Every finding on record at Oakview Nursing & Rehablitation - Marion

Based on observation, clinical record review, facility documentation, interviews, and policy review the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. A Certified Nurse's Aide (CNA) and a nurse became aware of allegations of abuse and did not report to facility management or the designated state agency. When the facility became aware of an allegation of abuse, they didn't report it to the state agency in a timely manner for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 39 residents.Findings include:The Minimum Data Set (MDS) for Resident #2 dated 11/20/25 identified a Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The MDS included diagnoses of multiple sclerosis ( MS, an autoimmune disease that affects the nerves that effects coordination, memory, and emotions), dysarthria (speech disorder caused by muscle weakness), and anarthria (motor speech disorders affecting muscle control), and chronic pain. On 3/9/26 at 11:14 AM observed Resident #2 in bed propped up on pillows. She lifted her left arm and then it dropped to the bed against the side rail. she said was for holding during cares. She stated they (her arms) 'flop around' all of the time due to her disease (multiple sclerosis/MS). She pointed out her new glasses as the interview started. Resident #2 reported a staff member broke her old pair of glasses during cares. Resident #2 said as a CNA cleaned her, she asked her to hold the rail. She stated she couldn't because of her disease and they flipped her too hard which caused her head to bump the rail and break her glasses. She said the staff wore 'these things in their ears' for music, talked about their boyfriends, and didn't listen to her. She stated 'one girl' swatted her shoulder to make her let go as she held on to the rail when she felt like she was falling. She thought she just had to go with the flow when things happened because she couldn't move or get up. When asked if she reported her concerns, Resident #2 said it was her choice whether or not to report and she was capable. She indicated she told a CNA someone hit her shoulder and later told another staff person who used to come visit her (Staff A, Activities Assistant). She stated it came down to the fact that everything hurt because of the MS and staff needed to be more careful.Documents titled Record of One-on-One Activities noted the following:1/2/26 - Resident #2 shared concerns with Staff A that were passed on to management1/12/26 - Resident #2 shared concerns with Staff A that were passed on to nursing1/12/26 - Resident #2 shared concerns with Staff A that were passed on to the Life Enrichment Director (Staff B) and the MDS Coordinator.1/13/26 - Resident #2 shared concerns with Staff A that were passed on to Staff BThe facility provided a summary document dated 1/29/26 regarding Resident #2's concerns which documented the following timeline:a. 1/2/26 - no documentationb. 1/12/26 -The Assistant Director of Nursing (ADON) met with Resident #2 about a CNA who accidentally spilled urine on her nightgown and said it was painful to have it changed. c. 1/13/26 - Staff A reported to Staff B, Resident #2 said staff were rude to her, when they rolled her, she felt like she would fall, and staff would 'smack' her for holding on. Resident #2 stated staff still did this and it was best to go with the flow because when she complained they ignored her. She stated the person still worked at the facility. She did not say who the person was, when it occurred, or what was 'rude.' Resident #2 later reported to the Administrator that she did not say hit and that her arms flop around due to her disease. d. 1/15/26 - During a meeting with Staff A the Administrator acknowledged the complaint Staff A reported to Staff B for Resident #2. e. 1/16/26 - Staff A notified Staff B and the Administrator she reported Resident #2's abuse allegation to an outside agency.f. 1/25/26 - On 1/22/26 Staff F was interviewed about the current allegation of abuse. She indicated she was not aware of any abuse and Resident #2 had not reported someone slapped her. On 1/25/26 Staff F recalled a conversation with Resident #2 from December. Staff F asked Resident #2 if the current investigation was related to the incident she had reported to her in December, including that someone had done something to her. Resident #2 confirmed it was the same and the staff still worked at the facility. g. Dependent Adult Abuse training was provided to the staff and completed on 1/29/26.An incident report for Resident #2 dated 1/25/26 documented a CNA reported someone hit her in the arm in December.A document titled Statement, signed by Staff F on 1/28/26, recorded Resident #2 told Staff F in December 2025, someone did something to her, and Staff F did not report it. The Statement corroborated the facility's summary.The personnel file for Staff F, reviewed 3/10/26, indicated she successfully completed Dependent Adult Abuse Mandatory Reporter training on 11/4/23, 6/18/24, 5/20/25, and 1/27/26. A Disciplinary Report Form dated 1/27/26 documented the employee failed to report dependent adult abuse in a timely manner.An interview with Staff A on 3/9/26 at 3:41 PM revealed she was upset after Resident #2 reported the allegations to her so she went to her boss. She stated if it were her mother or grandmother, she would want the allegations reported. She was worried the report would be brushed off because the last time she went to them about Resident #2 they (Staff B and the Administrator) said they didn't want to hear it anymore and that made her feel uncomfortable. On 3/10/26 at 2:08 PM Staff B stated Resident #2 and Staff A hit it off and Staff A went in for 1:1 visits. The first time there was a concern (Monday 1/12/26), Staff A reported Resident #2 said someone hit her. During the facility follow up, Staff B said Resident #2 denied saying she was hit but that when staff rolled her for cares her arms flopped and she was afraid of falling. The next day Staff B said Staff A came to her again because Resident #2 alleged she was being abused and they took that seriously. She thought that happened on 1/13/26. She confirmed with Staff A that Resident #2 used the word abused. She stated the Administrator started a full investigation of the abuse allegation.A document provided by the facility that listed Self-Reports to the department did not include a report submitted on 1/13/26. On 3/11/26 at 11:56 AM Staff C, Licensed Practical Nurse (LPN), stated she learned about the allegation in report. In February, Staff C asked Resident #2 about the incident. Resident #2 told her that CNAs broke her glasses and upset her, and Resident #2 named them. The nurse did not follow up with the CNAs, the Director of Nursing (DON), or the Administrator.During an interview on 3/11/26 at 12:09 PM Staff G, CNA, stated Resident #2 never complained to her about broken glasses or staff hurting her. She did not hear about the allegation from anyone else and she was not asked if she was involved.On 3/11/26 at 1:32 PM the Administrator confirmed the summary information provided and that Staff F failed to follow the facility's abuse reporting policy. She stated she did not report the abuse allegation to the department on 1/13/26 because she spoke to Resident #2 herself and thought it was more of a medical and health issue. They reported on 1/25/26 when Staff F told them Resident #2 made the initial statement in December. The Administrator stated they (she and the DON) didn't know about Resident #2's report that staff broke her glasses until an interview with Resident #2 the day before. She expected the staff to notify a supervisor immediately with any allegation of abuse or care concerns.A policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated July 2024 documented all residents had the right to be free from abuse. All allegations of abuse or mistreatment should be reported immediately to the charge nurse who was responsible for reporting to the Administrator. All allegations of mistreatment should be reported to the Iowa Department of Inspections, Appeals, and Licensing not later than 24 hours after the allegation was made.

Based on record review, interviews, and the Medicare Claims Processing Manual the facility failed to provide residents ending skilled care with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non Coverage (NOMNC) documents for 3 of 3 residents reviewed (Residents #22, #41, #42). The facility reported a census of 36.Findings include: 1) The Minimum Data Set (MDS) dated [DATE] for Resident #22 documented an admission date of 4/17/25 and a Medicare end date of 5/5/25. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by their representative on 5/2/25. The document footnote was Form CMS 10123-NOMNC (approved 12/31/2011). A document titled Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) for the resident was signed by their representative on 5/2/25. The document footnote was Form CMS-10055 (2018). 2) The Minimum Data Set (MDS) dated [DATE] for Resident #41 documented an admission date of 5/5/25 and a discharge date of 6/3/25. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by the resident on 5/29/25. The document footnote was Form CMS 10123-NOMNC (approved 12/31/2011). 3) The Minimum Data Set (MDS) dated [DATE] for Resident #42 documented Medicare start date of 2/25/25 and a Medicare end date of 3/7/25. A document titled Notice of Medicare Non-Coverage (NOMNC) for the resident was signed by their representative on 3/5/25. The document footnote was Form CMS 10123-NOMNC (approved 12/31/2011). A document titled Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) for the resident was signed by their representative on 3/5/25. The document footnote was Form CMS-10055 (2018). Form CMS-10055 has a current footnote of Form CMS-10055 (2024). Form CMS-10123 has a current footnote of Form CMS 10123-NOMNC, OMB approval 0938-0953, Exp. 11/30/27. During an interview on 8/21/25 at 10:28 AM the Director of Nursing (DON) indicated she was responsible for completing ABN's and NOMNC's. She stated the forms currently used were given to her, and filling them out was the standard process unless residents used an Advantage Plan. She stated she never thought about needing updated forms and didn't know the process for getting new ones. On 8/21/25 at 10:32 AM the Administrator stated she was not aware the forms had been updated. When asked how she would get new forms she reported she would look to CMS or their consulting company for guidance. CMS manual Medicare Claims Process Manual issued 10/31/24, Chapter 30, 50.5 B., documented ABN's were effective as of the OMB approval or expiration date given at the bottom of each notice and routine approval was for 3 year use. Notifiers were expected to exclusively use the current version of ABN's. Manual section 260.3.2 further documented providers must use the OMB-approved NOMNC (CMS-10123).

Based on observation, clinical record review, staff and resident interviews the facility failed to prevent one resident from wandering into another resident room and putting their hand on a resident for 1 out of 6 residents reviewed (Resident #1). The facility reported a census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of non-Alzheimer's dementia, and stroke. The Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive impairments). The MDS revealed Resident #1 showed verbal and physical behavior towards others on 1-3 days of the look back period. The MDS reflected Resident#1 wandered 2-6 days in the look back period. The Care Plan dated 3/11/25, identified Resident #1 had impaired cognition related/to dementia. Cue, reorient and supervise as needed. The Care Plan dated 3/14/25, identified Resident #1's physical and verbal behavioral symptoms toward others (e.g. hitting, kicking, pushing, scratching). The Care Plan listed a goal that Resident #1 not harm others secondary to physically aggressive behavior. The Care Plan dated 3/14/25, revealed Resident #1 experienced wandering. He will wander safely within specified boundaries. The interventions included: Remove resident from other resident's rooms and unsafe situations. The CAA Worksheet dated 3/14/25, triggered communication identified Resident #1's severe dementia which inhibits his ability to understand others and make himself understood. At baseline, resident resided in a memory care and required assistance with activities of daily living (ADL) and decision making. Resident required interventions focused at dementia vs. communication deficits. The CAA Worksheet dated 3/14/25, reflected Resident #1's behavioral symptoms include physical aggressiveness, verbal, and wandering (see electronic health record documentation from 3/6/25 to 3/13/25). Resident #1's severe dementia that limits ability to understand others and self. He required assistance with ADL's and mobility. The Medication Administration Record (MAR) dated 3/2025, directed check wander guard placement every shift for wandering. The Progress Note dated 3/7/2025 at 2:09 PM, identified Behavior Note, Resident #1 self-transferring to different chairs in the living room. Shortly after found ambulating down the hall by himself and into public bathroom. Staff assisted and able to redirect him to living room after using the toilet. The Progress Note dated 3/8/2025 at 9:51 PM, reflected Resident #1 needed a lot of attention today. Staff walked resident often, found activities for him and 1 on 1. He often wanted to get up without assistance. If not approached carefully he can easily get mad/aggressive. The Progress Note dated 3/9/2025 at 9:50 AM Resident #1 up on own often and if aggressive/behaviors one assist is necessary sometimes. Extra staff over stimulate him, he gets physical et balance is worse. no aggression yet today. Review of the POC Response History for Resident #1 dated 3/2025, showed behaviors on 7 out of days 13 that included hitting/kicking, pushing, grabbing and wandering 9 out of 13 days. The Minimum Data Set (MDS) assessment for Resident #3 dated 2/3/25, listed diagnoses of Multiple Sclerosis, high blood pressure, and malnutrition. The BIMS reflected a score of 15 (intact cognition). The MDS identified Resident #3 required substantial/maximal assistance with upper body dressing, rolling in bed and dependent on staff for lower body dressing, toileting hygiene, and chair to chair transfer. The Care Plan for Resident #3 dated 1/6/25, identified she's non-ambulatory and transferred with the assist of 2 staff and a full boy lift. Observation on 3/24/25 at 1:00 PM, Resident #3 laid in her bed with the head of the bed up approximately 30 degrees, covered with her blankets. The tray table next to her with her items of choice on top of it. Her call light secured to the grab bar to her left. During an interview on 3/24/25 at 1:00 PM, Resident #3 reported Resident #1 entered her room [ROOM NUMBER] times last week. She stated the 1st two times he came in her room he wandered and looked at her things. She said the 3rd time he came in and closed the door, he used one of her stuffed animals to dust the art on the walls. She revealed she thought he may break something. Resident #3 stated then he came over to her while she laid in the bed and tapped her lap and groin like a set of Bongos. Resident #3 reported he pulled on the blankets however they were tucked under her tray table and he couldn't get them to move far. She reported he'd seemed confused and talked nonsensical. She reported she told him to get out several times. She reported as soon as he came in her room she turned on the call light and the Staff A, Certified Nurse Aid (CNA) came and escorted him out of her room. She reported she's not sure how long it took the staff to come, 10, 15, 20 minutes. Resident #3 revealed Resident #1 hit Staff A several times while she took him out of her room. Resident #3 reported she feared he may break her things, and she failed to know what his intention were. She revealed she felt he failed to know his intentions as well. During an interview on 3/25/25 at 2:55 PM, Staff A, reported on 3/19/25 on the evening shift around bedtime Resident #1 went into Resident #3's room and touched her things. She reported and she got him out of her room, and told Resident #3 she would try to keep an eye on him. Staff A said she went and helped another resident to bed. Staff revealed when she came out that room the wife of another resident alerted her that Resident #1 entered Resident #3's room again. Staff A reported she ran to Resident #3's room as she entered the room she saw Resident #1 stood on the right side of Resident #3's bed while his hand sat on her mattress. She reported she removed Resident #1 from the room and told Staff D, Licensed Practical Nurse (LPN) that Resident #1 wandered into Resident #3's room again. Staff A, reported Resident #3 seemed upset that Resident #1 entered her room and touched her things. She stated she reported to the nurse that he got up on his own daily and would wander. During an interview on 3/25/25 at 3:05 PM, Staff B, CNA, stated she reported to the nurses that Resident #1 got up on his own daily and would wander. She reported they failed to keep an eye on him all the time due to caring for other residents. Staff B, stated she thought he needed more supervision to keep him safe. She said Resident #1 hit at the staff sometimes. During an interview on 3/25/25 at 3:45 Staff D, Licensed Piratical Nurse (LPN) reported Resident #1 wandered on the Unit. She knew in the last week he lived here he went into Resident #3's room a few times and messed with her things. She stated on one of the last evenings he lived here a CNA paged her to come help her get him out of Resident #3's room. Staff D reported they did they best they could to keep an eye on him and keep him out of another residents' space. She reported he got resistive with the CNAs when they redirected. During an interview on 3/26/25 at 1:00 PM, the Director of Nursing (DON) reported Resident #1's wandering consisted of walking around and looked at things. She reported the wandering appeared aimless. The DON stated Resident #3 requested her to come and talk to her on 3/20/25. The DON reported Resident #3 told her Resident #1 went into her room, touched her things then went over to her and pulled on the extra cover she always placed on her chest/abdomen. The DON stated Resident #3 said she knew Resident #1 lacked a purpose in the room. The DON revealed she lacked a concern for Resident#1 entering Resident #3's room. She reported he's never shown aggressive behavior to other residents. She acknowledged behaviors to the staff. The DON acknowledged the Care Plan addressed aggressive behaviors. The DON denied knowledge of Resident #1 tapping Resident #3 like a Bongo. The DON denied any knowledge Resident #1 entered her room the day before or earlier on the shift. The DON stated she communicated this situation with the Administrator and the consulting company. On 3/26/25 at 1:35 PM, the Administrator reported the facility failed to have a separate policy for resident to resident incidents. She reported it's covered on the Incident Report policy. The facility provided a policy titled Incident Report Completion of dated 8/10/18, directed a written report shall be maintained on any incident or unusual incident involving residents, visitors, employees or agency staff, occurring within the facility or on the premises. An incident report shall be initiated for any unusual incidents involving residents whether they occur at the facility or not, whether injury is apparent or not. Unusual incidents include but are not limited to: -Resident to resident physical aggression or verbal threat (complete a report for each resident involved). -Resident to resident sexual encounter (complete a report for each resident involved).

Based on observation, policy review, and staff interview, the facility failed to hold hot foods at an adequate minimum temperature for 1 of 1 meal service observed. The facility reported a census of 39 residents. Findings include: The 2/24 facility Dietary Policies and Procedures with the subject of Food Temperatures stated the minimum temperature of hot foods was 135 degrees Fahrenheit. On 8/13/24 at 12:29 p.m., Staff D Dietary Aide served the last meal in the B Wing. Immediately after the service, he obtained the following temperatures: Sweet potatoes 119 degrees Fahrenheit Green Beans 120 degrees Fahrenheit Pork 130 degrees Fahrenheit. Pureed meatballs 96 degrees Fahrenheit. Pureed sweet potatoes 99 degrees Fahrenheit. Gravy 90 degrees Fahrenheit. Pureed green beans 108 degrees Fahrenheit. On 8/14/24 at 9:51 a.m. the Dietary Manager stated hot food should be held at a minimum temperature of 135 degrees Fahrenheit. She stated she stood around the corner while Staff D obtained the temperatures on 8/13/24. She stated the facility would order more lids and cover the food in order to ensure adequate hot holding temperatures.

Based on observation, policy review, and staff interviews, the facility failed to store and prepare food under sanitary conditions for 3 of 3 kitchen areas reviewed. The facility reported a census of 39 residents. Findings include: The facility undated [name redacted(name of detergent company)] Detergent Services policy stated (dishwasher) rinse temperatures should reach between 176 degrees Fahrenheit to 185 degrees Fahrenheit. The 2/24 facility Dietary Policies and Procedures with the subject of Good Safety and Sanitation Guidelines stated the facility would utilize the current food code for standards of practice for the dietary department to meet the needs of safe food handling and sanitation of the kitchen. The 2/24 facility Dietary Policies and Procedures with the subject of Personal Hygiene stated food service employees must wear a hair restraint to effectively keep hair from coming in contact with exposed food or clean equipment. The facility 8/14/24 Kitchenette Daily Cleaning List included direction for staff to clean the microwave and refrigerator. The initial main kitchen tour on 8/12/24 at 9:38 a.m., revealed the following concerns: The dishwasher had a thick brown substance on the top of the side panels of the machine. A vent on the ceiling above the dishwasher had dust particles hanging from it. The vent was located above and in close proximity to the location clean dishes exited the dishwasher. Dust particles hung from 3 spigots of the fire suppression system, located directly above stove burners. Multiple boxes in the walk-in freezer covered with thick ice which appeared to come from melted water. The Dietary Manager stated the freezer broke recently and reached in and took out a round object covered with ice. She did not discard the other ice-covered boxes. Observations of the main kitchen on 08/13/24 at 9:58 a.m. revealed the following concerns: Dust-like particles covered a shelf which held spice containers. Dust remained on the fire suppression system spigots. 2 covered pots sat under the spigots on the stove burners. White food debris was present under the microwave and all 6 interior walls were covered with food debris and splatters. The hinges of the door also contained pieces of food debris. The outside of the microwave was covered with greasy looking finger prints. Brown food debris and fingerprints covered the outside control panel of the commercial toaster. Cooking oil bottles sat on a tray covered with multiple crumbs. Dust remained on the ceiling vent above the dishwasher. Multiple ice-covered boxes remained in the walk-in freezer. The Dietary Manager stated the round object she removed yesterday was sugar cookie dough and stated the ice covered boxes which remained included boxes containing 120 cinnamon rolls, crab, and turnovers. She stated these needed removed but she did not have time yet. Observations of the B Wing Kitchenette on 8/13/24 at 11:56 a.m. revealed the following concerns: The second cupboard from the right contained a spilled red liquid in contact with blue plastic lids. The floor of the second left lower cupboard contained onion skins and crumbs. Bowls sat on a plastic sheet of an upper cupboard. Crumbs and what appeared to be an eyelash were present on the plastic sheet. The sides of the door and the interior top of the dishwasher had a white build-up approximately 2 inches thick. Clean dishes were present in the dishwasher in close proximity to the buildup on the sides of the doors and on the top of the interior dishwasher. Fingerprints and splatters were present on the outside of the oven. Two staff members without hair nets entered the kitchenette and washed their hands during the noon meal service. Staff D Dietary Aide placed a disc thermometer into the dishwasher and ran a cycle. Upon completion of the cycle, the thermometer read a maximum temperature of 149 degrees Fahrenheit. Staff E [NAME] stated he would contact the dishwasher company. A toaster sat in a pile of crumbs on a bottom shelf. Staff D stated he utilized the toaster every day. All 6 interior walls of the microwave were covered with brown splatters and the outside of the microwave was sticky to the touch. Observations of the C Wing kitchenette on 8/14/24 at 9:03 a.m. revealed the following concerns. The outside of the dishwasher contained a brown build-up. Dish racks sat in a thick layer of crumbs and pieces of food in a lower cupboard. All 6 interior walls of the microwave were covered with food debris and brown splatters. Plastic cup lids were wet and sat in crumbs in a drawer. Brown splatters covered the outside cabinet doors to the right of the sink. Plates and bowls to the upper left of the stove sat in a cupboard in crumbs. Tongs and scoops sat in crumbs and large food particles in a drawer to the left of the refrigerator. The B Wing Dish Machine Temps sheet directed staff to record the temperatures at the end of the cycle and stated the temperature should read 160 degrees Fahrenheit or above. If the temperature did not reach the minimum, the document directed staff to contact the manager. The log included the following temperatures which were below 160 (in degrees Fahrenheit): 8/1/24 breakfast 149 8/2/24 breakfast 138, dinner 154 8/3/24 breakfast 152, lunch 158 8/4/24 lunch 157 8/5/24 breakfast 152, dinner 155 8/6/24 lunch 153, dinner 143 8/7/24 lunch 145 8/9/24 breakfast 153, lunch 148, dinner 158 8/10/24 dinner 154 8/11/24 breakfast 153, lunch 147, dinner 153 8/12/24 dinner 158 8/13/24 lunch 151 On 8/14/24 at 9:51 a.m. the Dietary Manager stated there was a kink in the hose of the B Wing dishwasher that caused the machine not to reach the adequate temperature. She stated the disc should reach a minimum of 160 degrees. She stated staff should inform her if they obtained temperatures below this. She stated drawers, cabinets, and appliances should be kept clean and free of food debris and splatters. She stated staff should wipe down these surfaces. She stated they had in their books what staff should carry out with regard to cleaning but stated staff did not fulfill these duties. She stated she and Staff E would begin monitoring the completion of this. She stated staff should not enter the kitchen to wash their hands without a hair net.

Based on review of Quality Assurance and Performance Improvement(QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance(QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 39 residents. Findings include: The Centers for Medicare and Medicaid Services(CMS) 2567, dated 2/15/24, listed, in part, the following concerns: F812 QAPI Sign-In Sheets documented the facility had QAPI meetings on the following dates: 4/19/24 and 7/26/24. The current survey, conducted 8/12/24-8/15/24 also identified the above concern. The undated facility QAPI Plan stated the facility would address key issues to continuously improve services. The plan stated the QAA committee would prioritize areas that were problem-prone. On 8/15/24 at 8:59 am., the Administrator stated with regard to QA activities, the facility hadn't done as much with dietary. She stated they needed to focus on this and focused more on nursing after the last survey.

Based on observation, record review, staff interview, and policy review, the facility failed to ensure dignity was provided to residents with catheters by not placing the catheter bags in dignity bags for 2 of 4 residents reviewed for catheters (Residents #8 and #143). The facility reported a census of 39 residents. Findings include: 1. A Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) of 13 indicating intact cognition. The MDS further documented the resident had diagnoses including neurogenic bladder, chronic kidney disease, congestive heart failure, and diabetes mellitus. The resident required assistance of staff for toileting, personal hygiene, bathing, and transfers. She had an indwelling catheter and was frequently incontinent of bowel. The Care Plan dated 7/3/24 revealed a focus area for Resident #8's need for an indwelling urinary catheter related to a neurogenic bladder with a goal the resident's catheter care would be managed appropriately to prevent signs of infection or urethral trauma. Interventions included: assessing for continued need for the catheter at least quarterly, providing catheter care twice a day and as needed, and the use of a catheter strap. In an observation on 8/13/24 at 7:43 AM, Resident #8 was noted to be lying in bed and the catheter bag was hanging from the bed frame and not in a dignity bag and visible to staff, residents, and visitors that may pass by in the hallway. In an observation on 8/13/24 at 8:30 AM, Resident #8 was noted to be lying in bed and the catheter bag was hanging from the bed frame and not in a dignity bag and visible to staff, residents, and visitors that may pass by in the hallway. In an observation on 8/13/24 at 10:15 AM, Resident #8 noted to be sitting in the recliner in her room and the catheter bag was hanging from the recliner and not in a dignity bag. In an observation on 8/14/24 at 8:03 AM, Resident #8 noted to be sitting in the recliner in her room and the catheter bag was hanging from the recliner and not in a dignity bag. 2. An initial MDS assessment was not completed for Resident #143 related to this resident admitting on 8/1/24 and discharging to home on 8/13/2 prior to completion of the MDS. Resident #143 carried diagnoses of atrial fibrillation, diabetes mellitus, chronic kidney disease, neuromuscular dysfunction of the bladder, multiple sclerosis, and epilepsy. The baseline Care Plan dated 8/3/24 indicated Resident #143 was alert and oriented. The resident required set up assistance with eating, the assistance of 1 staff for personal hygiene and the assistance of 2 staff for bed mobility, transfers, toileting, and bathing. Resident #143 had a Foley catheter. Resident was independent with mobility in an electric wheelchair. In an observation on 8/12/24 at 1:34 PM, Resident #143 noted to be seated in his electric wheelchair in his room with the catheter bag hanging from the elevated leg rest and not in a dignity bag. It was visible to staff, residents, and visitors that may pass by in the hallway. In an observation on 8/13/24 at 8:05 AM, Resident #143 noted to be seated in his electric wheelchair in his room and the catheter bag was hanging from the electric wheelchair and not in a dignity bag and visible to staff, residents, and visitors that may pass by in the hallway. In an observation on 8/13/24 at 12:11 PM, Resident #143 noted to be seated in his electric wheelchair at a table in the dining room for lunch and the catheter bag was hanging from the electric wheelchair and not in a privacy bag. The bag was visible to any staff, residents, and visitors that may have come by. In an interview on 8/15/24 at 8:48 AM, the Director of Nursing (DON) stated it was the expectation that dignity bags be used on urinary catheter bed bags when in the community environment and the staff were educated they only had to be used in the community areas. A facility provided Policy titled Catheter Care effective on 10/1/18 stated the catheter bag must be covered with a dignity cover when in a public area.

Based on clinical record review, policy review, and staff interviews, the facility failed to ensure residents remained free of physical abuse when a staff member hit a resident on the shoulder for 1 of 1 residents reviewed for abuse(Resident #23). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 6/13/24, listed diagnoses for Resident #23 which included diabetes, non-Alzheimer's dementia, and morbid obesity. The MDS stated the resident required substantial to maximal assistance for dressing and was dependent on staff for toileting hygiene, showering, and transfers. The MDS listed the resident's Brief Interview for Mental Status Score (BIMS) as 6 out of 15, indicating severely impaired cognition. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, dated July 2019, stated all residents had the right to be free from abuse and defined physical abuse to include hitting and slapping. Care Plan entries, dated 1/30/23, stated the resident had verbal behavioral symptoms directed toward staff (yelling, name calling) and directed staff to: avoid power struggles with the resident. convey an attitude of acceptance toward the resident. maintain a calm environment and approach to the resident. offer the resident a soda. refocus the conversation when the resident became verbally abusive. A 4/14/23 Care Plan entry stated the resident had a mood problem related to Neurocognitive disorder (a disorder which can affect cognitive abilities). A 3/26/24 Care Plan entry directed staff to redirect the resident's behavior and stated if the resident was resistive to cares, leave him alone and attempt again in a few minutes. A statement written by Staff C, CNA (Certified Nursing Assistant) on 8/5/24 stated as staff helped the resident lie down after his shower at 1:45 p.m., Staff A CNA argued with the resident and he hit her. Staff A then punched the resident in the left shoulder and said to him if you punch me then I will punch you and next time I'll give you a black eye and tell everyone I don't know how it happened. A statement written by Staff A on 8/5/24 stated she helped to put Resident #23 in his chair when he tried to hit her in the chest. She told him to stop trying to hit her and told him that was why [name redacted] was with [name redacted]. A statement written by Staff B CNA on 8/5/24, stated she entered Resident #23's room and he was set up to transfer with Staff A and Staff C. Staff B entered the room and ran the machine. After the transfer, Staff B exited the room and did not witness anything. An 8/5/24 Incident Report stated a shower aide reported that she and another CNA assisted a resident to lie down at approximately 1:45 p.m. and the resident and the other CNA began arguing. The resident then hit the CNA and the CNA punched the resident in the left shoulder. On 8/13/24 at 2:29 p.m., Staff C CNA stated she, Staff A, and Staff B assisted the resident to transfer with the mechanical lift. She stated Staff B ran the lift and she(Staff C) was on the resident's right and Staff A was on the resident's left. Staff C stated the resident and Staff A argued and the resident stated that Staff A didn't like him. Staff C stated Staff A told the resident that his wife didn't love him and cheated on him with [name redacted]. Staff C stated then the resident hit Staff A but she did not see where. Staff C stated Staff A then hit the resident in the left shoulder. She stated the hit was hard enough she could hear it. Staff C stated Staff A then said if he hit her, she would punch him back and next time she would punch him in the face and give him a black eye. Staff C stated she did not observe any red marks on the resident's shoulder after the hit. On 8/15/24 at 4:09 p.m., Staff C stated when Staff A hit the resident she had a closed fist. She stated the hit was not in response to the resident hitting Staff A but occurred after that. On 8/14/24 at 12:56 p.m. Staff A CNA stated on the day of the incident as she lifted the resident up in the mechanical lift, he tried to strike her but she stepped back and his hit did not connect. She stated she put her hand up and blocked his hit and they connected at the forearms. She stated if she had not put her hand up to block him, he would have hit her in the chest. She stated she told the resident that was why [name redacted] was with [name redacted-the resident's wife]. She stated there was no meaning behind this and she said this to try to be funny. Staff A denied that she hit the resident and stated the only thing she was guilty of was making this comment. On 8/15/24 at 10:08 a.m., the Administrator stated she expected staff to treat residents with respect and dignity and to go above and beyond.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure sanitary conditions of a food service area, failed to monitor and record resident refrigerator temperatures according to facility schedule, failed to ensure all staff entering kitchenettes wore a hair covering during food service, and failed to cover all food and drinks transported through the hallway to resident rooms to prevent contamination. The facility further failed to serve one resident, on a pureed texture diet, all menu items when side dish and dessert were omitted for 1 of 1 meal services observed. The facility reported a census of 39 residents. Findings Include: On 2/12/24 at 10:40 AM, observation of the C-Wing kitchenette refrigerator, which contained resident food and drinks, noted with splatters of liquid and crumbs collected on shelves. A log of refrigerator temperatures located on the outside of the kitchenette refrigerator had various shifts and entire days without a temperature recording. The steam table lids had spots of crusted food, water spots, and crumbs across the tops of lids. Noted a cleaning schedule posted on the outside of the kitchenette refrigerator, dated for the week of 2/04/24, missing documentation of kitchenette cleaning on 4 out of the 7 days. On 2/13/24 at 11:58 AM, observation of the lunch meal served to residents from the C-Wing kitchenette steam table. During service, observed a non-dietary staff member enter the kitchenette twice without hairnet covering to retrieve drinks from the refrigerator. One resident served pureed texture diet of the main course gumbo and rice, however pureed side of cornbread and cupcake were omitted and remained in the refrigerator throughout entirety of service. A room tray sent out of kitchenette, noted the plate covered but drinks remained uncovered during transportation through the hallway to resident room. On 2/13/24 at 12:50 PM, Staff D, Dietary Aide, reported that Dietary Staff are responsible for wiping down surfaces and sweeping the floor in the C-Wing kitchenette. On 2/13/24 at 2:50 PM, the C-Wing kitchenette refrigerator remained with splattered liquids and crumbs inside and steam table lids continued to appear soiled with spots of food. On 2/14/24 at 8:40 AM, observed two room trays sent from C-Wing kitchenette and transported through the hallway to resident rooms without a cover over food or drinks. When queried, Staff E, Dietary Aide, indicated plates sent a short distance did not require a cover. On 2/14/24 at 1:50 PM, the Dietary Manager revealed the expectations that refrigerator temperatures are checked by Dietary Staff each shift, hairnets are worn by any staff entering a kitchen during food service, and all items transported from the kitchen to a resident's room, must be covered, even for short distance travel. The Dietary Manager explained plans to update and revise kitchenette cleaning schedules. The facility policy titled, Dietary- Refrigerators and freezers, dated 4/17, informed that the record of refrigeration temperature log should be kept and temperatures monitored daily by the Food Service Supervisor. The facility policy titled, Dietary- Sanitation of the Dietary Department, dated 4/17, directed that all tasks will be addressed as to frequency (day and time or shift) of cleaning and notified a cleaning schedule will be posted with all cleaning tasks listed and employees will initial tasks when completed. The facility policy titled, Dietary- Head covering, dated 4/17, documented food service employees must wear a hair restraint to effectively keep hair from coming in contact with exposed food or clean equipment or utensils.

Based on observations, staff interview, and facility policy review, the facility failed to cover clean linen carts in compliance with infection control protocol while transported through 2 of 2 hallways. The facility reported a census of 39 residents. Findings include: 1. On 2/12/24 from 2:10 PM to 2:35 PM, observed a clean linen cart, with all but one side covered, being pushed through C-Wing Hallway as various staff passed through the area. Noted inside the cart were folded bed pads, clean sheets, and towels. The clean linen cart pushed by a Certified Nursing Assistant (CNA) from room to room as it remained uncovered and frequently left unattended throughout the 25 minutes of continuous observation. On 2/13/24 from 2:28 PM to 2:47 PM, observed a clean linen cart with all but one side covered, pushed through C-Wing Hallway as various staff passed through the area. The exposed side contained clean folded bed pads, wash clothes, and towels. The clean linen cart pushed by a CNA from room to room, remained uncovered and frequently left unattended throughout 19 minutes of continuous observation. On 2/14/24 at 2:50 PM, observed a clean linen cart, with all but one side covered, pushed through C-Wing Hallway by Laundry Staff as various staff and 2 residents passed through the area. The exposed side contained clean resident personal clothing. On 2/15/24 at 2:00 PM, the Laundry Supervisor revealed the expectation that all clean linen carts are kept completely covered throughout transportation through hallways. 34821 2. On 2/14/24 at 12:29 PM, Staff A, Laundry Job Coach pushed a laundry basket on wheels down the B-Wing Hallway. The cart passed the dining room (DR) stacked over 12 inches higher then the top of the basket. The basket held a table cloth over the top of the basket. The cloth failed to cover the 4 sides stacked with pads and blankets. On 2/14/24 at 12:32 PM, Staff A, removed the top of the items with the cover and left the side exposed as she pushed the laundry basket to the storage room at the end of the B-Wing Hallway on the left. The facility policy titled, Infection Prevention and Control- Laundry, dated 8/01/2017, informed staff that clean linen shall be handled, transported, and stored by methods that will ensure it's cleanliness.

Based on clinical record review, observations, staff interviews and facility policy review the facility failed to serve 2 out of 16 resident in the dining room (DR) in a dignified manner when meals served on trays (Residents # 12 and 17). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #12 dated 12/21/23, included diagnoses of Alzheimer's Disease, and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating severely impaired cognition. The MDS identified Resident #12 required partial or moderate assistance for eating. The Care Plan for Resident 12 dated 7/7/23, directed to provide adaptive equipment per the dietary list. The Dietary Seating Chart dated 2/6/24, failed to include a tray for Resident #12 while eating. 2. The MDS Assessment for Resident #17 dated 2/1/24, included diagnoses of non-Alzheimer's dementia, depression and dysphagia (difficulty swallowing). The MDS showed short and long term memory problems, severely impaired decision making skills. The MDS identified Resident #12 required substantial assistance for eating. The Care Plan for Resident 12 dated 10/28/23, directed to provide adaptive equipment s needed. The Dietary Seating Chart dated 2/6/24, failed to include a tray for Resident #17 while eating. The observations in the DR of Resident #12 and #17 at meal times revealed the following: a. On 2/12/24 at 12:18 PM, Resident # 17 sat in a chair at the DR table, his meal and drinks remained on a tray. b. On 2/12/24 at 12:36 PM, Resident #12 sat at the bar while her plate on a tray. c. On 2/13/24 at 08:27 AM, Resident #12 and #17's breakfast sat on trays throughout breakfast. d. On 2/13/24 at 12:34 PM, Resident #12 and Resident # 17's meal sat on a tray during the meal. e. On 2/14/24 at 8:14 AM, Resident # 12 and Resident #17 ate their meals off trays for the breakfast. f. On 2/14/24 at 12:33 PM, Resident #12 and Resident #17 ate their meals off a plate that sat on trays. On 2/14/24 at 1:55 PM, the Dietary Manager reported no one that she knew of needed to have their meals left on a tray while they ate a meal. On 2/15/24 at 8:59 AM, the Director of Nursing(DON) reported unsure why Resident #12 and #17 ate their meals off trays this week in the DR. On 2/15/24 at 9:00 AM, the Restorative Nurse failed to know why 2 residents in the DR ate meals off trays. On 2/15/24 at 9:20 AM, the DON stated she expected the staff to remove resident's food from the tray and place the food dishes in font of them. The Facility Admission Packet dated 12/23, included the Resident [NAME] of Rights that directed Residents Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (a) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. (b) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

Based on clinical record review, staff interview, and Facility Assessment Tool review, the facility failed to include anti-depressant and diuretic medications in Care Plan for one of five residents (Resident #2) reviewed for unnecessary medications. The facility reported a census of 39 residents. Findings Include: The Medication Administration Record (MAR), dated February 2024, revealed current orders for Furosemide (diuretic) 40 milligrams (mg) one tablet daily for Chronic Diastolic Heart Failure, initiated on 11/28/23, and Trazodone (antidepressant) 50 mg one tablet at bedtime for generalized anxiety disorder, initiated on 11/27/23. The Care Plan, revised on 2/12/24, lacked a focus areas to inform care needs and the side effects related to anti-depressant and diuretic medications. The Minimum Data Set (MDS), dated [DATE], revealed Resident #2 required both anti-depressant and diuretic medications. Diagnoses included: Heart failure and anxiety disorder. On 1/15/24 at 1:15 PM, the Director of Nursing (DON) confirmed that Resident #2's Care Plan lacked anti-depressant and diuretic medications and informed the expectation that these medications are included on resident care plans. The facility provided document titled, Facility Assessment Tool, dated 1/19/24, revealed the expectation of Nursing Staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well being of each resident as determined by individual plans of care.

Based on clinical record review, observations, resident interview, and Call Light Log review, the facility failed to answer resident call lights in a timely manner resulting in long wait times for 2 of 39 residents reviewed for call light response time (Residents #1 and #3). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (intact cognition). Resident required substantial/maximal staff assistance for transfers and dependence on staff for toileting hygiene. Resident #3 diagnoses included: End Stage Renal Disease, Neurogenic bladder, arthritis, seizure disorder, anxiety disorder, and depression. The Care Plan, revised on 01/03/24, revealed focused areas related to risk of falling and deterioration in ability to perform activities of daily living. On 2/12/24 at 10:57 AM, Resident #3 reported waiting a long time for help in the mornings and stated it often took greater than 15 minutes for staff to answer a call light. Resident #3 informed using a clock mounted on wall next to recliner to identify how long the wait time had been. On 2/12/24 at 11:14 AM, during a continuous observation of Resident #3's call light on above doorway to the room as well as from the monitor on the wall of hallway which displayed unanswered call lights with amount of time call light had been on. Noted a Certified Nursing Assistant (CNA) passed Resident #3's call light several times and Dietary Staff had been present in the area. Resident #3's call light answered by a CNA at 11:31 AM, after 17 minutes of wait time. Review of facility provided Call Light Log revealed Resident #3's call light response times included: a. On 2/12/24 at 6:34 AM, response time of 24 minutes and 47 seconds. b. On 2/12/24 at 7:09 AM, response time of 22 minutes and 44 seconds. c. On 2/12/24 at 8:54 AM, response time of 36 minutes and 52 seconds. d. On 2/13/24 at 6:24 AM, response time of 16 minutes and 32 seconds. e. On 2/15/24 at 7:39 AM, response time of 25 minutes and 31 seconds. 34821 2. The MDS for Resident #1 dated 1/17/24, included diagnoses of heart failure, hypertension, and arthritis. The MDS reflected a BIMS score of 15 out of 15, intact cognition. The Resident Council Meeting Minutes dated 1/24/24, reflected residents report sometimes it's a wait to get up in the morning. The Resident Council Meeting Minutes date 11/29/23, reflected under Nursing, residents report sometimes they say they'll be right back and then don't come back for a long time. On 2/25/24 at 7:48 AM, the television screen mounted to the wall by the C Hall Dining room (DR) showed the a call light time of 53 minutes for room [ROOM NUMBER]. On 2/15/24 at 7:50 AM Resident #1 reported she turned on her call light about 7:00 am, she reported it's been on for a long time. She stated it happens a lot that she has to wait a long time for help. She explained maybe because she is at the end of the hall or maybe they don't have enough staff to help. On 2/15/24 at 7:55 AM, the TV monitor read the call light for room [ROOM NUMBER] activated 17 minutes. Staff B, Licensed Practical Nurse (LPN) called for a CNA to get the call light on for extended time. On 2/15/24 09:23 AM, the Director of Nursing (DON) reported she expected call lights be answered in 15 minutes. She reported felt the facility staffed better than other facilities. The facility provided the Staffing Plan that identified 2 Nurses, and 4 CNA's for the day shift for the 2 wings and 1 and a 1/2 shift Bath Aides.

Based on clinical record review, employee file review, staff interview and facility policy review, the facility failed to implement the facility's Abuse Policy for 1 out of 1 residents reviewed (Resident #2) and failed to have 1 out of 4 Certified Nursing Assistants (CNA) complete the required Abuse training in the required time frame. The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident # 2 dated 7/7/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed Resident #2 with a Brief Interview of Mental Status (BIMS) score of 12 out of 15 (moderately impaired cognition). The MDS read Resident #2 required extensive assist of 1 staff for bed mobility, toileting, dressing, and transfers. The MDS revealed Resident #2 exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 1-3 days in the reference period. Resident #2's Progress Note dated 9/15/22, read Skin/Wound Note at approximately 10:00 AM, when resident was getting undressed for his bath, CNA alerted this nurse to bruising to resident's peri area. Upon further assessment the noted: Underneath scrotum: purple bruise, 4 centimeters (cm) by 6 cm and across penis: purple bruise, 8 cm by 8 cm. Resident's wife present at time of assessment and aware. The facility's undated investigation, included an Confidential Incident Report completed by Staff C Registered Nurse (RN), statements from 1 CNA and 2 other RN's. The facility failed to include the statement or interviews from other CNA's that cared for Resident #2 in the days before the bruised areas were found. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/2019, read on page 6 Injuries of unknown Source A injury should be classified as injuries of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area that is not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injury overtime. On page 7 of Investigation Protocols directed staff: Should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the Administrator or his/her designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of the resident abuse and collected any supporting documents relative to the alleged incident and complete the following: a. Review documentation in the resident record. b. Assess the resident for injury if the allegation involved physician or sexual abuse. c. Provide proper notification to the Primary Care Provider and the responsible party. d. Attempt to obtain Witness Statements (oral and/or written) from all known witnesses. e. If there is physical evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse with out fear of recrimination or intimidation. Following the investigation, the Administrator or designated agent will be responsible for forwarding the investigation to reporting that to the State Agency (SA). The written report will be sent to the SA within 5 days of the initial report. Review of the Individual Timecard for Staff D, Certified Nursing Assistant (CNA), reflected a hire date of 1/25/22. Review of the Shift Assignment from 9/6/22 though 10/2/22, revealed Staff D worked 19 shifts during that time period. Review of the employee file for Staff D, CNA reflected the completion of the Mandatory Abuse Training completed on 10/5/22, over 8 months after hired. On 10/05/22 at 4:20 PM, the Administrator confirmed that she found Staff D failed to complete the Mandatory Abuse training. The Administrator reported she called Staff D and directed her to complete the Mandatory Abuse training today. The Nursing Facility's Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/2019, directed new employees will complete a 2 hour Abuse training with in the required 6 months of hire.

Based on clinical record review, staff interview and facility policy review the facility failed to report injuries of unknown source to the State Agency (SA) for 1 out of 1 residents reviewed (Resident # 2). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #2 dated 7/7/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed Resident #2 with a Brief Interview of Mental Status score of 12 out of 15 (moderately impaired cognition). The MDS read the resident required extensive assist of 1 staff for bed mobility, toileting, dressing, and transfers. The MDS revealed Resident 2 exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 1-3 days in the reference period. Resident #2's Progress Note dated 9/15/22, read Skin/Wound Note at approximately 10:00 AM, when resident was getting undressed for his bath, the Certified Nursing Assistants (CNA's) alerted this nurse to bruising to resident's peri area. Upon further assessment the noted: Underneath scrotum: purple bruise, 4 centimeters (cm) by 6 cm and across penis: purple bruise, 8 cm by 8 cm. Resident's wife present at time of assessment and aware. The facility's Investigation File included an Confidential Incident Report completed by Staff C, Registered Nurse (RN), statements from 1 Certified Nurse Aid (CNA) and 2 other RN's. The facility failed to include statements or interviews from other CNA's that cared for Resident #2 in the days before the bruised areas were found. The Confidential Incident Report dated 9/15/22 at 10:00 AM, identified Resident #15 alert and confused. On 10/10/22 at 9:20 AM, Staff C, Registered Nurse (RN) reported Resident #2's wife is normally here after breakfast by 10:00 AM and leaves before supper (6 PM). The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/2019, on page 5 reflected examples injuries that could indicate abuse include but are not limited to: a. Injuries that are non-accidental or unexplained. b. Bruises that are found in unusual location head, neck, lateral location on the arm, or posterior torso and trunk, or bruises in shapes. Page 6 read Injuries of unknown Source- An injury should be classified as Injuries of unknown Source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area that is not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injury overtime. The policy directed on page 7, the facility would report to the SA in 2 hours and complete the investigation in 5 days and sent that to the SA also.

Based on the facility investigation, staff interviews and facility policy review the facility failed to complete a thorough investigation into the bruising found on 1 out of 1 residents reviewed (Resident # 2). The facility reported a census of 39 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #2 dated 7/7/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed Resident #2 with a Brief Interview of Mental Status score of 12 out of 15 (moderately impaired cognition). The MDS read the resident required extensive assist of 1 staff for bed mobility, toileting, dressing, and transfers. The MDS revealed Resident 2 exhibited verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 1-3 days in the reference period. Resident # 2's Progress Note dated 9/15/22, read Skin/Wound Note: At approximately 10:00 AM when resident was getting undressed for his bath, CNAs alerted this nurse to bruising to resident's peri area. Upon further assessment the noted: Underneath scrotum: purple bruise, 4 centimeters (cm) by 6 cm and across penis: purple bruise, 8 cm by 8 cm. Resident's wife present at time of assessment and aware. The facility's investigation included an Incident Report completed by Staff C, Registered Nurse (RN), statements from 1 Certified Nurse Aid (CNA) and 2 other RN's. The facility failed to include statements or interviews from other CNA's that cared for Resident #2 in the days before the bruised areas were found. According to the schedule dated 9/14/22, reflected 6 CNA's on the the B Wing, where Resident #2 resides. The schedule dated 9/13/22 reflected 5 CNA's on the B Wing. On 10/10/22 at 9:20 AM Staff C, RN reported, Resident #2's wife is normally here after breakfast by 10 am and leaves before supper (6 PM). On 10/10/22 at 8:28 AM, the Administrator confirmed the facility lacked additional staff statements about the bruising to R# 2's groin and penis area. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/2019, read on page 6 Injuries of unknown Source A injury should be classified as injuries of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident. b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area that is not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injury overtime. The Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy dated 7/2019, read on page 7 investigation protocols: Should an incident or suspected incident of resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The Administrator or designee will complete documentation of the allegation of the resident abuse and collect any supporting documents relative to the alleged incident and then complete the following: a. Review documentation in the resident record. b. Assess the resident for injury if the allegation involved physician or sexual abuse. c. Provide proper notification to the primary care provided and the responsible part. d. Attempt to obtain witness statements (oral and/or written) from all known witness. e. If there is physical evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse with out fear of recrimination or intimidation. Following the investigation, the Administrator or designated agent will be responsible for forwarding the investigation to reporting that to the State Agency (SA). The written report will be sent to the SA within 5 days of the initial report.

Based on clinical record review, observation, staff and resident interviews, and policy review, the facility failed to revise Resident Care Plans with changes in resident needs for 3 of 12 residents reviewed (Resident #15, #19, and #27). The facility reported a census of 39 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 entered the facility on 6/10/21. The resident's Brief Interview for Mental Status (BIMS) score was 15 indicating intact cognition. The MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coded Resident #19 as being independent with set up help only for eating, extensive assist of 2 persons for transfer, bed mobility and toileting, total dependence of 2 persons for bathing, and total dependence of 1 person for mobility. Progress Notes indicated the following relating to the resident's activity of daily living: a. On 10/20/2021 at 4:55 PM, documented Resident #19 was to be up out of bed and in the chair for meals, but refused frequently. Resident stated, I'm ok, I'm not going to choke, I know what I'm doing. b. On 11/4/21 at 11:47 AM, documented Resident #19 had refused to get out of bed for all her meals and that it had been an ongoing refusal for resident. Resident stated I'm not going to choke, I know what I am doing. c. On 11/8/21 at 2:16 PM, documented Resident #19 refused to sit in the recliner for meals as ordered. d. On 8/15/22 at 8:25 AM, documented Resident #19 refused to allow staff to give her scheduled bed bath. The resident stated she would do it the next day but then later stated she would take her bath on Wednesday 8/17/22. e. On 9/2/22 at 1:16 PM, documented the nurse and Bath Aide explained to Resident #19 it was unsafe for her to get into the whirlpool tub or shower chair due to her inability to hold herself sitting upright related to her trunk support getting weaker which could result in her sliding off the chair and onto the floor. The Bath Aide explained it had been tried numerous times and determined unsafe. They explained the facility was looking into a shower chair that would provide the safety she needed in the shower. Resident #19 stated she did not want a bed bath or a shower for the rest of her life and wanted the facility to buy a new tub with a chair that worked for her. The Care Plan dated 8/11/22 revealed a Focus Area related to Resident #19's ability to complete activities of daily living had deteriorated related to chronic pain, [CONDITION(S)], wheelchair dependence and weakness, The Care Plan included interventions that the resident was recommended to sit upright in the recliner for all meals and to document if refused (initiated on 7/7/21), the resident prefers to sleep in her recliner (initiated 6/23/21), and the resident was to get a whirlpool/shower two times per week and have hair and nail care as needed (initiated 6/22/21). In an observation on 10/4/22 at 8:58 AM, Resident #19 was lying in bed on her back with the head of the bed elevated eating her breakfast. In an interview on 10/4/22 at 8:58 AM, Resident #19 reported she no longer got a whirlpool bath or a shower related to not being safe in the chairs. The resident reported she got a bed bath once a week. She reported she rarely gets out of bed and eats all of her meals in bed. In an observation on 10/5/22 at 1:57 PM, Resident #19 was lying in bed with the head of the bed elevated watching TV. In an observation of cares on 10/6/22 at 9:18 AM, Resident #19 was lying in bed on her back with the head of her bed elevated when staff entered the room. The facility failed to update the Care Plan Interventions when the resident was no longer able to take a whirlpool bath or shower, when she was no longer getting up in her chair for meals and when she no longer slept in her recliner. 2. The Admission MDS assessment dated [DATE] indicated Resident #27 entered the facility on 8/25/22. The resident's BIMS score was 14 indicating intact cognition. The MDS revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS was coded as Resident #27 being independent with set up help for eating, and extensive assistance of 2 staff with bed mobility, transferring and toileting. The MDS indicated the resident was frequently incontinent of urine and occasionally incontinent of bowel. She had falls in the 2 to 6 months prior to admission which resulted in a fracture and had 2 or more falls since admission without any major injury. Res #27 received an antidepressant, antibiotic, diuretic and opioid daily during the 7 day observation period. Progress Notes indicated the following related to resident #27 falls since admission: a. On 8/26/22 at 6:05 AM, documented a Certified Nursing Assistant (CNA) reported Resident #27 was on the floor. The resident was noted to be on the floor in her room next to the bottom of the bed in a supine position. Resident #27 reported she had experienced a moment of weakness during a transfer and the CNA was easing her to the floor when she slid out of the CNA's arms. The resident complained of left shoulder pain but had good range of motion to area. b. On 8/26/22 at 9:51 AM, documented Resident #27's husband was notified of the fall and an x-ray of the left shoulder was ordered. c. On 8/29/22 at 5:05 AM, documented Resident #27 walking to the bathroom with a CNA using a gait belt and walker. The resident lost her strength while turning to the toilet and was eased to the floor by the CNA. No new injuries were noted. d. On 8/30/22 at 9:00 PM, documented a CNA reported Resident #27 on the floor. The resident was noted to be sitting on her buttocks on the bathroom floor. It was reported the resident's knees buckled while being assisted to transfer from the toilet and the resident dropped to her knees and with staff assistance, was turned and placed on her buttocks. No new injuries were noted. e. On 8/31/22 at 4:33 PM, documented the Nurse Practitioner noted the left shoulder x-ray was negative for fracture or dislocation. The resident's spouse was notified. f. On 9/15/22 at 9:30 AM, documented Resident #27 ambulating in the hallway with 2 staff from the Therapy Department when her knees buckled and she was lowered to the floor onto her knees. The resident was assisted back to the wheelchair by the 2 staff members using a gait belt. No injuries were noted. The resident's husband notified of the fall. The Care Plan dated 9/2/22, revealed a Focus Area for Resident #27 being at risk for falls related to requiring assistance with activities of daily living and [CONDITION(S)] with a goal the resident would transfer and ambulate with assistance while minimizing the risk for falls. It included the following interventions for the resident: a. To utilize grab bars to assist with bed mobility and repositioning. b. Keep personal items and frequently used items within reach. c. Provide toileting assistance before and after meals, at bed time and as needed. d. Transfer the resident using a pivot transfer with a gait belt and the assistance of 2 staff and a walker. Review of the Incident Reports for each of the 4 falls did not include any new interventions put in place to assist in prevention of further falls. In an interview on 10/10/22 at 9:45 AM, Staff E, Assistant Director of Nursing (ADON)/MDS Nurse, stated all falls were reviewed at the daily stand up meeting and an intervention was put in place and placed in the communication book. The interventions that were reportedly put in place with each fall for Resident #27 were as follows: a. The intervention for the fall on 8/26/22 - follow the resident with a wheelchair during ambulation. b. The intervention for the fall on 8/29/22 - wear socks and shoes when out of bed. c. The intervention for the fall on 8/30/22 - keep a commode in the room for toileting. d. The intervention for the fall on 9/13/22 - therapy to decrease the distance they ambulate the resident. The facility failed to update the Care Plan with the fall interventions put into place after each fall to direct staff in the care of the resident. 3. The Minimum Data Set (MDS) Assessment for Resident # 15 dated 8/4/22, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the Resident's BIMS score of 7 out of 15(severe cognitive impairment). The MDS reflected the resident required extensive assist of 1 staff for bed mobility transfers ambulation, dressing and toileting. The MDS documented Resident # 15 received anti-psychotic medication for the 7 days of the reference period. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan for Resident #15 with a targeted date of 10/27/22, failed to identify the use of the anti-psychotic medication, failed to direct the staff the side effects to monitor and failed to identify the symptom the anti-psychotic is prescribed to treat. 4. On 10/3/22 at 11:04 AM, the top Resident #15's left hand held a clear dressing in place, with red drainage under the dressing. The Skin Condition Record for Resident # 15 dated 8/26/22, identified the left posterior hand skin tear measured 3.5 centimeters (cm) by 1.7 cm and 0.1 cm deep on 9/28/22. The Care Plan for Resident #15 with a targeted date of 10/27/22, failed to identify the skin tear on Resident # 15's left hand. In an interview on 10/6/22 at 3:55 PM, the Administrator stated it was her expectation if something had changed with a resident, it would be discussed in the Daily Stand-Up Meeting and the Care Plans updated as appropriate. In an interview on 10/10/22 at 2:17 PM, Staff E, ADON/MDS Nurse stated it was her expectation the Care Plans be updated with interventions following each fall. She stated it was not the expectation that a one-time intervention be placed on the Care Plan but any intervention to be done on a regular basis should be placed on the Care Plan so staff know how to care for the resident. The facility provided policy titled Comprehensive Care Plan, revised 7/18/22, directed staff are to regularly review and revise the plan of care, treatment and services. It also stated the Care Plan should be updated if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change.

Based on clinical record review, observation, staff interview and facility policy review the facility failed to provide proper catheter care to minimize the occurrence of urinary tract infections for 1 of 1 sampled residents who required a urinary catheter (Resident #28). The facility reported a census of 39 residents. Findings Include: 1. A Significant Change Minimum Data Set (MDS) assessment dated [DATE] for Resident #28 revealed she admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderate cognitive impairment. Resident #28 required extensive assistance of 2 staff for bed mobility, transfers, and toileting. The MDS also revealed the resident had an indwelling catheter, was frequently incontinent of bowel and had a [CONDITION(S)]. The Care Plan dated 8/12/22 revealed Resident #28 required an indwelling urinary catheter related to her stroke and had a goal to have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. Interventions included keeping the catheter system closed, providing catheter care twice a day and as needed, and to report signs and symptoms of a urinary tract infection. Observation on 10/6/22 at 12:37 PM, during catheter care for Resident #28 revealed staff A, Certified Nursing Assistant (CNA) with the assistance of Staff B, CNA entered the room, closed the door and performed hand hygiene. They set up their supplies on the tray table using a towel as a barrier. The resident was lying in bed on her back watching TV. Staff told resident what they were going to do. They performed hand hygiene again and put gloves on. Staff B removed the blanket from the resident and placed at her feet. Staff A used the one wipe one swipe method for cleaning the resident with washcloths, soap and water. She washed, then rinsed and then dried the areas as she went. Staff washed the pubis area, the groin and then the thighs. She did one swipe down the labia from front to back. Staff B then assisted resident to turn onto her left side and Staff A washed, rinsed and dried her right hip and buttock area as well as anus. Staff B assisted the resident to turn onto her right side and Staff A washed, rinsed and dried her left hip and buttock area. Once completed Resident #28 was placed on her back and covered up. Hand hygiene was completed appropriately throughout the process and good infection control practices maintained. Resident was made comfortable. Staff A failed to cleanse around the urethra or down the catheter tubing during catheter care to help prevent infection. Record review revealed Resident #28 had two urinary tract infections ([CONDITION(S)]'S) since her admission to the facility. One on 8/27/22 which was treated with [MEDICATION(S)] 800-160 milligrams (mg) 1 tablet by mouth twice a day for 7 days. The second [CONDITION(S)] on 9/24/22 which was treated with [MEDICATION(S)] 250 mg 1 tablet by mouth twice a day for 3 days. In an interview on 10/6/22 at 12:34 PM, the Director of Nursing (DON) acknowledged staff did not complete catheter care to her expectations. The DON stated it was her expectation staff cleanse around the urethra and down the catheter tubing with every catheter care. A facility provided Prompt for Catheter Care/Measuring Output revised on 3/1/17 indicated staff were to do the following: a. Cleanse with soap and water around the meatus, where the catheter enters the body, using a clean area/side of washcloth with every swipe. b. Hold/anchor the catheter and cleanse tubing with one swipe away from the meatus down the Y or connection site. Do not clean tubing back and forth. c. Rinse with warm water in the same order, and pat dry.

Based on observation, record review, staff and resident responsible party (RP) interviews, the facility failed to maintain an environment free of accident hazards and failed to provide adequate supervision of meal services for residents dependent on feeding assistance and supervision from staff that resulted in a serious burn injury for 1 of 4 resident records reviewed (Resident #4). The failure of supervision resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 36 residents. Findings Include: The 4/14/22 Minimum Data Set (MDS) Discharge Assessment tool revealed Resident #4 admitted to the facility 4/8/22 as a transfer from another nursing home. The MDS identified the resident with diagnoses that included displaced fracture of 2nd cervical vertebra, repeated falls, and severe cognitive impairment with symptoms of [CONDITION(S)] present. The resident required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed and chair, eating, dressing, toileting, bathing and personal hygiene, the resident unable to stand or ambulate. The resident documented with physical behaviors directed at others from 1 to 3 days of the 7 days that preceded the assessment. Additional information obtained from a hospital emergency room History and Physical report dated 3/3/22 revealed the resident had left leg weakness from post-polio syndrome, placed in a Miami J Collar brace due to the cervical fracture diagnosed on that visit, and staff reports of concerns for aspiration risk. (A Miami J Collar immobilizes the neck area, movement of the head from side to side, rotation of the head, and flexion/extension of the head from the neck movements all severely restricted by the collar, such as placement of chin on the chest that assists swallowing for people with swallowing deficits such as dysphagia). Admission orders transcribed by the physician and dated 4/8/22 directed staff: a. Provide General diet, pureed texture, nectar thick consistency liquids. b. Urinary catheter size 14 French with 10 milliliter (ml) sized balloon, changed every 30 days and as needed. c. Speech Therapy to evaluate and treat. d. Physical Therapy to evaluate and treat. e. Occupational Therapy to evaluate and treat. The Baseline Care Plan, dated 4/8/22, directed staff: a. Cognition status confused. b. Risk for swallowing problems. c. Risk for weight loss. d. Pureed diet, nectar thick liquids with 2 handled cups, eats in dining area. e. Stage 2 pressure sore on coccyx, 0.5 centimeters (cm) by 0.5 cm, [MEDICATION(S)] border dressing to the area. f. Urinary catheter used, risk for bowel incontinence related to weakness, incontinence briefs used. g. Toilet resident before and after meals, at bedtime and as needed. h. Non-ambulatory, full body mechanical lift for transfers. The facility's Investigation Summary, submitted 4/15/22 with their Self-Reported Incident # 4-I, stated: a. Resident admitted [DATE], diagnoses included displaced fracture of the 2nd cervical vertebrae and dementia, required mechanical lift transfer and assistance with all activities of daily living (ADL's). b. On the evening of 4/8/22, a Dietary Aide (DA) served the resident a cup of thickened coffee as the resident waited for his meal, and continued to serve other drinks to other residents as the Certified Nursing Assistants (CNA's) continued to bring residents to the dining room for supper. c. A few minutes later, a CNA and the DA heard a cup land on the floor. The DA cleaned the coffee spill, and the resident gave no indication he had spilled coffee on himself. He told the DA the coffee was hot. d. After supper, staff noticed a pink/red area on his right thigh when they undressed the resident for bed, got the nurse immediately and placed a cold cloth on the area. The nurse assessed the area, documented the assessment on a Skin Sheet and notified the physician via facsimile (Fax). e. The burn measured 17 centimeters (cm) by 2.5 cm and blistered the following day. The resident did not complain of pain to the area. A Skin Condition Record dated 4/8/22 completed by Staff D, Licensed Practical Nurse (LPN) described a 17 cm by 2.5 cm area on right hip where coffee had spilled on resident. The area was pink, blotchy, blanchable and without blisters. Silver cream applied to the area. An Incident Report dated 6:30 p.m. on 4/8/22, completed by Staff D, LPN, stated per CNA, resident was drinking coffee and it was spilled on his right hip/upper thigh area, witnessed by Staff B, CNA and Staff C, CNA. Staff D was called to the resident's room to assess area as CNA's prepared the resident for bed. Staff D applied Silver cream on area that was pink, blotchy, and measured 17 cm by 2.5 cm. Staff D stated the physician was notified at 9:35 p.m. on 4/8/22 (method of contact not reported), and family notified at 4:00 p.m. on 4/12/22. Signatures by the Director of Nursing (DON) and Administrator, both required on the form, were not on the copy of the form that was provided to the Surveyor on Survey on 5/2/22. A Nursing Progress Note entry recorded by Staff D, LPN, at 8:24 p.m. on 4/8/22 stated: Resident was up for evening meal with staff assistance, was drinking coffee and spilled coffee on his right side. When CNA's were changing resident for bed it was noted the resident has blotchy red area size of 17 cm by 2 and 1/2 cm, applied cold wash cloth. Resident states that it doesn't hurt at all. Applied SilvrSTAT Gel on area and left open due to area hard to wrap. Will fax doctor to get order for SilverSTAT Gel and update family in a.m. The Dining Room Assistance Policy dated 4/17 directed staff: a. At least one person from Nursing Services will be stationed in the dining room during meal service to assist residents with eating and to handle any emergency situation that might arise. The Coffee Brewing and Service for Safe Temperature Policy dated 5/2022 directed staff: a. Coffee will be brewed at 195 degrees Fahrenheit (F) as recommended by the coffee company for a palatable cup of coffee. b. Coffee and hot water for meals will be cooled to a safe temperature of 140 degrees F or below for meal service. c. Temperatures will be documented on the Coffee/Hot Water Temperature log. Observations revealed: a. Posted Meal Times: Breakfast 8:00 a.m., Lunch 12:00 p.m., Supper 6:00 p.m. b. On 5/3/22 at 8:25 a.m., temperature of 145.4 F recorded by the surveyor from a cup of coffee dispensed out of a thermal container on the B Wing Kitchenette, coffee served to B Wing residents was dispensed from that container. Dietary staff recorded a temperature of 155 degrees F for the coffee on their log that morning. c. On 5/4/22 at 8:12 a.m., a bowl covered with cellophane wrap that contained a serving of pureed eggs was removed from the stationary steam table on the B Wing, steam rose from the eggs when the cover was removed and Staff K, DA obtained a temperature of 189 degrees F from the eggs. Staff K stated they were too hot to serve, covered the bowl loosely with aluminum foil and set it aside. A continuous observation on 5/4/22 between 11:41 a.m. and 12:34 p.m. in the B-Wing dining area revealed: a. At 11:41 a.m., cold beverages were positioned on tables, 6 residents seated at tables. b. At 11:56 a.m., CNA's continued to bring residents to the dining area. The medication cart was near the dining room, but the Nurse was not in the area. The Administrator, who is a nurse, and the facility's Corporate Nurse arrived to the area at this time and remained in the hall by the dining area. c. At 12:02 p.m., the B Wing Nurse stood by the serving area, Staff K, DA asked her if she would remain in the dining room, she said yes and Staff K stated he would serve Resident #1's food, a pureed diet. The CNA's continued to bring residents to the dining room. d. At 12:06 p.m., 15 residents seated in the dining room, CNA's were not present. e. At 12:07 p.m., Staff H, RN/Restorative Nurse, walked a resident to the dining room. f. At 12:08 p.m., the Nurse delivered Resident #1's food to the table, sat down and provided feeding assistance to the resident. No CNA's in the dining area. g. At 12:11 p.m., Staff H offered to assist with delivering food to seated residents, Staff K stated he would start to serve the dining room and plated the first meal. No CNA's present. h. At 12:12 p.m., one CNA arrived to the dining room and assisted with meal delivery and set-up assist. i. At 12:14 p.m., the remaining 2 CNA's arrived in the dining room, then left with a room tray for a resident. j. At 12:16 p.m., the 2 CNA's returned to the dining room. k. At 12:27 p.m., all residents seated in the dining room had received their meal. On 5/5/22 at 7:40 a.m., temperature of 138.7 degrees F recorded by the surveyor from a cup of coffee dispensed from the B Wing Kitchenette thermal container. Staff recorded a 136.4 degree F temperature for the coffee on their log that morning. Cold drinks were positioned on dining room tables. On 5/9/22 at 5:27 p.m., cold drinks were dispensed on tables in the B Wing Dining Room. Staff L, DA, was able to state the location and provide the list of resident's that required feeding assistance, and stated they could not serve hot liquids until Nursing Staff were in the dining room. During an interview on 5/5/22 at 11:12 a.m., Staff A, DA, stated he served thickened coffee to the resident because he asked for it around 5:30 p.m. on 4/8/22. He didn't know or remember if any Nursing Staff were in the dining room when he gave him the coffee. The cup fell to the floor within a few minute from when he served it, he picked the cup up, there was coffee on the floor, he did not know if there was coffee on the resident, and supper served at 6:00 p.m. In another interview on 5/5/22 at 2:22 p.m., Staff A stated the resident said this coffee is hot when he spilled it, and he didn't tell staff about the coffee because he thought it was spilled on the floor. On 5/3/22 at 4:12 p.m., Staff B, CNA, stated on the 4/8/22 evening shift, the resident was taken to the dining room between 5:00 p.m. and 5:30 p.m., she was in the dining room but faced a different direction and heard the cup fall, turned and saw coffee spilled on the floor, the resident didn't yell or say anything so she didn't think anything was wrong. She continued to bring residents to the dining room at the time. When the resident was taken to his room after supper, she noticed his pants were wet and realized he had spilled coffee on himself. His skin on the right leg was red, blotchy, it wasn't blistered but you could tell it was raised and needed to be looked at. She called for the nurse, Staff D, LPN looked at the area and directed her to get the other nurse on duty, Staff E, LPN. On 5/3/22 at 4:33 p.m., Staff C, CNA, stated as she brought residents to the dining room for supper on 4/8/22 she heard a noise and thought it was a cup dropped. She went to pick it up, there was coffee on the floor a little ways from the resident. When she took the resident to his room after supper around 7:00 p.m. his pants were wet, and realized he'd spilled coffee on himself, his skin on the right leg was raised, pink but the color wasn't a lot different then the skin around it. The resident didn't say it hurt and thought he could have said if it did. She called the nurse in (Staff D), she looked at it and called the other nurse over (Staff E). She didn't receive any other instructions related to the resident's effected skin. A few days later, it looked a lot worse. On 5/4/22 at 9:34 a.m., staff D, LPN, stated around 5:30 p.m. on 4/8/22, she was busy in a different resident's room when Resident #1 was in the dining room. Sometime between 5:30 p.m. and 6:00 p.m., she administered an oral medication to the resident seated in the dining room, he had the Miami J Collar on his neck and she noticed his pants were wet. She asked Staff B and Staff C why his pant were wet, they said it must have been from the coffee he spilled. Staff D didn't know how he had coffee because he was on thickened liquids and was supposed to have assistance in the dining room. The resident had involuntary/uncontrolled movements of his arms and legs, similar to someone with [CONDITION(S)]. She asked if the coffee was hot, staff didn't know and she didn't know why the coffee had been given to him. Staff D stated she has had to instruct different Dietary Staff, at different times, not to serve drinks or place utensils on the feeding assistance table until staff present, due to their cognitive status and safety. She had reported the issue to Management Staff several times before 4/8/22. She had also instructed Dietary Staff several times that certain resident's required lids on their drinks, but Dietary Staff reported they didn't have enough lids, until now, after the 4/8/22 incident, now the lids are on the cups. When she looked at the resident's skin on 4/8/22, after the aides put him in bed, between 7:00 p.m., and 7:15 p.m., his skin on the right upper thigh area was pink, blanchable and not blistered, and she called for the other nurse, Staff E, LPN, to assist her with measurements of the area. On 5/4/22 at 12:45 p.m., Staff I, RN, (Registered Nurse) and Assistant Director of Nursing (ADON) stated Dietary Staff were not supposed to serve residents with mechanically altered liquids until nursing staff were present, and didn't know why the resident would have been served coffee when staff not there. Staff I reported the Nurse should have known to call the Dietary Manager, or the Manager On-Call if there were problems with Dietary Staff and she was unaware of the problem with Dietary Staff serving when staff not present, it had not been reported to her before the 4/8/22 incident. They initiated staff education after the incident and she checked off facility staff from her list as the education was completed, and thought the Corporate Nurse had made sure that Agency Staff were educated on the changes since the incident. On 5/4/22 at 11:24 a.m., Staff K, DA, stated they are not supposed to serve hot liquids in the dining room unless Nursing Staff are present. On 5/11/22 at 10:28 a.m., the facility's Dietary Manager stated she knew that Dietary Staff that included Staff A, were educated as a group at least twice since she began employment 3/1/22, that they were not to serve hot liquids or altered texture foods/liquids unless Nursing Staff were present in the dining room. Prior to 4/8/22, there were not enough lids for cups, the recommendations made by Therapy Staff and the Dietician. The lids were ordered through their supplier but back-ordered, the Corporate Dietician was able to obtain some lids from other facilities where they weren't in use, and they had enough now for the resident's that required them. On 5/5/22 at 11:29 a.m., Staff M, the resident's Physician, stated the resident had a superficial, partial thickness burn wound from the hot coffee spill on 4/8/22, based on photo images of the resident's burn that she had seen. The resident's responsible party and POA interviewed on 5/2/22 at 6:08 p.m., stated the resident loved coffee and would always ask for it, had developed weakness, had more falls at home as a result and difficulty swallowing either from more weakness or wearing the neck brace, or both, and needed assistance with everything and why he was at the nursing home. The State Agency notified the facility of the Immediate Jeopardy on 5/9/22 at 12:30 p.m. The Immediate Jeopardy situation started on 4/8/22. The facility removed the Immediate Jeopardy on 4/26/22 by the following actions: a. Staff educated on Hot Liquid Safety on 4/14/22. b. All nursing staff educated prior to working their next scheduled shift that hot liquids were not to be served to residents until nursing staff present to supervise and assist, and educated on the location of the list of residents that required dining assistance. c. The facility completed a restorative assessment for all residents on 5/9/22 that included dining ability, sensory deficits, need for adaptive equipment, and determined what residents required assistance with hot beverages. A list of the residents that require dining assistance is available to nursing and dietary staff, and the restorative nurse is responsible to keep the resident list up to date. d. All current dietary staff were educated by 4/17/22 they could not serve hot liquids to residents until nursing staff were stationed in the dining room. The scope lowered from J to D at the time of the survey after ensuring the facility implemented staff education.

Based on record review, and staff and resident's responsible party (RP) interviews, the facility failed to provide accurate assessments with timely interventions, failed to obtain appropriate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4). The facility reported a census of 36 residents. Findings Include: The 4/14/22 Minimum Data Set (MDS) Discharge Assessment tool revealed Resident #4 admitted to the facility 4/8/22 as a transfer from another nursing home. The MDS identified the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed and chair, eating, dressing, toileting, bathing and personal hygiene, the resident unable to stand or ambulate. The resident documented with physical behaviors directed at others from 1 to 3 days of the 7 days that preceded the assessment. Additional information obtained from a Hospital emergency room History and Physical report dated 3/3/22 revealed the resident had left leg weakness from post-polio syndrome, placed in a Miami J Collar brace due to the cervical fracture diagnosed on that visit, and staff reports of concerns for aspiration risk. admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Provide General diet, pureed texture, nectar thick consistency liquids. b. Urinary catheter size 14 French with 10 milliliter (ml) sized balloon, changed every 30 days and as needed. c. Speech Therapy to evaluate and treat. d. Physical Therapy to evaluate and treat. e. Occupational Therapy to evaluate and treat. The Baseline Care Plan, dated 4/8/22, directed staff: a. Cognition status confused. b. Risk for swallowing problems. c. Risk for weight loss. d. Pureed diet, nectar thick liquids with 2 handled cups, eats in dining area. e. Stage 2 pressure sore on coccyx, 0.5 centimeters (cm) by 0.5 cm, [MEDICATION(S)] border dressing to the area. f. Urinary catheter used, risk for bowel incontinence related to weakness, incontinence briefs used. g. Toilet resident before and after meals, at bedtime and as needed. h. Non-ambulatory, full body mechanical lift for transfers. A Nursing Progress Note entry recorded by Staff D, Licensed Practical Nurse (LPN) at 8:24 p.m. on 4/8/22 stated: Resident was up for evening meal with staff assistance, was drinking coffee and spilled coffee on his right side. When Certified Nursing Assistants (CNA's) were changing resident for bed it was noted the resident has blotchy red area size of 17 centimeters (cm) by 2 and 1/2 cm, applied cold wash cloth. Resident states that it doesn't hurt at all. Applied SilvrSTAT Gel on area and left open due to area hard to wrap. Will fax doctor to get order for SilvrSTAT Gel. (SILVRSTAT® Antibacterial Wound Dressing is a water-based gel wound dressing for use in the management of first and second degree [CONDITION(S)]). There were no other entries related to the resident's burn area on the right upper leg recorded in the resident's record until 4/12/22 at 5:30 p.m. A form sent via Facsimile (Fax) to the physician 4/8/22 at 10:40 p.m., included the Nursing Progress Note transcribed above, the Physician, Staff M, approved the request for the treatment order and also wrote please send me admit orders too, signed and dated the form 4/11/22. Per interview 5/4/22 at 12:45 p.m. with Staff I, the Assistant Director of Nursing (ADON), and the facility had not received the returned fax from the physician as of 4/12/22. On 4/12/22 she called Staff M to notify her of the resident's injury on 4/8/22 with request for treatment orders, and was informed the physician returned the fax on 4/11/22, but it was sent it to an incorrect fax number, and provided a copy of the form to the facility for their records. A Skin Condition Record dated 4/8/22 completed by Staff D, LPN described a 17 cm by 2.5 cm area on right hip where coffee had spilled on resident. The area was pink, blotchy, blanchable and without blisters. Silver cream applied to the area. There were no other skin assessments of the right hip area recorded on the form. An Incident Report dated 6:30 p.m. on 4/8/22, completed by Staff D, LPN, stated per CNA, resident was drinking coffee and it was spilled on his right hip/upper thigh area, witnessed by Staff B, CNA and Staff C, CNA. Staff D was called to the resident's room to assess area as CNA's prepared the resident for bed. Staff D applied Silver cream on area that was pink, blotchy, and measured 17 cm by 2.5 cm. Staff D stated the physician was notified at 9:35 p.m. on 4/8/22 (method of contact not reported), and family notified at 4:00 p.m. on 4/12/22. Signatures by the Director of Nursing (DON) and Administrator, both required on the form, were not on the copy of the form that was provided to the Surveyor on Survey on 5/2/22. An order transcribed by Staff I, ADON, dated 4/12/22 at 4:30 p.m. , received from Staff M, the resident's Physician, directed staff to gently cleanse the right thigh wound with Wound Wash, pat dry, apply SilvrSTAT Wound Gel topical to wound twice daily until healed. The Incident Report Completion policy dated 8/10/18 directed staff on the following: a. Staff shall complete an Incident Report for any unusual incident involving residents, whether injury is apparent or not. b. Unusual incidents include, but are not limited to bruises, skin tears, abrasions or skin injuries. c. An accurate account of the incident must be written in the resident's clinical record and should include pertinent observations, measurements, instructions and actions taken. d. All written reports and documentation shall be completed during the shift in which the incident occurred and as soon as possible after the situation has been brought under control. e. A 24-hour, 48- and 72-hour follow-up notation, pertinent to the incident will be made by the Charge Nurse. f. The complete incident report will be submitted to the Director of Nursing (DON) for review. The DON will investigate the report and submit findings to the Administrator. The Administrator will review the incident report for completeness before signing it. During an interview on 5/5/22 at 11:12 a.m., Staff A, Dietary Aide (DA), stated he served thickened coffee to the resident because he asked for it around 5:30 p.m. on 4/8/22. The cup fell to the floor within a few minute from when he served it, he picked the cup up, there was coffee on the floor and he did not know if there was coffee on the resident. In another interview on 5/5/22 at 2:22 p.m., Staff A stated the resident said this coffee is hot when he spilled it, and he didn't tell staff about the coffee because he thought it was spilled on the floor. On 5/3/22 at 4:12 p.m., Staff B, CNA, stated on the 4/8/22 evening shift, the resident was taken to the dining room between 5:00 p.m. and 5:30 p.m., she was in the dining room but faced a different direction and heard the cup fall, turned and saw coffee spilled on the floor, the resident didn't yell or say anything so she didn't think anything was wrong. When the resident was taken to his room after supper, she noticed his pants were wet and realized he had spilled coffee on himself. His skin on the right leg was red, blotchy, it wasn't blistered but you could tell it was raised and needed to be looked at. She called for the nurse, Staff D, LPN looked at the area and directed her to get the other nurse on duty, Staff E, LPN. On 5/3/22 at 4:33 p.m., Staff C, CNA, stated on 4/8/22 evening shift she heard a noise and thought it was a cup dropped. She went to pick it up, there was coffee on the floor a little ways from the resident. When she took the resident to his room after supper around 7:00 p.m., noted his pants were wet, and realized he'd spilled coffee on himself, his skin on the right leg was raised, pink but the color wasn't a lot different then the skin around it. The resident didn't say it hurt and thought he could have said if it did. She called the Nurse (Staff D) to the room, she looked at it and called the other nurse over (Staff E). She didn't receive any other instructions related to the resident's effected skin. A few days later, it looked a lot worse. On 5/4/22 at 9:34 a.m., Staff D, LPN, stated sometime between 5:30 p.m. and 6:00 p.m., she administered an oral medication to the resident seated in the dining room, he had the Miami J Collar on his neck and she noticed his pants were wet. She asked Staff B and Staff C why his pant were wet, they said it must have been from the coffee he spilled. She asked if the coffee was hot, staff didn't know. When she looked at the resident's skin after the aides put him in bed, between 7:00 p.m. and 7:15 p.m., his skin on the right upper thigh area was pink, blanchable and not blistered, he said it didn't hurt and she called for the other nurse, Staff E, LPN, to assist her with measurements of the area. She did not think it was a serious injury, thought it would be resolved by the next day so she didn't think she needed to notify the physician by phone that evening, did not complete an Incident Report that evening because she didn't think it was like a fall, and she did not notify the Manager on call because she thought it was a minor injury and not warranted. She directed the CNA's to apply a cool cloth to the area until she obtained SilvrSTAT gel from another resident's supply (Resident #3) and applied to the resident's right thigh burn area. On 4/8/22, she faxed both the facility's Medical Director, and Staff M, the resident's Physician, with information about the resident's injury and request for SilvrSTAT treatment orders. She was shocked when she observed the wound on 4/11/22, it was opened, and nobody told her that it blistered, she didn't anticipate it was going to turn out the way it did and felt horrible about the resident's condition and situation that evolved because she had not made the appropriate calls on the evening of 4/8/22. On 4/13/22, she was directed to complete an Incident Report for the 4/8/22 injury and did so at that time. On 5/3/22 at 1:12 p.m., Staff E, LPN, (scheduled and worked 6:00 p.m. 4/8/22 to 6:00 a.m. on 4/9/22) stated on the evening of 4/8/22, Staff D came over to her hall and asked if she had First Aide cream on her treatment cart. She learned of Resident #4's injury then and went to assist Staff D with wound measurements. The skin area looked pink, no blistering, it didn't look bad, there was a cool rag on it, the resident denied pain but he had a spinal injury so may not have been able to feel it. Staff E stated if that had been a resident assigned to her she would have notified the Manager on call, the family, and would have notified the Physician by phone call or fax, depending on the condition, it didn't seem like it was a severe burn. On 5/3/22 at 1:23 p.m., Staff F, CNA, stated on the 4/9/22 day shift, the resident's right upper thigh was red, looked like raw skin, nothing about the matter was communicated in report that morning, so she asked the Nurse on Duty (Staff G, LPN) who said he was burned by spilled coffee the day before. She thought the nurse had seen it since she knew about it. The resident didn't say he had any pain in the area and could make his needs known. On 5/3/22 at 12:30 p.m., Staff G, LPN, (worked from 6:00 a.m. to 2:00 p.m. on 4/9/22 and 4/11/22), stated on the morning of 4/9/22, she was informed by Staff E, the off-going Night Shift Nurse the resident had hot liquid spilled on him and to monitor the area. When she assessed the area that morning, the area was pink, blanchable, and the resident denied pain in the wound area. When she observed the wound on 4/11/22, it looked bad, she had the Wound Nurse, Staff H, look at it that day, and at some point there were treatment orders for it. Staff G stated if staff reported a resident had spilled hot liquid on them, she would take them to their room, remove clothing, assess area, apply cool compress to area, would call manager on call and physician, she would not notify the physician by fax on something like that. On 5/4/22 at 11:26 a.m., Staff H, Registered Nurse (RN)/Facility Wound and Restorative Nurse, stated she observed the resident's skin after lunch on 4/11/22, there was a brownish colored scabbed area approximately 4 inches by 6 inches in size located on the right upper thigh. She asked the CNA what happened and informed the resident had coffee spilled on him. She thought they meant the previous night, and immediately informed the ADON about the spilled coffee, she asked her if it was something that he came to the facility with and she told the ADON she didn't know. They both assumed it was something that had just happened. Staff H stated she had not received any other instructions specific to the resident, and denied the ADON had instructed her to get with the nurse and ensure there was a treatment ordered for the wound. On 5/4/22 at 12:45 p.m., Staff I, RN, ADON/MDS Nurse stated she went to the resident's room on the afternoon of 4/11/22 to complete her portion of the MDS Assessment, the resident's spouse asked about a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The spouse stated the incontinence brief had rubbed on his leg, and learned the spouse had dementia. When she left the resident's room, she saw Staff H in the hall who asked her if she had seen the resident's skin issue, she cut her off and told Staff H she had, then directed her to get with nursing staff and make sure there was a treatment order for it. On 4/12/22, around 4:00 p.m., the Marketing Director came to her office with the resident's family members that included the spouse and the Power of Attorney (POA) who wanted to speak to her. She told them it wasn't a good time and would have to wait. The POA said it was a pretty significant matter, the resident was burned, they had not been notified of the injury and they were going to talk about it right then. Staff I called Staff M for a treatment order, put the order in the computer before 4:30 p.m. to ensure the pharmacy would deliver the SilvrSTAT gel that evening, and directed the nurse on duty, Staff J, RN to make sure the treatment was provided that evening after delivered by pharmacy. Staff I stated she was not informed the resident was burned by spilled coffee until that time, it was not reported to the on call manager, and there wasn't an Incident Report about it. Staff I stated when staff send a fax to a physician with request for orders, the fax form was placed on a clipboard by the fax machine, where it remained until they received the fax back from the physician, which was supposed to occur within 24 hours, and all nursing staff expected to check for fax returns throughout their shifts. After this incident, all nursing staff were educated on physician notification, manager notification, family notification, documentation requirements, skin/wound assessment protocols, and incident reporting and fax procedures. On 5/3/22 at 12:01 p.m., Staff J, RN, stated she worked day shift at the facility on 4/10/22, in morning report, the off-going Night Shift Nurse instructed her not to give the resident hot liquids because he would spill them on himself. That morning, the CNA told her she needed to check the resident, she observed intact fluid-filled vesicles/blisters on the right thigh area that measured approximately 8 cm by 12 cm, maybe longer, forgot to chart about it but thought it was already taken care of as far as notifications. She then worked the evening shift on 4/12/22, the resident's POA cried as they approached her around 4:00 p.m., stated what the Hell happened to their family member. She went to the resident's room with the POA, who directed her to look at the right thigh wound, and she informed the POA that was where the resident had spilled coffee on himself. Neither the POA nor the spouse, also present at the time, knew anything about the injury. At that time, the blisters were no longer intact, there was an open wound bed, pink/healthy red colored. Around 4:30 p.m. that evening, the ADON and another office staff employee were in the chart room, and the ADON instructed staff this was a big deal, and no one was to talk about the incident anymore. Staff J stated if this happened to one of her resident's she would have notified the physician by phone and requested treatment orders, would have notified the manager on call. On 5/4/22 at 4:10 p.m., the facility Administrator stated staff should have notified the physician by phone about the resident's injury and requested treatment orders on the evening of 4/8/22, and they should have notified the On-Call Manager. Staff could not administer medications or treatments prescribed to a resident from another resident's supply, could not administer a treatment without Physician authorization and order, and the facility replaced Resident #3's SilvrSTAT gel with a new supply. On 5/5/22 at 11:29 a.m., Staff M, the resident's Physician, stated Hospice staff sent her photos of the resident's burn injury on 4/14/22, after the resident discharged home from the facility, she had not seen the injury prior, and stated the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's responsible party and POA interviewed on 5/2/22 at 6:08 p.m., stated they were not aware of the resident's burn injury until they visited the resident on 4/12/22 and saw it. The nurse told her the resident was burned by coffee that he spilled on himself on 4/8/22. The resident's spouse was present, had visited the day before, and stated Staff I, RN told her the right thigh wound was caused by the brief rubbing on his leg, and the POA stated you didn't have to be a nurse to know that was not what caused that wound.