Every finding on record at Parkway Health & Rehab LLC

Based on observation, interview, record review, and facility policy review the facility failed to follow infection prevention and control practices during medication administration and Enhanced Barrier Precautions (EBP) for two (2) of three (3) residents observed for infection control practices. (Resident #9 and Resident #81).Findings include: A record review of facility policy Enhanced Barrier Precautions undated, revealed, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi- drug-resistant organisms (MDROs) to residents . Record review of the facility policy Infection Prevention and Control with a revision date of December 2023 revealed The facility adopted infection prevention and control policies and procedures.to help prevent and manage transmission of diseases and infections. Record review of the medication Procedure Guideline provided by the facility did not provide specific instructions on infection control.Resident # 9At 1:20 PM on 2/24/26, during an observation, Licensed Practical Nurse (LPN) #2 was observed performing percutaneous endoscopic gastrostomy (peg) tube site care for Resident #9. Prior to performing care, LPN#2 failed to don (put on) a gown. In an interview at 1:26 PM on 2/24/26, LPN #2, stated that she forgot to don a gown prior to admission but noted that the facility had a green dot in place on the door name tag to remind staff to wear gowns for care. She stated following EBP would prevent spreading infection to the peg tube site which is susceptible to infection when performing care that requires direct contact On 2/25/26 in an interview with facility Infection Preventionist (RN#1) at 2:30 PM, she stated the purpose of EBP was to prevent staff and residents from catching infection and to keep the staff from transferring infection to another room. She further stated that not wearing Personal Protective Equipment (PPE) as specified in the facility policy can lead to the transfer of bacteria from one resident to another and cause infection and other issues. On 2/26/26 11:30 AM in an interview with the Director of Nursing (DON) she stated that not wearing a gown to follow EBP leads to increased risk of spreading infection and that the importance of EBP is to prevent spreading infection from staff to the residents. It is her expectation that staff follow EBP guidelines as instructed by facility policy. A record review of Resident #9's admission Record revealed she was admitted [DATE] with diagnoses that included Alzheimer's disease with early onset A record review of Resident #9's Minimum Data Set (MDS) with an Assessment review Date (ARD) of 11/26/25 revealed she was unable to complete a Brief Interview for Mental Status (BIMS) assessment to determine mental status. Section K of the MDS revealed the resident had an enteral feeding tube.Resident # 81On 02/25/2026 at 8:37 AM, during a medication administration observation, observed LPN #1 with Resident # 81. During the medication administration, LPN #1 placed medications fluticasone (Nasal Spray) and inhaler (Budesonide) on the bedside table without disinfecting or using a barrier. She then placed those medications back on the cart without disinfecting their packages.In an interview at 8:41 AM on 2/25/26 with LPN #1, she stated she should have disinfected the surface of the bedside table before placing medications on the bedside table or used a barrier to place them on during medications to avoid spreading infection to other residents as the items went directly from a contaminated surface back to the medication cart.In an interview with the Infection Preventionist/ RN#1 on 2/25/26 at 2:30 PM, she stated LPN #1 should have either wiped off the bedside table with disinfectant prior to medication administration She stated that placing the medications on the contaminated bedside table and then placing the medications back on the cart without being disinfected would cause germs to be spread because germs from the nasal cavity and the mouth in the case of the inhaler are being spread then to other residents. In an interview with the DON at 1:05 PM on 2/26/26, she stated that LPN #1 should have wiped off the table and used a barrier prior to medication administration to and not placed the contaminated medications back on the medication cart without disinfecting to prevent the spread of infection. She stated that the nurse in this instance should have disinfected the medication packages before placing on the medication cart with other resident's drugs.A record review of the admission Record revealed Resident #81 was admitted on [DATE] with diagnoses that included influenza due to identified novel influenza A virus with pneumonia.A record review of the Order Summary Report revealed an order dated 2/16/26 for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT (microgram/actuation) two (2) puffs inhale orally every twelve (12) hours rinse and spit after each use and an order dated 2/16/26 for Fluticasone 50mg/ACT (milligram/actuation) propionate two (2) sprays in each nostril one time a day.

Based on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice to address abdominal distention and fecal burden in a timely manner, which resulted in hospitalization for fecal impaction for one (1) of three (3) residents reviewed for hospitalization. Resident #56. Findings include:Record review of Radiology Interpretation dated 11/28/25 revealed .Impression: Acute process. Mild fecal loading.A record review of an XR (x-ray) Abdomen 1 view report dated 12/22/25 revealed .Impression.2. Moderate gaseous distention of the small bowel, unchanged in comparison with the prior.Record review of the CT (computer tomography) Abdomen WO (without) Pelvis dated 12/22/25 revealed Impression: 1. Large fecal burden with findings suggesting stercoral proctitis.Record review of the December 2025 Medication Administration Record (MAR) revealed Dulcolax suppositories had been administered on 12/10/25 and 12/24/25. Lactulose was also administered on 12/25/26, 12/26/26 and 12/27/26. There was no documentation of preventive bowel medications following CT findings of fecal burden on 12/22/25.Record review of the Hospital Course with an encounter date of 12/27/25 revealed CT chest abdomen and pelvis showed rectal fecal impaction with perirectal stranding concerning for stercoral colitis with large colonic fecal burden.On 2/24/26 at 9:24 AM, during a telephone interview, the resident's brother reported he was upset when he learned the resident had to be hospitalized for constipation and stated he felt the facility let him get stopped up.On 2/25/26 at 3:30 PM, during an interview, the Director of Nursing (DON) reported the resident was receiving Colace and Miralax for bowel function and had bowel movements on 12/21/25 and 12/22/25. She stated the resident developed abdominal distention and imaging was completed. She reported CT results were not available and reviewed by staff until 12/24/25. She confirmed the resident was hospitalized on [DATE] after blood sugar dropped and further evaluation revealed fecal impaction.On 2/26/26 at 10:27 AM, during an interview, the DON reported the resident began facial grimacing and abdominal tenderness on 12/10/25 and Dulcolax was administered. She confirmed the resident continued to have bowel movements during this period.On 2/26/26 at 11:30 AM, during an interview, the Nurse Practitioner reported the resident was not placed on routine preventive bowel medication because he had no prior history of constipation. She stated residents are typically placed on preventive medications when receiving pain medications. She acknowledged that although CT results may sometimes be available the same day, results are occasionally delayed. She stated that earlier treatment could have benefitted the resident but indicated she initially suspected a urinary tract infection rather than bowel issues due to clinical presentation.On 2/26/26 at 11:40 AM, during an interview, medical records staff reported CT results are typically available the same day or by the following day and acknowledged the results from 12/22/25 were not retrieved until 12/24/25. She stated she was unsure why there was a delay.On 2/26/26 at 12:39 PM, during a follow-up interview, the DON reported the facility does not have a specific hospitalization prevention policy and follows Centers for Medicare and Medicaid Services (CMS) critical pathway guidance. She stated that because CT findings on 12/22/25 showed mild fecal burden and treatment was not initiated until 12/24/25, it was possible the subsequent hospitalization on 12/27/25 for fecal impaction could have been prevented.A record review of the admission Record revealed the facility admitted Resident #56 on 1/24/20 with diagnoses including Cerebrovascular Accident (CVA) and Acute Respiratory Failure with Hypoxia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/25 revealed Resident #56 had a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident's cognition was severely impaired. Documentation noted the BIMS was unable to be completed due to mental impairment and aphasia.

Based on observation, interview, record review and facility policy review, the facility failed to implement the comprehensive person-centered care plan by not maintaining Enhanced Barrier Precautions (EBP) during care for one (1) of three (3) residents reviewed for infection control practices. Resident #9.Findings include:Record review of the facility policy Care Plans Comprehensive Person-Centered revised December 2016 revealed A comprehensive person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical psychosocial and functional needs is.implemented for each resident.Record review of the Care Plan Report with a revision date of 1/13/26 revealed Focus.Resident is NPO (nothing by mouth) gastrostomy tube.Interventions/Tasks.Maintain Enhanced Barrier Precautions.On 2/24/26 at 1:20 PM, during an observation, Licensed Practical Nurse (LPN) #2 performed Percutaneous Endoscopic Gastrostomy (PEG) tube site care for Resident #9 without donning a gown prior to initiating care.On 2/24/26 at 1:26 PM, during an interview, LPN #2 reported she forgot to apply a gown prior to performing PEG tube care. She acknowledged the facility uses a green dot indicator on the door name tag to remind staff to wear gowns for care and stated that following Enhanced Barrier Precautions helps prevent the spread of infection during direct contact care.On 2/25/26 at 2:30 PM, during an interview, the Infection Prevention (IP) Nurse reported the purpose of Enhanced Barrier Precautions is to prevent transmission of bacteria between staff and residents and stated failure to wear required personal protective equipment (PPE) can contribute to the spread of infection.On 2/26/26 at 11:30 AM, during an interview, the Director of Nursing (DON) stated she is responsible for ensuring care plans are developed and implemented. She reported that failure to follow the care plan intervention to maintain Enhanced Barrier Precautions could increase the risk of infection transmission and stated it is her expectation that staff follow care plans as written.A record review of the admission Record revealed the facility admitted Resident #9 on 10/8/20 with diagnoses that included Alzheimer's Disease with early onset.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/25 revealed Resident #9 was unable to complete a Brief Interview for Mental Status (BIMS) due to cognitive impairment.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure that dietary staff support and respect a resident's right to make choices about his or her meal preferences for two (2) of (18) sampled for Residents reviewed for food preferences. Resident #45 and #47.Findings include: A review of the facility policy, Dietary Preference & Nutritionally Accuracy undated, revealed, Objective: To ensure the Dietary Department provides meals that align with each resident's personal tastes .3. 2 .Menu Substitution Log: If a resident expresses a new dislike, the DM must update their Permanent Profile and ensure the production staff is notified of the change to avoid food waste.Resident #45During an interview with Resident #45 on 2/23/26 at 11:15 AM, she shared her worries about her current dietary preferences not considered in light of her diabetes diagnosis. For her, managing blood sugar levels is essential, and it has been quite frustrating that the meals provided at the facility do not match her dietary preferences. While she mentioned that medication can help control her condition, she pointed out that at home, she avoided starchy, high-carbohydrate foods, and she would like to maintain that practice here as well. Resident #45 remarked that at lunchtime and dinnertime, her meals often include rice and potatoes, which she tries to avoid because they tend to spike her blood sugar. For breakfast today, she said her tray included a blueberry muffin and grits. She mentioned that the typical breakfast options usually include waffles, pancakes, biscuits, or muffins. Despite raising her dietary concerns several times to the Dietary Manager who visited her room, the manager only responded with We'll work on it, without any noticeable improvements. Additionally, her meal ticket hasn't been updated to reflect her preferences, which results in trays that overlook her food choices and dietary needs. She then pointed to her lunch tray, just delivered, and said, Look at this. It has red beans, sausage, and a huge helping of white rice. She added, I simply can't eat the rice.During an observation of the lunch meal tray on 2/23/26 at 11:19 AM, the SA confirmed Resident #45 had beans, sausage, and a large amount of white rice.A record review of the meal ticket for Resident #45 on 2/23/26 and 2/24/26 revealed there are no likes or dislikes referencing dietary preferences on the tray card.In an interview on 2/25/26 at 11:35 AM, the Dietary Manager, stated that residents had never mentioned concerns to her about meals being high in carbohydrates or not meeting their dietary preferences. She acknowledged, however, that she has gone to speak with Resident #45 several times because the resident has made many complaints, though she reported the concerns were mainly about her tea being sweet when she has asked for unsweetened. The DM further admitted that the resident's current meal ticket does not list any preferences because it has been a few months since she last updated it. She stated that the meal ticket should reflect each resident's likes, dislikes, and preferences, and that these preferences should be honored at every mealDuring an interview with Certified Nursing Assistant (CNA) #1 at 12:36 PM on 2/25/26, confirmed that she has worked with Resident #45. She mentioned that Resident #45 frequently expresses concerns about her meals, specifically stating that she doesn't want to eat certain foods because of their impact on her blood sugar levels. CNA#1 noted that she informs the dietary staff whenever the resident voices these preferences. However, she explained that even though the dietary staff responds with a simple ok, this feedback doesn't make it onto the tray card. As a result, each day, the kitchen continues to send meals that the resident dislikes, forcing her to repeatedly notify the staff about the mismatched orders. This ongoing cycle never seems to end.A record review of the admission record reveals the facility admitted the Resident #45 on 11/24/25 with diagnosis including Type 2 Diabetes Mellitus with Other Specified Complications and Essential (Primary) Hypertension. A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/28/26 revealed a Brief Interview Mental Score (BIMS) summary score of (15) indicating the resident is cognitively intact.Resident #57On 2/23/26 at 12:47 PM, during an interview, Resident #57 expressed her preference for eating in her room. She shared her concerns about the meals provided by the kitchen, stating that they don't accommodate her dietary needs given her current diagnosis. She feels that the staff hasn't informed her about her options to choose different items or healthier alternatives, leaving her feeling trapped with the meals she's served. She noted that the posted menus don't mention any alternatives available to her. For instance, she recalled being served red beans and rice for lunch. While she felt the rice was unnecessary for her diet, she had no better choices and had to eat it anyway. For breakfast, grits are offered, which she simply doesn't enjoy. She voiced her desire for more consistent and appropriate meal options that she could actually look forward to. On 2/24/26 at 8:07 AM, during a follow-up interview, Resident #57 shared details about her dinner. She mentioned that it included butter beans and corn, expressing concern that any of the vegetables should typically be served to someone with her diagnosis. Despite feeling this way, she admitted she ate them anyway, feeling that the kitchen often fails to provide consistent, healthier options.During an observation of the breakfast tray on 2/24/26 at 8:09 AM, the SA observed Resident #57 was served grits and a biscuit.A record review of the breakfast tray card on 2/24/26 revealed no likes or dislikes that reflect dietary preferences.During a phone interview with the Dietitian on 2/24/26 at 11:52 AM, it was stated that resident preferences are important. The kitchen should strive to avoid placing undesired items on their trays and make necessary adjustments, as long as they fall within dietary guidelines. Furthermore, it's essential to ensure that the tray card is updated to accurately reflect these preferences.On 2/25/26, at 12:00 PM, the Dietary Manager shared some insights during a brief interview. She mentioned that the menus are displayed on the television hanging on the wall before entering the dining area. While viewing the television with the SA, the Dietary Manager confirmed that no alternative options were displayed on the screen and admitted she was unaware of this issue.On 2/25/26, at 12:28 PM, Licensed Practical Nurse #1 (LPN) was interviewed and confirmed that she occasionally works with Resident #57. During the interview, she shared that Resident #57 often worries that the meals she receives will cause her blood sugar to spike. The resident has expressed concerns that the kitchen does not offer options that align with her dietary preferences. LPN #1 mentioned that she tries to reassure the resident, telling her that if her blood sugar does increase, she'll be ready to administer her medication. She also noted that this issue has been communicated to the kitchen staff multiple times, yet no changes have been made to address the residents' concerns.A record review of the admission record reveals the facility admitted Resident #57 on 11/24/25 with diagnosis including Type 2 Diabetes Mellitus with Other Specified Complications and Essential (Primary) Hypertensive Heart Disease without Heart Failure. A record review of the MDS with an ARD of 12/1/25 revealed a BIMS summary score of (11) indicating the resident has moderate cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure dietary staff followed proper hand hygiene practices and monitor food temperatures in a manner that prevented cross-contamination for one (1) of two (2) kitchen tours. Findings Include: Review of the facility policy titled Hand and Single Use Glove Sanitation Practices with a revision date of October 2017, revealed Policy: Facility employees shall follow sanitary practices when handling food to prevent the spread of foodborne illness . Review of the facility policy titled Guidelines for Using Thermometers with a revision date of October 2017, revealed Policy: the facility shall monitor temperatures of hazardous foods to maintain quality and safety of food served using an appropriate thermometer . An observation of the kitchen on 3/12/25 at 11:00 AM revealed Dietary Staff #2, located near the 3-compartment sink, gathering kitchen utensils. He walked over to the steam table with a white dish cloth in his hands and began setting up to check food temperatures. Dietary Staff #2 did not wash his hands before proceeding. After measuring the temperature of the hamburger patties, he picked up the dish cloth from the plate rest and wiped the end of the thermometer probe. He then inserted the thermometer into a pan containing lettuce and tomatoes. After removing the thermometer, he again wiped the probe with the dish cloth, continuing this same process - checking temperatures and wiping the probe with the dish cloth - until all food temperatures were measured. An interview with Dietary Staff #2 on 3/12/25 at 11:16 AM confirmed that he did not wash his hands before checking the food temperatures. He stated, I just had my hands in Clorox water, and acknowledged that this practice could cause cross-contamination of the food. He further explained that it was common practice to use a dish cloth to wipe the thermometer probe between uses, and that this was how he had been trained to do it. Dietary Staff #2 admitted that this could potentially make a resident sick due to cross-contamination from the dish towel to the food. An interview with the Dietary Manager (DM) on 3/12/25 at 11:36 AM confirmed that dietary staff were required to perform hand hygiene before checking food temperatures and anytime they handle food. She explained that the kitchen had disposable wipes that should be used to clean the thermometer probe between uses. The DM acknowledged that improper hand hygiene and improper cleaning of the thermometer could result in cross-contamination and the spread of harmful bacteria to food.

Based on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Quarter 1 2025 Findings include Record review of facility policy titled, Submission Timeliness and Accuracy dated April 2016, revealed, Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2025 (October 1-December 31), revealed the facility triggered on this report for excessively low weekend staffing. During an interview on 3/11/25 at 11:50 AM, the Administrator revealed I don't understand how we were running excessively low weekend staffing; we were adequately staffed during that time. He revealed we were transitioning between payroll systems then, and maybe it didn't transition accurately. Record review of the facility staffing grid for the weekends of quarter 1 revealed no issues with low weekend staffing. During an interview on 3/13/25 at 9:33 AM, the Human Resources Director revealed that after reviewing the discrepancy of low weekend staffing for the first quarter of 2025, we have determined that all of the nursing hours did not show up accurately. She revealed we were transitioning to a different payroll system, and the hours did not transition over accurately. Therefore, the facility didn't report the required staffing information and ensure it's accuracy.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a splint was applied for a resident with contractures for one (1) of 35 residents with limited range of motion (ROM) residing in the facility. Resident #12 The scope/severity of this deficiency was increased to E Pattern due to prior citation on the last Annual Recertification Survey. Findings Include: Review of the facility policy titled Resident Mobility and Range of Motion with a revision date of July 2017, revealed under, Policy Statement: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable . An observation of Resident #12 on 3/11/25 at 9:37 AM revealed he had a left upper extremity contracture with no contracture device in place. An observation of Resident #12 on 3/12/25 at 8:08 AM and again at 9:30 AM revealed the resident continued to have no device in place for the left extremity contracture. Record review of Resident #12's March 2025 Medication Administration Record (MAR) revealed an order dated 6/11/24, Resident to wear resting hand splint to LUE (left upper extremity) daily. Put on at 8:00 AM. Leave on resident 4-6 hours as resident will allow. One time a day to prevent declining contracture report to OT (Occupational Therapy) any complications. An observation and interview with the Assistant Director of Nursing (ADON) on 3/12/25 at 9:45 AM confirmed Resident #12 was not wearing the ordered splint. She revealed the aides were responsible for applying the device and the nurses were to ensure it was applied. The ADON revealed failing to apply the splint could cause worsening contractures. An interview with Licensed Practical Nurse (LPN) #3 on 3/12/25 at 9:51 AM confirmed she did not ensure Resident #12 had on his hand splint yesterday or today. She revealed she was unsure where the splint was but thought it could be in the laundry. She confirmed she signed off on the MAR as administered yesterday and admitted she did not go back to ensure it was applied. An interview with Certified Nurse Aide (CNA) #1 on 3/12/25 at 10:15 AM revealed she worked last night, and Resident #12 did not have his splint in his room. She stated, I guess someone took it to laundry because he didn't have it. She confirmed she did not look for it. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/24 revealed under section GG, Resident #12 had upper extremity (shoulder, elbow, wrist, hand) functional limitation in Range of Motion (ROM) on both sides. Record review of the Admission Record revealed the facility admitted Resident #12 on 12/19/24 with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease and End Stage Renal Disease.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to develop and/or implement care plans related to Activities of Daily Living (ADL) care for Residents #1, #34, #61 and #67, failed to develop a care plan related to Post-Traumatic Stress Disorder (PTSD) for Resident #41, and failed to develop a care plan related to activities for Resident #68. Additionally, the facility failed to implement a care plan intervention for a contracture device for Resident #12 for seven (7) of 23 resident care plans reviewed. The scope/severity of this deficiency was increased to E Pattern due to prior citation on the last Annual Recertification Survey. Findings include: Record review of the policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed its Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident # 1 Record review of Resident #1's ADL care plan revealed, Focus: Resident requires supervision-total assistance with ADL's r/t (related to) impaired mobility urostomy and colostomy status right aka above knee amputation) left bka (below knee amputation), DM . Interventions .Shave resident prn (as needed) .Shower three (3) times a week sponge bath on other days. On 3/11/25 at 9:34 AM, an observation and interview revealed Resident #1's facial hair was approximately 3/4 inch long on his chin, sides of his face, and neck area. His hair was unkempt and thick. Resident #1 revealed the barber hadn't been here in quite some time; and stated I would like to have a haircut and be shaved. He revealed no one had asked him if he wanted to be shaved or have a haircut, and it's been a very long time. On 3/12/25 at 9:35 AM, during an observation and interview the Director of Nurses (DON) confirmed that Resident #1 needed to be shaven, and his hair needed to be cut. The DON confirmed that Resident #1 had a care plan to shave the resident prn, and his plan of care was not being followed. A record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Hypoglycemia without Coma, and Functional Quadriplegia. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/20/25 revealed, in Section C, a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident #61 Record review of Resident #61's ADL care plan revealed, Focus: Resident requires assistance with ADLs 's d/t (due to) decreased mobility, colostomy status, incontinence of bladder, schizophrenia and depression .Interventions. Shower 3 times a week sponge bath on other days. On 3/11/25 at 9:55 AM, an observation and interview revealed Resident #61 had facial hair approximately one and a half inches long to his cheeks, chin, and neck and hair that was unkempt, long, and greasy. Resident #61 stated it's been a long time since he had been shaved and had a haircut. During an interview on 3/12/25 at 3:05 PM, the DON confirmed that the staff is responsible for addressing the residents' grooming needs daily and ensuring they are adequately groomed, which includes shaving and hair care. During an interview on 3/12/25 at 1:30 PM, the Medicare Nurse revealed she and the MDS nurse are responsible for developing the residents' nursing care plans. She revealed that the purpose of the care plan is to paint a thorough picture of the resident's individualized needs, and anyone can look at their care plan and know exactly their needs. She confirmed that the care plan for Resident #61 was not developed to reflect his shaving and that it should have been. After reviewing the care plans for Resident #1 and Resident #61, she revealed they were very vague about the interventions needed for their hygiene and grooming needs. A record review of Resident #61's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Paranoid Schizophrenia and Depression. A record review of the MDS with an ARD of 01/06/25 revealed, in Section C, a BIMS score of 15, which indicated Resident #61 was cognitively intact. Resident #41 Record review of Resident #41's Admission Record revealed the resident was readmitted to the facility on [DATE] with medical diagnoses that included Post Traumatic Stress Disorder (PTSD), and Bipolar Disorder. Record review of Resident #41's Care Plan Detail revealed under, Focus: Resident has a dx (diagnosis) of PTSD related to killing other humans with a machine gun in combat. Resident has experienced other trauma such as death of close family, being assaulted in lifetime. Under, Interventions/Tasks, the care plan was not developed for triggers or trigger-specific interventions. On 3/12/25 at 8:35 AM, during an interview, Resident #41 confirmed that he does have PTSD that stems from when he came home from Vietnam and the treatment that he received during the war. In an interview on 3/12/25 at 8:50 AM, CNA #5 revealed Resident #41 doesn't have behaviors now, but he use to have a lot of behaviors. She stated that she wasn't sure if the resident had PTSD or not. On 3/12/25 at 9:40 AM, in an interview the Social Worker (SW) stated that she didn't know what Resident #41's triggers were. She revealed she had never discussed his PTSD or triggers with the him and confirmed he did not have a PTSD care plan that addressed any triggers. On 3/12/25 at 10:00 AM, during an interview the DON confirmed that Resident #41 has PTSD. She revealed his trigger were being awakened in the middle of the night by staff knocking on the door and entering the room. She confirmed that the resident did not have a PTSD care plan that addressed trigger-specific interventions, so therefore the staff were not made aware so that they could try and prevent re-traumatization. Record review of Resident #41's MDS with an ARD of 1/15/2025 revealed in Section C, a BIMS score of 15, which indicated the resident is cognitively intact. 47874 Resident #12 Review of Resident #12's Care Plan revealed, The resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) decreased mobility and function, incontinent of bowel and bladder, HTN (hypertension), PVD (peripheral vascular disease), GERD (gastroesophageal reflux disease), Pain, ESRD (end stage renal disease), multi contractures, Hx (history) dysphagia. Additionally revealed under, Interventions/task: Resident will wear resting hand splint on LUE (left upper extremity) x (times) 4-6 hours daily, report to OT (occupational therapy) any complications. On 3/11/25 at 9:37 AM, an observation of Resident #12 revealed he was lying in bed with a left upper extremity contracture without a device in place. On 3/12/25 at 8:08 AM and again at 9:30 AM, an observation of Resident #12 revealed he was lying in bed without a contracture device in place on the left extremity. On 3/12/25 at 9:45 AM, an observation and interview with the Assistant Director of Nursing (ADON) confirmed Resident #12 was not wearing the ordered splint. An interview with the Medicare Nurse on 3/13/25 at 8:02 AM confirmed the staff did not follow the care plan for Resident #12's splinting device. Record review of the Admission Record revealed the facility admitted Resident #12 on 12/19/24 with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 Chronic Kidney Disease and End Stage Renal Disease. Resident #68 Record review of Resident #68's Care Plans revealed a care plan was not developed for activities. An interview with the Medicare Nurse on 3/13/25 at 8:05 AM confirmed an activity care plan was not developed for Resident #68 and should have been. She revealed the Activity Director is responsible for developing the activity care plans. An interview with the Activity Director (AD) on 3/13/25 at 8:20 AM revealed she had been working at the facility for one year. She revealed Resident #68 did participate in activities but was more of a sit and watch person due to her poor attention span even though she did like to talk. The AD admitted that when the facility changed charting systems in August 2024 she did not develop an activity care plan for the resident and confirmed that it should have been done to determine the resident's functional abilities and preferences. Record review revealed the facility admitted Resident #68 on 3/07/23 with a medical diagnosis that included Dementia. 48845 Resident #34 Record review of Resident #34's care plan related to ADLs, last revised on 10/11/2024, revealed the focus area indicated that he required extensive assistance with personal hygiene related to muscle weakness, decreased mobility, pain, and history of falls. Interventions/tasks revealed resident requires extensive assistance with personal hygiene. On 3/11/25 at 10:30 AM, an observation and interview revealed Resident #34 to be unshaven and his hair appeared oily with visible white flakes around the scalp edges. He expressed a desire to be shaved and have his hair washed but was unable to recall the last time he received such care. Record review of Resident #34's MDS Kardex Report also noted that he required extensive assistance with personal hygiene. An interview on 3/12/25 at 8:31 AM, with the Medicare Nurse confirmed, after reviewing the ADL care plan for Resident #34, that staff had not implemented the required personal hygiene interventions outlined in the ADL care plan. Record review of Resident #34's Admission Record revealed he was admitted to the facility on [DATE], with diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1 through Stage 4 Chronic Kidney Disease, and Malignant Neoplasm of Bladder. Record review of Resident #34's MDS Section C, with an ARD of 12/16/2024, revealed a BIMS score of 14, indicating the resident was cognitively intact .Section GG 0130 Self Care was coded dependent. 47157 Resident #67 A review of Resident #67's Care Plan titled, Resident requires assistance with ADLs r/t incontinence, dementia, and muscle weakness, last revised on 2/16/25, revealed no interventions related to personal hygiene assistance. On 3/11/25 at 10:00 AM, during an observation and interview with Resident #67 the resident was noted to be unshaven with unkempt facial hair and his face and hair appeared oily. When asked about his personal care routine, the resident stated he had not been shaved in a while and could not recall when his hair was last washed. An interview with the Medicare Nurse on 3/13/25 at 8:35 AM confirmed that after reviewing Resident #67's ADL care plan, it was not developed to include personal hygiene interventions. She stated that comprehensive care plans should accurately reflect a resident's needs and guide staff in providing necessary care. An interview with the DON on 3/13/25 at 8:50 AM acknowledged that if care plans related to ADL's do not include personal hygiene interventions, staff may not provide essential hygiene assistance, leading to unmet care needs. A review of Resident #67's Admission Record revealed that he was admitted on [DATE], with a diagnosis of Infrarenal Abdominal Aortic Aneurysm. A review of the MDS Section C with an ARD of 2/12/25, revealed a BIMS score of 7, indicating severe cognitive impairment. Section GG ADL was coded as Item 01301 Personal Hygiene dependent.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for residents that require assistance for four (4) of seventy-nine (79) residents observed during the initial tour. Resident's #1, #34, #61 and #67 The scope/severity of this deficiency was increased to E - Pattern due to prior citation on the last Annual Recertification Survey. Findings include: Review of the facility policy titled, Quality of Life, revised August 2009, revealed Policy Interpretation and Statement: 3.) Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc. (et cetera). Resident #1 An observation and interview on 3/11/25 at 9:34 AM revealed Resident #1's facial hair was approximately 3/4 inch long on his chin, sides of his face, and neck area. His hair was unkempt and thick. Resident #1 stated, The barber has not been here in quite some time. I would like to have a haircut and be shaved. He admitted that no one had asked him if he wanted to be shaved or have a haircut, and it's been a very long time. An observation on 3/12/25 at 8:20 AM revealed Resident #1 with no change in appearance from the previous day. During an interview and observation on 03/12/25 at 9:25 AM, Certified Nurse Aide (CNA) #1 revealed she was assigned to Resident #1 and confirmed he had long facial hair and needed a haircut. She admitted she was not sure if the resident wanted to be shaved because she had not asked and confirmed that she should have put him down on the barber list for a haircut. During an observation and interview on 3/12/25 at 9:35 AM, the Director of Nurses (DON) confirmed that Resident #1 needed to be shaven, and his hair needed to be cut. She stated, He's able to tell the staff when he wants it to be done. Resident #1 replied, But I don't know when the man comes to cut our hair. He stated to the DON that he had his haircut last year, and the barber also shaved him at that time, but that was the last time he was shaven. Resident #1 then confirmed that he would like to be shaved and have his hair cut. A record review of the Daily Barber Shop Charges revealed Resident #1's last haircut was on 10/8/24. A record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Hypoglycemia without Coma, Tachycardia, and Functional Quadriplegia. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed, in Section C, a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident #61 An observation and interview on 3/11/25 at 9:55 AM revealed Resident #61 had facial hair approximately 1.5 (one and one-half) inches long to his cheeks, chin, and neck and his hair was long, and greasy. Resident #61 admitted that it had been a long time since he had been shaved and had a haircut, and he wanted to have those things taken care of. An observation on 3/12/25 at 8:20 AM revealed Resident #61 with no change in appearance from the previous day. In an interview and observation on 3/12/25 at 8:55 AM, CNA #5 confirmed that Resident #61 needed to be shaved and have his hair washed and cut. She revealed that she was assigned to Resident #61 today and stated that he was looking rough. She then stated that she wasn't sure how long it had been since the resident had a haircut or had been shaved. A record review of Resident #61's Admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Hypokalemia and Depression. A record review of the MDS with an ARD of 1/6/25 revealed, in Section C, a BIMS score of 15, which indicated Resident #61 was cognitively intact. 48845 Resident #34 An observation and interview on 3/11/25 at 10:30 AM, revealed Resident #34's hair was greasy with white flakes around the scalp edges and his face had visible facial hair. He stated he could not remember the last time his hair was washed, or he was shaved but he wanted it done. An observation on 3/12/25 at 8:25 AM, with CNA #4, confirmed that Resident #34 appeared to have gone without a shower or hair wash for an extended period. An observation on 3/12/2025 at 8:27 AM, with Registered Nurse (RN) #3, she confirmed Resident # 34 looked scruffy and unkempt. Record review of Resident #34's Admission Record revealed he was admitted to the facility on [DATE], with diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1 through Stage 4 Chronic Kidney Disease, and Malignant Neoplasm of Bladder. Record review of Resident #34's MDS Section C, with an ARD of 12/16/2024, revealed a BIMS score of 14, indicating the resident was cognitively intact. Section GG 0130 Self Care was coded dependent. 47157 Resident #67 During an observation and interview with Resident #67 on 3/11/25 at 10:00 AM, the resident's face and hair appeared oily with long unkempt facial hair. The resident stated he had not been shaved in a while and could not remember when his hair was last washed. An observation with CNA #6 on 3/12/25 at 8:16 AM confirmed that Resident #67's facial hair was unkempt, needed to be shaved, and his face and hair were oily and needed washing. During an interview with the DON on 3/13/25 at 8:50 AM, she confirmed that all residents should receive personal hygiene daily and as needed. She acknowledged that a lack of personal hygiene could lead to potential skin issues. Review of the ADL documentation for Resident #67 from 2/27/25-3/12/25 revealed only two days of documentation for personal hygiene. A review of Resident #67's Admission Record revealed that he was admitted on [DATE], with a diagnosis of Infrarenal Abdominal Aortic Aneurysm. A review of the MDS, Section C, dated 2/12/25, revealed a BIMS score of 7, indicating severe cognitive impairment. A review of the MDS-Nursing (7) Seven-Day Look Back Report dated 3/12/25 documented that Resident #67 was coded as dependent for Section GG: 01301 - Personal Hygiene.

Based on dialysis staff and facility staff interview, record review, and facility policy review, the facility failed to provide nutritional and hydration care and services to meet the needs of a resident receiving both enteral feedings and dialysis for one (1) of four (4) residents reviewed for nutrition. Resident #12 Cross reference F580 Findings Include: Review of the facility policy titled Enteral Nutrition with a revision date of January 2014, revealed under, Policy Statement: adequate nutritional support through enteral feeding will be provided to residents as ordered. Additionally revealed under, 8. The Dietician will monitor residents who are receiving enteral feedings and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings . Record review of the Registered Dietician Note dated 2/18/25 for Resident #12 revealed, RD (Registered Dietician) spoke with RD from dialysis regarding resident having issues with fluid overload. RD suggests changing TF (tube feeding) to Nutren 2.0 in order to meet needs for weight gain/wound healing without having excess fluids to prevent overload. Dialysis RD agrees and will monitor dialysis labs for elevated phosphorous. Dialysis RD states that fluid restriction for resident is 1000 ml (milliliters) H20 (water), however online orders (facility physician orders) show 1500 ml (milliliters) H20 (water). Additionally revealed under, Interventions: 1. Consult MD (physician) for fluid restriction clarification. 2. Change TF (tube feeding) to Nutren 2.0 (1) can 5 times per day. Flush with 50 ml (milliliters) H20 (water) after each feeding. TF (tube feeding) will provide 2500 calories, 100 grams protein, 1125 milliliters free H20 (water) 1500 milliliters total H20 (water). 3. Change med flushes to 15 ml (milliliters) H20 (water) before and after meds. Med flushes will provide 60-90 milliliters H20 (water). Goal: WG (weight gain) to IBW (ideal body weight), TF (tube feeding) to meet needs for dialysis and desired WG (weight gain). Record review of Resident #12's Medication Administration Record (MAR) revealed the RD recommendations dated 2/18/25 were not put in place. Record review of Resident #12's MAR revealed an order dated 2/12/25, Enteral Feed Order . Nepro 1 can 6 times per day via bolus. Flush with 30 ml (milliliters) H20 (water) after each feeding. Tube feeding will provide: 2560 calories, 115 grams protein, 1394 cc (cubic centimeter) free H20 (water), 1782 cc (cubic centimeter) total H20 (water). Also revealed an order dated 3/7/25, Enteral Feed Order every shift: Flush peg tube (Percutaneous Endoscopic Gastrostomy) with 15cc (cubic centimeters) of water before and after administration of medication and 5cc (cubic centimeters) in between each medication. Record review of Resident #12's MAR revealed an order dated 1/09/25, Dialysis Fluid Restriction 1,500cc (cubic centimeters). On 3/12/25 at 10:40 AM, a telephone interview with the facility RD revealed the last time she saw Resident #12 was on 2/18/25. She stated that she talked with the dialysis RD because the resident was having fluid overload during his dialysis treatments. She admitted they also discussed concerns about the resident's enteral feedings and not gaining weight. The RD revealed that after speaking with the dialysis RD, she was made aware that the resident should be on a 1200 ml fluid restriction. The RD explained that she made recommendations to the Director of Nurses (DON) or the Assistant Director of Nurses (ADON) that day to change the enteral feedings to Nutren 1 can bolus 5 times daily and to change up the flushes. She revealed she also recommended contacting the MD for a clarification on the fluid restriction. Furthermore, she confirmed failure to act promptly on these recommendations could place the resident at risk for continued fluid overload. On 3/12/25 at 10:53 AM, an interview with the DON confirmed that she remembered talking to the RD and then going back and forth about Resident #12's changes. She revealed that once the RD makes a recommendation, she usually places it in the physician's folder for him or the nurse practitioner to review. She admitted that those recommendations must have been misplaced because she was unable to locate it and confirmed that they should have been put into place. On 3/12/25 at 1:18 PM, a telephone interview with Proper Name of Dialysis Company RD confirmed she spoke with the Facility RD related to Resident #12 being NPO (nothing by mouth) and receiving Nepro enteral feedings and losing weight, plus concerns related to the resident's interdialytic (between dialysis sessions) weight gain. She stated that she had faxed a 1200 ml (milliliter) fluid restriction physician order to the facility on [DATE], but the facility continued to have the resident on a 1500 ml (milliliter) fluid restriction. She expressed that the resident was normally over his pre-dialysis target weight with excessive fluid. She confirmed that if the resident did not follow the recommended fluid restriction, and the RD recommended enteral feedings/flushes then that could result in elevated blood pressure. Record review of the (Proper Name Dialysis) Orders Log for Resident #12 confirmed an order dated 2/20/25, Patient to follow a fluid restricted diet, limiting fluid intake to 1200 ml (milliliters) per day. Monitor fluid closely and report any concerns to dialysis unit. On 3/12/25 at 1:26 PM, a telephone interview with Proper Name of Dialysis Company Registered Nurse (RN) Clinical Director revealed that Resident #12 was normally 3-4 kilo's (kilograms) (6.6 to 8.8 pounds) over on his pre-dialysis weight and the goal was not to be above 1 kilo (2.2) pounds or to exceed 2 kilos (4.4) pounds. She stated that the residents' last visit was on Monday 3/10/25, and he was 4 kilos (8.8) pounds over. An interview with the DON on 3/12/25 at 2:48 PM revealed the physician was not made aware of Resident #12's new Registered Dietician (RD) recommendations via telephone because the nurse practitioner intended to come to the facility a couple of days later and could review it then. She confirmed the resident's fluid volume status was of high importance and acknowledged the physician should have been made aware as the resident had had a delay getting the care. She revealed they (the facility) did not receive the faxed physician order from dialysis to reduce Resident #12's fluid restriction to 1200 milliliters. Record review of the Weights and Vitals Summary for Resident #12 revealed the following weights: 12/03/24 115.3 pounds 12/26/24 110.4 pounds 1/03/25 - 106.9 pounds 1/17/25 - 109.1 pounds 2/03/25 - 117.7 pounds 2/17/25 - 116.6 pounds 3/07/25 - 112.6 pounds Record review of the Admission Record revealed the facility admitted Resident #12 on 12/19/24 with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease and End Stage Renal Disease.

Based on dialysis staff and facility staff interview, record review, and facility policy review, the facility failed to promptly notify the physician of a resident change in both nutrition and hydration status for one (1) of four (4) residents reviewed for nutrition. Resident #12 Cross Reference F692 Findings Include: Review of the facility policy titled Change in a Resident's Condition or Status with a revision date of May 2017, revealed, Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . Record review of Resident #12's MAR revealed an order dated 1/09/25, Dialysis Fluid Restriction 1,500cc (cubic centimeters). Record review of the Registered Dietician Note dated 2/18/25 for Resident #12 revealed, RD (Registered Dietician) spoke with RD from dialysis regarding resident having issues with fluid overload. RD suggests changing TF (tube feeding) to Nutren 2.0 in order to meet needs for weight gain/wound healing without having excess fluids to prevent overload. Dialysis RD agrees and will monitor dialysis labs for elevated phosphorous. Dialysis RD states that fluid restriction for resident is 1000 ml (milliliters) H20 (water), however online orders (facility physician orders) show 1500 ml (milliliters) H20 (water). Additionally revealed under, Interventions: 1. Consult MD (physician) for fluid restriction clarification. 2. Change TF (tube feeding) to Nutren 2.0 (1) can five (5) times per day. Flush with 50 ml (milliliters) H20 (water) after each feeding. TF (tube feeding) will provide 2500 calories, 100 grams protein, 1125 milliliters free H20 (water) 1500 milliliters total H20 (water). 3. Change med flushes to 15 ml (milliliters) H20 (water) before and after meds. Med flushes will provide 60-90 milliliters H20 (water). Goal: WG (weight gain) to IBW (ideal body weight), TF (tube feeding) to meet needs for dialysis and desired WG (weight gain). Record review of Resident #12's Medication Administration Record (MAR) revealed the RD recommendations dated 2/18/25 were not implemented. Record review of Resident #12's MAR revealed an order dated 2/12/25, Enteral Feed Order . Nepro 1 can six (6) times per day via bolus. Flush with 30 ml (milliliters) H20 (water) after each feeding. Tube feeding will provide: 2560 calories, 115 grams protein, 1394 cc (cubic centimeter) free H20 (water), 1782 cc (cubic centimeter) total H20 (water). Also revealed an order dated 3/7/25, Enteral Feed Order every shift: Flush peg tube (Percutaneous Endoscopic Gastrostomy) with 15cc (cubic centimeters) of water before and after administration of medication and 5cc (cubic centimeters) in between each medication. A telephone interview with the facility RD on 3/12/25 at 10:40 AM revealed she last saw Resident #12 in the facility on 2/18/25. She revealed she called and spoke with the dialysis RD. The RD revealed that after speaking with the Dialysis RD, she was made aware that the resident should be on a 1200 ml fluid restriction. The RD explained that she made recommendations that day to change the enteral feedings to Nutren 1 can bolus 5 times daily and to change up the flushes. She revealed she also recommended contacting the MD for a clarification on the fluid restriction. She revealed she gave the recommendation to the Director of Nursing or the Assistant Director of Nursing while she was at the facility. An interview with the Director of Nursing (DON) on 3/12/25 at 10:53 AM confirmed the RD recommendations should have been put into place for Resident #12. She explained that she remembered talking to the RD and then going back and forth about his changes. The DON revealed the RD recommendation must have been misplaced because she was unable to locate it. She revealed once the RD makes a recommendation, it was given to her, and she placed it in the physician's folder for him or the nurse practitioner to review. A telephone interview with Proper Name of Dialysis Company RD on 3/12/25 at 1:18 PM revealed the facility had the resident on a 1500 ml (milliliter) fluid restriction, which was not what the dialysis physician had ordered. The RD revealed that she faxed a 1200 ml (milliliter) fluid restriction physician order to the facility on [DATE]. A follow up interview with the DON on 3/12/25 at 2:48 PM confirmed that the physician was not made aware of Resident #12's new RD recommendations via telephone because she thought the nurse practitioner intended to come to the facility a couple of days later and could have reviewed it then. She acknowledged the physician should have been made aware as the resident had had a delay getting the care. Record review of the Dialysis Orders Log for Resident #12 revealed an order dated 2/20/25, Patient to follow a fluid restricted diet, limiting fluid intake to 1200 ml (milliliters) per day. Monitor fluid closely and report any concerns to dialysis unit. Record review of the Admission Record revealed the facility admitted Resident #12 on 12/19/24 with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure with Stage 5 Chronic Kidney Disease and End Stage Renal Disease.

Based on staff and resident interview, record review and facility policy review, the facility failed to ensure care was delivered to a resident with Post Traumatic Stress Disorder (PTSD) in a manner that would minimize triggers and the possibility of re-traumatization for one (1) of two (2) residents reviewed with PTSD. Resident # 41 Findings Include Review of the facility policy titled, Trauma Informed Care with no revision date revealed under, Purpose .To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. Record review of Resident #41's Admission Record revealed the resident was readmitted to the facility on [DATE] with medical diagnoses that included Post Traumatic Stress Disorder (PTSD) and Bipolar Disorder. Record review of Resident #41's Care Plan Detail revealed under, Focus: Resident has a dx (diagnosis) of PTSD related to killing other humans with a machine gun in combat. Resident has experienced other trauma such as death of close family, being assaulted in lifetime . Under Interventions/Tasks, the care plan was not developed for triggers or trigger-specific interventions. During an interview on 3/12/25 at 8:35 AM, Resident #41 confirmed that he does have PTSD that stems from when he came home from Vietnam and the treatment that he received during the war. In an interview on 3/12/25 at 8:50 AM, Certified Nurse Assistant (CNA) #5 revealed she had no idea if Resident #41 had PTSD. In an interview on 3/12/25 at 9:40 AM, the Social Worker (SW) confirmed that Resident #41 did have PTSD, but that she didn't know what his triggers were and had never discussed his PTSD or triggers with him. During an interview on 3/12/25 at 10:00 AM, the Director of Nurses (DON) confirmed that Resident #41's plan of care did not address any triggers. She stated that she knew what his triggers were, and they included being awakened in the middle of the night by staff knocking on the door and entering the room. She confirmed that since the staff were not made aware of the resident's triggers and interventions to prevent them it could lead to re-traumatization. Record review of Resident #41's MDS revealed an ARD of 1/15/2025 and, in Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure medications were stored appropriately and not left in the resident's room for one (1) of 23 sampled residents. Resident #10 Findings include: A review of the facility policy titled, Storage of Medications revised April 2007 revealed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. An observation on 3/11/25 at 10:15 AM revealed Resident #10 had a bottle of Tums Ultra Strength 1000 mg (milligrams)and Equate Nasal Spray 3 fluid (fl) ounces (oz) sitting on his overbed table. An observation and interview on 3/12/25 at 11:10 AM revealed Resident #10's medication of a bottle of Tums Ultra Strength 1000 mg and Equate Nasal Spray 3 fl. oz remained sitting on his overbed table. Resident #10 revealed that he has bad indigestion and needs his medicine and stated, If they come in here and try to take them, I'll walk out right now. A record review for Resident #10 revealed there was no self-administration of medication assessment. During an interview on 3/12/25 at 11:15 AM Licensed Practical Nurse (LPN) #4 revealed she is assigned to Resident #10 and gives him his medicines; she revealed she was not aware that the resident had medicine sitting on the overbed table because she gives him all of his medications and stands there while he takes them. During an observation and interview on 3/12/25 at 11:25 AM LPN #4 confirmed that the resident had medications sitting on his overbed table and revealed he was not supposed to have them. She revealed his family brought these medicines in for him, and she had overlooked them sitting there. In an interview on 3/12/25 at 11:35 AM, the Assistant Director of Nurses (ADON) confirmed that Resident #10 did not have a medication self-administration form filled out and had not been evaluated to self-administer medications. She confirmed the medications were not supposed to be left at the bedside, but all medications were to be kept locked in the medication cart. She revealed with the resident having access to these medications, he could take too much, or someone could wander into his room and take them. A record review of Resident #10's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease, and Gastro-Esophageal Reflux Disease. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/2024 revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated Resident #10 has moderate cognitive impairment.

Based on observation, resident representative and staff interviews, record review, and facility policy review, the facility failed to ensure proper catheter care and infection control practices were implemented for one (1) of four (4) residents direct care areas observed (Resident #37). Findings include: A review of the facility policy titled, Catheter Care Urinary, revised September 2014, revealed under Infection Control: b.) Ensure the catheter tubing and drainage bag are kept off the floor. Further review of the policy under Steps in the Procedure revealed: 31.) Use a clean washcloth with warm water and soap or cleansing wipe to cleanse and rinse the catheter from insertion site to approximately four inches outward. An observation of Resident #37 and interview with the resident's representative on 3/11/25 at 2:23 PM revealed a catheter bag hanging on the left side of the resident's wheelchair, with the catheter bag and tubing observed resting on the floor. During an interview at that time with the resident's representative, she revealed the resident has a history of frequent urinary tract infections and has the catheter because her bladder does not empty. An observation of catheter care for Resident #37 on 3/12/25 at 10:20 AM revealed upon entrance to the room, the catheter bag and tubing were laying on the floor. Certified Nurse Assistant (CNA)# 6 was observed performing hand hygiene and cleansing the urinary meatus and catheter tubing with a wet washcloth. There was no observation of soap or cleansing products added to the water basin or washcloth. CNA #6 then dried the urinary meatus and catheter tubing with a dry cloth, completed the procedure, and performed hand hygiene. In a concurrent interview, CNA #6 confirmed the catheter bag should not have been placed on the floor. She also acknowledged she cleaned the urinary meatus, perineal area, and catheter tubing using only water without soap or cleansing product. CNA #6 stated she avoided using soap because she did not want to irritate the resident's skin. Record review of the Order Summary Report for Resident #37 revealed an active order dated 1/29/25 to clean urinary catheter with soap and water every shift. During an interview with the Director of Nursing (DON) on 3/12/25 at 11:14 AM, she confirmed the catheter bag should not have been placed on the floor and that staff performing catheter care should have used soap and water to clean Resident #37 as ordered. She stated that placing the catheter bag on the floor and failing to cleanse with soap and water increases the risk of infection for the resident. Record review of Resident #37's Admission Record revealed the resident was admitted on [DATE] with diagnoses including Retention of Urine and Urinary Tract Infection. Record review of Resident #37's Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 2/5/25, revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Section H-Bladder and Bowel was coded as having an indwelling catheter.

Based on observation, staff and resident interviews, record review, and facility policy, the facility failed to ensure a resident's right to be free from physical restraints when a bed alarm pad and a wheelchair alarm pad were used that restricted the resident's movements. The alarms caused the resident to stop moving to avoid triggering the alarm sounds, demonstrating a restrictive effect for one (1) of two (2) residents reviewed for restraints. (Resident #67) Findings include: Review of the facility policy titled Use of Restraints, revised April 2017, revealed Policy Interpretation and Implementation: 'Physical Restraints' are defined as any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . An observation and interview with Resident #67 on 3/11/25 at 10:15 AM revealed a bed alarm pad attached to the resident's bed. During the interview, Resident #67 stated that the bed alarm went off frequently and voiced, I hate it. He reported that when the alarm sounds, he stops moving so it will stop alarming. During an interview with Certified Nurse Assistant (CNA) #6 on 3/13/25 at 8:16 AM, she confirmed that Resident #67 had a bed alarm pad in place due to a history of frequent falls. When asked if the resident had ever complained about the alarm pad, CNA #6 stated that she had observed the resident stop moving or attempting to get up when the alarm sounded, as he did not want it to continue. When asked if she reported this behavior, she stated that she believed she did. A record review of the Order Summary report for Resident #67 revealed no physician order for a bed alarm pad. Further review revealed an order dated 10/15/24 for a wheelchair/chair alarm pad to alert staff of attempts to get up unassisted. An interview with the Medicare Nurse on 3/12/25 at 8:35 AM confirmed that if Resident #67 stated he stops moving to make the alarm stop and staff reported observing the resident stopping movement in response to the alarm, the alarms would be considered a restraint. She confirmed that no restraint assessments had been completed for either alarm devices because she was unaware that the alarm was restricting the resident's movement. She also revealed the resident only had an alarm pad ordered for the wheelchair and was not aware that he had an alarm pad to the bed. During an interview with the Director of Nursing (DON) on 3/13/25 at 8:50 AM revealed that she was unaware that Resident #67 had voiced his dislike for the alarm or that it caused him to stop moving. She confirmed that while the resident had an order for an alarm pad on the wheelchair, there was no order for an alarm pad on the bed. The DON stated she did not know when or by whom the bed alarm pad was placed. She confirmed that if the resident expressed distress about the alarm and staff verified his behavior of stopping movement to silence it, both alarm devices would be considered restraints. During an interview with the Assistant Director of Nursing (ADON)/Infection Control Nurse on 3/13/25 at 3:34 PM revealed concerns about the use of restraints, stating that they could lead to anxiety or depression and hinder residents from performing daily activities independently. Record review of the Admission Record revealed Resident #67 was admitted on [DATE], with a diagnoses which included Repeated Falls. A record review of Resident #67's Minimum Data Set (MDS), Section C with an Assessment Reference Date (ARD) of 2/12/2025, revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident was severely cognitively impaired.

Based on staff interview, record review, and facility policy review, the facility failed to accurately complete section N of the Minimum Data Set (MDS) for a resident taking an antiplatelet medication for one (1) of 23 MDS assessments reviewed. Resident #42 Findings Include: Review of the facility policy titled Resident Assessment Instrument with a revision date of September 2010 revealed under, Policy Statement: A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission. Additionally revealed, 4. Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practical level of functioning. Record review of the Annual MDS with an Assessment Reference Date (ARD) of 12/3/24 revealed, under Section N, Resident #42 was coded as receiving an anticoagulant (blood thinner) medication during the 7-day look back period. Record review of the Medication Administration Record (MAR) for November and December 2024 revealed Resident #42 did not receive an anticoagulant (blood thinner) medication. Additionally, the resident did receive the antiplatelet medication Plavix. An interview with the Medicare Nurse on 3/12/25 at 9:40 AM confirmed Resident #42 did not receive an anticoagulant medication and revealed that Section N was coded wrong. She explained that the antiplatelet box should have been marked. The Medicare Nurse revealed they follow the Resident Assessment Instrument (RAI) manual for guidance in completing the assessments, and acknowledged Resident #42's MDS should be accurate to reflect the resident's status. Record review of the Admission Record revealed the facility admitted Resident #42 on 1/04/23 with a medical diagnosis that included Alzheimer's Disease.

Based on complainant and staff interview, record review and facility policy review, the facility failed to revise a pressure risk care plan for a resident who developed a pressure ulcer for one (1) of (3) three residents care plans reviewed. (Resident #1) Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with no revision date revealed, Policy Interpretation and Implementation: .13.) Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change . Record review of Resident #1's care plan titled Resident is a risk for pressure ulcers/further impaired skin integrity related to (r/t) incontinence dementia, with onset date of 12/11/24 and revision date of 1/27/25, revealed no revisions to the care plan prior to the onset of the deep tissue injury (DTI) identified on 1/19/25. On 1/31/25 at 4:00 PM, during a phone interview with the complainant, she revealed her mom (Resident #1) was sent to the hospital on 1/19/25 and was assessed to have an open pressure ulcer on her right heel that was black and draining. She then stated cannot understand how a wound on her foot that was open, black in color and draining had not already been identified and addressed. Record review of Resident #1's hospital notes dated 1/19/25 confirmed that the resident presented to the hospital on 1/19/25 at 10:23 PM with a pressure injury of deep tissue injury (DTI) with epithelial separation, revealing partial thickness pink wound bed with deep purple discoloration, scant drainage, and devitalized tissue surrounding wound noted to right heel on initial wound care exam. On 2/3/25 at 10:30 AM, an interview with the Director of Nursing (DON) confirmed that the pressure risk care plan should have been revised when the resident had a decline in function increasing her pressure ulcer risk and any new interventions should have been put in place for pressure prevention. She stated that she had determined after the resident was transferred to the hospital that she had a decline for approximately two weeks prior in her activities of daily living (ADL) function that included mobility and self-feeding. She revealed that she reviewed the residents Kardex, and it did not reflect any pressure reducing measures in place prior to the onset of the pressure injury to the right heel. Record review of the Minimum Data Set (MDS) Kardex Report for Resident #1 dated 12/11/24 revealed no revisions to the Kardex related to skin and ulcer treatment. On 2/3/25 at 11:00 AM, during an interview with the MDS Nurse she confirmed that since Resident #1 showed a decline in her ADL function and nutrition then she was at a higher risk for pressure injury and extra precautions should have been put in place to reduce the risk. She confirmed that the residents care plan had not been revised after that decline or prior to the return from the hospital with the onset of the pressure injury. She revealed the purpose of the care plan is to inform staff of the specific resident care needed to care for that resident. Review of the Admission Record revealed Resident #1 was admitted by the facility on 12/11/24 with diagnoses that included Unspecified Dementia and Aphasia.

Based on complainant, resident representative and staff interviews, record review, and facility policy review, the facility failed to provide necessary services to prevent new pressure ulcers from developing for one (1) of three (3) residents with wounds reviewed. (Resident #1) Findings include: Review of the facility policy titled, Prevention of Pressure Ulcers/Injuries, with no revision date, revealed, Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. In a phone interview with the complainant on 1/31/25 at 4:00 PM, she revealed her mom (Resident #1) was sent to the hospital on 1/19/25 and was assessed to have an open pressure ulcer on her right heel that was black and draining. She stated she was concerned because Resident #1 had started declining about a week before being sent to the hospital, requiring increased assistance with all her care and transfers. She then revealed she also cannot understand how a wound on her foot that was open, black in color and draining had not already been identified and addressed. The complainant admitted that the only thing that staff put on Resident #1's feet prior to the discovery of the wound were socks and her heels were never floated or had foot pillows. Record review of the hospital notes dated 1/19/25 revealed Resident #1 presented to the hospital on 1/19/25 at 10:23 PM with a deep tissue injury (DTI) with epithelial separation, revealing partial thickness pink wound bed with deep purple discoloration, scant drainage, and devitalized tissue surrounding wound noted to right heel on initial wound care exam. During an interview with Resident #1's Representative on 2/3/25 at 10:20 AM, he stated that he visits with his wife (Resident #1) for several hours every day, and he had noticed that over a week prior to being sent to the hospital, she kept leaning to the left in the wheelchair. He stated she stopped feeding herself and had to be fed and required more assistance from staff for toileting and transfers. He admitted that he could not physically assist her anymore because she was unable to help at all. He stated he was not aware of any wound on her foot until the nurse who called about her going to the hospital said she had a blister on her right heel. The Resident Representative confirmed that he had never seen Resident #1's heels floated, foot pillows or any kind of positioning device used for her prior to the wounds being discovered and that the only thing that was ever on his wife's feet were socks. In an interview with the Director of Nursing (DON) on 2/3/25 at 10:30 AM, confirmed that it was determined that Resident #1 showed a decline in function approximately two weeks before being sent to the hospital on 1/19/25. She stated the resident was mobile short distances with staff assistance and limited on standing with assistance upon admission but declined requiring two staff members assistance for transfers, toileting, and bed mobility. She then stated she was informed by staff on 1/19/25 at the time of transfer to the hospital that the resident had a blister on her right heel. Furthermore, she stated there was no documentation in the medical record of the wound before that date. She stated she was not informed that the wound was dark purple/black in color and open and draining. The DON revealed when the resident began declining in Activities of Daily Living (ADL) function and requiring more assistance with care, she was at a higher risk for pressure injury and should have had resident specific interventions put in place. She confirmed, after review of Resident #1's medical record, she could not find where any resident specific interventions were put in place to reduce the risk of pressure injury and that could have led to the development of a pressure injury. Record review of the Active Order Summary Report dated 1/20/25 for Resident #1 revealed no orders related to skin or pressure relief prevention. In an interview with Licensed Practical Nurse (LPN)#1 on 2/3/25 at 10:50 AM, she revealed she had cared for Resident #1 several days over the few weeks before she went to the hospital and noticed that the resident had been leaning in the wheelchair. She confirmed that the resident had to be fed and required more care by staff for transfers, toileting, and mobility. She also confirmed that the resident did not wear foot pillows or have orders to float heels prior to the discovery of the wound. In an interview with Certified Nurse Assistant (CNA) # 1 on 2/3/25 at 10:50 AM confirmed that Resident #1 had started declining a couple of weeks ago requiring two staff members to assist with transfers and toileting because the resident had quit assisting with pivoting, no longer ambulating or following simple direction. She also stated she was no longer feeding herself or repositioning herself. In an interview with the Minimum Data Set (MDS) Nurse on 2/3/25 at 11:00 AM she revealed she was not aware that Resident #1's condition had declined before her hospital stay, but confirmed if she was no longer ambulating, declined in ADL function, and nutrition then she was at a higher risk for pressure injury and extra precautions should have been put in place to reduce the risk. She then confirmed that their failure to put interventions in place could have led to the development of the pressure ulcer. In an interview with LPN #2 on 2/3/25 at 11:30 AM, she revealed she assisted LPN #3 get Resident #1 ready to transfer to the hospital on 1/19/25. She stated they both were working 7:00 AM-7:00 PM that day and did observe an open dark purple/blackish blister area to the resident's right heel that she would have considered to be one-half (1/2) dollar in size. She confirmed the resident only had socks on her feet, heels were not floated, and no heel protectors were on. In an interview with LPN #3 on 2/3/25 at 11:50 AM revealed she was assigned Resident #1 on 1/19/25 when she was sent to the hospital. She stated during her assessment; she observed an open draining dark purple blistered area with dried drainage noted to the resident's right sock and her fitted sheet of the bed. She stated she had never been informed of the wound before, but stated, it was obvious from the condition of the wound that it did not just form. She then stated she would say the size was about the size of a half dollar. In an interview with CNA #2 on 2/3/25 at 3:00 PM, confirmed that Resident #1 had needed additional assistance from staff over the past few weeks, because she was no longer able to assist with her care. She confirmed that the resident was leaning in the wheelchair and would not move unless staff assisted her, which was different from her norm. She stated that she had never seen a wound on the resident's foot, stating she always had socks on, and confirmed the resident did not have any foot pillows in her room. Record review of Resident #1's Admission Record revealed the facility admitted the resident on 12/11/24 with medical diagnoses that included Unspecified Dementia and Aphasia.

Based on observation, staff interview, record review, and facility policy, the facility failed to ensure a resident's right to be free from misappropriation of property when a bottle of Morphine Sulfate was found altered in color composition and not properly accounted for on the medication administration record for (1) one of three (3) residents reviewed for misappropriation. (Resident #1) Findings include: Review of the facility policy titled, Abuse Prevention Program, with no revision date revealed, Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Review of the facility policy titled, Controlled Substances, with no revision date revealed under the Policy Statement :The facility complies with the laws, regulations and other requirements related to handling, storage, disposal, and documentation of controlled substances . An interview on 1/14/25 at 8:00 AM, with the Director of Nursing (DON) confirmed there had been a narcotic diversion investigation back in September 2024 regarding Resident #1. During a continued interview with the DON and record review of the facility investigation/video surveillance on 1/14/25 at 9:10 AM, she revealed that on the morning of Monday 9/16/24 the day shift nurse Licensed Practical Nurse (LPN) #1 reported to her that after drawing up Resident #1's morphine from her only vial that was dated 9/6/24, he discovered that the medicine was not the color it was supposed to be. She stated that he immediately brought it to her, and she confirmed that the liquid inside the vial was clear and was supposed to be a light blue. She reported that the Hospice nurse was notified and that they brought a new bottle of morphine, and the medicine was blue in color. The DON stated she immediately contacted all nurses who had access to the morphine on the 100-hall cart and requested that they meet at the clinic on 9/16/24 for a random drug screen related to a narcotic concern. She revealed that all the nurses complied with the random drug screen except for LPN #2. She stated that after LPN #2 did not comply with a drug screen, the Administrator reviewed the video footage of the 100 hallways for the weekend and found on 9/14/24 at approximately 3:00 PM, LPN #2 was observed to position her medication cart in front of room [ROOM NUMBER] with the medication drawers facing the inside of the room. LPN #2 was observed to reach into the narcotic box, pull out the Morphine box, insert the syringe into the morphine bottle, pull back on the syringe, remove the syringe and go into the bathroom of room [ROOM NUMBER]. She then returned to the medication cart, inserted the syringe into the morphine again, pulled back on the syringe, then went back into the bathroom of room [ROOM NUMBER]. The DON also confirmed based on the investigation, the video, and the failure of LPN #2 to submit to a drug screen, the undeniable change in the color of the liquid morphine, the allegation of diversion was substantiated by the facility. An observation and interview on 1/14/25 at 9:20 AM of the Morphine vial dated 9/6/24 compared to the vial dated 9/16/24 with the DON confirmed that the morphine dated 9/6/24 was notably a few shades lighter blue than the one dated 9/16/24. The DON confirmed there were no other bottles of morphine in the 100-hall medication cart at the time of the incident. Record review of the Termination Report for LPN #2 revealed the facility terminated her on 9/17/24 for failure to comply with narcotic investigation. LPN #2's last day to work was 9/15/24. Record review of Resident #2's September 2024 Order Summary Report revealed this residents' location was room [ROOM NUMBER] and there were no orders for any narcotics for this resident. Record review of the Admission Record revealed Resident #2 was admitted by the facility on 6/05/24 and discharged on [DATE]. An interview with LPN #1 on 1/14/25 at 10:10 AM, revealed that on the morning of 9/16/24 he went in to give Resident #1 some morphine and did not see anything in the syringe. He then revealed he shook the medicine up and attempted to withdraw the morphine again and realized the liquid in the syringe was clear. He stated that he had administered the morphine to Resident #1 on Friday 9/13/24 and the medication was blue at that time. He confirmed that there were no other bottles of morphine on the medication cart at the time that the morphine was found to be a different color. LPN #1 stated he notified the DON, the Administrator, and called hospice to have a new bottle of morphine delivered. LPN #1 stated the new bottle of morphine that was delivered was a much brighter blue color. Record review of the Order Summary Report for Resident #1 revealed an order to admit to Hospice on 9/05/24 related to Chronic Obstructive Pulmonary Disease (COPD) and Morphine Sulfate Oral Solution 20 mg (milligram) 5 (five) ml (milliliters): give 0.5 ml sublingual every 4 (four) hours as needed for pain and wheezing for 14 days, dated 9/05/24. Record review of the Individual Patient Narcotic-Controlled Drug form for Resident #1 for Morphine Sulfate 100 mg/5 ml was received on 9/6/24 by LPN #1 with 30 ml in the bottle. A record review of the Individual Patient Narcotic-Controlled Drug form for Resident #1 morphine sulfate revealed on 9/14/24 that five doses of morphine were signed out by LPN #2 at 8:30 AM, 11:00 AM, 2:00 PM, 6:00 PM, and 9:00 PM; on 9/15/24 a dose of morphine was signed out by LPN #2 at 2:00 PM. Record review of the Admission Record revealed Resident #1 was admitted by the facility on 10/14/22 with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia. Record review of Resident #1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/24, revealed Section O: Special Treatments, Procedures, and Programs coded as receiving Hospice services while a resident.

Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of narcotic diversion/misappropriation of property to the State Agency (SA) for one (1) of three (3) residents reviewed for narcotic diversion/misappropriation of property. (Resident #1) Cross Reference F602 Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation- Reporting and Investigating, with a revision date of 09/2022 revealed under the Policy Interpretation and Implementation .1. If resident .misappropriation of property .is suspected, the suspicion must be reported immediately to . 2. a. The state licensing/certification agency responsible for surveying/licensing the facility . Upon entrance to the facility on [DATE] at 8:00 AM, the Director of Nursing (DON) confirmed that they had one reportable incident that was a narcotic diversion investigation involving Resident #1 in 09/2024. Record review of the facility investigation, dated 9/19/24 involving Resident #1, revealed there was no notification of the narcotic diversion investigation to the State Agency. In an interview with the DON regarding the narcotic diversion investigation on 1/14/25 at 9:10 AM, she revealed on the morning of Monday 9/16/24 the day shift nurse Licensed Practical Nurse (LPN) #1 came to her and let her know that the liquid narcotic for Resident #1 was not the color it should be. She stated the liquid morphine the facility receives is a clear blue color. The DON and LPN #1 together assessed the morphine to be clear once again when pulled in the syringe. The Hospice nurse was called and brought a new bottle of morphine to the facility for Resident #1. The DON revealed the bottle of morphine delivered on 9/6/24 and the new bottle of morphine was delivered on 9/16/24 for Resident #1 were compared, and the bottle dated 9/6/24 was a lighter clear blue color than the new bottle recently delivered. She stated the Morphine in question was removed from the narcotic count and locked up securely. The DON stated she immediately contacted all nurses who had access to the morphine on the 100-hall cart to meet at the clinic at 1:00 PM on 9/16/24 for a random drug screen related to a narcotic concern. She revealed all the nurses complied with doing the random drug screen with no positive results for narcotics, except for LPN #2. She stated that after LPN #2 did not comply with a drug screen, the Administrator reviewed the video footage of the 100 hallways for the weekend and found on 9/14/24 at approximately 3:00 PM, LPN #2 was observed to position her medication cart in front of room [ROOM NUMBER] with the medication drawers facing the inside of the room. LPN #2 was observed to reach into the narcotic box, pull out the Morphine box, insert the syringe into the morphine bottle, pull back on the syringe, remove the syringe and go into the bathroom of room [ROOM NUMBER]. She then returned to the medication cart, inserted the syringe into the morphine again, pulled back on the syringe, then went back into the bathroom of room [ROOM NUMBER]. Review of the Order Summary Report for Resident #1 revealed an order for Morphine Sulfate Oral Solution 20 mg (milligram) 5 (five) ml (milliliters): give 0.5 ml sublingual every 4 (four) hours as needed for pain and wheezing for 14 days, dated 9/05/24. In an interview with the DON on 1/14/25 at 9:00 AM, she revealed she thought she had reported it to the SA, but she was unable to find any documentation that she had reported the incident and confirmed that she should have reported it. She then confirmed the allegation of narcotic diversion should have been immediately reported as part of the investigation process to ensure thorough investigation and follow-up is completed for the investigation. Review of the Admission Record revealed Resident #1 was admitted by the facility on 10/14/22 with diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with Hypoxia.

Based on observation, staff interview, record review and policy review, the facility failed to prevent the potential for aspiration for a resident receiving continuous tube feeding during incontinent care as evidenced by resident's coughing/choking when head of bed lowered to provide care. This is for one (1) of six (6) care observations (Resident #5). Findings include: Resident #5 Record Review on 4/29/13 revealed Resident #5 moved into the home on 7/5/94 with readmission date of [DATE] with [DIAGNOSES REDACTED]. Observation of Incontinent Care on 5/1/13 at 10:15 a.m. revealed CNAs #3 and #4 preparing to perform care for Resident #5. CNA #3 asked CNA #4 to lower resident's head of bed. CNA #4 stated that the nurse would have to put Resident #5's tube feeding on hold first. CNA #4 left resident's room to get nurse. Licensed Practical Nurse (LPN) #6 stopped resident's tube feeding and left room. CNA #4 began to lower resident's head of bed and Resident #5 began to make coughing/gurgling sounds. A large amount of thick, white phlegm was seen in resident's mouth as he coughed. CNAs proceeded on with lowering the head of the bed while resident was laying on his back coughing/gurgling. At this point, Surveyor left room and found LPN #6 and brought her to Resident #5's room. Upon arriving back in resident's room with LPN #6, Resident #5 was on right side, no longer coughing, CNAs were cleaning Resident #5. Resident #5 was then placed on his back and head of bed raised. LPN #6 proceeded to suction resident and a small amount of fluid was suctioned from Resident #5's mouth. LPN #6 asked Resident #5 if he was ok and, being non-verbal, the Resident #5 smiled and moved his eyes up and down. LPN #6 thanked Surveyor for getting her. On 5/1/13 at 3:00 p.m. Surveyor interviewed the Director of Nursing (DON) regarding concerns with CNAs proceeding with care as resident was coughing/gurgling and not calling for nurse or raising Resident #5's head of bed. The DON agreed that CNAs should have stopped care and called nurse. DON stated that "they know that." Observation of Resident #5 on 5/15/13 at 7:30 p.m. revealed resident sitting up in bed, awake and alert watching tv. HOB was elevated. Resident was smiling and moving eyes. [MEDICATION NAME] AC running at 70 ml/hr. Resident #5 noted to have very wet sounding cough but appeared to be in no distress. Director of Nursing (DON) stated resident has been doing well. DON had LPN suction resident when Surveyor and DON left resident's room. Resident #5 was smiling at that time. Review of hospital records for Resident #5 on 5/16/13 at 10:00 a.m. reveals resident has had 4 hospital admissions dated 11/20/10 for "Healthcare-associated pneumonia"; 8/31/11 for "Sepsis, Health care acquired pneumonia"; 12/21/11 for "Healthcare associated pneumonia"; and most recently 4/16/13 for "Hospital-acquired pneumonia". Review of Registered Dietitian (RD) notes with beginning date of 5/27/09 revealed Resident #5 received [MEDICATION NAME] feedings until 5/31/11 when he was changed to continuous feedings of [MEDICATION NAME] AC at 70 ml/hr (milliliters per hour). Feeding was increased to 75 ml/hr 7/27/11. Feedings were decreased to 70 ml/hr January 2012 and increased to 75 ml/hr March 2012. Feedings were decreased in April 2012. July 2012 RD note has feedings at 65 ml/hr. Next change was April 8, 2013 to 70 ml/hr. Feeding continues at 70 ml/hr at this time. During record review, surveyor could find no correlation between feeding rate increases and hospitalization s for pneumonia. Observation of Resident #5 on 5/16/13 at 10:30 a.m. revealed resident sitting up in bed sleeping. Tube feeding running, HOB elevated. Observation on 5/16/13 at 2:00 p.m. revealed Resident #5 sitting up in bed awake, smiling, watching tv. HOB elevated. Tube feeding running at 70 ml/hr. Interview on 5/16/13 at 4:45 p.m. with Medical Director, Resident #5's physician, stated that Resident #5 has inadequate [MEDICAL CONDITION] function, excess secretions, [MEDICAL CONDITIONS]. Medical Director also stated resident is a quadriplegic who has poor accessory muscle function which hampers resident's ability to cough up secretions. He also stated that he was unable to say that resident's pneumonia was caused from resident's head of bed being lowered during care. Medical Director stated resident is at greater risk for wounds if pericare not provided properly than he is for aspiration. He stated resident could also aspirate while sitting up. Surveyor received a written statement from Medical Director on 5/17/13 at 9:00 a.m. dated 5/16/13 which states the following: "Mr. (Resident #5) is a long term patient at Forest Hill Nursing Home. He has multiple medical problems including [MEDICAL CONDITIONS](Hypertension), [MEDICAL CONDITION], DM (Diabetes Mellitus), and [MEDICATION NAME] tx (treatment). He is at high risk for aspiration 2* (secondary to) [MEDICAL CONDITION] and [MEDICAL CONDITION] dysmotility. He has had recurrent episodes of pneumonia in the past which are most likely aspiration related. Although recumbent positioning for adequate hygiene may increase his risk of aspiration, the benefits of adequate hygiene, especially pericare (decreased incidence of UTI (Urinary Tract Infection), skin issues, etc.) greatly outweigh any risk." Signed "Medical Director". Observation of Resident #5 on 5/17/13 at 11:00 a.m. revealed resident sitting up in bed awake and smiling with HOB elevated. [MEDICATION NAME] AC running at 70 ml/hr. Resident #5 coughed/gurgled then smiled and moved eyes up and down when Surveyor asked if he was ok.