Every finding on record at Natchez Rehabilitation and Healthcare Center

Based on observations, interviews and record reviews the facility failed to identify and provide needed resident-centered care for a resident who is unable to carry out Activities of Daily Living (ADL) to maintain good personal hygiene for one (1) of three (3) sampled residents, Resident #1. Findings include:Record review of the admission Record for Resident #1, revealed the facility initially admitted the resident on 9/04/2018 and the resident had diagnoses of diabetes, schizophrenia, peripheral vascular disease (PVD), and malignant neoplasm of prostate.Record review of the Other Payment Assessment Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/29/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. Record review of the Care Plan for Resident #1 revealed the resident had a Focus listed as Resident is at risk for further decline in cognition with intervention included as COMMUNICATION .The resident understands consistent, simple directive sentences. Provide the resident with necessary cues- stop and return if agitated. On 12/02/25 at 10:59 AM during a telephone interview with the complainant for Complaint 2668575, she revealed that she was concerned because the last time she had been able to visit in 2024 Resident #1 was wearing clothes wet with urine and had an odor.On 12/02/25 at 1:00 PM observation and interview revealed Resident #1 walking in the hallway of the facility and sitting in the front lobby. The resident was neat, clean, and dressed appropriately with a malodorous smell. Resident #1 had a slight, short, grey facial beard, and reported that the staff assisted him with shaving on his shower days and that he was satisfied with that.On 12/02/25 at 1:20 PM an interview with the Social Services Director (SSD) revealed she was familiar with Resident #1 and his family member who had his Power of Attorney. She stated that she had spoken several times with the complainant regarding care plans, care plan meetings and the financial account of Resident #1. She reported that the complainant had visited the facility last on 7/26/24 and that the complainant refused to sign paperwork related to becoming the Resident Representative (RR) for the resident, who preferred at the time to act as his own RR and at the time had the capability to do so. The SSD confirmed that in July to August 2025 Resident #1 had a change in cognition and behavior with increased confusion; she confirmed that the resident was no longer cognitively able to make decision for himself regarding his care.On 12/02/25 at 4:35 PM observation and interview with Resident #1 revealed the resident had a foul odor of urine and feces. He sat in a chair with [NAME] upholstery, when he stood up he left two wet spots on the chair and there were corresponding wet spots approximately five (5) inches by three (3) inches, approximately the size of a standard index card, on each side of the back of his cotton pants.On 12/02/25 at 4:45 PM observation of the Room of Resident #1 revealed Resident #1's bed was unmade and there was fecal matter on the fitted and top sheet on his bed, and the room had a foul odor of urine and feces observable from outside the resident's room in the hallway.On 12/02/25 at 4:50 PM observation of Resident #1 and interview with the Director of Nursing (DON) revealed she stated that Resident #1 smelled awful and noted that the resident had a colostomy bag and was incontinent of bladder and wore incontinence briefs, which he insisted on changing himself. She stated that the resident had a history of refusal of care. She said the resident also had history of picking at his colostomy bag resulting in leakage of his bag, but that the facility had not attempted any intervention to prevent the behavior. Observation revealed that during an interaction between the DON and Resident #1, the DON offered assistance to the resident with hygiene and the resident told the DON that he did not smell bad, which indicated a lack of self-awareness, but went with her willingly and without complaint to his room where the DON changed the sheets on the resident's bed, and provided supplies and assistance for hygiene and incontinence care for Resident #1 without problem. She stated that the residents also frequently refused bathing activities, and the facility staff had not attempted provision of incentives to cooperate with care.On 12/03/25 at 11:40 AM observation revealed Resident #1 was walking around in the hallway and lobby wearing cotton knit pants with an approximately three (3) by five (5) inch wet area in the middle of the seat of his pants. The resident's pants left a corresponding wet spot on the chair he sat in in the DON's office.On 12/03/25 at 2:45 PM an interview with Certified Nursing Assistant (CNA) #1 revealed the facility had provided in-service training via computer software regarding provision of care for residents with dementia, confusion and difficult behaviors. She confirmed that Resident #1 was able to provide some self-care and required supervision and set-up assistance. She explained that he required reminders and encouragement for bathing activities and that he would go change his pants if they became wet with urine upon request/reminders by staff. On 12/03/25 at 2:51 PM during an interview Licensed Practical Nurse (LPN) #1 confirmed that the facility provided in-service training via computer software regarding provision of care for residents with dementia, confusion and difficult behaviors. She confirmed that Resident #1 was able to provide some self-care and required supervision and set-up assistance. She explained that he required reminders and encouragement for bathing activities and that he would go change his pants if they became wet with urine upon request/reminders by staff.

Based on observation, interview, record review, and facility policy review the facility failed to ensure oxygen (O2) therapy was safely and effectively administered and monitored reviewed as evidenced by, failure to post oxygen signage outside the resident's room to indicate oxygen in use, and the nasal cannula was not worn as ordered for one (1) of three (3) residents reviewed for oxygen therapy. (Resident # 48)Findings include:Record review of the facility's policy Oxygen Administration and Oxygen Safety review and revised dated 07/23/2025 revealed .6. The No Smoking/Oxygen in Use signs; shall be visible where oxygen is stored or administered .During an observation on 9/22/25 at 1:05 PM, Resident #48 was observed lying in bed, alert and talkative, though she stated she was tired. Oxygen was in progress at 2 liters per minute (L/min) via nasal cannula. The nasal cannula was noted to be under the resident's chin and not properly in use. Additionally, there was no signage on the door indicating that oxygen was in use in the room. The Director of Nursing (DON) was brought to the room and confirmed the absence of the signage. She immediately placed an oxygen precaution sign on the door.During an interview on 9/24/25 at 8:35 AM, Licensed Practical Nurse (LPN) #2, stated that the resident is often noncompliant with keeping her nasal cannula in place and that staff frequently check to ensure the cannula is worn appropriately.During an interview on 9/24/25 at 11:05 AM, the Administrator acknowledged understanding of the importance of oxygen signage for fire safety and staff awareness. During an interview on 9/24/25 at 11:08 AM, the DON also confirmed understanding of the importance of posting an oxygen sign on the door when oxygen therapy is in use.A record review of the admission Record revealed the facility admitted Resident #48 on 8/29/23 with diagnoses including morbid (Severe) obesity with alveolar hypoventilation and unspecified anxiety disorder. The resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. Section O of the MDS indicated the resident required oxygen therapy.A record review of the physician orders revealed an order 8/15/24 O2 at 2 liters per minute via nasal cannula every shift related to morbid obesity with alveolar hypoventilation.

Based on observation, interview, record review, and facility policy review the facility failed to reasonably accommodate the food preference communication needs of two (2) of (18) residents reviewed for choice and preferences (Resident #27 and Resident #45). Findings include: A review of the facility policy, Resident Rights (Federal) revised 1/11/24 reveals, Resident has right to a dignified existence, self-determination and communication with and access to persons and services inside and outside Facility.1. Exercise of Rights.b. Resident is encouraged and assisted in the exercise of his/her rights.During an interview on 9/24/25 at 2:42 PM, the Social Services Director stated that Neighbors are department heads assigned to specific resident rooms and are responsible for visiting residents daily before the morning meeting. She explained their duties include informing residents of the menu options and collecting their meal preferences, particularly for those who do not or cannot leave their rooms.During an observation and interview at 2:53 PM, on 9/24/25 revealed that no food menus were posted or visibly available in the shared room of Residents #27 and #45. Observed a color photo of the Business Office Manager (BOM) as the Neighbor assigned to Resident's #27 and #45's room. Resident #27 stated she does not typically leave her room except to smoke, and she is unaware of the daily menu. She stated that she would like the opportunity to choose her meals but often sends trays back when the food provided is unappealing. She noted that due to her eye condition, she cannot see the posted menus and needs either a large-print menu or someone to read it aloud to her. She also stated that someone used to come around and ask for her food preferences, but no one has done so in months. She added that she was unaware of having a designated Nexion Neighbor. During an interview at 2:56 PM on 9/24/25, with Resident #45, the resident shared that due to mobility challenges related to her legs, she is unable to leave her room without staff assistance. She expressed concern regarding the facility's food service, stating that she frequently sends her meal tray back because the food provided does not align with her preferences. The resident indicated a desire to be informed of her meal options prior to tray delivery so she can make a selection based on her preferences. She mentioned that she has occasionally asked a Certified Nursing Assistant (CNA) about the menu but refrains from doing so regularly, as she does not want to inconvenience staff during mealtimes. The resident reported that she does not have a menu available in her room and wishes her dietary needs could be better accommodated. Additionally, she noted that it has been some time since anyone has come to assist or volunteer in showing residents the menu, and she was unaware that a designated individual was assigned to help with this process.During an interview at 3:13 PM on 9/24/25, Licensed Practical Nurse (LPN) #1 confirmed that Resident #27 has a diagnosed vision impairment and is generally room-bound due to fear of germs. She reported that she had seen the resident using a magnifying glass and agreed the resident could benefit from an enlarged or verbally presented menu.During an interview at 4:10 PM on 9/24/25, the Administrator stated that each department head is assigned as a Neighbor to specific rooms. Their responsibilities include greeting residents, ensuring cleanliness, and informing them of the daily and alternate menu options. The residents' preferences are to be relayed to dietary staff. She also stated that each Neighbor's picture is placed in the resident's room for identification.During an interview at 4:13 PM on 9/24/25, with the BOM, the assigned Neighbor for Residents #27 and #45, she confirmed that she did not enter the room on 9/24/25 and only briefly entered on 9/23/25 while both residents were asleep. She stated she did not discuss or collect menu choices during these visits and has not done so in the past.Resident #27A record review of the admission Record revealed the facility admitted Resident #27 on 9/13/23 with diagnoses including macular degeneration, bilateral and muscle weakness.A record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/8/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #45A record review of the admission Record, revealed the facility admitted the Resident #45 on 2/26/25 with diagnoses that included muscle weakness (generalized) and fibromyalgia.A record review of the MDS with an ARD of 8/19/25 revealed a BIMS score of eight (8) indicating the resident had moderate cognitive impairment.

Based on observation, facility policy review, record review and interviews, the facility failed to ensure a cognitively impaired resident received adequate supervision to prevent elopement when Resident #1 was left unattended and unsupervised in the facility van at a local gas station. Resident #1 exited the facility van and was unsupervised by facility staff for (40) minutes until the resident was observed by a community member 0.8 miles from the gas station where the resident had exited the van and was walking along the sidewalk. This was 1.3 miles from the facility. Resident #1 was returned to the facility. This was for one (1) of four (4) sampled residents dependent on the facility for transportation. Resident #1.The facility's failure to provide adequate supervision to prevent the elopement of Resident #1 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death. The facility's failure to identify the need for adequate supervision and ensure a secure environment contributed to Resident #1's elopement and placed all residents who were admitted with or developed wandering/exit seeking behaviors at risk. This failure resulted in Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 10/10/25.The SA notified the facility's Administrator of the IJ and SQC on 10/14/2025 at 3:15 PM and provided the Administrator with the IJ templates. Based on the facility's implementation of corrective actions on 10/13/25, the State Agency (SA) determined the IJ and SQC to be Past Non-compliance (PNC) and the IJ removed on 10/14/25.Findings Included:Record review of the facility policy titled, Driver and Vehicle Safety Policy revised 3/2025, revealed .Employees driving the company vehicle shall also: Have another employee ride with the driver if transporting residents who need assistance, including, but not limited to, lifting or medical assistance; Never leave a resident unattended in a vehicle.Record review of the facility policy titled, Wander Management, Monitoring System & Resident Elopement Protocol revised 7/01/25, revealed, Purpose To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible.Record review of the final facility investigation, dated 10/13/25 revealed that on 10/10/25 at approximately 1:30 PM, Resident #1 was left unattended and unsupervised in the facility van during transportation back to the facility from a physician appointment and exited the van without knowledge of the facility Transportation Aide (TA) who discovered that he was missing from the van at approximately 1:38 PM. According to the Facility Investigation Resident #1 was located by a community member at approximately 2:14 PM, walking along a sidewalk approximately 0.8 miles from the gas station and returned to the facility at approximately 2:17 PM; the resident was unsupervised by facility staff for approximately (40) minutes.Record review of the Wander Data Collection assessment dated [DATE] revealed the facility assessed Resident #1 as low risk for unsafe wandering/elopement. On 10/14/25 at 11:00 AM, during an interview the Director of Nursing (DON) stated that she was notified of the elopement of Resident #1 by the Transportation Aide (TA) at approximately 1:47 PM on 10/10/25. She reported that the State Agency (SA) was notified of the elopement on 10/10/25 at 4:45 PM, and thorough investigation was conducted. She stated that based on security camera footage at the gas station it was confirmed Resident #1had exited the van unaccompanied and unsupervised at approximately 1:38 PM. The DON stated that a community member familiar with the resident was driving in the area and observed Resident #1 walking along a sidewalk approximately 0.8 miles from the gas station and returned him to the facility. The DON confirmed that the Quality Assurance (QA) committee met and determined that the root cause of the elopement was determined to be that the cognitively impaired resident was left unsupervised in the facility van during transport and the during the QA meeting on 10/13/25 facility procedure for transportation of residents was changed to include two staff for all transportation of residents to ensure at least one staff would be present to always provide supervision of residents during transportation. She reported that Resident #1 had had a change of cognition for which a Significant Change Minimum Data Set (MDS) was completed on 9/29/25 with a Brief Interview for Mental Status (BIMS) assessment resulting in a score of 6, which indicated severe cognitive impairment. She stated that Resident #1 had no previous elopement behaviors and was assessed as low risk for elopement during 9/27/25 assessment. On 10/14/25 at 11:35 AM, an interview with the Administrator revealed that on 10/10/25 she was out of state and the Director of Nurses (DON) served as her designee at the facility during her absence.On 10/14/25 at 1:00 PM, an interview with the Transportation Aide (TA) revealed she had transported Resident #1 to a physician's appointment in a town approximately sixty (60) miles away and during transport back to the facility following his appointment, she stopped at a local gas station and put gas into the facility van. She stated that after putting gas into the van she went into the station to pay for the gas and left Resident #1 unattended and unsupervised in the facility van. She said that upon her return to the van approximately two (2) minutes after she left the resident seated in the front passenger seat of the van wearing his seatbelt, she observed that the resident was not seated in the van as she had left him. She said she had immediately searched the van and the outdoor area around the van and station and inside the station and its bathrooms without locating the resident. She said she then telephoned the facility DON as the Administrator was out of the state.On 10/14/25 at 1:30 PM, observation at the gas station where Resident #1 was last observed by facility staff prior to elopement on 10/10/25 revealed the station was situated between four streets with one traffic light in front and one traffic light behind and to the south of the building. The speed limit was (25) miles per hour with no noted crosswalks. The station had (12) pumping stations in front and (12) parking spots in front with one handicapped parking space. There were four (4) vehicles at pumping stations and six (6) vehicles in parking spaces. During a five (5) minute observation there were (15) vehicles that traveled the street to the north of the station and (26) vehicles that traveled the street to the south of the station. The concrete parking and pumping areas in front of the station were well maintained and even with a slight decline down to the street to the south. Observation revealed the place where Resident #1 was located was approximately 0.8 miles from the gas station on a mixed commercial/residential street with intact and well-maintained sidewalks and a (25) mile an hour speed limit.On 10/15/25 at 3:30 PM, an interview with the facility Administrator confirmed that all steps on the facility's Corrective Action Plan had been completed as of 10/13/25.Record review of the weather history according to Weather25.com, revealed the weather in the locale of and on the date of the elopement was overcast with no rain and seventy-seven (77) degrees Fahrenheit with winds at six (6) miles per hour.Record review of the admission Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included undifferentiated schizophrenia and anxiety disorder.Record review of the Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/29/25 for Resident #1 revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. The facility assessed the resident with the ability to walk at least 150 feet in a corridor or similar space.Corrective Action Plan:1. The facility failed to provide supervision to prevent the elopement of Resident #1, who was severely cognitively impaired and was left in the facility van unattended and exited the van unattended. This failure allowed Resident #1 to be unsupervised on October 10, 2025, from 1:36pm until 2:17pm, at which Resident #1 returned to the facility. Facility was immediately aware of Resident #1 exiting the van and immediately took appropriate action to locate the resident.2. The following parties were notified of the incident: Natchez Police Department was notified October 10, 2025 at 1:57pm. Local Ombudsman was notified October 10, 2025 at 2:46pm. Primary Physician was notified October 10, 2025 at 3:07pm. Medical Director was notified October 10, 2025 at 3:07pm Mississippi State Department of Health was notified October 10, 2025 at 4:55pm. Mississippi State Attorney General was notified October 10, 2025, at 4:55pm.3. Resident #1 returned to facility at 2:17pm.4. Fully body audit performed by Director of Nursing (DON) at approximately 2:20pm October 10, 2025, with no negative findings.5. Wander Guard placed on Resident #1 at 2:20pm by Director of Nursing (DON).6. On October 10, 2025, beginning at approximately 2:30pm the Unit Manager initiated education with staff, including Certified Nursing Assistants, licensed nurses, housekeeping staff, business office staff, therapy staff, dietary staff and administrative staff on Elopement Policy with corresponding quiz, Abuse and Neglect Prohibition Policy, Resident Rights, Vulnerable Adult Act. Education was initiated with all authorized van drivers on Safe Transportation of Residents.7. An elopement drill and 100% census verification was conducted by Director of Nursing (DON) at approximately 2:47pm October 10, 2025 for 2 shifts. The 3rd shift elopement drill and census verification was conducted by Director of Nursing (DON) at 7:00am October 11, 2025.8. Resident was placed on 1:1 observation at 3:00pm October 10, 2025 and remained on 1:1 until 7:00am October 13, 2025.9. Incident reported initiated by Director of Nursing (DON) at 3:04pm October 10, 2025.10. Wander guard assessments were reviewed for accuracy by Director of Nursing (DON) at approximately 3:30pm October 10, 2025 for all residents to ascertain the risk for wandering, and to ensure appropriate interventions were implemented.11. Wander Guard system checked at approximately 3:30pm October 10, 2025 on all exit doors by Director of Nursing (DON) with no negative findings.12. Elopement Risks Binder was reviewed and updated as needed by Director of Nursing (DON) at approximately 3:45pm 10/10/2025.13. Care plans related to residents identified as elopement risk were reviewed and updated accordingly by Minimum Data Set Coordinator (MDS) at approximately 4:00pm October 10, 2025.14. Certified Nursing Assistant #1 was issued a Disciplinary Action for not following policy at approximately 5:00pm October 10, 2025.15. On October 13, 2025, at 10:44am, the Medical Director, Administrator, Director of Nursing, Unit Manager, Social Services Director, Activities Director, Business Office Manager, Director of Rehab, Minimum Data Set Coordinator, Wound Care RN, Medical Records Director, Dietary Manager, Environmental Services Manager, Human Resource Generalist held Quality Assurance Performance Improvement meeting to review steps initiated to prevent future reoccurrence. There were no new policy changes, but new procedures were put in place.16. All corrective actions were completed on October 13, 2025, and the Immediate Jeopardy was removed on October 14, 2025.17. In order to monitor current residents for potential risk, residents will be monitored by the Director of Nursing (DON) through incident report review, observations and communication with staff. The Administrator or Maintenance Director will conduct elopement drills quarterly for up to a year and then bi-annually thereafter. The Administrator or Maintenance Director will conduct staff training elopement drill monthly with rotating shifts until all shifts are completed for three(3) months and then quarterly thereafter. The facility Quality Assurance Committee will meet weekly for the next eight(8) weeks to review compliance with the Corrective Action Plan. If no further concerns are noted, we will continue to monitor as per routine facility Quality Assurance Committee.On 10/15/25, SA validations were completed onsite during the complaint investigation through interviews, observations and record reviews that all corrective actions had been taken by the facility on 10/13/25 to remove the IJ and the IJ was removed on 10/14/25.

Based on interviews and record review of the Certification and Survey Provider Enhanced Reports (Casper) reporting data review, the provider failed to ensure their Payroll Based Journal (PBJ), (information on the staffing hours for the appropriate care of the residents) had been corrected before submitting to the Center for Medicare and Medicaid Services (CMS) for the first Quarter of the 2024 Fiscal Year (October 1, 2023-December 31, 2023). Findings Include: Review of the provider's [NAME] reporting data revealed the facility triggered excessively low weekend staffing for the first quarter of the 2024 fiscal year. Record review of facility policy titled, Staffing Policy, revised October 2017 revealed,Policy Statement: Our facility provides sufficient numbers of staff with skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. Policy interpretation and implementation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and skill requirements of direct care staff are determined by the needs of residents based on each plan of care . 4. Direct care staffing information per day . is submitted to CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter . On 06/03/24 at 1:45 PM, an interview with the Director of Nurses (DON) revealed she is responsible for making schedules monthly for Certified Nurse Aides (CNA) and Nurses. She explained the facility nurses operate on 8 (eight) hour shifts, with staffing 4 -5 (four to five) CNAs on the 7:00 AM to 3:00 PM shift; 3-4 (three to four) CNAs work on during the 3:00 PM to 11:00 PM shift, and 2-3 (two-three) CNAs work on the 11:00 PM to 7:00 AM shift. The facility has 2 (two) Licensed Practical Nurses (LPNs) that serve as medication carts nurses on each shift and a Registered Nurse (RN)/Charge Nurse that works 7:00 AM to 3:00 PM on weekdays and 6:00 AM to 6:00 PM on Saturdays and Sundays. The DON also revealed that the facility has PRN (as needed) staff to fill in gaps on weekends. A record review of facility staffing of the facility staffing grid and working schedule for October 1, 2023-December 31, 2023, revealed sufficient staffing. During an interview on 6/03/24 at 2:13 PM, the Administrator and HR Generalist confirmed the facility failed to accurately report there were sufficient staff to meet the facility needs. She revealed the HR (Human Resource) Generalist is responsible for putting staffing hours into the system. However, the HR Specialist was new and unaware that she was supposed to submit documentation to the corporate office regarding the staff that worked and salaried employees that work additional hours as needed to meet the needs of the residents, and any overtime hours. The Administrator explained that the facility system data is submitted to the Corporate office, and that, along with any additional staffing hours submitted by the HR Specialist, are added to adjust the hours prior to the Corporate office submitting the PBJ to CMS. The Administrator confirmed she was not aware the PBJ triggered low weekend staffing for the first quarter for excessively low weekend staff. The HR Generalist confirmed that after working with the corporate office to investigate the issue regarding the reported low weekend staffing during the first quarter of the 2024, the facility had failed to accurately report additional staffing hours that were worked to corporate. Those addition staffing hours would have been added by the corporate office to the system prior to submission of the PBJ to CMS.

Based on observation, staff and resident interviews, record reviews, and facility policy reviews, the facility failed to provide an ongoing weekend activity program to support residents in their choice of activities for two (2) of seventeen (17) sampled residents. Resident #18 and Resident #47. Findings Include: A review of the facility policy titled, Activity Program, dated 2001 revealed, Policy Statement: An ongoing program of activities is designed to meet the needs of each resident .Policy Interpretation and Implementation . 6. Individualized and group activities are provided that- a. Reflect the schedule, choices, and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays, and weekends; c. Reflect the cultural and religious interests of the residents . During the resident council meeting on 6/02/24 at 2:00 PM, several residents expressed they were disappointed the facility was not providing group activities on the weekend. The residents revealed that the facility leaves coloring books and puzzles for them, which makes them feel belittled and insulted because those are children's activities. Resident #18 On 6/5/24 at 9:10 AM, during an interview with Resident # 18, she revealed she regularly volunteers to do activities with the residents. She pointed out that activities on weekdays are not done consistently. They have not had services on Sunday in several weeks, despite it being listed on the calendar. She said that she and the others have repeatedly expressed to the Activities Director that they are offended by the puzzles and coloring sheet activities, because they are not second and third graders. She exclaimed that the people around here think because these residents are in the nursing home, they are brain-dead. They do not realize we are still adults with adult minds, so they need to provide better weekend activities that are more age appropriate. Record review of the Admission Record for Resident #18 revealed the facility admitted the resident on 10/28/22 with diagnoses including Malignant Neoplasm of Upper Outer Quadrant of Right Breast and Osteoporosis. Record review of the Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #18 was cognitively intact. Review of Section F revealed it is very important to the resident to have books, newspapers, and magazines, listen to music, be around pets, keep up with the news, do things with groups of people, do her favorite activities, get outside and get fresh air, and participate in religious practices. Resident #47 On 6/2/24 at 10:00 AM, upon Sunday's arrival at the facility, Resident #47 was observed alone in the activity area, seated at a table, looking at a blank television screen while in his wheelchair. The observation revealed that there were no churches services being held, although it was scheduled on the calendar. During an in-room interview with Resident #47 on 6/02/24 at 02:42 PM, he revealed that on the weekends, he does not have much to do regarding activities. He stated that he likes being among people and going outside but doesn't get to do that as much as he would like. On 6/3/24 at 12:22 PM, in an interview with Resident # 47, he indicated he is bored on the weekends, does not like to do puzzles or coloring, and wished there were more fun stuff to do. Record review of the Admission Record for Resident #47 revealed the facility admitted the resident on 4/24/24 with diagnoses that included Hypertension and Chronic Kidney Disease. Record review of the Admission MDS, with an ARD of 5/1/24, revealed a BIMS score of 10, which indicated Resident #47 had moderate cognitive impairment. Review of Section F revealed it was very important to the resident to do things with groups of people, perform his favorite activities, go outside to get fresh air when the weather is good, listen to music, and have books, newspapers, and magazines to read. On 6/2/24 at 10:28 AM, in an interview with the Activity Director, she indicated she does not come in on Saturdays or Sundays, and there is no other staff assigned to do activities on the weekend. She mentioned that a Certified Nursing Assistant (CNA) or nurse is supposed to do the morning exercises with residents, but there is no specific assignment. She also mentioned that, as referenced on the monthly activity calendar, there are coloring sheets and word puzzles for the residents to entertain themselves on the weekends. On 6/4/24 at 9:20 AM, in an interview with the Activity Director, she indicated they have not had church services in several weeks because the pastor, who used to come passed away. She added that they have been working on getting someone else scheduled. On 6/5/24 at 10:43 AM, during an interview with CNA #1, she revealed she has worked in the facility for the last seven years and confirms working in the facility on the weekends from time to time. She indicated that many residents watch television on the weekends, and some of them may do puzzles for activities. She also stated that no nurses or CNAs perform any type of activity with the residents from what she has observed while working on the weekends. On 6/5/24 at 10:46 AM, in an interview with the Administrator, she revealed activities are very important to their residents and that having activities can help keep them alive and going. She indicated she cannot say when the Activities Director has last reassessed the current residents to ensure the puzzles and color sheets meet their desired form of activity on the weekends. A record review of the Activity Calendar, for the month of June revealed that on both weekend days (Saturday and Sunday), the activities listed were an 8:30 AM Sit and Fit Exercise program, at 2:00 PM, there were independent activities listed, with in-room materials available at the nurse's desk, and at 6:00 PM, the activity listed was Word Puzzles/Coloring Sheets. There was an additional activity listed for Sunday, which included church services at 10:00 AM.

Based on observation, interview, and record review, the facility failed to provide positioning hand rolls for a dependent resident with contractures for one (1) of 15 residents sampled. Findings Include: Observation on 05/21/23 at 02:54 PM revealed contractures of bilateral upper extremities. The resident's fingers and hand were bent in toward the wrist. Nails were short and not pushing into the hand of the resident. No open areas noted. No hand rolls in hands. Resident nods when asked if she would like to use a hand roll for the contractures in bilateral upper extremities (BUE). Observation with Resident #35, Director of Nurses, and Charge Nurse on 05/22/23 at 01:57 PM revealed Resident was observed with contractures bilaterally. The DON and Charge nurse stated the resident does not want roles placed in hands for positioning. When the resident was asked about hand rolls she nodded yes, she would like hand roles. The DON stated previously she did not like the type of roles in hands but that maybe a different type could be used. The resident nodded. The DON stated she was going to tell PT of the resident's wishes. On 05/23/23 at 09:43 AM, an interview with the occupational therapist (OT) revealed resident wore hand roles for a while but that she when she was readmitted from hospital the hand rolls were not restarted. He stated the resident used to wear the hand rolls from late evening through the night. He says she has not been wearing them lately. On 05/23/23 09:48 AM, an interview with Physical Therapist (PT), revealed the facility has a restorative program with the CNAs, The program has check offs for the CNAs to do and stated that Nursing is over the restorative program. The last restorative training provided by PT for the CNA staff was on 4/20/23 and this is completed annually. When asked if Resident #35 is gotten up out of bed, PT stated they are a awaiting a special wheelchair for her to be able to get up. The chair has been ordered with a Medical Supply. The facility was unable to provide an order request for the wheelchair. On 05/23/23 at 10:00 AM, an observation revealed the resident with hand role carrot role in right hand. No role was observed in left hand. Review of the resident's Minimum Data Set (MDS) with assessment reference date (ARD) of 3/17/23 revealed under Section G that resident was extensive assist and totally dependent on staff for positions and mobility. The resident Brief Interview for Mental Status (BIMS) score was 99.

Based on observation, interview, record review, and facility policy review the facility ailed to implement the comprehensive care plan related to oral hygiene and positioning for one (1) of 15 sampled Residents. Resident #35 Findings Include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revealed A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The facility failed to develop a care plan for hand rolls for a resident with bilateral upper extrememity and hand contractures. Review of the resident's care plan revealed no care plan for hand rolls. Observation on 05/21/23 at 02:54 PM revealed contractures of bilateral upper extremities. The resident's fingers and hand were bent in toward the wrist. Nails were short and not pushing into the hand of the resident. No open areas noted. No hand rolls in hands. Resident nods when asked if she would like to use a hand roll for the contractures in bilateral upper extremities (BUE). Observation with Resident #35, Director of Nurses (DON), and Charge Nurse on 05/22/23 at 01:57 PM revealed Resident was observed with contractures bilaterally. When the resident was asked about hand rolls she nodded yes, she would like hand roles. On 05/23/23 at 09:43 AM, an interview with the occupational therapist (OT) revealed resident wore hand roles for a while but that she when she was readmitted from hospital the hand rolls were not restarted. He stated the resident used to wear the hand rolls from late evening through the night. He says she has not been wearing them lately. Review of Resident #35's care plan revealed the facility failed to implement the care plan for personal hygiene. Care Plan review revealed Resident is at risk for complications r/t almost totally dependent on staff for all her ADLs (Activities of Daily Living) following CVA (stroke). Observation on 05/21/23 at 02:49 PM revealed Resident #35 had mouth odor present. Teeth and mouth had build up of white sticky substance. Observation revealed approximate 0.5 inch of hair growth on [NAME]. Interview with Resident #35 on 05/21/23 at 02:49 PM revealed she was interviewable by nodding and shaking head to yes and no questions. The resident nodded yes that she would like her mouth cleaned. On 05/22/23 at 09:50 AM, observation revealed Resident's mouth remained coated with white sticky substance and hairs remained on [NAME]. Resident nodded when asked if she would like her mouth clean. Resident shook her head when asked if she likes to leave hairs on [NAME]. On 05/22/23 at 01:57 PM, observation revealed resident's [NAME] had been shaved. Record review of the Minimum Data Set (MDS) reviewed an Brief Interview for Mental Status score of 99 and was coded as responds adequately to simple direct communication only. Interview with DON revealed care plan should be followed. The DON stated the resident was under PT currently since returning from the hospital. She stated restorative would pick up once the resident comes off the PT schedule.

Based on observation, interview, record review, and facility policy review, the facility failed to provide mouth care for a dependent resident for one (1) of 15 sampled residents. Findings Include: Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Observation on 05/21/23 at 02:49 PM revealed Resident #35 had mouth odor present. Teeth and mouth were not clean as evidenced by the resident's mouth had build up of white sticky substance. Observation also revealed approximate 0.5 inch of hair growth on [NAME]. Interview with Resident #35 on 05/21/23 at 02:49 PM revealed she was interviewable by nodding and shaking head to yes and no questions. The resident nodded yes that she would like her mouth cleaned. On 05/22/23 at 09:50 AM, observation revealed Resident's mouth remained coated with white sticky substance and hairs remained on [NAME]. Resident nodded when asked if she would like her mouth clean. Resident shook her head when asked if she likes to leave hairs on [NAME]. On 05/22/23 at 01:57 PM, observation revealed resident's [NAME] had been shaved. Interview, on 05/22/23 at 01:57 PM, with the Director of Nurses, DON, and Charge Nurse revealed resident's [NAME] had been shaved this morning and mouth care had been provided. The charge nurse nodded that the care had been provided. The DON stated mouth care must be done frequently because the resident drools and requires and towel to prevent the soaking of the resident's clothing. Observation revealed towel present to protect clothing. Record review of the Minimum Data Set (MDS) reviewed an Brief Interview for Mental Status score of 99 and was coded as responds adequately to simple direct communication only.

FACILITY Kitchen Based on observation, interview, and facility policy review, the facility failed to ensure supplemental nutritional shakes were thawed in a manner to prevent potential foodborne illness. This deficient practice had potential to affect four (4) of 4 residents who received nutritional shake supplements of 52 residents in the facility. Findings Include: A review of the Facility's Policy titled Food: Preparation states the cook(s) will thaw frozen items using one of the following methods: thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination; thawing the item in a microwave oven then transferring immediately to conventional cooking equipment; completely submerging the item under cold water (at a temp of 70 degrees Fahrenheit) or below that is running fast enough to agitate and float off loose ice particles; cooking directly from the frozen state, when directed. An observation on 05/21/23 at 02:35 PM during the Initial Brief Tour of the kitchen revealed approximately 24 tray of supplemental shakes, strawberry flavor, on a tray on a shelf in kitchen. The shakes were thawed and sitting at room temperature, about 84 degrees as read on thermometer. An interview with Dietary Staff (DS) #1 at 2:55 PM revealed another dietary staff person (DS #2) had pulled the shakes out to thaw and placed them on the tray prior to her leaving after the lunch meal. DS #1 stated he was supposed to put them in the refrigerator and forgot. DS #1 calibrated thermometer to 32 and tested temperature of one the shakes. The shake temperature was 69 degrees. DS #1 stated he was going to throw the shakes out as the temperature was too high for them to be served. He again stated they should have been in the refrigerator until serving time. A review of facility listing of therapeutic diets revealed four of 52 residents in the facility were prescribed supplemental Mighty Shakes. An interview on 05/22/23 @ 3:00PM with DS #2 confirmed she was the person who took the Mighty shakes out freezer to thaw. DS #2 states she put them on a tray and told DS #1 to put the tray in the refrigerator to thaw. DS#2 stated the normal way they thaw shakes is by putting them on a tray in the refrigerator and the milkshakes should be stored in refrigerator until time to serve. DS #2 , stated if shakes were too warm they may cause residents to have stomach upset, or could make them sick. DS #2 estimated the shakes were taken out between 11:30AM to 12:00PM DS #2 stated shakes should not have temp above 41 as they contain milk.

Resident #42 Respiratory Care Based on observation, record review, and staff and resident interview, the facility failed to provide respiratory care consistent with professional standards of practice as evidence by a resident receiving oxygen therapy with no physician's order, monitoring or plan of care for one (1) of 15 sampled residents. Resident #43 Findings Include: An observation and interview on 05/22/23 at 03:20 PM revealed Resident #43 lying in bed with bilateral nasal cannula in nares, oxygen concentrator on administered at 2.5 Liters(L). Resident #43 noticed my observation of concentrator setting and commented the setting should be on 1.5L. A record review of Resident # 42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/23/2023 revealed in Section O regarding O2 use, the resident was marked as not receiving O2 therapy. A record review of Resident #42's cumulative Physician's orders with an order review date of 04/15/2023 revealed the resident did not have an physician's order for the use of O2. A record review of Resident #42's care plan revealed the resident did not have a care plan related to O2 therapy. An Interview on 05/22/23 at 02:20 PM with Resident # 42 revealed she had been using O2 mostly just at night to assist with breathing. Resident #42 stated she believes she has sleep apnea but has never had a sleep study. When asked about who puts the O2 on and sets the concentrator rate, Resident #42 stated she does it herself and uses every night to help her sleep. An Interview on 05/23/23 at 11:20 AM with LPN #1 revealed she was aware Resident utilizes O2 at night when she has shortness of breath and it helps her sleep. An Interview on 05/23/23 at 11:42 AM with Registered Nurse (RN) #2 and the Director of Nursing (DON) revealed they were unaware the resident was using O2. The DON stated the resident's order for O2 was discontinued. Neither were aware the resident continued to use the O2. Both agreed there were no orders for the use of O2 and the resident was not being monitored for use of O2. Interview on 05/23/23 at 11:55 PM with the MDS nurse confirmed the resident was not assessed as using O2 and no care plan was developed for the use of O2. A record review of Resident # 42's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/23/2023 revealed the resident had a brief interview for mental status (BIMS) score of 15 and the resident was admitted by the facility on 01/03/2023 with active diagnoses including Morbid (SEVERE) Obesity with Alveolar Hypoventilation and Peripheral Vascular Disease.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) related to medication, for one (1) of 21 MDS assessments reviewed, Resident #35. Findings include: Review of the RAI (Resident Assessment Instrument) manual for coding section N0410E, Anticoagulant (e.g., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. Review of the Resident #35's MDS with an Assessment Reference Date (ARD) of 9/24/19, revealed Section N0410E was coded 7, related to the number of days taking an anticoagulant. Review of Resident #35's physician orders, dated 9/17/19, revealed she was currently taking [MEDICATION NAME] ([MEDICATION NAME]) 75 milligram (mg) every day and ASA (Aspirin) 81 mg every day. Review of Resident #35's Medication Administration Record [REDACTED]. During an interview on 10/29/19 at 4:08 PM, Registered Nurse (RN) #1, MDS Nurse, confirmed Resident #35 was on aspirin and [MEDICATION NAME], and had coded the MDS in error. She stated she was told to code the MDS the same as you would for an anticoagulant. She said she had a sticky note on her computer as a reminder to code [MEDICATION NAME] as an anticoagulant. RN #1 reviewed the RAI manual and stated [MEDICATION NAME] ([MEDICATION NAME]) was not to be coded in Section N as an anticoagulant.

Based on observation, staff interview, record review, and facility policy review, the facility failed to remove expired medication (med) from the storage room and medication cart for one (1) of five (5) med pass observations. Findings include: Review of a facility's Storage of Medication policy, dated (MONTH) (YEAR), revealed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. On [DATE] at 11:15 AM, an observation with Licensed Practical Nurse (LPN) #1, of the medication storage room, revealed [MEDICATION NAME] tablets USP 180 milligram (MG) [MEDICATION NAME] 24 hour relief Allergy, with an expiration date of ,[DATE]. On [DATE] at 11:40 AM, an observation of Medication Cart A, with LPN #2, revealed [MEDICATION NAME] tablets USP 180 MG/[MEDICATION NAME] 24 hour relief Allergy, with an expiration date of ,[DATE]. Record review revealed a monthly medication room inspection by the pharmacist dated [DATE]. During an interview on [DATE] at 11:55 AM, the Director of Nursing (DON) stated the medication ([MEDICATION NAME]) should have been pulled on or by the expiration date. She stated medications are rotated when they come in, by the central supply staff. The DON stated the Pharmacist comes in the facility once a month to check the medication room.

Based on record review and staff interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) Assessment in a timely manner for one (1) of 19 Resident MDS Assessments reviewed; Resident #1. Findings include: Record review revealed Resident #1's most recent Omnibus Budget Reconciliation Act (OBRA) MDS was an Annual assessment dated [DATE]. Further review revealed Resident #1 did not have an OBRA Quarterly MDS assessment completed since the most recent Annual MDS with an ARD of 7/25/18. On 11/28/18 at 1:15 PM, an interview with the MDS Coordinator/Registered Nurse (RN), revealed she had completed an OBRA Quarterly MDS assessment since the most recent Annual MDS assessment with an ARD of 7/25/18. The MDS Coordinator stated, I should have combined the Quarterly MDS with the Medicare 5-Day MDS assessment, no I do not have one done (referring to the Quarterly MDS). On 11/29/18 at 2:35 PM, an interview with the Director of Nursing (DON), revealed she would expect the MDS nurse to complete the MDS because she is in charge of the MDS, and is the MDS Coordinator. The DON also stated she would expect the MDS nurse to let her know if she is running behind so she could get back-up help for her as needed. On 11/29/18 at 2:40 PM, an interview with the Administrator (Adm), revealed he would expect the MDS to be done within the regulatory period, and as timely as possible. A review of the facility's Face Sheet, revealed the facility admitted Resident #1, on 07/17/17, with [DIAGNOSES REDACTED]. The most recent Annual MDS assessment, with an Assessment Reference Date (ARD) of 07/25/18, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated no cognitive impairment.

Based on observation, staff interviews, record review, and facility police review, the facility failed to ensure infection control measures were maintained to prevent the possible spread of infection/contamination during incontinent care for Resident #8 and Resident # 9, for two (2) of seven (7) incontinent care observations. Findings include: Review of the facility's policy titled, Standard Precaution: Hand Hygiene, dated 05/15/2013, revealed to assume every person is potentially infected or colonized with organisms that could be transmitted in the facility and apply the infection control guidelines during the delivery of health care. Review of the facility's policy titled, Infection Control Precautions, dated 05/15/13, revealed the facility will comply with all regulations and Center of Disease Control (CDC) standards related to infection control by having appropriate procedures in place to prevent the spread of infection. Resident #9: An observation of Resident #9, on 08/02/2017 at 1:50 PM, revealed Certified Nursing Assistant (CNA) #1 performed incontinent care on Resident #9. After completing the care, CNA #2 did not remove the soiled gloves, and touched Resident #9's clean brief and incontinent pad that was placed under the resident. An interview on 08/02/2017 at 2:45 PM, with CNA #2, revealed she had forgotten to take her gloves off before putting on the clean brief and placing the pad for Resident #9. CNA #2 revealed not changing her gloves was and infection control issue. A review of the facility's Face Sheet revealed the facility admitted Resident #9 on 04/15/2017. Resident #9's [DIAGNOSES REDACTED]. A review of Resident's #9 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2017, revealed staff assessed Resident #9 with moderately impaired cognition. Resident #8 An observation of Resident #8 on 08/02/2017 at 2:05 PM, revealed CNA #3 brought linen to the room which had previously been in another resident's room. CNA #3 performed incontinent care on Resident #8 using the linen. After completing the care, CNA #3 did not remove her soiled gloves, and touched Resident #8's clean brief and incontinent pad that was placed under the resident. An interview with CNA #3, on 08/02/2107 at 2:35, revealed she had brought the linen from the previous room and had used them on Resident #8. CNA #3 revealed she had also forgotten to change her gloves prior to putting the new brief and incontinent pad under Resident #8. CNA #3 revealed this was a potential for spread for infection. In an interview, on 08/02/2017 at 2:50 PM, the SD RN #1 revealed the training with the CNAs covered infection control during peri-care. RN #1 revealed that CNA #2 and #3 had only been working in facility for less than a month and did not have a skills check list at this time. A review of the facility's Face Sheet revealed the facility admitted Resident #8 on 01/05/2017. Resident #8's [DIAGNOSES REDACTED]. A review of Resident's #8's MDS with an ARD of 07/03/2017, revealed Resident #8's Brief Interview for Mental Status (BIMS) score was 6, which indicated severely impaired cognition.

Based on observation, interview and record review, the facility failed to follow the care plan for Resident #6, one (1) of two (2) residents reviewed for care plans who had a Percutaneous Endoscopic Gastrostomy (PEG) tube. Findings include: A review of facility's Care Plan Policy, dated 05/28/2013, revealed an individualized comprehensive care plan that includes measurable objectives and time tables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The Care Planning/Interdisciplinary Team maintains (carries out) the comprehensive care plan. A review of Resident #6's Care Plan, revised 07/12/2107, revealed a high risk for re-occurring swallowing issues related to previous [MEDICAL CONDITIONS]. Further review of the Care Plan revealed an intervention for the PEG tube to be flushed with 30 cubic centimeters (cc) water before and after medication administration and to verify tube placement every shift via aspiration and auscultation prior to feedings, flushes and medication administration. An observation on 8/1/2017 at 2:00 PM, revealed Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] 10 milligram (mgs) and [MEDICATION NAME] 100 mgs, via Resident #6's PEG tube. Observation during medication pass revealed LPN #1 did not check placement of the PEG tube prior or flushing or administration of medications. During an interview on 08/01/2017 at 4:30 PM, LPN #1 revealed she did not auscultated the PEG tube for placement prior to flushing or administering of medications for Resident #6. LPN #1 revealed she had checked placement earlier in the morning and thought she didn't have to check prior to giving the medications. A review of the facility's Face Sheet revealed the facility admitted Resident #6 on 12/23/2016, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2017, revealed staff assessed Resident #6 with severely impaired cognition.

Based on staff interview, record review, and facility policy review, the facility failed to investigate an injury of unknown origin for Resident #6, for one (1) of 12 residents reviewed. Findings Include: Resident #6 A review of the facility's Abuse Prevention Program, dated September 2016, revealed: All allegations of abuse and injuries of unknown origin are reported immediately to the charge nurse and/or administrator of the facility along with other officials in accordance with State law through established guidelines. All allegations will be investigated and reported to the appropriate agencies. Families will be notified of the outcome of the investigation. A review of the facility's: Incident Specific Investigation Process Guidelines actual or suspected abuse/neglect allegation (including injuries of unknown origin, dated 10/6/2016, revealed the facility will develop an investigation plan and implement the plan. A review of the facility's policy, Abuse Investigations, dated March 2013, revealed all reports of alleged resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. During an interview on 7/31/2017 at 12:20 PM, Resident #6's sister revealed she had reported head injuries of the resident to the Ombudsman on two (2) separate occasions. She said the first injury occurred in March 2017, and the second injury occurred in April 2017. Resident #6's sister stated that the facility told her that they were investigating the injuries and would let her know the outcome. Resident #6's sister also said if the facility would have done an investigation and training on the lifts, her brother might not have sustained another open head injury. During an interview on 8/1/2017 at 10:00 AM, the Ombudsman confirmed Resident #6's sister called and complained of an open injury to Resident #6's head on two (2) separate occasions. The Ombudsman said the sister showed him pictures of the injuries of the open wounds. The Ombudsman also said that the Director of Nursing (DON) reported that they suspected the resident's head was injured during transfer with the Hoyer lift and they were still investigating the incident. There was no documented report of a March 2017 incident report or investigation for an incident/accident for Resident #6. Record review revealed an incident report for Resident #6, dated 4/26/17 at 12:25 PM, which documented staff was called to the front porch with a noted abrasion that measured 1.2 x 1 x 0.1 (centimeters). No witnesses to the event was documented. There was no evidence of an investigation for the injury of unknown origin. In an interview on 8/2/17 at 10:15 AM, Certified Nursing Assistant (CNA) #1 stated he didn't know how Resident #6 received the injury to his head (April 2017). During an interview on 8/2/2017 at 9:00 AM, the Administrator confirmed the facility failed to investigate Resident #6's injury in March. The Administrator said she had only been working two (2) weeks and she called the old Administrator to ask about the investigations and was unable to get any information. During an interview on 8/2/2017 at 9:30 AM, the DON said the prior Administrator was responsible for the investigation on the first injury, but she could not find an incident report or the investigation for Resident #6 in March 2017. The DON said she could not find documentation of an investigation for the March incident with Resident #6. The DON also said she started the investigation on the second injury, in April, but did not finish the investigation or follow up. The DON stated that she had gotten statements from some of the staff and provided in-services to the staff on the use of the Hoyer lift. During an interview on 8/2/2017 at 10:30 AM, Registered Nurse (RN) #1 confirmed the staff was trained on how to properly transfer residents with full body lifts, sit to stand lifts and the gait belts. A review of the facility's in-service titled In-service dated 5/4/2017, revealed staff was trained on transfers with full body lift, sit to stand and gait belt transfers. A review of the facility's face sheet revealed the facility admitted Resident #6 on 6/04/2014, with [DIAGNOSES REDACTED]. A review of Resident #6's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/30/2017, revealed staff assessed Resident #6 with severely impaired cognition.

Based on observation, record review, staff interview, and the facility's policy review, the facility failed to check the placement of Resident #6's Percutaneous Endoscopic Gastrostomy (PEG) tube, by auscultation with air, to ensure the tube was in the correct position, prior to medication administration. This was for one (1) of two (2) PEG tubes observed during medication (med) pass. Findings include: A review of the document used by the facility for policy, Enteral Feeding Procedure Guidelines, 20-1 Journal of [MEDICATION NAME] and Enteral Nutrition, with a date of 2009, revealed the procedure for checking PEG tube placement. The policy revealed to check placement of the PEG tube by using a catheter-tipped syringe, inject 30 cubic centimeters (cc) of air while listening with a stethoscope positioned at the epigastric area, inject 10 milliliters (ml) of air into the tube. The policy revealed auscultation of a whooshing or bubbling sound, assisted in confirmation of proper tube placement. An observation on 8/1/2017 at 2:00 PM, revealed Licensed Practical Nurse (LPN) #1 administered [MEDICATION NAME] 10 milligram (mgs) and [MEDICATION NAME] 100 mgs, via Resident #6's PEG tube. LPN #1 did not check the placement of the PEG tube prior to flushing or administration of medications. A review of Resident #6's physician's orders [REDACTED]. During an interview on 08/01/2017 at 4:30 PM, LPN #1 stated she had not auscultated the PEG tube for placement prior to flushing or administering medications for Resident #6. LPN #1 revealed she had checked placement that morning (AM) and thought she didn't have to check prior to giving the medications. LPN #1 stated that checking for placement is the way for making sure the PEG tube is in the right position. During an interview on 08/01/2017 at 4:33 PM, Registered Nurse RN #1 stated that LPN#1 should have checked for placement prior to flushing or administrating medications to make sure the PEG tube was in the correct position for Resident #6. She revealed that checking for placement of the PEG is to make sure the tube is in right position. An interview with Director of Nursing (DON), on 08/01/2017 at 4:35 PM, revealed checking for placement of a PEG tube is important in making sure the tubing is in the correct position. The DON revealed that LPN #1 should always check for placement prior to flushing and administration of medications. A review of the facility's Face Sheet revealed the facility admitted Resident #6 on 12/23/2016, with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/30/2017, revealed staff assessed Resident #6 with severe cognitive impairment.

Based on observation, interview, record review and facility policy review the facility failed to document on the Medication Administration Record (MAR) for Resident #2, three (3) doses of [MEDICATION NAME] 7.5 milligrams (mg)/[MEDICATION NAME] 325 mg that had been signed out on the Controlled Substances Proof of Use/Individual Narcotic or Sedative Record; for one (1) of four (4) residents reviewed. Findings include: The facility's policy, entitled Documentation of Medication Administration, undated, revealed the facility shall maintain a medication administration record to document all medications administered. Review of physician's orders [REDACTED]. A review of Resident #2's November 2016 MAR revealed seven (7) doses of [MEDICATION NAME] 7.5 milligrams (mg)/[MEDICATION NAME] 325 mg documented as having been given. The Controlled Substances Proof of Use/Individual Narcotic or Sedative Record revealed ten (10) doses had been signed out for November 2016. Three (3) doses were signed out but not recorded on the MAR. The three (3) doses were for 11/2/16 at 8:00 PM, 11/3/16 at 5:00 AM and 11/7/16 at 8:00 AM. An interview with Licensed Practical Nurse (LPN) #1 on 2/22/17 at 2:10 PM, revealed she forgot to sign the MAR for [MEDICATION NAME] 7.5 milligrams (mg)/[MEDICATION NAME] 325 mg for Resident #2 on 11/7/16 and confirmed her signature for signing out the medication. Interview with LPN #2 on 2/22/17 at 3:40 PM, revealed each nurse is responsible for documenting on the MAR when they administer medications. An interview with the Pharmacy Consultant on 2/22/17 at 3:10 PM, revealed the MAR should match the Controlled Substance Sign Out Sheet for every dose given. In a review of Resident #2's Face Sheet, the facility admitted Resident #2 on 6/4/14, with the [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 1/13/17, revealed Resident #2 was unable to complete the Brief Interview for Mental Status (BIMS) because Resident #2 was severely impaired cognitively.

Based on observation, record review, staff interview, and facility policy review, the facility failed to provide incontinent care in a manner to prevent the potential for infection for three (3) of five (5) incontinent care observations. (Resident #2, Un-sampled Residents A and B). Findings Include: Review of the Clinical Nurse Skills and Techniques by Perry and Potter, 8th edition, pages 403 and 404, on perineal care, revealed wipe from the perineum to rectum (front to back). With females retract the labia from the thigh. Wash and dry between the skin folds. Repeat on the opposite side then, wash the urethral meatus and vaginal opening and wash from pubic area down towards the rectum. Use a separate side of the towel for each stroke. With a male, gently raise the penis and wash the head of the penis with circular motions and repeat with a clean cloth until the penis is clean. Gently clean the shaft of the penis and scrotum. Lift the scrotum and wash the underlying skin folds. Resident #2 Observation of Resident #2's incontinent care on 9/27/16, at 10:00 AM, with Certified Nurse Aide (CNA) #5, and CNA #8, revealed CNA #5 used the same side of the wipe several times to clean the resident's inner thighs, buttocks, and anal area. CNA #5 wiped from the pubic area upward to the head of the penis, and from the buttocks towards the scrotum. CNA #5 should have wiped the penis from the head, down the penal shaft, and wiped the buttocks from the bottom to the top, or from front to back. Staff interview with Licensed Practical Nurse (LPN) #1/Staff Development Nurse, on 9/29/2016 at 10:10 AM, revealed we show videos of incontinent care to staff when they are hired. LPN #1 said she observes the staff perform incontinent care on a resident. LPN #1 stated the staff should wipe one time, and throw the wipe away, and not refold the wipe, and wipe the resident again. Staff interview on 9/29/16, at 8:15 AM, with Certified Nurse Aide (CNA) #5 revealed he did not follow the facility's policy during Resident #2's incontinent care. CNA #5 stated he used the same wipe to wipe the inner thighs, penis, buttocks, and anal area with several swipes of the same wet wipe. CNA #5 confirmed wiping the penis from the groin to the end of the penis, and wiping the anal area, and buttocks with back to front strokes. Review of the facility's Face Sheet revealed the facility readmitted the Resident #2 on 9/13/16. Resident #2's [DIAGNOSES REDACTED]. Review of the current five (5) day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/20/2016, revealed Resident #2 had a Brief Mental Status (BIMS) score of 99, indicating the resident was unable to complete the test. Section C1000, concerning Cognitive Skills for Daily Decision Making revealed a two (2) was coded, which indicated moderate impairment with decisions, requiring cues and supervision. Further review of the MDS revealed Resident #2 was always incontinent of bowel and bladder. Un-sampled Resident A: On 9/27/16 at 8:55 AM, CNA #9 assisted by CNA #3 performed incontinent care on Un-sampled Resident A. CNA #9 washed her hands, pulled the privacy curtain, used the bed remote to elevate the bed, and pulled back the bed linens. Without changing gloves/washing hands, CNA #9 pulled back the resident's soiled brief. CNA #9 re-wiped the resident on 3 (three) occasions with the same wet wipe. She wiped the resident's genital area with downward strokes, then upward strokes. CNA #9 used the same gloves to reposition the resident, and the bed linens. Attempted staff interview with CNA #9 on 9/29/16 at 10:45 AM, per telephone. A voice message was left for CNA #9, however, at the end of the survey she had not returned the call. Review of the facility's Face Sheet revealed the facility readmitted Unsampled Resident A on 2/21/12. Un-sampled Resident A's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 8/10/2016, revealed Un-sampled Resident A had a Brief Mental Status (BIMS) score of 99, indicating the resident was unable to complete the test. Review of the Cognitive Skills for Daily Decision Making revealed Unsampled Resident A was coded a two (2), which indicated moderate impairment with decisions, requiring cues and supervision. Further review of the MDS revealed Unsampled Resident A was always incontinent of bowel and bladder. Un-sampled Resident B: Observation of incontinent care for Un-sampled Resident B,on 9/27/16, at 9:40 AM, provided by CNA #3 and CNA #5, revealed CNA #5 washed his hands, and applied gloves, removed the resident's soiled brief, and continued the incontinent care wearing the same gloves. CNA #5 wore the same gloves during the incontinent care, including removing the soiled brief, repositioning the resident, bed linens, bed remote to adjust the head of the resident's bed. CNA #3 provided Unsampled Resident B's incontinent care without proper hand washing, and glove changing at appropriate times. During staff interview with CNA #5 on 9/29/16 at 8:25 AM, he confirmed he failed provide Unsampled Resident B's incontinent care in a manner to prevent an infection. Review of the facility's Face Sheet revealed the facility readmitted the Unsampled Resident B on 12/11/14. Un-sampled Resident B's [DIAGNOSES REDACTED]. Review of the Significant Change MDS with an ARD of 9/02/2016, revealed Un-sampled Resident B had a Brief Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. Further review of the MDS revealed Unsampled Resident B was always incontinent of bowel, and was coded for a catheter (indwelling/condom), urinary ostomy, or no urine output for the entire seven (7) day look back. Unsampled Resident B required extensive assistance with two (2) person assist for toilet use.

Based on observations, interviews, records review, current policy review, and the content of equipment user manuals, the facility failed to ensure the necessary safety devices and supervision for one (1) of four (4) sampled residents as evidenced by staff placed Resident #1 in hazardous situations during two transfers, with one transfer resulting in a subsequent fall. (Resident #1) Findings include: According to the undated facility policy entitled "Lift Policy", "Any resident that needs to be lifted and/or transferred MUST be lifted and/or transferred with the aid of the mechanical lifts provided." According to the undated user manual entitled "Stand Up Patient Lift RPS350-2" the manufacturer documented safe operating instructions and warned the mechanical lift device could cause "injury or damage" if the user failed to follow the products written warnings, cautions, and instructions. Warnings to prevent injury on page sixteen revealed the following: 1) "Individuals that use the standing patient sling MUST be able to support the majority of their own weight"; 2) Before the lift, staff needed to secure the patient's knees against the devices knee pad; and 3) The patient's arms always needed to remain outside the sling. If for any reason staff needed to adjust the patient or the equipment, the patient needed to return to a safe seated position first. Further, the device had a "Mechanical Emergency Release," that would safely "bring the boom down" if the battery operated hand control did not function properly. Resident #1 Review of the facility's "Lift Evaluation Form", dated 05/28/2014, revealed Resident #1 experienced weakness, lacked upper body strength, had impaired weight bearing abilities, did not routinely follow instructions, demonstrated unpredictable behaviors, and subsequently needed minimally two staff members and a " total body lift" for all transfers. Review of the Minimum Data Set (MDS), dated [DATE], revealed Resident #1 had severely impaired cognition, did not walk, and required minimally two staff members to provide extensive assistance for all transfers and toilet use. Based on this MDS assessment, staff determined Resident #1 was a "high" fall risk. Review of Physician orders, dated 06/05/2014, documented staff needed to use a mechanical lift and bedside commode to meet the toileting needs of Resident #1. On 06/19/2014 at 1:00 PM, observations made in the community bathroom on Unit A revealed Certified Nursing Assistant (CNA) #1 supervised Resident #1, who sat on an elevated commode seat above the toilet. CNA #1 attempted to transfer Resident #1 off the toilet using a sit to stand lift. During the observation, CNA #1 secured a standing sling around the resident' s waist, keeping the resident's arms outside of the sling. CNA #1 then hooked the standing sling to the mechanical lift, keeping the resident's arms outside the sling. CNA #2 assisted by placing Resident #1's feet on the lift. However, neither CNA secured the resident's knees against the kneepad, leaving her legs unsecure and lacking stability. CNA #1 then pushed the up button on the electronic hand control to raise Resident #1 from the toilet, but the lift did not work. With Resident #1 still seated safely on the toilet, CNA #1 left to get another lift battery. Once the batteries were changed, CNA #1 used the lift to elevate Resident #1 into the air. Resident #1 did not bear any weight on her legs while on the mechanical lift, both her legs buckled and her full weight rested solely on the sling. Once CNA #1 and CNA #2 had positioned Resident #1 over her wheelchair, CNA #1 pushed the down button on the electronic hand control to lower Resident #1, but again, the lift did not work. CNA #1 called out into the hallway for another battery, as Resident #1 began to exhibit facial grimacing and moaning that indicated discomfort. The lift's sling now pressed firmly against the residents armpits. While the resident was suspended approximately four (4) inches above the seat of the wheelchair, CNA #1 said "Oh no, we ain't waitin. She's hurtin." No longer following the manufacturer's instructions and without providing additional supervision, CNA #1 elevated Resident #1's right arm over her head and placed it inside the sling. The sling became unstable and Resident #1 fell down into the wheelchair. CNA #1 then said, "Ya gotta do, what ya gotta do." When interviewed, CNA #1 failed to know the lift device had a mechanical emergency release button. Interview on 06/19/2014 at 1:40 PM, just prior to the above observations, CNA #2 said, she and CNA #1 transferred Resident #1 from her wheelchair to the toilet without the use of any mechanical lifts. CNA #1 said, we "physically lifted her". CNA #2 said she knew her actions were against facility policy, but being new to her position, she did what CNA #1 told her to do. Interview on 06/19/2014 at 3:00 PM, Director of Nursing #1 said staff members are not to use sit to stand lifts for Resident #1 because she does not bear weight. DON #1 confirmed Resident #1 required a full (Hoyer) lift for all transfers. Interview on 06/19/2014 at 3:20 PM, Physical Therapist (PT) #1 stated facility staff could not safely transfer Resident #1 on a sit to stand lift because Resident #1 did not consistently bear weight.