Every finding on record at Wesley Commons Health And Rehabilitation Center

Based on observation, interview, facility document and policy review, the facility failed to ensure medications were stored safely and securely for 1 (Medication Cart #2) of 4 medication carts. Findings include: Review of the facility policy titled, Storage of Medications, revised on 06/07/2024, indicated, To ensure that medications are stored safely, securely and properly. Medication supply is accessible only to licensed nursing personnel and pharmacy personnel. The policy further indicated, 2. Medication rooms, carts and medication supplies should be locked or attended by persons with authorized access. During an observation and concurrent interview on 02/11/2026 at 5:26 PM, an unattended sealed blue bag was observed on top of Medication Cart #2. Medication Cart #2 was in the hallway outside of a resident room. Registered Nurse (RN)2 stated that the bag contained nine non-narcotic medications that were delivered to the facility. RN2 stated she usually left the newly delivered medications inside the nurses' station. RN2 stated she should not have left the bag containing the medications on top of the medication cart unattended, as anyone, including residents, could have taken them. RN2 stated residents might have taken medications that were not intended for them, which could result in a medication allergy or adverse drug effect. Review of a facility document titled, Prescriptions Delivered to [name of facility, address of facility] dated 02/11/2026 at 10:37 AM, indicated the following medications were delivered: milk of magnesia oral suspension (a medication used to treat constipation), Aquaphor ointment (a medication used to keep wounds moist), cyclobenzaprine hydrochloride tablets (a medication used to treat muscle spasms), metoprolol tablets (a medication used to treat high blood pressure and heart failure), irbesartan tablets (a medication used to treat hypertension), levothyroxine sodium (a medication used to treat low thyroid hormone) tablets, lactulose solution (a medication used to treat constipation or to maintain ammonia levels), pantoprazole sodium tablets (a medication used to treat excessive stomach acid), and ondansetron tablets (a medication used to treat nausea and vomiting). The document further indicated, I certify the above items/services provided by [name of pharmacy] have been authorized by the prescriber and received by me on behalf of the listed patients. The form was not signed by anyone to indicate the medications had been delivered and received. During an interview on 02/13/2026 at 10:55 AM, the Director of Nursing (DON) stated the facility staff should follow their policy in ensuring medications they received from the pharmacy were locked. The DON stated anyone could have access to medications if left on top of the medication cart. During an interview on 02/13/2026 at 2:00 PM, the [NAME] President of Operations/Administrator (VPO/ADM) stated the facility staff should not leave medications on top of the medication cart, as any resident could take them. The ADM stated staff should store medications in the medication cart or medication storage room.

Based on observation, interview, record review, facility policy review, and manufacturer guideline review, the facility failed to ensure the medication administration error rate was less than 5 percent (%). The facility had 2 medication errors out of 31 opportunities, affecting 2 residents (Residents (R)48 and R65) of 8 residents reviewed during the medication administration task, resulting in a medication error rate of 6.45%. Findings include: 1. Review of the facility policy titled, Insulin Injection Administration Procedures, revised on 10/10/2024, indicated, the purpose was, To aid oxidation and utilization of the blood sugar by the tissues and to control the blood sugar levels in residents with diabetes mellitus through the correct administration of insulin. The policy also indicated, If using insulin pen expel 2 units of insulin to prime the needle then dial up correct dose of insulin to be given. Review of an Instructions for use Humalog ([NAME]-ma-log) KwikPen [a disposable insulin pen used to control blood sugar levels in people with diabetes] (insulin lispro) injection, for subcutaneous use 3 mL [milliliter] single-patient-use pen (100 units per mL), instruction manual, revised in 07/2023, indicated, Prime before each injection. The document also indicated, Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. The manufacturer instructions continued, Step 9: Turn the Dose Knob to select the number of units you need to inject. The manufacturer instructions continued, Step 10: Choose your injection site. then, Step 11: Insert the Needle into your skin. Review of a Clinical/Charting Snapshot, dated 02/11/2026, indicated the facility admitted R48 on 08/04/2025. According to the Clinical/Charting Snapshot, the resident had a medical history that included but was not limited to diagnoses of type 1 diabetes mellitus (an autoimmune disease where the body does not produce enough insulin to maintain blood glucose levels) with unspecified complications and Alzheimer's (a brain condition that causes memory loss and cognitive impairment) disease. Review of R48's Physician Orders for the timeframe 02/01/2026 through 02/28/2026, contained an order, with a start date of 08/04/2025 for Humalog KwikPen 100 units/1 milliliter solution (insulin lispro) subcutaneous, per sliding scale. The Physician Orders also contained an order for Humalog KwikPen 100 units/1 milliliter solution (insulin lispro) 2 units subcutaneous with breakfast, lunch, and dinner at 8:00 AM, 12:00 PM, 5:00 PM. During an observation of medication administration on 02/11/2026 at 12:12 PM, Licensed Practical Nurse (LPN)1 stated R48's blood glucose level was 184 milligrams per deciliter (mg/dL) and that the resident would receive 2 units of Humalog KwikPen insulin per sliding scale coverage and another 2 units of Humalog KwikPen insulin per routine order. LPN1 applied a new needle onto the Humalog KwikPen and primed the pen with 2 units of insulin. LPN1 then removed the needle and applied a new needle to the Humalog KwikPen. LPN1 did not reprime the Humalog KwikPen after applying the new needle. LPN1 then dialed the Humalog KwikPen to 4 units of insulin and administered the medication. During an interview on 02/11/2026 at 5:50 PM, LPN1 stated she should have primed R48's Humalog KwikPen insulin with 2 units after changing the needle. LPN1 stated the purpose of priming the insulin pen was to get air bubbles out of the pen and to ensure the resident received the ordered dose of insulin. 2. Review of the facility policy titled, Oral Inhalers, revised on 05/03/2021, indicated, Resident may need to rinse mouth with water after certain inhalers. Review of a How to Use Wixela Inhub (generic equivalent for Advair Diskus) (a medication used to prevent asthma attacks), instruction manual, dated 2021, indicated, Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. Review of a Clinical/Charting Snapshot, dated 02/12/2026, indicated the facility admitted R65 on 05/07/2024. According to the Clinical/Charting Snapshot, the resident had a medical history that included but was not limited to a diagnosis of unspecified asthma, uncomplicated. The Clinical/Charting Snapshot also included an active physician order, dated 11/24/2025 for Advair Diskus 250/50 disk (fluticasone propionate/salmeterol xinafoate) one puff inhalation twice a day. During an observation of medication administration on 02/12/2026 at 9:02 AM, Registered Nurse (RN)3 administered R65's Wixela Inhub (Advair diskus). RN3 did not instruct the resident to rinse their mouth and spit out the water after breathing in the medication. During an interview on 02/12/2026 at 2:20 PM, RN3 stated there was no need for R65 to rinse their mouth after breathing in the inhaler because there was no doctor's order to do so. RN3 stated she did not know there was a need to rinse the resident's mouth following the inhaler administration. During an interview on 02/12/2026 at 3:24 PM, RN3 stated she should have instructed the resident to rinse their mouth after administering Wixela Inhub (Advair diskus) to prevent thrush or mouth irritation. During an interview on 02/13/2026 at 10:55 AM, the Director of Nursing (DON) stated the facility staff should follow their policy and the manufacturer's recommendations when administering medications. During an interview on 02/13/2026 at 2:00 PM, the [NAME] President of Operations/Administrator (VPO/ADM) stated the facility staff should have followed the manufacturer's instructions when administering the medications. The VPO/ADM stated the facility staff should have primed the insulin pen for R48 and should have instructed R65 to rinse their mouth.

Based on record review, interviews and review of the facility's policy, the facility failed to provide adequate supervision and protect 1 of 1 residents from entrapment in the quarter side rails of the resident's bed, resulting in death. Specifically, Resident (R)1 was found by staff on [DATE] at 2:30 AM unresponsive. R1's head was trapped on the inside on the side rail and her body was off the bed against the wall. On [DATE] at 5:30 PM the Administrator was notified that the failure to protect a resident from entrapment in a bed rail, that resulted in death, constituted immediate jeopardy at F689. On [DATE] at 5:30 PM the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.25 Quality of Care. On [DATE] at 10:15 AM, the facility provided an acceptable IJ Removal Plan. The survey team, validated the facility's corrective actions and verified the facility did their due diligence to address the non-compliance. The IJ is considered at Past Non-compliance as of [DATE]. An Extended Survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility's policy titled, Side Rails dated [DATE], revealed, To utilize a person-centered approach when determining the use of grab bars/side rails/bed rails and enhance resident's mobility and functional independence. Item 1 stated, Side rail/Bed Rail screen, (to be completed in the electronic medical record (EMR), to be completed upon admission and quarterly thereafter, which will address alternatives attempted and how these alternatives failed to meet the resident's assessed needs. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to; depression, hypertension, diabetes type 2, chronic kidney disease stage 3, and unspecified dementia. Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of of [DATE] revealed R1 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R1 was severely cognitively impaired. Further review of the MDS revealed R1 required extensive assistance with activities of daily living. Review of R1's Progress Note dated [DATE] at 7:00 AM, revealed at approximately 4:30 AM during routine rounds, Certified Nursing Assistant (CNA)1 stated she entered room [ROOM NUMBER] and observed R1 entangled in quarter length side rail on the right side of the bed (if standing at foot of bed). CNA1 notified this nurse of this situation and I went immediately to the room. I observed R1 being unresponsive and entangled inside the side rail. I called Emergency Medical Services (EMS) immediately. EMS arrived at the facility at approximately 5:00 AM and was unable to revive R1. EMS manager and coroner notified by EMS staff. EMS manager arrived at facility at approximately 5:15 AM and assistant corner arrived at approximately 5:30 AM. During an interview on [DATE] at 9:50 AM, the Administrator (with the Director of Nursing present), revealed that the facility conducted an internal investigation and concluded that the facility would no longer use the quarter side rails and they have since removed them. The Administrator stated the facility did a bed measurement on all beds with the Bionix device on [DATE] and on [DATE] removed all the devices from each bed in the facility. The Administrator further stated the facility used the quarter rails on each resident bed since the opening of the facility in 2018 and this was the first death in relation to the use of the rails. The Administrator concluded, [R1] was a DNR (do not resuscitate) and when EMS arrived at the facility, they place the leads on her and the leads read asystole (represents the cessation of electrical and mechanical activity of the heart). During an interview on [DATE] at 11:20 AM, R1's daughter revealed that her brother got a call from the facility on [DATE] at 6:30 AM notifying that EMS came to the facility due to an accident where R1 was found unresponsive. R1's daughter stated that she got to the facility and saw the coroner leaving and was told by the coroner that R1 fell out of the bed, her head got stuck on the bed rail and she was paralyzed and she broke her left leg. R1's daughter stated that she had an autopsy performed and the autopsy did not mention anything about R1 being paralyzed or having a broken leg but listed the cause of death as asphyxiation. During an interview on [DATE] at 11:45 AM, CNA1 stated she and CNA2 went to check on R1 on [DATE] at 2:30 AM and CNA2 went inside the room first. CNA2 came out and said R1 is not breathing. R1's neck was caught between the rail and the wall. CNA2 had to unlock the bed to get to R1, as R1 was still warm to touch. CNA2 attempted to get as close as possible to dislodge her neck from the rails and the wall and she said, I was not able to get [R1's] neck out of the rail and the wall so we called for the nurse to come help. [Registered Nurse (RN)1] came and she could not get close enough to get [R1's] neck from the bed so she called 911. CNA1 stated, EMS came and I cannot remember what else occurred because I was so upset. CNA1 further stated she has been working for the facility for [AGE] years and this was the first death as a result of the quarter rails. CNA1 confirmed that the quarter rails were at the head of the bed. CNA1 concluded that she did not receive in-service training for side rails prior to or after the incident. During an interview on [DATE] at 12:16 PM, RN1 stated that on [DATE] CNA1 went to R1's room at 4:30 AM and reported to her that R1 was not responsive. R1's head was inside on the rail and her body was up against the wall and she had gotten stuck between the wall and the bed. R1 was warm to touch but she was not responsive and R1 did not have a pulse. RN1 stated, I tried to move the bed to keep her neck from further moving so I made a decision to call 911. RN1 further stated when the paramedics arrived, they told her to unplug the bed and they put the leads on her and it registered asystole and we started calling everyone. During an interview on [DATE] at 12:50 PM, the Director of Therapy stated, [R1] initially was on the rehabilitation unit and transitioned to Medicare unit. [R1] was a full body lift, a 2-person assistance and a Hoyer stand and lift patient. The Director of Therapy concluded, regarding R1's deficits in upper body strength, she could feed herself, but staff would have to provide assistance to get out of bed. During an interview on [DATE] at 2:31 PM, Licensed Practical Nurse (LPN)1 stated, the facility conducted an assessment for [R1's] side rails at admission and quarterly and all residents have a quarter side rail prior to the removal of all on [DATE]. LPN1 stated that all patients and family are told the benefits and negatives of having the quarter rails. LPN1 stated that R1 had quarter side rails for position in bed mobility and for staff assistance. LPN1 said to her knowledge, the quarter rails and the handrails were not considered a restraint and she was not sure why no physician orders were in place for the use of the rails. LPN1 further stated on [DATE] she conducted an assessment for continued use of the quarter side rails. R1 was not very mobile at admission, she was able to scoot out of chair and over time she was more mobile, to include being able to feed self, assist staff with turn and reposition in bed, and could hold on to rails for staff to assist her. During an interview on [DATE] at 2:48 PM, LPN2 revealed she conducted an assessment on [DATE] for the use of the quarter side rails. LPN1 stated that R1 had quarter rails for turning, mobility and to aid with her moving from side to side. LPN2 concluded, At admission [R1] had an aid device, but she was not able to recall which one. Multiple attempts were made to interview CNA2 with no success. On [DATE] the facility provided a removal plan, which included the following: 1. Immediate action(s) taken for the resident(s) found to have been affected include: Resident CR1, expired [DATE]. 2. Identification of other residents having the potential to be affected was accomplished by: Residents with quarter length (,d+[DATE]) side rails have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk off uture occurrence include: 100% audit of bed measurement to mattress with Bionix device on 11 beds, empty and occupied by maintenance on [DATE]. Resident CR1's Bed Inspected by Maintenance [DATE]. Attachment A 100% side rail screens completed on [DATE] by the therapy department. Any noted side rails for removal removed [DATE] by maintenance. 100% side rail re-assessment completed [DATE] by MDS Department with resident/resident representative notification of results or assessment. [DATE] DON and Administrator reviewed Bionix Bed Checks conducted in the past for Resident CR1. [DATE] DON, Administrator, Lead Maint Tech, Facility Services Director went to CR1's room and utilized the Bionix device and measured Zone 1 with a regular mattress with CR1's bed and all areas passed. Bed checked again with Low Air Loss Mattress inflated and deflated, Zone l again passed. [DATE] 100% audit of all beds, by the Admission Coordinator, noted 8 beds against the wall as care plan approach for fall prevention. Maintenance notified to remove the side rail against the wall in rooms 204 (left), 208 (right), 209 (right), 210 (left), 211 (left), 214 (left), 301 (right), 318 (right). Side rails removed [DATE]. [DATE] In-Service held by Lead Maintenance Tech, Administrator, and DON on Bionix Safety Technologies Bed System Measuring Device Test Results and Worksheet reviewed with the Maintenance Department. Maintenance Techs provided return demonstration regarding utilization of the Bionix device and measuring of the bed/side rails with pass/fail results. The entire Maintenance Department reiterated that they had and continue to have knowledge of the Bionix process of measuring mattress/bed. [DATE] DON and Administrator re-educated Admission Nurse, RN Manager, Health Services Nurse Specialist, MDS Coordinator, and MDS Assistant on completion of the side rail assessment, notifying resident/resident representative. Will utilize therapy screens for appropriateness of side rails in conjunction with nursing services. [DATE] DON and Administrator reviewed electronic call light monitoring system reviewed for activity from CR1's room and there was none with a date range of [DATE]-[DATE]. [DATE] Scheduled QA meeting conducted. Incident from [DATE] discussed including action plan/plan of correction. [DATE] Ad Hoc QA Committee meeting scheduled for 9:00 am [DATE]. [DATE] Ad Hoc QA Committee Meeting. [DATE] After investigation/review by the Ad Hoc QA Committee, to eliminate the possibility of future entrapment, all quarter side rails removed by Maintenance [DATE]. Admission Nurse, LPN, RN Manager, Health Services Nurse Specialist, LPN, notified resident/resident representative of removal of quarter side rails. Therapy Department re-screened residents for the need for alternatives to side rails, [DATE]. Care Plans/ Kardex's updated by MOS, [DATE]. [DATE] After investigation/review by the Ad Hoc QA Committee, the 8 beds, against the wall, as care plan approach for fall prevention, were moved away from the wall and an additional fall mat was put in to place related to the therapy screen or another appropriate intervention was put in place from the therapy screen by the Therapy Department. Care plans/Kardex updated by MDS Nurses. [DATE] Current staff were educated regarding the elimination of side rails, alternatives to side rails, fall precautions and location. Staff were re-educated regarding two hour rounding process and newly hired nursing staff will be informed of all of the above including two hour rounding process by Director of Nursing or Designee and/or Health Services Manager/CNA Mentor. All staff were educated before their next scheduled shift. [DATE] Social Worker held a special Resident Council meeting to explain the discontinuation of quarter length side rails in the facility to eliminate the possibility of entrapment. Social Worker discussed alternative options to quarter length side rails. [DATE] In order to ensure alternatives to quarter length side rails were implemented/documented MD orders reviewed and revised as needed, Care Plans reviewed and revised as needed, Point of Care Kardex reviewed and revised as needed by MDS Coordinator, RN, MDS Assistant, LPN, and Health Services Nurse Specialist, LPN. [DATE] Side Rail Policy, 2100.211 revised by Administrator and communicated to staff. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: Newly hired maintenance department employees will receive training on the use of the Bionix measuring system by the lead maintenance technician and Relias (On Line Training) and instructed to remove bed rails from any newly purchased beds. 100% audit daily times one week and then weekly for one month by Maintenance Department to ensure no side rails present. Audits will be given to the VP of operations. POC, Investigation reviewed by Ad Hoc QA Committee on [DATE] and will become part of the QA process for the next three months to ensure continued compliance. Corrective action completion date: [DATE] 47257

Based on interviews and record review, it was determined that the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was completed accurately for 1 Resident (R)42 of 1 resident reviewed for PASARR. Findings include: During an interview on 04/12/2023 at 10:43 AM, the Administrator stated the facility did not have a PASARR policy. Review of a Clinical/Charting Snapshot revealed the facility admitted R42 on 11/07/2022 with a diagnosis of bipolar disorder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed R42 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS indicated the resident had bipolar disorder and took an antipsychotic medication. A review of the Plan of Care-Current for R42, with an effective date of 11/17/2022, revealed the resident had a diagnosis of bipolar disorder and received an antipsychotic medication daily and/or as needed. A review of a Discharge Summary indicated R42 was discharged from a local hospital on [DATE] with diagnoses that included bipolar disorder, which was noted on 06/16/2011 and 09/09/2020. A review of a PASARR - Level 1 Screening Form, with a review date of 11/07/2022, revealed the form was completed by the social worker (SW) from the local hospital and it indicated R42 did not have a diagnosis of a mental illness and no further evaluation was recommended. The hospital SW indicated the information to complete the form was obtained from the resident and the resident's chart. During an interview on 04/12/2023 at 4:06 PM, SW2 stated the Level I PASARR was completed by the hospital the resident was discharged from and was completed before the resident was admitted to the facility. SW2 stated the admission nurse, Licensed Practical Nurse (LPN) #3, reviewed the Level I PASARR for accuracy and uploaded it to the resident's electronic health record (EHR), and then SW2 reviewed it for accuracy once it had been uploaded. SW2 stated she reviewed R42's Level I PASARR, and the document indicated there were no further recommendations. SW2 stated if there were any findings on the Level I PASARR, then she would refer them to the Community of Long Term Care (CLTC), a contracted company that completed Level II PASARRs. SW2 stated she should have reviewed R42's Level I PASARR to ensure it was accurate before the resident was admitted to the facility. During an interview on 04/13/2023 at 10:05 AM, LPN3 stated SW2 was responsible for reviewing the Level I PASARR for accuracy. LPN3 stated she did not review them, she only scanned them into the resident's EHR. During an interview on 04/13/2023 at 10:08 AM, the Director of Nursing (DON) stated the referring hospital was responsible for completing a resident's Level I PASARR before the resident was admitted to the facility. The DON stated the medical team, which included the nurse practitioner and medical doctor, would review the Level I PASARR for medical accuracy, but not until after the resident had been admitted to the facility and the medical team completed the resident's initial review. The DON stated she was not sure who was reviewing the Level I PASARRs for accuracy. The DON stated LPN3 ensured the facility had a Level I PASARR on every resident before admittance. The DON stated she completed all the referrals to the facility, and it should probably be the DON that reviewed the Level I PASARRs for accuracy, but she had not been doing so. During an interview on 04/14/2023 at 8:18 AM, the Administrator (ADM) stated if the resident was admitted from a hospital, the hospital was responsible for completing the resident's Level I PASARR. The ADM stated the social worker, or the admissions coordinator, or a combination of the two staff, were responsible for ensuring the Level I PASARR was accurate. The ADM acknowledged the hospital did not indicate R42 had a diagnosis of bipolar disorder on the Level I PASARR. The ADM stated she expected the social worker and admissions coordinator to review the Level I PASARR for accuracy.

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure the medication error rate was not 5% or greater. Observation of medication administration revealed there were 3 errors out of 28 opportunities observed which resulted in a medication error rate of 10.71%. This effected 1 (Resident (R)23) of 2 residents observed during medication administration. Findings included: A review of the facility's policy titled, Administration of Medication, revised 08/23/2023, revealed, when preparing medication to administer to a resident, staff should Comply with the Five Rights of Medication Administration: Right resident; Right drug; Right dose; Right time; Right route. During observation of medication administration on 04/12/2023 at 8:18 AM, Licensed Practical Nurse (LPN)1 prepared medication for R23 to administer orally. The medications prepared and administered to the resident included: - Tums Ultra (calcium carbonate) 1000 milligrams (mg), two chewable tablets - Acetaminophen 500 mg, one tablet - Flonase (fluticasone propionate) nasal spray 50 micrograms (mcg), one spray in each nostril A record review of R23's Medication Record and Physician Orders revealed that during the 9:00 AM medication administration, the resident was to receive the following medications: - Tums regular strength (calcium carbonate) 500 mg, two tablets (1000 mg) by mouth one time a day for reflux. - Acetaminophen 650 mg, one tablet by mouth three times a day for pain. - Flonase (fluticasone propionate) 0.05 mg actuation spray, instill two sprays into each nostril one time day for nasal congestion. The record review revealed the Tums, acetaminophen, and Flonase were not administered to Resident #23 as ordered. An interview with LPN1 on 04/12/2023 at 10:25 AM revealed there were two bottles of Tums in the medication cart for R23. One bottle contained a strength of 500 mg per tablet and the other bottle contained tablets that were 1000 mg per tablet. LPN1 stated the Tums that were provided to R23 were from the bottle containing the 1000 mg tablets. LPN1 stated she gave the resident two tablets, which equaled 2000 mg, and the resident's order was for 1000 mg. LPN1 stated she did not realize there were different strengths available. LPN1 then pulled out a medication card for acetaminophen 650 mg tablets. The LPN stated she had discarded the card for the acetaminophen 500 mg tablets because it was empty. LPN1 stated the 500 mg acetaminophen was ordered for R23 to be used as-needed (PRN) and the acetaminophen 650 mg was ordered on a routine basis. She stated it appeared that she provided the resident with the PRN dose instead of the routine dose. LPN1 stated she instilled one spray in each nostril of the Flonase and, according to the resident's physician's orders, the resident should have received two sprays in each nostril. LPN1 stated she should have double checked the physician's order before providing the resident with the medications. During an interview on 04/13/2023 at 10:14 AM, the Director of Nursing (DON) stated that for staff to ensure the resident was receiving the correct medication, staff should follow the five Rs, which were the right resident, right route, right time, right dose, and right frequency. During an interview on 04/13/2023 at 10:21 AM, the Administrator (ADM) stated that for staff to ensure the resident was receiving the correct medication, staff should use the five rights, which were the right resident, right time, right medication, right route, and right dose. The ADM stated if a nurse had a question about a medication, they should stop and get clarification.

Based on observations, interviews, and facility policy review, it was determined the facility failed to ensure 1 (300 Hall) of 4 medication carts observed were locked when unattended to limit access to only authorized personnel. Findings include: A review of the facility's policy titled, Storage of Medication, revised 06/27/2018, revealed, Medication rooms, carts and medication supplies should be locked or attended by persons with authorized access. A review of the facility's policy titled, Administration of Medication, revised 08/23/2023, revealed staff should, Lock the cart when not in use and Leave the cart at the door of the resident's room within direct line of vision when unlocked. During a concurrent observation and interview on 04/12/2023 at 7:50 AM, Licensed Practical Nurse (LPN)1 parked the medication cart in front of room [ROOM NUMBER] to administer medications to the resident in that room. LPN1 removed medications from the cart and took the medications into room [ROOM NUMBER], leaving the medication cart unlocked and unattended. The medication cart was located against the wall in front of room [ROOM NUMBER] and was not visible to LPN #1 once LPN1 entered the resident's room. At 7:55 AM, LPN1 exited room [ROOM NUMBER] and opened the top drawer of the medication cart without attempting to unlock it. LPN1 acknowledged she had left the medication cart unlocked. The LPN stated it should have been locked when unattended, and she did not know why she left it unlocked. Observation of the contents of the medication cart on 04/12/2023 at 8:18 AM revealed the cart included antidiabetic medications, antihypertensive medications, and stool softeners that could be potentially harmful if ingested by a resident for whom the medication was contraindicated. During an interview on 04/13/2023 at 10:14 AM, the Director of Nursing (DON) stated staff should ensure medication carts were locked when unattended. During an interview on 04/13/2023 at 10:21 AM, the Administrator (ADM) stated medication carts should be in the nurse's line of vision or in another person of authority's line of vision; if not, the medication cart needed to be locked.

Based on observation, record review and interview, the facility failed to provide a privacy cover for Resident (R) 216's urinary catheter bag per the baseline care plan, 1 of 3 sampled residents with Urinary Catheters. The findings included: The facility admitted R216 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/28/21 at 3:42 PM, R216 was observed from the hallway outside of his/her room. The resident was lying in bed. The catheter bag was hanging from the bed rail, on the side of the bed facing the hallway. The catheter bag appeared to contain clear, yellow urine. There was no privacy cover on the catheter bag to prevent staff, visitors and other residents from observing R216's urine. On 09/29/21 at 8:45 AM, R216 was observed from the hallway outside of his/her room. R216 was lying in bed and the catheter bag was hanging from the same location as the previous observation. The catheter bag was uncovered and appeared to contain clear, yellow urine. Record review of R216's baseline care plan, on 9/29/21 at 9:39 AM, revealed a problem area indicating R216 had a urinary catheter due to urinary retention. Interventions listed for the urinary catheter included Watch to be sure that my urine is draining freely and the catheter bag is covered and emptied frequently. During an interview with Certified Nursing Assistant (CNA) 1, in the hallway outside R216's room on 09/29/21 at 8:45 AM, CNA 1 confirmed the catheter bag was uncovered. CNA 1 also confirmed the uncovered catheter bag could be observed from the hallway. CNA 1 was asked if the facility provided privacy covers for urinary catheters. CNA 1 stated, yes they are supposed to have a privacy cover, and s/he would go get one for R216. During an interview with the DON, on 9/29/21 at 10:30 AM, the DON confirmed the baseline care plan indicated the resident's catheter bag should be covered.

Based on observation, interview and review of facility policy, the facility failed to promote and maintain the dignity of Resident (R) 216, 1 of 3 sampled residents with Urinary Catheters. R216 was not provided a privacy cover for their catheter bag. The findings included: The facility admitted R216 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/28/21 at 3:42 PM, R216 was observed from the hallway outside of his/her room. The resident was lying in bed. The catheter bag was hanging from the bed rail, on the side of the bed facing the hallway. The catheter bag appeared to contain clear, yellow urine. There was no privacy cover on the catheter bag to prevent staff, visitors and other residents from observing R216's urine. On 09/29/21 at 8:45 AM, R216 was observed from the hallway outside of his/her room. R216 was lying in bed and the catheter bag was hanging from the same location as the previous observation. The catheter bag was uncovered and appeared to contain clear, yellow urine. Certified Nursing Assistant (CNA) 1 was interviewed in the hallway outside R216's room on 09/29/21 at 8:45 AM. CNA 1 confirmed the catheter bag was uncovered and could be observed from the hallway. CNA 1 was asked if the facility provided privacy covers for urinary catheters. CNA 1 stated, yes they are supposed to have a privacy cover, and s/he would go get one for R216. CNA 1 was re-interviewed on 9/29/21 at 9:47 AM. CNA 1 stated since R216 was in a private room s/he didn't necessarily have to have a privacy cover for the catheter bag. CNA 1 stated all residents with a urinary catheter need a privacy cover if they are outside their rooms. CNA 1 was asked why residents would need a privacy cover outside of their rooms as opposed to inside their rooms. CNA 1 stated it would be a dignity issue if everyone could see the resident's uncovered catheter bag, so they cover them when residents leave their rooms. During an interview with the Director of Nursing (DON), on 9/29/21 at 9:52 AM, the DON stated the facility considers a resident's private room to be their personal space. The DON stated it is not a dignity issue if they do not have a privacy cover on their catheter bag in their personal space. The DON stated it is the resident's preference to use a privacy cover in their room or not to use one. The DON stated it would be a dignity concern if a resident with a urinary catheter was outside of their room in public spaces with no privacy cover for the catheter bag. The DON was asked would it not also be a dignity concern if a resident's uncovered catheter bag could be observed from the hallway by staff, visitors and other residents. The DON did not answer that question and replied it is the resident's preference whether or not to use a privacy cover when in their private room. During an interview with the DON, on 9/29/21 at 10:30 AM, the DON stated there was no documentation to indicate if it was R216's preference to have the catheter bag covered or not when in his/her room. The DON confirmed the baseline care plan indicated the resident's catheter bag should be covered. Review of the facility's Promoting/Maintaining Resident Dignity policy revealed resident dignity was promoted by maintaining the resident's privacy. Review of the facility's Urinary Catheter Care policy revealed residents with a urinary catheter, who have a private room, will not be provided with a privacy bag, when in their room, unless privacy bag specifically requested.

Based on interviews, record review, and review of facility policy, the facility failed to ensure that one (1) of five (5) sampled residents (Resident #5) was free of sexual abuse. Resident #4 had a history of [REDACTED]. Resident #4 was observed with his/her hand down Resident #5's shirt touching his/her breast. Resident #5 did not have the mental capacity to consent to sexual interaction. Findings include: Review of the facility policy Resident Neglect, Abuse, & Prevention revised 6/28/2019 revealed the following: Purpose: Residents of(NAME)Commons have the right to be free from verbal abuse, involuntary seclusion, neglect, misappropriation of resident property, physical abuse, mental abuse, sexual abuse, and any other abuse or neglect which might put the resident's physical health, mental health, or welfare in jeopardy. Policy: Residents shall be free from abuse and neglect. Staff members, other residents, consultants, volunteers, staff of other agencies serving the resident, family members and/or legal guardians (responsible party), and friends shall not abuse, neglect or jeopardize in any way the welfare of any resident. Review of Resident #4's clinical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed with [REDACTED]. Resident #4 exhibited no behaviors directed towards other residents but refused care one (1) to three (3) days during the assessment period. Resident #4 was not receiving any [MEDICAL CONDITION] medications. The resident received Physical Therapy and Occupational Therapy and expected to return to the community. Review of the resident's Nursing Progress Notes and hospital Discharge Summary revealed Resident #4 was admitted to the hospital for a transurethral resection of the prostate on 3/20/2020 and returned to the facility on [DATE]. An MDS dated [DATE] assessed the resident's BIMs score at 11, indicating moderate cognitive impairment at the time of the assessment. Review of Resident #4's comprehensive care plan revealed a handwritten entry dated 4/10/2020 on the Activities of Daily Living care plan that stated, makes inappropriate comments to staff at times. There was no description of the nature of the comments and no interventions in place to address the behavior. A review of the Nurse's Note dated 5/3/2020 at 2:10 p.m. revealed the resident had one to one (1:1) care from Certified Nursing Assistant (CNA) from 10 a.m. until he/she was discharged home at 2:10 p.m. with family member picking him/her up. There was no documentation in the medical record indicating Resident #4 had displayed inappropriate sexual behavior to another resident. A review of the facility's investigation revealed the following: An Incident/Accident Report written by RN #1, dated 5/3/2020 revealed the following occurrence in the Common Area at 10:15 a.m.: Was told by Laundry/Housekeeping Staff that he/she witnessed the resident with his/her hand down in another resident's shirt. (His/her) hands were more over (his/her) breast. Separated resident from all residents and he/she had 1:1 contact with CNA. D/ced (discharged ) safely home with (son/daughter) 5/3/2020 approximately two (2). A statement by Housekeeper #1 noted he/she observed Resident #4 in Commons area sitting with Resident #5. He/she stated he/she saw Resident #4, lean in and rub Resident #'5's shoulder area. Housekeeper #1 stated he/she looked back to see Resident #4 rubbing Resident # 5's breast outside of his/her shirt. As staff approached Resident #4, He/she had his/her hand down Resident #5's shirt and was rubbing the resident's breasts. The staff member returned and stopped Resident #4 and reported it to RN #1. In a typed statement dated 5/3/2020 at approximately 10:20 a.m., RN #1 noted Resident #4 was interviewed regarding the incident with Resident #5 and he/she denied the incident. The resident stated, I don't think I did anything wrong; won't you give me another chance? Further review of the facility investigation documents revealed that on 5/4/2020 - 5/5/2020 72 nursing employees were interviewed by the Administrator and Director of Nursing (DON). Three employees reported they had noted the Resident #4 is his/her room with his/her genitals exposed. There was no documentation of when this had occurred. Three (3) employees stated the resident made inappropriate comments to them. There was no documentation describing the comments or when they occurred. Review of the facility's investigation dated 5/5/2020 at 5:30 a.m. revealed 11 housekeeping, laundry, and janitorial staff were interviewed by the Administrator and Director of Nursing (DON). One staff member reported seeing Resident #4 with his/her hand on another resident's arm but did not observe any inappropriate behavior. Another employee reported seeing Resident #4 with his/her hand on another resident's knee but did not observe inappropriate behavior. There was no documentation revealing when this behavior had occurred. A Police Report dated 5/3/2020 documented the incident between Resident #4 and Resident #5 had been reported to Law Enforcement. During an interview conducted with the Director of Nursing (DON) on 10/7/2020 at 9:35 a.m., he/she reviewed Resident 4's care plan and confirmed that staff had written that Resident #4 made inappropriate comments to staff. He/she was unable to identify the writer. The DON confirmed the behavior should have been more thoroughly described and interventions put into place to address the behavior. An interview was conducted with Social Worker (SW) #1 on 10/7/2020 at 11:00 a.m. SW #1 stated he/she had not been made aware of any inappropriate sexual behaviors exhibited by Resident #4. During a telephone interview with RN#1 on 10/7/2020 at 11:30 a.m., RN #1 stated Resident #4 initially denied the incident and then stated he/she would, not do it again. RN #1 stated Resident #4 did not seem confused and was alert and oriented. An interview conducted with Licensed Practical Nurse (LPN) #1 on 10/7/2020 at 1:42 p.m. revealed that Resident #4 made comments about his/her breast size when he/she served meals but he/she could not recall him/her touching anyone inappropriately or making other inappropriate comments until the incident with Resident #5. LPN #1 stated he/she didn't, think much about the comments or he/she would have reported them to the Director of Nursing (DON). LPN #1 stated that sometimes when the resident was in his/her private room, his/her genitals would be exposed. LPN #1 stated he/she did not believe the exposure was deliberate. During an interview conducted with RN #2 on 10/7/2020 at 2:11 p.m., RN #2 stated Resident #4 had been observed lying on top of the covers of the bed in his/her room with his/her genitals exposed, but he/she did not believe the exposure to be deliberate. During an interview conducted with Certified Nursing Assistant (CNA) #1 on 10/7/2020 at 2:24 p.m., he/she revealed that Resident #4 made kidding remarks with staff telling them they had nice breasts or buttocks, but never observed him/her make an inappropriate comment or touch another resident inappropriately. He/she stated he/she was not concerned about Resident #4's comments because he/she felt he was, cutting up. CNA #1 stated he/she received training on abuse and that he/she would have notified the nurse if he/she believed Resident #4's comments were inappropriate or if the resident was observed making inappropriate comments to another resident or touching another resident inappropriately. CNA #1 revealed he/she was caring for Resident #4 on the day of the incident with Resident # 5 and he/she observed Resident #4 sitting with Resident #5 and feeding him/her breakfast. CNA #1 stated Resident #4 fed Resident #5 a bit of his/her food and then took a bite off of the same plate. CNA #1 stated that Resident #4 was instructed not to feed Resident #5 and not to eat off Resident #5's plate. Resident #4 responded he/she was trying to help Resident #5. CNA #1 stated Resident #4 did not seem confused on that date. During a telephone interview conducted with Resident #4's Physician on 10/7/2020 at 3:00 p.m., he/she stated that the Administrator called and advised him/her that Resident #4 had touched another resident inappropriately and felt that Resident #4 should be discharged because of the risk to other residents. The Physician stated that he/she okayed the discharge and felt that Resident #4 was safe to discharge. A telephone interview was conducted with Housekeeper #1 on 10/7/2020 at 3:25 p.m. He/she revealed that while passing through the Commons area Resident #4 was observed sitting very close to Resident #5 and rubbing his/her arm. He/she stated the behavior was concerning and he/she decided to make the nurse aware to keep an eye on them. Housekeeper #1 stated that he/she returned to the Common Area to find the Nurse and observed Resident #4 with his/her hand down Resident #5's blouse and rubbing Resident #5's breast. Housekeeper #1 stated that Resident #4 was told to stop and that he/she could not do that. Housekeeper #1 moved Resident #4 away from Resident #5. He/she stated that Resident #4 stated, It's okay, we are friends. Housekeeper #1 stated she moved Resident #4 away from Resident #5, instructed him/her to return to his/her room and reported the incident to the Nurse. He/she stated that Resident #5 was sitting in his/her chair and did not seem upset by the incident or aware that anything had happened to him/her. Review of Resident # 5's clinical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS revealed Resident #5 scored a three (3) on the BIMs assessment, indicating severe cognitive impairment. Resident #5 exhibited no hallucinations, delusions, or behaviors during the assessment period. The resident required supervision with eating, moderate assistance with bed mobility, locomotion on unit, and extensive assistance with transfers, dressing, and locomotion off the unit. The resident was dependent for toileting and used a wheelchair for mobility. The resident did not receive any [MEDICAL CONDITION] medications. A review of Resident 5's Quarterly MDS dated [DATE] revealed Resident #5 did not exhibit any behaviors. A review of the facility's investigation report revealed that the Administrator and DON attempted to interview the Resident #5 on 5/4/2020, but the resident was not interviewable. A review of Resident #5's Social Progress notes on 5/6/2020 revealed SW #1 visited with resident to assess if any distress or anxiety. Resident #5 was not alert and oriented. SW #1 noted that Resident #5 had periods of confusion and lacked the ability and insight to follow conversation. The note revealed the resident appeared to be maintaining previous social and daily routine without worries. On 5/7/2020 SW #1 documented a follow up with Resident #5's family member regarding the previous incident. The family member requested the social worker continue to follow up with the resident. On 5/14/2020 SW #1 documented a 1:1 visit with Resident #5 to assess the resident's mood. Resident #5 reported she was okay. The note revealed the resident continued to verbalize positive statements asking about daughter and lunch. SW#1 documented she would follow up as needed with Resident #5. An observation of Resident #5 on 10/6/2020 at 10:10 a.m. revealed the resident in the Common Area in a wheelchair. The resident did not respond verbally to the surveyor's greeting. A subsequent observation at 12:30 p.m. revealed the resident remained in the common area eating. The resident looked at the surveyor when spoken to but did not respond. An observation on 10/7/2020 at 2:00 p.m. revealed Resident #5 sitting in the Common Area in a wheelchair. The resident responded appropriately to the surveyor's greeting but did not respond to questions. During an interview conducted with SW #1, on 10/7/2020 at 3:10 p.m., he/she stated that Resident #5 did not seem to be affected by the incident with Resident # 4. He/she stated she one on one visits were conducted with Resident #5 for two weeks to make certain there were no untoward effects, and the resident did not display any behaviors that indicated he/she had been affected by the incident.

Based on staff interview and record review, the facility failed to ensure appropriate discharge documentation was obtained prior to discharge for one (1) of five (5) sampled residents (Resident #4). The facility initiated an immediate discharge of Resident #4 following an incident of sexual abuse by Resident #4 towards Resident #5. The physician's orders [REDACTED].#4 was not documented. The Physician failed to document the reason for the discharge and what the facility's efforts consisted of to meet Resident #4's needs prior to the discharge. Findings include: Review of Resident #4's clinical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was assessed with [REDACTED]. Resident #4 exhibited no behaviors directed towards other residents but refused care one (1) - three (3) days during the assessment period. Under Functional Status, Resident #4 was assessed to require limited assistance for bed mobility, transfers, ambulation in the room and hygiene. The resident required extensive assistance with locomotion on the unit, dressing, hygiene and was dependent for toileting. The resident was admitted with a Foley catheter. The resident used a walker and wheelchair for mobility. A review of the resident's medications revealed the resident was not receiving [MEDICAL CONDITION] medications. The MDS revealed the resident received Physical Therapy and Occupational Therapy and expected to return to the community. Review of the resident's Nursing Progress Notes and Hospital Discharge Summary revealed Resident # 4 was admitted to the hospital for a transurethral resection of the prostate on 3/20/2020 and returned to the facility on [DATE]. A five-day MDS dated [DATE] assessed the resident's BIMs score at 11, indicating mild cognitive impairment at the time of the assessment. A review of the facility's abuse investigation revealed the following: An Incident/Accident Report written by RN #1 and dated 5/3/2020 revealed the following occurrence in the Common Area at 10:15 a.m. : Was told by Laundry Staff #1 that (he/she) witnessed the resident (Resident #4) with his/her hand down in another (male/female) resident's shirt (Resident #5). His/her hands (Resident #4) were more over (his/her) breast. Separated resident (Resident #4) from all residents and he/she had 1:1 contact with CNA. D/ced (discharged ) (Resident #4) safely home with(son/daughter) 5/3/2020 approximately two (2:00 p.m.). A statement by Housekeeper #1 noted he/she observed Resident # 4 in Commons area sitting with Resident # 5. He/she stated he/she saw Resident #4 lean in and rub Resident #5's shoulder area. Housekeeper #1 stated he/she looked back to see Resident #4 rubbing Resident #5's breast outside of his/her shirt. As staff approached Resident #4, He/she had his/her hand down Resident #5's shirt and was rubbing the resident's breasts. The staff member stopped Resident #4 and reported to RN #1. A review of the Nurse's Note dated 5/3/2020 at 2:10 p.m. revealed Resident # 4 had one to one (1:1) care from Certified Nursing Assistant (CNA) from 10:00 a.m. until he/she was discharged home at 2:10 p.m. with a family member picking him/her up. An undated typed statement by the Admissions Coordinator in the investigation packet documented that on 5/3/2020 he/she spoke with Resident #4's Responsible Party (RP) and advised him/her that staff had witnessed Resident #4 with his/her hand down the shirt of another resident who was fully demented. The Admissions Coordinator informed the RP that this was considered sexual abuse and that Resident #4 would be discharged from the facility that day. The RP apologized and stated he/she would pick the resident up. Resident # 4's Physician order [REDACTED]. Review of Resident #4's physician progress notes [REDACTED]. There was no documentation indicating the reason for Resident 4's discharge or what the facility's efforts consisted of to meet Resident # 4's needs prior to the discharge. During an interview conducted with the Administrator on 10/6/2020 at 9:45 a.m., he/she revealed that Resident #4 was discharged the day of the incident on 5/3/2020. The Administrator stated the resident was a risk to other residents. The Administrator stated the Responsible Party (RP) had no problem with taking the resident home. An interview was conducted with the Admissions Coordinator on 10/7/2020 at 10:45 a.m. The Admissions Coordinator revealed that he/she was contacted at home and made aware of the incident on 5/3/2020. The Administrator informed him/her that the Interdisciplinary Team had decided that Resident # 4 should be discharged . The Admissions Coordinator revealed that he/she contacted the RP and advised him/her that Resident #4 touched another resident inappropriately. She stated that the Responsible Party (RP) agreed to come and get the resident. He/she confirmed that the RP was asked to pick up Resident #4 as soon as possible. An interview was conducted with Social Worker (SW) #1 on 10/7/2020 at 11:00 a.m. SW #1 stated Resident # 4 was discharged on a weekend and the discharge was unplanned. SW #1 was not at the facility at the time of discharge. SW #1 revealed that Resident #4 was initially admitted for a short stay with plans to return to the community, but about halfway through his/her stay he/she decided to remain in the facility as he/she did not like being alone at home. SW#1 stated that Resident # 4 used up his/her skilled days and converted to a private pay status. An interview was conducted with the Administrator on 10/7/2020 at 2:40 p.m. in the Conference Room. The Administrator revealed that she spoke with Resident # 4's Physician on the date of the incident and obtained a telephone order to discharge the resident. The Administrator stated that he/she did not document the order in the medical record and there was no documented physician's orders [REDACTED]. During an interview conducted with Certified Nursing Assistant (CNA) #1 on 10/7/2020 at 2:24 p.m. he/she revealed that she was caring for Resident #4 on the day of the incident with Resident # 5. CNA #1 stated Resident #4 did not seem confused on that date but was very upset and did not want to leave the facility at the time of discharge. During a telephone interview conducted with Resident #4's Physician on 10/7/2020 at 3:00 p.m., he/she stated that the Administrator called and advised him/her that Resident #4 had touched another resident inappropriately and felt that the resident should be discharged because of the risk to other residents. The Physician stated that he/she recalled Resident #4 was mentally competent and was not aware of Resident #4 exhibiting any behaviors until the date of the incident. The Physician stated that he/she okayed the discharge and felt that Resident #4 was safe to discharge. The Physician confirmed he/she did not examine Resident #4 the day of discharge.

Based on staff interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident #4) was adequately prepared to ensure a safe and orderly discharge from the facility. The facility initiated an immediate discharge of Resident #4 following an incident of sexual abuse by Resident #4 towards Resident #5 without adequate preparation for Resident #4 and his/her family. The findings include: Review of Resident # 4's clinical record revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident #4 was assessed with [REDACTED]. Resident #4 exhibited no behaviors directed towards other residents but refused care one (1) to three (3) days during the assessment period. Under Functional Status, Resident #4 was assessed to require limited assistance for bed mobility, transfers, ambulation in the room and hygiene. The resident required extensive assistance with locomotion on the unit, dressing, hygiene and was dependent for toileting. The resident was admitted with a Foley catheter. The Resident used a walker and wheelchair for mobility. A review of the resident's medications revealed the resident was not receiving [MEDICAL CONDITION] medications. The MDS revealed the resident received Physical Therapy and Occupational Therapy and expected to return to the community. A review of the facility's abuse investigation revealed the following: An Incident/Accident Report written by RN #1 and dated 5/3/2020 revealed the following occurrence in the Common Area at 10:15 a.m. : Was told by Laundry Staff #1 that (he/she) witnessed the resident with his/her hand down in another (male/female) resident's shirt. His/her hands were more over (his/her) breast. Separated resident from all residents and he/she had 1:1 contact with CNA. D/ced (discharged ) safely home with son 5/3/2020 approximately two (2:00 p.m.). A statement by Housekeeper #1 noted on 5/3/2020 he/she observed Resident # 4 in Commons area sitting with Resident # 5. He/she stated he/she saw Resident #4 lean in and rub Resident #5's shoulder area. Housekeeper #1 stated he/she looked back to see Resident #4 rubbing Resident #5's breast outside of his/her shirt. As staff approached Resident #4, He/she had his/her hand down Resident #5's shirt and was rubbing the resident's breasts. The staff member stopped Resident #4 and reported to RN #1. An undated typed statement by the Admissions Coordinator in the investigation packet documented that on 5/3/2020 he/she spoke with Resident #4's Responsible Party (RP) and advised him/her that staff had witnessed Resident #4 with his/her hand down the shirt of another resident who was fully demented. The Admissions Coordinator informed the RP that this was considered sexual abuse and that Resident #4 would be discharged from the facility that day. The RP apologized and stated he/she would pick the resident up. Review of Resident #4's medical record revealed there was no care plan or any other document addressing or planning for Resident #4's discharge from the facility. A Nurse's Note dated 5/8/2020 revealed the resident was discharged home on[DATE] with (son/daughter) and home health. Further review of Resident #4's medical record revealed the resident's history and physical, patient information report, and medications were faxed to a homecare agency on 5/11/2020, eight (8) days after discharge. During an interview conducted with the Administrator on 10/6/2020 at 9:45 a.m., he/she revealed that Resident #4 was discharged the day of the incident on 5/3/2020. The Administrator stated the resident was a risk to other residents. The Administrator stated the RP had no problem with taking the resident home, and home health was to be involved in his/her care. The Administrator could not say when a Home Health referral was made. An interview was conducted with the Admissions Coordinator on 10/7/2020. At 10:45 a.m. The Admissions Coordinator revealed that he/she was contacted at home and made aware of the incident on 5/3/2020. The Administrator informed him/her that the Interdisciplinary Team had decided that Resident # 4 should be discharged . The Admissions Coordinator revealed that he/she contacted the RP and advised him/her that Resident #4 touched another resident inappropriately. She stated that the Responsible Party (RP) agreed to come and get the resident. He/she confirmed that the RP was asked to pick up Resident #4 as soon as possible. An interview was conducted with Social Worker (SW) #1 on 10/7/2020 at 11:00 a.m. SW #1 stated Resident # 4 was discharged on a weekend and the discharge was unplanned. SW #1 was not at the facility at the time of discharge. SW #1 revealed that Resident #4 was initially admitted for a short stay with plans to return to the community, but about halfway through his/her stay he/she decided to remain in the facility as he/she did not like being alone at home. SW#1 stated that Resident #4 used up his/her skilled days and converted to a private pay status. SW #1 stated that after Resident #4 was discharged , the RP contacted him/her to fax paperwork to an Assisted Living Facility and he/she also faxed information to a home health agency. SW #1 did not recall when a referral was made for Home Health. SW #1 stated the medical record was closed and he/she did not document follow up in the record. SW #1 confirmed he/she had worked the week after Resident # 4's discharge and confirmed the paperwork was faxed to the homecare agency on 5/11/2020, eight (8) days after Resident #4's discharge. SW #1 could not produce any documentation or care plan regarding discharge planning for Resident #4 and did not recall contacting the RP the week after Resident #4 was discharged . A telephone interview was conducted with RN #1 on 10/7/2020 at 11:30 a.m. RN #1 stated that when the RP picked up the resident, she met him/her in the vestibule of the facility and reviewed Resident 4's medications. RN #1 stated that Resident #4 cared for his/her catheter, and he/she did not give the RP instructions regarding catheter care or other needs of Resident #4. RN #1 stated the RP asked, What do I need to do? and he/she was instructed to contact the Social Worker the next morning for assistance. During an interview conducted with Certified Nursing Assistant (CNA) #1 on 10/7/2020 at 2:24 p.m. he/she revealed that Resident #4 was very upset and did not want to leave the facility when he/she was discharged . An interview was conducted with the Administrator on 10/7/2020 at 2:40 p.m. which revealed that he/she spoke with Resident #4's Physician on the date of the incident and obtained a telephone order to discharge the resident. During a telephone interview conducted with Resident #4's Physician on 10/7/2020 at 3:00 p.m., he/she stated that the Administrator called and advised him/her that Resident #4 had touched another resident inappropriately and felt that the resident should be discharged because of the risk to other residents. The Physician stated that he/she okayed the discharge and felt that Resident #4 was safe to discharge. The Physician confirmed he/she did not examine Resident #4 the day of discharge. An attempt was made to reach Resident #4's RP by telephone and a message was left, but the RP did not return the surveyor's call.

Based on record review and staff interviews, the facility failed to monitor COVID-19 screening tools completed by staff to ensure that staff were properly checking and recording temperatures. Three Certified Nurse Aides (CNA) (CNA #1, CNA #2 and CNA #3) documented a low abnormal temperature, with no evidence of a temperature recheck. This deficient practice took place during the COVID-19 pandemic, and had the ability to affect all residents. The census was 58. The findings included: On 07/31/20, a record review was conducted of the facility's Infection Control Policy, COVID-19 policy, dated 03/24/20. It revealed that in order to prevent the introduction of COVID-19 into their campus, they would Monitor all staff upon entrance to building using screening tool and monitoring their temperatures. On a separate memo, dated 07/11/20, the Director of Nursing (DON) required, All staff will need to begin screening twice a shift, at the beginning of the shift and the middle of the shift. You may leave the building for lunch break but you must screen including temps when you return. There is now a screening notebook and thermometer at each touchdown unit. A sample of screening tools were reviewed on 07/31/20 and found the following abnormal temperatures on staff. - On 07/22/20, CNA #1 recorded a temperature at 83.2 degrees Fahrenheit (F). There was no other temperature recorded to indicate that it was rechecked. - On 07/23/20, CNA #2 recorded a temperature at 79.2 degrees F. There was no other temperature recorded to indicate that it was rechecked. - On 07/24/20, CNA #3 recorded a temperature at 85.9 degrees F. There was no other temperature recorded to indicate that it was rechecked. On 07/31/20 at 4:20 PM, the receptionist was interviewed about staff screening. S/he arrived to work at 8:30 AM, 90 minutes after the first shift arrived, so many staff recorded their own temperature. When the receptionist assisted with screening, s/he asked questions regarding signs and symptoms of COVID-19 and recorded it on the log. A temporal scan had been used to place in front of foreheads to record temperature. The device ran on batteries, indicating when it was low, and s/he changed the batteries weekly. In general, the receptionist had found the temporal thermometer to be less accurate than the oral thermometer, but many staff decline oral readings. If any staff temperatures were recorded above 99.9 degrees F, they cannot work. On 07/31/20 at 5:19 PM, Registered Nurse (RN) #1 was interviewed about recording the temperature of staff. The receptionist was responsible for monitoring the temperature book and would inform her/him about anything s/he had flagged. Recently the thermometer fell , was damaged and had to be replaced. They had extra back up thermometers. RN #1 shared that the receptionist did mention to her/him that some of the temperatures were reading low. Staff temperatures cannot be higher than 99 degrees F. On 07/31/20 at 5:25 PM, the Administrator was interviewed and relayed that staff had been told to get their temperatures rechecked if abnormal. S/he suspected that staff might have to go on the unit to get the oral thermometer. S/he felt it was likely that staff took a second temperature, but might not have returned to the desk to record it on the log.

Based on observation, interview, clinical record, and facility policy review, the facility failed to provide preventative measures to prevent the development of an avoidable pressure ulcer for 1 of 3 residents (Resident (R) 26) and failed to prevent infection of the pressure ulcer. Specifically, R26 developed a stage four pressure ulcer on her right heel within a week of admission and developed a bacterial infection of the pressure ulcer within 48 days of wound treatment by the facility. This deficient practice impacted R26's ability to walk and caused her pain during care of the pressure ulcer. The findings included: Observation on 09/23/19 at 08:46 AM, revealed R26 was observed lying on her back in bed. R26 stated, I usually stay in bed and watch television or read because of my foot. I have a sore on my foot and I can't put my shoe on. I've had it for a long time. R26 did not have an air mattress for pressure reduction and there were no pillows for positioning. Review of R26's Record of Admission, located in the resident's paper chart, indicated the facility admitted the resident on 04/22/19 with [DIAGNOSES REDACTED]. Review of R26's 48 Hour Care Plan, not dated, indicated, Resident is here for short-term rehabilitation.nursing and therapy will assist you with off-loading while in bed or chair to prevent pressure areas on your skin. The care plan was signed by R26. Review of the comprehensive care plan, dated 05/05/19, indicated a concern at risk for skin breakdown had revisions dated 05/05/19 which included routine body audits, provide supplements, consult wound MD, assist resident with turning and repositioning, float heels, provide treatment, monitor signs and symptoms of wound infections, encourage po intake, assess for pain, administer antibiotics, bunny boots as ordered. The revised care plan 06/18/19 arterial dopplers, culture right heel, follow new treatment orders. The care plan was revised. R26's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/19, indicated the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated cognitive impairment. R26 had no behaviors of rejection of care and required two persons assistance for bed mobility, extensive assistance for transfer and limited assistance for walking. R26 had no pressure ulcers on admission and was at risk for developing pressure ulcers according to the MDS. Review of R26's Nutritional Evaluation, dated 04/29/19, indicated Current diet order-regular.[MEDICAL CONDITION] slight lower extremity.skin condition intact.no pressure ulcers. R26's quarterly MDS, with an ARD of 07/24/19, indicated R26 continued to require two persons assistance for bed mobility, extensive assistance for transfer but no longer walked in her room, or corridor on the unit. R26 had no nutritional concerns and had not experienced weight loss. The MDS indicated the resident had an unhealed stage four pressure ulcer. (Stage 4 pressure ulcer-full thickness loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. If slough or eschar obscures the wound bed, the wound is considered unstageable). Review of R26's Nurse's Notes, dated 04/30/19 at 07:00 PM, indicated, Resident alert.resident has blister to right heel.feet floated off pillows. Nurse's notes, dated 05/05/19 at 07:00 PM, indicated, Right heel dressing changed. Blister open now but skin is in place Review of R26 Physician Orders, dated 05/08/19, indicated, .right heel, skin prep daily then cover with calcium alginate and cover with bordered gauze. These orders were discontinued and changed as the wound went from unstageable, was debrided and then was identified as a stage 4. Review of R26's Active physician's orders [REDACTED].cleanse with wound cleanser, pat dry with gauze, apply Santyl ointment, apply gauze island dressing.change daily.[DIAGNOSES REDACTED].bunny boots bilateral heels.ensure placement at all time except when ambulating or transferring. Review of a Wound Specimen, laboratory report, dated 06/20/19, revealed the wound on R26's right heel had a bacterial infection. The laboratory report indicated, Wound specimen from right heel collected on 06/18/19 was verified on 06/20/19 with final results-[MEDICAL CONDITION] Resistant Staph Aureus. (MRSA-[MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) is a cause of staph infection that is difficult to treat because of resistance to some antibiotics). Reference: Centers for Disease Control, (CDC). Review of the Treatment Administration Record, (TAR), dated 06/21/19, indicated R26 required an antibiotic due to the infection in the pressure ulcer on her right heel. The TAR indicated, [MEDICATION NAME] 50 mg by mouth twice daily for 10 days for [MEDICAL CONDITION] Staphylococcus aureus infection, give two tablets (100 mg) twice daily. Review of the Nurse's Notes, dated 06/21/19 at 11:00 PM, revealed there was no documentation regarding signs or symptoms of infection of the wound on R26's right heel. The notes indicated, Resident started antibiotic therapy [MEDICAL CONDITION] to the right heel wound. R26's Specialty Wound Physician Notes, dated 07/10/19, indicated, Surgical excision of pressure wound right heel, stage 4 pressure wound with moderate serous exudate. After excision of the dead tissue by the wound physician, the wound was a stage 4. Observation on 09/23/19 at 12:59 PM, revealed R26 lying on her back in bed with both heels against the mattress. The bunny boot (pressure reducing device) was not on her right heel and was lying at the foot of the bed. R26 stated, I can't put it on myself but when someone comes in, I'll get some help. The facility failed to ensure the preventative device was in use and pillows were used to keep the heel from the surface of the mattress. During an interview with the Director of Nursing (DON) on 09/24/19 at 12:54 PM, the DON stated, She (referring to R26) was deconditioned when she was admitted . She's a lot more mobile now. She was found to have [MEDICAL CONDITION] (impaired circulation) and that's what caused the pressure ulcer. The pressure ulcer was unavoidable because of the vascular disease. The DON verified the wound was identified by the facility as a pressure ulcer. On 09/24/29 at 03:00 PM, R26 was observed in bed lying on her back in bed. The right foot was out of the bed covers and did not have a bunny boot (pressure relieving device) on her foot. The bunny boot was at the top of the bed near R26's head. The facility failed to ensure the preventative device was in use and pillows were used to keep the heels off the surface of the mattress. During a follow-up interview on 09/25/19 at 08:18 AM, the DON stated, I agree not all residents with impaired circulation will develop a pressure ulcer. The DON was unable to find documented evidence that the facility provided pressure relieving interventions to prevent the development of the pressure ulcer. The DON stated, We typically don't use bunny boots for prevention. We started aggressively using them for her (referring to R26) when we discovered the pressure ulcer. She does take the boot off and we have to put it back on. On 09/25/19 at 8:21 AM, R26 was observed in bed on her back with both legs out of the covers. R26 was wearing socks and did not have a bunny boot on her right foot. The bunny boot was observed next to the resident's head. The facility failed to ensure the preventative device was in use. There were no pillows or device in use to keep the heels free from the surface of the mattress. On 09/25/19 at 10:13 AM, the DON verified that the facility could find no documentation that the resident had taken the bunny boots off. The DON stated, I couldn't find any documentation that the right heel was pressure off-loaded by direct care staff. There is no documentation in the nurses notes or the care plan that she takes the boot off herself. Review of an email, dated 09/25/19, from the Registered Dietitian indicated, Based on information from nutritional data collection, resident was not at nutritional risk for skin breakdown. Med pass (nutritional supplement) was added based on meal percentage consumed not consistently meeting nutritional needs. During an interview on 09/25/19 at 01:27 PM, the Certified Dietary Manager (CDM) stated, She (referring to R26) was not high risk for pressure ulcer development. Her pre-[MEDICATION NAME] level (laboratory test of the body's protein status for wound healing) was good and she had no pre-existing pressure wounds on admission. Her weight has been stable. On 09/25/19 at 3:15 PM, the wound care physician was observed providing wound care to R26. The wound care physician cleansed the wound on the residents' right heel, measured the wound and began to use a sharp instrument to debride the wound (Debride-remove dead tissue). When the wound doctor started cutting tissue from R26's heel, she pulled her foot back and said, Ow, that hurts. The wound care physician then sprayed [MEDICATION NAME] on the residents' right heel ([MEDICATION NAME] is used to temporarily numb and relieve pain). During an interview on 09/25/19 at 3:24 PM, the wound care physician stated, I have been providing services to the resident since (MONTH) of this year. She has dementia and [MEDICAL CONDITION] and was at risk for development of a pressure ulcer. Not all residents with [MEDICAL CONDITION] will end up with a pressure ulcer. On 09/25/19 at 03:33 PM, following the wound care treatment by the wound care physician, R26 stated, It didn't hurt very much in the beginning, but when they start cutting it hurts. I'm glad it's getting better. The resident was not wearing a bunny boot and did not have a positioning device to prevent the heel from lying on the surface of the mattress. During an interview on 09/26/19 at 02:03 PM, the Infection Preventionist (IP) who was also the facility MDS Coordinator (MDSC) stated while reviewing the MDS on line, Yes, she (referring to R26) was admitted with no pressure ulcers but she was at risk. I see where she had a decline in ambulation from her admission MDS. It was possibly because she had the wound on her right heel. She had an order for [REDACTED]. All the nurses provided daily wound care dressings and once a week the wound care doctor treats the wound and takes measurements. I'm not sure how the wound got infected. I didn't do any education to staff at that time regarding wound care. Review of the policy titled Skin Care Guidelines, dated (MONTH) 9, 2019, indicated, Stage Four.Cleanse and change dressings daily and as needed, air mattress, bunny boots.heels floated.ensure pressure reduction.turn and reposition every 2 hours and as needed.avoid pressure.avoid positioning.on existing pressure ulcers.low air loss mattress utilization.may use pillows to assist with positioning.off load every 2 hours.elevate heels from surface of bed using pillows so heel is completely off mattress.

Based on observation, interview, and review of the facility information Relias-Protecting Resident Rights in Nursing Facilities, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life. During dining observations, staff was observed to knock and/or state knock, knock and enter resident rooms without the resident's permission (2 of 2 dining observations). The findings included: During meal observation on 9/23/19 at approximately 12:47 PM, Certified Nursing Assistant (CNA) #3 and CNA #4 were observed knocking on resident room doors and/or saying knock, knock and entering resident rooms without the resident's permission. On 9/26/19 at 1:00 PM, during the meal observation, CNA #5 and CNA #6 were observed to knock on the resident's door or say knock, knock and enter the resident's rooms without the resident's permission. On 9/26/19 after the observation was made, CNA #5 and CNA #6 confirmed s/he entered the room without the resident's permission. CNA #5 stated after knocking on the resident's door you should wait for the invitation to enter. During an interview with CNA #6, s/he stated after knocking on the resident's door you were supposed to wait on a response. Review of information provided by the facility titled Relias-Protecting Resident Rights in Nursing Facilities, revealed the following: Before entering a resident's room you should knock on the door, ask for permission to enter, and allow the resident the time to respond before entering the room.

Based on record review and interview, the facility failed to follow infection control practices in the laundry (1 of 1 observations of the laundry). In addition, Resident #72 developed an infection in a pressure ulcer wound (1 of 2 residents with infections in the pressure ulcer). The findings included: Observation of the laundry on 9/25/19 at 10:23 AM revealed Laundry Staff #1 gathered clothes in a resident's room and placed the items in a clear bag. During the observation, the bag was placed on the floor while clothes were inserted into the bag. The laundry bag was brought out of the resident's room and placed on the floor near the resident's door. Laundry Staff #1 removed his/her gloves, obtained a sharpie pen from the top of the cart, initialed the bag, and sanitized his/her hands. Upon arrival to the laundry, Laundry Staff #1 placed hangers, which were hanging off of the soiled linen cart, in a box on the clean side of the laundry. S/he entered the soiled side of the laundry room where covered clean carts were located. The dirty linen carts were in close proximity to the clean linen carts. Laundry Staff #1 washed hands, donned a gown, removed clean items from the washers, placed them in the clean cart and pushed the cart to the clean side of the laundry. Laundry Staff #2 was observed to load the washer, close and lock the washer door, and start the washer with his/her soiled gloved hand. Laundry Staff #1 was observed to sort soiled items and load the washer. S/he was observed to obtain a sharpie located on the dirty cart, enter room numbers in unlabeled clothing, and place the sharpie pen back onto the soiled cart. S/he loaded the small washer, removed gloves, closed washer doors, started washers, and removed his/her gown. After waiting a few moments, this surveyor asked was there anything else that needed to be done and Laundry Staff #1 stated, Oh, I need to wash my hands. While in the laundry, Laundry Staff #2 was observed to leave out of the clean side of the laundry with gloves on and re-enter the clean side wearing gloves. During an interview with Laundry Staff #1 after the observation, s/he stated machines were sanitized after removing clean linen a couple of times a day. This was not demonstrated during the observation of removal of clean linen. S/he continued by confirming the soiled sharpie pen was placed back onto the dirty cart. Review of the facility policy titled Laundry Care and Cleaning revealed the following: 2. Washing Machine a. washing machines will be cleaned and sanitized daily. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the medical record on 9/25/19 revealed Resident #72 developed a decubitus ulcer on the left calf on 8/16/18 due to an immobilizer which was in place with physician orders to have the immobilizer at all times. Resident #72 was seen and treated weekly by the Wound Care physician. On 10/4/18, the wound cultures were positive for [MEDICAL CONDITION]-resistant Staphylococcus Aureus, [MEDICATION NAME] (non [MEDICATION NAME]-resistant [MEDICATION NAME]), and Proteus Mirabilis. Further review of the medical record revealed oral antibiotics were prescribed and eventually intravenous antibiotics were needed for the wound. During an interview with the Director of Nursing on 9/26/19 at 4:45 PM, s/he stated the splint was not to be removed per physician orders and was to be on the resident at all times. S/he continued by stating s/he was unaware of how the area became infected and the Wound Care Physician and staff treated and dressed the area. During an interview with the Infection Control Preventionist on 9/26/19 at 4:55 PM, s/he stated s/he did not know how the infection started in Resident #72's wound and would have to speculate it was due to cross contamination at some point.

Based on record review and interview, the facility failed to administer medications in a timely manner for 1 of 1 resident reviewed for [MEDICAL TREATMENT] (Resident #121). On [MEDICAL TREATMENT] days, Resident #121 did not receive all of his/her medications. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. Record review on 9/24/19 at 3:34 PM revealed Resident #121 had physician's orders [REDACTED]. Further record review revealed Resident #121 received the medications prior to going to [MEDICAL TREATMENT] from 9/11/19-9/23/19. On 9/14/2019, 9/17/19, and 9/21/19, medications were held due to [MEDICAL TREATMENT]. On 9/22/19, a note was written by pharmacy stating the resident was not receiving medications related to [MEDICAL TREATMENT] and suggested the prescriber re-evaluate when medications were to be held. On 9/24/19, the administration time for the medications was changed to 12:00 PM. During this time on [MEDICAL TREATMENT] days, Resident #121 was not in the facility to receive the medications. All of Resident #121's medications were missed on 9/24/19 due to being out of the facility to [MEDICAL TREATMENT]. During an interview on 9/26/19 at approximately 1:45 PM with Registered Nurse #1, s/he confirmed Resident #121 would not be in the building at the prescribed time for the medications and s/he would have to notify the physician. During an interview on 9/26/19 at 2:30 PM with the Administrator, s/he stated the time of the administration of the medications should have been caught sooner.

Based on record review, interview, and review of the Hospice agreement, the facility failed to ensure all documentation related to Hospice services were available for 1 of 1 resident reviewed for Hospice services. Resident #18's Hospice chart did not include all documentation for Certified Nursing Assistant (CNA), Registered Nurse (RN), and Volunteer visits. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Record review on 9/24/19 at 11:48 AM revealed hospice services for Resident #18 started on 3/21/19. Review of the Hospice care plan stated CNA's were to visit 1-3 times per week, RN visits were 1-3 times per week, and Volunteers were to visit 2-4 times per month. Further review of the hospice notes revealed there was no documentation CNA's had visited from 9/6/19 to present. No volunteer visits were documented in the hospice record. The last nursing visit record was dated 8/2/19. During an interview with the Hospice Nurse on 9/26/19 at 2:25 PM, s/he stated it was her responsibility to ensure the nursing notes were in the facility. S/he further stated s/he understood all discipline notes should be in the Hospice record. Review of the Hospice Agreement on 9/26/19 revealed the following under the medical records section: The nursing home shall prepare and maintain medical records for each Hospice patient receiving services pursuant to this agreement the medical records shall consist of progress notes and clinical notes.

Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment (SCSA) after election of Hospice Services for Resident #4, 1 of 1 resident reviewed for Hospice. The findings included: The facility admitted Resident #4 on 04//03/18 with [DIAGNOSES REDACTED]. On 07/26/18 at 02:03 PM, review of the MDS assessments revealed an Admission Assessment with an ARD (Assessment Reference Date) of 04/07/18. Section J, Health Conditions, question J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of of less than 6 month?, was coded as no. Section O Special Treatments, Procedures, and Programs, question O100K2, Hospice while a resident was coded no. Further review revealed a Quarterly MDS assessment with an ARD of 07/02/18 with both questions coded as yes. Review of the physician's telephone orders revealed an order to admit to hospice with an original order dated 04/08/18. There was no evidence in the record that a Significant Change in Status Assessment was conducted. Review of the CMS's (Centers for Medicare and Medicaid Service) RAI (Resident Assessment Instrument) Version 3.0- Manual, (MONTH) (YEAR), page 2-23 revealed A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. During an interview on 07/26/18 03:25 PM, MDS Coordinator #1 confirmed the resident was admitted to Hospice on 4/8/18. The nurse further confirmed an admission assessment was completed with an ARD 04/07/18. MDS nurse #1 also confirmed a SCSA was not completed stating the facility's consultant had told her/him it was not necessary as the resident was at his baseline.

Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident #17 and # 55 at the time of a facility initiated transfer. 2 of 2 reviewed for transfer to the hospital. The findings included: The facility admitted Resident # 17 on 01/25/2018 with [DIAGNOSES REDACTED]., left hand contracture and Irritab(e Bowel Syndrom. During review of the Nurses Notes there was no documentation that a written notice was given to the resident / Resident Representative (RR) at the time of the transfer to the hospital on [DATE] through 03/21/2018. Further review revealed Resident #17 was also hospitalized [DATE] through 04/16/2018 with no written notification to the resident/RR. The facility admitted Resident # 55 on 03/23/2016 with diagnoses, including but not limited to, Type II Diabetes Mellitus with Diabetic [MEDICAL CONDITIONS], Hypertension, cerebral infarct due to unspecified occlusion or stenosis of unspecified cerebral artery, paralyti[DIAGNOSES REDACTED] following Cerebro Vascular Accident affecting left non dominate side, elevated Sedimentation Rate, long term use of anticoagulant, Stage 3 [MEDICAL CONDITION],, [MEDICAL CONDITION], constipation, [MEDICAL CONDITION], Cognitive impairment, [MEDICAL CONDITION] with behavioral disturbance and a history of Urinary Tract Infections. During review of the Nurses Notes there was no documentation that a written notice was given to the resident / Resident Representative (RR) at the time of the transfer to the hospital on 05/06-08/2018. Further review revealed that Resident # 55 was also hospitalized ,[DATE]-[DATE] and no written notification was provided to the resident/RR. 07/25/18 08:50 AM- Interview with the Administrator confirmed that the facility was unaware that they were to be giving written notification of transfer to the hospital to the resident/ RR and had not been doing so but would implement that as of today. Notification to the Ombudsman was done monthly and the Bed Hold Policy reviewed- does accompany residents in the transfer packet when he/she is transferred to the hospital Documentation of bed hold policy is in the Social Services Notes.

Based on record review and interview, the facility failed to post the staffing information on a daily basis by category of licensed staff. The total number of hours worked by Registered Nurses and Licensed Practical Nurses or Licensed Vocational Nurses was combined on the posting. The findings included: On 07/26/18 at approximately 10:15 AM, review of the staff postings for the last 30 days revealed the total hours worked was listed for all licensed staff and for all unlicensed staff. The total number of hours worked by Registered Nurses (RNs) and by Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) was not listed separately on the posting. During an interview at 10:27 AM, the Nursing Home Administrator confirmed the postings combined all licensed staff hours and did not list RNs and LPNs/ LVNs separately.