Every finding on record at Reliable Health & Rehab at Lakewood

Based on observations, staff interviews, and review of the facility's policy titled, Infection Prevention and Control Program, the facility failed to prevent cross-contamination of dirty laundry from clean laundry. This deficient practice had the potential to cause the spread of infection throughout the facility. The census was 94.Findings include:Review of the facility's policy titled Infection Prevention and Control Program, reviewed 01/06/2026, under Policy Explanation and Compliance Guidelines revealed: .12. Linens: b. Clean linen shall always be separated from soiled linen.Review of the facility's policy titled Handling Soiled Linens reviewed February 2024, revealed under Policy Explanation and Compliance Guidelines: . 11. Soiled linen shall always be kept separate from clean linen.An observation of the laundry area on 04/30/2026 at 10:25 AM revealed that all doors to the washers and dryers were open upon entering the clean linen area. The clean linen, sheets, towels, blankets, and washcloths were folded on the table to the left of the washer and dryer room. Next to the dryers on the right side of the room were residents' clean clothes on a rack, piles of folded clean clothes to be hung, a rack of unlabeled clothes, and a bag of unlabeled clothes, all next to the dryers and directly in front of the dirty laundry room that had an open door allowing exposure of possible pathogens from the dirty laundry to the clean resident clothes. It was also observed that, to bring the dirty clothing and linen to the washer, the dirty barrels had to be pushed past the clean clothing on the racks. An interview with Environmental Staff DD and EE, who were working in the laundry on 04/30/2026 at 10:30 AM, revealed that they felt they had reduced the spread of infection by keeping all doors open, covering the dirty barrels, and circulating the air. They revealed that the one rack of clothes (not covered) and the bagged clothes on the floor next to the dirty area were no-name clothes that were sometimes distributed to residents in need. The rack of clean clothing parked in front of the open door to the dirty linen room was personal resident clothes that need to be distributed. They stated that the staff member who distributed clean clothes worked only at night, when the clothes were delivered to the residents.An interview with the Environmental Services Director on 04/30/2026 at 11:00 AM revealed that the door to the dirty side of the laundry should always be closed and that there should be no linen on top of the dirty barrels.An interview with the Infection Preventionist nurse on 04/30/2026 at 11:50 AM revealed that when she was shown pictures and concerns about cross-contamination between dirty and clean laundry, she confirmed there was a problem with cross-contamination in the laundry, but she was not aware of the concern until then. An interview with the Administrator on 04/30/2026 at 1:40 PM revealed that the residents' clothes should not be where they were at this time; they should be handed out immediately once they were clean. She expected the laundry to be organized to prevent cross-contamination between dirty and clean clothes, and a negative outcome could be the spread of infection through the laundry.

Based on record review, staff interviews, and review of the facility's policy titled, Comprehensive Care Plan, the facility failed to revise the comprehensive care plan for one of 33 sampled residents (R) (R92) to reflect interventions implemented. This deficient practice had the potential to result in staff being unaware of current interventions, placing R92 and other residents at risk of not receiving the care and services needed.Findings include:Review of the facility's policy titled, Comprehensive Care Plan, reviewed on 01/15/2026, revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under Policy Explanation and Compliance Guidelines revealed: . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.Review of R92's care plan revealed a focus, initiated 02/22/2019 and most recently revised on 01/27/2024, which stated R92 is resistive to care and noncompliant with smoking, and that he continues to go outside beyond facility property to smoke. A documented intervention dated 08/08/2023 stated: Review smoking policy with resident. An additional care plan focus, initiated 05/23/2019, identified R92 as a smoker who requires supervision while smoking, with documented interventions stating: The resident requires SUPERVISION while smoking and Notify charge nurse immediately if it is suspected resident has violated smoking policy.Review of R92's care plan revealed no revisions were made to reflect interventions implemented in response to R92's repeated and ongoing noncompliance with the non-smoking policy. Interventions not reflected in the care plan included daily room searches for smoking paraphernalia, placement of a smoke detector in R92's room, relocation of R92's room closer to the nursing station, every-two-hour visual rounds to check for smoke, nursing checks upon return from outings, the PAR (Patient at Risk) process initiated 04/03/2026 for vaping noncompliance, and the 30-day discharge notice issued on 04/13/2026 for repeated violation of the non-smoking policyReview of R92's Smoking Materials Monitoring Form for the month of April 2026 revealed initials documented on April 3, 2026, April 6, 2026, April 7, 2026, April 8, 2026, April 9, 2026, April 10, 2026, April 13, 2026, April 14, 2026, April 15, 2026, April 16, 2026, April 20, 2026, April 21, 2026, April 22, 2026, April 23, 2026, April 24, 2026, and April 25, 2026, with no initials documented on the remaining days of the month, indicating daily room searches were not consistently completed and documented.Review of the Patient at Risk (PAR) Smoking PAR Tracking form revealed a PAR was initiated on 04/03/2026 with the reason documented as: Resident observed by Certified Nursing Assistant (CNA) and Activity Assistant vaping in room. Resident issued 30-day discharge. Week 1 Interdisciplinary Team (IDT) assessment dated [DATE] documented: Resident continued to violate smoking policy. Checked daily for smoking. Vapor and being removed. Week 2 IDT assessment dated [DATE] documented: Resident room check. Vapor device removed. Resident refused to comply with facility policies. Week 3 IDT assessment dated [DATE] documented: Resident room check, no sign of vapor. Resident has been in compliance out of time. Continued to check for vapor. Week 4 and Week 5 reflected no IDT signatures and no documentation completed.Review of the PAR Patient at Risk Grid revealed five entries for R92, all listed under the problem of Violating Non-Smoking Policy, with initiation dates of 05/16/2024, 05/22/2024, 05/29/2024, 06/05/2024, and 06/13/2024, with the 06/13/2024 entry reflecting a date resolved noted as discharge from PAR.Interview on 04/28/2026 at 12:53 PM with the MDS Coordinator BB revealed that R92's non-compliant behavior related to smoking and vaping had been ongoing and that his room had always had to be searched for cigarettes and vaping paraphernalia. She stated the facility became a non-smoking facility in 2020 and she became aware of R92 smoking in the facility since that time. She stated the current interventions include weekly room searches and that the facility recently had a meeting with the Veterans Administration (VA) regarding discharge.Interview on 04/30/2026 at 10:22 AM with the MDS Coordinator BB revealed she stated the care plan should have been updated to reflect the interventions put in place for the resident related to his non-compliance with the smoking policy. She stated the failure to update the care plan was an oversight. She stated the potential negative outcome was that no one would have known about his non-compliance with the smoking policy, and that he could have brought danger to other residents.Interview conducted on 04/30/2026 at 9:22 AM and 04/28/2026 at 1:34 PM with the Administrator revealed the care plan should have been updated to reflect the new interventions related to the resident's non-compliance with the smoking policy. She stated she did not know why the care plan was not updated. She stated her expectation for the Minimum Data Set (MDS) Coordinator was to update the care plan to reflect interventions when they were put in place. She stated the potential negative outcome was that other nurses would not be able to see the new interventions that were put in place for the resident.

Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage in the Facility, the facility failed to securely lock the Treatment Cart. This deficient practice had the potential to create a hazardous condition in which any resident could access the treatment cart and come into contact with topical creams that could be toxic if ingested. The census was 94.Findings include:Review of the facility's policy titled Medication Storage in the Facility, effective date 10/01/2025, revealed under Policy: . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Section B revealed that Medication rooms, carts, and medication supplies are locked or attended by authorized personnel. An observation and interview on 04/29/2026 at 9:35 AM revealed that, after observing wound care for R3 with the Wound Care Licensed Practical Nurse (LPN), the treatment cart was left in the [NAME] hall, across the hall from R3's room, which was been unlocked and unattended for 30 minutes. An interview with the wound care LPN revealed that he confirmed the treatment cart was unlocked and unattended. An interview with the Infection Preventionist (IP) LPN on 04/29/2026 at 11:09 AM revealed that she had spoken with the wound care nurse about this after the incident. She confirmed that he told her the treatment cart was left unlocked.An interview with the Administrator on 04/30/2026 at 1:40 PM revealed that she expected all medications, including topical medications, to be locked when not in sight of a licensed nurse or authorized person.

Based on observations, staff interviews, and review of the facility's policy titled, Maintenance Service, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment including stained and damaged ceiling tiles in one resident bedroom (room [ROOM NUMBER]A), near the facility nurses' station, in the glass day room, and in the middle of the east hall.Findings include:Review of the facility's policy titled, Maintenance Service review date January 2024, revealed under Policy Interpretation and Implementation:1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to:a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. Maintaining the building in good repair and free from hazards.1. During initial screening and observation on 04/28/2026 at 10:07 AM, several ceiling tiles revealed tannish-brown stains, varying in size, located near the facility nurses' station on the side that you would approach the desk.Observation on 04/28/2026 at 11:12 AM, noted the presence of brown rings, roughly 16 inches in diameter, on the ceiling tiles located directly above the bed in room [ROOM NUMBER]A.Observation on 04/30/2026 at 10:47 AM, several ceiling tiles contained stains in circular shapes and variation in sizes located near the facility nurses' station.Observation on 04/30/2026 at 10:51 AM in the glass day room, specifically near the window in the seating area above a resident's chair, two ceiling tiles were noted with stains, each exhibiting brown circular stains approximately three inches in diameter on each side.Observation on 04/30/2026 at 11:00 AM, the east hall's ceiling tiles revealed a brown circular shape approximately 10 inches in diameter on the ceiling tile in the middle of the hall.Observation on 04/30/2026 at 12:30 PM noted a white, moldy substance on the ceiling tile near the facility nurses' station.Interview and observation during the walking tour on 04/30/2026 at 11:04 AM, the Maintenance Director inspected room [ROOM NUMBER]A and noted the ceiling tiles exhibited tan and brown stains, along with bulging. The Maintenance Director indicated that this issue was a result of rain; however, there was a risk that the tiles could fall on the resident. It was confirmed that immediate replacement was necessary. Additionally, he verified that two separate ceiling tiles in the glass dayroom also displayed tan and brown stains. Furthermore, he confirmed the presence of several circular brown stains of varying sizes located near the nurse station.Interview and observation on 04/30/2026 at 11:38 AM with the facility Maintenance Director on the east hall revealed that the Maintenance Director was in the process of replacing the ceiling tile subsequent to the photograph being taken, but he verified the existence of the discolored ceiling tile.Interview on 04/29/2026 at 2:14 PM with the Administrator disclosed that there were leaks in the roof, which was repaired on 12/16/2025. She confirmed that the brownish stains were due to recent rainfall. She mentioned that she had been conducting daily inspections and had not observed any issues, having performed rounds on 04/28/2026. Nevertheless, stains were appearing as a consequence of leaks from the rain that fell yesterday. She shared there was a potential risk of tile overload that could drop on a resident.

Based on observations, staff interviews, record review, and review of the facility policy titled, Catheter Management Catheter Care, the facility failed to ensure proper indwelling catheter care, securing of the catheter tubing and proper use of personal protective equipment (PPE) for one of 33 sampled residents (R) (R3). The deficient practice created the potential for R3 to experience tears of the meatus, urethral trauma, and urinary tract infection (UTI).Findings include:Review of the facility's policy titled Catheter Management Catheter Care, revised 01/24/2026 revealed under Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity when indwelling catheters are in use.10. Observe enhanced barrier precautions or any other transmission-based precautions as indicated. Under Compliance Guidelines: . 3. Provide privacy by closing the door, closing the door, closing the blinds/curtains, and pulling the room-dividing curtain, etc. Under Male revealed: . 15. Gently grasp the penis and draw the foreskin back if applicable. 16. Using circular motion, cleanse the meatus with a clean wipe or a clean cloth moistened with water and perineal cleaner. 17. With a new wipe or a new moistened cloth, starting at the urinary meatus, move down and cleanse the shaft of the penis.18. With a new wipe or a new moistened cloth, starting at the urinary meatus, move outward and wipe the catheter, making sure to hold the catheter in place so as not to pull on the catheter. 19. Pat the area dry.Review of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, dementia, post-traumatic stress disorder, pressure ulcer of the sacral region, pressure-induced deep tissue damage of the left heel and right heel, malignant neoplasm of the right male breast and prostate.Review of R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated R3 had moderate cognitive impairment. Section GG, functional status, revealed R3 required clean-up assistance for meals and oral hygiene, and was dependent on staff for all other activities of daily living (ADLs), including bowel incontinence. Section H, Bowel and Bladder, revealed resident is coded for an indwelling catheter for urinary output.Review of R3's care plan dated 03/13/2026 indicated a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer. Goals included, but not limited to, the resident will remain free from catheter-related trauma through the review date. Interventions included but were not limited to. CATHETER: The resident has (18 Fr (French) (Indwelling Catheter). Position the catheter bag and tubing below the bladder level and away from the room entrance. Monitor and document intake and output as per facility policy. Monitor for pain/discomfort due to the catheter. Monitor/report to MD for s/sx (signs/symptoms) UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. There is no mention of the amount of water to be placed in the bulb, placement of a leg strap, or securement device to prevent tension, or catheter care.Review of the Physician's Orders for R3 included, but was not limited to:Cath (catheter): Check the leg strap to ensure it is present and in place every shift for Facility protocol related to Malignant neoplasm of prostate. Cath: Resident admitted with 18F catheter attached to a bedside drainage bag.An observation on 04/29/2026 at 9:35 AM revealed that during the wound care observation with R3, the resident had a Foley catheter positioned under his left leg, and there was no Foley catheter leg strap or tubing securement.An observation of Foley catheter care performed on R3 on 04/29/2026 at 11:15 AM was conducted by Certified Nursing Assistant (CNA) AA. CNA AA was from an agency, but she stated she worked at this facility frequently. It was observed that the drainage bag was covered for privacy. The catheter tubing was pulled behind the resident, and there was no securement device or leg strap to secure the tubing from pulling on the resident. CNA AA entered the room after using alcohol hand gel; she did not wear a gown, nor did she knock. She explained to the resident what she was about to do, then uncovered the resident, and left him uncovered and exposed while she was washing her hands in the bathroom. The resident was cold and voiced this to the CNA. CNA AA prepared warm water and two washcloths. She stated that one was for washing and one was for rinsing. She did not provide privacy by closing the resident's door. She donned (put on) gloves, rolled the resident on his back, and removed the front of his brief. She then stated that since she touched the brief, she had to change her gloves, so she removed her gloves and donned clean gloves, without hand hygiene. She then sprayed the residents' peri area, groin, and catheter tubing with peri cleanser and took a wet washcloth and wiped starting at the penis and wiped from the testes back to front, through both sides of the groin. She then took a clean washcloth and wiped the catheter tubing from distal (away from) to proximal (situated nearer to the center) toward the meatus. She then reapplied the brief and made R3 comfortable, with the call light within reach. An interview with CNA AA following the catheter care indicated that she was very conscious of infection control and felt she did everything correctly.An interview with the Infection Control Preventionist on 04/29/2026 at 3:03 PM revealed after Foley care was presented to her, she stated that she had in-services and that she did allow the agency CNAs and nurses to attend. When there were in-services, she expected the correct process for Foley and peri (perineal-around the genitals) care. She said she was not sure that she could educate the agency staff. She stated that the negative outcomes that potentially could come from improper indwelling catheter care and no securement device include tears of the meatus, urethral trauma, and urinary tract infection.An interview with the Administrator on 04/30/2026 at 1:30 PM revealed that the physician's order for the Foley catheter should be completed to reflect the catheter size, balloon size, change frequency, leg strap or securement device, and daily Foley care. The Administrator's stated expectations were that indwelling catheter care be performed properly with proper personal protective equipment, hand hygiene when changing gloves, and aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) procedures.

Based on observations, record review, staff interviews, and review of the facility's policy titled, Smoking Policy, the facility failed to ensure the environment remained free from accident hazards for one of two residents (R) (R92) reviewed for accident hazards. Findings Include:Review of the facility's policy titled, Smoking Policy, revised May 2017, revealed under Policy: The facility will ensure that the safety of the residents is protected by close supervision of residents who smoke. This will include completion of a smoking assessment, supervised smoking schedule, daily searches for tobacco products, matches, and lighters on non-compliant smokers, and weekly searches of compliant smokers. These searches will be documented. The policy further stated under Procedure: 1. Residents will not be allowed to keep cigarettes, cigars, pipes, matches, or lighters in their personal possession or in their rooms. Daily searches for matches, cigarettes, pipes, cigars, and lighters will be conducted for all residents who are not compliant with the Smoking Policy by nursing and documented daily until compliance with the Smoking Policy is established for 30 days. The policy further stated under Smoking Incident Reports, under Policy: An incident report will be completed if any smoking materials are found with a resident or in their room. Under Procedure: When cigarettes, cigars, matches, or lighters are found in a resident's room or on their person, it will be reported immediately to the Charge Nurse or Management Staff. The Charge Nurse will complete an incident report. The smoking materials will be retrieved from the resident and placed in the appropriate storage area. This incident will be reviewed in 'Patients at Risk' meeting and followed for four weeks or until the issues are resolved. Interventions and care plans will be completed as indicated. The policy further stated under Room Searches under Policy: Resident searches and room searches for cigarettes, cigars, pipes, matches, and lighters for all non-compliant smokers will be completed daily. Weekly searches will be completed for compliant smokers. Under Procedure revealed: Evening Nursing Staff will do daily searches (prior to midnight) of all non-compliant smoking residents and document findings on a form of their choice or the MAR (medication administration record). If any smoking devices are found, the nurse will retrieve the smoking devices and complete an incident report.Review of R92's Electronic Health Record (EHR) revealed he was admitted on [DATE] with diagnoses including, but not limited to, cerebral aneurysm nonruptured, cerebral infarction unspecified, major depressive disorder recurrent severe with psychotic symptoms, post-traumatic stress disorder (PTSD) unspecified, hemiplegia and hemiparesis following other cerebrovascular disease affecting the left non-dominant side, other speech and language deficits following other cerebrovascular disease, and cerebral atherosclerosis.Record review of R92's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG (Functional Abilities and Goals) documented functional limitations in range of motion (ROM) with impairment on one side of both the upper and lower extremities, with use of a manual wheelchair.Review of R92's care plan revealed a focus, initiated 02/22/2019 and most recently revised on 01/27/2024, which stated R92 is resistive to care and noncompliant with smoking, and that he continues to go outside beyond facility property to smoke. A documented intervention dated 08/08/2023 stated: Review smoking policy with resident. An additional care plan focus, initiated 05/23/2019, identified R92 as a smoker who requires supervision while smoking, with documented interventions stating: The resident requires SUPERVISION while smoking and Notify charge nurse immediately if it is suspected resident has violated smoking policy.Record review of R92's Smoking Materials Monitoring Form for the month of April 2026 revealed staff initials documented on April 3, 2026, April 6, 2026, April 7, 2026, April 8, 2026, April 9, 2026, April 10, 2026, April 13, 2026, April 14, 2026, April 15, 2026, April 16, 2026, April 20, 2026, April 21, 2026, April 22, 2026, April 23, 2026, April 24, 2026, and April 25, 2026, with no initials documented on the remaining days of the month, indicating daily room searches were not consistently completed and documented.Review of the Patient at Risk (PAR) Smoking PAR Tracking form revealed a PAR was initiated on 04/03/2026 with the reason documented as: Resident observed by Certified Nursing Assistant (CNA) and Activity Assistant vaping in room. Resident issued 30-day discharge. Week 1 Interdisciplinary Team (IDT) assessment dated [DATE] documented: Resident continued to violate smoking policy. Checked daily for smoking. vape devices and being removed. Week 2 IDT assessment dated [DATE] documented: Resident room check. Vape device removed. Resident refused to comply with facility policies. Week 3 IDT assessment dated [DATE] documented: Resident room check, no sign of vapor (sic). Resident has been in compliance out of time. Continued to check for vapor. Week 4 and Week 5 reflected no IDT signatures and no documentation completed.Review of the PAR Patient at Risk Grid revealed five entries for R92, all listed under the problem of Violating Non-Smoking Policy, with initiation dates of 05/16/2024, 05/22/2024, 05/29/2024, 06/5/2024, and 06/13/2024, with the 06/13/2024 entry reflecting a date resolved noted as discharge from PAR.Review of progress notes revealed the following documentation related to R92's noncompliance with the facility's non-smoking policy:Review of a social/psychosocial note dated 01/02/2026 documented: Resident can be non- compliant with smoking policy and often is checked for safety.Review of an activity note dated 04/03/2026 at 10:40 AM documented: R92 was observed by the Respiratory nurse using a vapor device in his room. The Respiratory nurse reported visible vapor present in room at the time of observation. Resident was informed that behavior was a violation of the non-smoking facility policy. At this time resident was pending a discharge due to violation of the facility's non-smoking policy.Review of a physician note dated 04/03/2026 documented: Facility name has a strict on site non- smoking policy. R92 has broken this multiple times by vaping in his room. He was accepted to a personal care home and I was informed he is going to be given a discharge notice.Review of an activity note dated 04/14/2026 at 2:19 PM documented: On Tuesday, April 14, 2026, writer was informed by Activity Assistant that she and CNA observed R92 vaping in his room. Resident was asked to surrender the vape device but, resident refused to cooperate with staff. Male charge nurse intervened and was able to retrieve the vape without further incident. Resident complied with charge nurse. Resident has been issued a 30-day discharge at this time.Review of a nurse's note dated 04/17/2026 at 8:02 AM documented: Resident was observed vaping in the room. Resident remains alert and verbally responsive. No signs of pain or distress.Review of a nurse's note dated 04/17/2026 at 10:40 AM documented: Resident seen smoking, informed we are a smoke free facility and he can not smoke in the rooms. Resident replied he is about to leave and to go talk to [NAME] and the higher ups, they know.Review of a nurse's note dated 04/20/2026 at 5:38 PM documented: Nurse on duty reported that she saw R92 vaping in his room. Spoke to resident about it, resident stated that he needs to vape every day, that why he's leaving.Review of a social/psychosocial note dated 04/20/2026 at 6:23 PM documented: R92 was found Vaping in the Room, Resident told the charge nurse he will continue to vape in the room because that is the reason why he is getting a discharge.Review of an activity note dated 04/29/2026 at 4:54 PM documented: R92 was observed by State Surveyor smoking a vape device in his room. Staff followed the facility policy and addressed the concern with the resident.Review of an activity note dated 04/29/2026 at 4:59 PM documented: R92 room check on 04/29/2026 for the possession of a vape device. Writer and Social Service conducted a room search and discovered three vape devices under the sheets. During the interaction, resident became angry and verbally aggressive, stating, 'I can't stand y'all .I hope I never see you again. Y'all make me sick.' Writer and Social Worker informed the resident of facility's nonsmoking policy and reiterated that vape devices are not permitted in his possession. The items were removed in accordance with the facility policy.Review of a nurse's note dated 04/29/2026 at 10:19 AM documented: It was reported to me that the resident was vaping in his room in the presence of the State Surveyor. Resident alert and verbally responsive.Review of a nurse's note dated 04/30/2026 at 9:53 AM documented: Resident in the room as nurse was doing her rounds found resident with a vape device. Resident stated that if you take it, its okay because he will just get another one.Review of a social/psychosocial note dated 04/30/2026 at 9:09 AM documented: R92 was observed by State Surveyor smoking a vape device in his room. Staff followed the facility policy and addressed the concern with the resident, upon Room search some vapors was found in R92's room the vapors was taken away from him.Observation on 04/28/2026 at 2:37 PM in R92's room revealed two cans of name brand Air Freshener on the bedside table.Observation on 04/28/2026 at 11:48 PM in R92's room revealed a cloud of smoke upon entering and a blue vape pen was found on the resident's bed. When asked about the vape pen, R92 stated the social worker let him have it and repeatedly stated go see the social worker. Two cans of Name brand Air Freshener were also observed on the bedside table. R92 stated he used the air freshener to spray his blanket because it smelled like urine and would not allow staff to remove it.Observation on 04/29/2026 at 11:42 AM in R92's room revealed two cans of Name brand Air Freshener remained on the bedside table.Interview on 04/29/2026 at 11:42 AM with Certified Nursing Assistant (CNA) AA revealed she stated she had been told to be on the lookout for any items residents were not supposed to have, including medications and other items, for safety purposes. She stated that when she previously reported the air freshener to nursing, she was told R92 could have it because he was independent. She stated that when she attempted to remove items, he became upset and combative. She stated she had never seen a vaping situation in a facility before and acknowledged it was unacceptable. She stated the potential negative outcome related to the vape pen was that another resident could access it, that he could overdose on it, or that it could cause lung problems. She stated the potential negative outcome related to the air freshener was that it could be sprayed in someone's eyes.Interview conducted on 04/28/2026 at 12:04 PM with the Social Worker revealed she stated the facility was in the process of discharging R92 due to his smoking behaviors, as the facility was a non-smoking facility. She stated interventions in place include searching his room and confiscating any vapes or cigarettes found. She stated R92 had smoked cigarettes in his room in the past and now vapes. She stated they had caught him smoking in his room on more than one occasion, including both cigarettes and vapes. She stated the last time his room was checked was two days prior to the survey observation and that his room was not checked the day before the survey due to competing demands. She stated the potential negative outcome from his smoking in the room is that he could set the entire building on fire, endangering all residents. She stated she was not aware he had air freshener at his bedside. She stated R92 does whatever he wants regardless of what staff tell him and that when staff attempted to speak with him about his behavior, he responded by saying, I don't care, I'm going to leave anyway.Interview on 04/28/2026 at 12:38 PM with the Infection Preventionist and the Social Worker revealed the Infection Preventionist stated that regardless of what staff told him, R92 did not comply, and that even when vapes and prohibited items were confiscated, he found ways to obtain new ones shortly after. The Social Worker stated the interventions in place included daily room checks, involvement of the Activities Director, and family education. She stated approximately one month prior, when she went to confiscate items, she spoke with him calmly and he allowed her to search the room and had never outright refused to allow staff to take the vapes. The Infection Preventionist stated the unsecured items posed a hazard because any resident could enter the room, access the items, and cause harm, including having the air freshener sprayed in their eyes.Interview on 04/28/2026 at 12:53 PM with MDS Coordinator BB revealed that R92's non-compliant behavior related to smoking and vaping had been ongoing and that his room had always had to be searched for cigarettes and vaping paraphernalia. She stated the facility became a non-smoking facility in 2020 and she became aware of R92 smoking in the facility since that time. She stated the current interventions include weekly room searches and that the facility recently had a meeting with the Veterans Administration (VA) regarding discharge.Interview on 04/29/2026 at 1:14 PM with the Activities Director revealed she stated R92 was very non-compliant, had broken several facility policies, and could be verbally abusive and at times physically aggressive. She stated his non-compliance regarding smoking in his room had increased in frequency and she had been aware of him smoking in his room since 2025, with vaping more recently. She stated interventions in place included placement of a smoke detector in his room and daily room checks conducted by herself and nursing. She stated she maintained a log of room checks which began on 04/03/2026 and also kept a record of all items confiscated from his room. She stated she had instructed nursing to check him upon return from outings. She stated the facility was not currently conducting smoking assessments because it was not a smoking facility. She stated the potential negative outcome related to the vape pen was fire risk and respiratory harm to R92 and other residents.Interview on 04/28/2026 at 1:34 PM with the Administrator revealed she stated R92 was very non-compliant and cursed at staff when they attempted to redirect him. She stated he went out frequently and returned with smoking items, and that every time staff had observed him with smoking paraphernalia, it had been confiscated. She stated the facility became a non-smoking facility in 2020 and first observed R92 being non-compliant with the smoking policy in 2025, with vaping becoming more frequent in 2026. She stated interventions included smoke detectors in his room, frequent rounds every two hours with visual checks for smoke, and relocation of his room closer to the nursing station. She stated the facility did not maintain logs of the every-two-hour rounds conducted in his room. She stated the potential negative outcome of R92's smoking behavior was that if he were to drop ashes, the facility could catch fire.

Based on observations, staff and resident family interviews, record review, and a review of the facility policy titled, Comprehensive Care Plan, the facility failed to develop and implement a comprehensive care plan for two of eight sampled residents (R44 and R3). The deficient practice placed R44 and R3 at risk for unmet care and services.Findings include: Review of the facility's policy titled, Comprehensive Care Plan, reviewed 1/15/2026, revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Further review of the section Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Policy Explanation and Compliance Guidelines revealed: (1) The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. (2) The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. (3) The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR (Pre admission Screening and Resident Review) recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. 1. A review of R44's care plan dated 03/11/2026 revealed no care plan in place for antipsychotic medication use or indication. A review of the Physician's Orders for R44 included but was not limited to an order dated 06/10/2025 for Haloperidol oral tablet 10mg, give 1 tablet by mouth two times a day for Schizophrenia. Additional orders dated 05/09/2025 included behavior monitoring and psychiatric medication side effect monitoring. During an interview on 04/29/2026 at 12:56 PM, the MDS Coordinator stated that all residents receiving antipsychotic treatment should have a comprehensive care plan in place. The MDS further revealed that this care plan should be implemented beginning with the date the medication was originally ordered to ensure proper monitoring. During an additional interview on 04/29/2026 at 2:00 PM, the MDS Coordinator conducted a review of R44's clinical record and revealed that a care plan for antipsychotic medication management was not in place. The MDS Coordinator acknowledged the omission and stated a care plan was added to the resident's record during the course of the survey. During an interview on 04/30/2026 at 1:25 PM, the Administrator stated that the process for reviewing residents with antipsychotics includes the Interdisciplinary Team (IDT) reviewing the order, consent, and initiating behavior monitoring. The Administrator stated that during that process, the expectation was that a care plan be initiated and revised as needed. 2. Review of R3's care plan dated 03/13/2026 indicated a problem of an indwelling catheter secondary to neurogenic bladder related to prostate cancer. Goals included, but not limited to, the resident will remain free from catheter-related trauma through the review date. Interventions included but were not limited to. CATHETER: The resident has (18 Fr (French) (Indwelling Catheter). Position the catheter bag and tubing below the level of the bladder and away from the room entrance. Monitor and document intake and output as per facility policy. Monitor for pain/discomfort due to the catheter. Monitor/report to MD for s/sx (signs/symptoms) UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul-smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. There is no mention of the amount of water to be placed in the bulb, placement of a leg strap, or securement device to prevent tension, or catheter care. Review of the Physician's Orders for R3 included, but was not limited to: Cath (catheter): Check the leg strap to ensure it is present and in place every shift for Facility protocol related to Malignant neoplasm of prostate. Cath: Resident admitted with 18F catheter attached to a bedside drainage bag. Observation and interview on 04/29/2026 at 9:35 AM with R3 revealed that, during a wound care observation, the resident had a Foley catheter positioned under his left leg, and there was no Foley securement device or leg strap to prevent tension on the catheter. Observation made on 04/29/2026 at 11:15 AM of R3 receiving Foley catheter care revealed that the resident again had the Foley catheter positioned under his leg rather than over his leg to allow free flow of urine, and that no securement device or leg strap was present to prevent pulling and tension on the Foley catheter. An interview with Certified Nursing Assistant (CNA) AA on 04/29/2026 at 11:40 PM revealed that she was assigned to R3 that day but had not seen the resident with a Foley catheter leg strap and was unaware that he required one. An interview with the Infection Preventionist (IP), Licensed Practical Nurse (LPN) on 04/29/2026 at 3:03 PM revealed that she has previously provided education on Foley catheter care and the use of leg straps for Foley catheters to the CNAs. Still, there were several agency CNAs she had not yet educated. An interview with the MDS Coordinator on 04/30/2026 at 2:20 PM confirmed that interventions were missing from R3's care plan. The physician had ordered a leg strap to secure the Foley catheter on R3, but it was not included in the care plan. She stated that the negative outcomes include trauma to the residents' meatus, bleeding, and dislodgement of the Foley catheter. An interview with the Administrator on 4/30/2026 at 1:30 PM revealed that she agreed that the care plan was missing components of standards of care for a Foley catheter, as was the physician's order. The Administrators stated that the care plan was expected to be complete and that the physician's orders be clear and complete.

Based on record review, staff interviews and review facility policy titled, Abuse Policy, the facility failed to protect one resident (R) (R113) from sexual abuse perpetrated by another resident (R12) out of 4 residents reviewed for abuse. This deficient practice had the potential to result in harm and emotional distress.Findings include:Review of the facility's policy titled, Abuse Policy, reviewed on January 2025revealed under Policy: Our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, or staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. It is our goal to achieve and maintain an abuse free environment. Under Definitions: Sexual Abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault.1. Review of R113's electronic health record (EHR) revealed she was admitted on [DATE] with diagnoses including, but not limited to, senile degeneration of the brain, restlessness and agitation, and Alzheimer's disease, unspecified.Review of R113's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. Section GG (Functional Abilities and Goals) documented R113 was fully dependent on toileting, showering and bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. Section O (Special Treatments, Procedures, and Programs) documented R113 was receiving hospice care.2. Review of R12's EHR revealed he was admitted on [DATE] with diagnoses including, but not limited to, vascular dementia moderate with mood disturbance, Alzheimer's disease unspecified, major depressive disorder recurrent mild, obsessive-compulsive personality disorder, unspecified psychosis not due to a substance or known physiological condition, and unspecified mood affective disorder.Review of R12's MDS assessment dated [DATE] documented a BIMS score of 4, indicating severely impaired cognition. Section GG documented impairment on one side of the lower extremities with use of a manual wheelchair, and documented R12 was fully dependent for toileting, showering and bathing, lower body dressing, and putting on and taking off footwear.Review of R12's care plan revealed a focus, initiated 08/31/2017 which stated: R12 has a behavior problem Sexually verbally and physically inappropriate. 1/18/24-Resident inappropriately touch a female resident. 3/9/24. R12 enter into a female room attempted to touch her. Documented interventions included: If reasonable, discuss the resident's behavior. Explain/behavior is inappropriate and/or unacceptable and Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation to alternate location as needed. A separate care plan focus, initiated 01/24/2024, identified R12 as receiving a mood stabilizer medication to manage indicators of behavior related to (r/t) physical behavioral symptoms directed towards others (abusing others sexually touch female residents inappropriately), with an intervention to Monitor/record occurrence of target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/sexual aggression towards staff/others, etc.) and document per facility protocol.Review of R12's physician orders revealed a physician order dated 01/15/2026 for Sertraline Hydrochloride (HCl) 50 milligrams (mg) orally once daily documented as ordered for obsessive compulsive disorder (OCD) related sexual obsession.Review of the facility's Incident Investigation Report (Facility Incident Number 202600337) revealed that on 01/09/2026, a Certified Nursing Assistant (CNA) observed R12 in R113's room with his right hand inside R113's pants while she was seated in a geriatric chair. R12 was immediately removed from the room and escorted to a separate hall. The investigation concluded: Based on the investigation and the C.N.A. statement, R12 did touch R113 inappropriately. The facility substantiated the allegation of abuse.Record review of a witness statement authored by the CNA , dated 01/09/2026, revealed she documented she was taking a resident to the lunch room when she noticed R12 in R113's room and observed his right hand in her pants, after which she entered the room, directed him to stop, removed him from the room, and reported the incident to the Director of Nursing (DON) and the charge nurse.Review of a second witness statement, authored by staff member Licensed Practical Nurse, revealed: Writer notified by staff that 107 B (R12) was in resident's room [ROOM NUMBER] A (R113) with his hand in her pants.Review of progress notes revealed a nurse's note dated 01/09/2026 at 1:22 PM documenting: Resident noted by staff, resident from room [ROOM NUMBER]b in residents' room with his hand in her pants.Review of a nurse's notes revealed a note dated 01/09/2026 at 1:48 PM that documented: Call placed to 911. Awaiting arrival. A nurse's note dated 01/09/2026 at 5:37 PM documented the responding law enforcement officer's name, badge number, and case number.Interview on 04/30/2026 at 9:22 AM with the Administrator revealed a CNA notified the nurse after observing R12 in R113's room with his right hand in her pants while she was seated in her wheelchair. She stated there was no evidence that he had gone into her brief and a skin assessment was conducted with no findings. She stated that R12 was immediately removed from the room and escorted to another room. She stated the facility immediately followed protocol, law enforcement was contacted, the family was notified, and the incident was reported to the state and to corporate office. She stated R12 was sent to the acute care hospital, and the facility conducted an abuse in-service and initiated an investigation. She stated through the investigation it was found that R113 unintentionally called people to come to her room, and the facility care planned this behavior. She stated R12 was diagnosed with a urinary tract infection (UTI) upon admission to the acute care hospital and was subsequently moved from the west hall to the south hall, as the south hall houses primarily male residents. She confirmed the abuse allegation was substantiated. She stated the potential negative outcome was that if he had gotten into her brief, he could have sexually assaulted her, and she would not have been able to communicate it.

Based on observations, record review, staff interviews, and review of the facility's policies titled, Self-Administration of Medications, and Bedside Medication Storage, the facility failed to ensure they had a physician's order for medication stored at the bedside and the residents had been assessed for the ability to safely self-administer medications for one of two residents (R) (R92) reviewed for self-administration of medications. This deficient practice had the potential to cause adverse reactions if unsecured medications were accessed or ingested. Findings include:Review of the facility's policy titled, Self-Administration of Medications, reviewed on 08/01/2025, revealed under Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Under Procedures: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. C. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan.Review of the facility's policy titled, Bedside Medication Storage, reviewed on 08/01/2025, revealed under Policy: Bedside medication storage is permitted for residents who are able to self-administer medications, upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Under Procedures: A. A written order for the bedside storage of medication is present in the resident's medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and the medication label for the appropriate medications. F. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.Review of R92's electronic health record (EHR) revealed he was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction unspecified, major depressive disorder recurrent severe with psychotic symptoms, post-traumatic stress disorder (PTSD) unspecified, hemiplegia and hemiparesis following other cerebrovascular disease affecting the left non-dominant side, other speech and language deficits following other cerebrovascular disease, and cerebral atherosclerosis.Review of R92's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section B (Hearing, Speech, and Vision) documented R92 used corrective lenses. Section GG (Functional Abilities and Goals) documented functional limitations in range of motion (ROM) with impairment on one side of both the upper and lower extremities.Review of R92's physician orders revealed three active orders for ophthalmic medications: Name brand Celluvisc Ophthalmic Gel 1% (percent) (Carboxymethylcellulose Sodium) ordered to instill one drop in both eyes four times a day for dry eyes, with an order date of 12/10/2025. No physician order for self-administration of medications or bedside storage of medications was identified in R92's EHR.Review of R92's EHR revealed no assessment for self-administration of medications was found.Observation on 04/28/2026 at 10:52 AM in R92's room revealed an open box of Name brand Classic lubricant eye drops on the bedside table.Observation on 04/29/2026 at 11:42 AM in R92's room revealed an open box of Name brand Classic lubricant eye drops on the bedside table.Interview and observation on 04/28/2026 at 11:42 AM with Certified Nursing Assistant (CNA) AA revealed no residents self-administer medications in the facility and that only nurses gave medications. She stated she had been told to be on the lookout for any items residents were not supposed to have, including medications and other items, for safety purposes. She stated the facility's protocol when prohibited items were found was to let a nurse know, and the nurse then got a supervisor involved. She stated that when she previously reported eye drops to nursing, she was told R92 could have them because he was independent. She stated the potential negative outcome related to the eye drops being unsecured at the bedside was that another resident could access them and ingest them, causing harm.Interview and observation on 04/28/2026 at 12:53 PM with the Infection Preventionist (IP) revealed she had the two boxes of Name brand Classic lubricant eye drops in her hands. The IP revealed R92 had an order for eye drops and stated he must have received the eye drops from the Veterans Association (VA). She stated he did not care what they told him. She stated he should not be having the Name brand Classic lubricant eye drops because it was a hazard for other people. Any residents could come in and take eye drops, could drink the eye drops and could cause harm. Interview on 04/28/2026 at 1:34 PM with the Administrator revealed that typically if a resident had medications at the bedside, the resident would need to be assessed for self-administration of medications. She stated the resident should not have eye drops in his room. She stated the potential negative outcomes included another resident accessing the items and adverse effects related to ingestion.

Based on staff interviews, record review, and review of the Long-Term Care (LTC) Resident Assessment Instrument (RAI) 3.0 Manual, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for three (3) of three (3) sampled residents (Resident (R) #24, R#25, and R#74) reviewed for hospice care. The MDS Assessments for the sampled residents did not reflect the residents had terminal illnesses. Findings include: Review of the LTC Facility RAI 3.0 dated October 2024 revealed J1400: Prognosis: Steps for Assessments: 1. Review the medical record for documentation by the physician that the resident's condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness. 2. If the physician states that the resident's life expectancy may be less than 6 months, request that they document this in the medical record. Do not code until there is documentation in the medical record. 3. Review the medical record to determine whether the resident is receiving hospice services. Coding Instructions: Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services .O0110: Special Treatments, Procedures and Programs: .O0110K1, Hospice Care - Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. 1. Review of Resident #24's electronic medical record (EMR) revealed the resident was admitted to the facility with diagnoses which included, but were not limited to congestive heart failure, dementia, atrial fibrillation, bipolar disorder and type 2 diabetes mellitus. Review of Resident #24's Physician's Order dated 11/6/24 revealed Admit to Hospice - (name of hospice). #1 to name of hospice #2 per daughter's request. Admission completed today, resident, hospice and resident's daughter made aware. Review of Resident #24's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #24's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #24's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #24's Annual MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #24's Name of Hospice- Hospice Certification and Plan of Care for certification period 12/10/21 to 2/7/22 revealed I certify that this patient is terminally ill with a life expectancy of six (6) months or less if the terminal illness process runs its normal course. The statement was e-signed by the Hospice Physician. Review of Resident #24's Name of Hospice - Physician Certification/Recertification for certification period 2/4/25 to 4/4/25 revealed I certify, in my clinical judgement, based on my review of the patient's medical record and/or examination of the patient named above, that this patient's medical prognosis is terminal with a life expectancy of six (6) months or less, if the illness runs its normal course. The statement was electronically signed by the Hospice Physician. During an interview on 3/13/25 at 11:45 a.m., the MDS Coordinator stated R#24 was admitted to Name of Hospice #1 and continuously used that hospice until recently when the daughter requested she be switched to Name of Hospice #2 in November of 2024. 2. Review of Resident #25's EMR revealed the resident was admitted to the facility with diagnoses which included, but not limited to Alzheimer's Disease, dementia, type 2 diabetes mellitus, hypertension, altered mental status and aspiration of fluid. Further review of the resident's medical record reviewed the resident was admitted to hospice on 7/19/24. Review of Resident #25's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #25's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #25's Significant Change MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. 3. Review of Resident #74's EMR revealed the resident was admitted to the facility with diagnoses which included dementian epididymitis, hypertension, post-traumatic stress disorder and seizures. Review of Resident #74's Physician's Orders dated 10/3/24 revealed Admit to hospice (name of hospice). Review of Resident #74's Annual MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #74's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #74's Quarterly MDS dated [DATE] revealed the resident was not assessed as having a terminal illness prognosis at J1400. Review of Resident #74's Certification from Hospice Physician dated 6/28/24 revealed I attest that I have completed the face-to-face encounter. The clinical findings of this encounter have been provided to the certifying physician for use in determining whether the patient continues to have a life expectancy of six (6) months or less, should the illness run its normal course. The statement was electronically signed by the Nurse Practitioner. During an interview on 3/14/25 at 9:45 a.m., the MDS Coordinator stated she had overlooked coding the residents' prognoses for hospice. She stated she will review all the hospices residents' documentation and send corrections. She stated she used the Resident Assessment Instrument (RAI) 3.0 Manual for direction and reference when coding an MDS Assessment. She stated she does know J1400 Prognosis should be coded for hospice residents once an order has been received.

Based on observations, staff interviews, record review, and review of facility policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurate for one (resident (R) #61 of seven residents reviewed. Specifically, the facility failed to ensure the PASRR was completed accurately upon admission. Findings include: Review of the facility policy titled Admission Criteria dated November 2017 read in part: Policy Statement: Our facility will admit only those residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation . 7. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medical Pre-Admission Screening and Resident Review. Review of the electronic medical record (EMR) revealed R #61was admitted to the facility with diagnoses that included, but were not limited to bi-polar disorder and vascular dementia. Review of the Preadmission Screening Resident Review (PASRR) Level I Assessment (Form: DMA-613): Review Request dated 3/22/24 did not reveal the resident had the diagnosis of bi-polar disorder. During an interview on 3/14/25 at 11:38 a.m., the Director of Social Services (DSS) explained the process for PASRR stating it was dependent on the diagnosis. The DSS stated the hospital staff submitted the Level I to the Georgia state agency prior to admission to the nursing home facility. She stated they (the facility) received a copy of The Level I prior to admission for review and to see if it was pending or approved. The DSS stated she reviewed the form to ensure the diagnosis were documented accurately for the resident. She stated one of the sister facilities had completed an audit about six months ago and identified there was an issue. The DSS reviewed the PASRR for R#61 and stated it was not completed accurately and submitted a new form on 3/11/25. The DSS stated it was important to complete timely so the patient can be taken care of if they have behaviors and treated timely. She stated she should have completed a new Level I because the hospital did not include diagnoses of Bipolar. During an interview on 3/14/25 at 12:05 pm, the Nursing Home Administrator (NHA) did not know if a new Level I should have been submitted since the hospital did not indicate the resident had Bipolar on The Level I when they submitted it. The NHA stated there was not additional information for R#61's PASRR and it should have been resubmitted.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to carry out activities of daily living (ADL) for a dependent resident for one (1) (Resident (R) #9) of 30 sampled residents reviewed. Specifically, the facility failed to provide nail care to a dependent resident. Findings include: Review of the facility policy titled Nail Care dated July 2024 read in part: Policy: Purpose of this procedure is to provide guidelines for the provisions of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: .3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Routine nail care, to include trimming and filing, will be provided on a regularly scheduled shower/bath day. Nail care will be provided between scheduled occasions as the need arises.6. Principles of nail care: a. nails should be kept smooth to avoid skin injury. Review of the electronic medical record (EMR) revealed Resident (R)#9 was admitted to the facility with diagnoses that included, but were not limited to muscle weakness, and hemiplegia and hemiparesis following infarction affecting the left dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] included the Brief Interview for Mental Status (BIMS) score of two (2) out of 15, which indicated the resident was severely cognitively impaired. The assessment revealed the resident was dependent on staff for ADLs to include personal hygiene and nail care. Review of R#9's Care Plan identified the resident was dependent on staff for ADL care. Review of Shower Documentation & CNA (Certified Nursing Assistant) Skin Assessment Form read in part:1/29/25 nail care was left blank, 2/4/25 fingernails cleaned and cut, 2/14/25 fingernails cleaned, 2/28/25 fingernails cleaned, 3/4/25 fingernails cleaned and cut. Observation on 3/11/25 at 12:23 pm revealed the resident was in her room lying in bed with family visiting. The resident's nails appeared long with jagged edges and dark color debris under the nails. Observation on 3/12/25 at 3:25 pm revealed the resident was lying in bed with hands crossed. R#9's nails appeared long and jagged with debris under the nails. Observation on 3/13/25 at 3:02 pm revealed the resident was sitting up in bed. The resident's nails appeared long and jagged with debris under the nails. During an interview and observation on 3/13/25 at 3:05 pm, CNA CC stated nail care was completed on shower days, two times a week, unless they noticed that they needed to be cut and cleaned during daily patient care that included cutting and trimming. CNA CC stated R#9's shower days were Tuesday and Friday mornings. She observed the residents' nails and stated they needed to be cleaned and cut. She stated documentation was completed on the Shower Documentation & CNA Skin Assessment Form after completion of the task. During an interview and observation on 3/13/25 at 3:10 pm, Licensed Practical Nurse (LPN AA) stated resident nails were cleaned and trimmed daily if needed. He stated they did not have a specific nail clipping day, it could be completed on the shower days or as needed. LPN AA stated the CNAs documented on the shower sheet if it was done and would let nurses know as needed. He stated if the nurse saw a hangnail or something it was documented in the nurses' notes. Observation of R#9's nails in her room, LPN AA said, dirt or something is under her nails, and about medium length, in need of a trim. He said, the left hand, which was contracted, nails in need of nail care, cleaned and trimmed. LPN AA stated it was important to complete nail care so residents would not injure themselves and good hygiene. During an interview and observation on 3/13/25 at 3:26 pm with the Director of Nursing (DON) stated ADL care included personal hygiene, which included nail care. He stated that dependent residents' nails were cleaned and trimmed during the shower at a minimum and as needed. He stated daily care included personal hygiene and nail care. Observation of Resident #9's nails with the DON, he said, I see dirt under the nails, long jagged nails and the left-hand contracture longer and jagged, they can be more clean.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure the resident did not experience a reduction in motion for one of one resident (R#9) reviewed. Specifically, the facility failed to assess and provide services to prevent contractures. Findings include: Review of the facility policy titled Contracture Management dated January 2024 read in part: Policy: Potential for contractures development and range of motion will be assessed upon admission, readmission, significant change in condition, and quarterly to identify any limitations in range of motion or potential for contracture development. Residents will be referred to the Therapy Department in accordance with this policy for screening and contracture identification. Therapy Department will screen all new admissions for the presence of contractures and the presence or absence of contractures will be noted on the Therapy Screen and/or the evaluation form. Therapy will continue to monitor the presence and/or severity of a contracture once identified or for the development of a new limitation/contracture during the quarterly/annual/significant change therapy screening process with the help of the nursing ROM (range of motion) Evaluation Tool and Contracture Potential Assessment. Resident (R)#9 was admitted to the facility with diagnoses that included, but were not limited to muscle weakness, and hemiplegia and hemiparesis following infarction affecting the left dominant side. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] included the Brief Interview for Mental Status (BIMS) score of two (2) out of 15, which indicated the resident was severely cognitively impaired. The assessment revealed the resident was dependent on staff for Activities of Daily Living (ADL) to include personal hygiene and nail care. The resident received occupational therapy from 9/9/24 through 10/24/24. Review of the current Physician Orders did not include an order for use of a splint or restorative therapy. Review of R#9's Care Plan initiated 3/13/25 identified the resident required restorative nursing for left hand contracture. The resident goal was to have no skin breakdown or other complications related to splint use. The interventions included staff was to explain to the resident every time the splint was put on or removed; staff to apply the resting hand splint to the left hand two hours on and two hours off; check for adequate circulation and signs and symptoms of skin breakdown when removed. Review of the Contracture Potential Assessment revealed: On 8/9/24 a score of 16 which indicated the resident had severe impairment /limitation on ROM tool and or contracture. Therapy Screen indicated/request completed. On 11/7/24 a score of 15 on the tool did not identify the impairment/limitation. On 2/7/24 a score of 15 on the tool did not identify the impairment/limitation. Observation on 3/11/25 at 12:23 pm revealed R#9 was in her room lying in bed with family visiting. The resident's left hand was contracted with no splint on. Observation on 3/12/25 at 3:25 pm revealed R#9 was lying in bed with hands crossed. The resident's left hand was contracted with no splint on. Observation on 3/13/25 at 3:02 pm revealed R#9 was sitting up in bed. The resident's left hand was contracted with no splint on. During an interview and observation on 3/13/25 at 3:05 pm, Certified Nursing Assistant (CNA CC) stated the resident's left hand was contracted and there was no injury. She stated the restorative department took care of the contractures, applied splints as ordered. During an interview and observation on 3/13/25 at 3:10 pm, Licensed Practical Nurse (LPN AA) stated he did not know if the resident had a splint. During an interview and observation on 3/13/25 at 3:26 pm with the Director of Nursing (DON), he stated he did not know about the contractures but would check. He did not return with information. During an interview on 3/14/25 at 9:44 am, the Director of Rehab (DOR) explained the process regarding splint use. She stated if a person was not on therapy, either the CNA or nursing would submit a referral to therapy and then Occupational Therapy (OT), Physical Therapy (PT) or Speech Therapy (ST) would screen the resident and decided if the person needed further evaluation for the next level and then they were picked up by therapy. The doctor or Nurse Practitioner sometimes made recommendations. She stated somebody made the referral and went from there. The DOR stated after the evaluation it was determined on the needs of the resident. She stated it took about 24-48 hours after referral to start the process. The DOR stated the resident received therapy services from 12/30/24 to 1/28/2025 and determined a resting hand splint was needed and ordered, the splints were shipped on 1/16/25. The DOR stated there should have been an order for restorative to follow and apply the splint up to four hours a time. She stated the resident was unable to tolerate 4 hours of splint use. She stated the resident should have had at least two hours and then off and tried again, should have minimum of two hours per day of wearing the splint. The DOR stated that after therapy was completed, a restorative form was completed and turned into the MDS coordinator who was in charge of the restorative program, but that was a process that started a few days ago, since she just started the position a few days ago. The DOR was unable to recall who gave the referral for restorative therapy for R #9. She stated the restorative CNA was responsible to place the splint on the resident as required. The DOR did not know if it was documented or who was responsible for documenting when the splint was placed on the resident or not placed on the resident. She stated they should document daily but the restorative CNA would know. The DOR stated he would look for documentation and if located would provide to the NHA to give to the surveyor. During an interview on 3/14/25 at 10:23 am, Restorative CNA (Restorative CNA CC) explained that once the rehab department discharged the resident they were then added to the restorative program. They were responsible to do ROM to the upper and lower extremities, splints, sit to stand, help dress and toilet residents. Restorative CNA CC stated the rehab department communicated verbally what needed to be done. She said, They (OT) said that the resident did have a splint, I never received a splint. I put one on her today. The Restorative CNA CC said, I would put wash clothes in her hands, when she was on restorative. R#9's restorative discontinued two Fridays ago. R#9 now back on restorative as of yesterday and I put the splint on this morning. Restorative CNA CC stated it was important to have the splint on because she had contractures and helped her open her hand somewhat. She said we do not document in restorative.

Based on observations, staff interviews, and review of the facility policies titled, Sanitation-Store Rooms/Freezer/Refrigerator and Dating and Labeling, the facility failed to ensure food was properly stored, prepared, distributed, and served in accordance with professional standards for food service safety as required for 89 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Findings include: Review of the facility policy titled Sanitation-Store Rooms/Freezer/Refrigerator dated [DATE] documented, It is the policy of the facility to store food in the appropriate location to ensure a safe and sanitary environment according to the State and Federal guidelines .Dry Storage Room .(a) Storerooms will be well lit and ventilated. The floors, walls, shelves and equipment in the storeroom will be kept clean and in good repair .(e) Shelving will be clean and allow for proper storage .(g) Storage containers with tight-fitting covers or plastic bags with closures will be used for storage .(i) Dry ingredient bins or designated containers will be labeled and dated .(j) All food will be labeled and dated if removed from the original container .Refrigeration .(b) Inside will be clean shelving, floors, dust free fan cover and clean storage containers .(c) Store food in a manner that will allow cold air to circulate around the food .(d) Cooked foods will be covered, dated and labeled and will be stored above the fresh and raw foods. Fresh foods will be stored above raw food. (e) Raw meats, poultry, eggs and fish will be wrapped, dated and labeled and placed on the bottom shelf. Frozen, thawing meat with juices will be placed in drip pans to catch liquids. Each type of meat will be in a separate drip pan to avoid cross contamination. Review of the facility policy titled Dating and Labeling documented dated [DATE] documented, The government has mandated with this statement that labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (when applicable) or discarded .Dating and labeling food stored in the coolers, dry storage and freezers ensures the safety of the food that will be served to the residents .Discard frozen foods that have expired or passed the manufacturer's used by date .Any package or containers that have been opened but do not have an open date on the containers must be discarded. 1. Observations during the tour of the kitchen on [DATE] at 10:43 am revealed: Plate covers, meal trays, and large cooking pots were stored on metal shelving units, observed resting directly on metal bars with extensive darkened rust and dried debris. Ceiling vents were observed with dried debris and dust above food preparation areas. Ceiling panels were observed with buckling and water damage above food preparation areas. Walk-in refrigerator light did not work. There were two large boxes of romaine lettuce that were wilted and had darkened edges. A cardboard box containing three 5-pound (lb.) bags of raw bacon was stored on the second shelf, with a box containing six 2 lb. bags of raw roast beef stored on top of it. There was red colored drainage observed on the bottom corners of the cardboard box. These items were stored above a box of green bell peppers and salad. Interview on [DATE] at 10:50 am with the Dietary Manager (DM), the DM said that the walk-in refrigerator light had not been functioning for approximately a week and maintenance had ordered a part. The DM verified that the meat products should have been placed on the bottom shelf to prevent dripping from the meat product onto the produce. 2. Observations during the tour of the kitchen on [DATE] at 10:55 am revealed: The walk-in refrigerator had two opened bags of shredded cheese with Best Use By [DATE] on them. There was a 10 lb. box of cucumber salad marinade with a use by date of [DATE]. There was an unopened 8.4 lb. box of mini cinnamon rolls that stated to Keep Frozen. The reach-in freezer had an opened and undated bag of breakfast sausages. The backsplash area and the hosing behind the three-compartment sink had significant dried liquid and debris. Plates were stored in a plastic bin on top of a wheeled cart. These plates were stored uncovered near the entrance door leading to the dining room. Observation on [DATE] at 11:41 am, Dietary Aide (DA)1 entered the kitchen from the dining room and passed the prepared meal service line. She was observed with shoulder length hair, which was not covered by a hair net. Interview on [DATE] at 11:20 am, the DM said that they normally placed the clean plates on the cart prior to meal service but did not cover the meal plates before service.

Based on record review, resident representative and staff interviews, and review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one of 18 sampled residents (R) (R28) reviewed for abuse. Specifically, Certified Nursing Assistant (CNA) CNA 1 was seen pulling R28 down the hallway by her legs, yelling to stay out of other resident's rooms. Finding include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021 indicated . Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to facility staff and other residents. Review of R28's electronic medical record (EMR) Admission Record, located under the Profile tab, indicated the resident was admitted to the facility with diagnoses not limited to Alzheimer's disease, and dementia with behavioral disturbances. Review of R28's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/2023 indicated R28 had a Brief Interview for Mental Status (BIMS) of 99 which revealed the resident was significantly cognitively impaired. The assessment indicated R28 wandered. Review of R28's EMR Care Plan, located under the Care Plan tab and dated 11/9/2023, indicated Resident has a dx [diagnosis] of Alzheimer's and she is a wanderer r/t [related to] wanders in and out of other (male) residents' rooms, Resident has a behavior problem aeb [abnormal eating behaviors], disrobing in public, and laying/sitting on floor r/t dx of Alzheimer's and dementia with behavioral disturbances. Resident has the potential for injury and is high risk for falls due to confusion, incontinence, unaware of safety needs, vision/hearing problems, and bilateral lower extremity weakness. Review of the documentation provided by the facility revealed on 10/2/2022 Licensed Practical Nurse (LPN) 1 heard yelling down the East Hallway and upon checking on the yelling, LPN1 witnessed CNA1 dragging R28 down the hallway by her legs while she was lying on the floor with no shirt on. LPN1 called out to CNA1 to stop what she was doing twice before CNA1 let go of the resident's leg. CNA1 then began yelling at R28 not to go into other residents' rooms and to stay out of men's rooms. LPN3 came from behind the nursing station and assisted R28 to bed and completed a head-to-toe assessment. There was no bruising or skin tears noted. R28 did not complain about pain at the time of the assessment. CNA1 was directed by LPN1 to do an immediate drug test and was walked out of the facility by LPN1. The police were made aware of the incident. R28's responsible party was updated on the incident. The Administrator made a call to CNA1 on 10/2/2022, the date of the alleged incident, and left a message. The Administrator received a return call on 10/2/2022 and when asked to explain what happened, CNA1 replied, It happened so fast, I was frustrated, R28 was on the floor in room [ROOM NUMBER] moving around on the floor. I was trying to get her out of the room because the resident in room [ROOM NUMBER]-A was saying to get R28 out of the room. 124-B was sound asleep so I grabbed her leg and pulled her, I was not thinking, it was not intentional. When asked why she was frustrated CNA 1 said, I don't know. When asked why she didn't get the nurse or another CNA to assist, she said, She was not thinking. Interview on 12/13/2023 at 1:05 pm with R28's resident representative (RR1) revealed being called about the situation and told that R28 was in another person's room and would not come out, so the CNA dragged her out of the room. RR1 expressed being upset about the whole situation but did not see a change in R28's behavior after the incident. Interview on 12/13/2023 at 1:19 pm with LPN1 she stated, Heard some yelling and saw CNA1 dragging R28 down the hallway on her bare back by her feet. She [CNA1] was just yelling 'come on, come on and get up and get off the floor'. CNA1 was really aggravated with R28. CNA1 was immediately drug tested and escorted out of the building. Interview on 12/11/2023 at 2:14 pm with the Administrator revealed the facility immediately followed the facility's abuse protocol by removing CNA1 from all residents, contacting the police and the resident representative, and reporting the incident to the health department. The Administrator stated that checks were frequently done on the resident, to ensure there were no adverse effects or notice in behavior. CNA1 was terminated, and information was provided with the registry.

Based on observations, staff interviews, record review, and review of the facility policy titled, Wound Management program for Pressure Ulcers, the facility failed to follow the doctor's order for one of six residents (R) (R 66) reviewed for pressure ulcers out of a sample of 18 residents. Specifically, the facility failed to consistently apply boots to the heels of R66 to relieve pressure to a stage three pressure ulcer. Findings include: Review of the facility policy titled, Wound Management Program for Pressure Ulcers provided by the facility and revised October 2023 revealed . elevate heels off of bed surface and use pillows between knees if indicated . Review of R66's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, indicated R66 was a long-term resident admitted to the facility with the following diagnoses but not limited to cerebral infarction (stroke), respiratory failure, aphasia (difficulty speaking), vascular dementia, and lack of coordination. Review of R66's Minimum Data Set (MDS), located in the EMR under the Resident Assessment Instrument (RAI) tab, with an Assessment Reference Date (ARD) of 7/15/2023, revealed R66's Brief Interview of Mental Status (BIMS) was a 10 out of 15, indicating that R66 was moderately impaired. Review of nursing notes located in the EMR, under the Progress Notes tab and dated 1/6/2023 revealed a skin check was performed with the following results, The resident noted with an unstageable pressure ulcer to her right lateral ankle that measured at 2.0 x 2.0 x unmeasurable cm (centimeters) [which was present upon admission per note dated 12/13/2022] and a scratch to the right side of her neck. Review of current physician orders, located in the EMR under the Orders tab and dated 12/12/2023 revealed, Apply heel boots to both feet at all times . A review of R66's Care Plan, last reviewed 8/17/2023, located in the EMR under the Care Plan tab, revealed The resident has a DTI [deep tissue injury] to her left heel or potential for pressure ulcer development .Immobility and Impaired bed mobility . apply heel boot to left foot and keep in place at all times . Review of the Skin and Wound Evaluation, located in the EMR under the Assessment tab and dated 12/5/2023 revealed R66's left heel ulcer measuring the following: Area 1.7 cm, Length; 1.3 cm; Width 1.6 cm and progress noted to be improving. Review of Weekly Skin Assessments, dated 10/28/2023, located in the EMR under the Assessment tab, revealed a stage three pressure wound remains to the left lateral heel. Observation on 12/12/203 at 11:10 am, R66 was observed in her room, lying in a geri chair (chair with lap tray attached) recliner. R66 was groomed and dressed appropriately, and it was noted that R66 was not wearing her heel floaters (boots designed to offer relief from pressure sores and prevent fragile skin from tearing). Interview on 12/12/2023 at 1:17 pm with Licensed Practical Nurse (LPN) 1, she stated, The resident heels should be floated to prevent further skin damage. I expect her heels to float in bed or while sitting in the geri chair. LPN1 further stated, The resident's right heel is healed, and the left heel is at stage three. LPN1 continued to share that wearing the boots ordered by the doctor would prevent further damage to the pressure ulcer. Interview on 12/12/2023 at 2:14 pm with the Director of Nursing (DON), the DON stated, I expect that doctor's orders are followed. The purpose of applying boots to R66's heels is to prevent further wound damage.

Based on record review, staff interviews, and review of the facility policy titled, Documentation-Behavior Monitoring, the facility failed to ensure behavioral and side effect monitoring for antipsychotic and psychiatric medications for two of five residents (R) (R42 and R81) reviewed for unnecessary medications. The deficient practice had the potential for residents to erroneously receive medications for unidentified behaviors and suffer side effects from such medications that were not monitored. Findings include: Review of the facility policy titled Documentation-Behavior Monitoring, dated 3/10/2016, documented, When the resident receives an antipsychotic medication that is medically indicated and may help promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the resident will be placed on behavior monitoring. 1. All residents receiving antipsychotic medications will have Behavior Monitoring to include side-effects monitoring in place .5. Behavior Monitoring including side effects documentation will be on the EMAR (electronic medical administration record) for residents on antipsychotics will include: the observed behavior, the number of episodes exhibited, the interventions used, and observed side effect .if the resident is on psychotropic medications the Behavior Monitoring with side effects will be utilized and the documentation on the EMAR will be as listed in #5. If the resident is not on any psychotropic medications, they will be placed on Behavior Monitoring Only and this will include: the observed behavior, the number of episodes exhibited, and the interventions used . 7. Behavior Monitoring will be documented each shift on the EMAR by the Charge Nurse. 1. Review of R42's undated Admission Record located in the EMAR under the Profile tab, documented R42 was initially admitted to the facility with diagnoses to include but not limited to cognitive communication deficit, alcohol dependence with alcohol-induced persisting dementia, and major depressive disorder. Review of R42's admission Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 9/7/2023, a Staff Assessment for Mental Status (SAMS), documented R42 had modified independence related to cognitive skills for daily decision making, indicating R42 had some difficulty in new situations. Review of R42's Care Plan, dated 9/1/2023, located in the EMAR under the Care Plan tab, documented R42 is receiving antipsychotic medication for management of dementia and agitation. Interventions included: Administer medication as ordered per physician. AIMS [Abnormal Involuntary Movement Scale] assessment quarterly and PRN [as needed]. Do not challenge illogical thinking. Document behaviors on MAR [Medication Administration Record] tracking form. Monitor for adverse medication reactions and report any to physician ., The resident is on sedative/hypnotic therapy related to insomnia .administer sedative/hypnotic medications as ordered by physician, monitor/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fracture, dizziness. Review of R42's Order Summary Report located in the EMAR under the Order tab, documented medication orders for, klonopin (psychotropic medication) for agitation, dated 10/25/2023 and mirtazapine (antidepressant) for depression, dated 8/31/2023. Further review of the report revealed there were no orders for behavioral and/or adverse effect monitoring for the psychotropic medications being administered. Review of R42's Behavior Monitoring Administration Record (BMAR) for September, October, and November 2023, located in the EMAR under the Order tab, revealed no behavior and/or adverse monitoring being documented. 2. Review of R81's undated Admission Record, located in the EMAR, under the Profile tab, documented R81 was admitted to the facility with diagnoses including but not limited to chronic post-traumatic stress disorder, major depressive disorder, and pain in left shoulder. Review of R81's quarterly MDS, located in the EMAR under the MDS tab, with an ARD of 10/18/2023, Brief Interview of Mental Status (BIMS) score, indicated R81 cognition was intact. The resident was assessed as not exhibiting behaviors through the look back period. Review of R81's Care Plan, dated 8/8/2023, located in the EMAR under the Care Plan tab, documented Resident verbally aggressive towards nursing staff r/t [related to] threatening nurses that he will report their licenses to the nursing board, interventions included Administer medications as ordered. Observe for side effects and effectiveness. Assess the resident's understanding of the situation. When the resident becomes agitated: Intervene before agitation escalates; staff to walk calmly away, and approach later., Resident receiving an antidepressant medication to manage indicators of mood secondary to depression interventions included Administer antidepressant medications as ordered by physician. Meet with resident on a 1:1 [one on one] basis and encourage expression of feelings. Monitor for worsening signs of mood/behavior; weight loss, poor appetite, increase in crying, verbalization of thoughts of suicide, hopelessness, sleeping all the time or insomnia, change in attention to personal care. Notify physician of mood/behaviors changes as indicated. Resident is on hypnotic therapy r/t insomnia interventions includes Administer hypnotic medications as ordered by physician, monitor/report PRN for following adverse effects of hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Review of R81's Order Summary Report located in the EMR under the Orders tab, active orders as of 12/14/2023, revealed the following orders: citalopram for depression, dated 4/11/2023. 1. Monitor for behaviors doc [document] observed behaviors using key code. Document # of episode 0. None, 1. Pacing, 2. Spitting, 3. Hitting, 4. Crying, 5. Yelling, 6. Picking, 7. Kicking, 8. Head banging, 9. Scratching, 10. Biting, 11. Hallucination, 12. Paranoia, 13. Delusions, 14. Other. Dated 4/11/2023, 2. Outcome of intervention use key code: I. Improved, U. Unchanged, and W. Worsened, and 4. Psych Med Use: observe for, and document observed side effects 0. None, 1. Pseudo-Parkinsonism (EPS), 2. Restlessness/Anxiety, 3. Tardive Dyskinesia, 4. Hypotension, 5. Falls/Dizziness, 6. Sedation, 7. Dry Mouth, 8. Constipation, and 9. Urinary Retention. Review of R81's BMAR located in the EMAR under the Orders tab, revealed for 9/1/2023 thru 9/30/2023, there was no documented behavior monitoring, outcome monitoring, and adverse effects monitoring for 17 shifts out of 60 shifts, for 10/1/2023 thru 10/31/2023, there was no documented behavior monitoring, outcome monitoring, and adverse effects monitoring for 12 shifts out of 62 shifts, for 11/1/2023 thru 11/30/2023, there was no documented behavior monitoring, outcome monitoring, and adverse effects monitoring for nine shifts out of 60 shifts, and for 12/1/2023 thru 12/11/2023, there was no documented behavior monitoring, outcome monitoring, or adverse effects monitoring for six shifts out of 12 shifts. Interview on 12/12/2023 at 2:30 pm with Licensed Practical Nurse (LPN) 4, LPN4 was questioned as to where nursing staff documented the resident's behavior monitoring, outcome monitoring, and adverse effects. LPN4 stated, It's documented in the BMAR, located in the resident's EMAR, every shift. Interview on 12/12/2023 at 4:57 pm with the Director of Nursing (DON), upon review of R42's and R81's EMARs, confirmed the lack of documentation for behavior monitoring, outcome monitoring, and adverse effects monitoring. The DON added If it's not documented, it's not done. Interview on 12/12/2023 at 5:10 pm with the Administrator, the Administrator stated the expectations are the licensed nurse who takes the order or does rounds with the Medical Doctor (MD), would put the behavioral monitoring and side effect monitoring in the EMAR. The nursing staff should be monitoring, and documenting the behaviors, adverse effects, and outcomes.

Based on interviews, record review, and review of facility policy, the facility failed to develop comprehensive care plans related to discharge planning for two of 10 sampled residents (R) (R#2 and R#8). Findings include: Review of the facility policy titled, Comprehensive Care Plans, Reviewed/Revised 7/13/22, revealed: 3. The comprehensive care plan will describe, at a minimum, the following: d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. 1. Review of the electronic medical record (EMR) for R#2 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for R#2, dated 4/15/22, documented hearing/vision as adequate; speech as unclear; sometimes understands/sometimes understood. The Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment; Mood score was 7, indicating mild depression; behaviors as verbal towards others, physical not directed towards others, & rejection of care. She required limited assistance for activities of daily living (ADLs) except extensive assist for bathing, supervision for locomotion on unit & toilet use, and independent for eating. She was occasionally incontinent of bladder and always continent of bowel and received scheduled & as needed (PRN) pain medications for severe pain. She received insulin, antianxiety, and antidepressant medications and there was no active plan to return R#2 to the community or refer to outside local resources. Review of the Care Plan for R#2 revealed focus for history (hx) of making false allegations to staff; risk for Covid-19; advance directive; independent room activities; self-care deficits; smoking; resistance to care/refusing medications; verbally abusive; physical aggression; mood problem/ anxiety; mood fluctuation/depression; [CONDITION(S)] (CHF); [CONDITION(S)]; fall risk; [CONDITION(S)] r/t cerebral vascular accident ([CONDITION(S)]); antiplatelet therapy; nerve pain; skin integrity; bladder incontinence; regular diet; and IBS. Appropriate goals and interventions in place. Review of the Progress Notes for 2022 for R#2 revealed no entries related to discharge planning. In a telephone interview with R#2's RP on 8/15/22 at 12:54 p.m., she stated she wanted to transfer R#2 to another facility but felt the language in the paperwork the facility was sending out was preventing the transfer from occurring. In an interview with the Director of Nursing (DON) on 8/22/22 at 6:10 p.m., she confirmed the facility was assisting R#2's RP in finding alternative placement for R#2. She also confirmed the facility had not developed a care plan for discharge or transfer. She stated they would develop care plans for discharge as appropriate in the future per the care plan policy. 2. Review of the EMR revealed R#8 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was discharged to the community on 6/3/22. Review of the admission MDS assessment dated [DATE] documented a BIMS score of 15, no cognitive impairment; Mood score of zero, indicating no depression; and no behaviors. In addition, there was no active discharge plan to return to the community. Review of the Care Plan revealed no focus on discharge planning. Review of the Progress Notes for R#8, dated 5/31/22 through 6/2/22, documented Social Worker notes related to R#8's discharge to the community. In a telephone interview with the Social Worker on 8/25/22 at 2:01 p.m., she confirmed R#2's RP had expressed a desire to transfer R#2 to another facility. She confirmed there was no documentation related to the facility's effort to assist in the transfer. She confirmed the care plan had not been developed for discharge planning. In addition, she confirmed one previously discharged resident, R#8, did not have a care plan developed for discharge. She stated, going forward, the facility would develop care plan for discharge for appropriate residents.

Based on interviews, record review, and review of facility policy titled Preparing a resident for Transfer or Discharge, the facility failed to develop and implement effective discharge planning for three of three sampled residents (R) (R#2, R#8, and R#9). Findings include: Review of the facility policy titled, Preparing a resident for Transfer or Discharge, Revised November 2017, revealed: (2) A post-discharge plan is developed for each resident prior to his or her transfer or discharge. 1. Review of the electronic medical record (EMR) for R#2 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE], readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment for R#2, dated 4/15/22, documented hearing/vision as adequate; speech as unclear; sometimes understands/sometimes understood. The Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment; Mood score was 7, indicating mild depression; behaviors as verbal towards others, physical not directed towards others, & rejection of care. She required limited assistance for activities of daily living (ADLs) except extensive assist for bathing, supervision for locomotion on unit & toilet use, and independent for eating. She was occasionally incontinent of bladder and always continent of bowel and received scheduled & as needed (PRN) pain medications for severe pain. She received insulin, antianxiety, and antidepressant medications and there was no active plan to return R#2 to the community or refer to outside local resources. Review of the Care Plan for R#2 revealed focus for history (hx) of making false allegations to staff; risk for Covid-19; advance directive; independent room activities; self-care deficits; smoking; resistance to care/refusing medications; verbally abusive; physical aggression; mood problem/ anxiety; mood fluctuation/depression; [CONDITION(S)] (CHF); [CONDITION(S)]; fall risk; [CONDITION(S)] r/t cerebral vascular accident ([CONDITION(S)]); antiplatelet therapy; nerve pain; skin integrity; bladder incontinence; regular diet; and IBS. Appropriate goals and interventions in place. Review of the Progress Notes for 2022 for R#2 revealed no entries related to discharge planning. In a telephone interview with R#2's RP on 8/15/22 at 12:54 p.m., she stated she wanted to transfer R#2 to another facility but felt the language in the paperwork the facility was sending out was preventing the transfer from occurring. In an interview with the Director of Nursing (DON) on 8/22/22 at 6:10 p.m., she confirmed the facility was assisting R#2's daughter in finding alternative placement for R#2. She also confirmed the facility had not developed a care plan for discharge or transfer. She stated they would develop care plans for discharge as appropriate in the future per the care plan policy. 2. Review of the EMR revealed R#8 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was discharged to the community on 6/3/22. Review of the admission MDS assessment dated [DATE] documented a BIMS score of 15, no cognitive impairment; Mood score of zero, indicating no depression; and no behaviors. In addition, there was no active discharge plan to return to the community. Review of the Care Plan revealed no focus on discharge planning. Review of the Progress Notes for R#8, dated 5/31/22 through 6/2/22, documented Social Worker notes related to R#8's discharge to the community. 3. Review of the EMR revealed R#9 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was discharged to the community on 8/10/22. Review of the Baseline Care Plan for R#9 revealed no focus on discharge planning. Review of the Progress Notes revealed two notes by the Social Worker, dated 8/10/22, related to R#9's discharge to the community. In a telephone interview with the Social Worker on 8/25/22 at 2:01 p.m., she confirmed R#2's RP had expressed a desire to transfer R#2 to another facility. She confirmed there was no documentation related to the facility's effort to assist in the transfer. She confirmed the care plan had not been developed for discharge planning. In addition, she confirmed two previously discharged residents, R#8 and R#9, did not have care plans developed for discharge. She stated, going forward, the facility would develop care plan for discharge for appropriate residents.

Based on observations, staff interviews, record review and review of the facility policy titled, Catheter Management Care, Anchoring and Changing the facility failed to promote, maintain, and protect a resident's (R) dignity for one (1) (R#15) of five (5) residents with a urinary catheter. Findings include: Review of the facility policy titled Catheter Management Care, Anchoring and Changing updated 9/2017, revealed: 16. Secure catheter drainage bag at below level of bladder, and above the floor. Catheter drainage bags will be covered when residents are in a public area. Review of R#15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Retention of urine, [CONDITION(S)] ([CONDITION(S)]), and urinary tract infection ([CONDITION(S)]). 18 French (F) with 10 milliliter (ML) bulb indwelling catheter: related to a diagnose of urinary retention. Review of R#15's quarterly Minimum Data Set, dated dated dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 14 indicating minor cognitive deficit; Section G-Functional Status: extensive assistance with bed mobility, eating, totally dependent for transfers, locomotion, dressing, toileting, personal hygiene, and bathing; Section H-Bowel and Bladder: resident has catheter. Review of R#15's Physicians orders revealed: Resident admitted with 18F/10 CC catheter attached to bedside drainage bag. During observations on 6/3/22 at 7:45 a.m. and 10:53 a.m. R#15 noted with a catheter, drainage bag was attached to bed, bed in low position, no dignity bag in place, and drainage bag was visible from the door. An interview held on 6/3/22 at 7:45 a.m. with the Registered Nurse (RN) Supervisor RN AA revealed residents with a catheter should have a catheter privacy bag in place. She verified the resident did not have a privacy bag and the catheter bag was visible from the door. An interview held on 6/3/22 at 8:30 a.m. with the Director of Nursing (DON) revealed all residents who have a catheter should have a privacy bag attached to the catheter bag for dignity. An interview held on 6/5/22 at 10:19 a.m. with the Administrator revealed she would expect all residents with a catheter to have a privacy bag.