Every finding on record at The Lutheran Village At Miller's Grant

Based on record review and staff interview, the facility failed to accurately code residents' status on the Minimum Data Set (MDS) assessments. This was evident for 2 (Residents #6 and #8) of 13 residents reviewed for MDS accuracy.The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. The findings include: 1) On 6/23/2026 at 8:43 AM, record review revealed that Resident #6 had an active physician's order for Aspirin (an antiplatelet medication) 81 mg daily, which was initiated on 10/01/2025. On 6/23/2026 at 8:50 AM, further record review revealed that MDS assessments dated 10/14/2025, 1/14/2026, and 4/16/2026 failed to reveal that Resident #6 had received antiplatelet medication during the applicable look-back periods. On 6/23/2026 at 11:17 AM, an interview with the Administrator revealed that the expectation was for Aspirin to be coded as an antiplatelet medication on the MDS when administered during the assessment look-back period. On 6/23/2026 at 11:19 AM, the findings were reviewed with the Administrator, who acknowledged and understood the concerns. 2) On 06/23/2026 at 9:52 AM, a review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded as not having experienced a fall since the previous MDS assessment. On 06/23/2026 at 10:05 AM, a review of the medical record revealed a Post Fall Evaluation and a Nurses' Note, both dated 05/26/2026, documenting that Resident #8 had sustained a fall during the MDS assessment look-back period. On 06/23/2026 at 12:36 PM, during an interview, the Administrator stated the facility's MDS Coordinator was a temporary coordinator who was covering the facility until a permanent MDS Coordinator was hired. When asked about the discrepancy in the MDS coding, the Administrator stated the temporary MDS Coordinator confirmed the fall should have been coded on the 06/09/2026 MDS assessment. The Administrator further stated the facility modified the MDS assessment following surveyor identification of the concern.

Based on record review and staff interview, it was determined that the facility failed to annually review and update its Antibiotic Stewardship Program. This was evident during a review of the facility's antibiotic stewardship program. This deficient practice had the potential to affect all residents. The Antibiotic Stewardship Program is a facility-wide program designed to promote the appropriate use of antibiotics, improve resident outcomes, reduce adverse drug events, and help prevent the development of antibiotic-resistant organisms. The program includes monitoring antibiotic use, educating staff and prescribers, and conducting an annual review to ensure the program remains current and effective. The findings include: On 6/24/2026 at 1:16 PM, record review revealed that the Antibiotic Stewardship Program was last updated on 2/15/2025. On 6/24/2026 at 1:18 PM, an interview with the Administrator revealed that the program dated 2/15/2025 was the most recently updated version. At the same time, the concern was discussed with the Administrator, who indicated that she understood. On 6/24/2026 at 1:31 PM, following survey intervention, the facility updated its Antibiotic Stewardship Policy.

Based on record review and staff interview, it was determined that the facility failed to provide written notification of the bed-hold policy to the resident representative. This was evident for 1 (Resident #5) out of 1 resident reviewed for hospitalization during the annual survey. The findings include: On 6/23/2026 at 9:33 AM, record review revealed that Resident #5 was hospitalized on [DATE]. On 6/23/2026 at 9:45 AM, record review revealed that documentation did not indicate the bed-hold policy had been provided to the resident or resident representative at the time of hospitalization. On 6/23/2026 at 11:26 AM, an interview with the Assistant Director of Nursing revealed that the bed-hold policy had not been provided when the resident was transferred to the hospital. At the same time the concerns were addressed with the Assistant Director of Nursing, and she indicated that she understood.

Based on observations and interviews, it was determined that the facility failed to: (1) discard expired food products, and (2) properly label food products with an expiration/use by date. This was evident during the initial tour of the kitchen and had the potential to affect all residents. The findings include: On 6/23/25 at 07:59 AM, a brief tour of the kitchen was conducted. The surveyor was accompanied by the facility's Chef, Staff #5. A brief interview with Staff #5 was conducted. When asked if food products should have an expiration date, he responded that it was the facility ' s expectation that all products have a use-by date. Additionally, Staff #5 stated that it's the facility ' s practice to discard expired items. A tour of the dry storage room revealed 3 bags of bread rolls that had an expiration date of 6/16/25. In each bag there were about 10 rolls. One bag was observed to have black-blue-greenish rolls. Additionally, the surveyor observed several fruit cocktail and artichoke hearts containers that had no expiration dates. There was a container with crushed peanuts that the staff #5 acknowledged was already expired and stated, It should not be in the storage. A brief tour of the refrigerator revealed 1 large container with olives and another container with shallots that had no expiration dates. On 6/24/25 at 09:55 AM, the Director of Nursing (DON) and facility administrator were made aware of the above findings.

Based on record review, observation and interviews, it was determined that the facility staff failed to provide nursing care within the standards of practice by (1) failed to implement fall prevention interventions, and (2) inaccurately documented an intervention that was not implemented. This was evident for 1 (Resident #5) of 2 residents reviewed for falls during the recertification survey. The findings include: On 6/23/25 at 10:00 AM, a review of Resident #5's medical records was conducted. The review revealed that the resident had sustained a fall in the facility. The resident had a care plan with interventions that included floor mats and hip protectors while in the wheelchair. Further review of records revealed an active order for Resident #5 to have hip protectors when sitting in a wheelchair at all times. On 6/23/25 at 10:28 AM, Resident #5 was observed sitting in a wheelchair with no hip protectors. On 6/23/25 at 12:40 AM, Resident #5 was observed sitting in a wheelchair in the living room area near the nurses' station. The resident had no hip protectors. On 6/23/25 at 12:41 PM, an interview with Staff #1 was conducted. When asked if the resident should have hip protectors when sitting in a wheelchair, the staff responded yes. Staff #1 confirmed that the resident did not have hip protectors as ordered. On 6/25/25 at 01:07 PM, Resident #5 was again observed in the dining area without hip protectors. This observation was verified by Staff #4 who at the time was assisting the resident with meals. On 6/25/25 at 01:15 PM, an interview with Staff #3 was conducted. She confirmed that the resident did not have hip protectors on. When asked if the resident should have hip protectors while sitting in the wheelchair, Staff #3 stated that the hip protector order had been discontinued a while ago. On 6/25/25 at 01:26 PM, an interview with the Director of Nursing (DON) was conducted. She confirmed that the hip protectors order was an active order and that the resident should have the hip protectors on while in the wheelchair. Furthermore, the DON also reported that Staff #3 had documented that she placed hip protectors on the resident in the morning. DON was made aware of the identified concerns.

Based on record review and interview, it was determined that the facility failed to ensure there was a system in place to ensure Geriatric Nursing Assistants (GNAs) completed 12 hours of in-service training annually. This was evident for 4 (GNA/Staff #6, GNA/Staff #7, GNA/Staff #8, and GNA/Staff #9) of 5 GNAs reviewed during the annual survey. The findings include: 1) On 06/24/25 at 09:53 AM, review of GNA/Staff #6's annual 12 hour GNA training provided by the facility revealed 0.5 hours completed in 2024. 2) On 06/24/25 at 09:53 AM, review of GNA/Staff #7's annual 12 hour GNA training provided by the facility revealed 0 hours completed in 2024. 3) On 06/24/25 at 09:53 AM, review of GNA/Staff #8's annual 12 hour GNA training provided by the facility revealed 0 hours completed in 2024. 4) On 06/24/25 at 09:53 AM, review of GNA/Staff #9's annual 12 hour GNA training provided by the facility revealed 0 hours completed in 2024. On 06/25/25 at 01:11 PM, the surveyor reviewed the concern with the Nursing Home Administrator. She agreed the facility was not in compliance for the 4 GNAs noted above.

Based on observations of the facility's kitchen food services, review of Dishwashing Machine temperature logs and staff interview it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This deficient practice has the potential to affect all the residents in the facility. The findings include: An initial environmental kitchen food services inspection was conducted in the facility's main kitchen on 8/30/22 at 8:50 AM. At the time of the kitchen tour the dishwashing machine was not observed in operation. The Dishwashing/Warewashing Machine Temperature log for August 2022 was reviewed. The document shown to have blank (no documentation) areas that could have been filled to show what are the minimum sanitation temperature requirements. The document instructed; Refer to machine data plate for temperature requirements. Review of the data plate on the dishwashing machine indicated a minimal wash temperature of 160 degrees Fahrenheit (F.) and a minimal final rinse temperature of 180 degrees F. The document shown that on 8 dates at the dinner meal the facility staff failed to assure the sanitation level of the dish machine as there was not any recording of the dish machine temperatures. There was not any recording of dishwashing machine temperatures for all three meals on 8/7/22. There was 53 times that the minimal wash temperature was documented to be below the minimal requirement of 160 degrees F. A tour of the kitchen facilities in the nursing home unit for long-term care and assisted living was conducted at 11:00 AM on 8/31/22. Review of the plate on the dishwashing machine in this area revealed a minimal wash temperature of 150 degrees F. and 180 degrees F. for the final rinse cycle. A dietary person was utilizing the dishwashing machine and the observed wash temperature was 120 degrees F. and the final rinse temperature was observed at 179 degrees F (Fahrenheit). Review of the temperature logs from a three ringed binder revealed consistently low wash temperatures ranging from 100 to 122 degrees F. in the month of August 2022. Review of the documented dishwashing temperatures for July 2022 showed times when the wash temperature and rinse temperature were both below the required minimal temperatures for sanitation. Review of the dishwashing temperature logs for June 2022 did not show any dates that the dishwashing wash temperature was above the minimum of 150 degrees F. and at least 35 times the final rinse temperature was documented to be below the required temperature of 180 degrees F. Review of the dishwashing temperature logs for May 2022 did not show any dates that the dishwashing wash temperature was above the minimum of 150 degrees F. There was less than 10 times that the dishwashing final rinse was recorded to be at or above the minimum temperature of 180 degrees F. On 8/31/22 at 2:30 PM a discussion was held with the Operations Manager (staff #2) and the Executive Chef (staff #3) to review the dishwashing machine temperature logs showing non-compliance with temperatures to maintain proper sanitation levels of the dishwashing/ware washing machines in the main kitchen and the kitchen on the Long-Term Care unit.

Based on review of the facility's Pharmacy Recommendation/Review policy, the facility failed to develop policies and procedures related to time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. All residents have the potential to be affected. The findings include: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. A copy of the facility's MRR policy was requested from the Nursing Home Administrator (NHA). On 8/31/22 at 12:05 PM, the facility's Pharmacy Recommendation/Review policy was reviewed. Review of the policy issued on 7/13/15 and revised on 9/9/21 revealed that there were no time frames for the different steps and there were no steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The identified non-compliance related to the lack of required information with the facility's Medication Regimen Review was reviewed with the Nursing Home Administrator at 3:16 PM on 9/1/22.

Based on observations and staff interviews, it was determined that the facility failed to remove expired drugs and medical supplies from the med cart and storage room. This was found to be evident in 1of 1 medication cart and medication storage room observed during the annual survey The findings include: On 08/31/22 at 09:30 AM, an exploration of the medication storage cart and Medication storage room of the facility with a Registered Nurse (RN #6) was conducted. It was observed that some of the medications and medical supplies had expiration dates on them. These were kept and currently being used for the residents. 08/31/22 09:35 AM: The Medication storage room and med cart review was done in the company of the Charge Nurse (Staff #6) and findings includes: 1. A 1/2 Empty bottle of Multivitamin Centrum silver with expiration date of 10/21 belonging to Resident (#164) 2. Vitamin A& D ointment with expiration date of 7/2022 3. Providine Iodine swab stick with an expiration date of 7/2021 4. BD Vacutainer Eclipse (2 Boxes) a blood collection needle device with an expiration date of 7/31/22. An Interview was conducted with the Charge Nurse, staff #6, on 08/31/2022 at 09:50 AM during the inspection of the medication storage room. The Charge Nurse indicated that the Director of Nursing (DON) was responsible for managing the supplies, stocking, and checking expiration dates in the med storage room. At 10:10 AM on 8/31/22, the DON was made aware of these findings and took the expired supplies and drugs away. These concerns were also shared with key staff during the exit conference.

Based on medical record review and staff interview, it was determined the facility failed to maintain staff documentation of education regarding the benefits, risks, and potential side effects of receiving the Coronavirus Disease 2019 (COVID-19) vaccine to Resident #11 and Staff #7. This was evident when the COVID- 19 vaccination for residents and staff was reviewed during the facility's annual Medicare/ Medicaid survey. The findings include: On 8/30/22 and 8/31/22 the facility's COVID-19 vaccination for residents and staff was reviewed. Upon review of Resident #11's COVID-19 status it revealed the resident received both the first and second dose of COVID-19 vaccine and one booster vaccine. The second booster vaccine was declined by Resident #11. Staff # 7 was reviewed and received a medical exemption for the COVID-19 vaccine. On 9/1/22 at 2:00 PM the Director of Nursing (DON) had a discussion with the survey team regarding COVID-19 education that is provided to residents and staff. The DON stated that staff and residents are given handouts about COVID-19 updates. The survey team asked the DON if she had documentation to track that residents and staff are provided education and she stated, no. On 9/2/22 at 9:00 AM the Administrator provided the survey team with a copy of COVID-19 vaccine updates for November and December 2021 and June and August 2022. There were no signage sheets to track that residents and staff received the updates. A copy of a staff meeting conducted on April 6, 2022, with a staff signage sheet was provided to the survey team. Staff # 7 that had a medical exemption was not on the signage sheet. The Administrator was made aware that the facility is to track and document education provided to residents and staff. The Administrator confirmed that this would be done moving forward.

Based on a review of employees' training records and interviews, it was determined that the facility failed to have a process to ensure that all Geriatric Nursing Assistants (GNAs) have no less than 12 hours of education per year and that the education includes annual dementia management training. This is evident for 1 (GNA #9) of 3 GNA training records reviewed during an annual survey. The findings include: On 9/2/22 at 9:03 AM, the Nursing Home Administrator (NHA) provided a requested list of the facility's all nursing staff with hire dates. Out of a list of 11 full-time GNAs, 3 employees were selected at random. The surveyor reviewed 3 GNAs education records on 9/2/22 at 10:09 AM. On 9/2/22 at 10:20 AM, the Director of Nursing (DON) confirmed that GNA #9 was hired in May 2016, resigned in May 2021, and re-hired in February 2022. The DON submitted staff education documentation, including GNA #9's online training record on 5/25/2016, competency records for 9/13/2018 and 10/9/2020, and all-day nursing in-service sign-in sheet on 2/18/2021. However, there was no evidence to prove that GNA #9 received any training in the years 2017 and 2019 for at least 12 hours of education per year. On 9/2/22 at 11:19 AM, an interview was conducted with the NHA. The NHA stated that the facility provided all-day in-service training (containing abuse and neglect, resident rights, dementia care, HIPPA, and resident condition changes) for all nursing staff every three months. The NHA was asked for GNA #9's education record in 2017 and 2019. The NHA answered that the documentation she submitted early was all she had. On 9/2/22 at 2:00 PM, the NHA and the DON were made aware of the above issue.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to: 1) review and revise resident care plans after each assessment or as resident care needs became apparent or changed over time. This was evident but not limited to 3 (#2, #3, #12) of 12 residents reviewed during the annual survey. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable). 1) Resident #3's medical record was reviewed on 8/31/22. Review of the MDS assessments revealed that the last quarterly assessment reverence date was 6/7/22. The social worker documented in a progress note of a care plan conference on 6/14/22. There was not any documented evidence found in the medical record that Resident #3's care plans were reassessed and evaluated related to the effectiveness of the care plan interventions. On 9/1/22 at 1:43 PM, the Director of Nursing was asked where the documentation that the care plans are reviewed and reassessed/evaluated towards the written goals of each care plan focus. The Director of Nursing described and guided the surveyor to the area in the care plans to show a date implying the date of 6/30/22 was the date that the care plans for Resident #3 were reviewed. Further review of Resident #3's care plans revealed a care plan with a focus area [name of resident] is prescribed Melatonin r/t insomnia. The Melatonin was discontinued on 6/17/22. The care plan was not revised to reflect the discontinuation of the prescribed Melatonin. 30440 2) On 8/31/22 at 1:45 PM Resident # 2 medical records were reviewed. The resident has the following but not limited diagnoses: Neurogenic Bladder (refers to what happens when the relationship between the nervous system and bladder function is disrupted by injury or disease) and Benign Prostatic Hyperplasia (an enlarged prostate gland which can block the flow of urine out of the bladder). The treatment options for Neurogenic Bladder can include medications, use of catheters, and lifestyle changes. Further review of a foley catheter care plan with a revision date of 5/6/22 indicated the following interventions for Resident # 2: -Perform treatment to right shin and right 2nd toe as per ordered -Staff to provide foley catheter care and services as ordered -Staff to toilet as needed An interview was conducted with the DON on 9/2/22 at 11:50 AM and she was made aware that the resident's foley catheter care plan did not reflect the resident's status. The DON reviewed the care plan list of interventions and confirmed that the interventions were not updated. The DON stated that she would change the care plan immediately. On the same date at 12:07 PM the DON brought an updated foley catheter care plan to the survey team. All concerns were discussed with the Administrator at the time of exit on 9/2/22 at 1:45 PM. 44441 3) A review of Resident #12's electronic record on 9/1/2022 at 2:40 PM showed that Resident #12 sustained a fall on 10/12/2021 by sliding out of his wheelchair to the ground, he/she did not sustain any injuries and this fall was not witnessed by staff. However, a review of Resident #12's Care plan dated 8/14/2021, showed that this resident had a fall care plan in place. The resident had fallen out of his bed on 3 occasions, notably on 8/14/21, 8/18/2021 and 8/20/21, However, on 3/4/22 he also slid off his wheelchair with no injuries documented and on 10/12/2021 when he sustained another fall out of his wheelchair, no updates to the care plan were made to reflect the fall. On 09/01/2022 at 1:10 PM-interview was conducted with the Director of Nursing (DON) and she told the surveyors that she was the one responsible for updating care plans. When asked about the missing care plan update, she said she would go and check on her computer as our screen was different from what was on her screen. On 09/01/2022 at 2:40 PM, The DON later came back to report that she could not find an updated care plan to reflect a new fall intervention put in place on 10/12/2021 for Resident #12. This concern was brought to the attention of the key staff present during the exit conference on 9/2/22 at 1:45 PM.

Based on record reviews, observation, and staff interview, it was determined that the facility failed to develop and implement comprehensive person-centered care that was resident-specific with measurable objectives and goals. This was evident for 2 (residents #3, and #12) of 12 residents reviewed during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On 8/31/22 at 9:30 AM Resident #3's medical record was reviewed and revealed a diagnosis of unspecified dementia with behavioral disturbances. Review of Resident #3's care plan, has mood and behavior issues such as putting staff out of room and a goal that the resident will have decreased/minimal mood and behavior through the next review date. The goal was not measurable. A care plan focus area for Resident #3 was written as [name of resident] plans to remain in this facility for long-term care. The goal was [name of resident] and family will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. This documented goal was the direct opposite of the Focus area. One of the interventions was written to establish a pre-discharge plan with the resident/family and evaluate the progress. The focus is for Resident #3 to remain in the facility. The care plan revealed that Resident #3 needs assistance with ADLs (activities of daily living) the goal was not person-centered as the goal related to staff to provide the care to Resident #3. Staff to assist [name of resident] with ADLs as needed through nest review date. A discussion and review of Resident #3's care plans were held with the Director of Nursing (DON) on 9/1/22 at 1:43 PM. The goals that were not resident oriented and the goals that were not quantitative or measurable were reviewed with the DON. 44441 2) On 9/1/2022 at 11:04 AM, Resident #12's medical record was reviewed and revealed a diagnosis of chronic obstructive pulmonary disease (COPD). Review of Resident #12's care plan initiated on 8/16/2021 with Focus area that stated, resident has potential for changes in respiratory status related to (R/T) COPD and COVID19 pandemic''. On the Goal section of the care plan, it was written as Nursing will manage resident respiratory symptoms, if infected, to maintain the greatest level of comfort possible while fighting against the COVID19 respiratory infection. This goal was not resident specific or measurable as this is a nursing intervention. This goal was written for staff to implement an intervention rather than a resident centered goal. On 09/01/202 at 1:10 PM an interview was conducted with the Director of Nursing (DON). The DON was asked about care plan interventions and revisions. She stated that revised care plans are noted by the dates written next to the plans. When asked if reassessment and re-evaluations of care plan goals are documented anywhere in the care plan, she could not provide proof that goals are being evaluated or met. The goals set for this resident are not specific or measurable

Based on medical record review and staff interview, it was determined the facility failed to provide the resident or resident representative with a summary of their baseline care plan on admission. This was evident for 1 (Resident #164) of 2 residents reviewed during the annual survey. The findings include: A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a copy of their medications, is to be given to the resident and/or resident representative and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive. On 08/31/22 at 11:00 AM, a review of Resident #164's electronic and paper medical records revealed the resident was admitted to the facility on [DATE]. The review of Resident #164's baseline care plan revealed that question E, Baseline Care plan reviewed with resident/POA (power of attorney), was answered no. Further review of medical records revealed no documentation about the facility staff providing information to the resident for the baseline care plan. During an interview with a Registered Nurse (RN #6) on 08/31/22 at 11:30 AM, she stated the facility staff had to complete a new admin resident's full assessment, including a baseline care plan. RN #6 confirmed that the baseline care plan details would be documented under PCC. The surveyor reviewed Resident #146's baseline care plan with the Director of Nursing (DON) on 8/31/22 at 2:00 PM. The DON confirmed that there was no documentation of signatures or evidence that the baseline care plan was given to the resident or the resident's representative.

Based on medical record review, facility documentation, and staff interviews it was determined that the facility: 1) failed to ensure accurate MDS assessment related to urinary and bowel toileting programs, and 2) failed to provide an accurate assessment for a resident with an indwelling foley catheter. This is exemplified for 2 (resident #3, #164) of 8 residents that were coded on their most recent MDS assessments to be on a urinary and/or bowel toileting program, and 1 (Resident # 2) of 3 residents reviewed for urinary catheter or incontinence during the facility's Annual Medicare/Medicaid survey. The findings include. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing homes to gather information on each resident's strengths and needs. Information obtained, drives the resident care planning decisions. The MDS assessments need to be accurate to ensure that each resident receives the care they need. From the mds-3.0-rai-manual-v1.17.1_october_2019 related to coding H0200 A to C = Toileting (or trial toileting) programs refer to a specific approach that is organized, planned, documented, monitored, and evaluated that is consistent with the nursing home's policies and procedures and current standards of practice. A toileting program does not refer to - simply tracking continence status, changing pads or wet garments, and random assistance with toileting or hygiene. 1a) Review of the completed Resident census and condition of Residents (Form CMS-672) on 9/1/22 revealed that the Director of Nursing coded the form at F98 as 10. This coding indicated 10 of the 12 residents in the facility were on a Systemically implemented, individualized urinary toileting program. The coding at F99 of 10, indicated 10 of 12 residents in the facility were in a systematically implemented, individualized bowel toileting program. Resident #3's medical record was reviewed on 9/1/22 for bladder and bowel incontinence. Review of the most recent quarterly MDS assessment date 6/7/22 revealed Resident #3 was assessed to be frequently incontinent of urine and always continent of bowel. At H0200 Urinary Toileting program C indicated Resident #3 was on a current urinary toileting program, and at H0500 the resident was on a Bowel toileting program. Review of Resident #3's care plans revealed a focus area indicating the resident is continent of bowel and occasional incontinent of bladder with a goal that Staff will provide bowel and bladder care to [the resident]. The interventions were documented as Provide incontinent care as needed to [name of resident], and toilet [name of resident] as needed. Review of the care plan related Resident #3's dependence on staff for assistance with activities of daily living included an intervention initiated on 9/27/21 and documented as Toileting program for [name of resident] before meals, after meals, Q hs (daily at bedtime) and PRN (as needed). Documentation related to the resident's responses to the toileting program were not found in the record. Documentation related to assessment or effectiveness of the toileting program was not found in the resident's medical record. There was an order documented as TOILETING PROGRAM BEFORE MEALS, AFTER MEALS, Q HS ANS PRN and the order was transcribed to the Treatment Administrative Record (TAR). The nurses signed off on the treatment twice daily for Days and night. On 9/1/22 at 11:00 AM the Charge Nurse (staff #6) was interviewed. The toileting program for Resident #3 was discussed she indicated that the Geriatric nursing assistants (GNAs) document on a form on a clip board to bowel movements for all residents per shift. She indicated that there was not any documentation as to the resident's continent status related to the prescribed toileting program. An interview was conducted with the Director of Nursing on 09/01/22, 01:43 PM. She was asked how the toileting times for Resident #3's toileting program were developed and where is the documentation to show that that the toileting program was being monitored and reassessed. She did not supply direct answers to the questions but insisted that this toileting plan was resident centered. On 9/2/22 at 11:30 AM the resident's assigned GNA was interviewed. She knew that the resident had a toileting order indicating that other resident(s) have the same order. She indicated that there was not any documentation of the resident's continent status when the resident is toileted. She indicated that there was a separate form on clip board that documents how many bowel movements (BM) a resident has per shift with the size and whether the BM is formed or liquid. 43096 1b) On 9/2/22 at 8:40 AM, the surveyor reviewed Resident #164's medical records. Resident #164 was readmitted to the facility on [DATE]. An order was written on 8/12/22 as Toileting program before meals, after meals, q hs and prn every shift. A review of MDS dated [DATE] revealed that Section H0200 Urinary Toileting Program, question A- Has a trial of a toileting program been attempted on admission/entry or reentry of since urinary incontinence was noted in this facility, was coded, yes. However, further review of Resident #164's medical record revealed that the resident did not have a past/current diagnosis of bladder issue, and there was no documentation that Resident #164 was referred to practitioners who specialize in diagnosing and treating conditions that affect bladder function. Also, there was no evidence of a trial of an individualized, resident-centered toileting program or records of voiding patterns (such as frequency, volume, duration, nighttime or daytime, quality of stream) over several days. During an interview with Resident #164 on 09/02/22 at 10:29 AM, the resident stated she/he didn't receive any training or schedule for toileting. The resident said, I needed to go to the bathroom urgently. Residents #4, #5, medical records were reviewed on 9/2/22 to reveal the same order of Toileting program before meals, after meals, q hs and prn On 9/2/22 at 1:00 PM, the surveyor discussed the above issue with the Director of Nursing. 30440 2) On 8/31/22 at 1:45 PM Resident # 2's medical record was reviewed. The resident has the following but not limited diagnoses: Neurogenic Bladder (refers to what happens when the relationship between the nervous system and bladder function is disrupted by injury or disease) and Benign Prostatic Hyperplasia (an enlarged prostate gland which can block the flow of urine out of the bladder). The treatment options for Neurogenic Bladder can include medications, use of catheters, and lifestyle changes. This review revealed the resident had a Quarterly Assessment on 8/23/22. A review of the assessment that was completed on 8/23/22 Section H0100 Appliances A. Indwelling Catheter was coded, yes. Further review of the MDS H0200 Urinary Toileting Program A. Has a trial of toileting program been attempted, was coded, yes. Further review of Resident # 2's most recent Urology Consult dated 7/23/21 revealed the resident now has a chronic foley catheter to be changed once a month and to follow up as needed. An interview was conducted on 9/2/22 at 11:50 AM with the DON who was also the MDS Coordinator. She was asked to explain the reason the MDS quarterly assessment was coded yes under section H0200 for attempting a trial toileting program when the resident has an indwelling foley catheter in place. The DON stated that the MDS was coded inaccurately. All concerns were discussed with the Administrator at the time of the exit on 9/2/22 at 1:45 PM.

Based on medical records review, investigative documentation, and interviews, it was determined that the facility failed to have an effective system to investigate abuse allegations thoroughly to determine if abuse occurred and take appropriate action. This was evident for 1 (Resident #163) out of 2 residents reviewed for abuse during the survey. The findings include: A review of facility self-report MD 440 on 8/30/22 at 12:04 PM revealed, Resident #163 reported that a Geriatric Nursing Assistant (GNA) grabbed his/her arm and pulled it across the bed. The resident reported that that hurt his/her arm on 7/12/21. On 8/30/22 at 2:00 PM, a review of Resident #163's medical records revealed that a Registered Nurse (RN #15) documented on 7/13/21 at 11:25 PM, at genesis of this shift, a small purple bruise was noted of resident LUE (left upper extremity) lateral elbow. Resident stated to this writer that the bruise may have occurred when staff was attempting to reposition her/him in bed or during incontinence care on the previous shift or evening shift 7/12/21. Further review of the investigation documentation on 8/30/22 at 2:20 PM revealed a Licensed Practical Nurse (LPN #15) sent a written statement via email to the Nursing Home Administrator (NHA) on 7/14/21. The written statement said that while LPN #15 worked on 7/12/21, 3-11 PM shift, Resident #163 wanted to see LPN #15 in her/his room and told her, an aide who was here broke my hand and now bruised. LPN #15 indicated in the statement that she assessed the resident, no bruising or redness was noted, and s/he applied an ice pack. However, further review of the investigation documentation revealed that the nursing staff's written statement did not include RN #15, Geriatric Nursing Assistant (GNA #16), and LPN #17, who worked on the 7/12/21 night shift (11 PM- 7 AM) and 7/13/21 day shift (7 AM-3 PM). On 8/31/22 at 3:00 PM, an interview was conducted with the NHA. The NHA stated that she recognized this incident by Resident #163's verbal report on her rounding on 7/13/21 and started investigating. The surveyor asked for additional documentation to support the facility and performed a thorough investigation with all nursing staff's statements and evidence for all staff receiving abuse training regarding this incident. The NHA said, I will look for more. On 9/1/22 at 7:40 AM, the abuse training record for August 2021 that the NHA submitted was reviewed. There were 14 nursing staff names and signatures listed on the staff attendance sheet. However, LPN #14, RN #15, GNA #16, LPN #17, and GNA #18 were not listed on the training records. On 9/1/22 at 2:00 PM, the surveyor reviewed the above concern with the NHA and the DON. As of the time of exit on 9/2/22 at 1:40 PM, no additional documentation was provided to support that the facility conducted a thorough investigation with all staff and educated all staff regarding abuse.

Based on record review and staff interview, it was determined that the facility failed to report allegations of abuse within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (Resident #163 and #164) of 2 residents reviewed for abuse during the annual survey. The findings include: 1) A review of facility self-report #MD 656 on 8/30/22 at 11:46 AM revealed Resident #164 reported that a Geriatric Nursing Assistant (GNA) yelled at him/her for not using a cane and did not want to help the resident. On 8/30/22 at 11:46 AM, this surveyor reviewed the facility's investigations regarding this incident. A written statement by GNA #13 revealed that the incident occurred on 8/21/22 around 11 AM. However, the facility's initial self-report form was submitted to the OHCQ on 8/22/22 at 9:57 AM, and there was no documentation for a case number and officer's name. During an interview with the Nursing Home Administrator (NHA) on 8/31/22 at 11:05 AM, the NHA stated since right after the incident, the GNA was removed from Resident #164's care, and the resident confirmed he/she felt comfortable, the facility did not report to the police. On 8/31/22 at 12:33 PM, an interview was conducted with the NHA. When asked if she reported the incident to OHCQ within the 2 hour window timeline, she said, since no injury occurred, I reported it within the 24-hour window. Even though, she did an investigation as abuse. 2) A review of the Facility Reported Incident (FRI) # MD 440 on 8/30/22 at 12:04 PM revealed that Resident #163 reported that a Geriatric Nursing Assistant (GNA) grabbed his/her arm and pulled it across the bed and that that incident hurt his/her arm on 7/12/21. On 8/30/22 at 1:30 PM, the surveyor reviewed Resident #163's medical records and the facility's investigation. Licensed Practical Nurse (LPN #14's) statement revealed that the incident occurred on 7/12/21 around 10:50 PM. However, the facility's initial self-report form was submitted to the Office of Health Care Quality (OHCQ) on 7/13/21 at 5:58 PM. Record review revealed that the resident reported the incident to the NHA and the NHA started an investigation. The NHA reported the incident to the police. During an interview with the NHA on 9/1/22 at 9:00 AM, the NHA stated that she identified the incident while she was on rounds. It was further revealed during the interview with the NHA, that LPN #14 was aware of this issue on 7/12/21. The interview revealed that the incident was not reported to OHCQ by the facility within 2 hours. The surveyor discussed these issues with the NHA and the Director of Nursing on 9/1/22 at 2:00 PM.

Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift. This was evident on 3 (8/30, 8/31, 9/1/22) of 4 days of the survey and for 1 (7/4/22) of 1 historical assignment sheet reviewed The findings include: Observations were made of the daily shift Healthcare Assignment sheet on 8/30/22, 8/31/22, and 9/1/22. Review of each day and each shift revealed that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Geriatric Nurse Aides (GNA) per shift. The facility staff failed to differentiate the nursing staff as the nurses were not identified as a RN or an LPN. On 09/01/22 at 02:37 PM the Nursing Home Administrator was requested to provide copies of the previous two days the Healthcare assignment sheet and the staffing on 7/4/22. Review of the historical document of 7/4/22 revealed that the staff failed to differentiate the nursing staff and failed to post the actual hours worked by the nursing staff on all three shifts. At 3:16 PM on 9/1/22 the identified non-compliance with the Federal requirements of the posting of staff was reviewed with the Nursing Home Administrator.

Based on record review and staff interview, it was determined that facility staff failed to provide written notice of the termination of Medicare coverage for one (Resident #2) of three residents sampled. The findings include: The surveyor requested documentation of the termination of Medicare coverage for three sampled residents. For Resident # 2, the facility was unable to provide evidence that written notice of the termination of Medicare coverage was provided to the resident. This was validated by interview of the Director of Nursing on January 31, 2018.

Based on observations and verified by facility staff, the facility staff failed to ensure that blood glucose monitoring supplies were dated after opening. This practice was evident on 1 of 1 medications carts and has the potential to affect any resident receiving blood glucose monitoring. The findings include: An observation conducted on 01/29/2018 at 9:30 AM revealed that the medication cart contained one opened vial of OneTouch® Ultra® test strips and one opened vial of OneTouch® Ultra® control solution (a solution that mimics blood that is used to test the accuracy of both the blood glucose meter and the test strips) that were not labeled with the discard date. This finding was verified by staff #1. Per the manufacturer of OneTouch® Ultra® test strips and control solutions, when the test strips and control solutions are first opened the discard dates (6months after first opening for the test strips and 3 months for the control solutions) should be written on the vials.