Every finding on record at Miller's Health & Rehab by Miller's Merry Manor

Based on observation, record review, and interview, the facility failed to ensure personal privacy was maintained related to the computer screen being left open with resident information visible on 1 of 2 units throughout the facility. (The 100 unit)Finding includes:During a random observation on 7/21/25 at 10:22 a.m., the computer screen on the front 100 unit medication cart was left open and resident information was visible. At 10:33 a.m., the computer screen was still open. RN 1 returned to the cart and walked away from the cart at 10:35 a.m. The RN did not close the computer prior to walking away. At 10:41 a.m., the RN returned to the medication cart. At 10:44 a.m., she walked away from the medication cart to answer a phone call, again, she did not close the computer prior to walking away. The RN returned to the medication cart at 10:46 a.m. At 10:50 a.m., the RN walked away from the medication cart with resident information visible. Staff and other residents were observed in the hallway at that time. During an interview on 7/23/25 at 4:45 p.m., the Nurse Consultant indicated the nurse should have closed the computer screen each time she walked away. The current facility policy titled, Medication Administration Procedure was provided by the Nurse Consultant on 7/23/25 at 4:55 p.m. The policy indicated the computer screen was to be locked prior to walking away. 3.1-3(o)

Based on record review and interview, the facility failed to ensure a stat (immediate) chest X-ray was reported timely, eye drops were administered as ordered by the physician, a skin tear was treated and monitored, and a resident was treated for constipation for 1 of 1 resident reviewed for hospitalization and 1 of 1 resident reviewed for constipation. (Residents B and G)Findings include: 1. The closed record for Resident B was reviewed on 7/22/25 at 1:30 p.m. Diagnoses included but were not limited to, anemia, kidney failure, heart failure, high blood pressure, falls, glaucoma, and heart disease. The admission Minimum Data Set (MDS) assessment, dated 3/14/25, indicated the resident was moderately impaired for daily decision making. A Care Plan, dated 3/10/25, indicated the resident had visual impairment related to glaucoma. The approaches were to instill medication as per physician orders. A Care Plan, dated 3/17/25, indicated the resident had a skin tear to the right great toe. A Care Plan, dated 3/18/25, indicated the resident tested positive for COVID-19.A Physician's Order, dated 3/7/25 and discontinued on 3/11/25, indicated Travoprost (an eye drop used for glaucoma) Solution 0.004 %, instill one drop in both eyes in the evening for glaucoma. A Physician's Order, dated 3/11/25 and discontinued 3/14/25, indicated Travoprost (an eye drop used for glaucoma) Solution 0.004 %, instill one drop in both eyes at bedtime for glaucoma. A Physician's Order, dated 3/14/25, indicated Travoprost (an eye drop used for glaucoma) Solution 0.004 %, instill one drop in both eyes at bedtime for glaucoma patient supplied. The Medication Administration Record (MAR) for the month of 3/2025, indicated the eye drops were not signed out as being administered and coded with a 3 (indicating the medication was not available) on 3/8, 3/9, 3/10, 3/11, and 3/12/25. Documentation in the nurses' notes, dated 3/8, 3/9, 3/10, 3/11, and 3/12/25, indicated Travoprost Solution 0.004 %, instill one drop in both eyes in the evening for glaucoma. The medication was unavailable at this time.Nurses' Notes, dated 3/12/25 at 7:46 p.m., indicated the resident's daughter brought the Travoprost eye drops due to them not being available from pharmacy. A Nursing Initial Occurrence, dated 3/14/25 at 10:10 p.m., indicated the resident's right great toe got stuck under the wheel of the wheelchair. A skin tear was sustained measuring 0.75 centimeters (cm) in length by 0.5 cm.in width. The CNAs were instructed to make sure the resident was wearing shoes or non-slip socks during transfers and transports. The skin tear was cleansed with soap and water and covered with ABD and tape. The next and last Nursing Occurrence Follow Up Assessments were completed on 3/15/25 at 3:28 p.m. and 10:56 p.m. The directions on the form indicated Complete follow-up assessments for all occurrences each shift for 24 hours, if an injury occurred complete each shift for 72 hours. A Physician's Order, dated 3/17/25, indicated cleanse the skin tear to the right great toe with normal saline and apply Comfitel (a silicone wound dressing) contact layer and cover with a bordered foam. Change twice weekly on Tuesday and Friday and as needed for soilage or dislodgement. There were no treatment orders for the skin tear until 3/17/25. The Treatment Administration Record (TAR) for the month of 3/2025 indicated the treatment for the skin tear was not signed out as being completed on Tuesday 3/18/25. A Nurses' Note, dated 3/15/25 at 2:37 p.m., indicated staff messaged the doctor to obtain an order for Zofran as needed for nausea and dry heaving. There was no other documentation earlier in the day to indicate the resident was nauseated or vomiting. A Physician's Order, dated 3/15/25 at 2:52 p.m., indicate Zofran (a medication used for nausea) give 4 mg by mouth every four hours as needed for nausea and vomiting. Nurse Practitioner (NP) Note, dated 3/21/25 at 11:43 a.m., indicated the patient had a cough with congestion and a chest X-ray would be ordered. A Physician's Order, dated 3/21/25 at 11:43 a.m., indicated stat chest X-ray for shortness of breath. A Nurses' Note, dated 3/21/25 at 6:26 p.m., indicated the daughter called and asked if the resident could get Tessalon Pearls (a medication used for cough). The physician ordered the Tessalon pearls 200 mg three times a day as needed. A Physician's Order, dated 3/21/25 at 9:04 p.m., indicated Benzonatate Capsule 200 mg, give one tablet every eight hours as needed for cough. The order was not put in the computer until 9:04 p.m. so it could be sent to the pharmacy. A Nurses Note, dated 3/22/25 at 8:41 a.m., indicated the chest X-ray results were received and daughter and physician were notified.There was no documentation in the clinical record regarding nursing staff following up on the results of the stat chest X-ray on 3/21/25. During an interview on 7/24/25 at 3:45 p.m., the Assistant Director of Nursing (ADON) indicated the eye drops were not available from the pharmacy. During an interview on 7/25/25 at 11:36 am., the ADON indicated there was no follow up vital signs after the skin tear on the right great toe and there was no treatment order for the skin tear until 3/17/25. The treatment was not signed out on 3/18/25. The Tessalon pearls were delivered to the facility on 3/22/25 at 6:25 p.m. There was no documentation or assessment of the resident having any nausea or vomiting on 3/15/25 prior to getting the order for the Zofran. The X-ray company was called by nursing staff at 1:02 p.m. (79 minutes after the order was written). The company arrived to the facility and obtained the chest X-ray at 2:55 p.m. and results were signed by the Physician on 3/22/25 at 1:07 a.m. She indicated a stat X-ray was to be obtained and completed within four hours. She would have expected nursing staff to follow up with the X-ray company as to what the results were. 2. During an interview on 7/22/25 at 10:50 a.m., the resident indicated she has not had a bowel movement in a while. The record for Resident G was reviewed on 7/23/25 at 9:45 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, fracture of left humerus, fracture of left wrist, hypothyroidism, and laceration of the eyelid. The admission Minimum Data Set (MDS) assessment was still in progress. A Care Plan, dated 7/20/25, indicated the resident had the potential for constipation. The approaches were to administer laxatives and/or stool softeners as ordered. A Nurses' Note, dated 7/21/25, indicated the resident had complaints of having no bowel movement in a few days. The physician was notified and new orders were obtained. There were no other nursing progress notes regarding the resident's complaints of constipation. A Physician's Order, dated 7/20/25, indicated Hydrocodone (a narcotic) 7.5-325 mg, give one tablet every six hours as needed for pain. Physician's Orders, dated 7/21/25, indicated Milk of Magnesia 400 milligrams (mg), give 30 milliliters (ml) every 24 hours as needed for constipation. Miralax oral powder 17 grams, give one scoop one time a day for constipation and Sennosides 8.6 mg, give two tablets one time for constipation. A Physician's Order, dated 7/22/25, indicated Hydrocodone (a narcotic) 7.5-325 mg, give one tablet two times a day for pain. The 7/2025 Medication Administration Record (MAR) indicated the resident received 5 doses of the as needed Hydrocodone from 7/21-7/22/25. The resident did not receive the as needed Milk of Magnesia. She received one dose of the Sennosides on 7/21/25, no dose on 7/22/25 and one dose on 7/23/25. The three-day bowel pattern record indicated no bowel movement was documented from 7/20/25 at 3:42 p.m. through 7/23/25 2:22 p.m. The bowel movement documentation every shift indicated a small bowel movement was recorded on 7/21/25 at 2:10 p.m. During an interview on 7/24/25 at 3:45 p.m., the Assistant Director of Nursing (ADON) indicated it was documented the resident had a bowel movement on 7/21/25 at 2:10 p.m. She was not aware the three-day bowel movement pattern indicated the resident had no bowel movement on 7/21/25. She was aware the resident did not receive the as needed Milk of Magnesia. There was no follow up documentation regarding the resident's complaints of constipation. The current 3/1/2001 Bowel Elimination policy, provided by the ADON on 7/25/25 at 11:40 a.m., indicated if a resident complained of constipation, or at least on the third day with no bowel movement, an ordered bowel aid or stool softener will be administered. This citation relates to Complaint 1554512. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure wound vac (vacuum) tubing was kept off the floor and treatments were followed as ordered by the physician for 2 of 4 residents reviewed for pressure ulcers. (Residents F and 44)Findings include:1. During random observations on 7/21/25 at 10:36 a.m., on 7/22/25 at 3:40 p.m., on 7/23/25 at 9:38 a.m., 11:40 a.m., 12:10 p.m., and 2:39 p.m., and on 7/24/25 at 11:14 a.m., Resident F was observed in bed. At those times a wound vac (a specialized dressing and a vacuum pump that creates gentle suction on a wound to help it heal faster) was contained in a bag and observed on the floor next to the bed. The wound vac tubing was not contained and was laying directly on the floor. On 7/24/25 at 11:26 a.m., LPN 1 entered the room and observed the wound vac tubing on the floor.During an interview at that time, LPN 1 indicated the tubing should be contained inside the bag and off the floor.During a wound treatment observation 7/25/25 at 10:30 a.m. the resident was observed with a large wound to the sacrum. The wound was pink with a scant amount of drainage noted. The record for Resident F was reviewed on 7/23/25 at 10:50 a.m. Diagnoses included, but were not limited to, osteomyelitis of the sacral region, COPD (Chronic obstructive pulmonary disease), acute respiratory failure, pressure ulcer of the sacral region, emphysema, major depressive disorder, and anxiety disorder.The admission Minimum Data Set (MDS) assessment, dated 6/10/25, indicated the resident was moderately intact for daily decision making and was admitted to the facility with one Stage 4 pressure ulcer (the most severe stage of a pressure injury, characterized by full-thickness skin and tissue loss with potential exposure of bone, tendon, or muscle).The Care Plan, dated 5/30/25, indicated the resident had a pressure ulcer to the coccyx region. A Physician's Order, dated 5/30/25 and discontinued on 6/20/25, indicated Meropenem (an antibiotic) Intravenous Solution Reconstituted 1 gram every eight hours for osteomyelitis of the wound. A Physician's Order, dated 7/1/25 indicated wound vac to coccyx, monitor for suction and functioning every shift. The wound was measured last on 7/23/25. The Stage 4 sacral wound measured 3.3 centimeters (cm) in length by 3.1 cm in width by .03 cm deep. The wound was moist and pink with new undermining noted from 6 o'clock to 10 o'clock 0.5 cm depth. During an interview on 7/24/25 at 1:45 p.m., the Nurse Consultant indicated the wound vac tubing should not have been on the floor. 2. The record for Resident 44 was reviewed on 7/23/25 at 11:58 a.m Diagnoses included, but were not limited to, dementia, diabetes, and pressure ulcer.The 5/30/25 admission Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment and required moderate assistance with activities of daily living (ADLs) and transfers. A Wound Care Plan, dated 5/23/25, indicated to administer treatments as ordered.A 6/4/25 Physician's Order indicated the following wound care: cleanse coccyx (tailbone area) wound with wound cleanser, pat dry, apply Dakin's (an antiseptic) soaked gauze (wet to moist) to wound bed, and cover with a bordered foam dressing; change daily and as needed for soilage or dislodgement. The July 2025 treatment record indicated this treatment was provided daily from 7/1/25 through 7/23/25. A 7/9/25 wound clinic note indicated the following coccyx wound care orders: cleanse with Dakin's, tuck Exufiber (a gelling fiber wound dressing) into the wound, apply 4X4 gauze, and cover with bordered foam dressing daily. Assessments of the coccyx wound indicated: 7/3/25 left upper coccyx, stage 4, 8.2 cm long, 6 cm wide, 1.7 cm deep, light serous (yellow/clear drainage), no tunnelling; 7/10/25 left upper coccyx, stage 4, 5.3 cm long, 4.4 cm wide ,1.5 cm deep, light serous drainage, no tunnelling; 7/17/25 left upper coccyx, stage 4, 4.6 cm long, 4 cm wide, 1.3 cm deep, light serous drainage, no tunnelling; During an interview on 7/24/2025 at 9:48 a.m., the Wound Nurse indicated she was not aware of the new treatment orders. The wound clinic would normally notify her of new orders, but she thought they must not have changed the treatment because the wound was healing. 3.1-40

Based on observation, record review, and interview, the facility failed to ensure indwelling Foley (urinary) catheter tubing was kept off the floor, urinary outputs were documented, and urinalysis was collected in a timely manner for 2 of 3 residents reviewed for catheters. (Residents H and E)Findings include:1. During random observations on 7/21/25 at 10:16 a.m. and 12:40 p.m., Resident H was observed sitting in a wheelchair. At those times, an indwelling Foley catheter was observed underneath the wheelchair and the bottom of the bag was on the floor. The record for Resident H was reviewed on 7/23/25 at 10:07 a.m. Diagnoses included, but were not limited to, right femur fracture, obstructive and reflux uropathy (a condition where urine flows backward from the bladder into the ureters and potentially the kidneys), urine retention and chronic kidney disease. The 6/26/25 admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and had an indwelling Foley catheter. The Care Plan, dated 6/13/25, indicated the resident required the use of a catheter due to untreatable urinary retention. The approaches were to document urinary output. A Physician's Order, dated 6/16/25, indicated Foley catheter #16 with a 10 milliliter balloon. A Physician's Order, dated 7/4/25, indicated the Foley catheter was to be switched to leg bag during the day and privacy bag at bedtime. A Physician's Order, dated 7/6/25, indicated Keflex (an antibiotic) 500 milligrams (mg) three times a day for seven days for an urinary tract infection. The urinary output documentation in the CNA task section indicated the output was incomplete on the day shift on 6/14, 6/15, 6/21, 6/27, 7/8, and 7/11/25, on the evening shift on 7/2 and 7/17/25 and on the midnight shift on 6/25/25. During an interview on 7/24/25 at 1:45 p.m., the Nurse Consultant indicated the Foley catheter bag should not have been touching the floor. During an interview on 7/24/25 at 3:45 p.m., the Administrator had no additional information to provide regarding the urinary output not being completed. The current 6/15/2010 Output Monitoring policy, provided by the Assistant Director of Nursing (ADON) on 7/25/25 at 11:40 a.m., indicated output will be monitored each shift and documented in the medical record in point click care. The current 8/30/2007 Foley Catheter and Maintenance policy, provided by the ADON on 7/25/25 at 11:40 a.m., indicated ensure the bag or tubing was not touching the floor. 2. During a random observation on 7/21/2025 at 1:02 p.m., Resident E was moaning, indicating her back hurt when she tried to move. At that time, LPN 2 indicated she informed the doctor of the pain. He told her to give the resident Tylenol and that he would come see the resident. The record for Resident E was reviewed on 7/23/25 at 10:45 a.m. Diagnoses included, but were not limited to, diabetes, heart failure, and acute kidney failure. The 5/29/25 5-Day Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, required moderate assistance with activities of daily living (ADLs) and maximal assistance with transfers. A Physician's Note, dated 7/21/25 at 6:34 p.m., indicated the resident had complaint of pelvic and back pain, and staff was to obtain a urine sample for urinalysis and culture with antibiotic sensitivity. A Physician's Order, dated 7/22/25, indicated to straight cath (insert temporary catheter to drain the bladder) the resident to obtain the urine sample. A Progress Note, dated 7/23/25, indicated a Foley catheter (tube inserted and maintained in the bladder to drain urine) was to be inserted due to an unsuccessful attempt to straight cath. During an interview on 7/24/25 at 1:45 p.m., the Nurse Consultant indicated the process for obtaining a urine sample for analysis should be more timely. This citation relates to Complaint 1554511. 3.1-41(a)(2)

Based on record review and interview, the facility failed to ensure food consumption logs and health supplements were completed for a resident with a history of weight loss for 1 of 1 resident reviewed for nutrition. (Resident 3)Finding includes:The record for Resident F was reviewed on 7/23/25 at 10:50 a.m. Diagnoses included, but were not limited to, osteomyelitis of the sacral region, COPD (Chronic obstructive pulmonary disease), acute respiratory failure, pressure ulcer of the sacral region, emphysema, major depressive disorder, and anxiety disorder. The admission Minimum Data Set (MDS) assessment, dated 6/10/25, indicated the resident was moderately intact for daily decision making and needed supervision and set up assistance with eating. She weighed 93 pounds and received a regular diet. The Care Plan, dated 6/20/25, indicated the resident was at nutritional risk related to a pressure ulcer. The approaches were to serve a four-ounce house supplement at breakfast, lunch, and dinner and to monitor meal intakes. The resident weighed 93 pounds on 5/31/25. The resident weighed 89 pounds on 6/10/25 and 100 pounds on 7/14/25. Her weight on 7/21/25 was 94 pounds. A Registered Dietitian's (RD) Progress Note, dated 6/24/25, indicated the resident's Body Mass Index was 16 (indicating the resident was significantly underweight) and was to receive a house supplement for all three meals. The food consumption meal intakes were not documented for breakfast on 6/9, 7/7, 7/17, 7/18, 7/19, and 7/20/25. They were not documented for lunch on 6/9, 7/7, 7/17, 7/18, 7/19, and 7/20/25 and dinner on 7/1 and 7/2/25. The house supplement intakes found in the CNA task section were not documented for breakfast on 7/1, 7/7 7/17, 7/18, 7/19, and 7/20/25. They were not documented for lunch on 7/1, 7/7, 7/17, 7/18, 7/19, and 7/20/25 and for dinner on 7/2/25. During an interview on 7/24/25 at 1:45 p.m., the Administrator had no additional information to provide. The current 9/23/14 Point of Care Documentation policy, provided by the Assistant Director of Nursing on 7/25/25 at 11:40 a.m., indicated documentation was required each shift for all tasks that were assigned to the resident. Routine tasks assigned to residents were documentation of meal intakes. 3.1-46(a)(2)

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed to self-administer medications and had physician's orders for the medications for 2 of 2 residents reviewed for self-administration of medication. (Residents 23 and F)1. During random observations on 7/21/25 at 11:00 a.m. and 3:24 p.m., on 7/22/25 at 10:18 a.m. and 3:33 p.m., on 7/23/25 at 9:37 a.m. and 2:38 p.m., and on 7/24/25 at 11:13 a.m., Resident 23 was observed sitting in a recliner chair. At those times, there was a tube of Neosporin cream on the over bed table. During an interview on 7/21/25 at 11:00 a.m., the resident indicated he used the cream for his dry skin on his arms. On 7/24/25 at 11:26 a.m., RN 1 entered the resident's room and observed the Neosporin cream on the over bed table. During an interview on 7/24/25 at 11:30 a.m., RN 1 indicated the resident told her his family brought it in and he used it on his arms for the scabs. She removed the cream and will see about getting an order for it and complete an assessment for the resident to apply the cream himself. The record for Resident 23 was reviewed on 7/22/25 at 3:16 p.m. Diagnoses included, but were not limited to, fracture of the left femur, anxiety disorder, major depressive disorder, heart disease, and high blood pressure. The admission Minimum Data Set (MDS) assessment, dated 6/8/25, indicated the resident was moderately impaired for daily decision making. There was no care plan for the resident to self-administer his own medications. There was no self-administration of medication assessment for the resident to use the Neosporin cream. There was no physician's order for the Neosporin cream. During an interview on 7/24/25 at 1:45 p.m., the Administrator had no additional information to provide. The current 3/1/2001 Self Administration of Meds Procedure and Assessment policy, provided by the Assistant Director of Nursing on 7/25/25 at 11:40 a.m., indicated an assessment of the resident's abilities to self-administer meds will be completed prior to initiation of training. Upon completion of the assessment, the nurse assessor must sign and date the form and forward to the Director of Nursing for follow up. A final decision will be made by the team, along with the family, resident, and Physician whether or not the resident will be given the right to self-administer the medications. 2. During random observations on 7/23/25 at 3:50 p.m. and on 7/24/25 at 11:14 a.m., Resident F was observed in her room. At those times, there was a facility labeled box of Fluticasone Nasal spray on the night stand. On 7/24/25 at 11:26 a.m., LPN 1 entered the room and observed the Fluticasone Nasal spray on the night stand. During an interview at that time, LPN 1 indicated the resident had no order for Fluticasone, nor could she self-administer the medication. The record for Resident F was reviewed on 7/23/25 at 10:50 a.m. Diagnoses included, but were not limited to, osteomyelitis of the sacral region, COPD (Chronic obstructive pulmonary disease), acute respiratory failure, pressure ulcer of the sacral region, emphysema, major depressive disorder, and anxiety disorder. The admission Minimum Data Set (MDS) assessment, dated 6/10/25, indicated the resident was moderately intact for daily decision making. There was no care plan for the resident to self-administer his own medications. There was no self-administration of medication assessment for the resident to use Fluticasone Nasal spray. There was no physician's order for the Fluticasone Nasal spray. During an interview on 7/24/25 at 1:45 p.m., the Administrator had no additional information to provide. The current 3/1/2001 Self Administration of Meds Procedure and Assessment policy, provided by the Assistant Director of Nursing on 7/25/25 at 11:40 a.m., indicated an assessment of the resident's abilities to self-administer meds will be completed prior to initiation of training. Upon completion of the assessment, the nurse assessor must sign and date the form and forward to the Director of Nursing for follow up. A final decision will be made by the team, along with the family, resident, and Physician whether or not the resident will be given the right to self-administer the medications. 3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure clinical records were complete and accurately documented related to a resident's temperature on the Infection Control Assessment for 1 of 1 residents reviewed for urinary tract and respiratory infections, completed meal consumption and monitoring intake of nutritional supplements for 1 of 1 residents reviewed for nutrition, discontinuing pressure injury treatments for 1 of 2 residents reviewed for pressure ulcers, and the documentation of oxygen when not in use for 1 of 3 residents reviewed for oxygen therapy. (Residents 25, 40, 48 and 11) Findings include: 1. The record for Resident 25 was reviewed on 5/20/24 at 2:02 p.m. Diagnoses included, but were not limited to, obstructive uropathy, urine retention, high blood pressure, chronic kidney disease, stroke, and Alzheimer's dementia. The 5/1/24 Admission minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. The resident was not receiving antibiotics for any infection. There was no Care Plan for antibiotic therapy. Physician's Orders, dated 5/12/24, indicated Amoxicillin-Pot Clavulanate (an antibiotic medication) 875-125 milligrams (mg), give 1 tablet by mouth every 12 hours for Atelectasis (occurs when the small sacs in the lungs (alveoli) can't inflate properly, leading to a partial or full collapse of the lungs) for 10 days. Physician's Orders, dated 5/14/24, indicated Cipro 500 mg (an antibiotic medication) give 1 tablet by mouth two times a day for an Urinary Tract Infection for 7 days. A Nursing Infection Assessment, dated 5/15/24 at 2:06 p.m., indicated the resident's temperature documented was from 5/14/24 at 10:45 a.m. A Nursing Infection Assessment, dated 5/19/24 at 9:45 a.m., , indicated the resident's temperature documented was from 5/18/24 at 7:40 p.m. During an interview on 5/21/24 at 8:45 a.m., the Director of Nursing indicated the Nursing Infection Assessment was completed daily on the evening shift while the resident was receiving antibiotics and the resident's temperature should be checked at the time the assessment was completed. 2. During a random observation on 5/20/22 at 12:10 p.m., the Resident 40 received her lunch meal. At that time, she was served a 4 ounce glass of a thick white substance. The record for Resident 40 was reviewed on 5/17/24 at 11:14 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included,but were not limited to, fractured ribs, Alzheimer's disease, high blood pressure, acute kidney failure, falls, type 2 diabetes, high blood pressure and anxiety. The 4/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. The resident's current weight on 5/13/24 was 101 pounds. The resident weighed 110 pounds on admission (4/17/24) which was a significant weight loss. The meal consumption in the last 30 days indicated the breakfast meal was not documented on 4/19, 4/23, 4/25, and 5/10/24. The lunch meal was not documented on 4/24 and 4/25/24 and the dinner meal was not documented on 4/18/24. A Nurses' Note, dated 5/16/24 at 12:14 p.m., indicated the IDT (Interdisciplinary Team) met to discuss the resident's current weight loss. The Dietary manager recommended 4 ounce sugar free healthshake three times a day with meals and monitor weekly weights. The Physician was notified and in agreement. A new order was received for sugar free healthshake with meals. There was no Physician's Order for the healthshake. There was no documentation of how much of the healthshake the resident consumed. During an interview on 5/21/24 at 8:45 a.m., the Director of Nursing (DON) indicated all health shakes were poured into a glass and not in individual cartons. The amount consumed after each meal should be documented on the Enteral/Supplement Administration Record and meal consumption should be documented after each meal. The current 8/23/23 Wound, Weight, and Hydration Meeting policy, provided by the DON on 5/21/24 at 1:47 p.m., indicated the Dietary Manager should review the menus online during the meeting to ensure supplements or food add-ons were included on the menu or added to the menu. The task list on the POC (computerized charting) would be monitored during the meeting to ensure house shakes were being documented along with intakes. 3. The record for Resident 48 was reviewed on 5/20/24 at 9:16 a.m. Diagnoses included, but were not limited to, fracture T9-T10 (Thoracic spine) vertebra, anemia, Parkinson's disease, and high blood pressure. The 5/2/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had a limitation in range of motion to both upper and lower extremities and was dependent on staff for transfers and bed mobility. The resident had no history of falls and had unhealed pressure injuries. A Care Plan, dated 1/12/24, indicated the resident was admitted with a wound that was caused by wearing a back brace. Physician's Orders, dated 3/20/24, indicated Santyl Ointment 250 units/grams, apply to upper back wound topically every day shift and cover with 6 by 6 bordered foam dressing. Physician's Orders, dated 5/8/24, indicated cleanse wound with normal saline and apply dermasyn AG gel to the wound bed and cover with 4 by 4 bordered foam dressing. The order was discontinued on 5/16/24. The Treatment Administration Record (TAR), dated 5/2024, indicated the Santyl was signed out as being completed 5/1-5/17/24. The dermasyn AG gel was also signed out as being completed 5/9-5/16/24. Both treatments were signed out as being done at the same time. During an interview on 5/21/24 at 1:05 p.m., the Director of Nursing indicated, from 5/9-5/16/24, the treatment to the wound was the dermasyn AG gel and not the Santyl. The Wound Nurse forgot to discontinue the Santyl. 48383 4. On 5/16/24 at 10:39 a.m., Resident 1 was observed not wearing any oxygen, there was an oxygen concentrator and tubing against the wall that was turned off. The resident indicated they were no longer using it. On 5/16/24 at 12:20 p.m., the resident was observed sitting in her wheelchair in the dining area for lunch. The resident was not wearing any oxygen. There was an order in the chart for continuous oxygen use at 2 liters. On 5/17/24 at 11:12 a.m., the resident was observed sitting in her wheelchair. She was not wearing any oxygen. The concentrator and tubing were placed against the wall. On 5/20/24 at 11:36 p.m., the resident was observed sitting in her wheelchair, she was not wearing any oxygen. The oxygen tank was off and stored against the wall. The resident indicated she no longer used the oxygen. The record for Resident 11 was reviewed on 5/17/24 at 2:14 p.m. The diagnoses included, but were not limited to, kidney failure, cellulitis of the lower leg, diabetes, respiratory failure, dementia, bipolar disorder, heart failure, sleep disorder, dysphagia (difficulty swallowing), depression, difficulty walking, hypertension (high blood pressure), and anxiety. The Significant Change Minimum Data Set (MDS) assessment, dated 2/15/24, indicated the resident was cognitively intact for daily decision making and she required oxygen therapy. A Physician's Order, dated 5/9/24, indicated to administer oxygen at 2 liters via nasal cannula every shift. The May 2024 Medication Administration Record (MAR) indicated the resident's oxygen was signed out as being administered on the following dates: 5/16/24, 5/17/24, 5/18/24, 5/19/24 and 5/20/24. During an interview on 5/21/24 at 9:13 a.m., the Director of Nursing (DON) indicated she understood the concern regarding Resident 11's oxygen being signed out as given and had no additional information to provide. 3.1-50(a)(1) 3.1-50(a)(2)

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate, for 2 of 3 residents reviewed for respiratory care (Residents 49 and 44) Findings include: 1. On 5/16/24 at 10:36 a.m., Resident 49 was observed sitting in a recliner chair in his room. At that time, he was wearing oxygen per nasal cannula and was connected to the room concentrator. The ball on the oxygen dial was all the way at the bottom of and well below 0.5 liters. On 5/17/24 at 8:59 a.m., the resident was observed wearing the oxygen and the ball on the oxygen dial was below the 0.5 liter mark. On 5/17/24 at 12:28 p.m., the resident was observed wearing the oxygen and the bottom of the ball on the dial was above the 0.5 liter mark. The record for Resident 49 was reviewed on 5/20/24 at 10:59 a.m. Diagnoses included, but were not limited to, fracture of left femur, COPD, heart failure, respiratory failure, type 2 diabetes, high blood pressure, and atrial fib. The 3/26/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident used oxygen while at the facility and received diuretic medication. A Care Plan, dated 5/17/24, indicated the resident had heart failure. The approaches were to provide oxygen as ordered. Physician's Orders, dated 3/19/24, indicated oxygen at 0.5 liters per minute per nasal cannula, continuously every shift. During an interview on 5/21/24 at 8:45 a.m., the Director of Nursing indicated the oxygen should be set on 0.5 liters and ball should be centered in the middle of the line of the amount to be administered. 48383 2. On 5/16/24 at 10:31 a.m., Resident 44 was observed lying in bed. She was wearing oxygen via nasal cannula and the flow rate was under the 3 liter line. On 5/16/24 at 11:22 a.m., the resident was observed sitting in her wheelchair. She was wearing oxygen via nasal cannula and the flow rate was set at just under the 3 liter line. On 5/17/24 at 11:11 a.m., the resident was observed not wearing oxygen. She had a portable tank attached to her wheelchair and the flow rate was on at 3 liters. The resident indicated she just had a bath and was taking an oxygen break for a moment. On 5/20/24 at 11:34 a.m., the resident was sitting in her wheelchair and her oxygen was on and in place. The oxygen flow rate was on at 3 liters. On 5/20/24 at 1:25 p.m., the resident was observed in her recliner eating lunch. She was wearing oxygen via nasal cannula and the flow rate was on at 3 liters. The record for Resident 44 was reviewed on 5/17/24 at 1:07 p.m. The diagnoses included, but were not limited to, arthritis right shoulder, atrial fibrillation, aphasia, anemia, hypertension, obstructive uropathy, and high cholesterol. The Admission Minimum Data Set (MDS) assessment, dated 2/19/24, indicated the resident was cognitively intact for daily decision making. The resident required oxygen therapy. There was no oxygen care plan. A Physician's Order, dated 2/13/24, indicated to check the oxygen flow rate was on at 2 liters. A Nurses Note, dated 2/13/24 at 12:07 p.m., indicated the resident's oxygenation level on room air was 87% and 2 liters of oxygen was applied. A Nurses Note, dated 3/8/24 at 1:32 p.m., indicated the nasal cannula was secured and oxygen was on at 2 liters. The Treatment Administration Record (TAR) for May 2024 indicated oxygen was signed out as being administered at 2 Liters on the following dates: 5/16/24, 5/17/24, 5/18/24, 5/19/24, and 5/20/24. During an interview on 5/21/24 at 9:13 a.m., the Director of Nursing (DON) indicated she understood the concern regarding the resident's oxygen not being on at the correct rate and had no additional information to provide. 3.1-47(a)(6)

Based on observation, record review, and interview, the facility failed to ensure individualized Care Plans were developed and implemented related to behaviors for 1 of 15 residents reviewed for care plan development and implementation. (Resident 22) Finding includes: During an observation and interview on 5/16/24 at 10:25 a.m., Resident 22 voiced concerns of another resident stealing items from her room and indicated the same resident smacked her in the face after she had snatched a marker out of the other resident's hand. The resident indicated this resident consistently steals from everyone and she was attempting to stop her from stealing the marker. She indicated the Director of Nursing was informed about the incident. The resident's allegations of abuse were reported to the Administrator on 5/16/24 at 11:55 a.m. The Administrator indicated she was unaware of this incident and would report and investigate the matter. Resident 22's record was reviewed on 5/16/24 at 11: 00 a.m. Diagnoses included, but were not limited to, major depressive and anxiety disorder. An Annual Minimum Data Set assessment, dated 4/10/24, indicated the resident was cognitively intact for daily decision making and had no behaviors. During an interview on 5/21/24 at 2:17 p.m., the Director of Nursing indicated there was a Care Plan regarding the resident's exaggerations and/or telling lies. A Care Plan, dated 5/20/24 after the resident's allegation, indicated the resident had a history of making false allegations that have been investigated and proven to be false. The resident reported that she had told staff concerns and then went back and told others she didn't report things. The Care Plan also indicated the resident's daughter reported that historically, the resident lied and not to believe anything that she said. During an interview on 5/22/24 at 8:30 a.m., the Administrator indicated a Care Plan meeting was held on 4/10/24 with the resident, her daughter, the Director of Nursing, and herself. At that time, the resident informed them that she had taken the marker out of another resident's hand, however, she never once said the resident had hit her. The Administrator indicated the resident would be very nice to the alleged resident and invite her in her room and give her cookies and candy, and then the next time the other resident went into her room, she was yelling at her to leave the room and accused her of taking items. She indicated there was no Care Plan in the resident's clinical record regarding her manipulative behavior with the alleged resident, or any interventions, prior to 5/20/24. 3.1-35(a)

Based on record review and interview, the facility failed to ensure blood pressure and diuretic medications were not administered outside of their physician ordered parameters for 3 of 6 residents reviewed for unnecessary medications. (Residents 40, 49, and 6) Findings include: 1. The record for Resident 40 was reviewed on 5/17/24 at 11:14 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included,but were not limited to, fractured ribs, Alzheimer's disease, high blood pressure, acute kidney failure, falls, type 2 diabetes, high blood pressure and anxiety. The 4/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Care Plan, dated 4/17/24, indicated the resident had chronic cardiovascular disease related to high blood pressure. The approaches were to administer medications as ordered. Physician's Orders, dated 4/30/24, indicated Clonidine (a medication used to reduce blood pressure) 0.1 milligrams (mg), give 1 tablet by mouth two times a day and hold if the systolic blood pressure (top number) was less than 140. Physician's Orders, dated 5/2/24, indicated Hydralazine (a medication used to reduce blood pressure) 50 mg, give 1 tablet by mouth every 6 hours and hold if the systolic blood pressure was less than 160. Physician's Orders, dated 5/6/24, indicated Metoprolol Tartrate (a medication to lower the heart rate and blood pressure) 50 mg, give 1 tablet by mouth two times a day and hold if the systolic blood pressure was less than 140 and pulse was less than 60. The 4/2024 and the 5/2024 Medication Administration Record (MAR) indicated the Clonidine was administered on 5/15/24 (p.m.) dose with a blood pressure of 111/58. The Hydralazine was administered on the following days and times against ordered parameters: - 5/9/24 11 a.m. dose with a blood pressure of 98/52 - 5/13/24 5 p.m. dose with a blood pressure of 136/60 - 5/7/24 11 p.m. dose with a blood pressure of 155/76 - The Hydralazine was held on 5/10/24 at the 5 a.m. dose with a blood pressure of 164/80 The Metoprolol was administered on the following days and times against ordered parameters: - 4/30/24 the 9 p.m. dose with a pulse of 49 - 5/13/24 9 a.m. dose with a blood pressure of 149/70 - 5/14/23 9 p.m. dose with a blood pressure of 159/66 - 5/18/24 with a pulse of 57 - The Metoprolol was held on 5/8/24 at 9 a.m. with a blood pressure of 145/68. During an interview on 5/21/24 at 1:05 p.m., the Director of Nursing indicated the blood pressure medication should have been given as ordered by the physician. 2. The record for Resident 49 was reviewed on 5/20/24 at 10:59 a.m. Diagnoses included, but were not limited to, fracture of left femur, COPD, heart failure, respiratory failure, type 2 diabetes, high blood pressure, and atrial fib. The 3/26/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. The resident used oxygen while at the facility and received diuretic medication. A Care Plan, dated 5/17/24, indicated the resident had heart failure. The approaches were to administer medication as ordered. Physician's Orders, dated 4/21/24, indicated the following: - Furosemide (a diuretic medication) 40 milligrams (mg), give 1 tablet by mouth two times a day for edema and hold if systolic blood pressure was less than 140. - Aldactone (a diuretic medication) 25 mg, give 1 tablet by mouth two times a day for edema and hold if systolic blood pressure was less than 140. The 4/2024 and 5/2024 Medication Administration Records (MAR) indicated the Furosemide and the Aldactone were administered on 4/29/24 for the a.m. dose with a blood pressure of 138/72. They both were administered on 4/29/24 for the p.m. dose with a blood pressure of 133/74. The Aldactone and the Furosemide were administered on 5/4/24 for the a.m. dose with a blood pressure of 136/85 and the Furosemide was administered on 5/1/24 for the a.m. dose with a blood pressure of 112/64. During an interview on 5/21/24 at 1:05 p.m., the Director of Nursing indicated the diuretic medications should have been administered as ordered by the physician. 48383 3. The record for Resident 6 was reviewed on 5/20/24 at 3:42 p.m. The diagnoses included, but were not limited to, heart failure, depression, kidney disease, and cellulitis of right leg. The Significant Change Minimum Data Set (MDS) assessment, dated 5/3/24, indicated the resident was cognitively intact for daily decision making. A Physician's Order, dated 3/23/24, indicated to administer Losartan Potassium tablet 100 milligrams (mg) daily. The medication was to be held if the resident's systolic blood pressure was less than 120. The Medication Administration Records (MAR) for March - May 2024 indicated the Losartan was signed out as given with the blood pressure less than 120 systolic on the following dates: - 3/21/24 with a blood pressure of 119/73. - 4/19/24 with a blood pressure of 97/78. - 5/9/24 with a blood pressure of 110/70. The resident's blood pressure was not documented on the Medication Administration Record (MAR) for the months of 10/2023, 11/2023, 12/2023, and 1/2024, nor was the resident's blood pressure documented in the vitals section of the electronic medical record on a consistent basis. During an interview on 5/21/24 at 11:39 a.m., the Director of Nursing (DON) indicated she understood the concern regarding the medication was administered outside of the ordered parameters and no additional information was provided. 3.1-48(a)(3) 3.1-48(a)(4)

Based on observation, record review, and interview, the facility failed ensure adequate supervision was provided for a resident related to fall interventions for 1 of 1 resident reviewed for falls. (Resident 48) Finding includes: During a random observation on 5/16/24 at 11:30 a.m., Resident 48 was observed in bed. At that time, the bed was observed in a high position and there was no floor mat next to either side of the bed. The resident's spouse was seated in a chair by the window. On 5/17/24 at 9:00 a.m., the resident was observed in bed and CNA 1 was getting him dressed. At that time, the bed was in a very high position and the floor mat was against the wall. The CNA indicated she was preparing to get him up in the wheelchair by using the hoyer lift. At 9:05 a.m., the CNA left the room to get the hoyer lift and left the bed in the high position with the floor mat against the wall while the resident was still in the bed. At 9:11 a.m., the CNA came back to the unit with the hoyer lift and proceeded to get the resident into the chair. On 5/20/24 at 9:12 a.m., the resident was observed in bed. At the time, the bed was in a low position, however, the floor mat was against the wall. The resident's spouse was seated in the chair by the head of the bed. On 5/20/24 at 11:45 a.m., the resident was observed in bed. At that time, the bed was in a very high position and the floor mat was against the wall and not beside the bed. The resident's spouse was seated in a chair by the window. The record for Resident 48 was reviewed on 5/20/24 at 9:16 a.m. Diagnoses included, but were not limited to, fracture T9-T10 (Thoracic spine) vertebra, anemia, Parkinson's disease, and high blood pressure. The 5/2/24 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had a limitation in range of motion to both upper and lower extremities and was dependent on staff for transfers and bed mobility. The resident had no history of falls and had unhealed pressure injuries. A Care Plan, initiated on 1/12/24, indicated the resident was at risk for falls due to Parkinson's disease and incontinence. Physician's Orders, dated 4/25/24, indicated place the bed in the lowest position and have a fall mat in place every shift for safety. During an interview on 5/21/24 at 8:45 a.m., the Director of Nursing indicated the bed should be in the lowest position with the floor mat on the side of the bed while the resident was in bed. The Unit Manager spoke to the resident's spouse, who said she told staff to keep the bed in the high position while she was there so she did not have to look down at the resident. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure bruised areas were assessed and monitored, and non-pressure skin treatments were completed as ordered, for 2 of 4 residents reviewed for non-pressure skin conditions. (Residents 40 and 6) Findings include: 1. During a random observation on 5/17/24 at 9:00 a.m., Resident 40 was observed in a recliner chair in her room. At that time, a bruise was noted under the left eye. On 5/20/24 at 12:10 p.m., the resident was observed sitting in a wheelchair eating lunch in the main dining room. At that time, the bruise remained under the left eye. The record for Resident 40 was reviewed on 5/17/24 at 11:14 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included,but were not limited to, fractured ribs, Alzheimer's disease, high blood pressure, acute kidney failure, falls, type 2 diabetes, high blood pressure and anxiety. The 4/24/24 Admission Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making. A Care Plan, initiated on 4/17/24, indicated the resident was at risk for skin breakdown. The approaches were to monitor skin daily with care and perform a weekly skin assessment by the nurse. Physician's Orders, dated 4/18/24, indicated to monitor bruise to left eye, face, neck, and back of head for 7 days and report any changes. The resident was admitted to the hospital on 5/3/24 and returned on 5/6/24. The Nursing Acute Return Assessment, dated 5/6/24, indicated the resident's skin was intact with no pre-existing bruising under the left eye. The Nursing-Assess Skilled (every shift times 72 hours then daily) Assessment, dated 5/7/24 at 12:30 a.m., indicated no skin issues old or new. There was no documentation in Nursing Progress Notes on 5/6-5/16/24 regarding the bruise under the left eye. During an interview on 5/17/24 at 1:45 p.m., CNA 1 indicated the resident had not had a fall since she had been here, and the bruise was old from when she was first admitted . During an interview on 5/17/24 at 2 p.m., RN 1 indicated the bruise was from her fall prior to coming into the facility and it was monitored on the Treatment Administration Record. During an interview on 5/21/24 at 8:45 a.m., the Director of Nursing indicated after the resident returned from the hospital on 5/6/24, the bruise should have been assessed as pre-existing and monitored again. The current 4/23/24 Wound (Pressure Injury) and Non-Wound Assessment and Documentation policy, provided by the Administrator on 5/21/24 at 1:37 p.m., indicated non-wound skin altercations such as bruising will be monitored at least daily for 7 days for complications such as pain that may indicate further assessment. 48383 2. On 5/16/24 at 10:02 a.m., Resident 6 was observed lying in bed with her heels floated. There was a dressing on the residents right foot dated 5/14/24. The resident indicated the treatment for her foot was to be completed daily. On 5/16/24 at 11:11 a.m., the resident was observed sitting up in bed. The dressing on her right foot had not been changed yet and was still dated 5/14/24. On 5/16/24 at 12:00 p.m., the resident was observed lying in bed with family at the bedside. The dressing had not been changed yet and was dated 5/14/24. During an interview at the time, the resident indicated the nurse communicated she would come back and change her right foot dressing on 5/15/24. The nurse had not come back to change it. The record for Resident 6 was reviewed on 5/20/24 at 3:42 p.m. The diagnoses included, but were not limited to, heart failure, depression, kidney disease, and cellulitis of the right leg. The Significant Change Minimum Data Set (MDS) assessment, dated 5/3/24, indicated the resident was cognitively intact for daily decision making and she had impairment of both legs. A Physicians' Order, dated 5/9/24, indicated to cleanse the right heel with saline, pat dry, apply betadine, cover with a non adherent dressing, and wrap with kerlix daily and as needed. A Nurses' Note, dated 5/9/2024 at 9:42 a.m., indicated the resident had a new non-pressure wound to the right posterior heel. Interventions were to cleanse with saline, apply betadine, cover with a non adherent dressing, and wrap with kerlix. The dressing was to be changed daily and as needed for soilage. During an interview on 5/16/24 at 12:06 p.m., Agency LPN 1 indicated the hospice nurse changed the dressings on days she provided care. When the hospice nurse was not in the facility, the nurse would be responsible for daily dressing changes. During an interview on 5/21/24 at 9:13 a.m., the Director of Nursing (DON) indicated she understood the concern regarding the missed dressing change and had no additional information to provide. 3.1-37(a)

Based on record review and interview, the facility failed to ensure a resident's preferences were honored related to the type of diet they received for 1 of 1 resident reviewed for choices. (Resident 50) Finding includes: During an interview on 5/16/24 at 10:23 a.m., Resident 50 indicated there was one issue that kept upsetting her. She indicated her doctor told her she could have whatever she wanted to eat, however, the staff here kept telling her she cannot have certain items. On Mother's Day, she was in the dining room and everyone at her table received ham and she got something else to eat. She asked the staff if she could have a piece of ham and was told No. She then handed the person the plate and said I want ham so get it for me please. The staff took the plate and brought back a piece of ham and mashed potatoes but there was no gravy on the potatoes. She asked the staff where the gravy was for the potatoes, and the staff stated, Well you wanted the ham so you do not get gravy on the potatoes because that is too much salt. During an interview on 5/20/24 at 9:10 a.m., the resident indicated she was able to get what she wanted for her meals over the past weekend with no issues, however, every day she has had to ask for bacon even though she wrote it on her meal ticket. Sometimes she received it and sometimes she did not. The meal ticked indicated the resident was to receive a 3-4 gram sodium diet. The record for Resident 50 was reviewed on 5/17/24 at 1:37 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, histoplasmosis (infection by a fungus found in the droppings of birds and bats in humid areas), chronic kidney disease, type 2 diabetes, respiratory failure, hepatic fibrosis, thrombocytopenic purpura, and high blood pressure. The 4/30/24 Admission Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making. A Care Plan, initiated on 4/23/24, indicated the resident needed limited to extensive assist with ADL's (Activities of Daily Living) since the recent hospital stay and required set up to supervision with eating. The approaches were staff will assess and honor her preferences. Physician's Orders, dated 4/24/24, indicated 3-4 gram sodium controlled carbohydrate diet. During an interview on 5/21/24 at 8:45 a.m., the Director of Nursing indicated the resident was cognitively intact and had not further information to provide. 3.1-3(u)(1)

Based on record review and interview, the facility failed to ensure a resident was not given a medication listed as an allergy, making them at risk for potential adverse consequences, related to antibiotics for an urinary tract infection (UTI), for 1 of 3 residents reviewed for infections. (Resident B) Finding includes: The closed record for Resident B was reviewed on 2/1/24 at 10:23 a.m., Diagnoses included, but were not limited to, heart failure, heart disease, high blood pressure, edema, and pulmonary hypertension. The resident was allergic to Sulfadiazine (an sulfonamide antibiotic used to treat many different kinds of bacterial infections, like those of the brain, ears, and urinary tract). The Admission Minimum Data Set (MDS) assessment, dated 10/4/23, indicated the resident was moderately impaired for daily decision making. The resident had a significant change in status on 10/31/23 at 9:49 a.m., and was sent to the hospital. The resident returned to the facility on [DATE] at 6:53 p.m. and was readmitted with an UTI and prescribed antibiotics. Physician's Orders, dated 11/2/23, indicated Levaquin (Levofloxacin - an antibiotic) tablet 250 milligrams (mg), give 1 tablet by mouth one time a day for a UTI for 7 days. A Nurses' Note, dated 11/3/23 at 12:18 p.m., indicated staff received the urine sensitivity report from the hospital and the resident had ESBL (extended spectrum beta-lactamase) in the urine. The antibiotic of Levaquin was resistant to the organism, so the Physician was notified and new orders were received to discontinue Levaquin and begin Bactrim DS (sulfonamide antibiotic) twice a day for 7 days. The urine culture results, dated 11/3/23, indicated the resident was positive for ESBL in the urine and the organism was resistant to Levaquin but was susceptible to Bactrim and Macrobid. Physician's Orders, dated 11/3/23, indicated Bactrim DS tablet 800-160 mg (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth every 12 hours times 7 days for an UTI. The 11/2023 Medication Administration Record (MAR), indicated the Bactrim was signed out as being administrated on 11/3/23 at 9 p.m., 11/4 at 9 a.m. the resident refused, 11/4 at 9 p.m. it was given, and 11/5/23 at 9 a.m., it was given. Nurses' Notes, dated 11/4/23 at 10:12 a.m., indicated the Physician was notified of resident's allergy to Sulfa and was also sent a copy of culture obtained from the hospital. The Physician ordered an intravenous (IV) antibiotic of Invanz, however, the resident refused the IV. Nurses' Notes, dated 11/5/23 at 7:16 a.m., indicated the Physician was sent the hospital culture for the resident's UTI and again was asked what he would like to order for it. A new order was received for Macrobid 100 mg twice a day for 7 days. A medication transaction sheet from the emergency drug kit, indicated the Bactrim was removed on 11/3 at 8:18 p.m., 11/4 at 9:42 a.m., and 11/4 at 7:42 p.m. and administered to the resident. During an interview on 2/1/24 at 2:30 p.m., the Director of Nursing indicated the pharmacy would have sent a fax over to the facility indicating the resident was allergic to the Bactrim, and would not have sent any of the medication. She indicated when nursing realized the medication had not been sent and saw the fax, the Physician was notified, however, the resident still received 3 doses of the Bactrim medication that she was allergic to because they pulled it from the emergency medication supply. This citation relates to Complaint IN00423376. 3.1-48(a)(5)

Based on record review and interview, the facility failed to ensure a resident was assessed and monitored after a fall, and failed to ensure the responsible party and Physician were notified after a fall for 1 of 3 residents reviewed for falls. (Resident C) The deficient practice was corrected on 10/31/23, prior to the start of the survey, and was therefore past noncompliance. The facility completed an investigation and inserviced staff regarding post fall procedures. Finding includes: Resident C's closed record was reviewed on 11/28/23 at 9:55 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, encounter for surgical aftercare following surgery of the digestive system, congestive heart failure and anxiety. The resident was transferred to the hospital on 10/20/23 where he later passed away. The Admission Minimum Data Set assessment, dated 10/20/23, indicated the resident had moderate cognitive impairment, and required partial/ moderate staff assistance for toileting and transfers. A General Note, dated 10/20/23 at 9:45 a.m., indicated at 8:00 a.m. the resident was noted to have a change in condition, was sleepy/ lethargic, confused, unable to respond appropriately to questions, garbled speech and unable to follow commands. Vitals signs were in normal limits. Unable to perform stroke assessment due to change in condition. The Physician was notified and orders received to send to emergency room for evaluation. Daughter was notified. A Grievance was made by the resident's daughter on 10/30/23, after the resident had passed away, asking if the resident had fallen in the bathroom on 10/20/23 and had to crawl back to bed. The investigation indicated the resident had slid off the toilet with staff assistance. There had been no documentation of the fall, any post-fall assessment, notification of family and Physician, or a fall occurrence initiated. A late entry General Note, dated 10/20/23 at 9:15 a.m. and recorded on 10/31/23, indicated the nurse was called into the room by a CNA. Upon entering the room, the resident was on the floor in the bathroom with a CNA holding him under the arms. The CNAs indicated he was falling off the toilet and they lowered him to floor, he had not hit his head. A change in condition was noted to level of consciousness, the Physician had been notified of the change in condition, and ordered to be sent to emergency room . Family was notified he was sent to hospital. Telephone interview with CNA 1 on 11/28/23 at 2:00 p.m., indicated she was in the resident's room assisting the roommate and another aide was with Resident C in the bathroom. Resident C was fidgeting and antsy, the aide indicated he was falling off the toilet, CNA 1 assisted her lowering the resident to the ground. She then notified the nurse, who checked his vital signs, then they assisted him into bed and got him dressed. Interview with the Administrator, on 11/28/23 at 11:20 a.m., indicated management knew nothing about the resident's fall until a phone call with the resident's daughter on 10/30/23. She had been told by her father's roommate he had seen the resident crawling on the floor after he fell in the bathroom. They initiated an investigation and determined the resident had been lowered to the floor and it had not been reported. The Administrator indicated it was an agency nurse, who was not aware a lowering to the floor was considered a fall. They had since completed education with the nurse and all nursing staff regarding fall management. The Administrator provided copies of fall in-services completed on 10/31/23. The current policy, Fall Management Procedure, was provided by the Administrator, indicated, .2. A. Complete a fall risk assessment located in the EMR [electronic medical record] upon admission, with each fall, annually and with significant change .B. Immediately post fall- an intervention must be put into place to prevent reoccurrence ., and .3. Post Fall Investigation .will be completed as soon as possible by completing the paper QAPI [Quality Assurance] protected OCCURRENCE INVESTIGATION form The citation relates to Complaint IN00421482. 3.1-45(a)

Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services related to the lack of an assessment for a resident when the family had concerns with the resident potentially being shocked from his ICD (implantable cardioverter defibrillator) (sends a shock and resets an abnormal heartbeat back to normal) and not documenting resident's pulse daily as part of the plan of care for 3 of 3 residents reviewed for pacemaker/defibrillator devices. (Residents B, C, and D) Findings include: 1. Record review for Resident B was completed on 8/29/23 at 9:21 a.m. Diagnoses included, but were not limited to heart failure, hypertension, orthostatic hypotension, atrial fibrillation and cardiac pacemaker. The Medicare 5 Day Minimum Data Set (MDS) assessment, dated 4/28/23, indicated the resident was cognitively intact. A Care Plan, dated 2/28/23, indicated the resident had a pacemaker in place. Interventions included to count and record the apical pulse rate and rhythm for one full minute daily and notify the doctor if above 100 or below 60. The May 2023 Vitals tracking indicated the resident's pulse was not documented on the following days: 5/1, 5/2, 5/4-5/9, 5/13, 5/14, 5/16, 5/18, 5/23, 5/25, 5/26, 5/28-5/31/23 A Progress Note, dated 5/26/23 at 10:44 a.m., indicated the doctor was notified that the resident had chosen to stop all treatments and wished to be palliative care only. The resident's family was there and agreed with decision. A Nursing Assessment, dated 5/27/23, indicated the resident's blood pressure was 105/70, pulse 107, respirations 18 and oxygen saturation 96% (percent) on room air. A Progress Note dated 5/31/23 at 9:07 a.m., indicated the resident was declining. They received an order from the physician to have the pacemaker company come out to turn off the resident's ICD pacemaker. The record lacked any documentation an assessment, including the resident's vitals, had been completed since 5/27/23. A Progress Note, dated 5/31/23 at 2:00 p.m., indicated the resident was found without vitals. The family was at the bedside. An order was received from the physician to release the body to the funeral home. Interview with RN 1 on 8/29/23 at 11:03 a.m., indicated she was the resident's nurse the night before he had passed away. There were no concerns or observations the resident had any problems with his pacemaker. The next morning she came into work and the family stopped her and told her the resident was getting shocked from his pacemaker. She then went and reported this to the resident's nurse. Interview with LPN 1 on 8/29/23 at 11:08 a.m., indicated RN 1 had told her the family had concerns the resident's pacemaker was shocking him. She went and observed the resident and did not believe the resident was getting shocked. The resident was incoherent at the time and was actively dying. She tried to explain to the resident's family the resident was dying and was probably having spasms from being in renal failure. The family requested to have the pacemaker turned off. She then went and spoke with the Unit Manager. They called the pacemaker company and they indicated they would come out to turn it off and the facility could place a magnet over the pacemaker to turn it off while waiting for a representative to arrive. LPN 1 indicated they did not have a magnet. They called a hospice company that came to the facility and borrowed one from them. She had placed the magnet and secured on the resident as best as she could with tape, but the resident was being restless and the magnet was not wanting to stay in place. She had not documented anything related to this incident or any assessment she had completed on the resident. Interview with the Unit Manger on 8/20/23 at 11:13 a.m., indicated LPN 1 had told her the resident's family was concerned he was getting shocked from his pacemaker and they wanted it turned off. She went and observed the resident and did not believe the resident was getting shocked. They notified the doctor and he said they could call the company and get it turned off. They called the company and were told they could use a magnet to turn it off until the company representative arrived. They tried to secure the magnet as best as they could with tape. The company came and turned off the resident's pacemaker prior to his passing that day. She had not documented anything related to the incident or any assessment she had completed on the resident. Interview with the Director of Nursing on 8/29/23 at 3:10 p.m., indicated she had worked at the facility for 7 months and nursing had not been in-serviced during that time for pacemakers/defibrillators. She indicated a magnet was used to turn off a pacemaker/defibrillator. They did not keep magnets in the facility because the nurses are not ACLS (advanced cardiac life support) certified. If an incident happened, they would send the resident out to the hospital. Resident B's family did not want him sent out to the hospital, so that is why the nurse received the magnet and put it on the resident before the pacemaker company could come and turn it off. She indicated the pulse checked daily was supposed to be done until the first pacemaker check up. The resident had a checkup completed in April 2023 so the pulse did not need to be checked daily. The resident's care plan should have been updated to not include that intervention. Nursing should have documented the incident and any assessments they had completed on the resident. 2. Record review for Resident C was completed on 8/29/23 at 12:45 p.m. Diagnoses included, but were not limited to, atrial fibrillation, heart failure, hypertension, and cardiomyopathy. The Admission MDS, dated [DATE], indicated the resident was cognitively intact. A Care Plan, dated 7/21/23 and revised 7/24/23, indicated the resident had a pacemaker. An intervention included to count and record the apical pulse for one full minute daily. The August 2023 Vitals indicated the resident's pulse was not documented on the following days: 8/2-8/4, 8/6, 8/7, 8/9-8/11, 8/13, 8/14, 8/16, 8/18, 8/20-8/24, and 8/27/23 Interview with the Director of Nursing on 8/29/23 at 3:10 p.m., indicated the pulse checked daily was supposed to be done until the first pacemaker check up. The resident had a checkup completed already and the pulse did not need to be checked daily. The resident's care plan should have been updated to not include that intervention. 3. Record review for Resident D was completed on 8/29/23 at 1:07 p.m. Diagnoses included, but were not limited to, atrial fibrillation, hypertension, heart failure, and cardiac pacemaker. The resident was admitted on [DATE]. The Admission MDS assessment, dated 8/10/23, indicated the resident was cognitively intact. A Care Plan, dated 8/3/23 and revised 8/4/23, indicated the resident had a pacemaker in place. An intervention included to count and record the apical pulse for one full minute daily. The August 2023 Physician's Order Summary indicated the resident had a pacemaker placed on 7/27/23. An order was to check the apical pulse rate and rhythm daily for 1 minute. Notify the physician if above 110 or below 60. The August 2023 Treatment Administration Record (TAR) was checked off every day that the pulse was checked, but lacked a documented rate of the pulse. The August 2023 Vitals indicated the resident's pulse was not documented on the following days: 8/7, 8/8, 8/10, 8/12, 8/17-8/22, 8/24, 8/26, 8/27/23 Interview with the Director of Nursing on 8/29/23 at 3:10 p.m., indicated the resident's pacemaker was new and nursing should have documented the pulse rate each day. A facility policy titled, Pacemaker Care Procedure and received as current from the facility on 8/29/23, indicated, .II. Check apical pulse rate & rhythm daily (MAR/TAR) for residents with new pacemaker . This Federal tag related to Complaint IN00412002. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure residents had Physician's Orders for medications and an assessment to self-administer their own medications for 1 of 1 residents reviewed for self-administration of medication. (Residents 36) Finding includes: On 4/10/23 at 9:42 a.m., Resident 36 was observed in bed. There was a container of Bacitracin ointment on a bedside table. The resident indicated the staff were applying it to his bottom at one time because it was reddened. On 4/11/23 at 9:57 a.m., the Bacitracin ointment was observed on a bedside table. On 4/12/23 at 11:39 a.m., the Bacitracin ointment was observed on a bedside table. Resident 36's record was reviewed on 4/12/23 at 1:23 p.m. Diagnoses included, but were not limited to, heart attack, heart failure, and renal insufficiency. The Quarterly Minimum Data Set (MDS) assessment, dated 1/11/23, indicated the resident was cognitively intact for daily decision making. There were no Physician's Orders for the Bacitracin ointment. There was no self-administration assessment of medication assessments completed for the resident. Interview with the Director of Nursing on 4/13/23 at 2:45 p.m., indicated the resident did not have an order for the Bacitracin so she was unsure where he would have obtained the medication. 3.1-11(a)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received the necessary care to maintain Activities of Daily Living (ADLs) related to turning and repositioning in bed and dirty fingernails for 2 of 4 residents reviewed for ADLs. (Residents 164 and 36) Findings include: 1. During an interview on 4/10/23 at 11:02 a.m., Resident 164 indicated a couple nights ago, the CNAs put him to bed with the hoyer lift and left the pad underneath him. The hoyer pad remained underneath him until the next morning. He has asked staff to be turned and repositioned but they do not come back to help him and he cannot do it by himself. The resident indicated the midnight shift was the worst, they do not come and turn him like he should be. During an interview on 4/11/23 at 9:55 a.m., the resident indicated getting turned at night time was still a problem. The record for Resident 164 was reviewed on 4/11/23 at 2:10 p.m. The resident was readmitted to the facility on [DATE]. Diagnoses included, but were not limited to, necrotizing fasciitis, chronic pain, cellulitis of the upper limb, neuromuscular of the bladder, prostate and stomach cancer. The Admission Minimum Data Set (MDS) assessment, dated 3/30/23, indicated the resident was cognitively intact and had an indwelling foley (urinary) catheter. The resident was an extensive assist with a 2 person physical assist for bed mobility and transfers. The Care Plan, dated 3/13/23, indicated the needed assistance with all ADLs, including bed mobility, eating, toileting and transfers. The bed mobility in the electronic charting point of care task section, completed by the CNA, indicated bed mobility: self performance - How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. In the last 30 days the following was documented for bed mobility (when the resident was turned and repositioned): 3/14/23 at 2:48 p.m. 3/17/23 at 10:16 a.m. and 5:15 p.m. 3/19/23 at 9:43 a.m., 7:52 p.m., and 11:39 p.m. 3/20/23 12:29 p.m. 3/23/23 9:11 p.m. and 11:27 p.m. 3/24/23 11:12 a.m. and 4:02 p.m. 3/28/23 9:26 a.m. and 10:33 p.m. 3/30/23 11:24 a.m. and 8:13 p.m. 4/5/23 10:33 a.m. and 9:26 p.m. 4/9/23 1:30 p.m. and 3:02 p.m. 4/10/23 5:17 a.m., 12:12 p.m., and 9:40 p.m. 4/11/23 6:26 p.m., 10:04 a.m., and 4:14 p.m. 4/12/23 1:39 a.m. and 7:53 a.m. There was no documentation on 3/21 or 3/22/23 the resident was turned or repositioned. Interview with the Director of Nursing on 4/13/23 at 10:15 a.m., indicated the documentation of the resident being turned and repositioned was lacking in the clinical record. All residents should be turned and repositioned every 2 hours. 45666 2. On 4/10/23 at 9:42 a.m., Resident 36 was observed in bed. His fingernails were long and there was an accumulation of dirt underneath them. Resident 36's record was reviewed on 4/12/23 at 1:23 p.m. Diagnoses included, but were not limited to, heart attack, heart failure, and renal insufficiency. The Quarterly Minimum Data Set (MDS) assessment, dated 1/11/23, indicated the resident was cognitively intact for daily decision making. He required extensive assistance with two persons physical assist for bed mobility, transfer, and toilet use. He required limited assistance with one person physical assist for personal hygiene. Interview with the Director of Nursing on 4/13/23 at 2:45 p.m., indicated the resident's fingernails should have been cleaned and trimmed. 3.1-38(a)(3)(E) 3.1-38(b)(6)

Based on observation, record review and interview, the facility failed to ensure the Physician was notified of treatment refusals for 1 of 1 residents reviewed for notification of change. (Resident 8) Finding includes: On 4/11/23 at 9:45 a.m., Resident 8 was observed in her room in bed. Her left elbow area did not have an ace wrap in place. On 4/12/23 at 10:33 a.m. and 1:52 p.m., the resident was observed in her room in bed. There was no ace wrap in use to the left elbow area. On 4/13/23 at 9:15 a.m., the resident was observed in her room in bed. There was no ace wrap in use to the left elbow area. The record for Resident 8 was reviewed on 4/11/23 at 1:20 p.m. Diagnoses included, but were not limited to, dementia with behavior disturbance and contracture (tightening of the muscles and tendons that cause the joints to become stiff) of the left elbow. The Quarterly Minimum Data Set (MDS) assessment, dated 3/21/23, indicated the resident was cognitively impaired for daily decision making and she had a functional limitation in range of motion (ROM) to one side of the upper extremities. A Physician's Order, dated 2/24/23, indicated the resident had left elbow edema and a gel pad was to be applied directly to the elbow and the elbow was to be wrapped with an ace bandage for compression every day and remove at night. The April 2023 Treatment Administration Record (TAR) indicated the resident refused the treatment on 4/1, 4/2, 4/3, 4/4, 4/5, 4/9, 4/10, 4/11, 4/12, and 4/13/23. There was no documentation indicating the Physician had been notified of the treatment refusals. Interview with the Director of Nursing on 4/14/23 at 12:20 p.m., indicated the Physician should have been notified of the resident refusals. 3.1-5(a)(2)

Based on record review and interview, the facility failed to protect the residents' right to be free from misappropriation of property related to stolen jewelry by CNA 1 for 2 of 2 residents reviewed for misappropriation of property. (Residents 50 and 23) The deficient practice was corrected by 2/17/23, prior to the start of the survey, and was therefore past noncompliance. The facility thoroughly investigated the missing jewelry as well as notified the police. A report was initiated by the police department and a detective was assigned to the case. CNA 1 was terminated as she failed to return phone calls or come back to the facility for a statement. The case was still open as some of the jewelry was still missing. Findings include: 1. During an interview, on 4/11/23 at 9:44 a.m., Resident 50 indicated 1 of her wedding rings was stolen about 2 months ago. She indicated she had heard the person confessed to stealing the rings, but was not sure if it was a CNA or a nurse who worked at the facility. They told her the staff member had pawned the jewelry. The record for Resident 50 was reviewed on 4/11/23 at 1:05 p.m. Diagnoses included, but were not limited to, heart disease, chronic pain, high blood pressure, and hearing loss. The Quarterly Minimum Data Set (MDS) assessment, dated 3/15/23, indicated the resident was cognitively intact. A General Note, dated 2/21/23 at 6:08 p.m., indicated staff spoke with the resident today about her missing ring. The resident indicated she had spoken with the police and they did have some leads, but hadn't heard anything more as of yet. The resident indicated she wanted to be hopeful of finding the ring but was doubtful of ever getting it back. The resident also indicated she had hoped the person was caught so they could not take from anyone else. An Incident Report, dated 2/17/23, indicated the resident reported to staff while they were providing care, her wedding band was missing. The resident had 3 rings and one was missing and she remembered seeing her ring the day before. The room was searched and the ring was not located. The resident's daughter was called and informed as well as the local police. An officer came into the facility to take the resident's statement. The investigation into the missing ring was initiated on 2/17/23. An interview with the Administrator and the resident on 2/17/23, indicated the resident realized her ring was missing this morning around 4 or 4:30 a.m., when the CNAs came in her room to provide care. The resident had 3 rings on her finger and only 2 were present, as the outside band was missing. The resident indicated 2 to 3 weeks ago, while she was sleeping in her bed, she woke up abruptly to someone tugging on her finger. She pulled her hand back and saw a staff member kneeling on the side of her bed. The staff member indicated she was checking to see if she was wet. The resident thought the situation was weird, because normally staff turn on the light and announce themselves, but this time the lights were not on. The resident described the staff member as having blonde hair and was of medium build. The resident had informed her daughter about the incident but did not tell the facility staff. Another staff interview (no date), from CNA 3 indicated I was sitting in the nurses station and heard yelling from [Resident 50's] room. I walked in and another aide [CNA 1] was standing in front of her trying to calm her down. [Resident 50] then told me she felt someone pulling on her ring finger and there was a band missing. I asked her if she saw anything and she described a 'short tiny blonde girl', but could not see her face. [CNA 1] got very defensive and swearing it wasn't her. After that I left the room and told the nurse everything I heard and saw. A statement from the Director of Nursing (DON) on 2/17/23, indicated [CNA 1] came into my office stating that [Resident 50] reported to her that her ring was missing. Per [CNA 1], her and [CNA 3] were in the room together when the resident reported the ring missing. [CNA 1] states they looked all over the room to see if they could locate the ring. The ring was not located and [CNA 1] states she told the resident to call the police. Follow up to the investigation, added on 2/24/23, indicated the investigation revealed that suspected aide provided care to resident multiple times the night prior to waking up and finding ring missing. Employee has not been cooperative with investigation and is not returning phone calls or text messages. Employee has been terminated. Follow up by Social Service has been done with resident and no signs of distress has been noted. Resident voices disappointment that ring is gone, but happy that employee is no longer working at the facility. Facility is still working with local police department as needed for additional information. Interview with the Administrator on 4/12/23 10:27 a.m., indicated on or around January 27, 2023 she was approached by a resident's daughter (who since had passed away) about a missing ring. The daughter was not sure the ring was even at the facility and thought that maybe one of her sisters might have taken it home with them. The daughter told the Administrator not to worry about it and she was going ask her siblings if they took her ring. A couple days later, the daughter came back to the facility to pay the remainder of the bill, and informed the Administrator she had spoken with her siblings and no one took her mother's ring, so she filed a police report on her own. On 2/17/23, CNA 1 informed the DON that Resident 50 had reported to her one of her rings was missing. At that time, CNA 1 was working midnights, so she reported the incident right before she left and her shift was over. Neither Resident 50 nor her daughter reported to her about someone tugging on her finger during the night. A Police Detective came to the facility and requested video tapes and other statements from the staff and copies of schedules. The detective indicated she could not find the CNA, however, the facility gave the detective the emergency file information and they located CNA 1 and were able to tell her to come to the police station for a statement. The detective informed them they were able pull video and the CNA's driver license information from the pawn shop. 2. During an interview on 4/10/23 at 11:06 a.m., Resident 23 indicated she had two gold and diamond rings missing. The record for Resident 23 was reviewed on 4/11/23 at 1:08 p.m. Diagnosis included, but were not limited to major depressive disorder, high blood pressure, and slurred speech. The Annual Minimum Data Set (MDS) assessment, dated 2/20/23, indicated the resident was cognitively intact. An Incident Report, dated 2/17/23 at 2:30 p.m., indicated the resident reported 2 of her rings were missing. The resident looked down at her hand and didn't see her engagement ring and was not sure when the ring went missing. The resident indicated a wedding band also went missing last week. The family was called to confirm the resident had the rings in the facility and to get a description of the rings. The local police were notified and the investigation was initiated. The suspected employee had been suspended pending investigation. Follow up to the investigation, added on 2/24/23, indicated the investigation revealed that suspected aide provided care to resident multiple times the night prior to waking up and finding ring missing. Employee has not been cooperative with investigation and is not returning phone calls or text messages. Employee has been terminated. Follow up by Social Service has been done with resident and no signs of distress has been noted. Resident voices disappointment that ring is gone, but happy that employee is no longer working at the facility. Facility is still working with local police department as needed for additional information. Interview with the Administrator on 4/12/23 at 10:27 a.m., indicated on 2/17/23, the resident reported that she had rings missing. They started the investigation and with Resident 50's description of the staff member, the Administrator was able to identify the CNA. A Police Detective came to the facility and requested video tapes and other statements from the staff and copies of schedules. The detective indicated she could not find the CNA, however, the facility gave the detective the emergency file information and they located CNA 1 and were able to tell her to come to the police station for a statement. The detective informed them they were able pull video and the CNA'S driver license information from the pawn shop. The current 12/4/17 Abuse Prohibition, Reporting, and Investigation policy, provided by the Administrator on 4/11/23 at 9:00 a.m., indicated it was the facility's policy that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 3.1-28(a)