Every finding on record at Riverdale Center for Nursing and Healing

Based on observations, staff interviews, and review of the facility policy titled Food Receiving and Storage, the facility failed to ensure that opened food items in the dry storage area were properly labeled and dated. In addition, dietary staff failed to ensure that opened food items were properly refrigerated. This deficient practice had the potential to place the 130 residents receiving nutrition and hydration from the kitchen at risk of foodborne illness. Findings include: Review of the facility policy titled Food Receiving and Storage, dated April 2024, revealed the Guidelines section included, . 6. Dry foods that are stored in bins will be removed from original packing, labeled, and dated. 7.All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Observation on 03/13/2026 at 08:35 AM of the dry storage area revealed a five-pound bag of grits that had been opened with no date, and a three-pound box of potato pearls opened with no open date. During an interview on 03/13/2026 at 10:55 AM, the Dietary Manager (DM) confirmed that the open bag of grits and open box of potato pearls had no open date. The DM confirmed that the date on each that is in black marker was the date the food item was delivered to the facility. The DM revealed that dietary staff are to date any opened/used food items before placing them in the storage area. The DM stated that he generally conducted rounds and checked for issues, such as undated food items. Observation on 03/15/2026 at 10:05 AM in the dry storage area revealed a large, clear, resealable plastic bag containing egg noodles. The egg noodles had been removed from their original packaging. This bag had no label and had a date of 09/13/2026 in black marker. Continued observation of the dry storage area revealed a one-gallon container of cole slaw dressing that had been opened and partially used, stored on the shelf, and not refrigerated. The opened cole slaw dressing did not have an open date. During an interview on 03/15/2026 at 10:05 AM, the DM confirmed that the egg noodles had been removed from their original packaging and were not properly labeled or dated. The DM stated that the date 09/13/2026 on the plastic bag is their use-by date. The DM confirmed that the partially used gallon container of cole slaw dressing was stored in the dry storage area and was neither refrigerated nor marked with an open date. The DM revealed that dietary staff should have dated any opened food items and that the opened cole slaw dressing should have been stored in the refrigerator, not the dry storage area.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that residents' medications were free from misappropriation by licensed nursing staff during medication administration observations.Findings include: A review of the facility's policy titled Medication Administration, revised 04/2025, revealed the Policy Explanation and Compliance Guidelines section included . 12. Compare medication source (bubble pack, vial, etc.) with MAR [medication administration record] to verify resident name, medication name, form, dose, route, and time.Review of the MAR for R45, dated 03/01/2026 - 03/31/2026, revealed an order for metoprolol succinate oral capsule extended release (ER) 24-hour sprinkle 25 milligram (mg), give 25 mg by mouth one time a day for hypertension (high blood pressure). Review of the MAR for R92, dated 03/01/2026 - 03/31/2026, revealed an order for metoprolol tartrate oral tablet 25 mg, give one tablet by mouth two times a day. Observation during medication administration for R45 on 03/14/2025 at 9:02 AM revealed that Licensed Practical Nurse (LPN) HH stated that R45's metoprolol ER 25 mg was not available on the medication cart. Continued observation and interview at 9:03 AM revealed LPN HH stated she would obtain the medication from R92's medication packet since he was ordered the same medication. LPN HH removed the medication from the pill card of R92 and placed it in a medicine cup. Further observation at 9:04 AM revealed LPN HH administered the metoprolol tartrate oral tablet 25 mg from R92's medication supply to R45. In an interview on 03/14/2025 at 9:50 AM, near the nurses' station on the East Wing, Unit Manager GG stated that LPN HH should not have administered medication to R45 from another resident's medication card. Unit Manager GG further stated that the protocol was to obtain the correct medication from the back-up medication dispensing system. In an interview on 03/14/2025 at 11:20 AM, the Director of Nursing (DON) stated that if a resident's medication was not available, the nurse should obtain it from the facility's backup medication-dispensing system, and if it was not available in the backup system, the nurse should call the pharmacy.

Based on record review, staff interviews, and review of the facility policy titled MDS 3.0 Completion, the facility failed to complete a Minimum Data Set (MDS) comprehensive assessment for one resident (R) (R70) out of 57 sampled residents.Findings include: Review of the facility policy titled MDS 3.0 Completion, with a reviewed/revised date of 10/2025, revealed the Policy Explanation and Compliance Guidelines section included 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate, and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 2. c. Annual Assessment - a comprehensive assessment completed using an ARD no >366 days from the most recent prior comprehensive assessment and no >92 days from the most recent quarterly assessment (counting ARD to ARD). Review of R70's electronic medical record (EMR) admission Record revealed an admission date of 02/18/2024, with diagnoses including, but not limited to, bradycardia, epilepsy, and vascular dementia. Record review for R70 Clinical-MDS revealed the facility last completed a full comprehensive MDS assessment on 01/24/2025. An interview on 03/14/2026 at 1:57 PM with MDS Coordinator II revealed that a comprehensive assessment was not completed for R70 in February 2026. She stated that the previous MDS Coordinator failed to complete the comprehensive assessment for R70. The MDS Coordinator stated she will complete R70's annual comprehensive assessment. An interview on 03/14/2026 at 2:10 PM with the Administrator stated that the MDS department should follow the Resident Assessment Instrument (RAI) Manual for guidance. An interview on 03/15/2026 at 10:00 AM with the MDS Coordinator II explained that the facility has a system in place to ensure assessments are conducted in accordance with the specified timeframes for each resident. MDS Coordinator II stated that when a resident is admitted to the facility, an entry tracking assessment is completed, and further MDS assessments are driven by the resident's insurance (payor source) type. She stated that the MDS department should refer to the MDS Clinical List, and that, under the MDS tab, it will identify which assessment and when it is due.

Based on observations, staff interviews, record review, and review of the facility policy titled MDS 3.0 Completion, the facility failed to accurately reflect the status on the Minimum Data Set (MDS) assessments for two of 57 sampled residents (R) (R70 and R1). Findings include: Review of the facility policy titled MDS 3.0 Completion, with a reviewed/revised date of 10/2025, revealed the Policy section included, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. 1. Review of R70's electronic medical record (EMR) admission Record revealed an admission date of 02/18/2024, with diagnoses including, but not limited to, bradycardia, epilepsy, and vascular dementia. Review of the quarterly MDS assessment for R70, dated 01/19/2026, revealed that section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 2 (indicating severe cognitive impairment). Section J (Health Conditions) documented that the resident was assessed as having no falls. Review of the Facility Incident Form Report dated 12/06/2025 revealed that R70 fell, was unresponsive, did not respond to commands, 911 was called, and the resident was transported to the hospital. The unwitnessed fall was substantiated. In an interview on 03/14/2026, R70 stated he had fallen in the past and had gone out to the hospital once. The resident stated he has not had any recent falls. In an interview on 03/14/2026 at 10:55 AM, Licensed Practical Nurse (LPN) JJ stated R70 had sustained two unwitnessed falls. She stated the resident was sent out to the hospital in December 2025 for a fall and possible seizure activity. In an interview on 03/14/2026 at 1:57 PM, the MDS Coordinator confirmed that R70 had a fall on 12/06/2025. She confirmed that, in the quarterly MDS assessment on 01/19/2026, Section J falls was not accurately coded for R70. The MDS Coordinator stated she would make the necessary correction to R70's quarterly MDS assessment of 01/19/2026. 2. Review of the facility's EMR revealed R1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, peripheral vascular disease. Review of the quarterly MDS assessment for R1, dated 12/18/2025, revealed that section C (Cognitive Patterns) documented a BIMS score of 15 (indicating intact cognition). Section P (Restraints and Alarms) documented R1 used bed rails daily. Review of the care plan for R1, dated 12/21/2025, documented no focus area for the use of restraints. Review of the physicians' orders for R1 documented no order for restraints. Observation on 03/13/2026 at 10:31 AM revealed R1 lying in bed. Observation revealed there were no bed rails on R1's bed. Observation on 03/14/2026 at 8:40 AM revealed R1 sitting up in bed watching television. Observation revealed there were no bed rails on R1's bed. Observation on 03/15/2026 at 1:31 PM revealed R1 in his room watching television and listening to music. Observation revealed there were no bed rails on R1's bed. In an interview on 03/14/2026 at 8:44 AM, R1 stated that he did not have bedrails on his bed and was able to transfer without them. In an interview on 03/14/2026 at 8:49 AM, the MDS Coordinator confirmed that the MDS assessment for R1, dated 12/18/2025, incorrectly documented the use of bedrails. She stated that if there were no bed rails on the bed, the MDS should not document that the resident used bed rails. In an interview on 03/14/2026 at 9:36 AM, Unit Manager (UM) GG stated R1 did not use bed rails. She stated that an audit was recently conducted on residents with and without bedrails, and the results were given to the MDS Coordinator to update the residents' MDS. She confirmed there were no physicians' orders for bed rails for R1, and that R1 did not need or use bedrails. In an interview on 03/15/2026 at 11:56 AM, the Administrator stated her expectations were for the MDS assessments to be timely and accurate. She stated that the facility conducted a bedrail in February 2026, and the audit results were sent to her and the MDS Coordinator.

Based on record review and staff interviews, the facility failed to ensure one of 57 sampled residents (R) (R36) received restorative care services as recommended by therapy staff. This deficient practice had the potential to place R36 at risk of unmet needs and a diminished quality of life. Findings include: Review of the clinical record revealed R36 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, contractures of the right and left hands, contractures of right and left knees, contractures of right and left ankle, contractures of right and left foot left hand. Review of the significant change Minimum Data Set (MDS) assessment for R36, dated 02/12/2026, revealed section GG (Functional Abilities and Goals) documented R35 was dependent on staff for all activities of daily living (ADL's). Review of the occupational therapy (OT) discharge documentation revealed R36 was discharged from services on 06/08/2025. The OT document stated, Discharge Recommendations restorative. During an interview on 03/15/2026 at 12:00 PM, the Assistant Director of Nursing (ADON) stated that she was responsible for the facility's restorative care program. The ADON stated that R36 was currently not receiving restorative care. She stated that once a resident is discharged from therapy services, therapy would make recommendations if restorative services were needed. During an interview on 03/15/2026 at 12:15 PM, the Director of Therapy (DT) revealed that R36 was last seen and discharged from physical therapy and occupational therapy on 06/09/2025. The DT reviewed the OT discharge documentation and confirmed that the OT recommended R36 to receive restorative care post-discharge from therapy services. The DT stated that once the OT marked the recommendations for restorative services therapy, staff completed a paper form indicating the required care needs, and that form was handed to her. The DT stated that she reviewed the form, placed the resident's name on a list, and that list was provided to the ADON, who is responsible for the restorative program. Continued interview with the DT revealed that she was unable to locate the paper form that the occupational therapist should have completed. The DT stated that the OT should have completed the paper form and provided it to her when R36 was discharged from therapy services. The DT revealed that therapy staff did not follow the proper process for ensuring a resident is placed on the list to receive restorative services. During an interview on 03/15/2026 at 12:40 PM, the ADON revealed that a resident can receive restorative services without a therapy consultation. The ADON stated that if a Certified Nursing Assistant (CNA) noticed that a resident had a decrease in mobility, they could recommend restorative services. The ADON stated that once nursing staff recommends a resident for restorative services, the team, consisting of nurses, the Director of Nursing (DON), ADON, and therapy staff, discusses whether restorative services would be beneficial for the resident during the morning meeting. The ADON stated that if a CNA notices a resident in need of restorative services, they should report it to the charge nurse, who should then notify the DON to add the resident to the list for discussion during the morning meeting. The ADON revealed that R36 had not been discussed during the meetings regarding receiving restorative services. During an interview on 03/15/2026 at 12:50 PM, CNA MM revealed that R36 was currently not receiving restorative services. The CNA stated that if she notices a resident with decreased mobility, she would notify the charge nurse. The CNA stated she has notified the charge nurse that R36 has mobility issues. During an interview on 03/15/2026 at 1:10 PM, Licensed Practical Nurse (LPN) GG stated that she was the charge nurse for the unit where R36 resides. LPN GG stated that she assumed R36 was receiving restorative services. Continued interview revealed that she does not recall the CNA notifying her of R36's decrease in mobility.

Based on observations, record review, staff interviews, and a review of the facility policy titled Hospice Services Facility Agreement, the facility failed to maintain communication and coordination of care with hospice for one of six residents (R) (R7) receiving hospice palliative care services. This deficient practice had the potential to place R7 at risk of unmet care needs. Findings include:A review of the facility policy titled Hospice Services Facility Agreement, last reviewed/revised date of September 2023, revealed that, It is the policy of this facility to provide and/or arrange for hospice services to protect a resident's right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility has a designated Director of Nursing to be responsible for working with hospice representatives to coordinate care to the resident provided by the facility and hospice staff. The designated member of the facility working with hospice representative is responsible for: (A) collaborating with hospice representatives and coordinating LTC facility participation in the hospice care planning process for those residents receiving services. (B) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions to ensure quality of care for the resident and family. (D) Obtaining the following information from hospice: (i) The most recent hospice plan of care specific to each resident. (E) Ensuring that the facility provides orientation to hospice staff on the following: (iv) record-keeping requirements. The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.Review of the electronic medical record (EMR) revealed that R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, senile degeneration of brain, eosinophilic esophagitis, type 2 diabetes mellitus, long-term use of antithrombotic /antiplatelet, depression, essential hypertension, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, history of other venous thrombosis and embolism, contracture, right knee, contracture, left knee, contracture, left hand, and vitamin d deficiency.Review of the physician orders revealed that R7 was admitted to hospice on 09/06/2024 due to the diagnosis of senile degeneration of the brain. Review of the annual Minimum Data Set (MDS) assessment for R7, with an Assessment Review Date (ARD) date of 01/23/2026, revealed that R7 presented with a Brief Interview for Mental Status (BIMS) score of zero, indicating that the resident is rarely or never understood, and that R7 was receiving hospice care.A review of the Hospice Care Plan created by the facility, dated 02/26/2026, revealed that R7 began receiving hospice services on 09/06/2024. It was noted that the resident would experience the highest quality of life throughout their life journey; that the facility staff would notify hospice of significant changes, clinical complications needing (plan of care) change, the need to transfer the client, and/or death; the facility would assess for pain, restlessness, agitation, constipation, and other symptoms of discomfort; the facility would medicate as ordered and evaluate effectiveness; the facility would provide non-pharmacological approaches to aid in decreasing discomfort; that bereavement service would be provided by hospice (as needed) to help with grief and loss; and that support to the resident and family would be provided, including caregivers and other residents, before and after death. It was further noted that the hospice provider would provide over and beyond services, which include, but are not limited to, spiritual counseling, increased social services, increased clinical visits, and expanded pain/comfort control; provide emotional and social support to the patient and family to address anticipatory grief, end-of-life wishes/planning needs, and other identified items; and collaborative care with hospice staff.A review of the Hospice and Nursing Facility Services Agreement dated 8/28/2024 revealed, This Hospice and Nursing Facility Services Agreement is entered into as of this 28th day of August 2024 by and between (skilled nursing facility) and (Hospice company) for patient (R7). Section VII of the Service Agreement revealed that, hospice and skilled facility each agrees to cooperate with the other in revising the quality and appropriateness of Hospice services rendered in the Skilled Facility. To this end, Skilled Facility and Hospice will each appoint two individuals who, together, constitute a liaison committee which will meet, when appropriate, to review working relationships between Hospice and Skilled Facility to discuss services rendered to Residents who are Patients, and to make recommendations for improving the contractual agreement between the parties. Discussions and recommendations for improving the contractual agreement between parties. Discussions and recommendations of the Liaison Committee will be considered advisory to Skilled Facility and Hospice, and not binding upon either party. The written agreement will set out at least the following: d. a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are met 24 hours per day. It is further noted that, The facility has designated the Director of Nursing to be responsible for working with hospice representatives to coordinate care to the resident provided by the facility and hospice staff. On 03/14/2026 at 12:46 PM, R7 was observed in bed with some type of hand roll in her right hand and lying on the right side with a wedge behind her. The resident was nonverbal and unable to express her needs.During an interview on 03/14/2026 at 1:00 PM, Licensed Practical Nurse (LPN) JJ stated that they only have a facility care plan. She confirmed that there was no plan of care from the hospice provider coordinating or outlining the services they provide to R7. When asked how the facility staff would know what services the hospice staff provided, LPN JJ stated that all the information should be in the facility care plan.During an interview on 03/14/2026 at 1:10 PM, Registered Nurse (RN) KK stated that she checked the EMR, and there was no documentation of the interventions or services the hospice provided for R7. She confirmed that, at this time, she couldn't determine what hospice does or was responsible for. She stated she would not be able to inform the nursing staff if the resident had a shower, vitals, or any other services by hospice. She stated that the hospice provider does not have access to the facility's EMR and that they document in their own electronic system, which the facility staff does not have access to. During an interview on 03/14/2026 at 1:26 PM, the Director of Nursing (DON) confirmed that they did not have a hospice care plan or a hospice communication book. She stated that the hospice staff just verbally reports to the facility nursing staff on what they have done. She confirmed that they do not have a copy of the hospice plan of care, but they are reaching out to obtain it.During an interview on 03/14/2026 at 1:37 PM, R7 was observed in bed with Certified Nursing Assistant (CNA) LL assisting her with her meal. She stated that she was not assigned to care for R7, but she has cared for residents in the facility who are receiving hospice services. When asked how she knows what care or services are provided to a resident by hospice, she stated, We don't know. They sometimes will tell you when they are here, but sometimes we don't even know if they came or what they did.During an interview on 03/14/2026 at 1:37 PM, the Wound Care Nurse stated that she provided all wound care, including for residents receiving hospice services. She stated that the hospice provider does not do any wound care for R7. When asked how she would know if the hospice nurse was looking at the wound or measuring the residents' wounds, she stated, I just know. We do all that. During an interview on 03/14/2026 at 1:50 PM, CNA MM stated that the hospice aide comes in and gives the resident showers. She stated that sometimes she will help or just leave a towel on the bed, but that was pretty much all the aide does. She confirmed that she was not sure if that was written anywhere.During a telephone interview on 03/14/2026 at 2:40 PM, the Triage Hospice Nurse stated that he could only provide general information due to HIPAA (Health Insurance Portability and Accountability Act) laws. He stated that they have their own electronic medical record system for documenting care. He further stated that the hospice care manager comes out weekly, and the hospice staff should have verbal and written communication with the facility staff on the services provided to the residents. He could not answer questions related to the specific means of communication of activities of daily living (ADL) care or nursing services provided by hospice staff. During an interview on 03/14/2026 at 2:56 PM, the Nursing Home Administrator (NHA) stated that the Social Worker (SW) was the designated Interdisciplinary Team (IDT) member responsible for communicating with hospice.During an interview on 03/14/2026 at 3:00 PM, the SW stated, We are not involved in hospice care planning. She stated that hospice has a CNA come in every day. She stated that the hospice provider has not had an SW, and if they have one, they have not been in the facility. The last time she spoke with the SW related to R7 was in November 2024. She was asked to confirm that there was no plan of care for R7; she stated, They have a plan of care. They come in and provide her hospice services. When asked what services, she stated that the plan of care is verbal communication. Unless it pertains to social services, she does not review the plan of care. During an interview on 03/15/2026 at 9:08 AM, the NHA confirmed that she had just received the hospice plan of care and the coordination of care documents from the hospice provider. She stated that the communication liaison was the facility's SW, but she was not sure of the communication process for hospice. She provided notes dating back to 2024 that the resident has been receiving hospice services. She confirmed that the hospice documentation for the coordination of care for R7 was retrieved on 03/14/2026.During an interview on 03/15/2026 at 9:55 AM, the DON stated that she had not read the hospice policy and was not involved in the care planning for residents receiving hospice services. She stated she did make sure that, when they are in the building, they check in. During an interview on 03/15/2026 at 10:05 AM, the NHA confirmed that the policy noted that the DON is responsible for the coordination of care.

Based on observations, staff interviews, record review, and review of the facility's policies titled Catheter Care and Infection Prevention and Control Program, the facility failed to follow infection control process during indwelling catheter care for one of 11 residents (R) (R1) with an indwelling urinary catheter. This deficient practice had the potential to place R1 at risk of avoidable infection due to cross-contamination.Findings include: Review of the facility's policy titled Catheter Care, revised October 2025, revealed Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.Review of the facility's policy titled Infection Prevention and Control Program revised April 2025 documented Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.Review of the facility's electronic medical records (EMR) revealed R1 was admitted to the facility on [DATE] and was readmitted [DATE] with a diagnosis that included, but was not limited to, retention of urine.Review of the quarterly Minimum Data Set (MDS) assessment for R1, dated 12/18/2025, revealed that section H (Bladder and Bowel) documented that R1 had an indwelling catheter.Review of the care plan for R1, dated 12/21/2025, documented R1 has a supra-pubic catheter related to (r/t) diagnosis (dx) of neurogenic bladder, retention of urine, bilateral hydronephrosis, obstructive and reflux uropathy, and benign prostatic hypertrophy (BPH). The goal was that R1 would show no signs or symptoms of a urinary infection and would be/remain free from catheter-related trauma through the review date. Interventions included cleaning the catheter stoma site as ordered, reporting any abnormalities to the physician, and enhanced barrier precaution in place.Review of the Physicians' Orders for R1, dated 02/20/2026, documented orders included, but not limited to, Supra Pubic Catheter 18_french (FR) with_10_cubic centimeter (cc) balloon to bedside straight drainage. May change when catheter is occluded, leaking or obtaining a new specimen, as needed for catheter change and every shift for care and as needed for care. Perform Supra Pubic Catheter Care with Soap and Water every day and evening shift for catheter care.Observation on 03/14/2026 at 11:25 AM of catheter care for R1 revealed Licensed Practical Nurse (LPN) FF did not wear a gown during the catheter care, she did not clean a pair of scissors she used to cut the old dressing from the indwelling urinary catheter before placing the scissors in her uniform pocket, and she did not clean the resident's bedside table after removing the wash basin from the bedside table she used for the catheter care. Further observations revealed that Enhanced Barrier Precaution (EBP) signage was on R1's room door, personal protective equipment (PPE) was accessible in the hallway near R1's room, and personal items were observed on R1's bedside table used during the catheter care procedure.In an interview on 03/14/2026 at 11:40 am, LPN FF confirmed she did not wear a gown during catheter care, did not clean the pair of scissors she used to cut the old dressing from the indwelling urinary catheter, and did not clean the resident's bedside table after removing the wash basin. She stated she should have worn a gown because the resident was on EBP, and she should wear a gown whenever certain procedures were done for the resident, which involved high contact. She stated that performing indwelling urinary catheter care was a high-contact procedure, and she should have worn a gown. She further stated that the gowns were available in the hallway across from the resident's room, and the EBP signage was on the door. LPN FF further stated she should have cleaned the resident's bedside table after removing the wash basin, and she should have cleaned the pair of scissors after cutting the old dressing on the catheter before placing it back into her pocket, because it could cause cross-contamination and infection for the resident. She confirmed the resident prefers to eat his meals in his room, and the meal tray would be placed on the resident's bedside table, so if the bedside table was not cleaned, the resident could get an infection. She stated that if the scissors were not cleaned, she could reuse them on R1, and that would cause cross-contamination and spread of infection to R1.In an interview on 3/15/2026 at 7:33 AM, the Director of Nursing (DON) stated her expectations were for the staff to wear appropriate PPE, such as gloves and gowns, when performing catheter care because there could be cross-contamination and the residents could get infections. She stated that if the wash basins were placed on the residents' bedside tables, the staff needed to clean the tables since the residents use the bedside tables to eat, and they may consume contaminated foods or get an infection by touching the table. The DON further stated that whenever scissors were used to remove dressings, the scissors should not be placed in the staff's pockets before being cleaned, and they should be cleaned appropriately because they could cause cross-contamination and infection to the residents if they were used on the residents without being cleaned.In an interview on 03/15/2026 at 10:12 AM, the Infection Preventionist (IP) stated her expectations were for the staff to wear appropriate PPE when providing catheter care. She stated the staff needs to wear gowns and gloves for catheter care because the gown provides a barrier between the staff and the residents during care. The IP further stated that if gowns were not worn by the staff, bacteria could spread to the residents. The IP stated that when wash basins were used on the residents' bedside tables, the tables should be sanitized after use because the residents placed personal items on the bedside tables, so there was an increased risk of transferring infection to the residents. The IP further stated that scissors should be cleaned after use, and not placed in the staff's uniform pocket without being cleaned. The IP stated there could be a high risk of infection to the residents when the scissors were not cleaned.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Food Preparation and Service - Sanitation, the facility failed to ensure residents were free from safety and sanitation hazards in the kitchen to include: keeping an air vent soiled with dust and debris; allowing an electrical outlet without a face plate in the dishwashing room; allowing paint chips to hang over the stove and oven area; using metal food trays that were warped and unserviceable; and maintaining an eye wash sink with a visible, brown substance pooled in it. The deficient practice had the potential to affect 121 of 121 residents who receive an oral diet. Findings include: Review of facility policy, Food Preparation and Services - Sanitation last revised April 2024 documented in Guidelines: 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Observations on 3/16/2025 at 1:25 pm of the facility kitchen during the initial tour with [NAME] AA revealed the ceiling vent in the dietary hallway was soiled with dust and debris. An exposed electrical outlet was observed in the dishwashing room right beside the dishwasher. Observed peeling paint above the oven/stove. Observed numerous food trays with visible dirt and debris on them. The eyewash sink area was noted to have a tray in it covering a dried, brown substance pooled in the sink. Observations on 3/18/2025 at 11:10 am of the kitchen area with the Dietary Services Manager (DSM) revealed the vent in the dietary hallway that previously had dust and lint on it was cleaned. The rack of trays that had been identified as dirty and unserviceable had been replaced with brand new trays. The electrical outlet in the dishwashing room that had previously been missing had been repaired. The eyewash sink area that had been previously dirty had appeared clean. The paint above the stove no longer has loose paint hanging off it and was recently painted. Interview on 3/19/2025 at 7:22 am with DSM revealed the Maintenance Director (MD) was responsible for in-house repairs. She stated that some equipment must be ordered, and it took time. She went on to reveal that the eye wash sink was repaired this week. The pipe dropped, and that's what caused the need. A repair request was entered in the electronic work order system. The sheet pans do need to be clean and free of debris. We disposed of the old pans. The pans we threw away were warped and junked up. When I saw peeling paint above the stove, I put a work order in the system. Maintenance scraped and repainted the area. I didn't know about the face of the electrical outlet in the dishwashing room. The MD repaired the electrical outlet on 3/16/2025. The front plate was off the outlet, and that's why we repaired it. I wasn't aware that the vent in the hallway was dirty. Maintenance cleaned the vent. Interview on 3/19/2025 8:34 am with the MD revealed the facility had an electronic system for making work orders. The DSM knew how to use the work order system, and he could enter them. The MD stated it did need cleaning. The MD personally scraped and painted the area where the paint was chipping. He stated it needed painting. A metal cover was put on the electrical outlet. It was missing the cover, and it needed replacement. We fixed the drain in the eyewash sink, and it needed it. Interview on 3/19/2025 at 9:10 am with the Administrator revealed expectations were that food was stored and prepared in a clean environment. The Administrator stated they weren't aware of the dirty vent in the hallway, chipping paint over the stove, and the sink needing repair.

Based on observations, staff interviews, record review, and review of the facility policy titled, Accommodation of Needs, the facility failed to ensure that one of 50 sampled residents (R) (R60) needs were being met in regards to the call light being within reach. Findings include: Review of the policy titled Accommodation of Needs revised March 2023 revealed under Policy: The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. Under Policy Explanation and Compliance Guidelines: .2. The facility will ensure that common areas frequented by residents are accommodating physical limitations and enhance their abilities to maintain independence. 3. Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible. Review of the electronic medical record (EMR) revealed R60 was admitted to the facility with diagnoses including but was not limited to dysphagia, muscle weakness (generalized), cerebral palsy, hypothyroidism, gastro-esophageal reflux disease without esophagitis, hypertension, other seizures(g40.89), diverticulum of esophagus, convulsions, shortness of breath and systemic inflammatory response syndrome (SIRS). Review of R60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not assessed. Section GG- Functional Status, revealed-Upper/ Lower extremity-on one side and Section O - Special Treatments, Procedures, and Programs revealed oxygen therapy. Review of R60's care plan dated 12/26/2024 did not reveal goals or interventions related to R60's call light being within reach. An observation on 3/17/2025 at 10:53 pm revealed R60 to be nonverbal. R60 was lying in bed watching tv. The call light was out of reach. An observation on 3/17/2025 at 1:35 pm revealed R60 lying in bed watching tv. The call light was out of reach. An observation on 3/17/2025 at 2:01 pm revealed R60 lying in bed watching tv. The call light was out of reach. During an interview/observation at 3/17/2025 at 3:25 pm with Licensed Practical Nurse (LPN) JJ confirmed the call light was out of reach as she has never seen R60 use her call light button. During an interview on 3/19/2025 at 1:45pm with the Unit Manager (UM) KK confirmed R60 cannot use her call light, however staff checks on her frequently. UM KK confirmed something should be put in place for R60 to alert staff if she was in any distress due to her not being able to utilize the call light. During an interview on 3/20/2025 at 12:15 pm with the Administrator confirmed she was not aware that R60 could not use her call light as she can offer her a bed light. The Administrator confirmed that R60 needed to have something in case of an emergency as she cannot rely on her roommate to assist.

Based on observations, staff interviews, record review, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to implement an oxygen (O2) care plan for one of 50 sampled residents (R) (R60) to ensure the resident reaches his/her highest practicable physical, mental, and psychosocial well-being. The deficient practice had the potential for R60's needs to go unmet. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered updated December 2022 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: .b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of R60's care plan dated 12/26/2024 revealed Focus Area R60 requires oxygen therapy r/t (related to) ineffective gas exchange. R60 often removes oxygen from her nose and can be resistant to allowing staff to replace. Goal-R60 will have no signs of poor oxygen absorption through the review date. Intervention-change oxygen tubing as ordered, give medications as ordered by physician, monitor/document side effects and effectiveness. If R60 is resistant to have oxygen (O2) delivery through a nasal cannula (NC), replaced, explain why oxygen is needed and try again. Review of the Physician's Orders for R60 included but was not limited to an order dated 12/2/2024-Oxygen at 3.5 L/min (LPM) via nasal cannula (NC) continuously. During an observation on 3/17/2025 at 10:53 am, R60 was noted to be nonverbal. R60 was lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The oxygen flow was set at 2.5 LPM. During an observation on 3/17/2025 at 1:35 pm, R60 was noted to be lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The O2 flow was set at 2.5 LPM. During an observation on 3/17/25 at 2:01 pm, R60 was lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The O2 flow was set at 2.5 LPM. During an interview/observation at 3/17/2025 at 3:25 pm with Licensed Practical Nurse (LPN) JJ confirmed that R60's O2 was not attached to her nose with the tubing sitting on her forehead. An interview on 3/19/2025 at 1:45 pm with Unit Manager (UM) KK confirmed that R60's O2 should be set at 3.5 LPM per physician orders and it should be in her care plan. UM KK confirmed the O2 flow level was set at 2.5 LPM and the physician order was not noted in the care plan. During an interview on 3/20/2025 at 11:25 am with the Director of Nursing (DON), she confirmed there was no documentation in the care plan for R60's O2 orders. She stated that staff should be following orders per physicians' recommendations. If the resident was known for taking off her O2, staff should visit the room more frequently. The DON stated the physician's orders, care plan, and O2 flow should be consistent with each other. The DON also stated the RT (Respiratory Therapist) should be communicating with medical team to include nurses, the DON, Assistant Director of Nursing (ADON), and the physician, as well as sharing information during clinic meetings regarding attempts to wean residents to a lower O2 flow. The DON expected staff to follow the physician's orders with all residents. An interview on 3/20/2025 at 12:15 pm with the Administrator confirmed orders, antibiotics and behaviors should be added to the care plan. The administrator stated all orders should be followed according to the physician's recommendations.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, Comprehensive Person- Centered, the facility failed to revise a care plan for three of 50 sampled residents (R) (R17, R60, and R98). The deficient practice had the potential for residents not to receive prescribed and needed care and services. Findings include: Review of the policy titled Care Plans, Comprehensive Person-Centered, revised December 2022 revealed under Policy Interpretation and Implementation: . 13. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. 1. Review of R17's care plan dated 2/16/2025 indicated a focus problem of altered respiratory status/difficulty breathing r/t (related to) chronic respiratory failure, chronic obstructive pulmonary disease (COPD) and requires oxygen 3L (liters) continuously. Goals included but not limited to R17 will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern. Interventions included but not limited to administer medication/puffers as ordered. Elevate the head of bed to 45 degrees. Medication and oxygen as ordered. Oxygen (O2) settings: O2 via nasal cannula NC as ordered. Review of the Physician's Orders for R17 included but not limited to: 1/22/2025 Trelegy Ellipta Inhalation aerosol powder breath activated 100-62.5-25 MCG/ACT (micrograms per actuation) (fluticasone-umeclidinium-vilanterol) 1 puff inhale orally in the morning for (COPD). 1/23/2025 albuterol-budesonide inhalation aerosol 90-80 MCG 2 puffs inhaled orally every 6 hours as needed for wheezing or shortness of breath (SOB). 2/12/2025 oxygen at 3 L/min (LPM) via nasal cannula continuous every shift for oxygen management-(COPD). An observation of R17 on 3/16/2025 at 3:27 pm revealed she received O2 continuously which she placed the NC on and off at her discretion. She did not have it on during this time when checked to see where the dosage was on the concentrator (machine that delivers O2) via flow meter. The flowmeter was set at 3 LPM as ordered. An observation on 3/17/2025 11:05 am revealed the O2 NC lying in bed with the concentrator on. Also, an O2 tank hanging on the back of the wheelchair while the resident was not present in the room. Observation on 3/17/2025 at 11:32 am revealed R17 was not in her room. She was in the dining area in activities. She was not wearing her O2 via concentrator nor tank to the wheelchair, as ordered continuously. An observation of R17 on 3/20/2025 at 11:00 am revealed she was in the hallway not wearing her O2. Interview on 3/17/2025 at 3:17 pm in the resident's room with Licensed Practical Nurse (LPN) EE revealed the resident was prescribed O2 at 3 LPM continuously. R17 was not wearing O2. Interview on 3/20/2025 at 11:25 am with the Director of Nursing (DON), she confirmed there was no documentation in the care plan that stated R17 was allowed to take her O2 off when she wanted to. She said staff should be following orders per physicians' recommendations and if the resident was known for taking off her O2, staff should be visiting the room more frequently. The DON stated the orders, care plan and O2 flow should be consistent with each other. The DON also stated the Respiratory Therapist (RT) should be communicating with the medical team to include nurses, DON, ADON (Assistant Director of Nursing), and physician, and sharing information during clinic meetings regarding attempts to wean resident to a lower O2 flow. The DON expectations were that the staff would follow the physician's orders with all residents. During an interview with the DON on 3/20/2025 at 11:30 am it was revealed that the MDS Staff were responsible for developing care plans for residents when they are non-complaint with doctors' orders and not wanting O2 or any other medical device on as ordered. 49138 2. Review of R60's care plan dated 12/26/2024 not reveal O2 orders per physician's orders. Review of the Physician's Orders for R60 included but was not limited to: 3/7/2025-Oxygen at 3.5L/min via nasal cannula continuously every shift for oxygen management. Observation on 3/17/2025 at 10:53 am revealed R60 to be nonverbal, lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The O2 flow was on 2.5 LPM. Observation on 3/17/2025 at 1:35 pm revealed R60 lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The O2 flow was on 2.5 LPM. Observation on 3/17/2025 at 2:01 pm revealed R60 lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The O2 flow was on 2.5 LPM. During an interview on 3/19/25 1:25pm with MDS Coordinator HH stated the care plan for R60 was correct and the physician oxygen order of 3.5 LPM did not need to be included in the care plan. During an interview/observation at 3/17/2025 at 3:25 pm with Licensed Practical Nurse (LPN), LPN JJ confirmed that R60's O2 was not attached to her nose as the tubing was sitting on her forehead. During an interview on 3/19/2025 at 1:45 pm with Unit Manager (UM) UM KK confirmed that R60's O2 should be set at 3.5 LPM per physician orders and it should be in her care plan. UM KK confirmed the flow level was set at 2.5 LPM and the physician order was not noted in the care plan. During an interview on 3/19/2025 at 1:57 pm with RT LL revealed the level of R60's O2 changed in efforts to wean her off O2. RT LL stated he did not document his attempts or talk with the physician about his efforts to wean R60's O2 level. During an interview on 3/20/2025 at 11:25 am with the DON, she confirmed there was no documentation in the care plan for R60's O2 orders. Review of R98's care plan dated 2/9/2025 revealed the care plan was not updated to address to incident of sexual abuse/inappropriate touching to identify R98 as being vulnerable. Review of the Physician's Orders for R60 included but was not limited to: Order dated 2/26/2025-trazodone HCl (hydrochloride) Oral Tablet (trazodone HCl)-Give 12.5 mg by mouth at bedtime for insomnia/restlessness. Order dated 2/1/2024-Observation: Antidepressant Behavior Monitoring - Observe for change in mood or depressed state, little interest or pleasure doing things, hopelessness, sad facial expression, crying, sleep pattern changes, appetite changes trouble concentrating, moving and speaking slowly, fidgety, restlessness, or thoughts of harming oneself (every shift for antidepressant behavior monitoring). Order dated 11/26/2024-Skin Assessment to be done on Tuesdays (3-11). Open Skin Check Form and Complete from UDA. Durning an observation on 3/17/2025 at 10:42 am, R98 was observed sitting in the activity room watching television. The surveyor attempted to speak with R98, but she did not reply. During an interview on 3/19/2025 at 1:25pm with MDS Coordinator confirmed that she did not see an update on the care plan regarding the inappropriate touching. During an interview on 3/19/2025 at 2:45 pm with MDS HH and the Social Services Director confirmed there was no care plan for R98 to address the incident that occurred regarding inappropriate touching. During an interview on 3/20/2025 at 11:25 am with the DON confirmed that R98's care plan should have been updated after the incident that occurred between. The DON stated adding R98 being vulnerable to inappropriate behavior made sense. During an interview on 3/20/2025 at 12:15 pm with the Administrator confirmed that R98's care plan should have been updated after the incident.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide grooming care for one of 50 sampled residents (R)(R70) dependent on staff for care. This deficient practice had the potential to cause a decline in R70. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) revised January 2024 revealed under Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Under Policy Explanation and Compliance Guidelines: . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the electronic medical record (EMR) revealed R70 was admitted to the facility with pertinent diagnoses including but not limited to abnormal electrocardiogram, unspecified diastolic (congestive) heart failure, hypertension, paroxysmal (comes and goes) atrial fibrillation, chronic kidney disease, chronic respiratory failure with hypoxia (low oxygen (O2) level) and dependence on supplemental oxygen. Review of R70's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicates R70 had severe cognitive impairment and Section GG, Functional Status, revealed R70 had no impairment but required assistance with ADLs. Review of R70's care plan dated 10/1/2024 indicated a problem of R70 has an ADL self-care performance deficit. Goals included but not limited to R70 will show Interventions improvement in current level of ADL function through the review date. Interventions included but not limited to one staff assistance with bathing, showering, eating, with personal hygiene. Staff will also check for nail length and trim and clean on bath day and as necessary. Review of the Physician's Orders for R70 included but was not limited to: Order dated 1/18/2024-Enhanced barrier precautions with high contact care activities every shift. Order dated 2/25/2025-mirtazapine 30 mg tablet-give one tablet by mouth daily for depression (30 mg (milligram). *Order dated 12/28/2024-albuterol sulfate HFA (hydrofluoroalkane) 90 mcg (micrograms), Inhaler-inhale two puffs by mouth every four hour(s) as needed for chronic obstructive pulmonary disease. An interview/observation with R70 on 3/16/2025 at 2:25 pm revealed staff refused to shave R70. R70 stated he told staff he needed a shave but was denied a shave. Observation revealed R70 needed a shave by evidence of hair on R70's face. An interview/observation on 3/17/2025 at 9:25 am with R70 revealed staff would not shave him. Observation revealed R70 still needed shave by evidence of facial hair. Durning an interview/observation with R70 on 3/17/2025 at 11:02 am revealed R70 was not feeling well as his foot was hurting due to wearing his foot brace. R70 stated he was still in need of a shave. Observation revealed R70 still needed a shave by evidence of facial hair. R70 stated he asked for a shave several times but was told staff did not have time. Interview on 3/20/2025 at 9:25 am with Licensed Practical Nurse (LPN) II the facility does not keep a grooming log. LPN II was not able to provide documentation of resident grooming. Interview on 3/20/2025 11:25 am with the Director of Nursing (DON) confirmed residents should not have waited days to get a shave if requested. The DON stated all staff should document if a resident refused care. Interview on 3/20/2025 at 12:15 pm with the Administrator confirmed she conducted monthly meetings regarding grooming. Staff have been informed that all residents must be touched with water weekly, bedding needs to be changed, and residents should be groomed. The Administrator stated if a resident requested a shave, it should have been honored.

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to ensure that two of four residents (R) (R60 and R17) receiving O2 were administered O2 therapy in accordance with the physician orders. The sample size was 15. The deficient practice had the potential to place R60 and R17 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Oxygen Administration revised December 2022 revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Under Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under the orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: .2. When to administer, such as continuous or intermittent and/or when to discontinue. C. Equipment setting for the prescribed flow rates. D. Monitoring of SpO (oxygen saturation) levels and/or vital signs, as ordered. 1. Review of the electronic medical record (EMR) revealed R60 was admitted to the facility with diagnoses including but not limited to dysphagia, muscle weakness (generalized), cerebral palsy, hypothyroidism, gastro-esophageal reflux disease without esophagitis, hypertension, other seizures, diverticulum of esophagus, convulsions, shortness of breath, and systemic inflammatory response syndrome (SIRS). Review of R60 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was not assessed. Section GG, functional status, revealed R60 GG-Upper/ Lower extremity- on one side and Section O - Special Treatments, Procedures, and Programs revealed oxygen therapy. Review of R60 care plan dated 12/26/2024 revealed no O2 goals and interventions. Review of the Physician's Orders for R60 included but was not limited to an order dated 3/7/2025-Oxygen at 3.5L/min (LPM) via nasal cannula (NC) continuously every shift for oxygen management. An observation on 3/17/2025 at 10:53 am revealed R60 to be nonverbal. R60 was lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The O2 flow was noted to be on 2.5 LPM. An observation on 3/17/2025 at 1:35 pm revealed R60 lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The oxygen flow was noted to be on 2.5 LPM. An observation on 3/17/2025 at 2:01 pm revealed R60 lying in bed watching tv, O2 not attached, with tubing sitting on her forehead. The oxygen flow was noted to be on 2.5 LPM. An observation at 3/17/2025 at 3:25 pm with Licensed Practical Nurse (LPN) JJ confirmed that R60's O2 was not attached to her nose and the O2 tubing was sitting on her forehead. An interview on 3/19/2025 at 1:45 pm with Unit Manager (UM) KK confirmed that R60's O2 should be set at 3.5 LPM per physician orders and it should be in her care plan. UM KK confirmed the flow level was set at 2.5 LPM and the physician orders were not noted in the care plan. During an interview on 3/19/2025 at 1:57 pm with Respiratory Therapist (RT) LL revealed the level of R60's O2 changed in efforts to wean her off O2. RT LL stated he did not document his attempts or talk with the physician about his efforts to wean R60's O2 level. During an interview on 3/20/2025 at 11:25 am with the Director of Nursing (DON), she confirmed staff should be following orders per physicians' recommendations. The DON expected staff to follow the physician's orders with all residents. During an interview on 3/20/2025 at 12:15 pm with the Administrator confirmed all orders should be followed according to the physician recommendations. 48338 2. Review of the EMR revealed R17 was admitted with diagnoses of but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), diabetes mellitus 11 (DM11), paroxysmal atrial fibrillation, morbid severe obesity, anxiety disorder, osteoarthritis of the right shoulder and dysphasia. Review of the quarterly MDS dated [DATE] revealed R17 had a BIMS score of 13, indicating intact cognition, Section GG, Functional Status, required extensive assistance of one person with Activities of Daily Living (ADLS), Section O, Special Treatments, Procedures, and Programs, dependence on supplemental oxygen. Review of the Care Plan revealed a focus of R17 has COPD, chronic respiratory failure, history of chronic respiratory failure with and hypoxia. Shortness of breath lying flat and on exertion. She is on oxygen via nasal cannula at 3 liters per minute. The goal was for R17 to be free of signs of respiratory infections through the next review date. Interventions included keeping the head of bed elevated to at least 45 degrees or out of bed upright in a chair during episodes of difficulty breathing; monitor for difficulty breathing on exertion; Remind resident not to push beyond endurance; monitor for signs of acute respiratory insufficiency; administer medication/puffers as ordered, oxygen settings via nasal cannula at 3 liters per minute. Review of the physician's orders revealed an order dated 2/12/2025 for oxygen 3 liters per minute through nasal cannula continuous, every shift for oxygen management, (COPD). Observations on 3/16/2025 at 3:27 pm and on 3/17/2025 at 8:35 am of R19 revealed the resident was receiving O2 at 3 LPM via NC. Observation on 3/17/2025 at 11:32 am revealed R17 was not in her room. R17 was in the dining area in an activity. She was not wearing her O2 via concentrator nor tank to the wheelchair, as ordered continuously.

Based on record review, staff and family interviews, and review of the facility's policy titled Wound Treatment Management the facility failed to review, verify, and obtain physician orders for one of three sampled residents (R) (R11). Specifically, R11 had no post operative surgical wound care for the right [NAME] (a part of the shinbone that makes up one part of the ankle) which were not obtained from the physician. Actual harm occurred on 11/18/2022 when wound care was not implemented to the right [NAME] surgical site and an infection developed. The facility also failed to transcribe physician orders for one of one sampled residents R30 which resulted in the resident receiving phosphate binders (inhibits phosphorus into the blood stream during meals) without food. The sample size was four. Findings included: 1. A review of the policy titled Wound Treatment Management dated August 2023 revealed .Wound care treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence if the treatment nurse . A review of the medical record revealed R11 was admitted to the facility on [DATE] with diagnoses which included displaced bicondylar fracture of right tibia, acute pain, and muscle weakness. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed R11 had a Brief Interview for Mental Status Score (BIMS) score of 15 indicating no cognitive impairment. A review of the undated Baseline care plan revealed R11 was captured to have a surgical wound on the right lower extremity. A review of the care plan dated 12/6/2022 revealed .The resident has an actual impairment to skin impairment to skin integrity of the left [sic] lower leg r/t [related to] surgical wound . A review of the Skin Checks dated 10/12/2022, 10/19/2022, 11/2/2022, and 11/9/2022 revealed the assessment to the surgical wound to the right ankle was not captured. A review of the hospital records dated 10/17/2022 revealed .R [right] ankle XR [x-ray] from 10/17/2022 There is redemonstration of the plate and screw stabilization of the healing distal tibial fracture. Good anatomic alignment is maintained. No loosening or hardware complication seen on the current study. Additionally there is healing comminuted distal fibular fracture. Overall alignment of the ankle mortise is maintained . A review of the Nurse Practitioner notes dated 11/6/2022 revealed .Patient was followed up at [named hospital] Ortho appointment on 10/17/2022. Per discharge orders, patient is weight bearing as tolerated and range of motion as tolerated. Ortho follow up had concerns for right lower extremity wound and patient received new orders for antibiotics, Bactrim DS b.i.d. [twice daily] x10 days. Patient is to follow up with [named physician] on 11/11/2022 . A review of the progress notes dated 11/18/2022 revealed .Resident sent out for appointment to [named hospital] was admitted to hospital for leg infection . A review of the hospital record dated 11/18/2022 revealed .[named R11] is a [AGE] year old male with above injury and subsequent procedures. States his current facility us not changing his dressing or providing PT/OT; denies pain, does notes foul smell from leg bandages; states his bandages have not been changed since his last visit with [named physician] .dressing to R lower leg soiled, foul smelling with copious brown/yellow drainage present. Flap well inset; scattered hyper granulation tissue present about the posterior flap, anteromedial flap .Cultures positive for MRSA [methicillin-resistant staphylococcus aureus . I&D [incision and drainage] RLE [right lower extremity] w [with]/flap elevation . During a telephone interview on 1/29/2024 at 11:42 am, the family of R11 stated they had asked the facility nurses to check R11's wound. They refused because he did not have discharge orders to assess the wound. R11 had missed a doctor's appointment, and the family requested the nurses to look at R11's wound. They refused and gave another reason because his appointment was rescheduled. R11 went to a doctor's appointment on 11/18/2022 and it was noted the surgical wound was open and the wound was bleeding. The physician told them the wound was infected. The Family of R11 told the hospital physician the nurses refused to change the wound dressing because of no physician and the physician told them it was their job to care for the wound regardless of if there were orders from the hospital upon discharge. During a telephone interview on 1/30/2024 at 10:46 am, the Unit Manager VVV stated there was a treatment nurse on in the facility at the time R11 was admitted . The Treatment Nurse was responsible for getting wound care orders to assess all wounds. The Treatment Nurse was responsible for adding all wound care orders for new admissions. During an interview on 1/30/2024 at 12:20 pm, the Nurse Practitioner ZZZ stated she expected the nurses to contact the Nurse Practitioner or the Physician to receive for assessment, monitoring, and care of a wound to prevent infection. During a telephone interview on 2/7/2023 at 9:37 am, the Medical Director stated, wound care was everyone's responsibility. The expectation was for a full skin assessment be conducted on a resident with wounds and the Nurse Practitioner, physician, wound care team, be contacted for evaluation. During a telephone interview on 2/7/2024 at 10:35 am, the Former Treatment Nurse GGGG state R11 was already at the facility when she started working at the facility. When she started, she did not know anything about the resident. All she knew was that he was transferred to the hospital a then readmitted . There was no Treatment Nurse prior to her starting at the facility. A lot of things were missed at the facility. The NP would show the Treatment Nurse who was on her list, and she would pull up their treatments. If their treatments were there the Treatment nurse would do the skin assessments. If a skin assessment is conducted and a wound is discovered an order should be added for treatment. During a telephone interview on 2/7/2024 at 11:00 am, the Nurse Practitioner CCCC stated she started rounding in the facility late 2022 and she was always with a nurse. When she arrived at the facility she was always told of any new admittances with wounds. The medical provider standing orders until she arrived to assess the wound. The Nurse Practitioner CCCC only read only access to the electronic record and the Treatment Nurse would be responsible for updating all orders. 2. A review of R30's Admission Record, dated 12/23/2022, revealed diagnoses which included ESRD and dependence on renal dialysis. A review of R30's care plan, dated 11/13/2023, revealed the resident required hemodialysis related to diagnosis of ESRD. A review of R30's physician orders, dated 6/26/2023, revealed an order to give sevelamer carbonate tablet 800 mg by mouth three times a day with meals to lower phosphorus. A review of R30's physician orders, dated 12/18/2023, revealed an order to give sevelamer carbonate Tablet 800 MG by mouth three times a day. No special instructions to be given with meals. A review of R30's Medication Administration Record (MAR), dated January 2024, revealed Sevelamer Carbonate 800 MG tablet was to be given three times a day at 9:00 am, 2:00 pm, and 9:00 pm. There were no special instructions to be given with meals. On 1/24/2024 at 3:00 pm, the Nurse Practitioner ZZZ pulled up the order for sevelamer carbonate and stated it was a binder for phosphate. She stated it was to be taken with meals. She stated when the resident came back from the hospital the order was put into the computer wrong. She stated the 9:00 pm time was the time which was concerning to her. On 1/25/24 at 11:25 am, Licensed Practical Nurse (LPN) SS stated she remembered that the resident did not come in with orders from the hospital and if they do not come in with orders, they call the provider and get orders. She stated that was a while back, but she was pretty sure the Nurse Practitioner told her to use the orders the resident had when they left the facility. That was usually the protocol. She stated she did not document reaching out to the provider. On 1/25/2024 at 11:54 am, the pharmacist AAAA stated sevelamer carbonate should be given three times a day with meals. She stated it needed to be given with meals for absorption purposes. On 1/25/2024 at 12:44 pm, the Director of Nursing (DON) BB stated if a resident was not admitted with hospital orders, she would expect the staff to contact the on-call physician or the NP to get physician orders. She stated she would expect the orders to be transcribed into the computer the way the physician gave the orders. On 1/25/2024 at 3:35 pm, the Nurse Practitioner ZZZ stated she spoke with R30. She stated she wanted to take the Reglan with her other medications. She stated R30 was educated. She stated the phosphate binder R30 agreed to take with their meals and the Reglan at the same time. She stated the times were changed and the instructions were updated for giving with meals per the order. 49685

Based on observations, record review, and resident/staff interviews, the facility failed to honor the rights for three of five sampled residents (R) (R26, R27 and R43) related to maintaining personal property within their possession and ensuring possessions are rightfully returned to the residents. Findings included: Record review of the facility policy titled Resident Personal Belongings last revised June 2023 documented the following: It was the policy of the facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and to assure the personal belongings and or possessions are rightfully returned to the resident's representative in the event of the resident's death or discharge from the facility. All residents' possessions, regardless of their apparent value, will be treated with respect. The facility will support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence. All resident personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room and the facility will exercise reasonable care for the protection of the resident's property from loss or theft. 1. A review of the clinical record revealed R26 was admitted to the facility on [DATE] with diagnoses including but not limited to Chronic Kidney Disease, Cerebral Infarction, and Contracture of the right hand. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented R26 possessed adequate hearing, impaired vision, clear speech, was understood and understandable. She was assessed to present with a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. During an interview on 1/23/2024 at 9:45 am, R26 revealed the facility does not treat her personal belongings with respect. She stated approximately three weeks ago, she observed R27 dressed in her personal dress. She was very upset because the dress was a gift from her family. She confirmed that all her clothes are labeled with her name on it. R26 and R27 are in different rooms. This was reported to Laundry Aide VV. 2. A review of the clinical record revealed that R27 was admitted to the facility on [DATE] with diagnoses including but not limited to difficulty in walking, vascular dementia, and cerebrovascular disease. A review of the MDS assessment dated [DATE] documented R27 possessed adequate hearing, impaired vision, clear speech, was understood and understandable and presented with a BIMS score of 11, indicating moderate cognitive impairment. During an interview on 1/23/2024 at 9:51 am, R27 revealed she always tried to remind staff to bring her clothes in the same bag after laundry. Her clothes easily get lost. Staff gave her a dress that belonged to R26 and that R26 was very upset when she had the dress on. She stated that she wanted to do the right thing, so she returned the dress to R27. 3. A review of the clinical record revealed R43 was admitted to the facility on [DATE] and was discharged on [DATE] with diagnoses including but not limited to diabetes, benign prostatic hyperplasia, and acute kidney failure. A review of the MDS assessment dated [DATE] documented R43 possessed adequate hearing, clear speech, was understood and understandable. The BIMS score was 13, indicating cognitively intact. A review of the facility grievance form dated 12/29/2023 documented that R43 filed a grievance, stating that five pants outfits were missing. During an observation of the laundry department on 1/18/2024 at 10:26 am revealed two aides folding linen. There were two racks of personal resident clothing approximately six feet tall. During an interview with Laundry Aide KK at that time, she revealed the two racks were unlabeled and unclaimed clothing and stated that the staff did not know who the clothing belonged to. She stated that the unclaimed clothes would be donated to charity. During an interview on 1/22/2024 at 1:12 pm, Laundry Aide VV revealed there were two racks of unidentified clothes, and the staff did not know who the clothes belonged to. Laundry Aide VV stated that there was a breakdown in communication because sometimes the nurses bring in unlabeled clothes. She confirmed that she is responsible for cleaning residents personal clothes and that she has received multiple complaints from residents related to not getting their clothes back. She stated that some of the residents stated they had no clothes to wear because their clothes aren't returned to them. She stated that they utilized the unclaimed pile of clothes when residents run out of clean clothes. She further stated that in December 2023, R26 and R27 engaged in a verbal argument because R26 stated R27 was wearing her dress. R26 claimed the dress was bought by her family. R26 wanted her dress returned. R27 said she was aware the dress did not belong to her and revealed staff gave her the dress. Laundry Aide VV stated that the nursing staff should label residents clothing before they send the clothing to the laundry department. During an interview on 1/22/2024 at 2:15 pm, Housekeeping Supervisor UU revealed personal laundry should be marked at pick up. Housekeeping Supervisor UU stated there are two racks of unclaimed clothes in the laundry department. It would not be appropriate for any resident to wear clothes that belonged to another resident. The unclaimed pile used to be much larger and was donated. Several families came up and asked for missing clothes that were never found. All clothes should be labeled on admission. Staff should be more focused on getting laundry back to the residents as soon as possible. During an interview on 1/23/2024 at 9:55 am, Social Services (SSD) WW revealed families are requested to label personal clothing on admission. SSD WW explained that some residents do not have an inventory list showing their personnel clothing and belongings on their medical record. S/he confirmed that R26 and R27 do not have an inventory list on their medical record and that residents who were admitted at the facility more than a year ago do not have an inventory list on their medical record. S/he confirmed that a inventory list should be used on every resident and that handing out clothes that belong to another resident is not appropriate and is inconsistent with residents' rights. During an observation of the North Wing S shower room on 1/23/2024 at 2:10 pm, there were two piles of dirty personal clothes. During an interview with Certified Nursing Assistant (CNA) XX at that time, s/he stated there was a delay in the laundry department in picking up clothes and that the laundry staff had not picked up clothes for at least a week. During an interview on 1/23/2024 at 3:30 pm, CNA RR revealed that the laundry department is in the basement and the laundry staff uses the elevator to transport laundry to the laundry department. S/he stated that the elevator was out of order, so the laundry staff had not picked up laundry. During an interview on 1/30/2024 at 3:12 pm, the current Administrator revealed when families bring clothes for residents, staff are expected to use permanent markers to label the residents clothes. She expects the facility to inventory all residents' personal belongings. The facility will not reimburse missing or lost clothes without a receipt and the facility policy required residents and their families to provide proof of purchase. During an interview on 2/7/2024 at 4:37 pm, the previous Administrator revealed she was the administrator from May 2023 through November 2023. She stated that during that period, she purchased a tag machine used for labeling residents clothing. She stated that she left the tag machine at the facility after her employment ended. She stated that it would not be appropriate for any resident clothes to be worn by another resident without their consent and that resident's property must be treated with respect.

Based on interview and record review, the facility failed to ensure money taken from the Resident Trust Account was accounted for and used for resident needs for six of 15 sampled residents (R 29, R33, R34, R35, R36, and R37). Findings include: Review of the Resident Statement Landscape dated 11/20/2023 for R29 revealed a charge for MCD Spendown for $1593.27 on 10/5/2023, which was credited back on 11/27/2023. Review of the Resident Statement Landscape dated 11/29/2023 for R33 revealed a charge for Personal Needs Item for $800.00 on 10/30/2023, which was credited back on 11/24/2023. Review of the Resident Statement Landscape dated 11/29/2023 for R34 revealed a charge for Personal Needs Item for $950.00 on 10/27/2023, which was credited back on 11/27/2023. Review of the Resident Statement Landscape dated 11/29/2023 for R35 revealed a charge for MCD Spendown for $750.00 on 10/24/2023, which was credited back on 11/24/2023. Review of the Resident Statement Landscape dated 11/29/2023 for R36 revealed a charge for MCD Spendown for $1544.07 on 10/3/2023, which was credited back on 11/27/2023. Review of the Resident Statement Landscape dated 11/29/2023 for R37 revealed a charge for MCD Spendown for $1636.74 on 9/22/2023, which was credited back on 11/27/2023. Review of the Withdrawal Record revealed the former Business Office Manager (BOM) transmitted the following amounts to the petty cash account: R29- $1593.27 on 10/5/2023. R33 - $800.00 on 10/30/2023. R34 - $950.00 on 10/27/2023. R35 - $750.00 on 10/24/2023. R36 - $1544.07 on 10/3/2023. R37 - $1636.74 on 9/22/2023. Review of the checks from the facility petty cash account revealed the above indicated amounts were made out to the former BOM, with the back of the check also being endorsed by the former BOM. Review of facility records revealed no evidence showing what the monies taken from the resident trust for R29, R33, R34, R35, R36, and R37 was spent on. A review of the former BOM employee file revealed an employment date of 3/13/2023 and a resignation effective date of 10/13/2023. Review of email communication provided by the facility between the Financial Controller and the Chief Operations Officer from 11/20/2023 through 11/22/2023 revealed there were no other checks made out to the former BOM. They determined that the original check pops up in a window to print, then disappears once printed. The only way to see it again is to reprint the check . she likely made a withdrawal from residents account, edited the payee prior to printing, then after printing, reedited back to resident/RP. Post survey interview with the Chief Operations Officer on 4/2/2024 at 5:02 pm revealed that the former BOM was trusted to handle the resident trust accounts. The former BOM was going into the accounts and changing the name of the record to a spend down for accounts that were going over the limit. The expectation was that anyone requesting a check, even the BOM, would make the request and take it to a second person, usually the Administrator, for validation, and the receipts for anything purchased would be kept as part of the record. She feels this wasn't happening at that time because the previous Administrator had resigned and was distracted while working their notice. Continued interview revealed that the Quarterly Statements were sent out and a family member noticed the charge and contacted the facility to question the charge on the statement, which prompted the facility to review all resident accounts. Six residents were affected, and all money was returned to the residents by 11/27/2023. Cross refer to F602.

Based on interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure narcotic medications for Resident (R13) and resident funds for Residents (R29, R38, R39, R40, R41 and R42) were not misappropriated for seven of fifteen sampled residents reviewed for misappropriation. This had the potential to affect 58 residents which had physician orders for medications which were stored in the locked narcotic drawer and had the potential to affect 105 residents whose funds were managed by the facility. Findings included: 1. A review of a facility policy titled, Abuse/Neglect/Exploitation, revision date [DATE], revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. A review of R13's Admission Record, dated [DATE], revealed the resident had diagnosis of opiod dependence. A review of R13's physician orders, dated [DATE], revealed the resident had a physician order for oxycodone-acetaminophen oral tablet ,d+[DATE] milligram (mg) give one tablet by mouth every eight hours for pain. A review of R13's care plan, revision date [DATE], revealed the resident had pain related to gout, muscle spasms, neuropathy, phantom pain, Charcot's joint of right ankle and foot, and pain in joint of left hand. A review of R13's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A review of the shipping manifest (a list of medications received from the pharmacy), dated [DATE], revealed that R13's Oxycodone-Acetaminophen ,d+[DATE] mg with 60 pills were received by staff at the facility at 8:25 PM. A review of R13's medication administration record (MAR), dated [DATE], revealed the resident had taken their scheduled oxycodone at 10:00 pm and missed the scheduled 6:00 am dose on [DATE]. A review of the facility investigation, dated [DATE], revealed after the facility completed a thorough investigation, the center substantiated the allegation of misappropriation of R13's medications. The facility was unable to locate the medications and the nurse was terminated. On [DATE] at 5:51 pm, Licensed Practical Nurse (LPN) OOO stated the staff sign off on the narcotic count sheets. She stated when staff change shifts both staff members count the cart and sign off on the narcotic log to show the cart was counted. On [DATE] at 8:25 am, the Director of Nursing (DON) BB stated if narcotic medications were missing the staff should report the incident directly to her. She stated after it was reported an investigation would be conducted. She stated she received a phone call about the missing narcotic medication on [DATE]. She stated the supervisor notified her they had searched all the medication carts to try to locate the medication and was unable to find the narcotic. She stated the staff should sign the log when their shift begins and ends. She stated staff should complete a count together to ensure the narcotics were in the cart. She stated according to one statement the nurse was unsure if the two nurses counted. There were no signatures on the log to show the cart was counted. She stated the off going nurse stated the two nurses counted the cart. There was another witness who said they observed the off-going nurse receiving the medications that night from the pharmacy. She stated the day shift nurse was terminated for failure to follow the policy to sign the narcotic sheets on the cart, count the cart, and sign the sheet with the Hospice RN. She stated R13's narcotics were not located. On [DATE] at 12:38 pm, Certified Medication Aide (CMA) SSS stated the night charge nurse received the narcotic medication from the pharmacy and signed for the medication. She stated when the nurse received the medications, she documented the medication amount in the narcotic log and put the pills in the narcotic drawer. She stated the nurse gave one narcotic pill to the resident at the scheduled time. She stated she was the CMA in charge of the cart, but the nurse was the one who passed the narcotics. She stated the narcotic box only had one key and the nurse kept the key. She stated she saw both nurses at the cart before leaving that night doing a count. She stated that morning they could not find the narcotic. She stated there was a resident who died that night and a hospice nurse picked up the deceased residents narcotics. She stated maybe they gave R13's narcotic to the hospice nurse. She stated she could not really say what happened to the missing narcotic. On [DATE] at 2:35 pm, LPN HHH stated the process was to give a report, count the narcotic drawers, and sign the back of the narcotic book to show the carts were counted. She stated R13's narcotic medication was on order and had been delivered by the pharmacy that night. She stated she gave R13 their narcotic medication when it came in because it was due. She stated the oncoming nurse came in to relieve her. She stated we counted the cart on the back hall and the Northeast Hall. She stated she could not remember if the log was signed to indicate the cart had been counted. She stated when she left there were 60 oxycodone for the deceased resident and 59 oxycodone for R13. She stated the hospice nurse had arrived as she was leaving the facility. On [DATE] at 11:09 am, Registered Nurse (RN) DDDD was contacted. He stated there was a signed list of the medications he had picked up from the facility. He stated he only received the medications from the resident who had deceased that night. He stated the facility nurse signed next to his name on a medication list after the medications were verified. He stated the list was sent to the facility. On [DATE] at 2:39 pm, LPN NNN stated when she went to give the scheduled oxycodone to R13 the medication was not in the lock box. She stated her and the off going nurse counted the cart. She stated the off going nurse called out the narcotic from the sheet and she verified the narcotic was on the cart. She stated she had not signed the log to verify the cart was counted. She stated she had given some narcotics to a hospice staff that night due to a resident expiring, but she had signed off on the medications which were given to the RN. On [DATE] at 3:21 pm, Unit Supervisor RN RRR stated the narcotic medications were delivered at night about 8:25 pm and gave to R13 about 10:00 pm. She stated the next morning at 6:45 am the nurse told me the resident had no more oxycodone pain pills. She stated she went to look for the medication. The narcotic book said 59 of oxycodone ,d+[DATE], but there was not a card with the medication in it. She stated the facility called the Hospice nurse to see if it was given to them by mistake. She stated the nurse said he did not have the medication. She stated the facility staff kept searching for it and could not find it. She stated she called the police and made a report. She stated it was facility protocol to have a face-to-face count, for narcotics. She stated the staff should look at the book and the narcotics to ensure they match. She stated it was facility protocol staff should come in and sign the book and when they leave, they should sign the book. On [DATE] at 4:24 pm, R13 stated the night before the pain medications had come up missing, they had gotten their medication at 10:00 pm. R13 stated they did not get their pain medications at 6:00 am and was told their pain medication was missing. 2. A review of a facility policy titled, Abuse/Neglect/Exploitation, with revision date of [DATE], revealed Misappropriation of Resident' property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. A review of the clinical record revealed that R29 was admitted to the facility on [DATE] with multiple diagnosis of but not limited to of cerebral palsy, dysphagia, Contracture of left and right wrist, abdominal distention, and postlaminectomy syndrome. R29 has a BIMS of 12, which indicated the resident had moderate cognitive impairment. A review of the facility grievance log revealed R29 filed a grievance about missing funds from R29's trust account. The grievance form dated [DATE] documents Resident reports missing money out of RFMS account. A review of a facility document indicated a thorough investigation was conducted. The investigation revealed that the previous Business Office Manager (BOM) misappropriated R29's funds in the amount of $1593.27. During an interview on [DATE] at 8:17 am with R29's Responsible Party (RP) revealed that the police contacted her about R29's funds being misappropriated. The RP stated someone from the facility called her before the facility contacted her. The RP stated the facility was very illusive about the details of how this could have happened. The facility controller completed an audit of the resident trust accounts to reveal that other residents were also affected; R233, R34, R35, R36 and R37. The following amount was misappropriated by the previous BOM: R33 - $800.00; R34 - $950.00, R35 - $$750.00, R36 - $1157.00 and R37 - $1636.74. During an interview on [DATE] at 11:11 am with the Regional Director of Clinical Operations (RDCO), revealed that the previous BOM transferred from a sister facility in [DATE]. A review of the previews BOM employee file revealed an employment date of [DATE] and a resignation effective date of [DATE]. 49687

Based on record reviews and interviews the facility failed to provide Activity of Daily Living (ADL) care for six of 36 sampled residents (R) (R8, R19, R10, R16, R18, and R21). Findings included: 1. A review of the clinical record revealed that R8 was admitted to the facility on [DATE]. Resident has diagnoses of unspecified injury at unspecified level of cervical spinal cord quadriplegia, Ogilvie syndrome, adhesive capsulitis of right and left shoulder, hyperlipidemia, seborrheic dermatitis, dysphagia, gastro-esophageal reflux disease, hypotension, abnormal blood-gas, hypersomnia, major depressive disorder, and vitamin D deficiency. A review of the care plan revealed that R8 presented with an ADL self-care performance deficit related to cervical spinal injury and quadriplegic. Interventions included that R8 was totally dependent for toileting; give incontinent care as warranted. Resident is totally dependent for repositioning and turning in bed; two staff as needed. Resident is totally dependent for showers/baths. Resident has contractures of the upper and lower extremities. Provide skin care to keep clean and prevent skin breakdown. Resident is totally dependent for dressing and personal hygiene. A review of resident's preferences revealed that R8 prefers bed baths, with interventions to include ensuring that R8's preferences are honored. A review of the Minimum Data Set (MDS) dated [DATE] showed that R8 has a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident is cognitively intact. A review of the most recently updated care plan revealed that R8 was care planned for bladder and bowel incontinence with interventions to include wash, rinse and dry perineum, change clothing as needed after incontinence episodes, clean peri-area with each incontinence episode, conduct skin checks as scheduled, monitor and document intake and output as per facility policy, and monitor/document for signs and symptoms of a urinary tract infection such as 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. A review of the bath schedule showed that R8 was scheduled to be bathed on Tuesdays and Thursdays during the 3:00 pm to 11:00 pm shift. A review of the February 2023 bath sheets for R8 revealed that the resident received a scheduled bath on the 14th, 16th, 21st and 23rd. A review of the documentation of ADL as needed sheets for February 2023 revealed that the resident did not receive baths on the 1st, 2nd, 3rd, 4th, 6th, 7th, 8th, 18th, 25th and 28th. A review of the documentation of ADL for March 2023 revealed that the resident did not receive baths on the 1st, 5th, 9th, 11th, 12th, 13th, 17th, 19th, 21st, 22nd, 23rd, 24th, 25th, and 29th. A review of the documentation of ADL care for April 2023 showed that resident did not receive baths on the 3rd, 4th, 5th, 8th, 24th, 25th, 29th and 30th. During an interview on 1/23/2023 at 9:27 am, R8 stated that he had a bath the day before. Resident stated that it's difficult for him to get assistance. Resident states that he has to call family members to call to the nurse's station to get him some assistance. Resident stated that sometimes his roommate has to go out in the hallway to get assistance. Resident stated that it primarily happens on the weekends. Resident stated that he dreads seeing the weekend come. During an interview on 1/18.2023 at 12:17 pm a family member stated that R8 is wet and soiled often. Family member stated that resident is left two to four hours before receiving assistance. Family stated that resident will call her when he initially asks for assistance and will call her back when someone actually comes to assist him and she would record the times. During an interview on 1/23/2024 at 9:27 am, R8 stated that he had a bath on the day before. Resident stated that it's difficult for him to get assistance. Resident states that he has to call family members to call to the nurse's station to get him some assistance. Resident stated that sometimes his roommate has to go out in the hallway to get assistance. Resident stated that it primarily happens on the weekends. Resident stated that he dreads seeing the weekend come. 2. A review of the record for R19 showed that resident was initially admitted to the facility on [DATE]. Resident had diagnoses of hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, type 2 diabetes, peripheral vascular disease, atherosclerosis heart disease, hypertension, sarcoidosis, gout, major depressive disorder, anxiety disorder, hyperlipidemia, pectic ulcer, dysphasia, alcohol abuse, and anemia. A review of the MDS dated for 1/8/2024 showed that R19 has a BIMs score of 15. A review of the care plan for R19 showed that prefers bed baths. Intervention included to ensure the resident's preferences are honored. Resident is also care planned for an ADL self-care performance deficit related to CVA with right side hemiplegia. Interventions include assisting resident with dressing and grooming. Assist resident with extensive to total assistance with toileting; provide incontinent care. Provide extensive to total assistance with transfers; 2x staff member as warranted. Resident is further care planned for having bladder and bowel incontinence r/t impaired mobility. Interventions include assisting resident with incontinent care. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. Clean peri-area with each incontinence episode. Monitor/document for signs and symptoms of a UTI: 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 pattern. A review of the bath schedule showed that R19 was scheduled to be bathed on Tuesdays and Thursdays during the 11:00 pm to 7:00 am shift. A review of the January 2023 bath sheets for R19 showed that the resident did not receive a bath on 6th, 8th, 10th, 13th, 15th, 16th, 20th, 21st, 22nd, 23rd, 24th, 25th, 27th, 28th, 29th, and 30th . During an interview on 1/25/2024 at 11:08 am family member for R 19 stated that resident had to go out to the hospital on 1/22/2024 and resident was soaking wet and not wearing his oxygen. Family member stated that the issue with resident not being changed is still happening. Family member also stated that she has to get on to staff about bathing resident. She stated that some days that she come to visit, resident has a musty odor, and she has to bathe him. 3. A review of the medical record revealed R10 was admitted to the facility on [DATE] with diagnoses which included end Stage Renal Disease, Type 2 Diabetes, Gastrostomy, and Anemia. A review of the Admission MDS assessment dated [DATE] revealed R10 had a BIMS score of 11 indicating moderate cognitive impairment. R10 required total care with two staff members for bathing. A review of the Weekly bath and skin report dated 10/4/2022, 10/16/2022, and 11/1/2022 revealed R10 had one shower per those months and his skin was normal. A review of the point of care report from September 2022, October 2022, and November 2022 revealed R10 did not have any bathing or showers marked as completed or the activity did not occur. Continued review revealed there was not a place for the certified nurse aides to chart whether they administered a shower or not. During an interview on 1/30/2024 at 11:10 am, Certified Nursing assistant (CNA) EEE stated she offered showers depending on if they were on the shower list for that day. The showers that were administered or refused by a resident was documented in the shower book. Any skin issues were documented in the shower book. The weekly baths were documented on the weekly bath and skin report. All bed baths are documented on the report. The charge nurse signs off on it. Continued interview revealed CNA EEE thought R10 was a hospice patient and so the hospice staff would administer the baths. The hospice staff had their own area to chart baths. During an interview on 1/30/2024 at 12:01 pm, CNA FFF stated that normally the residents are assigned a shower day and if they refuse their shower on their assigned day the nurse was notified, and the refusal was charted. The CNAs chart residents shower refusals in the point of care (POC). We ask the residents three times during the shift if they want their shower. During an interview on 1/31/2024 at 3:54 pm, Registered Nurse (RN) RR stated there was a list of residents assigned to showers on certain days and it is added on the assignment sheet. If the resident refuses a shower, we talk with them and let the family know of the refusal. We document it in the shower booklet and computer. During an interview on 2/6/2023 at 4;15 pm, the Director of Nursing (DON) stated Unit Manager are supposed to add the task for showers and bathing in the POC. That happens during the creation of the baseline care plan. 4. Review of R16's Electronic Medical Record (EMR) revealed an original admitted [DATE] with multiple diagnosis of but not limited to acute kidney failure, hyperkalemia, muscle weakness, type II diabetes, anemia, dermatitis, and constipation. R16 has a BIMS score of 15. Record review of the most recent Care Plan assessment for R16 dated 7/14/2023 revealed the resident required two staff assistance for transferring, one staff assist for toileting, and one staff assist for bathing. Record review of R16's grievance form dated 2/01/2023 documents (complaints of) not receiving shower. Record review of R16's Point of Care documents three showers were performed the month of February 2023. Record review of R16's Point of Care documents five showers were performed the month of April 2023. During a phone interview on 2/1/2024 at 3:33pm with R16 revealed that the staff would constantly ignore R16's request for showers. R16 stated that on scheduled shower days, the staff would put it off on purpose and would leave at shift change. R16 stated R16's roommate at the time would receive visitors and would notice how much R16 smell. R16 stated it was so embarrassing. 5. Review of R18's EMR revealed an original admitted [DATE] with multiple diagnosis of but not limited Cramp and Spasm, Aphasia following cerebral infraction, hypertension, vascular dementia, Psychotic disturbance, mood disturbance, Hyperlipidemia, and reduced mobility. R18 has a BIMS of 15. Record review of the most recent Care Plan assessment for R18 revised 1/10/2024 revealed the resident required Resident requires staff assistance with dressing and grooming, staff assistance with personal hygiene, staff assistance with toileting and requires staff assistance with shower/baths as scheduled and PRN. R18 shower sheets were requested. Record review of R18's bath sheet dated January 2024 revealed two bathing dates noted for 1/23/2024 and 1/26/2024. Interview on 1/31/2024 at 4:45 pm with DON revealed this was the only shower sheet available for R18. 6. Review of R21's EMR revealed an original admitted [DATE] with a discharge date of [DATE]; with multiple diagnosis of but not limited Major depressive disorder, hypertension, unspecified psychosis, asthma, Chronic Kidney disorder, and old Myocardial infarctions. R21 has a BIMS of 11. Record review of the most recent Care Plan assessment for R21 revised 1/31/2023 for R21 revealed the resident required staff Assist with dressing and personal hygiene, Assist resident with showers/baths. Review of facility shower assignments reveals that the showers are offered on a specific schedule per wing twice a week. Interview on 1/30/2024 and 12:02 pm, CNA FFF revealed staff would offer resident shower and document on the resident's corresponding shower the shower sheet and the Point of Care. CNA FFF continued by stating the resident is offered showers after breakfast and it offered at least three times before notifying the Nurse resident refused. Interview on 2/7/2024 at 5:13 pm, CNA FFFF revealed when showers are provided, it is recorded on the computer and recorded on paper. CNA FFFF revealed there is a book that determines which residents will require a shower. When a resident refuses a shower, the nurse is notified. Interview On 2/7/2024 at 5:23 pm, CNA YY revealed staff document on the sheet when residents are showered. CNA YY Stated some residents refuse a shower are given a bed baths. CNA YY revealed CNA YY does not document anything on the computer regarding showers. R21's shower sheets were requested. Interview on 1/31/2024 at 4:45 pm with DON revealed no shower sheets were available for R21. 49475 49687

Based on observation, interview, record review, and review of the facility policy titled, Resident and Family Grievances, the facility failed to make prompt efforts to resolve grievances and failed to ensure that grievances were documented and investigated thoroughly for three of 36 sampled residents (R) (R20, R8, and R19). Findings included: A review of the Resident and Family Grievances Policy (not dated) revealed the following: Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with stated and federal agencies as necessary in light of specific allegations. Grievances may be voiced in the following forums: verbal complaint to a staff member or Grievance Official; Written complaint to a staff member or Grievance Official; Written complaint to an outside party; Verbal complaint during resident or family council meetings; Via the company toll free Customer Service Line (if applicable); A grievance may be filed anonymously. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. 1. A review of the clinical record revealed that R20 was admitted to the facility on [DATE] with diagnoses including but not limited to dementia without behavioral disturbances, bipolar disorder, hypertension, fibromyalgia, and weakness. A review of R20's care plan, revision date of 9/7/2023, revealed the resident required assistance with activities of daily living (ADL) care. A review of R20's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident presented with a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. There was a Grievance/Concern Form regarding R20, dated 11/23/2023, authored by the Director of Nursing (DON) that the resident stated that she was not changed in a timely manner. The form indicated the date assigned was 11/23/2023 and the date resolved was 11/26/2023. The action listed that was to resolve grievance/concern was staff educated on ADL care. There was no documented follow-up with the resident related to her concerns. An interview with the DON on 2/8/2024 at 1:45 pm revealed she did not remember who or what was reported to her regarding R20. She stated it must have had something to do with ADL care since the documented in-service referred to ADL care. She verified there were statements from one Registered Nurse (RN) and one Certified Nurse Assistant (CNA) regarding the grievance dated 11/23/2023 for R20. She stated there was no investigation completed to rule out neglect. The DON verified there was no follow-up documented regarding the grievance. The DON stated she would not be the person to speak to about the grievance. She stated the licensed practical nurse (LPN) SS (the unit manager of the East Wing) was who would have the information regarding the grievance, actions and follow-up. During the interview the DON, she also verified the procedure that was to be followed according to the grievance policy, was not followed according to the lack of documentation. The DON also stated the Social Service Director (SSD) WW should have documentation regarding follow-up for grievances. An interview with LPN SS on 2/8/2024 at 1:55 pm revealed the statements the staff composed was a reflection of what occurred on 11/23/2023. The statements indicated R20 put her light on and requested to be changed. The RN informed the resident the CNA was on break and would take care of her when he returned. An interview with the SSD WW on 2/8/2024 at 2:20 pm revealed she did not follow-up with R20's grievance. She stated she was the grievance official. She verified there was no documentation regarding any follow-up and any further investigation. 2. A review of the clinical record revealed that R8 was admitted to the facility on [DATE] with diagnoses of unspecified injury at unspecified level of cervical spinal cord quadriplegia, Ogilvie syndrome, adhesive capsulitis of right and left shoulder, hyperlipidemia, seborrheic dermatitis, dysphagia, gastro-esophageal reflux disease, hypotension, abnormal blood-gas, hypersomnia, major depressive disorder, and vitamin D deficiency. A review of the MDS assessment dated [DATE] revealed that R8 presented with a BIMS score of 15, indicating that the resident was cognitively intact. A review of the care plan for R8 revealed that the resident has an ADL self-care performance deficit related to cervical spinal injury and diagnosis of quadriplegia. Interventions include that the resident is totally dependent with toileting and to provide incontinent care as warranted; the resident is totally dependent for repositioning and turning in bed and requires two-person assistance; the resident is totally dependent for showers/baths; the resident has contractures of the upper and lower extremities and to provide skin care to keep clean and prevent skin breakdown; and that the resident is totally dependent for dressing and personal hygiene. The care plan for R8 further revealed that the resident's preferences are bed baths and to ensure resident's preferences are honored; that the resident has bladder and bowel incontinence and to wash, rinse and dry perineum, change clothing as needed after incontinence episodes, clean peri-area with each incontinence episode. A review of the grievance dated 8/29/2023 revealed R8 reported that he had not received a shower. The resolution included an in-service for staff on 9/4/2023. A second grievance was filed on 9/4/2023 by R8. He stated that he was laying in his feces for three hours on 9/3/2023. Resolution included an in-service on incontinence care for staff on 9/5/2023. There was no documented follow-up with the resident. During an interview on 1/18/2024 at 12:17 pm the family member of R8 stated that the resident would often be left wet and soiled for long periods of time. S/he stated that resident will call them when he initially asks for assistance and will call them back when someone actually comes to assist him; they record the time. They stated that it is sometimes two to four hours before he receives assistance. During an interview on 1/23/2024 at 9:27 am, R8 stated that it's difficult for him to get assistance and that he has to call family members to call to the nurse's station to get him some assistance. The resident stated that sometimes his roommate must go out in the hallway to get assistance. He confirmed he reported this but there has been no resolution, as it still happens. 3. A review of the clinical record revealed that R19 was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, type 2 diabetes, peripheral vascular disease, atherosclerosis heart disease, hypertension, sarcoidosis, gout, major depressive disorder, anxiety disorder, hyperlipidemia, pectic ulcer, dysphasia, alcohol abuse, and anemia. A review of the MDS assessment dated [DATE] revealed that R19 presented with a BIMS score of 15, indicating that the resident is cognitively intact. A review of the care plan for R19 revealed that the resident prefers bed baths with intervention to ensure the resident's preferences are honored; the resident presented with an ADL self-care performance deficit related to CVA with right side hemiplegia with interventions to include assisting the resident with dressing, grooming, extensive to total assistance with toileting, assistance with incontinent care, and two-staff extensive to total assistance with transfers. During an interview on 1/25/2024 at 11:08 am with a family member of R19. They stated that resident had to go out to the hospital on 1/22/2024 and resident was soaking wet and not wearing his oxygen. They stated that this was reported to the facility but the issue with the resident not being changed is still happening. During an interview with the Administrator on 1/30/2024 at 3:25 pm stated that the facility has an audit system that they use, and they follow up with resident and family concerns online. The system is accessed in the electronic medical record, and it allows the staff to be able to monitor the process. 49472 49687

Based on interviews, record review, and review of the facility policy titled, Transfer and Discharge (including AMA), the facility failed to develop a discharge care plan and set up home health timely for one of four sampled residents (R) (R14). Findings included: A review of the facility policy titled, Transfer and Discharge including Against Medical Advice (AMA), revealed .Non-Emergency Transfers or Discharges initiated by the facility, return not anticipated .Orientation for transfer or discharge will be provided and documented ot ensure safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team .For a community discharge, a discharge summary and plan of care should be prepared for the resident. Document in the medical record that written discharge instructions were given to the resident and if applicable, the resident's representative . A review of R14's Admission Record, dated [DATE], revealed the resident had diagnoses which included protein calorie malnutrition, paraplegia, osteomyelitis of the right ankle/foot and multiple sclerosis. A review of R14's care plan, revision date [DATE], revealed the resident had a stage four pressure ulcer to the left hip, a stage three pressure ulcer to the right ankle, stage three pressure ulcer to the sacrum, left knee stage two pressure ulcer, and a pressure ulcer to the right ischium. There were no discharge plans on R14's care plan. A review of R14's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview of Mental Status (BIMS) score of three, which indicated severe cognitive impairments. The MDS indicated the resident had three stage three pressure wounds, two stage four pressure wounds, and one deep tissue injury. A review of R14's discharge planning assessment, dated [DATE], revealed the resident would discharge home with home health. A review of R14's social service notes, dated [DATE], revealed the resident discharged home with the support of family. The note revealed the resident was discharged home with all medications, home health, and Durable Medical Equipment (DME). On [DATE] at 12:40 pm, R14's family member stated the facility basically just kicked R14 out. The family member stated the facility said R14's insurance stopped paying. The family member stated a week and a half or two weeks later the facility called and told them R14 had to immediately come home. The family member stated they appealed the insurance decision, but they did not win the appeal. The family stated they asked if there were any programs or anything they could do. The facility recommended R14 be sent home and have home health come in and help take care of him. The family member stated they had missed a training opportunity for a scheduled discharge which the facility wanted to provide. The family member stated the facility was going to train them to take care of the resident. The family member stated R14 had to come to their house by an ambulance. The family member stated home health had not come in until New Year's Day. The family member stated the facility sent R14 home and by the time home health had seen the resident they only had five bandages left. On [DATE] at 9:21 am, Registered Nurse (RN) WWW stated the family had very minimal supplies to care for the residents wounds. She stated the family needed training to take care of R14. She stated the patient should not have been sent home in those conditions. She stated the resident was sent home and the family had no training. She stated the family, and the resident was in a bad situation. She stated the whole thing was horrible. She stated she thought the resident's insurance had terminated. She stated from what the care giver said once the resident's insurance expired the family was required to take the resident home. On [DATE] at 1:47 pm, the social services director WW stated the resident was discharged home with family. R14 wanted to be discharged . She stated discharge planning started at the time we had the first care plan meeting on [DATE]. She stated R14 and family wanted the resident to go back home. During a follow up interview on [DATE] at 10:11 am, she stated if a resident required home health the facility started discharge packets and sent them to the home health company. She was asked to provide documentation as to when the home health company was contacted for discharge. She stated she did not know if she could provide the information as to when the home health company was contacted. She stated there was no discharge care plan developed. On [DATE] at 10:55 am, the Director of Nursing (DON) BB stated the discharge assessment was what the facility used to document when the company was contacted. She stated staff should also be documenting the contact in a social service note. She stated the facility should have meetings to discuss the process at care plan meetings. She stated she would then expect them to contact the home health company and DME at that time. On [DATE] at 9:39 am, the Administrator AA stated the home health facility was contacted before the [DATE]. She gave the surveyor a phone number to contact the home health facility. On [DATE] at 10:25 am, the Chief Innovation Officer XXX stated the home health company received the referral for R14 on [DATE]. She stated the resident was seen for the first time on [DATE].