Mi Casa Nursing Center

Based on clinical record review, staff interviews, facility documentation, and review of facility policy and facility assessment, the facility failed to ensure it had adequate staffing to meet the needs of the residents.

Review of Resident Council meeting minutes revealed the following staffing related concerns:

-March 02, 2023: The Director of Nursing (DON / Staff #122) "spoke to residents about staffing and the efforts to hire more staff.
-October 05, 2023: concerns with Saturday and Sunday staffing
-January 04, 2024: concerns with "call lights being turned off only after the Residents' needs/wants are met".
-February 08, 2024: Discussion of business with executive director (ED / Staff #505): regarding call lights, "staff could forget. Put the call light back on", and "Doing the best we can to keep up with shower schedule".
-March 14, 2024: a resident discussed with the ED earlier in the day about concerns discussed in last month's resident council meeting, which she learned have not been addressed, by neither the ED nor the DON.
-May 09, 2024: Old business discussed on March, 2024 still unresolved. New concerns included no showers, short staffed, no staff on weekends, staff idle at the nurse's station. Additionally, one resident reported he cannot get "a hold of anyone, when he has difficulty breathing". Another resident was revealed to state that night shift took too long to change and put back to bed.

Review of the facility's Grievance Log and Concern and Comment Forms revealed:

-January 09, 2023: a resident revealed that one time she waited over an hour to have someone help her off the bedside commode, and that she had to call the front desk.
-February 08, 2023: a resident revealed that her call light was on from 8:00 PM to 10:30 PM, when she was given her night time medications that should have been given at 8:00 PM. The Investigation Findings on the form revealed that an In-Service was given for staff to monitor call lights closely.

Direct Care Staffing was reviewed via the daily staff posting, staff schedule, and staff punch logs, for the date of March 16, 2023, and revealed the following staff for the whole facility. The census for that day was 116 residents.

Day:

-Registered Nurses (RN): 3
-Licensed Practical Nurses (LPN): 2
-Certified Nursing Assistants (CNA): 4

Evenings:

-CNA: 6
Nights:
-RN: 1
-LPN: 4
-CNA: 6

An observation was conducted on December 30, 2024, on the 300 hall unit. At 1:19 AM, a call light was observed to be on for room 327. A nurse was observed at the nurse's station, and was working at a computer. There were no care staff observed on the floor.

The observation continued, and at 1:30 PM, a staff member entered the hall, and wheeled a different resident from another room out of the hallway in a wheelchair. The call light for room 327 was still unanswered.

The observation continued. At 1:48 PM, the call light was still unanswered. The floor nurse was observed to tell a nurse from a different hallway that he is going on break, and then he left the unit.

At 1:49 PM, a male resident was observed on the unit yelling for help and stated "she's in my room" and "eating my stuff". The DON was on the unit at the nurse's station, and responded to the resident yelling for help. The DON was observed to take a female resident who was in a wheelchair out of the male's room, and the DON then wheeled the female resident in the wheelchair off the unit. The call light for room 327 was still unanswered. Besides a housekeeper, there were no other staff observed on the unit.

The observation continued, and at 1:54 PM, a CNA was observed to enter the unit and responded to the call light for room 327. The call light was turned off, and the CNA exited the room. The time that the call light was observed to be on was 35 minutes.

After the CNA left room 327, a follow-up interview was conducted at 1:56 PM, with the resident in that room. The resident in bed A stated that he said he needed to be changed, and that the staff member stated that she would be back. He further stated that "sometimes it feels like they don't care at all". He stated that at night it is "really bad", that the CNAs won't answer your call light for 45 minutes to an hour. He stated he hears the staff joking around in the hallway at night.

The observation continued, and at 2:41 PM, the nurse returned to the unit from his break. The time that the nurse was observed to be off of the unit was 53 minutes.

An additional observation was conducted on the 400 hall on December 31, 2024, at 10:15 AM. Two call lights were observed to be on in rooms 403 and 406. The ED (Staff #505) entered the unit and responded to one of the rooms with the call light on. The DON (Staff #122) entered the unit at 10:44 AM, and entered room 403, with the call light still on, and exited the room at 10:45 AM, with the call light still on.

At this time, an interview was conducted with the resident in room 403. The resident stated that his call light had been on for "awhile", and that staff had just come in and said they would get a CNA because he needed to be changed. The surveyor then left the room.

The observation continued from the hallway, and at 10:48 AM, a CNA entered room 403, and the call light was turned off. The call light for room 403 was observed to be on for 33 minutes.

An interview was conducted with a member of the Resident Council on January 2, 2025, at 11:24 AM. The resident stated that staffing and long call light wait times had been a repeated concern discussed during meetings since she had been a member of Resident Council. She stated that "I think we all have had to wait, for more than 30 minutes". She stated that a couple times, "I've noticed 45 minutes".

An interview was conducted with the DON on January 2, 2025, at 11:34 AM. The DON stated that her expectation for staff taking a break during their shift would be a half hour, and that if a staff took longer than 40 minutes, she would consider that too much. The DON stated that in regard to call light wait times, that she considered 20 to 30 minutes too long. She stated that there has been an issue with finding staff, and that it has been ongoing. She stated that staffing requirements for the facility for the year of 2023 was 2 nurses every shift for station 1 and 2, and 1 nurse for station 3 every shift. For CNAs, the facility required 2 CNAs for station 1 every shift, and station 2 would have 3 to 4 CNAs for every shift, and that station 3 would have 2 CNAs every shift. She clarified that this was for census over the number of 104 residents. The staffing schedule for March 16, 2023, was reviewed with the DON, who stated that staffing would not meet her expectation, that she would consider it short-staffed, and that she would want more staff. The DON stated that the risks to residents of understaffing would be falls, skin issues, and residents not having the total care that they need to have.

An interview was conducted with the Staffing Coordinator (Staff #180). The staffing data for March 15 and 16, 2023, was reviewed together with Staff #180. who stated that 6 CNAs to cover the whole building for a shift would not meet the staffing requirements. She stated during that timeframe, the care was not at the level it should have been, and that "we are still a little understaffed", but that it has improved.

The ED stated that there was no staffing policy, and that the Facility Assessment was used to guide staffing.

Review of the Facility Assessment, revised June 24, 2024, revealed the average daily census was 104 to 117 residents. The Direct Care Staffing needs were as follows:

Station 1 Day:

-Registered Nurses (RN):0-2
-Licensed Practical Nurses (LPN): 0-2
-Certified Nursing Assistants (CNA): 3

Station 1 Night:

-RN:0-2
-LPN: 0-2
-CNA: 2-

Based on review of records and staff interviews, it was revealed that the facility failed to ensure that dignity was maintained for one resident (#33).

Findings include:

Resident #33 was readmitted to the facility on April 6, 2023 with diagnoses that included acute and chronic respiratory failure with hypoxia, Type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease.

Progress note dated August 9, 2023 indicated resident #33 neuro was alert and oriented x3 and psych was calm cooperative.

Review of the Minimum Data Set (MDS) assessment dated October 3, 2023, revealed a Brief Interview of Mental Status (BIMS) of 15. The MDS also indicated the resident did not have any behavior or mood issues. The assessment also revealed that resident #33 needed substantial/maximal assistance with toileting.

The facility 5-day investigation report dated August 11, 2023 revealed on August 11, 2023, resident #33 was upset and indicated a Certified Nursing Assistant (CNA) staff #313 was "very mean" to the resident. Resident #33 reported her call light was turned off by the CNA staff #313 and care had not been provided. Resident reported she was upset to the CNA staff #313. CNA informed resident that she was unable to wake resident. Resident and CNA started arguing per report and while resident #33 was speaking CNA staff #313 put her hand up to "shoosh" the resident. Resident #33 reported that the CNA did not respect her. CNA #313 stated to resident "you better watch your tone as I did nothing wrong" and further stated to the resident "you better respect me as your CNA because I am trying to help you." The report further indicated that CNA staff #313 got another CNA staff #507 to help her with the care of the resident but would not allow CNA #507 to take over the care of resident.

In a handwritten statement by CNA staff #313, dated August 11, 2023 she reported she asked resident #33 to watch her tone because she did nothing wrong to resident. CNA staff #313 indicated she got another CNA staff #507 to be a witness while she changed the resident to avoid any allegations.

Employee file contained a Corrective Action Form for CNA staff #313 dated August 16, 2023 regarding the incident on August 10, 2023. The form described the incident which indicated while producing care to a resident, CNA #313 rudely told the resident #33 to stop talking while the resident was expressing her concern for the delayed care. The form was signed by the DON and CNA staff #313.

During a telephone interview with CNA staff #313 on December 31, 2023, she stated resident put call light on and when she went to the room, the resident was asleep and she was unable to wake the resident so she turned the call light off. CNA staff #313 stated a few hours later call light was back on and resident was angry and yelling. CNA informed resident she tried waking her but that resident not easy to wake due to loud CPAP machine. CNA also stated that resident had a history of behaviors but there was no documentation in the clinical record that resident had any behavior issues.

Call placed to witness, CNA staff #507. CNA staff #507 stated that CNA staff #313 asked for help with resident #33 as the resident had a bad attitude. CNA staff #507 stated she tried to be a buffer between resident #33 and CNA staff #313 as the two kept "bickering." CNA staff # 507 offered to take over care for the resident as she was tired of listening to CNA staff #313 and Resident #33 bicker but CNA staff #313 stated no that she would finish with the resident as it was her resident.

Attempts were made to LPN staff #17, who was also present during the incident, left voicemail on both December 31, 2024 and January 2, 2025 but did not receive a call back.

During an interview with the director of nursing (DON/staff #122) conducted on January 2, 2025, she stated staff are to complete training on dignity and respect upon hire and annually. DON stated it is her expectation that staff are not rude to a resident and if that should occur, she would expect another staff member to take over the care of that resident. DON stated she was familiar with Resident #33 and that she was a lovely lady. DON also stated resident #33 was very anxious and the incident would not have been good for the resident's health. DON also stated CNA staff #313 had a lot of attitude concerns and that CNA staff #313 has been written up for past incidents with the last one being May 28, 2024 for being insubordinate to supervisors.

The facility policy titled "Resident Rights" revised September 10, 2024 stated that the resident has a right to a dignified existence and the resident has the right to be treated with respect and dignity.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that one resident (resident #47) was free from verbal abuse from an employee. The deficient practice could result in further instances of verbal abuse from an employee, creating an unsafe resident environment.

Findings include:

-Resident # 47 was admitted on December 21, 2022 with a diagnosis of encounter for orthopedic aftercare following surgical amputation, anxiety disorder, muscle weakness, cognitive communication deficit, bipolar disorder, depression. Then, discharged on January 11, 2023.

A five-day admission MDS (minimum data set) dated December 28, 2022 revealed a BIMS (Brief Interview for Mental Status) score of 10, indicating that Resident #47 had moderate cognitive impairment. The MDS also revealed that the resident required maximal assistance to complete lower body dressing and putting on/taking off footwear. Indicating that a helper does more than half of the effort, assisting with lifts or holds trunk or limbs.

Resident #47's progress notes revealed no evidence of documentation regarding the incident that occurred on January 1, 2023 at approximately 6:55PM.

An interview was conducted on December 31, 2024 at 8:27AM an accounting clerk (Staff #25) were the personnel record of the perpetrator (previous employed certified nursing assistant/CNA/Staff #510) was reviewed. The review revealed two employee statements completed by the perpetrator dated November 8, 2022 and November 9, 2022, a corrective action form of a 2nd written warning with the date of November 10, 2022, an incomplete employee statement regarding the perpetrator's behavior dated December 30, 2022, and, a personnel action form of voluntary termination dated January 10, 2023 with an employee statement from the perpetrator. It was determined with Staff #25 that there was no documentation of a corrective action form of a 1st written warning, and as well as no other documentation of the incomplete employee statement dated December 30, 2022 regarding inappropriate behavior of the perpetrator.

A review of the perpetrator's (previous employed CNA/Staff #510) corrective action form of a 2nd written warning dated November 10, 2022 revealed that the perpetrator continued to refuse their assignments verbally stated that she was not going to do the new room assignments and walked away from the station. The form also revealed that the perpetrator made her co-workers feel intimidated and uncomfortable to work with, and that the perpetrator creates their own assignments.

A phone interview with the witness (a previous employed certified nursing assistant/Staff #509) on December 31, 2024 at 9:46AM but were unsuccessful as she did not respond or return the call.

An interview was conducted on December 31, 2024 at 9:49AM with a previous employed licensed practical nurse (LPN/Staff #508), where staff #508 stated that the perpetrator could be very inappropriate and required consistent re-direction with their language with staff and residents. She also stated that the perpetrator (Staff # 510) was observed with intimidating behavior. During this interview, Staff #508 did require additional assistance with the incident details, to which this surveyor read their witness statement. Following this review, Staff #508 stated that they could re-call the incident but remembers that a CNA (/Staff #509) came to them with the allegation of verbal abuse from the perpetrator to resident #47. Staff #508 stated that the perpetrator could have said, "when I tell you to put your motherf***ing feet up, you get your mother f***ing feet up", and if not those exact words, then worse. Staff #508 also stated that they were concerned for retaliation due to the intimidating and taunting behavior of the perpetrator, following this incident.

A phone interview with the alleged CNA (Staff #510) on January 2, 2025 at 8:55AM but was unsuccessful as she did call back at 8:59AM and quickly disconnected the call after this surveyor introduced themselves. An attempt to call back was made immediately after with no response or call back.

A phone interview with a CNA who completed a statement in the facility's investigation (Staff #21) was attempted on January 2, 2025 at 9:10AM but was unsuccessful as she did not respond or call back.

An interview was conducted with an LPN (Staff #39) on January 2, 2025 at 9:57AM, where staff #39 stated that they could recollect the perpetrator to have a 'bad' attitude. Staff #39 stated an example where she and the perpetrator had a disagreement regarding CNA assignments, which resulted into the perpetrator having to go home due to refusing to work that assignment. Staff #39 also stated that the perpetrator was not approachable and was not kind to other staff members, that at one point, they were put on separate shifts to limit their interactions. Staff #39 stated that they did not observe any behaviors with residents, however, has heard of inappropriate interactions with residents from other staff.

An interview with the director of nursing (DON/ Staff # 122) was conducted on January 2, 2025 at 9:57AM where the shared their understanding of verbal abuse as telling someone they can't have something that is theirs, yelling and cussing at a resident, and providing inappropriate and rude customer service to residents. During this interview, a review of the incident report was done with the surveyor and Staff #122. Following this review, Staff #122 stated that their involvement with the reporting process does not extend into the investigation, but were familiar of the incident between the perpetrator and resident #47. Staff #122 stated that they were unaware of any behaviors regarding the perpetrator, however, did state that if an employee were to say, "when I tell you to put your motherf***ing feet up, you get your mother f***ing feet up", then that is verbal abuse, without a doubt.

A policy titled, "Abuse - identification of types" revealed that examples of verbal abuse include but are not limited to harassing a resident, mocking, insulting, ridiculing, yellowing or hovering over a resident, with the intent to intimidate, and, threatening or isolating residents.

A policy titled, "Abuse - prevention," revealed the facility will identify, correct and intervene in situations in which abuse, neglect, exploitation and/or misappropriation of resident property, and that will include having trained and qualified (registered, licensed, and certified) staff on each shift in sufficient numbers to meet the needs of the residents. The policy also revealed that assigned staff will have the knowledge of the individual residents' care needs and behavioral symptoms, if any.

Based on clinical record reviews, interviews, facility documentation and policies, the facility failed to ensure that three residents (# 3, # 8, # 11) received consistent showers. The sample size was four residents.

Findings include:

Resident # 3 was admitted to the facility on May 15, 2024, with diagnoses that included atrial fibrillation, dysphagia, morbid obesity, and chronic pain syndrome.

A care plan with the revision date of October 5, 2023 revealed the resident's preference to not have a male assist with shower or baths.

The quarterly Minimum Data Set (MDS) dated December 4, 2024 revealed a Brief Interview Mental Status (BIMS) score of 14 indicating the resident is cognitively intact. The MDS also indicated the resident has complete dependence for showers and shower transfers.

A Weekly Skin Integrity Data Assessment dated January 1, 2025 indicated the resident had a rash on the arms and groin.
A progress note dated June 9, 2024 revealed resident refusal of a shower and was advised that another shower would not be offered until his next shower day.

A progress note dated June 13, 2024 revealed the resident requested a day time shower, but "it was explained to him that he would be showered this evening". The resident also requested to have a female Certified Nurse Assistant (CNA) shower him, and declined the offer for a shower with the male CNA twice.

A progress note dated August 6, 2024 revealed the resident was educated regarding his refusal of a shower.

The interventions and task reports for May 2024 through December 2024 provided by the facility revealed the resident bath days were Saturday and Wednesdays. Based on the documentation received by the facility, the following was revealed:

- May 2024, 8 of 9 ordered bi-weekly showers were missed.
-June 2024, 8 of 9 ordered bi-weekly showers were missed.
-July 2024, 9 of 9 ordered bi-weekly showers were missed.
-August 2024, 6 of 9 ordered bi-weekly showers were missed.
-September 2024, 1 of 7 ordered bi-weekly showers were missed.
-October 2024 ,3 of 9 ordered bi-weekly showers were missed.
-November 2024 ,2 of 9 ordered bi-weekly showers were missed.
-December 2024, 3 of 8 ordered bi-weekly showers were missed.

Regarding Resident # 8

Resident # 8 was admitted to the facility on June 29, 2024, with diagnoses that included paralysis of dominant side after a stroke, lupus, morbid obesity, diabetes, congestive heart failure, and muscle weakness.

The quarterly MDS dated December 15, 2024 revealed a Brief Interview Mental Status (BIMS) score of 14, which indicated resident was cognitively intact. The MDS also indicated the resident required supervision or touching assistance for showers/bathing.

A care plan with the revision date of December 20, 2024, revealed the resident required extensive assistance by one staff member while showering.

A progress note dated August 9, 2024, revealed the resident was educated about refusing showers.

A progress note dated January 6, 2023 revealed the resident required an anti-fungal powder to be applied to the resolving rash in the skin folds after showers.

The interventions and task reports for May 2024 through December 2024 provided by the facility revealed the resident bath days were Tuesdays and Fridays. The documentation revealed the following:

-May 2024, 4 of 9 ordered bi-weekly showers were missed.
-June 2024, 6 of 8 ordered bi-weekly showers were missed.
-July 2024, 6 of 9 ordered bi-weekly showers were missed.
-August 2024, 6 of 9 ordered bi-weekly showers were missed.
-September 2024, 2 of 8 ordered bi-weekly showers were missed.
-October 2024, 7 of 9 ordered bi-weekly showers were missed.
-November 2024, 1 of 9 ordered bi-weekly showers were missed.
-December 2024, 8 of 9 ordered bi-weekly showers were missed.

Regarding Resident # 11,

Resident # 11 was re-admitted to the facility on September 13, 2024 (original admit date of April 6, 2023) with diagnoses that included an enlarged heart, leukemia, muscle weakness, depression, anxiety and morbid obesity.

The quarterly MDS dated October 11, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact. The assessment also indicates the resident needs partial/moderate assistance with showering/bathing.

A care plan with the revision date of October 21, 2024 revealed the resident required assistance of one staff member with bathing/showering.

The interventions and task reports for May 2024 -through June 2024 and September 2024 through December 2024 provided by the facility revealed the resident bath days were Mondays and Thursdays. The documentation revealed the following:

-May 2024, 7 of 9 ordered bi-weekly showers were missed.
-June 2024, 8 of 8 ordered bi-weekly showers were missed.
-September 2024, 3 of 5ordered bi-weekly showers were missed.
-October 2024, 3 of 8 ordered bi-weekly showers were missed.
-November 2024, 4 of 8 ordered bi-weekly showers were missed.
-December 2024, 7 of 9 ordered bi-weekly showers were missed

Regarding Facility,

The Quality Assessment and Assurance Meeting Agenda and Minutes dated August 17, 2023, revealed the facility needed a personal improvement plan for showers.

The resident council meeting minutes dated February 28, 2024 revealed the Executive Director (ED/Staff # 505) discussed the facility doing their best to keep up with the shower schedule.

The resident council meeting minutes dated May 9, 2024 revealed the concern of not receiving showers.

A staff schedule /assignment sheet dated June 11, 2024 has written towards the bottom "All Showers on NOC need to be done per Donna your DON".

A staff schedule/assignment sheet dated June 12, 2024 has written towards the bottom "All Showers are to be done per Donna your DON".

The resident council meeting minutes dated June 13, 2024 revealed that a meeting for the Certified Nurse Assistants (CNA) was held to remind them to do their showers as scheduled.

The resident council meeting minutes dated July 10, 2024 revealed the residents' outcry of "No showers!!!".

An interview was conducted on December 30, 2024 at approximately 12:30 p.m. with the Ombudsman (Staff # 515). The Ombudsman stated there has been an issue with residents not receiving showers for months, and states this is often a topic of concern at resident council meetings as well. She further explained when these matters are bought to the attention of management, but has yet to see any plan implemented or successful resolution.

An interview was conducted on December 31, 2024 at 9:37 a.m. with resident # 8. The resident would like to see more staff on the floor that answer call lights, and give showers as they should. The resident feels there is not enough staff to provide the right amount of care for the residents. The resident states when in resident council they continually bring up the issue of showers not being completed, and becomes disappointed when there is no change. Resident also reported that he was not reciving showers on the night shift so he has been making request to start day shift showers.

An interview was conducted on December 31, 2024 at approximately 10:20 a.m. with resident #3. The resident revealed there is much improvement needed in the performance of the care aides and completing showers. The resident stated he is supposed to get 2 showers a week, but it hardly gets done because they only have one person doing the showers

An interview was conducted on December 31, 2024 at approximately 10:45 a.m. with resident # 11. The resident revealed that they go long stretches, once as long as two weeks, without receiving a shower. The resident continued to voice that when the staff were not helping keep her skin folds clean and dry, they allo

Based on clinical record reviews, resident and staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of two residents (#30 and #20) to be free from abuse by a staff and another resident. The deficient practice could result in further abuse and injury of residents.

Findings include:

Regarding resident #30

Resident #30 was admitted to the facility on June 21, 2023 with diagnoses of Covid-19, Type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease (COPD) and mild Protein-Calorie Malnutrition.

Review of the 5-day Minimum Data Sat (MDS) dated June 25, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating resident had moderate cognitive impairment. Further review of the MDS revealed that the resident had no behaviors exhibited; and that the resident required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene.

The care plan dated July 10, 2023 revealed the resident needed assistance with ADL (activities of daily living) to maintain or attain the highest level of function. Intervention included to assist the resident with mobility and ADLs as needed.

The NP (nurse practitioner progress note dated August 2, 2023 revealed that the resident was transferred to the facility for rehabilitation and continued medical management. Physical examination included that the resident was alert and oriented x 3.

Review of the facility's investigation report dated August 5, 2023 revealed that on August 3, 2023 at approximately 11:35 a.m. the resident reported to a certified nursing assistant (CNA/staff #108) that a licensed practical nurse (LPN/staff #100) threw thrown his television remote at him because his volume was too high; and that, the LPN removed the batteries from his television remote. Per the report, in an interview with the resident conducted by the facility, the resident reported that he did not like being alone so he had his TV on; and, he fell asleep and may have rolled onto his TV remote causing it to turn his TV up. The documentation also included that the resident reported that the (LPN/staff #100) came in his room and told him that he cannot have his TV on; and that, the LPN grabbed his remote, turned the TV down and left his room with his remote. The resident reported that the LPN came back in his room and tossed the remote back to him; however, the resident noticed that the batteries to his remote had been removed. Per the documentation, the resident screamed back at the LPN and used profanity that he wanted his batteries back; and, the LPN brought the batteries back and "tossed them on his lap".

The facility report also included documentation of an interview was conducted with (LPN/staff #100) conducted by the facility. The documentation included that the incident took place at approximately 2:00 a.m. on August 3, 2023 and the LPN (staff #100) reported that she went to the resident's room to turn down his TV because it was very loud and found the resident sleeping. She reported that she picked up his remote from the bedside table and turned the TV down. The LPN reported that the resident woke up and yelled at her to give the remote back to him as he was grabbing her hand. The LPN reported that this startled her and she dropped the remote; and, while she was picking up the remote she noticed that the back had fallen off so she replaced it and handed the remote back to the resident. She further stated that when she was stepping out of the door, she stepped on a battery, picked it up and handed the battery to the resident. Further, the LPN denied throwing the remote and batteries at the resident and reported that she "underhand tossed" the remote into the resident's lap because she was afraid that the resident would hit her.

Continued review of the facility report revealed an email from another LPN (staff #184) addressed to the director of nursing (DON/Staff #11) dated August 3, 2023. The documentation that staff #184 was working with the alleged LPN (staff #100) the night of the alleged event. Staff #184 reported that the alleged LPN was walking into the resident's room and said that the resident needed to turn his TV down. She stated the alleged LPN then went to where staff #184 was and told staff #184 that the alleged LPN took the remote from the resident; and then, the alleged LPN walked away and came back to tell her that the alleged LPN gave the remote back to the resident but the alleged LPN took the batteries out of it. The documentation also included that the alleged LPN told staff #184 that the alleged LPN should open the resident's room door as the alleged LPN had closed it. It also included that staff #184 told the alleged LPN that she (referring to the alleged LPN) needed to open the resident's door immediately and the alleged LPN was not to close the resident's room door. Further, the email included that she heard a dayshift CNA reporting to the dayshift nurse that the resident reported that the alleged LPN had thrown the remote at the resident, had taken his remote and had given it back to him without the batteries.

Further review of the facility investigative report revealed that the alleged LPN denied taking the resident's remote; but, there were statements from the resident and another LPN (staff #184) that the alleged LPN did. The facility concluded that the allegation of abuse was unable to be substantiated but there was a customer service issue with the alleged LPN.

Review of the employee file of the alleged LPN (staff #100) revealed that a disciplinary action was taken for the alleged event; and that, the alleged LPN was terminated August 7, 2023 for failing to provide good customer service to a patient.

A phone interview with the alleged LPN (staff #100) was attempted on June 5, 2024 at 2:10 p.m. but was unsuccessful. There was no answer and the alleged LPN did not return the call.

A phone interview with the other LPN (staff #184) was attempted on June 5, 2024 at 2:12 p.m. but was unsuccessful. There was no answer and staff #184 did not return the call.

In an interview with the Executive Director (ED/Staff #33) and the DON Staff #11) conducted on June 5, 2024 at 3:58 p.m., the ED stated that he unsubstantiated the allegation of abuse due to the interviews conducted with Resident #30 and the alleged LPN (Staff #100) The DON stated the alleged LPN was terminated due to her inappropriate behavior with the resident and based on the email submitted by another LPN (staff #184) who was on shift with the alleged LPN at the time of the incident had occurred.

Regarding residents #15 and #20

-Resident #20 (alleged victim) was admitted to the facility on January 24, 2022 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, oropharyngeal phase and cerebral infarction without residual deficits.

The care plan dated January 25, 2022 revealed that the resident was dependent on staff for meeting his emotional, intellectual, physical and social needs related to physical limitations.

A care plan dated March 2, 2022 included that the resident had ADL self-care performance deficit related to limited mobility.

The health status note dated January 5, 2023 revealed the resident was alert and oriented and was able to make needs known.

-Resident #15 (alleged aggressor) was admitted on December 11, 2022, with diagnoses of Parkinson's disease, delusional disorders, aphasia following cerebral infarction, and unspecified dementia.

The care plan with revision date of October 14, 2029 included that the resident was at risk for change in mood or behavior due to medical condition, cognitive communication defect, depression and history of declining care and treatments. Interventions incl

Based on clinical record review, staff interviews, and facility documentation and policies, the facility failed to ensure care and treatment were provided for one resident (#10) according to professional standards of practice. The deficient practice resulted in the hospitalization of the resident.

Findings include:

Resident #10 was admitted to the facility on 04/02/2024 with diagnoses of chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end stage renal disease, and hyperkalemia.

The nutrition care plan dated 04/04/2024 included a goal for the resident's skin to improve.

The skin integrity documentation dated 04/09/2024 included cellulitis and blisters to the left lower extremity (LLE) and right lower extremity (RLE).

The provider note dated 04/10/2024 included that the resident had cellulitis on bilateral lower extremities (BLE) and edema. Treatment included antibiotics for 5 days which was noted as completed; and that, the problem still persisted.

A physician order dated 04/10/2024 included a treatment to cleanse bilateral foot blister with NS (normal saline), pat dry, wrap with kerlix daily every day shift and as needed if soiled.

A provider note dated 04/14/2024 revealed that the resident still had BLE swelling; and that, antibiotics were ordered for leg cellulitis.

The physician order dated 04/15/2024 revealed an order to cleanse left lower extremity open blister with saline, apply non-adherent pad to open area and wrap with ace wrap one time a day for cellulitis.

The skin integrity note dated 04/16/2024 included right and left lower extremity cellulitis with blisters.

The skin integrity note dated 04/23/2024 revealed right and left lower extremity cellulitis (lymphedema) with blisters.

The skin integrity dated 04/30/2024 included lymphedema.

The Wound Observation Tool was dated 04/30/2024 revealed that the left lower extremity wound was unchanged and had large serous drainage. Wound measurement was 40 cm (centimeter) length x 40 cm (width) x 0 cm (depth). Per the documentation, there were no signs of infection and treatment included iodoform and kerlix dressing.

The wound treatment orders for the bilateral foot blisters and the left lower extremity were transcribed onto the Treatment Administration Record (TAR) for April 2024 and revealed the resident refused treatment and dressing change on 04/15/2024; and, treatment/dressing change on bilateral foot blisters was not documented as administered on 04/14/2024, 04/21/2024, 04/26/2024 and 04/30/2024.

Continued review of the TAR revealed that treatment/dressing change on the left lower extremity was not documented as administered on 04/21/2024, 04/26/2024 and 04/30/2024.

The TAR for May 2024 revealed that the treatments for the bilateral foot blisters and the left lower extremity were documented as refused on 05/01/2024.

Despite documentation of the wounds and treatment orders, the clinical record revealed no evidence that the resident's wounds were care planned with interventions.

The clinical record revealed that the resident was transferred to the hospital on 05/02/2024 and returned at the facility on 05/15/2024.

The physician orders dated 05/16/2024 included the following:
-Cleanse the right foot with wound cleanser, pat dry, apply alginate with silver, cover with dry dressing, abd pad and secure with tubi grip every day shift for wound care; and,
-Cleanse BLE with wound cleanser, pat dry, apply impregnated bismuth, cover with dry dressing, abd pad and secure with ace wrap every day shift for wound care.

These orders were transcribed onto the TAR for May 2024 and revealed that treatment to the right foot and the BLE were documented as administered from 05/16/2024 through 05/21/2024.

The clinical record revealed no documentation that the resident refused treatment for the right foot and the BLE.

Further, the resident's refusal and/or noncompliance with wound care was not identified as a focus area with interventions placed in the care plan.

Review of the nursing progress note on 05/21/2024 included that the resident remained non-compliant with wound care; and that, the wound doctor is aware. The documentation included that on this day, the resident allowed staff to change his bandages; and, upon removal of all the bandages from his LLE, maggots were noted on his foot. Per the documentation, the wound doctor was notified and orders were received to send the resident to the ER (emergency room) for evaluation and treatment.

In an interview with the Assistant Director of Nursing (ADON)/Wound Nurse (staff #117) conducted on 06/05/2024 at 1:45 p.m., the ADON stated that she will first see the residents with wound, go with the wound provider on rounds; and, the only treatments that she performs were wound vacs and complex dressings. Regarding resident #10, the ADON said that Resident #10 did not have a complex dressing so she did not do the resident's wound dressing. The ADON stated that the staff nurses were responsible for the treatments of the resident #10's wound.

An interview with the Director of Nursing (DON) was conducted on 06/05/2024 at 2:45 p.m. The DON stated that the expectation was for wound care to be documented in the TAR when they are completed. The DON said that if there was a concern, staff can document in a nursing note or they notify the wound nurse. Further, the DON said that besides the documentation of the TAR, the bandages are dated per the wound nurse.

According to the Centers for Disease Control and Prevention (CDC), myiasis is a parasitic infection of fly larva (maggots) in human tissue and that people who have untreated or open wounds have a higher risk for getting myiasis. The CDC also noted that prevention is key to protecting oneself from myiasis and precautions to take include cover open wounds.

Based on clinical record reviews, resident and staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of two residents (#30 and #20) were not subjected to abuse a staff and another resident.

Findings include:

Regarding resident #30:

Resident #30 was admitted to the facility on June 21, 2023 with diagnoses of Covid-19, Type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease (COPD) and mild Protein-Calorie Malnutrition.

Review of the 5-day Minimum Data Sat (MDS) dated June 25, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating resident had moderate cognitive impairment. Further review of the MDS revealed that the resident had no behaviors exhibited; and that the resident required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene.

The care plan dated July 10, 2023 revealed the resident needed assistance with ADL (activities of daily living) to maintain or attain the highest level of function. Intervention included to assist the resident with mobility and ADLs as needed.

The NP (nurse practitioner progress note dated August 2, 2023 revealed that the resident was transferred to the facility for rehabilitation and continued medical management. Physical examination included that the resident was alert and oriented x 3.

Review of the facility's investigation report dated August 5, 2023 revealed that on August 3, 2023 at approximately 11:35 a.m. the resident reported to a certified nursing assistant (CNA/staff #108) that a licensed practical nurse (LPN/staff #100) threw thrown his television remote at him because his volume was too high; and that, the LPN removed the batteries from his television remote. Per the report, in an interview with the resident conducted by the facility, the resident reported that he did not like being alone so he had his TV on; and, he fell asleep and may have rolled onto his TV remote causing it to turn his TV up. The documentation also included that the resident reported that the (LPN/staff #100) came in his room and told him that he cannot have his TV on; and that, the LPN grabbed his remote, turned the TV down and left his room with his remote. The resident reported that the LPN came back in his room and tossed the remote back to him; however, the resident noticed that the batteries to his remote had been removed. Per the documentation, the resident screamed back at the LPN and used profanity that he wanted his batteries back; and, the LPN brought the batteries back and "tossed them on his lap".

The facility report also included documentation of an interview was conducted with (LPN/staff #100) conducted by the facility. The documentation included that the incident took place at approximately 2:00 a.m. on August 3, 2023 and the LPN (staff #100) reported that she went to the resident's room to turn down his TV because it was very loud and found the resident sleeping. She reported that she picked up his remote from the bedside table and turned the TV down. The LPN reported that the resident woke up and yelled at her to give the remote back to him as he was grabbing her hand. The LPN reported that this startled her and she dropped the remote; and, while she was picking up the remote she noticed that the back had fallen off so she replaced it and handed the remote back to the resident. She further stated that when she was stepping out of the door, she stepped on a battery, picked it up and handed the battery to the resident. Further, the LPN denied throwing the remote and batteries at the resident and reported that she "underhand tossed" the remote into the resident's lap because she was afraid that the resident would hit her.

Continued review of the facility report revealed an email from another LPN (staff #184) addressed to the director of nursing (DON/Staff #11) dated August 3, 2023. The documentation that staff #184 was working with the alleged LPN (staff #100) the night of the alleged event. Staff #184 reported that the alleged LPN was walking into the resident's room and said that the resident needed to turn his TV down. She stated the alleged LPN then went to where staff #184 was and told staff #184 that the alleged LPN took the remote from the resident; and then, the alleged LPN walked away and came back to tell her that the alleged LPN gave the remote back to the resident but the alleged LPN took the batteries out of it. The documentation also included that the alleged LPN told staff #184 that the alleged LPN should open the resident's room door as the alleged LPN had closed it. It also included that staff #184 told the alleged LPN that she (referring to the alleged LPN) needed to open the resident's door immediately and the alleged LPN was not to close the resident's room door. Further, the email included that she heard a dayshift CNA reporting to the dayshift nurse that the resident reported that the alleged LPN had thrown the remote at the resident, had taken his remote and had given it back to him without the batteries.

Further review of the facility investigative report revealed that the alleged LPN denied taking the resident's remote; but, there were statements from the resident and another LPN (staff #184) that the alleged LPN did. The facility concluded that the allegation of abuse was unable to be substantiated but there was a customer service issue with the alleged LPN.

Review of the employee file of the alleged LPN (staff #100) revealed that a disciplinary action was taken for the alleged event; and that, the alleged LPN was terminated August 7, 2023 for failing to provide good customer service to a patient.

A phone interview with the alleged LPN (staff #100) was attempted on June 5, 2024 at 2:10 p.m. but was unsuccessful. There was no answer and the alleged LPN did not return the call.

A phone interview with the other LPN (staff #184) was attempted on June 5, 2024 at 2:12 p.m. but was unsuccessful. There was no answer and staff #184 did not return the call.

In an interview with the Executive Director (ED/Staff #33) and the DON Staff #11) conducted on June 5, 2024 at 3:58 p.m., the ED stated that he unsubstantiated the allegation of abuse due to the interviews conducted with Resident #30 and the alleged LPN (Staff #100) The DON stated the alleged LPN was terminated due to her inappropriate behavior with the resident and based on the email submitted by another LPN (staff #184) who was on shift with the alleged LPN at the time of the incident had occurred.

Regarding residents #15 and #20

-Resident #20 (alleged victim) was admitted to the facility on January 24, 2022 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, oropharyngeal phase and cerebral infarction without residual deficits.

The care plan dated January 25, 2022 revealed that the resident was dependent on staff for meeting his emotional, intellectual, physical and social needs related to physical limitations.

A care plan dated March 2, 2022 included that the resident had ADL self-care performance deficit related to limited mobility.

The health status note dated January 5, 2023 revealed the resident was alert and oriented and was able to make needs known.

-Resident #15 (alleged aggressor) was admitted on December 11, 2022, with diagnoses of Parkinson's disease, delusional disorders, aphasia following cerebral infarction, and unspecified dementia.

The care plan with revision date of October 14, 2029 included that the resident was at risk for change in mood or behavior due to medical condition, cognitive communication defect, depression and history of declining care and treatments. Interventions included medications as ordered and to consult with the resident on preferenc

Based on clinical record review, staff interviews, and facility documentation and policies, the facility failed to ensure nursing care services were provided for one resident (#10).

Findings include:

Resident #10 was admitted to the facility on 04/02/2024 with diagnoses of chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end stage renal disease, and hyperkalemia.

The nutrition care plan dated 04/04/2024 included a goal for the resident's skin to improve.

The skin integrity documentation dated 04/09/2024 included cellulitis and blisters to the left lower extremity (LLE) and right lower extremity (RLE).

The provider note dated 04/10/2024 included that the resident had cellulitis on bilateral lower extremities (BLE) and edema. Treatment included antibiotics for 5 days which was noted as completed; and that, the problem still persisted.

A physician order dated 04/10/2024 included a treatment to cleanse bilateral foot blister with NS (normal saline), pat dry, wrap with kerlix daily every day shift and as needed if soiled.

A provider note dated 04/14/2024 revealed that the resident still had BLE swelling; and that, antibiotics were ordered for leg cellulitis.

The physician order dated 04/15/2024 revealed an order to cleanse left lower extremity open blister with saline, apply non-adherent pad to open area and wrap with ace wrap one time a day for cellulitis.

The skin integrity note dated 04/16/2024 included right and left lower extremity cellulitis with blisters.

The skin integrity note dated 04/23/2024 revealed right and left lower extremity cellulitis (lymphedema) with blisters.

The skin integrity dated 04/30/2024 included lymphedema.

The Wound Observation Tool was dated 04/30/2024 revealed that the left lower extremity wound was unchanged and had large serous drainage. Wound measurement was 40 cm (centimeter) length x 40 cm (width) x 0 cm (depth). Per the documentation, there were no signs of infection and treatment included iodoform and kerlix dressing.

The wound treatment orders for the bilateral foot blisters and the left lower extremity were transcribed onto the Treatment Administration Record (TAR) for April 2024 and revealed the resident refused treatment and dressing change on 04/15/2024; and, treatment/dressing change on bilateral foot blisters was not documented as administered on 04/14/2024, 04/21/2024, 04/26/2024 and 04/30/2024.

Continued review of the TAR revealed that treatment/dressing change on the left lower extremity was not documented as administered on 04/21/2024, 04/26/2024 and 04/30/2024.

The TAR for May 2024 revealed that the treatments for the bilateral foot blisters and the left lower extremity were documented as refused on 05/01/2024.

Despite documentation of the wounds and treatment orders, the clinical record revealed no evidence that the resident's wounds were care planned with interventions.

The clinical record revealed that the resident was transferred to the hospital on 05/02/2024 and returned at the facility on 05/15/2024.

The physician orders dated 05/16/2024 included the following:
-Cleanse the right foot with wound cleanser, pat dry, apply alginate with silver, cover with dry dressing, abd pad and secure with tubi grip every day shift for wound care; and,
-Cleanse BLE with wound cleanser, pat dry, apply impregnated bismuth, cover with dry dressing, abd pad and secure with ace wrap every day shift for wound care.

These orders were transcribed onto the TAR for May 2024 and revealed that treatment to the right foot and the BLE were documented as administered from 05/16/2024 through 05/21/2024.

The clinical record revealed no documentation that the resident refused treatment for the right foot and the BLE.

Further, the resident's refusal and/or noncompliance with wound care was not identified as a focus area with interventions placed in the care plan.

Review of the nursing progress note on 05/21/2024 included that the resident remained non-compliant with wound care; and that, the wound doctor is aware. The documentation included that on this day, the resident allowed staff to change his bandages; and, upon removal of all the bandages from his LLE, maggots were noted on his foot. Per the documentation, the wound doctor was notified and orders were received to send the resident to the ER (emergency room) for evaluation and treatment.

In an interview with the Assistant Director of Nursing (ADON)/Wound Nurse (staff #117) conducted on 06/05/2024 at 1:45 p.m., the ADON stated that she will first see the residents with wound, go with the wound provider on rounds; and, the only treatments that she performs were wound vacs and complex dressings. Regarding resident #10, the ADON said that Resident #10 did not have a complex dressing so she did not do the resident's wound dressing. The ADON stated that the staff nurses were responsible for the treatments of the resident #10's wound.

An interview with the Director of Nursing (DON) was conducted on 06/05/2024 at 2:45 p.m. The DON stated that the expectation was for wound care to be documented in the TAR when they are completed. The DON said that if there was a concern, staff can document in a nursing note or they notify the wound nurse. Further, the DON said that besides the documentation of the TAR, the bandages are dated per the wound nurse.

According to the Centers for Disease Control and Prevention (CDC), myiasis is a parasitic infection of fly larva (maggots) in human tissue and that people who have untreated or open wounds have a higher risk for getting myiasis. The CDC also noted that prevention is key to protecting oneself from myiasis and precautions to take include cover open wounds.

Based on observation the facility failed to maintain several special locking exit doors located in the facility. Failing to ensure the correct amount of force needed to release of the exit doors could cause harm to patients and/or staff in an emergency

NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2.2.2.4 "Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side." Exception No. 2 "Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. Section 7.2.1.6.1 "Special Locking Arrangements" " (c) An irreversible process shall release the lock within 15 to 30 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbs nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only."

Findings include:

Observations made while on tour on June 15, 2023, revealed the following;

1) the back employee entrance delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 23 lbf for the door.
2) the station 2 shower delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 20 lbf
3) the station 3 shower delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 80 lbf
4) the station 3 dayroom delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 22 lbf
5) the station 1 dayroom delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 20 lbf
6) the wellness center delayed egress door exit door failed to open with a force of less than 15 lbf. The panic bar was pushed and and set off the irreversible process at 21 lbf

During the exit conference on June 15, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on June 15, 2023, revealed the following;

1) room 310 door had a 1/2 inch gap on the upper handle side
2) room 320 door had a 1/2 inch gap on the upper handle side
3) room 207 door failure to latch secure
4) room 205 door was warped had a 1/4 inch gap on the upper handle side
5) room 108 door had a 1/2 inch gap on the upper handle side

During the exit conference conducted on June 15, 2023, the above findings were again acknowledged by the management team.

Based on observation and staff interview, the facility failed to ensure a remote stop or kill switch for the generator was installed. This affected the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm to the patients and/or staff.

Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

During a facility tour conducted on June 15, 2023, through observation it was revealed the facility generator did not have remote stop or kill switch.

During the exit conference on June 15, 2023, the above findings were acknowledged by the management team.

Based on observation, the facility failed to ensure that staff did not use multiplug adapters. The use of multiplug adapters could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on June 15, 2023, revealed the following;

1) one (1) multiplug adapter in the Staff Development Coordinator's office
2) three (3) multiplug adapters in the beauty salon

During the exit conference conducted on June 15, 2023, the above findings were again acknowledged by the management team.

Based on observations, staff interviews and a review of the facility policies, the facility failed to ensure that two medication carts were secured while left unattended.

Findings include:

An observation of a medication cart on the 100 hallway was conducted on June 7, 2023 at 12:05 pm. The cart was left unlocked by nursing staff and was left unattended for over five minutes. During this time, there were multiple staff members passing by and did not notice the unlocked medication cart.

In another observation conducted on June 7, 2023 at 12:47 p.m., the medication cart was unlocked and unattended outside of a resident room in the 200 hall. A nurse returned to the medication cart within two minutes of the observation.

An interview was conducted with a registered nurse (RN/staff #55) on June 7, 2023 at 12:55 p.m. The RN stated her expectation was that the nurse will lock the med cart, ensure that there were no medications on the med cart surface and lock the computer monitor when leaving the med cart. The RN stated that the controlled substance lock box was within the med cart and the controlled count log was kept on top of the med cart; and that, nursing staff maintains the medication cart. The RN stated that the facility had 6 medication carts and that if she finds it unlocked, she will lock the cart, notify and educate the nurse. Staff #55 stated that an unlocked med cart could result in another resident or visitor or staff removing medications from the cart. Staff #55 stated that if the controlled count book ever went missing, they would do a med count, review the MAR (Medication Administration Record) and notify the pharmacy.

In another observation conducted June 7, 2023 at 3:00 p.m. the treatment cart was unlocked and had supplies on the top of the cart.

An interview with another RN (staff #145) was conducted on June 8, 2023 at 9:21 a.m. The RN stated that medication carts should be locked and that each med cart has one external lock that will lock all of the drawers. Staff #145 stated that if she observed an unlocked med cart, she would lock it, notify the nurse and educate the nurse. Staff #145 stated if the medication cart was not locked another resident or visitor or staff would have access to the medications.

Based on observations, staff interviews and a review of the facility policies, the facility failed to ensure that two medication carts were secured while left unattended. The deficient practice could result in unauthorized personnel having access to the medications.

Findings include:

An observation of a medication cart on the 100 hallway was conducted on June 7, 2023 at 12:05 pm. The cart was left unlocked by nursing staff and was left unattended for over five minutes. During this time, there were multiple staff members passing by and did not notice the unlocked medication cart.

In another observation conducted on June 7, 2023 at 12:47 p.m., the medication cart was unlocked and unattended outside of a resident room in the 200 hall. A nurse returned to the medication cart within two minutes of the observation.

An interview was conducted with a registered nurse (RN/staff #55) on June 7, 2023 at 12:55 p.m. The RN stated her expectation was that the nurse will lock the med cart, ensure that there were no medications on the med cart surface and lock the computer monitor when leaving the med cart. The RN stated that the controlled substance lock box was within the med cart and the controlled count log was kept on top of the med cart; and that, nursing staff maintains the medication cart. The RN stated that the facility had 6 medication carts and that if she finds it unlocked, she will lock the cart, notify and educate the nurse. Staff #55 stated that an unlocked med cart could result in another resident or visitor or staff removing medications from the cart. Staff #55 stated that if the controlled count book ever went missing, they would do a med count, review the MAR (Medication Administration Record) and notify the pharmacy.

In another observation conducted June 7, 2023 at 3:00 p.m. the treatment cart was unlocked and had supplies on the top of the cart.

An interview with another RN (staff #145) was conducted on June 8, 2023 at 9:21 a.m. The RN stated that medication carts should be locked and that each med cart has one external lock that will lock all of the drawers. Staff #145 stated that if she observed an unlocked med cart, she would lock it, notify the nurse and educate the nurse. Staff #145 stated if the medication cart was not locked another resident or visitor or staff would have access to the medications.