Every finding on record at Southpointe Healthcare and Rehabilitation

Based on record review, interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Resident (R)1, for one of three sampled residents reviewed for behaviors, and for R11, for one of three residents reviewed for skin conditions. Failure to code the MDS correctly has the potential to lead to inaccurate assessments and care planning of the resident.Findings Include:Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2025 revealed, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment .Review of R1's Face Sheet indicated the facility admitted R1 on 06/16/25 with diagnoses including but not limited to, quadriplegia, pressure ulcer of sacral region, Post Traumatic Stress Disorder (PTSD), contracture of muscles in multiple sites and depression.Review of R1's Annual MDS with an Assessment Reference Date (ARD) of 05/26/26, indicated that R1 did not have any instances of rejection of care.Review of R1's Progress Notes for May 2026 revealed the following:05/22/26 at 3:15 PM, Upon arrival from hospital this nurse attempted to do a body audit on resident. Resident refused to get in bed for body audit.05/23/26 at 12:37 PM, .Refused all medications but Baclofen.05/24/26 at 5:19 PM, Refused all wound care.Refused all medications but Baclofen.05/25/26 at 9:16 AM, Resident was in the hospital and unable to see wound MD. Resident refused body audit upon return to the facility. Resident is a serious risk for infection due to refusals.05/26/26 at 6:20 AM, .Resident refused care and dressing change.Review of R11's Face Sheet indicated the facility admitted R11 on 04/27/18. Further review revealed diagnoses including but not limited to paraplegia. Review of R11's Quarterly MDS with an ARD of 06/18/26, indicated that R11 did not have any unhealed pressure ulcers/Injuries nor any other type of ulcers, wounds or skin problems. Review of R11's Wound History revealed R11 had wounds on the right thigh and right hip, identified on 04/11/25 and were discontinued on 07/08/26. Review of R11's Order revealed, Start date 04/11/26, End date 06/30/26, Daily Wound Treatment: R hip; cleanse with 1/4 strength dakins. [sic] cut polymem to size of wound and apply to wound bed, cover with signed and dated border gauze . and Start date 04/11/26, End date 06/30/26, Daily Wound Treatment: R thigh; cleanse with 1/4 strength dakins. [sic] cut polymem to size of wound and apply to wound bed, cover with signed and dated border gauze .Review of R11's Care Plan revealed, Problem start date 04/01/25, [R11] has a current wound/disruption of skin surface. shearing right thigh and hip and, a goal of The resident's wound will decrease in size as evidenced by wound documentation with no complications and comfort will be maintained. Review of R11's Progress Notes revealed the following:06/16/26 10:32 AM, Residents dressings changed by the wound nurse . 06/12/26 9:57 AM, Residents dressings on thigh and hip intact at this time .During an interview on 07/21/26 at 1:02 PM, Registered Nurse (RN)1 stated that He [R1] does lots of refusals with wound care and sometimes gets agitated with it.During an interview on 07/21/26 at approximately 2:45 PM, the MDS Coordinator stated information used to complete assessments is pulled from the Medical Administration Record, notes, hospital paperwork and notes from providers. The MDS coordinator stated that social services is responsible for completing the behaviors section of the MDS. During an interview on 07/21/226 at approximately 3:00 PM, Social Services stated that the lookback period for all assessments is 7 days and progress notes are included in that review. She stated she didn't have a reason for not coding rejection of care for R1 and that she missed it.

Based on review of facility policy, record review, and interview, the facility failed to ensure a resident received a required Level II PASARR evaluation, for 1 of 4 residents reviewed. Specifically, Resident (R)3 was identified through the Level I PASARR screening as requiring a Level II evaluation; however, the facility did not maintain documentation showing that the Level II PASARR had been completed. This failure had the potential to result in the resident not receiving necessary specialized services or an appropriate level of care.Findings include:Review of the facility's policy titled, PASARR Documentation Policy, with a complete revision date of 06/09/23, revealed, PASARR: Federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not appropriately placed in nursing homes for long care. PASARR requires that 1) all applicant to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.Review of R3's Face Sheet revealed he was originally admitted to the facility 06/19/25 with a re-entry date of 06/20/25. His diagnoses included, but were not limited to, lack of coordination, benign prostatic hyperplasia without lower urinary tract symptoms, Alzheimer's disease with early onset, restlessness and agitation, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Review of R3's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/26 revealed R3 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R3 was moderately cognitive impaired. Further review of the MDS revealed R3 used a manual wheelchair independently and needed partial assistance from others for personal care. R3 was not on any antipsychotics or antidepressants.Review of R3's Level 1 PASRR Screening Tool dated 03/19/26, revealed under Section C. Mental illness treatments and/or services indicated, Currently receiving services for mental illness, Previously received services for mental illness, and Referred for mental illness services. Further review revealed under section A. Has the applicant shown any of the following behaviors? indicated that R3 was a danger to others, aggressive, and assaultive. R3 has a history of altercations, serious difficulty in sustaining focused attention, serious difficulty in maintaining concentration, and inability to complete simple tasks. Under section B. Has the applicant had any of the following due to mental illness? Law enforcement intervention was checked as yes with a date of 2/21/26 police officer came to facility. Under the section IV: Level 1 PASRR Completion, no recommendations were checked off as to R3 needing or not needing further evaluation of a PASSR Level II.Review of R3's Care Plan revealed R3 had mood and behavior needs, evidenced by episodes of throwing soiled briefs into the hallway, related to his dementia diagnosis. Interventions included: removing the resident from other residents to a safe, less stimulating environment if he became physically agitated or aggressive; setting firm limits by instructing the resident to stop the behavior; informing the resident care would resume once he had calmed sufficiently to allow safe completion of tasks; and notifying nursing staff as appropriate.Review of R'3's progress notes revealed no nursing notes regarding the allegation resident-to-resident abuse that happened on 06/29/26.During an interview with the Administrator on 07/21/26 at approximately 2:34 PM, she stated, I see that [R3] qualifies for a Level II PASARR because of his behavior issues, but I don't know why there is not one showing. I will get the Social Services Director for you and maybe she can find it.During an interview with Social Services (SS) on 07/21/26 at 2:55 PM, she stated, I'm working on the document at the moment. I am waiting for the medical director at the hospital to fill out the paper and send it over so that I can complete it and submit the forms. I will get them to you when I am finished.

Based facility policy review, observation, and interview, the facility failed to ensure housekeeping chemicals were securely locked and stored outside of resident areas. Findings include:Review of the facility's Maintenance/Housekeeping policy titled Micro-organisms with an original date of 03/2006, revealed, Maid Carts: . 4. Never leave maid carts unattended with chemicals exposed for patient/resident safety. Chemicals should be kept with housekeeper. During a random observation on 06/29/26 at 11:20 AM, revealed two housekeeping carts unattended in the Resident lounge of the 100 Hall. Six residents were noted to be seated in the lounge watching tv. Both housekeeping carts were unlocked and contained a liquid smelling of bleach in the mop bucket. Inside the unlocked compartment of the first cart was a can of air freshener. A bottle of liquid soap was on the lower shelf. Inside the unlocked compartment of the second cart was: Tylex spray, Xotic Team air freshener spray, Pure Bright RTU germicidal spray, and Glass cleaner spray. Both Housekeeping Aide (HA)1 and HA2 verified the housekeeping carts were left unattended and unlocked in a resident area. During an interview on 06/29/26 at 11:23 AM, HA1 and HA2 revealed they were short-staffed today, and HA2 had just arrived to fill in. Both housekeeping aides stated they knew the carts should be locked at all times. HA1 showed this Surveyor the keys she had for the housekeeping carts. HA1 and HA2 revealed they were in the housekeeping office for only a few minutes to discuss the schedule for the day.During a phone interview on 06/29/26 at 12:43 PM, the Housekeeping Director revealed his expectation was for staff to never leave a housekeeping cart unattended. He stated if the housekeeping aide is not using the cart, the cart should be back in the hallway locked away or pushed out onto the dock. The Housekeeping Director revealed the carts should never be left open within a resident's reach. He further stated the cart should remain locked. Housekeeping Director stated it is rare for this to happen, but regardless, housekeeping carts should never be left open within resident areas.During an interview on 06/29/26 at 1:43 PM, the Director of Nursing (DON) stated she educated the housekeeping personnel on locking housekeeping carts when the cart is not attended. During an interview on 06/29/26 at 6:10 PM, the Administrator revealed the housekeeping carts should be locked at all times or be placed out on the dock. He confirmed the carts should not be stored in resident areas.

Based on review of facility policy, record review, observation, and interview, the facility failed to ensure resident health information was properly concealed from unauthorized viewing during a random observation of medication administration.Findings include:Review of the facility policy titled Safeguarding Electronic Protected Health Information with an email revision date of 04/29/22, revealed, Procedures: . 1. F. Access to electronic protected health information is limited to employees who need the information for treatment, payment or facility operations purposes. H. Employees log off the network or, at a minimum, lock their workstation when leaving the work area.During a random observation on 06/29/26 at 11:25 AM, revealed an unattended medication cart that was unlocked with the narcotics book open and the computer showing a resident's information, clearly visible. Registered Nurse (RN)1 verified this observation. During an interview on 06/29/26 at 11:26 AM, RN1 revealed the medication cart should have been locked, and the narcotics book and the computer should have been closed so that patient information was not visible. She stated she was going back and forth to a resident's room giving the resident her medications, and the resident asked several questions. RN1 revealed she was going back and forth from the cart to the room to look at the resident's information, to gather the information the resident was asking for, and she forgot to lock the medication cart and close the narcotics book and computer. During an interview on 06/29/26 at 11:26 AM, the Unit Manager (UM)1 verified the medication cart should have been locked, and the computer and narcotics book should have been closed to prevent resident health information from being visible. She stated the electronic medical record is sometimes difficult to log out of. During an interview on 06/29/26 at 12:17 PM, the Director of Nursing (DON) revealed RN1 is an agency nurse. She stated RN1 was well aware surveyors were in the building. The DON revealed she was glad RN1 acknowledged she knew the cart should have been locked and the computer closed. The DON stated they only use one agency, and their nurses get the same education as the facility staff does. She revealed when they have something they need to educate the staff on, they call ShiftKey (staffing agency) and upload the documents. She further stated the agency staff have to sign that they reviewed the information before they are allowed to work another shift.During an interview on 06/26/26 at 6:10 PM, the Administrator revealed the medication carts should be locked at all times when not attended, and resident information should be covered and not visible to anyone passing by.

Based facility policy review, record review, observation, and interview, the facility failed to ensure medication was properly and securely stored during two random observations. Findings include:1. Review of the facility policy, Medication Management Program with an email revision date of 01/15/25, revealed, Security and Safety Guidelines: . 3. The medication cart is locked when not in use and in direct line of sight.During a random observation on 06/29/26 at 11:25 AM, revealed an unattended medication cart that was unlocked with the narcotic book open. Registered Nurse (RN)1 verified the observation. During an interview on 06/29/26 at 11:26 AM with RN1, she revealed the medication cart should have been locked. She stated she was going back and forth to a resident's room giving the resident her medications. RN1 revealed she was going back and forth from the cart to the room to look at the resident's information and she forgot to lock the cart and close the narcotics book and computer. During an interview on 06/29/26 at 11:26 AM, the Unit Manager (UM)1 verified the medication cart should have been locked. During a random observation on 06/29/26 at 4:18 PM, revealed an unattended medication cart that was unlocked on the Blue Unit. Licensed Practical Nurse (LPN)2 verified the observation. During an interview on 06/29/26 at 12:17 PM, the Director of Nursing (DON) revealed she was glad RN1 acknowledged she knew the cart should have been locked. During an interview on 06/26/26 at 6:10 PM, the Administrator revealed the medication carts should be locked at all times when not attended.2. Review of the facility policy, Self-Administration of Medications with a revision date of 04/17/24, revealed, Procedures: . 5. Facility should provide a secured compartment for storage of such medications in accordance with facility policy (see BEDSIDE STORAGE OF MEDICATION). Surveyor requested the document, Bedside Storage of Medication that was referenced in the policy but was told by the DON that the document did not exist. Review of R1's active orders did not show a current order for chlorhexidine mouthwash. Review of R1's medication administration record for 06/2026 revealed three past orders for chlorhexidine gluconate 0.12% mouthwash 15 cc. The first order read, Chlorhexidine gluconate mouthwash 0.12% swish 15 cc for 30 seconds twice a day for 7 days. The first order started on 05/31/26 and ended on 06/03/26. The second order read, Chlorhexidine mouthwash 0.12% swish 15 cc for 30 seconds three times a day after meals. May keep at bedside. The second order started on 06/03/26 and ended on 06/08/26. The third order read, Chlorhexidine mouthwash 0.12% swish 15 cc for 30 seconds three times a day after meals. May keep at bedside. The third order started 06/10/26 and ended 06/17/26. During an observation on 06/29/26 at approximately 3:00 PM, revealed a bottle of prescription chlorhexidine mouthwash on R1's bedside table. No lock box or lock on her bedside table drawer was observed. During an interview on 06/29/26 at approximately 3:15 PM, Licensed Practical Nurse (LPN)1 revealed R1 would keep the mouthwash at her bedside in the top drawer of her nightstand next to her bed.During an interview on 06/29/26 at 3:35 PM, the Director of Nursing (DON) revealed she believed R1's bedside table had a lock on it for her to store the chlorhexidine mouthwash in. During an interview on 06/26/26 at 6:10 PM, the Administrator revealed no medications should be left at the bedside. He stated the resident would be given a lock box to keep the medication in, or they can keep it in their bedside table if there is a lock.

Based on review of facility policy, record review, observation, and interview, the facility failed to properly assess Resident (R)1 for the appropriateness of the self-administration of prescription chlorhexidine mouthwash, for 1 of 3 residents reviewed. Findings include:Review of the facility policy titled Self-Administration of Medications with a revision date of 04/17/24, revealed, Policy: The resident may choose to self-administer medication(s) according to applicable state and federal law and regulation upon completion of an assessment by the Interdisciplinary Care Team (IDT). Procedures: 1. A Resident choosing to self-administer medications will be assessed and evaluated by the Interdisciplinary Care Team (IDT) in order to determine if it is safe for him/her to self-administer medication. Review of R1's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses included, but not limited to, dental caries (cavities), hemiplegia (paralysis on one side of the body) affecting her right dominant side, visual loss in the right eye, cognitive communication deficit, and personal history of traumatic brain injury. Review of R1's active orders did not show a current order for chlorhexidine mouthwash. Review of R1's Medication Administration Record (MAR) for 06/2026, revealed three past orders for chlorhexidine gluconate 0.12% mouthwash 15 cc. The first order read, Chlorhexidine gluconate mouthwash 0.12% swish 15 cc for 30 seconds twice a day for 7 days. The first order started on 05/31/26 and ended on 06/03/26. The second order read, Chlorhexidine mouthwash 0.12% swish 15 cc for 30 seconds three times a day after meals. May keep at bedside. The second order started on 06/03/26 and ended on 06/08/26. The third order read, Chlorhexidine mouthwash 0.12% swish 15 cc for 30 seconds three times a day after meals. May keep at bedside. The third order started 06/10/26 and ended 06/17/26. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/26, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she had no cognitive deficits.Review of R1's Care Plan revealed she had a focus on requiring an antibiotic related to dental pain/infection starting 05/14/26. The goal was to have decrease in pain and improvement of condition through end of treatment. Interventions included, but were not limited to, antibiotic as ordered; assess condition of oral cavity, teeth, tongue, lips; dental evaluation and intervention as needed; and encourage fluids to keep oral cavity moist. A second focus was related to R1 experiencing mouth pain related to probable cavity starting on 03/24/26. The goal was for R1 to not exhibit mouth pain or infection. Interventions included, but were not limited to, antibiotic started for tooth pain; assess condition of oral cavity, teeth, tongue, lips; dental evaluation and intervention as needed; and provide mouth care every day and PRN (as needed). No focus items, goals, or interventions were found in R1's care plan related to the self-administration of medications, including chlorhexidine gluconate mouthwash. During a random observation on 06/29/26 at approximately 3:00 PM, revealed a bottle of chlorhexidine mouthwash on R1's bedside table. The resident was not present in the building at the time of the observation. No lock box or lock on her bedside table drawer was observed. During an interview on 06/29/26 at approximately 3:15 PM, Licensed Practical Nurse (LPN)1 revealed R1 was alert and oriented x4. He stated R1 had nine teeth pulled at one time and was ordered two different mouthwashes. The first mouthwash was lidocaine mouthwash, which was kept on the medication cart. The second mouthwash was chlorhexidine mouthwash for R1 to use after each meal. This mouthwash was kept at the bedside. LPN1 revealed R1 wanted to have the chlorhexidine mouthwash at her bedside to make it easy for her to use after she was finished eating her meals. He stated R1 wanted to ensure she did not get any complications from the extractions. LPN1 revealed the chlorhexidine mouthwash was re-ordered a couple of times. He stated R1 would keep the mouthwash at her bedside in the top drawer of her nightstand next to her bed. He revealed R1 has had no problems with self-administering the mouthwash. He stated he has not worked in the facility for a few days, so he is not sure why the mouthwash was not removed from R1's bedside when the order ended on 06/17/26.During an interview on 06/29/26 at 5:30 PM, the Director of Nursing (DON) provided a copy of Self-Administration of Medication Observation Detail dated 05/31/26 at 11:45 AM. She revealed they have morning meetings where the administration talks about all residents and any changes to their care. She stated the meetings include the Administrator, herself, Assistant DON, and department heads. She described the meeting as an interdisciplinary team (IDT) meeting. She stated they would have discussed R1 requesting to self-administer her chlorhexidine mouthwash in this meeting and then the care plan would have been updated by the Minimum Data Set (MDS) Nurse. Surveyor requested to see the written records or notes of the meeting when R1's request to self-administer chlorhexidine mouthwash was discussed.During an interview on 06/29/26 at 6:00 PM, the MDS Nurse revealed she makes notes at every morning meeting where they discuss all the residents and any changes. She stated her process is to notate anything that indicates a change is needed to a resident's care plan or MDS. During the interview, the MDS Nurse looked through her morning meeting notes for June. She did not find any notes indicating they discussed R1's request to self-administer her prescription mouthwash. She stated if the discussion happened, she would have written a notation of the discussion and the need to revise the care plan.During an interview on 06/26/26 at 6:10 PM, the Administrator revealed no medications should be left at the bedside. He stated if a resident wants to self-administer medications, the nurse should complete an assessment and get a physician's order. He revealed the request would typically be discussed in the morning meeting where all disciplines attend, and the self-administration of medication would need to be added to the resident's care plan.During an interview on 06/29/26 at 6:30 PM, the DON confirmed no IDT meeting or discussion had occurred regarding R1 self-administering her prescribed chlorhexidine mouthwash.

Based on review of facility policy, interview and record review, the facility failed to ensure Resident (R)12's right to be free from misappropriation of resident property by failing to prevent or protect the resident's three rings from being taken without the resident's consent. This deficient practice was identified in 1 of 4 residents reviewed for misappropriation of property.Findings include:Review of the facility's policy titled Abuse, Neglect, Exploitation, or Mistreatment, revised on 11/01/17, revealed that the facility's leadership prohibits neglect, mental, physical, and verbal abuse, involuntary seclusion, corporal punishment, and misappropriation of a resident's property or funds. The policy states that alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately. The policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent.Review of R12's Face Sheet revealed the resident was admitted to the facility on [DATE] at 11:36 AM, with diagnoses including, but not limited to, senile degeneration of the brain, unspecified dementia, cognitive communication deficit, and urinary tract infection.Review of R12's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/26, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment.Review of R12's admission Inventory Sheet dated 05/05/26 revealed the resident was admitted with three gold rings.Review of the Grievance Summary dated 05/14/26, categorized as Missing items and reported by R12's responsible party, revealed the grievance was resolved on 05/26/26. The grievance stated that three gold tone rings were missing, including one worn on the resident's left pointer finger and two worn on the resident's left ring finger. On 05/14/26, the resident's daughter notified the facility that the three rings were missing, describing them as two gold bands and one gold band with diamond like stones, and identifying the items as family heirlooms. She reported that the rings were present on the resident's hand on the evening of admission and observed they were no longer present during a visit the following week. The daughter stated she contacted local law enforcement prior to notifying the facility administrator on 05/14/26. The facility's investigation included interviews with the resident, family, and staff; searches of the resident's room, belongings, and laundry; review of admission observations; and communication with law enforcement. The facility was unable to determine how or when the rings became missing, and no evidence was identified to substantiate misappropriation by facility staff. An addendum dated 05/26/26 documented that the Sheriff's Department reported the three rings had been located at a local pawn shop and had been sold by an agency nurse.During an interview with R12's Responsible Party (RP), the resident's daughter and Power of Attorney (POA), was conducted on 06/29/26 at 4:44 PM, following a returned call. The RP reported the resident was admitted on [DATE] from the hospital and had been wearing three rings at the time of admission, including two solid gold bands and one solid gold band with diamonds. The RP stated the resident was still wearing all three rings upon admission; however, during a visit on 05/09/26, she observed the resident was no longer wearing any of the rings. She reported notifying the nurse on duty, who informed her that because it was a Saturday, no administrative staff were available to address the concern. When she returned to the facility the following Monday, she was again unable to meet with administrative staff. On Tuesday, she spoke with the facility's Social Worker, who stated she would file a grievance. The RP reported she later contacted administration and the Director of Nursing, both of whom stated they were unaware of the missing rings and would initiate an investigation. The RP stated she became frustrated with the lack of information from the facility and subsequently contacted law enforcement and filed a police report. According to the RP, staff informed her that interviews were conducted but no one reported knowledge of what happened to the rings. The RP reported that law enforcement later identified an agency staff member, subsequently confirmed to be an agency Licensed Practical Nurse (LPN)5, as the individual who sold the resident's rings to a local pawn shop after comparing photographs of the rings with pawn shop transaction records. The pawn shop had collected a photo ID from the seller, which matched LPN5. The RP stated she was able to recover all three rings with the assistance of law enforcement and reported that the facility informed her they would report the staff member to the appropriate licensing board. The RP voiced no additional concerns during the interview.During an observation and attempted interview of R12 on 06/19/26 at approximately 5:50 PM, revealed the resident was sleeping. Due to the resident's dementia diagnosis and condition at the time of observation, the resident was unable to be interviewed.During an interview with the Facility Administrator (FA) was conducted on 06/29/26 at 6:03 PM. The FA reported he had been in his role for less than one year and was familiar with R12, who was admitted on [DATE]. The FA stated that on 05/14/26, he and the Director of Nursing (DON) met with the resident's daughter regarding concerns that the resident's three rings were missing. One daughter was present in person. During the discussion, the daughter described the missing items as two gold bands and one gold band with diamond like stones, and reported the rings were visible on the resident's hand on the evening of admission. She provided a cell phone video that appeared to show the resident wearing the rings. The FA stated the daughter was asked whether the rings could have been removed by family due to the resident's cognitive impairment and risk for losing valuables; however, the daughter reported the rings remained in the resident's possession following the visit. The daughter stated that during a visit the following week, she observed the rings were no longer present and contacted law enforcement on 05/13/26 before notifying the Assistant Director of Nursing (ADON), DON, and FA on 05/14/26. The FA stated that on 05/14/26, the facility contacted the local police department regarding the missing property and was informed a report had already been initiated. Facility staff were instructed to follow up with the assigned officer the next day. On 05/15/26, the FA reported the responding officer requested a list of all employees working at the facility, and it was through this list that the identified perpetrator was later matched to pawn shop records. The FA stated that during this follow up communication, the Sheriff's Office reported they had the information needed at that time and advised the facility to report any additional findings if they arose. The FA further stated that several days later, the police officer returned to the facility and reported that an agency staff member, later identified as LPN5, matched the individual who pawned the resident's rings. Upon receiving this information, the FA contacted the staffing agency to request the employee be placed on the agency's do not return list and provided law enforcement with the agency's contact information. The FA stated an addendum was then submitted to the Department of Public Health (DPH) regarding the new findings. The FA stated his expectation is zero tolerance for misappropriation of resident property, noting that no situation is too small or too big when it comes to protecting residents and their belongings.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure medication was discontinued after the physician's ordered end date. Specifically, the facility failed to remove chlorhexidine mouthwash from Resident (R)1's bedside, for 1 of 3 residents reviewed. Findings include:Review of the facility policy titled Self-Administration of Medications with a revision date of [DATE], revealed, Procedures: . 4.G. The nursing staff will rotate bedside stock and will remove expired, discontinued, or recalled medications. Review of R1's Face Sheet revealed she was admitted to the facility on [DATE], with diagnoses included, but not limited to, dental caries (cavities), hemiplegia (paralysis on one side of the body) affecting her right dominant side, visual loss in the right eye, cognitive communication deficit, and personal history of traumatic brain injury. Review of R1's active orders did not show a current order for chlorhexidine mouthwash. Review of R1's Medication Administration Record (MAR) for 06/2026 revealed three past orders for chlorhexidine gluconate 0.12% mouthwash 15 cc. The first order read, Chlorhexidine gluconate mouthwash 0.12% swish 15 cc for 30 seconds twice a day for 7 days. The first order started on [DATE] and ended on [DATE]. The second order read, Chlorhexidine mouthwash 0.12% swish 15 cc for 30 seconds three times a day after meals. May keep at bedside. The second order started on [DATE] and ended on [DATE]. The third order read, Chlorhexidine mouthwash 0.12% swish 15 cc for 30 seconds three times a day after meals. May keep at bedside. The third order started [DATE] and ended [DATE]. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she had no cognitive deficits.During a random observation on [DATE] at approximately 3:00 PM, revealed a bottle of prescription chlorhexidine mouthwash on R1's bedside table. The resident was not present in the building at the time of the observation. No lock box or lock on her bedside table drawer was observed. During an interview on [DATE] at approximately 3:15 PM, Licensed Practical Nurse (LPN)1 revealed R1 would keep the mouthwash at her bedside in the top drawer of her nightstand next to her bed. He stated he has not worked in the facility for a few days, so he is not sure why the mouthwash was not removed from R1's bedside when the order ended on [DATE].During an interview on [DATE] at 3:35 PM, the Director of Nursing revealed R1 asked to have the mouthwash continued after the initial order ran out. The DON verified no current order for the mouthwash was in place. She revealed the last order for the chlorhexidine mouthwash ended on [DATE].During an interview on [DATE] at 6:10 PM, the Administrator revealed there should have been an order to continue the mouthwash after [DATE] or the mouthwash should have been removed from R1's bedside. The Administrator stated they will have to discuss the process for removing medications from a resident's bedside once a medication that is self-administered is discontinued. During an interview on [DATE] at 6:30 PM, the DON confirmed no new order was obtained to continue the chlorhexidine mouthwash past [DATE], and the medication should have been removed from R1's room when the last order expired.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided nail care to residents unable to carry out activities of daily living (ADLs), which affected 1 (Resident (R)87) of 2 residents reviewed for ADL assistance. Findings included: Review of a facility policy titled, Activities of Daily Living, Optimal Function, revised 05/05/2023, indicated, The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Review of a Resident Face Sheet revealed the facility admitted R87 on 02/09/24. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of depression, chronic obstructive pulmonary disease, hypotension, and unspecified intellectual disabilities. An Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/15/2026, revealed R87 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident required partial/moderate assistance for showering or bathing and required supervision or touching assistance for personal hygiene. R87's Care Plan, included a problem statement initiated 02/22/24, that indicated the resident required assistance with ADLs related to their intellectual disability and mobility impairment. Interventions initiated 02/22/24 directed staff to provide assistance with bathing and personal hygiene as needed with one to two staff members. During an interview on 03/23/26 at 9:43 AM, R87 stated that the nails on their thumb and fifth digit (little finger) on their left hand were longer than they wanted. The resident stated that their nails had been breaking off. An observation at this time revealed the resident had seven fingernails that were jagged, and three nails that were approximately 0.5 centimeters (cm) to 1 cm past their fingertip. An observation on 03/25/26 at 9:35 AM revealed no change in R87's nails. During an interview at that time, the resident stated facility staff had not come to cut them. R87's electronic health record revealed staff documented that R87 received a bath on the following dates: - 03/22/2026 by Certified Nurse Aide (CNA)5 - 03/23/2026 by CNA6 - 03/25/2026 by CNA5 During an interview on 03/25/26 at 12:49 PM, CNA5 stated that she offered residents nail care daily when she got them up as well as when providing a bed bath or shower. She stated that she last provided nail care to the resident on 03/23/26 during a bed bath. CNA5 observed Resident #87's nails and stated that she thought they looked the same as they did on 03/23/26. R87 stated at this time that their nail on their fifth digit hurt them. CNA5 stated that they would cut the nail shorter that day. She stated that she thought the resident preferred to have longer nails. During an interview on 03/25/26 at 1:54 PM, CNA6 stated that nail care was provided every Sunday, when a resident requested, or if staff noticed nails being too long or having dirt under them. She stated that nail care was also provided when baths were provided if they needed it. She stated that she did not think R87 liked having long nails; she said she thought the resident preferred them short. CNA6 stated that she bathed the resident on 03/23/26 but did not remember what the resident's nails looked like. CNA6 stated that the provision of nail care was important so that residents did not cause an injury to themselves. On 03/25/26 at 2:35 PM, Licensed Practical Nurse (LPN)7 stated that she had taken care of the situation and cut R87's nails. During a follow up interview on 03/26/26 at 8:28 AM, LPN7 stated that R87 had several nails that were few centimeters long. She stated that resident nail care was provided with showers or if the nursing staff saw it in passing. She stated that she was a unit manager and expected nursing staff to check daily on if there was any need for nail care and if so, to provide it. She stated she would not want a resident to end up cutting themselves. She stated that situations that would necessitate nails to be trimmed included if the resident's nails were long or dirty, if a resident said their nail was hurting, if they had a hang nail, or if the resident asked. During an interview on 03/26/26 at 2:31 PM, the Director of Nursing (DON) stated she expected nursing staff to provide nail care when providing a shower or bed bath, or if the staff noticed long nails or dirty nails. She stated that if a resident was demented and there was a risk of harm by scratching oneself, she expected nails to be trimmed. The DON stated that if a resident was cognitively intact, then she expected their preference for nail length to be documented on the care plan. Per the DON, it was a part of ADL care. She stated that staff talked to her about R87's nails being a little long during the survey. She stated she directed them to start on nail care because staff reported to the DON that the surveyors were asking about nail care. During an interview on 03/26/26 at 3:06 PM, the Administrator stated that he expected facility staff to provide nail care as part of their routine. He stated that he expected them to identify if the resident's nails were dirty and long, and if so, to trim them. He stated that this was important because it could lead to ingrown nails, or the resident's nails snagging on their own skin.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors, which affected 1 (Resident (R)10) of 8 residents reviewed for medication administration. Findings included: A facility policy titled, Medication Management Program, revised 05/05/25, revealed, The Facility implements a Medication Management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements. The policy also indicated, Preparing for Medication Pass included, 4. Authorized staff must understand: A. Indications or reason for therapy, B. Effectiveness for achieving therapeuticgoal [sic], C. Drug actions, and D. The '8 Rights' for administering medication, which included 1) The Right Patient/Resident, 2) The Right Drug, 3) The Right Dose, 4) The Right Time, 5) The Right Route, 6) The Right Charting, 7) The Right Results, and 8) The Right Reason. The policy revealed, Administering the Medication Pass included, 5. The authorized staff member validates the following information is documented on the MAR [medication administration record], which included, A. Correct physician's order and diagnosis for each medication and B. Medication and label are correct. The policy continued, 6. The authorized staff member reads the label on the medication three (3) times, which included, A. Before removing the medication from the drawer, B. Before dispensing the medication, and C. After dispensing the medication. A Resident Face Sheet revealed the facility admitted R10 on 03/14/25. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of pain, personal history of pulmonary embolism (a blood clot in a lung causing blockage of blood flow), paroxysmal atrial fibrillation (an intermittent irregular heartbeat that can last up to seven days), difficulty walking, muscle weakness, and abnormalities of gait and mobility. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/26, revealed R10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident received a scheduled pain medication regimen and experienced occasional pain over the five days prior to the MDS assessment. R10's Care Plan included a focus area revised 03/19/26, that indicated the resident was at risk for pain related to a kidney stone and chronic pain related to fibromyalgia. Interventions initiated 03/14/25 directed staff to administer medications as ordered, monitor and record effectiveness, and report adverse side effects. The Care Plan also included a focus area revised 02/09/26, that indicated the resident was prescribed anticoagulant therapy with a history of pulmonary embolism and a history of deep vein thrombosis (a blood clot in one or more of the deep veins in the body). Interventions initiated 03/14/25 directed staff to administer anticoagulant medication as ordered, evaluate and record effectiveness, evaluate and report adverse side effects, and observe for signs of active bleeding. R10's Physician Order Report, for the timeframe from 03/01/26 to 03/26/26, contained an order, dated 12/23/25, for acetaminophen (an analgesic) 325 milligrams (mg), two tablets by mouth every eight hours for pain. The Physician Order Report also contained an order, dated 01/22/26, for apixaban (an anticoagulant) 5 mg, one tablet by mouth twice a day for paroxysmal atrial fibrillation. During an observation of medication administration on 03/25/26 at 7:45 AM, Licensed Practical Nurse (LPN)3 prepared medication to administer to Resident #10, which included removing two 325 mg tablets of aspirin (an antiplatelet medication) from the medication cart. LPN3 entered R10's room and handed the cup of medications to the resident. Prior to R10 taking the medications, the surveyor requested LPN3 to verify the resident's medication orders. LPN3 took the cup of medications from R10 and exited the room to review the resident's medication orders. LPN3 reviewed R10's medication orders and verified that the resident was ordered to receive two 325 mg tablets of acetaminophen, not two 325 mg tablets of aspirin. LPN3 stated that he normally verified the medication order by verifying the right dose, for the right resident, at the right time, the right medication, and the right route prior to administering a medication to a resident. R10's Physician Order Report, for the timeframe from 03/01/26 to 03/26/26, revealed no order for aspirin. During a telephone interview on 03/27/26 at 10:07 AM, the Consultant Pharmacist (CP) stated medication errors occurred when nursing staff administered the wrong medication, the wrong dose of a medication, administered a medication outside of the ordered time, or several other factors. The CP stated there could potentially be an adverse reaction if a resident who was on apixaban was administered a dose of aspirin because the two medications were contraindicated in most cases. The CP stated that if a resident who was on apixaban was administered 650 mg of aspirin in error, he would consider it to be a significant medication error because it would require nursing staff to contact the resident's physician and a need for monitoring of potential increased bleeding or bruising issues for seven to 10 days. During an interview on 03/27/26 at 11:01 AM, the Director of Nursing (DON) stated that if a resident received a 650 mg dose of aspirin in error, she would consider it to be a significant medication error because it would increase the resident's likelihood of bleeding issues or a change in the resident's condition. During an interview on 03/25/26 at 3:28 PM, the DON stated nursing staff were educated to verify the five rights of medication administration, which included the right patient, right route, right time, right dose, and right medication when administering medications to a resident. The DON stated a medication error could occur if nursing staff did not follow the rights of medication administration when administering medications to residents. During an interview on 03/26/26 at 3:09 PM, the Administrator (ADM) stated he expected nursing staff to follow the physician's orders and follow the rights of medication administration that they were educated on. The ADM stated that a medication error could occur if the nursing staff did not follow the rights of medication administration.

Based on facility policy review, record review, observation, and interview, the facility failed to ensure staff provided food that accommodated residents' food allergies and preferences, which affected 1 (Resident (R)110) of 1 resident reviewed for food concerns. Findings included: A facility policy titled Food Preferences; Diet History, revised 10/15/25, indicated, Food Preferences will be completed upon admission for each patient/resident and documented in the medical record. The policy indicated Procedures included, D. If the preference list is not completed on or prior to admission, the Certified Dietary Manager (CDM) or designee reviews and updates food preferences with the patient/resident within 72 hours of admission as part of the initial patient/resident visit and documents in the medical record, and G. The CDM refers to the preferences list when making the tray ticket and when collecting data. A Resident Face Sheet indicated the facility admitted R110 on 03/03/26. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of constipation, type 2 diabetes mellitus, heart disease, gastro-esophageal reflux disease (GERD), and dementia. The Resident Face Sheet indicated R110 had an intolerance to dairy, milk, and peppermint. R110's hospital After Visit Summary, dated 03/03/26, indicated R110 had allergies that included corn-containing products, milk-containing products (dairy), and mint flavor. An admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 03/09/26, indicated R110 had a Brief Interview for Mental Status (BIMS) of 14, which indicated the resident had intact cognition. The MDS indicated that R110 had clear speech and was usually able to make themself understood. R110's Care Plan included a problem statement initiated 03/03/26, that indicated the resident was at nutritional risk related to dementia, diabetes mellitus, seizure disorder, altered mental status, and heart disease. Interventions directed staff to honor the resident's food preferences as feasible (likes/dislikes/food allergies). R110's Nutritional Assessment, completed 03/08/26, indicated that the assessment was completed based on a medical record review. Per the assessment, R110 had food allergies that included dairy, milk, and peppermint. The Nutritional Assessment revealed no food preferences were noted. The Nutritional Assessment included interventions, which included honoring the resident's food preferences as able and omitting listed allergens from the resident's diet. During an interview on 03/23/26 at 7:41 AM, R110 stated that breakfast was not good because they had food allergies and the facility was not paying attention to their allergies. R110 stated that their caregiver had notified the facility of their allergies, but nothing was done about it. During an observation and interview on 03/23/26 at 1:12 PM, R110's lunch tray included chicken tenders, dinner roll, creamed corn, and fruit cobbler. R110 stated they could not eat corn. An observation on 03/25/26 at 7:59 AM revealed R110's breakfast tray included oatmeal with brown sugar, a biscuit or roll with cream sausage gravy, and juice. During an interview at that time, R110 stated they could not eat the oatmeal because there was sugar in it. During an interview on 03/25/26 at 1:18 PM, the Dietary Manager (DM) stated she was in the process of linking allergies to recipe ingredients that were in the electronic tray card program so the system would correctly identify any food allergies and remove the food from a resident's tray card. The DM stated she met with residents when they were admitted in order to obtain food preferences or when they had concerns. The DM stated that when she updated a care plan, she indicated that the facility honored resident food preferences. The DM stated that nursing staff entered any food allergies into the medical record. The DM stated she had not met with Resident #110 to obtain food preferences. The DM stated that R110 should not have had the creamed corn if the resident was allergic to corn. During an interview on 03/26/26 at 1:34 PM, Licensed Practical Nurse (LPN)1 stated that if a resident received a food item they did not like, she would get them a substitute and report it to the DM so the DM could meet with the resident to update their food preferences. During an interview on 03/26/26 at 1:44 PM, Registered Nurse (RN)2 stated that the certified nurse aides (CNAs) checked the meal trays for accuracy but may not always know what they were looking for. RN2 stated if a resident did receive something listed as an allergy, she would remove it immediately and notify the DM. RN2 stated if a resident received something that they did not like on their tray, she would get them a substitute. RN2 stated that if a resident continued to receive items they did not like, it could lead to weight loss. During a telephone interview on 03/26/26 at 10:56 AM, the Registered Dietitian (RD) stated she started working for the facility one week prior and had not had a chance to meet with R110. The RD stated that she expected the DM to meet with new residents within 48 hours of admission to obtain food preferences and enter the preferences into the tray card program. The RD stated residents should not receive any food item that was listed as an allergy, and the facility tried to honor food preferences as much as possible. During an interview on 03/26/26 at 2:40 PM, the Director of Nursing (DON) stated that if a resident had food allergies, she expected the allergies to be entered on the resident's profile so that all staff would be aware of it. The DON stated that the CNAs checked the meal trays for accuracy. The DON stated that if a resident communicated food preferences to staff, the staff member should communicate those preferences to the DM. The DON stated that if a resident received food that they were not going to eat, it could lead to weight loss. During an interview on 03/26/26 at 3:04 PM, the Administrator (ADM) stated the DM should meet with residents upon admission and as needed to update food preferences. The ADM stated he expected resident food allergies and preferences to be care planned and followed. The ADM stated that food was important to residents, and if they received things they did not like, it could lead to weight loss.

Based on observations, record review, interviews, facility policy and the Department of Health and Human Services Centers for Medicare & Medicaid Services pathway, the facility failed to maintain infection prevention and control practices for 1 of 1 residents reviewed for colostomy care, Resident (R)1. Findings include: Review of the Department of Health and Human Services Centers for Medicare & Medicaid Services Infection Prevention, Control & Immunizations Pathway, dated 8/2024 Enhanced Barrier Precautions (EBP): EBP use is evaluated when investigating specific care activities, such as wound care, enteral feeding, urinary catheter care, etc. EBP are indicated during high contact care activities for residents with infection or colonization with a CDC targeted MDRO (when contact precautions do not apply) or for any resident who has a chronic wound and/or indwelling medical device.High-contact resident care activities include dressing, bathing/showering, transferring, toileting, providing hygiene, changing linens or briefs, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, or wound care: generally, for residents with a chronic wound(s), not skin breaks or tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. Review of a facility policy titled Infection Prevention and Control Policies and Procedures. Subject: Transmission Based/Standard Precautions, and Enhanced Barrier Precautions. Policy: 4. Health care workers will implement enhanced barrier precautions according to policy with additional measures to protect residents and staff from Multidrug-resistant Organisms (MDRs). MDROs refers to microorganisms predominantly bacteria that are resistant to one or more classes of antimicrobial agents. Procedures: Enhanced Barrier Precautions (EBP) 1. Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. A. EBP will be implemented for All residents with the following: 2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. B. EBP will be implemented during the following high-contact resident care activities: . 4) providing hygiene, 6) changing briefs or assisting with toilet, 7) device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator. C. EBP requires the following PPE: 1) gloves, 2) gown, 3) face protection if performing activity with risk of splash or spray .F. The facility will post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE (gowns and gloves). G. The facility will post signage that clearly indicates the high-contact resident care activities that require the use of gown and gloves. H. The facility will provide gowns and gloves immediately outside of the resident's room .J. The facility will provide education to the facility staff on the implementation and procedure for EBP . Review of R1's Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to: Other lack of coordination, muscle weakness (generalized), cerebral palsy, unspecified, restlessness and agitation, other symptoms and signs involving appearance and behavior, colostomy status, anxiety disorder, unspecified, GERD, irritant contact dermatitis due to friction or contact with body fluids, unspecified, gastrostomy status, crohn's disease, unspecified, without complications, other symptoms and signs involving cognitive functions and awareness and depression, unspecified. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/04/2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R1 has intact cognition. Review of R1's Physician Order documented, Clean area around colostomy stoma and abdomen with soap and water, apply stoma powder to irritated open skin around stoma, gently brush away excess powder with hand, then spray area with skin prep spray or can dab area with skin prep pad to make area tacky, then apply colostomy wafer and bag. replace as needed Twice A Day 07:00 AM - 07:00 PM, 07:00 PM - 07:00 AM, and Enhanced Barrier Precaution with start date of 04/18/24. Review of R1's Care Plan documented, Problem: Resident is on enhanced barrier precautions r/t peg tube and ileostomy with start date 06/13/2024. Goal(s): Resident will have no signs or symptoms of infection r/t peg tube site and ostomy site with target date: 10/10/2024. Approach: Use enhanced barrier precautions during peg tube site care and ostomy appliance care and changing appliance, Use universal precautions at all times and specifically EBP (enhanced barrier precautions) during routine care when site/appliance will be exposed during care, Use enhanced barrier precautions cart set up on unit for supplies, Enhanced Barrier precautions means always wearing gloves, gown if needed during personalized care, bathing, dressing changes, toileting, wound care where you are specifically touching resident for care. Serving food trays, educations and answering call light does not call for EBP with start date of 06/13/2024. During an observation and interview on 09/23/24 at 1:11 PM, the surveyor observed Enhanced Barrier Precautions signage and Personal Protective Equipment (PPE) on R1's door. The surveyor entered R1's room and observed R1 sitting in the wheelchair and Licensed Practical Nurse (LPN)1 getting supplies together. LPN1 was wearing gloves and a face mask. R1 was observed to already have pants down to thighs and shirt up above the abdomen, which LPN1 reported that the resident had completed in preparation after being instructed to go to room for care. R1 transferred himself from wheelchair to bed with standby assistance from LPN1. LPN2 entered the room to assist. LPN1 stated that the resident had an ostomy clinic appointment at 2:00 PM. When asked about the ostomy site, LPN1 stated the dressing was about to be changed because it does not stick on the reddened irritated skin. LPN2 stated that the only time the skin seemed to improve was when the resident returned from the last hospitalization where he was receiving TPN. LPN2 reported that several things had been tried but nothing seemed to help. LPN2 was observed wearing only a face mask and gloves. The surveyor informed LPN1 and LPN2 that they would need to talk more once the care was completed. During an observation and interview on 09/23/24 at 1:18 PM, the surveyor re-entered the room to ask about the Enhanced Barrier Precautions signage noted on the door after observing care being provided with only a face mask and gloves. LPN2 stated that they had not gotten used to the new state law and should be wearing a gown. LPN2 went to obtain a PPE gown for both nurses providing care. During an interview on 9/23/24 at 1:29 PM with Certified Nursing Assistant (CNA)1, she reveal the resident will pick and pull at the ostomy site/bag often. CNA1 reported that care has to be provided multiple times during the shift with an average of 2-3 times. When CNA1 is made aware of the need to have ostomy care provided, the nurse is notified. Prompt care is given due to leaking feces. CNA1 will assist the nurse. CNA1 confirmed that Enhanced Barrier Precautions required the use of gown, gloves, mask related to ostomy care. During an interview on 9/23/24 at 1:34 PM with LPN1 revealed that the resident goes for ostomy care at a clinic due to the rash making it hard for the dressing to stick. LPN1 reported that the ostomy was changed this morning during the medication pass and had instructed LPN2 to meet in R1's room after being notified of needing care provided for the second time today. LPN1 reported that R1 will communicate needs but since R1 is independent, moves a lot, and transfers independently, it makes it challenging to keep the bag secure. It was reported that on an average of 2-3 times a shift, care is provided. LPN1 denied having any knowledge of family having concerns regarding neglectful care. When asked about the Enhanced Barrier Sign on the R1's door, it was reported that it was in place related to having a colostomy. LPN1 admitted that a gown should have been applied as the precautions included gown, gloves, and mask during care and it had been omitted related to being in the moment and rushing to get R1 ready to leave for the 2 pm appointment. During an interview on 9/23/24 at 1:40 PM, R1 stated that care is provided by the staff for the colostomy upon request. There were no concerns voiced related to not being able to get the assistance needed. During an interview on 09/23/24 at 2:59 PM the Director of Nursing (DON) stated that the expectations related to Enhanced Barrier Precautions included that staff were to wear PPE anytime care is being provided such as during ostomy care. The PPE required will be according to what is listed on the sign and staff have been educated to the requirement.

Based on review of facility policy, record review, interviews, and review of video footage, the facility failed to protect Resident (R)1 from mental and verbal abuse for 1 of 3 residents reviewed for abuse. Specifically, 2 (two) Certified Nursing Assistants (CNA)s video recorded their interaction with R1 and posted the video to social media. On 04/12/24 at 12:45 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 04/09/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 04/12/24 at 1:19 PM, the facility provided an acceptable IJ Removal Plan. On 04/12/24, the survey team, validated the facility's corrective actions and determined the facility put forth good faith attempts to address the non-compliance. The IJ is considered at Past Non-Compliance as of 04/10/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600, constituting substandard quality of care. Findings include: Review of the facility policy titled Dress Code/Phone Policy Updates updated on December 2019, documented, Phones/Social Media/Misc: 1) No using personal mobile phones while in patient care/reception areas 3) No pictures of patients/residents other than as part of activity where legal disclosures are signed. 7) No posting of patient information on social media sites. Review of the facility undated Employee Handbook, documented, Telephone Use Taking photographs or recordings of a resident and/or his/her private space without a resident's or designated representative's written consent is a violation of the resident's right to privacy and confidentiality. Review of the facility policy titled Organizational Ethics Abuse, Neglect, Exploitation, or Mistreatment with an email revision date of 10/23/19, documented, Policy 7. The facility strictly prohibits staff from taking or using photographs or recordings obtained in any manner on any type of device (e.g , camera, smart phone or other electronic device) that would demean or humiliate a patient or resident. Definitions as defined by CMS section 483.5: 1. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 5. Mistreatment means inappropriate treatment or exploitation of a resident. Component IV: Identification 2. Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. Types of abuse include BUT ARE NOT LIMITED TO: B. Mental Abuse: 1) Humiliation 2) Harassment 5) Intentional disrespect or disregard for an individual's right to privacy and dignity as it relates to their person and property. This may include but is not limited to photographing or recording video or audio of a patient/resident or their personal environment or property without consent. D. Verbal abuse includes any use of: 1) Oral language Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia, chronic obstructive pulmonary disease, anxiety disorder, need for assistance with personal care, dysphagia, cognitive communication deficit, and major depressive disorder. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/24, revealed a Brief Interview for Mental Status (BIMS) was not conducted due to R1 being rarely/never understood. Further review of the MDS, under section GG-Functional Abilities and Goals, revealed R1 is dependent on staff (helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Review of R1's Care Plan with a problem start date of 08/16/23, documented, [R1] is dependent on staff for meeting emotional, intellectual, physical, and social needs. Further review of the Care Plan revealed a Care Plan with a problem start date of 06/03/22, documented, [R1] requires extensive to total assist with ADL's [activities of daily living] due to confusion and weakness. Another Care Plan with a problem start date of 11/04/21, documented, [R1] is at risk for complications related to impaired communication and cognition. The goal for this Care Plan stated, [R1's] dignity and self-esteem will be preserved and quality of life improved by minimizing risk associated with cognitive and communication impairment . Review of video footage provided by the facility, revealed text at the bottom of the video which read, Southpointe Healthcare and Rehabilitation Greenville, SC. The text at the top of the video revealed a name (later identified as CNA2) and the time of 10:29. Further review of the video footage revealed CNA1 and CNA2 (later verified by the Administrator and Director of Nursing) mocking and laughing at R1. CNA1 could be heard stating, we ain't got no wee wee for you. CNA2 begins to laugh out loud at the remark made by CNA1. R1 could be heard yelling and telling the CNAs to get out. R1 continues to yell unintelligibly through the remainder of the video. At one point, the video shows R1, with a linen covering her upper body and head. R1's legs were visible from the bottom of the linen and were kicking as if R1 was in distress. CNA2 continues to laugh out loud. CNA2 stated, I bought you a fresh blanket. CNA1 responded, . if you yell, I'm going to take it back . CNA2 can be seen exiting R1's room. Review of a Witness Statement dated 04/09/24, written by the Director of Nursing (DON), revealed at 10:30 PM, I received a phone call from Social Services Director about a possible video that was made by possible staff members. At 10:45 PM, I received a call from Human Resources that the video was received and I needed to call and suspend the staff involved. At 10:50 PM, I called to the facility and spoke with [CNA2], I asked him who was inside the room with him when he made that footage on the self-deleting app. He stated nobody. I then made him aware that he was suspended pending investigation. He hung up the phone. At 10:56 PM, I called back to facility and spoke with [Licensed Practical Nurse], I asked her who was assigned to [R1] she stated [CNA1]. I asked to speak with her. Once on the phone I asked [CNA1] was she inside of the room with [CNA2] when he made the video on the self-deleting app and she stated yes ma ' am. I then made her aware that I was so disappointed in her and that I would have to suspend her at this time pending investigation. She stated ok. Review of a Witness Statement signed on 04/11/24, by the Administrator, revealed, On 04/09/24, I received a call at 10:52 PM from the DON. She explained that she was notified by the Social Worker there was video that had been posted on social media of two employees and the video showed the employees in a resident room and the resident could be seen . Review of [local police department] County Sheriffs Office Victim/Witness Assistance Program dated 04/10/24, revealed the local police department conducted an investigation related to Abuse Vulnerable Adult. Review of a Suspension Form dated 04/09/24, revealed Certified Nursing Assistant (CNA)1 was suspended Due to an allegation of abuse, employee was heard on a video that was posted on social media, the employee could be heard telling the resident we don't have a wee wee for. Employee could also be heard saying stop yelling. DON [Director of Nursing] notified employee by phone that she was being suspended pending an investigation. Review of a Termination Form dated 04/10/24, revealed CNA1 was terminated from employment due to gross misconduct. Further review revealed CNA1 was terminated for Employee Termed for Resident Abuse. Review of a Suspension Form dated 04/09/24, revealed CNA2 was suspended Due to allegation of abuse. Employee was seen in a video while another CNA was providing care. This video was posted on social media. [CNA2] was heard/seen mocking the resident who has diagnosis of dementia. The video had the facility name shown. The employee was notified by the DON that he was being suspended pending an investigation. Review of a Termination Form dated 04/10/24, revealed CNA2 was terminated from employment due to gross misconduct. Further review revealed CNA2 was terminated for Employee Termed for Resident Abuse. Multiple attempts were made to contact CNA2, but were unsuccessful. During an interview on 04/12/24 at 11:58 PM, the DON stated, I got a call Tuesday night from Social Service Director and she said there is possibly a video of a staff of ours. But she did not have the actual footage. Somehow she got the footage and notified HR, and HR called me stating they got the footage and to suspend the CNAs. I came on site and saw the video and identified the male CNA. I questioned the male CNA and he said he was alone, I told him he was suspended and he hung up the phone. I talked to the nurse on duty and she verified [CNA1] was the other CNA. [CNA1] stated she was in the room with [CNA2] when he took the video. I informed her she was suspended. I notified everyone. During an interview on 04/12/24 at 12:28 PM, CNA1 stated, unfortunately I cannot talk about it without my attorney present. During an interview on 04/12/24 at 1:18 PM, Social Services (SS) stated, I got a call from a member stating I need to see something. The member wanted to remain anonymous. She facetimed me and showed me the video that was on Snapchat (a social media platform). After I saw the video, I called the DON and HR. I was able to identify who was in the video and I saw the patient. I knew the staff member by face but not by name. I initially thought it was agency, and I knew he was in the building. On 04/12/24 at 1:19 PM, the facility provided a removal plan of the IJ which included: Alleged perpetrators suspended pending investigation immediately upon discovery. Head to toe completed on identified Resident #1 on 4-9-24 with no negative outcomes. Psychosocial evaluation completed on resident by licensed social worker on 4-10-24. Resident #1 was referred to psychiatry and psychology for follow up. A review of the 24 hour report and facility activity report was completed on 4-10-24 by the Director of Nursing beginning 4-9-24 through 4-10-24 to identify possible allegations of abuse or neglect. No concerns identified at this time. The Administrator and Director of Nursing will be re-educated by the Clinical Consultant on Abuse and Neglect policy including: -Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect -Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse -Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness -Immediate identification and removal of the alleged perpetrator -Identification and assessment of the alleged victim -Reporting immediately to State Survey and Certification agency -Resident dignity -HIPPA -Cellphone usage in the facility and Social Media usage in the facility. This reeducation was completed on 4-10-2024 Facility Staff were re-educated by the Administrator on 4-9-24 Abuse, Neglect and Misappropriation policy including: -Identification of abuse or neglect, by observable and objective evidence, witness reports of unusual occurrence or patterns or trends of potential abuse or neglect -Abuse is the willful infliction of injury unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual of goods or services that are necessary to maintain physical, mental and psychosocial wellbeing. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse -Neglect is the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish or mental illness -Immediate identification and removal of the alleged perpetrator -Identification and assessment of the alleged victim -Reporting immediately to Facility Abuse Coordinator, Director of Nursing, and Social worker regardless of time of day Facility Staff were re-educated by the Administrator on 4-9-24 including -Process of reporting -Resident dignity -HIPPA -Cellphone usage in the facility and Social Media usage in the facility. This reeducation began immediately and will be completed by 4-12-24. Any staff not receiving this information prior to this date will receive prior to next scheduled shift. This education will be presented in New Hire and agency staff orientation. Administrator contacted Regional Ombudsman on 4-10-24. Administrator and Director of Nursing will review incident reports and grievance reports daily for identification of possible allegations of abuse. Members of nursing Management will interview 3 random residents daily for one week, then weekly for three months validating residents feel safe and have no care concerns. The results of this monitoring will be presented to the Quality Assurance/Performance Improvement Committee for a period of three months for review and recommendation. Any identified concerns will be addressed at the time of discovery. Human Resources will interview 3 random employees daily for one week, then weekly for three months for compliance with Abuse, Neglect, Misappropriation, resident dignity, process of reporting, resident dignity, HIPPA, cellphone usage in the facility and Social Media usage. Ad Hoc QAPI was held on 4-10-24. The Medical Director was notified of the Immediate Jeopardy on 4-12-24. Allegation of Compliance- 4-10-24.

Based on record review and review of facility's weight policy, titled Weighing the Resident, the facility failed to provide documentation that Resident (R)1 had a 5 % or more weight loss with reviews by facility's dietitian regarding nutritional status with recommendations for interventions for 1 of 1 resident reviewed for weight loss. Findings include: Review of the facility policy titled, Weighing the Resident with a revision date of 5/5/23 indicates; 3. Record all weights on the Monthly Weight form or per facility protocol. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Nutrition/Culinary Services Director. Document this notification per facility protocol. 5. The facility dietitian reviews the patient's/resident's nutritional status and makes recommendations for intervention in the nutritional progress notes if significant weight change is noted. 6. Review significant, unplanned changes and insidious gradual weight loss or gain trends in weights at the weekly Long-Term Care Coordination meeting. 7. Update the plan of care with goals and approaches/ interventions listed. R1 was admitted to facility on 2/28/23 with diagnoses including, but not limited to: dementia, congestive heart failure, type 2 diabetes, chronic kidney disease and hypertension. Review of an unspecified Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/23 indicated R1 had a Brief Interview Mental Status (BIMS) score of 9, indicating mild cognitive impairment. A review of R1's medical record revealed that on 7/7/23, R1 weighed 214 pounds. On 8/4/23, R1 weighed 187 pounds. On 8/28/23, R1 weighed 179.8 pounds and on 11/27/23 weight was 154.1 pounds. Review of the dietary notes revealed there was no dietary note addressing significant weight changes with recommendations for interventions. The medical record revealed the last dietary note for R1 was date 3/20/23. A review of R1's care plan revealed: Resident with weight fluctuation related to dialysis. Interventions: Encouragement of nourishment and fluids/fluid restrictions. A review of R1's progress notes dated 6/19/23 revealed, R1 continues on dialysis, weight continues to fluctuate due to Lymphedema improving, physician and registered dietitian made aware. During an interview with the Director of Nursing (DON) on 2/8/24 at 2:40 PM, she stated, She was the guardian angel for R1, and she spoke with R1's daughter daily about R1's care needs. The DON stated that R1 had Lymphedema when he was admitted , and he lost a great deal of weight due to the fluid loss. The resident is also a dialysis patient, and his weight fluctuates. During an interview with the Administrator on 2/8/24 at 2:45 PM, the Administrator stated that R1 had stopped eating. He was difficult to care for and he frequently refused care, include turning and positioning. R1 was frequently non-compliant with dialysis and all refusals were care planned. The Administrator stated that R1's daughter was updated daily on R1's behavior and condition. The Administrator stated there was not a documented dietary note with interventions or recommendations regarding R1's significant weight loss. The Administrator stated that R1 was started on an appetite stimulant on August 25, 2023 and was also on a dietary supplement for weight loss. A review of R1's Physician orders and Medication Administration Records (MARs) revealed R1 was not receiving a dietary supplement or ordered for one.

Based on interview, observations, record review and review of facility policies the facility failed to protect 3 of 4 sampled residents from accidents and/or accident hazards, Residents (R)99, R70 and R71. On 07/10/23 at 1:25 PM, the Administrator was notified that the facility's failure to protect residents from accidents and/or accident hazards by allowing R99, R70 and R71 to sign out of the facility to smoke and not signing back in the allowing the facility to not having the knowledge of knowing were the residents are located. Furthermore, a vaporizer (inhalation device) was discovered in the possession of R99. Administrator was notified that the allegations constituted Immediate Jeopardy (IJ) at F689, with an effective date of 06/14/23 and the IJ template was presented. On 07/11/23 at 10:38 AM the Administrator provided an acceptable IJ removal plan for F689, the immediacy of the IJ was removed and the IJ was lowered to the scope and severity of E, no actual harm with the potential for more than mini al harm that is not IJ. In addition, the facility failed to ensure a resident's room and wheelchair were free of potential accidents and hazards for R40. Specifically, R40 was observed with an unsecured oxygen cylinder in their room, and a wheelchair that did not fit properly and had unsecured wheelchair arms. Findings Include: Review of policy titled Leaving the Facility in the facility's Admission Handbook, revised on 02/2022, revealed that Residents may leave the facility at any time with written permission from their physician. It is essential that you sign-out with the charge nurse or supervisor when you leave the facility and that you check-in with them upon your return. Review of policy titled Smoking Policy in the facility's Admission Handbook, revised on 02/2022, revealed that All residents are prohibited from keeping any type of smoking materials in their rooms or on their person. Violations of this policy endanger the health and safety of others at the facility. Review of facility policy titled, Day Outings/Therapeutic Leave of Absences, with a revision date of 10/01/20 states .The LOA must be consistent with the resident's goals for care which are evaluated by means of the Comprehensive Assessment and incorporated into the Comprehensive Plan of Care. Facility staff will document Voluntary Leave Notification and Release of Liability information in the patient's/resident's medical record for use in coordinating day outings/LOAs. Alternatively, the facility may use a log with individual Voluntary Leave Notification and Release of Liability forms for signature that are added to the electronic medical record . Review of R99's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/23 revealed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating the resident was moderately, cognitively impaired. Review of R99's care plan revealed that R99 was not care planned to smoke nor for leave of absences as stated in the facility policy. Review of R99's Progress Notes revealed the following : On 06/15/23 SW and ADON educated resident about signing in and out, also about not having paraphernalia on campus. On 06/20/23 3:25 PM Administrator met with resident to educate that facility is smoke/vape free. Went over that resident has to sign in and sign out. No paraphernalia allowed on campus including alcohol. Resident was also explained that a warning letter and 30 day dc notice will be given if not in compliance. On 06/22/23 at 4:08 PM staff reported resident up at store with sign asking for money. resident was educated about riding up the road and other activities. resident continued to go further up road On 07/06/23 at 4:43 PM Resident went LOA after lunch . resident refused to get out of electric chair & stated I need to get my book & find some where else to stay resident went outside without signing himself out On 07/06/23 5:34 PM Resident left building without signing out, resident remained in electric chair. Resident had his walker [NAME] to back of electric chair when he went out the door. On 07/06/23 at 6:12 PM Resident requested PRN oxycodone, given as ordered. Resident was instructed to stay inside for a while after taking to that staff could monitor for safety, resident said he was going to eat food & go out to smoke. On 07/08/23 1:12 AM This resident has been in and out of facility this shift. Staff member located this resident outside in driveway earlier and requested for resident to sign himself out when leaving property, Resident stated that he is looking for another facility to go to because this one is too strict. This writer attempted to reorient resident to safety precautions. Resident resting in bed at this time. Call light in reach. On 07/10/23 . administrator went over sign in and out , not to have lighters, cigarettes/vapes, alcohol, and resident has the right to go to a facility that allows smoking. Resident was also given a warning violation letter with required signature. During an observation of R99's room on 07/10/23 at 9:02 AM revealed R99 lying in bed and a pink vaporizer was lying on the residents bedside table, LPN1 was then notified and confiscated it. During an interview with Licensed Practical Nurse (LPN)1 on 07/10/23 at 9:06 AM, LPN1 stated that she has a bag of confiscated items that they have taken from residents after they had signed themselves out and left the premises. LPN1 then confirmed that residents should be checking with staff before signing themselves in and out. LPN1 stated that R99 is known to leave the facility multiple times per day and that the staff does not always know if he is in or out of the building. During an interview with the Administrator on 07/10/23 at 3:30 PM, she stated that they are a non-smoking facility and therefore they do not do smoking assessments. She also stated that they do not care plan for smoking because residents can have therapeutic leave. The facility only has 3 residents that sign themselves out and they have decisional capacity, which is what the facility uses to determine if a resident has the ability to do so. The Administrator further revealed that when residents are going out to smoke, they try to confiscate any cigarettes or lighters they may have, but the residents are not always cooperative and they can't search them or force them because they have rights. During an interview on 07/12/23 at 07:49 AM, the Medical Director (MD) stated these smoking patients have the decisional capacity to sign themselves in and out of the facility. We advise the residents against drinking, smoking, and using illegal substances. We can't chain the residents to the bed. The nurses have been telling me about everything involving the residents smoking. The resident stated we can't stop him from going out and smoking. He stated he doesn't care what we say. We have offered smoking cessation and we offer nicotine patches and that doesn't help. I fear if they do, we do not let them sign themselves out, they will smoke in their rooms. During an interview on 07/12/23 at 8:21 AM, the Director of Nursing (DON) stated We are a non-smoking facility. The local hospitals know we are a non-smoking facility. Our admission packets have a non-smoking clause in them. The residents review the smoking policy and smoking materials are prohibited in the facility. When we screen residents for smoking history, we offer cessation. Because we are a non-smoking facility, we don't do smoking assessments. We can't deem them safe to smoke because that would be violating our own policy. The policy says you can't smoke in or around the facility. Residents can sign themselves out if they are decisional. They can go off the property and they are aware that they have to go off the property Realistically, there's one way in and one way out. We have completed smoking cessation more than once. We put yellow flags on their chairs for safety, so that cars can see them. The residents take them off. We can't stop them from smoking when they leave the property, but we can try to keep them safe when they leave off the property. They have been given discharge notices. Social services, the Administrator and I have met with them in the facility to let them know if they did not comply with the non-smoking rules, they would be given discharge notices. The residents are supposed to sign in and out. We ask the residents to check in with the nurse when they come back in to hand over your smoking material. Because we are a non-smoking facility, we should not be the gate keeper for smoking material. Technically, the residents should be taken off the property to smoke and not bring those materials into the facility. In the past, family members would take residents out to smoke. 48448 A review of R71's Face sheet revealed the facility admitted the resident with diagnoses which included, myasthenia gravis, insomnia, opioid use, recurrent depressive disorders, supraventricular tachycardia, gastro-esophageal reflux disease without esophagitis, fusion of spine cervical region, and mixed hyperlipidemia. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/19/2023, revealed R71 had a Brief Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A review of R71's comprehensive care plan initiated 04/19/2023 revealed there was no care plan to address the resident leaving the facility to go smoke off the property. A review of R71's progress note on 06/15/2023 at 11:50 AM written by the social worker (SW) stated, SW and Assistant Director of Nursing (ADON) educated resident about signing in and out, also about not having paraphernalia on campus. Also not allowing other residents to hold on to his chair to go up the road. A review of R71's progress note dated 06/19/2023 at 05:55 AM written by Licensed Practical Nurse (LPN)4 revealed, Resident's room had strong odor of cigarette smoke. When questioned, resident admitted to 'burning something'. When asked about smoking a cigarette he stated, that's what I burned. Resident refused to give Nurse his lighter. Informed resident that I would have to report the incident to management. A review of R71's progress note dated 06/19/2023 at 09:04 AM written by the SW revealed, Staff contacted SW about resident smoking in room and would not give cigarette and lighter to the staff. SW will talk with administrator about plan. A review of R71's progress note dated 06/19/2023 at 03:16 PM written by the SW revealed, Administrator met with resident to educate that facility is smoke/vape free. Went over that resident has to sign in and sign out. No paraphernalia allowed on campus including alcohol. Resident was also explained that a warning letter and 30-day dc notice will be given if not in compliance. Review of R71's Release of Responsibility for leave of absence Signing Out revealed the following: 5/26/23 1:43 PM 5/30/23 3:21 PM 6/2/23 (no time written by date) 6/3/23 2:33 PM 6/4/23 3:24 PM 6/7/23 1:56 PM 6/8/23 2:27 PM 6/9/23 2:43 PM 6/15/23 2:23 PM 6/16/23 2:18 PM 6/20/23 2:44 PM 6/21/23: 4:57 PM 6/22/23 12:27 PM 6/23/23 3:45 PM 6/28/23 3:30 PM 6/30/23 2:44 PM 7/1/23 5:23 PM 7/3/23 11:47 AM 7/7/23 2:40 PM The Signing IN revealed dates and times of: 5/6/23 3:25 PM 5/26/23 2:30 PM was struck out. 6/25/23 2:30 PM 6/1/23 9:21 PM An interview with R71 on 07/10/2023 at 9:43 AM revealed the resident left the facility a few times a day, unsupervised. R71 stated, I go outside and ride around. I sign in and out at the front desk. I don't smoke cigarettes; I only smoke black and mild. I don't buy packs of anything; I only buy one and I smoke them before I come back to the facility. I'm usually back by dinnertime. An interview with the SW on 07/10/2023 at 10:53 AM revealed the SW worked at the facility since 2014. The SW stated R71 was one of the smokers in the facility. She also stated, The smokers have been educated to sign themselves in and out and not have lighters or paraphernalia on their person. We are a smoke free facility, and we have residents who are non-compliant. The resident had a lighter and refused to give it to a staff member. Resident was educated on the fact that he could have smoking paraphernalia on them, and they would be given a 30 day notice if behavior persisted. The resident was re-educated on 7/10/23. During an interview on 07/10/2023 at 11:02 AM, Licensed Practical Nurse (LPN)4 stated, I was doing a med pass and I went passed the residents' room and I smelled the cigarette smoke. When I walked into R71's room I smelled the smoke. I asked the resident were they smoking, and they stated they had just lit something. I asked was it a cigarette and they stated yes, but I wasn't smoking. I asked for their lighter and cigarette and they refused to give them to me. I informed them I would let the administrator know and they didn't care. I made the facility aware, and the resident still refused to give them to anyone. This was only incident I've had with this resident with smoking. It's hard to keep up with the residents who smoke. They will come in and leave back out. It's hard to keep up with the smoking resident's when doing a medication pass. I have come to work and they're on the corner of the street. They could easily get hurt with the traffic on the roads. During an interview with the Administrator on 07/10/23 at 3:30 PM, the Administrator stated that the facility is a non-smoking facility and therefore the facility does not complete smoking assessments. The Administrator also stated that the facility does not care plan for smoking because residents can have therapeutic leave. The facility only has 3 resident that sign themselves out and the residents have decisional capacity. Decisional capacity was what the facility used to determine if a resident can make decisions. The Administrator further revealed that when residents are going out to smoke, the staff try to confiscate any cigarettes or lighters the residents may have. The residents are not always cooperative, and the facility can't search the residents or force the residents because the residents have rights. During an interview on 07/12/2023 at 07:49 AM, the Medical Director (MD) stated the smoking residents have the decisional capacity to sign themselves in and out of the facility. We advise the residents against drinking, smoking, and using illegal substances. We can't chain the residents to the bed. The nurses have been telling me about everything involving the residents smoking. R71 stated we can't stop R71 from going out and smoking. The MD stated R71 stated they don't care what the facility says. The facility has offered smoking cessation and nicotine patches and that doesn't help. The Medical Director states she fears if the facility does not let the smokers sign themselves out, smokers will smoke in their rooms. During an interview on 07/12/2023 at 08:21 AM, the Director of Nursing (DON) stated the facility was a non-smoking facility. The residents who smoked reviewed the smoking policy and know that smoking materials are prohibited in the facility. When we screen residents for smoking history prior to admission. We offer cessation. Because the facility is a non-smoking facility, the facility doesn't complete smoking assessments. The facility can't deem the smokers safe to smoke because that would be violate the facility's policy. The policy says you can't smoke in or around the facility. Residents can sign themselves out if they are decisional. The residents can go off the property. The staff have completed smoking cessation more than once with the smoking residents. The facility can't stop them from smoking when the residents leave the property, but the facility can try to keep them safe when they leave off the property. Social services, the Administrator and the DON have met with the smokers to let them know when they do not comply with the non-smoking rules, they would be given discharge notices. The residents are required to sign in and out of the facility. The facility has asked the residents to check in with the nurse when they come back in the facility and to hand over their smoking material. Although, the facility was a non-smoking facility, the staff should not be the gate keepers for smoking material. Technically, the residents should be taken off the property to smoke and not bring those materials into the facility. 31846 The facility admitted R70 on 05/23/2023 with diagnoses including, but not limited to, physical debility, muscle weakness, alcoholic cirrhosis of the liver, muscle wasting and atrophy of the left and right hand, chronic pain, alcohol abuse and nicotine dependence. Review on 07/10/2023 at 12:10 PM of the medical record for R70, revealed sign out sheets for leave of absence starting on 06/14/2023 through 07/09/2023. R70 went out to smoke, signing a leave of absence 40 times during that period of time. He only signed back in 16 times. There is no documentation to ensure the smoking supplies were taken from the resident and secured in a locked area or compartment any of the 40 days. On 06/16/2023, R70 signed out, leave of absence at 9:23 AM to smoke and signed back in on 06/16/2023 at 8:20 PM. On 06/19/2023, R70 signed out, leave of absence to smoke and signed back in at 8:00 PM. Review on 07/10/2023 at 1:25 PM of a form titled, Authorizations, Consents, & Acknowledgements, revealed, Policies. The policies include: Admission, Discharge and Readmission Policies. Smoking Policies. Rules and regulations governing resident conduct. Policies/procedures for bringing personal items into the facility and securing personal belongings, valuables and money. Policies and procedures for filing grievances. These are all signed by the resident. Further review of the forms revealed a form titled, Addressing Decisional Capacity, The form is signed by the physician on 04/05/2023 and states, This patient DOES possess the decisional capacity to make healthcare decisions for self. R70 has a BIMS score on a a MDS assessment dated [DATE] of 14 out of 15. Review of R70's medical record revealed no physicians order for R70 to sign out as a leave of absence and smoke. Review on 07/10/2023 at 2:20 PM of the progress notes revealed: Progress note dated: 6/23/23 5:50 AM -Nurse from the Blue Hall Unit brought resident back to the Pink Hall Unit stating that resident had been outside with another resident and that it was after 10:00 PM and that it was time to come in and go to rooms. Resident on Blue Hall Unit came in and went to room. This resident came in but did not come back to the unit. When the nurse brought resident to this unit he was sitting in wheelchair with his head laid over to the side. Resident was unable to hold eyes open. Resident did slightly open eyes when touched on the shoulder with calling out his name. Resident did respond that he had been drinking when asked by co nurse on Pink Hall Unit. Resident urinated on himself when in wheelchair at desk. This is not normal for this resident as he normally uses a urinal. VS taken, DON called and was made aware of situation. On call Nurse Practitioner (NP) called with vital signs given and recount of the situation. NP stated to let resident sleep and monitor resident through the shift. Resident's contact called and made aware of situation. Resident is currently up yelling out this morning. Resident does not remember the events of earlier in shift. Progress note dated: 6/14/23 3:58 AM-Second shift CNA went out to her car and heard someone hollering help at the cul-de-sac in front of facility. CNA told nurse on the other unit and that nurse called this nurse. Walked to cul-de-sac and found resident sitting in his wheelchair. Liquor bottles and beer cans found laying on ground at curb. This nurse asked resident if he had been drinking and resident stated yes. Resident smelled of alcohol. Resident was unable to wheel himself back to facility. Resident had hard time holding eyes open and speech was slurred. Resident normally is able to propel self in wheelchair. Called Nurse Practitioner (NP) on call to notify of resident. Called Assistant Director of Nursing and Director of Nursing and made aware. Vital signs taken and vitals were stable. All bedtime medications held. Resident is currently resting in bed with no further distress noted at this time. Progress note dated: 6/23/2023 06:39 PM-Resident continues with PT/OT, resident has displayed verbal aggressiveness towards staff for unknown cause/reason. Resident currently out of facility. There is no documentation on the form titled, Release of Responsibility for Leave of Absence, that R70 even left the building that day in the afternoon. The removal plan for F689 included: R99, R70 and R71 are currently in the building. R99's vaporizer was removed from his possession with their consent by the Unit Manager and stored in Unit Manager's office. Resident's family notified to obtain vaporizer from the facility. A Review of the Release of Responsibility for leave of absence forms was completed by the Director of Nursing. Residents who are currently signed out were located in the facility and reeducation was provided to residents who sign themselves out regarding signing back in upon return and notifying nurse they have returned on 7/10/23 at approximately 2:30 PM. On 7/10/23 at 11:30 AM, Administrator has spoken with residents who sign themselves in and out and requested any smoking materials be turned into the nurse for secured storage in locked medication areas. Staff- both licensed and non-licensed staff and residents who sign themselves out via leave of absence form will be reeducated by Director of Nursing /Designee on 7/10/23 on the following: o Residents will sign in and sign out with the nurse or facility representative at the nurse's station when they leave the building. o Residents check in with charge nurse or facility representative upon return-facility representative will sign next to resident signature to validate. o Residents are prohibited from keeping any type of smoking materials in their rooms or on their persons. If residents do not surrender smoking materials upon reentry, appropriate discharge planning by Social Services will occur if smoking materials are identified. Any staff not receiving this education on 7/10/23 will receive prior to working the next scheduled shift. This will be presented in New Hire Orientation and for agency staff. The Director of Nursing will randomly interview a minimum of 2 staff and 2 interview residents weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with leave of absence sign in/out process. Director of Nursing/designee will review sign out logs twice a shift for 5 days then daily for 3 additional weeks, then monthly for 2 additional months to validate residents remain compliant with signing in and out of the facility. Administrator/designee will round in resident rooms 2 times per day for 5 days, then daily for 3 additional weeks then monthly for 2 additional months to validate there are no smoking materials in residents' rooms or on their persons. Any concerns will be addressed at time of discovery. The Medical Director was notified on 7/10/23 of the Immediate Jeopardy. Ad Hoc Quality Assurance Performance Improvement Meeting was held on 7/10/23 to discuss contents of this plan. Administrator will oversee compliance of this plan for three months. 48810 Additional findings include A review of a facility policy titled, Safety and Health Policies and Procedures, dated 11/01/2018, indicated, General Oxygen Safety, 1. Oxygen cylinders shall be stored in racks with chains, sturdy potable carts, or approved stands. 8. Oxygen cylinders shall not be dragged or slid across floors. 10. Oxygen cylinders shall never be left freestanding. Also indicated while at work, use good judgement regarding safety and that all times remember, an accident/injury cannot be undone. A review of the Face Sheet indicated the facility admitted R40 with diagnoses that included sepsis, hypokalemia, peripheral vascular disease (PVD), difficulty walking and lack of coordination. The quarterly MDS with an ARD of 04/12/2023, revealed R40 had a BIMS score of 15, which indicated the resident was cognitively intact. The resident was independent with bed mobility, eating and toileting. On 07/09/2023 at 12:00 PM, R40 was observed in their room with an oxygen cylinder at doorway leaning against the wall without being placed in a stand or secured from tipping over. Oxygen tubing was still attached to the oxygen cylinder and loosely wrapped around the cylinder and concentrator. During a concurrent observation and interview on 07/09/2023 at 12:00 PM, R40 was observed sitting in a wheelchair at bedside with the arm rest on the wheelchair raised up high with resident's arms resting on the arm rest at chest level. R40 stated that the arm rests were loose. R40 showed surveyor how the arm rests were loose and moved back and forth freely. R40's hips were pushing against the arm rests. R40 stated their hips hurt because the wheelchair was too small. During an interview on 07/09/2023 at 1:35 PM, Certified Nursing Assistant (CNA)3, stated that the oxygen cylinder was not supposed to be in the resident's room unsecure and was a hazard. During an interview on 07/09/2023 at 1:45 PM, LPN1, stated she was called in to work and that she was the one that removed the cylinder from the resident's room. She stated that was a hazard because the oxygen cylinder was not on a stand and was leaning against the wall. During an interview on 07/12/2023 at 12:07 PM, the Social Service Director (SSD) stated that she was not aware of problems with R40's wheelchair and that she would let therapy know so that R40 could be evaluated. During an interview on 07/12/2023 at 12:21 PM, LPN1, stated that she checked the wheelchair and seen the arm rest. She stated the arm rests were too high for R40's stature, and the wheelchair was too tight. She stated that she was going to check to see if they have other arm rest available to fit R40. During an interview on 07/12/2023 at 12:32 PM, the Director of Nursing (DON) stated that she expected oxygen cylinders to be in a holder or secured. She stated that she was not aware of R40's wheelchair and had not evaluated it herself. She stated therapy was responsible for measuring wheelchairs for the resident and expected a resident's wheelchair to fit appropriately and to be in a safe operating manner. During an interview on 07/12/2023 at 1:04 PM, the Administrator (ADM) stated that oxygen cylinders should be secured in a cart or on a stand and not leaning up against the wall unsecured. She stated that when an oxygen cylinder was not being used the oxygen cylinders should be put in the oxygen storage closet. She stated that she did not know about R40's wheelchair. She stated she expected oxygen cylinders to be stored properly. She expected residents' wheelchairs to be maintained safe and fit properly.

Based on review of the facility policy titled, Medication Storage, observations, and interviews, the facility failed to ensure 1 of 4 medication carts and 1 of 1 treatment carts was locked and secured away from ambulating residents. The facility further failed to ensure expired medications were removed from 4 of 4 medication carts, 1 of 2 med storage rooms, and 1 of 1 treatment carts. The findings included: Review of the facility's policy titled, Medication Storage, revealed Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biological's in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. The medication and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members. Procedures: Number 5 states, Medications with manufacturer's expiration date expressed in month and year will expire on the last day of the month, (unless a sooner expiration date has been placed on the package by the pharmacy). Number 6 states, Once any medication or biological is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. Number 7 states, Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhalers, insulin, ophthalmic's, optics and the like) with the date opened ad follow manufacturer/supplier guidelines with respect to expiration dates. An observation on 07/09/2023 at 10:15 AM revealed an unlocked medication cart on the Pink Hall, and an unlocked treatment cart on the Pink Hall, both unattended. Some residents were observed ambulating in the hallway past the carts and some were propelling themselves in wheel chairs in front of the carts. An interview on 07/09/2023 at 10:15 AM with Licensed Practical Nurse (LPN)3 confirmed the unlocked carts, stating she was an agency nurse. An observation on 07/11/2023 at 10:00 AM of the Pink Hall medication cart 1 revealed: Hydroxyzine HCL 25 milligrams (mgs) 1 by mouth (po) every (q) 6 hours, Manufactured by North Star RX#1234413 30 tablets expired on 6/6/2023. Thera Multi Vitamin, 1 bottle Lot#601002, expired on 06/2023 An interview on 07/11/2023 at 10:05 AM with LPN6 confirmed the findings. An observation on 07/11/2023 at 10:20 AM of the Pink Hall med storage room revealed: One Covid-19 AG Lot#135906 exp 9/16/21 AWLB195430 Rev 2. One bottle of Extra Strength Pain Relief Tabs with Acetaminophen 250mg/Aspirin 250mg/Caffeine 65mg, Manufactured by Medline 24 tabs expired 06/2023. The findings were confirmed by LPN5. Further review of the Pink Hall medication storage room revealed: Hydroxyzine HCL Tabs 25mg 70 tablets, Manufactured by North Star, Lot#96338 Exp 05/01/2023 Hydroxyzine HCL Tabs 25mg 30 tabs Manufactured by North Star Lot#99856 Exp on 07/06/23 Divalproex Sprink DR 125mg, 60 capsules Manufactured by Dr. Reddy's Lot#C2111637 expired on 06/06/2023. An interview on 07/11/2023 at 10:30 AM with LPN6 confirmed the findings. An observation on 07/11/2023 at 01:20 PM of the Pink Hall medication cart 2 revealed: One Bottle of Evencare Blood Glucose Test Strips Lot#16822022006 open with no open date; One Combivent - Respimat Inhaler 20mcg/100mcg per actuation, RX#1344869, Lot#201122A, Opened on 01/30/2023 States on the inhaler instructions Expires 3 months after insertion of cartridge into inhaler. Evencare G2 Glucose Control Solution Lot#16819082101/201, expired 08/18/2021. LPN5 confirmed the findings. An observation on 07/11/2023 at 1:30 PM of the Blue Hall crash cart revealed: One bottle of Prefilled Humidifier 340 mls of Sterile Water expired on 05/07/2023. Ten (10) packs of lubricating Jelly 0.9 oz per pack, Ref #MD50322732, Expired on 11/2022. The findings were confirmed by LPN9. Review on 07/11/2023 at 01:40 PM of the treatment cart on the Blue hall revealed: One Bottle of Curad - Sterile Packing strips, Lot#05949 - Opened and used and placed back on the cart and is no longer sterile. Remedy 1 tube 4oz. expired on 05/2023. Curad Petrolatum Dressing 3 x 9 - 9 packets expired. Medline Skin Integrity - Hydrogel impregnated gauze, Lot#18475, 2x2 squares, 21 packages, expired 08/2022. Medline Puracal-Ultra Powder Collagen Wound Dressings Lot#(10) 11141 - 4 packages expired on 02/18/2020 Good Sense Hemorrhoidal Suppositories, Lot#9D6814, 22 suppositories expired on 03/2021 [NAME] 1 tube of Nystatin Oint. USP, RX#1025903, 100,000 USP Nystatin Units, 30 grams ID10433, Expired on 02/2023. Nystatin and Triamcinolone Creme, 60 gram tube, Lot#05210993, Expired on 04/2023. Cutimed Sorbact, Sterile, Hydrophobic Microbe Binding Dressing with Hydrogel. Lot#017093, 3x3 dressings, 17ct, expired on 04/23/2020. The expired medications and biological's in the Blue Hall treatment cart were confirmed by LPN1. Review on 07/11/2023 at 01:45 PM of the Blue Hall medication cart 1 revealed: One Symbicort inhaler RX#1417438 expired on 01/02/2023. One Symbicort inhaler RX#1456909 expired on 02/07/2023 One Symbicort inhaler RX#1519547 expired on 11/21/2022. One Symbicort inhaler RX#1375496 expired on 01/13/2023. One Symbicort inhaler RX#1430200 expired on 03/03/2023. The expired inhalers were confirmed by LPN9. Review on 07/11/2023 at 2:00 PM of the Blue Hall medication cart 2 revealed: One bottle of Thera Lot#601V02 expired on 06/2023. Pro-stat AWC 1 bottle Lot #220906 expired on 07/08/2023. Two (2) bottles of Acetaminophen Lot #2IJJA046 expired on 06/2023. Metoprolol one blister pack RX#1209078 expired on 06/06/2023. Famotidine 1 blister pack RX#1238519, expired on 07/05/2023. Lisinopril 1 blister pack RX# 12398102 expired on 07/05/2023. Metoprolol 1 blister pack, RX#1238103 expired on 07/05/2023. Hemorrhoidal Supp 1 box Lot#11-7-0435 expired on 05/2023. The expired medications were confirmed by LPN9.

Based on interview, observation, and record review the facility failed to ensure that 1 Resident (R)69 out 3 residents dressings were changed according to the physician's orders. In addition, the facility failed to ensure that the wound care was provided as physician ordered for 1 (R40) of 3 residents reviewed for wound care. Specifically, R40 did not receive wound care on 07/07/2023. Findings Include: A review of the facility's policy, Wound Care Policy and Procedures, revised on 06/01/2015 revealed the cover dressing should have a date, time, and initial on it. A review of Resident 69's Face Sheet revealed the facility admitted the resident with diagnoses which included Type 2 diabetes mellitus, other encephalopathy, gastrostomy status, pressure ulcer of other site unstageable, pressure ulcer of left heel unstageable, dementia, diabetic neuropathy, and chronic diastolic congestive heart failure. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R69 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating the resident has a severe cognitive impairment. Further review of the R69's MDS revealed the resident had a stage four pressure ulcer. Interventions included to provide skin and ulcer/injury treatment and pressure reducing device for chair and pressure reducing device for bed. A review of R69's comprehensive care plan initiated on 06/27/2023 revealed the resident was at risk for skin breakdown related to diabetes mellitus and mobility issues. The care plan also revealed R69 has current wounds. An intervention in R69's care plan stated wound care as ordered. A review of R69's physician orders dated 06/26/2023 revealed an order daily wound treatment to left Heel, clean with normal saline, pat dry, place Hydrofera blue foam on the wound bed, wrap with kerlix, and secure with tape daily. Change every Monday, Wednesday, and Friday. An observation on 07/09/2023 revealed the dressing to R69's left heel was dated for 07/05/2023. A review of R69's Treatment Administration Record (TAR), for the month of July 2023, revealed R69's wound care was not completed on 07/07/2023. Initials with parentheses around the initials signifying the wound care was not completed was left by licensed Practical Nurse (LPN)7 for the date of 07/07/2023. Under the Comment/Reason section on the TAR, a comment was left by LPN 7 stating due on previous shift. During an interview on 07/11/2023 at 10:17 AM, LPN8 stated she cared for R69, but she could not remember anything regarding 07/07/2023. LPN8 stated she would be honest; she was unsure if she changed the dressing on 07/07/2023. The wound care nurse was not at the facility on 07/07/2023. An attempt was made to reach LPN7 on 07/11/2023 at 10:24 AM. There was no answer, but a voicemail was left. During an interview on 07/11/2023 at 10:36 AM, the Director of Nursing (DON) stated she expected the nurses to follow the physician orders regarding wound care. She stated nurses receive competencies on wound care during orientation, when an issue occurred, and when the facility initiated new types of wound care or brands of products. The DON stated she expected nurses to encourage residents to have wound care completed, and when a resident refused wound care, the nurse should go back and try again later or try to get the resident to let a different nurse perform the wound care. She stated when a nurse does not perform the treatment as ordered, the DON expected the nurse to let the next shift know, call the physician to inform the provider of the missed dressing change, and/or get an order to complete the dressing change on the next day. The DON also stated when looking at the TAR, when a box had initials with parentheses around the initials, that indicated the treatment was not completed and there should be a reason or comment left under the reasons/comments section. A review of a facility policy titled, Performing a Dressing Change, revise date 06/01/2015, indicated policy: a dressing change will follow specific manufacture's guidelines and general infection control principles. Procedures: 9. Follow manufacturer's guidelines and physician orders when using any wound care product. A review of the Face Sheet, indicated the facility admitted Resident #40 with diagnoses that included type 2 diabetes mellitus with unspecified complications, chronic obstructive pulmonary disease, sepsis, hypokalemia, peripheral vascular disease, difficulty walking and lack of coordination. The quarterly Minimum Data Set (MDS), dated [DATE], revealed R40 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident was independent with bed mobility, eating, and toileting. Review of R40's Care Plan, dated 04/18/2023, revealed the resident had a diagnosis of diabetes and was at risk for hypo-hyperglycemia. Interventions included observing signs and symptoms of poor wound healing, and to notify the Medical Doctor (MD). Review of R40's Care Plan, initiated on 08/05/2022 and revised 04/18/2023, revealed the resident is at risk for pressure ulcers r/t immobility. Interventions include notifying MD and wound nurse of any areas of concern. Interventions also included weekly body audits. A review of R40's Physician Orders, for the month of 06/2023, revealed an order, dated 06/12/2023, for daily wound treatment on Monday, Wednesday, and Friday to the right foot: clean with normal saline, pat dry, apply leptospermum (an antimicrobial paste) on wound, place calcium alginate (a dressing) on wound, wrap with kerlix, secure with tape three times a week. A review of R40's Physician Orders, for the month of 06/2023, revealed an order, dated 06/12/2023, for daily wound treatment on Monday, Wednesday, and Friday to the right heel: clean with normal saline, pat dry, apply leptospermum honey (an antimicrobial paste) to wound, wrap with kerlix, secure with tape three times a week. Review of the Treatment of Administration Record (TAR), for the month of 07/2023, revealed a treatment order for once a day on Monday Wednesday, and Friday to the right foot to clean with normal saline, pat dry, apply leptospermum on wound, place calcium alginate on wound, wrap with kerlix, secure with tape three times a week. A treatment order for once a day on Monday, Wednesday, and Friday to the right heel to clean with normal saline, pat dry, apply leptospermum honey to wound, wrap with kerlix, secure with tape three times a week. Review of the TAR dated 07/07/2023 revealed an asterisk next to the initials for Licensed Practical Nurse (LPN)12 agency nurse. Asterisk denoted to see comments. Comments noted charted late. On 07/09/2023 at 12:00 PM, R40 was observed with a dressing on their right foot that was dated 07/05/2023. R40 stated their shoe had rubbed the wound on the top of their foot and on the heel of their foot while wearing them. R40 stated they normally had their dressing changed on Mondays, Wednesdays, and Fridays. On 07/10/2023 at 10:01 AM, R40 was observed with a dressing on their right foot that was dated 07/05/2023. On 07/11/2023 at 9:15 AM, R40 gave both surveyors permission to observe wound care and dressing change. Licensed Practical Nurse (LPN)11 moved the meal tray from the bedside table to the nightstand table to perform wound care and dressing change. LPN11 placed a disposable non-sterile pad on the bedside table with unwashed bare hands and placed wound care supplies on top of the pad. Registered Nurse (RN)/ Assistant Director of Nursing (ADON)1 was assisting LPN11with wound care. RN1 with gloved hands, pulled the dirty privacy curtain, from the wall, and without washing her hands or changing gloves, touched the top of R40's foot located next to three middle toes. RN1 placed a bag at the foot of the R40's bed. LPN11 cut the old kerlix dressing off the resident's foot. A small round wound was observed on the heel of R40's foot and on the top of their foot to include partial part of the three middle toes. LPN11 took off her gloves and retrieved forgotten supplies from a wound care cart in hallway, washed hands after returning and gloved hands. LPN11 washed wound to the heel and then the top of the foot with normal saline. LPN11 then placed medicated paste to the heel of the foot, and then the top of the foot. LPN11 then placed the calcium alginate on top of the paste to cover the heel and top of the foot. LPN11 then wrapped the resident's foot with sterile kerlix and secured it with tape. During a phone interview on 07/11/2023 at 11:49 AM, LPN #12, stated she worked night shift and R40's wound care was supposed to be done on the day shift. She stated that she initialed the TAR for 07/07/2023 for it to stop coming up red on the screen but she did not perform the wound care on R40 07/07/2023. She stated that she expected wound care to be done per physician order. She stated that there are a lot of agency staff working in the facility, and not a lot of continuity of care. During an interview on 07/11/2023 at 12:17 PM, LPN11 stated that she did not follow proper infection control practices during R40's wound care. She stated she did not wash her hands before setting up the bedside table with disposable pad and wound supplies. She stated she expected proper infection control to be followed. During an interview on 07/11/2023 at 12:46 PM, RN/ADON #1, stated that she touched the top of R40's foot with gloved hand after touching the privacy curtain first, and did not change gloves or wash her hands before touching the top of R40's wound. She stated she should have washed her hands and put new gloves on after touching the privacy curtain and before touching the top of R40's foot. She stated she expected to follow proper infection control practices during wound care. During an interview on 07/12/2023 at 12:48 PM, the Director of Nursing (DON) stated that staff should be dating wound care dressings after wound care was provided. She stated that she did not know why the wound care dressing did not get done. She stated for 07/07/2023, that R40's wound care may not have been able to be done on the day shift since they were already tapped out of staffing and had used their back up staffing plan. She stated that on 07/07/2023 all shifts were agency staff and two of which didn't show up. She stated she expected when wound care could not be done as physician ordered, for staff to call the physician to get an order for the dressing change to be done the next day, or for staff to ask the next shift to complete the wound care treatment. She stated she was aware that the agency nurse signed the TAR like it was completed but was not completed. She stated that staff should not be signing on the TAR as if the treatment was done if it was not done. She expected wound care to be done as ordered by the physician. The Administrator (ADM) was interviewed on 07/12/23 at 1:09 PM. The ADM stated that she expected wound care to be completed as physician ordered. She stated that she expected staff not to sign off on the TAR if the treatment was not actually done.

Based on interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan for 2 (Resident (R)69 and R71) of 22 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to develop a comprehensive care plan for R69 for a diagnosis of diabetes and R70 for smoking. Findings include: Review of the facility's policy titled, Care Plan Process, Person-Centered Care revised on 05/05/23 indicated, The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1. A review of R69's Face Sheet revealed the facility admitted the resident with diagnoses which included but was not limited to; type 2 diabetes mellitus, other encephalopathy, gastrostomy status, major depressive disorder, pressure ulcer of other site unstageable, pressure ulcer of left heel unstageable, dementia, diabetic neuropathy, overactive bladder, and chronic diastolic congestive heart failure. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R69 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating R69 has severely impaired cognition. Further review of the MDS revealed R69 had a diagnosis of diabetes and received insulin injections seven days in the last seven days. A review of R69's Care Plan initiated on 03/30/23, revealed the resident did not have a care plan for diabetes or diabetic care. During an interview on 07/11/23 at 11:22 AM, the MDS coordinator revealed it was the responsibility of the MDS coordinators to develop and update the care plans for each resident. She stated if a resident had a diagnosis of diabetes, then the resident should have a care plan for diabetes. The MDS coordinator stated she was unsure why there wasn't a diabetes care plan for R69 since they had a diagnosis of diabetes. During an interview on 07/11/23 at 11:33 AM, the Director of Nursing (DON) revealed the MDS coordinators were responsible for developing and updating care plans. The DON stated that when a resident had a diagnosis of diabetes, there should be a care plan for diabetes. The DON was unsure why R69 did not have a care plan for diabetes. 2. Review of R70's Face Sheet revealed the facility admitted R70 on 05/23/23 with diagnoses including, but not limited to, physical debility, muscle weakness, alcoholic cirrhosis of the liver, muscle wasting and atrophy of the left and right hand, chronic pain, alcohol abuse and nicotine dependence. Review of R70's Care Plan located in the electronic medical record (EMR), revealed a care plan that did not include smoking with goals and interventions for R70. During an interview on 07/10/23 at 10:00 AM, the Administrator confirmed that there was no care plan for smokers. She stated that the facility is a smoke free facility and the entire campus. She stated, that if a resident goes on leave of absence then the facility would not need to put that on the care plan. During an interview on 07/10/2023 at 1:25 PM with the Director of Nursing, she stated that residents have a right to sign out and go anywhere they want to. She went on to say that there was not need to care plan the 3 smokers for smoking.

Based on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)13 was provided care and services daily related to bathing for 1 of 3 residents reviewed for activities of daily living (ADLs). Findings include: Review of the facility's policy titled Nursing Policies and Procedures, Subject: Activities of Daily Living, Optimal Function, Complete Revision: May 5, 2023 Definition: Activities of daily living (ADL's), refer to tasks related to personal care including grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. Review of R13's Face Sheet revealed the facility admitted R13 with diagnoses including, but not limited to, cellulitis of the right lower limb, candidal stomatities, morbid obesity, and need for assistance with personal care. During an interview on 07/09/23 at 1:23 PM, R13 stated that the facility staff were not providing the care and services she needed for bathing, changing, and to get dressed in clean clothes daily. Review of R13's electronic medical record (EMR) revealed a plan of care that indicated that R13 requires assistance with ADLs. Further review of R13's plan of care revealed R13 is incontinent of bowel and bladder. Review of R13's daily bathing log revealed no documentation indicating R13 received a bath on the following days: 06/3/23, 06/4/23, 06/7/23 , 06/10/23, 06/11/23, 06/15/23, 06/17/23, 06/18/23, 06/19/23, 06/24/23, 06/25/23, 06/28/23, 06/29/23, 07/1/23, 07/2/23, 07/3/23, 07/5/23, 07/6/23, and 07/8/23. During an interview on 07/11/23 at 4:40 PM the Licensed Practical Nurse (LPN) Unit Manager stated, she did not know why this resident was not receiving baths and showers. The LPN Unit Manager further stated she would go in and check on the resident. She was unable to find any additional documentation that R13 had received daily baths.

Based on review of the facility policy, observations, interviews, and record review, the facility failed to maintain a resident's dignity during meal service for 1 (Resident (R)40) of 6 residents reviewed for dignity. Findings include: A review of a facility policy titled Patient/resident Rights, revised 10/01/2020, indicated, the facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. The facility treats each resident with respect and dignity. The facility provides care for each resident in a manner that promotes, maintains, or enhances quality of life, recognizing each resident's individuality. A review of a facility policy titled Nutrition Policies and Procedures, revised 08/01/2020, indicated, Subject: Meal Delivery; Policy: Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to an improved appetite and can enhance quality of life. Procedures: 2. Make every effort to deliver the trays at the same time each day so patients/residents and nursing staff can anticipate the approximate arrival time. 8. Pull trays from the cart in the order they are set up. 10. Pass meals promptly upon tray cart's delivery to the nursing unit. Review of R40's Face Sheet revealed, the facility admitted R40 with diagnoses that included but was not limited to; sepsis, hypokalemia, peripheral vascular disease (PVD), difficulty walking, and lack of coordination. Review of R40's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/23, revealed R40 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review of the MDS revealed R40 was independent with bed mobility, eating and toileting. Review of R40's Care plan initiated on 04/18/23, revealed R40 had diabetes and was at risk for hypo-hyperglycemia. Interventions included diet as ordered. Further review of the care plan initiated on 07/20/22, revealed R40 is at nutritional risk due to dysphasia and altered mental status (AMS). Interventions included to encourage intake of food and fluids. Review of R40's Physician Orders for the month of 07/23, revealed an order, dated 04/06/23, for a regular diet. During an observation on 07/11/23 at 8:22 AM, revealed the breakfast meals trays being passed out on the 100 hallway. During an observation on 07/11/23 at 8:35 AM, R40's roommate (R88)'s meal tray was observed in their shared room. R88 was being fed by Certified Nursing Assistant (CNA)4. R40 was observed without a tray and stated that they didn't know why they didn't receive their tray and that they had been waiting for it. During an observation on 07/11/23 at 8:59 AM, R40 was observed in their room still without a meal tray. R88 was done with their meal. CNA4 indicated R88 ate 100 percent of their meal and was finished. During an observation on 07/11/23 at 9:00 AM, revealed all trays on the 100 hall were being picked up from residents that were finished with their trays. During an interview on 07/11/23 at 9:04 AM, Licensed Practical Nurse (LPN)10, stated she did not realize R40 did not receive their breakfast tray and considered it a dignity issue when her roommate received a tray and finish eating and R40 was still waiting for a tray. During an observation on 07/11/23 at 9:11 AM, revealed R40's breakfast meal tray being delivered by the Dietary Manager (DM). During an interview on 07/11/23 at 9:12 AM, the DM stated that R40's meal tray was on the meal cart and that he did not know why they did not receive their tray. The DM stated the staff must have missed passing the tray to them. The DM stated that staff were required to pass trays to residents in the order that they are positioned in the cart. During an interview on 07/12/23 at 12:35 PM, the Director of Nursing (DON) stated the DM was the only one saying R40's meal tray was on the meal cart during a meeting they had, but multiple staff stated they went to ask for the meal tray, and it was not on the meal cart. The DON further stated she expected residents to receive their meal tray and to receive their meal when their roommate received their meal tray. During an interview on 07/12/23 at 1:04 PM, The Administrator stated she expected R40 to receive their tray at the same time as their roommate. She considered it a dignity issue for R40 not to receive their tray, and for not receiving their tray when their roommate received their tray.

Based on record review and interview, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status. Resident #5 was admitted to the facility on [DATE] and did not receive an order for [REDACTED]. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's hospital Discharge Summary dated 1/28/16 revealed the resident had 6 liters of fluid removed via paracentesis on 1/21/16 and 3 liters removed on 1/27/16. The Discharge Summary indicated the nursing home should arrange for Resident #5 to have weekly paracentesis done. Resident #5 should continue to receive enteral nutrition. The resident's enteral diet was indicated as [MEDICATION NAME] 1.2, with no rate indicated. Review of Resident #5's admission orders [REDACTED]. There was no rate indicated. Review of Resident #5's Administration Record revealed no entry for [MEDICATION NAME] 1.2. Review of the resident's Nursing Data Collection Tool dated 1/28/16 revealed nutritional approaches indicated the resident had a PEG. The gastrointestinal section included an area for height and weight and neither section was completed. Review of the Nutritional Data Collection/Evaluation dated 1/29/16 indicated Resident #5 had an order for [REDACTED].#5 had orders for complete nutrition via tube feeding of [MEDICATION NAME] 1.2 The Registered Dietitian indicated nursing was to obtain a physician's orders [REDACTED]. Complete assessment will be completed when weight obtained. Review of Resident #5's physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of Resident #5's Administration Record revealed the orders to check residual amount and placement every shift, change peg site dressing every evening and change syringe every evening had been transcribed and were signed off as completed on 1/30/16. The order for [MEDICATION NAME] 1.5 at 57 ml/hr x 18 hours was not transcribed to the resident's Administration Record. Review of Resident #5's physician's orders [REDACTED]. Review of the SBAR Communication Form dated 1/31/16 indicated Resident #5 had decreased responsiveness and was observed to be weak and fatigued. In an interview with the surveyor on 3/2/16 at approximately 4:40 PM, Registered Nurse (RN) #2 stated Resident #5 was admitted at 3:15 PM and was a routine admission. Resident #5 could say his/her name but that was all. RN #2 stated that the kitchen manager stated the Registered Dietitian (RD) would follow up because the resident had an order for [REDACTED].#2 expected the Registered Dietitian to follow up and proceeded with the admission process. RN #2 reported at 7:00 PM to the oncoming nurse that the RD was supposed to address the tube feeding. When RN #2 came in the next morning it was reported to him/her the the 7P-7A nurse had called the hospital. The nurse was not able to get any information on the resident since the resident had been discharged from the hospital. RN #2 talked with the kitchen manager around lunch time on 1/29/16 and asked for the RD's phone number. The kitchen manager stated the RD was in the building and would come to the unit. RN #2 left at 3:00 PM that day and told the oncoming nurse the RD was coming to write the tube feeding orders. RN #2 did not work again until 2/2/16. RN #2 stated the CNAs (certified nurse aides) obtain vitals and weights on new admissions. RN #2 stated that s/he received vitals on Resident #5 on admission but not a weight. RN #2 did not ask the CNA about the resident's weight. The surveyor requested Resident #5's weight record and was provided a print out by the Director of Nursing that indicated on 1/30/16 the resident weighed 111.7 pounds. There were no additional weights on the form. On 3/2/16 at approximately 3:55 PM, the Director of Nursing stated that was the only weight documented. Review of the facility's Weight Management policy revealed procedures included to weigh and obtain a height on each resident within twenty-four hours of admission. Newly admitted residents were to be weighed daily for three days and then weekly for three weeks. Review of the facility's Nutrition Policies and Procedures for Enteral and [MEDICATION NAME] Feedings revealed procedures with general guidelines that included to obtain a physician's orders [REDACTED]. The orders are to include the brand name of the formula and rate/frequency/duration of feedings. In an interview with the surveyor on 3/2/16 at approximately 3:35 PM, the Director of Nursing (DON) stated s/he was working at the facility at the time of the incident as MDS (minimum data set) nurse. The DON stated they usually have a handwritten MAR indicated [REDACTED]. The handwritten MAR indicated [REDACTED]. The DON stated height and weight should be obtained on admission and is the first thing the Certified Nurse Aide does along with vital signs. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the resident's Discharge Orders from the hospital dated 12/24/15 revealed the resident had tube feeding orders for Nepro Renal, one can QID (four times a day). Review of the Medication Administration Record [REDACTED]. Three times on 12/25/15 and twice on 12/26/15. Per the physician's orders [REDACTED]. The 12/26/15 physician's orders [REDACTED]. Provide Nepro Renal 300 ml's via tube QID. Flush with 250 mls, H2O (water) q (every) 6 HRs (hours) The resident did not receive the fourth feeding on 12/24/15 and 12/25/15.