Every finding on record at Pendleton Manor

Based on observation and staff interviews the facility failed to provide food at a safe appetizing temperature. This failed practice had the potential to affect all residents in the facility. Resident identifiers #'s 79 and 38 Facility census: 87 a) During facility walkthrough and resident interviews, Resident #79 stated that food was a sore point; the food is terrible. Whoever cooks it .ruins it. and it has been cold. In an interview with Resident # 38 on 02/26.26, at 2:15 PM, she stated The food is ok but sometimes its too cold when it gets here. During an observation on 02/27/26 at 1:15 PM of the 400 hall meals being passed without a heated cart and only 2 staff members delivering all trays to residents on that hall. The dietary manager took the temperature of the food, at time of service. The food temperatures were as follows: Lasagna 57 degrees Fahrenheit.Vegetables 53 degrees Fahrenheit. During an interview with the Dietary Manager on 02/27/26 at approximately 1:25 PM, she temp-tested the last tray and confirmed that the food was not served at 120 degrees Fahrenheit at time of service. She stated there are not enough heated carts for the entire facility. The 400 hall was the only hall without a heated cart on that date.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantries. This had the potential to affect all residents in the facility. Facility census: 87Findings included:a) On 02/25/2026 12:36 PM During the initial kitchen visit and walk through with the Dietary Manager, who acknowledged the following:Freezer :-one box of opened frozen hamburger patties stored in an opened box with the inside plastic wrap left open to air-one box of opened frozen fish filets stored in an opened box with the inside plastic wrap left open to air-one box of sugar cookie dough stored in an opened box with the inside plastic wrap left open to air Pantry:-Tea bags not sealed and left open to air-Plastic bags of All Bran, [NAME] Wheats, and Creme of Wheats cereals unsealed and left open to air Utensil drawers -utensils were found stored in different directions,- plastic box holding utensils taken directly out of the dishwasher stored in different directions b) 500 Hall Nourishment Room and Dining Area:-On 02/26/2026 at 9:00 AM, during an observation of the 500 Hall nourishment room and dining area found the following:-Freezer:Klondike Ice Cream Bar w/out label or date-Fridge: lunchmeat left open to air -Right top cabinet found an unopened sleeve of Ritz crackers w/out date or label Staff Interviews: During an interview with Nurse Aide Employee #125, she acknowledged the lunchmeat was left open to air in the refrigerator and removed it. at 10:15 AM in a later interview with the Administrator, she stated the ham should have been stored inside a sealed bag with a label and date. c) During an observation of the 300 Hall Nourishment Room on 02/26/2026 at 9:00 AM, it was observed:-Upper Cabinet an opened sleeve of Ritz crackers without a dated label staff interviews:In an interview on 02/26/26 at 10:15AM with The Administrator, she acknowledged the sleeve of Ritz crackers and stated they should have had a dated label then sent staff to remove the crackers from the cabinet shelf d) Dining Room Storage Cabinets:On 02/26/26 at 10:15AM, during a walk through and observations of the dining room storage cabinets with the Facility Administrator who acknowledged the following: Counter and Bottom Cabinet:-One box of All Bran Cereal left out on the counter opened with unsealed inner package left open to air-three plastic packages of cereal, Corn Flakes, Toasted Oats, and Raisin Bran were left open to air in the cabinet beneath the counter e) 300 Hall Nourishment Room/Dining Area:On 02/26/26 at 10:20AM During a walk through of the 300 Hall Nourishment Room/Dining Area with the Facility Administrator who acknowledged the following: Freezer:-pint size carton of Ben and Jerrys Ice cream w/out label or date -Frozen toaster pastries w/out label or date left open to air- One box of Banquet sausage gravy/biscuits w/out label or date-Tostitos Pizza Rolls w/out label or date unsealed, left open to air -Individual Ice Cream bars w/out label or dates Upper Cabinet:-Honey Nut Cheerios Bars w/out label or date on the middle shelf-Loaf of bread with green mold on the middle shelf -One lone stick of gum on bottom shelf no package F) Facility Food Storage Policies:On 02/25/26 at 4:30PM a review of the Facility Food Storage Policy Statement number 5-a. stated Non -perishable foods are stored in re-sealable containers with tightly fitting lids and 5-b stated perishable foods are stored in resealable containers with tightly fitting lids in a refrigerator, Containers are labeled with name and date, the item, and the use by date

Based upon observations, staff interviews and record reviews, the facility failed to ensure that it remained free from accident hazards in resident accessible areas. There were multiple areas with accident hazards or hazardous products that could be reached by residents while under the care and control of the facility. This was discovered during the normal Long Term Survey Process and has the ability to affect more than a limited number of residents. Census 84.a) At 9:50 AM, an observation of the 500 hall nourishment room and resident dining area revealed that residents had access to the mini-kitchen. Under the sink, a can of Scrubbing Bubbles and a gallon of white vinegar were found. Additionally, a manual can opener with sharp edges was left on the stovetop. In the dining area, a cart containing two uncovered metal cans filled with food waste was left unattended for approximately 20 minutes while residents were present. At 10:00 AM, Employee #125 acknowledged the unattended waste carts and the can opener. She confirmed the carts are used for leftover food, stated the can opener should not have been left out, and removed it. At 10:15 AM, the Facility Administrator acknowledged the unattended waste carts. While she did not believe the can edges were sharp, she committed to finding a solution to prevent resident access to open food waste. At 1:50 PM, during a walkthrough with the Dietary Manager, two (2) unattended waste carts with uncovered lunch waste were observed in the 200 hallway, an area actively used by residents. The Dietary Manager acknowledged the presence of the waste carts and immediately instructed staff to remove them from the hallway. b) At approximately 11:50 AM, two single resident oxygen tanks were observed stored in a cubby area in the 100 hall. The tanks lacked regulators and were not labeled as full or empty. Storing tanks in non-designated areas poses a fire and explosion hazard. LPN #31 confirmed the tanks were improperly stored. During a follow-up at 12:29 PM, administration and maintenance confirmed the facility currently lacks a compliant indoor area for oxygen storage and stated they would contact the OHFLAC office to discuss necessary adjustments for compliance. At approximately 11:45 AM an observation on the 400 Hall revealed Sani-Wipes (purple top) unattended on a treatment cart near the 400 hall nurses' station. These wipes are poisonous if ingested and posed a chemical burn risk. The Registered Nurse confirmed these should not be accessible to residents and moved them to secure storage. At approximately 12:02 PM, an observation on 500 Hall revealed a linen cart with a side pouch containing zinc skin tubes, moisturizer, and calamine lotion packets. Additionally, a large wooden storage cabinet in the 500 hall living area was found unlocked and labeled only staff only. The cabinet contained linens, soap, incontinence briefs, hand sanitizer, alcohol wipes, and skin prep pads. RN #109 confirmed the contents and committed to removing the supplies from the cart and securing or clearing the cabinet. c) On 02/25/26, at approximately 1:50 PM during the initial resident interview process, the surveyor found the shower room door open and unattended. The following items were found on a table, easily accessible to residents: 1. A sharps container overflowing with three blue razors. 2. An opened can of Scrubbing Bubbles. 3. An opened container of whirlpool disinfectant. Activity Director #152 confirmed that the door was open and that these items were left unsecured. These findings were reported to the administrator at 2:00 PM on the same day.

Based on record review, observation and staff interview, the facility failed to ensure the resident's environment maintained or enhanced dignity and respect during the dining experience. The failed practice had the potential to affect a limited number of residents. Facility Census: 84. Findings included: a) The facility's policy and procedure for The Dining Experience: Staff and Responsibilities stated, Staff should provide service that will help to make dining a special event that individual patients/residents look forward to and that will create lasting memories. On 02/25/26 at 12:25 PM in the Day Room/Sitting Room, four (4) of five (5) residents were served their lunch meal without their food being removed from their plastic trays. Licensed Practical Nurse (LPN) #32 confirmed the residents were served their lunch meal on a plastic tray.

Based on observation, record review and staff interview, the facility failed to ensure an infection prevention and control program per professional standards was maintained and followed. This failed practice had the potential to affect more than a limited number of residents. Resident #'s 17 and 58 Facility Census: 84. Resident #17 During an interview with Resident #17 on 02/25/25 at 3:50 PM, observation revealed the wheelchair she was sitting in, had cracks and tears, exposing padding on both armrests. Resident #38 During resident observation and interviews on 02/25/26 4:08 PM, it was observed Resident #38's wheelchair had a tear with exposed padding on the back rest . In an interview with the infection preventionist on 02/25/2026 at 2:30 PM, she acknowledged the two (2) wheelchairs for Resident #'s 38 and #17 had exposed padding causing an infection control issue. She stated she would have them taken care of immediately. During the routine walk-through of the facility on 02/26/2026, at approximately 11:30 AM on the 400 resident hall it was noted that there was an Enhanced Barrier Protection (EBP) sign on the door of room [ROOM NUMBER]. The sign had no markings or indications as to which resident the precautions (EBP) were for. RN #149 confirmed there was no markings on that sign to indicate what resident it would pertain to. They (chuckled), It figures you found the one sign without a mark on it right as you entered the building. The facility's policy and procedure for Infection Prevention and Control Program stated, the program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility's policy and procedure for The Dining Experience: Staff Responsibilities stated, 6. Individuals will be provided with proper hand hygiene prior to each meal or snack, prepared for the meal by the nursing staff (i.e. hearing aids in place, dentures in, hair combed, dressed properly, and eyeglasses on), and assisted to the dining area as needed. On 02/25/2026 at 11:45 AM, in the main dining room, no hand hygiene was observed to be completed prior to the lunch dining experience for the residents. Six (6) ambulatory residents utilizing an assistive device and five (5) residents propelling their wheelchairs were observed entering the dining room with no hand hygiene completed upon being seated at the table for the lunch meal At 2:06 PM, Nursing Aide #120, confirmed no hand hygiene was completed for the residents in the dining room and stated, They should be taking residents and washing their hands.

Based on medical record review and staff interview, the facility failed to ensure Resident #7 received medications as ordered by the physician. Insulin aspart [NovoLog] (a medication used to control blood sugar in people with diabetes mellitus) was not administered and documented in accordance with professional standards of practice. This affected one (1) of five (5) residents reviewed for unnecessary medications during the long-term care survey process. Resident identifier: #7. Facility census: 84.Findings included: a) Physician Order for Resident #7 An electronic medical record review, completed on 03/01/2026 at 10:10 AM, revealed the following physician order:Insulin Aspart Injection Solution (Insulin Aspart)Inject 10 units subcutaneously three times a day related to TYPE 1 DIABETES MELLITUS WITH HYPERGLYCEMIA (E10.65) Give insulin immediately after each meal, EXCEPT when blood sugar is >400, then administer the full 10 units, regardless of amount eaten. If >50% of meal is eaten, give full dose. If <=50% of meal is eaten, give half dose. b) Review of Medication Administration RecordsA subsequent review of the Medication Administration Records (MAR) revealed the following dates and times that Resident #7 received a dose of Insulin aspart but the percentage of the meal consumed and the number of units administered had not been recorded on the MAR:-08/05/25 Breakfast Meal-08/05/25 Lunch Meal-08/05/25 Dinner Meal-08/13/25 Breakfast Meal-08/13/25 Lunch Meal-08/13/25 Dinner Meal-08/18/25 Breakfast Meal-08/18/25 Lunch Meal-08/18/25 Dinner Meal -08/19/25 Lunch Meal-08/19/25 Dinner Meal-08/21/25 Lunch Meal-09/01/25 Breakfast Meal-09/01/25 Lunch Meal-09/01/25 Dinner Meal-09/02/25 Lunch Meal-09/02/25 Dinner Meal-09/10/25 Breakfast Meal-09/10/25 Lunch Meal-09/10/25 Dinner Meal-09/11/25 Lunch Meal-09/11/25 Dinner Meal-09/15/25 Breakfast Meal-09/15/25 Lunch Meal-09/15/25 Dinner Meal-09/16/25 Lunch Meal-09/16/25 Dinner Meal-09/17/25 Lunch Meal-09/17/25 Dinner Meal-10/22/25 Lunch Meal-10/22/25 Dinner Meal-10/23/25 Breakfast Meal-10/23/25 Lunch Meal-10/23/25 Dinner Meal-10/27/25 Breakfast Meal-10/27/25 Lunch Meal-10/27/25 Dinner Meal-10/28/25 Breakfast Meal-11/10/25 Breakfast Meal-11/10/25 Lunch Meal-11/10/25 Dinner Meal-11/11/25 Dinner Meal-11/19/25 Breakfast Meal-11/19/25 Lunch Meal-11/19/25 Dinner Meal-11/20/25 Lunch Meal-11/20/25 Dinner Meal-11/25/25 Breakfast Meal-11/25/25 Lunch Meal-11/25/25 Dinner Meal-12/03/25 Breakfast Meal-12/03/25 Dinner Meal-12/08/25 Breakfast Meal-12/08/25 Lunch Meal-12/08/25 Dinner Meal-12/09/25 Breakfast Meal-12/09/25 Lunch Meal-12/09/25 Dinner Meal-12/17/25 Lunch Meal-12/17/25 Dinner Meal-12/18/25 Lunch Meal-12/18/25 Dinner Meal-12/31/25 Breakfast Meal-12/31/25 Lunch Meal-12/31/25 Dinner Meal-01/01/25 Breakfast Meal-01/01/25 Lunch Meal-01/01/25 Dinner Meal-01/02/25 Lunch Meal-01/02/25 Dinner Meal-01/10/25 Breakfast Meal-01/10/25 Lunch Meal-01/10/25 Dinner Meal-01/11/25 Breakfast Meal-01/11/25 Lunch Meal-01/11/25 Dinner Meal -01/19/25 Breakfast Meal-01/19/25 Lunch Meal-01/19/25 Dinner Meal-01/20/25 Breakfast Meal-01/20/25 Lunch Meal-01/20/25 Dinner Meal-01/24/25 Breakfast Meal-01/24/25 Lunch Meal-01/24/25 Dinner Meal-01/25/25 Breakfast Meal-01/25/25 Lunch Meal-01/25/25 Dinner Meal-01/28/25 Breakfast Meal-01/28/25 Lunch Meal-01/28/25 Dinner Meal-01/29/25 Breakfast Meal-01/29/25 Lunch Meal-01/29/25 Dinner Meal-02/02/25 Breakfast Meal-02/02/25 Lunch Meal-02/02/25 Dinner Meal-02/03/25 Breakfast Meal-02/03/25 Lunch Meal-02/03/25 Dinner Meal-02/04/25 Lunch Meal-02/07/25 Breakfast Meal-02/07/25 Lunch Meal-02/07/25 Dinner Meal-02/08/25 Breakfast Meal-02/08/25 Lunch Meal-02/08/25 Dinner Mealc) Interview with DONDuring an interview on 03/02/26 at 10:20 AM, the Director of Nursing confirmed that MARs on the above-mentioned dates and times did not have the percentage of the meal consumed and the number of units administered recorded.

Based on record review and staff interview, the facility failed to notify the physician of a change in condition for a resident's admission to hospice services. Resident Identifier: #47. Facility Census: 84.Findings included: a) Resident #47 The facility's policy stated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc. ).On 09/24/25, a progress note for Resident #47 documented a decline with nursing reporting a significant change. No documentation was found for physician notification of the decline/significant change. A nursing progress note dated 10/14/25, documented admission to hospice services with family in attendance. On 10/29/25, a progress note documenting the care conference documented, Nursing Significant Change due to hospice placement.On 02/26/26, the Administrator verified there was no documentation for the resident's change of condition for hospice, including physician notification, in the progress notes. A change in condition Minimum Data Set (MDS) was initiated on 10/15/2025. On 03/02/2026, the state surveyor requested documentation of physician inclusion in hospice decision making process and notification of change of condition No additional information was obtained.

Based on record review and staff interview, the facility failed to send a copy of the Notice of Transfer/Discharge form to the Long-Term Care Ombudsman when a resident was discharge to an acute care setting. Resident Identifier: #7. Facility Census: 84. Findings included: a) Resident #7 An electronic medical record review was completed on 03/01/2026 at 12:08 PM. Resident #7 was transferred to the hospital on [DATE]. There was no evidence in resident's medical record to reflect the Long-Term Care Ombudsman had received a copy of the Notice of Transfer/Discharge paperwork or had been made aware of the hospitalization. The Administrator was asked if the facility could produce evidence staff had shared the appropriate notice of transfer/discharge with the ombudsman. During an interview, on 03/02/26 at 10:40 AM, the Social Worker confirmed the Notice of Transfer/Discharge paperwork had not been shared with the Long-Term Care Ombudsman prior to Surveyor intervention. It was noted that it had been accidentally overlooked.

Based on observation, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 in regard to, precaution signage on the entrance, positive Covid-19 precaution signage on resident doors, water management and expired Sani Wipes. This has to potential to affect all residents that reside in the facility. Identifier: room [ROOM NUMBER]. Facility Census: 77. Findings Include: a) Precaution Signage on Entrance Door An observation on [DATE] at 12:00PM of the facility's front entrance revealed no precautionary signage located on the door informing visitors of Covid-19 in the building. During an interview on [DATE] at 4:02 PM, the Director of Nursing verified there was no precautionary signage for visitors on the front entrance. b) Precaution Signage room [ROOM NUMBER] Observations during the initial tour on [DATE] at 12 noon revealed no signs near the door frames of room [ROOM NUMBER]. Continued review revealed Resident # 65's clinical record revealed the resident was admitted to the facility on [DATE], and was on precautions for Covid-19. Subsequent review revealed Resident # 128 was admitted to the facility on [DATE], and was on precautions for Covid-19. During an interview on [DATE] at 4:02 PM the Director of Nursing verified there was no precautionary signage for Covid-19 on room [ROOM NUMBER] where resident's #65 and #128 is residing. She stated there should be precaution signs on the door. c) Water Management During facility record review of the water management plan revealed, the documentation was not maintained to prevent growth of water borne pathogens including the description of the building water system. The facility did not have a flow diagram or text that Identified the buildings water systems for which Legionella control measures are needed. Subsequent review found there was no documentation in regard to flushing the water system in dead leg areas. On [DATE] at 11:43 AM the Maintenance Director verified the facility did not maintain documentation describing the building water systems using text, flushing, or testing protocols. d) 100 Hall Medication Room An observation on [DATE] at 2:30 PM during the medication storage task revealed Sani wipes Large Canister (160 Count) in the 100-hall medication room that expired ,d+[DATE]. During an interview on [DATE] at 2:31 PM Licensed Practical Nurse #109 confirmed the Sani wipes were expired and should not be in the medication room.

Based on observation and staff interview, the facility failed to provide an environment which was free from accident hazards over which they had control. The facility did not identify a toaster that was plugged in and operable in the Kitchenette on the 500 Hall as a hazard. This had the potential to affect every resident residing on the 500 hall. Resident identifiers: #64, #7, #30, #56, #26, #3, #6, #39, #19, #65, #42, #8, #28. Facility census: 77 Findings include: a) Toaster in the 500 Hall Kitchenette An observation, made on 04/30/24 at 10:25 AM, found the 500 hall kitchenette had a toaster plugged in and accessible to any passerby. Further investigation confirmed when the handle/lever was pushed down, the coils began to glow red which indicated the toaster was fully operable. During an interview on 04/30/24 at 10:35 AM, the Director of Nursing (DON) verified the plugged in toaster was an accident hazard, unplugged it, and removed the toaster from the area.

49467 Based on record review and staff interview, the facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident and possible serious mental disorders. This was true for three (3) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: #11, #28, and #49. Facility census: 77. Findings include: A) Resident #11 At approximately 11:00 AM on 04/30/24, a record review was conducted for Resident #11. During record review, it was noted Resident #11 had been admitted to the facility on [DATE]. On 07/25/23, Resident #11 was diagnosed with Major Depressive Disorder. Resident #11 had a new PASARR submitted on 01/29/2024, which did not include the new diagnosis of Major Depressive Disorder. At approximately 8:40 AM on 05/01/24, an interview was conducted with the Director of Nursing (DON) concerning the PASARR for Resident #11. The DON confirmed the absence of major depressive disorder on the PASARR. At approximately 9:45 AM on 05/01/24, an interview was conducted with Social Worker (SW) #45 regarding the PASARR for Resident #11. SW #45 confirmed the missing major depressive disorder diagnosis and that there has been no new PASARR completed for Resident #11 to reflect the diagnosis. B) Resident #28 At approximately 1:20 PM on 04/30/24, a record review was conducted for Resident #28. During the record review, it was noted Resident #28 had been admitted to the facility on [DATE]. A diagnosis of major depressive disorder was entered into the system for Resident #28 on 06/28/23, classified as during stay. Upon review of Resident #28's PASARR, it was noted there was no diagnosis of major depressive disorder present on the PASARR. At approximately 8:40 AM on 05/01/24, an interview was conducted with the Director of Nursing (DON) concerning the PASARR for Resident #28. The DON confirmed the absence of major depressive disorder on the PASARR. At approximately 9:45 AM on 05/01/24, an interview was conducted with Social Worker (SW) #45 regarding the PASARR for Resident #28. SW #45 confirmed the missing major depressive disorder diagnosis and that there has been no new PASARR completed for Resident #28 to reflect the diagnosis. c) Resident #49 A record review, completed on 04/30/24 at 3:46 PM, revealed Resident #49 was admitted to the facility on [DATE]. Review of the 02/21/20 PASARR revealed Section III. MI/MR Assessment Question #30 Current Diagnosis was answered NONE. No other PASARR was on file. On 07/22/21 Resident #49 was given a new diagnosis of Major Depressive Disorder, Recurrent. During an interview on 05/01/24 at 8:50 AM, Social Worker #71 confirmed a new PASARR had never been completed to capture the Major Depressive Disorder diagnosis.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. Physician Orders for Scope of Treatment (POST) forms were incomplete and/or inaccurate for two (2) of three (3) records reviewed for accurate POST forms. Resident identifiers: #176 and #9. Facility census: 77. Findings include: a) Review of Using the POST Form Guidance for Health Care Professionals, 2021 Edition The 2021 POST form guidance states: -The patient or incapacitated patient's Medical Power of Attorney (MPOA) or Health Care Surrogate (HCS) must sign and date for the form to be legally valid. -The health care provider / physician completing this form must print their name, sign, and date for the form to be legally valid. b) Resident #176 An electronic medical record review, completed on 04/29/24 at 2:34 PM, found: -A POST form signed by resident's legal representative but not dated -The POST form was signed and dated by the physician on 04/16/24 A subsequent review of the original POST form at the nurses' station revealed it had also not been dated by Resident #176's legal representative. During an interview on 04/30/24 at 2:50 PM, Social Worker #71 acknowledged the form was not legally valid. c) Resident #9 An electronic medical record review, completed on 04/30/24 at 10:11 AM, found: -A POST form signed and dated by resident's legal representative on 03/20/24 -The POST form was not signed and dated by Resident #9's physician. A subsequent review of the original POST form at the nurses' station revealed it had also not been signed and dated by the physician. During an interview on 04/30/24 at 2:53 PM, Social Worker #71 acknowledged the form was not legally valid.

Based on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to collaborate with Hospices services. This was true for one (1) of one (1) residents reviewed for hospice services during the long term care survey. Resident Identifier: Resident # 63. Facility Census: 77. Findings Include: a) Resident #63 A medical record review revealed Resident #63 was receiving Hospice Services starting on 03/27/24. A continued record review of physician's orders showed an order for: -- Admit to Hospice, DX dementia. Review of Resident # 63's Hospice documentation notebook showed it did not contain an active care plan or collaborating documentation from Hospice Services. During an interview with the Director of Nursing on 05/01/24 at 2:13 PM, She verified Resident #63 was receiving Hospice Services and had no current coordinated plan of care with the Hospice provider identifying the provider responsible for performing each or any specific services/functions that had been agreed upon. She stated, she had to call hospices services today and have documentation faxed to the facility.

Based on record review and staff interview, the facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents admitted to the facility diagnosed with possible serious mental disorders. This was true for one (1) of six (6) residents reviewed for PASARRs during the survey process. Resident Identifier: 23 . Facility census: 77. Findings include: A) Resident #23 At approximately 11:30 AM on 04/30/24, a record review was conducted for Resident #23. During the record review, it was noted Resident #23 had been admitted to the facility on [DATE]. A diagnosis of cerebral palsy was entered into the system for Resident #23 on 02/06/23 as the principal/admitting diagnosis. Upon review of Resident #23's PASARR, it was noted there was no diagnosis of cerebral palsy present on the PASARR. At approximately 8:40 AM on 05/01/24, an interview was conducted with the Director of Nursing (DON) concerning the PASARR for Resident #23. The DON confirmed the absence of cerebral palsy on the PASARR. At approximately 9:45 AM on 05/01/24, an interview was conducted with Social Worker (SW) #45 regarding the PASARR for Resident #23. SW #45 confirmed the missing cerebral palsy diagnosis and that there has been no new PASARR completed for Resident #23 to reflect the diagnosis.

Based on observation and staff interview, the facility failed to secure and keep confidential residents personal and medical information. A restorative note was visible on a rolling workstation desk in the 400 hallway for Resident #47. The form identified Parkinson's as a diagnosis for the resident. This was a random opportunity for discovery and was true for only Resident #47. Resident #47. Facility census: 77. Findings include: a) Resident #47 On 05/01/24 at 7:54 AM, a paper restorative note was sitting on top of a rolling workstation desk in the 400 Hallway. The restorative note indicated that Resident #47 was at risk for decline in range of motion related to a diagnosis of Parkinson's. During an interview on 05/01/24 at 8:00 AM, Registered Nurse (RN) #5 verified the restorative note was visible for any passerby and should not have been left out and unattended. On 05/01/24 at 8:15 AM, the Director of Nursing confirmed the practice of leaving a restorative note on a rolling workstation desk failed to protect the privacy of the resident's medical record.

Based on record review and staff interview the facility failed to thoroughly investigate all allegations of abuse and or neglect. This was a random opportunity for discovery and was found to be true for Resident #51, #62, #37 and #49. Resident Identifier: #51, #62, #37, and #49. Facility Census: 64. Findings Included: a) Allegations against Former Nurse Aide (NA) #148 involving Resident #51, #62, and #37. A review of the facility's reportable incidents found a reportable incident dated 07/21/22. The allegation contained on this report read as follows: Allegedly (First and last Name of Former Nurse Aide #148) was making sexually inappropriate comments to the male residents on the 200 hall. A review of the investigation found the following statements: -- Statement from Nurse Aide #75. Typed as written: I want to report at 200 CNA (certified nursing assistant) for having sexual conversations with male 200 residents. The 200 CNA is (first and last name of former NA #148). I have witnessed her talking with Residents (First and Last Name of Resident #62), (First and Last Name of Resident #51), (First and Last Name of Resident # 37). I have told her to stop multiple times. (Conversation between (first name of Resident #62), (First name of Former NA #148) and me). (First name of Former NA #148) asked me to help lay (First name of Resident #62 down). (First name of Resident #62 asked why it taked 2 to lay him down. I said I wasn't sure, (First name of Resident #62) asked me if she ((First name of Former NA #148) was the one with 20 some boyfriends? I looked at (First name of Former NA #148) and (First name of Former NA #148) said no (first name of Resident #62) I don't have that many (First name of Resident #62 ) said well if there not all boyfriends than what are they (First name of Former NA #148) then said well haven't you had friends you just have fun with (First name of Resident #62) said, No I haven't had sex since my wife put me in here and that's been three years (First name of Former NA #148) said you haven't had sex with anybody else but your wife. (First name of Resident #62) said no (First name of Former NA #148) said well. [Please note the remainder of this conversation was written on the back of the sheet and the facility failed to copy the back of the page when requested therefore it can not be fully quoted here] She's (First name of Former NA #148) had made comments to (Resident #51) such as: (First name of Former NA #148) :You want her to climb in bed with you? (First Name of Resident #51): Yes I don't care she can if she wants (First name of Former NA #148) : Oh what would you do if she did? (First name of Resident #51: Climb in here and find out what this (grabs him self) can do. (I walked out after saying that gross to (First name of Former NA #148)). (First name of Former NA #148) has also said to me something about bouncing on (First name of Resident #51's) area 'penis'. I told her that was disgusting. There are more conversations like these also. Its an everytime she works thing. She can turn anything sexual also with her coworkers. The only other statements contained in the investigation was from two (2) female residents who reside on the 200 hall both of which denied any inappropriate comments. There was also two (2) additional statements from NA's who reported NA #75 had told them the same thing she wrote in her statement. There were not statements obtained from NA #148 who was the alleged perpetrator. There was also not statement from Resident #51, #62 and #37 who were named as the alleged victims. A review of the most recent Minimum Data sets for Resident #51, #62 and #37 found the following in regards to their cognitive status: Resident #51 had a Brief interview for mental status (BIMS) score of a 12 which indicates a moderate impairment but no severe. Resident #62 did not have a BIMS score but the MDS did indicate his long term and short term memory was not impaired. Resident #37 had a BIMS score of 15 which indicated he was cognitively intact. A list of all residents residing on the 200 hall at the time of the allegation was requested. On the list was 5 additional males. The following information is the BIMS scores for the remaining males on the 200 hall: Resident #55 had a BIMS of 15 indicating he was cognitively intact. Resident #38 had a BIMS of 14 indicating her was cognitively intact. Former Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #5 had a BIMS of 5 which indicated a severe impairment. Resident #54 had a BIMS of 15 which indicated he was cognitively intact. Of the eight (8) men who resided on the 200 hall only one (1) Resident #5 had a cognitive impairment which would have made it difficult to obtain a statement from regarding Former NA #148's behavior. At 4:00 PM on 08/30/22 SW #142 was interviewed regarding the investigation for this allegations. When asked why she only obtained statements from Females when the allegation was Former NA #148 was talking inappropriately to males, she stated, I tried to ask people who were cognitively able to answer questions. When the BIMS scores of Resident #55, #38, #51, Former Resident #1, #37, #62, and #54 were reviewed with her she stated, Your right I should have interviewed the males. She agreed she did not obtain statement from Former NA #148, nor any of the males residing on the 200 hall including the three (3) named victims. The allegation was unsubstantiated without conducting a through investigation. b) Resident #49 A review of the facility reportable incidents found a Reportable dated 07/19/22 concerning an incident which took place on 07/17/22. A review of the Immediate Fax reporting of allegations found the following allegation: (First Name of Nurse Aide (NA) #23) allegedly placed her hand over (First Name of Resident #49's) mouth while changing her to make her stop yelling and informed the aide helping her that she does it all the time when she change's (First Name of Resident #49) by herself. The statements gathered during the investigation contained the following pertinent statements: -- Statement from former NA # 148 regarding the incident typed as written: Interview conducted via phone with (First and Last Name of NA #148) on 07/19/22 at 3:40 PM with (First and Last Name of Registered Nurse (RN) #121), (First and Last Name of the Director of Nursing (DON), and (First and Last name of Licensed Practical Nurse (LP) #120) present. (First Name of former NA #148) state that she did not witness any abusive activity towards (First and Last Name of Resident #49) on 07/17/22. She stated that she never has seen anyone put a hand over (First Name of Resident #49)'S mouth. She state she did not provide care to (First name of Resident #49) on 07/17/22 and that (First and Last Name of NA #35) and (First and last Name of NA #23) provided care to (First name of Resident #49). -- Statement provided by NA #35 statement is hand written by NA #35. Statement typed as written with multiple misspelled words. (First name of NA #23) always puts her hand over (First name of Resident #49)'S mouth when yells to make her stop. She also showed (First name of Resident #52) a picture of girls viginia. She will come up behind me and smack me with briefs. She put pictures of her viginia and boobs in my face when I tell her not to. She pulled her pants down in the tub room and told me to look at her hairy monkey. (First Name of former NA #142) an I went to change (first name of Resident #28) got half way through and (First name of NA #23) came in an yelled at both of becuas it does not take two people to change (first name of Resident #28). She buts in and told us to get out of her way and finished changing (first name of Resident #28) by herself even though (first name of Resident #28) is a total. Every time she has to do the vitals she [NAME] them. She always chooses who does totals and singles and makes us do like 6 sets of rounds. After she got at me for the (first name of Resident #28) thing she almost fit me in the head with the vital machine. The first time I saw (First Name of NA #23) put her hand over (First Name of Resident #49)'s mouth was Sunday. She told me that she does it all the time when she changes her by herself. -- Statement Provided by NA #23. Typed as written: As we were doing rounds after supper, I went to help (First Name of NA #35) change (First name of Resident #49), and she told me to go on and start changing (First Name of Resident Resident #52). I went on over and changed (First name of Resident #52), and waited for her to come help me pull her up. She never came, so I said (First name of NA #35) three times, and got no answer. I then went to find her, and found (First name of Resident #28)'s door closed. So I went in and asked her to come help me pull her up. She said she would, so I went back to (first name of Resident #52)'s room and waited, she never came so I went back again, she and (First Name of former NA #148) were in there and when they were done she came back and met me in (first name of Resident #52's) room. As for (First name of Resident #49) I didn't have any part in her care for that evening. After reviewing the above statements the Documentation Survey Report was requested for Resident #49 for the date of 07/17/22. This report was reviewed to determine who documented they provided care for Resident #49 on the evening of 07/17/22. A review of the report found NA #23 documented providing the following care for Resident #49 on the evening of 07/17/22: -- Bed mobility ar 3:26 pm. -- Dressing at 3:26 pm. -- Locomotion off Unit at 3:26 pm. -- Locomotion on unit at 3:26 pm. -- Oral care at 3:27 pm. -- Personal Hygiene at 3:26 pm. -- Toileting at 3:29 pm, 4:56 pm, 6:07 pm, and 8:46 pm. -- Transferring at 3:26 pm. During an interview on 08/30/22 at 4:07 pm the review of the survey documentation report was shared with Social Worker (SW) #142. When asked if she had reviewed the report to confirm NA #23's statement that she did not provide care to Resident #49 on 07/17/22. She indicated she had not. When she reviewed the report and saw NA #23 had in fact provided care to Resident #49 on 07/17/22 she stated, This was poorly investigated. She agreed, the allegations needed to be looked into further. The allegation was unsubstantiated without conducting a through investigation.

Based on record review, policy review and staff interview the facility failed to implement their abuse and neglect policy in regard to reporting allegations of abuse and neglect for Resident #52 and #36. In addition the facility failed to thoroughly investigate all allegations of abuse and neglect for Resident #51, #62, #37, and #49. This was a random opportunity for discovery found during the long term care survey process. Facility Census: 64. Findings Included: a) Allegations against Former Nurse Aide (NA) #148 involving Resident #51, #62, and #37. A review of the facility's reportable incidents found a reportable incident dated 07/21/22. The allegation contained on this report read as follows: Allegedly (First and last Name of Former Nurse Aide #148) was making sexually inappropriate comments to the male residents on the 200 hall. A review of the investigation found the following statements: -- Statement from Nurse Aide #75. Typed as written: I want to report at 200 CNA (certified nursing assistant) for having sexual conversations with male 200 residents. The 200 CNA is (first and last name of former NA #148). I have witnessed her talking with Residents (First and Last Name of Resident #62), (First and Last Name of Resident #51), (First and Last Name of Resident # 37). I have told her to stop multiple times. (Conversation between (first name of Resident #62), (First name of Former NA #148) and me). (First name of Former NA #148) asked me to help lay (First name of Resident #62 down). (First name of Resident #62 asked why it taked 2 to lay him down. I said I wasn't sure, (First name of Resident #62) asked me if she (First name of Former NA #148) was the one with 20 some boyfriends? I looked at (First name of Former NA #148) and (First name of Former NA #148) said no (first name of Resident #62) I don't have that many (First name of Resident #62 ) said well if there not all boyfriends than what are they (First name of Former NA #148) then said well haven't you had friends you just have fun with (First name of Resident #62) said, No I haven't had sex since my wife put me in here and that's been three years (First name of Former NA #148) said you haven't had sex with anybody else but your wife. (First name of Resident #62) said no (First name of Former NA #148) said well. [Please note the remainder of this conversation was written on the back of the sheet and the facility failed to copy the back of the page when requested therefore it can not be quoted by the surveyor] She's (First name of Former NA #148) had made comments to (Resident #51) such as: (First name of Former NA #148) :You want her to climb in bed with you? (First Name of Resident #51): Yes I don't care she can if she wants (First name of Former NA #148) : Oh what would you do if she did? (First name of Resident #51: Climb in here and find out what this (grabs him self) can do. (I walked out after saying that gross to (First name of Former NA #148)). (First name of Former NA #148) has also said to me something about bouncing on (First name of Resident #51's) area 'penis'. I told her that was disgusting. There are more conversations like these also. Its an everyday she works thing. She can turn anything sexual also with her coworkers. The only other statements contained in the investigation was from two (2) female residents who reside on the 200 hall both of which denied any inappropriate comments. There was also two (2) additional statements from NA's who reported NA #75 had told them the same thing she wrote in her statement. There were not statements obtained from NA #148 who was the alleged perpetrator. There was also no statements from Resident #51, #62 and #37 who were named as the alleged victims. A review of the most recent Minimum Data sets for Resident #51, #62 and #37 found the following in regards to their cognitive status: Resident #51 had a Brief interview for mental status (BIMS) score of a 12 which indicates a moderate impairment but not severe. Resident #62 did not have a BIMS score but the MDS did indicate his long term and short term memory was not impaired. Resident #37 had a BIMS score of 15 which indicated he was cognitively intact. A list of all male residents residing on the 200 hall at the time of the allegation was requested. On the list was 5 additional males. The following information is the BIMS scores for the remaining males on the 200 hall: Resident #55 had a BIMS of 15 indicating he was cognitively intact. Resident #38 had a BIMS of 14 indicating her was cognitively intact. Former Resident #1 had a BIMS of 15 indicating he was cognitively intact. Resident #5 had a BIMS of 5 which indicated a severe impairment. Resident #54 had a BIMS of 15 which indicated he was cognitively intact. Of the eight (8) men who resided on the 200 hall only one (1) Resident #5 had a cognitive impairment which would have made it difficult to obtain a statement from regarding Former NA #148's behavior. However; the facility obtained no statements from any male resident residing on the 200 hall. At 4:00 PM on 08/30/22 Social Worker (SW) #142 was interviewed regarding the investigation for these allegations. When asked why she only obtained statements from Females when the allegation was Former NA #148 was talking inappropriately to males, she stated, I tried to ask people who were cognitively able to answer questions. When the BIMS scores of Resident #55, #38, #51, Former Resident #1, #37, #62, and #54 were reviewed with her she stated, Your right I should have interviewed the males. She agreed she did not obtain statement from Former NA #148, nor any of the males residing on the 200 hall including the three (3) named victims. The allegation was unsubstantiated without conducting a through investigation. b) Resident #49 A review of the facility reportable incidents found a Reportable dated 07/19/22 concerning an incident which took place on 07/17/22. A review of the Immediate Fax reporting of allegations found the following allegation: (First Name of Nurse Aide (NA) #23) allegedly placed her hand over (First Name of Resident #49's) mouth while changing her to make her stop yelling and informed the aide helping her that she does it all the time when she change's (First Name of Resident #49) by herself. The statements gathered during the investigation were reviewed and contained the following pertinent statements: --Statement from former NA # 148 regarding the incident typed as written: Interview conducted via phone with (First and Last Name of NA #148) on 07/19/22 at 3:40 PM with (First and Last Name of Registered Nurse (RN) #121), (First and Last Name of the Director of Nursing (DON), and (First and Last name of Licensed Practical Nurse (LP) #120) present. (First Name of former NA #148) stated that she did not witness any abusive activity towards (First and Last Name of Resident #49) on 07/17/22. She stated that she never has seen anyone put a hand over (First Name of Resident #49)'S mouth. She stated she did not provide care to (First name of Resident #49) on 07/17/22 and that (First and Last Name of NA #35) and (First and last Name of NA #23) provided care to (First name of Resident #49). -- Statement provided by NA #35 statement is hand written by NA #35. Statement typed as written with multiple misspelled words. (First name of NA #23) always puts her hand over (First name of Resident #49)'S mouth when yells to make her stop. She also showed (First name of Resident #52) a picture of girls viginia. She will come up behind me and smack me with briefs. She put pictures of her viginia and boobs in my face when I tell her not to. She pulled her pants down in the tub room and told me to look at her hairy monkey. (First Name of former NA #142) an I went to change (first name of Resident #28) got half way through and (First name of NA #23) came in an yelled at both of because it does not take two people to change (first name of Resident #28). She buts in and told us to get out of her way and finished changing (first name of Resident #28) by herself even though (first name of Resident #28) is a total. Every time she has to do the vitals she [NAME] them. She always chooses who does totals and singles and makes us do like 6 sets of rounds. After she got at me for the (first name of Resident #28) thing she almost fit me in the head with the vital machine. The first time I saw (First Name of NA #23) put her hand over (First Name of Resident #49)'s mouth was Sunday. She told me that she does it all the time when she changes her by herself. --Statement Provided by NA #23. Typed as written: As we were doing rounds after supper, I went to help (First Name of NA #35) change (First name of Resident #49), and she told me to go on and start changing (First Name of Resident Resident #52). I went on over and changed (First name of Resident #52), and waited for her to come help me pull her up. She never came, so I said (First name of NA #35) three times, and got no answer. I then went to find her, and found (First name of Resident #28)'s door closed. So I went in and asked her to come help me pull her up. She said she would, so I went back to (first name of Resident #52)'s room and waited, she never came so I went back again, she and (First Name of former NA #148) were in there and when they were done she came back and met me in (first name of Resident #52's) room. As for (First name of Resident #49) I didn't have any part in her care for that evening. After reviewing the above statements the Documentation Survey Report was requested for Resident #49 for the date of 07/17/22. This report was reviewed to determine who documented they provided care for Resident #49 on the evening of 07/17/22. A review of the report found NA #23 documented providing the following care for Resident #49 on the evening of 07/17/22: -- Bed mobility ar 3:26 pm. -- Dressing at 3:26 pm. -- Locomotion off Unit at 3:26 pm. -- Locomotion on unit at 3:26 pm. -- Oral care at 3:27 pm. -- Personal Hygiene at 3:26 pm. -- Toileting at 3:29 pm, 4:56 pm, 6:07 pm, and 8:46 pm. -- Transferring at 3:26 pm. During an interview on 08/30/22 at 4:07 pm the review of the survey documentation report was shared with Social Worker (SW) #142. When asked if she had reviewed the report to confirm NA #23's statement that she did not provide care to Resident #49 on 07/17/22. She indicated she had not. When she reviewed the report and saw NA #23 had in fact provided care to Resident #49 on 07/17/22 she stated, This was poorly investigated. She agreed, the allegations needed to be looked into further. The allegation was unsubstantiated without conducting a through investigation. c) Resident #52 A review of the facility's reportable incidents on 08/30/22 found a reportable dated 07/19/22 concerning an incident which took place on 07/17/22. Contained in this reportable was a statement from Resident #52 which read as follows: Were you shown any pictures on Sunday? (First Name of Resident #52) reports she was shown a picture of a woman's butt and that it wasn't the best picture. (First name of Resident #52) reports that the girls look to her as a mother figure and come to her about things. (First Name of Nurse Aide (NA) #23) came to her for advice because her boyfriend was paying money to look at these pictures on a website. An interview with Social Worker (SW) #142 on 08/30/22 at 2:34 pm found the allegation reported on 07/19/22 did not involve Resident #52 and was reported in regard to incident that took place with Resident # 49. When asked if the incident where Resident #52 was shown inappropriate pictures by NA #23 was reported and/or investigated she stated, No it was not. She indicated it was statement obtained during another investigation and she did not think to report it as a separate allegation, but agreed it should have been reported and investigated once the statement from Resident #52 was obtained. d) Facility Policy A review of the facility's policy titled Abuse and Neglect - Rehab/Skilled, therapy and Rehab with a reviewed revised date of 03/31/22 contained the following regarding the reporting and investigation of all allegations of abuse, neglect, and injury of unknown origin: .4. Notification Procedures: a. Alleged or suspected violation involving any mistreatment, neglect, exploitation or abuse including injuries of unknown origin will be reported immediately to the administrator. b. In case of absence of the administrator, follow the chain of command for notification (director of nursing services, social worker, etc.) If the alleged perpetrator is one's supervisor or department manager, notify his or her supervisor. Document the notification in the Risk management Module of PCC (Point Click Care). c. Designated agencies will be notified in accordance with state law, including the state survey and certification agency. If applicable, Adult Protective Services will be notified where state law provides for jurisdiction in long term care centers 9. The investigation may include interviewing employees, residents or other witnesses to the incident. Interview all involved (employee, resident and family) individually, not as a group so that their descriptions of the incident can be compared to determine inconsistencies. Consider having each person his or her memory of the event. If possible, get signed and dated statements from any witnesses 45173 e) Resident #36 On 08/30/22 12:30 PM, an incident report dated 07/14/22 was reviewed for Resident #36. The incident was regarding a fall with a major injury, which resulted in a closed torus fracture of the distal end of the left femur. The following progress note dated 07/14/22 at 1:30 PM stated the following: Called to room by CNA (certified nursing assistant) , sitting in upright position on floor mat, right leg crossed under left at window side, back against bed frame, bed bolster behind resident back, alarm sounding, CNA reports while providing care for roommate, she heard this resident screaming. Not sure what I was doing, just slid down there, got to get home (Typed as written.) An additional progress dated 07/14/22 at 7:23 PM stated the following: Resident returned from (Name of acute care facility) ER (emergency room ) via (Name of transport service). She is A&OX3 (alert and oriented times three) and able to make her needs known. She has closed Torus fracture of the distal end of left femur. She is in a knee immobilizer at this time. She is very painful when moving. ER sent script (prescription) for Oxycodone 5mg 1 tab Q6H (every six hours) PRN (as needed) pain. She is to follow up with Ortho (orthopedics) ASAP (as soon as possible). No orders to remove knee immobilizer at this time. Resident resting in bed at this time with no complaints (Typed as written.) A review of the Facility Abuse and Neglect policy under section 4c found the following: --Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency . --i. If there is an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. On 08/30/22 at 12:57 PM, Social Worker (SW) #142 confirmed the fall with a major injury was not reported to the appropriate state agencies. If it's not there .there isn't one.

Based on Resident council meeting, record review and staff interview, the facility failed to resolve a group grievance concerning call lights in a timely manner. This was discovered during the resident council meeting and had a potential to affect more than a limited number of residents. Facility census 64. Findings included: a) Resident council minutes A review of the past Resident council meeting minutes revealed that there were complaints about staff turning off the call lights and saying they will be right back, but not coming back. The dates these complaints were found from the resident council meeting minutes on the following dates: *12/06/21 *There was not another meeting until March due to COVID-19 outbreak. *03/15/22 *04/05/22, problem with turning off call lights continue. *08/02/22, again the group complained about the call lights being turned off without having their needs met. b) Facility grievance/concern forms A review of the facility forms titled, Suggestion or Concern, found the following: *12/06/21 a Suggestion or Concern Person making report: Resident Council Report of concern: Staff turn off their call light before their need is met. States staff do not come back to take care of needs. *Residents were encouraged to tell charge nurse at time of concern. Completed by: Director of Social Services (DSS) #143. *03/15/22 a Suggestion or Concern, Person making report: Resident Council group Report of Concern: Resident state staff are turning off call light before need is met. States also waited 45 minutes. Reviewed the previous concern forms from January Resident Council minutes: follow-up states call light issue still a problem at times. Informed will place on concern form for nursing to address. Completed by: DSS #143. *04/05/22 a Suggestion or Concern, from 03/15/22, was still attached to the minutes still unresolved. *05/03/22 a Suggestion or Concern from 03/05/22, was attached without any improvements or resolution, to the resident council minutes. *08/02/22 a Suggestion or Concern form was attached to the August resident group meeting. Report of concern: Named Resident #35, 1. turning call lights off and then not coming back. 2. On Sunday evening the staff told Resident #35 that if she wanted to be put to bed that she had better come now when she was visiting with the roommate. Completed by: Social Worker #142. A form titled, For Center/Campus Use Only Investigation: Updated team in morning meeting Staff development Coordinator states there was scheduled nursing and nurse aide meetings soon. She will address issues during meeting. Meetings for Nurses will be on 03/23/22 and 03/24/22. Nurse aides will have meetings on 03/28/22 and 03/29/22. Completed by SW #142 on 03/18/22. Resolution: Met with residents and they state they still turn off call light at times. Residents were updated that on one of the monthly meetings for nurses and nurse aides, the staff development coordinator discussed the concerns with them. Resident voiced having to wait too long. Completed by: DSS #143 on 04/05/22. Follow-up comments/reviewed with concerned party: Met with Resident about concern. Completed by: DSS #143 on 04/25/22. A note at bottom of form read: Updated Residents noting issue with call light still occurs at times. Completed by: DSS #143 on 05/03/22. *08/18/22 a Suggestion or Concern Reported by: Residents Report of concern: Resident asked, Do staff treat you with respect and dignity? Resident stated Nurse Aide #137 turns off call lights and walks out. States when she comes in room and Resident tells her she needs to use bathroom, NA #137 looks at her - turns off light and walks out. Resident states she turns the light back on and hopes a different NA will come. c) Resident Council with Surveyor During an in-person meeting with the Resident Council Group, on 08/30/22 at 11:00 AM it was asked if the staff answer the call lights timely? As a group the residents said no and were shaking their heads to indicate no. The group said the staff turn the light off and say they will be back. Resident #35 stated she waits 15 minutes and pushes the call light again She was asked how many times they must do this. She indicated three (3) to four (4) times before her need is met. Two (2) other residents stated they also do this and have had to wait 45 minutes or more. d) Staff interview On 08/30/22 at 12:00 PM, SW #142 was asked about the ongoing problem with the call lights, and she stated she was aware of it. SW #142 stated it was being handled by Health Information Coordinator (HIC) #139. On 08/30/22 at 12:10 PM, HIC #139 was asked if the facility had any documentation on call light audits. HIC #139 could not provide any type of audits which had been done by the close of the survey. HIC #139 was unable to provide proof the facility had worked to resolve this repetitive grievance voiced by the resident council.

Based on medical record review, observation, resident, and staff interview; the facility failed to notify Resident #65's physician and family of resident's traumatic laceration on the resident's left lower leg. This was true for one (1) of one (1) residents reviewed for the care area of notification of change. Resident identifier: #65. Facility census: 64. Findings include: a) Resident #65 On 08/29/22 at 9:46 am, during an interview with Resident #65, this surveyor observed a bandage covering the resident's left lower leg. Resident was asked about her left lower leg, and she said, One of the nursing assistants (NA) was helping me and her watch caused a laceration on my left lower leg and now the area hurts, and is red and swollen, and I am worried about it healing. I have not been seen by a doctor yet. Review of Resident #65's nurses notes found a note written by Employee #96, Registered Nurse (RN) on 08/23/21 at 10:06 am which read: Resident has an open wound on the front of her left lower leg. She states this happened when one of the aides' watch caught her leg. the area is open and reddened with some bleeding noted. area cleansed with wound cleanser, xeroform gauze applied and then covered with border gauze. This is to be done daily and prn until healed. Review of physician orders for Resident #65 found on 08/24/22 at 7:45 am, an order which read: Cleanse left lower front leg with wound cleanser, apply xeroform gauze, cover with border gauze daily and prn to unspecified open wound to left lower leg. Wound RN assessment on 08/23/22 at 10:11 am by RN #96, found the type of wound listed as traumatic with a partial thickness loss. Physician notification and care plan were left blank. Wound data collection found the laceration measured three (3) centimeters (cm) in length and two (2) cm in width and 0.1 cm in depth. Additional review of nurses note had a note written on 08/28/22 at 10:42 am which read: Cleaned wound on residents left lower leg, area slightly reddened and leg has some edema noted and resident reports that it is sore. Some drainage noted to the area. Interview with the Director of Nursing (DON) on 08/29/22 at 2:00 pm, found no incident report had been filed, no indication on what had happened to cause the traumatic injury to Resident #65's left lower leg, and no indication the family and physician had been notified.

Based on Resident interview, staff interview, and record review the facility failed to ensure all residents were able to have their choices honored in regard to bathing and bedtime. This was a random opportunity for discovery discovered during the resident council meeting held on 08/30/22. Resident identifier: #35. Facility census 64. Findings included: a) Resident #35 During a resident council meeting on 08/30/22 at 10:00 AM, Resident #35 stated she gets told because it takes longer to assist her to bed, she must be the last person to get help to go to bed. Resident #35 said she would like to go to bed around 7-7:30 PM, but now it is around 9-9:30 PM, before she can go to bed. A review of medical records in the electronic chart revealed Resident #35 prefers three (3) whirlpool baths a week before bed. The following is the dates and times Resident #35 received her whirlpool; baths: *08/01/22 at 10:30 PM. *08/03/22 at 8:44 PM. *08/05/22 at 7:47 PM. *08/08/22 at 10:36 PM. *08/10/22 at 8:50 PM. *08/12/22 at 9:06 PM. *08/15/22 at 10:09 PM. *08/17/22 at 7:57 PM. *08/19/22 at 9:56 PM. *08/22/22 at 10:35 PM. *08/24/22 at 9:17 PM. *08/26/22 at 9:51 PM. *08/29/22 at 8:10 PM. During an interview with Charge Nurse (CN) #120 in the afternoon of 08/30/22 confirmed the times documented above are the times the NA's give the resident her bath and get her ready for bed. She stated, the Nurse Aides I talked to indicated the try to get Resident #35 to bed between 9:00 pm and 9:30 pm. CN #120 was also asked if it takes longer to help Resident #35 to bed. CN #120 confirmed Resident #35's care would take longer than others. CN #120 went on to say hearing Resident #35 is being told she must be last and has to wait so long to go to bed makes her sad.

Based on record review, staff interview, and family interview, the facility failed to prevent weight loss in one (1) of sixteen (16) sampled residents by not providing the nutritional care and services deemed necessary and planned for in the nursing interventions of the comprehensive plan of care to meet the needs of the resident's clinical condition. Resident identifier: #6. Facility census: 85. Findings include: a) Resident # 6 A review of Resident #6's medical record revealed she had resided at the facility since 02/22/07. She was alert, confused, and pleasant and her resident assessment from October 2010 indicated she exhibited no challenging behaviors (such as refusing care). She received a mechanically altered diet and required substantial assistance for meals and snacks. Her weights began falling in November 2010 as follows: On 10/10/10 - 110# On 11/10/10 - 105# On 12/10/10 - 102# On 01/11/11 - 87# This represented a significant unplanned weight loss of 14.7% in thirty (30) days; a weight loss of 20.91% in ninety (90) days; and a weight loss of 21.6% in one hundred-eighty (180) days. Further review of the medical record disclosed documentation by the aides of the resident's oral intake, but there was no mention in the nurses' notes of any concerns about her weight loss, no assessment was completed to explore causal factors of her poor oral intakes as reported by the aides, nor was there any description of her eating habits or needs. During an interview with the dietary manager at 2:10 p.m. on 01/11/11, she stated she obtained the information needed for her resident assessments from the nurse aide sheets and direct observation, because there was usually nothing in the nurses' notes. The dietary manager reported she was responsible for completing the care plan and nutrition section of the resident assessment instruments. During an interview with the DON at 11:15 a.m. on 01/11/11, she stated she had recognized the lack of documentation regarding the eating abilities and habits of the residents, especially the ones who were experiencing weight loss. She presented to this surveyor an educational posting issued to the nurses on 11/23/10, instructing them to document the specifics when a resident refuses nourishments and that staff should attempt again later. However, review of Resident #6's medical record from 11/23/10 to 01/11/11 found nothing in the nursing notes addressing concerns about the resident's poor meal intake or any refusal of meals. .

Based on closed record review, staff interview, and facility policy review, the facility failed, for one (1) of seventeen (17) sampled residents, to thoroughly assess a resident who experienced an acute change in condition (increased confusion and yelling out, in addition to elevated temperature), to rule out underlying medical causes and to ensure prompt treatment. Resident #87 exhibited acute behavioral changes on [DATE]. There was no evidence of a thorough nursing assessment of the resident until 5:00 p.m. on [DATE], after he experienced several episodes of foul-smelling diarrhea; at that time, he was treated for [REDACTED]. Resident #87 was transported to the hospital on the evening of [DATE], and expired on the morning of [DATE]; the cause of death was noted to be [MEDICAL CONDITION] secondary to urosepsis. Facility census: 86. Findings include: a) Resident #87 Closed record review, on [DATE], revealed Resident #87 had a history of [REDACTED]. According to the comprehensive admission assessment completed on [DATE], he was able to make himself understood and usually understands others. He required two-person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was frequently incontinent of urine, and he left twenty-five percent (25%) or more of his food on the tray at meals. On [DATE], a nurse recorded that his lungs were clear per auscultation, he was receiving oxygen at a rate of 2 liters per minute, his mucous membranes were moist, and his mood was pleasant. On [DATE], a nurse noted he was exhibiting behavioral changes, becoming really confused and yelling at staff to get out of his room. There was no evidence of a thorough nursing assessment of the resident's overall status (e.g., neurological, respiratory, cardiac, urinary output, etc.) after these behavioral changes were exhibited. On [DATE] at 5:00 p.m., a nurse recorded he had foul-smelling diarrhea times three (3) in two (2) hours, his temperature was elevated at 102.7 degrees Fahrenheit (F), his pulse rate was elevated at 105, respirations were elevated at 24, lungs sounds were clear to auscultation, respiration were shallow and unlabored, bowel sounds were audible times all four (4) quadrants. He was medicated with Tylenol and [MEDICATION NAME] for the elevated temperature and, at 7:30 p.m., and the physician was notified that the medication was effective for treating the elevated temperature. Later that night at 8:30 p.m., a nurse recorded his temperature remained elevated at 101 degrees F; at 10:00 p.m., it was 101.6 degrees F; and at midnight, it remained elevated at 101 degrees F. At 2:00 a.m., 3:15 a.m., and 4:10 a.m. on [DATE], his temperature was slightly elevated at 99.8 degrees F, and at 5:50 a.m., it was 98.7 degrees F. On [DATE] at 7:30 a.m., his blood pressure was noted to be low at ,[DATE]. The next nursing note was not completed until [DATE] at 8:00 p.m.; it recorded an oral temperature of 98.6 degrees F, pulse 90, blood pressure ,[DATE], respirations 22, and oxygen saturation was ninety-four percent (94%) on 2 liters of oxygen. Beyond checking and recording his vital signs, there was no evidence of a thorough nursing assessment of the resident. On [DATE] at 12:20 a.m., his temperature elevated again to 100.4 degrees F. On [DATE] (time not noted in the nursing note), his blood pressure was again low at ,[DATE], and he was noted to report, "I do not feel well." On [DATE] at 2:45 p.m., the physician was notified and ordered staff to check the resident's blood pressure every shift for her to review on Friday. At 6:30 p.m., his blood pressure decreased to ,[DATE], and his prescribed hypertensive medication was held after notifying the physician. Again, beyond checking and recording his vital signs, there was no evidence of a thorough nursing assessment of the resident. At 8:45 p.m. on [DATE], the physician was again notified and requested the family be contacted for approval to transport him to the hospital to determine the cause of the intermittent fever. At 9:00 p.m., the family agreed, and the ambulance service transported him to the hospital at 9:18 p.m. On [DATE] at 1:30 a.m., the facility called the hospital and was notified that they were in the process of giving him a [MEDICATION NAME] of fluids and were not sure if he would be admitted . At 4:00 a.m., the hospital was again contacted, and he was admitted to the hospital with [REDACTED]. According to the hospital history and physical and discharge / death summary, dated [DATE], Resident #87 was admitted from the nursing home. Over the past two (2) days, he was noted to have episodes of fever, decreased level of consciousness, and decreased urinary output. He was found to have significant urosepsis in the emergency room , for which he was given 1 liter of saline and an antibiotic ([MEDICATION NAME]). On [DATE], he became unresponsive, had a small amount of vomitus, and went into [MEDICAL CONDITION]. A full code was initiated and, at 0701, death was pronounced. Discharge [DIAGNOSES REDACTED]. During an interview on [DATE], the nurse manager (Employee #55) was asked about the facility's policies and procedures for notification of the physician when there is a change in a resident's condition. She identified that a purple book was used, and the surveyor requested a copy of the book to review. The book was titled "Protocols for Physician Notification - Assessing and Collecting Data on Nursing Facility Patients". Review of the contents found a table on page 1 which contained the following under the column heading "Condition": "Agitation and behavioral disturbances (may be the first sign of acute physical change, e.g. bacterial or [MEDICAL CONDITION] infection, blood sugar change, recent neurological change, or heart related conditions including impending MI ([MEDICAL CONDITION] infarct) or arterial fibrillation)". Under the column heading "Physical Data" in association with agitation and behavioral disturbances found the following were to be assessed: 1. Vital signs 2. Neurological, cardiac, [MEDICAL CONDITION], and abdominal assessment 3. Blood sugar if patient is diabetic 4. Any signs or symptoms of infection / acute illness including dehydration 5. Description of current bowel and bladder function (assess urine for S&S (signs and symptoms) of UTI (urinary tract infection) 6. Assess for bruising or any other signs of an unreported / unwitnessed fall 7. Pain assessment (location, character, and severity) 8. Assess patient for change in mood, behavior, orientation or alertness. The facility failed to follow their own policy and procedures for conducting a thorough nursing assessment of Resident #87 when he experienced increased agitation and a behavioral change, to rule out underlying medical causes and to ensure prompt treatment. .