should not be left at bedside unless a resident had an order for them to be self administered. Nurses were to watch medications taken by residents to ensure they did not have any complications if they missed a medication. She said medication should not be left unattended in the resident's room as another resident may take them and cause them a reaction. LPN #3 was interviewed on 6/28/23 at 7:07 p.m. He said medications should not be left at bedside because the resident may not take them or another resident could take them, causing them health issues. LPN #3 said he was shown he could leave medications in the resident's room when he oriented the facility upon being hired back in February or March 2023. The DON was interviewed on 6/29/23 at 4:31 p.m. She said if a physician order indicated a specific time to be given with meals, on empty stomach or at bedtime, it should be followed. If a medication was not given on time per physician order it was considered a medication error unless the nurse called the provider to notify it was late. V. Record review Resident #15's medical record failed to reveal physician notification for administration of Insulin late. Resident #11's medical record failed to reveal the resident was evaluated for self administration of medication.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference citations: -F677 activities of daily living; -F689 accident hazards; and, -F692 hydration. Findings include: I. Resident census and conditions According to the 6/26/23 Resident Census and Conditions of Residents report, the resident census was 68 and the following care needs were identified: -61 residents needed assistance of one or two staff with bathing and seven residents were dependent. No residents were independent. -52 residents needed assistance of one or two staff members for toilet use and two residents were dependent; 14 residents were independent. -57 residents needed assistance of one or two staff members for dressing and nine were dependent; two residents were independent. -41 residents needed assistance of one or two staff members and ten were dependent for transfers; 17 residents was independent -Seven residents needed assistance of one or two staff members with eating and 61 were independent. II. Staffing requirements for each station North Station One licensed nurse 12 hours for the day shift and two certified nurse aides (CNAs); The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. South Station Two licensed nurses 12 hours for the day shift and three CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. The unit had one licensed nurse for medication administration who worked from 1:00 p.m. to 9:00 p.m. III. Resident council minutes The 4/14/23 Resident Council minutes revealed resident concern: -Call lights take longer to get answered particularly during meal times. The review of the Resident Council minutes from 5/12/23 revealed resident concerns: -Call lights answering times were long. The director of nurses (DON) responded the facility had three CNAs on the South unit and two on the North unit and a bath aide. -Showers not were received. The DON responded there were hot water issues. She said the facility was working on hiring more staff. -The council documented a resident asked about the Saturday shower aide. The DON responded she had to ensure there was proper coverage on the floor. The review of the Resident Council minutes from 6/12/23 documented the assistant director of nurses (ADON) introducing herself and said she was working on staffing to use less agency and to keep their own staff. IV. Resident interviews Resident #38 was interviewed on 6/26/23 11:30 a.m. The resident said there was not enough staff. She said the facility recently switched the nurses to 12 hour shifts and they were overworked and did not get things done, such as answering call lights or medications getting passed timely. Resident #62 was interviewed on 6/26/23 at 2:30 p.m. The resident said there were too many agency nurses in the building. Resident #62 was interviewed on 6/26/23 3:03 p.m. The resident stated she had to wait until after lunch to get her brief changed. Resident #49 was interviewed on 6/26/23 at 4:07 p.m. The resident said there was not enough staff to ensure not having to wait a long time. She said the evening/night shift was the worst. She said the staff work 12 hour shifts. She said there had been times there was only one CNA on her floor. She said showers were not provided as scheduled due to no staff. Resident #48 was interviewed on 6/26/23 at 4:15 p.m. The resident said there was not enough staff. The call lights were not answered timely. There had been changes since the facility changed ownership in March 2023. Resident #219 was interviewed on 6/26/23 at 4:26 p.m. The resident said she had difficulty receiving assistance to the bathroom. She said it could take 15 minutes for staff to answer her call light, the CNA would come to the room, then the CNA left and she had to wait another 15 minutes. She said then it took time for them to come back to assist after she was in the bathroom. Resident #44 was interviewed on 6/27/23 at 8:52 a.m. The resident said there was not enough staff and call lights were not answered timely. Resident #319 was interviewed on 6/27/23 at 9:47 a.m. The resident said he was told to not go to the dining room as there was not enough staff because of call offs. Resident #217 was interviewed on 6/27/23 at 10:02 a.m. The resident said there was not enough staff for showers. V. Resident group interview The resident group interview was conducted on 6/28/23 at 3:00 p.m. The group consisted of five residents (#4, #8, #19, #43 and #45) who were interviewable based on assessment and facility. The residents stated they continued to have concerns with follow up on staffing issues. The concerns were as follows: -Showers not provided as scheduled; -Call lights not answered timely; -Weekend staffing was low; and. -Breakfast trays were served late. VI. Interviews A certified nurse aide (CNA) who wished to stay anonymous was interviewed. The CNA said the facility did not have enough staff to provide the care in particular showers. The CNA said there was not always a shower aide and because the floor CNA could not get it done, then resident showers did not get done. The CNA said they attempted to get all done, but it was a lot of rushing around. CNA #4 was interviewed on 6/28/23 at 6:26 p.m. The CNA said at times they have had to work with less staff. CNA #4 said the building had recently been through some changes and since the changes, they have less staff. CNA #2 was interviewed on 6/28/23 at 6:30 p.m. She said the North unit had two CNAs. The shower aide left at 6:00 p.m., so it remained at two CNAs. During the meal times and when assisting residents to bed, it was difficult to get the job done. The scheduler was interviewed on 6/29/23 at 11:12 a.m. The scheduler said he was responsible to staff the facility with nursing staff. He said the facility went by the resident census to schedule staff. He said agency was used quite a bit and the goal was to get agency out of the facility. He said he staffed the South unit with three CNAs for both day and evening. Then it dropped to two for the night shift. The North unit was two CNAs and sometimes three depending on the census. He said there was a bath aide who worked 12 hours which covered both the South and North units. He aid the facility was behind on providing showers to residents. He said the facility currently had two CNA positions open and four licensed nurse positions. The scheduler said when there was a call off, it was difficult to get agency to cover the shift, as there was not enough time. He said that at times the shower aide was pulled to work the floor. He said they like to keep the ratio of one staff to 15 residents. A licensed nurse who wished to be anonymous was interviewed. The licensed nurse said the staffing ratios had changed when the new ownership took over. The licensed nurse said one more additional CNA would make a difference, as they could help with vitals, weights and with the resident who required mechanical lifts. The extra CNA could rotate through the entire facility and not stay on one unit. The director of nurses (DON) was interviewed on 6/29/23 at 5:45 p.m. The DON said the facility staffed according to both resident acuity and census. She said for CNAs, they staffed six for the whole building- three CNAs on the South unit and two CNAs on the North unit with one shower aide. She said the shower aide worked from 6:00 a.m. to 6:00 p.m. She said the previous company had a ratio of one staff to six residents, however, that was not feasible with their company. She said she had heard complaints on staffing, however, she believed the staffing was where it needed to be. She said they did have agency for licensed nurses which she was working on getting out of the building. 43950

Based on observations, interviews and record review, the facility failed to ensure five (#62, #13, #217, #5 and #49) of six residents reviewed out of 38 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Ensure dependent Residents #62, #13, #217 and #49 were provided with showers; and, -Reposition Resident #5 in accordance with her plan of care. Findings include: I. Facility policy The Activities of Daily Living policy, revised October 2022, was provided by the director of nursing (DON) on 6/29/23 at approximately 2:00 p.m. It read in pertinent part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his or her abilities. ADL (activity of daily living) self-performance measures what the resident actually did within each ADL category. Extensive assistance is defined as while the resident performed part of the activity, he or she required weight bearing support into order to complete the activity. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff. ADL documentation will be maintained in the electronic health record under tasks, care plan, assessments and therapy documentation including personal hygiene. ADL's will be care planned to reflect the resident specific needs. II. Resident #62 A. Resident status Resident #62, over age 90, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included dementia, diabetes mellitus type two, protein-calorie malnutrition, visual loss, muscle wasting, heart failure and chronic kidney disease. The 6/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, and toilet use; extensive assistance of one person while walking in her room and corridor, ambulating on and off the unit and dressing and hygiene; and, she was a one person assist with bathing. Resident #62's vision was severely impaired; no vision or saw only light, colors or shapes. B. Resident interview Resident #62 was interviewed on 6/26/23 at 2:30 p.m. She said she had not received a shower for two weeks. She said the staff wanted to give her a shower before breakfast and she did not want that, so the staff left her room and never came back. C. Record review Resident #62's bath preference sheet completed 4/24/23 revealed the resident preferred a shower or bed bath offered once a week. Resident #62's ADL care plan, initiated 3/2/23 and revised 3/10/23, revealed she had a self-care performance deficit related to blindness to both eyes and limited mobility. She could make some of her needs known and staff also anticipated her needs. She was limited-to-maximum assistance with bed mobility, dressing, toileting, personal hygiene and bathing. Pertinent interventions included bathing with the assistance of one person, initiated and revised 3/2/23; resident shower preference one day a week, initiated 5/12/23. Resident #62's Kardex (resident care overview) indicated her bathing preference was Wednesday with the assistance of one person. Resident #62's electronic health record bathing task sheet revealed she had a shower on 6/2/23 (Friday) and refused a shower on 6/7/23 (Wednesday). A 6/9/23 progress note documented Resident #62 did not have a shower or bath documented in the electronic health record within four days due to refusals and a shower was offered to the resident and the resident declined. -There were no additional documented shower refusals in the electronic health record or progress by Resident #62 except on 6/7/23. Resident #62's electronic record task sheet documented the response of not applicable marked on 6/21/23 (Wednesday) and she had a shower on 6/27/23 (Tuesday). -The documentation provided revealed Resident #62 went 25 days without a bath or shower and at least 18 days without being offered a bath or shower. -Per the resaident's interview, she refused to shower due to not being offered at her preferred time (see above). III. Resident #217 A. Resident status Resident #217, age 86, was admitted on [DATE] and discharged on [DATE]. According to the June 2023 CPO, diagnoses included bleeding on the brain, fall, sciatica (pressure to lower back nerve), back pain, diabetes mellitus type two and muscle weakness. The 6/22/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She required extensive assistance of one-person with bed mobility, transfers, ambulating on and off the unit, dressing, toileting and bathing. She was independent and needed set up help only with eating, and needed supervision with two person assistance walking in her room and hallway. Bathing support provided and bathing self-performance was marked as did not occur. B. Resident interview Resident #217 was interviewed on 6/27/23 at 8:40 a.m. She said she had been at the facility for 10 days and wanted to have a shower but the staff had not given her one. C. Record review The care plan, updated 1/4/23, identified Resident #217 was mostly independent/supervision for ADL care in grooming, transfer, walking/locomotion toileting and eating and required assistance of one staff for bathing, bed mobility and dressing. Pertinent interventions included for bathing: Resident #217 needed staff assistance with her bathing, initiated and revised 6/19/23. Resident #217's kardex documented the resident preferred bathing Tuesday and Friday; and wash hair. Resident #217 needed staff assistance with her bathing. Resident #217's electronic health record bathing task sheet documented not applicable on 6/18/23 and Resident #217 was not available on 6/21/23 and 6/27/23. -There was no documentation of bathing offered to the resident or resident refusal of bathing. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed 6/28/23 at 6:38 p.m. She said the facility usually scheduled a bath aide so she did not provide too many resident showers but she had done some previously. She said showers were documented and charted showers in the resident's electronic health record. She said the staff documented the type of shower or bath, how much help the resident needed and how many staff needed to help the resident. If the resident refused, the staff asked the resident a couple more times if they wanted their shower or bath and then charted the resident's response. She said they then had to tell the nurse if a resident refused. She said she did not know if the nurse charted why the resident refused a shower or bath in the resident's progress notes. She said the shower aide worked 6:00 a.m. to 6:00 p.m. for showers and sometimes the facility was short staffed and the shower aide was required to stop providing showers and move onto the floor to help the residents and to substitute for the missing CNA. The director of nursing (DON) was interviewed on 6/29/23 at 4:30 p.m. She said the staff should tell a nurse if a resident refused a shower. She said she did ask staff to ask Resident #62 if she wanted a shower yesterday. She said the facility was working with staff to acclimate to the electronic health record as they were using paper charting when the new management started in March 2023. 20287 V. Resident #49 A. Resident status Resident #49, age 87, was admitted on [DATE]. According to the June 2023 CPO diagnoses included unspecified fracture of shaft of humerus, left arm, heart failure and chronic pain. The 7/27/22 MDS assessment documented the resident had no cognitive impairment with a BIMS score of 15 out of 15. The resident required extensive assistance with personal hygiene which included showers. She had no behaviors or refusal of care. B. Resident interview Resident #49 was interviewed on 6/26/23 at 4:10 p.m. The resident said her showers were not provided as scheduled. She said she had been scheduled for two a week, however, she had not received due to staffing. However, she did receive one today. C. Record review The care plan, last updated 3/15/23, identified the resident had an ADL self-care performance deficit related to impaired mobility. Pertinent approaches were the resident required assistance as needed. The Kardex showed the resident's shower days were Tuesdays and Fridays The bathing record from 5/30/23 to 6/29/23 confirmed the resident received a shower on 6/6/23 and 6/27/23 (resident said she received on 6/26/23 and not on 6/27/23). D. Staff interview Certified nurse aide (CNA) #5 was interviewed on 6/29/23 at approximately 3:00 p.m. The CNA said the resident was able to assist with her shower, however did require assistance. She said the resident was cooperative and did not refuse showers. E. Facility follow-up The facility sent a sheet with names of several residents who received showers on certain dates. There was a signature line for the licensed nurse and the CNA who provided the shower. Resident #49 showed she received a shower on 6/6/23, as documented. The sheet showed a shower on 6/13/23 was given. The 6/20/23 sheet showed a signature from the CNA, however no license nurse signature. -There was no documentation which showed the resident received showers in May 2023. 47064 VI. Resident #13 A. Resident status Resident #13, [AGE] years old, admitted on [DATE]. According to the June 2023 CPO diagnoses included dementia (abnormal memory), hypertension (increase in blood pressure) and traumatic brain injury. The 5/23/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. He required two person physical assistance with transfers and toileting. One person physical assistance with bed mobility, dressing, eating and personal hygiene. Resident #13 required substantial to maximal assistance with showering. B. Observations On 6/27/23 at 1:27 p.m. Resident #13 was sitting at nurses station in his wheelchair, his hair was unkempt, shiny and greasy in appearance. At 3:45 p.m. Resident #13 was observed laying in bed with greasy, shiny hair. On 6/28/23 at 11:45 a.m. Resident #13 was sitting in a wheelchair in the main dining room with shiny, greasy, slicked back hair. C. Record review According to the electronic medical record reviewed on 6/27/23 at 3:52 p.m. Resident #13 received three showers out of possible eight in the last 30 days. The residents preference sheet dated 4/19/23 indicted Resident #13 prefers showers two times a week. The Kardex indicated bathing was scheduled for Mondays and Wednesdays with one to two person assistance. D. Facility follow-up The facility provided more documentation that revealed Resident #13 received a shower on 6/5/23, 6/26/23 and 6/28/23. -However, the resident had three showers out of possible eight for the month of June 2023. VII. Resident #5 A. Resident status Resident #5, age 95, was admitted on [DATE]. According to the June 2023 CPO diagnoses included dementia, depression, peripheral vascular disease (decrease in circulation), candidiasis of skin (fungal infection) and heart failure (decrease heart function). The 6/16/23 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of nine out of 15. She required two person physical assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #5 was at risk for pressure ulcer development and was incontinent of bowel and bladder. B. Observations On 6/26/23 at 4:00 p.m. Resident #5 was sitting in her recliner with feet touching the floor in her room. Her feet were not offloaded to prevent skin breakdown. On 6/27/23 during continuous observation from 12:00 p.m. to 4:30 p.m. Resident #5 was sitting in her recliner with feet elevated and a pillow under calves. Resident #5 had the Hoyer (mechanical lift) sling under her during this time. She sat square in the chair and did not shift her weight in her seat independently at any time during the continuous observation. No position changes were offered nor toileting during this time. C. Record review The CNA documentation for transfer self performance for the past 30 days revealed the resident required extensive assistance where resident involved in activity staff provided weight bearing support or total dependence on full staff performed transfer. It indicated two person physical assistance was provided when she moved between surfaces to or from bed, chair, wheelchair and in standing position. The CNA documentation providing turn and repositioning for Resident #5 revealed she was only turned and repositioned at the following times during the survey: 6/26/23 repositioned twice at 6:36 a.m. and 4:15 p.m. 6/27/23 repositioned twice at 11:34 a.m. and 8:16 p.m. 6/28/23 repositioned once at 9:39 p.m. 6/29/23 repositioned twice at 11:59 a.m. and 4:14 p.m. The 6/20/23 care plan revealed: -Activities of daily living (ADL) indicated the resident required a hoyer lift for transfers. -Potential for pressure ulcer development with interventions of air mattress, float heels, monitor nutritional status, and notify physician as needed for skin status changes. -Potential for bowel/bladder incontinence with interventions of resident uses disposable briefs, change frequently and as needed, check as required for incontinence, wash rinse and dry perineum, change clothing as needed after incontinence episode and monitor for signs and symptoms of urinary tract infections. D. Staff interviews LPN #3 was interviewed on 6/27/23 at 4:36 p.m. He said residents who need assistance with repositioning should be repositioned by staff every 15 to 30 minutes to prevent skin issues like pressure injuries. LPN #3 said Resident #5 was a hoyer transfer and required two people for transferring and she was unable to shift her weight in the chair so she would need one to two staff members to help off load pressure while in the chair. The DON was interviewed on 6/27/23 at 4:45 p.m. She said dependent residents should be repositioned every two hours to prevent skin breakdown. The DON saidResident #5 was able to independently shift her weight in her chair and currently did not have any open skin concerns. -However, according to LPN #3, Resident #5 was not able to shift her weight. The DON was notified of the observation of Resident #5 not being repositioned or offered/encouraged to be repositioned for at least four and half hours during continuous observation (see above). The DON said she would assess the resident's skin and educate the staff about repositioning. The DON was notified Resident #5's feet had been touching the ground and not off loaded (see observation above). She said offloading heels was an important preventative measure to prevent skin breakdown. 43950

Based on observations, resident interview, record review, and staff interviews, the facility failed to ensure residents maintained continence or received treatment and services to restore continence to the extent possible for one (#219) of two residents out of 38 sample residents. Specifically failed to ensure Resident #219's catheter was secured. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. [NAME] Missouri, pg 1187. Securing catheter reduces risk of movement, urethral erosion, or accidental catheter removal. Attachment of securement device at the catheter bifurcation prevents occlusion of catheter. II. Facility policy and procedure The Indwelling Urinary Catheter Care policy and procedure, revised March 2023, was received from the nursing home administrator (NHA) on 6/29/23 at 12:00 p.m. It revealed, in pertinent part, to promote hygiene, comfort and decrease the risk of infection for a resident with an indwelling urinary catheter. Secure the tubing with a securement device to prevent migration, friction or tension of the catheter. Make sure the resident was comfortable. III. Resident #219 status Resident #219, age 76, admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) medical diagnosis included fracture of right pubis (broken pubic bone), obstructive uropathy (obstructed urinary flow), neoplasm of the right kidney (cancerous tumors) and B-cell lymphoma (type of cancer). The 6/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMs) score of 15 out of 15. She required one person assistance with bed mobility, transfers, dressing, toileting and personal hygiene. She required set up assistance with eating. It indicated the resident used an indwelling catheter. A. Resident interview and observations On 6/26/23 at 4:26 p.m., Resident #219 was observed sitting on the side of the bed. The tubing from the catheter was hanging off the resident leg. A securement device was not observed for the catheter tubing. Resident #219 said the sticky device she had on her leg would no longer stick. She said a nurse told her they would get her a new one or another device to hold it in place last week but still had not received anything. She said she had to hold the tubing during transfers, but would often forget and it was uncomfortable and sometimes hurt when it would get pulled. On 6/28/23 at 3:21 p.m., Resident #219 was observed sitting on the side of the bed. She said the nurse had secured the catheter tubing to her leg that day. She lifted her blanket and showed that the tubing was secured to her leg with a self adhering elastic compression wrap. She said it was not the appropriate securement device but this was the nurses temporary solution. On 6/29/23 at 11:00 a.m. Resident #219's catheter was observed secured with self adhering compression wrap. B. Record review The indwelling foley catheter care plan, revised on 6/16/23, documented the resident used an indwelling foley catheter due to urinary obstruction from a renal mass. The interventions included monitoring and documented for pain and discomfort. The Kardex (an overview of the resident's care) indicated the facility staff should assist Resident #219 with toileting and provide indwelling catheter care every shift. IV. Staff interviews The assistant director of nursing (ADON) was interviewed on 6/28/23 at 5:34 p.m She said central supply (CS) and the director of nursing (DON) were responsible for ordering supplies for the facility. The DON was interviewed on 6/28/23 at 5:40 p.m. She said a catheter should be secured to a resident's leg with a leg strap or a catheter stat lock (specialized securement device for catheters). The DON said securing the catheter lines to a residents' thighs would help prevent the catheter tubing from being pulled on, pulled out and cause injury to the resident. Registered nurse (RN) #2 was interviewed on 6/29/23 at 11:00 a.m. She said that Resident #219's catheter tubing had been secured to her leg with a self adhering compression wrap. RN #2 said she saw the tubing secured with the self adhering wrap yesterday evening. She said she was unable to find the proper securement device for the resident. CS was interviewed on 6/29/23 at 11:11 a.m. He said he was informed by the nursing staff verbally when supplies were running low. CS said he would provide a list to the DON weekly of supplies that needed to be ordered. During a review of the south wing supply room with CS, he was unable to locate a catheter securement device. CS was observed entering a larger supply room in the basement for the catheter securement device. He had to move several boxes to access the shelf with all the urinary supplies. He was unable to identify the two types of catheter securement devices on the shelf. RN #2 was interviewed on 6/29/23 at 11:45 a.m. She said Resident #219 had complained that her catheter securement device was not functioning properly over the past weekend. She said she was unable to locate one to replace it at the time so the resident went without a securement device. The DON was interviewed on 6/29/23 at 4:31 p.m. She said she completed the ordering of supplies for the facility. She said the facility did not have a supply issue. She said education needed to be provided to the facility staff on where items could be found.

Based on observations, record review and interviews, the facility failed to ensure two (#13 and #7) of two residents received adequate supervision to prevent accidents out of 38 sample residents. Specifically, the facility failed to ensure two staff members were present during the transfers of Resident #7 and Resident #13 using a mechanical lift. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. [NAME] Missouri, pg 812. If a patient was unable to cooperate or does not have sufficient upper or lower body strength, use ceiling, hydraulic floor, or power driven lift to transfer the patient from bed to chair. Use a minimum of two to three caregivers. II. Resident #13 A. Resident status Resident #13, age 93, admitted on [DATE]. According to the June 2023 computerized physician orders (CPOs), the diagnosis included dementia (abnormal memory), hypertension (increase in blood pressure) and traumatic brain injury. The 5/23/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMs) score of three out of 15. He required two person physical assistance with transfers and toileting and one person physical assistance with bed mobility, dressing, eating and personal hygiene. B. Observations On 6/27/23 at 4:21 p.m., certified nurse aide (CNA) #1 was observed transferring Resident #13 from her bed to her wheelchair with a mechanical lift. CNA #1 placed the sling underneath the resident, set up the mechanical lift over the resident, secured the sling to the lift, instructed the resident to his cross arms and began to lift the resident up off the bed. -CNA #1 moved the mechanical lift over the wheelchair, turned the resident and began lowering the resident into the wheelchair. The resident was four to five inches in the air above the wheelchair when the mechanical lift slid backwards away from the wheelchair and the CNA. Resident #13 said I am going to slide off and appeared to be reaching for something to grab onto. CNA #1 continued to lower the resident into the wheelchair. Once resident was in the wheelchair, CNA #1 disconnected the sling from the mechanical lift and then had to manually adjust the resident by pulling him with the sling as his hips were not all the way back in the wheelchair. -CNA #1 failed to ensure a second staff member was present to assist with the mechanical lift transfer. CNA #1 failed to lock the breaks on the mechanical lift prior to lowering the resident into the wheelchair. C. Record review The activities of daily living (ADL) care plan, revised on 3/9/23, documented the resident had a self-care deficit related to weakness. It indicated the resident required one to two person assistance with transfers (initiated on 3/9/23). The June 2023 CNA point of care (POC) documentation revealed Resident #13 required extensive assistance to total dependence on staff during transfers. III. Resident #7 A. Resident status Resident #7, age 77, was admitted on [DATE]. According to the June 2023 CPOs the diagnosis included cerebral infarction, hemiplegia (paralysis) affecting the right side, type two diabetes (abnormal insulin), chronic kidney disease (decrease in kidney function) and heart failure (decrease in heart function). The 5/11/23 MDS assessment revealed the resident was cognitively intact with a BIMs score of 15 out of 15. He required two person physical assistance with transfers and toileting and one person physical assistance with bed mobility, dressing, and personal hygiene. B. Observations On 6/27/23 at 3:38 p.m., Resident #7 was observed laying in bed. -At 4:10 p.m. CNA #1 was observed entering Resident #7 ' s room alone with a mechanical lift. -At 4:17 p.m. CNA #1 exited room with Resident #7 in a wheelchair, returned to the room, disinfected the mechanical lift and left it in the hallway. No other staff were seen entering or exiting Resident # 7 ' s room. -CNA #1 failed to ensure a second staff member was present while transferring Resident #7 with a mechanical lift. C. Record review The ADL care plan documented the resident had a self care deficit related to the disease process and limited mobility. It indicated a mechanical lift was to be used for all transfers (initiated on 3/22/23). The June 2023 CNA POC documentation indicated that Resident #7 required extensive assistance to total assistance with transfers. -It indicated that the resident was transferred with the physical assistance of two or more staff members. IV. Staff interviews CNA #1 was interviewed on 6/27/23 at 4:33 p.m. She said the Kardex documented each resident's transfer status. CNA #1 said one or two staff members were able to transfer a resident with the mechanical lift. She said using one or two staff members depended upon staffing. She said agency staff were difficult to find, so she would often transfer residents using the mechanical lift by herself. CNA #1 said she had not been given any training on mechanical lift transfers upon hire. CNA #1 confirmed she transferred Resident #7 and Resident #13, using the mechanical lift, by herself. Licensed practical nurse (LPN) #3 was interviewed on 6/27/23 at 4:36 p.m. He said two staff members were required to transfer a resident with the mechanical lift to prevent a resident from falling or coming in contact with the lift and sustaining an injury. The director of nursing (DON) was interviewed on 6/27/23 at 4:38 p.m. She said mechanical lift transfers were to be completed with two staff members for the safety of a resident.

Based on record review and interviews the facility failed to ensure one (#40) of one out of 38 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to: -Identify the continued system breakdown of ensuring changes to treatment orders were translated from the physician wound notes to the treatment administration record (TAR) timely, specifically, that Resident #40 received wound treatments as ordered by the physician; and -Ensure interventions ordered by the physician were included and updated on the comprehensive care plan. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. [NAME] Missouri, pg 1262. A health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. [NAME] Missouri, pg 277. Changes in patients' condition, needs or abilities makes alterations of the care plan necessary. This will require you to continue interventions either as planned or less/more often, or you will choose to add interventions focused on the factors affecting goal achievement. II. Facility policy and procedure The Pressure Ulcer Skin Monitoring and Management policy and procedure, revised March 2023, was provided by the nursing home administrator (NHA) on 6/29/23 at 5:07 p.m. It revealed in pertinent part, a resident having a pressure ulcer receives necessary treatment and services to promote healing, prevent infections, and prevent new, avoidable sores from developing. Once the wound has been identified, assessed , and documented, nursing shall administer treatment to each affected area as per the physician order. III. Resident #40 A. Resident status Resident #40, age 81, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included pressure ulcer (wound over bony prominence) of the sacral region, pneumonitis (inflammation of lung tissues), compression fracture of the lumbar spine, chronic obstructive pulmonary disease (air flow blockage) and type two diabetes (abnormal glucose levels). The 5/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required two person physical assistance with transfers and one person physical assistance with bed mobility, dressing, eating, toileting and personal hygiene. It indicated the resident had a stage II pressure ulcer (partial thickness skin loss). B. Record review The May 2023 TAR documented the following physician orders: -Wound care to coccyx area: cleanse area, apply medi honey (specialized ointment for wounds) to the wound bed and cover with a foam dressing to be changed daily and as needed every evening shift - ordered on 5/24/23 and discontinued on 6/7/23; -Air mattress: check placement and function every shift - ordered on 5/24/23; and -Pressure reduction cushion - ordered on 3/15/23. The June 2023 TAR documented the following physician orders: -Wound order for coccyx: cleanse area, apply santyl to the wound bed and cover with foam dressing, change daily and as needed - ordered on 6/7/23, and discontinued on 6/23/23; and -Wound order for coccyx: cleanse the area, apply medi honey to the wound bed, cover with foam dressing, change daily and as needed - ordered 6/23/23. The 5/25/23 physician wound notes indicated the wound orders for the coccyx wound: cleanse with normal saline, apply santyl, cover with foam dressing daily. It indicated additional orders for an air mattress and wheelchair cushion. -However, the treatment documented in the physician notes did not match the treatment documented on the TAR. The 6/1/23 physician wound notes indicated the following wound orders for the coccyx: cleanse with normal saline, apply santyl, cover with foam dressing and change daily. -However, according to the TAR, the wound treatment was not changed to match the physician's new order until 6/7/23. The 6/8/23 and the 6/15/23 physician wound notes indicated the following wound care orders for the coccyx: cleanse with normal saline, apply santyl, cover with foam dressing, change daily. Additional interventions, documented on 6/8/23, were to turn and reposition the resident frequently while in bed or chair, shift weight while in bed or chair. The treatment that was provided to Resident #40 from 5/25/23 to 6/7/23 was not the treatment ordered by the wound physician. -The facility failed to ensure the treatment changes made by the wound physician were transcribed onto the TAR and implemented timely. Cross-reference F867: the facility failed to identify the continued system breakdown of ensuring changes to treatment orders were translated from the physician wound notes to the treatment administration record (TAR) timely. The skin breakdown care plan, revised on 3/9/23, documented the resident had a pressure ulcer. The interventions, initiated on 3/9/23, included the resident would have intact skin, free of redness, blisters or discoloration; floating the resident's heels as tolerated; monitoring the resident's nutritional status; serving the resident's diet as ordered and monitoring the resident's intake; and monitoring, documenting and reporting skin changes to the physician. -The care plan failed to address and implement interventions that were ordered by the physician, to include: an air mattress, wheelchair cushion and frequent turning and repositioning of the resident. IV. Staff interviews The DON was interviewed on 6/29/23 at 4:31 p.m. She said it was important to follow physician treatment orders to promote the healing of pressure injuries. The DON said she completed wound rounds weekly with the wound physician and it was her responsibility to enter new treatment orders into the residents chart from wound rounds. The DON confirmed the physician notes provided during the survey indicated orders for santyl and not medi honey from 5/25/23 to 6/7/23. The minimum data set resource (MDSR) was interviewed on 6/29/23 at 5:24 p.m. She said new skin interventions should be added to the comprehensive care plan. The MDSR confirmed the physician ordered interventions for Resident #40's coccyx wound (discovered on 5/24/23) were not documented in the resident's comprehensive care plan. The MDSR said the physician orders for an air mattress and the wheelchair cushion should have been added to the comprehensive care plan. V. Additional information received from the facility The facility provided additional wound physician progress notes on 7/5/23 at 2:33 p.m. The wound physician progress notes documented the following: The wound physician notes dated 5/25/23, 6/1/23, 6/8/23 and 6/15/23 were altered to add medi honey can be used if Santyl was not available. The 5/25/23 notes were digitally signed on 6/29/23 at 3:57 p.m. The 6/1/23, 6/8/23 and the 6/15/23 wound physician notes were digitally signed on 6/29/23 at 3:58 p.m

Based on interviews and record review, the facility failed to timely and thoroughly investigate an alleged violation of physical abuse for one (#219) of three reviewed for abuse out of 38 sample residents. Specifically, the facility failed to investigate an abuse allegation reported by Resident #219 to her hospice nurse and licensed practical nurse (LPN) #3. Findings include: I. Facility policy and procedure The Abuse: Prevention of and Prohibition against policy and procedure, revised January 2023, was received from the nursing home administrator (NHA) on 6/26/23 at 1:17 p.m. It revealed in pertinent part, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the administrator or his/her designee. II. Resident status Resident #219, age 76, admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included fracture of right pubis (broken pubic bone), obstructive uropathy (obstructed urinary flow), neoplasm of the right kidney (cancerous tumors) and B-cell lymphoma (type of cancer). The 6/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMs) score of 15 out of 15. She required one person assistance with bed mobility, transfers, dressing, toileting and personal hygiene. She required set up assistance with eating. The resident had an indwelling foley catheter (collects urine) and was occasionally incontinent of bowel. III. Resident and family interview Resident #219 was interviewed on 6/26/23 at 4:26 p.m. She said sometimes staff were rude or crude to her. Resident #219 explained it was either a nurse or certified nurse aide (CNA) last week around 4:00 a.m. when she requested to have a brief change and was told she could do it herself and to use the bed chucks (protective covering on bed for incontinence episodes) to have a bowel movement. Resident #219 said she told the staff member she would report her and the staff member said she did not care. She was unable to identify the staff member by name or recall the date of the incident. She identified the staff member as female. Resident #219 said she felt disrespected by staff and degraded. Resident #219 reported she told her hospice nurse about it the next morning, who told her good help could not be found anymore. Resident #219 said she told her sister about the situation via the telephone. She was under the impression the hospice nurse was going to tell someone about what happened to her. Resident #219's sister was present during the interview and stated she recalled her sister calling her and telling her about a situation that happened with a staff member last week but was unable to recall the day her sister told her about it. The information indicated by the resident was reported to the regional clinical consultant (RCC) on 6/26/23 at 5:08 p.m. IV. Record review There were no progress notes in the electronic medical record (EMR) about Resident #219 ' s reported incident. There was no hospice progress notes in the EMR and there was not a hospice binder in the facility for resident #219. The 6/12/23 comprehensive care plan was reviewed and documented the resident had a self care deficit for activities of daily living (ADL) interventions implemented on 6/12/23 were one staff member for toileting, transfers and bed mobility. V. Facility abuse investigation The abuse investigation the facility completed was reviewed on 6/29/23 at 1:30 p.m. The interview facility completed with Resident #219 told the facility at 4:00 a.m. sometime last week she was told by a staff member to use the bed chucks to have a bowel movement. She described the staff member. Resident #219 reported she had the staff member as a caregiver since the incident. Resident #219 said she felt disrespected. Staff assisted Resident #219 through the facility via wheelchair to see if the staff member was in the facility and if the resident was able to identify. Resident #219 did not identify any staff member in the facility as the staff member from that night. Facility completed staff interviews: The hospice nurse interview confirmed the resident reported an incident between the resident and a staff member possibly around 6/23/23. The hospice nurse said Resident #219 told her it happened around 4:00 a.m. when she asked to have her brief changed and was denied by staff. Licensed practical nurse (LPN) #3 reported Resident #219 mentioned that a nurse on a previous shift was rude to her. LPN #3 thought it was Monday morning (6/26/23) after his weekend off. He felt the situation did not pose as an abusive situation. -However, LPN #3 did not report it to the administration to be investigated to rule out potential abuse. VI. Staff interviews The RCC was interviewed on 6/27/23 at 10:00 a.m. She said the facility started the investigation immediately after they became aware on 6/26/23. The RCC said the interview with Resident #219 resulted in a very descriptive staff member which did not match any staff in the facility and she personally escorted Resident #219 around the facility to see if she could identify the staff member. LPN #3 was interviewed on 6/29/23 at 3:52 p.m. He said abuse could be verbal, physical, sexual, emotional and neglect. Any type of abuse should be reported to the NHA or the director of nursing (DON) as soon as possible. LPN #3 said Resident #219 had reported a staff member being rude to her. He said he felt Resident #219 was not very concerned with what she reported to him. He said she held a normal conversation with him like every day he worked, she did not express anger so he did not report it to a supervisor or the NHA. The social worker resource (SWR) was interviewed on 6/29/23 at 5:38 p.m. She said it was the facility ' s expectation staff were to report any allegation of abuse to the abuse coordinator immediately to ensure the safety of the resident. She said if the allegation occurred on the evening shift/night shift it was to be called in to the NHA or DON and investigation should be started at time of report. The SWR said if abuse by a staff member was suspected the staff member was to be suspended until the investigation was complete. She said an investigation was used to determine if something happened and why it happened for determination of a root cause to to help prevent it from occurring again. The SWR said investigation for Resident #219 started on 6/29/23 after the facility was made aware of the allegation and the facility did not substantiate this allegation. The SWR said the facility had four verbal abuse allegations on 6/26/23 that were brought to their attention so the facility interviewed many staff members and looked at resident assessments and follow up interviews. She said three of the allegations were reported by state surveyors and one from resident interviews. She said the facility found one staff member and one agency nurse who did not have a great attitude, flat during their interviews and felt their overall demeanor could make others perceive they did not have a great approach towards residents. The SWR said the facility felt the two nurses were the reason they received these complaints and the agency nurse would not be returning to the facility and the staff nurse was given a final write up with education on customer service with a one-on-one approach. The SWR said the facility was out of touch with the residents and were implementing ambassador rounds to meet with residents individually on a weekly basis now. The SWR said even if a situation voiced by a resident was not abuse, the allegation should be reported for follow up. The DON was interviewed on 6/29/23 at 6:12 p.m. She said the two identified nurses only worked from 6/17/23 to 6/25/23. The DON said hospice staff were not trained by the facility on abuse; it was to be completed by their place of employment and the hospice nurse should have reported what Resident #219 told her to the facility staff immediately. The DON said staff from providers were mandated to report allegations of abuse to the staff and the facility staff had access to NHA and DON phone numbers at each nurses station. The DON said LPN #3 had a great rapport with his residents and should have reported what Resident #219 told him about the staff being rude to rule out abuse.