Every finding on record at Moran Manor Rehabilitation & Skilled Nursing

The facility reported a census of 36 residents with one kitchen. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage to prevent the spread of food borne illness to the residents of the facility. This placed the residents at risk for food-borne illness. Findings included: - Initial tour of the kitchen on 06/02/35 at 02:51 PM with Dietary Manager BB, revealed the following areas of concern: The stand-up freezer in the kitchen area contained BBQ ribs open to air and undated. There were frozen vegetables in a bag, opened and not dated. The stand-up refrigerator in the kitchen contained salad opened to air and not dated. It also contained cottage cheese, sour cream, and cream opened but not dated. The dry storage area had a freezer with frozen peas that was open to air. The kitchen area had a cutting board with deep grooves and scratches on it. During an interview on 06/02/25 at 03:05 PM, Dietary Manager BB reported she expected all food to be dated and covered. Dietary Manager BB further stated all equipment should have cleanable surfaces with no scratches. Dietary Manager BB immediately discarded the cutting board. During an interview on 06/04/25 at 01:53 PM, Administrative Staff A reported that once the food was open, it had to be labeled and dated. Administrative Staff A said that after three days of storage, food should be thrown out. Administrative Staff A also reported that utensils were to be replaced if damaged or contaminated. The facility's Food Safety Requirements policy dated 01/21/25 documented that all foods in the kitchen would be labeled and include the name of the food and expiration date. Additionally, all items were to be covered or in airtight containers. All equipment used in the kitchen will be cleaned and sanitized.

The facility reported a census of 36 residents. The sample included 14 residents. Based on interviews, record reviews and observation, the facility failed to maintain an effective pest control program to ensure the kitchen was free from insects and/or pests. This deficient practice placed the residents at risk for contaminated food, illness and discomfort. Findings included: - During an observation on 06/02/25 at 02:51 PM, there was an abundance of flies throughout the kitchen area. Further observation revealed no methods to prevent or eradicate the insects. During an observation on 06/03/25 at 12:20 PM, observation revealed flies throughout the kitchen and dining room area. During an observation on 06/04/25 at 09:13 AM, the west door that led from outside into the kitchen would not close completely without force. During an observation on 06/04/25 at 09:20 AM, the east dining room door that led directly into the courtyard had a significant gap at the bottom large enough to allow pests and/or rodents to enter the dining room. During an observation on 06/04/25 at 09:25 AM, an outer screen on the east kitchen wall had the top metal frame bent, and the screen was not sealed to the window. A review of the Facility Pest Control Service Agreement, with service start date of 10/2023, indicated that pest control vendor provided monthly service to the facility for pests and as needed for rodent control. The agreement further indicated that the service would not provide service/treatments for termites, bed bugs or flying insects. During an interview on 06/04/25 at 08:15 AM, Administrative Staff A reported that the kitchen and facility should have been free and clear of pests and rodents. Administrative Staff A said if there was an issue with either, she expected that the pest control service provider would be contacted to implement a plan to combat the pest issue. During an interview on 06/04/25 at 08:47 AM, Maintenance U reported that a private pest control vendor provided monthly pest and rodent control inside and outside of the facility. Maintenance U said if there was a pest or rodent issue that arose beyond the monthly service, staff would contact the pest control vendor to provide additional services. The facility policy Pest Control Program, dated 01/21/25 indicated that the facility would maintain a written agreement with a qualified outside pest control service that would provide pest control services on a regularly scheduled basis. The policy also indicated that the facility would utilize a variety of methods that were deemed appropriate by the outside pest control service for controlling seasonal pests such as flies.

The facility reported a census of 36 residents with 14 residents sampled including one resident reviewed for positioning. Based on observation, interview, and record review, the facility failed to ensure appropriate wheelchair positioning for Resident (R)23, regarding the positioning of her feet on the foot pedals. This placed the resident at risk for accidents and decreased comfort. Findings included: - Review of R23's Electronic Medical Record (EMR) revealed a diagnosis of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). R23's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS noted R23 was independent with mobility in her wheelchair and had no limitation in range of motion (ROM). The Functional Abilities Care Area Assessment (CAA), dated 07/01/24, documented the resident required staff assistance for the completion of activities of daily living (ADL). The Quarterly MDS, dated 03/27/25, documented the resident had a BIMS score of eight, indicating moderately impaired cognition. The MDS noted she was independent with mobility in her wheelchair and had no limitations in ROM. R23's Care Plan, revised 05/30/25, instructed staff the resident required limited assistance with mobility in her wheelchair. R23's EMR, from 05/06/25 through 06/03/25, revealed the resident required partial/moderate staff assistance to total dependence on staff for mobility in her wheelchair. Observation on 06/02/25 at 07:15 AM revealed R23 sat in her wheelchair in the front common area. The resident wore shoes. The center of the resident's feet rested on the distal (far) edge of the wheelchair's foot pedals with her heels several inches above the foot pedals and the toe of her shoes pointed down towards the floor. On 06/03/25 at 07:41 AM, R23 sat in her wheelchair at the dining table. The resident wore shoes. The center of the resident's feet rested on the distal edge of the wheelchair's foot pedals with her heels several inches above the foot pedals and the toe of her shoes pointed down towards the floor. On 06/03/25 at 08:47 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair to her room. Her feet remained in the same position as earlier. On 06/03/25 at 08:57 AM, CNA M confirmed R23's feet did not sit flatly on the foot pedals of the wheelchair. On 06/03/25 at 09:01 AM, CNA N stated R23's feet would often come off the foot pedals because her feet did not fit properly on the foot pedals. On 06/04/25 at 09:45 AM, Licensed Nurse (LN) G stated R23's feet had never fit properly on the foot pedals of her wheelchair. On 06/04/25 at 10:17 AM, Administrative Nurse D stated the resident's feet did not fit the foot pedals of her wheelchair properly. The facility did not provide a policy for wheelchair positioning.

The facility reported a census of 36 residents with 14 residents sampled, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to ensure dignified care for Resident (R)28, when staff failed to cover the resident while receiving care when staff entered and exited his room. This placed the resident at risk for embarrassment and decreased psychosocial well-being. Findings included: - A review of R28's Electronic Medical Record (EMR) revealed a diagnosis of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS noted he required staff assistance with toileting. R28's Urinary Incontinence/Indwelling Catheter Care Area Assessment dated 04/17/25 documented the resident required staff assistance with toileting needs due to weakness and cognitive loss. The Quarterly MDS, dated 01/17/25, documented R28 had a BIMS score of five indicating severe cognitive impairment. The MDS noted he required staff assistance with toileting. R28's Care Plan, revised 06/02/25, instructed staff to provide catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care every shift. On 06/03/25 at 09:07 AM, Licensed Nurse (LN) G provided peri-care for R28. The resident lay on top of his bed, uncovered; he was naked from the waist down. While LN G provided care, Certified Nurse Aide (CNA) N knocked on the resident's door and entered without awaiting a response from LN G. CNA N entered R28's room which exposed the resident to any residents, staff, and visitors who may have been outside of his door. On 06/03/25 at 09:35 AM, CNA N confirmed she entered the resident's room without awaiting a response which caused the resident to be exposed to anyone in the hall. On 06/03/25 at 09:37 AM, LN G stated staff should not enter and exit a resident's room during care. On 06/04/25 at 09:41 AM, Administrative Nurse D stated she expected staff not to enter a resident's room while the resident was not covered during care. Review of the facility policy Promoting/Maintaining Resident Dignity, implemented 01/21/25, included: The facility shall promote and protect each resident's rights with respect and dignity.

The facility identified a census of 36 residents. The sample included 14 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood) review. Based on observation, interview, and record review, the facility failed to complete a Significant Change Minimum Data Set assessment for Resident (R) 31 when the resident started dialysis. This deficient practice placed the resident at risk for unidentified care needs after a significant change in health status. Findings: - R31's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. R31's 02/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R31 was not on dialysis services at that time. R31's 05/09/25 Quarterly MDS documented a BIMS of 13. The MDS noted R31 was on dialysis services at that time. R31's Care Plan, dated 05/09/25, documented R31 had dialysis treatment and instructed staff to coordinate care in collaboration with the dialysis center. The plan directed staff to communicate with the dialysis center regarding medications, diet, and lab results. The plan documented R31 had a central venous catheter (CVC-a thin, flexible tube inserted into a large vein, usually in the neck, chest, or groin, and threaded up to a vein near the heart) located in his upper left chest. R31's Care Plan instructed staff to keep it clean and dry; change R31's dressing as directed by the dialysis center and monitor for signs and symptoms of infection. The plan directed staff that dressing changes were done by the dialysis nurse on a routine basis; staff were to reinforce loose dressings. R31's EMR under the Physician Orders documented the following orders: Dialysis: Change dressing as directed by dialysis and reinforce loose dressings. Dressing will be changed at dialysis on Monday, Wednesday, and Friday. Call the dialysis site with questions. Change when soiled, ordered 05/20/25. Dialysis: If dressing is in place change as needed when soiled. Ordered on 05/20/25. Dialysis: Monday Wednesday, and Friday at 02:00 PM. Complete the Pre/Post Dialysis Assessment under the assessment tab on dialysis days. Send a snack with R31. Ordered on 05/20/25. Dialysis: Monitor the dialysis catheter in the left chest area for signs of infection, every shift. Ordered on 05/20/25. Dialysis Precautions: No lab draws, or blood pressure taken on the left arm ordered on 5/28/25. R31's EMR revealed the following: R31's Pre/Post Dialysis Evaluation was not completed on 04/11/25, 04/14/25, 04/16/25, 04/18/25, 04/23/25, 05/05/25, and 05/23/25. R31's Dialysis Communication Form was not provided for 04/14/25, 04/21/25, and 05/21/25. R31's Dialysis Communication Form from 04/18/25 had a note from the dialysis center that instructed staff to please keep the CVC dressing clean, dry, and intact. During an observation on 06/03/25 at 08:12 AM, R31 lay in bed. His CVC dressing over his dialysis catheter port was soiled with light red areas and areas of dried dark blood. The dressing was not tightly secured to his chest. R31's chest was exposed and appeared to have a light red area to his chest. R31 had a drink that appeared to be the same light pink color on the dressing and his chest. During an interview on 06/04/25 at 12:35 PM, LN H and Consultant Staff GG stated they expected the MDS to be correct and timely. They acknowledged a Significant Change MDS should have been completed following the start of R31's dialysis. During an interview on 06/04/25 at 01:30 PM, Administrative Nurse D stated that she expected the MDS to be completed timely and accurately. The MDS policy documented the facility will conduct initial and periodic comprehensive, accurate, standardized reproducible assessments. The Resident Assessment Instrument (RAI- is a comprehensive, standardized tool used in long-term care facilities to assess residents, guide care planning, and monitor quality of care.) will be used as a basis for assessment and care planning. A comprehensive assessment will be completed within 14 days of a significant change that is not likely to resolve itself.

The facility reported a census of 36 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set for Resident (R) 2. This placed the resident at risk for unidentified care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (class of medications that calm and relax people), depressive disorder (major mood disorder which causes persistent feelings of sadness), obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning), and dementia (a progressive mental disorder characterized by failing memory and confusion). R2's 10/28/24 Annual Minimum Data Set (MDS) documented R2 had a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition, and a PHQ-9 severity score of zero indicating no depression. The MDS noted R2 had no behaviors and took an antidepressant (a class of medications used to treat mood disorders). The MDS inaccurately documented that R2 did not take an antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality). The 10/28/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R2 took psychotropic medications to manage psychiatric illness/condition and a licensed nurse monitored for side effects every shift. The CAA noted a pharmacist consultant will review medications monthly and the physician will review medications with each visit. R2's 05/07/25 Quarterly MDS documented a BIMS of 15. The MDS noted R2 took an antidepressant, antianxiety, and an antipsychotic medication. R2's Care Plan dated 11/22/18 noted R2 received psychotropic medications and instructed staff to monitor her every shift for targeted behaviors. R2 has a diagnosis of anxiety, depression, and obsessive-compulsive disorder. R2's Care Plan instructed staff to re-direct the resident when behaviors were present. The plan notified staff that R2 received antipsychotic medication. R2's Physicians Orders documented: A discontinued order for Seroquel (antipsychotic) 25 milligrams (mg), take two tablets three times a day for depression and anxiety. This was started on 12/22/23 and was discontinued on 01/24/25. Seroquel 25 milligrams mg, take one tablet by three times a day for obsessive-compulsive disorder. This was started on 04/30/25. During an observation on 06/02/25 at 12:33 PM, R2 sat in her recliner in her room. She stated she was unhappy with her medications. She said she just did not feel like the medications were helping. During an interview on 06/04/25 at 12:35 PM, LN H and Consultant Staff GG stated they expected the MDS to be correct and timely. They acknowledged the MDS should have been coded with the antipsychotic medication to properly assess the resident. During an interview on 06/04/25 at 01:30 PM, Administrative Nurse D stated she expected the MDS and CAAs to be completed accurately. Administrative Nurse D said the MDS should have been coded that R2 was taking the antipsychotic medication. The MDS policy documented the facility will conduct initial and periodic comprehensive, accurate, standardized reproducible assessments. The Resident Assessment Instrument (RAI- is a comprehensive, standardized tool used in long-term care facilities to assess residents, guide care planning, and monitor quality of care) will be used as a basis for assessment and care planning.

The facility identified a census of 36 residents. The sample included 14 residents with one sampled for dialysis (a procedure where impurities or wastes were removed from the blood) review. Based on observation, interview, and record review, the facility failed to provide the necessary dialysis assessment, care, and services for Resident (R) 31. This deficient practice had the risk of adverse outcomes and dialysis complications for R31. Findings: - R31's Electronic Medical Record (EMR) documented a diagnosis of end-stage renal disease (ESRD-a terminal disease of the kidneys) and dependence on dialysis. R31's 02/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R31 was not on dialysis services at that time. R31's 05/09/25 Quarterly MDS documented a BIMS of 13. The MDS noted R31 was on dialysis services at that time. R31's Care Plan, dated 05/09/25, documented R31 had dialysis treatment and instructed staff to coordinate care in collaboration with the dialysis center. The plan directed staff to communicate with the dialysis center regarding medications, diet, and lab results. The plan documented R31 had a central venous catheter (CVC-a thin, flexible tube inserted into a large vein, usually in the neck, chest, or groin, and threaded up to a vein near the heart) located in his upper left chest. R31's Care Plan instructed staff to keep it clean and dry; change R31's dressing as directed by the dialysis center and monitor for signs and symptoms of infection. The plan directed staff that dressing changes were done by the dialysis nurse on a routine basis; staff were to reinforce loose dressings. R31's EMR under the Physician Orders documented the following orders: Dialysis: Change dressing as directed by dialysis and reinforce loose dressings. Dressing will be changed at dialysis on Monday, Wednesday, and Friday. Call the dialysis site with questions. Change when soiled, ordered 05/20/25. Dialysis: If dressing is in place change as needed when soiled. Ordered on 05/20/25 Dialysis: Monday Wednesday, and Friday at 02:00 PM. Complete the Pre/Post Dialysis Assessment under the assessment tab on dialysis days. Send a snack with R31. Ordered on 05/20/25. Dialysis: Monitor the dialysis catheter in the left chest area for signs of infection, every shift. Ordered on 05/20/25. Dialysis Precautions: No lab draws, or blood pressure taken on the left arm ordered on 5/28/25. R31's EMR revealed the following: R31's Pre/Post Dialysis Evaluation was not completed on 04/11/25, 04/14/25, 04/16/25, 04/18/25, 04/23/25, 05/05/25, and 05/23/25. R31's Dialysis Communication Form was not provided for 04/14/25, 04/21/25, and 05/21/25. R31's Dialysis Communication Form from 04/18/25 had a note from the dialysis center that instructed staff to please keep the CVC dressing clean, dry, and intact. R31's EMR, reviewed on 06/04/25, lacked evidence that the doctor or dialysis center was notified of the soiled dressing on 06/03/25. During an observation on 06/03/25 at 08:12 AM, R31 lay in bed. His CVC dressing over his dialysis catheter port was soiled with light red areas and areas of dried dark blood. The dressing was not tightly secured to his chest. R31's chest was exposed and appeared to have a light red area to his chest. R31 had a drink that appeared to be the same light pink color on the dressing and his chest. During an interview on 06/04/25 at 12:10 PM, Licensed Nurse (LN) G stated that prior to dialysis the nurse filled out the Dialysis Communication Form, obtained vital signs, and assessed the resident. LN G said after dialysis, facility staff did not assess R31 because R31 typically came back from dialysis and went straight to supper. During an interview on 06/04/25 at 01:30 PM, Administrative Nurse D stated that she expected staff to follow the orders and the policy for dialysis for residents including following orders and doing an assessment on the residents before and after each dialysis treatment. Administrative Nurse D said she also expected the catheter area to be assessed and clean and dry. Administrative Nurse D stated that the dialysis nurses changed the dressing. The facility's Hemodialysis policy, dated 01/21/25, documented the facility would provide the necessary care and treatment consistent with professional standards of practice, physician's orders and the residents care plan. The facility will coordinate and collaborate with the Dialysis Center. The facility will monitor and document the status of the resident's access site upon their return from a treatment.

The facility reported a census of 36 residents. Based on record review and interview, the facility failed to display accurate and identifiable staffing information, which contained the actual nursing hours worked. Findings included: - Review of the facility's Daily Staffing Sheets, from 05/01/25 through 06/02/25, revealed the actual hours worked had not been completed on the daily staffing sheets. On 06/04/25 at 07:11 AM, Administrative Nurse D verified the actual hours worked had not been filled in on the daily staffing sheets, as required. The facility did not provide a policy regarding the accurate completion of the Daily Staffing Sheets.

The facility reported a census of 34 residents, with one resident sampled for accidents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free of accident hazards during transportation. On 01/21/25, Transportation Staff E and Certified Nurse Aide (CNA) D did not ensure R1 was safely secured in the transportation vehicle before operating the vehicle. CNA D, who secured R1 in the transportation vehicle, lacked appropriate training and competency evaluation. Transportation Staff D failed to ensure R1's wheelchair was appropriately secured then operated the vehicle in a manner that caused the CNA to fear for her safety and the safety of the resident, by frequently looking at his phone which caused the vehicle to cross the [NAME] strips (corrugated pavement along the side of the road that causes rumbling and vibration when driven over to alert inattentive drivers of potential danger) on the right and left (center and shoulder) sides of the road multiple times during transportation. The driver of the vehicle rapidly brought the vehicle to a stop at an intersection which caused R1 to slide partially out of her wheelchair to the floor, injuring her left ankle. Transportation Staff E and CNA D failed to accurately communicate to the facility that the resident was injured and failed to activate 911 so the resident could be appropriately assessed. Additionally, the staff continued to the doctor's appointment and then drove approximately 50 miles back to the facility where the resident was then assessed to have an injury. This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR) revealed diagnoses that included diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cerebral (of or related to the brain) aneurysm (an abnormal bulge or ballooning in the wall of a blood vessel and if ruptured could cause serious internal bleeding with a potential to be life-threatening), and nontraumatic intracerebral hemorrhage (loss of a large amount of blood in a short period of time). The 11/24/24 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment documented R1 utilized a manual wheelchair and mechanical lift. The Care Plan reviewed 03/20/25, lacked instructions for staff related to securement in the facility vehicle during transportation. Review of the Progress Notes dated 01/21/25 at 12:30 PM, written by Administrative Nurse B, documented Transportation Staff E notified the facility that the facility vehicle stopped abruptly and R1 slid out of her chair. The note included R1 had not completely fallen to the ground and R1's left foot became entangled in a locking mechanism on the floor. Transportation Staff E and CNA D assisted R1 back into her wheelchair and returned to the facility. R1 was assessed for injuries and had a swollen left ankle. The staff notified R1's physician. Review of the facility's investigation revealed the following: On 01/20/25 at an unknown time, Transportation Staff E received a verbal warning related to excessive use of speed and vehicle safety based on reports from citizens of the community. On 01/21/25 at an unknown time, CNA D documented in a witness statement Transportation Staff E drove the facility vehicle while looking away from the road as if Transportation Staff E was looking at his phone. CNA D documented Transportation Staff E drove on the [NAME] strips numerous times. CNA D documented Transportation Staff E delegated securing R1 in the vehicle to CNA D. CNA D documented Transportation Staff E came to a sudden stop and CNA D turned to check on R1 and discovered R1 had slid almost completely out of the wheelchair with R1's left foot stuck on the right wheelchair strap. CNA D documented R1 complained of pain to her left ankle and CNA D and Transportation Staff E assisted R1 back into her wheelchair. On 01/21/25 at an unknown time, Transportation Staff E documented in a witness statement the vehicle was operated doing the speed limit of 40 miles per hour (mph) when the traffic light turned to red when the vehicle was approximately one-half of a block away. Transportation Staff E documented brakes were applied heavily to stop due to a police officer being parked nearby. Transportation Staff E documented CNA D checked on R1 and discovered R1 had slid out of the wheelchair. Transportation Staff E documented the vehicle pulled into a nearby gas station. Transportation Staff E documented R1's foot was caught behind the anchor lock on the right front of the wheelchair and then assisted CNA D to return R1 to the wheelchair. The witness statement lacked documentation of R1 complaining of pain. On 01/22/25 at 03:56 PM, an x-ray report documented transverse (horizontal) impacted (a type of fracture where the broken ends were driven into each other) fractures of the distal (lower) tibia and fibula (bones of the lower leg), displaced approximately one quarter shaft width, and marked osseous (bone) demineralization (loss of minerals from bones which makes them more prone to fractures). On 01/27/25 at 10:30 AM, Transportation Staff E was terminated due to inability to follow basic safety procedures and rules of the road. During an interview on 03/20/25 at 09:58 AM, R1 revealed on 01/21/25 her seatbelt was on, but it was not tight. R1 said, when the driver of the facility vehicle stopped suddenly, she slid under the seatbelt and partially onto the floor and injured her left leg. R1 stated the driver then drove the vehicle to a gas station and both staff members assisted R1 back into her wheelchair. R1 reported she told both staff members about the pain in her left ankle. R1 was unable to recall which staff member secured her and the wheelchair in the facility vehicle. During an interview on 03/20/25 at 12:45 PM, CNA D revealed she had not received any training or completed any competencies related to securing residents or the resident's wheelchairs in the facility vehicle. CNA D revealed on 01/21/25, Transportation Staff E requested CNA D secure R1 and R1's wheelchair in the facility vehicle and confirmed she had not received any training to perform this task. CNA D revealed on 01/21/25 while Transportation Staff E operated the vehicle, he looked away from the road at his phone which caused the vehicle to drift and crossed the [NAME] strips multiple times. CNA D revealed while riding in the vehicle operated by Transportation Staff E, she felt unsafe and was concerned for her own safety and the safety of R1. CNA D revealed after Transportation Staff E stopped the vehicle quickly, she turned around to check on R1 and noticed she had slid out from under the seatbelt and was partially on the floor. CNA D stated R1 complained of pain to the left ankle and the left ankle appeared swollen compared to the right ankle. Transportation Staff E then drove the van to the nearest gas station a short distance away and CNA D assisted R1 off the floor and directed Transportation Staff E to contact the facility for instructions. Transportation Staff E did not communicate to the facility that R1 was injured and complained of left ankle pain and received instructions to assist R1 back into her wheelchair and continue to their destination, then return to the facility. CNA D revealed neither her or Transportation Staff E considered calling 911 to activate EMS (emergency medical services) or go to the nearest emergency department (ED) During an interview on 03/20/25 at 01:08 PM, Transportation Staff E reported on the morning of 01/21/25 he had difficulty maintaining lane position due to strong winds and denied being distracted by looking at his phone. Transportation Staff E confirmed information documented in his witness statement listed above and revealed that he was unaware of any complaints of pain by R1. Transportation Staff E reported that he secured R1 and R1's wheelchair During an interview on 03/20/25 at 12:05 PM, Administrative Nurse B reviewed the progress note documentation from 01/21/25 at 12:30 PM and stated she could not recall if staff provided a time when the resident slid out of the wheelchair or if the staff reported to her any complaints of pain or injury. Administrative Nurse B revealed the expectation was that only staff members who were trained and had performed competencies would secure residents in the facility vehicle. Administrative Nurse B reviewed the facility investigation's witness statement from CNA D and confirmed documentation that indicated R1 had pain and restated staff did not communicate the discovery of pain when they called. Administrative Nurse B further stated that if transportation staff (driver or attendant) were alerted to pain after a similar incident, they should call 911 to activate EMS and/or go to the nearest ED to have the resident evaluated for injury. Administrative Nurse B defined a fall as an unintentional change in plane, and the incident on 01/21/25 should have been considered a fall with the appropriate response from staff. During an interview on 03/20/25 at 11:35 AM, Administrative Staff A revealed the driver of the facility vehicle was ultimately the one responsible to ensure residents were appropriately secured in the vehicle. Administrative Staff A reported that Transportation Staff E was terminated and remaining authorized drivers were reeducated related to their roles and responsibilities. Administrative Staff A revealed all CNA personnel have been instructed if they were riding in the facility's vehicle the driver of the vehicle was responsible to ensure the residents, and their wheelchairs were secured. The facility's undated Transporting a Resident (Facility Van) policy documented each resident would be secured in a seat with a seatbelt or in their wheelchair secured with wheelchair tie-downs. The facility failed to ensure Resident (R)1 remained free of accident hazards during transportation. On 01/21/25, Transportation Staff E and CNA D did not ensure R1 was safely secured in the transportation vehicle before operating the vehicle. The CNA who secured the resident lacked appropriate training and competency evaluation. Transportation Staff D failed to ensure R1's wheelchair was appropriately secured then operated the vehicle in a manner that caused the CNA to fear for her safety and the safety of the resident by frequently looking at his phone which caused the vehicle to cross the [NAME] strips (corrugated pavement along the side of the road that causes rumbling and vibration when driven over to alert inattentive drivers of potential danger) on the right and left (center and shoulder) sides of the road multiple times during transportation. The driver of the vehicle rapidly brought the vehicle to a stop at an intersection which caused R1 to slide partially out of her wheelchair to the floor, injuring her left ankle. Transportation Staff E and CNA D failed to accurately communicate to the facility that the resident was injured and failed to activate 911 so the resident could be appropriately assessed. Additionally, the staff continued to the doctor's appointment and then drove approximately 50 miles back to the facility where the resident was then assessed to have an injury. This deficient practice placed R1 in immediate jeopardy. On 03/20/25 at 03:35 PM, Administrative Staff A, Administrative Nurse B, Administrative Staff F and Consultant Nurse G were provided the Immediate Jeopardy (IJ) Template for failure ensure R1 remained free of accidents The facility immediately implemented corrective measures following the incident that involved R1 on 01/21/25. The facility's corrective measures included the following, which were verified by the surveyor on-site during the investigation. 1. All staff received education related to the roles and responsibilities of staff during transportation outside the facility, completed 01/23/25 at 01:00 PM 2. All staff authorized to drive for the facility were reeducated related to their roles and responsibilities, completed 01/28/25 at unknown time. 3. Transportation Staff E was terminated, completed 01/27/25 at 10:30 AM. All corrections were completed prior to the onsite survey, therefore the deficient practice was cited as past noncompliance at a scope and severity of G.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to properly store, prepare and distribute food under sanitary conditions to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility. Findings included: - During the initial tour of the kitchen on 08/30/23 at 01:05 PM, the following areas of concern were noted: 1. The bottom shelf of the cup rack contained dried food debris. 2. Four plastic pitchers had a brownish stain on the inside. 3. A reach-in refrigerator had an open gallon paper container of potato salad which was undated. 4. The shelf below the microwave had dried food debris. 5. Two reach in freezers had food debris on the bottom shelves. 6. Two coffee pots were heavily stained on the inside glass of the pots with a build-up of dried on coffee on the spout and handle of the pots. 7. A large pork loin was in a dry sink thawing inappropriately. 8. The spice shelf had a layer of dust. 9. The inside of the microwave had multiple areas of dried on food substances. 10. Two drawers which held kitchen utensils had dried on liquid on the outside of the drawer as well as food debris on the inside of the drawers. 11. The large plastic container of flour had flour on top of the lid as well as around the flour container. 12. The top and sides of the trash can by the microwave table had dried on food and liquid spots. 13. The inside and outside of the toaster was dirty with dried on food and dried on liquids. 14. A plastic container of butter was left out on the counter and contained food debris on the butter. A large spoon was stuck inside of the plastic container of butter which also contained food debris. 15. The stationery can opener had dried-on food debris. 16. The stove tops six burners were dirty with food debris dried on top and around the burners. 17. The knife holder on the wall by the window air-conditioner had food debris dried on the top. 18. A storage area for clean cutting boards had multiple dead bugs and food debris. 19. Four large cutting boards were heavily scratched and notched, making them unsanitizable. 20. A pan which held home grown cucumbers and summer squash contained multiple dead bugs. 21. A shelf below the steam table had dried food debris. 22. The window air conditioner, over the food prep table, had multiple dead bugs on the front cover of the air conditioner and multiple dead bugs on either side of the air conditioner. On 08/30/23 at 01:08 PM, Dietary Staff CC stated the potato salad should not be uncovered in the refrigerator and should have the date in which it was opened. On 08/30/23 at 01:13 PM, Dietary Staff DD stated she will always put the meat in the refrigerator to defrost. She will put the pork loin in the reach in refrigerator when she leaves for the day. On 08/30/23 at 03:18 PM, Administrative staff A stated she oversaw the kitchen at this time until the facility was able to hire a new dietary manager. Administrative staff A confirmed there were several areas in the kitchen which needed to be addressed. The facility policy for Sanitation, revised 10/2008, included: The food service area shall be maintained in a clean and sanitary manner. The facility failed to properly store, prepare and distribute food under sanitary conditions to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses for the residents of the facility.

The resident reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. Findings included: - During the initial tour of the kitchen on 08/30/23 at 01:05 PM, the following area of concern was noted: The floor throughout the kitchen had areas which contained a dried, liquid, sticky substance. The parameter of the floor had a heavy build-up of dirt and grime. On 08/30/23 at 03:18 PM, Administrative Staff A stated it was the expectation the kitchen floor would be kept clean at all times. The facility policy for Sanitation, revised 10/2008, included: The food service area shall be maintained in a clean and sanitary manner. The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff.

The facility reported a census of 32 residents. Based on observation, interview, and record review, the facility failed to ensure sanitary catheter care for two Residents (R)10 and R87, failed to sanitize a nasal inhaler and utilize proper hand hygiene for this task for R15 and dietary staff failed to don personal protective equipment prior to entry to R30's room who was in isolation due to active COVID infection. Findings included: - Observation, on 09/29/23 at 09:26 AM, revealed Dietary Staff BB entered Resident (R)30's room which required personal protective equipment (PPE) due to the resident's positive COVID-19 status and isolation protocol, without donning (putting on) PPE, as instructed, on the signage near the door to the resident's room. Interview, on 09/29/23 at 09:28 AM, with Dietary Staff BB, revealed she did not know she needed to wear PPE as she delivered breakfast to the resident. Interview on 09/29/23 at 11:20 AM, with Licensed Nurse G, confirmed R 30 was in isolation for COVID and he would expect all staff to don and doff PPE. Interview, on 09/31/21 at 11:40 AM, with Administrative Nurse E, revealed she would expect all staff to don/doff (put on/take off) PPE appropriately when exiting/entering isolation rooms. The facility policy Managing Positive or Symptomatic Residents, revised 07/26/23, instructed staff to use full PPE, gowns, gloves eye protection, and an approved N95 (size of particles filtered) or higher-level respirator (mask) when caring for residents with suspected or confirmed COVID-19. The facility failed to ensure all staff followed PPE guidelines for entering a COVID-19 positive resident's room to prevent the spread of infection. - Observation, on 08/30/23 at 10:34 AM, revealed Resident (R)87 positioned in bed with her urinary catheter bag attached to the bedframe. Certified Nurse Aide (CNA) M prepared to drain the urine in the tubing and catheter bag and placed the urine collection bag directly on the floor. CNA M placed the plastic urine collection device (a urinal) directly on the floor without a barrier. CNA M unclamped the urine drainage spout and allowed the urine to drain into the urinal, then reclasped and attached the spout to the urine collection bag without sanitizing the end. Interview at that time with CNA M, confirmed staff should sanitize the end of the drainage spout with a cleansing wipe or alcohol pad prior to and after the drainage procedure. Interview, on 08/31/23 at 11:20 AM, with Administrative Nurse E, revealed she would expect staff to provide catheter care in a sanitary manner which included wiping off the urine drainage spout with an alcohol wipe. The facility policy Catheter Care, undated, instructed staff to provide appropriate catheter care and maintain dignity and privacy. The facility failed to ensure staff provided sanitary catheter care for this resident with a history of urinary tract infections. - Observation, on 08/31/23 at 10:00 AM, revealed Licensed Nurse (LN)G with ungloved hands, administered Resident (R)15 his nasal inhaler. LN G then replaced the cap on the inhaler without sanitizing it and put it back in its box and placed it in the medication cart. LN G reached for the medication drawer to pull out another resident's medication cards from the drawer without sanitizing his hands. Interview at that time with LN G confirmed he should wear gloves when handling the inhaler and sanitize the nasal end of the inhaler and his hands to prevent the spread of infection, especially since the facility has a current outbreak of COVID. Interview, on 08/31/23 at 11:20 AM, with Administrative Nurse E, revealed she would expect staff to provide nasal inhalers with gloved hands and sanitize the contaminated inhaler before returning it to the cart. She would expect staff to perform hand hygiene after inhaler procedures. The facility Infection Control Policy, dated 04/17/23, instructed staff to perform hand hygiene before and after contact with a resident. This policy instructed staff to perform hand hygiene after touching body fluids and contaminated items and to sanitize contaminated items with approved sanitizer. The facility failed to ensure staff performed hand hygiene and gloving during and after the administration of a nasal inhaler and failed to provide sanitation of the nasal inhaler post use to prevent the spread of infection. 34056 - Review of Resident (R)10's electronic medical record (EMR) included a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Admission Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He required limited assistance of one staff for toileting and had an indwelling urinary catheter (a sterile tube placed into the bladder to drain urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/19/22, documented the resident had urinary retention (inability to pass urine) and required assistance to maintain his urinary catheter needs. The Quarterly MDS, dated [DATE], documented a BIMS score of six, indicating severe cognitive impairment. He required supervision of one staff for toileting and had an indwelling urinary catheter. The urinary catheter care plan, revised 06/14/23, instructed staff to flush the urinary catheter tubing with sterile water, as ordered, and to perform catheter care every shift (QS), and as needed, PRN. Review of the resident's EMR revealed the following physician's order: Flush and irrigate the urinary catheter with 60-120 cubic centimeter (cc's) of sterile water every day (QD) and as needed, PRN, ordered 05/11/23 On 08/30/23 at 01:52 PM, Licensed Nurse (LN) G entered the resident's room to provide catheter care and flush the resident's catheter tubing. LN G placed all needed supplies on the small dresser without a barrier. LN G assisted the resident to lower his pants down to his ankles. The urinary catheter tubing anchored to resident's left leg. LN G cleansed the urinary catheter tubing from the Y connection up to the tip of the penis and back down to the Y connection, back and forth several times, using the same alcohol swab. Once LN G completed cleansing the catheter tubing, he disconnected the tubing at the Y connector and flushed with 60 cc's of sterile water, then reconnected the tubing, without cleansing the tubing or the connector. On 08/31/23 at 10:58 AM, Administrative Nurse E stated she was aware the facility needed to do some training and education with catheter care. The facility policy for Catheter Care, undated, included: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. The facility failed to provide appropriate infection control techniques for this resident that required a urinary catheter.

The facility reported a census of 32 residents with 16 residents selected for review, which included five residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to ensure five residents (R)11, R15, R2, R25 and R26 had facial hair groomed appropriately and one resident, R25 had clean and trimmed fingernails. Findings included: - Review of Resident (R)11's electronic medical record, revealed diagnoses included dysarthria (difficulty speaking due to muscle weakness), hypertension (elevated blood pressure), and epilepsy (brain disorder characterized by repeated seizures). The Annual Minimum Data Set, dated dated [DATE], assessed the resident with normal cognitive function and required limited assistance with personal hygiene. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 08/02/23, assessed the resident was dependent with transfers. The Care Plan, revised 08/21/23, instructed staff to assist the resident with personal hygiene. Observation, on 08/29/23 at 12:24 PM, revealed the resident seated in his wheelchair, outside on the patio. The resident had several days' worth of facial hair. Observation, on 08/30/23 at 08:30 AM, revealed the resident in an isolation room due to testing positive for COVID-19 on 08/30/23. The resident remained with unkempt facial hair. Observation, on 08/30/23 at 04:00 PM, revealed the resident in his room with isolation, and continued with unkempt facial hair. Interview, on 08/30/23 at 04:15 PM, with Certified Nurse Aide (CNA) P, revealed staff shaved the resident without difficulty usually on his shower days in the evening. CNA P did not know when staff last shaved the resident. Interview, on 08/31/23 at 11:42 AM, with Administrative Nurse D, confirmed the resident required assistance with shaving and she would expect staff to provide good grooming. The facility policy Activities of Daily Living (ADL) dated 10/2022, instructed staff to provide the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving opportunities to this resident to maintain good grooming. - Review of Resident (R)15's Physician Order Sheet, dated 08/26/23, revealed diagnoses included chronic obstructive lung disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and heart failure. The Admission Minimum Data Set (MDS), dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The resident had limitation in functional range of motion on one side of his upper and lower extremities and required one person assistance for personal hygiene. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA ), dated 03/23/23, assessed the resident required extensive assistance with bathing and personal hygiene and received therapy for strengthening. He was compliant with staff assistance with daily cares. The Care Plan, reviewed 08/17/23, instructed staff the resident had little use of his right arm and required moderate assistance with upper body dressing. Observation, on 08/29/23 at 08:30 AM, revealed the resident with several days' worth of facial hair. Interview with the resident at that time revealed he fractured his arm and required staff assistance to shave. Interview, on 08/30/23 at 10:41 AM, with Certified Nurse Aide (CNA), stated the resident preferred a whirlpool bath, and was not always cooperative. CNA M confirmed the resident was unkempt on 08/29/23. Interview, on 08/31/23 at 11:42 AM, with Administrative Nurse D, confirmed the resident required assistance with shaving and she would expect staff to provide good grooming. The facility policy Activities of Daily Living (ADL) dated 10/2022, instructed staff to provide the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving opportunities to this resident to maintain good grooming. - Review of Resident (R)2's Physician Order Sheet, dated 08/23/23, revealed diagnoses included dementia (progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder), diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The resident required limited assistance for personal hygiene and bathing. The ADL (Activity of Daily Living) Functional/Rehabilitation Care Area Assessment (CAA), dated 07/05/23, assessed the resident required assistance with transfers. The Care Plan, revised 07/23/23, instructed staff the resident required total assistance with personal hygiene. Observation, on 08/29/23 at 9:30 AM, revealed the resident seated in a recliner in the common lobby area. The resident had dry flaking facial skin and several days' worth of facial hair. Observation, on 08/29/23 at 01:24 PM, revealed the resident seated in a recliner in the front lobby. The resident continued with dry flaking facial skin and several days' worth of facial hair. Interview, on 08/30/23 at 07:45 AM, with Certified Nurse Aide (CNA) O, revealed the resident had skin issues and was difficult to shave. Interview, on 08/31/23 at 11:42 AM, with Administrative Nurse D, confirmed the resident required assistance with shaving and she would expect staff to provide good grooming. The facility policy Activities of Daily Living (ADL) dated 10/2022, instructed staff to provide the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving opportunities to this resident to maintain good grooming. - Review of Resident (R)26's Physician Order Sheet, dated 06/13/23, revealed diagnoses included dementia (progressive mental disorder characterized by failing memory and confusion), heart failure, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The resident required extensive assistance of one staff for personal hygiene. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/15/23, assessed the resident did not trigger for this resident. The Quarterly Minimum Data Set, dated dated [DATE], assessed the resident with a BIMS score of five, indicating severe cognitive impairment, and required extensive assistance of one staff for personal hygiene. The Care Plan, reviewed 08/04/23, instructed staff to monitor the resident for his general awareness as he had difficulty understanding others and difficulty with personal hygiene. Observation, on 08/29/23 at 08:30 AM, revealed the resident seated in his wheelchair in the dining room. The resident had several days' worth of facial hair. Observation, on 08/29/23 at 03:30 PM, revealed the resident continued with several days' worth of facial hair. Observation, on 08/30/23 at 08:00 AM, revealed the resident moved to an isolation room for positive COVID test results on 08/30/23. The resident continued with several days' worth of facial hair. Interview, on 08/30/23 at 03:14 PM, with Certified Nurse Aide (CNA) P, revealed the resident was cooperative with shaving and usually staff showered him on evenings. CNA P did not know when staff last shaved the resident. Observation, on 08/30/23 at 04:00 PM, revealed the resident continued with several days' worth of facial hair. Interview, on 08/31/23 at 11:42 AM, with Administrative Nurse D, confirmed the resident required assistance with shaving and she would expect staff to provide good grooming. The facility policy Activities of Daily Living (ADL) dated 10/2022, instructed staff to provide the necessary services to maintain good grooming and personal hygiene. The facility failed to provide shaving opportunities to this resident to maintain good grooming. 34056 - The Physician Order Sheet (POS), dated 08/23/23, for Resident (R)25, included a diagnosis of cerebral infarction (CVA [stroke] - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She required total assistance of one staff for personal hygiene. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/25/22, documented the resident was dependent on staff for all ADL's. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required total assistance of two staff for personal hygiene. The care plan for ADL's, revised 06/09/23, instructed staff the resident was totally dependent on staff for ADL's. Review of the resident's electronic medical record (EMR), from 08/01/23 through 08/29/23, revealed the resident required extensive to total assistance of one staff for personal hygiene. On 08/29/23 at 09:45 AM, the resident rested in bed. She had long, curled chin hair and long, jagged, dirty fingernails. On 08/30/23 at 08:43 AM, the resident remained to have long, curled chin hair and long, jagged, dirty fingernails. On 08/29/23 at 09:45 AM, a family member of the resident stated the resident had always kept herself neat and wished the facility would keep her nails done and her face shaven. On 08/30/23 at 03:39 PM, Certified Nurse Aide (CNA) P stated staff should ensure the resident was kept neat and clean. On 08/31/23 at 08:13 AM, CNA, M stated staff should shave residents and do nail care on their bath days. CNA M stated it was hit and miss on completing showers. On 08/30/23 at 09:28 AM, Licensed Nurse (LN) G stated staff shave residents and cut and clean their fingernails on shower days. On 08/31/23 at 10:58 AM, Administrative Nurse E stated it was the expectation for staff to ensure residents were shaven and had clean, smooth fingernails. The facility policy for Activities of Daily Living, revised 10/2022, included: A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure this dependent resident had clean, trimmed fingernails and failed to ensure she was shaven.

The facility reported a census of 32 residents with 16 selected for review. Based on observation, interview, and record review, the facility failed to review and revise the care plan for Resident (R)15 to include use of an arm immobilizer after the resident had a fractured humerus and inability to utilize a walker, R25 for chin hair removal, R18 for toilet times and use of bedpan, and R 23 for use of foot pedals on her wheelchair. Findings included: - Review of Resident (R)15's Physician Order Sheet, dated 08/26/23, revealed diagnoses included fractured humerus (bone between shoulder and elbow), chronic obstructive lung disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and heart failure. The Admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The resident had limitation in functional range of motion on one side of his upper and lower extremities and required one person assistance for personal hygiene. The resident utilized a walker and wheelchair for mobility. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA ), dated 03/23/23 assessed the resident required extensive assistance with bathing and personal hygiene and received therapy for strengthening. He was compliant with staff assistance with daily cares. The Quarterly Minimum Data Set, dated dated [DATE], assessed the resident with intact cognition and had impairment on one side of his upper and lower extremities. The resident required extensive assistance of two staff for bed mobility and toileting and limited assistance for mobility. The Care Plan, reviewed 08/17/23, instructed staff the resident had little use of his right arm and required moderate assistance with upper body dressing. The resident used a four wheeled roller walker for ambulation and at times my choose to use a wheelchair and was able to propel himself. On 08/10/23, nonskid strips were added to his bathroom and the resident was reminded to use the call light for needs. Staff instructed to ensure the resident always wore nonskid footwear. This care plan lacked mention of the resident's fractured left humerus (from a fall on 08/10/23), arm immobilizer, and inability to utilize his walker. Observation, on 08/29/23 at 08:30 AM, revealed the resident sat in a wheelchair with his left arm in an immobilizing sling. Interview with the resident at that time revealed he fractured his arm and required staff assistance for activities of daily living. Interview, on 08/30/23 at 08:24 AM, with Consulting Therapy Staff HH, revealed the resident received therapy for strengthening for transfers and bed mobility. The resident had limited range of motion due to the left humerus fracture. Interview, on 08/30/23 at 10:41 AM with Certified Nurse Aide (CNA) M, revealed the resident used to use a walker, and take himself to the bathroom, but since his fall, he was no longer able to use the walker. Interview, on 08/30/23 at 03:08 PM, with CNA P, revealed the resident required two-person assistance to stand and transfer and had not used a walker since he fractured his left arm. Interview, on 08/31/23 at 10:10 AM, with Licensed Nurse G, confirmed the resident could not use his walker to ambulate and needed to keep his left arm in the immobilizing sling. Interview, on 08/30/23 at 02:25 PM, with Administrative Nurse F, confirmed the care plan did not include updates for inability to use the walker and use of an arm immobilizer after his fall with a fractured humerus. Administrative Nurse F stated any nurse could add to the care plan when needed. The facility policy Activities of Daily Living, revised 10/2022, instructed staff to maintain individual objectives of the care plan and periodic evaluation and review. The facility failed to review and revise this resident's care plan to include the arm immobilizing sling and inability to utilize his walker for ambulation. 34056 - The Physician Order Sheet (POS), dated 08/23/23, for Resident (R)25, included a diagnosis of cerebral infarction (CVA [stroke] - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She required total assistance of one staff for personal hygiene. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/25/22, documented the resident was dependent on staff for all ADL's. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required total assistance of two staff for personal hygiene. The care plan for ADL's, revised 06/09/23, lacked staff instruction for shaving the resident. Review of the resident's electronic medical record (EMR), from 08/01/23 through 08/29/23, revealed the resident required extensive to total assistance of one staff for personal hygiene, including shaving. On 08/29/23 at 09:45 AM, the resident rested in bed. She had long, curled chin hair and long, jagged, dirty fingernails. On 08/30/23 at 08:43 AM, the resident remained to have long, curled chin hair and long, jagged, dirty fingernails. On 08/29/23 at 09:45 AM, a family member of the resident stated the resident had always kept herself neat and wished the facility would keep her nails done and her face shaven. On 08/30/23 at 03:39 PM, Certified Nurse Aide (CNA) P stated staff should ensure the resident was kept neat and clean at all times. On 08/31/23 at 08:13 AM, CNA, M stated staff should shave residents and do nail care on their bath days. CNA M stated it was hit and miss on completing showers. On 08/31/23 at 09:44 AM, Consultant Staff GG stated the care plans can be updated by anyone. The facility policy for Activities of Daily Living, revised 10/2022, included: The facility will maintain individual objectives of the care plan and periodic review and evaluation. The facility failed to review and revise the care plan to include staff instruction regarding shaving and nail care for this dependent resident. - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of overactive bladder (OAB--causes a frequent and sudden urge to urinate). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. She required limited assistance of one staff for toileting and was frequently incontinent of urine. She lacked a toileting program. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/19/23, documented the resident required limited assistance with toileting and was frequently incontinent. Staff were to ensure the resident received assistance with toileting and to ensure her brief was changed following each incontinent episode. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and was frequently incontinent of urine. She lacked a toileting program. The care plan for bowel and bladder, revised 06/19/23, instructed staff to assist the resident with following her toileting program, however, there was no documented toileting program. Review of the resident's EMR documented she required extensive assistance of one to two staff for toileting and was always incontinent of urine. Review of the resident's EMR from 08/02/23 through 08/30/23, documented staff were to toilet the resident at the following times: 07:00 AM, 09:00 AM, 11:00 AM, 01:00 PM, 03:00 PM, 06:00 PM, 08:00 PM and 03:00 AM. On 08/30/23 at 07:30 AM, the resident rested in bed with her eyes closed. The resident remained in bed without an offer to toilet until 11:00 AM, when CNA N entered the room to dress the resident. CNA N removed the resident's wet brief and performed peri-care (the cleansing of the genitals), put on a new brief and dressed the resident. CNA N did not offer the resident the use of a bedpan for urination. On 08/30/23 at 01:45 PM, the resident sat in her wheelchair looking out of the dining room window. At 04:00 PM, the resident remained in her wheelchair in the dining room. No staff offered to a bedpan/toilet to the resident for urination. On 08/30/23 at 11:00 AM, CNA N stated the resident's brief was wet when changed. CNA stated the bedpan would be offered at times for the resident, but not always. CNA N confirmed the resident did not currently have a bedpan in her room. On 08/30/23 at 11:19 AM, CNA O stated the resident was able to say when she needed to toilet at times. CNA O confirmed the resident did not have a bedpan in her room. Staff were currently just changing her brief every couple of hours. The resident had mostly been continent of urine before her hospitalization in July, 2023. The resident was working with therapy to regain strength. On 08/30/23 at 03:39 PM, CNA P stated the resident was currently just check and change for her toileting needs. CNA P stated she had not offered the resident a bed pan for urination. On 08/30/23 at 03:51 PM, Licensed Nurse (LN) G stated the resident was able to say when she needed to toilet. Staff toilet her every two and a half hours or so. They do not offer her a bed pan to help with her bladder continence. On 08/31/23 at 09:44 AM, Consultant Staff GG stated the care plans can be updated by anyone. The facility policy for Activities of Daily Living, revised 10/2022, included: The facility will maintain individual objectives of the care plan and periodic review and evaluation. The facility failed to review and revise the care plan for this dependent resident related to toileting. - Review of Resident (R)23's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion on the unit. She had no impairment in her functional range of motion (ROM) and used a wheelchair for locomotion. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/26/23, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required total assistance of one staff for locomotion on the unit, had limited ROM on one side of her lower extremities and used a wheelchair for locomotion on the unit. The care plan for safety, revised 08/09/23, instructed staff the resident used a wheelchair for locomotion, but lacked staff instruction on the use of foot pedals for the wheelchair. Review of the resident's EMR, from 08/02/23 through 08/30/23, documented the resident required extensive to total assistance of one staff for locomotion in the facility. On 08/30/23 at 07:49 AM, Certified Nurse Aide (CNA) M and CNA Q transferred the resident from a recliner in the commons area to her wheelchair. CNA Q propelled the resident from the commons area to the shower room in her wheelchair to toilet. The resident's socked feet skimmed the floor during transport. The wheelchair lacked foot pedals. After toileting, CNA M propelled the resident from the shower room to the dining room for breakfast. The resident's feet skimmed the floor during transport. The wheelchair lacked foot pedals. On 08/30/23 at 09:03 AM, CNA O propelled the resident from the dining room to her recliner in her wheelchair. The resident's feet skimmed the floor and the wheelchair lacked foot pedals. On 08/30/23 at 07:56 AM, CNA M stated the resident did not have foot pedals for her wheelchair as she was able to propel herself at times. On 08/30/23 at 09:03 AM, CNA O stated the resident did not have foot pedals for her wheelchair. On 08/31/23 at 09:44 AM, Consultant Staff GG stated the care plans can be updated by anyone. The facility policy for Activities of Daily Living, revised 10/2022, included: The facility will maintain individual objectives of the care plan and periodic review and evaluation. The facility failed to review and revise the care plan to include foot pedals for this dependent resident's wheelchair.

The facility reported a census of 32 residents with 16 residents sampled, including three residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards for one Resident (R)23, regarding the lack of foot pedals on her wheelchair. Findings included: - Review of Resident (R)23's electronic medical record (EMR) included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She required extensive assistance of one staff for locomotion on the unit. She had no impairment in her functional range of motion (ROM) and used a wheelchair for locomotion. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/26/23, did not trigger. The Quarterly MDS, dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required total assistance of one staff for locomotion on the unit, had limited ROM on one side of her lower extremities and used a wheelchair for locomotion on the unit. The care plan for safety, revised 08/09/23, instructed staff the resident used a wheelchair for locomotion. Review of the resident's EMR, from 08/02/23 through 08/30/23, documented the resident required extensive to total assistance of one staff for locomotion in the facility. On 08/30/23 at 07:49 AM, Certified Nurse Aide (CNA) M and CNA Q transferred the resident from a recliner in the commons area to her wheelchair. CNA Q propelled the resident from the commons area to the shower room in her wheelchair to toilet. The resident's socked feet skimmed the floor during transport. The wheelchair lacked foot pedals. After toileting, CNA M propelled the resident from the shower room to the dining room for breakfast. The resident's feet skimmed the floor during transport. The wheelchair lacked foot pedals. On 08/30/23 at 09:03 AM, CNA O propelled the resident from the dining room to her recliner in her wheelchair. The resident's feet skimmed the floor and the wheelchair lacked foot pedals. On 08/30/23 at 07:56 AM, CNA M stated the resident did not have foot pedals for her wheelchair as she was able to propel herself at times. On 08/30/23 at 09:03 AM, CNA O stated the resident did not have foot pedals for her wheelchair. On 08/31/23 at 10:04 AM, Administrative Nurse E stated the resident should have foot pedals on her wheelchair if she was unable to hold her feet up while staff propelled her in the wheelchair. The facility lacked a policy regarding the use of foot pedals on wheelchairs. The facility failed to ensure an environment free from accident hazards for this dependent resident while staff propelled in her wheelchair.

The facility reported a census of 35 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)15, received laboratory blood monitoring as ordered by the physician. Findings included: - Review of Resident (R)15's Physician Order Sheet, dated 08/26/23, revealed diagnoses included chronic obstructive lung disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic kidney disease, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS) dated [DATE] assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, which indicated intact cognition. The resident received seven days of insulin injections, antipsychotic (medication to manage major mental health disorders,) antidepressant (medication used to treat depression) diuretic (medication to remove excess fluid from the body) and opioid (narcotic medications for pain) medications during the seven-day look-back period. The Cognitive Loss /Dementia Care Area Assessment (CAA), dated 03/23/23, assessed the resident had mild cognitive impairment and impaired memory. The Care Plan, revised 08/17/23, instructed staff to check blood sugar per order and obtain A1C per order (initiation date 04/17/23 ). On 03/16/23 the physician instructed staff to administer ferrous sulfate (medication containing iron) 325 milligrams (mg), daily for anemia. On 03/16/23 the physician instructed staff to administer Fluticasone (a medication for asthma that is in the classification of steroids) 50 micrograms inhaler twice a day. On 03/16/23 the physician instructed staff to administer furosemide (a medication that removes excess fluid from the body) 20 mg, daily, for edema. On 03/16/23 the physician instructed staff to obtain a current blood count (CBC), comprehensive metabolic panel (CMP), and thyroid stimulating hormone (TSH), every six months. Review of the medical record revealed a CBC, CMP and TSH completed on 03/29/23. On 04/09/23, the physician's order instructed staff to obtain an A1C (a blood test that measure the average blood sugar levels over the past three months), CBC, and CMP every three months. On 06/03/23 the physician's order instructed staff to administer of Levemir (a type of long-acting insulin) 30 units, subcutaneously (beneath the skin in subcutaneous fat,) twice a day. On 06/03/23, the physician instructed staff to administer the following sliding scale (amount of insulin required based on blood glucose level) for Novolog insulin (a short acting insulin) subcutaneously three times a day and at hour of sleep: For a blood sugar of 150-200 milligram per deciliter (mg/dL) 4 units of Novolog For a blood sugar of 201-250 mg/dL 6 units of Novolog. For a blood sugar of 251-300 mg/dL 10 units of Novolog. For a blood sugar of 301-350 mg/dL 12 units of Novolog. For a blood sugar of 351-400 mg/dL 14 units of Novolog. For a blood sugar of greater than 400 mg/dL notify the physician. On 06/05/23 the physician instructed staff to administer Metformin (a medication to lower blood sugar,) 750 mg, ER (extended release) twice a day. On 06/07/23, the physician instructed staff to administer Farxiga (a medication the removes blood sugar through the kidneys,)10 mg, daily. The facility failed to obtain an A1C for this resident as ordered by the physician on 04/09/23. In addition, the facility failed to obtain a CBC and CMP as the physician ordered, every 3 months. Interview, on 08/31/23 at 11:42 AM, with Administrative Nurse E, confirmed the two sets of lab orders (written on 03/29/23 for six months monitoring and 04/09/23 for every three-month monitoring with A1C) needed clarification. The facility lacked a policy for following physician orders. The facility failed to follow the physician orders for laboratory monitoring for this diabetic resident.

The facility reported a census of 32 residents with 16 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one Resident (R)32, regarding pain. Findings included: - Review of Resident (R)32's electronic medical record (EMR) included a diagnosis of fractured ribs (broken ribs). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. He reported frequent pain with worse pain in past five days being five out of a one to ten pain assessment tool. Pain did affect his sleep but did not affect his day to day activities. He received as needed (PRN) pain medications. The Pain Care Area Assessment (CAA), dated 08/21/23, documented the nursing staff would monitor the resident for pain and work on finding effective pain management interventions, including medication and non-medical options for pain. The care plan, dated 08/14/23, instructed staff the resident had pain, but lacked staff instruction for non-medical pain interventions for the resident. Review of the resident's EMR from 08/14/23 through 08/30/23, revealed the resident had pain rated from 2-8 and received pain medication, with effective results, for the pain. The EMR lacked non-medical pain interventions attempted by the staff. On 08/30/23 at 03:39 PM, Certified Nurse Aide (CNA) P stated the resident complained of pain a lot and would receive pain medication. CNA P was unaware of any non-medical pain interventions to assist the resident with his pain. On 08/30/23 at 03:51 PM, Licensed Nurse (LN) G stated the resident had an order for pain medication every four hours. LN G was unaware of any non-medical pain interventions. On 08/31/23 at 10:04 AM, Administrative Nurse E stated the staff should be attempting non-medical pain interventions before administering pain medication. The facility policy for Activities of Daily Living, revised 10/2022, included: The facility will maintain individual objectives of the care plan. The facility failed to complete a comprehensive care plan for this resident, regarding pain.

The facility reported a census of 32 residents with 16 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set (MDS) for one Resident (R)25, regarding anti-psychotic medications (class of medications used to treat psychosis and other mental emotional conditions). Findings included: - Review of Resident (R)25's electronic medical record (EMR) included diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain disorder (a mental and behavioral disorder), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness emptiness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The MDS documented the resident received anti-psychotic medications seven days of the seven-day assessment period. The MDS further documented the resident did not receive any antipsychotic medications during the seven-day assessment period. The Psychosocial Well-Being Care Area Assessment (CAA), dated 09/25/22, documented the resident often yelled out and had difficulty expressing her needs. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She received anti-psychotic medications seven days of the seven-day assessment period and received anti-psychotic medications on a routine basis only. The care plan for mental wellness and psychotropic medication use, revised 06/09/23, instructed staff the resident would cry out and yell at times. The resident had psychotropic medications. Review of the resident's EMR revealed the following order: Risperidone (an anti-psychotic medication), 0.5 milligrams (mg), via percutaneous endoscopic gastrostomy tube (PEG-tube is a tube inserted through the abdomen directly into the stomach), twice daily (BID), for depression, ordered 07/29/22. On 08/31/23 at 09:44 AM, Consultant Staff GG stated the significant change MDS, dated [DATE], was inaccurate. The resident received anti-psychotics on a routine basis during the assessment period. On 08/31/23 at 10:58 AM, Administrative Nurse E stated it was the expectation for the MDS's to be completed accurately. The facility utilizes the Resident Assessment Instrument (RAI) in completion of the MDS. The facility failed to complete an accurate comprehensive assessment for this dependent resident.

The facility reported a census of 32 residents with 16 residents sampled, including three residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)25, when staff failed to close the blinds while providing peri-care (cleansing of the genitals), R 10, when staff failed to provide dignity as two staff opened and closed the door to his room while he was exposed from the mid chest to his ankles, and R26, when the resident had his abdomen exposed in the dining room, common living area. Findings included: - The Physician Order Sheet (POS), dated 08/23/23, documented Resident (R) 25 had diagnoses which included: anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), panic (sudden uncontrollable fear or anxiety, often causing wildly unthinking behavior) and cerebral infarction ((CVA [stroke] sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She required extensive assistance of two staff for bed mobility and total assistance of two staff for toileting. She was always incontinent of bowel and bladder. The Activity of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/25/22, documented the resident was dependent on staff for all ADL's. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of three, indicating severe cognitive impairment. She required total assistance of two staff for bed mobility and toileting. She was always incontinent of bowel and bladder. The care plan for ADL's, revised 06/09/23, instructed staff the resident was totally dependent on staff for ADL's. On 08/30/23 at 09:17 AM, Licensed Nurse (LN) G entered the resident's room to assist with cares. Certified Nurse Aide (CNA) N and LN G turned the resident onto her left side in bed, exposing her bare buttocks to the window, which had opened blinds. LN G provided peri-care with the resident's buttocks fully exposed. On 08/30/23 at 09:20 AM, CNA N stated the window blinds should be closed when staff perform cares with the resident. On 08/30/23 at 09:28 AM, LN G stated the blinds should have been closed while staff were providing cares. On 08/31/23 at 10:58 AM, Administrative Nurse E stated the staff should always close the window blinds while performing cares with residents. The facility policy for Quality of Life--Dignity, revised August 2009, included: Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The facility failed to provide dignity for this dependent resident while providing peri-care by failing to close the window blinds, which exposed the resident's bare buttocks. - Resident (R)10's electronic medical record (EMR), revealed a diagnosis of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. He had an indwelling urinary catheter (a closed sterile system with a catheter and retention balloon that is inserted through the urethra or to allow for bladder drainage). He required total assistance of one staff for toileting. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/19/23, documented the resident had urinary retention (inability to urinate). He required staff assistance to maintain his catheter. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of six, indicating severe cognitive impairment. He had an indwelling urinary catheter and required supervision for toileting. The urinary catheter care plan, revised 06/14/23, instructed staff to flush the catheter with sterile water, as ordered. Review of the resident's EMR, revealed the following order: Flush and irrigate the resident's urinary catheter with 60-120 cubic centimeters (cc's) of sterile water every day and as needed (PRN), ordered 05/11/23. On 08/30/23 at 01:52 PM, Licensed Nurse (LN) G gathered his supplies and entered the resident's room to flush the catheter tubing and provide catheter care. LN G had the resident assist to lower his pants down to his ankles and sit on the recliner while performing cares. While performing cares, Administrative Nurse E knocked on the door and walked through the door without waiting for an answer from the resident or the staff. Administrative Nurse E then left the room by opening the door to the resident's room, which placed the resident into view of other residents, staff or visitors in the hallway, as he sat naked from mid-chest to his ankles. At one point while performing cares, LN G opened the resident's door and exited for further supplies. LN G then re-opened the door to re-enter the room, which placed the resident into view of other residents, staff or visitors in the hallway, as he sat naked from mid-chest to his ankles. On 08/30/23 at 03:51 PM, LN G stated the resident did not want his blinds closed at any time but the resident should have been covered before the door to his room was opened as the resident was half naked in his chair and the door being opened put him into view of anyone in the hallway. On 08/31/23 at 10:58 AM, Administrative Nurse E stated the resident should not be exposed at any time. The facility policy for Quality of Life--Dignity, revised August 2009, included: Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. The facility failed to cover this dependent resident during catheter cares when the door to his room was opened two times by staff, exposing him to anyone who may have been in the hallway. 28560 - Review of Resident (R)26's Physician Order Sheet, dated 06/13/23, revealed diagnoses included dementia (progressive mental disorder characterized by failing memory and confusion,) heart failure, and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin.) The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The resident required limited assistance of one staff for dressing. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/15/23, assessed the resident did not trigger for this resident. The Quarterly Minimum Data Set, dated dated [DATE], assessed the resident with a BIMS score of five, and required extensive assistance of one staff for dressing. The Care Plan, dated 08/04/23, instructed staff to monitor the resident for his general awareness, he had difficulty understanding others and difficulty with personal hygiene. Observation, on 08/29/23 at 08:30 AM, revealed the resident seated in his wheelchair in the dining room. The resident's tee shirt hem was scrunched up above his exposed abdomen. Observation on 08/29/23 at 11:03 AM, revealed the resident seated in the common lobby area with his tee shirt scrunched above his exposed abdomen. Various Nursing Staff walked by the resident without assisting him with clothing adjustment. Observation, on 08/29/23 at 11:15 AM, R12 walked by the resident and suggested he pull his shirt down. The resident did not respond to the request. Interview, on 08/29/23 at 11:30 AM, with Licensed Nurse G, revealed he would expect staff to assist the resident to adjust clothing. Interview, on 08/30/23 at 03:14 PM, with certified Nurse Aide (CNA) P, revealed the resident required extensive assistance with ADL's and cooperated with instructions. Interview, on 08/31/23 at 11:21 AM, with Administrative Nurse E, revealed she would expect staff dress the resident appropriately and adjust clothing as needed. Administrative Nurse E stated she would investigate to ensure the resident had clothing that fit appropriately. The facility policy for Quality of Life--Dignity, revised August 2009, instructed staff to promote maintain and protect resident privacy. The facility policy Activities of Daily Living (ADL) dated 10/2022, instructed staff to provide ADL's for residents to maintain good grooming and personal hygiene. The facility failed to ensure this resident's dignity in the common areas of the facility, when staff failed to assist clothing adjustment for this resident that required extensive staff assistance with dressing.

The facility reported a census of 32 residents with 16 residents sampled including one resident reviewed for bowel and bladder. Based on observation, interview, and record review, the facility failed to develop and implement an effective individualized toileting program to maintain as much bladder function as possible for one Resident, (R)18. Findings included: - Review of Resident (R)18's electronic medical record (EMR) revealed a diagnosis of overactive bladder (OAB--causes a frequent and sudden urge to urinate). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. She required limited assistance of one staff for toileting and was frequently incontinent of urine. She lacked a toileting program. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 06/19/23, documented the resident required limited assistance with toileting and was frequently incontinent. Staff were to ensure the resident received assistance with toileting and to ensure her brief was changed following each incontinent episode. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and was frequently incontinent of urine. She lacked a toileting program. The care plan for bowel and bladder, revised 06/19/23, instructed staff to assist the resident with following her toileting program, however, there was no documented toileting program. Review of the resident's EMR documented she required extensive assistance of one to two staff for toileting and was always incontinent of urine. Review of the resident's EMR from 08/02/23 through 08/30/23, documented staff were to toilet the resident at the following times: 07:00 AM, 09:00 AM, 11:00 AM, 01:00 PM, 03:00 PM, 06:00 PM, 08:00 PM and 03:00 AM. On 08/30/23 at 07:30 AM, the resident rested in bed with her eyes closed. The resident remained in bed without an offer to toilet until 11:00 AM, when CNA N entered the room to dress the resident. CNA N removed the resident's wet brief and performed peri-care (the cleansing of the genitals), put on a new brief and dressed the resident. CNA N did not offer the resident the use of a bedpan for urination. On 08/30/23 at 01:45 PM, the resident sat in her wheelchair looking out of the dining room window. At 04:00 PM, the resident remained in her wheelchair in the dining room. No staff offered to a bedpan/toilet to the resident for urination. On 08/30/23 at 11:00 AM, CNA N stated the resident's brief was wet when changed. CNA stated the bedpan would be offered at times for the resident, but not always. CNA N confirmed the resident did not currently have a bedpan in her room. On 08/30/23 at 11:19 AM, CNA O stated the resident was able to say when she needed to toilet at times. CNA O confirmed the resident did not have a bedpan in her room. Staff were currently just changing her brief every couple of hours. The resident had mostly been continent of urine before her hospitalization in July, 2023. The resident was working with therapy to regain strength. On 08/30/23 at 03:39 PM, CNA P stated the resident was currently just check and change for her toileting needs. CNA P stated she had not offered the resident a bed pan for urination. On 08/30/23 at 03:51 PM, Licensed Nurse (LN) G stated the resident was able to say when she needed to toilet. Staff toilet her every two and a half hours or so. They do not offer her a bed pan to help with her bladder continence. On 08/31/23 at 10:58 AM, Administrative Nurse E stated the staff should offer the resident a bedpan for toileting to assist the resident to retain as much bladder continence as possible. The facility policy for Activities of Daily Living, revised 10/2022, included: The facility will provide a maintenance program to assist the resident to achieve and maintain the highest practicable outcome. The facility failed to develop and implement an effective individualized toileting program to maintain as much bladder function as possible for this resident.

The facility reported a census of 34 residents, with 6 selected for review. Based on observations, interview, and record review, the facility failed to adequately assess a change in condition and seek treatment in a timely manner, for one (#4) of the 6 selected residents with signs or symptoms of [MEDICAL CONDITION], and required blood transfusion. Findings included: - A review of resident #4's computerized medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A significant change MDS (minimum data set), dated [DATE], revealed staff assessed the resident as severely impaired cognitively with a BIMS (Brief Interview for Mental Status) score of 3. Furthermore, staff assessed the resident with, disorganized thinking that fluctuated throughout the day, and verbal behavior symptoms directed toward others for ,[DATE] days, during the 7 day look-back period. The resident required: extensive assistance of 2 persons for bed mobility, transfer, toilet use, and personal hygiene; and limited assistance of 1 person for eating. The care plan, last reviewed on [DATE], directed staff, "...The nurses monitor me each shift for potential side effects and report to my doctor if any are seen. ...Pharmacist and PCP (primary care physician) reviewed meds (medications) for drug to drug interactions, labs (laboratory values) monitored as needed." A physician's orders [REDACTED]. A nurses note, dated [DATE] at 1:39 PM, documented, "Resident out of facility in AM via facility van with staff for Dr. appt. (appointment) and returned to facility at 12:10 (PM) with orders to continue [MEDICATION NAME] 5 mg PO daily and may increase to 7.5 mg in one week if continual agitation and pain med (medication) seem satisfactory..." A nurses note, dated [DATE] at 11:05 PM, documented, "Resident noted to have black stools this evening. (Physician L) faxed and notified of this and reminded (the physician) of recently starting [MEDICATION NAME] as this is a known s/e (side effect) of this drug. Resident has no c/o (complaints of) GI (gastrointestinal) distress (abdominal discomfort, excess bloating/girth, etc (etcetera))." The clinical record lacked evidence the facility received a response from the fax sent to the resident's physician and lacked evidence the facility attempted to contact the physician by a different means, when the facility lacked a physician response to the fax. Routine lab results, date collected [DATE], and date reported [DATE], revealed a low RBC (Red Blood Cell) count of 2.38 with a reference range of 3.90- 5.20, a low hemoglobin (HGB) of 7.7 with range of 11XXX,[DATE].0, a low hematocrit (HCT) of 26.2 with a reference range of 34XXX,[DATE].5. Previous lab results, on [DATE] and on [DATE], revealed RBC, HGB, and HCT all normal within the reference range. A nurses note, dated [DATE] at 10:14 AM (six days after the abnormal lab reported and 12 days after the resident had a black stool, a symptom of a [MEDICAL CONDITION]), documented, "Phone call made to PCP office, spoke with (the office nurse), (the physician's) nurse. Asked nurse to have PCP review res (resident) latest Lab results of [DATE] especially noting H/H (HGB/HCT) results. (Physician's office) nurse indicates that (he/she) does not find these results in their computer & (and) asked that they could be refaxed & this is done. Awaiting return call from PCP at this time." A nurses note, dated [DATE] at 11:11 AM, documented, "Rec'd (received) return call from PCP with the following orders: 1) Type & cross for 2 units of packed red blood cells, give 2 units of packed red cells (6 days after HGB value of 7.7); 2) Pretreat with Tylenol 500 mg & [MEDICATION NAME] 12.5 mg orally; 3) 20 mg of IV [MEDICATION NAME] between units; 4) draw Vitamin B12 level & foliate acid level and a ferritin level; 5) Resident's HGB on [DATE] was 7.7..." On [DATE] at 9:10 AM, direct care staff I, assisted the resident into the dining room via wheel chair. Staff I fed the resident, and then the resident picked up (his/her) own toast. The resident yelled out, " Help me God, I died and went to Heaven. " On [DATE] at 10:12 AM, direct care staff I and E assisted the resident to the toilet in the central bathroom. The resident stated, " Put me on my bed before I fall. I falled ... I fell , (he/she) won ' t let me. ... I fell ," and the resident sat back down onto the toilet. On [DATE] at 2:00 PM, the resident returned to the facility, direct care staff N reported the resident returned from the hospital for lab work. On [DATE] at 4:45 PM, staff reported the resident was out of the facility to receive a blood transfusion. On [DATE] at 8:30 AM, the resident rested in bed with (his/her) eyes closed and heavy breathing/ snoring. On [DATE] at 2:30 PM, licensed nursing staff B reported the physician was on vacation the first of the month. The physician usually returns faxes/ calls promptly, this is unusual for this physician. Staff B added, the resident returned to the facility at 7:15 AM this morning and "(The resident) was tired. (He/She) wouldn't get up this morning." The facility provided a copy of the lab results which included "Faxed [DATE] (initials of the nurse)," a line and "Refaxed [DATE] (initials), [DATE] (initials)." The fax notification included, "Resident noted to have black stools this p.m. (not usual for res) - Res recently started [MEDICATION NAME] ([DATE]) & this is a possible side effect. What would you like to do? [DATE] refaxed (initials), [DATE] (initials) refaxed, [DATE] 4th fax (initials), [DATE] refaxed (initials)." On [DATE] at 3:43 PM, administrative nursing staff A reported an attempt to call the night nurse (from the nurses note on [DATE] related to the black stool, "To see if (the nurse) called (the physician that night)," but the nurse failed to return the call to the facility. Staff A confirmed no additional documentation of staff notification of the physician located in the medical record. Furthermore, staff A reported, "They (facility nursing staff) should have called (the physician)," and referred to a program of, "Interact- Critical Care Pathways... We've had it, but we haven't had our in-service on the 3.0 (a new version). ...It would have been a judgement call, but yeah (the nurse) should have." On [DATE] at 4:00 PM, physician L reported, "(The resident's) hemoglobin in the past, it's been 8. something ...(He's/She's) had some [MEDICAL CONDITION]. At what point in time do you not aggressive treat, and the question of, What are we going to do about this?' ...I was gone for two weeks, and got back Sunday ([DATE]). I think, on the 6th it (the lab results) came to the office." Surveyor R read the report date collected ,[DATE], received ,[DATE], and not reported until [DATE]. The physician again replied, "It hit our computer system on ,[DATE]." Upon questioning of the coverage of the resident when Physician L is out of town, physician L replied, "...There is usually a nurse clinician or my partner, (another physician)." Physician L added, "In the past, at 8.5 we would think about giving blood ... The standard in the hospital is below 8 to transfuse. ...When I came back on the 11th, and I would have looked at it. ...If anyone's in error, I didn't look at it until the 12th." On [DATE] at 4:14 PM, when questioned for the reasoning the lab completed on [DATE] as routine, administrative nursing staff C replied, "Yeah, that's what it looks like (routine laboratory draw). " A nurses note, dated [DATE] at 11:42 AM, by administrative nursing staff A, documented, " On [DATE] at 23:05 (11:05 PM) the charge nurse on duty received report from staff that elder had a ' black stool. ' The charge nurse that it was reported to did not see the ' black stool ' but did fax the elder ' s PCP to inform (him/her) of what was reported to (the nurse). The charge nurse included information from healthyplace.com that stated ' black stools ' are a rare side effect of [MEDICATION NAME] use in the fax. ...Charge nurse reported to this DON (director of nursing) that there were no further reports of ' black stools ' from staff. " From " healthyplace.com- [MEDICATION NAME], " retrieved on [DATE] at 12:20 PM, included, " Other adverse events ... Digestive System -- Frequent: ...melena (abnormal black tarry stool that has a distinctive odor and contains digested blood)..." The facility policy, "Change in Condition- When to report to the MD (medical doctor) /NP (nurse practitioner) /PA (physician ' s assistant), dated ,[DATE], directed staff, " Immediate Notification Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and : A Marked Change (i.e. (for instance) more severe) in relation to usual symptoms and signs ... A Critical lab value ... " The facility failed to adequately assess and ensure timely notification of the physician with response, in regards to the drop in hemoglobin, and in regards to a black, potentially bloody stool. The resident required medical treatment and received a blood transfusion to stabilize their condition.