Every finding on record at Warsaw Rehabilitation and Healthcare Center

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of indwelling urinary catheter,hospice care, smoking and prescribed medication, for 4 of 18 residents reviewed for MDS accuracy (Resident #10, #71, #43 and #8). 1. Resident #10 was admitted to the facility on [DATE]. Resident #10 did not have a diagnosis for the use of an indwelling urinary catheter. Review of Resident #10's physician orders did not reveal an order for an indwelling urinary catheter. Resident #10's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident was coded as having an indwelling urinary catheter. A telephone interview was conducted with MDS Coordinator #1 on 6/3/26 at 2:05 PM. MDS Coordinator #1 explained that she worked at a sister facility and around the time of this MDS assessment was when she had first started helping the facility with their MDS assessments and did not know the residents. She stated she coded Resident #10 as having an indwelling urinary catheter in error. An interview was conducted with the Administrator on 6/4/26 at 1:43 PM. The Administrator stated it was her expectation that the coding on MDS assessments to be accurate. 2. Resident #71 was admitted to the facility on [DATE] with diagnoses which included quadriplegia and adult failure to thrive. Review of Resident #71's Physician Orders revealed an order dated 1/14/26 to admit to hospice. Resident #71's quarterly Minimum Data Set (MDS), dated [DATE], was not coded for receiving hospice care. A telephone interview was conducted with MDS Coordinator #1 on 6/3/26 at 2:05 PM. MDS Coordinator #1 explained that she worked at a sister facility and around the time of Resident #71's 4/21/26 MDS was when she had first started helping the facility with their MDS assessments and did not know the residents. She stated she did not code Resident #71 as receiving hospice care and felt it was an oversight. An interview was conducted with the Administrator on 6/4/26 at 1:43 PM. The Administrator stated it was her expectation that the coding on MDS assessments be accurate. 3. Resident #43 was admitted into the facility on 1/2/24 with a diagnosis of end stage renal disease. Resident #43's annual Minimum Data Set (MDS) dated [DATE] revealed he was coded for current tobacco use. Resident #43's safe smoking screening dated 1/28/26 indicated he required supervision while smoking. Resident #43's annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and was not a current tobacco user. A telephone interview was conducted with the MDS Coordinator on 6/2/26 at 3:41 PM who confirmed she completed Resident #43's annual MDS dated [DATE]. She revealed she was aware that Resident #43 smoked and it was an oversight that current tobacco use was marked incorrectly. An interview with the Administrator on 6/2/26 at 12:15 PM indicated she expected all MDS assessments to be completed accurately. 4. Resident #8 was admitted to the facility on [DATE] with diagnoses that included encounter for orthopedic aftercare following surgical amputation, congestive heart failure and chronic obstructive pulmonary disease. His diagnoses did not include diabetes. Resident #8's medication orders did not include a prescription of any hypoglycemics. A review of Resident #8's medication administration record (MAR) from 3/12/26 through 5/9/26 revealed hypoglycemic medication had not been administered to Resident #8 during that period. A quarterly MDS dated [DATE] coded Resident #8 as cognitively intact. He was coded as having received a hypoglycemic (including insulin) during the last 7 days look back period. He did not have a diagnosis of diabetes. During an interview on 6/3/26 at 2:16 PM with the MDS Nurse she revealed that she had completed Resident #8's quarterly MDS dated [DATE]. She stated that she had incorrectly indicated in the 5/9/26 MDS that Resident #8 had received a hypoglycemic during that look back period and that it was an oversight since Resident #8 did not have a diagnosis of diabetes or any hypoglycemic medication. During an interview on 6/3/26 at 10:49 AM with the Director of Nursing (DON), she indicated that she expected the MDS Nurse to accurately code the MDS to reflect the resident's status. An interview was conducted on 6/3/26 at 11:44 AM with the Administrator. She stated that she expected the MDS to be coded accurately and that the MDS Nurse should not have included a hypoglycemic in Resident #8's MDS since he did not have a prescription for a hypoglycemic.

Based on observation and staff interviews, the facility failed to protect private health information of Resident #37 leaving confidential medical information visible and accessible to the public on an unattended medication cart for 1 of 4 medication carts (unit 4 hall medication cart). The findings included:A continuous observation of an unattended medication cart on unit 4 hall was made on 06/04/2026 at 9:01 AM to 9:25 AM. Nurse #1 left the medication cart with the computer screen visible while she retrieved vital signs and administered medications to Resident #37 in the resident's room. Resident #37's Face Sheet (a summary sheet containing medical information) was visible on the screen. Visitors, residents and staff were present in the hallway during the observation. During an interview on 06/04/2026 at 9:25 AM with Nurse #1, she indicated she had left the computer screen unattended in the hallway while she went to retrieve vital signs and administer medications to Resident #37. Nurse #1 explained she forgot to close the electronic medical record prior to walking away from the cart. Nurse #1 explained she should have locked the screen and not left Resident #37's medical information visible to others in the hallway.An interview was conducted on 06/03/2026 at 12:18 PM with the Director of Nursing (DON). She indicated Nurse #1 should not have left the computer screen visible when she went into Resident #37's room to retrieve vital signs and administer medications. She also stated nurses were responsible for protecting residents' medical information from others' visibility.During an interview on 06/03/2026 at 12:12 PM with the facility Administrator, she indicated Nurse #1 should not have left the computer screen visible while she went into residents' rooms. The Administrator further stated private health information should never be left on the computer screen where it was visible to the public.

Based on record review and staff interviews, the facility failed to complete the annual Minimum Data Set (MDS) to address the preferences of 1 of 18 residents reviewed for MDS accuracy (Resident #45).The findings included:Resident #45 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] noted Resident #45 was cognitively intact. The Preferences for Customary Routine and Activities sections were not complete and did not include any information. The MDS nurse who completed the annual MDS dated [DATE] was not available for an interview. An interview with the Regional Clinical Reimbursement Consultant was conducted on 6/2/2026 at 1:20 PM. She stated the annual MDS dated [DATE] for Resident #45 was coded incorrectly. She explained because the assessment had incorrectly noted that the facility was not Medicare or Medicaid certified, this caused the Preferences for Customary Routine and Activities section to not be opened for completion. She stated all MDS assessments must be coded accurately. An interview with the Administrator was conducted on 6/3/2026 at 12:12 PM. She stated she expected the staff to code the MDS assessments accurately.

Based on record review, resident and staff interviews, the facility failed to assist a resident with a bath (Resident #45) and failed to provide showers as scheduled and failed to wash the hair of a resident who was totally dependent on staff assistance for showers and bathing (Resident #4). Resident #4 was observed on 6/1/26 with matted hair on the back of her head and knotted ends of sections that were standing up on the top and sides of her head. This was found for 2 of 26 residents reviewed for activities of daily living (ADL). 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, persistent vegetative state, other disorders of the autonomic nervous system, and contracture of muscles, multiple sites. Resident #4's annual Minimum Data Set (MDS), dated [DATE], indicated Resident #4 was in a persistent vegetative state and had no behaviors. The assessment indicated the resident had impairment on both of her upper and lower extremities and was totally dependent on staff for her activities of daily living (ADLs) which included oral hygiene, toileting hygiene, showers/bathing, upper and lower body dressing, and personal hygiene. The MDS indicated Resident #4 was dependent on staff for tub/shower transfers, had an indwelling catheter and was always incontinent of her bowels. It indicated she was 60 in height and weighed 182 pounds. Resident #4's care plan, last revised 5/9/26, indicated the resident required assistance with her ADLs related to being in a persistent vegetative state. The care plan indicated Resident #4 required a 1-person assist with bed mobility, toileting, and/or repositioning as needed. It directed the staff that Resident #4 required a total mechanical lift with 2 staff assisting. Review of the master shower schedule indicated Resident #4 was to receive two showers a week on Mondays and Thursdays during the hours of 3:00 PM to 11:00 PM. Review of the Nurse Aide documentation report for May 2026 revealed no evidence Resident #4 received her showers on Mondays and Thursdays. In addition, there was no evidence that the resident received a shower on any day or shift during the month of May 2026. Review of Resident #4's Nurse Progress Notes for the month of May 2026 did not reveal any notes written about showers not being administered. During an observation of Resident #4 on 6/1/26 at 12:26 PM and accompanied by Nursing Assistant (NA) #3, the resident was observed lying on her back in her bed with the head of her bed elevated approximately 35 degrees. Her eyes were open, but she did not respond when spoken to. A pole that held a tube feeding pump and bag of enteral nutrition (a nutrient-rich liquid designed to replace regular food) were positioned to the right of her bed. Resident #4 had a gastrostomy tube (a soft medical tube inserted directly into her stomach through a small opening in her stomach) and her liquid nutrition was administered continuously. On the lower part of the pole and around the base of the pole on the floor, was a dried light brownish substance. A urinary collection bag from the resident's urinary catheter (a tube connected to her bladder that allows urine to flow into the collection bag) was observed hanging off the frame of the bed on the right side of the bed. The resident was dressed in a hospital gown which was not completely snapped shut, which allowed her arms to be exposed. A palm guard had been placed in her left hand but was not positioned under her contracted fingers. She was covered with a white flat sheet to her chest area. The sheet had light brownish stains observed in the area near the right of her waist. The resident was African-American, and her hair was pushed straight up on the top part and sides of her head in sections with the remnants of what might have once been braids observed on the ends of some of the sections. NA #3 lifted the resident's head, and the back of her hair was matted flat. NA #3 attempted to position the palm guard under her fingers correctly. Approximately 10 or more flies were observed flying around the room and landing on the pole, feeding pump and bag of liquid nutrition. The flies were also observed landing on the resident's face and arms. NA #3 was observed waving her arms, trying to shoo the flies away from the resident. When the flies would land on Resident #4's face, she would jerk her head and make a loud groan. An interview was conducted with NA #3 on 6/1/26 at 12:40 PM. NA #3 had been assigned to Resident #4's care on 6/1/26 from 7:00 AM to 3:00 PM. NA #3 stated she had not bathed Resident #4 that morning and stated the resident got her showers during the second shift, from 3:00 PM to 11:00 PM. NA #3 explained residents are supposed to receive showers twice a week and explained she did not know which days Resident #4 was supposed to get her showers, nor when her last shower had been given. NA #3 picked through Resident #4's hair while she talked and tried to unknot the hair in one of the sections. As she did this, she made a pile of whitish lint and/or debris and hair that she picked out from that section of the resident's hair. NA #3 agreed her hair was dirty and said she thought it had not been washed in a long time. She said that she heard the resident's family had given permission to have her hair cut and thought that might have been about a month or so ago. NA #3 said she and another NA had planned to stay over that afternoon to give her a good shower and wash her hair. A second interview was conducted with NA #3 via telephone on 6/16/26 a 10:04 AM. When asked if they had given Resident #4 a shower and washed her hair after their day shift hours of 7:00 AM to 3:00 pm on 6/1/26, she said they had. When asked why she and the other NA decided to give the shower that particular day, she said she was going to be honest and said she knew the State had been in the building and were questioning why the resident appeared so dirty and why her hair looked like it did that on 6/1/26. An observation of Resident #4 was conducted on 6/2/26 at 8:43 AM. The resident was lying in her bed on her back, the head of the bed was elevated. She was awake but again did not speak or groan. The hospital gown she wore was correctly snapped and her bed linens were free of any stains, and there were no odors noticed in the room. She had a set of palm guards in both of her hands, different from the one she had worn on her left hand the day prior. Her hair was brushed and sections of hair were put into a pom-pom style using hair elastics. The tube feeding pump, pole and floor was free of any dried substance. There were still flies in her room, though not as many noted as the day prior. They landed about the room as well as on the resident. An observation of Resident #4 was conducted on 6/2/26 at 2:38 PM. The resident was sitting up in her bed and had her hair tied up in a poof on top of her head. Her hospital gown and bed linens were free of any stains. The pole, tube feeding pump, bag of enteral nutrition and floor did not have any dried fluids on them. There were several flies observed in her room, flying about and landing on her upper body and arms. When the flies would land on the resident she would make a jerking motion and groan. A telephone interview was conducted with NA #9 on 6/4/26 at 11:22 AM. NA #9 stated she had taken care of Resident #4 on many occasions. She explained that the resident is a 2-person assist and they only have 3 nursing assistants (NAs) scheduled on 2nd shift (3:00 PM to 11:00 PM). She explained that one of the reasons Resident #4 had not been getting her showers was because of lack of help. She further explained that on 2nd shift, one of the NAs had to go to the dining room for the supper meal, which left 2 NAs on the floor with all the residents. NA #9 said that between passing out and then picking up meal trays, doing rounds on the residents, and answering call lights, they did not have time to do the scheduled showers. She said it is impossible to do everything they are supposed to do if there is only 3 NAs assigned to the back (part of the facility). When asked if she had reported her concerns to administration, NA #9 said it had been mentioned at their monthly meetings and that the Director of Nursing (DON) was present at those meetings. NA #9 agreed that Resident #4's hair was dirty and matted and that she had not had a shower for a while. She could not recall when the resident's last shower had been. NA #9 said that she had heard the resident was supposed to have her hair cut but did not know how long ago she heard that. She stated that she attempted to wash the resident's hair using one of those shampoo caps about 2 weeks prior, but it just did not work on the resident's air. She explained that she had seen all the flies on Resident #4 the day before (6/3/26) and she thought if she washed her, that might help. NA #9 said she also turned the air conditioning on trying to get rid of the flies in the room and it didn't help. A telephone interview was conducted with NA #4 on 6/15/26 at 2:08 PM. NA #4 confirmed she worked the 3:00 PM to 11:00 PM shift. She explained that Resident #4 required a total mechanical lift which required 2 staff to operate. She then said they work short-staffed, which made it hard to give Resident #4 and other residents a shower. She stated that Resident #4 is very heavy and that she and other nursing assistants try to do the best they can for her. NA #4 stated administration had been made aware of the issues, but stated nothing ever changed. NA #4 stated she could not recall the last time Resident #4 had a shower. A telephone interview was conducted with NA #5 on 6/15/26 at 2:42 PM. NA #5 confirmed she has been assigned to care for Resident #4 on her usual 11:00 PM to 7:00 AM shifts but also when she occasionally works from 3:00 PM to 11:00 PM. She explained the main reason Resident #4 does not get her scheduled showers on second shift is because she is a 2-person assist. She further explained that on the 3:00 PM to 11:00 PM shift, they are allowed to have 3 NAs in the back (part of the facility). When 1 NA has to go to the dining room at supper, that leaves only 2 NAs working on the floor. She said that during survey when State was in the building they got a 4th nursing assistant but as soon as State left, that staffing returned to usual with just 3. NA #5 said it was not fair for the residents because many of them require total mechanical lifts and it was nearly impossible to get Resident #4, or any resident for that matter, to the shower. As far as Resident #4's hair, NA #5 that with her type of hair, it has to be brushed or combed every day, and that it is not consistently being brushed or taken care of. She said they tried using the shampoo cap, but it did not work. She wondered if the Resident is what attracted all the flies because she sometimes has a foul odor. She recalled a time when she gave her a bed bath and the washcloths she used on her were filthy afterwards. She did not recall how long ago that had been. After seeing how dirty those washcloths had been, she wondered if she had been getting her bed baths like she was supposed to. NA #5 stated that she and other nursing assistants had informed the Administrator that they cannot get Resident #4 to the shower without the help of 4 NAs in the back, but nothing ever changed except when State came in for their survey. She said that as soon as the State left, it went back to how it always was with just 3 nursing assistants in the back. NA #5 said she could guarantee that Resident #4 would get her shower if they had that 4th NA because they work together to get care done. A telephone interview was conducted with NA #6 on 6/15/26 at 3:15 PM. NA #6 states that she works PRN (as needed) at the facility, maybe 1 or 2 times a week. She explained that they are supposed to give showers on 2nd shift (3:00 PM to 11:00 PM) but when they are short-staffed, they cannot get the residents to the showers. When asked what short-staffed meant, NA #6 said they are short if they have 3 NAs assigned to the back. She said between meals and lights going off, and everything else they had to do, they just could not find time to do the residents' showers. A telephone interview was conducted with NA #7 on 6/16/26 at 11:15 AM. NA #7 stated that she worked from 11:00 PM to 7:00 AM. She explained that Resident #4's hair is always disheveled and matted when she had her in her assignment. She said she has never tried to do anything with her hair because she had been told that she is not supposed to disturb the residents for 6 hours at night because that was when the residents are supposed to be sleeping. Therefore, she did not address her hair or her hygiene issues. She said she has never reported Resident #4's hygiene issues because she felt that by the time she comes into work, she felt like it should have already been reported to someone. NA #7 stated she does get report from the off-going NA. She said no one had ever reported to her that Resident #4 had her shower on 2nd shift (from 3:00 PM to 11:00 PM) and said that she never thought to report that. A telephone interview was conducted with NA #8 on 6/15/26 at 4:08 PM. NA #8 stated he worked 3rd shift, from 11:00 PM to 7:00 AM. NA #8 stated he had noticed Resident #4's hair was long and dirty and knotted in back, but he said he never had anything on him like hair bands. He explained that he never gives showers on his shift, unless a resident has an appointment the following morning and stated Resident #4 never had appointments. NA #8 said they did not have time to give bed baths to residents on night shift but will provide incontinence care to Resident #4 when needed. He said he never told anyone about her hair or hygiene concerns. He said he used to give report to the oncoming nursing assistants but admitted he had not been doing that recently. A telephone interview was conducted with Nurse #4 on 6/15/26 at 12:51 PM. Nurse #4 confirmed she worked the 7:00 PM to 7:00 AM shift. Nurse #4 stated the only reason that she could think of as to why the nursing assistants are not giving Resident #4 her scheduled shower is because she required a total mechanical lift to get her up and out of bed and thought the staff do not want the resident to fall out of it. Nurse #4 stated she had noticed Resident #4's hair had grown tremendously since she was admitted and agreed it was matted down in the back. Nurse #4 said she does what she can for the residents and explained she stays busy when she's working the back. She agreed Resident #4 had a lot of flies in her room and wondered if they were attracted to the liquid nutrition she received. She admitted that if she spills some of the liquid nutrition that she will clean it up. She said she will stand in the room and try to kill some of the flies and try to keep them from landing on Resident #4. She said she would even turn the air conditioner on to 68 degrees. She said she did not know what else she could do because she could not stay in Resident #4's room all of the time because she had other residents to care for as well. A telephone interview was conducted with Nurse #5 on 6/15/26 at 1:03 PM. Nurse #5 stated she worked the 7:00 PM to 7:00 AM shift. She explained that she was aware that scheduled showers are not being given as scheduled on second part of 2nd shift from 7:00 PM to 11:00 PM unless there happens to be a 4th NA scheduled. Nurse #5 said she was aware of the condition of Resident #4's hair and her lack of a showers. She said she tries to do a lot for the resident but said she did not know how to do black hair. She said she tries to get the nursing assistants to do the things they are supposed to do and said they will not listen to her or do what she asks. She says she had reported a lot of what happens or what does not happen on the shift to administration, but nothing ever gets done about it. An interview was conducted with the DON on 6/3/26 at 10:51 AM. The DON stated the residents are offered two showers a week and that showers occur on both first and second shift. She stated it was her expectation that nursing assistants check the shower schedule at the beginning of their shift and do those showers. A second interview was conducted with the DON on 6/4/26 at 1:56 PM. The DON stated she expected the nursing staff to perform daily bed baths and hair care on the residents. The DON stated she could not provide any additional staff, however, she stated she could re-evaluate the needs of the residents and possibly move some of the resident baths to day shift where there is more manpower. An interview was conducted with the Administrator on 6/4/26 at 1:43 PM. The Administrator stated it was her expectation that staff keep Resident #4 kempt, her hair unmatted and for staff to keep the residents clean as per the standards of nursing care. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses including coronary artery disease (CAD). The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #45 coded as cognitively intact and was dependent on ADL care. A review of the concern form from Resident #45 dated 2/15/2026 revealed she was not bathed on Sunday 2/15/2026. The resolution for the concern included the staff member being disciplined and an apology was made to the resident. An interview with Resident #45 was conducted on 6/1/2026 at 12:00 PM. The Resident stated she had completed a concern form because on 2/15/20256 she did not receive a bath of any kind. She also stated she does not refuse baths or showers. An interview with Nurse Aide (NA) #3 was conducted on 6/4/2026 at 12:12:40 PM. She stated she was Resident #45's aide on 7:00 to 3:00 PM shift on 2/15/2026. She stated she asked Resident #45 if she wanted a bath or shower and she refused. The nurse aide also stated if a resident refused activities of daily living (ADL) care then she must report it to the nurse. NA #3 did not recall if she reported this to the nurse. A telephone interview with Nurse #2 was conducted on 6/3/2026 at 12:40 PM. She stated she worked with Resident #45 on 7:00 to 3:00 PM shift on 2/15/2026 and did not recall a nurse aide coming to report a refusal for a bath or shower on that day for Resident #45. Nurse #2 indicated if there was a refusal, then it would be in her notes. A review of nursing notes for 2/15/2026 revealed no documentation of Resident #45 refusing care. An interview with the Administrator was conducted on 6/3/2026 at 12:12 PM. The Administrator stated on 2/15/2026 there was a written concern about missing ADL care for Resident #45. The concern was investigated and it was substantiated. The staff member was written up, and an apology was offered to Resident #45.

Based on observation, record review and staff interviews, the facility failed to ensure a dependent resident's toenails were trimmed and podiatry services were arranged for 1 of 3 residents reviewed for foot care (Resident #9).The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses that included demyelinating disease (a condition that affects the nerve signals) of the central nervous system, flaccid hemiplegia (paralysis of one side of the body) affecting the right dominant right side, generalized muscle weakness and lack of coordination.A physician order dated 4/21/26 indicated dentist/podiatrist/psychiatrist/ophthalmologist/ counseling/wound services as indicated.An admission head to toe/skin assessment completed by the Wound Treatment Nurse on 4/22/26 indicated that Resident #9's toenails were long. The assessment did not indicate Resident #9 was referred for podiatry services.Resident #9's care plan had a care focus area initiated 4/22/26 that indicated that Resident #9 had an activity of daily living (ADL) self-care performance related to demyelinating disease of nervous system with right flaccid hemiplegia, lack of coordination, and muscle weakness. Interventions included provide one (1) person assistance with bathing/showers, check nail length, trim and clean on bath day and as necessary and report any changes to the nurse.An admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #9 as having moderately impaired cognition and functional limitation in range of motion on one side of the upper and lower extremities. She required partial to moderate assistance with personal hygiene, showers/bathing and rolling left to right in bed, substantial to maximal assistance with transfers and was dependent with toileting and putting on/taking off footwear. She was not coded for rejection of care during the assessment period.Resident #9's head-to-toe skin assessments dated 4/30/26 and 5/12/26 did not indicate that Resident #9's nails were long.A review of the facility's podiatry clinic schedule dated 5/18/26 revealed Resident #9 was not seen by the podiatrist and was not on the list to be seen on that day.An observation of Resident #9 and interview was conducted on 6/2/26 at 10:58 AM in the company of the Wound Treatment Nurse. All of Resident #9's toenails on both feet were observed to be thick and long. When Resident #9 was asked if she wanted her toenails trimmed, she stated that she was not able to take care of her feet or toenails herself and that she would like her toenails trimmed. The Wound Treatment Nurse stated that normally the nurse aides would notify the primary nurses if a resident required podiatry services and the nurses would notify the Social Worker to add the resident to the list to be seen by the podiatrist who came to the facility on a quarterly basis.During a follow up interview on 6/4/26 at 10:18 AM with Wound Treatment Nurse she stated that she had completed Resident #9's admission skin assessment on 4/22/26 and noted her toenails to be long but she could not recall if she had told the Social Worker to add her to the podiatry list to be seen during the podiatry clinic on 5/18/26. She stated that she should have followed through and ensured that Resident #9 was added to the podiatry list so that she could have been seen on 5/18/26.An interview was conducted on 6/2/26 at 11:30 AM with the Social Worker who stated that he added residents to the podiatry list when he received the referrals from nurses that a resident needed podiatry services. He stated that the podiatrist came to the facility on a quarterly basis and that he was last at the facility on 5/18/26 but Resident #9 was not seen by the podiatrist during that visit because he (the Social Worker) was not aware that Resident #9 needed podiatry services since no one had asked him to add Resident #9 to the podiatry list. During an interview with Nursing Assistant (NA) #1 on 6/3/26 at 2:00 PM she revealed that she frequently cared for Resident #9 during the first shift (7:00 AM to 3:00 PM). NA #1 explained that she had noticed that Resident #8's toenails were long and thick from when she was admitted to the facility in April 2026 and that she had attempted to trim them without success. NA #1 stated that she had mentioned this to an agency nurse about 2 weeks ago, but she could not recall the name of the agency nurse.During an interview with the Unit Manager (UM) on 6/4/26 at 10:00 AM she indicated that nurses were supposed to inform the Social Worker to add the residents to the podiatry list or request podiatry referral from the physician if the resident required podiatry services. She stated that nurses would know that a resident required podiatry services when they completed the admission head-to-toe skin assessment, weekly skin assessments or when they were notified by the nursing assistants of their observations during ADL care. The UM explained that normally the Wound Treatment Nurse completed the admission skin assessment and weekly skin assessments when Wound Treatment Nurse was at the facility and if she was not at the facility the primary nurses completed the skin assessments. The UM reported that the Wound Treatment Nurse had completed Resident #9's admission head to toe skin assessment on 4/22/26 and noted long toenails and the Wound Treatment Nurse should have referred Resident #9 to the Social Worker to be added to the podiatry list so that she could have been seen during the 5/18/26 podiatry clinic at the facility.An interview was conducted with the Director of Nursing (DON) and the Administrator on 6/4/26 at 11:46 AM. The DON stated that the Wound Treatment Nurse should have informed the Social Worker to add Resident #9 to the podiatry list after she completed her admission skin assessment on 4/22/26 so that Resident #9 could have been in house by the podiatrist on 5/18/26. The Administrator stated that she was not aware that Resident #9's toenails were long and that after she was made aware on 6/3/26, Resident #9 had been scheduled to be seen at an offsite podiatry clinic on 6/17/26. The Administrator explained that the Wound Treatment Nurse should have ensured that Resident #8 was added to the podiatry list to be seen at the facility on 5/18/26 to ensure that she received appropriate foot care. The Administrator further stated that she expected all residents to receive podiatry services when needed.

Based on observation, record reviews, and interviews with Police Officer, staff, Resident, Psychiatric Nurse Practitioner, and Physician, the facility failed to protect a Resident's right to be free from staff to resident abuse perpetrated by Nurse Aide (NA) #3 while giving care to a resident with a history of being combative. On 03/08/2025 during morning rounds, Medication Aide #2 observed Resident #9 in his bed with scratches on the left side of his forehead, side of face, nose and left eye redness (bruising). This affected 1 of 4 Residents reviewed for abuse (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses including cerebral infarct (stroke). The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #9 coded as cognitively intact and needed total care with activities of daily living (ADL). There were no behaviors or moods reported. His vision was severely impaired, and he was also always incontinent with bowel and bladder. The care plan dated 01/24/2025 had a focus of Resident #9 needing total assistance with ADL, was incontinent of bowel and bladder, had a history of behaviors: verbal insults towards staff, will refuse medication at times, verbal aggression towards staff during ADL care, behaviors (striking out at staff and roommate) and cussing at staff during care. Review of the Initial Allegation Report (2-hour report) dated 03/08/2025 revealed an allegation of abuse. The incident was reported at 7:15 AM. The details of the report stated Nurse #1 was informed that Resident #9 had an injury to his forehead, nose, and left eye. Visible injuries include scratches to the forehead, side of head, and left eye redness noted (initial stages of bruising). He complained of pain with palpitation to nose and left eye. Resident #9 stated that this morning around 6:45 AM, She told me to turn on the bed and I did not want to, then she hit me in the face. The resident denied any other injuries or complaints of pain other than his nose and left eye. The incident was reported to the local law enforcement. Immediate interventions include suspension of the accused nurse aide, facial x- ray, and neurological checks. Currently, there was no ongoing risk to other residents. We are conducting a thorough investigation to ensure the safety and well-being of everyone in our care. A review of a witness statement from Nurse #1 dated 03/08/2025 revealed at around 6:45 AM Medication Aide #2 came to her and reported Resident #9 had visible injuries to his forehead, side of head and left eye. The resident complained of pain from his nose and left eye area. She asked what happened and he stated, she hit me. The Nurse asked when it happened and if he knew her name. The Resident stated it just happened this morning. She told me to turn in the bed and he did not want to then she hit him in the face. The resident stated just his head and face hurt. A telephone interview with Nurse #1 was conducted on 03/19/2025 at 9:43 AM. The nurse stated she worked the night shift from 7:00 PM to 7:00 AM and worked in facility that night but was not Resident #9's nurse. On 03/08/2025, around 6:45 AM, Med Aide #2 reported to her to look in on Resident #9 because he had scratches on head and believed he was hit. She went to Resident #9's room and saw he had small scratches to the left side of his forehead, nose and eye. His eye was swollen and it would not fully open. She told Resident #9 he had an injury to his head and asked if he remembered what happened and he said, she hit me. The Nurse also asked if he remembered who hit him and stated, she told him to roll over in bed and he did not want too and then she hit me. She did not know if it was a slap or punch. He could not say a name but stated, she worked with him that night. The Nurse also stated his injuries were fresh because the scratches had not clotted yet and were easy to clean. The Nurse asked Resident #9 if she could touch the areas, and he allowed. She used normal saline to clean his face and offered a cold pack, but he refused. He said he was not in pain. The areas stopped bleeding when cleaned. The wounds did not look as if he could inflict them on himself and he never had a history of making anything up. He can be combative at times. The NA that worked with him that night was NA #3. The Nurse stated she asked if it was okay to leave him and if he felt safe, he stated he did. She went to find NA #3 and she had left the building. She then called the Unit Manager on-call supervisor. A review of a witness statement from Medication Aide (Medication Aide #2) no date revealed on March 08, 2025, as she was in the middle of her morning med pass and giving medicine to a resident. She heard Resident #9 yelling and then he stopped. When this Med Aide went into his room, she noticed blood and cuts on his face. She immediately notified Nurse #1 on duty. A telephone interview with Medication Aide #2 was conducted on 03/19/2025 at 4:11 PM. Medication Aide #2 stated she was the med aide on 03/07/2025 at 11:00 PM to 03/08/2025 at 7:00 AM. On 03/08/2025 at approximately 5:45 to 6:00 AM, she and NA #2 were getting supplies from the supply room. As they passed Resident #9's room, his roommate, Resident #69, yelled out for help. He wanted his television turned on. She observed Resident #9 at that time, and he was fine and did not have any scratches or bruises. She went to get the medications for Resident #69 and came back to the room and while giving him his medications, NA #3 came in and told Resident #9 she was there to change his brief. Resident #9 and NA#3 were calm, and he allowed her to assist him. She left the room and went to another resident's room to give medications. While in the Residents room, she heard Resident #9 yell out but could not understand what he was saying. It was not out of the ordinary for him to yell out and he did not yell after that. She exited the resident's room and saw NA #3 walk by and figured she took care of Resident #9's needs. NA #3 looked normal and did not seem angry. She went to her next resident room to administer medications and after she finished administering medications to that resident, she went to peek in on Resident #9. She observed scratches on his face and forehead, he had scratches on his left side of his eye and left inner eye. The scratches were fresh, and she noticed blood on his face. She asked the resident what happened to his face, and he did not say anything. She then went to get Nurse #1. The nurse went into Resident #9's room and took care of the resident, and she went back to administering medications. The Medication Aide also stated Resident #9 was alert and oriented and he cannot see very well. To her knowledge, he had never made false allegations against staff and his nails were short and neat. The Medication Aide further stated she worked with Resident #9 regularly after the incident and he had not had any behavior changes. He did not appear to be afraid, had not had any sleeping changes and he still yells out if he needed something. A telephone interview with NA #2 was conducted on 03/19/2025 at 12:31 PM. The NA stated he worked 7:00 PM o 3/07/25 to 7:00 AM on 03/08/2025 and he was familiar with the care for Resident #9. Resident #9 needed total assistance with activities of daily living (ADL) care. The morning of 03/08/2025 he saw NA #3 walk in the room and within a minute he heard her tell Resident #9 to roll over to be changed and she did sound agitated. Within another minute he heard sounds like a hand hitting a hand and was walking away from the room. He would usually go in and see what was going on, but NA #3 was not the type of person that you confront when she was upset. When she (NA #3) left the room, he and Medication Aide #2 went in and observed blood coming down Resident #9's left or right temple. Medication Aide #2 asked if he was okay, but he did not hear what the Resident said because they left to find a nurse and went in opposite directions. The NA also stated he had not observed NA #3 abusing residents or treating them roughly in the past. A review of the witness statement from NA #3 dated 03/08/2025 revealed she was assigned to rooms 64-70 and she did her roll call at 11:30 PM. All of her residents were accounted for and did her 1st round at 12:30 AM. Resident #9 was not soiled at all, and he doesn't like to be bothered throughout the night. She doesn't get too close to him because he is a fighter and he can't see and is afraid at times, but she checked on him every round. At 5:30am she asked if she could check him to see if he needed to be changed and he said, Yes. As she was changing him, she talked with him, so he knew what she was doing, so he didn't get afraid and fight her. He let her change him and she left the room. She didn't see anything on him because he didn't let anybody get close to him. He wasn't upset at all when she changed him. A telephone interview with NA #3 was conducted on 03/19/2025 at 2:28 PM. The NA stated she came in on overtime on 03/07/2025 for a 11-7 shift. It was a pleasant night. She was in a good mood and Resident #9 was in good spirits as well. She went in to do her rounds and the last round was around 5:30 AM. He was fine when she left the room around 5:45 AM. The NA also stated she would always announce what she was going to do and loud enough for him to hear her. The Resident is half blind, so you must tell him what you are there for. She told him she was there to check and change his brief and he allowed it. There were no other interactions with the Resident. She left and she did not return to the room. The NA also stated she feels she was being set up at the facility because she and Resident #9 got along well, and she would never do anything like this. A review of an x-ray dated 03/08/2025 revealed a history of injury and pain, 4 views of facial bones with no prior studies. There were no definite displaced or depressed facial fractures. A review of the local Police Department incident/investigation report dated 03/08/2025 revealed on 03/08/2025 the Police Officer #1 was dispatched to [name of the facility] in reference to an elderly man who was assaulted by an employee. When he arrived, he and Officer #2 walked to Resident #9's room where he spoke to the resident. Resident #9 stated that earlier that morning a he-she hit him in the face and scratched his head. He asked the resident who it was and what they were doing. He was having a hard time communicating but was able to inform me that she was there to give him a bath and when she asked him to sit up, he didn't move fast enough for her, and she struck him. Officer #1 asked Resident #9 if it was possible that it was an accident and if she apologized and doctored him up afterwards and he stated No, she was mean. I observed a bruised left cheek below his eye, a small amount of dried blood in his tear duct, and a long scratch going from the top of his left eye to the top of his head. It was easy to see due to the resident not having hair on his head. A telephone interview with Police Officer #2 was conducted on 03/18/2025 at 2:49 PM. Officer #2 stated they were called in on 03/08/2025 for alleged abuse of a Resident from a staff member. They went to the Residents room and asked if he could tell them what happened and he stated he was hit by a he/she, because he did not move fast enough and that it just happened. The Resident just said he was hit and did not explain how he was hit. The Resident also showed signs of an altercation with bruises and scratches that were visible on his face. There was no arrest yet and the case was still open. A telephone interview with Nurse #2, the 7:00 PM to 7:00 AM nurse on 03/08/2025 was conducted on 03/19/2025 at 1:42 PM. The nurse stated she did work the night shift when the incident occurred and was Resident #9's nurse. That morning (3/08/25), she was completing her night rounds and did not see or hear anything but was told about it after it happened. The Nurse stated the last time she was in Resident #9's room was in the middle of her shift around 1:00 AM. Resident #9 did not have any bruising or scratches. A review of a witness statement from Nurse #3, no date, revealed at the start of my shift on 03/08/2025, as charge nurse (7:00 AM to 7:00 PM), it was reported to him a potential abuse involving Resident #9. Upon going to assess Resident #9, he was adamant he was hit. He had visible injuries to forehead, left eye and head. When asked when and by whom, the Resident stated, early this morning by this girl. Emotional support was offered to Resident #9, and first aid was offered. A telephone interview with Nurse #3 was conducted on 03/19/2025 at 9:23AM. The Nurse stated he still worked at the facility as 7:00 AM to 7:00 PM charge nurse. An incident happened on Saturday morning, 03/08/2025 at end of the night shift. Nurse #1 reported to him that suspected abuse may have happened to Resident #9 and went to his room a little after 7:00 AM to assess him. He noticed he had injuries including and a bruise on his left eye and scratches on his face. He did not complain of pain at that time. Resident #9 allowed him to apply an ice pack to the bruise on his face. He did a full assessment and body check and there were no other issues found. The resident stated, That girl hit me, when asked what girl he said it was the girl working with him that night. He could not give her name. The Resident worked with NA #3 that night shift. The Nurse also stated he had not seen NA #3 treat or had any reports of her treating the residents any other residents ruff or would have reported it. The Nurse also stated Resident #9 had dementia and got agitated at times and refuses his care. The Resident's behavior had not changed since the incident and, he had not complained about the pain. An interview with the Unit Manager was conducted on 03/20/2025 at 1:01 PM. She stated the incident was reported to her by phone between 7:00 AM and 7:30 AM because she was the on-call Nurse that weekend. Nurse #1 reported Resident #9 had a developing bruise on the inner left eye and small scratches on his forehead, left side of nose and face. Resident #9 had a history of being combative with staff in the past. The Unit Manager also stated she told Nurse #1 to start neurological checks and then she contacted the provider and DON. The provider gave orders for a facial x-ray and there were no fractions found. She also contacted the Responsible Party (RP) to say that there was an alleged abuse involving Resident #9. The DON completed the reports and notified authorities. The DON stated she would handle the investigation. The Unit Manager further stated the Resident had not had any change of behavior or sleep habits. When she went to visit him on that Monday, 03/10/2025, he was his normal self and stated he was okay and did not have any pain or discomfort. An observation and interview with Resident #9 were conducted on 03/18/25 at 02:03 PM. Resident #9's face was observed to be free from bruising and scratches. He stated he did not have any pain. The Resident stated he was hit by a girl that worked at the facility. She asked him to lie down so she could change him, and he guessed it wasn't fast enough for her, and she started hitting him in the face and head. He did not remember who she was, but it was the person that was working with him that night. He stated he feels safe at the facility, he was mad, but the incident did not bother him at all anymore because she must have been crazy. He has not seen the NA at the facility since the incident. He was already seeing psychiatric services but not for this issue. He also stated he still can sleep without any issues and his moods had not changed. An interview with Resident #69, Resident #9's roommate was conducted on 03/18/2025 at 02:13 PM. The Resident stated he did not hear or see anything because he was asleep. A follow up interview with Resident #9 was conducted on 03/19/2025 at 12:02 PM. The Resident stated he could not see how she was hitting him but knew she was hitting him. The Resident also stated there was no need to go to the hospital when it happened, and he was fine. A review of the Trauma Informed Screen completed 03/11/2025 revealed Resident #9 was in a recent confrontation with a staff member. Resident #9 stated he was, OK. There were no anxiety issues, the Resident denied any mental anguish or anxiety. X-ray of face was obtained and is included. The resident was also followed up by the provider and that note is also included. A review of a social services note dated 03/11/2025 revealed he met with Resident #9 in his room. Questions concerning Trauma Inform Screen and discussions of altercation with staff member. Resident #9 stated he was, OK and has no anxiety issues. The Resident also stated he was not in need of any other psychological services at present and was thankful for his visit. An interview with the Social Worker (SW) was conducted on 03/21/2025 at 9:09 AM. The SW stated he was made aware of the incident with Resident #9 that happened the past weekend (03/08/2025). He went down to Resident #9's room to check on him and to make sure he was not in any distress or suffering from trauma. He completed the screen for trauma, and it did not show any trauma. He stated he was okay; he was not fearful or in any pain. A telephone interview with the Psychiatric Nurse Practitioner was conducted on 03/20/2025 at 10:36 AM. She stated she visits Resident #9 twice a month on Wednesdays for his combative behaviors and diagnosis of vascular dementia with behavioral disturbances. On 03/12/2025 Resident #9 had a scheduled chronic visit and med review. He was in his bed, asleep and easily aroused. He was calm and content, alert and oriented. He stated he did not have any anxiety or issues sleeping and eating well. When asked if there were any issues, he wanted to discuss, he stated, no, and did not mention the incident. On 02/26/2025, he was ordered a new as needed (PRN) order for 0.5 milligrams Ativan for agitation prior to the incident and it was not administered within that look back period of 14 days. He had a history of being agitated and striking out at times during care. He can identify people by voices. Resident #9 had not had a history of fabrications. He was still alert and oriented even though he is blind. The Nurse Practitioner also stated Resident #9 did not have any notable bruising or scratches visible or complained of pain on 03/12/2025 when she visited him. A review of a physician note dated 03/12/2025 revealed Resident #9 was stable and there were no new complaints. His skin was normal temperature and normal color. Summary from 03/08/2025 revealed resident noted with multiple scratches to forehead, left side of scalp, and on the inner corner of his left eye. Bruising was noted to left eye and nose as well. When asked what happened the resident stated that he was told by a nursing assistant to turn over and he did not want to and when he said that he did not want to she hit me in the face. The resident reported pain to the left side of face and nose. The area was cleansed with wound cleanser and patted dry. The provider was notified and gave telephone order for an x-ray of nose and left orbit and neurological checks were implemented. A telephone interview with the Physician was conducted on 03/20/2025 at 1:44 PM. The Physician stated she was new to the facility but did visit Resident #9 on 03/12/2025 as her note indicated. She did not observe any facial bruises or scratches on his face and there were no complaints of pain. If there was, she would have addressed it in her note. She also stated she could not say if the scratches could have been self-inflicted due to the incident because she did not see the areas when the incident happened. The physician also stated she would expect all residents at the facility to be free from abuse. A review of the investigation Report (5-day report) dated 03/14/2025 revealed the alleged employee (NA#3) was suspended starting 03/08/2025 through the duration of the investigation. After investigation, NA #3 was terminated. Skin audits were completed on the residents with BIMS scores less than or equal to 11. Interviews completed with resident with BIMS greater than and equal to 12. Statements were received from the resident, resident's roommate, and other staff that were present during the day of the incident. Staff were re-educated on the abuse policy. Employees were re-educated about abuse and the importance of timely notification to management. Weekly skin checks will be continued on in-house residents. No other residents were noted to be in any immediate danger. An interview with the Director of Nursing (DON) was conducted on 03/20/2025 at 1:31 PM. The DON stated she received a call from her Unit Manager a little after 7:00 AM on 03/08/2025 and reported Resident #9 had been hit in the face and had some scratches and bruise under the left eye forming with fresh blood. The DON asked which NA was scheduled and was told NA #3 and her shift ended at 7:00 am and she had already left the facility. The DON had the Unit Manager take NA #3 off the schedule and look for a replacement. She then called NA #3 and asked if she had Resident #9 the last shift and if anyone was in the room with her. She stated she did have him last night and no one else was in the room with her when she finished his care. She said he can fight you and be combative at times, but it went ok and there were no issues. NA #3 emailed her the statement. The DON called her back and told her he was hit in the face and was observed with fresh blood and a bruise that was forming. The DON informed the NA #3 she would investigate the incident and get back to her. The DON had the Unit Manager contact the physician and got an order for an x-ray and no fractures were found. Skin was assessed for Resident #9 and no other issues aside from the face scratches and redness, bruise to left eye. He did not require treatment for his face, it resolved on its own. He also did not require pain medication, just an ice pack. The DON stated she completed the Initial Report and called 911 and reported it to police and their investigation was ongoing. The DON received a statement from Nurse #1. The abuse and neglect education began on 03/08/2025 by Nurse #3. Resident #9 or any other resident were not in immediate danger. He was not showing any emotional distress and stated he was fine and did have a psychiatric visit on 03/12/2025. He has not complained of pain since the incident and did not require further treatment for his face. The DON indicated she reported the incident to the Administrator. The DON also stated she called NA #3 and let her know the allegation was substantiated and had to let her go. There were no previous issues with Resident #9 and NA #3 ever reported. The Resident did have a history of striking out at staff but that was no excuse. The DON stated she expected her staff not to abuse residents and for her residents to be free of abuse and feel safe at the facility. An interview with the Administrator was conducted on 03/20/2025 at 3:52 PM. The Administrator stated he was called by the DON on 03/08/2025 who reported there was a situation with Resident #9 and NA #3. She stated it looked like the NA, that worked that night, may have abused the resident. The nurses evaluated the resident for any other issues to his body and skin. There were scratches and a bruise on his left eye and there were x-rays completed and there were no fractures found. The resident did not complain of pain after the day of the incident and his bruising and scratches went away quickly. The Administrator also stated he made sure the DON completed the initial review and reported the incident to the police who were in the building while he was on the phone with her. He also reminded the DON that the NA could not work there until the investigation was completed. The NA had not been in the facility since that morning at 6:50 AM. The Administrator also stated the RP was made aware. The investigation was substantiated. The staff member was fired but there were no prior issues with NA #3 before the incident and there were no problems between her and Resident #9. There was no abuse found by the alert and oriented Residents that completed questionnaires and interviews. The staff were questioned about what happened and they received witnesses' statements. They educated the staff that they must report abuse as soon as possible and that abuse is not supposed to happen and will continue to educate staff about abuse. The Administrator stated he expected the residents to be free from abuse.

Based on record review, and staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council, resolve repeat grievances, and to communicate the facility's efforts to address grievances voiced during Resident Council meetings for 6 of 6 consecutive months: October 2024, November 2024, December 2024, January 2025, February 2025 and March 2025. The findings included: A review of the Resident Council minutes completed by the Activities Director dated 10/10/24 revealed it was attended by Residents #20, #14, #21, #30, #3, #61, #48, #32, #38, #23 and #39. The following grievances were expressed: the need to provide locks for the nightstands, a better verbal response to patients in need from the nursing assistants, a timelier response to call lights, and bed baths were not being completed. A review of the Resident Council minutes completed by the Activities Director dated 11/14/24 indicated it was attended by Residents #34, #21, #61, #3, #38, #56, #48, #32, #58, and #20. There was no indication in the 11/14/24 minutes that the grievances voiced during the 10/10/24 Resident Council meeting were addressed. The following grievances were expressed: ice was not passed on Saturdays or Sundays, and no snacks were available at night. A review of the Resident Council minutes completed by the Activities Director dated 12/5/24 revealed it was attended by Residents #30, #14, #10, #48, #6, #23, #38, #56, #32, #39, #61, #58, #19, and #27. The minutes indicated there had been no improvement in the prior months' grievances. The following grievances were expressed: coverage for when staff took breaks, not receiving showers only bed baths, the need of a better showerhead in back, having healthy snacks for the snack cart, ice was not passed on Saturdays or Sundays (repeat grievance from the previous month's meeting), no snacks available at night (repeat grievance from the previous month's meeting), more activities geared towards men, better salads, more bacon and breaded fish on the menu, staff was forgetting to pick up food trays after meals. A review of the Resident Council minutes completed by the Activities Director dated 1/9/25 indicated it was attended by Residents #48, #14, #10, #21, #20, #51, #12, #30, #39, #38, #23, #6, #32, and #56. The minutes indicated there was no improvement regarding the snack cart or ice being passed on Saturdays and Sundays. The following grievances were expressed during the meeting: nursing assistants with bad attitudes, staff forgetting to pick up food trays after meals, the bed control not replaced on bed 52-B, the television remote for room [ROOM NUMBER] was missing, the television remote for room [ROOM NUMBER] was not working, staff was not setting up residents to eat breakfast, and staff not getting a resident up when requested. A review of the Resident Council minutes completed by the Activities Director dated 2/6/25 revealed it was attended by Residents #32, #39, #38, #23, #33, #14, #49, #21, #20, #10, #34, #36, and #58. The minutes indicated the following for grievances voiced during the previous month's meeting: ice being passed was somewhat improved and verbal responses from the staff were somewhat improved. There was no indication the other grievances from the previous month's meeting were addressed. The following grievances were expressed during the meeting: there was no cleaning after housekeeping left for the day, they would like to have more salad toppings, and the staff needed to be quieter during the night when assisting other residents. A review of the Resident Council minutes completed by the Activities Director dated 3/12/25 indicated it was attended by Residents #38, #48, #32, #36, #39, #61, #60, #58, #48, #34, #14, #10, #21, #54, and #23. There was no indication in the 3/12/25 minutes that the grievances voiced during the 2/6/25 Resident Council meeting were addressed. The following grievances were expressed during the meeting: call light response time. A Resident Council meeting was held on 3/20/25 at 3:00 PM with Residents #48, #23, #38, #59, #20, #58 and #56. During the meeting, Resident #58 expressed that the Resident Council was not informed of resolutions or progress of grievances voiced at the previous meeting. Resident #48 stated it was if what the Resident Council said did not matter. All of the residents present agreed with Resident #48's statement. The members present at the Resident Council meeting expressed their collective frustration regarding the feeling of powerlessness in attempting to get their voices heard. Resident #38 stated that it seemed pointless to express any grievances because nothing was ever done about them, which the members present collectively agreed with. An interview with the Activities Director on 3/20/25 at 3:30 PM revealed that she did not fill out a grievance form for issues brought up in Resident Council. She stated she gave the department heads a copy of the minutes of the meeting after she completed them and waited for a response to the concerns. She further indicated that she was not sure what process she was supposed to follow and was unaware of whether or not a grievance form should have been filled out with the grievances brought forth by the Resident Council. She stated that if she did not receive a response from the department head(s) within a week or two then she either went to that department head or mentioned it in the morning meeting. She added that she did not always get a response from the department head. The Activity Director revealed that she had not reported to the Administrator or Director of Nursing if she received no response from a department head. She further revealed that if she had received a response she just noted it in the notes and did not inform Resident Council of the response. An interview with the Administrator on 03/21/25 at 08:48 AM revealed he was the Grievance Official, and he had not received a grievance form related to grievances brought up in the monthly Resident Council meeting. The Administrator stated that moving forward, he will check with the Activities Director on the day of the Resident Council meetings to ensure that a grievance is filled out with each concern and the grievance form is completed and reviewed at the next Resident Council meeting. He further stated that the process was for a grievance form to be filled out with each individual grievance voiced by the Resident Council and the Resident Council updated on the solution or progress to the solution for each grievance.

Based on record review and staff interviews, the facility failed to provide a CMS-10055 (Center for Medicare and Medicaid Services) Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNF ABN) prior to discharge from Medicare part A services for 2 of 3 residents (Residents #27 and #280) reviewed for SNF Beneficiary Protection Notification Review. The findings included: 1. Resident #27 was admitted to the facility under part A Medicare Services on 12/3/24. A review of Resident #27's medical record revealed a CMS 10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #27's court appointed designee on 12/20/24. The notice indicated that Medicare coverage for skilled services were to end on 12/22/24 and the resident would remain in the facility. A review of Resident #27's medical record revealed that a CMS-10055 SNF ABN was not provided to Resident #27, or his court appointed designee. An interview conducted with the Business Office Manager on 3/21/25 at 10:00 AM indicated that she was confused over the SNF ABN process and did not realize she had to administer one to every Medicare Part A resident who had days remaining when discharged from Medicare Part A services. She now understood the process and will ensure an SNF ABN was provided appropriately. An interview conducted with the Administrator on 3/21/25 at 10:30 AM indicated that SNF ABNs should have been issued and would be discussed at the morning meeting with therapy when they were getting ready to discharge a Medicare part A resident to ensure the SNF ABN was issued. 2. Resident #280 was admitted to the facility under part A Medicare Services on 2/11/25. A review of Resident #280's medical record revealed a CMS 10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by his responsible party on 2/28/25. The notice indicated that Medicare coverage for skilled services were to end on 3/2/25 and the resident would return home on 3/3/25. A review of Resident #280's medical record revealed that a CMS-10055 SNF ABN was not provided to Resident #280 or his responsible party. An interview conducted with the Business Office Manager on 3/21/25 at 10:00 AM indicated that she was confused over the SNF ABN process and did not realize she had to administer one to every Medicare Part A resident who had days remaining when discharged from Medicare Part A services. She now understood the process and will ensure an SNF ABN was provided appropriately. An interview conducted with the Administrator on 3/21/25 at 10:30 AM indicated that SNF ABNs should have been issued and would be discussed at the morning meeting with therapy when they were getting ready to discharge a Medicare part A resident to ensure the SNF ABN was issued.

Based on record review and staff interviews, the facility failed to follow and implement abuse policies for identifying and intervening in situations of abuse for 1 of 4 residents reviewed for abuse (Resident #9). When Nurse Aide (Nurse Aide) #2 thought he heard a physical altercation between NA #3 and Resident # 9, NA #2 did not enter the room, did not intervene, or report NA #3. Resident #9 was observed with scratches to his forehead, nose and eye. His eye was swollen and it would not fully open. The findings included: A review of the abuse policy revised/reviewed 04/29/2024 revealed III. Prevention of abuse neglect and exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse neglect misappropriation or resident property and exploitation that achieves: B. Identifying correcting and intervening in situations in which abuse neglect exploitation and or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered licensed and certified staff on each shift. Review of the investigation completed by the Director of Nursing (DON) related to Resident #9's incident revealed the following: A review of a witness statement from NA #2 dated 03/12/2025 revealed at around 5:00 to 6:00 AM (03/08/2025) in the morning when he was able to see NA #3 walk into Resident #9's room to change him. He was waiting for time to pass to do a shower for a resident closer to 6:30 AM to accommodate the resident. At that time Medication Aide #2 was still passing meds, so she would pop in and out of rooms. He heard NA #3 say something along the lines of Roll over [Resident #9], I'm trying to change you in a very agitated tone, soon after I was able to hear what sounded like a physical altercation between her and Resident #9. In that moment I began to move away from the room. It wasn't long after that, NA #3 stepped out of the room in a hurried manner, she disappeared up the hall. He and Medication Aide #2 walked into the room, when she needed to give his roommate, Resident #69 his medicine. He followed in, that's when he and Med Aide #2 saw blood on Resident #9's right temple, bruising at the time wasn't visible but the blood was a clear indication of the severity of the situation. Soon after, Med Aide #2 asked Resident #9 if he was feeling alright, and they left the room. A telephone interview with NA #2 was conducted on 03/19/2025 at 12:31 PM. The NA stated he worked 7:00 PM o 3/07/25 to 7:00 AM on 03/08/2025 and he was familiar with the care for Resident #9. Resident #9 needed total assistance with activities of daily living (ADL) care. The morning of 03/08/2025 he saw NA #3 walk in the room and within a minute he heard her tell Resident #9 to roll over to be changed and she did sound agitated. Within another minute he heard sounds like a hand hitting a hand and was walking away from the room. He would usually go in and see what was going on, but NA #3 was not the type of person that you confront when she was upset. When she (NA #3) left the room, he and Medication Aide #2 went in and observed blood coming down Resident #9's left or right temple. Medication Aide #2 asked if he was okay, but he did not hear what the Resident said because they left to find a nurse and went in opposite directions. The NA also stated he had not observed NA #3 abusing residents or treating them roughly in the past. An interview with the DON was conducted on 03/20/2025 at 1:31 PM. The DON stated Med Aide #2 reported the incident immediately after she observed Resident #9's face. NA #2 was educated on abuse and neglect, and he should have gone to find someone as soon as he thought abuse was happening. The DON stated she expected to have an abuse free facility and if abuse is suspected then the staff is to intervene immediately. An interview with the Administrator was conducted on 03/20/2025 at 3:52 PM. The Administrator stated NA #3 had been out of the facility since 03/08/2025 at 6:50 AM. NA #2 was educated and should have known to go get help when he suspected abuse. Staff have been educated on reporting and intervening when abuse is suspected and will continue to be educated. The Administrator stated he expected his staff to intervene if they believe a resident is being abused.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents (Resident #57) reviewed for PASRR. The findings included: Resident #57 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, generalized anxiety disorder and bipolar disorder. Record review indicated Resident #57 had a level II PASRR number issued 12/13/24. The annual MDS assessment dated [DATE] indicated a No to question A1500 which asked if Resident #57 had been evaluated by a level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. During an interview with the MDS Coordinator on 3/19/25 at 3:38 PM, he confirmed that Resident #57 had a level II PASRR. The MDS Coordinator verbalized that the MDS was coded inaccurately and that it was an oversight. An interview was conducted with the facility Administrator on 3/20/25 at 2:29 PM. He indicated Resident #57's MDS should have been completed accurately to reflect level II PASRR.

Based on observation, record review, resident, and staff interviews, the facility failed to apply a left-hand splint for 1 of 3 sampled residents reviewed for limited range of motion (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included contracture of left-hand muscle, hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (muscle weakness or partial paralysis). Resident #3's annual Minimum Data Set Assessment (MDS) dated [DATE] coded the resident as moderately cognitively impaired. She was coded as dependent with toileting and transfers. She required setup/clean-up assistance with eating and required substantial assistance with bathing and rolling in bed. Her functional limitation in range of motion indicated she had impairment on one side to her upper extremity and lower extremity. A review of Resident #3's medical record revealed an Occupational Therapy (OT) discharge summary note dated 10/18/24 that indicated a splint/brace program had been established, and a left-hand splint was to be worn 6 hours daily. The summary note also indicated the prognosis to maintain Resident #3's level of function at that time was good with consistent staff follow-through. The note further indicated that nursing staff had been trained and demonstrated the ability to don and doff the splint to ensure carryover of splinting schedule after OT discharge. A review of Resident #3's Kardex (care card) revealed a task under devices that indicated apply resting hand splint to the left arm. Resident #3 was observed on 3/18/25 at 11:27 AM without a splint to the left hand and the left hand was noted to be flaccid (limp and lacking voluntary movement). During an interview, Resident #3 stated she was supposed to have a splint to her left hand, but nursing staff did not put it on most of the days. During an interview conducted in conjunction with an observation with Nurse #4 on 3/19/25 at 1:43 PM. Resident #3 was observed in bed without a splint to her left hand. Nurse #4 found the splint in Resident #3's bedside drawer and stated she was not sure if Resident #3 was still supposed to utilize the left-hand splint, and she would find out from OT. Nurse #4 stated it would be noted on the Kardex (care guide) if nursing assistants were supposed to put the splint on. During an interview with Medication Aide (MA) #1 on 3/19/25 at 1:46 PM she stated therapy staff normally put the splint on Resident #3. MA #1 stated she could not recall if she had seen Resident #3's care card indicating to apply the splint. During an interview on 3/19/25 at 1:55 PM with the Assistant Director of Nursing (ADON), she stated that Resident #3's splint should have been applied as indicated and nursing staff should have reached out to OT if they were having any difficulties putting the splint on. An interview was conducted on 3/20/25 at 12:37 PM with the Occupational Therapist. She stated when she discharged Resident #3 from OT services on 10/18/24 the resident had built up a tolerance to wear the left-hand splint for up to 6 hours. The Occupational Therapist indicated she had trained nursing staff at that time, and they had demonstrated the ability to don and doff the splint and were to continue utilizing the splint for at least 6 hours a day. The Occupational Therapist stated if nursing staff had any issues applying the splint or needed more training, they should have notified her, and she would have retrained or provided the assistance the staff needed. She further stated the splint was for joint protection to prevent injury because Resident #3's left hand was flaccid, and to prevent any potential contractures and skin breakdown. The Occupational Therapist indicated she had just evaluated Resident #3 prior to the interview and Resident #3's left hand mobility had not gotten worse since the last evaluation on 10/18/24 and she had not developed any skin breakdown or new injury to the left-hand. During an interview on 3/20/25 at 1:19 PM with the Director of Nursing (DON), she stated if the splint was noted on Resident #3's care card then nursing staff should ensure that they put it on. The DON stated it was her expectation for nursing assistants to apply the splint and if they had any difficulties then they should have informed their supervising nurse or OT so they could be retrained. During an interview on 3/20/25 at 3:58 PM with the facility Administrator, he stated the nursing staff should have applied the splint as indicated.

Based on record review, and staff, Pharmacist, Nurse Practitioner and Medical Director interviews the facility failed to document the continuing need of a psychotropic medication in the Electronic Medical Record for 1 of 2 residents reviewed for psychotropic medication (Resident #34). The findings included: A review of Resident #34's discharge summary from the hospital dated 12/6/23 indicated she was admitted to the hospital due to visual hallucinations and sundowning (increased agitation, confusion, disorientation, and anxiety that typically occurs in the late afternoon or evening). She was started on an Seroquel (a medication that helps regulate mood, behaviors, and thought) 50 mg at bedtime while at the hospital and discharged to the facility. Resident #34 was admitted into the facility on [DATE] with diagnoses of unspecified dementia unspecified severity without behavioral, psychotic, or mood disturbance and anxiety. A review of Resident #34's annual Minimum Data Set, dated [DATE] indicated she was cognitively intact, exhibited no signs of delirium, had no mood indicators, no hallucinations or delusions, no rejection of care and no behavioral symptoms. She had active diagnoses of non-Alzheimer's dementia and depression and had received an antipsychotic with no gradual dose reduction attempted and the physician had not documented a gradual dose reduction as clinically contraindicated. A review of Resident #34's Physician orders for December 2024 revealed an order for Seroquel 50 milligrams (mg) at bedtime for behaviors with a start date of 9/6/2024. A review of Resident #34's quarterly Minimum Data Set, dated [DATE] indicated she was severely cognitively impaired, exhibited no signs of delirium, had no mood indicators, no hallucinations or delusions, no rejection of care and no behavioral symptoms. She had an active diagnoses of non-Alzheimer's dementia and depression and had received an antipsychotic with no gradual dose reduction attempted and the physician had not documented a gradual dose reduction as clinically contraindicated. A review of Resident #34's comprehensive care plan revised on 2/19/25 included a focus problem of: Resident has displayed behaviors of fall allegations and false claims against staff. She rejects care by pulling away from staff while staff is giving care. Interventions include, in part: gently inform her that false accusations against staff or other residents will not be tolerated, Social Worker to speak with resident about her behavior, investigate resident claim with her encouraging her to speak honestly remembering details, psychiatric consult as needed, take her to a calm quite place if she became upset to allow her to calm down. A review of Resident #34's Physician orders for March 2025 revealed an order for Seroquel 50 mg at bedtime for behaviors with a start date of 12/6/2024. A review of Resident #34's nursing and physician progress notes from 1/1/25 through 1/31/25 revealed there were no behaviors or symptoms documented related to her psychiatric diagnosis. A review of Resident #34's MAR for 2/25 revealed no behaviors related to the use of psychoactive medication. The MAR did reflect non-pharmacological interventions to deter behaviors or symptoms related to her psychiatric diagnosis. A review of Resident #34's nursing and physician progress notes from 2/1/25-2/28/25 indicated there were no behaviors or symptoms documented related to her psychiatric diagnosis. A review of Resident #34's MAR for 3/25 noted on 3/6/25 a behavior of compulsive behavior was indicated and 3/17/25 a behavior of striking out was noted. The MAR did reflect non-pharmacological interventions to deter behaviors or symptoms related to her psychiatric diagnosis. A review of the nursing notes for 3/1/25 through 3/21/25 revealed there were no behaviors or symptoms related to her psychiatric diagnosis. Specifically, on 3/6/25 there was no documentation as to what the compulsive behavior was, where the behavior occurred, what interventions were used to deter the behavior and the effectiveness of those interventions, and on 3/17/25 there was no documentation of what caused the documented behavior on the MAR, who did Resident #34 strike out at, where the behavior occurred, what interventions used and the effectiveness of those interventions. The physician progress notes indicated there were no behaviors or symptoms documented related to her psychiatric diagnosis. Observations of Resident #34 on 3/19/25 at different times during the day noted no behaviors. An interview conducted on 3/19/25 at 2:00 PM with Nurse Assistant #1 indicated that she was unaware of any behavioral issues related to Resident #34. An interview conducted on 3/19/25 at 12:30 PM with Medication Aide #2 indicated that she was unaware of any behavioral issues related to Resident #34. A telephone interview was conducted with the Pharmacy Consultant on 3/20/25 at 8:23 AM revealed that he had requested a gradual dose reduction (GDR) in September of 2024 which was declined by the Physician due to Resident #34 was stable and a change in medication would risk decompensation. He stated that he does medication reconciliation reviews monthly and noted for Resident #34 that there had been marked non-pharmacological interventions used which meant (to him) that she was having a behavior of some type, and he had not noticed the behavior monitoring had reflected no behaviors. He further stated that he does not look at the Minimum Data Set assessment for behaviors. He indicated that he had sent another gradual dose reduction request to the physician for the month of March 2025 but had not received it back yet. A telephone interview with the Nurse Practitioner on 3/20/25 at 10:13 AM indicated she had only been at this facility for a couple of months; however, she had no concerns regarding Resident #34's behaviors the three times that she had seen her. She was unable to answer why a GDR was not attempted or why the psychoactive medication was still ordered in light of no behaviors were exhibited. An interview conducted on 03/20/25 at 11:14 AM with the Corporate Nurse Consultant stated that if the interventions were being used to prevent a behavior the documentation would be correct on the Medication Administration Record however, with the word deter the interventions are inappropriate because there are no behaviors marked. The MDS coding was correct due to the nurses coding no behaviors on the Medication Administration Record. She further stated that there were times when if the resident was not in distress related to a behavior they were exhibiting, then an intervention is not needed. An interview conducted on 3/20/25 at 11:45 AM with the Director of Nursing revealed education to the staff regarding documentation has taken place and the team will look at the MAR to decide how the documentation of non-pharmacological interventions will be documented. She further revealed she had planned to educate the staff on documentation of what the behavior is, why it occurred (as best they could), what interventions were used, and if the interventions were effective. She further stated that she had only been the Director of Nursing for a month and was unaware of Resident #34 having any behaviors. A telephone interview with the Medical Director on 3/20/25 at 2:37 PM indicated that the nursing staff had not informed her of any behavioral issues related to Resident #34. She stated that she had not been the Medical Director for long, approximately 4 months, and was unable to state why a gradual dose reduction of Resident #34's psychoactive medication had not been completed or state the reason for the psychoactive medication. An interview conducted on 3/20/25 at 2:15 PM with the Administrator revealed that Resident #34 should have been being seen by the psychiatric services and he was aware that a consultation request had been issued today. He further stated that he was unaware of any behaviors of Resident #34 other than when she was first admitted . He further stated that the process for all new admissions with a psychoactive medication was to ensure a psychiatric consult was made, that the reason for the medication still existed after the physician and psychiatric services had seen and evaluated the resident, and that if appropriate a gradual dose reduction be conducted or possibly a discontinuation of the medication. He indicated that Resident #34 had some how fallen between the cracks when she was admitted .

Based on record review, staff, pharmacist, and police interviews the facility failed to protect residents right to be free from the diversion of a controlled narcotic pain reliever on three occasions for 2 out of 3 residents (Resident #1 and #6) reviewed for narcotic diversion. The findings included: 1a. The facility Administrator, during an interview on 1/8/25 at 9:45 AM, stated he was informed by the Assistant Director of Nursing on 7/24/24 that Resident #6's Oxycodone 5 milligrams (mg)medication cards had holes where it appeared medication was removed with tape covering the holes on the back of the card and it also appeared to her that a different medication had been placed in the card. One full card was sent back to the pharmacy for identification and the remaining pills on the other card were destroyed at the facility. He further stated that on 7/25/24 the Administrator was emailed by the facilities pharmacist that the card returned on 5/31/24 for Resident #6's Oxycodone 7.5 mg tablets had the Oxycodone 7.5 mg replaced with another medication. A review of the narcotic sheet dated 5/31/24 for Resident #6 for Oxycodone 7.5 mg noted Nurse #1 and Nurse #2 had both counted and sent back this medication to the pharmacy for destruction due to the order being changed on 5/17/24. A review of the written statement dated 7/24/25 by the Assistant Director of Nursing indicated she had called the facility pharmacy and informed them during shift count Resident #6's Oxycodone 5 mg medication cards it was noticed the cards had tape on the back and had possibly been tampered with. She was instructed to send one back for the pharmacy for identification and to destroy the medication remaining in the other card. The Administrator stated during an interview on 1/8/25 at 9:45 AM that on 7/25/24 the former Director of Nursing conducted an audit of all four of the medication carts to ensure no other controlled medications had signs of tampering, interviews were conducted with the staff, and with residents receiving controlled medications. The result of the audit indicated no issues with the blister packs in the medication carts, no residents were missing any medication, and no residents had complaints of pain or pain not being controlled. A review of interviews with the staff indicated they had no knowledge of tampering or replacement of medication. A telephone interview was attempted with the former Director of Nursing, but she was unavailable. An interview with the Assistant Director of Nursing on 1/7/25 at 8:30 AM indicated that on 7/24/24 Nurse #2 approached her with an issue with the narcotic cards. She stated that Nurse #2 showed her two cards of Oxycodone 5 mg belonging to Resident #6 with tape on the back. She stated upon further inspection it was noted that there were holes in the back of the card covered with tape and it appeared to her that the medication was not Oxycodone 5 mg. She stated she informed the Director of Nursing of the issue and called the pharmacy who instructed her to destroy the remaining pills on one card and to send the full card back to the pharmacy. She further stated that she made the pharmacy aware that the cards were a controlled medication. She also indicated that she could not legally determine what the medication in the card was and was waiting to hear from the pharmacy if the medication was Oxycodone 5 mg or something else before a diversion could be established, she was not aware of the results as of 1/7/25. A telephone interview with Nurse #2 on 1/7/25 at 10:15 AM revealed that during the narcotic count on 7/24/24 she noted tape on the back of Resident #6's Oxycodone 5 mg cards, she asked Nurse #3, who worked the prior shift, about the tape, and she responded that the cards were crowded together and something else that she could not remember. After the count was completed Nurse #2 went to find the Assistant Director of Nursing and informed her of tape on the back of the two cards, when she went back to the medication cart Nurse #3 was gone. A telephone interview was attempted to Nurse #3, but she was unavailable. An interview with the facility Administrator on 1/8/24 at 9:45 AM indicated he was informed on 7/24/24 during narcotic count between Nurse #2 and Nurse #3 that two medication cards of Oxycodone 5 mg for Resident #6 had tape on the back of the card. Upon examination of the cards, it was noted that the blisters had been punctured, and it appeared the medication had been replaced with a different medication. He further indicated that one of the cards had been returned to the pharmacy so the medication could be identified. He also revealed he had received an email from the facility pharmacy on 7/25/24 which revealed the Oxycodone 7.5 mg for Resident #6 sent back to the pharmacy on 5/31/24 for destruction had been identified as having the Oxycodone 7.5 milligrams (mg) replaced with another medication, later determined by the pharmacy to be an over-the-counter medication. The Administrator notified the Division of Health Service Regulation and the police department on 7/25/24 of the diversion and an immediate investigation was started. A telephone interview conducted on 1/8/24 at 4:04 PM with the General Manager of the Pharmacy revealed that when she emailed the facility on 7/25/24 Resident #6 medication card returned on 5/31/24 had 8 tablets of Oxycodone 7.5 mg replaced with an over-the-counter medication. 1b. On 7/31/24 a narcotic sheet for Resident #6 was filled out by Nurse #3 for the removal of one Oxycodone 5 mg pill at 8:25 AM. It was determined Nurse #3 worked night shift and was not in the facility at 8:25 AM on 7/31/24. It was further determined that Resident #6 did not have a medication card for Oxycodone 5 milligrams, or a pharmacy labeled narcotic count sheet at the time of the audit. A review of the former Director of Nursing's (DON) written statement dated 8/1/24 revealed she had been approached by Nurse #2 and informed that Nurse #3 had documented she had given Resident #6 a dose of Oxycodone 5 milligrams (mg) at 8:25 AM on 7/31/24. It was determined that Nurse #3 worked the night shift and was not at the facility at 8:25 AM on 7/31/24. The former DON conducted a random narcotic count and noted that Resident #6 did not have a medication card for Oxycodone 5 mg, or a narcotic count sheet labeled by the pharmacy. When she asked Nurse #5 why Resident #6 did not have a card of Oxycodone Nurse #5 stated it would be later that day it was delayed due to an authorization issue. The former DON requested Nurse #3 to wait in her office and when the former DON went back to her office Nurse #3 had left the facility. She attempted to contact Nurse #3 via phone calls and text messages, on the 2nd text message Nurse #3 responded that she was at an appointment and would call when it was over. The former DON did not hear from Nurse #3 again and Nurse #3 did not respond to calls from Human Resources. Nurse #3 was terminated and the facility pressed charges against Nurse #3. A review of the narcotic sheet with Nurse #3's signature revealed she gave Resident #6 one tablet of Oxycodone 5mg at 8:25 AM with 30 pills remaining. A review of the delivery slip revealed Resident #6's Oxycodone 5 mg was sent out on 7/31/24 and was received by the facility at 1:45 PM. A telephone interview with the former DON was attempted on 1/7/25 and 1/8/25 but she was not available. An interview with the Administrator on 1/8/24 at 9:45 AM indicated he was aware of Nurse #3 had signed off Resident #6's Oxycodone 5 mg for a time she was not in the building. He stated that both the former DON had attempted to contact her, but she never called the former DON back and did not answer other calls made by the facility. He stated he had notified the Department of Health Service Regulation, local authorities, and Department of Social Services on 8/1/24. He further stated that when Nurse #3 did not answer calls or messages after the initial contact with the former DON, Nurse #3 was terminated on 8/1/24. A telephone interview with Nurse #3 was attempted but she was not available. 2. During the interview on 1/8/25 at 9:45 the Administrator revealed he was notified on 12/6/24 of a potential missing blister pack of Oxycodone 10 milligrams (mg) that belonged to Resident #1. The initial sweep of the facility found no issues with medication cart locks and the blister pack of Oxycodone was not found. The facility immediately began an investigation and notified the Division of Health Service Regulation, County Department of Social Services, and local law enforcement. The investigation included identifying staff who had previous access to the medication cart and narcotic drawer, staff statements and drug tested the staff identified. A review of Nurse #4 written statement on 12/6/24 included she had notified the Unit Supervisor of Resident #1 required a refill of his Oxycodone 10 mg. The Unit Supervisor told her that the medication could not be refilled as it was to early and she (the Unit Supervisor) notified the Administrator. A telephone interview was attempted on 1/8/25 with Nurse #4, but she was unavailable. A review of the Unit Supervisors written statement dated 12/6/24 revealed Nurse #4 had requested a refill of Oxycodone 10 mg be made for Resident #1 because he had 4 tablets remaining. She contacted the pharmacy to request the refill and per the pharmacy staff Resident #1 had 120 tablets delivered on 11/13/24. The Unit Supervisor then checked the medication cart to ensure it had not been overlooked but was unable to find the medication or a narcotic sheet for the missing card. She then checked all the other medication carts, and no medication cards were found for Resident #1. She then informed the regional nurse consultant and the Administrator of the missing medication. A review of the delivery slip dated 11/13/24 indicated 120 tablets of Oxycodone 10 mg for Resident #1 was delivered. An interview with the Unit Supervisor on 1/8/25 at 1:30 PM indicated that she had no further information to add to her written statement. An interview with the Administrator on 1/8/25 at 9:45 AM revealed he was informed on 12/6/24 of a missing Oxycodone 10 mg medication card and after a sweep of the facility it was still missing. He revealed that after the card was not found he contacted the local law authorities, the Division of Health Service Regulation, and the County Department of Social Services and an immediate investigation began. The investigation included identifying who had access to the medication cart, obtained their statements, and performed a drug test on those identified individuals, all the drug tests were negative. He further indicated a new process where two nurses signed in all controlled medications when they are delivered was initiated. The Administrator stated as of 1/8/25 the medication card had not been found. A review of the identified staff statements dated 12/6/24-12/9/24 revealed that no one knew what had happened to the card of Oxycodone 10 mg for Resident #1. A telephone interview with the General Manager of the pharmacy on 1/8/25 at 4:04 PM revealed each medication card had a unique bar code and all controlled medication was verified by either her or the other pharmacist prior to being sent to facilities. She further revealed that each medication was scanned prior to being placed in the controlled medication bag to ensure the correct amount was sent to the facilities. She stated that the scan showed 4 cards of Oxycodone 10mg for Resident #1 were sent to the facility on [DATE].

Based on observation, record review and staff interviews the facility failed to update the care plan to address a resident who was known to keep medication in his room and did not have an order or assessment for self-administration of medication for 1 of 7 (Resident #1) residents reviewed for care plans. The findings included: Resident #1 was admitted into the facility on [DATE] with most recent readmission on 4/2/24 with diagnoses of non-Alzheimer's dementia, constipation, nasal congestion and hypertension. Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Resident #1's comprehensive care plan revised on 11/27/24 noted there was not a care plan for self-administration of medication or the potential for the family to continue to bring medications to Resident #1. On 1/8/25 at 8:00 AM an observation of Resident #1's room noted there were two medications on his bedside table and an undetermined number of medications in a clear box on his bedside table. Resident #1 was in bed with his bedside table located beside his bed. The Assistant Director of Nursing went to Resident #1's room on 1/8/25 at 8:10 AM, after being notified of the medications being observed, and found 1 box of nasal decongestant, 1 bottle of eye drops, 1 bottle of throat spray, and 1 bottle of stool softener and removed these medications from the room. An interview with the Assistant Director of Nursing on 1/8/25 at 8:30 AM indicated that she was not aware Resident #1 had medication in his room. She further indicated that she was aware Resident #1 had a history of keeping medications in his room in the past and the Unit Manager had spoken to the family regarding bringing medication into the building. Resident #1 declined to be interviewed. An interview with the Unit Manager on 1/8/25 at 8:50 AM revealed she had been aware that Resident #1 had medication in his room in the past but not on this date. She stated the nursing assistants had usually reported when Resident #1 had medication in his room. An interview with the MDS Coordinator on 1/8/25 at 9:30 AM revealed that she was not aware that Resident #1 had medications in his room in the past or that he had medication in his room on this date. The MDS Coordinator further revealed that it had not been care planned because she was not made aware of the issue and the potential for it to happen again. The MDS Coordinator stated that the issue should have been care planned. An interview with the Administrator on 1/8/25 at 9:15 AM indicated he was not aware Resident #1 had medications on his bedside table on this date. The Administrator stated he was not aware that Resident #1 did not have a care plan regarding the issue, and it should have been addressed in the care plan.

Based on observations, record review and staff interviews the facility failed secure medications observed at bedside for 1 of 1 resident reviewed for medication storage (Resident #1). The findings included: Resident #1 was readmitted to the facility on [DATE] with diagnoses of non-Alzheimer's dementia, hypertension, constipation and nasal congestion. A review of Resident #1's most recent annual Minimum Data Set, dated dated dated [DATE] revealed he was cognitively intact. On 1/8/25 at 8:00 AM an observation was made of medication in Resident #1's room noted there were two medications on his bedside table and an undetermined number of medications in a clear box on his bedside table. Resident #1 was in bed with his bedside table located beside his bed. The Assistant Director of Nursing went to Resident #1's at 8:10 AM, room after being notified of the medications being observed, and found 1 box of nasal decongestant, 1 bottle of eye drops, 1 bottle of throat spray, and 1 bottle of a stool softener and removed these medications from the room Resident #1 declined to be interviewed. A review of Resident #1's January 2025 physician orders revealed on 12/7/24 an order for stool softener 2 tablets two times a day and nasal decongestant one tab twice a day. The review also revealed there were no orders found for the throat spray or eye drops. An interview with the Assistant Director of Nursing on 1/8/25 at 8:30 AM indicated that she was not aware Resident #1 had medication in his room. She further indicated that she was aware of Resident #1 had a history of keeping medications in his room in the past and the Unit Manager had spoken to the family regarding bringing medication into the building. An interview with the Unit Manager on 1/8/25 at 8:50 AM revealed she had been aware of Resident #1 having medication in his room in the past but not on this date. She stated the nursing assistants will usually report when the Resident has medication in his room. The Unit Manager stated that she had spoken to the family member who was bringing in the medication regarding any medication had to have a physician's order and to not bring in any medication for Resident #1. The Unit Supervisor stated the family member stated she understood. The Unit Manager further stated that Resident #1 was probably okay mentally to have the medications but was unsure if he could manipulate the containers due to his arthritis. An interview with the Administrator on 1/8/25 at 9:15 AM indicated he was not aware Resident #1 had medications on his bedside table on this date. He stated he knew the Unit Manager had talked to a family member in the past regarding she could not bring medications in for Resident #1 and no resident should have medications at the bedside unless ordered by the physician.

Based on record review, and resident, Physician, Surgical Technician, and staff interviews, the facility failed to leave Resident #4 in place to be assessed by a medical professional following a fall in the facility ' s transportation van. Resident #4 was transported to a medical appointment in the facility transport van and when Transporter #1 arrived at the appointment site and parked, Resident #4 stated he was sliding from his wheelchair. Transporter #1 was not trained for transferring residents and went to back of van and transferred Resident #4 from the floor of the van back into his wheelchair. Transporter #1 did not inform the facility about the fall until he returned Resident #4 to the facility from his follow up appointment with the surgeon for a left leg above the knee amputation completed on 10/12/24. Resident #4 ' s right hand became swollen and painful later in the day and x-ray results were negative. There was a high likelihood of a serious adverse outcome including further injury when moving a resident after a fall prior to being assessed by a licensed medical professional. This occurred for 1 of 3 residents reviewed for falls (Resident #4). Immediate jeopardy began on 11/15/24 when Transporter #1 lifted Resident #4 from the floor of the transportation van without being assessed by a medical professional. Immediate jeopardy was removed when 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensuring monitoring systems put into place for resident assessment following a fall. The findings included: Resident # 4 was admitted to the facility on [DATE] with a most recent readmission on 10/21/24. His diagnoses included type 2 diabetes mellitus, right leg below the knee amputation and left leg above the knee amputation (10/12/24). A care plan initiated 10/4/24 revealed a focus that Resident #4 required assistance with ADL (activities of daily living) related to: cognition, muscle weakness, bilateral BKA (below the knee amputation). The interventions included transfer with one-person physical assistance and reposition with one-person physical assistance as needed. Review of a physician ' s order dated 10/21/24 revealed an order for Hydrocodone 5mg-Acetaminophen 325 mg (milligrams)- Take 1 tablet by mouth every 6 hours as needed for pain. The Admission Assessment Minimum Data Set (MDS) dated [DATE] indicated Resident #4 had moderate cognitive impairment. He required extensive assistance plus one-person physical assistance for transfers and bed mobility. Resident #4 had functional limitation of range of motion to both lower extremities and used a wheelchair as a mobility device. Resident #4 weighed 114 pounds. Review of a statement by Transporter #1 dated 11/15/24 revealed he had taken Resident #4 to a medical appointment in the transportation van. When he got to the destination, Resident #4 stated he was sliding. Transporter #1 reported he went to the back of the van and put his arm in front of the resident to support him. The note said the transport driver removed the van shoulder belt and Resident #4 slid down slowly off his wheelchair. The note said the transport driver was right beside Resident #4 and partially supporting him. The note said Transporter #1 instructed Resident #4 to put his arms around his neck and he assisted him back into the chair by lifting him up by the waist of his pants. An interview was conducted with Transporter #1 on 12/2/24 at 2:22 PM. Transporter #1 reported that on the morning of 11/15/24, Resident #4 wasn ' t ready when it was time to leave, so he was sent without his prosthesis. Transporter #1 stated when he arrived at the medical appointment and stopped the van, Resident #4 stated he was starting to slip. Transporter #1 indicated he went to the resident and unbuckled the seatbelt securement system, and the resident was assisted to the floor of the van. Transporter #1 stated Resident #4 ' s buttocks were almost at the very edge of the wheelchair seat when he went to assist, and he felt that Resident #4 would have continued to slide if the seatbelt securement system had not been removed. Transporter #1 stated he had one arm in front of the resident and was standing to the side and he slowly assisted him to the floor of the van. Transporter #1 described he instructed Resident #4 to put his arms around his neck and he picked up resident by his belt loops to lift him back up into the wheelchair. Transporter #1 stated Resident #4 had no complaints of pain at that time and the surgeon ' s office staff came out and pushed the resident inside. Transporter #1 picked the resident up after the appointment and returned to the facility. Transporter #1 stated he would have called back to the facility if the resident was hurt but since the resident stated he was not hurt he reported the fall to Nurse #1 when he returned to the facility. Transporter #1 confirmed he had no training in transferring residents. An interview was conducted with Surgical Technician #1 and Surgical Technician #2 on 12/3/24 at 12:52 PM. Surgical Technician #1 stated 12/3/24 she was asked to go the Resident #4 ' s medical exam room to assist with repositioning him and Surgical Technician #2 assisted. Surgical Technician #2 stated Resident #4 mentioned he had slipped from his chair to the floor in the transportation van. Surgical Technician #2 stated she did not assess Resident #4 for injury because that was outside of her scope of practice. A review of Transporter #1 ' s education completion history revealed no module for safe transfer of residents. Transporter #1 completed the online Falls training required for all staff on 1/21/24 which included residents were to be assessed by a nurse before moving the resident. Transporter #1 completed online training titled Provide Safe Transportation on 12/14/23. Review of the videos revealed there was no content regarding not moving the resident if there was a fall or accident or calling the facility if there was an accident or incident immediately. A nurse ' s note written by Nurse #1 dated 11/15/24 at 11:02 AM indicated Resident #4 was on the transport van and slid out of wheelchair onto the floor. Resident #4 did not complain of pain and had no injury at that time. The transport driver reported Resident #4 had not hit his head and the resident was unable to keep his balance in chair. A nurse ' s note written by Nurse#1 dated 11/15/24 at 4:21 PM indicated Resident #4 ' s right hand was swollen, warm to touch and painful. Resident #4 was unable to recall if he had hurt his hand when he slid out of the wheelchair in the transport van. The on-call health provider was notified and an order a new order for a stat (urgent order) x-ray was given. Resident #4 received as needed pain medication which was effective. An interview was conducted with Nurse #1 on 12/3/24 at 9:00 AM. Nurse #1 stated she was working on Unit 3 on 11/15/24 and she spoke with Transporter #1 when he returned with Resident #4. Nurse #1 stated she was informed Resident #4 had slid out of the wheelchair when Transporter #1 stopped at the appointment. Nurse #1 stated Resident #4 reported that he was sliding when Transporter #1 went to assist him. Resident #4 reported Transporter #1 unbuckled the seat belt and assisted the resident to slide to the floor. Resident #4 reported he did not hit his head. Nurse #1 indicated she assessed Resident #4 and did not find any injury. Nurse #1 reported at 4:30 PM on 11/15/24 Medication Aide #1 reported Resident #4 ' s right hand was warm and swollen. Nurse #1 stated she asked Resident #4 if he had hurt his hand while on the van and the resident could not remember being on the van at that time. Nurse #1 stated she notified the physician and received an order for an x-ray. Review of an on-call physician ' s service Triage Note dated 11/15/24 revealed Resident #4 was seen due to a fall injury that happened on 11/15/24. The note indicated Resident #4 ' s right hand was swollen and warm to the touch. Orders were given for stat x-ray of right hand and prn (as needed) hydrocodone (a narcotic pain medication). Resident #4 was to be seen by his primary physician for follow up. Review of a physician order dated 11/15/24 revealed an order for a stat x-ray to be completed on Resident #4 ' s right hand. The x-ray results dated 11/15/24 revealed no acute fracture or dislocation. There was mild osteopenia and a mild degree of osteoarthritis. An interview was conducted with Resident #4 on 12/2/24 at 1:56 PM. Resident #4 stated he had a fall on the transportation van on the way to the surgeon ' s office a few weeks ago. He reported he was strapped in his wheelchair when he began to slide out of the wheelchair. Resident #4 recalled calling out to Transporter #1 he was sliding. Resident #4 stated he slid onto his buttocks onto the transport van floor. Resident #4 stated the transport driver assisted him back up into the wheelchair. Resident #4 recalled he did not have any pain at that time, but his hand became swollen and painful a few hours later. Resident #4 stated during previous transports he felt himself sliding in the wheelchair but was able to reposition himself back up using his prosthetic leg. The interview further revealed Transporter #1 was a different driver, not the ladies that usually took him to appointments. Review of a physician progress note dated 11/18/24 revealed Resident #4 was evaluated with concerns of pain and swelling in the right hand. The note indicated Resident #4 was complaining of pain and swelling on the dorsum (the back or the top of the hand) of his right hand but stated his symptoms were better. Resident # 4 reported he had an x-ray and was told the results came back negative. Resident #4 stated the pain, and swelling had improved a lot but had not completely resolved. The note further indicated Resident #4 was on hydrocodone for pain as needed. An interview was conducted with the Physician on 12/4/24 at 1:11PM. The Physician stated residents should always be assessed after a fall by a licensed medical professional prior to moving them. The Physician stated the resident could have experienced additional injury without a clinical assessment prior to being moved. The Physician further stated he did not feel that Resident #4 ' s fall would have been prevented with his prosthetic leg in place. An interview was conducted with the Administrator on 12/3/24 at 3:51PM. The Administrator stated he was not made aware of the fall until the next day (11/16/24) and he went to see Resident #4 on Monday 11/18/24. The Administrator stated Resident #4 indicated he did not have his prosthetic leg on, so he fell on ce he got to his appointment. Resident #4 reported that he did not get hurt when he fell . The Administrator stated Resident #4 reported the transport driver took off his seatbelt and had to catch him. The Administrator stated Transporter #1 had not been trained in transferring residents. The Administrator further stated Resident #4 was assessed by the nurse when he arrived back at the facility, and he had no known injury at that time. The Administrator stated all three transporters had received education on falls, providing safe transportation and viewed the manufacturer ' s videos on use of the van ' s securement system prior to transporting any residents. The Administrator indicated the falls training included residents being assessed for injury by the nurse/MD before moving them. The Administrator stated Transporter #1 had asked the resident if he was hurt prior to moving him and the transporter did what any other person would have done. He felt that the resident was alright because he went to his appointment and back to the facility without any complaints of pain or injury. The facility Administrator was notified of immediate jeopardy on 12/3/24 at 12:04 PM. The facility provided the following Immediate Jeopardy removal plan. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: o Resident #4 slid from his wheelchair on 11/15/24 while being transported to an outside physician appointment. Resident was noted to be sliding down in his wheelchair and when Transporter #1 removed the securement device, he was assisted to the floor of the van by Transporter #1. When he complained of no distress or injury, Transporter #1 assisted him to his chair by instructing Resident #4 to place both arms around Transporter #1 ' s neck and then Transporter #1 grabbed Resident #4 ' s pant belt loops to lift him back up into the wheelchair. After returning Resident #4 to his chair Transporter #1 proceeded into the physician ' s office. Resident #4 was assisted with repositioning in his chair by two surgical techs in the physician ' s office. Transporter #1 is not a medical professional and does not have specific training on transferring or assessing a resident. After returning to the facility, Transporter #1 notified the nurse on duty of the incident and the resident was immediately assessed by the licensed nurse on duty. Upon initial assessment the resident denied any type of pain or injury. The facility nurse practitioner was notified of the fall by the nurse on duty, later the same day when the nurse was notified by the CNA that the resident ' s hand was reddened, swollen and painful. An x-ray was ordered and obtained that same day. Resident #4 complained of pain 3 out of 10 and was administered one dose of hydrocode-acetaminophen 5-325 at 3:49 PM which was documented as effective at 6:36 PM. Results of the x-ray showed no acute fracture or dislocation, mild osteopenia and osteoarthritis. The resident was assessed in person by the physician on 11/18/24 and per the physician note Resident #4 was found to have mild swelling and Resident #4 stated that his symptoms were better. o Residents experiencing a fall have potential to be affected. o Unit Manager and Assistant Director of Nursing reviewed facility falls for the previous 30 days to ensure proper assessment, trained staff transferring, proper notification and intervention prior to moving resident. No issues were found. (12/3/24) o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Direct 1:1 education was provided by the Administrator to staff currently working in the facility that should a resident experience a fall, they must not be moved before being assessed by a nurse or physician. Those not currently on shift shall be educated prior to the start of their next shift. (Completed 12/3/24) Current staff, including agency staff, were educated by the Administrator that only staff who are trained to transfer a resident may do so. Those not currently working will be educated prior to the start of their next shift. (12/3/24) Current staff, including agency staff, were educated by the Administrator that following a fall, facility staff who are qualified to perform clinical assessments for injury must be notified, if none are present at the time of the fall. Those not currently working will be educated prior to the start of their next shift. (12/3/24) New hire staff will be educated on the process for staff notification of falls, safely transferring residents, and qualifications of clinical assessment through online education platform learning and 1:1 education by the Administrator during orientation. The Corporate Nurse/Consultant Nurse then educated Director of Nursing, Assistant Director of Nursing and Unit Managers on the facility fall related policies, how to properly assess a resident prior to being mobilized after a fall. (Completed 12/3/24) Moving forward, a Certified Nursing Assistant (CNA) or nurse will be present on transportations provided by the facility. Should the driver of the facility van not be a certified or licensed medical professional, a CNA or Nurse will accompany the resident and transport driver for the appointment. All staff including agency staff were notified of this change through the proprietary software system as well as in person education provided to transport staff by the Administrator. The transport coordinator will be responsible for ensuring a CNA or a nurse is present on all transports. (Completed 11/14/24) The Regional Director of Clinical Compliance provided 1:1 education with the Transport Coordinator that all facility transports will be accompanied by a CNA or nurse. (12/4/24) In the event of a new hire transport coordinator, the Administrator will be responsible for 1:1 education regarding the responsibility to ensure a CNA/nurse is present on all transports. This will be completed in orientation. Moving forward, should a resident experience a fall outside of the facility while under the care of facility staff, if a licensed nurse is not present, the resident will be made safe. If not in imminent danger, 911 will be activated to assess the resident prior to transferring/mobilizing. If a licensed nurse qualified for clinical assessment is present, that nurse will assess the resident and determine the need to call 911. All staff, including agency staff were educated on this through in person education by the Assistant Director of Nursing. (Completed 12/3/24). The Director of Nursing/designee will be responsible for providing this education to new hire transport staff. The Administrator/designee will track and provide education to those staff not present prior to their next shift to ensure completion. Alleged date of IJ removal: 12/05/24 The IJ removal plan was validated on 12/9/24 and it concluded the facility had implemented an acceptable corrective action plan on 12/05/24. Review of staff education materials and sign-in sheets for the education were reviewed to determine that education was provided to all transportation staff including Transporter #1, nursing and nursing assistant staff that a resident who experiences fall must not be moved without being assessed by a nurse, physician or a licensed medical professional. The education also included only staff trained to transfer residents may do so and if there is no one qualified to perform a clinical assessment when a resident has a fall outside the facility, then 911will be activated to assess the resident prior to transferring/mobilization. Review of the facility documents revealed audits were done per the facility ' s plan of correction. Interviews were conducted with the nursing staff and nurse aides who confirmed they received education regarding a licensed medical professional needing to assess a resident prior to transferring them after a fall and call 911 if the fall happens outside of the facility before moving

Based on observation, record review, and resident, staff and physician interviews, the facility failed to ensure Resident #4 was safely secured in the transportation van. During transport on 11/15/24 Resident #4 reported to the driver, Transporter #1, he felt like he was sliding out of his wheelchair. Transporter #1 had arrived at the resident's doctor's office and came to a complete stop at the front entrance to the appointment location at the time the resident reported this to him. Transporter #1 got into the back of the van and removed the seatbelt securement system. Resident #4 continued to slide down from wheelchair and onto the floor of the van with Transporter #1's assistance. Transporter #1 stated Resident #4 was almost at the very edge of the wheelchair when he went to assist, and he felt that Resident #4 would have continued to slide if the seatbelt had not been removed. Transporter #1 stated he secured the resident the same way on the return trip to the facility. Later that day, Resident #4's right hand was swollen, warm to touch, and painful requiring narcotic pain medication. There was a high likelihood of serious harm, injury, or death from unsafe securement in the transportation van. This deficient practice affected 1 of 3 residents reviewed for accidents. The findings included: The manufacturer's instructional video indicated to Pull the seat belt over the occupants' chest and buckle seat belt to removable pelvic belt. Adjust the seat belt height so that belt rest on occupant's shoulder. Resident # 4 was admitted to the facility on [DATE] with a most recent readmission on 10/21/24. His diagnoses included type 2 diabetes mellitus, right leg below the knee amputation and left leg above the knee amputation (10/12/14). The Admission Assessment Minimum Data Set (MDS) dated [DATE] indicated Resident #4 had moderate cognitive impairment. He required extensive assistance plus one-person physical assistance for transfers and bed mobility. Resident #4 had functional limitation of range of motion to both lower extremities and used a wheelchair as a mobility device. Resident #4 weighed 114 lbs. A nurse's note written by Nurse #1 dated 11/15/24 at 11:02 AM indicated Resident #4 was on the transport van and slid out of wheelchair onto the floor. Resident #4 did not complain of pain and had no injury at that time. The transport driver reported Resident #4 had not hit his head and the resident was unable to keep his balance in chair. A nurse's note written by Nurse #1 dated 11/15/24 at 11:40 AM indicated Resident #4 returned from his follow up appointment related to his left above the knee amputation (AKA) with no new orders. The note further indicated the surgical wound had satisfactory healing. A nurse's note written by Nurse#1 dated 11/15/24 at 4:21 PM indicated Resident #4's right hand was swollen, warm to touch and painful. Resident #4 was unable to recall if he had hurt his hand when he slid out of the wheelchair in the transport van. The on-call health provider was notified and an order a new order for a stat (urgent order) x-ray was given. Resident #4 received as needed pain medication which was effective. Review of a Fall Note dated 11/15/24 at 5:01 PM indicated Resident #4 was on transport van and Resident # 4 slid out of wheelchair to floor. Resident #4 was buckled in but continued to slide. Resident #4 did not complain of pain. There was no apparent injury noted at that time. The transport driver noted Resident #4 did not hit his head. Resident could not keep balance in chair. The fall interventions that were in place at the time of the fall was the wheelchair was to be locked. The immediate intervention to prevent recurrence was to transport Resident #4 with 2 staff. Review of a statement by Transporter #1 dated 11/15/24 revealed he had taken Resident #4 to a medical appointment in the transportation van. When he got to the destination, Resident #4 stated he was sliding. Transporter #1 reported he went to the back of the van and put his arm in front of the resident to support him. The note said the transport driver removed the van seat belt and Resident #4 slid down slowly off his wheelchair. The note said the transport driver was right beside Resident #4 and partially supporting him. The note said Transporter #1 instructed Resident #4 to put his arms around his neck and he assisted him back into the chair by lifting him. An interview was conducted with Transporter #1 on 12/2/24 at 2:22 PM. Transporter #1 reported that on the morning of 11/15/24, Resident #4 wasn't ready when it was time to leave, so he was sent without his prosthesis. Transporter #1 stated when he arrived at the medical appointment and stopped the van, Resident #4 stated he was starting to slip. Transporter #1 indicated he went to the resident and unbuckled the seatbelt securement system, and the resident was assisted to the floor of the van. Transporter #1 stated Resident #4's buttocks was almost at the very edge of the wheelchair when he went to assist, and he felt that Resident #4 would have continued to slide if the securement belt had not been removed. Transporter #1 stated he had one arm in front of the resident and was standing to the side and he slowly assisted him to the floor. Transporter #1 described he instructed Resident #4 to put his arms around his neck and picked up resident by his belt loops to lift him back up into the wheelchair. Transporter #1 stated Resident #4 had no complaints of pain at that time. Transporter #1 stated when he got back to the facility, he reported the fall to Nurse #1. An interview was conducted with Resident #4 on 12/2/24 at 1:56 PM. Resident #4 stated he had a fall on the transportation van on the way to the surgeon's office a few weeks ago. He reported he was strapped in his wheelchair when he began to slide out of wheelchair. Resident #4 recalled calling out to Transporter #1 he was sliding. Resident #4 stated he slid onto his buttocks onto the transport van floor. Resident #4 stated the transport driver assisted him back up into the wheelchair. Resident #4 recalled he did not have any pain at that time, but his hand became swollen a painful a few hours later. Resident #4 stated during previous transports he felt himself sliding in the wheelchair but was able to reposition himself back up using his prosthetic leg. An interview was conducted with Resident #4 on 12/3/24 at 12:45 PM. Resident #4 stated he did not touch the seat belt because he knew it was there for his safety. Review of a statement by Medication Aide #1 dated 11/15/24 revealed Resident #4 went out to an appointment, and they did not have time to get his prosthetic leg on as he was already late for his appointment. Medication Aide #1 reported when Resident #4 came back she went to check his blood sugar and noticed his right hand was swollen. Medication Aide #1 notified the nurse immediately. An interview was conducted with Medication Aide #1 on 12/2/24 at 3:14 PM. Medication Aide #1 stated she was asked by Transporter #1 if Resident #4 was ready for his appointment. Medication Aide #1 stated she was being rushed and she had not looked at the appointment log that morning. She reported the nurse assistant that was assisting Resident #4 was new, so she went in and assisted her. Medication Aide #1 stated they were having difficulty getting Resident #4's prosthetic leg in place that morning and she did not want him to be late or miss his appointment. Medication Aide #1 stated she decided to send Resident #4 without his prosthetic leg. Nurse Aide #1 that assisted with getting Resident #4 ready on 11/15/24 was not available for interview. An interview was conducted with Nurse #1 on 12/3/24 at 9:00 AM. Nurse #1 stated she was working on Unit 3 and Medication Aide #1 was working on Unit 4. Nurse #1 stated she was not notified that the aides were having difficulty placing Resident #4's prosthetic leg until after he had left the building. Nurse #1 stated she spoke with Transporter #1 when resident returned. Nurse #1 stated she was informed Resident #4 had slid out of the wheelchair when he stopped and at the appointment. Nurse #1 stated Resident #4 reported that he was sliding when Transporter #1 went to assist him. Transporter #1 unbuckled the restraint and assisted the resident to slide to the floor. Resident #4 reported he did not hit his head. When Resident #4 came back to the facility, she assessed him and he stated he was not hurt. Nurse #1 reported at 4:30PM on 11/15/24 Medication Aide #1 reported Resident #4's right hand was warm and swollen. Nurse #1 stated she asked Resident #4 if he had hurt his hand while on the van and the resident could not remember being on the van at that time. Nurse #1 stated she notified the physician and received an order for an x-ray. A review of the x-ray results dated 11/15/24 revealed no evidence of fracture or dislocation. Mild osteopenia and mild degree of osteoarthritis. Review of a statement by the Administrator dated 11/18/24 revealed Resident #4 had a fall from his wheelchair and the transport driver was there to help him. Resident #4 indicated he did not have his prosthetic leg on, so he fell on ce he got there. Resident #4 reported that he did not get hurt and did not hit the ground when he fell . Resident #4 reported the transport driver took off his belt and had to catch him. Resident #4 stated he did not know what happened to his hand. Resident #4 was unable to state whether he hurt his hand when he slid out of the chair. An interview was conducted with the Administrator on 12/3/24 at 3:51PM. The Administrator stated he was not made aware of the fall until the next day 11/16/24. The Administrator stated he prompted the former Director of Nursing on the steps that she needed to take to complete the fall investigation. The Administrator stated the facility had put a full plan of correction in place related to the resident's fall. An interview was conducted with the physician that followed up with Resident #4 on 12/4/24 at 1:11PM. The physician stated he saw Resident #4 on 11/18/24 and he reported that his hand was better. The physician stated Resident #4 was unable to state what had happened to his hand. The physician further stated he did not feel that Resident #4's fall would have been prevented with his prosthetic leg in place. The Administrator was notified of immediate jeopardy on 12/3/24 at 12:07PM The facility provided the following corrective action plan with a completion date of 11/19/24. Address how corrective action will be accomplished for those residents found to have been affected the deficient practice. On 11/15/24 Transporter #1 failed to safely secure Resident #4 in his wheelchair in the facility transport van. During the transport, Resident #4 reported to Transporter #1 that he felt like he was sliding out of his wheelchair. When arriving to the appointment location, Transporter #1 got into the back of the van and removed the securement system. Resident #4 continued to slide down from the wheelchair and Transporter #1 assisted him to the floor of the van. After returning to the facility, Transporter #1 notified the nurse on duty of the incident and the resident was immediately assessed by the licensed nurse on duty. Upon initial assessment resident denied any type of pain or injury. The facility nurse practitioner was notified of the fall by the nurse on duty, later the same day when the nurse was notified by the CNA that the resident's hand was reddened, swollen and painful. An x-ray was ordered and obtained that same day. Resident #4 complained of pain 3 out of 10 and was administered one dose of hydrocode-acetaminophen 5-325 at 3:49 PM which was documented as effective at 6:36 PM. Results of the x-ray showed no acute fracture or dislocation, mild osteopenia and osteoarthritis. The resident was assessed in person by the physician on 11/18/24 and per the physician note Resident #4 was found to have mild swelling and Resident #4 stated that his symptoms were better. Address how the facility will identify other residents having the potential to be affected by the same deficient practice All residents who are transported by the facility have the potential to be affected. An audit of all transports for the last 30 days was completed by the Administrator and the Transport Coordinator. No deficient practice was identified (Completed 11/18/24) Address what measure will be put into place or systemic changes made to ensure that the deficient The Maintenance Director inspected all securement devices in facilities transport buses. All were found to be in proper working order. (11/15/24) All policies and procedures specific to resident transports were reviewed by Regional Director of Clinical Services to ensure compliance with manufacturer's recommendations and guidelines. No revisions were warranted. (11/18/24) The Administrator facilitated transport staff education through a manufacturer's video on the use of the bus securement system, return demonstration and a validation checklist. The Transport Coordinator, the Maintenance Director, and Maintenance Assistants were included in this education. (11/18/24). Prior to transports, all residents' securements will be checked by 2 separate staff who have current transportation skills validation checklist completed with return demonstration. This may include transport staff, Transport Coordinator, Maintenance Director, Maintenance Assistants, and Administrator. Transport staff will have a competency completed upon hire and annually to ensure knowledge of proper procedures. This will include the manufacturer's video on the bus's securement system, return demonstration, and validation check off sheet. The Maintenance Director will be responsible for observing return demonstration and validation check off sheets. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Plan of correction was reviewed and discussed by the Quality Assurance (QA) committee. In attendance were the Administrator, Assistant Director of Nursing/Infection Prevention Coordinator, Unit Managers (2), Maintenance Director, Human Resources, Activities Director, MDS Coordinator, Dietary Manager and Director of Rehab. The Medical Director was notified of the plan of correction via phone conversation. (11/18/24) The Maintenance Director/Designee will inspect each transport vehicle ' s securement system monthly to ensure proper functioning. Five residents will be observed weekly by Administrator or Transport Coordinator to ensure proper securement prior to leaving facility x 4 weeks then the plan of correction will be reassessed by the Administrator to determine if further monitoring is required. The results will be reported to the QA Committee by the Administrator monthly for review and discussion. Alleged date of IJ removal: 11/19/24 The correction date of 11/19/24 was validated on 12/9/24. Review of staff education materials and sign in sheets for the education were reviewed to determine that education was provided to Maintenance staff and Transportation drivers, and a return demonstration and validation check off had been conducted. Review of the facility documents revealed audits were done per the facility's plan of correction. Interviews were conducted with the transport drivers who confirmed they received education regarding the proper use of the facility bus seatbelt system and that 2 separate staff would check the resident's securement system prior to transport. Observations were conducted of transport staff connecting the securement system and properly securing a resident in a wheelchair. The 11/19/24 completion date for the corrective action plan was validated.

Based on a lunch meal tray line observation, staff interviews and record review the facility failed to follow the approved menu in that pureed bread was not served to 6 of 6 residents on a minced and moist diet and 5 of 5 residents on a pureed diet. Residents on a pureed diet only received one scoop of pureed meat instead of 2 scoops per the menu. This had the potential to affect 11 residents with diet orders for minced and moist and pureed texture diets. The findings included: 1. Review of the diet Resident Listing Report dated 4/10/24 revealed 5 residents received pureed foods and 6 residents received minced and moist textured foods. Review of the Daily Spreadsheet Menus revealed residents on a pureed diet were to receive a cheeseburger pureed (PU), including cheese and bun. The menu noted residents on a minced and moist diet were to receive a pureed burger bun (PU). The menu also listed mashed potatoes instead of French fries and vegetables. An observation on 04/10/24 at 9:51 AM revealed Cook #1 prepare pureed foods. Cook #1 put 7 burger patties into the food blender and added beef gravy. Cook #1 pureed the patties, then added 5 more patties into the blender with more gravy and blended. Cook #1 put 3 teaspoons of food thickener into the blender. Cook #1 did not add bread or cheese to the blender to puree with the patties. Cook #1 said she pureed vegetables and was also serving mashed potatoes. A continuous observation of the lunch meal tray line on 11/28/23 from 12:00 - 12:33 PM revealed cheeseburgers were available to serve. There was no pureed bread on the tray line. Observations of service revealed minced and moist diets were served ground burger patties and pureed diets were served the pureed patties. No pureed bread was served to pureed diet trays or to minced and moist diet trays. One 4-ounce scoop was used to serve mashed potatoes on each tray. In an interview on 4/10/24 at 12:33 PM, Cook #1 confirmed bread was not served and was not pureed with the patties. Cook #1 said the mashed potatoes, which was served instead of French fries, also took the place of the starch on the menu and counted as bread being served. In an interview on 4/10/24 at 12:41 PM the Certified Dietary Manager (CDM) of the serving error. The CDM confirmed that there was no bread served and the mashed potatoes took the place of the bread. The CDM confirmed the menu included bread for each diet that was not served. The CDM was unable to provide the recipe for the pureed cheeseburger. 2. Review of the diet Resident Listing Report dated 4/10/24 revealed 5 residents received pureed foods. Review of the Daily Spreadsheet Menus revealed residents on a pureed diet were to receive two #8 (4 ounces) scoops of pureed cheeseburger. A continuous observation of the lunch meal tray line on 11/28/23 from 12:00 - 12:33 PM revealed a pan of the pureed beef patties were available to serve. Observation of service revealed Cook #1 served residents on a pureed diet one #8 scoop of the pureed patties. In an interview on 4/10/24 at 12:33 PM, Cook #1 stated she used one scoop of meat for regular sized portions and one-and-a half or two scoops for residents on large or double portions. She stated she knew who would eat the amount served and who would not. In an interview on 4/10/24 at 2:41 PM the Certified Dietary Manager (CDM) of the serving error. The CDM confirmed the menu called for 2 scoops of the pureed meat and that Cook #1 should have followed the menu. An interview was conducted with the Administrator on 4/10/24 at 3:00 PM. He confirmed kitchen staff should serve the foods and portions of the meal according to the diet spreadsheet.

Based on record review, observations, staff and resident interviews, and test tray, the facility failed to provide palatable food to residents on a regular diet that was appetizing in temperature for 1 of 1 meal reviewed for food palatability. This failure had the potential to affect 58 residents on a regular diet. The findings included: Review of the diet Resident Listing Report dated 4/10/24 revealed that 58 residents received regular diets. Review of Resident #40's Minimum Data Set, dated dated dated [DATE] revealed the resident was cognitively intact and required set-up assistance for eating. During an interview with Resident #40 on 04/08/24 at 10:07 AM, revealed she answered questions appropriately. She reported that the food was so-so and was served lukewarm daily. Resident #40 stated she ate her meals both in her room and in the dining room. A test tray was completed for the lunch meal on 04/10/24. The test tray was plated in the kitchen at 12:33 PM. At 12:35 PM, the test tray left the kitchen and headed to a hall adjacent to the hall where Resident #40 resided. At 12:38 PM, the last hall tray was served. The test tray consisted of a cheeseburger on bun, French fries, lettuce and tomato, and ambrosia. Upon removal of the lid, there was no visible steam coming from the food on the tray. At 12:39 PM the surveyor and Certified Dietary Manager (CDM) tasted the cheeseburger, French fries, and ambrosia. The cheeseburger was tepid and lukewarm. The CDM confirmed the burger was lukewarm. During an interview with the Administrator on 04/10/24 at 3:00 PM revealed he expected food to be served to residents that was hot, fresh, and palatable.

Based on staff and resident interview and record reviews, the facility failed to obtain advanced directives for 2 of 18 residents reviewed (Resident #18 and Resident #62). Findings included: 1. Resident #18 was admitted to the facility on [DATE]. His admission Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. Record review did not indicate advanced directives for Resident #18. During an interview on 03/21/2023 at 3:30 PM, the Admissions Coordinator revealed she went over advanced directives in the admission packet in the past, but the form was no longer in the admission packet. She was unsure why the form was removed. During an interview on 03/22/2023 at 3:00 PM, Resident #18 indicated that the facility had not asked him about his preferences regarding advanced directives. He indicated his code status was do not resuscitate. During an interview on 03/23/2023 at 10:10 AM, the Administrator revealed that advanced directives were discussed in the admission packet in the past, but with turnover it must have been missed. She was not aware it was not discussed with the admission packet. 36573 2. Resident #62 was admitted to the facility on [DATE]. Review of the admission entrance forms dated 08/24/2022 in Resident #62's medical record provided no indication if the resident wanted to formulate an advance directive or if he refused one. Quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #62's cognition was moderately impaired. Review of the computerized medical record for Resident #62 revealed no advanced directive noted in the resident's medical record. During the interview with Admission Coordinator (AC) on 03/21/2023 at 03:30 PM, she stated after the residents were admitted they review advance directives as part of the admission process. She stated she did not see an Advanced Directive Form for Resident #62. She stated she saw a note from the hospital mentioning an advanced directive, but the facility did not have a copy of any advanced directive decisions in the record. During the interview with Director of Nursing (DON) on 03/23/2023 at 08:30 AM, she stated that the Admission's Coordinator (AC) usually reviewed the advance directive forms with the residents or responsible party during the admission to the facility. The DON further indicated she did not find the advance directive in Resident #62's medical record and there was no documentation found that stated the resident refused. During the interview with Administrator on 03/23/2023 at 8:30 AM, she stated the advanced directives should have been in Resident #62's medical record or a note indicating refusal. The Administrator further stated the Admission Coordinator should have ensured the residents' advanced directives were placed in the medical records if a resident had formulated one. She added that the advanced directive should have been scanned in Resident #62's computerized medical record and/or a note indicating the resident's refusal to formulate an advance directive.

Based on record review, observation, and staff, family, and police interviews, the facility failed to prevent a severely cognitively impaired resident (Resident #2) with known wandering and exit seeking behaviors from exiting the facility unsupervised. Nurse #1 failed to look for the resident when a wanderguard (a bracelet device that alarms within several feet of doors) was found in the laundry room during the day shift on 2/23/22 which allowed Resident #2 to leave the facility through the front doors on 2/24/22 without the doors alarming and without staff's knowledge. The resident walked approximately 0.2 miles away from the facility when he was observed by a police officer during a routine patrol in the area at approximately 2:30 AM. This was for 1 of 4 residents reviewed for wandering behaviors. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia, [CONDITION(S)], and unsteadiness on his feet. An active care plan focused on elopement risk initiated 11/1/20 included a goal for Resident #2 to remain safe and secure through the review period. Interventions included safety checks, elopement risk assessment as needed, and check wanderguard placement every shift. Record review of Resident #2's physician's orders for February 2022 revealed an active order initiated on 8/15/21 for check wanderguard placement and functioning each shift (7 AM -7 PM and 7 PM -7 AM). A nursing progress note dated 2/9/22 completed by Nurse #3 indicated Resident #2 was attempting to exit through a side door and had set off the alarm. He required encouragement for several minutes before returning to the building. A nursing progress note dated 2/13/22 completed by Nurse #1 indicated Resident #2 attempted to exit through the front door to go home but was returned to the unit by a staff member. A quarterly Elopement Risk Data Collection Tool dated 2/21/22 completed by Nurse #4 indicated Resident #2 was at high risk to wander due to exit seeking behaviors, verbalizing the desire to go home, and independent mobility. Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident # 2's cognition was severely impaired. The MDS did not indicate wandering behavior was exhibited. Resident #2 was independent with walking and transfers. Record review of Resident #2's Medication Administration Record (MAR) indicated that the wanderguard check was completed on 2/23/22 day shift. During an interview on 4/27/22 at 2:10 PM, Laundry Aide #1 recalled she found a wanderguard in the laundry during the day shift on 2/23/22 and brought it to Nurse #1. She recalled the wanderguard was unopened, like it had been slipped over a resident's hand. During an interview on 4/26/22 at 3:45 PM, Nurse #1 revealed that a laundry aide brought her a wanderguard she had found in the laundry on 2/23/22 during the day shift. There was construction on the unit, and she got distracted and did not find the owner of the wander guard. She did not notify anyone else of the found wander guard. A nursing progress note dated 2/24/22 at 3:08 AM completed by Nurse #2 indicated she received a phone call at 2:30 AM from the police stating they found Resident #2 at a school next door and emergency medical services (EMS) had been called. Resident #2 was brought back to the facility with no injuries noted. The note indicated Resident #2 was last seen at 2:15 AM. During an interview on 4/27/22 at 3:30 PM, Nurse #2 revealed that she received a call from the police on 2/24/22 around 2:30 AM stating they had found Resident #2 at the school next door. He was not injured but EMS had been called. She recalled Resident #2 was last seen between 2:00-2:15 AM walking the halls which was normal for him. He usually wore a wanderguard which would alert when he got to the front door. She was not told at the beginning of shift that Resident #2 did not have his wanderguard in place and she had not identified that it was missing prior to the police bringing the resident back to the facility. She did not know Resident #2 was missing until the police called. She recalled Resident #2 was wearing blue jeans, a t-shirt, jacket, and socks and shoes when he returned to the facility. During an interview on 4/28/22 at 9:20 AM, the police officer recalled patrolling the area on 2/24/22 around 2:00 AM and seeing Resident #2 walking in front of the school. Resident #2 stated he was out for a walk and told the officer his name but did not answer additional questions appropriately. The police officer called EMS and called the facility questioning if he lived there. Resident #2 was not injured. The police officer reviewed body camera footage which revealed Resident #2 was wearing blue jeans, a jacket or sweater, and shoes. An observation was made on 4/27/22 at 4:00 PM looking out the front door of the facility down the street to the school. The school and facility sat at a T-intersection with a large ditch on either side of the cross-street. The school was surrounded by a long fence. The speed limit of the major roadway was 35 miles per hour and then entered a school zone. Only one streetlight was observed prior to the end of the fence and the entry to the school parking lot. A web search revealed the temperature on 2/24/22 at 2:00 AM was 60 degrees Fahrenheit (wunderground.com). The distance between the facility and school was 0.2 miles and was a 3-minute walk (googlemaps.com). During an interview on 4/26/22 at 3:10 PM, Nurse Aide (NA) #1 recalled Resident #2 pacing the halls on night shift of 2/23/22 but did not see him exit the building. He recalled the front doors were not locked and not alarmed. He revealed the last time he saw Resident #2 was around 2:00 AM. He did not know Resident #2 was gone until the police called. During an interview on 4/27/22 at 4:15 PM, the Director of Nursing (DON) revealed that on 2/24/22 Resident #2 had exited through the front door, and it was believed he walked down the major roadway to the school. The side doors required a code to exit but the front door was the egress door and remained unlocked. She indicated that Resident #2's wanderguard would have set off the alarm at the front door had he been wearing it. She revealed the wanderguard was last seen on Resident #2's wrist on 2/23/22 around 9:00 AM. During an interview on 4/26/22 at 11:15 AM, Resident #2's family member revealed the wanderguard had been in place since Resident #2 was admitted to the facility due to exit seeking behaviors. He recalled the facility informing him Resident #2 was found at the school next door after exiting through the front doors around 2:00 AM. During an interview on 4/27/22 at 4:45 PM, the Administrator revealed that Resident #2 was able to leave through the front door as it remained unlocked. The wanderguard would have set off an alarm prior to him exiting the front door. Nurse #1 should have located the resident who the wanderguard belonged to immediately when the wanderguard was found. An observation was made on 4/26/22 at 10:20 AM of Resident #2 in his room packing up his clothes. He was wearing his wanderguard on his right wrist and was calm. Another observation was made on 4/26/22 at 11:30 AM of Resident #2 standing alone at the front nurse's station near the exit. His wanderguard was in place. The facility provided the following corrective action plan with a completion date of 3/4/22: Problem identified: Nurses on duty are to document the placement and function of the wanderguards each shift on the medication administration record. If a wanderguard is not present or nonfunctional it should be replaced immediately by the nurse on duty. On 2/23/22 during the day shift laundry staff found a wanderguard in the laundry when she pulled the linen from the unit. She located the nurse (Nurse #1) on the unit and gave her the wanderguard. The nurse failed to identify the resident (Resident #2) who was missing the wanderguard and failed to report this discrepancy to the oncoming nurse. She failed to follow the process that all wanderguards would be replaced immediately. Resident #2 was able to leave the facility unsupervised and without staff's knowledge on 2/24/22 since his Wanderguard was removed. He was seen by the local police department at a school nearby the facility at approximately 2:24 AM. EMS was called by the local Police Department on 2/24/2022 at 2:24 a.m. EMS arrived at 2:31 a.m. The EMS report states that patient (Resident #2) had no injuries and vitals were normal. Patient was safely returned to the facility without incident. Immediate action identified: An audit was completed to ensure 100% of residents were in the building by Nurse #2, NA #1, NA #2, NA #3, and NA #4 immediately after phone call received from the local Police Department. All other residents in facility were present. Resident #2 was placed on 1 on 1 [monitoring] immediately upon return to facility. 1 on 1 ended on 3/3/2022. No further incidents occurred, and staff education had been completed. Identification of other residents who might be affected: All residents with wanderguards were checked for placement and function by the unit manager on 2/24/22. All wanderguards were in place and functioning properly per physician order. Measures put in place to prevent recurrence: All licensed nurses were trained to check wanderguards at the start of each shift. Wanderguard placement checks were added to the NA care guide to increase staff awareness of resident elopement risk. All CNAs were educated on this addition to the card guide. All staff were educated by Staff Development Coordinator on effective techniques to monitor and supervise residents and elopement. Residents will be assessed for elopement risk upon admission, quarterly, and as needed by the nurse on duty. A physician order is written when a new wanderguard is placed on a patient. Nurses on duty are to document the placement and function of the wanderguards each shift on the medication administration record. If wanderguard is not present or nonfunctional it should be replaced immediately. Staff were also educated on checking door alarms every shift. Education was completed on 2/28/2022. This included full-time, part-time, as needed, and contracted staff. New staff will be educated upon hire and current be staff will in-serviced annually. Wanderguard book continues to be at each nurse station as part of the normal facility protocol. The DON and/or designee monitored and ensured that the wanderguard books were up to date and present at each nurse station 5 days a week for 2 weeks then weekly for 4 weeks. Systemic changes made: the facility's protocol for checking door alarms as a precautionary measure to prevent unsupervised exits. Prior to the incident the maintenance department checked the doors and alarms weekly. A door alarm book was placed at the front nurse's station on 2/24/2022 for the Nurse on duty and/or designee on the rehab unit to monitor all exit doors throughout facility for 5 days a week for 2 weeks, then weekly for 4 weeks. As part of the systemic change Maintenance will check the doors daily and report any malfunctions to nurse supervisor immediately. The Director of Nursing reviewed audits weekly for compliance and to ensure the process was effective. Monitoring process: The process will be reviewed by the Quality Assurance (QA) Committee by the DON or designee every month and ongoing to ensure the process remains effective and changes will be made as needed with any concerns identified. The QA committee consists of: Chief Administrative Officer, Director of Nursing, and two additional staff members monthly and Medical Director and Pharmacist quarterly. To ensure substantial compliance once the Quality Assurance (QA) Committee determines the problem no longer exits, then the review will be completed on a random basis by the DON or designee. Person responsible: All corrective action was completed by 3/4/22. The Director of Nursing is responsible for implementing the acceptable plan of correction. Onsite validation was completed on 4/28/22 through staff interviews and record review. Staff were interviewed to validate in-service completion on monitoring and preventing elopements and process for monitoring wanderguards for placement and function. Observations were made of a sample of residents with orders for wanderguards for placement. Documentation of wanderguard and door alarm audits was reviewed. QA meeting signatures were reviewed. The facility's correction action plan was validated to be completed as of 3/4/22.

Based on staff and physician interviews and review of medical records, the facility failed to notify the primary care physician (PCP) of a change in a resident ' s bowel function for 1 of 3 sampled residents (Resident #1) who was reviewed. Failing to notify the resident ' s physician resulted in a lack of treatment and hospitalization [MEDICAL CONDITION]. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/15/16 Quarterly Minimum Data Set (MDS) indicated Resident #1 had both short and long term memory impairment and severely impaired cognitive skills for daily decision making. The resident was identified as requiring extensive assistance with bed mobility, transfer, walking in his room, locomotion, dressing, eating toilet use and was coded as totally dependent for personal hygiene. The MDS coded the resident as always incontinent of bowel and bladder. Review of the August 2016 monthly orders included [MEDICATION NAME] (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements) 17 grams to be given daily. Review of the August Medication Administration Record [REDACTED]. Review of Resident #1 ' s bowel movement (BM) record from August 1-15 indicated the resident had from 2-4 BM ' s per day. From August 16-23, 2016, Resident #1 ' s BM record indicated from 3-6 BMs per day with 6 BMs recorded on 8/21/16 and 6/22/16. There was no documentation of BMs on 8/23/16 for the 7:00 AM to 3:00 PM shift. The form only indicated Resident #1 was in the hospital. On 8/23/16 at 2:45 PM, the nurse documented the resident had increased respirations, agitation with an oxygen saturation (oxygen saturation is the measurement of the amount of oxygen in the blood stream) of 87% (Any measurement of less than 90% is considered low). Oxygen was applied at 2 liters per minute. Vital signs were respirations 52. The PCP was notified and orders obtained to send Resident #1 to the hospital for evaluation. The resident's primary care physician (PCP) was interviewed via telephone on 8/30/16 at 3:00 PM. He stated he was disturbed about Resident #1 ' s recent hospitalization , adding the resident was admitted to the hospital with [REDACTED]. diff - an intestinal infection causing increased bowel movements). The PCP stated he had received information from a hospitalist that Resident #1 had C.diff and was acutely ill. He stated he had not received any notification the resident had loose stools and in going through the records and speaking with staff, he only knew about the one episode of loose stools that had happened during the morning of 8/23/16. Nursing Assistant (NA) #3 was interviewed on 8/30/16 at 3:31 PM. She confirmed she had cared for Resident #1 on Monday, 8/22/16 on the 3:00 PM to 11:00 PM shift. The NA reported Resident #1 had a loose, but not watery BM prior to the end of her shift. She stated she had not reported the loose BM to the nurse. During a telephone interview with NA #4 on 8/30/16 at 3:59 PM. The NA stated she had been assigned to Resident #1 on the 11:00 PM to 7:00 AM shift on 8/22/16. The NA reported the resident had 3 loose stools with the first being small and the last 2 being large. NA #4 added she reported the loose stools to Nurse #4. A telephone interview was held with Nurse #4 on 8/30/16 at 4:07 PM. The nurse stated she had cared for Resident #1 on the 11:00 PM to 7:00 AM shift on 8/22/16. Nurse #4 denied receiving any reports of diarrhea from the previous shift. She stated she had given Resident #1 [MEDICATION NAME] (a medication to stop diarrhea) on 8/19/16. The nurse stated she knew the resident had one BM on her shift, but stated she could not remember if other episodes of diarrhea had been reported. NA #5 was interviewed by phone on 8/31/16 at 8:42 AM. She acknowledged she had worked with Resident #1 during the 11:00 PM to 7:00 AM shift on 8/22/16. The NA stated during the shift the resident had 3 large, loose BM's. NA #5 added she had not reported this to Nurse #4 since Nurse #4 had assisted with incontinent care and knew the resident was having large, loose stools. The PCP was interviewed again on 8/31/16 at 9:57 AM. The information gathered during interview and review of the BM record was reviewed with the PCP. He stated only one loose BM had been reported to him during the 7:00 AM to 3:00 PM shift on 8/23/16. The PCP stated he was unaware of the multiple loose BMs and had been unaware Resident #1 had 3-6 BMs recorded daily for the week prior to his 8/23/16 hospitalization . The PCP added it was not normal for any resident, including Resident #1 to have 3-6 BMs per day. He stated in retrospect, with the new information, he believed the multiple stools was part of the resident's illness. He stated while foul smelling stools was an indication of [DIAGNOSES REDACTED]icile, it was possible to have [DIAGNOSES REDACTED] without a temperature and malodorous stool. The MD stated had he been notified of the multiple BMs and multiple episodes of diarrhea, he would have ordered lab work to rule out C.diff. and possibly altered the resident ' s outcome. Nurse #1 was interviewed on 8/31/16 at 10:10 AM. She stated she had not worked with Resident #1 from August 17th through the 22nd and had only worked with Resident #1 on the 23rd. The nurse reviewed the BM record and stated the PCP should have been notified of the 3-6 BMs per day for the week prior to his hospitalization . She stated none of the diarrhea episodes had been reported to her, so therefore she had not had the information to notify the PCP. On 8/31/16 at 10:20 AM, Nurse #5 was interviewed. The nurse acknowledged she had worked Resident #1 several times from 8/17/16 through 8/22/16. The nurse stated the NAs informed her of how many BMs the residents had. Nurse #5 stated she had not received information regarding the large number of BMs Resident #1 had and had not received information about any episodes of diarrhea. She stated she had not reported any changes to the PCP because she had been unaware of changes. The Director of Nursing and Administrator were interviewed on 8/31/16 at 10:31 AM. The DON stated if Resident #1 had episodes of diarrhea or multiple BMs per day she expected staff to notify the PCP for guidance. The DON reviewed the BM record for Resident #1 and stated her expectation would have been for staff to call the PCP. The Administrator stated she would have expected the NAs to report to the nurse the numbers and types of BMS the resident was experiencing so the nurse could have called the PCP. The DON and the Administrator agreed the nurses had a responsibility to check the BM record and inform the PCP of irregularities. During a telephone interview with NA #6 on 8/31/16 at 11:12 AM, she reported she had received information during morning report on 8/23/16 that Resident #1 had multiple episodes of diarrhea during the previous shift. The NA stated she reported the information she had received to Nurse #1.

Based on staff and physician interviews and review of medical records, the facility failed to assess, monitor and manage the resident's overall gastrointestinal condition with respect to medications and bowel movements for 1 of 3 sampled residents (Resident #1). On 8/23/16, Resident #1 was admitted to the hospital with [REDACTED]. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/15/16 Quarterly Minimum Data Set (MDS) indicated Resident #1 had both short and long term memory impairment and severely impaired cognitive skills for daily decision making. He was rarely able to make his needs known. The MDS indicated Resident #1 exhibited physical behaviors 1 to 3 days during the assessment period. The resident was identified as requiring extensive assistance with bed mobility, transfer, walking in his room, locomotion, dressing, eating toilet use and was coded as totally dependent for personal hygiene. The MDS coded the resident as always incontinent of bowel and bladder. Review of the August 2016 monthly orders included [MEDICATION NAME] (an iron supplement that can cause constipation) 325 milligrams daily and [MEDICATION NAME] (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements) 17 grams daily for constipation. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the August 2016 bowel record, completed by the nursing assistants (NAs) indicated from August 1 through August 15, 2016, Resident #1's usual bowel routine was 2 to 4 times per day. Review of the bowel record for August 16, 2016 to August 23, 2016, indicated Resident #1 averaged from 3 to 6 bowel movements (BM) per day. There was no documentation that indicated if the BM was formed or loose. The 8/22/16 weekly nursing note indicated Resident #1 was lying in bed with his eyes closed, but was easily aroused. Respirations were even and unlabored with an oxygen saturation of 96% on room air. No pain or discomfort was reported. Bowel sounds were documented as active. Vital signs on 8/22/16 during the 3:00 PM to 11:00 PM shift were recorded as BP of 110/58, pulse of 64, respirations 20 and temperature of 97.6 degrees. During the 11:00 PM to 7:00 AM shift, Resident #1's vital signs were recorded as a temperature of 98.8 degrees, pulse of 78, respirations of 20 and BP of 128/72. On 8/23/16 at 2:45 PM, Nurse #1 documented Resident #1 had increased respirations, agitation with an oxygen saturation of 87% (oxygen saturation measures the amount of oxygen in the blood stream. Normal is considered any value greater than 90%). Oxygen was applied at 2 liters per minute. Vital signs were recorded as a temperature of 96.8 degrees, pulse of 97, BP of 142/80 and a respiratory rate of 52 (the normal range for respirations is considered to be 16 to 20 breaths per minute). The primary care physician (PCP) was notified and an order was obtained to send the resident to the hospital. Hospital Emergency Department (ED) notes, dated 8/23/16, indicated the resident's admitting [DIAGNOSES REDACTED]. Under History of Present Illness, the physician had documented the resident presented complaining of reported multiple episodes of diarrhea since the previous day. The physician noted while the resident was unable to speak, information had been received by the emergency crew. Resident #1's white blood cell count was 62,000 (normal range is 4,500-10,000 white blood cells per milliliter. Elevated white blood cells is an indication of infection). [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) were started. The physician noted the resident had no urinary output and was also in acute [MEDICAL CONDITION] and indicated Resident #1's prognosis was extremely grim. The Hospital History and Physical (H & P), dated 8/23/16, indicated under Assessment/Plan that Resident #1 had a presumptive [DIAGNOSES REDACTED].dificile- a gastrological infection that causes multiple loose stools). Also listed as [DIAGNOSES REDACTED]. difficile and increased sodium level with dehydration secondary to fluid loss secondary to the C.dificile. Nurse #1 was interviewed on 8/30/16 at 2:20 PM. She acknowledged she had cared for Resident #1 on 8/23/16 and was the nurse that was responsible for calling the PCP and sending the resident to the hospital. On 8/23/16, Nurse #1 stated she first observed the resident between 7:00 AM and 9:00 AM. At that time, she noticed nothing unusual and Resident #1 was in no distress. The nurse added the only thing out of the ordinary was the resident was not agitated and took his morning medicine on the first try. She stated while he had good days and bad days, typically it took several tries to get him to take his medication; therefore, she decided to keep her eye on him. The nurse added around 2:00 PM, Resident #1 was sitting at the nurse's station. He looked lethargic and was napping in his chair. Nurse #1 stated she requested the nursing assistant (NA) take Resident #1 ' s vital signs and then she checked them again to make sure the values were correct. She added Resident #1 was breathing rapidly and his respirations were 52 breaths per minute. Initially, Nurse #1 said she thought Resident #1 was having a panic attack since he had no temperature or any other signs of illness. Nurse #1 stated she had been surprised to hear Resident #1 was diagnosed with [REDACTED]. The nurse stated the morning of 8/23/16 Resident #1 had a large BM, which was not unusual. She gave his [MEDICATION NAME] as was ordered. The nurse was unaware the resident had received [MEDICATION NAME] for diarrhea. NA #1 was interviewed on 8/30/16 at 2:48 PM. The NA stated she had cared for Resident #1 on 8/22/16, the day prior to his hospitalization . She stated on that day, he was his normal self and had actually slept until 11:30 AM. The NA added that Resident #1 had no elevated temperature or any symptoms that would make anyone think he was sick. The NA stated she was unaware Resident #1 had any BMs during her scheduled shift. On 8/30/16 at 2:54 PM, the treatment nurse was interviewed. She stated prior to completing a treatment for [REDACTED]. The Treatment Nurse stated there was no unusual odor associated with the BM. Resident #1's primary care physician (PCP) was interviewed via telephone on 8/30/16 at 3:00 PM. The PCP stated he found out from a hospitalist the admitting [DIAGNOSES REDACTED].#1 was acutely ill. He stated typically, the facility reported any change in a resident ' s condition immediately. The PCP added since the resident's hospitalization , he had reviewed the record and spoken to staff and found evidence of one large, loose BM that occurred on the morning of 8/23/16 and could not understand what had happened and why it had happened so quickly. On 8/30/16 at 3:15 PM, Nurse #2 was interviewed. She stated she had cared for Resident #1 on 8/22/16, prior to his hospitalization . She stated the resident was his normal self with no temperature, diarrhea or any other symptom that indicated he was acutely ill. Nurse #3 was interviewed on 8/30/16 at 3:19 PM. The nurse stated Resident #1 was discharged to the hospital on [DATE] close to change of shift. She added while Nurse #1 took care of PCP notification, she assisted getting Resident #1 ready for transport. Nurse #3 described Resident #1 as having rapid respirations. Oxygen was started. When the resident was returned to bed, the nurse stated the resident ' s respirations had decreased to 24 breaths per minute. She added when Resident #1 was placed in bed, he had had a large loose BM. She added stool kept pouring out even as the resident was changed. Nurse #3 stated the smell of the BM was horrible and quite different than the smell the night before. Even when a clean brief was placed on Resident #1, the BM continued. The night before, 8/22/16, Nurse #3 stated she had worked on the 3:00 PM to 11:00 PM shift. She stated one loose stool around 10:30 PM had been reported. When she went to assess the resident, she had not noted a strong odor. The nurse stated she gave the resident [MEDICATION NAME] (a medication given to correct loose BMs) and had given the next shift information about Resident #1's diarrhea. Review of the Medication Administration Record [REDACTED]. NA #3 was interviewed on 8/30/16 at 3:31 PM. The NA stated she had cared for Resident #1 on Monday, 8/22/16 on the 3:00 PM to 11:00 PM shift. The resident ate good, napped and was his usual self. The NA stated Resident #1 had one BM that was loose, but not watery with no odor on her shift. She added he ate 100% of his supper. The NA stated she documented the BMs in the activities of daily living (ADL) book kept at the nurse's station. The book was kept there so both NAs and nurses could review the information as needed. On 8/30/16 at 3:59 PM, a telephone interview was held with NA #4. She stated Resident #1 seemed ok when she worked with him on the 11:00 PM to 7:00 AM shift beginning on 8/22/16. The NA reported the resident had 3 loose stools with the first being small and the last 2 being large. She denied any odor. The NA stated she reported the loose stools to Nurse #4. A telephone interview was held with Nurse #4 on 8/30/16 at 4:07 PM. She stated she had worked with Resident #1 during the 11:00 PM to 7:00 AM shift on 8/22/16. The nurse stated when she arrived for work around 11:00 PM, Resident #1 seemed ok. She had not received any report of fevers, diarrhea or the use of [MEDICATION NAME] during the previous shift. She stated she had actually given the resident [MEDICATION NAME] on the previous Friday, August 19th when she worked due to a report of loose stools from the NA (name unknown). She added on 8/23/16 between 6:00 AM and 7:00 AM she had assisted the NA (unsure of which NA) with incontinent care. At that time, the nurse reported Resident #1 had a large semi-formed stool. The nurse stated she was unable to remember if she had received other reports during her shift about the resident having diarrhea. NA #5 was interviewed by phone on 8/31/16 at 8:42 AM. She acknowledged she had helped care for Resident #1 during the 11:00 PM to 7:00 AM shift on 8/22/16. The NA stated during the shift the resident had 3 large, loose BM's. She stated she had not reported this to the nurse, because the nurse had helped her provide incontinent care. The NA stated there was no unusual odor associated with the resident's 3 large loose BM's. She stated the BMs were documented in the ADL book kept at the nurse's station. Resident #1's PCP was again interviewed via telephone on 8/31/16 at 9:57 AM. The result of the interviews and review of the BM record was shared with the MD. The PCP stated none of the multiple BM's from August 16-23, 2016 had been reported to him; adding it was not good for any resident to have that many BM's on a daily basis. The PCP stated it was not normal for Resident #1 to have 3-6 BM's per day. The PCP stated if any resident had that many BM's he expected for the resident to be checked for impaction and to be notified of the results. He stated in retrospect, with the new information, he believed the multiple stools was part of the resident's illness that resulted in hospitalization . He stated while foul smelling stools was an indication of [MEDICAL CONDITION] (C.diff), it was possible to have [DIAGNOSES REDACTED] without a temperature and malodorous stool. The MD stated had he been notified of the multiple BMs he would have ordered lab work to rule out C.diff. The MD stated 2 other residents on the resident's hall had [DIAGNOSES REDACTED], but they had received antibiotics which increased their risk. He added Resident #1 had received no antibiotic and to the best of his knowledge had no risk factors. The MD stated knowing about the multiple stools would have made a difference in his course of action with treatment and possibly the resident's outcome of being hospitalized in serious condition. Nurse #1 was interviewed on 8/31/16 at 10:10 AM. She stated she had not worked with the resident during from 8/17th until she cared for him on 8/23/16. The nurse reviewed the BM list and stated none of the multiple BMs had been reported to her. She added had she known, she would not have given the [MEDICATION NAME]. Nurse #5 was interviewed on 8/31/16 at 10:20 AM. The nurse acknowledged she had worked with Resident #1 multiple days from 8/17/16 through 8/22/16. She stated she had not been advised of the large number of BMs Resident #1 had on a daily basis. The Director of Nursing (DON) and the Administrator were interviewed on 8/31/16 at 10:31 AM. The DON stated if a resident was having multiple stools or episodes of diarrhea the staff would be expected to call the PCP and ask for guidance. The Administrator stated she would have expected the information about Resident #1's diarrhea and multiple BMs per day to be shared nurse to nurse during report and she would have expected the NA to report to the nurse the number of BMs so the nurse could have called the PCP. Both the DON and the Administrator stated the nurse caring for Resident #1 had responsibility to check the BM record prior to the administration of a scheduled laxative. The DON added if Resident #1's PCP had all the information, he probably would have chosen a different treatment plan. NA #6 was interviewed by telephone on 8/31/16 at 11:12 AM. She acknowledged she had cared for Resident #1 on the 7:00 AM to 3:00 PM shift on 8/23/16. The NA stated she had received in report from another NA (unknown) that Resident #1 had diarrhea during the previous shift. The NA stated she reported the diarrhea to Nurse #1. The NA stated on the 7 to 3 shift, the resident had one large, loose stool around 9:30 to 10:00 AM with no odor.

Based on staff and physician interviews and review of medical records, the facility failed to hold a laxative for 1 of 3 sampled residents (Resident #1) who was reviewed for medications. Failing to hold the laxative when the resident had multiple bowel movements (BMs) per day resulted in the resident ' s hospitalization . Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/15/16 Quarterly Minimum Data Set (MDS) indicated Resident #1 had both short and long term memory impairment and severely impaired cognitive skills for daily decision making. The resident was identified as requiring extensive assistance with bed mobility, transfer, walking in his room, locomotion, dressing, eating toilet use and was coded as totally dependent for personal hygiene. The MDS coded the resident as always incontinent of bowel and bladder. The care plan, last reviewed on 6/22/16, identified Resident #1 as totally incontinent. The review indicated the resident was offered incontinent care every 2 hours. Review of the August 2016 monthly orders included [MEDICATION NAME] (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements) 17 grams to be given daily as a scheduled medication. Review of the August 2016 Bowel Movement (BM) record indicated Resident #1 had an average of 2-4 BMs per day from 8/1-15/2016 and an average of 4-6 BMs per day from August 16-23rd when he was hospitalized . Review of the August Medication Administration Record [REDACTED]. The Emergency Department (ED) notes, dated 8/23/16, indicated Resident #1 had been taken to the ED with reports of multiple episodes of diarrhea that had started the previous day. He was admitted with a [DIAGNOSES REDACTED]. The ED physician documented the resident ' s prognosis was grim. The resident was admitted to the hospital. Lab results indicated a white blood cell count (elevated white blood cell counts are indicative of infection) was recorded as 62,000 (normal white blood cell count is 4,500 to 10,000 cells per microliter of blood). A telephone interview was held with Nursing Assistant (NA) #4 on 8/30/16 at 3:59 PM. The NA stated she had cared for Resident #1 on the 11:00 PM to 7:00 AM shift starting on 8/22/16. NA #4 reported Resident #1 had 3 loose stools with the first BM described as a small BM and the last 2 BMs described as large. The NA stated she reported Resident #1 ' s loose stools to Nurse #4. On 8/30/16 at 4:07 PM, a telephone interview was held with Nurse #4. The nurse stated when she arrived for work on her 11:00 PM to 7:00 AM shift beginning 8/22/16, she had not received a report or any information that Resident #1 had diarrhea. She stated she had actually given the resident [MEDICATION NAME] (an anti-diarrheal medication) on the previous Friday, August 19th when she worked due to a report of loose stools from the NA (name unknown). The nurse stated the NAs had not reported any episodes of loose stools to her. NA #5 was interviewed by phone on 8/31/16 at 8:42 AM. She acknowledged she had worked with the resident during the 11:00 PM to 7:00 AM shift on 8/22/16. The NA stated during the shift the resident had 3 large, loose BM's. She stated she had not reported this to the nurse, because the nurse knew since she had helped her provide incontinent care to Resident #1. During a telephone interview with Resident #1 ' s primary care physician (PCP) on 8/31/16 at 9:57 AM, the results of the BM record for 8/16/16 through 8/23/2016 and interviews with staff were reviewed. The PCP stated it was not normal for residents, including Resident #1 to have 3-6 BMs per day. He stated if any resident had that many BMs, he would expect nurses to check the resident for impaction and to be notified of the results. The PCP stated if he had known Resident #1 had that many BMs, he would have ordered lab work to rule out other illnesses. Nurse #1 was interviewed on 8/31/16 at 10:10 AM. The nurse stated she had not worked with the resident from August 17th through the 22nd and had only cared for him on 8/22/16. The nurse reviewed the BM record from 8/16-8/22/2016 and stated Resident #1 ' s [MEDICATION NAME] should not have been given due to the large number of BMs per day. She stated if she had known about the number of BMs he was having, she would not have given him the [MEDICATION NAME] on 8/23/16. On 8/31/16 at 10:20 AM, Nurse #5 was interviewed. The nurse acknowledged she had cared for Resident #1 several days during the preceding week, including 8/22/16 and confirmed she had given the resident [MEDICATION NAME] on the days she had worked. She stated [MEDICATION NAME] was used as a laxative and to help residents have BMs without trouble. Nurse #5 stated if a resident had consistent diarrhea or not having problems with having BMs she would not give the [MEDICATION NAME]. Usually, the nurse added, NAs reported the number of BMs. The nurse reviewed the BM record for the week prior to Resident #1 ' s hospitalization and stated she was unaware Resident #1 had from 3-6 BMs per day. The Director of Nursing (DON) and Administrator were interviewed on 8/31/16 at 10:31 AM. The DON stated [MEDICATION NAME] was used as a laxative and should not be given if a resident had liquid stools or a large number of stools per day. The DON reviewed the BM record and the MAR for Resident #1 and stated her expectation would have been the staff to call the PCP prior to giving the [MEDICATION NAME]. The DON and the Administrator agreed it was the responsibility of the nurses to check the BM record prior to giving laxatives. The Administrator stated she would call the [MEDICATION NAME] an unnecessary medication since the Resident #1 had diarrhea from 3-6 BMs per day from August 16th through August 23rd when he was hospitalized .

Based on observation, record review and staff interviews, the facility failed to provide the necessary care to maintain a resident's well being for 1 of 4 sampled residents (Resident #13) by failing to identify (from 2/15/11 through 2/18/11), test and possibly treat a resident exposed to a blood borne infection and created an immediate jeopardy to the resident's health. The Immediate Jeopardy began on 2/15/11 at 4:10 PM and identified on 2/19/20 at 8:45 AM. Immediate Jeopardy was removed on 2/19/11 at 4:35 PM, when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (with potential for more than minimal harm that is not immediate jeopardy). Findings include: Resident #12 was admitted to the facility on [DATE] and readmitted [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the resident's clinical record revealed a physician order [REDACTED]. Observation on 2/15/11 at 4:10 PM revealed Nurse #1 preparing to obtain a finger stick blood sugar for Resident #12. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse #1 walked up to the medication cart, opened the medication cart drawer and took out a glucometer and test strips. She was observed putting on gloves, inserted a test strip into the glucometer, and wiped the resident's finger with an alcohol pad. She obtained a blood sample by disposable lancet, and applied a drop of blood to the test strip. After reading the test results, Nurse #1 removed the test strip. Nurse #1 disposed of the used test strip, alcohol pad, and lancet. Nurse #1 placed the glucometer on top of her med cart. Nurse #1 removed her gloves and washed her hands. Nurse #1 did not clean or disinfect the glucometer before or after use. During a continuous observation, Nurse #1, pushed the med cart down the hall and was observed preparing to obtain a finger stick blood sugar for Resident #13. Resident #13 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the resident's clinical record revealed a physician order [REDACTED]. Nurse #1did not clean or disinfect the glucometer before use. Nurse #1 was observed putting on gloves. Nurse #1 was observed picking up from her med cart the glucometer she had used on Resident #12. Nurse #1 inserted a test strip into the glucometer. Nurse #1 wiped the resident ' s finger with an alcohol pad, obtained a blood sample by disposable lancet, and applied a drop of blood to the test strip. After reading the test results, Nurse #1 removed the test strip. Nurse #1 disposed of the used test strip, alcohol pad, and lancet. Nurse #1 was observed to drop the glucometer on the floor, walked to the feeding tube cart and pulled the bottom drawer open and a bottle labeled, " 10 % Clorox solution was observed. " Nurse #1 stated she did not have any paper towels on the cart to clean the glucometer and was observed getting paper towels. She picked up the bottle of 10% Clorox solution, squirted the solution onto the paper towel and then she cleaned the glucometer. After cleaning the glucometer, she removed her gloves and washed her hands. During an interview on 2/15/11 at 4:20 PM, Nurse #1 stated she needed to clean the glucometer with the Clorox solution because she had dropped it on the floor. She further stated she had cleaned the glucometer with alcohol between the residents. Nurse #1 stated the facility policy was to clean the glucometer with Clorox solution between residents, but she thought it was okay just to use alcohol wipes. She further stated it really did not matter if she cleaned it because she had gone online and knew that you could not transmit any diseases from not cleaning the glucometer. There was no observation of Nurse #1 cleaning the glucometer with alcohol. In an interview on 2/16/11 at 8:30 AM, the Director of Nursing (DON), was notified Nurse #1 had not cleaned the glucometer between Residents #12 and #13. The DON stated Nurse #1 had been trained to clean the glucometer with the 10% Clorox solution before and after use for each resident. The DON stated every diabetic resident had his or her own glucometer and there was no reason for her to use one glucometer on more than one resident. In an interview on 2/19/11 at 8:20 AM, the DON stated it was not until after the survey left the faciity on (2/17/11), she realized that Resident #12 had a communicable disease. She stated as soon as she realized Resident #12 had a communicable disease, she immediately (2/18/11) called the Medical Director and he immediately (2/18/11) gave her orders to test for 2-communicable diseases on all diabetic residents at her facility. The DON further stated when Nurse #1 looked at the MAR, the information that Resident #12 had two communicable diseases was on the MAR. She had been trained to clean and sanitize the glucometer before and after each use. During an interview on 2/19/11 at 9:30 AM, the DON stated she had completed all diabetic residents ' blood testing for two communicable diseases. The test she used was what was available at her lab. The DON further stated she would be re-testing all residents with diabetes at 3 months, 6 months and one year from 2/18/11 and 2/19/11. The Administrator was notified of the Immediate Jeopardy on 2/19/11 at 8:45 AM. The facility provided a credible allegation of compliance on 2/19/11 at 4:35 PM. The allegation of compliance indicated: ? The (Resident #13) who was exposed was blood tested for two communicable diseases on 02/18/2011. 33 diabetic residents were tested on [DATE], and will be tested subsequently at 3 months, 6 months, and 1 year. The medical director was alerted to the exposure, and ordered the above labs, for the diabetic residents. Depending upon the outcome of the blood testing, the medical director will treat the diseases according to specification. ? Each resident has their own glucometer for blood sugar testing, however, in the event that one must be shared, the glucometer will be cleaned prior to each use, and after each use with a 10% bleach solution according to manufacturers guidelines. In the event that a non-diabetic resident requires blood glucose, monitoring, additional monitors will be available to be assigned to that resident. ? All nurses will demonstrate competency in correct blood sugar monitoring upon hire to the DON or ADON each week for three months beginning immediately. The documentation of this competency will be kept in the employees file in the DON ' s office. The DON or ADON will conduct quality assurance checks on three nurses per week (one on each shift) during blood sugar monitoring for correct procedure to include sanitizing the glucometers after each use, and included disinfecting the glucometers for six months. A monitoring tool was developed. ? The nurse involved with the deficient practice was terminated on 2/17/11 following the deficient practice and was reported to the board of nursing on 2/18/11. ? All nurses will be re-trained in correct blood sugar monitoring by 02/22/2011. No nurse or med aide will be allowed to monitor blood glucose prior to receipt of this training, which included disinfecting the glucometers and identifying that communicable diseases could be spread through glucometers. ? The DON and ADON will bring their findings of observations of blood glucose monitoring to the quality assurance committee for review quarterly. On 2/19/11 at 4:35 PM, the credible allegation was validated by reviewing the list of 33 residents with diabetes to confirm they were tested for two communicable diseases. Each of the 33 residents ' charts were reviewed and documentation revealed the testing had been completed. The facility has been instructed to notify the DHSR with the results of the testing on 2/18/11 and with the results of the 3 months, 6 months and 1 year. Resident #13 was observed to have her own glucometer in a case labeled with her name. Each resident with diabetes was observed to have his or her own glucometer. Observations and interviews with nurses revealed they knew to clean the glucometer between residents, knew that communicable diseases could be spread through glucometers, and knew competency in correct blood sugar monitoring. An interview with the Director of Nursing revealed she would not allow a nurse to monitor blood glucose prior to receiving the training. Results of the initial test revealed all 33 residents including Resident #13 were negative for the two communicable diseases.

Based on observation, record review and staff interviews, the facility's policy and procedures were not following Center for Disease Control (CDC) guidelines, by failing to clean and disinfect a glucometer between residents for 1 of 4 sampled residents (Resident #13) observed receiving blood glucose monitoring. The Immediate Jeopardy began on 2/15/11 at 4:10 PM and the facility was informed of the IJ on 2/19/11 at 8:45 AM. Immediate Jeopardy was removed on 2/19/11 at 4:35 PM, when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level D (No actual Harm with the potential for more than minimal harm that is not immediate jeopardy). Findings include: The manufacturer's recommendation titled, "Caring For your Monitor" read in part, "Store your monitor in its carrying case. If the surface of your monitor gets dirty, you may clean it. Healthcare professionals: acceptable cleaning solutions include 10% Bleach, 70% Alcohol, or 10% Ammonia." The facility's policy dated October 2010 titled; " Procedure Blood Glucose Monitoring," before procedure read in part, "7. Clean monitor with 1:10 bleach solution. " After the procedure the policy read, "19. Disinfect meter with 1:10 bleach solution." The Center for Disease Control (CDC) and Prevention Guidelines for Glucose Monitoring read in part, "Any time blood glucose monitoring equipment is shared between individuals there is a risk of transmitting viral hepatitis and other blood borne pathogens. Decontaminate environmental surfaces such as glucometers regularly and any time contamination with blood or body fluids occurs or is suspected. Glucose test meters approved for use with more than one person must be cleaned and disinfected following disinfection guidelines." Resident #12 was admitted to the facility on [DATE] and readmitted [DATE] with multiple [DIAGNOSES REDACTED]. Observation on 2/15/11 at 4:10 PM revealed Nurse #1 preparing to obtain a finger stick blood sugar for resident #12. A review of the Medication Administration Record dated 2/1/11 - 2/28/11 revealed [DIAGNOSES REDACTED]. Nurse #1 walked up to the medication cart, opened med cart drawer and took out a glucometer and test strips. She was observed putting on gloves. Nurse #1 inserted a test strip into the glucometer, wiped the resident's finger with an alcohol pad, obtained a blood sample by disposable lancet, and applied a drop of blood to the test strip. After reading the test results, she removed the test strip and disposed of the used test strip, alcohol pad, and lancet. Nurse #1 placed the glucometer on top of her med cart, removed her gloves and washed her hands. Nurse #1 did not clean or disinfect the glucometer before or after use. During a continuous observation, Nurse #1 was observed preparing to obtain a finger stick blood sugar for Resident #13. Resident # 13 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the resident ' s clinical record revealed a physician order [REDACTED]. Nurse #1 did not clean or disinfect the glucometer before use. Nurse #1 was observed putting on gloves took the same glucometer used for Resident #12 from the top of the med cart, inserted a test strip into the glucometer. She wiped the resident ' s finger with an alcohol pad, obtained a blood sample by disposable lancet, and applied a drop of blood to the test strip. After reading the test results, she removed the test strip. She disposed of the used test strip, alcohol pad, and lancet. Nurse #1 was observed to drop the glucometer on the floor, walked to the feeding tube cart and opened the bottom drawer and got out a bottle labeled, "10 % Clorox solution." Nurse #1 stated she did not have any paper towels on the cart to clean the glucometer and was observed getting paper towels from the med room bathroom. She picked up the bottle of 10% Clorox solution, squirted the solution onto the paper towel and then she cleaned the glucometer. After cleaning the glucometer, she removed her gloves and washed her hands. During an interview on 2/15/11 at 4:20 PM, Nurse #1 stated she needed to clean the glucometer with the Clorox solution because she had dropped it on the floor. She further stated she had cleaned the glucometer with alcohol between the residents. Nurse #1 stated the facility policy was to clean the glucometer with Clorox solution between residents, but she thought it was okay just to use alcohol wipes. She further stated it really did not matter if she cleaned it because she had gone on line and knew that you could not transmit any diseases from not cleaning the glucometer. There was no observation of Nurse #1 cleaning the glucometer with alcohol wipes. In an interview on 2/16/11 at 8:30 AM, the Director of Nursing (DON), was notified Nurse #1 had not cleaned the glucometer between Residents #12 and #13. The DON stated Nurse #1 had been trained to clean the glucometer with the 10% Clorox solution before and after use for each resident. The DON stated every resident with diabetes had his or her own glucometer and there was no reason for her to use one glucometer on more than one resident. The DON received a statement from Nurse #1 regarding the glucometer not being cleaned between the residents on 2/15/11. A review of Nurse #1 ' s statement dated 2/16/11 revealed prior to being called to the Assistant Director of Nursing ' s (ADON) office (2/15/11), she had been preparing to make a list of residents that needed finger sticks. The statement revealed once she had completed the list, she got the glucometer out and cleaned it with Clorox. When she was called over the intercom to the office, she returned the glucometer and supplies to the drawer inside her med cart and locked it. Nurse #1 wrote when she returned to her cart, she did three blood sugar checks. With the first resident, she had already cleaned the machine with Clorox and she wrote she "failed to tell the state she had already cleaned the glucometer." She further wrote she got the Clorox out and sprayed liberally on a paper towel and did the second blood sugar check. During an interview on 2/19/11 at 8:20 AM, the DON stated on the day (2/15/11) Nurse #1 was called to her office, she had been given a written warning for medication errors done in January 2011. She stated Nurse #1 denied the errors and refused to sign the written warning. After Nurse #1 left her office, she stated she went outside to make sure Nurse #1 was okay. While she was talking to Nurse #1, the DON received a call and Nurse #1 volunteered to do her own finger sticks. The DON further stated Nurse #1 was sent to the Nurse Supervisor and she instructed her on where the 10% Clorox solution was located in the feeding tube cart. The DON further stated it was not until after the survey left the facility (2/17/11), she realized that Resident #12 had a communicable disease. She stated as soon as she realized Resident #12 a communicable disease, she immediately (2/18/11) called the Medical Director and he immediately (2/18/11) gave her orders to test for 2 communicable diseases on all diabetic residents at her facility. During an interview on 2/19/11 at 12:30 PM, the Nurse Supervisor stated Nurse #1 was always assigned to the same hall and worked 3 to 11 shift every other day. She stated she (Nurse #1) had worked at the facility for the past two years and Nurse #1 already knew the glucometers were stored in a basket in the med room. The Nurse Supervisor stated she pulled the bottom drawer of the feeding tube cart open and showed her where the 10% Clorox solution was located before she was observed. The Nurse Supervisor stated she did not know why Nurse #1 did not use the residents' own glucometers. During an interview on 2/19/11 at 10:25 AM, the infection control coordinator stated all nurses were in-serviced according to the facility protocol. Nurses were instructed to clean the glucometers with 10% Clorox before and after use. Nurse #1 always worked that hall and she was in-serviced more than once concerning proper cleaning of the glucometers. A review of Nurse #1 ' s skills competency checklist sheets dated 1/5/09 and 1/8/10 revealed she was checked off on Accu-checks and instructor had signed as completed. During an interview on 2/19/11 at 4:00 PM, with the Administrator, DON, and Nurse #1. Nurse #1 stated she was not aware of Resident #12 having any infectious disease. She stated she would never put a resident at risk. She stated she cleaned the glucometer with Clorox before she talked to the DON and that was why the state did not see her clean the glucometer before she did Resident #12 ' s fingerstick. Furthermore, she stated she was told she had to do the finger sticks because of an emergency with another nurse and she was in no shape to do finger sticks. She stated she walked down the hall to her medication cart and stated the glucometer had already been cleaned. After she finished the fingerstick for resident #12, she went to Resident #13 ' s room and stated the surveyor turned her head and that was why she did not see her clean the glucometer with Clorox. Nurse #1 was asked how she cleaned the glucometer between the two residents and she stated with alcohol. Nurse #1 then stated she used Clorox but because the surveyor had her head turned around and was so busy looking at the Clorox bottle, she (state) failed to watch her clean the glucometer. Nurse #1 ' s statement was in contradiction with what was observed on 2/15/11. During an interview on 2/19/11 at 4:20 PM, the DON stated Nurse #1 worked from her med cart and there was no Clorox solution on her med cart. She stated Nurse #1 had changed her story from using alcohol to Clorox. Nurse #1 had told her (DON) that there was no way you could get a communicable disease from not cleaning a glucometer. The Administrator was notified of the Immediate Jeopardy on 2/19/11 at 8:45 AM. The facility provided a credible allegation of compliance on 2/19/11 at 4:35 PM. The allegation of compliance indicated: ? The resident who was exposed, was blood tested for Communicable Diseases on 02/18/2011. 33 diabetic residents were tested on [DATE], and will be tested subsequently at 3 months, 6 months, and 1 year. The medical director was alerted to the exposure, and ordered the above labs, for the diabetic residents. Depending upon the outcome of the blood testing, the medical director will treat the diseases according to specification. ? Each resident has their own glucometer for blood sugar testing, however, in the event that one must be shared, the glucometer will be cleaned prior to each use, and after each use with a 10% bleach solution according to manufacturers guidelines. In the event that a non-diabetic resident requires blood glucose monitoring, additional monitors will be available to be assigned to that resident. ? All nurses will demonstrate competency in correct blood sugar monitoring upon hire to the DON or ADON each week for three months beginning immediately. The documentation of this competency will be kept in the employees file in the DON ' s office. ? The DON or ADON will conduct quality assurance checks on three nurses per week (one on each shift) during blood sugar monitoring for correct procedure for six months. ? The nurse involved with the deficient practice was terminated on 2/17/11 following the deficient practice and was reported to the board of nursing on 2/18/11. ? All nurses will be re-trained in correct blood sugar monitoring by 02/22/2011. No nurse or med aide will be allowed to monitor blood glucose prior to receipt of this training. ? The DON and ADON will bring their findings of observations of blood glucose monitoring to the quality assurance committee for review quarterly. On 2/19/11 at 4:35 PM, the credible allegation was validated by reviewing the list of 33 diabetic residents to confirm they were tested for Communicable Diseases. Each of the 33 diabetic residents' charts were reviewed and documentation revealed Communicable Diseases testing had been completed. The facility was instructed to notify DHSR with the results of the testing on 2/18/11 and with the results of the 3 months, 6 months and 1 year. Residents #12 and 13 were observed to have their own glucometers in a case labeled with their names. Each resident with diabetes was observed to have his or her own glucometer. Observations and interviews with nurses revealed they knew competency in correct blood sugar monitoring. An interview with the Director of Nursing revealed she would not allow a nurse to monitor blood glucose prior to receiving the training. During an interview with the DON, she stated she had completed all diabetic residents' blood testing for Communicable Diseases. The test she used was what was available at her lab. The DON further stated she would be re-testing all Diabetics at 3 months, 6 months and one year from 2/18/11 and 2/19/11.