Every finding on record at Mccormick's Creek Rehabilitation and Healthcare

Based on interview and record review, the facility failed to ensure the facility had a Registered Nurse (RN) on site for 8 hours a day that was not the Director of Nursing Services (DNS) when the facility was over 60 residents for 3 of 45 days reviewed. This had the potential to affect 73 of 73 residents residing in the facility.Findings include:On 1/14/26 at 11:32 a.m., the December 2025 nursing schedule was requested. On 1/14/26 at 1:10 p.m., the DNS presented the Nursing Daily Staffing sheets for December 2025. They indicated the following:- On 12/6/25, the only RN that worked was the DNS. The Daily Nurse Staffing Posting indicated the census was 73 residents.- On 12/20/25, the only RN that worked was the DNS. The Daily Nurse Staffing Posting indicated the census was 73 residents.- On 12/21/25, the only RN that worked was the DNS. The Daily Nurse Staffing Posting indicated the census was 73 residents.During an interview on 1/14/26 at 1:13 p.m., the DNS indicated she had a couple of RNs who would call-in and she was responsible for working the shifts when nurses called-in. She did not clock in if she covered a shift.On 1/14/26 at 2:42 p.m., the DNS provided the facility policy, Staffing, Sufficient and Competent Nursing, dated 2/2025 and indicated it was the policy currently being used by the facility. A review of the policy indicated, .c. The director of nursing services [DNS] may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents .3.1-17(b)(3)3.1-17(e)

Based on observation, interview, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services to promote wound healing for 1 of 3 residents reviewed for pressure ulcers. (Resident 10)Findings include:During an interview on 1/9/26 at 2:39 p.m., Resident 10 was observed in bed and had a gauze bandage on his right elbow. He indicated he had a pressure wound on his elbow for a long time, and he was observed to utilize his right elbow to reposition himself throughout the interview.On 1/12/26 at 11:57 a.m., the resident was observed in bed with a bandage on his right elbow.On 1/13/26 at 12:07 p.m., the resident was observed in bed with a bandage on his right elbow.On 1/12/26 at 12:08 p.m., the resident's clinical record was reviewed. The diagnoses included, but were not limited to weakness, quadriplegia, and muscle wasting and atrophy.A 12/31/25 quarterly Minimum Data Set Assessment indicated the resident was cognitively intact. He had upper and lower extremity impairment of both sides in functional range of motion. A 9/11/25 physician's order indicated the resident was to have OT (occupational therapy) to evaluate and treat him for a protective elbow device.The clinical record lacked an OT evaluation for a protective elbow device.A 9/16/25 Wound Assessment Report from a wound specialist indicated the resident had 3 newly acquired stage 3 (an ulcer where tissue damage results in full-thickness loss of the skin and the layer of fat under the skin may be visible) wounds to his right elbow. A right proximal wound measured 0.5 cm (centimeter) by 0.6 cm by 0.1 cm. A right distal wound measured 1 cm by 0.8 cm by 0.1 cm. A right lateral wound measured 2 cm by 3.2 cm by 0.1 cm. During an interview on 1/14/26 at 11:20 a.m., the DON (Director of Nursing) indicated the facility did not have access to the therapy department's charting because the facility changed therapy companies in October of 2025. She indicated the resident's right elbow wound was a chronic wound which developed due to the resident frequently applying pressure to his right elbow.During an interview on 1/14/26 at 2:19 p.m., the DON and the interim Administrator indicated the facility could not get access to the former company's charting and they could not prove the resident had the OT evaluation.On 1/14/26 at 2:46 p.m., the DON provided a copy of the facility policy, Physician Services and Orders, dated 12/1/25, and indicated it was the policy currently being used. A review of the policy indicated, . 11. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded in the resident's medical record during that shift .3.1-40(a)(2)

Based on observation, interview, and record review, the facility failed to keep the urinary catheter (flexible tubing which drains urine from the bladder) drainage bag and tubing from touching the floor for a resident being treated for an urinary tract infection (UTI) for 1 of 4 residents reviewed for urinary catheter. (Resident 70) Findings include: On 1/27/25 at 2:34 p.m., Resident 70 was observed to be resting in her bed with her urinary catheter tubing touching the floor. On 1/28/25 at 2:46 p.m., Resident 70 was observed to be resting in her bed with the urinary catheter tubing touching the bottom of the rolling table beside her bed. On 1/29/25 at 9:32 a.m., Resident 70 was observed to be resting in her bed with the urinary catheter tubing touching the floor. On 1/29/25 at 1:40 p.m., Resident 70 was observed to be sitting in her wheelchair with her urinary catheter tubing touching the floor. On 1/30/25 at 2:10 p.m., Resident 70 was observed to be resting in her bed with the urinary catheter drainage bag touching the floor. On 1/30/25 at 2:15 p.m., Resident 70's clinical record was reviewed. The diagnoses included, but were not limited to, UTI, weakness, and neuromuscular dysfunction of the bladder (a condition where the bladder muscles and nerves do not function properly). Resident 70's January 2025 Physician Order indicated the following: - 18 French 5-30 ml (milliliters) (size of catheter) catheter for neuromuscular dysfunction, initiated on 12/8/24. - Provide catheter care each shift and maintain the drainage bag below the bladder. Do not allow the tubing or the bag to drag/touch the floor, initiated 12/10/24. - Amoxicillin-Pot Clavulante (antibiotic) 875-125 mg (milligrams) by mouth two times a day for UTI, initiated 1/27/25. The care plan, revised 1/25/25, indicated Resident 70 had a UTI. The interventions were to administer medications and treatments as ordered and to observed to side effects of the antibiotic. The care plan lacked documentation of placement of the catheter tubing or drainage bag. The Hospital Discharge Instructions, dated 1/22/25, indicated Resident 70 had been in the hospital with a diagnosis of UTI. The Infection Charting, dated 1/30/25 at 10:17 p.m., indicated Resident 70 was on Amoxicillin-Pot Clavulante for a UTI. The progress notes indicated the following: - On 1/28/25 at 1:29 p.m., Resident 70 continued to be on an antibiotic for UTI. - On 1/28/25 at 5:55 p.m., Resident 70 continued to be on an antibiotic for UTI. - On 1/29/25 at 7:38 a.m., Resident 70 continued to be on an antibiotic for UTI. Her urine was dark with no sediment. - On 1/30/25 at 1:45 p.m., Resident 70 continued to be on an antibiotic for UTI. Her urine was amber (color of urine) with no sediment. During an interview on 1/30/25 at 2:20 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident 70 had a urinary catheter due to urinary retention and Resident 70 had a history of UTI's. During an interview on 1/30/25 at 2:23 p.m., CNA 1 indicated Resident 70 had a catheter. When Resident 70 was in bed, the catheter bag or tubing should not touch the floor. CNA 1 observed Resident 70's drainage bag touching the floor and indicated it should not touch the floor. On 1/31/25 at 12:14 p.m., the Administrator provided the facility's policy, Indwelling Catheter Use and Removal, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures . 3.1-41(a)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received the physician ordered therapeutic diet for 1 of 3 residents reviewed for therapeutic diets. (Resident B) Finding included: On 3/11/24 at 8:41 a.m., observed a meal tray sitting on a meal cart in front of room [ROOM NUMBER] with a meal tray for Resident B. The meal ticket for Resident B, dated 3/11/24, indicated the tray was for breakfast. Resident B was on a controlled carbohydrate diet and Resident B was to receive a waffle with syrup, sausage patty, and scrambled eggs. A 1.5 ounce packet of [NAME] Farms table syrup was observed that did not indicate if the syrup was sugar free on Resident B's tray. At that time, observed CNA 1 take Resident B's tray from the cart and into Resident B's room. During an interview on 3/11/24 at 8:42 a.m., CNA 1 indicated Resident B was on a controlled carbohydrate diet. The 1.5 ounce packets of [NAME] Farms table syrup was not sugar free. During an interview on 3/11/24 at 9:05 a.m., CNA 2 indicated Resident B should have received sugar free syrup on the meal tray. The staff should have returned the regular syrup to the kitchen and exchanged it for sugar free syrup. During an interview on 3/11/24 at 9:22 a.m., the Dietary Manager indicated the facility ran out of sugar free syrup for breakfast. The clinical record for Resident B was reviewed on 3/11/24 at 9:48 a.m. The diagnoses included, but were not limited to, Diabetes Mellitus and renal insufficiency. An Admission MDS (Minimum Data Set) assessment, dated 2/2/24, indicated Resident B was cognitively intact and received a therapeutic diet. A care plan, initiated on 1/30/24, indicated Resident B was at risk for altered nutritional status. The interventions included, but were not limited to, diet as ordered and provide meals and snacks based on residents food preferences and physician's orders. A physician's order initiated on 1/30/24, indicated controlled carbohydrate diet with regular texture and regular fluid consistency. During an interview on 3/11/24 at 11:00 a.m., Resident B indicated she had diabetes and was on a controlled carbohydrate diet. Resident B was not aware she was served regular table syrup instead of sugar free syrup. Resident B did not request regular syrup. On 3/11/24 at 11:44 a.m., the Administrator provided a copy of an undated facility policy, titled Therapeutic Diets, and indicated this was the current policy used by the facility. A review of the policy indicated the facility will provide a therapeutic diet that is individualized to meet the clinical needs of each resident. This citation relates to Complaint IN00428670. 3.1-20(a)

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services) for Quarter 4 (July 1 through September 30) of fiscal year 2023. Findings include: On 2/12/24 at 11:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN coverage on 8/5/23, 8/13/23, 8/20/23, and 9/10/23. On 2/14/24 at 3:25 p.m., a review of the fourth quarter staffing schedules indicated there was no RN coverage for 8 hours a day on 8/5/23, 8/13/23, 8/20/23, and 9/10/23. During an interview at that time, the Executive Director (ED) indicated the PBJ report was correct and there was not 8 hours of RN coverage on those days. On 2/14/24 at 10:15 a.m., the ED provided the facility policy, Nursing Services RN Coverage, revised on November, 2023, and indicated it was the policy currently being used. A review of the policy indicated, . except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 3.1-17(b)(3)

Based on observation, interview, and record review, the facility failed to label the eye drop bottle with an open date for 2 of the 3 medications carts observed. (Long Short Medication Cart, South Front Medication Cart) Findings include: 1. On 2/15/24 at 10:45 a.m., the long short medication cart was observed to have Resident 65's Ofloxacin (antibiotic eye drops) bottle. The eye drop bottle lacked an open date. The Assistant Director of Nursing (ADON) could not find an open date. On 2/15/24 at 11:20 a.m., Resident 65's clinical record was reviewed. The diagnoses included, but were not limited to, right fibula (bone in the leg) fracture, cerebral palsy (disorder that affect a person's ability to move and maintain balance), and conjunctivitis (pink eye). A Physician's Order, dated 2/1/24, indicated Ofloxacin 0.3 % solution was ordered four times a day for conjunctivitis for 7 days. 2. On 2/15/24 at 10:50 a.m., the south front medication cart was observed to have Resident 49's eye drop bottle. The eye drop bottle lacked an open date. The ADON could not find an open date. On 2/15/24 at 11:30 a.m., Resident 49's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, dry eye syndrome, and seasonal allergies. The February 2024 Physician Orders indicated ketotifen fumarate ophthalmic 0.025% (medication for itching eyes) one drop in both eyes as needed for dry eyes (start date of 7/15/23). On 2/15/24 at 11:00 a.m., the Director of Nursing (DON) provided the facility's policy, Medication and Biological Storage Requirements, dated 5/20/22 and indicated it was the policy being used by the facility. A review of the policy lacked documentation of dating opened eye drops bottles. 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag attached to a Foley catheter F/C (flexible tube which passed through the urethra and into the bladder to drain urine) was positioned off the floor for 1 of 1 resident reviewed for urinary catheter. (Resident 59) Findings include: On 2/13/24 at 10:22 a.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to be touching the floor. On 2/14/24 at 9:15 a.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to be touching the floor. On 2/14/24 at 11:09 a.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to be touching the floor. On 2/14/24 at 3:13 p.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to have been touching a mat that was lying on the floor. On 2/15/24 at 11:17 a.m., Resident 59 was observed to be awake in bed. A urinary drainage bag attached to a F/C was observed to have been touching a mat that was lying on the floor. On 2/15/24 at 2:36 p.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed sitting in a gray tub touching the floor. Resident 59's clinical record was reviewed on 2/15/24 at 11:30 a.m. The diagnosis included, but was not limited to, neuromuscular dysfunction of the bladder. Physician orders, dated 2/15/24, for Resident 59 indicated . Foley catheter 16 french 30 ml [milliliter] balloon to gravity drainage every shift for neurogenic bladder . During an interview on 2/15/24 at 9:36 a.m., Certified Nursing Assistant (CNA) 1 indicated the urinary drainage bag should be positioned off the floor. During an interview on 2/15/24 at 11:18 a.m., the Assistant Director of Nursing (ADON) indicated the urinary drainage bag should be positioned off the floor. During an interview on 2/15/24 at 2:35 a.m., the ADON and CNA 2 indicated they had just been told they now have to start putting the urinary drainage bags in tubs and Resident 59 had not been known to play with his F/C tubing. CNA 2 indicated, he has been out of it all week. On 2/15/24 at 12:35 p.m., the DON provided the facility's policy,Policy for Using Urinary Catheter Drainage Bags/Dignity Covers with a revised date of 11/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Hang closed Foley drainage bag on resident's bed . preventing Foley bag from touching the floor . The policy did not indicate putting the urinary drainage bag in a tub to prevent it from being on the floor. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a room containing soiled linens and biohazard materials was secured when unattended by staff during 1 of 1 continuous observation of the room. (Southwest Hallway) Findings include: On 2/11/24 from 10:30 a.m. to 12:45 p.m., the biohazard/soiled linen room on the southwest hallway was observed to be unlocked and unattended by staff. Three residents were observed ambulating by the room and 2 residents were observed passing the room via wheelchairs during this time period. An observation of the biohazard/soiled linen room keypad lock at 12:40 p.m., indicated the lock had been disengaged so as to enable access to the room without the use of the keypad. Inside the room were 3 uncovered linen bins filled with soiled linens, one trash can filled with soiled linens, and a biohazard container which contained a full sharps container and 2 specimen cups which contained a yellow liquid. An unlocked cabinet contained a spray bottle labeled Bleach, a spray bottle of glass cleaner, and a spray bottle labeled 7 in One Concentrate and .Hazardous to humans . During an interview on 2/11/24 at 1:00 p.m., the Administrator indicated the keypad to the door had been disengaged, the room was unattended by staff, and this could have posed a risk to residents. On 2/14/24 at 10:15 a.m., the facility Administrator provided the policy and procedure entitled Homelike Environment, effective date 12/1/23 and indicated this was the policy used by the facility. A review of the policy indicated, .it is the policy of the facility that the residents are provided with a safe .environment . 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure wheelchair arm pads were in good repair, call light and overbed light cords were repaired, and a resident wall was clean for 8 of 24 residents reviewed for environmental. (Resident 20, Resident 45, Resident 46, Resident 59, Resident 63, Resident 60, Resident 25, and Resident 51) Findings include: 1. On 12/28/22 at 11:20 A.M. and on 1/3/23 at 2:40 P.M., the armpad coverings of Resident 20's wheelchair were observed to be cracked, revealing the underlying padding. 2. On 12/28/22 at 11:40 A.M. and on 1/3/23 at 2:50 P.M., the left armpad covering of Resident 45's wheelchair was observed to be cracked, revealing the underlying padding. 3. On 12/28/22 at 11:50 A.M. and on 1/3/23 at 2:55 P.M., the right armpad of Resident 46's wheelchair was observed to be missing. 4. On 12/28/22 at 12:05 P.M. and on 1/3/23 at 3:10 P.M., the armpad coverings of Resident 59's wheelchair were observed to be cracked, revealing the underlying padding. 5. On 12/28/22 at 12:15 P.M. and on 1/3/23 at 3:20 P.M., the armpad coverings of Resident 63's wheelchair were observed to be cracked, revealing the underlying padding. 6. On 12/28/22 at 9:43 A.M. and on 1/4/23 at 2:00 P.M., the call light cord in Resident 60's bathroom was observed to be broken, with approximately 2 inches of cord remaining. 7. On 12/28/22 at 10:25 A.M. and on 1/4/23 at 2:10 P.M., the wall next the the bed of Resident 25 was observed to be stained with a dry brown substance. 8. On 12/28/22 at 2:22 P.M., the light above the head of Resident 51's bed was observed to be broken, with approximately 2 inches of cord remaining. During an interview on 1/4/23 at 2:21 P.M., the Administrator indicated the wheelchair arm pads, bathroom call light cord, and the bed light cord were in need of repair, and the dirty wall was in need of cleaning. 3.1-19(f)

Based on interview and record review, the facility failed to ensure the Notice of Transfer or Discharge were provided to the residents or resident representatives for 2 of 2 residents reviewed for discharge.(Resident 125, Resident 15) Findings include: 1. On 1/3/23 at 2:55 p.m., Resident 125's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on 10/10/22. There was no documentation the resident or resident's representative had been provided the Notice of Transfer or Discharge. 2. On 1/3/23 at 2:55 p.m., Resident 15's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on 10/4/22 and 11/29/22. There was no documentation the resident or resident's representative had been provided the Notice of Transfer or Discharge. During an interview on 1/4/22 at 3:00 p.m., the Executive Director indicated the notice of transfer requirements had been sent to the hospital with the resident's paperwork. There was no other documentation or policy available for review. On 1/4/23 at 3:00 p.m., the Executive Director provided the facility policy, Notice Requirements before Transfer/Discharge, undated, and indicated it was the policy currently being used. A review of the policy indicated, It is the policy of the facility to notify the resident and or their legal guardian of the before [sic] transfer and/or discharge according to state and federal regulations . 3.1-12(a)(8)(D)

Based on interview and record review, the facility failed to ensure that a bed hold policy was provided to residents that transferred to the hospital for 2 of 2 residents reviewed for hospitalization . (Resident 125, Resident 15) Findings include: 1. On 1/3/23 at 2:55 p.m., Resident 125's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on 10/10/22. Review of the resident's clinical record revealed no documentation that a bed-hold policy permitting the resident to return and resume resident in the facility was provided to the resident or resident's representative. 2. On 1/3/23 at 2:55 p.m., Resident 15's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on 10/4/22 and 11/29/22. Review of the resident's clinical record revealed no documentation that a bed-hold policy permitting the resident to return and resume resident in the facility was provided to the resident or resident's representative. During an interview on 12/30/22 at 1:16 p.m., the Executive Director indicated the bed-hold policy was sent to the hospital with the resident. There was no other documentation or policy available for review. 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure the resident had a care plan developed for insulin and antipsychotic medication use for 1 of 5 residents reviewed for unnecessary medications. (Resident 64) Finding includes: On 12/30/22 at 12:19 p.m., Resident 64 was observed to be watching her television. On 1/4/23 at 9:49 a.m., Resident 64 was observed to be lying in her bed asleep. On 12/29/22 at 3:06 p.m., Resident 64's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, schizoaffective disorder bipolar type, and psychosis. Resident 64's January 2023 Physician Orders included, but were not limited to: - Insulin glargine solution (long acting insulin), inject 10 units subcutaneously at bedtime for diabetes mellitus, initiated 11/7/22. - Quetiapine fumarate 25 mg (milligrams) tablet (antipsychotic medication) by mouth at bed time for schizoaffective disorder bipolar type, initiated 11/7/22. Resident 64's clinical record lacked documentation of a diabetes mellitus care plan for the use of insulin and a psychosis care plan for the use of quetiapine fumarate medication. During an interview on 1/4/23 at 3:34 p.m., the Director of Nursing (DON) indicated the clinical record lacked a care plan related to insulin and antipsychotic use. On 1/4/23 at 3:11 p.m., the Executive Director provided the facility's policy, Care Plans Protocol, undated, and indicated this was the policy currently being used by the facility. A review of the policy indicated .The care plan should be revised and on and on-going basis to reflect changes in the resident and the care the resident is receiving. 3.1-35(a)

Based on interview and record review, the facility failed to ensure staff provided necessary care and services consistent to the resident's needs and choices for 1 of 1 resident reviewed for ADLs (activities of daily living). (Resident B) Findings include: During an interview on 12/30/22 at 12:17 p.m., Resident B indicated she did not receive consistent showers while she resided at the facility. On 12/30/22 at 12:30 p.m., Resident B's closed clinical record was reviewed. The diagnoses included, but were not limited to, fracture of left talus (broken leg), person injured in motor-vehicle accident, injury of head, pain in left ankle and joints of left foot, and acute pain due to trauma. An Admission MDS (Minimum Data Set) assessment, dated 4/12/22, indicated the resident was cognitively intact and required the supervision of 1 staff member with personal hygiene. A care plan, dated 4/6/22, indicated the resident was at risk for self-care deficit as evidenced by the resident needed assistance with ADLs. An intervention included staff supervision with personal hygiene. The clinical record indicated the resident was scheduled for showers on Wednesdays and Saturdays. A review of the resident's bathing/shower logs indicated the resident did not receive a shower between 5/8/22 and 5/19/22 (discharge). This was 12 days without a shower. On 1/4/23 at 3:30 p.m., the MDS Coordinator indicated she could not find any additional documentation in regard to the resident's showers. On 12/27/22 at 2:00 p.m., the Executive Director provided the policy, Resident Rights, updated 3/15/17, and indicated it was the policy currently being used. A review of the policy indicated, .You have the right to . Receive the services and/or items included in the plan of care. This Federal tag relates to Complaint IN00396323. 3.1-38(a)(2)(A)

Based on observation, interview, and record review, the facility failed to ensure the daily posted nurse staffing sheet had the name of the facility and the actual hours worked by staff for 9 of 9 days of daily posted nurse staffing reviewed. Findings include: During an observation on 1/4/23 at 3:39 p.m., the daily posted nursing staff sheet lacked the name of the facility or the actual hours worked. On 1/04/23 at 3:46 p.m., the staffing coordinator provided the daily posted nursing staff sheet dated 12/27/22 through 1/4/23. The daily posted nursing staff sheet, dated 12/27/22 through 1/4/23, lacked documentation of the name of the facility or the actual hours worked by staff. During an interview on 1/4/23 at 3:58 p.m., the Executive Director (ED) indicated the daily posted nursing staff sheet dated 12/27/22 through 1/4/23 lacked the name of the facility name and the total actual hours worked. She indicated they did not have a policy. They followed the federal regulations for the daily posted nursing staff sheets.

Based on interview and record review, the facility failed to ensure staff did not use resident belongings and money without the residents' consent for 4 of 4 residents reviewed for misappropriation of identity and funds. (Resident E, Resident G, Resident H, Resident I) Findings include: During an interview, on 12/2/21 at 2:00 P.M., the facility Administrator indicated CNA (Certified Nurse's Aide) 1 was under investigation for theft of personal items/identity and money from Resident E, Resident G, Resident H, and Resident I. The Facility Administrator indicated the following information was reported to her by the indicated residents, and that information was reported to the local law enforcement agency: -On 10/20/21 at 11:44 A.M., Resident G reported she was missing her wallet, medicaid and medicare cards, state identification card, social security card, birth certificate, and $40.00. -On 10/31/21 at 12:01 P.M., Resident I reported she was missing her wallet and credit card. -On 11/2/21 at 1:00 P.M., Resident H reported he was missing his wallet, credit card, health insurance cards, and driver's license. He had called to cancel his credit card and discovered $500 had been taken out in cash by CNA 1. During an interview, on 12/3/21 at 10:05 A.M., Resident E indicated the local law enforcement agency had notified him that photographs of his credit card were found on the telephone of CNA 1. On 12/3/21 at 10:10 A.M., Resident E's clinical record was reviewed. The 11/11/21, quarterly Minimum Data Set assessment (MDS) indicated he was cognitively intact. During an interview, on 12/3/21 at 10:20 A.M., Resident G indicated on 10/20/21 she discovered she was missing $40.00, her medicaid and medicare cards, state identification card, social security card, and birth certificate. She reported this to staff. On 12/3/21 at 10:25 A.M., Resident G's clinical record was reviewed. The 10/27/21, quarterly MDS assessment indicated she was cognitively intact. During an interview, on 12/3/21 at 10:35 A.M., Resident I indicated on 10/31/21 she discovered her credit card was missing. She reported this to staff. On 12/3/21 at 10:40 A.M., Resident I's closed clinical record was reviewed. The 11/30/21, discharge MDS assessment indicated she was cognitively intact. On 12/3/21 at 11:00 A.M., Resident H's clinical record was reviewed. The 11/4/21 discharge MDS assessment indicated he was cognitively intact. During an interview, on 12/3/21 at 12:45 P.M., the local law enforcement agency's investigating officer indicated a search of CNA 1's phone contained photographs of the reported missing items of Resident G, Resident H, and Resident I. Also found on the phone were photographs of a credit card and identifying information of Resident E. Resident H's credit card was found to have had $500 transferred to CNA 1. On 12/3/21 at 1:00 P.M., CNA 1's personnel file was reviewed. The review indicated CNA 1 was arrested at the facility on 11/18/21, and her employment at the facility was terminated. On 12/3/21 at 1:15 P.M., the facility Administrator provided the Abuse Policy, dated 11/15/21. A review of the policy indicated, .any individual who willfully .misappropriates a resident's property or money will be terminated . This Federal tag relates to Complaint IN 253. 3.1-28(a)

Based on observation, interview, and record review, the facility failed to ensure residents received and consumed foods which met their daily nutritional and special dietary needs as prescribed by their physician for 3 of 3 residents reviewed for therapeutic diets (Resident B, C, and D.) Findings include: 1.) On 12/2/21 at 1:00 p.m., Resident B was observed eating lunch in their bedroom. The resident had 2 pieces of chicken, cooked carrots, bread stuffing, fruit cocktail, and an 1/8th slice of cherry pie. At that time, a review of the meal tray card indicated the resident was on a CCHO diet (controlled carbohydrate diet: a diet which focuses on eating the same amount of carbohydrates every day). During an interview, on 12/2/21 at 2:00 p.m., the regional dietary manager indicated Resident B was not served a slice of pie because their family does not want them to have pie. She verified the resident's tray at lunch time had only fruit cocktail. A diabetic could have pie, however, the slice would be half of a normal slice of pie, a 1/16th slice. On 12/2/21 at 2:10 p.m., Resident B's clinical record was reviewed. Diagnosis included, but was not limited to: type 2 diabetes mellitus. Resident B's current, December, 2021, physician's orders indicated, on 8/27/21, the resident was ordered a CCHO (diabetic diet) with NCS (No Concentrated Sweets diet: foods without the addition of sugar.) During an interview, on 2:12 p.m., CNA (certified nursing assistant) 1 indicated she passed out Resident B's lunch meal and the resident did not have pie, rather, they had fruit. She went down to the kitchen and got them a piece of pie, because she knew they would want a slice. She indicated the resident did not ask for the dessert and they were on an unrestricted diet. 2.) On 12/2/21 at 2:42 p.m., Resident D was observed in their bed with an 1/8 of a slice of cherry pie on their bedside table with a few bites taken. The resident indicated they were saving the pie for later, however, they always get the normal dessert since they weren't on a restricted (diabetic) diet. On 12/2/21 at 2:45 p.m., Resident D's clinical record was reviewed. Diagnosis included, but was not limited to: type 2 diabetes mellitus. Resident D's current, December, 2021, physician's orders indicated, on 9/2/21, the resident was ordered a CCHO (controlled carbohydrate) diet. During an interview, on 12/2/21 at 2:00 p.m., the Regional Dietary Manager indicated a diabetic could have pie, however, the slice would be half of a normal slice of pie, a 1/16th slice. 3. During an interview, on 12/2/21 at 2:15 p.m., Resident C indicated she was a diabetic and was on a diabetic diet. For lunch, she had chicken, dressing, carrots, and a slice of pie. The slice of pie was not a small piece. On 12/3/21 at 12:30 p.m., Resident C's clinical record was reviewed. The diagnosis included but were not limited to, diabetes mellitus and [CONDITION(S)]. Resident C's Order Review Report, dated 12/3/21, indicated CCHO (Consistent Carbohydrate diet) (start date 9/23/20). A care plan, initiated on 12/4/20 and current through target date 11/7/21, for Resident C indicated: Focus: .[Resident name] has nutritional problem r/t [related to] .Alt [alternate] nutrition status r/t CDK [[CONDITION(S)]] stage 4, T2D [ type 2 diabetes mellitus] .Goal: .[Resident name] will have a gradual weight loss .Interventions .Provide, serve diet as ordered . The Diet Spreadsheet for week 4 indicated a CCHO diet would receive a 1/16th slice of pie. During an interview, on 12/3/21 at 1:30 p.m., the Regional Dietary Manager indicated residents with CCHO diet would receive a 1/16th slice of pie which is a half slice of regular slice of pie. On 12/3/21 at 1:07 p.m., the Director of Nursing (DON) provided the facility's policy, Dietary Services - Menus and Nutritional Adequacy, dated 7/21/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .3. Be followed . This Federal tag relates to Complaint IN 677. 3.1-20(a)

During observation, interview, and record review, the facility failed to ensure a Minimum Date Set (MDS) was coded correctly for a resident who was edentulous for 1 of 2 residents reviewed for dental. (Resident 48) Findings include: During an observation, on 9/28/2021 at 10:16 a.m., Resident 48 was observed to be in her room and was edentulous. Resident 48's clinical record was reviewed on 9/30/2021 at 9:40 a.m. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 48's Annual Minimum Data Set (MDS) assessment, dated 1/29/2021, indicated, . No to no natural teeth or edentulous . A care plan, initiated on 7/28/2021 and current through target date 8/4/2021, for Resident 48 indicated, . Focus: [resident name] is at risk for a self-care deficit r/t [related to] weakness, low back pain and abnormalities of gait and mobility, seizures, dysphagia, [CONDITION(S)] [hypertension], a-fib and [CONDITION(S)] [[CONDITION(S)]] . Goals: [resident name] will be clean, dry, well-groomed through next review date . Interventions/Tasks: Oral Care. The resident is edentulous . During an interview, on 9/30/2021 at 10:16 a.m., Resident 48 indicated she did not have any teeth and hadn't had for a couple years. During an interview, on 9/30/2021 at 10:36 a.m., the MDS Coordinator indicated Resident 48 has not had any teeth for as long as she has known her and the Annual MDS dated [DATE], should have been coded Yes to no natural teeth or edentulous. On 9/30/2021 at 1:45 p.m., the Director of Nursing provided the facility policy, Resident Assessment Instrument [RAI] undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . PROCEDURE: Completion of the Minimum Data Set: 6. The assessment will accurately reflect the resident's status . 3.1-31(d)

Based on observation, interview, and record review the facility failed to ensure a safe environment after the beauty salon was found to be unlocked and unattended with hazardous materials inside for 1 of 1 beauty salon observed during a random observation. Findings include: On 9/26/2021 from 11:13 a.m. to 11:20 a.m., during entrance tour of the facility, the beauty salon was found to be unlocked and unattended with a piece of tape covering the door lock. Inside the beauty salon were a fire extinguisher, hair dryers, an unlocked closet which contained hair perm solutions, cleaners which indicated not to drink and bleach wipes. An unlocked drawer was observed to contain a pair of scissors. The beauty salon was located on a hallway which housed residents. On 9/26/2021 at 11:15 a.m., Resident 59 was observed to be passing the unlocked beauty shop in his wheelchair. Resident 59's Annual Minimum Data Set (MDS) assessment, dated 1/29/2021, indicated, . No to no natural teeth or edentulous . During an interview, on 9/26/2021 at 11:24 a.m., Licensed Practical Nurse (LPN) 1 indicated the beauty salon should be locked and the door should not be taped open. On 9/30/2021 at 1:45 p.m., the Director of Nursing (DON) provided the facility's document titled, Resident Rights undated. The document indicated, . PROCEDURE: This policy will included: 33. Safe . environment . 3.1-45(a)(2)

Based on observation and interview the facility failed to ensure staff implemented new weight loss interventions for a resident with an assessed weight loss for 1 of 5 residents reviewed for nutrition (Resident 35). Findings include: On 9/28/21 at 12:36 p.m., Resident 35 was observed eating in the 100 hall TV room near the nurses' station. The resident was slowly taking bites of food and eat less than 50% of their meal. No nutritional supplements were observed on the tray. On 9/30/21 at 12:34 p.m., Resident 35 was observed eating in the main dining room without any nutritional supplements on the tray. On 9/29/21 at 10:00 a.m., Resident 35's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 35's annual MDS (Minimum Data Set) assessment, dated 8/10/21, indicated the resident required supervision of staff with meals. Resident 35's weight record log indicated the following: -On 5/4/21, the resident weighted 138.4 lbs. -On 6/16/21, the resident weighed 131.8 lbs. -On 7/7/21, the resident weighed 126.6 lbs. -On 8/3/21, the resident weighed 127.8 lbs. -On 9/9/21, the resident weighed 121.4 lbs. -On 9/16/21, the resident weighed 121 lbs. A review of Resident 35's September, 2021, current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 1/19/21, the resident was ordered a regular/thin consistency, mechanical soft textured diet. -On 6/29/21 the resident was ordered Med Pass (a nutritional supplement) four times a day. -On 7/23/21, the resident was ordered Magic Cup (a nutritional supplement dessert) daily. -On 1/18/21, the resident was ordered to have monthly weights and vitals. A nutritional assessment, dated 8/10/21, indicated, . dementia, dysphagia. Noted sig [significant] weight loss 7.5% X 90 day, likely r/t [related to] varied intake 25-75% . Noted low recorded fluid intake. Will continue to monitor at high risk r/t sig weight change and now a BMI [body mass index] low for age. During an interview, at 11:00 a.m., the Assistant Director of Nursing indicated the Registered Dietician had not completed a nutritional assessment for Resident 35, after 8/10/21, and was rather monitoring the resident since they were on the maximum amount of nutritional supplements. Review of progress notes indicated the following: -8/24/21 at 9:43 p.m., WEIGHT WARNING: . Dietitian notes: Current weight 127.8 lbs. Noted sig [significant] weight change. Patient is on medpass QID [four times a day] and magic cup . Noted varied intake. Will talk to FSD [food service director] about sending high calorie foods. BMI is now low for age, will continue to monitor at high risk r/t [related to] poor and varied intake. -9/9/21 at 10:41 a.m., Weight loss . 6.4 pounds/month. New orders for weekly weights. -9/9/21 at 6:24 p.m., .weight loss with orders to c/t [continue to] monitor weekly weights. Resident continues on supplements and does tolerate them well. A care plan, [Resident name] has lat [sic] nutrition r/t [related to]: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, [Resident name] prefers to eat her food/meals slowly, initiated on 9/30/21 and current through 11/8/21. The resident's clinical record lacked documentation of any additional care plans which were initiated to address the assessed weight loss. During an interview, on 9/30/21 at 12:01 p.m., CNA 1 indicated Resident 35 was sometimes a picky eater. She indicated the floor CNA's will perform weights and the resident was not a weekly weight. During an interview, on 9/30/21 at 2:00 p.m., the Dietary Manager indicated Resident 35 gets a magic cup supplement with breakfast and dinner. A review of the resident's meal card indicated, [Resident Name] Diet: Regular. Diet txtr [texture]: Dental Soft . Notes: MAGIC CUP . The ticket did not indicate frequency for the magic cup nor high calorie foods. On 9/30/21 at 2:33 p.m., the DON provided the facility policy, WEIGHTS, dated 5/1/21, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .11. Care plans will be updated accordingly to ensure plan of care meets resident need. 3.1-46(a)(1)

Based on observation, interview, and record review, the facility failed to ensure oxygen delivery tubing was changed as ordered by the physician for 1 of 1 resident reviewed for respiratory services (Resident 8). Findings include: On the following dates and times, Resident 8 was observed lying in bed, with nasal cannula in place and oxygen being delivered, through oxygen tubing attached to the nasal cannula, at 2 liters per minute: 9/27/21 at 1:45 P.M. 9/29/21 at 10:10 A.M. 9/30/21 at 9:24 A.M. The oxygen delivery tubing had a white piece of tape on it which read, 9/8/21. On 9/29/21 at 10:40 A.M., Resident 8's clinical record was reviewed. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set assessment, dated 6/22/21, indicated the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record lacked documentation of the resident's oxygen tubing having been changed every week on Sunday and as needed. During an interview, on 9/30/21, at 9:30 A.M., Resident 8 indicated he did not know when his oxygen tubing was last changed, but it was not changed very often. During an interview, on 9/30/21 at 9:41 A.M., the facility Administrator indicated the tape on the resident's oxygen tubing indicated it had last been changed on 9/8/21. On 9/30/21 at 12:10 P.M., the Director of Nursing provided the policy, Oxygen & Respiratory Equipment-Changing/Cleaning, revised date 1/17/19, and indicated this was the policy used by the facility. A review of the policy indicated, .nasal cannulas are to be changed once a week and PRN [as needed] . 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure correct indwelling urinary catheter placement and assessment of urine return after catheter placement as indicated by facility policy and Lippincott professional standards for 1 of 2 residents reviewed for indwelling catheter care which resulted in traumatic indwelling catheter insertion and then removal with significant hemorrhage and sever pain. (Resident #A) Findings include: Resident #A's clinical record was reviewed on 10/01/15 at 1:30 p.m. [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) documented on 9/14/15, was scored as 14 out of 15 (cognitively intact). Physician orders [REDACTED].#A had an order for [REDACTED].#A would need to be supine (lie flat) for a longer period of time for the MRI. The clinical record lacked documentation the indwelling catheter had been placed and that Resident #A had left the facility for the MRI. Nursing notes dated 9/25/15 at 2:25 p.m., indicated an indwelling catheter was anchored prior to Resident #A leaving for the MRI earlier that day (time left not documented). There was no documentation related to an assessment for the placement of the indwelling catheter. Interview with LPN #1 on 10/02/15 at 10:00 a.m. (nurse who placed and anchored the catheter on 9/25/15), indicated Resident #A was voiding urine while being cleansed for catheter placement. LPN #1 waited at few minutes for Resident #A to void. LPN #1 then re-cleansed Resident #A and inserted the catheter, without any concerns from the resident. LPN #1 indicated not having observed any urine return after catheter placement, but didn't think anything about this because Resident #A had just voided urine. LPN #1 had not charted how Resident #A tolerated the insertion procedure nor that there was no return of urine after the catheter insertion. LPN #1 had also not reassessed for any urine in the catheter drainage bag prior to Resident #A having left the facility to go to a local acute care hospital for the MRI. Nurses notes dated 9/25/15 at 3:00 p.m., indicated Resident #A had returned to the facility. Resident #A was noted to be bleeding around the tip of the penis, to be in pain, and areas on their underwear were noted to be blood stained. Urine output was approximately 100 cc of red liquid. The DON (Director of Nursing) was called into the room to assess. Resident #A was alert and oriented and indicated no concerns, just tired. Per physician order [REDACTED].#A. Documentation indicated a 30 cc balloon was deflated and catheter tip was visualized and fell out without physical assistance. Blood was noted coming out of Resident #A's penis. Pressure was applied, the DON was notified, and vital signs taken were within normal limits. Nurses notes dated 9/25/15 at 6:30 p.m., indicated Resident #A requested to go to the bathroom and was noted to be chilling. Resident #A noted to have shortness of breath, respirations at 26, blood pressure at 186/60, Pulse 100, and oxygen saturations (SATs) were 63% (normal is 95 %) on room air. Resident #A was immediately placed on oxygen and oxygen SATs increased to 93%. Resident #A continued to have a towel over their groin and noted to have pink tinged urine. EMS (emergency medical service) was called and Resident #A was transported to a local acute care hospital emergency room physician's notes dated 09/25/15 dictated at 7:30 p.m., indicated Resident #A was in the emergency room (ER) with a [DIAGNOSES REDACTED]. ER notes did indicate chills without fever. ER physician indicated spouse indicated Resident #A was normal and awake today until he had an indwelling catheter that was placed then removed after an MRI today. Resident #A was admitted to critical care unit. Initial admission notes from the hospital attending physician dated 9/25/15, indicated chief complaint was penile pain and the patient (Resident #A); had a fairly traumatic indwelling catheter insertion and then removal with significant hemorrhage (blood loss) and sever pain. Shortly thereafter the patient (Resident #A) developed [MEDICAL CONDITION] (below normal blood pressure), [MEDICAL CONDITION] (slow heartbeat), hypoxemia (decreased arterial oxygen concentration) and severe alteration of mental status with near obtundation (less than full alertness).he received aggressive IV (in the vein) fluid hydration. His blood pressure, mental status, and oxygenation have since improved quite well. emergency room lab values dated 9/25/15, for hematocrit (percent of total blood volume) was 34.0% (normal range 42-52% per Mosby's diagnostic and laboratory test reference, ninth edition), and hemoglobin (red blood cells/oxygen carrying cells) was 11.6 GM/dl (normal range 14 -18 g/dl per Mosby's diagnostic and laboratory test reference). Review of the facility's policy related to indwelling catheter, received from the DON on 10/1/15 at 1:40 p.m., as current included, .regular monitoring of urine quality and characteristics and monitor for catheter related complications. Lippincott nursing procedure book, 2009, indicated after insertion of an indwelling catheter, document the amount, color, and consistency of return urine and patient's tolerance to the procedure. Interview with the DON on 10/1/2015 and 10:00 a.m., indicated she had a 1:1 (one on one) inservice with LPN #1 and the Administrator indicated at the same time, she called LPN #1 and gave her a final written warning over the phone. This Federal tag relates to Complaint IN 505. 3.1-41(a)(2)