Every finding on record at Mesun Health and Rehabilitation Center

Based on staff interview, record review, and facility policy review, the facility failed to ensure deposited monetary funds were returned timely after discharge to the family of one resident (Resident (R) 88) out of a total of 23 residents reviewed in the sample. The facility's failure to ensure funds were returned to the resident's family in a timely manner after her discharge created the potential for the resident/resident's family to experience negative financial outcomes related to their inability to access the funds.Findings include:Review of the facility's undated Refund Policy (incorrectly) indicated, Refunds will be reviewed and issued for Deposits, Prepaid Room and Board, Advance Payments, and Ancillary Services. Approved refund requests will be processed and issued within forty-five [45] days. Review of the admission Record found in the Electronic Medical Record (EMR) under the Profile tab revealed R88 was admitted to the facility on [DATE]. The resident's diagnoses included heart failure and early onset Alzheimer's disease, and the record indicated R88 was admitted to the facility for hospice services. The record indicated Family Member (FM) 1 was R88's Responsible Party (RP) and that the resident was discharged from the facility upon her death on [DATE] (four days after her admission to the facility).Review of a Progress Note, dated [DATE] and found in the EMR under the Notes tab, indicated the resident was severely cognitively impaired.Review of R88's financial documents, provided by the facility, revealed the resident received hospice services covered by Medicare; however, her room and board fees were paid privately. The records indicated a deposit of $9,750.00 was made by FM1 to cover R88's room and board costs on the date of her admission to the facility ([DATE]). The financial documentation indicated the out-of-pocket cost of the resident's room and board services for her stay ([DATE] - [DATE]) was $1,300.00 (or $325.00 per day).Review of an email document from FM1 to the Business Office Manager (BOM), dated [DATE] and provided by the facility, indicated, How soon can I get our refund since [R88] passed on Monday night [[DATE]].Review of an email document from the BOM to FM1, dated [DATE] and provided by the facility, indicated, My condolences, I'm actually working on the paperwork now.Review of an email document from FM1 to the BOM, dated [DATE] and provided by the facility, indicated, I'm guessing the refund should be between $8 - $8.5K [thousand]. Will you [just] return the credit to the charge card I paid you with?Review of an email document from FM1 to the BOM, dated [DATE] and provided by the facility, indicated, Hitting you up again. I need to close [R88's] accounts, but if you are crediting the credit card, I have to leave it open. I need to know how and when you are crediting please.Reveal of an email document from the BOM to FM1, dated [DATE] and provided by the facility, indicated, I called to inform [with] you that yes, we are working on getting the refund of the balance over to you as well as to let you know it is our policy to issue a check form of a refund. Please let me know if you have any questions or concerns, I'm here to assist in any way I can.Review of an email document from FM1 to the BOM, dated [DATE] and provided by the facility, indicated, Would you be so kind to tell me when you will be mailing our refund check, as we are getting ready to move. Also, the amount.Review of an email document from the BOM to FM1, dated [DATE] and provided by the facility, indicated, I will look into the time frame, and I will let you know.Review of an email document from FM1 to the facility's Corporate Financial Department, dated [DATE] and provided by the facility, indicated, I'm just checking the status of the refund check on the resident named above [R88]. The resident passed away four days after initial payment of $9,750.00 was made. The total refund due is $8,550.00 . Can you tell me what date the check was mailed out if it's been mailed as of yet?Review of an email document from the facility's Corporate Financial Department to the BOM, dated [DATE] and provided by the facility, indicated, I forwarded this to [staff member] who handles accounts payable.Review of an email document from the facility's Corporate Financial Department to the BOM, dated [DATE] and provided by the facility, indicated, Thank you for following up. The refund check has not been mailed out yet. It is expected to be mailed next week. I will keep you posted once it has been sent.Review of an email from the facility's Corporate Financial Department to the BOM, dated [DATE] (32 days after R88's discharge from the facility) and provided by the facility, indicated, I'd like to let you know that the payment [to FM1 for R88's refund] will be sent today as follows: Refund Amount: $8,150.00. Check Payable To: [FM1]. During an interview with the Administrator on [DATE] at 4:00 pm, he acknowledged the facility's policy indicating funds were to be returned to a resident within 45 days after discharge did not reflect the Federal Regulation indicating a 30 day time frame for the return of funds after discharge, confirmed R88's money had not been mailed to the family until [DATE], and stated his expectation was excess funds deposited by residents/their responsible parties for resident care in the facility were expected to be returned no later than 30 days after discharge.

Based on record review, interviews, and facility policy review, the facility failed to protect residents from abuse by ensuring chemical restraints were not used unless medically necessary for two residents (Resident (R)16 and R47) out of a total of six residents reviewed for unnecessary medication. The facility's failure to ensure identified behaviors and potential side effects were consistently monitored for these residents created the potential for the residents to experience side effects related to the administration of unnecessary medication. A total of 23 residents were reviewed in the sample.Findings include:1. Review of the admission Record found in the Electronic Medical Record (EMR) under the Profile tab revealed R16 was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's disease and schizophrenia.Review of R16's Care Plan, dated 7/16/2025 and found in the EMR under the Care Plan tab, indicated the resident had a diagnosis of schizophrenia and was to be given her antipsychotic medication as ordered. Target behaviors and side effects related to the medication were to be monitored each shift. The care plan did not indicate specific behaviors to be monitored related to the administration of the medication.Review of R16's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2025 and found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. R16 had received antipsychotic medication and displayed no behaviors during the reference dates.Review of R16's Order Summary Report, dated 11/21/2025 and found in the EMR under the Orders tab, indicated an order, with an original order date of 07/15/25 for Haldol (an antipsychotic medication) five milligrams (mg) by mouth every night at bedtime for schizophrenia. There were no orders for the tracking of specified behaviors or potential side effects related to the administration of the resident's Haldol.Review of R16's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 11/1/2025 through 11/21/2025 and found in the EMR under the Orders tab, revealed nothing to indicate specific behaviors or side effects related to the administration of the resident's antipsychotic medications were being monitored.2. Review of the admission Record found in the EMR under the Profile tab revealed R47 was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke, depression, anxiety, insomnia, and vascular dementia with agitation. The record indicated the resident received hospice services.Review of R47's Care Plan, dated 7/7/2023 and found in the EMR under the Care Plan tab, indicated the resident received antidepressant, antianxiety, and antipsychotic medication for behavior management to address his anxiety, depression, and agitation. The care plan indicated, Administer psychotropic medications as ordered by physician, Monitor for side effects and effectiveness every shift, Monitor/document/report as needed any adverse reactions of psychotropic medications, including unsteady gait, tardive dyskinesia, [extrapyramidal symptoms] EPS [shuffling gait, rigid muscles, shaking], frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, and behavior symptoms not usual to the person. The care plan indicated that R47 was to be monitored for behaviors associated with his depression, anxiety, and agitation.Review of R47's quarterly MDS, with an Assessment Reference Date (ARD) of 9/15/2025 and found in the EMR under the MDS tab, revealed the resident had a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. R47 received antidepressant, antianxiety, and antipsychotic medications and displayed behaviors during the reference period.Review of R47's Order Summary Report, dated 11/21/2025 and found in the EMR under the Orders tab, revealed orders with original order dates: -8/21/2024 trazodone (an antidepressant medication) 50 mg every night at bedtime for insomnia-5/20/2025 Ativan (an antianxiety medication) one mg every two hours as needed for anxiety-10/6/2025 Haldol (an antipsychotic medication) two mg every two hours as needed for agitation-9/8/2025 Monitor for behaviors each shift, including restlessness, agitation, hitting, increase in complaints, continuous yelling out, delusions, hallucinations, psychosis, aggression, and refusing care.-11/21/2023 Monitor for side effects related to depression, including dry mouth, dizziness, increased sedation, constipation, gastrointestinal upset, nausea/vomiting, decreased appetite, gait disturbances, and restlessness.The order set did not indicate an order for monitoring side effects related to the resident's antianxiety or antipsychotic medication administration.Review of R47's MAR and TAR, dated 11/1/2025 through 11/21/2025 and found in the EMR under the Orders tab, revealed nothing to indicate side effects related to the administration of the resident's antianxiety or antipsychotic medications were monitored.During an interview with the Director of Nursing (DON) on 11/20/2025 at 1:56 pm, she confirmed behaviors and side effects related to the administration of R16's antipsychotic medication and side effects related to the administration of R47's antianxiety and antipsychotic medications were not monitored. She stated her expectation was potential side effects and target behaviors related to the administration of all psychotropic medication were monitored each shift and documented on each resident's MAR/TAR. Review of the facility's Use of Psychotropic Medication Policy, reviewed most recently in June 2025, indicated, It is the intent of this policy to ensure residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint and Psychotropic medications are to be used only when a practitioner determines the medication[s] is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication[s] is beneficial to the resident, and demonstrated by monitoring and documentation of the resident's response to the medication[s].

Based on record review, staff interviews, and facility policy review, the facility failed protect residents from abuse by ensuring timely reporting of an allegation of financial abuse for one (Resident (R) 5) out of three residents reviewed for abuse. The facility's failure to ensure timely reporting of the allegation of abuse created the potential for this and other residents to experience ongoing effects related to abuse. A total of 23 residents were reviewed in the sample.Findings include:Review of the facility's Compliance with Reporting Allegation of Abuse/Neglect/Exploitation Policy, dated 12/22/2023, indicated, It is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes and The Administrator or designee will notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after the discovery of the incident.Review of the admission Record found in the Electronic Medical Record (EMR) under the Profile tab revealed R5 was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke and Alzheimer's disease. The document indicated that the resident's Responsible Party (RP) was Family Member (FM) 3.Review of R5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/2025 and found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired.Review of R5's financial documentation, dated 10/2/2023 through 11/21/2025 and provided by the facility, revealed although FM3 was R5's Responsible Party and was named as the resident's Rep Payee (the person who received R5's Social Security payments issued each month by the government), FM3 did not respond to any of the facility's attempts to reach her during that time period to provide payment for R5's services while at the facility or provide R5 with personal spending money to meet his needs. The documentation revealed R5 did not have access to any of his money and had not had access since 10/2/2023.During an interview with the Director of Nursing (DON) on 11/20/2025 at 1:48 pm, she confirmed FM3 was still listed as R5's RP and was still the resident's Rep Payee. She stated the facility had been unable to reach FM3 for a long time. She stated FM3 still received R5's Social Security checks but would not respond to the facility to ensure R5 received his own money. The DON stated she thought R5 was being taken advantage of financially by FM3. During an interview with the Social Services Director (SSD) on 11/20/2025 at 2:33 pm, she stated R5 was admitted to the facility in August of 2023. She stated R5 initially received rehabilitation services under his Medicare benefits, but it became clear that the resident required long-term care services. She stated FM3 was involved in R5's care until October of 2023 when the facility requested financial information to ensure qualification for Medicaid financial assistance and requested R5's access to his money to ensure continued care, treatment, and quality of life. The SSD confirmed FM3 never provided the documentation to ensure R5 could qualify for Medicaid and to ensure he had access to his funds to pay his bills and provide for any additional basic necessities not covered by general room and board. The SSD stated she had reported her concerns regarding potential financial abuse of R5 by FM3 to the previous Administrator in December of 2023, but nothing had been done. The SSD indicated she reported her concerns to Adult Protective Services (APS) during that time as well but confirmed R5 still did not have access to his own money almost two years later.During an interview with the Business Office Manager (BOM) on 11/20/2025 at 2:57 pm, she stated she had been employed by the facility for a year and had concerns about R5 being financially abused by FM3 since shortly after being hired. The BOM stated she had been trying to assist R5 to obtain access to his bank funds, but due to the resident's poor cognition, she had been unable to do so. She stated the previous Administrator had been aware of her concerns, but as far as she knew, the concerns were not reported to the State Agency or investigated by the facility.During an interview with the Administrator on 11/20/2025 at 3:31 pm, he stated he had been employed by the facility for about two months. He confirmed he was aware of the concerns related to R5 potentially being financially abused by FM3. He stated the concerns had been reported to APS and the local Police Department since he had become aware of the concerns and stated the local Police Department was investigating the report. The Administrator stated he was concerned R5 was being financially abused by FM3 but had not reported the potential abuse to the local State Agency as required by the facility's abuse policies and procedures. The Administrator stated the potential financial abuse of R5 by FM3 should have been reported to the State Agency as soon as the facility became aware of the potential abuse.

Based on record review, staff interviews, and facility policy review, the facility failed to protect residents from abuse by ensuring a thorough investigation into allegations of potential abuse was conducted for two out of three residents (Resident (R) 5 and R3) reviewed for abuse. The facility's failure to ensure thorough investigation of potential financial abuse for R5, and of an injury for R3, created the potential for these and other residents to experience ongoing effects related to abuse. A total of 23 residents were reviewed in the sample.Findings include:Review of the facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 12/22/2023, revealed V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: . 4. identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse. neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.1. Review of R5's admission Record, found in the Electronic Medical Record (EMR) under the Profile tab revealed R5 was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke and Alzheimer's disease. The document indicated that the resident's Responsible Party (RP) was Family Member (FM) 3.Review of R5's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/7/2025 and found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired.Review of R5's financial documentation, dated 10/2/2023 through 11/21/2025 and provided by the facility, revealed although FM3 was R5's Responsible Party and was named as the resident's Rep Payee (the person who received R5's Social Security payments issued each month by the government), FM3 did not respond to any of the facility's attempts to reach her during that time period to provide payment for R5's services while at the facility or provide R5 with personal spending money to meet his needs. The documentation revealed R5 did not have access to any of his money and had not had access since 10/2/2023.Review of the facility's internal investigation documentation for 10/1/2023 through 11/20/2025 revealed nothing to indicate the facility initiated an investigation related to potential financial abuse of R5 by FM3.During an interview with the Administrator on 11/20/2025 at 3:31 pm, he stated he had not initiated an internal investigation into the potential abuse as required by the facility's abuse policies and procedures. The Administrator stated the potential financial abuse of R5 by FM3 should have been investigated internally by the facility as soon as the facility became aware of the potential abuse.2. Review of R3's five-day Medicare MDS with an ARD date of 7/30/2025, located in the MDS tab of the EMR, revealed an admission date of 7/25/2025 and a BIMS score of 14 out of 15, indicating R3's cognition was intact. R3 had diagnoses of paroxysmal atrial fibrillation, heart failure, and diabetes mellitus.During an interview on 11/20/2025 at 2:40 pm, the Director of Therapy (DOT) was asked about R3's lower extremity bleeding during a therapy session in July 2025. The DOT stated R3 had vascular and swelling issues in her lower left extremity before coming to the therapy session, and the bleeding was the bursting of a vessel. When asked if the incident was investigated, the DOT stated she documented in the daily therapy note on her computer but did not write a statement.During an interview on 11/20/2025 at 8:23 am, the DON was asked for the investigation related to R3's LLE injury on 7/28/2025. The DON stated the incident report for R3's LLE injury was also the investigation and stated she obtained CNA1's statement. The DON stated there was no incident report or investigation for R3's ruptured hematoma during therapy on 7/29/2025 as a note was added to the incident report referencing the bleeding episode.During an interview on 11/21/2025 at 12:19 pm, the DON stated the nurse that completed the incident report would have interviewed R3 and documented in the progress notes. The DON reviewed the EMR for R3's statement and stated, It's not here, but the nurse would have interviewed R3. The DON was asked about the facility policy instructing staff to interview all persons involved in an allegation. The DON acknowledged that by not interviewing R3, pertinent details may have been missed. The DON was asked if the nurse (Licensed Practical Nurse (LPN)2) who CNA1 reported the incident to had completed a statement. The DON stated LPN2 documented her statement in the incident report. During an interview on 11/21/2025 at 1:23 pm, LPN2 stated that CNA1 reported bumping R3's lower leg causing her hematoma. LPN2 stated soon after the incident was reported, R3 complained of leg pain. LPN2 stated that R3 was interviewable but as far as she knew, no statement was obtained. LPN2 stated she did not talk with R3 about the incident. LPN2 stated the next shift would have followed up with an investigation. LPN2 was asked if she wrote or gave a statement besides what she wrote about the incident in the incident report. LPN2 stated, No and said no one asked her to give a statement.

Based on record review and staff interviews, the facility failed to ensure one resident (Resident (R) 55) and their representative out of one resident reviewed for hospitalization out of a total sample of 23 residents received a written bed hold policy and transfer notice. This failure had the potential to result in the resident and/or their representative not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and had the potential to cause confusion or distress regarding re-admission to the facility.Findings include:Upon request, the facility failed to provide any policies related to the process of transferring a resident to the hospital.Review of R55's Census Record located under the Resident tab in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had been transferred to the hospital four times in the past ten months.Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/2025 and located under the MDS tab of the EMR revealed a Brief Interview of Mental Status (BIMS) score of four out of 15, indicating severe cognitive impairment. R55's diagnoses included multiple sclerosis, personal history of traumatic brain injury, and cerebral infarct (stroke).Review of R55's Misc [Miscellaneous] tab of the EMR revealed no bed hold or notice of transfer forms related to the hospitalizations.During an interview on 11/20/2025 at 1:30 pm, Licensed Practical Nurse (LPN) 1 stated she had never filled out a transfer/discharge notice and was not aware one needed to be filled out and provided to the residents and their representatives.During an interview on 11/20/2025 at 2:41 pm, the Administrator stated that the Social Services Director (SSD) was responsible for providing the transfer notice and bed hold policy to the residents and resident representatives.During an interview on 11/20/2025 at 2:51 pm, the SSD stated she did not provide residents or their representatives with a written transfer/discharge notice or the bed hold information. The SSD stated she was not the person responsible for that task.During an interview on 11/20/2025 at 3:15 pm, the Business Office Manager (BOM) stated that the facility did not send bed hold policies or written transfer notices to the resident or resident representative because they made a courtesy phone call to the resident representative at the time of transfer to the hospital.

Based on record review, observations, staff interview, and facility policy review, the facility failed to ensure a consistent program of activities was in place for one (Resident (R) 16) out of three residents reviewed for activities. The facility's failure to ensure activities were consistently provided per, and documented according to, R16's assessed preferences created the potential for the resident to experience negative psychosocial effects related to social isolation. A total of 23 residents were reviewed in the sample.Findings include:Review of the facility's Activities Policy, dated 7/9/2020, indicated, It is the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident.Review of the admission Record found in the electronic medical record (EMR) under the Profile tab revealed R16 was admitted to the facility on [DATE]. The resident's diagnoses included Parkinson's disease and schizophrenia.Review of R16's Care Plan, dated 8/30/2025 and found in the EMR under the Care Plan tab, revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and immobility. Interventions included, Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed [such as large print, holders if resident lacks hand strength, task segmentation], Compatible with individual needs and abilities; and Age appropriate; and Introduce the resident to residents with similar background, interests and encourage/facilitate interaction; and Invite the resident to scheduled activities and The resident needs assistance/escort to activity functions.Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2025, found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.Review of R16's Activities - Initial Review Assessment, dated 11/12/2025 and found in the EMR under the Assessment Tab, indicated R16 enjoyed praying and worshiping, spending time with family, being outside, and listening to Christian music. The assessment indicated the resident wished to participate in activities while in the facility, including group activities, outings, 1:1 (one to one) visits with staff, and independent activities. The assessment indicated R16 required assistance from staff to get to activities.Review of R16's Individual Resident Activities Participation Log dated 10/19/2025 through 11/21/2025 revealed no documentation to show the resident attended any activities during that time. (The log was blank).During observations on 11/19/2025 at 1:29 pm and 4:11 pm, on 11/20/2025 at 10:19 am, 2:13 pm and 4:33 pm, and on 11/21/2025 at 9:48 am, R16 was observed in her room or seated in front of the nurses' station while group activities were ongoing. The resident was not observed to be engaged with other residents or staff or participating in any kind of activity during the observations.R16 declined an interview during the survey.During an interview with the Activities Director (AD) on 11/21/2025 at 9:23 am, she confirmed R16 enjoyed participating in facility group activities, especially BINGO and music related activities; however, R16 had not been in activities much that week. She stated all activity participation was expected to be documented in each resident's Activities Participation Log. The AD confirmed there was no documentation to show R16 had participated in any activities since 10/19/2025 and stated it was usually the job of the activity assistant to complete participation logs; however, she had not had an assistant since the beginning of November 2025. The AD stated her expectation was activities should be offered to all residents based on their individual preferences, and participation in activities was to be documented on each resident's activity log.Review of the facility's Activities Department Calendar, dated November 2025 and posted throughout the facility, revealed activities offered during the survey timeframe included chair pilates, card games, crafts, Good Morning Vibes, BINGO, bowling, cornhole, puzzles, balloon tennis, and happy hour/movie time.

Based on record review, staff interview, and facility policy review, the facility failed to ensure physician orders for the use of an indwelling urinary catheter device were in place for one (Resident (R) 1) of two residents reviewed for urinary catheters. The facility's failure to ensure orders were in place for R1's suprapubic urinary catheter created the potential for the resident to go without appropriate catheter-related care and services. A total of 23 residents were reviewed in the sample.Findings include:Review of the facility's Appropriate Use of Indwelling Catheters Policy, dated September 2024, indicated, The use of an indwelling urinary catheter will be in accordance with physician's orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change [if applicable]. Review of the admission Record found in the Electronic Medical Record (EMR) under the Profile tab revealed R1 was admitted to the facility on [DATE]. The resident's diagnoses included neurogenic bladder.Review of R1's Medicare 5-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/28/2025 and found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident was severely cognitively impaired. The record indicated the resident had an internal urinary catheter in place at the time of the assessment.Review of R1's Care Plan, dated 8/28/2025 and found in the EMR under the Care Plan tab, revealed the resident had a urinary suprapubic catheter in place in his bladder related to his diagnosis of neurogenic bladder. The document indicated the catheter was to be positioned below the level of the resident's bladder, and the resident was to be monitored for potential signs and symptoms of discomfort or infection related to the catheter.Review of R1's Physician's Order Report, dated 11/21/2025 and found in the EMR under the Orders tab, revealed orders for the maintenance and care of the resident's suprapubic catheter but revealed no orders for the resident's actual catheter (including the size or type of the indwelling catheter).During an interview with the Director of Nursing (DON) on 11/20/2025 at 2:03 pm, she confirmed she was unable to locate an order for R1's suprapubic catheter in the resident's record and stated her expectation was that an order for the actual catheter (size and type) was in place for the use of any indwelling catheter.

Based on observations, resident, resident family member, and staff interviews, record review, and facility policy review, the facility failed to ensure clinical criteria were met prior to prescribing and administering an antibiotic for a urinary tract infection (UTI) for one (Resident (R) 79) of one resident reviewed for antibiotic use out of a total sample of 23 residents. This failure had the potential to cause antibiotic resistance, increased risk of Clostridioides difficile infection, and adverse drug reactions.Findings include:Review of the facility policy titled Antibiotic Stewardship Program, dated 9/22/2025, revealed 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and notify the physician. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses the [CDC's [Centers for Disease Control] NHSN [National Healthcare Safety Network] Surveillance Definitions, updated McGeer criteria [evidence-based guidelines], or other surveillance tool] to define infections. iv. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics.Review of R79's five-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2025, located in the MDS tab of the electronic medical record (EMR), revealed an admission date of 11/7/2025. R79 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating R79's cognition was moderately impaired, and had diagnoses of metabolic encephalopathy, non-Alzheimer's dementia, and urinary tract infection (UTI) (last 30 days).Review of R79's Urine Culture, report dated 11/17/2025, located in the EMR under the Results tab revealed Culture, Urine source clean catch, Isolate Organism Enterococcus faecalis with a colony count of 60,000 cfu/ml [colony-forming units per milliliter]-70,000 cfu/ml.Review of R79's Physician Orders, dated 11/18/2025, located in the EMR under the Order tab, revealed Linezolid [an oxazolidinone antibiotic used to treat serious bacterial infections] Oral Tablet 600 MG [milligram] [Linezolid] Give 1 tablet by mouth every 12 hours for UTI for 7 Days.Review of R79's Care Plan dated 11/18/2025, located in the EMR under the Care Plan tab, revealed R79 has a UTI. An intervention included Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness Q [every]-shift.Review of R79's Revised McGeer Criteria for Infection Surveillance Checklist, dated 11/20/2025, provided by the facility, revealed a large X was placed over both sections 1 and 2 that included UTI without indwelling catheter Must fulfill both 1 AND 2 indicating these sections were not applicable. The sections included: 1. At least one of the following sign or symptom: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate _Fever or leukocytosis, and [at least] 1 of the following: _Acute costovertebral angle pain or tenderness _ Suprapubic pain _ Gross hematuria _ New or marked increase in incontinence _ New or marked increase in urgency _ New or marked increase in frequency _ If no fever or leukocytosis, then 2 of the following: _ Suprapubic pain _ Gross hematuria _ New or marked increase in incontinence _ New or marked increase in urgency _ New or marked increase in frequency.2. At least one of the following microbiologic criteria _ [greater than or equal to] 105 cfu/mL of no more than 2 species of organisms in a voided urine sample _ 102 cfu/mL of any organism[s] in a specimen collected by an in-and-out catheter. A large X was placed to indicate UTl criteria not met.During a concurrent observation and interview on 11/18/2025 at 1:27 pm, R79 was seated in his wheelchair, dressed and groomed, with a Family Member (FM) 2 at his side. FM2 stated R79 had just completed an antibiotic for a UTI in the hospital before he was admitted to the facility. FM2 stated R79 had a change in his demeanor but was not experiencing symptoms such as burning or frequency of urination. R79 stated he felt fine.During an interview on 11/20/2025 at 9:30 am, the Infection Preventionist (IP) was asked why a urine analysis was completed for R79. The IP stated it was because FM2 asked the nurse practitioner (NP) to have it completed due to odd statements R79 made. The IP stated the urine analysis and culture qualified as a UTI and so an antibiotic was prescribed. The IP stated they used McGeer criteria, and an organism grew from the urine sample. The IP was asked if the colony count should be 100,000 or greater according to McGeer. The IP reviewed the urine culture and stated, No. The IP stated R79 was on an antibiotic in the hospital also for a UTI, but the new round of antibiotics was started in the facility. During a follow up interview on 11/20/2025 at 10:42 am, the IP changed her statement and stated R79 did not meet the McGeer criteria for a UTI as he was not symptomatic, and the urine culture results did not meet the indicated level. The IP went on to say the physician instructed nursing to give the last dose on 11/21/2025 instead of 11/24/2025.During an interview on 11/20/2025 at 12:54 pm, R79 and FM2 confirmed R79 was just prescribed another antibiotic for seven days at the facility for a UTI. FM2 stated R79 had no symptoms.During an interview on 11/20/2025 at 1:43 pm, The NP was asked how R79's UTI was handled. The NP stated R79 had a new encephalopathy diagnosis, and FM2 was concerned he might have an UTI due to his behaviors, saying odd things. The NP stated FM2 asked her to retest F79's urine. The NP stated her intention was not to have the sample of urine cultured but that nursing did a culture. The NP stated the physician started an antibiotic after he saw the test results online. When the NP was asked if R79 should have been prescribed an antibiotic based on the culture results, she responded, No, he should not have been on an antibiotic.During an interview on 11/21/2025 at 12:25 pm, the Director of Nursing (DON) was asked if the IP made the physician aware that R79 did not meet criteria for a UTI. The DON stated the physician reviewed the laboratory report, and after the IP followed up with the physician on 11/20/2025, the physician reduced the duration of the antibiotic from seven days to three days.During a telephone interview on 11/21/2025 at 2:14 pm, Medical Doctor (MD) 1 was asked if he was informed R79 did not meet the McGeer criteria for a UTI. MD1 acknowledged R79's colony count was 60,000 but stated the family wanted to try an antibiotic because R79 was acting confused. MD1 stated R79's symptoms included, only the one thing [confusion] which was why he reduced the antibiotic duration from seven days to three days. MD1 stated, But it was based on the family's request to try it one more time. MD1 stated he was aware of antibiotic stewardship and that R79 had just completed a round of antibiotics in the hospital.

Based on record review, observations, staff interviews, and facility policy review, the facility failed to ensure a medication error rate of less than five percent. Errors were made during the administration of medication for two of seven residents (Resident (R) 85 and R92) observed for medication administration. A total of two errors were made out of 25 opportunities for error, which resulted in an eight percent medication error rate. Medication errors have the potential to result in adverse health outcomes.Findings include:Review of the facility's Medication Administration Policy, dated April 2025, indicated, Ensure that the six rights of medication administration are followed: a. Right resident b. Right drug c. Right dosage d. Right route e. Right time f. Right documentation. 1. Review of the admission Record found in the Electronic Medical Record (EMR) under the Profile tab revealed R85 was admitted to the facility on [DATE]. The resident's diagnoses included atrial fibrillation and history of stroke.Review of R85's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/5/2025 and found in the EMR under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident was moderately cognitively impaired.Review of R85's Physician's Order Report, dated 11/21/2025 and found in the EMR under the Orders tab, revealed orders, with an original order date of 10/30/25, for the resident to receive aspirin (chewable) 81 milligrams (mg) by mouth one time daily for his diagnoses of atrial fibrillation and history of stroke.Review of R85's Medication Administration Record (MAR) dated 11/1/2025 through 11/21/2025 revealed the resident was receiving his aspirin as ordered.Observation on 11/20/2025 at 9:00 am revealed R85 received his medication from Licensed Practical Nurse (LPN) 1. R85 was given enteric coated aspirin rather than the ordered chewable aspirin.During an interview with LPN1 on 11/20/2025 at 9:03 am, she confirmed she had given the resident enteric coated aspirin and stated that although both chewable and enteric coated aspirin were available in the medication cart, she usually administered the enteric coated aspirin to R85.2. Review of the admission Record found in the EMR under the Profile tab revealed R92 was admitted to the facility on [DATE]. The resident's diagnoses included history of pancreatic cancer, acute kidney failure, and morbid obesity.Review of an admission Note, dated 11/13/2025 and found in the EMR under the Notes tab, revealed the resident was alert and oriented times three (oriented to person, place, and time).Review of R92s Physician's Order Report, dated 11/21/2025 and found in the EMR under the Orders tab, revealed orders, with an original order date of 11/20/2025, for the resident to receive multivitamin with-minerals one tablet by mouth one time a day for a supplement. Review of R92's Medication Administration Record (MAR) dated 11/20/2025 through 11/21/25 revealed the resident was receiving his multivitamin with minerals as ordered.Observation on 11/20/2025 at 9:55 am revealed R92 received his medication from Registered Nurse (RN) 1. R92 was given a multivitamin without minerals instead of the ordered multivitamin with minerals.During an interview with RN1 on 11/20/2025 at 10:00 am, she confirmed she had administered a multivitamin without minerals to R92 rather than the ordered multivitamin with minerals. She stated the multivitamin with minerals was not available in the medication cart but stated she should have given the multivitamin with minerals according to the resident's physician's orders.During an interview with the Director of Nursing (DON) on 11/21/2025 at 12:41 pm, she stated her expectation was for medications to be administered according to physician's orders.

Based on observations, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to ensure food items were properly stored, labeled with expiration dates, and that expired foods were disposed of in a timely manner. The deficient practice had the potential to affect 47 of 49 residents who consumed an oral diet. Findings include: Review of the undated facility's policy titled Food Safety Requirements, under Policy revealed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Under Definitions revealed, Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Under Policy Explanation and Compliance Guidelines revealed, 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: (b) Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. (b) Dry food storage- keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. (c) Refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include .(iv) Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded. Observation of the kitchen on [DATE] at 9:00 am revealed a large dented can of corn. Observation of the pantry on [DATE] at 9:05 am revealed the following items which according to the manufacture label should be refrigerated after opening included: a container of (Name) soy sauce (not refrigerated after opening and no open date), a bottle of (Name) squeeze grape jelly 20 oz (ounce) (not refrigerated after opening and no open date), a container of Italian dressing (not refrigerated after opening and no open date), and a container of (Name) barbecue sauce (not refrigerated after opening and no open date). Observation of the kitchen pantry on [DATE] at 9:10 am revealed the following expired foods included: a bag of long grain rice with an expiration date of [DATE] with no open date and seven bags of (Name) marshmallows with an expiration date of [DATE]. Observation of the kitchen pantry on [DATE] at 9:20 am revealed the following foods with no label displaying the date after packages had been opened included: mashed potato granules, (Name) long grain wild rice, a container of (Name) baking soda, (Name) corn bread mix- 5 (five) lbs.(pound) bag, two gravy mix bags, one brown gravy mix bag , yellow cake mix -5 lb bag., fudge brownie mix -5 lb bag. spaghetti wrapped in saran wrap, box of (Name) spaghetti (opened, unsealed box and no open date), two bags of breadcrumbs (one bag was not sealed and both bags had no label dates), plain white rice, saltine crackers (opened saltine cracker packages found in box), a container of chopped onions, a bag of lettuce, minced garlic 32 oz., butter found open and unwrapped in box, white American cheese slices in bag, shredded mozzarella in bag, corned beef, a bottle of (Name) grape juice, two quarts of (Name) cranberry juice, unknown meat in bag, and salmon in a bag that was discolored. Observation of the freezer on [DATE] at 9:30 am revealed the following food items with frost bite: (Name) Meat covered in frost with no open date and a bag containing fish covered in frost with no open date. Interview on [DATE] at 9:45 am with [NAME] GG revealed that the Certified Dietary Manager (CDM) was on vacation, and she was unable to confirm who was in charge in her absence. She confirmed and verified that there should be no open containers without a labeled open date on them. She revealed that it was the responsibility of all kitchen staff to label items that were opened. Furthermore, she confirmed that if there are any dented cans, the kitchen staff still use them. She confirmed and verified that the saltine cracker packages should not be opened, and crackers should not be loose inside the box. Interview on [DATE] at 10:30 am with the Administrator revealed that the CDM BB was on vacation and in her absence, he oversaw the kitchen. He stated he did not think dented can should be used. He revealed that staff should be labeling foods as they are opened. Interview on [DATE] at 3:14 pm with the Registered Dietitian Consultant (RD) revealed that she was employed by (Name of Corporation), she stated she usually worked from home and reviewed records to make recommendations related to dietary needs of the residents. She stated recently she had been tasked with monthly observations of the kitchen to determine compliance. She stated in her last walk through the kitchen, she found that the staff had dated opened items with the open dates and the kitchen was clean. She revealed that CDM BB was a working manager and has had a lot of staff turnover. She stated she discovered CDM BB was on vacation this morning when she arrived at the facility. She revealed she did not know who was in charge in the CDM BB absence.

Based on staff interviews and review of the facility's policies titled, Infection Prevention and Control Program and Water Management, the facility failed to develop an effective water management plan which included routine water management activities to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens throughout the facility's water system. The facility's census was 49 residents. Review of the undated facility's policy titled, Infection Prevention and Control under Policy Explanation and Compliance Guidelines revealed the following: Number 17. Water Management, (b): Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. Review of the undated facility's policy titled, Water Management Program under Policy Explanation and Compliance Guidelines revealed the following: Number 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible. Number 9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness. During an interview on 7/17/2024 at 5:06 pm with the Infection Prevention and Control Nurse (IPCN), she stated the facility had a water management plan with policies and procedures in place to prevent the spread of Legionella. During an interview on 7/18/2024 at 9:03 am with the Administrator, he stated the facility conducted annual testing, but he was not aware of other measures used to prevent the growth and spread of Legionella. During an interview on 7/18/2024 at 9:18 am with the Maintenance Director, he stated he performed daily temperature checks throughout the facility and annual testing for the presence of Legionella in the water system, but he was not aware of any other measures to prevent the growth of water-borne pathogens.

Based on record review, staff interviews, and review of the facility's policy titled iQIES or Other System Downtime MDS, the facility failed to ensure that required Minimum Data Set (MDS) assessments were transmitted within regulatory guidelines to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for 31 residents (R) (R89,R55, R56, R8, R62, R7, R33, R85, R3, R19, R86, R84, R16, R31, R91, R15, R25, R72, R75, R88, R81, R90, R77, R38, R45, R20, R92, R78, R50, R278, and R368) out of 44 sampled residents. Findings Include: Review of the undated facility's policy titled iQIES or Other System Downtime MDS, under the Policy section revealed, It is the policy of this facility to transmit MDS data timely so that the facility will not be negatively impacted by iQIES or other system downtimes. Under the Policy Explanation and Compliance Guidelines section revealed, 1. All required MDS assessment files will be transmitted to iQIES using the CMS wide area network within regulatory guidelines: PPS, quarterly, and discharge assessments will be transmitted within 14 days of the completion date in Z0500B. Review of the Resident Assessment Task in the Long-Term Care Survey Process revealed, MDS assessments as being more than 120 days old indicated: R89's Discharge assessment dated [DATE] was coded as 'export ready'. R55's Discharge assessment dated [DATE] was coded 'In Progress'. R56's Discharge assessment dated [DATE] was coded 'In Progress'. R8's Discharge assessment dated [DATE] was coded 'In Progress'. R62's Discharge assessment dated [DATE] was coded 'In Progress'. R7's Discharge assessment dated [DATE] was coded 'In Progress'. R33's Discharge assessment dated [DATE] was coded 'In Progress'. R85's Discharge assessment dated [DATE] was coded 'In Progress'. R3's Discharge assessment dated [DATE] was coded as 'export ready'. R19's Discharge assessment dated [DATE] was coded as 'export ready'. R86's Discharge assessment dated [DATE] was coded 'In Progress'. R84's Discharge assessment dated [DATE] was coded 'In Progress'. R16's Discharge assessment dated [DATE] was coded as 'export ready'. R31's Discharge assessment dated [DATE] was coded 'In Progress'. R91's Discharge assessment dated [DATE] was coded 'In Progress'. R15's Quarterly assessment dated [DATE] was coded as 'In Progress'; Discharge assessment dated [DATE] coded as 'In Progress'. R25's Discharge assessment dated [DATE] was coded as 'export ready'. R72's Discharge assessment dated [DATE] was coded as 'export ready'. R75's Discharge assessment dated [DATE] was coded as 'export ready'. R88's Discharge assessment dated [DATE] was coded 'In Progress'. R81's Discharge assessment dated [DATE] was coded 'In Progress'. R90's Discharge assessment dated [DATE] was coded as 'export ready'. R77's Discharge assessment dated [DATE] was coded 'In Progress'. R38's Discharge assessment dated [DATE] was coded 'In Progress'. R45's Discharge assessment dated [DATE] was coded 'In Progress'. R20's Discharge assessment dated [DATE] was coded 'In Progress'. R92's Discharge assessment dated [DATE] was coded 'In Progress'. R78's Discharge assessment dated [DATE] was coded as 'export ready'. R50's Discharge assessment dated [DATE] was coded 'In Progress'. R278 's Admission assessment dated [DATE] was coded 'export ready'. R368 's Discharge assessment dated [DATE] was coded In Progress. During an interview on 7/18/2024 at 8:45 am with the MDS Coordinator revealed the coding was accurate as far as she knew. She stated she was unsure why the 'export ready' assessments had not been submitted. She stated that she was unable to submit them without a Registered Nurse (RN) signature and that the current Director of Nursing (DON) was the RN responsible for signing them and prior to that she had an RN that she worked with, but they let her go. The MDS coordinator confirmed and verified all 31 resident's assessments had not been submitted. During an interview on 7/18/2024 at 11:27 am, the Administrator stated that the DON had been out for 10-12 days, which was longer than they had expected and currently no one was responsible for signing off on the MDS. He stated they had an MDS RN that had led them to believe that she was going to take the job, but she did not take it and therefore they had got behind on the assessments. During an interview on 7/18/2024 at 11:30 am, the Assistant Director of Nursing (ADON) stated the workflow was for the MDS Licensed Practical Nurse (LPN) to complete the MDS assessments and to submit it to the DON for approval, but she was not sure who was responsible for submitting the assessments to CMS. She stated that they had several RN's who had been the MDS nurse, but they had quit or been let go. She stated that the position was currently open and that they were recruiting for the position. During a telephone interview on 7/18/2024 at 1:50 pm, the DON stated she did not set expectations of when the MDS assessments are submitted to CMS. She stated that she was asked by the Administrator to close the MDS assessments because the MDS RN coordinator had left employment at the facility. She stated that the MDS was overseen by the Administrator not the DON. She revealed that the practice of not completing the MDS assessments in time could have a negative consequence financially on the facility and this could have a negative effect on the quality of care provided to the residents. She stated she believed the MDS assessments were submitted late because there had been a lack of a consistent MDS RN coordinator in that department. She stated there had been four MDS RN Coordinator's in the last year, and each time one left, there was a back log of MDS assessments not completed.

Based on record reviews, staff interviews, and review of the facility's policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan within 48 hours of admission that addressed two medications, (an opioid and a diuretic) for one out of five sampled residents (R ) (R33) selected for unnecessary medications review. This had the potential to cause adverse medical effects for R33 with no known interventions for staff. Findings include: Review of the undated facility's policy titled; Baseline Care Plan under Policy Explanation and Compliance Guidelines revealed, 1. The baseline care plan will: (a.) Be developed within 48 hours of a resident's admission. (b.) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders; ii. Physician orders; iii. Dietary orders; iv. Therapy services; v. Social services; vi. PASARR recommendation, if applicable 2.(b.) Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk . 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. Review of R33's medical records revealed an admitted [DATE] with diagnoses that included, chest pain, unspecified, heart failure, unspecified, paroxysmal atrial fibrillation, anemia, unspecified, hypokalemia, chronic kidney disease, stage 4 (severe), muscle weakness (generalized), difficulty in walking, need for assistance with personal care, essential (primary) hypertension, and unspecified diastolic (congestive) heart failure. Review of R33's physician orders revealed, Pain Evaluation Q (every) shift (record numeric value. 0=No Pain. 1-3= Mild Pain. 4-6= Moderate Pain. 7-1-=Severe Pain), with start date of 7/5/2024. Further review of the physician orders revealed, hydrocodone acetaminophen oral tablet 10-325 mg (milligram) with a start date of 7/6/2024, give one tablet by mouth every 12 hours as needed for pain and furosemide oral tablet 20 mg give three tablets by mouth two times a day for daily diuretics; hold for SBP (systolic blood pressure) less than 110 and/or HR (heart rate) less than 60 with a start date of 7/6/2024. Review of R33's baseline care plan dated 7/8/2024 under section 3. Health Conditions and subsection D. Medications revealed, 1. Medications resident is taking provided the option to select the following: a. Psychotropic medications b. PRN Psychotropics c. Diuretics d. Insulin e. Antibiotics f. Anticoagulants g. Opioids (documentation) h. Black Box medications; however, none of the boxes were checked. Interview on 7/18/2024 at 2:20 pm with the Assistant Director of Nursing (ADON) revealed that the nursing staff monitor high risk medications on the MAR (medication administration record). She stated residents who have diuretics ordered are weighed daily on admission and depending on the dose ordered they would continue weekly weights. She stated if a resident were stable, they would complete monthly weights. She stated nursing completes a functional skilled assessment for skilled nursing residents daily. She stated opioid medications are monitored by the nurse practitioner and there was a tool in the EHR (electronic health record) that would trigger to monitor for side effects that was documented on the MAR. She confirmed the care plan should have interventions listed related to the high risk medications that nursing should be able to refer to for guidance. She stated she was not aware of how these items are care planned. Interview on 7/18/2024 at 4:43 pm with the ADON revealed, when a resident admits into the facility, nursing completes their portion of the baseline care plan along with the other different disciplines and try to do them [respective portions of the baseline care plan] within 24 hours. The ADON further revealed typically the DON (Director of Nursing) will check over it to make sure it was correct, if not the DON, the ADON. She stated, if the baseline care plans were not done correctly, that could cause the facility the inability to take care of the residents. She stated, the nurse on the floor would be asked to check for mistakes, make corrections, and make sure the care plans were aligned with the resident's care. Interview on 7/18/2024 at 3:59 pm with the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) revealed, she was responsible for developing care plans after the comprehensive assessments were completed. She stated she was familiar with R33 and stated she had been recently readmitted to the facility however, she has not been able to get to R33's baseline care plan but would be sure to correct it. She acknowledged and stated, by those (opioid and diuretic) medications not being care planned, could affect R33 because the care plan should address the medications and interventions for staff to provide.

Based on observation, staff and resident interviews, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to develop a care plan that included a communication or language preference for one of three sampled residents (R) (R179) whose primary language was not English. This deficiency had the potential to adversely impact the quality of care and quality of life provided to the resident. Findings include: Review of the undated facility's policy titled, Comprehensive Care Plans, under Policy Explanation and Compliance Guidelines revealed the following, Number 3. The comprehensive care plan will describe, at a minimum, the following: (f.) Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English-speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. Number 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: i. The RAI Coordinator. ii. Activities Director/Staff. iii. Social Services Director/Social Worker. iv. Licensed therapists. v. Family members, surrogate, or others desired by the resident. vi. Administration. vii. Discharge Coordinator. viii. Mental health professional. ix. Chaplain. Review of the electronic medical record (EMR) for R179 revealed, she admitted to the facility with diagnoses to include Covid-19, presence of cardiac pacemaker, hypothyroidism, and generalized muscle weakness. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] for R179 revealed Section A: Identification Information, indicated her preferred language was Korean; Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment; Section D: Mood, a Mood score of zero, indicating no depression and no behaviors and Section GG: Functional Abilities and Goals, which indicated she required setup for eating and moderate to maximum assistance for all other activities of daily living (ADLs). Review of the Care Plan for R179 dated 1/19/2024 revealed there was no focus concern related to communication or language until 7/18/2024 which documented her preferred language as Korean with a goal of being able to make her needs known. Interventions included anticipating her needs, her preference to communicate in Korean, and discussing with her/family concerns regarding communication difficulty. Observation and interview on 7/17/2024 at 1:20 pm with R179 revealed in a response to a greeting in English, she gestured to indicate that she did not speak English. When asked if she spoke Korean, she nodded affirmatively. She was able to understand text communication via Google translator and confirmed that staff took good care of her. During an interview on 7/17/2024 at 3:47 pm with the MDS Licensed Practical Nurse (LPN), she stated she was hired in January 2024 and was the only MDS nurse currently on staff. She stated she was self-taught, mostly through online courses, regarding her knowledge of the MDS process and her duties as the MDS Nurse. She confirmed the most recent MDS assessment included R179's preference for Korean language for communication. During an interview on 7/18/2024 at 10:51 am with Registered Nurse (RN) AA, she stated the staff utilize the translator telephone line when attempting to communicate with a resident who speaks a language that they cannot speak. In addition, she stated staff also use a communication board with symbols to communicate with residents. Finally, she stated the attending nurse can create or update the care plan, but it was usually handled by one or more of the interdisciplinary team (IDT) members. During an interview on 7/18/2024 at 11:04 am with Certified Nursing Assistant (CNA) II, she stated she communicated with residents who do not primarily speak English by facing them when speaking, using the language tools like the translator line, or calling a family member. In addition, she stated several staff members speak different languages and can be called to assist anytime. During an interview on 7/18/2024 at 11:30 am with the Assistant Director of Nursing (ADON), she confirmed communication/language was not part of R179's care plan until today. She stated it would benefit residents and staff if communication was part of the care plan related to potential challenges such as language, cognition, or diagnosis. She stated members of the IDT are mostly responsible for creating and updating the care plan. During an interview on 7/18/2024 at 2:30 pm with the Medical Director, he stated it would be helpful to the staff if communication was a focus concern in the care plan due to language(s) spoken by the resident or other challenges in communication whether cognitive, medical, or cultural.

Based on resident family interview, Staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the resident's (R) R1 right to be free from sexual abuse by (R5). Specifically, the facility failed to ensure a safe environment for (R1) from (R5) with known behaviors of exposing his penis, masturbating, and inappropriately touching female residents. Findings include: Review of the policy titled Abuse Neglect and Exploitation dated 8/1/2023 indicated under Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; F. Providing emotional support and counseling to the resident during and after the investigation, as needed. 1. Review of the Electronic Medical Record (EMR) for R1 revealed she was admitted to the facility on [DATE] with diagnosis of, but not limited to anemia, unspecified dementia, and osteoporosis. Review of R1's admission 5-day Medicare Minimum Data Set (MDS) 11/7/2023 was in progress. Review of the care plan initiated 11/1/2023 revealed that R1 has an impaired cognitive function related to dementia. Intervention to be implemented communicate with the resident, family, and caregivers regarding residents capabilities and needs. Review of the Facility Incident Report (FRI) dated 11/6/2023 revealed on 11/6/2023 at 3:05 p.m., R5 was observed exposing himself, asking female resident to touch his (R5) penis, and groping R1 chest, by the certified nursing assistant (CNA). 2. Review of the Electronic Medical Record (EMR) for R5 revealed he was admitted to the facility on [DATE] with diagnosis of, but not limited to Alzheimer's disease. Review of R5's admission 5-day Medicare MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 8, which indicated moderately impaired. Section D revealed mood none. Section E revealed no behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 10/31/2023 revealed that R5 has a behavior problem related to exposing his genitals to female residents. He will, at times, masturbate in public areas. Intervention to be implemented intervene as necessary to protect the rights and safety of others. An interview on 11/9/2023 at 10:36 am with Certified Nursing Assistant (CNA), CC stated on 11/6/2023 R1 and R5 was sitting across from the nursing station in view of her (CNA). She stated R5 exposed himself to R1 and grabbed her breast. She stated a coworker and herself intervened R5 became upset and stated I want to play with her (R1). The CNA stated R5 has a behavior of exposing his (R5) private parts to other residents and masturbating. An interview on 11/9/2023 at 10:42 am with Social Services Director revealed she did not check on R1 after the incident on 11/6/2023 to see if she was okay or having any anxiety, or fearful. The SSD confirmed that the facility did not have a Long-Term Care Resident Abuse Reporting Act poster. The SSD was asked how a resident or family would report abuse to the SSA. She stated they could tell someone in the facility. She was asked what if the person was uncomfortable with reporting to someone in the facility. She was not sure how the resident/family would report abuse without the phone number to the State Survey Agency (SSA). An interview on 11/9/2023 at 2:00 pm with Family Member of R1 revealed the facility did call her and made her aware of the incident. She stated she was not able to visit R1 on the day of the incident (11/6/2023). She stated the Unit Manager informed her that R1 was okay. She stated she arrived the next day and spoke with the resident, but R1 did not have any awareness of the incident due to her dementia. Further interview also revealed that when she arrived at the facility on the following day, she did look for the posting for the SSA, but she could not locate the posting with a phone number. She stated she did not ask the facility for the number because she wanted to report the incident herself. An interview on 11/14/2023 at 11:56 am with the Director of Nursing (DON) the Administrator (AA) and the onboarding Administrator (DD) was present during the interview. The DON stated a skin assessment or trauma assessment was not completed on R1. The DON stated there was no additional education provided to the staff after the incident. The DON stated moving forward the staff will be reeducated on abuse, to assess the wellbeing of the resident(s), complete skin assessment, and involve the social service department to make sure a trauma assessment is completed.

Based on staff interviews, record review, and review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act of an allegation of sexual abuse was reported to the State Survey Agency (SSA) within the required time frame for two of eleven residents (R) (R5 and R8). Specifically, the facility failed to report R5 exhibited sexually aggressive behavior, saying sexual things, and exposing his penis to R8. Findings include: Review of the policy titled Compliance with Reporting Allegations of Abuse, Neglect, Exploitation dated 8/1/2023 indicated under Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, are reported immediately to appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. 4. Identification: The facility will identify events, occurrences, patterns, and trends that may constitute: II Sexual Abuse is the non-consensual sexual contact of any type with a resident. 1. Review of the Electronic Medical Record (EMR) for R5 revealed he was admitted to the facility on [DATE] with diagnosis of, but not limited to Alzheimer's disease. Review of R5's admission 5-day Medicare Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 8, which indicated moderately impaired. Section D revealed mood none. Section E revealed no behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 10/31/2023 revealed that R5 has a behavior problem related to exposing his genitals to female residents. He will, at times, masturbate in public areas. Intervention to be implemented intervene as necessary to protect the rights and safety of others. Review of Incident Note dated 10/25/2023 revealed: I was alerted by activity coordinator that the resident rolled his wheelchair up to another female resident unzipped and unbuttoned his pants and asked the resident can you touch my cock. Resident placed at nurses' station where he was observed opening pants and attempting to expose himself. Nurse Practitioner and Director of Nursing made aware. Review of the Nurse Practitioner Psychiatric Diagnostic Evaluation date of service 10/27/2023 seen for psych evaluation and med management for Alzheimer's. The Resident alert and oriented times two. Able to make needs known. The Resident calm, cooperative, and participating with exam. Resident states I'm just playing with my cock; do you want to play with it? proceeded to grope his (R5) penis. The Facility staff made aware. Bizarre behaviors noted. Facility staff reports R5 has been making inappropriate sexual gestures to staff and other patients. No documented new orders. Review of the facility documents and interviews with staff revealed the perpetrator Resident R5 had a history of exposing himself, asking female resident and staff to touch his penis, and masturbating. This was documented in two residents records. 2. Review of the EMR for R8 revealed she was admitted to the facility on [DATE] with diagnoses of, but not limited to chronic obstructive pulmonary disease and emphysema. Review of R8's admission 5-day Medicare MDS dated [DATE] revealed a BIMS was assessed as 14, which indicated cognitively intact. Section D revealed the mood of feeling down, depressed, hopeless. Section E revealed no behavior exhibited. Review of the facility's internal Risk Management Tool provided to the surveyor dated 10/25/2023 revealed: Resident (R8) was sitting in the dining room and was approached by R5 who exposed himself and ask R8 to touch his (R5) private parts. An interview on 11/14/2023 at 11:56 am with Administrator AA stated he is the abuse coordinator for the facility. The Administrator stated he was aware of the incident that took place on 10/25/2023 of R5 exposing himself to the female resident. The Administrator confirmed that the incident was not reported to the SSA. The Administrator stated he did not think the incident should have been reported to the SSA because R5 only exposed himself and did not touch anyone. An interview on 11/17/2023 at 11:03 am with the Activities Assistant BB stated on the day of the incident the residents had just finished lunch and she was in the process of starting an activity (bingo). She stated R5 propelled his wheelchair up to R8. She stated R5 pulled out his private part and ask R8 to touch his (R5) cock. She stated R8 verbalized she was embarrassed and asked the activities assistant not to tell anyone. The Activities Assistant stated R5 had a behavior of unzipping his pants and pulling out his private part, staff would intervene and redirect R5 from the behavior. She stated he would only exhibit this behavior with the female residents.

Based on interviews, review of facility documentation, and policy review titled Quality Assurance Performance Improvement, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice. This had the potential to affect all 44 residents residing in the facility at the time of the survey. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement, dated 7/10/20, indicated . It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life . The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility . At a minimum, the QAPI will . Address all systems of care and management practices . Include clinical care, quality of life, and resident choice . Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a Skilled Nursing Facility . Further review of the QAPI program revealed no identification or tracking for the following deficient practices identified during the survey: There was no evaluation of general nursing issues and corrective action taken. There was no evaluation of an infection control program. There was no evaluation of an antibiotic stewardship program. There was no evaluation for exemptions for the COVID vaccines. There was no evaluation for development and implementation of care plans. There was no evaluation for pneumococcal vaccine guidelines. There was no evaluation of advance directives. There was no evaluation of potential restraints. During an interview on 5/25/22 at 4:16 p.m., the Administrator stated he did not have data to show how the facility tracks and trends potential deficient practice. The Administrator stated there have been very few issues that require a performance improvement plan (PIP) since the facility was newer.M

Based on record review, interviews, and review of facility policy titled Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly. The census was 44. Findings include: Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI), dated 7/20/20, indicated . Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. Review of documents titled QAPI Sign In Sheet, for the year 2021, indicated the facility held QAPI meetings on a monthly basis. The last QAPI meeting was held on 12/30/21. There was no additional information provided to show the facility held a quarterly QAPI meeting for the month of March 2022. During an interview on 5/25/22 at 4:16 p.m., the Administrator confirmed the March 2022 quarterly QAPI meeting was not held. The Administrator stated he just forgot to hold this meeting.

Based on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) policy, the facility failed to ensure that all residents and/or their representatives were informed by 5:00 p.m. the next calendar day following the occurrence of a single resident or staff confirmed COVID-19 positive infection, received cumulative updates, and informed of mitigating actions taken by the facility to prevent or reduce the risk of transmission. The census was 44. Findings include: Review of CMS QSO-20-29-NH, dated 5/6/20, indicated, Facilities must .Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and . Include any cumulative updates . During the entrance conference interview on 5/22/22 10:38 a.m., the Administrator stated that the facility had not had any COVID positive staff or residents in the past four weeks and acknowledged that he is responsible to inform the residents and responsible parties about the COVID-19 status in the facility, which he does by e-mail. The Administrator stated that he keeps a log to track the communications. During the entrance conference the policy for resident and staff notification of COVID-19 incidence in the facility was requested; however, none was provided during the duration of the survey. Line Listings of positive staff and residents was also requested during the entrance conference; however, none were provided. Interview on 5/24/22 at 10:04 a.m., the Director of Nursing (DON) acknowledged the facility was notified that Licensed Practical Nurse (LPN) NN tested positive for COVID 19 on 5/18/22. The DON stated that after working the night of 5/17/22, LPN NN performed a self-administered COVID-19 rapid test at home, tested positive, immediately went for a PCR COVID-19 test that was also positive. A line listing of COVID-19 positive residents and staff was requested again; however, none was provided. Review of the information provided in e-mails sent to resident, families, and friends for notification of COVID-19 occurrences in the facility revealed that communication for the COVID-19 positive result for LPN NN was not sent until 5/24/22. Interview on 5/23/22 at 1:19 p.m., the Medical Director acknowledged that the facility should follow CMS and CDC (Centers for Disease Control and Prevention) guidelines for their COVID-19 policies and procedures. Interview on 5/25/22 at 3:18 p.m., the Administrator acknowledged late notification of LPN NN's COVID positive test results to residents and families and upon questioning he did not provide an explanation for the late notification.

Based on record review, interviews, and review of the facility policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan for five of five residents (R) (R#242, R#1, R#40, R#193, and R#141), out of 20 sample residents Findings include: Review of the facility's policy titled Baseline Care Plan dated 1/1/21 revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident . A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 1. Review of the clinical record revealed R#242 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15, indicating R#242 had moderate cognitive impairment. Review of R#242's care plan revealed no evidence that a base line care plan was developed. During an interview on 5/24/22 at 9:37 a.m., family member of R#242 stated that he was in the facility for a care plan meeting scheduled for 10:00 a.m. and acknowledged that the facility had not previously provided a written summary of R#242's care plan to the family or resident; this was confirmed by R#242. 2. Review of the clinical record revealed R#1 was readmitted to the facility on [DATE] with fractures and other multiple traumas, [CONDITION(S)], dementia, and depression. Review of the admission MDS with an ARD of 5/15/22 revealed a BIMS score of 12 out of 15, indicating R#1 had moderate cognitive impairment. Review of Care Plan Meeting Notes revealed there was no evidence of a care plan note for the 5/12/22 readmitted . 3. Review of the clinical record revealed R#40 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS with an ARD of 5/9/22 revealed a BIMS score of five out of 15 indicating R#40 had severe cognitive impairment. Review of Care Plan Meeting Notes revealed a baseline care plan meeting was documented on 5/16/22, 10 days after admission to the facility. During an interview on 5/25/22 at 2:11 p.m., the MDS Coordinator, (MDSC) acknowledged that R#242, R#1, and R#40 had baseline care plans that were developed late. The MDSC acknowledged that the only paperwork she provides to residents and their families is a medication list and not their entire baseline care plan. 4. Review of the clinical record revealed R#193 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#193's clinical record revealed no evidence that R#193's representative was provided with the baseline care plan. Interview on 5/25/22 at 1:36 p.m., the Social Worker (SW) stated any staff member could initiate the baseline care plan and that the baseline care plan was to occur within 48 hours. Interview on 5/25/22 at 1:43 p.m., both the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator were present. Both the DON and the MDS Coordinator reviewed the EMR for R#193 and confirmed the resident's representative was not provided with a copy of the baseline care plan. 5. Review of the clinical record revealed R#141 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#141's comprehensive care plan dated 5/15/22 (six days after admission), indicated R#141 was dependent on staff for all emotional, intellectual, physical, and social needs related to non-verbal status and physical dependence. The care plan indicated R#141 required total care for all Activities of Daily Living (ADL-such as bathing, eating, dressing, toilet use) due to history of [CONDITION(S)] and [CONDITION(S)] on her right side. There was no evidence that a baseline care plan was developed. Interview on 5/23/22 at 11:12 a.m. with the DON and Registered Nurse (RN) BB a copy of the baseline care plan for R#141 was requested. RN BB verified that there was no baseline care plan for R#141.