Alvarado Meadows Nursing & Rehabilitation

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of care within 48 hours of the resident's admission for base line care plans for 1 of 13 (Resident #175) residents reviewed for care plans.<BR/>The facility failed to complete Resident #175's baseline care plan within 48 hours of admission that included the minimum required healthcare information of initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services.<BR/>This failure placed residents at risk of not receiving effective and person-centered care.<BR/>Findings include:<BR/>Review of the face sheet for Resident #175 reflected he was admitted to facility on 12/02/22 with diagnosis of: Hyperlipidemia, Schizophrenia, Recurrent Depressive disorder, HTN, Heart failure and unspecified pain.<BR/>Review of active physician's orders for Resident #175, dated 12/14/22, reflected he was to have pain management evaluation and treatment, Dental Care as needed, Psych Services evaluate and treat, Resident had shortness of breath when laying flat or on exertion, medication orders and full code status.<BR/>Review of assessments for Resident #175, on 12/14/22, reflected Care Plan Assessments were 12 days overdue. No comprehensive Care Plan was entered before the survey was completed on 12/15/22.<BR/>Review of the baseline care plan for Resident #175 reflected none was present on 12/13/22 and 12/14/22. On entering the facility on 12/15/22 surveyors found a document in the records which reflected a 48-hour Baseline Care Plan had been started on 12/2/22 and signed on 12/14/22 the document was signed by the LVN/MDS nurse.<BR/>Record review of 48-hour baseline care plan for Resident # 222 revealed and admission date of 12/02/2022 and a completion date with electronic signature on 12/07/2022 by the LVN/MDS.<BR/>In an interview on 12/15/22 at 8:50 am, CNA E, for the secured unit, stated she did not know where to find the care plan for Resident #175. She stated the daily list of tasks Resident #175 needed assistance with, was found in the [NAME] computer system. She stated Resident #175 was independent and could do most things for himself, he needed help for bathing and some dressing. She stated she could not find his Care Plan in the facility's computer system.<BR/>In an interview on 12/15/22 at 9:03 am, MDS F stated Resident #175's comprehensive care plan was due that day (12/15/22) since he was admitted on [DATE]. She stated the comprehensive care plan and his MDS assessment had to be closed that day. MDS F stated Resident #175's baseline care plan was started on 12/2/22 and was signed on 12/14/22. She stated the Baseline care plan did not show up in records until it was signed but was in place. MDS F stated she did not know why the Baseline care plan was not signed earlier.<BR/>In an interview on 12/15/22 at 9:10 am, the MDS nurse stated the Baseline care plan for Resident #175 was started on 12/2/22. She stated it was complete, it was just not signed before it showed as locked in the computer. The MDS nurse stated the computer did not show or highlight the Baseline care plan to be locked because things were often added or changed in the first 48 hours. When asked if there was any way to show the Baseline care plan was completed in the first 48 hours, she stated she did not know. The LVN/MDS nurse stated it was her job to enter and complete the Baseline care plan.<BR/>In an interview on 12/15/22 at 9:40 am, the Acting DON stated she did not know if there was a way of verifying the 48-hour baseline care plans were completed or implemented. She reviewed records for Resident #175 which reflected his Baseline care plan was started on 12/2/22 and locked on 12/14/22. She had no further comment at the time.<BR/>In an interview on 12/15/22 at 10:02AM, the Administrator said the Care Plan signature date was the date the care plan was completed. He said, bottom line, even if all information was provided on the form in the 48-hour time frame, if it was not signed and locked during that time frame, it was not completed in time. He said it had been difficult getting some things like that completed on time because a registered nurse had to open, sign, and lock the care plans but he was not aware the LVN/MDS Coordinator had been signing off and locking care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 of 7 residents (Resident #7 and Resident #22) reviewed for Resident Rights.<BR/>CNA G verbally abused Residents #7 and #22 when the residents requested to return inside the building following a smoke break, and she yelled at them telling they could not go inside and blocked the door.<BR/>The failure placed residents at risk of feelings of decreased self-worth.<BR/>The non-compliance was identified as PNC. The noncompliance began on 02/15/25 and ended on 02/21/25. The facility had corrected the non-compliance before the investigation began. <BR/>Finding included:<BR/>Record review of Resident #7's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #7's entry MDS sheet dated 02/08/25 reflected a BIMS score of 13 indicating her cognition was intact. Resident #7's functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and lower body dressing. Resident #7 was independent with eating, oral hygiene and upper body dressing, and partial assistance with personal hygiene. Resident #7's diagnoses included acquired absence of left leg above knee, muscle weakness, lack of coordination, and a history of falling. <BR/>Record review of Resident #7's care plan as of 02/16/25 reflected Resident #7 was a smoker. The care plan reflected a goal to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. The trauma was related to being angry at CNA G for saying that she could not go back inside after smoking. The care plan goal included maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included to arrange a licensed mental health provider as ordered by the physician. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include verbal threats, and physical aggression.<BR/>Record review of Resident #7's Safe Smoking assessment dated [DATE] and 03/04/25 reflected in summary: This resident required direct supervision while smoking: All smoking materials will be kept at the nurse's station: The evaluation has been explained to the family responsible party and to the resident.<BR/>Record review of Resident #22's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #22's entry MDS sheet dated 02/19/25 reflected a BIMS score of 15 indicating her cognition was intact. Resident #22's functional abilities indicated she was independent with eating, oral hygiene, toileting hygiene and required set up or clean up with shower/bathing, upper and lower body dressing, and personal hygiene. Resident #22 had use of a walker. Resident #22's diagnoses included muscle weakness and difficulty walking. <BR/>Record review of Resident #22's care plan as of 02/16/25 reflected Resident #22 was a smoker. The care plan gooal included to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. <BR/>Record review of Resident #22's Safe Smoking assessment dated [DATE] reflected in summary: This resident required direct supervision while smoking: All smoking materials would be kept at the nurse's station: The evaluation has been discussed with the resident. <BR/>Interview on 03/04/25 at 10:55 AM with Resident #7 revealed she liked to smoke at each smoke break. Resident #7 stated she was outside smoking with CNA G and finished earlier than others and wanted to return inside the facility. According to Resident #7, CNA G yelled at her saying, You can't go back inside until I go in. Resident #7 stated it made her upset. Resident #7 stated it was cold outside, and she should have been allowed to return inside the building if she wanted. <BR/>Interview on 03/04/25 at 1:40 PM with Resident #22 revealed she enjoyed smoking on the smoke breaks provided by the facility. According to Resident #22, she was outside when CNA G would not allow Resident #22 to return inside the building when she was finished smoking. Resident #22 stated CNA G was the only staff member, who would make residents stay outside until everyone was finished, and they all came back inside at one time. Resident #22 stated she was upset that CNA G did not allow residents to return inside the building yelling, Do not go any further. No one can go in without me. Resident #22 also stated CNA G stood in the walkway blocking residents from leaving the patio. Resident #22 stated she reported to the front desk that Resident #7 was not allowed to return to the building and the Administrator followed up with her about the incident. According to Resident #22, CNA G no longer worked at the facility and there had not been any further issues with residents returning inside the building when they were finished smoking. <BR/>Observation on 03/04/25 at 4:10 PM revealed residents on the patio with the Maintenance Director and revealed residents were able to exit the patio once they were finished smoking. <BR/>Observation and interview on 03/05/25 at 4:00 PM with the Laundry Aide revealed there was a schedule sheet that he followed which notified when his department took residents out to smoke. The Laundry Aide stated he recognized all residents were able to safely smoke. Laundry Aide stated he was responsible for ensuring all residents were safe before, during, and after smoking and should stay together just in case they needed help returning to the facility, for example if they were a fall risk. The Laundry Aide stated he thought all residents were supposed to wait together to go inside the building after smoking, but he could not stop anyone from going back inside the building if they wanted to leave. Therefore, he allowed residents to leave when they were done smoking. According to the Laundry Aide, trying to stop residents from returning inside the building after smoking would go against their rights to move around as they want. <BR/>Interview on 03/05/25 at 4:41 PM with RN I revealed she was aware of residents that smoked. There was a schedule that indicated nursing staff were responsible to take residents out during the evening hours. According to RN I, she was present on 02/15/25 when CNA G volunteered to take the residents out to the patio for smoking at 6:30 PM. RN I stated she was standing at the nursing station when Resident #22 informed RN H that Resident #7 wanted to return back into the building once she finished smoking and she was not allowed to and was told she had to wait. RN I stated according to Resident #22, she did not like that Resident #7 was told she could not leave, and that CNA G blocked the walkway to prevent anyone from leaving the patio. RN I stated she and RN H then began contacting the DON and the Administrator. <BR/>Interview on 03/05/25 at 5:09 PM with the ADON revealed she was in-serviced on resident rights after the 02/15/25 incident when CNA G would not allow residents to reenter the building after smoking. The ADON stated whomever was scheduled to take residents out to smoke was responsible for residents while they were smoking. The ADON stated if there were multiple residents smoking and one wanted to come back inside, and you did not have to leave residents smoking unsupervised, residents who were able to safely return to the building could do so. The ADON expressed that residents had the right to be able to return in the building after smoking, or anytime they wanted to come inside or move about the facility, not doing so violated their rights. <BR/>Interview on 03/06/25 at 9:10 AM with RN H revealed she was at the nursing station on 02/15/25 when CNA G took residents who smoke out to the patio at their 6:30 PM smoke break. RN H stated after the break, Resident #7 and Resident #22 reported to her that CNA G told them they could not come back in inside the building until everyone was done smoking. RN H stated, it was cold that night so residents were distraught they could not return in the building once they were done smoking. RN H stated she reported to the Administrator and the DON, what residents reported to her. RN H stated she was in-serviced on resident rights and the residents had the ability to move about the facility, being told they could not return in the building after they were ready, placed them at risk of their rights being violated. <BR/>Interview on 03/06/25 at 10:00 AM with the Administrator revealed he was notified by RN H that CNA G took residents out to smoke; once they were finished smoking and wanted to return inside the building because they were cold. The Administrator stated he was told CNA G yelled No one can go in without me and stood in the walkway preventing them from leaving the patio. The Administrator stated he asked residents to be assessed to ensure they were ok and not harmed in any way and to gather statements. The Administrator stated he alerted his corporate office and the human resources and suspended CNA G. The Administrator stated he entered the facility on 02/16/25 to interview residents and started in-services and monitoring. The Administrator stated there was a schedule to advise which department was responsible for taking the residents out to smoke at designated times. The Administrator advised he expected staff to allow residents to go out on the patio and smoke, if they were done and wanted to come back inside the building staff should allow that as it was their right to do so. The Administrator stated they completed in-services to educate staff to monitor residents while outside on the patio during smoking breaks; however, you could not keep residents outside against their will. <BR/>Interview on 03/06/25 at 10:07 AM with the DON revealed she was notified of the incident on 02/15/25 with CNA G refusing to allow residents to return in the building by standing in the walkway and yelling they had to wait on all residents to reenter together. The DON stated in-services on resident rights, abuse and neglect, and their smoking policy were started immediately. The DON stated she expected staff to follow the smoking schedule and take residents out to smoke. The DON stated at any time residents want to leave the patio after smoking, they have the right to do so and should be able to do so. The DON stated CNA G not allowing residents to return inside the building placed them at risk of not having their rights honored. <BR/>Interview on 03/07/25 at 11:39 AM with CNA G revealed she did take residents out to the patio for a smoke break right before her shift ended at 6:30 PM on 02/15/25. According to CNA G it was a bit cooler that evening, and Resident #7 attempted to leave the patio when she finished smoking. CNA G stated she expressed to Resident #7 you have to wait to go inside all together. CNA G stated the reason she did not allow residents to leave the patio was because it was not feasible. She stated Resident #7 was in a wheelchair and could have fallen. CNA G stated, I admit I kept her from going in. It was for her safety. According to CNA G, she was responsible for ensuring residents returned in the building safely. CNA G stated she was suspended and later terminated. CNA G stated she was not thinking residents were placed at risk of rights not being honored, she stated I was thinking of their safety.<BR/>Record review of a Employee Disciplinary Report for CNA G dated 02/15/25 reflected due to allegations, CNA G will be placed on unpaid investigatory suspension and will remain on investigatory suspension until the investigation is completed. CNA G will be notified when the investigation is completed.<BR/>Record review of Resident #7's statement reflected: <BR/>6:30 Smoke Break<BR/>At the 6:30 PM smoke break CNA G took the smokers outside the smoke area. When I was done smoking, I started to go back inside from the smoking area and CNA G stood in the opening that leads to sidewalk and said You can't go in until I go in. I stayed outside in the smoking area for about 15 minutes. I was cold and I did not have a coat on. When I came back inside, I told RN H and RN I what happened.<BR/>Record review of Resident #22's statement reflected:<BR/>6:30 PM Smoke Break<BR/>At the 6:30 PM smoke break CNA G took us outside. Before we went outside, she was talking really fast, and I could tell that she did not want to take us outside and stated she had other things to do. She did take us outside but kept coming back inside and to the smoke area. She was pacing back in forth in the smoke area and was yelling I do not want to talk to anyone. I am upset. Two of the smokers were finished and started to go down the sidewalk to go back inside like they normally do, and CNA G yelled Do not you go any further. No one can go in without me. She said she was going to search for everyone's lighters and cigarettes. I did not see her search anyone. CNA G stood in front of Resident #7 and would not let her leave the smoking area. I was still smoking. Another resident told her he was going inside when he finished his cigarette, and he went inside. CNA G was very short spoken with us while we were outside. When I returned to the building, I told RN H and RN I what happened during the smoke break. Once in my room I checked my cell phone, and I had a missed call from CNA G, I did not call her back. <BR/>Record review of CNA G's Witness Statement reflected: I work every time I am asked to, I work nights, I worked my Saturday day off. Residents all they want to do is smoke, I have COPD. This was signed by CNA G 02/17/25 and the Administrator. <BR/>An ADHOC QAPI meeting was held on 02/17/25 with the Interdisciplinary Team including the Medical Director to discuss the allegations and findings.<BR/>Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/21/25, reflected: <BR/>Description of Allegation:<BR/>[CNA G], CNA, took the residents out to smoke at the schedule[d] 6:30 PM time. Some of the residents were getting cold and wanted to go back inside after smoking a cigarette. [CNA G] yelled and told them that they couldn't go back inside without her, and she wasn't letting anyone back in until she was ready. [Residents #7 and #22] stated they felt this was verbal abuse by [CNA G] yelling and not letting them back inside.<BR/>Provider Response:<BR/>Details of this incident were found out after the staff member [CNA G] left after her shift. The staff member was immediately suspended pending investigation after administration found out about the incident. Safe surveys for smokers completed.<BR/>Investigation Summary:<BR/>Investigation summary shows that the incident did occur. [CNA G] was terminated on 2/18/2025 for verbal abuse occurring. Residents did not have any trauma from the incident.<BR/>Provider Action Taken Post Investigaiton:<BR/>In-serviced staff on abuse/neglect. [CNA G] was terminated for verbal abuse on 2/18/2025. No adverse effects for any residents involved.<BR/>Record review of Payroll Input/Personnel Action Form signed 02/18/25 reflected CNA G was terminated on 02/18/25. CNA G has failed to adhere to the Corporate Code of Conduct. CNA G was aware of the corporate code of conduct as indicated by the signature of the employee handbook acknowledgment. CNA G meet criteria for immediate termination. <BR/>Record review of an in-service record, dated 02/15/25 reflected the DON trained staff on the following topics: Abuse and Neglect, Resident Rights, and Smoking Policy. The in-service record reflected staff not present would receive the in-service training prior to assuming their duties on their next scheduled shift. Also, new and agency staff would received the in-service training prior to assuming patient care duties. <BR/>Interviews on 03/06/25 with LVN A, LVN B, RN H, RN I, Laundry Aide, Dietary Aide, DON, ADON, CNA J revealed they had been trained on residents' rights and were aware to allow residents to return in the building as they were finished smoking, not doing so placed residents at risk of violation of their rights being honored. <BR/>Record review reflected the facility implemented the following for monitoring from 02/16/25-02/21/25: ask 15-20 staff members per week; ask about 5 resident per week how staff is treating them; during incident/event review in standup; during facility rounds are there any sings of staff acting rudely or inappropriate with residents. <BR/>Record review of the facility's Resident Rights policy, revised 11/28/16, reflected:<BR/>Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. <BR/>Respect and dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience.<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. <BR/>Self-determination - The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. <BR/>1. <BR/>The resident has a right to choose activities, schedule and health care and providers of health care services consistent with his or her interest. <BR/>2. <BR/>The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort, which included incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 2 of 2 residents (Resident #4 and Resident #5) reviewed. <BR/>The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting for Resident #4 and Resident #5.<BR/>This failure could place residents at risk of not receiving necessary care or specialized services which could diminish the residents' quality of life and highest level of functioning. <BR/>Findings include:<BR/>Record review of Resident #4's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: autistic disorder (a neurodevelopmental condition that affects how people interacts with others, communicate, and behave), bipolar disorder (mental health condition that cause extreme shifts in moods), anxiety disorder (mental health condition that causes excessive and persistent worry, fear, and nervousness), and dementia (decline in thinking, remembering and reasoning skills that affect a person's daily life)<BR/>Record review of Resident #4's Quarterly MDS assessment, dated 05/05/2025, reflected the resident had a BIMS score of 15, which indicated cognitively intact. <BR/>Review of Resident #4's Habilitation Service Plan, dated 03/14/25, reflected in Section 5, Outcome Action Plan identify NF specialized services PT, OT, and ST.<BR/>Record review of Resident #5's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Dementia (decline in thinking, remembering and reasoning skills that affect a person's daily life), moderated intellectual disabilities (difficulty learning and understanding things), and Developmental disorder of scholastic skills (a learning difficulty that affects how a person acquires academic skills like reading, writing, and math.)<BR/>Record review of Resident #5's Quarterly MDS assessment, dated 03/20 /2025, reflected the resident had a BIMS score of 03, which indicated severe cognitive impairment. <BR/>Review of Resident #5's PASRR team IDT Sign-In Sheet), dated 01/13/25, reflected the purpose of the meeting to offer individual specialized services, habilitation coordination, and durable medical equipment to present CLO to the individual. <BR/>During an interview with the DOR on 06/10/25 at 1:35 PM, the DOR stated that the NFSS should be completed 20 days after the IDT meeting. DOR stated that the services offered to residents are OT, PT, ST, and day hab services. The DOR stated that PASRR representative, MDS Coordinator, DOR and a family representative usually attend the meetings. DOR stated she was not the DOR at the time of Resident #4 or Resident #5's meetings. The DOR stated a negative outcome for the NFSS not being completed in time could be the resident decline or the resident wouldn't receive services. <BR/>During an interview with the ADM on 06/10/25 at 1:45 PM , the ADM stated that the NFSS should be completed 20 days after the IDT meeting. The ADM stated that it's the DOR's responsibility to complete the NFSS within the appropriate time frame. The ADM stated there would be no way to verify the resident was receiving PASSR services if the NFSS wasn't completed timely.<BR/>A record review of the facility's PASRR PCSP /IDT policy, dated 03/06/19, reflected Policy: it is the policy of Creative Solutions in Healthcare facilities to ensure the IDT meetings are schedule per regulations (with 14 days of admission for Positive Confirmed PE ). The LIDDA and/or LMHA are notified and invited to the IDT Meetings for all PASRR Positive Resident. The NF will enter the PCSP initial and/or annual meeting in the portal within 3 business days of the IDT Meeting. The NF will notify appropriate staff if the IDT determined Specialized Services are recommended.<BR/>Procedure:<BR/>Review of process prior to the IDT meeting: After an individual or resident is determined to have MI, ID, or DD from the PE or resident reviewed has been admitted to a nursing facility, the NF must:<BR/>9. Once the IDT makes its determinations about specialized services, the NF must: <BR/>Include all specialized services and support activities in the resident's comprehensive Care Plan;<BR/>Provide the NF Specialized Services within 20 business days of the IDT Meeting; and <BR/>Annually document all specialized services in the portal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans.<BR/>The facility failed to ensure Resident #7's comprehensive care plan included a new intervention for a fall mat after Resident #7 fell on [DATE]. <BR/>This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings included:<BR/>A record review of Resident #7's face sheet, dated 02/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses that included Weakness (lack of strength), Muscle wasting and atrophy (decrease in muscle mass), lack of coordination (difficulties in controlling and organizing movement) Spastic Hemiplegia affecting right dominant side (causing muscle tightness and involuntary contractions in the limbs or extremities), unspecified abnormalities of gait and mobility (change in walking pattern), and other muscle spasm (when a muscle involuntarily or forcibly contract uncontrollably).<BR/>A record review of Resident #7's Quarterly MDS assessment, dated 12/28/23, reflected Resident #7 had a BIMS score of 15, which indicated cognitively intact. Section GG of the MDS indicated Resident #7 had impairment to one side of his upper extremity and had impairment to both sides of his lower extremities. Section GG also indicated that Resident #7 was dependent in the following areas upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>A record review of Resident #7's Active Physicians Orders, dated 02/06/24, reflected there was an order, dated 11/30/23, for Resident #7 to have a fall mat at bedside. <BR/>A record review of a Progress Note entry, dated 11/29/23, reflected Resident #7 was seen sitting on the floor next to the bed. According to the progress note Resident #7 stated that he slid to the floor trying to get out of bed.<BR/>A record review of Resident #7's care plan, dated 12/18/23, did not reflect a fall mat for Resident #7 nor did it reflect Resident #7's most recent fall on 11/29/23.<BR/>An observation of Resident #7 on 02/06/23 at 1:00 pm revealed the resident was lying in bed with the fall mat placed against the wall. <BR/>An observation of Resident #7 on 02/07/23 at 10:00 am revealed the resident was lying in bed with the fall mat placed bedside the bed. <BR/>In an interview with Resident #7 on 02/06/24 at 1:00 pm, Resident #7 stated sometimes the staff put the fall mat down and sometimes they don't. Resident #7 stated that his entire right side was contracted due to several strokes. Resident #7 stated his most recent fall was in October or November of 2023. Resident #7 stated his fall mat was not near his bed during his most recent fall. <BR/>In an interview with the MDS Coordinator on 02/07/24 at 12:15 pm. The MDS Coordinator stated she had worked at the facility for 10 years. The MDS Coordinator stated she was responsible for completing and updating the Care Plans. The MDS Coordinator stated during the morning meeting the DON would notify her if a resident had a fall and would notify her of any updated interventions that needed to be added to the care plan. The MDS Coordinator stated that if a resident had a fall mat, then it should have been used while the resident was in bed, and the fall mat should have been care planned. The MDS Coordinator stated if a resident''s fall mat was not placed beside the resident's bed, then the resident could have injured themselves if they had a fall. <BR/>In an interview with the DON on 02/07/24 at 12:25 pm. The DON stated that if the residents had reoccurring falls the care plan should have been updated, but not if a resident had an isolated fall. The DON stated if a resident had a fall mat, then it should have been used correctly, and care planned. The DON stated if the fall mat was not placed beside the resident's bed, then the resident could have sustained injuries such as broken or fractured bones. <BR/>In an interview with the Administrator on 02/07/24 at 12:35 pm. the administrator stated that if a resident had a fall the care plan should have been updated to reflect that fall and new interventions should have been added to the care plan. The administrator stated the MDS Coordinator was responsible for completing and updating the care plans. The administrator stated that if a resident had a fall mat, then it should have been care planned. The administrator stated if a resident has a fall mat, then it should have been correctly placed near the resident's bed when the resident was lying down. The administrator stated that if the mat was not placed on the floor near the bed, then the resident could have sustained injuries from falling.<BR/>Record review of the facility's Using the Care Plan policy, not dated, reflected The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. <BR/>Policy Interpretation and Implementation <BR/>1. <BR/>Complete care plans are placed in the resident's chart and/or 3-ring binder located at the appropriate nurses station.<BR/>2. <BR/>The Nurse supervisor uses the care plan to continue the CNAs daily/weekly work assessments sheets and/or flow sheets.<BR/>3. <BR/>CNAs are responsible for reporting to the Nursing Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved.<BR/>4. <BR/>Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and /or the MDS Assessment Coordinator.<BR/>5. <BR/>Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.<BR/>6. <BR/>Documentation must be consistent with the resident's care plan.<BR/>7. <BR/>Information contained on the care plan and other documents used by the nursing staff shall be maintained in a confidential manner in accordance with established facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview , and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents (Resident #1) reviewed for quality of care, in that:<BR/>The facility failed to conduct weekly skin assessments for Resident #1 for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25.<BR/>These failures placed residents at risk of physical harm, pain, and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that causes memory loss), chronic kidney disease stage 3 (when your kidneys are damage and can't filter blood properly), muscle wasting and atrophy (decrease in size and wasting of muscle tissues), and lack of coordination (having difficulty controlling your movements and making them work together smoothly). <BR/>Record review of Resident #1's Quarterly MDS assessment, dated 05/07/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. <BR/>Record review of Resident #1's care plan, dated 06/05/2025, reflected Resident #1 was care planned for terminal prognosis and/or receiving hospice services, impaired cognitive function/dementia or impaired though processes, ADL self-care performance deficit, risk for falls r/t unsteady gait, and potential for pressure ulcer development. <BR/>Review of Resident #1's weekly skin assessment in the EMR on 06/05/2024, reflect Resident #1 did not have a weekly skin assessment for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25.<BR/>Attempted to interview Resident #1 on 06/06/2025 at 11:30am., Resident #1 could not be interviewed due to his cognitive impairment. <BR/>During an interview with LVN B on 06/06/2025 at 12:00 PM, LVN B stated she was the nurse working with Resident #1 for 06/06/25. LVN B stated all resident in facility should be receiving weekly skin assessments. LVN B stated she was not sure why Resident #1 did not receive skin assessments for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. LVN A stated the charge nurse was responsible to complete weekly skin assessments. LVN B stated if a weekly skin assessment wasn't not completed the resident could have skin issues that go untreated.<BR/>During an interview with the DON on 06/06/2025 at 4:00 PM, the DON stated all residents were supposed to receive weekly skin assessments. The DON stated it was the nursing staffs' responsibility to complete the weekly skin assessments. The DON was not aware that Resident #1 had not had a skin assessment for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. The DON stated the purpose of a skin assessment was to identity and address any new skin concerns. The DON stated that if a resident did not receive weekly skin assessments, then the resident could have a skin condition go untreated. The DON stated she expected for weekly skin assessments to be conducted as scheduled. <BR/>During an interview with the ADM on 06/06/2025 at 5:00 PM, the ADM stated all residents were supposed to receive weekly skin assessments. The ADM stated it was the nursing staffs' responsibility to complete the weekly skin assessments. The ADM was not aware that Resident #1 had not had a skin assessment for the weeks of 05/11/25 through 05/17/25 and 05/18/25 through 05/24/25. The ADM stated the purpose of a skin assessment was to ensure residents did not have any adverse skin issues from the previous week. The ADM stated that if a resident did not receive weekly skin assessments, then the resident could have a skin condition go untreated. The ADM stated she expected for weekly skin assessments to be conducted as scheduled. <BR/>A record review of the facility's Skin Assessment policy, dated 12/24, reflected it is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner.<BR/>Procedure:<BR/>2. All residents should have a skin assessment on a weekly basis completed in (EMR system) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 4 residents (Resident #1) reviewed for discharge requirements.<BR/>The facility failed to ensure Resident #1 was readmitted to the facility, after being sent to the hospital for behaviors. <BR/>This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.<BR/>Findings included:<BR/>A record review of Resident #1's face sheet dated 01/21/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnosis was unspecified dementia(memory loss), blindness right eye(unable to see), hearing loss(unable to hear), and essential primary hypertension(high blood pressure).<BR/>A record review of Resident #1's Initial MDS assessment, dated 01/20/2025, reflected the resident had a BIMS score of 0, which indicated severe cognitive impairment. <BR/>A record review of Resident #1's care plan, dated 02/05/2025, reflected focus of discharge from the facility is not feasible as evidence by dementia. The goal reflected Resident #1 would be provided an opportunity to receive information on returning to the community. The intervention for Resident # 1 was to respect resident's rights to view nursing facility as his home<BR/>Review of Resident #1's 30-day discharge letter dated 01/21/2025, revealed Resident #1 was given the 30-day discharge letter on the same date (01/21/2025) he was discharged to the hospital. The discharge letter was delivered to hospital ER on [DATE] with Resident #1.<BR/>Review of Resident #1's Discharge Planning and Summary date 01/21/2025, revealed Resident #1 was sent to the hospital for behaviors. <BR/>Attempted an interview on 02/09/2025 at 12:10 p.m. left message for the local ombudsman to return call.<BR/>During an interview on 02/09/2025 at 3:00 p.m., the RP stated he received a text message from someone at the facility on 01/21/2025 late that evening ,time not recalled, that Resident # 1 could not come back to the facility. The RP stated he was not notified by the facility that a discharge had been in place. The RP stated Resident # 1 was not able to make any decision's and he was not able to participate in finding Resident # 1 placement at another facility. The RP stated no discharge paperwork was given to him and he had not signed anything for the Resident to be placed at another facility. The RP stated Resident # 1 was sent to the hospital for non-emergency and was not allowed to return to the facility. The RP stated Resident # 1 was discharged from the hospital to another nursing facility. <BR/>During an interview on 02/09/2025 at 3:30 p.m., the SW stated she was not aware Resident # 1 was discharged from the facility to the hospital on [DATE]. The SW stated she did not find out about the discharge until when she returned to the facility on [DATE]. The SW stated she had not been involved with an immediate discharge with Resident #1.<BR/>During an interview on 02/09/2025 at 3:45 p.m., the BOM stated she did not partake in the immediate discharge of Resident # 1. The BOM stated she just discharged Resident #1 out of the system. The BOM stated that she did not partake in the immediate discharges. The BOM stated the ADM and the DON handled the immediate discharge for Resident #1.<BR/>During an interview on 02/09/2025 at 4:16 p.m., the DON stated she had just started the facility on 02/07/2025 and was not in the facility when Resident # 1 was immediate discharged from the facility.<BR/>During an interview on 02/09/2025 at 4:20 p.m., the ADM stated the immediate discharge was given on 01/21/2025 the same day he was sent to the hospital for behaviors. The ADM stated no 30-day notice was given an immediate discharge was initiated for the safety and well being of all residents. The ADM stated he had been working as an ADM for two weeks when Resident # 1 as immediately discharged . The ADM stated corporate was in the building and it was thought you could issue an immediate discharge if there was a safety concern for all the other residents. The ADM stated Resident # 1 was sent out to the hospital for behaviors and not for a medical emergency. The ADM stated when a 30 day notice was not provided the family would not be able to participate in the decision of resident's stay.<BR/>Review of long-term care regulation provider letter dated 12/29/2022 reflected If a NF initiates a resident discharge, the facility must provide written notification of the discharge-in a language and manner the resident can understand-to the resident, the resident representative (if applicable), and a representative of the Long-Term Care Ombudsman Program, at least 30 days before the intended discharge date .<BR/>Review of nursing policy and procedure manual titled facility-initiated discharge date d 12/2017 revised 04/10/2024 reflected The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility. In the following circumstances this facility may initiate transfers and discharges. The safety of individuals in facility is endangered due to clinical behavioral status of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans.<BR/>The facility failed to ensure Resident #7's comprehensive care plan included a new intervention for a fall mat after Resident #7 fell on [DATE]. <BR/>This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings included:<BR/>A record review of Resident #7's face sheet, dated 02/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses that included Weakness (lack of strength), Muscle wasting and atrophy (decrease in muscle mass), lack of coordination (difficulties in controlling and organizing movement) Spastic Hemiplegia affecting right dominant side (causing muscle tightness and involuntary contractions in the limbs or extremities), unspecified abnormalities of gait and mobility (change in walking pattern), and other muscle spasm (when a muscle involuntarily or forcibly contract uncontrollably).<BR/>A record review of Resident #7's Quarterly MDS assessment, dated 12/28/23, reflected Resident #7 had a BIMS score of 15, which indicated cognitively intact. Section GG of the MDS indicated Resident #7 had impairment to one side of his upper extremity and had impairment to both sides of his lower extremities. Section GG also indicated that Resident #7 was dependent in the following areas upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>A record review of Resident #7's Active Physicians Orders, dated 02/06/24, reflected there was an order, dated 11/30/23, for Resident #7 to have a fall mat at bedside. <BR/>A record review of a Progress Note entry, dated 11/29/23, reflected Resident #7 was seen sitting on the floor next to the bed. According to the progress note Resident #7 stated that he slid to the floor trying to get out of bed.<BR/>A record review of Resident #7's care plan, dated 12/18/23, did not reflect a fall mat for Resident #7 nor did it reflect Resident #7's most recent fall on 11/29/23.<BR/>An observation of Resident #7 on 02/06/23 at 1:00 pm revealed the resident was lying in bed with the fall mat placed against the wall. <BR/>An observation of Resident #7 on 02/07/23 at 10:00 am revealed the resident was lying in bed with the fall mat placed bedside the bed. <BR/>In an interview with Resident #7 on 02/06/24 at 1:00 pm, Resident #7 stated sometimes the staff put the fall mat down and sometimes they don't. Resident #7 stated that his entire right side was contracted due to several strokes. Resident #7 stated his most recent fall was in October or November of 2023. Resident #7 stated his fall mat was not near his bed during his most recent fall. <BR/>In an interview with the MDS Coordinator on 02/07/24 at 12:15 pm. The MDS Coordinator stated she had worked at the facility for 10 years. The MDS Coordinator stated she was responsible for completing and updating the Care Plans. The MDS Coordinator stated during the morning meeting the DON would notify her if a resident had a fall and would notify her of any updated interventions that needed to be added to the care plan. The MDS Coordinator stated that if a resident had a fall mat, then it should have been used while the resident was in bed, and the fall mat should have been care planned. The MDS Coordinator stated if a resident''s fall mat was not placed beside the resident's bed, then the resident could have injured themselves if they had a fall. <BR/>In an interview with the DON on 02/07/24 at 12:25 pm. The DON stated that if the residents had reoccurring falls the care plan should have been updated, but not if a resident had an isolated fall. The DON stated if a resident had a fall mat, then it should have been used correctly, and care planned. The DON stated if the fall mat was not placed beside the resident's bed, then the resident could have sustained injuries such as broken or fractured bones. <BR/>In an interview with the Administrator on 02/07/24 at 12:35 pm. the administrator stated that if a resident had a fall the care plan should have been updated to reflect that fall and new interventions should have been added to the care plan. The administrator stated the MDS Coordinator was responsible for completing and updating the care plans. The administrator stated that if a resident had a fall mat, then it should have been care planned. The administrator stated if a resident has a fall mat, then it should have been correctly placed near the resident's bed when the resident was lying down. The administrator stated that if the mat was not placed on the floor near the bed, then the resident could have sustained injuries from falling.<BR/>Record review of the facility's Using the Care Plan policy, not dated, reflected The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. <BR/>Policy Interpretation and Implementation <BR/>1. <BR/>Complete care plans are placed in the resident's chart and/or 3-ring binder located at the appropriate nurses station.<BR/>2. <BR/>The Nurse supervisor uses the care plan to continue the CNAs daily/weekly work assessments sheets and/or flow sheets.<BR/>3. <BR/>CNAs are responsible for reporting to the Nursing Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved.<BR/>4. <BR/>Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and /or the MDS Assessment Coordinator.<BR/>5. <BR/>Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.<BR/>6. <BR/>Documentation must be consistent with the resident's care plan.<BR/>7. <BR/>Information contained on the care plan and other documents used by the nursing staff shall be maintained in a confidential manner in accordance with established facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 12 residents (Residents #28, #31, #33, #47, and #56) reviewed for personal hygiene.<BR/>The facility failed to ensure Residents #28, #31, #33, #47, and #56 received assistance with bathing, grooming, and personal hygiene.<BR/>These failures could result in the resident having decreased sense of self-worth. <BR/>Findings included:<BR/>1. Record review of Resident #28's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, morbid obesity, and muscle wasting. <BR/>Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she was totally dependent on staff for toileting, and needed maximum assistance with bathing and personal hygiene. <BR/>Record review of Resident #28's care plan, dated 01/20/25, reflected she had an ADL self-care performance deficit related to impaired balance with an intervention of Bathing: the resident requires assistance with bathing 3x a week, and as necessary. <BR/>Interview on 03/04/25 at 10:02 AM with Resident #28 revealed she only got bathed every two weeks because there was only one CNA on the evening shift, which was when her bath was scheduled. Staff would not bathe her unless she demanded it. She stated not being bathed made her feel uncomfortable so she didn't go out of her room much. <BR/>Record review of Resident #28's bathing task record from 2/09/25 to current date reflected she had been bathed twice (2/22/25 and 2/23/25). All other dates were documented as Activity did not occur. <BR/>2. Record review of Resident #31's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses which included heart failure, diabetes, seizures, and stroke.<BR/>Record review of Resident #31's admission MDS, dated [DATE], reflected a BIMS score of 11 indicating he had mild cognitive impairment. His Functional Abilities assessment indicated he required maximum assistance with bathing and toileting. <BR/>Record review of Resident #31's care plan, dated 02/22/25, reflected he had an ADL self-care deficit with an intervention for bathing to have 1 staff to assist. <BR/>Observation and interview on 03/04/25 at 9:41 AM with Resident #31 revealed he had not been bathed in over a week. The resident's hair was unkempt and appeared greasy. The resident stated he asked the CNAs to shower him. He stated they would say they would do it, but they never came back, so it never happened. He stated he did not need a lot of attention, but there still did not seem to be enough staff to help the residents. <BR/>Record review of Resident #31's bathing task record from 02/05/25 to current reflected he had been bathed twice (02/06/25, and 02/18/25), all other dates were documented Activity did not occur.<BR/>3. Record review of Resident #33's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included right sided paralysis related to a stroke, liver disease, seizures, and Schizoaffective disorder. <BR/>Record review of Resident #33's quarterly MDS, dated [DATE], reflected a BIMS score not assessed. Her Functional Abilities assessment indicated she was totally dependent on staff for her ADLs. <BR/>Record review of Resident #33's care plan, dated 02/24/25, did not reflect she had a self-care deficit related to her stroke and paralysis. <BR/>Observation on 03/04/25 at 10:00 AM revealed Resident #33 appeared to be asleep. Her hair was unkempt and appeared greasy. <BR/>Record review of Resident #33's bathing task record from 02/05/25 to current reflected she had been bathed on 02/26/25. All other dates were documented as Activity did not occur. <BR/>Phone interview on 03/05/25 at 1:57 PM with Resident #33's family member revealed they were at the facility almost every evening to visit with the resident. The resident did not respond to anyone unless she knew them, but she was unable to do anything for herself. They stated they knew for sure the resident had not been bathed in the last four days. They stated the staff were always busy, and they rarely came to her room when they were there to check on the resident. The family member stated they had to seek out staff to change the resident's brief, and it still took a while for them to come change her. He stated there did not appear to be enough staff to care for the residents. <BR/>4. Record review of Resident #47's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, bone infection of the spine, paraplegia (paralyzed from waist down), and heart failure. <BR/>Record review of Resident #47's admission MDS, dated [DATE], reflected only section A had been completed. <BR/>Record review of Resident #47's care plan, dated 03/01/25, reflected she had an ADL self-care deficit with an intervention for bathing to have 1 staff assist.<BR/>Interview on 03/04/25 at 10:07 AM with Resident #47 revealed she had not been bathed since she was admitted (02/08/25) and did not know there was a shower schedule. She stated she would like to be bathed twice a week at least. She stated she felt very dirty and her hair needed to be washed. <BR/>Record review of resident #47's bathing task record from 02/09/25 to current reflected she had not been bathed. All dates were documented as Activity did not occur. <BR/>5. Record review of Resident #56's face sheet dated 03/06/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. <BR/>Record review of Resident #56's MDS sheet dated 12/24/24 revealed a BIMS score was not entered because Resident #56 was unable to complete the interview. Resident #56 functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and personal hygiene. Resident #56's diagnoses included urinary tract infection (infection that affects part of the urinary tract), Type 2 Diabetes (high blood sugar), Dementia (group of symptoms affecting memory), abnormalities of gait and mobility, lack of coordination , and unsteady on feet. <BR/>Record review of Resident #56's care plan as of 08/06/24 revealed Resident #56 had an activities of daily living self care performance deficit due to dementia. Goal included the resident will maintain or improve current level of function in transfers, eating, dressing, toilet use and personal hygiene. Interventions included resident uses a geri chair, Transfer: the resident required (X2) staff participation with transfer. Bathing: provide the resident with a sponge bath when shower can not be tolerated. Resident was totally depend on staff to provide a bath (3x a week) and as necessary. The Resident required (x1) staff participation with bathing. <BR/>Interview on 03/04/25 at 3:36 PM with a family member of Resident #56 revealed she visited with Resident #56 daily. The family member stated she would find her soaked in her brief down to the sheets with urine and poop everyday, leaving her with an odor. According to the Family Member when she entered the facility, she would have to take matters into her own hands to clean and change Resident #56 along with her bedding. The Family Member stated they are very understaffed and do not have staff on the hall to care for the residents, it made me upset to see how they just leave my mom like that. The Family Member stated Resident #56 was on hospice which came in the mornings to bath, change and dress her for the day, however there was no one from the facility that checked on Resident #56 throughout the day to ensure she was dry or changed. The Family Member stated it would be nice to have someone check on her after lunch to change her brief. <BR/>Interview on 03/05/25 at 10:25 AM with LVN A revealed residents were showered or bathed three times a week by the CNAs. She stated the CNAs bring her their shower sheets to the nurse if there is a new finding like a bruise, or if the resident refuses their shower. She would check with the resident and encourage them to be bathed. She stated the risk of not getting bathed was skin breakdown and irritation.<BR/>Interview on 03/05/25 at 12:43 PM with the DON revealed showers and baths were documented in the computer under Tasks by the CNAs. She stated if it was not in the computer it did not happen. She stated there were no shower sheets. <BR/>Interview on 03/06/25 at 8:20 AM with the RNC revealed they had stacks of old shower sheets from several months, going back to before the change of ownership. She stated the current policy was for the staff to document everything in the computer because shower sheets get lost, and were difficult to track. She stated the expectation was the CNAs would bathe residents three times a week, less if the resident preferred it. All documentation was to be done in the computer. <BR/>Interview on 03/06/25 at 3:25 PM with CNA C revealed residents should be showered three times a week. When she showered a resident she filled out a shower sheet and turned it into the nurse. If a resident refused a shower she had them sign the shower sheet. She stated the risk of a resident not being showered was skin irritation or breakdown. <BR/>Interview on 03/06/25 at 3:30 PM with the DON and the RNC revealed they both stated the CNAs did not use a shower sheet to document showers. They documented showers in the computer under Tasks. The DON and the RNC both stated the Task document was the most accurate record of the resident's showers. The DON stated the residents were being bathed, but if they were not the risk could be anything. <BR/>Interview on 03/06/25 at 3:47 PM with CNA D revealed the residents should be showered three times a week. She stated she documented her showers on a shower sheet and then put it into the computer. The shower sheet was given to the nurse if there were findings like a bruise or redness found during the shower. She stated the risk of residents not being bathed was skin breakdown or irritation. <BR/>Interview on 03/06/25 at 3:58 PM with CNA E revealed residents were showered three times a week. She documented her showers on a shower sheet and then put it into the computer. The shower sheet was then given to the nurse. She stated the risk of residents not being bathed could be skin breakdown. <BR/>Interview on 03/06/25 at 4:04 PM with CNA F revealed she was supposed to be the designated shower aide Monday through Friday, but she was often called to be a CNA on one of the halls because someone called in. She stated she usually only had one day a week when she was functioning as the shower aide because the CNAs called in so often. <BR/>Record review of the facility's current, undated Bath, Tub/Shower policy reflected:<BR/>Bathing by tub bath or shower is done to removed soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation Frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although daily bathing or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 of 7 residents (Resident #7 and Resident #22) reviewed for Resident Rights.<BR/>CNA G verbally abused Residents #7 and #22 when the residents requested to return inside the building following a smoke break, and she yelled at them telling they could not go inside and blocked the door.<BR/>The failure placed residents at risk of feelings of decreased self-worth.<BR/>The non-compliance was identified as PNC. The noncompliance began on 02/15/25 and ended on 02/21/25. The facility had corrected the non-compliance before the investigation began. <BR/>Finding included:<BR/>Record review of Resident #7's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #7's entry MDS sheet dated 02/08/25 reflected a BIMS score of 13 indicating her cognition was intact. Resident #7's functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and lower body dressing. Resident #7 was independent with eating, oral hygiene and upper body dressing, and partial assistance with personal hygiene. Resident #7's diagnoses included acquired absence of left leg above knee, muscle weakness, lack of coordination, and a history of falling. <BR/>Record review of Resident #7's care plan as of 02/16/25 reflected Resident #7 was a smoker. The care plan reflected a goal to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. The trauma was related to being angry at CNA G for saying that she could not go back inside after smoking. The care plan goal included maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included to arrange a licensed mental health provider as ordered by the physician. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include verbal threats, and physical aggression.<BR/>Record review of Resident #7's Safe Smoking assessment dated [DATE] and 03/04/25 reflected in summary: This resident required direct supervision while smoking: All smoking materials will be kept at the nurse's station: The evaluation has been explained to the family responsible party and to the resident.<BR/>Record review of Resident #22's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #22's entry MDS sheet dated 02/19/25 reflected a BIMS score of 15 indicating her cognition was intact. Resident #22's functional abilities indicated she was independent with eating, oral hygiene, toileting hygiene and required set up or clean up with shower/bathing, upper and lower body dressing, and personal hygiene. Resident #22 had use of a walker. Resident #22's diagnoses included muscle weakness and difficulty walking. <BR/>Record review of Resident #22's care plan as of 02/16/25 reflected Resident #22 was a smoker. The care plan gooal included to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. <BR/>Record review of Resident #22's Safe Smoking assessment dated [DATE] reflected in summary: This resident required direct supervision while smoking: All smoking materials would be kept at the nurse's station: The evaluation has been discussed with the resident. <BR/>Interview on 03/04/25 at 10:55 AM with Resident #7 revealed she liked to smoke at each smoke break. Resident #7 stated she was outside smoking with CNA G and finished earlier than others and wanted to return inside the facility. According to Resident #7, CNA G yelled at her saying, You can't go back inside until I go in. Resident #7 stated it made her upset. Resident #7 stated it was cold outside, and she should have been allowed to return inside the building if she wanted. <BR/>Interview on 03/04/25 at 1:40 PM with Resident #22 revealed she enjoyed smoking on the smoke breaks provided by the facility. According to Resident #22, she was outside when CNA G would not allow Resident #22 to return inside the building when she was finished smoking. Resident #22 stated CNA G was the only staff member, who would make residents stay outside until everyone was finished, and they all came back inside at one time. Resident #22 stated she was upset that CNA G did not allow residents to return inside the building yelling, Do not go any further. No one can go in without me. Resident #22 also stated CNA G stood in the walkway blocking residents from leaving the patio. Resident #22 stated she reported to the front desk that Resident #7 was not allowed to return to the building and the Administrator followed up with her about the incident. According to Resident #22, CNA G no longer worked at the facility and there had not been any further issues with residents returning inside the building when they were finished smoking. <BR/>Observation on 03/04/25 at 4:10 PM revealed residents on the patio with the Maintenance Director and revealed residents were able to exit the patio once they were finished smoking. <BR/>Observation and interview on 03/05/25 at 4:00 PM with the Laundry Aide revealed there was a schedule sheet that he followed which notified when his department took residents out to smoke. The Laundry Aide stated he recognized all residents were able to safely smoke. Laundry Aide stated he was responsible for ensuring all residents were safe before, during, and after smoking and should stay together just in case they needed help returning to the facility, for example if they were a fall risk. The Laundry Aide stated he thought all residents were supposed to wait together to go inside the building after smoking, but he could not stop anyone from going back inside the building if they wanted to leave. Therefore, he allowed residents to leave when they were done smoking. According to the Laundry Aide, trying to stop residents from returning inside the building after smoking would go against their rights to move around as they want. <BR/>Interview on 03/05/25 at 4:41 PM with RN I revealed she was aware of residents that smoked. There was a schedule that indicated nursing staff were responsible to take residents out during the evening hours. According to RN I, she was present on 02/15/25 when CNA G volunteered to take the residents out to the patio for smoking at 6:30 PM. RN I stated she was standing at the nursing station when Resident #22 informed RN H that Resident #7 wanted to return back into the building once she finished smoking and she was not allowed to and was told she had to wait. RN I stated according to Resident #22, she did not like that Resident #7 was told she could not leave, and that CNA G blocked the walkway to prevent anyone from leaving the patio. RN I stated she and RN H then began contacting the DON and the Administrator. <BR/>Interview on 03/05/25 at 5:09 PM with the ADON revealed she was in-serviced on resident rights after the 02/15/25 incident when CNA G would not allow residents to reenter the building after smoking. The ADON stated whomever was scheduled to take residents out to smoke was responsible for residents while they were smoking. The ADON stated if there were multiple residents smoking and one wanted to come back inside, and you did not have to leave residents smoking unsupervised, residents who were able to safely return to the building could do so. The ADON expressed that residents had the right to be able to return in the building after smoking, or anytime they wanted to come inside or move about the facility, not doing so violated their rights. <BR/>Interview on 03/06/25 at 9:10 AM with RN H revealed she was at the nursing station on 02/15/25 when CNA G took residents who smoke out to the patio at their 6:30 PM smoke break. RN H stated after the break, Resident #7 and Resident #22 reported to her that CNA G told them they could not come back in inside the building until everyone was done smoking. RN H stated, it was cold that night so residents were distraught they could not return in the building once they were done smoking. RN H stated she reported to the Administrator and the DON, what residents reported to her. RN H stated she was in-serviced on resident rights and the residents had the ability to move about the facility, being told they could not return in the building after they were ready, placed them at risk of their rights being violated. <BR/>Interview on 03/06/25 at 10:00 AM with the Administrator revealed he was notified by RN H that CNA G took residents out to smoke; once they were finished smoking and wanted to return inside the building because they were cold. The Administrator stated he was told CNA G yelled No one can go in without me and stood in the walkway preventing them from leaving the patio. The Administrator stated he asked residents to be assessed to ensure they were ok and not harmed in any way and to gather statements. The Administrator stated he alerted his corporate office and the human resources and suspended CNA G. The Administrator stated he entered the facility on 02/16/25 to interview residents and started in-services and monitoring. The Administrator stated there was a schedule to advise which department was responsible for taking the residents out to smoke at designated times. The Administrator advised he expected staff to allow residents to go out on the patio and smoke, if they were done and wanted to come back inside the building staff should allow that as it was their right to do so. The Administrator stated they completed in-services to educate staff to monitor residents while outside on the patio during smoking breaks; however, you could not keep residents outside against their will. <BR/>Interview on 03/06/25 at 10:07 AM with the DON revealed she was notified of the incident on 02/15/25 with CNA G refusing to allow residents to return in the building by standing in the walkway and yelling they had to wait on all residents to reenter together. The DON stated in-services on resident rights, abuse and neglect, and their smoking policy were started immediately. The DON stated she expected staff to follow the smoking schedule and take residents out to smoke. The DON stated at any time residents want to leave the patio after smoking, they have the right to do so and should be able to do so. The DON stated CNA G not allowing residents to return inside the building placed them at risk of not having their rights honored. <BR/>Interview on 03/07/25 at 11:39 AM with CNA G revealed she did take residents out to the patio for a smoke break right before her shift ended at 6:30 PM on 02/15/25. According to CNA G it was a bit cooler that evening, and Resident #7 attempted to leave the patio when she finished smoking. CNA G stated she expressed to Resident #7 you have to wait to go inside all together. CNA G stated the reason she did not allow residents to leave the patio was because it was not feasible. She stated Resident #7 was in a wheelchair and could have fallen. CNA G stated, I admit I kept her from going in. It was for her safety. According to CNA G, she was responsible for ensuring residents returned in the building safely. CNA G stated she was suspended and later terminated. CNA G stated she was not thinking residents were placed at risk of rights not being honored, she stated I was thinking of their safety.<BR/>Record review of a Employee Disciplinary Report for CNA G dated 02/15/25 reflected due to allegations, CNA G will be placed on unpaid investigatory suspension and will remain on investigatory suspension until the investigation is completed. CNA G will be notified when the investigation is completed.<BR/>Record review of Resident #7's statement reflected: <BR/>6:30 Smoke Break<BR/>At the 6:30 PM smoke break CNA G took the smokers outside the smoke area. When I was done smoking, I started to go back inside from the smoking area and CNA G stood in the opening that leads to sidewalk and said You can't go in until I go in. I stayed outside in the smoking area for about 15 minutes. I was cold and I did not have a coat on. When I came back inside, I told RN H and RN I what happened.<BR/>Record review of Resident #22's statement reflected:<BR/>6:30 PM Smoke Break<BR/>At the 6:30 PM smoke break CNA G took us outside. Before we went outside, she was talking really fast, and I could tell that she did not want to take us outside and stated she had other things to do. She did take us outside but kept coming back inside and to the smoke area. She was pacing back in forth in the smoke area and was yelling I do not want to talk to anyone. I am upset. Two of the smokers were finished and started to go down the sidewalk to go back inside like they normally do, and CNA G yelled Do not you go any further. No one can go in without me. She said she was going to search for everyone's lighters and cigarettes. I did not see her search anyone. CNA G stood in front of Resident #7 and would not let her leave the smoking area. I was still smoking. Another resident told her he was going inside when he finished his cigarette, and he went inside. CNA G was very short spoken with us while we were outside. When I returned to the building, I told RN H and RN I what happened during the smoke break. Once in my room I checked my cell phone, and I had a missed call from CNA G, I did not call her back. <BR/>Record review of CNA G's Witness Statement reflected: I work every time I am asked to, I work nights, I worked my Saturday day off. Residents all they want to do is smoke, I have COPD. This was signed by CNA G 02/17/25 and the Administrator. <BR/>An ADHOC QAPI meeting was held on 02/17/25 with the Interdisciplinary Team including the Medical Director to discuss the allegations and findings.<BR/>Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/21/25, reflected: <BR/>Description of Allegation:<BR/>[CNA G], CNA, took the residents out to smoke at the schedule[d] 6:30 PM time. Some of the residents were getting cold and wanted to go back inside after smoking a cigarette. [CNA G] yelled and told them that they couldn't go back inside without her, and she wasn't letting anyone back in until she was ready. [Residents #7 and #22] stated they felt this was verbal abuse by [CNA G] yelling and not letting them back inside.<BR/>Provider Response:<BR/>Details of this incident were found out after the staff member [CNA G] left after her shift. The staff member was immediately suspended pending investigation after administration found out about the incident. Safe surveys for smokers completed.<BR/>Investigation Summary:<BR/>Investigation summary shows that the incident did occur. [CNA G] was terminated on 2/18/2025 for verbal abuse occurring. Residents did not have any trauma from the incident.<BR/>Provider Action Taken Post Investigaiton:<BR/>In-serviced staff on abuse/neglect. [CNA G] was terminated for verbal abuse on 2/18/2025. No adverse effects for any residents involved.<BR/>Record review of Payroll Input/Personnel Action Form signed 02/18/25 reflected CNA G was terminated on 02/18/25. CNA G has failed to adhere to the Corporate Code of Conduct. CNA G was aware of the corporate code of conduct as indicated by the signature of the employee handbook acknowledgment. CNA G meet criteria for immediate termination. <BR/>Record review of an in-service record, dated 02/15/25 reflected the DON trained staff on the following topics: Abuse and Neglect, Resident Rights, and Smoking Policy. The in-service record reflected staff not present would receive the in-service training prior to assuming their duties on their next scheduled shift. Also, new and agency staff would received the in-service training prior to assuming patient care duties. <BR/>Interviews on 03/06/25 with LVN A, LVN B, RN H, RN I, Laundry Aide, Dietary Aide, DON, ADON, CNA J revealed they had been trained on residents' rights and were aware to allow residents to return in the building as they were finished smoking, not doing so placed residents at risk of violation of their rights being honored. <BR/>Record review reflected the facility implemented the following for monitoring from 02/16/25-02/21/25: ask 15-20 staff members per week; ask about 5 resident per week how staff is treating them; during incident/event review in standup; during facility rounds are there any sings of staff acting rudely or inappropriate with residents. <BR/>Record review of the facility's Resident Rights policy, revised 11/28/16, reflected:<BR/>Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. <BR/>Respect and dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience.<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. <BR/>Self-determination - The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. <BR/>1. <BR/>The resident has a right to choose activities, schedule and health care and providers of health care services consistent with his or her interest. <BR/>2. <BR/>The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 of 7 residents (Resident #7 and Resident #22) reviewed for Resident Rights.<BR/>CNA G verbally abused Residents #7 and #22 when the residents requested to return inside the building following a smoke break, and she yelled at them telling they could not go inside and blocked the door.<BR/>The failure placed residents at risk of feelings of decreased self-worth.<BR/>The non-compliance was identified as PNC. The noncompliance began on 02/15/25 and ended on 02/21/25. The facility had corrected the non-compliance before the investigation began. <BR/>Finding included:<BR/>Record review of Resident #7's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #7's entry MDS sheet dated 02/08/25 reflected a BIMS score of 13 indicating her cognition was intact. Resident #7's functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and lower body dressing. Resident #7 was independent with eating, oral hygiene and upper body dressing, and partial assistance with personal hygiene. Resident #7's diagnoses included acquired absence of left leg above knee, muscle weakness, lack of coordination, and a history of falling. <BR/>Record review of Resident #7's care plan as of 02/16/25 reflected Resident #7 was a smoker. The care plan reflected a goal to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. The trauma was related to being angry at CNA G for saying that she could not go back inside after smoking. The care plan goal included maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included to arrange a licensed mental health provider as ordered by the physician. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include verbal threats, and physical aggression.<BR/>Record review of Resident #7's Safe Smoking assessment dated [DATE] and 03/04/25 reflected in summary: This resident required direct supervision while smoking: All smoking materials will be kept at the nurse's station: The evaluation has been explained to the family responsible party and to the resident.<BR/>Record review of Resident #22's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #22's entry MDS sheet dated 02/19/25 reflected a BIMS score of 15 indicating her cognition was intact. Resident #22's functional abilities indicated she was independent with eating, oral hygiene, toileting hygiene and required set up or clean up with shower/bathing, upper and lower body dressing, and personal hygiene. Resident #22 had use of a walker. Resident #22's diagnoses included muscle weakness and difficulty walking. <BR/>Record review of Resident #22's care plan as of 02/16/25 reflected Resident #22 was a smoker. The care plan gooal included to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. <BR/>Record review of Resident #22's Safe Smoking assessment dated [DATE] reflected in summary: This resident required direct supervision while smoking: All smoking materials would be kept at the nurse's station: The evaluation has been discussed with the resident. <BR/>Interview on 03/04/25 at 10:55 AM with Resident #7 revealed she liked to smoke at each smoke break. Resident #7 stated she was outside smoking with CNA G and finished earlier than others and wanted to return inside the facility. According to Resident #7, CNA G yelled at her saying, You can't go back inside until I go in. Resident #7 stated it made her upset. Resident #7 stated it was cold outside, and she should have been allowed to return inside the building if she wanted. <BR/>Interview on 03/04/25 at 1:40 PM with Resident #22 revealed she enjoyed smoking on the smoke breaks provided by the facility. According to Resident #22, she was outside when CNA G would not allow Resident #22 to return inside the building when she was finished smoking. Resident #22 stated CNA G was the only staff member, who would make residents stay outside until everyone was finished, and they all came back inside at one time. Resident #22 stated she was upset that CNA G did not allow residents to return inside the building yelling, Do not go any further. No one can go in without me. Resident #22 also stated CNA G stood in the walkway blocking residents from leaving the patio. Resident #22 stated she reported to the front desk that Resident #7 was not allowed to return to the building and the Administrator followed up with her about the incident. According to Resident #22, CNA G no longer worked at the facility and there had not been any further issues with residents returning inside the building when they were finished smoking. <BR/>Observation on 03/04/25 at 4:10 PM revealed residents on the patio with the Maintenance Director and revealed residents were able to exit the patio once they were finished smoking. <BR/>Observation and interview on 03/05/25 at 4:00 PM with the Laundry Aide revealed there was a schedule sheet that he followed which notified when his department took residents out to smoke. The Laundry Aide stated he recognized all residents were able to safely smoke. Laundry Aide stated he was responsible for ensuring all residents were safe before, during, and after smoking and should stay together just in case they needed help returning to the facility, for example if they were a fall risk. The Laundry Aide stated he thought all residents were supposed to wait together to go inside the building after smoking, but he could not stop anyone from going back inside the building if they wanted to leave. Therefore, he allowed residents to leave when they were done smoking. According to the Laundry Aide, trying to stop residents from returning inside the building after smoking would go against their rights to move around as they want. <BR/>Interview on 03/05/25 at 4:41 PM with RN I revealed she was aware of residents that smoked. There was a schedule that indicated nursing staff were responsible to take residents out during the evening hours. According to RN I, she was present on 02/15/25 when CNA G volunteered to take the residents out to the patio for smoking at 6:30 PM. RN I stated she was standing at the nursing station when Resident #22 informed RN H that Resident #7 wanted to return back into the building once she finished smoking and she was not allowed to and was told she had to wait. RN I stated according to Resident #22, she did not like that Resident #7 was told she could not leave, and that CNA G blocked the walkway to prevent anyone from leaving the patio. RN I stated she and RN H then began contacting the DON and the Administrator. <BR/>Interview on 03/05/25 at 5:09 PM with the ADON revealed she was in-serviced on resident rights after the 02/15/25 incident when CNA G would not allow residents to reenter the building after smoking. The ADON stated whomever was scheduled to take residents out to smoke was responsible for residents while they were smoking. The ADON stated if there were multiple residents smoking and one wanted to come back inside, and you did not have to leave residents smoking unsupervised, residents who were able to safely return to the building could do so. The ADON expressed that residents had the right to be able to return in the building after smoking, or anytime they wanted to come inside or move about the facility, not doing so violated their rights. <BR/>Interview on 03/06/25 at 9:10 AM with RN H revealed she was at the nursing station on 02/15/25 when CNA G took residents who smoke out to the patio at their 6:30 PM smoke break. RN H stated after the break, Resident #7 and Resident #22 reported to her that CNA G told them they could not come back in inside the building until everyone was done smoking. RN H stated, it was cold that night so residents were distraught they could not return in the building once they were done smoking. RN H stated she reported to the Administrator and the DON, what residents reported to her. RN H stated she was in-serviced on resident rights and the residents had the ability to move about the facility, being told they could not return in the building after they were ready, placed them at risk of their rights being violated. <BR/>Interview on 03/06/25 at 10:00 AM with the Administrator revealed he was notified by RN H that CNA G took residents out to smoke; once they were finished smoking and wanted to return inside the building because they were cold. The Administrator stated he was told CNA G yelled No one can go in without me and stood in the walkway preventing them from leaving the patio. The Administrator stated he asked residents to be assessed to ensure they were ok and not harmed in any way and to gather statements. The Administrator stated he alerted his corporate office and the human resources and suspended CNA G. The Administrator stated he entered the facility on 02/16/25 to interview residents and started in-services and monitoring. The Administrator stated there was a schedule to advise which department was responsible for taking the residents out to smoke at designated times. The Administrator advised he expected staff to allow residents to go out on the patio and smoke, if they were done and wanted to come back inside the building staff should allow that as it was their right to do so. The Administrator stated they completed in-services to educate staff to monitor residents while outside on the patio during smoking breaks; however, you could not keep residents outside against their will. <BR/>Interview on 03/06/25 at 10:07 AM with the DON revealed she was notified of the incident on 02/15/25 with CNA G refusing to allow residents to return in the building by standing in the walkway and yelling they had to wait on all residents to reenter together. The DON stated in-services on resident rights, abuse and neglect, and their smoking policy were started immediately. The DON stated she expected staff to follow the smoking schedule and take residents out to smoke. The DON stated at any time residents want to leave the patio after smoking, they have the right to do so and should be able to do so. The DON stated CNA G not allowing residents to return inside the building placed them at risk of not having their rights honored. <BR/>Interview on 03/07/25 at 11:39 AM with CNA G revealed she did take residents out to the patio for a smoke break right before her shift ended at 6:30 PM on 02/15/25. According to CNA G it was a bit cooler that evening, and Resident #7 attempted to leave the patio when she finished smoking. CNA G stated she expressed to Resident #7 you have to wait to go inside all together. CNA G stated the reason she did not allow residents to leave the patio was because it was not feasible. She stated Resident #7 was in a wheelchair and could have fallen. CNA G stated, I admit I kept her from going in. It was for her safety. According to CNA G, she was responsible for ensuring residents returned in the building safely. CNA G stated she was suspended and later terminated. CNA G stated she was not thinking residents were placed at risk of rights not being honored, she stated I was thinking of their safety.<BR/>Record review of a Employee Disciplinary Report for CNA G dated 02/15/25 reflected due to allegations, CNA G will be placed on unpaid investigatory suspension and will remain on investigatory suspension until the investigation is completed. CNA G will be notified when the investigation is completed.<BR/>Record review of Resident #7's statement reflected: <BR/>6:30 Smoke Break<BR/>At the 6:30 PM smoke break CNA G took the smokers outside the smoke area. When I was done smoking, I started to go back inside from the smoking area and CNA G stood in the opening that leads to sidewalk and said You can't go in until I go in. I stayed outside in the smoking area for about 15 minutes. I was cold and I did not have a coat on. When I came back inside, I told RN H and RN I what happened.<BR/>Record review of Resident #22's statement reflected:<BR/>6:30 PM Smoke Break<BR/>At the 6:30 PM smoke break CNA G took us outside. Before we went outside, she was talking really fast, and I could tell that she did not want to take us outside and stated she had other things to do. She did take us outside but kept coming back inside and to the smoke area. She was pacing back in forth in the smoke area and was yelling I do not want to talk to anyone. I am upset. Two of the smokers were finished and started to go down the sidewalk to go back inside like they normally do, and CNA G yelled Do not you go any further. No one can go in without me. She said she was going to search for everyone's lighters and cigarettes. I did not see her search anyone. CNA G stood in front of Resident #7 and would not let her leave the smoking area. I was still smoking. Another resident told her he was going inside when he finished his cigarette, and he went inside. CNA G was very short spoken with us while we were outside. When I returned to the building, I told RN H and RN I what happened during the smoke break. Once in my room I checked my cell phone, and I had a missed call from CNA G, I did not call her back. <BR/>Record review of CNA G's Witness Statement reflected: I work every time I am asked to, I work nights, I worked my Saturday day off. Residents all they want to do is smoke, I have COPD. This was signed by CNA G 02/17/25 and the Administrator. <BR/>An ADHOC QAPI meeting was held on 02/17/25 with the Interdisciplinary Team including the Medical Director to discuss the allegations and findings.<BR/>Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/21/25, reflected: <BR/>Description of Allegation:<BR/>[CNA G], CNA, took the residents out to smoke at the schedule[d] 6:30 PM time. Some of the residents were getting cold and wanted to go back inside after smoking a cigarette. [CNA G] yelled and told them that they couldn't go back inside without her, and she wasn't letting anyone back in until she was ready. [Residents #7 and #22] stated they felt this was verbal abuse by [CNA G] yelling and not letting them back inside.<BR/>Provider Response:<BR/>Details of this incident were found out after the staff member [CNA G] left after her shift. The staff member was immediately suspended pending investigation after administration found out about the incident. Safe surveys for smokers completed.<BR/>Investigation Summary:<BR/>Investigation summary shows that the incident did occur. [CNA G] was terminated on 2/18/2025 for verbal abuse occurring. Residents did not have any trauma from the incident.<BR/>Provider Action Taken Post Investigaiton:<BR/>In-serviced staff on abuse/neglect. [CNA G] was terminated for verbal abuse on 2/18/2025. No adverse effects for any residents involved.<BR/>Record review of Payroll Input/Personnel Action Form signed 02/18/25 reflected CNA G was terminated on 02/18/25. CNA G has failed to adhere to the Corporate Code of Conduct. CNA G was aware of the corporate code of conduct as indicated by the signature of the employee handbook acknowledgment. CNA G meet criteria for immediate termination. <BR/>Record review of an in-service record, dated 02/15/25 reflected the DON trained staff on the following topics: Abuse and Neglect, Resident Rights, and Smoking Policy. The in-service record reflected staff not present would receive the in-service training prior to assuming their duties on their next scheduled shift. Also, new and agency staff would received the in-service training prior to assuming patient care duties. <BR/>Interviews on 03/06/25 with LVN A, LVN B, RN H, RN I, Laundry Aide, Dietary Aide, DON, ADON, CNA J revealed they had been trained on residents' rights and were aware to allow residents to return in the building as they were finished smoking, not doing so placed residents at risk of violation of their rights being honored. <BR/>Record review reflected the facility implemented the following for monitoring from 02/16/25-02/21/25: ask 15-20 staff members per week; ask about 5 resident per week how staff is treating them; during incident/event review in standup; during facility rounds are there any sings of staff acting rudely or inappropriate with residents. <BR/>Record review of the facility's Resident Rights policy, revised 11/28/16, reflected:<BR/>Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. <BR/>Respect and dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience.<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. <BR/>Self-determination - The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. <BR/>1. <BR/>The resident has a right to choose activities, schedule and health care and providers of health care services consistent with his or her interest. <BR/>2. <BR/>The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 8 residents (Resident #18) reviewed for comprehensive assessments.<BR/>The facility failed to complete an accurate quarterly comprehensive assessment dated [DATE] for Resident #18 by not including hospice services.<BR/>This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.<BR/>The findings included:<BR/>Record review of Resident #18's face sheet, dated 02/06/24, documented a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #18 had diagnoses which included: Parkinson's Disease (a chronic degenerative disorder of the central nervous system that affects both the motor system and non-motor systems), dementia (general name for a decline in cognitive abilities that impacts a person's ability to perform everyday activities), heart failure (a syndrome, a group of signs and symptoms, caused by impairment of the heart's blood pumping function), and dysphagia (difficulty in swallowing). <BR/>Record review of Resident #18's Quarterly MDS assessment dated [DATE], reflected that the resident was not receiving hospice services. <BR/>Record review of Resident #18's Annual MDS assessment dated [DATE], reflected that Resident #18 had a BIMS score of 09 which revealed the resident was moderately cognitively impaired.<BR/>Record review of Resident #18's Physician's Orders, dated 02/06/24, reflected the resident had an order to admit to hospice on 09/19/22.<BR/>In an observation on 02/05/24 at 10:36 AM Resident #18 was outside smoking with staff present. Resident #18 appeared to be in no sign of distress. Resident #18 was dressed appropriately for temperatures. She stated things were fine and staff treated her well. She stated she had no complaints. <BR/>In an interview on 02/07/24 at 11:25 AM with the MDS nurse, she stated she had worked in the facility for about 14 years. She stated Resident #18 was no longer on hospice services, but that Resident #18 had been on hospice services from 10/30/22 to 07/04/23. She stated she had not been aware Resident #18's quarterly MDS assessment, which was completed on 05/12/23, had not reflected Resident #18 received hospice services. She stated the MDS assessments should have reflected if a resident received hospice services. She stated there was no correction done to the MDS assessment completed on 05/12/23. She stated Resident #18's hospice orders should have been discontinued when the resident came off of hospice. She stated she had been trained on how to complete an MDS accurately and she was not sure how that MDS assessment which was completed on 05/12/23 got by. She stated if an MDS assessment was completed inaccurately, the facility could have money taken back or they could lose money. <BR/>In an interview on 02/07/24 at 12:11 PM with the DON, she stated she had worked in the facility for about a year. She stated Resident #18 no longer received hospice care. She stated Resident #18 had received hospice care until around July of 2023. She stated they were not sure about taking Resident #18 off of hospice due to Resident #18's weight loss, so they had monitored Resident #18 closely. She stated the MDS nurse was responsible for completing all MDS assessments. She stated the MDS nurse worked at the facility before she did and she was not sure of the training the MDS nurse received. She stated she knew that the MDS's corporate supervisor came to the facility and worked with the MDS nurse on all those things. She stated she had not realized Resident #18's MDS assessment which was completed on 05/12/23 was not accurate. She stated MDS assessments should reflect if a resident was on hospice services. She stated a possible outcome could have been if the staff attempted to order medications from the hospice company, it could have prevented the medication from being delivered timely and could have caused all kinds of medication errors. She stated they had a process to keep them from doing that.<BR/>In an interview on 02/07/24 at 12:42 PM with the ADM, he stated he had worked at the facility for about 2 years. He stated Resident #18 was not on hospice services at that time, but she had been on hospice before. He stated he was not sure when Resident #18 came off of hospice services, but he knew it was some time last year. He stated he was not aware that the MDS assessment completed on 05/12/23 was not accurate. He stated the MDS assessment should reflect if a resident was on hospice. He stated the MDS nurse was responsible for completing the MDS assessment and it was overseen by the DON. He stated the MDS nurse had been trained on accurate completion of the MDS assessments. He stated the outcome of an inaccurate MDS assessment could be a resident not receiving proper care, medications, or treatment.<BR/>Record review of the facility's policy on Certifying Accuracy of the Resident Assessment, dated 2001, revised November 2019, reflected Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #7) reviewed for comprehensive care plans.<BR/>The facility failed to ensure Resident #7's comprehensive care plan included a new intervention for a fall mat after Resident #7 fell on [DATE]. <BR/>This failure could place residents at increased risk of not having their individual needs met and a decreased quality of life.<BR/>Findings included:<BR/>A record review of Resident #7's face sheet, dated 02/06/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses that included Weakness (lack of strength), Muscle wasting and atrophy (decrease in muscle mass), lack of coordination (difficulties in controlling and organizing movement) Spastic Hemiplegia affecting right dominant side (causing muscle tightness and involuntary contractions in the limbs or extremities), unspecified abnormalities of gait and mobility (change in walking pattern), and other muscle spasm (when a muscle involuntarily or forcibly contract uncontrollably).<BR/>A record review of Resident #7's Quarterly MDS assessment, dated 12/28/23, reflected Resident #7 had a BIMS score of 15, which indicated cognitively intact. Section GG of the MDS indicated Resident #7 had impairment to one side of his upper extremity and had impairment to both sides of his lower extremities. Section GG also indicated that Resident #7 was dependent in the following areas upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>A record review of Resident #7's Active Physicians Orders, dated 02/06/24, reflected there was an order, dated 11/30/23, for Resident #7 to have a fall mat at bedside. <BR/>A record review of a Progress Note entry, dated 11/29/23, reflected Resident #7 was seen sitting on the floor next to the bed. According to the progress note Resident #7 stated that he slid to the floor trying to get out of bed.<BR/>A record review of Resident #7's care plan, dated 12/18/23, did not reflect a fall mat for Resident #7 nor did it reflect Resident #7's most recent fall on 11/29/23.<BR/>An observation of Resident #7 on 02/06/23 at 1:00 pm revealed the resident was lying in bed with the fall mat placed against the wall. <BR/>An observation of Resident #7 on 02/07/23 at 10:00 am revealed the resident was lying in bed with the fall mat placed bedside the bed. <BR/>In an interview with Resident #7 on 02/06/24 at 1:00 pm, Resident #7 stated sometimes the staff put the fall mat down and sometimes they don't. Resident #7 stated that his entire right side was contracted due to several strokes. Resident #7 stated his most recent fall was in October or November of 2023. Resident #7 stated his fall mat was not near his bed during his most recent fall. <BR/>In an interview with the MDS Coordinator on 02/07/24 at 12:15 pm. The MDS Coordinator stated she had worked at the facility for 10 years. The MDS Coordinator stated she was responsible for completing and updating the Care Plans. The MDS Coordinator stated during the morning meeting the DON would notify her if a resident had a fall and would notify her of any updated interventions that needed to be added to the care plan. The MDS Coordinator stated that if a resident had a fall mat, then it should have been used while the resident was in bed, and the fall mat should have been care planned. The MDS Coordinator stated if a resident''s fall mat was not placed beside the resident's bed, then the resident could have injured themselves if they had a fall. <BR/>In an interview with the DON on 02/07/24 at 12:25 pm. The DON stated that if the residents had reoccurring falls the care plan should have been updated, but not if a resident had an isolated fall. The DON stated if a resident had a fall mat, then it should have been used correctly, and care planned. The DON stated if the fall mat was not placed beside the resident's bed, then the resident could have sustained injuries such as broken or fractured bones. <BR/>In an interview with the Administrator on 02/07/24 at 12:35 pm. the administrator stated that if a resident had a fall the care plan should have been updated to reflect that fall and new interventions should have been added to the care plan. The administrator stated the MDS Coordinator was responsible for completing and updating the care plans. The administrator stated that if a resident had a fall mat, then it should have been care planned. The administrator stated if a resident has a fall mat, then it should have been correctly placed near the resident's bed when the resident was lying down. The administrator stated that if the mat was not placed on the floor near the bed, then the resident could have sustained injuries from falling.<BR/>Record review of the facility's Using the Care Plan policy, not dated, reflected The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. <BR/>Policy Interpretation and Implementation <BR/>1. <BR/>Complete care plans are placed in the resident's chart and/or 3-ring binder located at the appropriate nurses station.<BR/>2. <BR/>The Nurse supervisor uses the care plan to continue the CNAs daily/weekly work assessments sheets and/or flow sheets.<BR/>3. <BR/>CNAs are responsible for reporting to the Nursing Supervisor any change in the resident's condition and care plan goals and objectives that have not been met or expected outcomes that have not been achieved.<BR/>4. <BR/>Other facility staff noting a change in the resident's condition must also report those changes to the Nurse Supervisor and /or the MDS Assessment Coordinator.<BR/>5. <BR/>Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made.<BR/>6. <BR/>Documentation must be consistent with the resident's care plan.<BR/>7. <BR/>Information contained on the care plan and other documents used by the nursing staff shall be maintained in a confidential manner in accordance with established facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for one (Resident # 30) of six residents reviewed for infection control.<BR/>CNA A failed to change gloves or wash her hands while performing perineal care when removing a soiled brief and applying a clean brief. <BR/>This failure could place residents at-risk of cross contamination which could result in infections or illness.<BR/>Findings included:<BR/>Record review of Resident #30's undated Face Sheet reflected a [AGE] year-old female who was admitted on [DATE] with a diagnosis of cerebral infarction (damage to tissues in the brain due to loss of oxygen and blood to the area causing the tissue to die also called a stroke or brain attack), mild protein calorie malnutrition, weakness, hypothyroidism (a hormone deficiency) , and hemiplegia (paralysis) following cerebral infarction (stroke). <BR/>Record review of Resident #30's Quarterly MDS assessment dated [DATE], reflected a BIMs score of 14 indicating Resident #30 was cognitively intact. Section H reflected Resident #30 was frequently incontinent of bladder and always incontinent of bowel. <BR/>Record review of Resident #30's care plan initiated 04/27/2022 and revised 01/22/2024 reflected Resident #30 had a care plan for bladder incontinence. Resident #30's goal was to remain free from skin breakdown due to use of incontinence briefs through review date. The care plan included an intervention to check the resident every 2 hours and as required for incontinence care, wash rinse, dry perinium, and change clothing as needed. <BR/>In an observation on 02/06/24 at 11:02 AM CNA A was observed performing incontinent care. CNA A washed her hands and donned gloves prior to the start of the observation. CNA A cleaned Resident #30's front perineal area. Resident #30 rolled over and CNA A was observed washing buttocks and patting it dry. CNA A then removed the soiled brief and proceeded to put a clean brief under the resident, fastened the brief sides, and covered Resident #30 up with her blanket. CNA A did not wash her hands or change gloves between removing soiled brief and applying a clean brief. <BR/>In an interview on 02/06/24 11:36 AM with CNA A she stated she had been a CNA for 10 years. CNA A reported she had been verbally trained in an in-service on perineal care and handwashing techniques. CNA A reported she was not trained to remove her dirty gloves and wash hands prior to applying a clean brief. CNA A stated the risk to the resident could have been a urinary infection.<BR/>In an interview on 02/07/24 at 12:15 PM with the ADON reported she expected the staff to follow policy and procedure for handwashing. The ADON reported the staff had been instructed on handwashing in an in-service. She reported the nursing staff were visually checked off annually on all skills including perineal care and handwashing. She stated she was responsible for ensuring the CNAs had been educated on handwashing techniques. The ADON stated the negative outcome for failing to wash hands between removing a soiled brief and applying a clean brief could lead to increased urinary tract infections. <BR/>In an interview on 02/07/24 at 12:33 PM with the DON she reported her expectation was for the staff to wash, wash, wash their hands and change their gloves when performing resident care. The DON reported the ADON was responsible for monitoring handwashing education for staff members and the DON monitored the ADON to ensure tasks were completed. The DON reported the negative outcome for not cleaning or washing hands between dirty and clean surfaces could increase urinary tract infections. <BR/>In a record review of a nurse aide proficiency dated 8/17/23 indicated CNA A had passed her handwashing skills check off and was signed by ADON. <BR/>In a record review of an in-service dated 11/30/23 reflected that CNA A had signed she had viewed perineal care video in-service with handwashing techniques included.<BR/>Record review of the facility's Policy and procedure for handwashing dated 2001 and updated in October 2023 reflected:<BR/>1) <BR/>indications for hand hygiene -(c) after contact with blood, body fluids, or contaminated surfaces (f) before moving from work on a soiled body site to clean body site on the same resident and (g) immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 1 (Resident # 1) of 5 residents reviewed for pharmacy services. <BR/>The facility failed to follow the physician orders when administering Resident # 1's medications causing the resident to aspirate, have labored breathing and being sent to the hospital and being admitted due to aspiration. <BR/>An (IJ) Immediate Jeopardy was identified on 8/24/2023 at 7:26pm. While the (IJ) Immediate Jeopardy was removed on 8/26/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. <BR/>This failure placed all residents at risk for inadequate therapeutic outcomes, and a decline in health. <BR/>Findings included: <BR/>Record review of Resident #1 face sheet dated 8/24/2023, reflected Resident # 1 was an 85- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with ATHEROSCLEROTIC HEART DISEASE (damage or disease in the hearts blood vessels), DYSPHAGIA (difficulty swallowing foods or liquids) FOLLOWING CEREBRAL INFARCTION (disrupted blood flow to the brain due to problems with the blood vessels that supply it.) <BR/>Record review of Resident # 1's care plan dated 6/27/2023, reflected Resident # 1 had a swallowing problem. Record review of Resident # 1's swallowing assessment reflected he required (Reg diet pureed texture, pudding thick consistency for fluids)<BR/>Record review of Resident # 1 significant change MDS dated [DATE] reflected a BIMS- high level of cognitive functioning. In the MDS section K swallowing/nutritional status reflected; pureed textured, thickened liquids therapeutic diet.<BR/>Record review of Resident # 1 physician orders dated 2/14/2023 reflected- Pureed texture, pudding consistency, for fortified at breakfast and an order dated 8/22/2023 reflected- Crushed medications and mix with food/fluids due to swallowing disorder, every shift related to Dysphagia, Oropharyngeal Phase. <BR/>In an interview on 8/24/2023 at 1:07pm with LVN A, revealed on 8/22/2023 the MA admitted he administered Resident #1 medications without crushing and without thickened liquids. LVN A stated when she asked the MA were Resident # 1's medications administered crushed he stated no were they supposed to be? When asked if the medications were given with water not a thickened liquid he stated yes. She stated these medications were not administered as prescribed in the orders. LVN A stated Resident # 1 was coughing and had labored breathing. She stated they sent Resident # 1 was sent for further evaluation and treatment. <BR/>In a phone interview on 8/22/2023 at 1:28pm with Resident # 1, revealed he had a choking incident on 8/22/2023, the resident was able to state he was feeling fine today. He stated on Tuesday he was not feeling very well. The resident stated he was not able to remember all of what happened but stated something was wrong.<BR/>In a phone interview on 8/22/2023 with (RP) at 1:30pm, revealed she was contacted by the facility and advised that that Resident # 1 started choking and wasn't recovering well, continuing to cough and complain of chest pains so they sent him to the hospital to ensure that he did not aspirate. She stated when he got to the hospital, he was still having some choking problems and was not able to formulate his words. <BR/>In an interview on 8/24/2023 at 5:53pm with MDS revealed, the MA administered the following medications to Resident # 1 without crushing or thickened liquid. The medications were as follows: Lodipine 10mg, Aspirin 81mg, Cholecalciferol 125mg 1 tablet, Clopidogrel Bisulfate tablet 75mg 1 tablet, Ferrous sulfate Iron 200mg 1 tablet, Finasteride tablet 5mg 1 tablet, Lactobacillus Capsule 1 caplet, Lasix tablet 20mg 1 tablet, Tamsulosin HCI Capsule 0.4 mg, Zinc tablet 50mg, buspirone HCI tablet 15mg 1 tablet, Metoprolol Tartrate tablet 25mg, Oxcarbazepine tablet 600mg, and Zanaflex tablet 4mg 1 tablet.<BR/>Interview on 8/24/2023 at 1:54pm with hospital staff revealed, Resident # 1 was admitted to the hospital on [DATE]<BR/>for aspirations and shortness of breath.<BR/>In an interview on 8/24/2023 at 2:23pm with the DON revealed, on 8/22/2023 a CNA (unknown) walking down the hall advised her that Resident # 1 was choking. She stated when she entered the room LVN C was already in the room assisting Resident # 1. She stated that's when she learned that the MA had given Resident # 1 his medications not crushed or with thickened liquids. She stated Resident #1 complained of his chest hurting really bad and that he stated he was choking. The DON stated she never spoke with the MA herself but did advise the nursing staff to in-service the MA before he administered medication to any of the other residents. The DON stated the nurses were responsible for ensuring that all agency staff are trained on the care needs for the residents. She stated Resident # 1 was sent to the hospital for further evaluation and possible aspiration. The DON stated Resident # 1 could have aspirated due to not having his medications crushed and administered with thickened liquids according to the orders.<BR/>In an interview on 8/24/2023 at 12:30pm with the ADM revealed, the incident happened on 8/22/2023 and he has not yet completed his five -day report. He stated he was advised that the MA gave Resident # 1 his medications without them being crushed. He stated when a person is not given their medication according to the orders the Resident could have an adverse reaction and could be terminal. He stated he contacted the staffing agency and advised that the agency staff should be placed on the DNR (do not return) list and advised that they could make a referral on the staff's certification. <BR/> Record review of facility progress note dated 8/22/2023 reflected, Resident # 1 was sent to the hospital on 8/22/2023 for aspirating. <BR/>Record review of hospital records dated 8/22/2023, reflected Resident # 1 was admitted to the hospital for aspiration. <BR/>Record review of facility Administering Medications policy dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed. <BR/>This was determined to be an (IJ) Immediate Jeopardy (IJ) on 78/24/2023 at 7:26pm. The ADM was notified. The ADM was provided with the IJ template on 8/24/2023 at 7:26pm. <BR/>A Plan of Removal was first submitted by the ADM on 8/25/2023 at 9:14am. The Plan of removal accepted on 8/26/2023 at 12:18pm. <BR/>Re: Plan of Removal of Immediate Jeopardy<BR/>The following is a plan of removal, which has been immediately implemented for the facility to remedy the immediate jeopardy which was imposed 8/24/23 at 7:26pm for F-755 facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of resident 1. MA administered residents 1 medication whole and with water instead of the order which stated to crush all medications and serve with thicken liquids due to swallowing issues. All residents could potentially be affected by deficient practice. <BR/>All items listed will be completed by 8/25/23 with continued follow up for scheduled staff. <BR/>1. <BR/>Resident #1was assessed by LVN#1 post the event and sent to the hospital for evaluation. The initial radiological exam showed no obstructions or complications. Local Hospital is providing a higher level of care in place for this resident continues. 8-24-2023 thru 8-25-2023 <BR/>2. <BR/>All residents will be reviewed by DON for correct medication administration order that includes liquid administration order type. 8-25-2023 thru 8-25-2023 <BR/>3. <BR/>All residents were assessed by the DON/ADON regarding medication administration for crushed medication orders and/or the need for crushed medications due to diagnosis documented swallowing disorders. 8-24-2023 thru 8-25-2023 <BR/>4. <BR/>All residents' orders were reviewed by DON/ADON/MDS for crushed medication and orders for thickened liquids accuracy including order communication to EMAR (electronic medication administration record) regarding order. 8-24-2023 thru 8-25-2023 <BR/>5. <BR/>All residents requiring crushed mediations and thickened liquids care plans were reviewed by MDS/DON/ADON. 8-24-2023 thru 8-25-2023 <BR/>6. <BR/>All Medication aides and nurses were in-serviced by the DON/ADON regarding medication administration policy and procedure with a special focus regarding order for crushed medications and those residents requiring thickened liquids. 8-24-2023 thru 8-25-2023 <BR/>7. <BR/>Regional Director of Care in -serviced DON/ADON/Admin on physician orders for crushed medication and thickened liquids. All staff were in-serviced by the Admin/DON/ADON regarding following physician orders for crushed medications and thickened liquids. 8-24-2023 thru 8-25-2023 <BR/>8. <BR/>A medication observation will be conducted by the DON/ADON 3 times a week randomly for 3 weeks. All negative findings will be immediately corrected and forwarded to QAPI for intervention change. 8-24-2023 thru 9-8-2023 <BR/>9. <BR/>Contracted pharmacy consult was contacted regarding the medication administration error and involvement in QAPI process/interventions, to schedule Inservice for September 4,2023 8-24-2023 thru 8-25-2023. <BR/>All residents' potential to be affected by this deficient practice. <BR/>If staff are unable to attend any of the in-services, they will be required to complete before starting their assigned shift. Staff will sign the Inservice sheet for each service that will be kept at the nurses station in a binder. All PRN and Agency Staff will be in-service before the start of shift by the DON/ADON/designee.<BR/>The Medical Director was initially made aware of the immediate jeopardy 8/24/23 at 10:11pm and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process.<BR/>To monitor for compliance the Administrator and/or designee will review all residents with swallowing disorders and medication administration passes as above with follow up if warranted for the next 30 days. The IDT will review and assess the orders in place to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. <BR/>This plan was initially implemented 8/24/23 and will be monitored through completion. It will be monitored thereafter 30 days by the regional director of care and regional director of operations. <BR/>Plan of Removal completion date is 8/25/23 by with continuation of oncoming staff and follow up. <BR/>The Surveyor monitored the Plan of Removal on 8/26/2023 as follows: <BR/>3:00pm Entrance of facility<BR/>3:10pm Entrance Conference with ADM and advised her the reason for the visit due to POR (Plan of Removal) monitoring. ADM was given a list of information needed. She stated the census is 58.<BR/>Review of nurse's progress dated 8/22/2023 reflected the resident had been assessed prior to going to hospital. The note reflected that the resident continued to have coughing and breathing problems, so the resident was sent to the hospital for further evaluation. The resident returned to the facility on 8/25/2023 late evening. Review of nurse's progress note dated 8/26/2023 reflected Resident # 1 was assessed upon return to the facility. <BR/>Record review reflected that the ADM and DON were in-serviced by the regional director of Operations on abuse/neglect dated 8/25/2023 <BR/>In an interview on 8/26/2023 at 3:30pm with the DON revealed she went through each resident's chart and reviewed their medications and orders to verify that they are current and correct for each resident. The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. <BR/>Record review of medication log for residents with crushed medications developed and placed on each medication cart for staff to review on every resident with crushed medications, thickened liquids and how to administer to resident. <BR/>Record review 8/26/2023 of resident roster will all residents who have a diagnosis of swallowing disorder, the facility had 47 residents with swallowing disorder. The DON stated she completed this task during the medication pass with the MA to ensure that all residents received the correct medication in the form required to take. <BR/>Records reviewed reflected all 47 residents with swallowing disorders, care plan and orders had been updated in PCC system<BR/>The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. <BR/>In an interview with MDS on 8/26/2023 at 4:00pm, revealed she updated all care plans to reflect how to administration the medication and how to cleanse the resident's pallet. She stated she also developed a medication log that is kept placed on each medication cart that shows each resident with crushed medications and how they are to be administered, the log is updated daily to ensure all residents with crushed medications are listed and how to administer according to the order to help ensure that when giving medications the form is reviewed and checked off for each resident. <BR/>Record review of in-services reflected 3 agency staff have completed the following in-services: Medication administration, crushing medications, Abuse/Neglect, Choking dated 8/26/2023. <BR/>Record review reflected 4 agency staff completed the in-service on Where to find and read Physician orders dated 8/25/2023. <BR/>Record review reflected 31 facility staff completed the following in-services Dysphagia dated 8/25/2023, 27 facility staff completed the in-service for Choking and Abuse/ Neglect dated 8/25/2023, 15 facility staff completed the in-service on Where to find and read physicians orders, crushing medications, and Medication administration dated 8/25/2023.<BR/>Record review of in-service Physicians orders, crushed medications and thickened liquids dated 8/26/2023 completed by the regional director. <BR/>Record review of two staff observations were completed by the DON administering medications. The staff were observed going through each step before administering to verify correct dosage, correct resident, and administered in the correct manner for, 1 MA and LVN on 8/25/2023 and 8/26/2023<BR/>Beginning at 3:56pm - Interview with 3 CNA's (agency staff) 6am to 6pm shift. <BR/>Stated they have been in-serviced on where to find the care needs for the residents in PCC. Stated they have been in-serviced on abuse/neglect stated the protocol is to report immediately if they see or suspect abuse/neglect. Stated they have never seen or suspected abuse/neglect at this facility. Stated they have been trained on choking and protocols to take when a resident may choke, stated they do not pass medications. <BR/>Beginning at 4:10pm -MA B (facility) doubles on the weekends 6am to 10pm. <BR/>Stated she has been in-serviced on abuse/neglect, dysphagia, choking, crushed medications, medication administration and physician orders. She stated she looks in the MAR to verify what medication a resident requires the dosage, and how it is to be administered. She stated the protocol for abuse/neglect is to report immediately to the admin. who is the abuse/neglect coordinator, stated she has never seen or suspected abuse/neglect at this facility. <BR/>Beginning at 4:34pm Interview with RN weekend supervisor double weekends (facility), LVN weekend nurse 6am- 10pn (facility) <BR/>Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated staff are to report if there is any discrepancy or error made when medications are administered. She stated a log has been placed on each medication cart as an added way for MA, and nurses will know which residents require crushed medications and thickened liquids, but they should still check the MAR. <BR/>4:40pm Interview with LVN B (facility staff) weekend nurse 6am- 10pm<BR/>Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated they check the medication log posted on the medication cart is one way to know and look in the MAR on the PCC system to see how medication is administered for the resident. <BR/>4:49pm Interview with Resident # 4 stated she as ok, stated she had no concerns at this time and stated she felt safe. <BR/>4:50pm Observation of Resident #1, appeared he was sleeping, did not appear to be in any pain or distress during this observation <BR/>5:00pm interview with Resident # 5 stated he was doing fine, stated he felt safe and had no concerns at this time. <BR/>4:53pm- Interview with ADMN. <BR/>Stated it was his expectation that staff follow all the training and protocols they have been given to provide the resident with the care needs they require that will allow them to have the best quality of life possible. <BR/>The ADM was informed that Immediate Jeopardy was removed on 8/26/2023 at 5:00pm. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 13 (Resident #54) reviewed for advanced directives. <BR/>The facility failed to ensure Resident #54's Full Code Status was listed in his records and physician's orders. <BR/>This deficient practice could place residents at risk of not having their end-of-life wishes honored.<BR/>Findings include:<BR/>Review of undated face sheet for Resident #54 reflected his code status was not indicated. Resident #54 was admitted on [DATE] with diagnosis of: COPD, unspecified dementia, major depressive disorder, malignant neoplasm (cancer) of prostate, hypothyroidism (underactive thyroid), type 2 diabetes, legal blindness, atrioventricular block 2nd degree (a disorder characterized by disturbance, delay, or interruption of atrial impulse conduction to the ventricles through eh atriventricular node and bundle), muscle wasting and atrophy, pacemaker.<BR/>Review of quarterly MDS assessment for Resident #54, dated [DATE], reflected a BIMS score of 00 indicating he could not complete the assessment and his cognitive skills were severely impaired. He was assessed with behaviors not directed towards others every one to three days. His functional assessment reflected he required extensive assistance for all ADLs. He was assessed as always incontinent of bowel and bladder.<BR/>Review of the care plan for Resident #54 reflected interventions were in place for: shortness of breath r/t COPD, arthritis, high blood pressure, diabetes, dementia/Impaired cognitive function, impaired vision, elopement risk, ADL performance deficit. His code status was not listed in his Care Plan.<BR/>Review of physician's orders for Resident #54 on [DATE] reflected no mention of his code status (After the surveyor questioned facility staff about the Resident's code status, the facility obtained and entered an order for Full Code status).<BR/>In an interview on [DATE] at 10:15 am, the Administrator stated residents should have their code status displayed in computer records, their care plan, and he would expect all residents to be treated as if they were a Full Code until their DNR status could be verified in records.<BR/>In an interview on [DATE] at 10:40 am, LVN K stated she would make all efforts to revive a resident until it was confirmed the resident had a DNR order in place. She stated the professional expectation was to continue life-saving efforts until a DNR order could be checked.<BR/>In an interview on [DATE] at 12:05 PM, LVN J stated she understood Resident #54 was a full code. She stated she clarified Resident #54's status with his RP and provider, and entered the physician's order on [DATE] after the surveyor questioned her. She stated she did not know why his code status had not been entered earlier. She stated all residents were to be responded to as if they were a full code person.<BR/>In an interview on [DATE] at 12:00 PM, the Acting DON stated unless stated otherwise, all residents were full code status. She stated when a resident had a DNR order in place, all life saving efforts were to be made until the DNR could be verified.<BR/>In an interview on [DATE] at 10:02 AM the Administrator said the care plan signature date was the date the care plan was completed. He said, bottom line, even if all information was provided on form in the 48 hour time frame, if it was not signed and locked during that time frame it was not completed timely. He stated it had been difficult getting some things like this completed on time because a registered nurse had to open, sign, and lock the care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician reviewed the resident's total program of care, including medications and how orders were transcribed into resident records for 3 of 13 (Resident #54, #175 and #45) Residents reviewed for medical records.<BR/>The facility failed to ensure residents Physician clarified the orders to state total dosage to be administered with each medication administration for Resident's #54, #175 and #45.<BR/>This deficient practice could place residents who receive care from the Medical Director/Physician at-risk of inadequate monitoring of medication dosages and confusion about total dosages to be administered.<BR/>Findings included:<BR/>Review of the undated Face sheet for Resident #54 reflected he was admitted on [DATE] with diagnosis of: COPD, unspecified dementia, major depressive disorder, malignant neoplasm (cancer) of prostate, hypothyroidism, type 2 diabetes, legal blindness, atrioventricular block 2nd degree, muscle wasting and atrophy, pacemaker.<BR/>Review of quarterly MDS assessment for Resident #54 dated 10/21/22 reflected a BIMS score of 00 indicating he could not complete the assessment and his cognitive skills were severely impaired. he was assessed with behaviors not directed towards others every one to three days. His functional assessment reflected he required extensive assistance for all ADLs. He was assessed as always incontinent of bowel and bladder.<BR/>Review of the undated Care Plan for Resident #54 reflected interventions were in place for: shortness of breath r/t COPD, arthritis, high blood pressure, diabetes, dementia/impaired cognitive function, impaired vision, elopement risk, ADL performance deficit. <BR/>Review of physician's orders for Resident #54 reflected:<BR/>Depakote Sprinkles 125 mg give 2 capsules by mouth two times a day related to dementia in other disease, Unspecified severity with behavioral disturbance.(The order did not specify dosage total to be given).<BR/>Metoprolol 25 mg give 0.5 mg tablet by mouth one time a day r/t essential hypertension***does not specify dosage.<BR/>Review of undated sheet for Resident #175 reflected he was admitted to facility on 12/02/22 with diagnosis of: hyperlipidemia, schizophrenia, recurrent depressive disorder, HTN, heart failure and unspecified pain.<BR/>Review of active physician's orders for Resident #175, dated 12/02/22, reflected he was prescribed: Seroquel tablet 100 mg, give three tablets by mouth three times a day related to schizophrenia (The order did not specify total dose for each administration).<BR/>Review of undated Face Sheet for Resident #45 reflected he was admitted [DATE] with diagnosis of: Alzheimer's disease, mild protein malnutrition, major depressive disorder, impulse disorder, chronic pain syndrome, dysphagia, urine retention, unspecified cognitive dysfunction, long term use of anticoagulants.<BR/>Review of the quarterly MDS assessment for Resident #45 dated 11/14/22 reflected a BIMS score of 4 indicating severe cognitive impairment. His functional assessment reflected he required supervision for most ADLs except toileting and hygiene which required extensive assistance. He was assessed as frequently incontinent of bladder and bowels.<BR/>Review of the Care Plan for Resident #45 dated reflected interventions were in place for: antidepressant medications, DNR status, pain management, high blood pressure, impaired cognitive processes, Alzheimer's disease, anti anxiety medication, physically abusive behaviors r/t Dementia and poor Impulse control, elopement risk, wandering.<BR/>Review of the Physician's orders for Resident #45 dated current on 12/14/22 reflected:<BR/>Depakote Sprinkles 125 mg 4 capsules by mouth two times a day, r/t Intermittent Explosive Disorder (F63.81)<BR/>Clonazepam 0.5 mg give 0.5 tablet by mouth two times a day r/t Impulse Disorder.<BR/>The above orders could create confusion about total dosage to be given.<BR/>In an interview on 12/14/22 at 2:35 pm, LVN J stated she understood the orders as written for Resident #45. <BR/>Depakote Sprinkles 125 mg 4 capsules by mouth two times a day, r/t Intermittent Explosive Disorder (F63.81)<BR/>Clonazepam 0.5 mg give 0.5 tablet by mouth two times a day r/t Impulse Disorder<BR/>When asked what the dosages to be given were, she stated the total for Depakote was to be 600 mg (incorrect) and the total for Clonazepam was 0.25 mg (correct).<BR/>In an interview on 12/15/22 at 9:40 am, the Acting DON stated she agreed the medication orders for Residents #175, #54 and #45 needed to be clarified. She stated the orders did not reflect what the total dose of medications ordered was and could be confusing for the staff administering medication.<BR/>In an interview on 12/15/22 at 10:01 am, the Administrator stated his expectation was the nurses should have reviewed and clarified any medication orders that are unclear. The Administrator stated a medication order which did not specify the milligrams or total dosage was likely to cause confusion for some.<BR/>In an interview on 12/15/22 at 10:40 am, LVN K stated she would call the physician to clarify the dosage on some medication orders. She stated the orders which called for 0.5 tablet or multiple tablets were unclear and did not give the total dosage. She stated she would call the physician immediately to correct the order.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 2 nurse medication carts (Hall F nurse cart) reviewed and failed to ensure expired medications were removed from one of two medication storage rooms (Hall D) reviewed for expired medications. <BR/>1. The facility failed to ensure the nurse medication cart for Hall F was locked and supervised. <BR/>2. The facility failed to ensure a contaminated medication on the secure female hall was disposed of properly. <BR/>3.The facility failed to ensure five bottles of Vit D 3 50,000 IU with expiration date 05/2022 and two bottles of Iron Supplement Liquid with expiration date 11/2022 were removed from the medication storage room on Hall D. <BR/>These deficient practices could place residents at increased risk of ingesting unprescribed and/or expired medications resulting in adverse health consequences. <BR/>Findings include:<BR/>An observation and interview on 12/14/2022 at 7:41 AM revealed LVN K threw a contaminated pill that had fallen on the cart in the trash bag at the side of her cart. When asked if that was the proper way to dispose of medications she stated no, pulled the trash bag out and left the cart unlocked to go to a room down the hall. <BR/>During an interview on 12/14/2022 at 8:14 AM, LVN K stated if the medication cart was left unlocked, anyone could come and get anything out of it. She further stated the cart was left unlocked on a secure unit and the residents take everything including the computer mouse. Regarding the medication thrown in the trash bag she stated, the risk is the residents could go through the trash and take and ingest the pill . <BR/>During an interview on 12/14/2022 at 2:24 PM, the Acting DON stated, the potential risk of expired medications was they would not be effective. She further stated all the nursing staff is responsible and no one person is solely responsible, so expired medications could get missed. <BR/>During an interview on 12/15/2022 at 9:27 AM, ADON stated expired medications would not have full potency and there could be a serious adverse reaction if past the expiration date. The cart being unlocked could cause a hazard as anyone could come along and ingest meds. She stated they could take meds to their room and hoard them and they could get ill and overdose. She stated if meds are dropped on the floor or contaminated, they have the nurse place them in the sharps container or bring them to us to waste. Anyone could have gotten it out of the garbage bag and ingested the pill and could have had an allergic reaction.<BR/>During an interview on 12/15/2022 at 10:37 AM, Acting DON stated if the medication cart was unlocked it was a safety issue as the residents could get access to medications that could be hazardous to their health. She further stated, the nurse should never throw medications in the trash bag, as the women on the secure unit do not have intact cognition. Taking non-prescribed meds could be hazardous to their health, they could have an allergic reaction and become ill. She stated the medication should have been placed in the sharps container if it was not a controlled substance.<BR/>During an interview on 12/15/2022 at 10:49 AM, ADMIN stated the ADON, and Charge Nurses were responsible for ensuring expired medications are removed from the storage room and the potential risk with expired medications is they could make the resident sick, and they wouldn't work as well. He further stated with the medication cart being unlocked, residents, staff, or visitors could take medications out of the cart. The resident could overdose or have an allergic reaction. Someone could reach in the garbage bag, remove the discarded pill, and ingest it. It could make them sick, and they could be allergic to that medication. <BR/>Record review of a facility policy dated April 2019 and titled Storage of Medications The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Unlocked medication carts are not left unattended. <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen reviewed for dietary services.<BR/>The facility failed to prevent the following:<BR/>1. Food and beverage items were not properly labeled with product and expiration date.<BR/>2. Food items were not properly sealed when not in use.<BR/>3. Food items were past expiration or use by date.<BR/>4. Food and beverage items were not discarded after 7 days of open date.<BR/>5. Frozen food was covered with freezer burn.<BR/>6. Food was not stored in appropriate containers.<BR/>7. Food was not held at appropriate temperature.<BR/>These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness.<BR/>Findings included:<BR/>An observation on 12/13/22 at 9:30AM revealed pistachio pudding dated 12/4/22, rice dated 12/10/22, cream of chicken dated , in the refrigerator, covered loosely with torn foil.<BR/>An observation on 12/13/22 at 9:30AM revealed a Styrofoam cup labeled tea. in refrigerator with no dates.<BR/>An observation on 12/13/22 at 9:30AM revealed salsa dated 12/3/22 with torn foil cover, soft butter dated 12/1/22, Teriyaki sauce dated 1/18/22, sweet and sour sauce opened 10/11/22, creamy salad dressing no open dated 1/4/22 used, cheddar cheese cubes dated 11/29/22, cheddar cheese cubes dated 11/28/22 in refrigerator with opened date greater than 7 days without manufacturer expiration date ,<BR/>An observation on 12/13/22 at 9:30AM revealed Worcestershire sauce, premium romaine salad best of used by date 12/10/22, in refrigerator with manufacturer expiration date of 12/1/21. <BR/>An observation on 12/13/22 at 9:30AM revealed 1 bag of whipped cream, 1 gallon of whole milk with very little inside container in refrigerator with no opened date.<BR/>An observation on 12/13/22 at 9:30AM revealed 4 bags of sealed whipped cream in refrigerator without the manufacturer expiration date. <BR/>An observation on 12/13/22 at 9:30AM revealed 2 bags of breakfast sausage patties, 2 bags of waffle fries, 4 bags of French fries, 3 bags of breaded vegetables, 2 bags of corn nuggets, 3 bags of winter vegetable blend, pot soup dated 12/6/22 sealed in freezer without the manufacturer expiration date.<BR/>An observation on 12/13/22 at 9:30AM revealed [NAME] fish dated 9/27/22, bag dated 6/16/22, breaded pork filet dated 9/16/22, hamburger patty dated 10/5/22 in unsealed bag, 1 bag labeled mix veg opened 11/8/22, freezer bag labeled meat dated 10/11/22 in freezer with opened date greater than 7 days and without manufacturer expiration date.<BR/>An observation on 12/13/22 at 9:30AM revealed 4 bags of fajita vegetable blend, 6 sealed containers of unlabeled sausage links, 1 bag of unlabeled cut sausage, salmon patties dated 12/5/22 inside freezer bag, salmon patties dated 8/8/22 inside freezer bag, freezer bag labeled salisb stk dated 11/15/22, 2 freezer bags with burritos all with freezer burn.<BR/>An observation on 12/13/22 at 9:30AM revealed 2 opened loaves of wheat bread and 2 opened packages of dinner rolls. in dry storage bread rack without manufacturer expiration date, open date, or expiration date.<BR/>An observation on 12/13/22 at 9:30AM revealed in dry storage room the following opened food: <BR/>An observation on 12/13/22 at 9:30AM revealed 1 bag of smart food white cheddar popcorn dated 11/22/22, jambalaya rice dated 4/21/22, light corn syrup 1/2 empty with no open date or manufacturer exp date, French's crispy fried onions dated 12/24/22, 2 containers of jet puffed marshmallow with expiration date 06/18/22, refried beans, balsamic vinegar, top ramen soy sauce soup, in dry storage room the following unopened food without manufacturer expiration date.<BR/>An observation on 12/13/22 at 9:30AM revealed Raisin Bran with use by date 12/4/22, Cheerios use by date 11/7/22, Fruit Loops use by date 12/4, rice crispies opened date 11/15/22, rainbow sprinkles with use by date 11/30/22, flour with used by date 12/6/22, sugar with used by date 10/18/22, corn meal with used by date 10/18/22 in dry storage area inside kitchen in plastic containers.<BR/>An observation on 12/13/22 at 9:30AM revealed food sitting uncovered on top of 2 freezers was 20 plated pieces of cake, 1 sheet pan with full cake, and 1 sheet pan with 1/2 of a cake.<BR/>An observation on 12/13/22 at 9:30AM revealed a black substance attached to the inside of ice machine where water filled the trays.<BR/>In an interview on 12/13/22 at 9:30AM with the DMGR, she said she was not aware all food had to have an expiration date on label. She was unsure how long food was good for once it was opened. She said they normally go through things quickly, so she had not thought to label with expiration dates. She said items without a manufacturer label were all taken from cardboard box where an expiration date was located but could not produce these boxes or dates. She said she did not have lids to fit the plastic containers and had always used foil. She said she was responsible for ensuring all expired food had been removed and must have missed the items observed. She said the food with freezer burn, she normally knocked it off then cooked as normal. She knew food was not to be left uncovered to open air but was busy and had not gotten around to covering it. She said she did not know the ice machine opened up from the top and was not aware of the black stuff growing inside. She said the ice machine had been cleaned the previous week by her and another kitchen member. <BR/>In a follow up observation on 12/14/22 at 10:37AM, the ice machine, inside of kitchen, had a black substance attached to the inside of ice machine where water trays are filled.and black substance seen inside of ice freezer below.<BR/>In an interview on 12/14/22 at 10:37AM, the DMGR said the black substance inside of ice freezer below was likely from where she had cleaned machine overnight and did not know what else to do about getting it cleaned. She said she did not have any documentation on when the maintenance company could have last cleaned it or if they even do clean it. She said she always cleaned it once a quarter. She said she would empty the ice from machine and deep clean it before serving ice to residents.<BR/>In an interview on 12/15/22 at 8:48AM with DMGR, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill.<BR/>In an interview on 12/15/22 at 8:48AM with ADON, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill.<BR/>In an interview on 12/15/22 at 8:48AM with DON, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill.<BR/>In an interview on 12/15/22 at 8:48AM with ADMIN, said food with no expiration date, expired food, food not held at correct temperature, black substance in ice machine, food not properly sealed, and food with freezer burn present, could result in a resident becoming ill.<BR/>Record review of policy Proper Labeling and Storage of Food (undated) revealed a 7-day rule, and a date mark system should be clear to employees and the regulatory authority that covers the following items: foods prepared in foodservice, foods from a processing plant must be marked at the time their original container is opened, and foods combined or mixed together. Leftovers should be stored in National Science Foundation approved foodservice containers with proper fitting lids or cover the food tightly, labeled with date prepared/opened and use by date, and identify product. General storage all refrigerated foods should be discarded within 7 days from the date prepared/opened.<BR/>Record review of policy Food Holding and Service, revised 06/01/19, revealed policy to serve all hot food at temperatures of 135 degrees Fahrenheit or greater. If hot food drops below 135 degrees Fahrenheit, reheat to 165 degrees Fahrenheit for a minimum of 15 seconds.<BR/>Record review of policy Manual Cleaning and Sanitizing of Utensils and Portable Equipment, dated 10/01/18, revealed monthly cleaning schedule for ice machine.

Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal health care information for one of two (Medication Cart B) medication carts reviewed for resident rights. <BR/>The facility failed to ensure LVN K protected the private healthcare information of all residents on the secure female unit by leaving her computer screen open to resident charts. <BR/>These failures could affect residents by placing them at risk for loss of privacy and dignity.<BR/>Findings included:<BR/>An observation on 12/14/2022 at 7:41 AM revealed the computer screen on Medication Cart B was left open, facing the hallway, and exposed resident confidential information. <BR/>During an interview on 12/14/22 at 8:16 AM, LVN K stated by leaving the computer screen unlocked, she could have compromised the privacy of residents by exposing their names, diagnoses, and what medications they were taking. <BR/>During an interview on 12/15/22 at 9:27 AM, ADON stated if the screen on the computer was left open with residents' information, it would violate their HIPAA privacy rights. She further stated it was possible for someone to come along and change information on the screen. <BR/>During an interview on 12/15/2022 at 10:37 AM, Acting DON stated the problem with leaving an open screen on the medication cart was that it's a HIPAA privacy issue. She further stated there was a lock icon that would hide the screen. <BR/>During an interview on 12/15/2022 at 10:49 AM, ADMIN stated if the computer screen was left open it's a HIPAA violation and someone could see the resident's confidential information.<BR/>Review of a facility policy titled Computer Terminals/Workstations revised April 2014 reflected Computer terminals and workstations will be positioned/shielded to ensure that protected health information and facility information is protected from public view or unauthorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality in 1 of 13(Resident #5 ) residents reviewed for resident rights.<BR/>The facility failed to prevent MA A and ADON from socializing with each other while MA-A was assisting Resident #5 with lunch.<BR/>These failures could place residents requiring assistance with activities of daily living at risk for impaired dignity.<BR/>Findings Included:<BR/>Record review of admission Record, dated 12/13/2022, revealed Resident#5 is a [AGE] year-old female with a diagnosis of epilepsy (brain disorder causes seizures), mild protein-calorie malnutrition, weakness, need for assistance with personal care, and cognitive communication deficit (difficulty with thinking and how someone uses language).<BR/>In an observation on 12/13/22 at 11:40 AM, MA A was sitting at table with Resident # 5 assisting her with eating. Throughout the observation, MA A was seen turning her upper body away from Resident #5 while speaking to ADON. When Resident #5 finished each bite, she had to wait for MA A to assist. Resident #5 then asked if she was done eating and begun pushing away from the table. MA A would respond by telling her not yet, here's another bite and go back to talking to ADON.<BR/>In an interview on 12/14/22 at 09:52 AM, DIET said Resident #5 was eating food well but required assistance. She said she stopped the order for her health shake and added fortified foods to prevent further weight loss. She said she had not witnessed Resident #5 during a meal. She said her plan for fortified food would not be successful if she were not eating majority of her meal. She said not paying attention to a resident while assisting them was rude and could be considered a dignity issue.<BR/>In an interview on 12/15/22 at 8:53 AM, MA-A said she was for having a conversation with an employee while assisting Resident #5 with eating. She said another employee pointed the error out to her the same day after the meal was completed. She said she knew better, but since it was her boss speaking to her, she did not consider how it could affect the resident at the time. She said she knew the resident had lost weight and got distracted easily so that was a concern for her, but also it was rude to the resident and could be considered a dignity concern.<BR/>In an interview on 12/15/22 at 9:42 AM, the ADON said she was wrong for having a conversation with an employee while they were assisting Resident #5 with eating. She said another employee pointed the error out to her the same day after the meal was completed. She said she knew better and there was no excuse. She said she knew the resident had lost weight and got distracted easily so that was a concern for her, but also it was rude to the resident and could be considered a dignity concern.<BR/>In an interview on 12/15/22 at 9:48 AM, the DON said an employee that was assisting a resident while eating should have been focused on the resident. She said an employee that was speaking to someone other than the resident, would not be respecting the resident's dignity.<BR/>In an interview on 12/15/22 at 10:02 AM, the ADMIN said an employee that was assisting a resident while eating, should have been focused on the resident. She said an employee that was speaking to someone other than the resident, would not have been respecting the resident's dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 12 residents (Residents #28, #31, #33, #47, and #56) reviewed for personal hygiene.<BR/>The facility failed to ensure Residents #28, #31, #33, #47, and #56 received assistance with bathing, grooming, and personal hygiene.<BR/>These failures could result in the resident having decreased sense of self-worth. <BR/>Findings included:<BR/>1. Record review of Resident #28's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, morbid obesity, and muscle wasting. <BR/>Record review of Resident #28's quarterly MDS, dated [DATE], reflected a BIMS score of 15, indicating she was cognitively intact. Her Functional Abilities assessment indicated she was totally dependent on staff for toileting, and needed maximum assistance with bathing and personal hygiene. <BR/>Record review of Resident #28's care plan, dated 01/20/25, reflected she had an ADL self-care performance deficit related to impaired balance with an intervention of Bathing: the resident requires assistance with bathing 3x a week, and as necessary. <BR/>Interview on 03/04/25 at 10:02 AM with Resident #28 revealed she only got bathed every two weeks because there was only one CNA on the evening shift, which was when her bath was scheduled. Staff would not bathe her unless she demanded it. She stated not being bathed made her feel uncomfortable so she didn't go out of her room much. <BR/>Record review of Resident #28's bathing task record from 2/09/25 to current date reflected she had been bathed twice (2/22/25 and 2/23/25). All other dates were documented as Activity did not occur. <BR/>2. Record review of Resident #31's undated admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses which included heart failure, diabetes, seizures, and stroke.<BR/>Record review of Resident #31's admission MDS, dated [DATE], reflected a BIMS score of 11 indicating he had mild cognitive impairment. His Functional Abilities assessment indicated he required maximum assistance with bathing and toileting. <BR/>Record review of Resident #31's care plan, dated 02/22/25, reflected he had an ADL self-care deficit with an intervention for bathing to have 1 staff to assist. <BR/>Observation and interview on 03/04/25 at 9:41 AM with Resident #31 revealed he had not been bathed in over a week. The resident's hair was unkempt and appeared greasy. The resident stated he asked the CNAs to shower him. He stated they would say they would do it, but they never came back, so it never happened. He stated he did not need a lot of attention, but there still did not seem to be enough staff to help the residents. <BR/>Record review of Resident #31's bathing task record from 02/05/25 to current reflected he had been bathed twice (02/06/25, and 02/18/25), all other dates were documented Activity did not occur.<BR/>3. Record review of Resident #33's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included right sided paralysis related to a stroke, liver disease, seizures, and Schizoaffective disorder. <BR/>Record review of Resident #33's quarterly MDS, dated [DATE], reflected a BIMS score not assessed. Her Functional Abilities assessment indicated she was totally dependent on staff for her ADLs. <BR/>Record review of Resident #33's care plan, dated 02/24/25, did not reflect she had a self-care deficit related to her stroke and paralysis. <BR/>Observation on 03/04/25 at 10:00 AM revealed Resident #33 appeared to be asleep. Her hair was unkempt and appeared greasy. <BR/>Record review of Resident #33's bathing task record from 02/05/25 to current reflected she had been bathed on 02/26/25. All other dates were documented as Activity did not occur. <BR/>Phone interview on 03/05/25 at 1:57 PM with Resident #33's family member revealed they were at the facility almost every evening to visit with the resident. The resident did not respond to anyone unless she knew them, but she was unable to do anything for herself. They stated they knew for sure the resident had not been bathed in the last four days. They stated the staff were always busy, and they rarely came to her room when they were there to check on the resident. The family member stated they had to seek out staff to change the resident's brief, and it still took a while for them to come change her. He stated there did not appear to be enough staff to care for the residents. <BR/>4. Record review of Resident #47's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, bone infection of the spine, paraplegia (paralyzed from waist down), and heart failure. <BR/>Record review of Resident #47's admission MDS, dated [DATE], reflected only section A had been completed. <BR/>Record review of Resident #47's care plan, dated 03/01/25, reflected she had an ADL self-care deficit with an intervention for bathing to have 1 staff assist.<BR/>Interview on 03/04/25 at 10:07 AM with Resident #47 revealed she had not been bathed since she was admitted (02/08/25) and did not know there was a shower schedule. She stated she would like to be bathed twice a week at least. She stated she felt very dirty and her hair needed to be washed. <BR/>Record review of resident #47's bathing task record from 02/09/25 to current reflected she had not been bathed. All dates were documented as Activity did not occur. <BR/>5. Record review of Resident #56's face sheet dated 03/06/25 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE]. <BR/>Record review of Resident #56's MDS sheet dated 12/24/24 revealed a BIMS score was not entered because Resident #56 was unable to complete the interview. Resident #56 functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and personal hygiene. Resident #56's diagnoses included urinary tract infection (infection that affects part of the urinary tract), Type 2 Diabetes (high blood sugar), Dementia (group of symptoms affecting memory), abnormalities of gait and mobility, lack of coordination , and unsteady on feet. <BR/>Record review of Resident #56's care plan as of 08/06/24 revealed Resident #56 had an activities of daily living self care performance deficit due to dementia. Goal included the resident will maintain or improve current level of function in transfers, eating, dressing, toilet use and personal hygiene. Interventions included resident uses a geri chair, Transfer: the resident required (X2) staff participation with transfer. Bathing: provide the resident with a sponge bath when shower can not be tolerated. Resident was totally depend on staff to provide a bath (3x a week) and as necessary. The Resident required (x1) staff participation with bathing. <BR/>Interview on 03/04/25 at 3:36 PM with a family member of Resident #56 revealed she visited with Resident #56 daily. The family member stated she would find her soaked in her brief down to the sheets with urine and poop everyday, leaving her with an odor. According to the Family Member when she entered the facility, she would have to take matters into her own hands to clean and change Resident #56 along with her bedding. The Family Member stated they are very understaffed and do not have staff on the hall to care for the residents, it made me upset to see how they just leave my mom like that. The Family Member stated Resident #56 was on hospice which came in the mornings to bath, change and dress her for the day, however there was no one from the facility that checked on Resident #56 throughout the day to ensure she was dry or changed. The Family Member stated it would be nice to have someone check on her after lunch to change her brief. <BR/>Interview on 03/05/25 at 10:25 AM with LVN A revealed residents were showered or bathed three times a week by the CNAs. She stated the CNAs bring her their shower sheets to the nurse if there is a new finding like a bruise, or if the resident refuses their shower. She would check with the resident and encourage them to be bathed. She stated the risk of not getting bathed was skin breakdown and irritation.<BR/>Interview on 03/05/25 at 12:43 PM with the DON revealed showers and baths were documented in the computer under Tasks by the CNAs. She stated if it was not in the computer it did not happen. She stated there were no shower sheets. <BR/>Interview on 03/06/25 at 8:20 AM with the RNC revealed they had stacks of old shower sheets from several months, going back to before the change of ownership. She stated the current policy was for the staff to document everything in the computer because shower sheets get lost, and were difficult to track. She stated the expectation was the CNAs would bathe residents three times a week, less if the resident preferred it. All documentation was to be done in the computer. <BR/>Interview on 03/06/25 at 3:25 PM with CNA C revealed residents should be showered three times a week. When she showered a resident she filled out a shower sheet and turned it into the nurse. If a resident refused a shower she had them sign the shower sheet. She stated the risk of a resident not being showered was skin irritation or breakdown. <BR/>Interview on 03/06/25 at 3:30 PM with the DON and the RNC revealed they both stated the CNAs did not use a shower sheet to document showers. They documented showers in the computer under Tasks. The DON and the RNC both stated the Task document was the most accurate record of the resident's showers. The DON stated the residents were being bathed, but if they were not the risk could be anything. <BR/>Interview on 03/06/25 at 3:47 PM with CNA D revealed the residents should be showered three times a week. She stated she documented her showers on a shower sheet and then put it into the computer. The shower sheet was given to the nurse if there were findings like a bruise or redness found during the shower. She stated the risk of residents not being bathed was skin breakdown or irritation. <BR/>Interview on 03/06/25 at 3:58 PM with CNA E revealed residents were showered three times a week. She documented her showers on a shower sheet and then put it into the computer. The shower sheet was then given to the nurse. She stated the risk of residents not being bathed could be skin breakdown. <BR/>Interview on 03/06/25 at 4:04 PM with CNA F revealed she was supposed to be the designated shower aide Monday through Friday, but she was often called to be a CNA on one of the halls because someone called in. She stated she usually only had one day a week when she was functioning as the shower aide because the CNAs called in so often. <BR/>Record review of the facility's current, undated Bath, Tub/Shower policy reflected:<BR/>Bathing by tub bath or shower is done to removed soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation Frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although daily bathing or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 of 7 residents (Resident #7 and Resident #22) reviewed for Resident Rights.<BR/>CNA G verbally abused Residents #7 and #22 when the residents requested to return inside the building following a smoke break, and she yelled at them telling they could not go inside and blocked the door.<BR/>The failure placed residents at risk of feelings of decreased self-worth.<BR/>The non-compliance was identified as PNC. The noncompliance began on 02/15/25 and ended on 02/21/25. The facility had corrected the non-compliance before the investigation began. <BR/>Finding included:<BR/>Record review of Resident #7's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #7's entry MDS sheet dated 02/08/25 reflected a BIMS score of 13 indicating her cognition was intact. Resident #7's functional abilities indicated she required substantial/maximal assistance with toileting hygiene, shower/bathing and lower body dressing. Resident #7 was independent with eating, oral hygiene and upper body dressing, and partial assistance with personal hygiene. Resident #7's diagnoses included acquired absence of left leg above knee, muscle weakness, lack of coordination, and a history of falling. <BR/>Record review of Resident #7's care plan as of 02/16/25 reflected Resident #7 was a smoker. The care plan reflected a goal to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. The trauma was related to being angry at CNA G for saying that she could not go back inside after smoking. The care plan goal included maintain resident's safety and integrity during post trauma episode, using appropriate interventions. The care plan interventions included to arrange a licensed mental health provider as ordered by the physician. Identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible. These triggers could include verbal threats, and physical aggression.<BR/>Record review of Resident #7's Safe Smoking assessment dated [DATE] and 03/04/25 reflected in summary: This resident required direct supervision while smoking: All smoking materials will be kept at the nurse's station: The evaluation has been explained to the family responsible party and to the resident.<BR/>Record review of Resident #22's face sheet dated 03/06/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. <BR/>Record review of Resident #22's entry MDS sheet dated 02/19/25 reflected a BIMS score of 15 indicating her cognition was intact. Resident #22's functional abilities indicated she was independent with eating, oral hygiene, toileting hygiene and required set up or clean up with shower/bathing, upper and lower body dressing, and personal hygiene. Resident #22 had use of a walker. Resident #22's diagnoses included muscle weakness and difficulty walking. <BR/>Record review of Resident #22's care plan as of 02/16/25 reflected Resident #22 was a smoker. The care plan gooal included to smoke in designated areas without occurrence of injury. The care plan interventions included perform smoking assessment according to facility policy. Explain/Show where designed smoking area was, and smoking times-repeat as needed. Monitor as needed when smoking to assure resident safety, keep all smoking material at nurse's station. The care plan reflected Resident #7 had a history of trauma that may have a negative impact. <BR/>Record review of Resident #22's Safe Smoking assessment dated [DATE] reflected in summary: This resident required direct supervision while smoking: All smoking materials would be kept at the nurse's station: The evaluation has been discussed with the resident. <BR/>Interview on 03/04/25 at 10:55 AM with Resident #7 revealed she liked to smoke at each smoke break. Resident #7 stated she was outside smoking with CNA G and finished earlier than others and wanted to return inside the facility. According to Resident #7, CNA G yelled at her saying, You can't go back inside until I go in. Resident #7 stated it made her upset. Resident #7 stated it was cold outside, and she should have been allowed to return inside the building if she wanted. <BR/>Interview on 03/04/25 at 1:40 PM with Resident #22 revealed she enjoyed smoking on the smoke breaks provided by the facility. According to Resident #22, she was outside when CNA G would not allow Resident #22 to return inside the building when she was finished smoking. Resident #22 stated CNA G was the only staff member, who would make residents stay outside until everyone was finished, and they all came back inside at one time. Resident #22 stated she was upset that CNA G did not allow residents to return inside the building yelling, Do not go any further. No one can go in without me. Resident #22 also stated CNA G stood in the walkway blocking residents from leaving the patio. Resident #22 stated she reported to the front desk that Resident #7 was not allowed to return to the building and the Administrator followed up with her about the incident. According to Resident #22, CNA G no longer worked at the facility and there had not been any further issues with residents returning inside the building when they were finished smoking. <BR/>Observation on 03/04/25 at 4:10 PM revealed residents on the patio with the Maintenance Director and revealed residents were able to exit the patio once they were finished smoking. <BR/>Observation and interview on 03/05/25 at 4:00 PM with the Laundry Aide revealed there was a schedule sheet that he followed which notified when his department took residents out to smoke. The Laundry Aide stated he recognized all residents were able to safely smoke. Laundry Aide stated he was responsible for ensuring all residents were safe before, during, and after smoking and should stay together just in case they needed help returning to the facility, for example if they were a fall risk. The Laundry Aide stated he thought all residents were supposed to wait together to go inside the building after smoking, but he could not stop anyone from going back inside the building if they wanted to leave. Therefore, he allowed residents to leave when they were done smoking. According to the Laundry Aide, trying to stop residents from returning inside the building after smoking would go against their rights to move around as they want. <BR/>Interview on 03/05/25 at 4:41 PM with RN I revealed she was aware of residents that smoked. There was a schedule that indicated nursing staff were responsible to take residents out during the evening hours. According to RN I, she was present on 02/15/25 when CNA G volunteered to take the residents out to the patio for smoking at 6:30 PM. RN I stated she was standing at the nursing station when Resident #22 informed RN H that Resident #7 wanted to return back into the building once she finished smoking and she was not allowed to and was told she had to wait. RN I stated according to Resident #22, she did not like that Resident #7 was told she could not leave, and that CNA G blocked the walkway to prevent anyone from leaving the patio. RN I stated she and RN H then began contacting the DON and the Administrator. <BR/>Interview on 03/05/25 at 5:09 PM with the ADON revealed she was in-serviced on resident rights after the 02/15/25 incident when CNA G would not allow residents to reenter the building after smoking. The ADON stated whomever was scheduled to take residents out to smoke was responsible for residents while they were smoking. The ADON stated if there were multiple residents smoking and one wanted to come back inside, and you did not have to leave residents smoking unsupervised, residents who were able to safely return to the building could do so. The ADON expressed that residents had the right to be able to return in the building after smoking, or anytime they wanted to come inside or move about the facility, not doing so violated their rights. <BR/>Interview on 03/06/25 at 9:10 AM with RN H revealed she was at the nursing station on 02/15/25 when CNA G took residents who smoke out to the patio at their 6:30 PM smoke break. RN H stated after the break, Resident #7 and Resident #22 reported to her that CNA G told them they could not come back in inside the building until everyone was done smoking. RN H stated, it was cold that night so residents were distraught they could not return in the building once they were done smoking. RN H stated she reported to the Administrator and the DON, what residents reported to her. RN H stated she was in-serviced on resident rights and the residents had the ability to move about the facility, being told they could not return in the building after they were ready, placed them at risk of their rights being violated. <BR/>Interview on 03/06/25 at 10:00 AM with the Administrator revealed he was notified by RN H that CNA G took residents out to smoke; once they were finished smoking and wanted to return inside the building because they were cold. The Administrator stated he was told CNA G yelled No one can go in without me and stood in the walkway preventing them from leaving the patio. The Administrator stated he asked residents to be assessed to ensure they were ok and not harmed in any way and to gather statements. The Administrator stated he alerted his corporate office and the human resources and suspended CNA G. The Administrator stated he entered the facility on 02/16/25 to interview residents and started in-services and monitoring. The Administrator stated there was a schedule to advise which department was responsible for taking the residents out to smoke at designated times. The Administrator advised he expected staff to allow residents to go out on the patio and smoke, if they were done and wanted to come back inside the building staff should allow that as it was their right to do so. The Administrator stated they completed in-services to educate staff to monitor residents while outside on the patio during smoking breaks; however, you could not keep residents outside against their will. <BR/>Interview on 03/06/25 at 10:07 AM with the DON revealed she was notified of the incident on 02/15/25 with CNA G refusing to allow residents to return in the building by standing in the walkway and yelling they had to wait on all residents to reenter together. The DON stated in-services on resident rights, abuse and neglect, and their smoking policy were started immediately. The DON stated she expected staff to follow the smoking schedule and take residents out to smoke. The DON stated at any time residents want to leave the patio after smoking, they have the right to do so and should be able to do so. The DON stated CNA G not allowing residents to return inside the building placed them at risk of not having their rights honored. <BR/>Interview on 03/07/25 at 11:39 AM with CNA G revealed she did take residents out to the patio for a smoke break right before her shift ended at 6:30 PM on 02/15/25. According to CNA G it was a bit cooler that evening, and Resident #7 attempted to leave the patio when she finished smoking. CNA G stated she expressed to Resident #7 you have to wait to go inside all together. CNA G stated the reason she did not allow residents to leave the patio was because it was not feasible. She stated Resident #7 was in a wheelchair and could have fallen. CNA G stated, I admit I kept her from going in. It was for her safety. According to CNA G, she was responsible for ensuring residents returned in the building safely. CNA G stated she was suspended and later terminated. CNA G stated she was not thinking residents were placed at risk of rights not being honored, she stated I was thinking of their safety.<BR/>Record review of a Employee Disciplinary Report for CNA G dated 02/15/25 reflected due to allegations, CNA G will be placed on unpaid investigatory suspension and will remain on investigatory suspension until the investigation is completed. CNA G will be notified when the investigation is completed.<BR/>Record review of Resident #7's statement reflected: <BR/>6:30 Smoke Break<BR/>At the 6:30 PM smoke break CNA G took the smokers outside the smoke area. When I was done smoking, I started to go back inside from the smoking area and CNA G stood in the opening that leads to sidewalk and said You can't go in until I go in. I stayed outside in the smoking area for about 15 minutes. I was cold and I did not have a coat on. When I came back inside, I told RN H and RN I what happened.<BR/>Record review of Resident #22's statement reflected:<BR/>6:30 PM Smoke Break<BR/>At the 6:30 PM smoke break CNA G took us outside. Before we went outside, she was talking really fast, and I could tell that she did not want to take us outside and stated she had other things to do. She did take us outside but kept coming back inside and to the smoke area. She was pacing back in forth in the smoke area and was yelling I do not want to talk to anyone. I am upset. Two of the smokers were finished and started to go down the sidewalk to go back inside like they normally do, and CNA G yelled Do not you go any further. No one can go in without me. She said she was going to search for everyone's lighters and cigarettes. I did not see her search anyone. CNA G stood in front of Resident #7 and would not let her leave the smoking area. I was still smoking. Another resident told her he was going inside when he finished his cigarette, and he went inside. CNA G was very short spoken with us while we were outside. When I returned to the building, I told RN H and RN I what happened during the smoke break. Once in my room I checked my cell phone, and I had a missed call from CNA G, I did not call her back. <BR/>Record review of CNA G's Witness Statement reflected: I work every time I am asked to, I work nights, I worked my Saturday day off. Residents all they want to do is smoke, I have COPD. This was signed by CNA G 02/17/25 and the Administrator. <BR/>An ADHOC QAPI meeting was held on 02/17/25 with the Interdisciplinary Team including the Medical Director to discuss the allegations and findings.<BR/>Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/21/25, reflected: <BR/>Description of Allegation:<BR/>[CNA G], CNA, took the residents out to smoke at the schedule[d] 6:30 PM time. Some of the residents were getting cold and wanted to go back inside after smoking a cigarette. [CNA G] yelled and told them that they couldn't go back inside without her, and she wasn't letting anyone back in until she was ready. [Residents #7 and #22] stated they felt this was verbal abuse by [CNA G] yelling and not letting them back inside.<BR/>Provider Response:<BR/>Details of this incident were found out after the staff member [CNA G] left after her shift. The staff member was immediately suspended pending investigation after administration found out about the incident. Safe surveys for smokers completed.<BR/>Investigation Summary:<BR/>Investigation summary shows that the incident did occur. [CNA G] was terminated on 2/18/2025 for verbal abuse occurring. Residents did not have any trauma from the incident.<BR/>Provider Action Taken Post Investigaiton:<BR/>In-serviced staff on abuse/neglect. [CNA G] was terminated for verbal abuse on 2/18/2025. No adverse effects for any residents involved.<BR/>Record review of Payroll Input/Personnel Action Form signed 02/18/25 reflected CNA G was terminated on 02/18/25. CNA G has failed to adhere to the Corporate Code of Conduct. CNA G was aware of the corporate code of conduct as indicated by the signature of the employee handbook acknowledgment. CNA G meet criteria for immediate termination. <BR/>Record review of an in-service record, dated 02/15/25 reflected the DON trained staff on the following topics: Abuse and Neglect, Resident Rights, and Smoking Policy. The in-service record reflected staff not present would receive the in-service training prior to assuming their duties on their next scheduled shift. Also, new and agency staff would received the in-service training prior to assuming patient care duties. <BR/>Interviews on 03/06/25 with LVN A, LVN B, RN H, RN I, Laundry Aide, Dietary Aide, DON, ADON, CNA J revealed they had been trained on residents' rights and were aware to allow residents to return in the building as they were finished smoking, not doing so placed residents at risk of violation of their rights being honored. <BR/>Record review reflected the facility implemented the following for monitoring from 02/16/25-02/21/25: ask 15-20 staff members per week; ask about 5 resident per week how staff is treating them; during incident/event review in standup; during facility rounds are there any sings of staff acting rudely or inappropriate with residents. <BR/>Record review of the facility's Resident Rights policy, revised 11/28/16, reflected:<BR/>Exercise of Rights - The resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. <BR/>Respect and dignity - The resident has a right to be treated with respect and dignity, including:<BR/>The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience.<BR/>The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. <BR/>Self-determination - The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. <BR/>1. <BR/>The resident has a right to choose activities, schedule and health care and providers of health care services consistent with his or her interest. <BR/>2. <BR/>The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #3) reviewed for resident rights. <BR/>The facility failed to ensure Resident #3's call light was within reach on 06/05/2025.<BR/>This failure could place residents at risk of their needs not being met. <BR/>Findings include: <BR/>Record review of Resident #3's admission record, dated 06/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: Alzheimer's disease with late onset (brain disorder that causes memory loss), bipolar disorder (mental health condition that cause extreme shifts in mood), essential primary hypertension (high blood pressure), and cognitive communication deficit (difficulty with thinking and using language). <BR/>Record review of Resident #3's Quarterly MDS assessment, dated 05/08/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #3 was dependent in the area of toileting hygiene. Resident #3 required substantial/maximal assistance in the areas of shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. <BR/>Record review of Resident #3's care plan, dated 06/05/2025, reflected Resident #3 was care planned for ADL self care performance deficit Alzheimer's had an intervention of ensure the resident to use bell to call for assistance. <BR/>During an interview and observation on 06/05/2025 at 9:05 AM., Resident #3's call light was observed pinned to the back upper left side of her bed, out her reach. Resident #3 was awake in bed at the time of the observation but could not be interviewed due to her cognitive impairment. The ADM observed Resident #3's call light pinned to the back upper left side of her bed and out of the resident's reach. <BR/>During an interview with CNA C on 06/06/2025 at 2:10 PM, CNA C stated CNAs make rounds at least every two hours to check to see if residents' need assistance. CNA C stated it's everyone's responsibly to ensure call lights are within reach at all times. CNA C stated that if a resident's call light was not within reach, then the resident would not be able to call for assistance if needed. <BR/>During an interview with the DON on 06/06/2025 at 4:00 PM, the DON stated all residents' call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents' call lights were always within reach. The DON stated if a resident's call light was not within reach, the resident would not be able to receive assistance if they needed it. <BR/>During an interview with the ADM on 06/06/2025 at 5:00 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a residents' call light was not within reach, then the resident's needs would not be met in a timely manner. The ADM stated his expectation was for staff members to ensure call lights were within reach prior to exiting the residents' rooms. ADM stated the facility doesn't have call light policy. <BR/>A request was made for a policy on call lights but was told by the ADM the facility doesn't have a call light policy.