Every finding on record at Trend Health & Rehab of Meridian LLC

Based on record review, staff interview, and facility policy review, the facility failed to ensure PRN (as needed) psychotropic medications were limited to a 14-day duration or renewed with documented physician rationale for one (1) of three (3) sampled residents. Resident #1. Findings include:A review of the facility's policy Use of Psychotropic Medication(s), dated 4/28/25 revealed .Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.Policy Explanation and Compliance Guidelines: 16. Psychotropic medications used on a PRN (as needed) basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted: a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days.b. PRN orders for antipsychotic medications only, shall be limited to 14 days with no exceptions. A record review of the admission Record revealed the facility admitted Resident #1 on 8/27/2024 and she had current diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/2026 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 00, which indicated her cognition was severely impaired. A record review of the Order Summary Report with active orders as of 3/1/26, revealed Resident #1 Physician's Orders, dated 12/30/2025, for Diazepam Oral Tablet 2 MG (Milligram) Give 1 tablet by mouth every 12 hours as needed for muscle spasms and Lorazepam Oral Concentrate 2 MG/ML (Milliliter) Give 0.5 ML by mouth every 6 hours as needed for agitation, dated 12/29/25. There was no stop date indicated on the Physician's Orders.A record review of the Pharmaceutical Consultant Report Psychoactive Gradual Dose Reduction dated 1/26/26, revealed, .This resident is prescribed the following psychoactive medications.Lorazepam 1 mg.5. Please not orders for PRN psychotropics are limited to 14 day supply. The form was signed by the Director of Nursing.On 3/10/26 at 12:34 PM, during an interview with the DON confirmed, physician orders for Resident #1 and confirmed that Lorazepam (Ativan) and Diazepam (Valium) are psychotropic medications, and PRN psychotropic medications are limited to a 14-day duration unless the physician documents a clinical rationale and specifies a longer duration. He confirmed the order summary revealed Lorazepam was ordered on 12/29/25 and Diazepam was ordered on 12/30/25, and the staff member who entered the orders did not include an end date for either medication. The DON further confirmed that during the pharmacy consultant review dated 1/26/26, the consultant recommended that PRN psychotropic medications such as Lorazepam should be limited to a 14-day supply unless otherwise justified and documented by the physician. He acknowledged that the absence of an end date for the psychotropic medications was not consistent with regulatory requirements or facility expectations for monitoring psychotropic medication use.On 3/10/26 at 3:45 PM, during an interview with the Administrator, she reviewed the physician orders for Lorazepam (Ativan) and Diazepam (Valium) and confirmed these medications as psychotropic medications. She confirmed that PRN psychotropic medications are limited to a 14-day duration unless a physician documents a clinical rationale for longer use, and acknowledged the orders dated 12/29/25 for Lorazepam and 12/30/25 for Diazepam did not include a 14-day stop date, which he confirmed should have been included when the orders were entered into the order summary.On 3/10/26 at 5:00 PM, an interview with the Pharmacy Consultant confirmed that the physician orders dated 12/29/25 for Lorazepam and 12/30/25 for Diazepam, both administered by mouth and classified as PRN psychotropic medications, should have been limited to a 14-day duration in accordance with federal regulations unless the physician documented a clinical rationale for continued use and issued a new order. She confirmed that both medications should have been discontinued by the facility after 14 days if no new physician order or documented justification for continuation was present. She further confirmed that allowing the medications to remain active without a documented stop date or reassessment was not consistent with regulatory expectations for PRN psychotropic medications. She stated the facility is responsible for ensuring PRN psychotropic medications are monitored and discontinued or renewed appropriately within the required timeframe.

Based record review, staff interview, and facility policy review, the facility failed to ensure the comprehensive care plan was revised when a resident experienced multiple falls and failed to ensure all care plan interventions were dated to reflect new or revised individualized interventions for one (1) of three (3) sampled residents. Resident #1Findings include:A review of the facility's policy Care Plans - Comprehensive, dated 10/2016, revealed .An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.Policy Interpretation and Implementation.6. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident.8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.A record review of the Care Plan Report revealed Resident #1 had a Focus of (Proper Name of Resident) had an actual fall 11/12/24. and then listed multiple dates of the falls in the Focus area of the care plan from 11/30/24 through 2/28/26. A review of the Interventions revealed there were multiple interventions listed but they were not dated to indicate that the care plan was revised after each fall to include new or individualized interventions to address the resident's continued fall risk.A record review of the admission Record revealed the facility admitted Resident #1 on 8/27/2024 and she had current diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/16/2026 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 00, which indicated her cognition was severely impaired. A record review of the facility's fall investigations revealed Resident #1 had a fall on 12/16/25 at 9:35 PM, 12/18/25 at 8:30 PM, 12/29/25 at 1:40 PM, and 2/2/26 at 5:00 PM. On 3/10/26 at 12:21 PM, during an interview and record review with License Practical Nurse (LPN)/ MDS Coordinator, revealed that care plans are required to be individualized based on the resident's assessed needs and updated when there is a change in condition, including after falls. She confirmed that when a resident experiences a fall, the interdisciplinary team should review the incident and implement new or revised interventions to prevent further falls. She further confirmed that interventions placed on a care plan should be clearly documented and dated to reflect when they were implemented and to ensure staff are aware of current interventions. The MDS Nurse reviewed the care plan for Resident #1 and confirmed the fall interventions listed were not dated, and the care plan did not reflect additional or updated interventions following subsequent falls. She confirmed that without dated interventions or updates following additional falls, it would be difficult to determine when interventions were implemented or if the care plan had been revised to address ongoing fall risk. She acknowledged that the care plan should have been updated with new individualized interventions following each fall incident to address the resident's continued risk.On 3/10/26 at 12:34 PM, during an interview with Director of Nurses (DON), he confirmed that resident care plans are expected to be individualized based on each resident's assessed needs, conditions, and risk factors. He stated that when a resident experiences a fall, the interdisciplinary team should review the circumstances of the fall and update the care plan with new or revised interventions to address the identified risk factors and prevent further falls. He further confirmed that interventions added to the care plan should be dated to reflect when they were implemented so staff can clearly identify current fall prevention strategies. The DON reviewed the care plan for Resident #1 and confirmed that although fall interventions were listed, the interventions were not dated and did not reflect additional or revised interventions following subsequent falls. He acknowledged that this was not consistent with the facility's expectation, as the care plan should have been updated with individualized interventions and appropriate dates following each fall incident to address the resident's continued fall risk.

Based on interview, record review, and clinical judgment, the facility failed to ensure a resident received treatment and care in accordance with professional standards and physician orders to maintain or improve respiratory status. This failure was evidenced by not administering Albuterol Sulfate HFA (Hydrofluoroalkane) Inhalation Aerosol Solution 108 (90 Base) mcg/act (micrograms/actuation) as ordered for shortness of breath and/or wheezing. This deficient practice affected one (1) of (1) resident (Resident #11) reviewed for respiratory care.Findings Include:A review of the facility's policy, Specific Medication Administration Procedures II B8 Oral Inhalation Administration, revised January 2018, revealed, . Sequencing of inhaler medication: Bronchodilators are given first (example: albuterol), short-acting agents before long-acting agents.A record review of Resident #11's admission Record revealed the facility admitted the resident on 6/24/25 with diagnoses including Chronic Diastolic Congestive Heart Failure and Essential (Primary) Hypertension.A record review of Resident #11's Order Summary Report with active orders as of 7/1/2025 revealed active prescriptions for Budesonide Inhalation Suspension 0.5 milligrams (mg)/2 mL(milliliters), to be inhaled orally twice daily for Chronic Obstructive Pulmonary Disease (COPD) (J44.9), and Albuterol Sulfate HFA Inhalation Aerosol Solution 108 mcg/act (90 mcg base), to be inhaled as two (2) puffs by mouth every four (4) hours as needed for shortness of breath (R06.02) and wheezing (R06.2).A record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section I6200 confirmed the presence of asthma or chronic lung disease.On 7/22/25 at 10:50 AM during an interview with Resident #11, she stated that on 7/19/25 and 7/20/25, she did not receive her inhalation medications as prescribed. Resident #11 reported she informed Licensed Practical Nurse (LPN) #1 that she had been receiving her inhaled medications in the same sequence for over three (3) years, specifically Albuterol Sulfate HFA prior to Budesonide Inhalation Suspension, and that this method was more effective in relieving her respiratory symptoms. Resident #11 stated that LPN #1 refused to administer the medications in the sequence she requested, and although the nurse checked on her several times, the Albuterol was withheld, contrary to the active physician order.On 7/22/25 at 3:50 PM, during an interview, the Director of Nursing (DON) stated he was contacted by the on-call nurse regarding the concern. The DON stated his reasoning for advising against giving Albuterol was based on a potential for tachycardia or increased heart rate with excessive beta-agonist use but acknowledged that there was no clinical assessment or documented justification to withhold the medication. He stated that if there was uncertainty about the medication regimen or sequencing, the provider should have been contacted for clarification. The DON acknowledged the medication was not administered as ordered.On 7/22/25 at 11:50 AM, during an interview, LPN #2 stated she was the nurse on call when LPN #1 called with concerns about giving Albuterol with Budesonide. LPN #2 confirmed she contacted the DON, who instructed her that if the nurse was uncomfortable, she should withhold the medication. LPN #2 confirmed no clinical rationale was documented to justify withholding the medication.On 7/22/25 at 6:50 PM, during an interview, LPN #1 stated she was the assigned nurse for Resident #11 from 7/19/25 through 7/21/25. LPN #1 stated that the resident requested administration of Albuterol prior to Budesonide, but she was not comfortable doing so and therefore contacted the on-call nurse, who consulted the Director of Nursing (DON). LPN #1 stated she was advised that if she was uncomfortable, she should not administer the medication, and as a result, the Albuterol was not given. She further stated that she did not contact the prescribing provider for clarification, did not consult a drug reference guide or policy, and did not document any clinical justification for withholding the medication. She stated her primary concern was avoiding harm but could not explain a clinical reason for not administering the medication.On 7/23/25 at 11:08 AM, during an interview, the Nurse Practitioner confirmed that Resident #11 had active orders for Albuterol Sulfate HFA every four (4) hours as needed for shortness of breath/wheezing and Budesonide twice daily for COPD. She stated the orders are to be followed as written.

Based on interviews, record review and facility policy review, the facility failed to provide necessary care and services to assist a resident with a known diagnosis of depression and anxiety in adjusting to a significant life stressor (bereavement) for one (1) of sixteen (16) sampled residents (Resident #9).Findings include:A record review of the policy Dignity and Respect, no date, revealed, You have the right to dignity and respect in the care you receive and the setting you live in. This includes the right .aims to reach or maintain for you the highest achievable level of physical, mental, and social well-being .On [DATE] at 2:20 PM, during an initial interview, Resident #9 told SA that her son had recently died, and she needed to talk with someone about it. When asked if she had informed staff, she stated, I have told every person who comes into my room. When asked if she would like to speak with Social Services or a therapist, she responded, Yes, one of them.On [DATE] at 2:27 PM, SA observed Certified Nursing Assistant (CNA) #1 outside Resident #9's room. CNA #1 stated she provides care for Resident #9 and confirmed that since the resident's son passed away, every time she enters the room, the resident expresses a need to talk about it. CNA #1 stated she tries to talk about other things to help distract the resident.On [DATE] at 10:01 AM, during a follow-up interview, Resident #9 told the State Agency (SA) that she needed prayer and support due to the recent death of her son. She reiterated her desire to speak with someone about her grief.On [DATE] at approximately 12:45 PM, during an interview with the Social Service Director, she stated she was unaware if the contracted psychiatric provider had visited Resident #9 since her son's death, adding that she had not scheduled a consultation. She confirmed the last visit occurred in June, prior to the resident's loss. The Social Service Director added she would check with staff to see if anyone else had arranged a visit and reported that the resident had been placed on bereavement watch, the facility's standard procedure following a resident's loss.On [DATE], at 1:18 PM, during an interview with Licensed Practical Nurse (LPN) #2 who is also the Medical Records Director, she stated that the contracted psychiatric service had not seen Resident #9 since [DATE]. She reported that there was no policy or procedure in place to support grieving residents other than placing them on bereavement watch, which entails monitoring residents for behavioral changes.On [DATE], at 8:01 AM, during an interview with the Director of Nursing (DON), he confirmed that the facility did not have a bereavement protocol beyond charting behaviors. He added that the Psychiatric Mental Health Nurse Practitioner (PMHNP) had last seen Resident #9 on [DATE]. He acknowledged a break in the process in this case regarding staff follow-up.On [DATE] at 9:00 AM, during a follow-up interview with LPN #2, the SA inquired whether psychiatric services had been provided to Resident #9. LPN #1 stated she knew the PMHNP had been in the facility earlier that week but had not reviewed his notes. While the SA was present, LPN #1 called the PMHNP, who confirmed he was in the facility on [DATE], but had not seen Resident #9 because he did not have time. He stated he would try to see her next time he came.Record review of the Psych (Psychiatric) Progress Note dated [DATE] revealed Resident #9 had been seen by the PMHNP and had the following presenting symptoms: Anxiety, Confused, Depressed/low mood and socially isolating. The active medical problem list included: Anxiety Disorder, Dementia, Depression, and Bipolar Disorder.A record review of the Transfer/Discharge Report revealed Resident #9 was admitted on [DATE] with diagnoses including Depression and Anxiety Disorder.A review of the Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were securely stored and not accessible to residents for one (1) of 16 sampled residents, Resident #16. Findings include: A review of the facility's policy titled, Medication Storage in the Facility, undated, revealed, .Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.On 7/22/25 at 8:33 AM, during an observation of Resident #16's room, a bottle of TUMS and a bag of cough drops were noted in the resident's bedside basket. On 7/22/25 at 11:15 AM, during an observation and interview, the Director of Nursing (DON) accompanied the surveyor to Resident #16's bedside and confirmed that the TUMS and cough drops were present in the resident's room.On 7/22/25 at 11:30 AM, during an interview, the DON stated that medications are not to be stored at the bedside due to the risk of residents self-administering them, which can result in double dosing, drug interactions, or other potential harm. The DON stated the facility provides in-service training and conducts rounds to monitor medication storage. The DON reported that Resident #16 is legally blind, wanders, and has episodes of confusion, which makes her unable to safely self-administer medications.A record review of Resident #16's Transfer/Discharge Report revealed the facility admitted the resident on 6/27/25 with diagnoses including Essential (Primary) Hypertension.A record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to prevent abuse of a resident for one (1) of four (4) residents reviewed for abuse. Residents #25 Findings include: A review of the facility's Abuse Policy and Procedure, undated, revealed, Each resident of this facility has the right to be free from .physical .abuse .Abuse is defined as the willful infliction of injury .with resulting physical harm, pain or mental anguish . In an interview, on 04/10/24 at 10:00 AM, with Resident #25, he stated that on 04/09/24 on the 3-11 shift while being transferred from his wheelchair to his bed. He stated Certified Nurse Aide (CNA) #1 was rough with him. Resident #25 revealed the CNA positioned the lift sling underneath him and when she put the leg straps around his legs, she jerked up on them real hard. He stated that he told her that it hurts when she does that and the other nurse aides do not have to do it that way, but she did not respond to him. He admitted that he had not reported this to anyone. An interview on 04/10/24 at 3:15 PM, with Resident #25, revealed the Administrator and the Social Worker talked to him about the concern from 4/9/24. The resident stated that CNA #2 was also in the room when the incident occurred, but she was not rough with him, and she was always really nice. An interview on 04/10/24 at 3:25 PM, with CNA #2, confirmed that she was in the room when CNA #1 transferred Resident #25 from his wheelchair to his bed on 4/9/24. CNA #2 confirmed that CNA #1 was rough handling the resident. CNA #2 confirmed that when CNA #1 got the lift pad underneath the resident prior to the transfer, she snatched the straps in a rough manner and the resident told CNA #1 that it hurt, but she snatched the other leg strap the same way. CNA #2 admitted that she did not report this to anyone, but she knew she was supposed to. She said Resident #25 had begged her not to mention it to anyone. An interview on 04/10/24 at 3:30 PM, with the Administrator, confirmed Resident #25 reported the incident to him regarding CNA #1 and CNA #2. The Administrator stated that he interviewed CNA #2, and she confirmed that CNA #1 was rude and snappy with Resident #25 during the transfer on 04/09/24 but that she did not think it was abuse and that's why she did not report it to anyone. The Administrator revealed that he had reported the allegation to the State Agency (SA) and was continuing the investigation. The Administrator confirmed that both CNA #1 and CNA #2 were suspended pending the investigation. An interview on 4/11/24 at 10:46 AM, with CNA#1, she confirmed that she and CNA #2 transferred Resident #25 from the wheelchair to his bed using a mechanical lift. She denied that Resident #25 reported that she was hurting him during the transfer. A record review of a document titled In-Service Training, revealed that both CNA #1 and CNA #2 received in-service training at the beginning of their scheduled shift on 04/09/24 regarding the facility's abuse policy, types of abuse, preventing abuse, neglect, exploitation and its definition, and Staff reporting policy. A record review of the Admission Record revealed the facility admitted Resident #25 on 1/5/22 with medical diagnoses that included Paraplegia. A review of the BIMS (Brief Interview for Mental Status) assessment, dated 2/20/24, revealed Resident #25 had a BIMS score of 15, which indicated he was cognitively intact.

Based on resident and staff interview, record review and facility policy review the facility failed to report abuse in a timely manner for one (1) of four (4) residents reviewed for abuse. Residents #25 Findings include: A review of the facility's policy, Staff Reporting, revised 3/21/22, revealed, All employees of this facility must immediately report any incidents or suspected incident of resident . abuse . Any employee who has knowledge or reason to believe that a resident has been a victim of abuse is under a duty to immediately report such incident or suspicion to the charge nurse or administrator without fear of reprisal . On 4/10/24 at 10:00 AM, in an interview with Resident #25, he stated that on 4/09/24 on the 3-11 shift, Certified Nurse Aide (CNA) #1 was rough with him during a transfer. He stated the CNA placed the sling underneath him and then she put the leg straps around his leg, and jerked on it hard, causing him pain. He stated he told the CNA that it hurt, and the other CNAs do not do it that way, but she did not respond to him. On 4/10/24 at 3:15 PM, Resident #25 stated the Administrator and Social Worker discussed the concern he had when CNA #1 was rough with him on 4/9/24. Resident #25 stated that CNA #2 was also in the room when the event occurred, but she was not rough with him and treated him nicely. On 4/10/24 at 3:25 PM, in an interview with CNA #2, she confirmed she was in the room when CNA #1 transferred Resident #25 from his wheelchair to his bed. CNA #2 confirmed that CNA #1 treated the resident roughly during the transfer by snatching the leg straps. She confirmed Resident #25 complained that it hurt, but CNA #1 snatched the other leg strap in the same rough manner. CNA #2 admitted that she did not report the abuse to anyone because Resident #25 did not want her to, but knew she was supposed to. She confirmed she was aware that abuse should be reported within two (2) hours. On 4/10/24 at 3:30 PM, in an interview with the Administrator, he confirmed Resident #25 reported the incident to him regarding CNA #1 and CNA #2. The Administrator stated that he interviewed CNA #2, and she confirmed that CNA #1 was rude and snappy with Resident #25 during the transfer on 4/09/24 but CNA #2 did not think that it was abuse and that was why she did not report it to anyone. The Administrator confirmed CNA #2 should have reported the abuse within two (2) hours of it occurring and he expected all staff to report abuse timely. A record review of a document titled In-Service Training, revealed that both CNA #1 and CNA #2 received in-service training at the beginning of their scheduled shift on 04/09/24 regarding the facility's abuse policy, types of abuse, preventing abuse, neglect, exploitation and its definition, and Staff reporting policy. A record review of the Admission Record revealed the facility admitted Resident #25 on 1/5/22 with medical diagnoses that included Paraplegia. A review of the BIMS (Brief Interview for Mental Status) assessment, dated 2/20/24, revealed Resident #25 had a BIMS score of 15, which indicated he was cognitively intact.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by no barrier used during eye drops (Resident #13) and not properly cleaning a glucometer between residents (Residents #12 and 24) for three (3) of nine (9) direct care observations. Resident # 12, Resident #13 and Resident #24. Findings Include: Review of the facility's policy, Infection Prevention and Control Program, revised 5/23 revealed, .Policy Explanation and Compliance Guidelines .10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . Review of the facility's policy, Specific Medication Administration Procedures, revised 1/2018 revealed, .Procedures .G. Use a barrier (e.g., clean disposable tray or plastic cup) to carry medication containers into the resident's room .This will serve as a barrier between the supplies and the over-the-bed table or other surface on which the supplies are placed while the medication is administered . An observation on 4/9/24 at 3:15 PM, revealed Licensed Practical Nurse (LPN) #1 removed Resident #13's eye drops from the eye drop box inside the medication cart, went to the residents room, administered one eye drop into the resident's right eye, placed the eye drop bottle down on the residents bedside table with no barrier, removed and replaced her gloves, picked up the eye drop bottle, administered one eye drop to the left eye, and returned it to the drawer in the medication cart. An observation on 4/9/24 at 3:34 PM, revealed LPN #1 removed a glucometer from the top drawer of her medication cart and carried it to Resident #12's room, performed a blood sugar check; returned to the medication cart and cleaned the glucometer with disinfectant wipes that had a 2-minute kill time (the surface should remain visibly wet for two minutes after the solution has been applied to completely eliminate or kill bacteria). This observation revealed the nurse wiped the glucometer with the disinfectant wipe for approximately 30 seconds and set it on a barrier on top of her medication cart and stated she would leave that there to air dry for about 3-5 minutes. An observation on 4/9/24 at 3:45 PM, revealed LPN #1 used the glucometer that was not properly cleaned after using it on the previous resident, went to Resident #24's room, performed a blood sugar check and returned it to the medication cart, cleaned it with disinfecting wipes for approximately 30 seconds, and sat it on a barrier to air dry. An interview on 4/9/24 at 3:55 PM, with LPN #1 confirmed that she did not use a barrier when she placed the eye drops on the bed side table and administered the second eye drop. She also confirmed that she failed to clean the glucometer according to the directions on the disinfectant wipes for a kill time of 2 minutes. She revealed she had received in-service training on the proper way to clean the glucometer and she knew she needed a barrier for the eye drops, but she was nervous. She revealed both of those things could lead to the spread of infection or cross contamination. An interview on 4/10/24 at 4:30 PM, with the Director of Nurses (DON) confirmed the nurse should have used a barrier before she placed the eye drop bottle down in the resident's room and should have cleaned the glucometer for the appropriate amount of time based on the kill time on the disinfectant wipes. He stated the facility had provided in-service training on both of those topics, and he had given them options on how to achieve the kill time. He confirmed that not using a barrier could have led to the spread of infection and not cleaning the glucometer appropriately could have led to the spread of a blood borne illness. Resident #12 Record review of the Admission Record revealed the facility admitted Resident #12 on 9/28/23 with medical diagnoses that included Type 2 Diabetes Mellitus. Record review of the Order Summary Report with active orders as of 4/1/24 revealed Resident #12 had a Physician's Order, dated 9/29/23, for .Accu-Chek AC (before meals) and HS (at hour of sleep) Resident #13 Record review of the Admission Record revealed the facility admitted Resident #13 on 8/30/23 with medical diagnoses that included Lack of Coordination. Record review of the Order Summary Reportwith active orders as of 4/1/24 revealed Resident #13 had a Physician's Order, dated 9/19/23, for Systane Ophthalmic Solution 0.4-0.3% . Instill 1 drop in both eyes every 2 hours as needed for r/t (related to) dry eye . Resident #24 Record review of the Admission Record revealed the facility admitted Resident #24 on 10/31/23 with medical diagnoses that included Type 2 Diabetes Mellitus. Record review of the Order Summary Reportwith active orders as of 4/1/24 revealed Resident #24 had a Physician's Order, dated 10/31/23, for .Accu-Chek at AC and HS .

Based on interview, record review, facility investigation and policy review, the facility failed to protect a resident from misappropriation of property for one (1) of four (4) residents sampled. Resident #1 Findings include: A review of the facility's policy, Abuse Policy and Procedure, dated 1/24/22, revealed .Each resident of this facility has the right to be free from verbal, sexual, physical and mental abuse, involuntary seclusion, corporal punishment, neglect and/or misappropriation of resident property . A review of the facility's policy Vulnerable Adult Act dated 3/21/22 revealed, A 'Vulnerable Adult' is any adult person unable to care for his or her self due to a physical or mental decline .Any nursing home resident is considered to be a vulnerable adult .the following situations are considered CRIMES OF ABUSE against a vulnerable adult .5. Theft or misuse of a resident's personal belongings, personal funds (sic), or bank account .It is the policy of this facility that no employee shall accept any gifts, money, or things from a resident . Record review of the facility's investigation revealed that it was reported to the facility on [DATE] that a Certified Nurse Aide (CNA) had received cash from a resident and that she had sent him an explicit video to his cell phone. The Administrator in Training (AIT) and the Preceptor interviewed the CNA involved and she admitted that she sent the resident an explicit video. The AIT and Preceptor also interviewed the resident and he denied that he gave the CNA any money. On 8/14/23 at 10:30 AM, in an interview with the Administrator in Training (AIT), he stated that the facility reported the incident of a CNA that had accepted money and had exchanged text messages with a resident, which included a video, but the CNA had claimed she was partially clothed in the video. The AIT reported that the CNA involved was a newly hired had received her certification in December of 2022. He explained that the CNA alleged she had financial problems with making a car payment. He further explained that the Attorney General's Office (AGO) had visited the facility and had investigated the event. He said that although the AGO was able to obtain an interview in which the resident claimed he had given the CNA approximately $300, the resident denied the event happened when the facility interviewed him. He confirmed the facility provided in-services regarding abuse and the Vulnerable Adult Act and also had an emergency Quality Assurance Performance Improvement (QAPI) meeting to discuss the event and what measures would be implemented. On 8/14/23 at 11:30 AM, in an interview with the Administrator, she stated that she completed one on one in-services with all staff and had them to sign the abuse policy and the vulnerable adult act. She stated that the amount of money that was given to the CNA by the resident had been inconsistent because the resident denied giving any money to the CNA and the CNA had originally stated the amount was $60, but then told the AGO it was $60 plus $281. On 8/14/23 at 1:10 PM, in an interview with CNA #2, she stated that she had received a phone call from CNA #1 because she wanted to know if people were talking about her. CNA #1 told CNA #2 that Resident #1 had given her $481 to pay her car note. CNA #2 said that she knew this was not right, so she called the facility and reported what had been told to her by CNA #1. On 8/14/23 at 1:22 PM, in an interview with CNA #1, she confirmed that she took money from the resident. She stated that Resident #1 gave her cash money one evening when she was taking in his supper tray. She said Resident #1 said, Here you go for doing a good job and she expressed that she intended to pay him back for the money. She said this happened at the first of July but was unable to recall an exact date and she had told him that this money was going to be used for her car note. She explained the resident would often text her, but she usually did not text him back. She confirmed that she received training upon hire related to abuse of residents and the Vulnerable Adults Act. On 08/14/2023 at 2:15 PM, during an interview with Resident #1, he stated he was aware of the situation, but it was all false. Resident #1 said there was no proof of any of the allegations and that no money had been transferred to anyone from him and that it was all lies. Review of the personnel file for CNA #1 revealed an Employee Checklist which indicated she had received training on the Vulnerable Adults Act. CNA signed acknowledgement of Resident's Rights signed 6/20/23. CNA #1 signed and dated the Vulnerable Adult Act on 6/20/23. CNA #1 signed and dated acknowledgement of the Abuse Policy and Procedure on 6/20/23. Record review of the Admission Record revealed the facility admitted the Resident #1 on 1/17/23 with diagnoses that included Major Depressive Disorder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Based on the facility's implementation of corrective actions on 7/28/23, the State Agency (SA) determined the deficiency to be Past Non-Compliance (PNC) and the deficiency was corrected as of 7/29/23, prior to the SA's first entrance on 8/14/23. Validation: On 8/14/23, the SA validated through staff interviews, record review, and facility policy review, the facility began an immediate investigation when the suspicion of misappropriation of the resident's money occurred. A review of the Monthly QAPI meeting minutes revealed the facility held a QAPI meeting on 7/28/23 at 10:00 AM, in which the Infection Preventionist (IP) was out of the facility for this emergency meeting and the Medical Director attended via phone. The SA verified through interview with the DON and Social Services Director that they attended the QAPI meeting to discuss the situation and the facility policies related to abuse were discussed and there were no changes needed. The QAPI meeting concluded that the Plan of correction was to in-service all staff, terminate the employee, and have Resident #1 assessed by psychiatric services. The SA reviewed in-service sign in sheets that began on 7/27/23 related to abuse and misappropriation and the Administrator conducted one on one in-services in which she had every employee sign the policies abuse and vulnerable adult act. A record review of the Behavioral Health Medication Recommendation, dated 8/1/23, revealed psychiatric services assessed the Resident #1 and made recommendations. On 8/14/23, the SA verified the facility reported the misappropriation to the SA and the AGO on 7/27/23. i

Based on staff, resident and Resident Representative interviews, record reviews, and facility's policy review, the facility failed to provide an activities program on weekends for three (3) of 49 residents. Resident #14, Resident #44, and Resident #45. Findings include: Review of the facility's policy, Activities Program dated 12/2008 revealed, .An ongoing program of activities is designed to meet the needs of each resident .2. Activities are scheduled daily .6. Individualized and group activities are provided that .b. Are offered at hours convenient to the residents, including evenings, holidays and weekends . Record review facility's Activities Calendar for December 2022 revealed there were scheduled activities on weekends that would require the assistance of the facility staff to implement for the residents. Resident #14 In an interview on 01/03/23 at 12:46 PM, with Resident #14's daughter, she said Resident #14 was a pastor of a church and enjoyed spiritual activities, such as listening to gospel music, talking to people, and having the Bible read to him. She stated that she had been told by facility staff that they have church services on Sundays, but most of the time they do not have church. She commented that when she visits on Sundays, she turns on the television so he can watch church services and during most of her visits, her father will be sitting in the front entrance near the nurse's station in a Geri-chair. She said had been told that the Activities Department only works Monday through Friday. The daughter confirmed her father is unable to physically do his own activities because he is contracted and has poor vision and is dependent upon the facility to assist with activities. A record review of the Admission Record revealed the facility admitted Resident #14 on 11/16/2012 with diagnoses including Hemiplegia and Hemiparesis, Dementia, and Anxiety Disorder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/21/22 revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated he had severe cognitive impairment. A record review of the annual MDS with an ARD of 7/5/22 revealed on Section F Interview of Activity Preferences it was Very important to Resident #14 to listen to music, do things with groups of people, do favorite activities, and participate in religious services or practices. Resident #44 During an interview on 01/03/23 at 3:47 PM, with Resident #44, she stated that the facility does not offer activities on weekends, and that sometimes the facility will have a church scheduled, but they don't show up. She said the residents usually sit in the hallway at the front entrance to gossip because they don't have anything else to do and that she gets bored. A record review of the Admission Record revealed the facility admitted Resident #44 on 07/09/2021 with diagnoses including Interstitial Pulmonary Disease and Hypertension. A record review of the Quarterly MDS with an ARD of 8/30/22 revealed Resident #44 had a BIMS score of 12 which indicated her cognition was moderately impaired. A record review of the Annual MDS with an ARD of 11/22/22 revealed on Section F Interview of Activity Preferences it was Very important to Resident #44 to listen to music, do things with groups of people, and do favorite activities. Resident #45 In an interview on 01/03/23 at 10:45 AM, with Resident #45, she said that she sits at the front entrance in the hallway because it is considered the gossip corner. Resident #45 stated the facility does not have activities on weekends and that although church is on the calendar, it does not happen. Resident #45 commented that she hates weekends because there is nothing to do and expressed that the facility needs to find something for them to do. A record review of the Admission Record revealed the facility admitted Resident #45 on 3/23/22 with a diagnosis of Dementia. A record review of the Quarterly MDS with an ARD of 9/8/22 revealed Resident #45 had a BIMS of 09 which indicated her cognition was moderately impaired. During an interview on 01/04/23 at 03:57 PM, with the Activity Director (AD), she confirmed the facility does not have activities on the weekends. The AD said she leaves word search puzzles and color pages for the residents that want to participate. The AD said she is the only person in the activity department and she only works Monday thru Friday. During an interview on 01/04/23 at 04:21 PM, the Administrator confirmed the AD only works Monday thru Friday. The Administrator said she has been trying to hire an activity aide. The Administrator confirmed the residents need activities seven days a week.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent care in a manner to prevent the possibility of urinary tract infections (UTI) for one (1) of two (2) residents reviewed for incontinent care. Resident #42. Findings include: Review of the facility's, Perineal Care Policy revised 1/2010, revealed .It is the policy of the facility to provide perineal cleanliness and comfort to the resident, to prevent infections .Procedure .For a female resident .b. Wash perineal area .c. Instruct or assist the resident to turn on her side .e. Wash the rectal area thoroughly . During observation of incontinent care on 01/03/23 at 11:00 AM, the State Agency (SA) observed Certified Nurse Aide (CNA) #1 providing incontinent care. CNA #1 began incontinent care by turning the resident on her side and wiping her rectal area. She then placed a clean brief on the resident and positioned her in the bed. CNA #1 did not clean the front perineal area of the resident. During an interview on 01/05/23 at 01:47 PM, the Director of Nursing (DON) confirmed CNA #1 failed to prevent the possibility of a UTI by not cleaning the resident's front perineal area and only cleaning the rectal area. The DON stated that the nursing staff have been trained to cleanse the perineal area every time care is provided, and the perineum should have been cleaned during care. During an interview on 01/05/23 at 03:15 PM, with CNA #1 she confirmed she failed to clean the front perineal area of the resident because she forgot. She stated the resident could acquire an infection by not providing incontinent care appropriately. Record review of the Admission Record revealed the facility admitted Resident #42 on 03/30/2021 with diagnoses including Hematuria, Retention of Urine, and Dementia. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/29/22 for Urinary and Bowel Continence revealed Resident #42 was frequently incontinent.

Based on observations, interviews, record reviews, and facility's policy review the facility failed to prevent the possible spread of infection by placing dirty linen directly onto the floor and not washing or sanitizing hands after contact with body fluids during incontinent care for one (1) of two (2) residents reviewed for incontinent care. Resident # 42. Findings Include: Review of the facility's policy, Infection Prevention and Control Program, dated 9/2022, revealed, .This facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .Policy Explanation and Compliance Guidelines: .9. Equipment Protocol .c. Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag .11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infections .e. Soiled linen shall be collected at the bedside and placed in a linen bag . Review of the facility's document, Procedure for Handwashing revised 4/2015 revealed, .When to Wash Hands (at a minimum) .After contact with any body fluids .After handling any contaminated items (linens, soiled diapers, garbage, etc.) During an observation on 01/03/23 at 11:00 AM, the State Agency (SA) observed CNA #1 providing incontinent care and changing Resident #42's linen. The SA observed that the dirty linen was placed directly on the floor and not in a container. CNA #1 turned the resident on her side and wiped her rectal area. CNA #1 then placed a clean brief on the resident. She did not wash or sanitize her hands or change her gloves before she positioned the resident in bed. She also placed a clean top sheet on the resident while wearing the same gloves that were used during incontinent care. During an interview on 01/05/23 at 1:47 PM, the Director of Nursing (DON) confirmed CNA #1 failed to prevent the possible spread of infection by not changing her dirty gloves prior to repositioning and placing a clean sheet on the resident. The DON stated that CNA #1 should have placed the dirty linen in a bag instead of on the floor. The DON expressed that nursing staff are trained on perineal care and hand hygiene. During an interview on 01/05/23 at 3:15 PM with CNA #1, she confirmed she would normally wash her hands and change her gloves after care, but she was nervous and forgot. CNA #1 also confirmed the dirty linen should have been placed in a plastic bag and not directly onto the floor. Record review of the Admission Record revealed the facility admitted Resident #42 on 03/30/2021 with diagnoses including Hematuria, Retention of Urine, and Dementia.

Based on staff and resident council interviews, record review, and facility policy review, the facility failed to ensure that residents have reasonable and ready access to their funds, as funds are not available on weekends for six (6) of 6 residents present in the Resident Council meeting. This had the potential to affect 38 of 38 residents who had funds held by the facility. Resident #19, #22, #25, #35, #38, and #44. Findings include: A record review of the facility's policy Resident Funds Weekend Availability, dated 5/18/2018 revealed, It is the policy of this facility to maintain Petty Cash availability on weekends to our residents who are participating in the Trust fund account option . On 1/04/22 at 3:00 PM, during the Resident Council meeting, six residents present in the meeting stated they have never been able to get personal funds on weekends (Resident #19, #22, #25, #35, #38, and #44). On 01/05/23 at 09:40 AM, during an interview with the Administrator, she revealed that she was unaware residents have not had access to their personal funds on weekends. She confirmed that the facility policy has a procedure that includes the Charge Nurse being responsible for the locked box with petty cash that is made available for the weekends. However, with staff turnover, there has not been a consistent Charge Nurse and therefore, the staff are not always aware of the money box. She stated that the facility needed to make sure all residents with Trust Fund Accounts were aware of the money box and how to get access to money on the weekend. Record review of the Trust Fund Account List provided by the facility revealed there were 38 residents who had trust fund accounts. Resident #19 Record review of the Admission Record for Resident #19 revealed, the facility admitted the resident on 12/09/21 with diagnoses including Pulmonary Hypertension and Essential (Primary) Hypertension. Record review of the Quarterly Minimum Data Set (MDS) for Resident #19, with an Assessment Reference Date (ARD) of 12/14/22 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the list of residents with Trust Fund Accounts provided by the facility revealed, Resident #19 had a Trust Fund Account. Resident #22 Record review of the Admission Record for Resident #22 revealed, the facility admitted the resident on 1/05/22 with diagnoses including Type 2 Diabetes Mellitus, Sleep Apnea, and Essential (Primary) Hypertension. Record review of the Annual MDS, with an ARD of 12/15/22, for Resident #22 revealed a BIMS score of 15, which indicated the resident was cognitively intact. A record review of the list of residents with Trust Fund Accounts provided by the facility revealed, Resident #22 had a Trust Fund Account. Resident #25 On 1/03/23 at 11:14 AM, in an interview with Resident # 25, she revealed since her admission to the facility last February, she has never been able to get money on the weekends. Record review of the Admission Record for Resident #25 revealed, the resident was admitted to the facility on [DATE], with diagnoses including Wedge Compression Fracture of Fifth Lumbar Vertebra, Spondylolysis, Paroxysmal Atrial Fibrillation, and Hypertension. Record review of the Quarterly MDS for Resident #25, with an ARD of 11/08/22, revealed a BIMS score of 15, which indicated the resident is cognitively intact. A record review of the list of residents with Trust Fund Accounts provided by the facility revealed, Resident #25 had a Trust Fund Account. Resident #35 Record review of the Admission Record for Resident #35 revealed, the resident was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, and Ataxia. Record review of the Quarterly MDS for Resident #35, with an ARD of 8/31/22, revealed a BIMS score of 15, which indicated the resident was cognitively intact. A record review of the list of residents with Trust Fund Accounts provided by the facility revealed, Resident #35 had a Trust Fund Account. Resident #38 Record review of the Admission Record for Resident #38 revealed, the facility admitted the resident on 10/06/20 with diagnoses including Chronic Obstructive Pulmonary Disease. Record review of the Quarterly MDS, with an ARD of 8/25/22, for Resident #38 revealed a BIMS score of 15, which indicated the resident was cognitively intact. A record review of the list of residents with Trust Fund Accounts provided by the facility revealed, Resident #38 had a Trust Fund Account. Resident #44 Record review of the Admission Record for Resident #44 revealed the facility admitted resident on 07/09/21 with diagnoses including Interstitial Pulmonary Disease and Essential (Primary) Hypertension. Record review of the Quarterly MDS for Resident #44, with an ARD of 8/30/22, revealed a BIMS score of 12, which indicated the resident had moderate cognitive impairment. A record review of the list of residents with Trust Fund Accounts, provided by the facility, revealed Resident #44 had a Trust Fund Account. Surveyor: [NAME], [NAME] 43283

Based on staff and resident council interviews, record review, and facility policy review, the facility failed to provide mail delivery on Saturday to residents for six (6) of 6 residents present in Resident Council. This had the potential to affect all 49 residents residing in the facility. Resident #19, #22, #25, #35, #38, and #44. Findings include: A record review of the facility's policy Mail Delivery Policy, dated 2/2009 revealed, It is the policy of this facility to deliver the resident's mail timely . If the resident receives mail on Saturday it will be delivered to the resident by the weekend Registered Nurse (RN) Unit Manager. On 1/04/22 at 3:00 PM, during the Resident council meeting, (6) of the (6) residents present in the meeting complained of not getting their mail regularly and not getting mail on Saturdays. (Resident #19, #22, #25, #35, #38, and #44). On 01/05/23 at 8:50 AM, during an interview with Activities #1, she explained she delivers mail to the residents Monday through Friday. She revealed the facility does not have a system in place to ensure mail is delivered on Saturdays. On 01/05/23 at 09:40 AM, during an interview with the Administrator she explained the Charge Nurse should deliver mail on Saturdays. The Administrator confirmed that mail should be delivered on Saturday, but due to the turnover in staff, the facility has not had a consistent Charge Nurse, so the mail may not have been delivered. Resident #19 Record review of the Admission Record for Resident #19 revealed, the facility admitted the resident on 12/09/21, with diagnoses including Pulmonary Hypertension and Essential (Primary) Hypertension. Record review of the Quarterly Minimum Data Set (MDS) for Resident #19, with an Assessment Reference Date (ARD) of 12/14/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #22 Record review of the Admission Record for Resident #22 revealed, the facility admitted the resident on 1/05/22, with diagnoses including Type 2 Diabetes Mellitus, Sleep Apnea, and Essential (Primary) Hypertension. Record review of the Annual MDS, with an ARD of 12/15/22, for Resident #22 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #25 Record review of the Admission Record for Resident #25 revealed, the resident was admitted to the facility on [DATE], with diagnoses including Wedge Compression Fracture of Fifth Lumbar Vertebra, Spondylolysis, and Hypertension. Record review of the Quarterly MDS for Resident #25, with an ARD of 11/08/22, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #35 Record review of the Admission Record for Resident #35 revealed, the resident was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, and Ataxia. Record review of the Quarterly MDS for Resident #35, with an ARD of 8/31/22, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #38 Record review of the Admission Record for Resident #38 revealed, the facility admitted the resident on 10/06/20 with diagnoses including Chronic Obstructive Pulmonary Disease. Record review of the Quarterly MDS, with an ARD of 8/25/22, for Resident #38 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #44 Record review of the Admission Record for Resident #44 revealed the facility admitted resident on 7/09/21 with diagnoses including Interstitial Pulmonary Disease and Essential (Primary) Hypertension. Record review of the Quarterly MDS for Resident #44, with an ARD of 8/30/22, revealed a BIMS score of 12, which indicated the resident was cognitively intact.