Every finding on record at Apollo Healthcare & Rehabilitation Center

Based on observations, interviews, and record review the facility failed to ensure proper temperatures and palatable meals were provided to two residents (#2, #6) out of three residents sampled. Findings included: 1. On 1/16/25 at 9:56 a.m., an observation of Resident #6 revealed he was lying in bed watching television. He stated every meal was cold. He stated meals are, Not even lukewarm. Resident #6 stated the food last night for dinner was cold. He described the meal he received as, A hamburger patty with a bun. Resident #6 stated, Happens all the time. A review of Resident #6's Admission Record revealed an admitted [DATE]. The Admission Record revealed diagnoses to include: sepsis, unspecified organism, muscle weakness (generalized), Type 2 Diabetes Mellitus without complications, atherosclerotic, and heart disease of native coronary artery without angina pectoris. A review of Resident #6's Comprehensive Minimum Data Set (MDS) Section C - Cognitive Patterns, dated 12/21/24, revealed a Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. 2. On 1/16/25 at 10:19 a.m., an observation of Resident #2 revealed she was lying in bed, with the bedside table in front of her, and her family member was sitting at the foot of the bed. She stated the temperature of the food for every meal is cold. Resident #2 stated when she requests hot oatmeal for breakfast, It's cold. A review of Resident #2's Admission Record revealed an admitted [DATE]. The Admission Record revealed diagnoses to include: unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing, cognitive communication deficit, Type 2 Diabetes Mellitus without complications, major depressive disorder, recurrent, moderate, muscle weakness (generalized), and chronic systolic (congestive) heart failure. A review of Resident #2's Comprehensive Minimum Data Set (MDS) Section C - Cognitive Patterns, dated 12/5/24, revealed a BIMS of 15, indicating the resident was cognitively intact. On 1/16/25 at 11:15 a.m., an interview with the Dietary Manager revealed was currently conducting food temperature audits. He stated he started the audits in December 2024. He stated residents were complaining that by the time they get their food, it's cold. The Dietary Manager stated most of the time the food is cold because the trays are sitting there. He provided an example related to residents who smoke. The Dietary Manager stated when residents go out to smoke, their meal is delivered, and when they return the food is cold. He stated another factor related to food being cold is, It's a waiting game on how fast the trays are going to be passed. The Dietary Manager stated when the meal cart gets to the floor the dietary staff let the nurse know, then the Certified Nursing Assistant (CNA's) start passing trays. He stated he's completed test trays and audits twice a week, and they are part of his normal process. The Dietary Manager confirmed he attended resident council meetings, and the main concerns have been about not receiving alternative/substitute meal choices. A test tray was requested and conducted with the Dietary Manager on 1/16/25. An observation of the lunch tray line revealed it started at 11:33 a.m. The Dietary Manager stated the Rapid hall is the first meal cart to go out. The two residents (#2 and #6), who expressed concerns about food being cold, reside in the Rapid hall. An observation of food temperatures being taken and recorded revealed the following: Carrots and peas - 185 degrees Fahrenheit ( F) Chicken - 172 F Mashed potato - 162 F Pureed protein - 160 F Pureed vegetables - 168 F White rice - 184 F Further observations revealed the loading of the Rapid hall meal cart, with lunch meal trays, started at 11:39 a.m. and ended at 11:45 a.m. The meal cart traveled from the kitchen to the floor at 11:47 a.m., where staff were observed immediately delivering the trays to the residents. The last resident was provided their lunch meal tray at 12:02 p.m. An observation of the meal cart, with the Dietary Manager present, revealed the test tray was not there. He stated before the Rapid meal cart went out to the floor, he confirmed it was there. He stated a test tray could be sent on the South side meal cart as it hadn't been loaded yet. On 1/16/25 at 11:40 a.m., during the lunch meal service, an observation of the drying rack revealed insulated plate bases. During the meal tray line, trays were not observed with the insulated plate base. Dietary staff were observed putting the insulated lid, but not the plate base. An interview with the Dietary Manager revealed the plate warmer hasn't been working since the end of October 2024. He stated the previous Nursing Home Administrator (NHA) knew about the plate warmer not functioning. He stated she handled communication about the plate warmer. The Dietary Manager stated he's not sure if the current NHA knows about it. An observation of the dining area, which is currently under renovation, revealed a large machine covered with what appeared to be a tablecloth. He stated they have the machine in the dining area, while he was observed lifting up the cloth, but thought it had something to do with the parts as to why it was not fixed/functional. Observation of the South side meal cart revealed it was loaded with the first tray at 12:00 p.m. and the last tray at 12:09 p.m. Further observations revealed the cook was putting food in styrofoam takeout containers. The Dietary Manager stated they were doing that because in the morning the plates were knocked over, and many of them broke. He stated the food in the takeout containers were for the last meal cart. The South side meal cart was observed on the floor at 12:10 pm. The nurse was observed telling staff members about the meal cart being on the floor. At approximately 12:13 p.m., the first lunch tray was delivered, and the last tray was provided at 12:20 p.m. An observation of food temperatures being taken and recorded revealed the following: Chicken - 111 F Carrots and peas - 125 F Mashed potato - 141 F An interview with the Dietary Manager revealed the temperatures were fine, except for the chicken. He stated he expected the chicken to be at 130 F. A review of the resident council minutes could not be completed as the resident council president denied permission. A request for documentation about the plate warmer, to include a work order and communication related to the equipment not functioning, was made to the Dietary Manager and NHA. The requested documents were not provided by the facility. On 1/16/25 at 2:20 p.m., an interview with the NHA revealed he reached out to a staff member in purchasing regarding the plate warmer. He stated he also communicated with the Director of Maintenance (DOM). The DOM called the company, [Vendor name], who makes the parts. The NHA confirmed they have the equipment at the facility, but it's missing a part. He stated the DOM received a quote today for the part. The NHA stated today he was made aware the plate warmer was not functioning. A review of the facility policy titled, P&P [Policy and Procedure] Final Cooking Temperatures, issued 1/1/22 and revised 10/1/23 revealed the following: Policy: Food is to be cooked to specified temperatures and times to mitigate the presence of dangerous microorganisms. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy. The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. A review of the facility policy titled, P&P Equipment Care, issued 4/122, revealed the following: Policy: It will be the policy of this facility that staff shall properly use and care for the property, equipment and supplies that assigned and/or necessary for use in their work. Further review of the policy revealed the following under procedure, . 9. Equipment or other maintenance related needs should be communicated with supervisor, Maintenance Director or Executive Director. Communication may be done verbally if the appropriate personnel are present and able to remedy the concern. A communication system and/or maintenance tracking log can be utilized to communicate maintenance or repair needs for off shift or other desired needs.

Based on observation, interview, and record review, the facility failed to ensure the notification and invitation to participate in the comprehensive care plan for two residents (#43 and #44) of two sampled residents. The findings include: Review of the Admission Record for Resident #43 revealed an admitted [DATE] with diagnoses to include: dementia; major depressive disorder, moderate protein-calorie malnutrition, hypertension; and other co-morbidities. An interview was conducted with Resident #43's representative on 6/25/2024 at 2:11 p.m. Resident #43's representative stated, I did not know they had care plan meetings, I have not received any information about any meetings. Review of the Admission Record for Resident #44 revealed an admitted [DATE], with diagnoses to include metabolic encephalopathy, cognitive communication deficit, dementia and other co-morbidities. An interview was conducted with Resident #44's representative on 6/26/2024 at 9:33 a.m. Resident #44's representative stated they have not received an invitation to attend care plan meetings. During an interview on 6/28/2024 at 10:34 a.m., Staff C, Social Services Director (SSD) stated the receptionist was responsible for completing the care plan meeting invitations. During an interview on 6/28/2024 at 10:40 a.m., Staff A, Receptionist said she had assisted with completing care plan meeting invitations in the past. Staff A stated this was no longer part of her responsibilities, the Minimum Data Set (MDS) nurse did this now. During an interview on 6/28/2024 at 11:10 a.m., Staff J, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Consultant stated the process for care plan meetings was as follows: the MDS nurse created a calendar 6-8 weeks out, the receptionist or SSD created and mailed the invitations to families/representatives. A copy of the invitation was scanned into the resident charts. The process was broken here, as this was not happening. Staff J stated not knowing why the process was not occurring as it was the expectation that the resident and resident representative be invited and encouraged to participate in the process. During an interview on 6/28/2024 at 12:30 p.m., the Director of Nursing (DON) stated the expectation was families and residents were invited to care plan meetings. Review of the facility's policies and procedures titled Care Planning - Interdisciplinary Team (IDT), not dated revealed: Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Policy interpretation and implementation: . 3. The IDT includes but is not limited to: . e. To the extent practicable, the resident and/or the resident's representative; and . 4. Resident, the resident's family and/or resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 5. Care plan meetings are scheduled at the best time of the day for the resident and family when possible. 6. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety. Findings included: A tour of the main kitchen conducted on 6/25/2024 at 9:15 a.m. and accompanied by the Dietary Manager (DM) showed the following: 1. A rag was noted on the main production counter that was not in any buckets or solutions, the solution bucket was sitting on the counter. A personal jacket was on the second shelf of the counter, sitting on top of the lids, and bowls. (Photographic Evidence Obtained). 2. A garbage can with no lid was at the entrance, another trash receptacle with no lid was next to the sink near the tray line. The DM stated the garbage should have lids on when not in use. (Photographic Evidence Obtained). 3. The second shelf of the tray line had a container of bleach sitting out next to a basket with crackers and open boxes of hot chocolate mix. The DM stated the chemicals should not be stored there. (Photographic Evidence Obtained). 4. The cooks prep cooler had chopped green fruit and pulled pork in containers, covered. A sticker on the containers had red ineligible writing with no date on the fruit and no date on the pork. A bin of sandwiches (meat/cheese) was dated but the plastic wrap was not sealed. A white bag tied shut with a sticker titled [Name] Food dated 6/24. The DM stated the items should be dated and sealed, and the bag was one of the staff's food and that it was okay to have personal items in the cooking prep fridge. (Photographic Evidence Obtained). 5. The dry storage area had 2 boxes of chemicals and a bottle of a chemical stored at the entrance. The dietary manager immediately removed them and stated they should not be there. An open bottle of Teriyaki Marinade and Sauce dated 5/24/24, the label on the bottle stated Refrigerate after opening. The dietary manager was unaware the sauce needed to be refrigerated after opening. (Photographic Evidence Obtained). 6. The walk-in freezer had a build up of ice on the entire floor as soon as the door was open. Condensation was noted on the freezer ceiling, and the fans had ice build-up on them. Two bags of ice were open with the ice exposed. The DM stated the freezer had been doing this on a regular basis since he started. The DM said the Maintenance Director looked at the freezer but had not fixed it. (Photographic Evidence Obtained). 7. The can opener had a significant build-up of a black sticky substance and brown color running down the length tool. The DM stated the opener needed to be soaked and cleaned. (Photographic Evidence Obtained). 8. The pipe next to the stove had a build-up of grease and dust that was visible, the stove had a brown sticky substance running down the front, the oven doors had a brown sticky build-up on the outside and a black substance on the bottom corner. The cook stated the items needed to be cleaned. (Photographic Evidence Obtained). 9. Items stacked on shelves for drying were not open to air and were wet. (Photographic Evidence Obtained). During an interview on 6/25/2024 at 10:25 a.m. the DM stated the kitchen had come a long way and still had a way to go. The DM stated they did not have a cleaning schedule and one needed to be made. During an interview on 6/28/2024 at 11:00 a.m., the Nursing Home Administrator (NHA) was made aware of the findings. Review of the facility's policy and procedure titled Food Storage: Cold dated October 2019 revealed: Policy Statement: it is the centers policy to ensure all time/temperature control for safety (TCS), frozen and refrigerated food items common will be appropriately stored in accordance with guidelines of the FDA food code. Action steps: 1. The dining service director is responsible for storing all items 6 inches above the floor and 18 inches from the sprinkler unit. 5. The dining services director/cook ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. Review of the facility's policy and procedures titled Food Storage-Dry Goods dated October 2019 revealed: Policy Statement: it is the centers policy to ensure all dry goods will be appropriately stored in accordance with guidelines of the FDA food code. Action steps: Dry Storage: 1. The dining services director or designee is responsible to store all items 6 inches above the floor on shelves. 6. The dining services director or designee ensures that the storage will be neat, arranged for easy identification, and date marked appropriate. 7. The dining services director will ensure that toxic materials are not stored with food. The facility's policy and procedures titled Environment dated October 2019 revealed: Policy: it is the center's policy that all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. Action steps: 1. The dining services director will ensure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. 2. The dining services director will ensure that all employees are knowledgeable of the proper procedures for cleaning all food services equipment and services. 3. The dining services director will ensure that all food contact surfaces are cleaned and sanitized after each use. 4. The dining service director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. 5. The dining services director will ensure that all dining areas are cleaned and sanitized after each use, including table surfaces, chairs, and floors. 6. The dining service director will ensure that all trash is contained in covered leak proof containers that prevent cross contamination. 7. The dining services director will ensure that all trash is properly disposed, and external receptacles dumpsters and that the area is free of debris.

Based on observation, interview, and record review,, the facility failed to implement and maintain an infection prevention and control program to mitigate and prevent the spread of infection related to: 1) not ensuring staff were donning appropriate Personal Protective Equipment (PPE) when entering a resident room under contact isolation precautions for one (#23) of one sampled resident observed for contact isolation precautions, 2) not ensuring resident medical equipment had a cleanable surface for one resident (#43) of five sampled residents, and 3) not ensuring linen was transported and stored in a way to prevent contamination with seven of seven carts observed. Findings included: An observation was conducted on 6/25/2024 at 10:03 a.m. during the initial tour of the facility. Resident #23's room door had a blue 8 1/2 by 11 (letter size) laminated paper sign that showed; Enhanced Barrier Precautions. The sign was hung on the door with mesh caddy with multiple pockets. The pockets contained gloves, isolation gowns, masks, and disinfecting wipes. (Photographic Evidence Obtained). On 6/26/2024 at 1:29 p.m., Staff G, Certified Nursing Assistant (CNA) was observed entering Resident #23's room. Staff G, CNA donned gloves prior to entering. Staff G, CNA stated Resident #23 needed to be assisted with incontinence care, Staff G, CNA provided privacy and closed the room door. Review of Resident #23's Admission Record revealed a re-admitted [DATE] with diagnoses: pressure ulcer left hip, local infection of the skin and subcutaneous tissue, Methicillin Resistant Staphylococcus Aureus infection (MRSA) and other co-morbidities. Review of the Order Summary Report with active physician orders as of 6/28/2024 for Resident #23 revealed the following: Keflex 500 milligram every 8 hours for wound infection for 10 days, with an order date of 6/21/2024. Culture right hip wound due to drainage/infection ordered dated 6/21/2024. Contact isolation - MRSA infection dated 4/11/2024. During an interview on 6/26/2024 at 1:40 p.m., Staff G, CNA stated Resident #23 was on enhanced barrier precautions. Staff G did not know why Resident #23 was on precautions but said, she could find out. Staff G said she did not wear a gown while providing incontinent care to Resident #23 and with enhanced barrier precautions a gown should have been worn with direct care being provided. During an interview on 6/26/2024 at 4:50 p.m., Staff I, CNA stated resident #23 was on enhanced barrier precautions and only needed to have personal protective equipment worn when providing direct resident care. During an interview on 6/26/2024 at 1:55 p.m., Staff H, Licensed Practical Nurse (LPN) stated being responsible for Resident #23. Staff H stated Resident #23 had a wound and that was why the resident was on enhanced barrier precautions. These precautions only required gowns when providing direct resident care. Resident #23 had no signs or symptoms of an infection. An interview was conducted with the Director of Nursing (DON) on 6/28/2024 at 11:07 a.m. She confirmed she was the infection preventionist and said residents with a Methicillin-resistant Staphylococcus aureus (MRSA) infection in the wound should be on contact precautions for the duration of the antibiotics plus three extra days. She confirmed Resident # 23 had an infection in the wound, was on intravenous antibiotics for the infection and was getting an X-ray of the wound. During an observation on 6/25/2024 at 10:41 a.m., Resident #43 was observed lying in bed, in a fetal position with bilateral side rails in the upright position. The siderails had colored [Brand name] padding (i.e., pool noodle) surrounding the bed rail attached with silver tape. The [Brand name] padding was textured with numerous pores throughout. (Photographic Evidence Obtained). During an interview with the DON on 6/28/2024 at 11:07 a.m., she confirmed she was also the infection preventionist and confirmed Resident # 43 had pool noodles on her bed rails and said We just wipe them down with the 3-minute dry time wipe. I would have to ask environmental services what they use to clean them. During an interview with the Environmental Service Supervisor (EVS) on 6/28/2024 at 12:07 p.m., he stated the bed rails were just wiped down nothing special was used. On 6/25/2024 to 6/28/2024 at various times of the day the facility linen carts were noted to be torn, thread-bare, and hanging open. (Photographic Evidence Obtained). During an interview with the DON on 6/28/2024 at 11:18 a.m., she confirmed the linen carts needed to be replaced but they would be able to be wiped off, if needed. An interview on 6/28/2024 at 12:07 p.m. with the EVS revealed he did not have an issue with the linen carts. He stated he had not seen any holes or rips lately in the covers of the linen carts. The EVS stated he reviewed the linen carts once or twice a week. He stated he reviewed the linen carts when the staff went to the linen room to pick up items. He stated if the cart was broken, he would expect maintenance to make repairs. The EVS stated the linen carts were cleaned once or twice, every other week. He stated one of his staff or himself cleaned the linen carts. He stated none of the housekeeping staff have reported issues to him. Review of the facility's policy and procedures titled Isolation - Categories of Transmission-Based Precautions dated September 2022 revealed: Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; Arrives for admission with symptoms of infection; Or has a laboratory confirmed infection; And is at risk of transmitting the infections to other residents. Policy Interpretation and Implementation: . 2. Transmission based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. 3. The Centers for Disease control and prevention (CDC) maintains a list of diseases, modes of transmission and recommendation precautions. 4. The facility makes every effort to use the least restrictive approach to managing individuals with potentially communicable infections. Transmission based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. Sign it informs the staff of the type of CDC precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room. b. Signs and notification comply with the resident's rights to confidentially or privacy. Contact precautions: 1. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by contact with the resident or indirect contact with environmental surfaces or resident care items in the residence environment. 2. Contact precautions are also used in situations when a resident is experiencing wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and suggest an increased potential for extensive environmental contamination and risk of transmission of a pathogen, even before a specific Organism has been identified. 3. Contact precautions are used for residents infected or colonized with MDRO's in the following situations: a. When a resident has wounds, secretions, or excretions that are unable to be covered or contained and b. On units or in facilities where, despite attempts to control the spread of the MDRO, ongoing transmission is occurring. 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room. 8. Staff and visitors wear a disposable gown upon entering room and remove before leaving the room and avoid touching potentially contaminated surface this with clothing after gown is removed.

Based on interview and record review, the facility failed to file a grievance on behalf of one resident (#44) of one resident reviewed for grievances. Findings included: Review of Resident #44's Admission Record showed admission to the facility on [DATE], with diagnoses to include metabolic encephalopathy, cognitive communication deficit, and dementia. An interview was conducted on 6/26/24 at 9:33 a.m. with Resident #44's family member. She said she reported to the facility concerns and had not received a response. The family member said one of the concerns was related to the death of Resident #44's roommate. In the presence of the family member, a member of the therapy team opened the roommate's curtain and said, oh she is dead and closed the curtain. The family member said this was immediately reported to the facility's leadership. The family member provided a written copy of concerns she discussed with the Director of Nursing (DON) earlier in the day. (Photographic Evidence Obtained.) An interview was conducted with the DON, Staff B, Licensed Practical Nurse (LPN), Unit Manager (UM), and Staff C, Social Services Director (SSD) on 6/27/24 at 11:36 a.m. Staff C said there had been two grievances filed for Resident #44 from the time of admission to the facility. Review of the facility's Receipt of Grievance/Concern for Resident #44, received on 6/20/24, initiated by a family member. The grievance description showed [Resident #44] does not use call light, recommend bell, [family member] approved. In the resolution section, the grievance was assigned to maintenance on 6/21/24 and the action taken to resolve the grievance showed provided bell on 6/26/24. The grievance was resolved on 6/26/24. The follow-up section of the form showed on 6/24/24 the family member was contacted and was satisfied with the resolution. The review section, the administrator signature section is unsigned and undated. Review of the facility's Receipt of Grievance/Concern for Resident #44, received on 6/20/24 initiated by a family member. The grievance description showed stated therapist was inconsiderate of resident's feelings when roommate passed away The resolution section showed the grievance was assigned to rehabilitation and nursing staff on 6/21/24. The action taken showed Psych will see resident for psychosocial wellbeing. Sensitivity education will be completed. The date resolved section was not completed. The follow-up section and review sections were not complete. A follow-up interview was conducted on 6/28/24 at 12:33 p.m. with Staff C, SSD. She said the facility's goal was to resolve grievances within 5 days. An interview was conducted on 6/28/24 at 12:40 p.m. with the Nursing Home Administrator (NHA). She said, grievances are not always documented. Review of the facility's policy titled, Grievance/Complaint, Filing, revised 5/2020 revealed: Policy Statement Resident and their representatives have a right to grievances, either orally or in writing, to the facility .The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. 1. Residents, family and resident representative have the right to voice or file grievances without discrimination or reprisal of any kind . .4. The administrator has delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is the [Social Services Director.] 5. Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within 5 working days of receiving the grievance and or complaint. .8. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed verbally upon close of the investigation of the findings and the actions that will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident/responsible party upon request.

Based on interview and record review, the facility failed to ensure advanced directive care plans were accurate or developed for three residents (#31, #4, #36) out of 41 sampled residents. Findings included: 1. Review of Resident #31's Admission Record revealed she was admitted to the facility on [DATE], she received hospice services, and had medical diagnoses not limited to type 2 diabetes, major depressive disorder, and protein-calorie malnutrition. Review of Resident #31's physician order with a start date of 5/1/24 and no end date revealed DNR [do not resuscitate]. Review of Resident #31's [name of state] Do Not Resuscitate Order revealed Resident #31's power of attorney (POA) signed the document on 4/10/24 and Resident #31's physician signed the document on 4/11/24. Review of Resident #31's care plan with a revision date of 2/16/24 revealed [Resident #31] has expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code, DPOA [durable power of attorney] for health care and finances. The goal revealed Resident's wishes regarding code status and advanced directives will be followed by staff. The intervention revealed Discuss Advanced Directives with resident and/or appointed health care representative. An interview was conducted with Staff C, Social Services Director (SSD), on 06/26/24 at 1:20 p.m. She said she was responsible for developing and revising advanced directive care plans. She said the care plan should be reflective of the resident's physician ordered code status. She said she had been in the SSD position since December 2024, and she had not created or revised any advance directive care plans. She reviewed Resident #31's physician orders and confirmed she had a physician's order for a DNR. Staff C, SSD reviewed Resident #31's care plans and confirmed she was care planned to be a full code. An interview was conducted on 06/26/24 at 2:03 p.m. with the Director of Nursing (DON). She said social service was responsible for the development and revision of advanced directive care plans and the care plan should be reflective of the physician's order. She reviewed Resident #31's physician orders and confirmed Resident #31 had orders in place for a DNR. She reviewed Resident #31's care plans and confirmed Resident #31 was care planned to be a full code before the advanced directive care plan was revised on 6/26/24. 2. Review of Resident #4's Admission Record revealed she was initially admitted to the facility on [DATE] and readmitted back to the facility from an acute care hospital on 6/23/24 with medical diagnoses, not limited to, specified injuries of right elbow, seizures, unsteadiness on feet, major depressive disorder, mild intellectual disability, generalized anxiety disorder, and schizoaffective disorder, depressive type. Review of Resident #4's physician orders revealed an order with a start date of 6/23/24 and no end date for FULL CODE. Review of Resident #4's care plans on 06/25/24 at 2:45 p.m. revealed no advanced directive care plan was in place. Review of Resident #4's care plans on 06/26/24 at 12:56 p.m. revealed no advanced directive care plan was in place. Review of Resident #4's census revealed she was initially admitted to the facility on [DATE] discharged to the hospital on 6/19/24 and returned to the facility on [DATE]. An interview was conducted with Staff C, Social Services Director (SSD), on 06/26/24 at 1:20 p.m. She reviewed Resident #4's medical record and confirmed the resident had a physician order in place for full code. Staff C, SSD reviewed Resident #4's care plans and confirmed she did not have an advanced directive care plan in place. An interview was conducted on 06/26/24 at 1:45 p.m. with the Nursing Home Administrator (NHA) and Staff L, Regional Nurse Consultant (RNC). They said social services and nursing were responsible for the development and revision of advanced directive care plans. They said advanced directive care plans should be reflective of the physician ordered code status. An interview was conducted on 06/26/24 at 2:03 p.m. with the Director of Nursing (DON). The DON reviewed Resident #4's physician orders and confirmed she was ordered to be a full code. She reviewed Resident #4's care plans and confirmed her advanced directive care plan as created on 6/26/24. 3. A review of Resident #36's Admission Record revealed an original admitted [DATE] and an admitted [DATE]. A review of Resident #36's Active Orders revealed a Do Not Resuscitate (DNR) with an order date of 4/3/24. A review of Resident #36's miscellaneous documents, under the category of Advanced Directives, revealed a [name of state] DNR order form signed by the resident and the physician. The [name of state] DNR order for Resident #36 showed a date of 1/9/24. On 6/26/24, a review of Resident #36's current care plan revealed a focus to include, [Resident #36] has expressed the following wishes regarding code status and has the following advanced directives in place: is Full Code, with an initiated date on 11/25/22 and created on 11/25/22. On 6/27/24 at 2:44 p.m., an interview with the Director of Nursing (DON) revealed advanced directive orders would be found under orders, the grey ribbon under the resident's picture, and a document scanned in the resident's electronic medical record. She stated she would expect the care plan to have the same information as the orders, the grey ribbon area and the scanned document. On 6/27/24, the Administrator provided the resident's current care plan which revealed a focus to include, [Resident #36] has expressed the following wishes regarding code status and has the following advanced directives in place: is DNR, with an initiated date of 11/15/22 and revised on 6/26/24. A review of the facility's policy titled, Advanced Directives, revised 9/2022, reflected the following under Policy Interpretation and Implementation: .2. Resident advance directive choices documented in electronic medical record. A review of the facility's policy titled, Care Planning - Interdisciplinary Team, revised 3/2022, reflected the following under Policy Interpretation and Implementation: .4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Surveyor: [NAME], Allegra 50570

Based on observation, interview, and record review, the facility failed to ensure splints were applied to prevent the decrease of range of motion for one resident (#35) of five sampled residents . Findings included: On 6/25/2024 at 10:57 a.m. Resident #35 was observed and interviewed. Resident #35 stated she was not able to utilize her left hand due to a stroke. Resident # 35's left hand was observed laying across the resident's abdomen in a fist. Resident #35 was unable to move her fingers and stated, it would be nice to have something keep my hand open, as it (hand) becomes 'smelly'. On 6/26/2024 at 11:17 a.m. Resident #35 was observed lying in bed with no splint on her left hand. Review of Resident #35's Admission Record revealed an admitted [DATE] with diagnoses: flaccid hemiplegia affecting left nondominant side, cerebral infarction, and other co-morbidities. Review of Minimum Data Set (MDS) assessment, dated 5/16/2024, Section GG Functional Status revealed Resident #35 was dependent on staff with mobility and activities of daily living (ADL) performance and had functional limitations in range of motion on one side for upper extremity (shoulder, elbow, wrist, hand). Review of the Order Summary Report with active physician orders as of 6/28/2024 for Resident #35 revealed the following: Apply splint to left wrist after AM care. Doff before PM or as tolerated. Skin check to be done before/after application, order start date of 2/23/2024. The care plan for Resident #35 revealed a focus area for potential for complications related to contractures of: left (L) wrist; Date Initiated: 05/16/2024. Interventions revealed: Apply/remove splint/brace for joint protection as ordered Date Initiated: 05/16/2024 An interview was conducted with Staff K, Certified Nursing Assistant (CNA) on 6/25/2024 at 1:16 p.m. Staff K, CNA confirmed being assigned to Resident #35. Staff K, CNA stated Resident #35 did not wear splints. An interview was conducted with Staff G, Certified Nursing Assistant (CNA) on 6/26/2024 at 1:40 p.m. Staff G, CNA confirmed being assigned to Resident #35. Staff K, CNA stated Resident #35 did not wear splints. An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 6/27/2024 at 12:14 p.m. Staff H, LPN stated Resident #35 did not have splints. An interview was conducted with the Director of Rehabilitation (DOR) on 6/27/2024 at 12:20 p.m. The DOR stated Resident #35 was last on case load on 12/27/2023, at that time, Occupational Therapy recommended a left-hand splint. Resident #35 was able to tolerate and wear the splint. An interview was conducted with the Director of Nursing (DON) on 6/27/2024 at 12:44 p.m. The DON stated Resident #35 had a physician order for a left hand splint and her expectation was that Resident #35's left hand splint was on as ordered. Review of the facility's policy and procedures titled Resident Mobility and Range of Motion with a revised date of July 2017 revealed: Policy Statement: 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility and less reduction in mobility is unavoidable. Policy interpretations and implementation: . 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.

Based on observations and interview, the facility failed to dispose of garbage appropriately for two of two dumpsters outside of the kitchen. Findings included: On 6/25/2024 at 9:50 a.m., during the initial tour of the kitchen, with the dietary manager, an inspection of the dumpster area was conducted, and the following was noted. -Two dumpsters were noted in the rear parking area near the kitchen door. An extreme odor was present. The walls of both dumpsters were soiled with brown/black substance surrounding most of the dumpsters. The walls of the dumpster's appeared to be black although at the top of the dumpster's were yellow in color. The top of one dumpster lid was fully open and the other closed. The side door of both dumpster's was open and exposing the garbage inside, additionally there were multiple trash bags, crates and significant amounts of debris noted to be stored on the side and back of the dumpster's. The debris consisted of used incontinent products, plastic utensils, gloves, empty pill wrappers, plastic cups, lids, straws, and numerous garbage bags. (Photographic evidence obtained). During an interview on 6/25/2024 at 9:55 a.m., the dietary manager stated the lids of the dumpster's should be closed, even the ones on the side. The dietary manager continued to state the area around the dumpster's should be clean and debris free. The dietary manager stated the debris was discussed everyday in morning meeting, although nothing changes, and no one cleans up the debris. Review of the facility's policy and procedure titled Food-Related Garbage and Refuse Disposal dated October 2017 revealed: Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws. Policy Interpretation and Implementation: 1. All food waste shall be kept in containers. 2. All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. 3. Housekeeping personnel will empty garbage and refuse containers daily and will clean the containers at least daily on the outside and at least weekly on the inside, taking care not to contaminate food, equipment, utensils, or food preparation areas while cleaning. 4. Brushes used for washing garbage and refuse containers will not be used for any other purposes. Wastewater from such cleaning operations will be disposed of properly to prevent any contamination. 5. Garbage and refuse containing food waste will be stored in a manner that is inaccessible to pests. 6. Storage areas will be kept clean at all times and shall not constitute a nuisance. 7. Outside dumpster's provided by garbage pickup surfaces will be kept closed and free of surrounding litter.

Based on observations, facility record review, and staff interview, the facility failed to ensure kitchen spaces, kitchen equipment, and eating ware were maintained, clean and sanitary during two of two meal services observed. Observations included, 1. Ceiling tiles above food preparation tables were caked with dust and debris, 2. Dishes were not washed from the day before meal service, 3. Dish washing equipment rusted and eroding, 4. Meal trays served to residents soiled, cracked and chipped. Findings included: On 5/15/2023 at 5:50 a.m. the kitchen was toured and met with a Dietary Aide Staff A, who indicated she was recently transferred from another facility about two months ago. She revealed that this time of morning was her normal time when she comes in to work and works the kitchen for both the breakfast and lunch meal service. Also, in the kitchen was the a.m. and afternoon cook, Staff B. Staff B indicated he has been employed in the kitchen for about three years. Staff A and B both confirmed that they were the only two kitchen employees at the time and two others will be in by 6:30 a.m. Staff B revealed the tray line for the breakfast meal begins at around 7:30 a.m., and that tray carts go out to the halls. He also confirmed the community dining room is not open during the breakfast meal service. Staff A and B did not have names of the other staff who were due in at 6:30 a.m. Both Staff A and B were asked what time the Dietary Manager, Staff C arrives at the facility. They both revealed Staff C comes in at 9:00 a.m. or just after. They confirmed this was a normal occurrence for Staff C to come in at and after 9:00 a.m., which is after the entire breakfast meal service. While speaking with Staff A and B at 5:40 a.m. the following observations were made: 1. Five ceiling tiles/light covers at and near ceiling vents, located above the dish machine area and above the food prep table and steam table were observed caked with dust and debris. The areas with heavy debris were directly above where the cook was plating food from the steam table. Photographic evidence was taken. 2. The dish machine area to include the stainless steel dish return table was observed with two crates of soiled cups and bowls (approximately 20 cups and bowls total). It was determined that the crate of bowls and cups were from the previous dinner meal from 5/14/2023. Photographic evidence was taken. 3. The same area on the dish machine table was observed with 8 stacked soiled plates that also appeared to be from the previous meal service from 5/14/2023. Photographic evidence was taken. 4. The crates of soiled bowls and cups as well as the stack of plates were observed with over 5 small flying insects flying around the area and landing on the soiled bowls/plates/cups. There were also small flying insects flying around the floor drain and undercarriage of the dish washing machine. 5. Observations under the dish machine area revealed a metal heating booster, with what appeared to be a white soiled towel draped on it. Further observations revealed the top metal surface of the booster was heavily oxidized, rusted and with metal flaking off of it. The booster was also observed leaking a red rust type of liquid from the bottom of it, causing a red in color pooled liquid on the floor. The staining from the pooled liquid as well as the actual pool of liquid appeared to be longstanding and did not just happen during the observation. Upon lifting the soiled towel most of the top metal lid to the booster was heavily eaten away from rust and exposing the inside components, as well as not leaving a cleanable surface. Photographic evidence was taken. 6. There were many (over forty) black in color plastic trays used to hold plates of food, cups of liquid, napkins and eating utensils. These trays are sent out each meal to residents while either in their rooms or in the main dining room. At least twenty of these trays were observed in disrepair with what appeared to be white oxidation and with cracked and chipped off ends, leaving sharp edges. The kitchen was toured at 6:30 a.m., with the same above listed observations. Two addition kitchen aides, Staff D and E had just arrived and were preparing for the breakfast meal service. Staff D and E both confirmed that the Dietary Manager has not arrived at the facility yet, and does not usually arrive until after 9:00 a.m. Staff A, B, D, and E did not know why the Dietary Manager doesn't come in until 9:00 a.m. or after. Another kitchen cook, Staff F arrived at the facility around 7:15 a.m. Interviews with Staff A, B, D, E and F at that time revealed they were not sure why there were crates of soiled dishes on the dish washing machine rack, and that the previous night shift must not have collected and washed all the dishes. They all also confirmed there were small flying insects at and near the soiled dishes, as well as under the dish washing machine and the floor drain. They all indicated that they have had a small fly problem for awhile now, and that an outside company has come out to treat but the flies keep coming back. At 11:00 a.m. the kitchen was toured again and the Dietary Manager was still not in the building to speak with. Interviews with Staff A, B, D, and E at that time indicated there was a daily cleaning schedule with cleaning expectations, but they did not know where it was. None of the staff interviewed could explain how and when the Ceiling tiles/vents are cleaned, when dishes are expected to be cleaned by, why soiled towels were draped over eroding mechanical equipment, and when serving trays are observed for cleanliness and maintenance. On 5/15/2023 at 11:25 a.m. the kitchen was toured with the Nursing Home Administrator. He confirmed the above listed observations of concern and indicated he did not have any current plans or work/repair purchase orders, nor any listed kitchen renovations to show the areas were identified and being worked on. He further confirmed he could not at that time verify why there were areas not maintained and sanitary as the Dietary Manager had not come in yet to be interviewed. The Nursing Home Administrator revealed he would look for the kitchen cleaning schedule to provide for review. The Nursing Home Administrator as of 1:30 p.m. was not able to provide the daily kitchen cleaning schedule for review. Throughout the morning from 5:40 a.m., 7:30 a.m. and 11:25 a.m., The Director of Nursing, the Nursing Home Administrator and Dietary Kitchen staff were all asked to have the Dietary Manager speak to the State surveyor upon his arrival. However, as of 1:30 p.m., just prior to the survey inspection exit, the Dietary Manager was not available or made himself available for interview. It was determined the Dietary Manager was not in the building from at least 5:40 a.m. through to 1:00 p.m. It could not be confirmed what type of cleaning is performed either generally, or deep cleaned on a daily basis; nor was the day shift kitchen staff aware of what the cleaning schedule entailed. The Nursing Home Administrator revealed that it is the Maintenance Department's responsibility to clean the ceiling vents and ceiling tiles and indicated that the TELS system notifies when the ceiling vents are to be cleaned. However, he confirmed the ceiling vents and tiles surrounding the vents were caked with dust/debris. He confirmed the areas should be cleaned more frequently. Interview with the Maintenance Director at 1:35 p.m. confirmed the ceiling vents/tiles in the kitchen were soiled and dusty. He revealed that they needed to be cleaned more often and that kitchen staff should also help to make him aware if the vents/tiles need to be dusted. The Maintenance Director also confirmed the small flying insects and indicated this has been a recent ongoing problem and he has been looking to purchase electronic fly traps for the kitchen. He also indicated that the pest control comes in routinely to treat for pests. He confirmed they cannot have an effective pest control program if staff leave unwashed and soiled dishes overnight in the kitchen. The Nursing Home Administrator did not have a Kitchen Cleaning/Maintenance policy and procedure for review.

Based on observations, facility record review and staff interviews, the facility failed to ensure resident spaces to include 1. Resident rooms floors 26 and 31 were cleaned and sanitary leaving soiled and sticky floors with refuse scattered around; 2. One of two activities/lounge rooms (South wing) observed with soiled towels placed on the seats of lounge chairs, and with a heavily gouged doorframe; and 3. Six of seventeen dining room chairs in disrepair and non cleanable. Findings included: On 5/15/2023 a first initial facility wide tour at 5:40 a.m. and tours at 10:00 and 1:00 p.m. revealed the following observations: 1. Resident room [ROOM NUMBER] bed (a) floor area was observed with a large spread of what appeared to be a black sticky substance. There was food debris all over the floor under the bed and in between the (a) and (b) bed. The trash can was also overflowing with refuse. Photographic evidence was taken. 2. Resident room [ROOM NUMBER] bed (a) was observed with a heavily soiled floor with a black sticky substance and with food debris. 3. Resident room [ROOM NUMBER] was observed with trash/refuse, food debris on the floor near the (b) bed area. The trash can in the room was also full and overflowing with refuse. 4. The South Wing Activity room/lounge area was observed with several tables and chairs. Two chairs were observed with what appeared to be soiled white towels either draped on the back of chair, or was placed on the seat of the chair. Photographic evidence was taken. 5. The South Wing Activity room/lounge area was observed with the entrance doorway/door frame heavily gouged and exposing the inner drywall and metal framing. The area in disrepair measured from off the floor approximately two feet in length and seven inches wide. 6. The main dining room was observed. There were 17 chairs at various tables. Observations revealed 6 of 17 chairs were not maintained with plastic/fabric seat areas ripped/torn and scrapped, leaving non cleanable surfaces. The areas were also heavily peeling. It appeared that residents utilize these chairs during dining. At 6:30 a.m. an interview with a housekeeper Staff K revealed that she comes on shift around 6:00 a.m. and there are usually not housekeepers during the late night shift. She revealed upon her and other housekeepers arrival, they only attempt to clean rooms for residents who are already awake, or clean other non resident spaces. Staff K revealed once she enters rooms to clean, she and other housekeeping staff will generally empty the trash cans, sweep the floor and mop if needed. She revealed there are times she comes in and there are soiled floors. She could not say for sure if the floors were soiled after the day crew left for the night, or if the floors were not cleaned prior to the end of their shift. Staff K was not sure why trash cans in resident rooms were full and overflowing, nor was she sure why there was sticky floors with food debris and other refuse in resident rooms at the time housekeeping arrived this a.m. The Housekeeping Director was not available for interview. Interview with the Nursing Home Administrator revealed they did not currently have any type of housekeeping or room cleaning policy and procedure. The Nursing Home Administrator confirmed he did not have any current maintenance facility work orders or current purchase orders that would indicate the facility was actively working on the above listed concerns. He confirmed the dining room chairs and indicated that he did not realize the chairs were that worn. The Nursing Home Administrator revealed that floor staff and housekeeping, or any other staff that see furniture in that condition, should report those concerns to maintenance once they see it. The Nursing Home Administrator confirmed there were six dining room chairs with seats that were not maintained and in disrepair.

Based on observations, staff and resident interviews, and facility record review, the facility failed to maintain an effective pest control program related to small flying insects in areas to include: One of one main dining rooms, the kitchen, the main activities room, and one of three unit station areas (south wing). Findings included: On 5/15/2023 During observations in the main dining room at 5:50 a.m., 10:00 a.m., during lunch meal service at 12:30 p.m. and again at 1:00 p.m., the main dining room was observed with over ten small flying insects near and at the sink area, near and at where the tray carts were stored near the kitchen entrance doors, and throughout the dining room at various tables. On 5/15/2023 during first tour of the kitchen at 5:50 a.m. and while interviewing the Kitchen Aide Staff A and the Kitchen Cook Staff B, the area near the dish machine and on the dish machine side table were two crates with what appeared to be food soiled bowls and cups. Also, there was a stack of seven food soiled plates in the same area. Upon interview with the Staff A and B, they both revealed that staff from the night before must not have washed all the dishes and that they were from the previous night's 5/14/2023 dinner meal service. Staff A and B confirmed several small flying insects flying around the crates of soiled eating ware. They were not sure where the insects came from but indicated the flying insects have been in the kitchen on and off for some time (exact timeframe not given). They also confirmed more flying insects under the dish machine carriage and near the floor drain. During the lunch meal service at 12:30 p.m. there were over ten residents seated at tables eating their lunch meal. It was further observed small flying insects were flying around tables where residents were seated as well as flying off and on resident meal trays. Random resident interviews with three residents who wished to remain confidential, revealed that the bug problem has been getting worse in the dining room and also in their rooms over the past few weeks. They have notified their nurse and maintenance director but with no resolution. On 5/15/2023 at 6:00 a.m. and 9:10 a.m. interviews with Direct care Staff G, H, I, and J, all revealed that they have noticed small flying insects, roaches, and ants in resident rooms, around the nurse stations, in the dining rooms, activities rooms and in the shower rooms. They were aware on how to report pests and have done so in the past but also revealed it does not appear that the pest control treatments are working. Staff G, H, I, and J, also revealed that residents do complain about bugs every so often. During the 7-3 shift on 5/15/2023 random resident interviews with five residents who all wished to remain as confidential interviews, all revealed that there are bugs to include small flying insects, ants and cockroaches throughout the building. They all indicated the pests have been ongoing for awhile and they have spoken to staff to include their nurse and maintenance director but pest control does not seem to get any better. On 5/15/2023 at 1:20 p.m. an interview with the Maintenance Director revealed the facility does have a current pest control service, which treats about once a week. He further revealed that he has made request calls for treatment other than scheduled visits with relation to ants, cockroaches and small flies. He confirmed through observation tour in the kitchen there were flying insects at and around the dish machine drain, the undercarriage of the dish washing machine, and in other areas throughout the kitchen. He revealed that he was planning on ordering an electronic fly trap which should take care of the insects in the kitchen. He was not sure where the insects were coming from, but did confirm that it had been reported from kitchen staff that the fly problem keeps coming back. The Maintenance Director also confirmed flying insects in the dining room, the south wing hall unit station and revealed he was not aware of them in those areas until just now. He did not know how or where the insects came from. On 5/15/2023 the Maintenance Director provided and explained the current pest control program contract and treatment log. The log indicated last routine pest treatment visits on: 3/7/234, 3/13/23, 3/21/23, 4/16/23, 4/21/23, 5/6/23, 5/7/23. The log indicated facility was trea [NAME] for various pests to include ants, roaches, spiders. Specifically, the pest control company treated for flies on 5/6/203 and 5/7/2023. On 5/15/2023 The Nursing Home Administrator provided the Pest Control policy and procedure (not dated), for review. The Policy Statement revealed; Our facility shall maintain an effective pest control program. The Policy Interpretation and Implementation section of the policy revealed; 1. The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services to be provided by (named pest control company). 3. Windows are screened at all times. 4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observations, interviews, and record review, the facility failed to ensure one of one kitchen dish washing machines was maintained in accordance with manufacturer recommendations, related to the wash and rinse temperature. Findings include: On 05/02/22 at 10:16 a.m., an initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). During the observed timeframe, two staff members were observed working in the dishwashing area. One staff member was observed placing soiled dishes on a crate to load into the dish machine and one staff member was removing clean dishes from a crate that had just came through the dish machine. The CDM was asked to demonstrate a washing/rinsing cycle. The following was observed: First Demonstration: The digital temperature panel indicated the wash cycle temperature reaching 132 degrees Fahrenheit; and the rinse cycle temperature reaching 114F. The CDM revealed he identified there was an issue with the dish machine this morning and called the dish washing machine repair company. The CDM was asked to provide confirmation of the work order submitted to the dish washing machine repair company. Second Demonstration: The digital temperature panel indicated the wash cycle temperature reaching 132 degrees Fahrenheit; and the rinse cycle temperature reaching 116 degrees Fahrenheit. Third Demonstration: The digital temperature panel indicated the wash cycle temperature reaching 132 degrees Fahrenheit; and the rinse cycle temperature reaching 118 degrees Fahrenheit. Continued observations of the dish machine revealed a specifications plate was not attached to the machine (photographic evidence obtained). This was confirmed by the CDM. The CDM stated he would pull paper products for lunch, and he would provide confirmation that the dish washing machine repair company was contacted this morning prior to the surveyor entering the kitchen. On 05/03/22 at 11:00 a.m., the CDM provided documentation from the dish washing machine repair company dated 05/02/22 at 11:58 am (after surveyor entered the kitchen). He reported he did not have any documentation that indicated the dish washing repair company was contacted prior to the survey. The work order dated 05/02/22 at 11:58 a.m. revealed the following: The rinse aid dispenser was over filled and had wrong (solid brilliance) rinse aid in the dispenser The rinse aid dispenser was leaking. Wash motor was leaking, rinse aid water line solenoid and the housing was faulty and corroded, and the incoming water line for dish machine was leaking. A rinse jet was clogged. Squeeze tubes were worn for chlorine sanitizer and rinse aid. The deter dispenser sensor was faulty. On 05/04/22 at 12:06 p.m., the CDM reported the dish washing machine repair company worked on the machine from 10:00 a.m. to 5:00 p.m. He stated he did not have documentation of when he initially put the work order in prior to the survey. On 05/04/22 at 2:36 p.m., the CDM reported he would check to see if the dish washing machine was a low temperature or high temperature machine. He stated the machine was leased so he did not know. On 05/04/22 at 3:00 p.m., the CDM reported he contacted the dish washing machine repair company and they reported the temperatures were in the work order he provided me. The work order indicated the wash temperature was 140 degrees Fahrenheit and the rinse temperature was 125 degrees Fahrenheit. The dish washing repair company also reported that the machine was low temperature, and they were going to order stickers indicating the manufacturers recommendation for temperatures. The CDM stated he would post signs in the kitchen with the recommended temperatures. On 05/05/22 at 1:14 p.m., the CDM stated he found the specifications plate and it was underneath the machine. The specifications plate read: Hot Water Sanitizing- 160 degrees Fahrenheit for the minimum wash tank temperature 180 degrees Fahrenheit for minimum final rinse temperature Chemical Sanitizing- 140 degrees Fahrenheit for the minimum wash tank temperature 120 degrees Fahrenheit for minimum final rinse temperature. On 05/05/22 at 10:18 a.m., the Administrator stated he would expect staff to not use the dish washing machine and use paper products until the machine was fixed. The policy provided by the facility Ware Washing dated October 2019 revealed the following: 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines.

Based on observations and interviews, the facility failed to store medications in a locked compartment for one (East Unit) of four medication carts, one (East Unit) of four wound treatment carts, two bags of pharmacy return medications, and failed to store controlled medication in separate locked compartment in one (Rapid Unit) of two medication storage rooms. Findings include: An observation was made on [DATE] at 10:15 a.m. of three bags of unsecured pharmacy return medication sitting on a cart in the East Unit nurses' station. This nurses' station was near the main entrance of the facility. All visitors must pass this station upon entering and leaving the facility. The nurses' station was also located on a main hall of resident rooms. An observation was made on [DATE] at 1:48 p.m. of the East Unit nurses' station. The three bags of medication remained unsecured, sitting on top of a wound treatment cart. One bag was labeled Used IV Pump and two bags were labeled Pharmacy Returns. The wound treatment cart was also unlocked with prescription medications in the drawer. No staff were in sight of the nurses' station (Photographic evidence obtained). An additional observation was made of the East Unit station nurses' station on [DATE] at 3:08 p.m. The pharmacy return bags remained unsecured on the wound treatment cart. The bags were opened and confirmed to be 37 bubble packs of resident medication. (Photographic evidence obtained). At that time, an interview was conducted with Staff I, Licensed Practical Nurse (LPN). Staff I stated the bags should be in the medication storage room on the Rapid Unit. She stated, pharmacy comes to pick the returns up around 3:00 p.m. and sometimes people forget they are in the storage room, so they get brought to the East Unit nurses' station or reception and left. She confirmed there was no place to lock the pharmacy return medications at the East Unit nurses' station and they should be locked up (Photographic evidence obtained). Staff I proceeded to take the medications to the locked medication storage room on the Rapid Unit. An interview was conducted on [DATE] at 3:20 p.m. with the Rapid Unit nurse, Staff J, LPN. Staff J confirmed all the pharmacy returns should be in the locked in the medication storage room and stated that is where she puts hers. She stated she never takes her pharmacy returns to the East nurses' station. She stated, they have to stay locked up. On [DATE] at 3:50 p.m. an observation was made of the East Unit medication cart. The medication cart was unlocked with no staff members in sight. Residents were moving through the hallway. Residents and visitors must pass this medication cart upon entering and exiting the building. This cart sits along a main resident hallway. On [DATE] at 3:55 p.m. an interview was conducted with Staff K, LPN. Staff K stated she knew the policy and the cart should be locked. She stated she had just started coming to this facility and the carts are different than what she is use too. She stated she forgot to push the button because she isn't used to the two-step locking process. An observation was completed of the Rapid Unit medication storage room on [DATE] at 10:55 a.m. The narcotics box was attached to the inside of the refrigerator; however, the box was unlocked with narcotics inside. The door to the storage room was locked and there was no additional lock on the refrigerator. An interview was conducted at that time with Staff J. Staff J confirmed narcotics were inside the narcotics box and the box was unlocked. She stated the box should be locked. Staff J locked the narcotics box and confirmed the lock functioned properly (Photographic evidence obtained). An interview was conducted on [DATE] at 12:46 p.m. with the Director of Nursing (DON). The DON stated medication should be stored properly and not expired. She stated medication carts should always be locked when left unattended. The DON confirmed pharmacy returns are picked up daily and the returns should be locked in one of the two medication storage rooms. The DON stated pharmacy return medications should not be left at the nurses' station or the front desk. The DON stated narcotics should be locked in a separate box which is secured to the refrigerator inside of the locked medication storage room. An observation was conducted on [DATE] at 9:06 a.m. at the East Unit nurses' station. The wound treatment cart was unlocked with medication in the top drawer. No staff are in sight; however, a resident and a visitor were observed walking past the cart. The Assistant Director of Nursing (ADON) provided a facility policy titled Storage of Medications, revised [DATE]. The policy stated: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access [NAME] locked medications. 3. Nursing staff is responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to, drawers, cabinets, rooms, a refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. 8. Schedule II-V controlled medications are store in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.

Based on observation, interview and medical record review, the facility failed to ensure a grievance was responded to in a timely manner for one (#4) of thirty-four sampled residents. Findings include: On 05/3/22 at 3:20 p.m. an interview was conducted with Resident #4 family members, who said they visit the resident four to five times a week and stay between two to three hours. Both family members spoke about the resident's missing upper dentures, stating it happened within a month after she was admitted to the facility, and they were never located. The family members confirmed they had reported the missing dentures to the Social Worker (SW) and the SW had provided a quoted cost for the teeth. The family members said they had called the SW to follow-up on the quoted cost, but the SW had not followed up with them. During the interview the resident smiled listening to her daughters speak. Resident #4 was noted with a cognitive deficit as she verbalized at times with confusion. When she spoke, no upper teeth were present with a few lower teeth in place. On 5/4/22 at 12:15 p.m. Resident #4 was observed sitting in bed eating her lunch meal. She smiled as she was eating a cup of pudding; the meal on the plate was not touched. The meat was in small pieces and the remaining food was of a soft texture. Review of the Grievance Tracking Log revealed on 11/04/2021 a concern was voiced by Resident #4's family member. The nature of the concern read Dental, missing items. The log indicated the Responsible Department was housekeeping (HSKING) and social services (SS). The Log's Resolution was omitted of any documentation. Medical record review reflected the Admission Record for Resident #4. The form indicated the resident was admitted to the facility in late April 2021. The form contained a photograph of the resident smiling, which revealed she had upper teeth. On 5/5/22 at 10:48 a.m. an interview was conducted with the SW. She confirmed the Grievance Log indicated a concern about Resident #4's dentures. She stated it was about the resident seeing a dentist and other missing items, not missing dentures. The SW said she had informed the resident daughters that a dentist would see the resident in December, and it would cost $1200.00 to replace the dentures. She said that she had attempted to make an appointment for the dentist, stating I sent over the paperwork that was needed. But I was told they could not see her because of pending Medicaid. And Medicare will not cover dental services. The SW confirmed she was aware the resident had missing dentures. She said the last Administrator would always look at resident's inventory form, and she confirmed the resident did not have a completed inventory form when she was admitted . The SW said the facility was hesitant on replacing her dentures. The Nursing Home Administrator was present during the interview and stated we are paying for another resident's dentures. We'll pay for Resident #4's dentures. At 1:23 p.m. on 5/5/22, the SW reviewed Resident #4's Admission Record form that contained a picture of the resident; the picture revealed the resident with upper teeth in place. The SW was unable to produce any documentation related to the resident's missing dentures nor any documentation of communication with the resident's family members. She additionally confirmed no dental services had been provided to the resident. Review of the facility-provided policy titled Grievances/Complaints, Filing, with a revision date of 5/2020 revealed: Policy Statement: Residents and their representative have to right to file grievances, either orally or in writing, to the facility staff or the agency designated to hear grievance (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy Interpretation and Implementation: 5. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or compliant. 7. The Administrator will review the findings with Grievance Officer to determine what corrective action, if any, need to be taken. 8. The resident, or the person filing the grievance and/or complaint on behalf of the resident, will be informed verbally upon close of the investigation of the findings and the actions that will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident/responsible party upon request.

Based on interviews and record review, the facility failed to develop a baseline care plan related to falls for one (#395) of thirty-four sampled residents. Findings include: A review of the clinical record for Resident #395 indicated a fall on 5/1/22, which resulted in the resident being sent to the hospital for evaluation. A review of the resident's care plans showed a care plan and interventions for falls risk was not initiated until 5/2/22. A review of admission records indicated Resident #395 had an initial admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #395's Admission Nursing Comprehensive Evaluation revealed a completion date of 4/14/22 by Staff A, Registered Nurse (RN,) Assistant Director of Nursing (ADON.) The evaluation indicated resident was not a fall risk. A review of the Baseline Care Plan/Summary indicated the following goal: I will remain free from fall related injury. The only intervention listed was, provide therapy to me as ordered. An updated evaluation or baseline care plan was not completed for the re-admission on 4/28/22. A review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA-3008) dated 4/20/22 for transfer on 4/28/22 indicated Resident #395 had a risk alert for falls. A review was conducted of Resident #395's Physical Therapy (PT) Evaluation and Plan of Treatment completed on 4/29/22. The evaluation indicated the resident was a fall risk. For standing balance the evaluation indicated resident's static standing was fair and dynamic standing was poor. Under Gait, the evaluation stated: Level Surfaces = Min (A); Distance Level Surfaces = 60 feet; Assistive Device = Front wheeled walker. The gait analysis indicated fall predictors including, reduced proactive balance, and reduced reactive balance. The evaluation also indicated: risk factors due to the documented physical impairments and associated functional deficits, the patient is at risk for; further decline in function and falls. An interview was conducted with Staff L, Physical Therapist on 05/05/22 at 3:04 p.m. Staff L explained the physical therapist must look at the AHCA-3008 form, but also do their own evaluation. He confirmed Resident #395 was evaluated on 4/29/22 by PT. Staff L confirmed the evaluation showed Resident #395 was a fall risk. The Physical Therapist explained the evaluation report related to gait. He stated the gait evaluation indicated resident can walk 60 feet with minimum assistance with a walker. He explained this is equivalent to a one person assist. Staff L stated the evaluation is typically performed in the resident's room and when the therapist finishes the evaluation, they educate the resident (if cognitively intact) on their safety and risks. Staff L said the therapist goes to the clinical staff prior to leaving the unit and lets them know the areas of concern and risks, including if the resident is a fall risk. An interview was conducted with Staff A, ADON on 5/4/22 at 3:32 p.m. Staff A stated when a resident comes to the facility a nursing evaluation is completed, if the resident scores a 10 or above they are considered a fall risk. If the AHCA-3008 form from the hospital transfer indicated they are a fall risk, but the nursing evaluation does not, they would put interventions in place. She confirmed she completed Resident #395's nursing evaluation on 4/14/22, stating the resident was alert and oriented and didn't score high enough to be a falls risk. Staff A reviewed the AHCA-3008 form and confirmed it stated the resident was a fall risk. On 5/5/22 at 11:55 a.m. interview was conducted with Resident #395's emergency contact, due to resident currently being in the hospital. The family member stated the resident had a scan of her head done at the hospital and there were no bleeds. An interview was conducted with Staff J, Licensed Practical Nurse (LPN) on 5/5/22 at 1:06 p.m. Staff J confirmed she cared for Resident #395 prior to her fall. She stated there were no fall interventions in place for the resident. She said, the resident seemed to move around ok, she never called for help, so I guess she moved around on her own. A review was conducted of the facility policy titled Falls and Fall Risk, Managing, dated March 2018. The policy stated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. A review was conducted of the facility policy titled Care Plans, Comprehensive Person-Centered, dated December 2016. The policy stated: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on observation, interview, and medical record review, the facility failed to ensure a splinting device was utilized for one (#48) out of three residents sampled for positioning and limited range of motion as evidenced by not scheduling the order accurately. Findings include: On 05/02/22 at 1:50 p.m. Resident #48 was observed in his wheelchair sitting in the street directly across from the facility entrance. He was alert and receptive to an interview. Resident #48 said that his left arm and hand did not work. He stated see as he picked up his left forearm and then let go of it as it dropped back on his lap. His left hand was contracted. Resident #48 confirmed he had a splint for his left-hand. He stated, the therapy department gave me one, but I can't put it on by myself. On 05/03/22 at 10:54 a.m. Resident #48 was in his bedroom; no splint was observed in place to his left hand. No splint was observed in his bedroom. On 05/03/22 at 1:00 p.m. Resident #48 was observed seated across the street from the facility with his peers; no splint was observed in place. On 05/04/22 at 3:00 p.m. Resident #48 was sitting in his bedroom with his splint lying on top of the bed. He confirmed it was his splint and said the therapy department are the ones that put it on. He denied the nurse or certified nursing assistants have ever applied it. He stated, they could do it; I just can't do it by myself. Medical record review of the Admission Record form that revealed Resident #48 was admitted to the facility in March 2022. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Splint may be removed as needed for activities of daily living (ADL), care and to check skin integrity dated 4/22/2022. On 05/04/22 at 4:00 p.m. an interview was conducted with the Director of the Therapy Department, who said she would follow-up in the morning about the resident's splint. Review of the Treatment Administration Record (TAR) dated April 2022 revealed the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hours/ scheduled section in the TAR for the donning and doffing were omitted. Further review of the TAR for May 2022 revealed the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/22 at 9:50 a.m. a second interview was conducted with the Director of the Therapy Department. She stated The Occupational Therapist had input the order in the TAR for the splint. But the details time of on and off were not scheduled. She said the scheduling part is a separate area that was not added. The Director confirmed the TAR contained no documentation from April 2022 to 5/5/22 on the donning and doffing of the hand splint. She was asked for a copy of his assessment that would be conducted. No assessment was provided prior to the exit of the facility. On 5/05/22 at 2:00 p.m. during an interview with the Minimal Data Sheet Coordinator (DISC), she confirmed after review of Resident #48's care plans, no care plan was in place for the resident's splinting device.

Based on record review and interviews, the facility failed to ensure [CONDITION(S)] Communication Forms were completed for one resident (Resident #50) out of the sampled three residents. Findings include: A review of the Admission Record revealed Resident #50 was initially admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Section O of the MDS revealed the resident received [CONDITION(S)] while a resident. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] on Tuesday, Thursday, and Saturday A review of the [CONDITION(S)] Communication Forms revealed no documentation was completed on 3/19/22, 03/22/22, 03/24/22, 03/26/22, 03/31/22, 04/16/22, 04/23/22, 04/26/22, and 05/03/22. A review of the Progress Notes from March to May 2022 did not reflect any documentation related to Resident #50 refusing to go to [CONDITION(S)] on the days the [CONDITION(S)] Communication Forms were not completed. A review of the care plan related to [CONDITION(S)] initiated on 03/15/22 revealed the following intervention: Complete [CONDITION(S)] communication tool on [CONDITION(S)] days and review upon return form [CONDITION(S)]. On 05/05/22 at 9:33 a.m., during an interview with Staff J, Licensed Practical Nurse (LPN), she said she was responsible for completing the [CONDITION(S)] Communication Forms and the forms are sent via fax. Staff J, LPN, reported she documents vital signs and medications administered. She stated Resident #50 was transferred from the South Unit and was not able to provide any additional [CONDITION(S)] Communication Forms from that wing. On 05/04/22 at 11:27 a.m., the Regional Clinical Director confirmed that Resident #50 did not have any progress notes related to refusals for [CONDITION(S)]. He confirmed [CONDITION(S)] Communication Sheets were not completed on the dates in question. On 05/05/22 at 9:27 a.m., the Director of Nursing (DON) reported the nurses should be completing the [CONDITION(S)] Communication Forms prior to the resident going to [CONDITION(S)] and when the resident returned from [CONDITION(S)].

Based on observation, interview, and medical record review, the facility failed to prevent duplicate therapy for one (#48) of five sampled residents, as evidenced by the application of a topical nicotine patch in conjunction with inhaled nicotine. Findings include: On 05/02/22 1:50 p.m. Resident # 48 was observed in his wheelchair sitting in the street directly across from the facility entrance. He was alert and receptive to an interview. The resident said he was waiting for a someone to come out and to bum a cigarette. He stated he smokes daily, but the administration says it can't be on the property. The resident said the facility holds the cigarettes at the receptionist desk in a locked box. On 05/03/22 at 1:00 p.m. Resident #48 was observed smoking a cigarette with his peers directly across the street from the facility. On 05/04/22 at 10:45 a.m. Resident #48 was observed across the street smoking a cigarette. Medical record review of the Admission Record form revealed Resident #48 was admitted to the facility in March 2022. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply 0900 Remove 0859 dated 3/29/2022. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 05/04/22 at 2:00 p.m. an interview was conducted with the Director of Nursing. Related to the nicotine patch, she stated he doesn't get that anymore. At 2:10 p.m. on 05/04/22, Resident #48 was observed in his bedroom, and confirmed he wears a nicotine patch; he said it was on his left arm. The resident said he smokes from 10 to 15 cigarettes a day, and stated, I'm aware of smoking while on the patch. I know I can have a heart attack. The Assistant Director of Nursing (ADON) was present and assisted the resident with his shirt to reveal a nicotine patch located on his left upper arm. At 2:24 p.m. on 05/04/22 an interview was conducted with Staff Member C. who was sitting at the entrance of the facility, and said she was filling in for the receptionist during her break. She opened a small tackle box that revealed five packages of cigarettes for Resident #48. She said when a resident leaves the facility for a Leave of Absence, they have to sign out on the 4 hour leave form. Staff C said she gives the residents their pack of cigarettes when they leave and locks them when they return. Staff C said they do not keep count on how many cigarettes the resident starts with or returns with. On 05/04/22 at 2:33 p.m. an interview was conducted with the Nursing Home Administrator. He stated he had spoken to Resident #48 about the risks of smoking and wearing the patch. He confirmed that there was documentation. Review of the Resident/Family Education Tool V2 dated 04/22/2022 revealed: Pt [patient] educated on the importance of smoking while on a smoking patch. Pt states he knows and doesn't need anyone telling him what to do. Writer explained the risk including return to hospital (RTH), pt. showed no interest. Writer asked pt. if he would like the smoking patch discontinued and he stated no, he wants the patch. MD [medical doctor] made aware. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Nicotine Dependence, cigarettes, with other nicotine-induced disorders. Notes: -History of [h/o] smoking 2 packs per day [ppd]. Agreeable to quit and so nicotine patch prescribed to help with cravings. Additionally, I informed him that he is not to smoke while using the patch. Expressed understanding. Nurse at bedside. On 05/04/22 at 3:45 p.m. an interview was conducted with the Regional Nurse and the Director of Nursing. The Regional Nurse stated, we are aware the resident is smoking while on the nicotine patch. And if you look under the resident family education tool you would find that. He stated. he was educated on smoking while on the nicotine patch. He is aware of the risk. If he wants the patch, it is his right. He knows the risk when he leaves the facility. The Regional Nurse said, the doctor knows about it, and he has the right on his leave of absence (LOA). The Regional Nurse further stated they have been aware of it for two weeks. On 05/04/2022 at 4:04 p.m. a phone interview was conducted with the facility Pharmacist. He said the nicotine patch is designed to aid with the side effects from the withdrawal of nicotine. He said if the facility does not know how much the resident is smoking, there are certain risks factors they should be aware of, such as increased heart rate and blood pressure. The Pharmacist said the Physician should be made aware the facility is administering the resident a nicotine patch while he is smoking. On 05/04/22 at 4:14 p.m. a phone interview was conducted with the Physician. She confirmed she knew Resident #48 and said that it sounded like him when informed the resident was smoking cigarettes. She said he is his own person, and we give education when we prescribe nicotine patches. The Physician stated, I recommend to the building the patch for an as needed basis or scheduled. Then added its best on an as needed basis. The Physician said the facility must have informed an on-call MD, as she was not aware. She confirmed she would have changed the nicotine patch order but said today was the first time the facility had notified her that the resident was smoking. She stated, If the resident wants to start smoking, I would stop the patch.

Based on staff and resident interviews, review of the Resident Council meeting minutes, and the facility policy related to Resident Council, it was determined that the facility had not addressed concerns voiced in Resident Council and resident interviews for nine ((Residents #3, #4, #5, #6, #8, #9, #10, #11, #12) of twelve residents related to the dietary service and quality of the meals. Findings included: During the initial tour of the facility, on 11/15/2021 beginning at 9:30 a.m., residents reported that they had not been served their breakfast or any coffee yet. At 9:48 a.m., Resident #6 was greeted while sitting up in bed and she responded that she was annoyed that there was no breakfast yet and no coffee either. She reported that it had been happening more and more frequently. When asked if she had ever told any facility staff of the concern, she reported no, because she didn't think anyone in the kitchen would care to answer the question or care to fix it. By 9:55 a.m., Resident #6 received her breakfast and was observed spreading jelly on a half of a slice of toast. She had scrambled eggs and a ground up sausage patty on her plate. She reported that she never ate the eggs and she did not understand why they had to grind up her sausage patty for her. She reported that the toast was soggy but warm and that she would eat the toast and her cornflakes. Interviews conducted with six residents (#6, #8, #9, #10, #11, #12) on 11/15/2021 between 9:30 a.m. and 10:20 a.m. revealed that posted meal times were not followed and the residents never knew when the meals would be served. A review was conducted of the Resident Council Meeting minutes from meetings held monthly beginning in May 2021 until October, 2021. Concerns with food service were reported every month, with similar concerns reported for a few months in a row. The Administrator provided Resident Council Concern follow up documents when asked what the resolutions had been to the concerns voiced at the meetings. The follow up notes for the 05/27/2021 meeting listed concerns about menus and the meals being served. The minutes included residents requesting different varieties of vegetables, larger print menus posted outside of the dining room, and that residents were receiving the wrong items on their trays. The resolution by the Administrator was documented as menus will be changing, a variety of different food substitutions will be served. The resolution did not address the request for larger print posted menus or residents receiving the wrong items. The Resident Council meeting held on 06/24/2021, documented a concern that the scrambled eggs were too runny and that the Council would like a bigger menu posted outside of the dining room. No resolution to these concerns was provided by the Administrator and it should be noted that this was the second month that a request was made for bigger print for the posted menu. The Resident Council meeting held on 07/29/2021, included requests and concerns made by the members for soup to be put back on the menu, more coffee served at all hours, the alternatives were not noticed on meal tickets, residents wanted more spaghetti and less pork, snacks at night including diabetic snacks, fish and grits at breakfast, and the toast was not brown enough. During the July meeting the Administrator announced new meal times would start on 08/01/2021. The follow up to the July meeting, dated 08/01/2021, provided the resolutions as: coffee was always available from 6:00 a.m. to 8:00 p.m. - coffee could not be left out due to COVID; and a variety of snacks were sent out daily. Additional information about the menus included letting residents know that the menus were created and approved by the contract company's Dietitian and that the menus were changed three times a year. Also the resolution included that a request for larger print menus had been submitted. The resolution did not include that the resident's requested items would be included in the new menus. The Resident Council meeting held on 08/19/2021, included residents reported that they were told there was no coffee when they asked for more and they were asking for a variety of evening snacks be made available. The follow up to the 08/20/2021 meeting again stated that coffee was always available from 6:00 a.m. to 8:00 p.m. and a variety of snacks were delivered to the floor each day. This resolution was a repeat from 08/01/2021. The Administrator, in an interview on 11/15/2021 that began at 2:40 p.m., was asked about the request for coffee. The Administrator reported it had been resolved as coffee was always available. She reported that residents only had to ask and their aide would go to the kitchen to get it. It was reported to the Administrator at that time that with the late breakfast that morning[11/15/2021], the residents had to wait for coffee also. Residents had reported that they only received coffee on their meal trays, and were told it was not available at other times. The Administrator was asked how residents would know that coffee was available from 6:00 a.m. to 8:00 p.m. She reported that if they asked staff for a cup of coffee, the staff would go get it for them. During an interview on 11/15/21 beginning at 3:20 p.m., Resident #5 stated that he had never been offered coffee throughout the day. He was not aware they could get coffee throughout the day. He stated that he had asked for a second cup of coffee with his meal. He stated that he had never tried to ask for coffee during the day, but they had not asked him if he wanted one either. During an interview on 11/15/21 beginning at 3:20 p.m., with Residents #3 and #4, they both stated that they had not been offered coffee during the day. Resident #4 stated that when he first came to the facility in May, they used to get him coffee at 6:30 a.m. and then he asked later on and was told he had to wait until 7:30 a.m. or breakfast. He stated he was told the cafeteria was closed. He stated he was not aware he could get coffee throughout the day. He stated he would love to get one at around 3:30 p.m. The Resident Council meeting held on 09/23/2021 included a report by the council that coffee was not being served or when they received it, it was not hot. Residents also reported at the meeting that there was not enough food being served and the fruit being served was old. The follow up documentation to the 09/27/2021 meeting included the statement, The culinary department will assure that the coffee leaves the kitchen at the right temperature. Coffee is available in the kitchen through out the day. Any resident that desires more food can request more be sent. The Resident Council meeting held on 10/21/2021 included the concern that the food was not bad, it was just in need of flavor. Residents also reported that when they received the food, it was either warm or cold. No follow up documentation to the October meeting was provided. Concerns brought up by Resident Council and not addressed included the coffee availability as several residents reported that they were unaware the coffee was available from 6:00 a.m. to 8:00 p.m. There was no discussion of the request having been granted for the larger print for the posted menu and no discussion of the new menus and when exactly they would begin. In the 09/23/2021 Resident Council meeting minutes, the concern that there was not enough food being served was illustrated at lunch on 11/15/2021. The main meal at lunch was Shepherd's Pie. Observations of the served meal revealed the serving of the Shepherd's Pie was as wide as a sugar packet and just a little longer than the length of a sugar packet. (Sugar packets measure 2 x 1.5 or 3 square inches.) Review of the recipe for the Shepherd's Pie called for an 8 ounce serving using an 8 ounce spoodle to serve. The Dietary Manager (DM), on 11/15/2021 at 1:50 p.m., confirmed that the cook had cut the Shepherd's Pie that had been prepared in a large rectangular pan into squares which should have measured 2 x 4. The DM confirmed that there was nothing left at the end of the meal service of the one pan of the Shepherd's Pie that had been prepared for the residents. The DM confirmed at that time that a resident would have to accept something else if they asked for seconds at lunch. Review of the menu revealed that the recipe should have provided 100 servings. The DM confirmed that some residents received double portion and the Shepherd's Pie would have been used for the pureed diets after pureeing portions of it. The facility policy on Resident Council was reviewed and noted to include the purpose of the resident council. The policy defined the purpose of the resident council as acting as a forum for input into the operation of the facility by residents, families and resident representatives. The policy stated that the Resident Council provided a time for discussion of concerns and a way to provide suggestions for improvement. The Resident Council provided a mechanism for consensus building and communication between residents and facility staff. Also it provided a way to disseminate information and to gather feedback from interested residents.

Based on a review of filed Grievances, the facility's policy on Grievances, and interviews with the Administrator and residents, the facility failed to ensure that grievances were fully resolved for four (Residents #4, #6, #7, #14) of four residents who filed grievances related to the dietary service between July 2021 and October 2021. Findings included: A review of the Grievance Log from July 2021 through October 2021 revealed four filed grievances related to Dietary. On 07/02/2021, Resident #4 reported that he received poor customer service from the kitchen staff regarding coffee and wait time. There was no resolution documented on the report. In an interview with the Administrator on 11/15/2021 beginning at 2:40 p.m., it was reported that the dietary staff received an inservice on customer service as a resolution. The follow up documented on the report indicated the resident did not have any further issues with the dietary staff. In an interview with Resident #4, on 11/15/21 at approximately 2:00 p.m as he was finishing up his chef's salad received from the kitchen, reported that he did not remember any follow up or visit from anyone from dietary. He reported that the food service had not improved. He reported that it was very difficult to know what was on the menu and to get an alternate. During an interview on 11/15/21 beginning at 3:20 p.m. with Resident #4, he stated that he had not been offered coffee during the day. Resident #4 stated that when he first came here in May, they used to get him coffee at 6:30 a.m. and then he asked later on and was told he had to wait until 7:30 a.m. or breakfast. He stated he was told the cafeteria was closed. He stated he was not aware he could get coffee throughout the day. He stated he would love to get a cup at around 3:30 p.m. On 08/09/2021, the husband of Resident # 14 reported that the resident was not receiving food items that were listed on her diet slip. The follow up to the concern was documented as dietary manager spoke with resident's husband to get food preferences and fix the tray ticket. This resolution did not match the grievance. The resident's husband reported that dietary was not following the diet slip and providing his wife with foods listed on the slip. The report did not include any details as to what the resident was not receiving. On 09/09/2021, a grievance was filed by Resident # 6 that indicated the lunches and dinners had not been good for last three days. The resident stated that she had received a hot dog without a bun, polish sausage that was burnt and stale cornbread. The resolution was to review the menu with the resident and document the resident's preferences. There was no indication that the concern for inadequate supplies of hot dog buns or burnt or stale product being served was investigated. An interview with Resident #6 was conducted on 11/15/2021 at approximately 1:10 p.m. The resident confirmed she spoke with the dietary manager and confirmed the dietary manager reviewed her diet preferences with her. But she had not seen an improvement in the food and she continued to have missing food items, like condiments. She reported that she did not bother to call [Dietary] as it did not help. On 10/15/2021, Resident #7's sister filed a grievance indicating the resident wanted to know the daily meal options and alternates. The facility follow up was a discussion with the resident about the meal options. In an interview with Resident #7, on 11/15/2021 beginning at 4:10 p.m., she stated that she only received the daily menu two or three times in the six weeks that she had been in the facility. She said that she solved the problem herself by self propelling in her wheelchair to the dining room where the menu was posted. She concluded that I resolved it by doing it myself. A review of the facility policy, Grievances/Complaints, Recording, and Investigating, included the Policy Statement: All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s).

Based on record review, observations, interviews, and photographic evidence, the facility failed to follow the comprehensive care plan intervention related to transfers as ordered by the physician for one resident (#2) of 5 residents sampled for Activities of Daily Living (ADLs), i.e. transfer services. During an attempt to transfer Resident #2 on 03/05/21 via a Sara 3000 mechanical lift from her bed to her wheelchair, Resident #2's legs gave out; she threw her arms in an upward motion and slid downward in the mechanical lift sling. On 03/07/21, Resident #2 was diagnosed with [REDACTED]. In addition, the facility failed to ensure that therapy assessed recommendations were followed for three residents (#3, #4, #5) of 5 sampled residents related to a mechanical lift. Findings included: 1. A review of Resident #2's care plan, documented focus areas as: Focus Area: The resident has an activity of daily living self-care performance deficit r/t (related to) Impaired balance, limited mobility, weakness, initiated on 02/13/18, and revised on 08/29/20. The goals were: Resident will be free of complications related to ADL deficit through next review date, 05/23/21; and Resident will improve current level of ADL function through the review date, 05/23/21. Current Interventions included: Report changes in ADL self-performance to the nurse. Resident currently requires assistance with ADLs: Bed Mobility: limited to extensive x 1; Transfer: total x 2, Hoyer; Walking: extensive x 1; Locomotion: set up Scooter; Dressing extensive x 1; Eating: set up. Focus Area: The resident is at risk for falls r/t fall history, limited Mobility, Medication use, risk score per fall screen, weakness, initiated 02/13/18 and no revision date listed. The goal was: Resident will not sustain a fall related injury by utilizing fall precautions through the review date, 05/23/21. Current interventions included: Anticipate and meet the resident's needs PRN (as needed). PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN. Review information on past falls and attempt to determine cause of falls. Transfer status changed to Hoyer from Sara lift. Focus Area: (Resident #2) has a potential for or has an alteration in comfort r/t recent fracture of: (R. (right) Shoulder fx(fracture)), initiated 03/10/21. Goal: Resident will exhibit sx/sx (symptoms) that pain is at an acceptable level of comfort thru the next review date, 05/23/21. Resident will voice an acceptable level of comfort thru the next review date, 05/23/21. A review of Resident #2's Admission Record, documented an admission date of [DATE], and a readmission of 06/23/19. [DIAGNOSES REDACTED]. A recent diagnosis, added on 03/08/21 was unspecified nondisplaced fracture of surgical neck of right humerus, initial encounter for closed fracture. A review of physician orders from 01/01/21 thru the date of survey, 03/18/21 showed: Order date: 11/11/20: mechanical lift transfer-Sara Steady for OOB (out of bed) activities. Order date: Active, revision date 03/05/21: mechanical lift transfer-Hoyer for OOB activities. A review of the SBAR (Situation, Background, Appearance and Review and Notify) Communication form, dated 03/05/21, at 12:00 a.m., documented primary care clinician was notified and the recommendation was an X-ray. The form documented the situation as, Trauma (fall related or other), with a start date of 03/05/21. The functional status for Resident #2 was documented as: Needs more assistance with ADLs (activities of daily living). The skin evaluation noted as, Discoloration. The Pain Evaluation showed the pain was new with an intensity level of an 8 on a scale of 1 to 10 and 10 being the worst. A review of the physician order, dated 03/06/21, 21:43 (9:43 p.m.) revealed: Right Shoulder, Humerus and Elbow X-Ray one time only for PAIN until 03/07/2021 23:59 (11:59 p.m.). A review of the Radiology Results Report, dated 03/07/21, revealed the examination was conducted on 3/7/21 at 19:20 (7:20 p.m.) and the Interpretation was noted as: Results: There is an acute [MEDICAL CONDITION] neck. There is no significant displacement. The osseous structures are diffusely demineralized. There is moderate [MEDICAL CONDITION] of the glenohumeral joint and acromioclavicular joint. The Conclusion showed: Acute [MEDICAL CONDITION] neck. Moderate. A review of the progress notes for Resident #2 revealed: 03/05/21, 11:30 a.m., The change in condition reported on this CIC (change in condition) evaluation were: Trauma (fall related or other.) Primary care provider responded with the following feedback: recommendations: x-ray. 03/05/21, 14:24 (2:24 p.m.): fall risk score is <b> 10 or higher </b>; RISK FOR FALLS therapy to eval and tx (treatment), signed by the DON. 03/05/21, 15:08 (3:08 p.m.): IDT (interdisciplinary team) met regarding resident sliding from sit to stand. Therapy referral sent. Sit to stand changed to Hoyer lift at this time. 03/05/21, 15:11 (3:11 p.m.): Pt (patient) was given PRN medication for the pain. No signs of bruising or bumps. Pt was informed that her family member had been called and that she would be receiving a call from her family member shortly. Pt resting in bed with call light in reach. Will continue to observe. 03/06/21, 06:33: c/o (complaint of) pain 5/10 right shoulder. Slight [MEDICAL CONDITION] noted. No bruising. Medicated with PRN [MEDICATION NAME]. Right arm elevated on pillow for comfort. 03/06/21, 21:30 (9:30 p.m.): Resident is alert and oriented. Having trouble sleeping and c/o pain due to arm being pulled in the Sara lift. Dr. (doctor) has ordered a (right) shoulder and arm x-ray. Patient request for tomorrow morning. 03/07/21, 19:50 (7:50 p.m.): xray results received at 19:41 (7:41 p.m.): Acute [MEDICAL CONDITION] neck noted with soft tissue swelling. Call placed to PCP (primary care physician) name of physician answering service at 19:45 (7:45 p.m.), awaiting return call. 03/07/21, 21:08 (9:08 p.m.): Spoke with (family member) regarding resident's change in condition. Floor nurse had notified her of transfer to ER (emergency room ) already 03/08/21, 00:15 (12:15 a.m.): Patient returned from hospital with EMT (emergency technician) on stretcher at about 0015. Vital signs WNL (within normal limits). Patient alert x 3. Skin from head to toe is intact and warm to touch. Patient has a right arm sling to stabilize her humeral neck fracture. Denies pain at this time will continue to monitor. On 03/18/21 at 9:55 a.m., Resident #2 was observed in bed and stated she had fallen and was unable to be mobile for two weeks. She further stated, she had never seen that type of machine before and one leg slid off. She said she pulled the other leg off and fell into the machine because she had no strength in her legs. There was one aide, and then ultimately two aides. The name plate near her room door was observed and it had a blue dot with a H (Hoyer Lift) present. On 03/18/21 at 11:28 a.m., Staff J, Certified Nursing Assistant (CNA) was interviewed about the event with Resident #2. Staff J stated the incident happened on Friday (3/5/21), it was before 12:00 p.m., before lunch. She stated the normal routine for the resident was to get up for a hair appointment, then lay down shortly afterward. Staff J confirmed that she had taken care of Resident #2 before, when she was on North (North Hall). She said, I was coming off of break and the aide (Staff I, CNA) that was working with her was asking for assistance to help get her up, and I was in the process of waiting for monthly weights. The aide that was working with her said she needed help getting her up for her hair appointment. Then, I told her that would be good, because I was in the process of doing monthly weights, and I needed to weigh her. So, the Sara 3000 is the machine that you take the weights on. She said, I brought the machine (Sara 3000) in the room. She confirmed that she had used this machine for Resident #2 before. She stated the Sara 3000 can be used for transfers. She stated, if she was not getting weights that she would use the Sara Stedy lift. The difference between the 3000 and the Stedy is that the 3000 has straps (harness/sling). So, once I got her up, and told her the weight, I was proceeding to put her in her mobile chair. She (Resident #2) said she was getting lightheaded and [MEDICAL CONDITION]. She started to release the grab bars and we moved her back to the bed. Staff J stated that she (Resident #2) started to do this and then demonstrated by putting her arms up in the air. The other aide (Staff I, CNA) said she would lower the bed. We got her back to the bed and eased her back on the bed. I asked the aide (Staff I) to go get the nurse. They came back and that is when, me and the other aide grabbed the back of the resident's pants trying to scoot her back farther, kind of like a cup (grab the pant and underneath the thigh and get her back on the bed), and after we moved her back, she was trying to hold onto the sling (on the lift) and I told her you can let go; and then we put her in the bed. She (Resident #2) was a little shaken and asked the nurse for something to put her to sleep at the time that we had put her in the bed. She told the nurse that her arm hurt. I think that happened with the sling. Therapy assesses the resident and puts it (type of lift) on the door. It is also on the Kardex. Therapy will let me know what kind of machine to weigh the resident with: Hoyer, Sara 3000, or stand on the scale. Sara 3000 is used for weights and transfers. I do not think it states whether 3000 or Stedy for the lift differentiation on the Kardex. On 03/18/21 at 12:00 p.m., Staff J, CNA showed the surveyor the Sara Stedy lift (Photographic Evidence Obtained). A mechanical lift that had plastic pads for the resident's buttocks that once the resident stood in position, the pads were lowered in position under the buttocks of the resident. She explained, that then the lift could be moved to the location to where the resident would be transferred to. Then Staff J showed the surveyor the Sara 3000 lift, (Photographic Evidence Obtained) with a demonstration of use. Where a back pad (sling) was used, legs were strapped in (the calf of the leg); she lifted the resident (imagined sitting position from the bed); the back pad supported, and the machine pulled the body in an upward motion (power lift). Staff J, CNA, stated they had moved the resident towards her chair on the lift, and that is when she had said that she felt faint, and moved her back to the bed. On 03/18/21 at 12:23 p.m., an interview was conducted with the Physical Therapist, (PT). He stated that Resident #2 always used the Sara Stedy for transfers. They use the Sara 3000 for weights. The Sara 3000, will lift, but you have to be able to bear the weight of your legs. The Stedy, the resident does it with assist. That way, it keeps the resident at their optimum strength level. We usually put an order in under mechanical lift. When asked if the Kardex showed whether a Sara Stedy or a Sara 3000 should be used, he stated they had changed it after the incident (3/5/21), we downgraded her to a Hoyer lift, and this should be in the care plan. We took out the Sara Stedy. He said it is up to him to assess her (Resident #2) and get an order for [REDACTED].#2 has high anxiety. I have worked with her a long time. She is one of the few patients that anxiety plays a role. She is a Hoyer lift now. On 03/18/21 at 1:13 p.m., an interview was conducted with the Regional Nurse. He confirmed that he had conducted the investigation for the event (3/5/21) with Resident #2. He reported that the event happened on 03/05/21 at 2:30 p.m., that two aides, Staff J, CNA, and an Agency aide, Staff I (CNA) were involved. The nurse was Staff K, Licensed Practical Nurse (LPN), she was the one that assessed the resident. He stated that an X-ray was ordered on Friday as routine. It was scheduled for Saturday, but the resident declined the X-ray, and so, it was done on Sunday (3/7/21) morning. He confirmed the resident was sent out to the hospital on Sunday, 03/07/21. They obtained the X-ray results and she had an acute fracture of right humeral neck (shoulder); you could see all the osteoarthritic changes on the film too. Also, on Friday (3/5/21), the Unit Manager (Staff L) called the physician and requested the resident be downgraded to the Hoyer lift. He also stated that Resident #2 went to the Emergency Department and then was sent back to them less than 24 hours later with a shoulder sling in place to immobilize and to follow up with ortho (orthopedic doctor) within a few days. He said that the root cause was that (Resident #2) had a decline in function. The resident told me her knees buckled; and that is what caused the change in plane. He stated Yes, when asked if the correct lift was used for the transfer. He explained the door (blue sticker on name plate) will specify the type of lift, Hoyer, Sara Stedy, or a Sara 3000 and this was in place prior to the event. During the interview he stated that Resident #2's blue dot on the door at the time of transfer event indicated a Sara Stedy and confirmed the physician order was for a Sara Stedy at the time of the transfer. When asked if you can you use the Sara 3000 for a transfer, he said, Yes. During this same interview the Regional Nurse stated the color dot placed on the residents' door were all blue and H=Hoyer; SS=Sara Stedy; and SL=Sara lift. He stated that the Sara 3000 is a higher level of assist; that the Sara Stedy is a lower assist. He was sure that the utilization of a Sara 3000 was acceptable. 2. A review of Resident #3's Admission Record, documented an admission date of [DATE]. [DIAGNOSES REDACTED]. A review of Resident #3's active physician orders as of 3/18/21 revealed a physician order, effective date 10/24/20, documented as mechanical lift transfer- Sara Lift for all transfers OOB and wheelchair. A review of Resident #3's active care plan revealed a focus area of: (Resident #3) has an ADL self-care performance deficit r/t ADL needs and participation vary, Alzheimer's Weakness, [MEDICAL CONDITION], initiated 06/08/20, revision on 02/11/21. Interventions included: Transfer: ext (extensive) x 2 Sera steady. On 03/18/21 at 1:57 p.m., in an interview with Staff B, CNA she stated that she had worked at the facility for about 6 months. She confirmed her assignment included Resident #3 and Resident #4. When asked how she would transfer Resident #3, she stated that she would get another aide and stand and pivot the resident. She stated No when asked if she would use a lift. During this interview with Staff B, CNA an observation of Resident #3 revealed that he was in his room, in bed talking, but confused somewhat, and stated that he lost his teeth. A fall mat was observed on the floor on the door side of the bed, and the bed was in a regular position with the bed side table over the bed toward one end. Resident #3 appeared to be attempting to get out of bed. Staff B, CNA went in, and talked to him. A review of the blue sticker on the door of Resident #3's name plate, stated, Sara 3000. A review of the PT (Physical Therapy) Evaluation & Plan of Treatment, dated 03/18/21, signed 4:31 p.m., documented: Current referral: Reason for referral: .Patient was referred to PT for assessment and update of functional mobility status since patient is demonstrating increased motor planning and attempts at self-transferring to and from wheelchair. Resident was last placed on Sara 3000 for OOB transfers. Assessment Summary: Impressions: Clinical impressions: Patient demonstrates an improvement in overall muscle strength, sitting/standing balance control and ability to follow simple 1 step commands. Recommend d/c (discharge) mechanical lift devices to limited assist of 1 person. 3. A review of Resident #4's Admission Record, documented an admission date of [DATE]. [DIAGNOSES REDACTED]. A review of Resident #4's active physician orders, effective date, 10/15/2020, documented: Mechanical lift transfer-Sara lift for OOB activities. A review of Resident #4's care plan revealed a focus area as: The resident has an ADL self-care performance deficit r/t Impaired balance, limited mobility, weakness. Is able to provide personal hygiene independently, will do this at times and put linens on the floor or forget to tell staff that linens need taken to the laundry, staff to continue to assist prn while allowing independence with reminders for proper protocols.(no effective date documented). Interventions included: Transfer: extensive x 2 with the sit to stand. A review of the PT-Therapist Progress & Discharge Summary, dated 10/20/20 revealed the general long term goal as: Goal not met, on 10/20/20, the patient will transfer sit to stand with Sara Steady and min (minimal) assist in order to facilitate transfers from bed<> (to and from) wheelchair. Explanation: Patient to remain on Sara Lift for future transfers OOB. During the interview on 03/18/21 that started at 1:57 p.m., Staff B, CNA stated that for Resident #4 she had not gotten him up yet. She stated that if she needed to know what kind of assistance the resident needed, that she could look at the Kardex. An observation of Resident #4 at this time revealed that he was in bed, eyes closed, and his bed was at a regular height. Staff B, CNA stated that the doors have a blue spot on them which identifies the type of lift. When asked if you could interchange a Sara Stedy and a Sara 3000 she stated, No. She said the Stedy is not remote control and the Sara 3000 is remote control. You have to stick with what is on the door (blue sticker). An observation on 03/18/21 of the blue sticker on the name plate for Resident #4, indicated Sara 3000. 4. A review of Resident #5's Admission Record, documented an original admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. On 03/18/21, an observation of Resident #5's name plate by the door revealed a blue sticker that stated, Sara 3000. A review of Resident #5's active physician orders, effective date 11/04/2020, documented mechanical lift transfer-Sara Lift (3000) for OOB transfers. A review of Resident #5's care plan revealed a focus area as: The resident has an ADL self-care performance deficit r/t Activity intolerance, ADL needs and participation vary, [MEDICAL CONDITION], Impaired balance, limited mobility, limited ROM (range of motion), Weakness, initiated, 04/06/18. Interventions included: Transfer: Extensive x 2, Sara 3000. Report changes in ADL self-performance to the nurse. A review of the PT-Therapist Progress & Discharge summary, dated 11/04/21, revealed the Analysis of Functional outcome/Clinical impression as: .Patient has been successful with SARA Lift device with 2nd person to assist with guiding LEs (lower extremities) closer together as the device raises the patient to partial stance to compensate for significant varus deformities in both knees. Recommend upgrade of transfers from hoyer lift to SARA Lift to facilitate OOB activities and reduce burden of care with support staff . Precautions: Fall risk Other Functional Deficits: Patient has been upgraded from hoyer lift to SARA Lift (3000) status with nursing staff. On 03/18/21 at 2:05 p.m., an interview was conducted with Staff C, CNA. He stated that Resident #5 was total care. He would use a Hoyer lift for the resident. He stated that there are stickers on the door. He confirmed that he has gotten Resident #5 up and stated, yes, he will have showers on the second shift. Whenever you use a lift, it is always a 2-person lift. When asked if the blue sticker indicated use of a Sara 3000, he stated, I do not know what a Sara 3000 is. An observation was conducted of Resident #5 at this time, and he was in bed, with his eyes closed. On 03/18/21 at 2:15 p.m. an additional interview with the Physical Therapist (PT) was conducted. He stated that he had to clarify the lifts. He stated that for the progression of assistance, that it would be the following: 1. Stedy 2. Sara 3000 (more support) 3. Hoyer He also stated that there was a change in the system (one software to another) that they used as of March 1st (2021). He confirmed that he had not been involved in any assessment of the residents for their current required lift status as a result of the event for Resident #2 on 3/5/21. On 03/18/21 at 4:25 p.m., an interview was conducted with Staff D, Registered Nurse (RN), (South hall). He stated that he worked 3:00 p.m. - 11:00 p.m. He confirmed that Resident #4 was in his assignment. He stated that room (**) (Resident #4) was a Sara Lift. He stated that the blue dots that are located next to the name of the resident identify the type of lift. On 03/18/21 at 4:30 p.m., an interview was conducted with Staff E, CNA. She stated that she was an Agency aide, that this was the 2nd time that she had worked at the facility. She was working 3:00 p.m. - 11:00 p.m. She stated that she was responsible for the rooms which included Resident #3 and Resident #4. She stated that she had not received any orientation, but that another aide (Staff C) had told her he would help her if she had any questions. When asked how she would know how to transfer a resident, she stated that she would go get another aide, that she always used two persons to transfer a resident. When Staff E, CNA, was asked what kind of lift she would use to transfer Resident #4, she stated that the transfer lift that had a belt on it, but, then she pointed to the Sara Stedy that was in the hall, (the one with the buttocks pad). She stated that she did not know the name of the lift. She stated that she would always get two people to transfer. She said she had never seen that kind of lift before. She stated that it was the first time she had seen a lift like that, and that she would have to have someone show her how to use it. On 03/18/21 at 4:39 p.m. an interview was conducted with Staff F, LPN. (North Hall). She stated that she was working 3:00 p.m. - 11:00 p.m. When asked how she would assist a CNA who had a question about how to transfer a resident, she stated that she would look in the system, show the CNA the Kardex information, that the system would indicate whether the transfer was with a Hoyer, a Sara 3000, or a Sara lift. When asked if the Sara 3000 and the Sara lift were interchangeable, she stated that she didn't believe so. For one of them, the resident has to stand on their own to put the butt rest under them. The other uses a pad to lift the resident. She stated, I think that the Sara 3000 uses the pad. On 03/18/21 at 4:50 p.m., a review of Resident #4's physician order with the Physical Therapist confirmed the physician order, start date of 10/15/20, was Mechanical lift transfer-Sara Lift for OOB (out of bed) activities. He stated that Sara Lift means the same thing as Sara 3000. During this interview he confirmed that he provided training to the staff about the lifts, but had no documentation. He stated there is an orientation that is given to the CNAs, nurses, and anyone that is a new CNA. The therapy department provides education about the lift devices and clarifies the name. On 03/18/21 at 4:56 p.m., an interview with Staff G, RN, Unit Manager, (UM) was conducted. She stated that she had been doing care plan meetings for the past week. She stated we do not have an MDS (Minimum Data Set) coordinator at this time, we are in the process of transition. On 03/18/21 at 4:59 p.m., during an interview with the PT and review of the care plan for Resident #4 which documented in the Focus Area for ADL (Activity of Daily Living), and with an intervention of: Transfer, extensive x 2 with the sit to stand, the PT stated he had no control over what the care plan stated. In addition during this continued interview with the PT, a review of Resident #5's PT-Therapist Progress & Discharge Summary, dated 11/04/20, documented: Other functional deficits: Patient has been upgraded from Hoyer lift to Sara Lift (3000) status with nursing staff. The PT stated that no staff have reported any change in condition for Resident #5. He confirmed that if staff utilized a Hoyer lift, that he would expect to be notified. He stated, yes or nursing will send a referral and of course, if there is a change in what is indicated on the blue dot. At this time, the care plan was reviewed for Resident #5, which reflected Sara 3000. On 03/18/21 at 5:13 p.m., Staff G, RN UM, confirmed the care plan for Resident #3 was Sara Steady, as of 02/11/21. On 03/18/21 at 5:13 p.m., the PT stated for Resident #3, that his recommendation of discontinuation of the mechanical lift had just been submitted as of this date (03/18/21). He stated that he had just gone into the computer and put the order in for the change. He stated that he would fill out a communication form to let MDS know that there had been a change. On 03/18/21 at 5:15 p.m., The PT stated that he had not done a whole house assessment. He stated that we print out a list weekly of the residents that use a mechanical lift. Staff H, a Rehab Technician, makes sure that everything matches. She makes sure that the blue dot system matches the order. She does not check anything else. On 03/18/21 at 5:35 p.m., an interview was conducted with the Regional Nurse, he stated that the event involving Resident #2 was unsubstantiated. He stated that the facility only has two kinds of lifts, not three kinds. During an interview on 03/19/21 at 11:49 a.m. with the Staff Educator, she stated that she initiated additional training and was approximately 80% done with the training of the staff. She reported that the staff that she educated were educated on the different kinds of machines; return demonstration; how to look at the dot system; how to review for information in the Kardex. She stated that for the CNAs, they are to use the machine that is listed. If they feel that the resident is too weak, they should communicate with therapy. If therapy is unavailable, then they communicate with the nursing staff and it is a nursing judgement call. She stated that CNAs are not to decide which machine to use. She stated that she has a roster, that she put the training on the form that she did on 03/08/21; and then she put the training on that she completed today, 03/19/21. A review of the facility policy titled, Standard and Guidelines: SG Comprehensive Assessments and Care Plans, revised on 10/18/19, revealed: Guidelines: 1. The facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set for at 483.10©(2) and 483.10(c (3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . 10. The plan of care reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Review of the Compliance Training attendance log dated 03/18/21 and 03/19/21, revealed a policy that showed: Standards and Guidelines: SG Mechanical Lifts, policy number 12.07.20.017, last revised 11/01/16: Standard: it is the standard of this facility to provide a safer environment for our residents and staff, this facility has adopted a safe lifting patient transfer philosophy. The Nursing and Therapy departments will coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning. Staff responsible for the transferring/repositioning residents will receive instruction on the safe operation of mechanical lifts. Guidelines: 1. Nursing and/or Therapy managers will coordinate the screening of the resident population to identify the residents appropriate for mechanical lift transfer. 2. The Nursing department/designee will maintain a list identifying all residents who need to be transferred using mechanical lifts. 3. Identification of residents requiring assistance with mechanical lifts should be present in the facility (i.e. blue dot sticker on resident's name plate by door denoting T for total or Hoyer transfers or S/S for sit to stand transfers, denotation on the resident's Kardex, etc.). 4. The use of the mechanical lift should be included in the resident's plan of care. 5. When using the mechanical lift, 2 staff members should assist with the procedure to ensure resident and staff safety. 6. Appropriate slings should be utilized per manufacturer's policy with mechanical lifts and should be cleaned as required to maintain infection control techniques. 7. Residents requiring isolation should no share slings or lifts without proper cleaning prior to use on another resident. 8. The Clinical Educator/DNS or therapy will be responsible for training of current staff members and the policy of avoiding manual lifting of the designated residents. Training will be conducted upon hire with re-instruction as needed. 9. The Director of Nursing will designate the individual (s) responsible for maintaining the list of residents designated to be transferred by the use of mechanical lift, unless maintained in the electronic health record, in which case a listing can be generated through that system. The information will also be on the resident's plan of care. 10. Nursing supervisors will monitor the appropriate use of the mechanical lifts by staff and provide instruction as deemed necessary. 11. The interdisciplinary team (IDT) or specified members of the IDT should meet to eliminate any fears or concerns expressed by residents or responsible party/resident representatives refusing the use of the mechanical lift for transfers) as is needed. 12. In the event of an extreme emergency situation, it may be deemed appropriate for staff to transfer the resident without the use of the mechanical lift. At that time, supervisor will determine safest mode of transfer and appropriate number of staff needed to perform safe transfer of resident. On 03/19/21 the ADON provided instructions for the use for the three types of lifts used: Instructions for use Sara Stedy Sara Stedy Compact with a photo and How to use the Sara Stedy, (2 pages). The form, Figure 12, documented the following: Transferring the Patient from a wheelchair: Make sure to apply the wheelchair brakes. Help or encourage the patient to achieve the standing position. The patient's knees should stay in contact with the kneepad, and the patient should sit back on the seat halves during the transfer. 1.) Have the patient hold the crossbar and use it to stand up. 2.) Pivot the two set halves down. 3. Ask the patent to sit. 4. Release the brakes and proceed with the transfer (the picture showed the patient holding onto the bars in front, knees bent slightly, the patient's buttocks supported by the seat halves while the patient stood on the Sara Stedy. Instructions for use, Sara 3000: The form, (3 p (TRUNCATED)

Based on record review, observations, interviews, and photographic evidence, the facility failed to ensure adequate supervision and use of appropriate transfer equipment to safely transfer one resident (#2) of 5 residents sampled for Activities of Daily Living (ADLs), i.e. transfer services. During an attempt to transfer Resident #2 on 03/05/21 via a Sara 3000 mechanical lift rather than the lift the resident was care planned for Resident #2 became weak, slid downward in the mechanical lift sling was positioned around her back. On 03/07/21, Resident #2 was diagnosed with [REDACTED]. In addition, the facility failed to ensure that therapy recommendations were followed for three residents (#3, #4, #5) of 5 sampled residents related to a mechanical lift. Findings included: 1. On 03/18/21 at 9:55 a.m., Resident #2 was observed in bed and stated she had fallen and was unable to be mobile for two weeks. She further stated, she had never seen that type of machine before and one leg slid off. She said she pulled the other leg off and fell into the machine because she had no strength in her legs. There was one aide, and then ultimately two aides. The name plate near her room door was observed with a blue dot with a H (Hoyer Lift) present. On 03/18/21 at 11:28 a.m., Staff J, Certified Nursing Assistant (CNA) was interviewed about the event with Resident #2. Staff J stated the incident happened on Friday (3/5/21), it was before 12:00 p.m., before lunch. She stated the normal routine for the resident was to get up for a hair appointment, then lay down shortly afterward. Staff J confirmed that she had taken care of Resident #2 before, when she was on North (North Hall). She said, I was coming off of break and the aide (Staff I, CNA) that was working with her was asking for assistance to help get her up, and I was in the process of waiting for monthly weights. The aide that was working with her said she needed help getting her up for her hair appointment. Then, I told her that would be good, because I was in the process of doing monthly weights, and I needed to weigh her. So, the Sara 3000 is the machine that you take the weights on. She said, I brought the machine (Sara 3000) in the room. She confirmed that she had used this machine for Resident #2 before. She stated the Sara 3000 can be used for transfers. She stated, if she was not getting weights that she would use the Sara Stedy lift. The difference between the 3000 and the Stedy is that the 3000 has straps (harness/sling). So, once I got her up, and told her the weight, I was proceeding to put her in her mobile chair. She (Resident #2) said she was getting lightheaded and [MEDICAL CONDITION]. She started to release the grab bars and we moved her back to the bed. Staff J stated that she (Resident #2) started to do this and then demonstrated by putting her arms up in the air. The other aide (Staff I, CNA) said she would lower the bed. We got her back to the bed and eased her back on the bed. I asked the aide (Staff I) to go get the nurse. They came back and that is when, me and the other aide grabbed the back of the resident's pants trying to scoot her back farther, kind of like a cup (grab the pant and underneath the thigh and get her back on the bed), and after we moved her back, she was trying to hold onto the sling (on the lift) and I told her you can let go; and then we put her in the bed. She (Resident #2) was a little shaken and asked the nurse for something to put her to sleep at the time that we had put her in the bed. She told the nurse that her arm hurt. I think that happened with the sling. Therapy assesses the resident and puts it (type of lift) on the door. It is also on the Kardex. Therapy will let me know what kind of machine to weigh the resident with: Hoyer, Sara 3000, or stand on the scale. Sara 3000 is used for weights and transfers. I do not think it states whether 3000 or Stedy for the lift differentiation on the Kardex. On 03/18/21 at 12:00 p.m., Staff J, CNA showed the surveyor the Sara Stedy lift (Photographic Evidence Obtained). A mechanical lift that had plastic pads for the resident's buttocks that once the resident stood in position, the pads were lowered in position under the buttocks of the resident. She explained, that then the lift could be moved to the location where the resident would be transferred to. Then Staff J showed the surveyor the Sara 3000 lift, (Photographic Evidence Obtained) with a demonstration of use. A back pad (sling) was used, the legs were strapped in (the calf of the leg); she lifted the resident (imagined sitting position from the bed); the back pad supported, and the machine pulled the body in an upward motion (power lift). Staff J, CNA, stated they had moved the resident towards her chair on the lift, and that is when she had said that she felt faint, and moved her back to the bed. On 03/18/21 at 12:23 p.m., an interview was conducted with the Physical Therapist, (PT). He stated that Resident #2 always used the Sara Stedy for transfers. They use the Sara 3000 for weights. The Sara 3000, will lift, but you have to be able to bear the weight of your legs. The Stedy, the resident does it with assist. That way, it keeps the resident at their optimum strength level. We usually put an order in under mechanical lift. When asked if the Kardex showed whether a Sara Stedy or a Sara 3000 should be used, he stated they had changed it after the incident (3/5/21), we downgraded her to a Hoyer lift, and this should be in the care plan. We took out the Sara Stedy for her. He said it is up to him to assess her (Resident #2) and get an order for [REDACTED]. She is one of the few patients that anxiety plays a role. She requires a Hoyer lift now. On 03/18/21 at 1:13 p.m., an interview was conducted with the Regional Nurse. He confirmed that he had conducted the investigation for the event (3/5/21) with Resident #2. He reported that the event happened on 03/05/21 at 2:30 p.m., that two aides, Staff J, CNA, and an Agency aide, Staff I (CNA) were involved. The nurse was Staff K, Licensed Practical Nurse (LPN), she was the one that assessed the resident. He stated that an X-ray was ordered on Friday as routine. It was scheduled for Saturday, but the resident declined the X-ray, and so, it was done on Sunday (3/7/21) morning. He confirmed the resident was sent out to the hospital on Sunday, 03/07/21. They obtained the X-ray results and she had an acute fracture of right humeral neck (shoulder); you could see all the osteoarthritic changes on the film too. Also, on Friday (3/5/21), the Unit Manager (Staff L) called the physician and requested the resident be downgraded to the Hoyer lift. He also stated that Resident #2 went to the Emergency Department and then was sent back to them less than 24 hours later with a shoulder sling in place to immobilize and to follow up with ortho (orthopedic doctor) within a few days. He said that the root cause was that (Resident #2) had a decline in function. The resident told me her knees buckled; and that is what caused the change in plane. He stated Yes, when asked if the correct lift was used for the transfer. He explained the door (blue sticker on name plate) will specify the type of lift, Hoyer, Sara Stedy, or a Sara 3000 and this was in place prior to the event. During the interview he stated that Resident #2's blue dot on the door at the time of transfer event indicated a Sara Stedy and confirmed the physician order [REDACTED]. When asked if you can you use the Sara 3000 for a transfer, he said, Yes. During this same interview the Regional Nurse stated the color dot placed on the residents' doors were all blue with marking of: H=Hoyer; SS=Sara Stedy; or SL=Sara lift. He stated that the Sara 3000 is a higher level of assist; that the Sara Stedy is a lower assist. He was sure that the utilization of a Sara 3000 was acceptable. A review of Resident #2's care plan, revealed focus areas that included: Focus Area: The resident has an ADL (activity of daily living) self-care performance deficit r/t (related to) Impaired balance, limited mobility, weakness, initiated on 02/13/18, and revised on 08/29/20. The goals were: Resident will be free of complications related to ADL deficit through next review date, 05/23/21; and Resident will improve current level of ADL function through the review date, 05/23/21. Current Interventions included: Report changes in ADL self-performance to the nurse. Resident currently requires assistance with ADLs: Bed Mobility: limited to extensive x 1; Transfer: total x 2, Hoyer; Walking: extensive x 1; Locomotion: set up Scooter; Dressing extensive x 1; Eating: set up. Focus Area: The resident is at risk for falls r/t fall history, limited Mobility, Medication use, risk score per fall screen, weakness, initiated 02/13/18 and no revision date listed. The goal was: Resident will not sustain a fall related injury by utilizing fall precautions through the review date, 05/23/21. Current interventions included: Anticipate and meet the resident's needs PRN (as needed). PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN. Review information on past falls and attempt to determine cause of falls. Transfer status changed to Hoyer from Sara lift. Focus Area: (Resident #2) has a potential for or has an alteration in comfort r/t recent fracture of: (R. (right) Shoulder fx(fracture)), initiated 03/10/21. Goal: Resident will exhibit sx/sx (symptoms) that pain is at an acceptable level of comfort thru the next review date, 05/23/21. Resident will voice an acceptable level of comfort thru the next review date, 05/23/21. A review of Resident #2's Admission Record, documented an admission date of [DATE], and a readmission of 06/23/19. [DIAGNOSES REDACTED]. A recent diagnosis, added on 03/08/21 was unspecified nondisplaced fracture of surgical neck of right humerus, initial encounter for closed fracture. A review of physician orders [REDACTED]. Order date: 11/11/20: mechanical lift transfer-Sara Steady for OOB (out of bed) activities. Order date: Active, revision date 03/05/21: mechanical lift transfer-Hoyer for OOB activities. A review of the SBAR (Situation, Background, Appearance and Review and Notify) Communication form, dated 03/05/21, at 12:00 a.m., documented primary care clinician was notified and the recommendation was an X-ray. The form documented the situation as, Trauma (fall related or other), with a start date of 03/05/21. The functional status for Resident #2 was documented as: Needs more assistance with ADLs (activities of daily living). The skin evaluation noted as, Discoloration. The Pain Evaluation showed the pain was new with an intensity level of an 8 on a scale of 1 to 10 and 10 being the worst. A review of the physician order, dated 03/06/21, 21:43 (9:43 p.m.) revealed: Right Shoulder, Humerus and Elbow X-Ray one time only for PAIN until 03/07/2021 23:59 (11:59 p.m.). A review of the Radiology Results Report, dated 03/07/21, revealed the examination was conducted on 3/7/21 at 19:20 (7:20 p.m.) and the Interpretation was noted as: Results: There is an acute [MEDICAL CONDITION] neck. There is no significant displacement. The osseous structures are diffusely demineralized. There is moderate [MEDICAL CONDITION] of the glenohumeral joint and acromioclavicular joint. The Conclusion showed: Acute [MEDICAL CONDITION] neck. Moderate. A review of the progress notes for Resident #2 revealed: 03/05/21, 11:30 a.m., The change in condition reported on this CIC (change in condition) evaluation were: Trauma (fall related or other.) Primary care provider responded with the following feedback: recommendations: x-ray. 03/05/21, 14:24 (2:24 p.m.): fall risk score is <b> 10 or higher </b>; RISK FOR FALLS therapy to eval and tx (treatment), signed by the DON. 03/05/21, 15:08 (3:08 p.m.): IDT (interdisciplinary team) met regarding resident sliding from sit to stand. Therapy referral sent. Sit to stand changed to Hoyer lift at this time. 03/05/21, 15:11 (3:11 p.m.): Pt (patient) was given PRN medication for the pain. No signs of bruising or bumps. Pt was informed that her family member had been called and that she would be receiving a call from her family member shortly. Pt resting in bed with call light in reach. Will continue to observe. 03/06/21, 06:33: c/o (complaint of) pain 5/10 right shoulder. Slight [MEDICAL CONDITION] noted. No bruising. Medicated with PRN [MEDICATION NAME]. Right arm elevated on pillow for comfort. 03/06/21, 21:30 (9:30 p.m.): Resident is alert and oriented. Having trouble sleeping and c/o pain due to arm being pulled in the Sara lift. Dr. (doctor) has ordered a (right) shoulder and arm x-ray. Patient request for tomorrow morning. 03/07/21, 19:50 (7:50 p.m.): xray results received at 19:41 (7:41 p.m.): Acute [MEDICAL CONDITION] neck noted with soft tissue swelling. Call placed to PCP (primary care physician) name of physician answering service at 19:45 (7:45 p.m.), awaiting return call. 03/07/21, 21:08 (9:08 p.m.): Spoke with (family member) regarding resident's change in condition. Floor nurse had notified her of transfer to ER (emergency room ) already 03/08/21, 00:15 (12:15 a.m.): Patient returned from hospital with EMT (emergency technician) on stretcher at about 0015. Vital signs WNL (within normal limits). Patient alert x 3. Skin from head to toe is intact and warm to touch. Patient has a right arm sling to stabilize her humeral neck fracture. Denies pain at this time will continue to monitor. 2. A review of Resident #3's Admission Record, documented an admission date of [DATE]. [DIAGNOSES REDACTED]. A review of Resident #3's active physician orders [REDACTED]. A review of Resident #3's active care plan revealed a focus area of: (Resident #3) has an ADL self-care performance deficit r/t ADL needs and participation vary, Alzheimer's Weakness, [MEDICAL CONDITION], initiated 06/08/20, revision on 02/11/21. Interventions included: Transfer: ext (extensive) x 2 Sera steady. On 03/18/21 at 1:57 p.m., in an interview with Staff B, CNA she stated that she had worked at the facility for about 6 months. She confirmed her assignment included Resident #3 and Resident #4. When asked how she would transfer Resident #3, she stated that she would get another aide and stand and pivot the resident. She stated No when asked if she would use a lift. During this interview with Staff B, CNA an observation of Resident #3 revealed that he was in his room, in bed talking, and stated that he lost his teeth. A fall mat was observed on the floor on the door side of the bed, and the bed was in a regular position with the bed side table over the bed toward one end. Resident #3 appeared to be attempting to get out of bed. Staff B, CNA went in, and talked to him. A review of the blue sticker on the door of Resident #3's name plate, showed, Sara 3000. A review of the PT (Physical Therapy) Evaluation & Plan of Treatment, dated 03/18/21, signed 4:31 p.m., documented: Current referral: Reason for referral: .Patient was referred to PT for assessment and update of functional mobility status since patient is demonstrating increased motor planning and attempts at self-transferring to and from wheelchair. Resident was last placed on Sara 3000 for OOB transfers. Assessment Summary: Impressions: Clinical impressions: Patient demonstrates an improvement in overall muscle strength, sitting/standing balance control and ability to follow simple 1 step commands. Recommend d/c (discharge) mechanical lift devices to limited assist of 1 person. On 03/18/21 at 5:13 p.m., Staff G, RN UM, confirmed the care plan for Resident #3 showed Sara Steady, as of 02/11/21. On 03/18/21 at 5:13 p.m., the PT stated for Resident #3, that his recommendation of discontinuation of the mechanical lift had just been submitted as of this date (03/18/21). He stated that he had just gone into the computer and put the order in for the change. He stated that he would fill out a communication form to let MDS know that there had been a change. 3. A review of Resident #4's Admission Record, documented an admission date of [DATE]. [DIAGNOSES REDACTED]. A review of Resident #4's active physician orders, effective date, 10/15/2020, documented: Mechanical lift transfer-Sara lift for OOB activities. A review of Resident #4's care plan revealed a focus area as: The resident has an ADL self-care performance deficit r/t Impaired balance, limited mobility, weakness. Is able to provide personal hygiene independently, will do this at times and put linens on the floor or forget to tell staff that linens need taken to the laundry, staff to continue to assist prn while allowing independence with reminders for proper protocols.(no effective date documented). Interventions included: Transfer: extensive x 2 with the sit to stand. A review of the PT-Therapist Progress & Discharge Summary, dated 10/20/20 revealed the general long term goal as: Goal not met, on 10/20/20, the patient will transfer sit to stand with Sara Steady and min (minimal) assist in order to facilitate transfers from bed<> (to and from) wheelchair. Explanation: Patient to remain on Sara Lift for future transfers OOB. During the interview on 03/18/21 that started at 1:57 p.m., Staff B, CNA stated that for Resident #4 she had not gotten him up yet. She stated that if she needed to know what kind of assistance the resident needed, that she could look at the Kardex. An observation of Resident #4 at this time revealed that he was in bed, eyes closed, and his bed was at a regular height. Staff B, CNA stated that the doors have a blue spot on them which identifies the type of lift. When asked if you could interchange a Sara Stedy and a Sara 3000 she stated, No. She said the Stedy is not remote control and the Sara 3000 is remote control. You have to stick with what is on the door (blue sticker). An observation on 03/18/21 of the blue sticker on the name plate for Resident #4, indicated Sara 3000. On 03/18/21 at 4:50 p.m., a review of Resident #4's physician order [REDACTED]. He stated that Sara Lift means the same thing as Sara 3000. During this interview he confirmed that he provided training to the staff about the lifts, but had no documentation. He stated there is an orientation that is given to the CNAs, nurses, and anyone that is a new CNA. The therapy department provides education about the lift devices and clarifies the name. On 03/18/21 at 4:59 p.m., during an interview with the PT and review of the care plan for Resident #4 which documented in the Focus Area for ADL (Activity of Daily Living), and with an intervention of: Transfer, extensive x 2 with the sit to stand, the PT stated he had no control over what the care plan stated. 4. A review of Resident #5's Admission Record, documented an original admission date of [DATE] and a readmission date of [DATE]. [DIAGNOSES REDACTED]. On 03/18/21, an observation of Resident #5's name plate by the door revealed a blue sticker that showed, Sara 3000. A review of Resident #5's active physician orders, effective date 11/04/2020, documented mechanical lift transfer-Sara Lift (3000) for OOB transfers. A review of Resident #5's care plan revealed a focus area as: The resident has an ADL self-care performance deficit r/t Activity intolerance, ADL needs and participation vary, [MEDICAL CONDITION], Impaired balance, limited mobility, limited ROM (range of motion), Weakness, initiated, 04/06/18. Interventions included: Transfer: Extensive x 2, Sara 3000. Report changes in ADL self-performance to the nurse. A review of the PT-Therapist Progress & Discharge summary, dated 11/04/21, revealed the Analysis of Functional outcome/Clinical impression as: .Patient has been successful with SARA Lift device with 2nd person to assist with guiding LEs (lower extremities) closer together as the device raises the patient to partial stance to compensate for significant varus deformities in both knees. Recommend upgrade of transfers from hoyer lift to SARA Lift to facilitate OOB activities and reduce burden of care with support staff . Precautions: Fall risk Other Functional Deficits: Patient has been upgraded from hoyer lift to SARA Lift (3000) status with nursing staff. On 03/18/21 at 2:05 p.m., an interview was conducted with Staff C, CNA. He stated that Resident #5 was total care. He would use a Hoyer lift for the resident. He stated that there are stickers on the door. He confirmed that he has gotten Resident #5 up and stated, yes, he will have showers on the second shift. Whenever you use a lift, it is always a 2-person lift. When asked if the blue sticker indicated use of a Sara 3000, he stated, I do not know what a Sara 3000 is. An observation was conducted of Resident #5 at this time, and he was in bed, with his eyes closed. In addition during this continued interview with the PT, a review of Resident #5's PT-Therapist Progress & Discharge Summary, dated 11/04/20, documented: Other functional deficits: Patient has been upgraded from Hoyer lift to Sara Lift (3000) status with nursing staff. The PT stated that no staff have reported any change in condition for Resident #5. He confirmed that if staff utilized a Hoyer lift, that he would expect to be notified. He stated, yes or nursing will send a referral and of course, if there is a change in what is indicated on the blue dot. At this time, the care plan was reviewed for Resident #5, which reflected Sara 3000. 5. On 03/18/21 at 2:15 p.m. an interview with the Physical Therapist (PT) was conducted. He stated that he had to clarify the lifts. He stated that for the progression of assistance, that it would be the following: 1. Stedy 2. Sara 3000 (more support) 3. Hoyer He also stated that there was a change in the computer system (one software to another) that they used as of March 1st (2021). He confirmed that he had not been involved in any assessment of the residents for their current required lift status after the event with Resident #2 on 3/5/21. On 03/18/21 at 4:25 p.m., an interview was conducted with Staff D, Registered Nurse (RN), (South hall). He stated that he worked 3:00 p.m. - 11:00 p.m. He confirmed that Resident #4 was in his assignment. He stated that room (**) (Resident #4) was a Sara Lift. He stated that the blue dots that are located next to the name of the resident identify the type of lift. On 03/18/21 at 4:30 p.m., an interview was conducted with Staff E, CNA. She stated that she was an Agency aide, that this was the 2nd time that she had worked at the facility. She was working 3:00 p.m. - 11:00 p.m. She stated that she was responsible for the rooms which included Resident #3 and Resident #4. She stated that she had not received any orientation, but that another aide (Staff C) had told her he would help her if she had any questions. When asked how she would know how to transfer a resident, she stated that she would go get another aide, that she always used two persons to transfer a resident. When Staff E, CNA, was asked what kind of lift she would use to transfer Resident #4, she stated that the transfer lift that had a belt on it, but, then she pointed to the Sara Stedy that was in the hall, (the one with the buttocks pad). She stated that she did not know the name of the lift. She stated that she would always get two people to transfer. She said she had never seen that kind of lift before. She stated that it was the first time she had seen a lift like that, and that she would have to have someone show her how to use it. On 03/18/21 at 4:39 p.m. an interview was conducted with Staff F, LPN. (North Hall). She stated that she was working 3:00 p.m. - 11:00 p.m. When asked how she would assist a CNA who had a question about how to transfer a resident, she stated that she would look in the system, show the CNA the Kardex information, that the system would indicate whether the transfer was with a Hoyer, a Sara 3000, or a Sara lift. When asked if the Sara 3000 and the Sara lift were interchangeable, she stated that she didn't believe so. For one of them, the resident has to stand on their own to put the butt rest under them. The other uses a pad to lift the resident. She stated, I think that the Sara 3000 uses the pad. On 03/18/21 at 5:15 p.m., The PT stated that he had not done a whole house assessment. He stated that we print out a list weekly of the residents that use a mechanical lift. Staff H, a Rehab Technician, makes sure that everything matches. She makes sure that the blue dot system matches the order. She does not check anything else. On 03/18/21 at 5:35 p.m., an interview was conducted with the Regional Nurse, he stated that the event involving Resident #2 was unsubstantiated. He stated that the facility only has two kinds of lifts, not three kinds. During an interview on 03/19/21 at 11:49 a.m. with the Staff Educator, she stated that she initiated additional training and was approximately 80% done with the training of the staff. She reported that the staff that she educated were educated on the different kinds of machines; return demonstration; how to look at the dot system; how to review for information in the Kardex. She stated that for the CNAs, they are to use the machine that is listed. If they feel that the resident is too weak, they should communicate with therapy. If therapy is unavailable, then they communicate with the nursing staff and it is a nursing judgement call. She stated that CNAs are not to decide which machine to use. She stated that she has a roster, that she put the training on the form that she did on 03/08/21; and then she put the training on that she completed today, 03/19/21. Review of the Compliance Training attendance log dated 03/18/21 and 03/19/21, revealed a policy that showed: Standards and Guidelines: SG Mechanical Lifts, policy number 12.07.20.017, last revised 11/01/16: Standard: it is the standard of this facility to provide a safer environment for our residents and staff, this facility has adopted a safe lifting patient transfer philosophy. The Nursing and Therapy departments will coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning. Staff responsible for the transferring/repositioning residents will receive instruction on the safe operation of mechanical lifts. Guidelines: 1. Nursing and/or Therapy managers will coordinate the screening of the resident population to identify the residents appropriate for mechanical lift transfer. 2. The Nursing department/designee will maintain a list identifying all residents who need to be transferred using mechanical lifts. 3. Identification of residents requiring assistance with mechanical lifts should be present in the facility (i.e. blue dot sticker on resident's name plate by door denoting T for total or Hoyer transfers or S/S for sit to stand transfers, denotation on the resident's Kardex, etc.). 4. The use of the mechanical lift should be included in the resident's plan of care. 5. When using the mechanical lift, 2 staff members should assist with the procedure to ensure resident and staff safety. 6. Appropriate slings should be utilized per manufacturer's policy with mechanical lifts and should be cleaned as required to maintain infection control techniques. 7. Residents requiring isolation should no share slings or lifts without proper cleaning prior to use on another resident. 8. The Clinical Educator/DNS or therapy will be responsible for training of current staff members and the policy of avoiding manual lifting of the designated residents. Training will be conducted upon hire with re-instruction as needed. 9. The Director of Nursing will designate the individual (s) responsible for maintaining the list of residents designated to be transferred by the use of mechanical lift, unless maintained in the electronic health record, in which case a listing can be generated through that system. The information will also be on the resident's plan of care. 10. Nursing supervisors will monitor the appropriate use of the mechanical lifts by staff and provide instruction as deemed necessary. 11. The interdisciplinary team (IDT) or specified members of the IDT should meet to eliminate any fears or concerns expressed by residents or responsible party/resident representatives refusing the use of the mechanical lift for transfers) as is needed. 12. In the event of an extreme emergency situation, it may be deemed appropriate for staff to transfer the resident without the use of the mechanical lift. At that time, supervisor will determine safest mode of transfer and appropriate number of staff needed to perform safe transfer of resident. On 03/19/21 the ADON provided instructions for the use for the three types of lifts used: Instructions for use Sara Stedy Sara Stedy Compact with a photo and How to use the Sara Stedy, (2 pages). The form, Figure 12, documented the following: Transferring the Patient from a wheelchair: Make sure to apply the wheelchair brakes. Help or encourage the patient to achieve the standing position. The patient's knees should stay in contact with the kneepad, and the patient should sit back on the seat halves during the transfer. 1.) Have the patient hold the crossbar and use it to stand up. 2.) Pivot the two set halves down. 3. Ask the patent to sit. 4. Release the brakes and proceed with the transfer (the picture showed the patient holding onto the bars in front, knees bent slightly, the patient's buttocks supported by the seat halves on the Sara Stedy. Instructions for use, Sara 3000: The form, (3 pages) page 10, documented the following: Using your Sara 3000, standing sling. Caution: An assessment must be made as to whether the patient requires the lower leg straps. Apply these if necessary. Use if necessary. Encourage the patient to lean forward slightly to enable the sling to be placed around his/her lower back. Position the sling around the patient's back so that the bottom of the sling lies horizontally about two inches above the patient's waistline, with the patient's arms outside of the sling. Ensure that the support strap is separated and brought loosely around the body and is not twisted or trapped behind the patient's back. To fasten the support strap securely, press the buckles together. The strap should be tight, but comfortable for the patient. Apply the clips to the attachment points and secure them for safety. Note: The patient should be supported by the sling, but not pulled forward too much. If possible, the patient should then hold on to the Patient Support grips with one or both hands. The patient is then ready to be lifted If the patient is able to offer some assistance to stand, this may be benefic (TRUNCATED)

Based on interviews with facility staff and review of medical records and policies, it was determined the facility failed to provide the level of oversight and supervision needed to ensure one (#1), of a total of 16 residents on modified diets, received and consumed the prescribed modified diet. At approximately 11:00 p.m., just prior to shift change, Resident #1 was provided a peanut butter and jelly sandwich by a Registered Nurse that was unaware of a diet order change in the previous 24 hours to pureed. While eating a bedtime snack, Resident #1 began choking, but was able to report that he was choking on a sandwich, which was a food item not consistent with his Physician-ordered Pureed diet. Emergency Medical Services (EMS) arrived and were able to intubate the resident to provide an oxygen source once they dislodged the material blocking his throat which facility staff said appeared to be ham. The resident's Certified Nursing Assistant (C.N.A.) confirmed he served the resident's roommate half of a ham sandwich at about 8:30 p.m. when he served Resident #1 a pudding cup. The C.N.A. reported he discarded the empty pudding cup and saw the ham sandwich still on the bedside table next to the roommate. The resident's nurse, unaware that the resident had a downgrade in diet texture (from mechanical soft to pureed), served Resident #1 a peanut butter and jelly sandwich. Resident #1 was ultimately not able to be revived and was admitted to the ICU and died 13 days later. Findings included: 1. Resident #1 had [DIAGNOSES REDACTED]. and depression. He had had a stroke and dysphagia which led to the use of a feeding tube beginning in [DATE]. According to the American Stroke Association (a division of the American Heart Association), a stroke, or Cerebral Hemorrhage, may cause a swallowing disorder called Dysphagia. If the dysphagia is not treated it can lead to poor nutrition, weight loss, choking and pneumonia. Aspiration is a common problem for people with dysphagia. It occurs when something swallowed enters the airway and lungs. Normally, aspiration causes a violent cough, but a stroke can reduce the sensation to cough which is referred to as silent aspiration. For some patients the only solution is a feeding tube. For others, the diet can be modified to allow for eating by mouth. The food items can be chopped into smaller pieces or pureed for easier eating. Sometimes beverages need to be thickened so the resident can swallow the beverage safely and ensure it doesn't flow into the lungs. https://www.stroke.org/en/about-stroke/effects-of-stroke/cognitive-and-communication-effects-of-stroke/difficulty-swallowing-after-stroke--dysphagia 2. On [DATE], according to a progress note located in the resident's medical record, around 2310 (11:10 p.m.) an aide heard the resident choke and called the nurse. His spO2 (oxygen in his blood) decreased to 70%, the [MEDICATION NAME] maneuver was performed, without much success, 911 was called. The facility provided a sequence of events that began on [DATE] at 8:30 p.m. when the C.N.A., Staff E provided evening snacks to Resident #1 and his roommate. Resident #1 received chocolate pudding and his roommate received a half of a ham sandwich. At 10:30 p.m. Staff E conducted his final rounds for his shift, saw no snack remaining for Resident #1, and the ham sandwich half still at the roommate's bedside. At 10:56 p.m. Staff A, RN, clocked in, was screened, and completed walking rounds while coming down to unit for shift report. Staff A noted that Resident #1 did not have a snack at the bedside, and roommate of resident did have a sandwich at the bedside. Nurse A went to the snack area and obtained a peanut butter and jelly sandwich and removed crust and gave to Resident #1. Nurse A then proceeded to the nurses station. At 11:14 p.m. on [DATE], Staff B, C.N.A., heard Resident #1 coughing. At 11:15 p.m., Staff C, a Licensed Practical Nurse (LPN) was called to the room to assess the resident who was coughing and speaking. At 11:17 p.m., Staff C, Licensed Practical Nurse (LPN) performed the [MEDICATION NAME] maneuver followed by finger sweeps. Staff A, a Registered Nurse, brought the crash cart and applied oxygen to the resident. At 11:19 p.m., Staff F, LPN, called 911 and called a code blue. The resident's fingers were turning blue and he could not speak. At 11:20 p.m., Staff D, RN performed the [MEDICATION NAME] maneuver and a small amount of food particles were dislodged. Staff G, LPN, recorded a heart rate of 107 and oxygen saturation of 64%. At 11:28 p.m., Staff F, LPN, and Staff G, LPN, reported the arrival of EMS to Resident #1's room. At 11:30 p.m., Staff F LPN and Staff G, LPN recorded oxygen saturation of 80% and heart rate of 36 with respirations and Resident #1 was unconscious. At 11:30 p.m., EMS assumed care of Resident #1. Staff H, LPN stated food, appearing to be ham was removed from Resident #1's airway by EMS using forceps. At 11:40 p.m., Staff G LPN records Cardiopulmonary Resuscitation (CPR) initiated by EMS who continued while exiting the facility with Resident #1. 3. On [DATE] at 8:10 PM, a telephone interview with Staff A, RN, revealed that when he arrived for his shift the evening of [DATE] (at 10:56 p.m. according to time card entry), he was concerned about Resident #1 getting a snack before he fell asleep because Resident #1 was known to be a diabetic resident whose blood sugar would get low overnight. Staff A, RN, stated he remembered that Resident #1 was on a mechanical soft diet and gave him a peanut butter and jelly sandwich after cutting off the crusts. Staff A, RN, stated that he was not aware that Resident #1's diet was downgraded the day before on [DATE] to a pureed diet. Staff A, RN, confirmed that he should have verified Resident #1's diet before giving him the sandwich. Review of the statement documented on [DATE] by Staff E, CNA, after the incident with Resident #1 on [DATE], indicated, On the evening of this event, both Resident #1 and his roommate were given snacks according to their diets. Resident #1's roommate received a ham sandwich which laid on his bedside table which is very common as he doesn ' t eat right away as both residents are night owls and like to move around at night. On [DATE] at approximately 2:00 p.m., Staff E, CNA, confirmed that he completed his walking rounds at 10:30 p.m. on [DATE] prior to leaving the facility after his shift (3:00 p.m. - 11:00 p.m.). Staff E, CNA stated that during his walking rounds, he observed half of a ham sandwich on the bedside table of the roommate. Staff E, CNA, confirmed that he had delivered that half of a ham sandwich to the roommate earlier in the shift. He also confirmed that he had delivered a chocolate pudding to Resident #1 at that same time. Review of the statement documented on [DATE] at 11:10 p.m., related to the event of [DATE] concerning Resident #1, Staff B, CNA, revealed, I was standing at South station when I heard a vomiting noise like someone was trying to throw up. I walked . to hear where the noise was coming from and it was Resident #1. I walked into his room, asked him if he was okay, he stated he was eating a sandwich. He was acting like he was trying to throw up. I looked into his mouth and tried to get him to spit the rest of what he was eating out. I asked the West evening nurse, 'What diet is he on?' She said pureed and then I asked, 'Well who gave him a sandwich?' Night nurse came to the room examine(d) him (Resident #1) left out. I asked South nurse to come here and he did. Noticed patient fingers was turning blue. South nurse checked his mouth and started doing the [MEDICATION NAME]. West evening nurse came into the room and started asking questions then went to call 911. Night nurse checked his (Resident #1) blood sugar. By that time the supervisor and the other nurses were in the room and I stepped out of their way. Review of the statement documented on [DATE], completed by Staff C, LPN, found, At about 11:10 p.m. responded to check on the patient who was choking (Resident #1). Checked the mouth and airway to see if there was any visible object. At that time there was nothing showing. Patient was having difficulty breathing and trying to throw up. Head of the bed was raised, turned patient with his back towards the writer and performed the [MEDICATION NAME] maneuver. After couple of times performing the [MEDICATION NAME] maneuver two nurses came. Patient became non-responsive. Patient had pulse and respirations. Airway was checked again. Patient had food particles coming out of his mouth. The supervisor cleared his airway by passing finger sweeps. The Emergency Medical Technician (EMT) arrived couple of minutes later. Patient was taken to the hospital. Review of the statement documented by Staff G, LPN, dated [DATE] revealed, I (Staff G) was in the therapy room checking in 11:00 p.m.-7:00 a.m. staff and was made aware that a resident needed assistance. Nursing staff responded quickly to assist in his room. When approached the room [ROOM NUMBER]:00 p.m.-7:00 a.m. supervisor was in the room with an 11:00 p.m.-7:00 a.m. nurse assisting with [MEDICATION NAME] maneuver. Nurse that came on duty for 11:00 p.m.-7:00 a.m. shift had apparently given resident sandwich. Crash cart was in the room at the time. Resident had a pulse and oxygen level was at 64%. 02 (oxygen) mask rebreather was on resident. Paramedics arrived and initiated intubation and CPR and begin to retrieve chunks of ham. Resident was sent to . Hospital. Son and MD (Medical Doctor) was notified via 11:00 p.m.-7:00 a.m. nurse on duty. Review of the statement documented on [DATE] by Staff D, RN, stated, Around 23:15 (11:15 p.m.), West nurse alerted me that . (Resident #1) was choking. Upon entering the room patient was seen in a high Fowler's position (head of the bed needs to be elevated as high as possible, upper half of the body is between 60 degrees and 90 degrees in relation to the lower half of the body) with non-rebreather applied. Initial 02 at 64% and Heart Rate (HR) 107. Sat patient to the side of the bed to approach from behind to attempt the [MEDICATION NAME] maneuver then turned on his side and finger sweep completed with small chunks of bread being dislodged. Patient was seen gasping for air, so several abdominal thrusts were completed with minimal food being dislodged each time. Reassessed 02 now 80% but HR 36. Paramedics arrived and immediately intubated and took over. Afterwards I had been informed patient was recently downgraded to a puree diet, but this evening had been given a ham sandwich by the oncoming nurse. Review of the statement documented by Staff H, LPN, on [DATE] pertaining to the event of [DATE] for Resident #1 revealed, This nurse went in to assist a fell ow nurse after receiving word that patient (Resident #1) was choking on a ham sandwich. This nurse went into the room while other nurses were performing [MEDICATION NAME] maneuver and monitoring vitals, offering assistance. 911 was already called, waiting arrival of EMS, monitoring vitals, immediately intubating and then EMS started CPR. Nurse witnessed EMS removing sandwich matter from patient and still continuing CPR. EMS then took the patient to hospital shortly after. The Hospital History and Physical, Final report, for an admission date of [DATE], provided The patient . presenting with cardiopulmonary arrest after apparent choking episode. Resident #1 was evaluated at the hospital upon arrival by a Neurologist who discussed his findings with the resident's son. The evaluation indicated the patient had pinpoint pupils that were nonreactive, no corneal reflexes, flaccid, no response to noxious stimuli, no cough reflex which the Neurologist made clear to the son that there was an extremely poor neurological prognosis to a meaningful recovery. Per the hospital progress notes dated [DATE], Contacted the patient's Extended Care Facility (ECF). The patient was bed and wheelchair bound for quite some time. Was at the facility for about the last 4 years. There has been a gradual and progressive decline in overall and more so this year. Approximately 1-,[DATE]-2 months ago when he came down with COVID he had a more dramatic decline in his overall function. Was no longer able to move himself around in bed, eating less and also less verbal interaction with the staff. Variably ate some days feeding himself and other days needing assistance. He used to be (able to) propel himself around (in) a wheelchair but had stopped doing that. He frequently because of his pureed diet and honey thickened liquids would grab things from other trays. Anything within reach. Overall, though his cognitive and physical functional level had declined significantly over this year and more so since COVID 19 infection. The resident expired on [DATE] at 5:30 p.m. An interview was conducted on [DATE] at 10:41 a.m. with Resident #1's Attending Physician. She confirmed that Resident #1 had been her patient for one year and she was knowledgeable about him. She stated that the resident had improved somewhat during the time she followed him, but he had issues with his health. She initiated Resident #1's diet change on [DATE] from mechanical soft to pureed. She remembered an incident a couple weeks prior where Resident #1 consumed a carrot ([DATE]) resulting in some choking and so to be certain, his diet was downgraded to pureed, but perhaps the carrot was not properly softened. They continued to follow the Resident and he followed the pureed diet until he was given a sandwich by a nurse. The physician said, to her understanding he was given a sandwich that he should not have had resulting in a respiratory arrest. She said, I have been doing this long enough to know that eating the wrong foods can lead to a respiratory arrest. As a precaution I gave an order, and that order was not followed. That nurse should be educated, and the facility needs to do all out checks and balances. Instructions were not followed. That's the bottom line. This happened in the course of a week. She had been notified that the resident was transferred to the hospital. She had been informed that Resident #1's code time was around 12 minutes and usually after 5 minutes when the brain is deprived of oxygen, the patient remains quite ill. The physician continued by saying she observed Resident #1's roommate, weeks ago, giving Resident #1 coffee and he shouldn't have been doing that due to the sugar in the coffee. She educated people on this problem and since then she did not have any issues. A Psychotherapy Note dated [DATE] summarized the visit with Resident #1 as: I spoke with the current speech therapist who reported the patient was impulsive and forgetful, but always positive. He was disoriented but would remember things he was told if prompted. The Psychotherapist provided support and positive reinforcement and reinforced positive coping skills. In an interview that was conducted with the resident's usual day C.N.A., Staff J, on [DATE] beginning at 12:00 p.m., she reported that when she came to work on [DATE] she heard the news and went to the resident's roommate and asked him what had happened. She reported that the roommate told her that the nurse had given the resident a sandwich and he choked. She confirmed that the roommate liked to keep food items from his meal to eat later on his bedside table. She suggested that maybe he had kept his bedtime sandwich around and somehow Resident #1 got it. She reported that other aides had told her that they had seen the roommate give Resident #1 food and drinks. She said that she never saw the roommate do that, and never told the nurses what she was told, but she said she told the other aides they needed to explain to the roommate that he shouldn't do that. She reported that she tells her residents not to share with the other residents, as you don't know their allergies [REDACTED]. She said by the end of her shift she would probably discard the food item and let the nurse and incoming aide know that the resident might be looking for his snack. When asked about the resident's room configuration, she reported that the beds had always been against the wall, perpendicular to each other. One bed was under the window and the other was against the side wall of the room. She confirmed that the over the bed table of the roommate was usually parallel to his bed, which meant that the short side of the table may have been near Resident #1. 4. Resident #1 had multiple re-admissions to the facility after hospital stays. On [DATE] the resident was readmitted to the facility after having a feeding tube inserted. A review of the quarterly nursing readmission evaluation, dated [DATE], revealed that Resident #1 was able to make his needs known, with the plan to remain long term in the facility. He was described during the assessment as verbally denying pain, smiling, and talking. He was admitted with a feeding tube for the [DIAGNOSES REDACTED]. He was assessed at admission as requiring extensive assistance with two staff using a mechanical lift as he was non-weight bearing for transferring, total dependence with two staff for toileting, extensive assistance with a device (wheelchair) to ambulate. The quarterly MDS (Minimum Data Set) Assessment, completed on [DATE] did not include a BIMS (Brief Interview for Mental Status) score as the resident was identified as rarely or never understood. On [DATE], a quarterly MDS was completed and the BIMS was attempted with the resident, but he scored a 00, indicating severe cognitive impairment. A significant change MDS, related to the resident's COVID-19 positive status, was completed on [DATE] which identified the resident's BIMS score as 6, indicating severe cognitive impairment. The resident's short- and long-term memory were not assessed at that time. The resident had no signs of [MEDICAL CONDITION] or any behaviors or moods identified. The resident continued to require extensive assistance with two staff for bed mobility and transferring. He was able to walk in his room and the corridor, or use a wheelchair or walker, but with extensive assistance with one staff. He was frequently incontinent of bladder and always incontinent of bowel and required extensive assistance by two staff for toilet use. His balance was not steady but would stabilize with staff assistance. He had no range of motion limitations. The MDS included [DIAGNOSES REDACTED]. anxiety and depression. He had a stroke and had dysphagia following the cerebral infarction and was at risk for malnutrition. In [DATE], the resident was 65 tall and weighed 146 lbs. There had been no change in his weight during the past six months. The MDS assessed the resident as having no swallowing disorders (no loss or liquids or solids from the mouth when eating or drinking; no holding food in his mouth or cheeks; no coughing or choking during meals or when swallowing medications, and no complaints of difficulty or pain when swallowing.) His eating ability was assessed as needing limited assistance by one staff. The MDS indicated the resident did not have a feeding tube but was receiving a therapeutic, mechanically altered diet. The resident was assessed as having no dental concerns - no broken or loosely fitting full or partial dentures, having teeth, no abnormal mouth tissue, no obvious cavities, no inflamed or bleeding gums, no loose natural teeth and no mouth or facial pain or discomfort or difficulty chewing. Therapies (Physical, Occupational, Speech) were not working with the resident in August, but the MDS documented that he had been seen by the Speech Therapist from ,[DATE] - [DATE]; and the Physical and Occupational Therapists from ,[DATE]- [DATE]. A restorative program for passive range of motion was identified for this resident. 5. An interview was conducted with the Speech Therapist on [DATE] beginning at 12:45 p.m. She confirmed that she was involved with Resident #1's care related to eating. She reported that he usually just needed a reminder about sitting up, to go slow and take his time, as he ate fast. She reported that she had asked the resident's aides to remind him of that and he was usually pretty good at following the reminders. She reported that he didn't always tolerate his thickened water, adding that she had seen him go back to the therapy room to drink water out of their water fountain. She reported that at first, he didn't like the chopped meat (received on a Mechanical Soft diet) and wanted a regular diet. She said that over time he seemed to accept the consistency changes as his condition progressed, but, at times, he requested regular foods. She added that his safety awareness fluctuated as sometimes he needed direction and sometimes, he was fine. The Speech Therapist reported that she discussed her recommendations with the direct care staff numerous times, including the need for more supervision as all of his meals were in his room, not the dining room. She confirmed that she was not aware how her recommendations were documented on the care plan for staff to refer to, but thought it was probably nursing who added them. A second interview was conducted with the Speech Therapist and Rehab Director on [DATE] beginning at 1:20 p.m. The Rehab Director reported that she was familiar with Resident #1 from his sessions with the Therapy department. She described him as a very social guy. She said she would see him in the halls, in his wheelchair, pulling himself along using the handrails. She didn't know him to ever ambulate, even from admission. She knew that last Fall he went out for a Percutaneous Endoscopic Gastrostomy (PEG) tube placement and when he returned, he was lethargic and just wanted to sleep. The Rehab Director reported that she saw Resident #1 a week or two before his incident and he called her by name. She said it surprised her that he remembered her and her name. She described him as having a great personality and a great attitude. She knew he didn't remember his limitations, such as not locking his wheelchair and then trying to get into bed from it. He didn't remember that he couldn't do some things anymore. She confirmed that she was aware his cognition was impaired and his ADLs and ability to perform them had started to decline. She stated that she was not aware that he had problems eating and only when he choked on the carrot ([DATE]) and speech got involved did, she become aware of his history. The Rehab Director reviewed therapy screenings that were conducted in [DATE] and reported that the Speech screening identified deficits for Resident #1 with oral motor strength, the resident's ability to swallow liquids, and difficulty with mastication (chewing). Speech Therapy was provided to Resident #1 from [DATE] - [DATE] and the recommendations made by the Speech Therapist in her report were compared to the approaches on the care plan. When it was noted that the recommendations were not included in the care plan, the reason given was that the recommendations were standards of care that should be provided to all residents. The Speech Therapist reiterated that the resident wasn't referred to the Restorative Dining Program in July as he did well by the end of therapy and remembered his cues. She reported that over time, with his progressing dementia, the carry over from the sessions would wane and he would be referred to therapy again. The Speech Therapist confirmed that she knew his roommate as a friendly guy. She was aware that he tried to give away what he had, would offer staff food from his meals, or ask staff for a snack. The resident had been followed by the Speech Therapist in [DATE] with her clinical impression as, Patient has had success with mechanical soft trials, diet progressed to three meals a day with mechanical soft. Patient has declined trials with the nectar liquids, continues to request regular water. Patient educated regarding risks and consequences of aspiration, choking, pneumonia and death. The section of the ST progress and updated plan of care notes entitled, 'Updates to Treatment Approach' read, Caregiver education to include instructions for setup, aspiration precautions, and recommended diet textures to include mechanical soft with regular liquids. The Impact on Burden of Care/Daily Life section read, Complicating factors that prevented the patient from achieving all established goals include decreased compliance with liquids, aspiration risk with regular liquids. The Updated Standardized Tests section of the document read, Patient has a history of dislike and refusing modified textures, often declines honey liquids. Patient had few natural teeth, poor condition, some broken, has partial (plate) - inconsistent wearing. A review was conducted of the Speech Therapists evaluation and treatment notes for the [DATE] sessions. A note by the Speech Therapist (ST) dated [DATE] read, Referral received from occupational therapy, patient eating at a very fast rate and choking observed. Patient has a PEG (percutaneous endoscopic gastrostomy) tube and had been tolerating PO (by mouth) meals three times a day with mechanical soft and nectar liquids. Noted recent downgrade to honey thick liquids by nursing. The Current Level of Function for the start of care on [DATE], read, The patient exhibits poor compliance with safe eating strategies exhibiting increased poor safety, impulsive eating and coughing during meals for pleasure. The Rehab potential was good due to able to follow one step directions. Demonstrated higher functional level compared to current condition. Positive results from previous treatment. A review of the end of care notes, dated [DATE], found the resident had not met many of the goals set by the ST for the therapy, which included mastication of food, a safe swallow, and progressing the texture of the diet and liquids. The ST Clinical Impression read: Patient had new [DIAGNOSES REDACTED]. Liquids had been downgraded following PEG dislocation and removal. Patient has a history of poor safety awareness during PO intake, fast intake pace, spillage, overfills mouth, sleepiness, decreased positioning and resistance at times. Therapy focused on improving tolerance of the current diet, possible progression to regular textures and improving compliance with protocol strategies. Patient requires 50 - 75% cues with positioning, meal set up, cues for strategies and carryover. Patient has had some weight loss since PEG removal. Discussed with MD. The Discharge Plan and Instructions included: Patient discharged to nursing with recommendations including assist with positioning, meal set up, adaptive equipment, assist, cueing, and extra time. The Discharge Summary read: Current - increase tolerance of the current diet, mechanical soft with honey thick liquids, needs positioning and tray set up, adaptive equipment, Numerous missing and/or broken teeth, poor condition, partials present, not utilized, decreased anchor on remaining teeth. PLOF (prior level of functioning) diet was mechanical soft with nectar liquids, nurse downgraded to honey liquid, increased coughing episodes during PO, fast intake rate, often refuses nectar liquid, needs assist with positioning, impulsive and decreased safety awareness, decreased carry over of strategies learned during prior therapy. History of aspiration during Modified [MEDICATION NAME] Swallow (MBS), not a candidate for regular liquids at this time. In an interview conducted with a Unit Manager (UM), on [DATE] beginning at 2:00 p.m., an incident where Resident #1 choked on a carrot at lunch was discussed. The UM reported that on [DATE], she heard the resident coughing and saw him cough up a piece of carrot that he had tried to swallow whole. The piece of carrot had no teeth marks on it indicating he had not chewed before attempting to swallow. The UM reported that she reminded him to chew his food and tried to remove the piece of carrot from his plate, but the resident asked for it back before chewing and swallowing it. The UM reported that she told the nurse and the resident's diet was downgraded to Pureed and an order for [REDACTED]. The UM reported during the interview that the resident needed his tray set up before the meal (containers opened), but then he could do for himself. She reported that she had not heard him cough before and didn't know him to have any other food problems. The Speech Therapist treated the resident, again, from [DATE] until [DATE] with the reason for the referral as, (taken from the progress notes), Choking episode reported during the noon meal yesterday. MD visited today; dysphagia evaluation/treatment order received. Discussed patient possibility being eligible for dentures/partials with unit manager and doctor. Current partials have poor connection due to missing and partial teeth. Nursing downgraded diet to puree, continue to have honey thick liquids. The Speech Therapist, on the Evaluation Form, documented the previous therapy as The patient has had previous speech therapy initiated on [DATE] for oropharyngeal dysphagia during episode of COVID-19. Patient had positive outcomes, returning to a modified diet, mechanical soft with honey thick liquid. Patient has a history of refusing modified textures and increased signs and symptoms of aspiration with regular and nectar liquids. Precautions listed: HOB (head of bed) elevated for all PO (by mouth) due to aspiration risk, oxygen 2 liters nasal cannula, fall risk, poor safety awareness due to cognitive deficits, needs assist with positioning. The assessment of the resident's swallowing abilities indicated; Choking episode, patient doesn't remember, was on mechanical soft, nursing downgraded to pureed, full assist with positioning, poor dentition, missing and broken teeth, partials do not attach to remaining teeth. Patient has poor safety awareness during intake, eating at a fast pace, large bites, delayed coughs, stating he's hungry. Discussed with nurse manager and MD possible eligibility for new partials/dentures could greatly impact thoroughness of mastication and decrease choking potential. The Rehab potential was indicated as Good due to demonstrated higher functional level compared to current condition. Positive results from previous treatment, responsive to cueing. Both the July and [DATE] Speech Evaluations indicated similar concerns that the resident was experiencing during eating. The resident was identified as having poor safety awareness during eating, he needed full assistance for positioning when eating, he ate at a fast pace, and overfilled his mouth or took large bites. 6. A review was conducted of the care plans developed for Resident #1 and no specific care plan for the resident's need for specific interventions recommended by the Speech Therapist during her July or [DATE] evaluations was located. Care plan focus, included ADL self-care performance deficit related [MEDICAL CONDITION], and limited mobility and weakness, included the intervention added on [DATE] for resident up in wheelchair for lunch and dinner. Care Plan focus, Has a nutritional problem related to [MEDICAL CONDITION], dysphagia, [MEDICAL CONDITIONS] disorder,[MEDICAL CONDITION](gastro-intestinal reflux disorder), [MEDICAL CONDITION], diabetes mellitus, and [MEDICAL CONDITION] included Interventions such as Adaptive equipment as ordered, explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply, explain consequences of refusal, obesity/malnutrition risk factors PRN - as necessary; provide, serve diet as ordered, monitor meal intakes; refer for screen as needed: OT, SLP, Mental Health, Registered D (TRUNCATED)

Based on record reviews and interviews, the facility failed to ensure that it developed an individualized discharge plan of care to ensure a safe discharge for 1 (#342) of 22 sampled residents. Failing to create and ensure an individualized discharge plan with communication to supportive family members for a resident with dementia can potentiate an unsafe discharge, potentiate self- neglect, leading to the resident being transferred to a hospital due to the resident not being able to care for themselves. Resident #342 was hospitalized 2 days after discharge from the nursing home due to her inability to care for herself. Findings include: A representative from a state agency was interviewed via phone on 12/01/17 at 9:14 a.m., she stated that she had gone to an apartment due to a call regarding self-neglect for Resident #342. She stated that when she got there the resident was very confused and stated that she did not know the type of living arrangement that she had signed up for, she thought there would be help there. The resident said she could not take care of herself. The apartment was a mess. The services coordinator at the independent apartment reported to the representative that the resident had come down stairs without bottoms on and defecated. The representative stated that she called an ambulance for the resident and she was glad she did because the resident had an irregular heartbeat and was taken to (a local hospital). A review of an Emergency Medical Services patient care report, dated 11/21/17, documented the nature of the call sick person (Resident #342). The Narrative: Responded emergency for a sick female. Per friend on scene, patient was in rehab, brought here two days ago and is unable to take care of herself. State agency on scene 3:45 p.m., stated she needs to be brought to the hospital until we can make better arrangements for her. Her friends noticed she was unable to care for herself, not eating or drinking. She is newly diagnosed with [REDACTED]. Patient alert and oriented x 3 siting in a chair talking with friend. Pt stated I feel ok I've just been having bladder issues. Pt denies any trouble urinating or burning when urinating Pt stated I'm so glad you're here, I can't take care of myself, I have no food left. Vital taken and pt placed on cardiac monitor. Pt has a hx of a-fib, a flutter noted on monitor and 12 lead performed . Primary impression: Mental Health-Dementia; Secondary Impressions; Cardio-[MEDICAL CONDITION] Fibrillation A review of a local hospital general admission history and physical, dated 11/21/17, documented: This is an afebrile female who is admitted for confusion with history of dementia. Patient is pleasant and realizes she has significant memory loss.she has occasional diarrhea, but does not remember (if) she has been on antibiotics lately .indicates she is incontinent .she was recently at hospital, then got transferred to SNF Skilled Nursing Facility, then was transferred to independent living 2 days ago, but, that did not work out A review of a local hospital Psychiatric consultation, dated 11/23/17, reason for consult: Capacity, Chief Complaint: I don't know why I'm here. History of present illness: female admitted for diarrhea and failure to thrive in independent living. Patient with history of dementia but, reportedly not this severe. Patient today states she came from (Independent Living Arrangement), which is correct, but she does not know why. She knows she has been her 2-3 days. She knows today is Thanksgiving. She is unable to state what she is being treated for [REDACTED]. She has no physical complaints.She states that she is fine with her (family member) making decisions for her as she plans to go live near him in . and she trusts him .The Assessment and Plan: female admitted for failure to thrive with psychiatry consult placed for capacity to make medical decisions evaluation. Patient does not know why she is here, what happened prior to admission, plan of care, mediations, proposed treatments, and she expresses disinterest in hearing about it. She states she would like her son to make the decisions. Agree that patient at this time lacks capacity to make decisions regarding medications or treatment options as she is unable to state risks/benefits/alternatives of them or even what they are despite education. Recommend use of proxy decision maker. A review of Resident #342's electronic Nursing Home clinical chart, documented an admission on 11/10/17; and a subsequent discharge date of [DATE]. The face sheet listed (Family Member #1), as POA-financial; POA care; emergency contact #1. No other name was present on the contact list. The [DIAGNOSES REDACTED]. A review of a Level I Screen, Preadmission Screening and Resident Review (PASRR), dated 11/10/17 and signed by a Registered Nurse, documented that Resident #342 had suspected Dementia in Section A., based on documented history. A review of the Social Services Initial Evaluation, effective date of 11/16/17, documented the resident reported she has 2 children; reports the children are supportive. The evaluation, #17 asked if the resident had a mental health issue; this was answered Yes, Dementia and Depression. The evaluation, further asked in section 17: Does the resident have a [DIAGNOSES REDACTED].? This was answered Yes; Dementia. The resident's goal was stated to be reports to go home. The evaluation documented the resident's long-term and short term memory to be intact and that the resident did not have fluctuation in memory. The daily decision making skills were documented to be modified independence. On page 4, the document listed previous Living arrangements. The form listed the resident's Family Member #1 with phone number. The form listed the former living arrangement to be (an independent living tower). The Discharge plan on Admission was Home independently. The form had a question: Does the discharge plan seem appropriate for the resident's needs? This was answered No. A review of the progress notes: Dated 11/19/17, 12:32 p.m.: Resident scheduled for discharge to home (Independent living apartment) today. She was to set up her own transportation per ss (social services) d/c (discharge) note, but resident at this time stating she has no transportation. Provided assistance to get her set up with care ride or taxi but resident refused stating she has no funds available to her at this time and refused to call Family Member #1. She reports her money is at home. Resident then stated she has no food at home. CNA offered to use her uber account for resident to go home and resident agreed, kitchen staff offered resident with cold cuts until tomorrow until she is able to get to her funds and to the grocery store. Resident requested to have lunch before discharge. 11/19/17 10:15: member alert and oriented. Member has moments of confusion. Requires redirection. Tolerates her medications well. Denies pain or discomfort. 11/18/2017, 19:17: Resident alert with some confusion. Able to make needs known . 11/17/17, 16:44: This writer spoke with the resident about potential discharge back home. Resident and Family verbalized understanding and is in agreement with the plan. Resident is able to make her decisions and Family is in agreement with the decisions being made. Resident's family is aware about discharge plans. The resident and family understand her medical needs and are able to follow up with doctor appointments. The resident and family have been provided materials on community services and how to obtain services. The resident will be with the family and family understands the medical needs of the resident and is coping well with the resident's illness. Nursing provided education .Upon admission, during care plan meetings, and prior to discharge, the resident and the family were given opportunity to voice opinions and concerns about care after discharge and participated fully in all discharge decisions. (signed by Staff Member C, LPN.) 11/14/17 22:33: Member has been ambulating in the hallway via her wheelchair and via walking. She has been having increased moments of confusion which requires redirection. 11/12/17 17:12: Member has been ambulating in the hallway via her wheelchair. She is alert but disoriented and needs redirection during conversation and had trouble locating her room. 11/11/17 17:12: .Is alert with confusion . 11/10/17 18:12: Resident came in wheelchair from hospital, Resident [DIAGNOSES REDACTED]. Resident is incontinent of bowl and bladder .Resident ambulates with assistance and transfers with 1 assist .Resident is alert, oriented with little confusion. Resident is a risk for falls. A review of Resident #342's Care plans: Initiated on 11/16/17: The resident /responsible party wishes to return /be discharged to community/prior living arrangements. The goal was stated: Resident's condition improved continued care no long is indicated. The interventions: Make arrangements with required community resources to support independence post-discharge HHC, MD; Prepare and give the resident, family member, caregiver contact numbers for all community referrals as indicated.; Provide services according to care plans in effort to enhance optimum well-being. Initiated on 11/10/17, documented a focus area: The resident has impaired cognitive function/dementia or impaired thought processes. The interventions listed included: Communicate with the resident/family/caregivers regarding resident's capabilities and needs PRN, initiated 11/13/17. Cue, reorient and supervise as needed, initiated 11/13/17. Initiated on 11/13/17, focus area: The resident has altered cardiovascular status r/t (related to) A-fib. Initiated 11/16/17: The resident has a perceived or actual mood problem r/t sad, apathetic, anxious or Fidgety/Restless Appearance, Verbal Expressions of Distress, DX: Depression and Dementia. Interventions included: Consultation with psychological/psychiatric. Provide services based upon resident/responsible party approval and physician order, initiated 11/16/17. An interview conducted on 12/06/17 at 9:30 a.m. with the Director of Nursing (DON), she was asked: What do you do for a resident that presents well, but has behaviors of being confused. (A short stay resident). We ask them about alternative, about going to an ALF (Assisted Living Facility). If we think that they are not safe and they do not have an incapacity decision and they insist on being discharged , we will call for an unsafe discharge. She was asked: Do you do home visits to ensure a safe environment? If you seem like you are confused, we can ask the psych doctor for an evaluation. He will make recommendations and write notes about what is going on with the resident. He will let us know if the resident is capable of making decisions. On 12/06/17 02:27 an interview was conducted with Staff Member E, Minimum Data Set (MDS) Coordinator, and Licensed Practical Nurse (LPN) regarding Resident # 342. Per the MDS coordinator, she was from an ALF, can tell from the hospital records. Then she stated that they do a meet and greet with the residents; this resident was at the facility because of a fib; [MEDICAL CONDITION] and UTI. Staff Member E confirmed that the clinical record had no evidence of a psychiatric evaluation being conducted on the resident. A review of the IP(NAME) (Interdisciplinary Plan of Care) Summary, dated 11/17/17, documented an area for Resident, Family, Responsible Party Communication; the area was blank. A review of the Discharge Goal area, which had boxes to designate Home Independently, Home with assistance, Assisted Living, Long Term Care in this Facility; the boxes were blank to indicate what the plan was. A review of the Signatures and Titles of IP(NAME) team members, Resident and/or Family Responsible party revealed the signature of Resident #342, the SSD (Social Services Director) and the Facility Rehab Director. No evidence appeared on the summary that a Registered Nurse or Certified Nursing Assistant involved in the care of the resident were present during the care plan meeting. The 3 signatures were reviewed and confirmed by Staff Member E. A review of the Physical Therapist (PT) Discharge Summary, dated 11/18/17, the analysis of functional outcome/Clinical impression, documented .Patient continues to require CGA (Care Giver Aid) and cueing with gait on level surfaces due to mild unsteadiness. Patient is Mod I (modified independence: assistive device or extra time needed) with all transfers. Patient is Mod I with all transfers. Patient progressed with fall risk factor from moderate risk to low risk with Tinetti Balance and Gait score of 24/28. Patient discharged to ILF (independent living facility) with limited support; recommend HH (Home Health Care) and PT for follow up care. Precautions: Fall risk, confusion. A review of the Occupational Therapist (OT) Discharge Summary, dated 11/27/17, with the end of care date of 11/18/17, documented Impact on Burden of Care/Daily Life: Patient can now complete toileting task with SBA (Stand by assist). Review of the Long Term Goal, documented Goal Not Met on 11/18/17, the patient will be Modified independent in basic self-care and functional mobility with good safety awareness in order to be able to return to ALF (Assisted Living Facility). Explanation: Patient discharged before meeting goal. A review of an OT treatment note, dated 11/18/17, documented: Patient required SBA (stand by assist) for UB (upper body) grooming, UB dressing, LB (lower body) dressing and for complete toileting task. A review of the MDS, Section C, Cognitive Patterns, signed by Staff Member I (SS Assistant) on 11/29/17 at 5:15 p.m. (10 days after the discharge from the facility, documented a Brief Interview of Mental Status (BIMS) summary Score of 15 (cognitively intact). The facility was not able to provide evidence of a BIMS evaluation conducted during the resident's stay. A review of physician orders [REDACTED]. A review of the Transmission Log paper provided by the SSD on 12/07/17 at approximately 2:00 p.m., documented a fax, dated 11/17/17, from the social services department to a doctor for STAT order for PT/OT; DME (durable medical equipment) rollator. A review of a Last Covered Day notice: notice of Medicare non-coverage for Resident #342, documented skilled nursing service end date of 11/18/17. Resident #342 signed the document on 11/16/17. During an interview conducted on 12/07/17 at 12:08 p.m. with the Social Service Director (SSD), she stated Normally, we start discharge planning from the time that they get here. She confirmed that she did the discharge planning for the resident. Normally, we go in and do an assessment, we ask them what their goals are; meet and great; I will ask them if they live alone, where they live and what their plans are. She stated, I spoke with the ( Family Member #1), a couple of days after the resident's discharge, cannot remember. He had concerns about the resident returning home. He did not know that the resident was going back to where she had been living. He told me that he thought the resident was going to an assisted living or something of that nature. She confirmed that she did not talk to the (Family Member #1) during the resident's stay. She confirmed that she was working during the resident's stay. She stated (Family Member #1) lived out of state. We include the family of the resident; it depends on if she is alert and oriented. She never gave me any indication to call her son. She was alert and oriented. She confirmed that the BIMS, dated 11/29/17, was the only BIMS that she could find that was done on the resident. (10 days after the resident was discharged .) She confirmed that she met with Resident #342. She confirmed that she made arrangements for Home Health for the resident by faxing the order to the physician. The SSD was asked how she would know if the resident's home was safe to go home to. She stated, We do not go to the house. We basically go on what the resident tells us, if they are alert and oriented. The SSD was asked: If the resident has dementia? What do you do? We pretty much get the family involved. We would call the family and do collaborative to find out what their plans are for discharge. Her insurance discontinued service; it was the insurance that discontinued the service. The SSD was asked: Did the resident decide to go? No, it was her insurance would not cover her stay. She was asked: If insurance had covered her, would she have stayed? Yes, probably until therapy and the team had determined that she had met her maximum potential. I explained to her that her insurance company was terminating services, which she had the right to appeal. She never said to me that she wanted to appeal, she said she was ready to go home. If she had dementia, we would have involved family. A review of Resident #342's Post Discharge Plan was conducted with the SSD. She stated that she starts the form in the system and the nurse will complete the form. She confirmed that her name was not present on the form and that the nurse, (Staff Member C), completed the form in all areas. The SSD stated that her part in the discharge was to call the resident's primary that she faxed over the request for the home health. A Review of the POS [REDACTED]. In the areas of Meals on Wheels, Housekeeping Services and other services/needs, these areas had either N/A (not applicable) or blank. The form documented Mental and psychosocial status: Able to make needs known; Cognitive status: Alert and oriented with periods of confusion. The form was electronically signed by Resident #342 and the nurse. The area for the family/responsible party notified of the discharge was blank. An interview was conducted on 12/07/17 at 2:00 p.m. with (Family Member #2). She confirmed that she had Power of Attorney, Medical for Resident #342. She stated that no one contacted her about the discharge from Apollo. She stated that she found out about the nursing home stay from a friend in the community. The next thing I know is that (Resident #342) called and told me she was at home from the nursing home. I called the facility and asked why she had been discharged . She (Resident #342) presents well sometimes. I do not think that she (#342) can remember to say that we are involved. She definitely needs to stay with someone. My (Family Member #1) is trying to find placement close to him in (out of state). Unfortunately, the medical coverage is better in Florida than it is in (out of state). That is where we are at with that at this time. I did not have any dialog with the social worker. During this most recent hospital stay, I asked the hospital why (the facility) let her go. It was negligent in my opinion. On 12/07/17 at 2:30 p.m., the Nursing Home Administrator (NHA), stated that she was unsure why the social worker would say that the facility does not do home visits. She stated that they did do a home visit for the resident; she had a CNA go with the resident to the apartment. An interview conducted on 12/07/17 at 3:02 p.m. with (Staff Member J), driver, not a CNA. We were called, it was a Saturday (18th), it was not the day of discharge. Came and picked her up, we drove to her place. We asked her if she had the keys to the apartment and she did not. So she went to the security guard; he got the master keys; we went up to her floor and he let us all in. she looked around, said her house was dirty because of the cat, she said it would not take her more than a day to clean it, she looked for some clothes; insurance papers; hair brush pair of shoes; and house keys; she found all of them. She had a litter box, food on the floor in a bowl; did not see the cat. There was cat poop on the kitchen floor; the litter box needed to be cleaned. She confirmed that she did not look in the refrigerator. She confirmed the presence of an odor in the apartment, a little from the cat, the feces and the urine and piles of clothes on the couch. She stated it was a studio apartment with all the furniture in one room and that the SSD needed to make sure the apartment was livable. She stated that she does not have a check list for this process, nor did she document the home visit. She stated that she communicated with the Social Worker when she returned. Staff Member J was asked: How do you know the place was safe? Well, I do not know what safe would be. I did not see any holes in the walls or wires. She (#342) was talking to us for the entire time; sometimes she was here or there. She would get side tracked for a minute; she would look for the insurance papers, stop and start looking for the shoes and clothes. I told the SSD everything that I told you. She stated that the SSD was working that Saturday (11/18). On 12/07/17 at approximately 4:00 p.m., the SSD was interviewed, she was asked if the driver of had relayed the information about the apartment to her. The SSD stated that she did not work that Saturday. On 12/07/17 at approximately 4:00 p.m., the NHA provided a Welcome sheet, initialed by Resident #342. The 2nd paragraph of the document stated: The Care Plan is established from these meetings and creates the road map for your rehabilitation success. This will be developed within the first few days of your stay and will establish an estimated date of discharge. Part of your rehabilitation is allowing us to help you discharge to the proper setting in a safe manner. It can take time to set up home health, order supplies and make changes to the home environment to ensure all appropriate resources are available to you upon discharge. 12/07/17 at approximately at 4:10 p.m. (Administrator in Training) AIT, confirmed that a representative had called from a state agency a couple of days after the resident had been discharged from the facility. He stated that the representative called and wanted to know if they could take the resident back; that the resident was in the hospital; he stated that they could not take the resident back. An interview was conducted on 12/07/17 at 4:25 p.m. with the facility doctor that was familiar with Resident #342. She stated, I saw her twice; provided post-acute care for her while she is in the facility; I am a family physician. (I) did not specifically assess her for cognition. I had 2 visits. My goal is that the [MEDICAL CONDITION]s was stable. The confusion that was documented in the progress notes was not communicated to me. It was not communicated that she did not have money for a ride at the time of discharge or no food in the refrigerator. Even so, that would be a social service area. She presented well during the 2 visits that I had with her. She could answer the questions that I posed to her. I wrote the discharge order. At the time of my review, I felt that she was safe to discharge. I reviewed the reason that she was here at the facility; the goals. Sometimes insurance will dictate and if I feel that they are not a safe discharge I will attempt to keep them longer; it is unusual to have one approved; she wanted to go home; she was fine during my visits. Interview conducted on 12/08/17 at 9:35 a.m. with Staff Member C, LPN. She stated that she called ( Family Member #2) on the date of d/c. She stated that she did not call him before that. She stated that she told him that we were discharging the resident to (her apartment.) where she had been before she came to the facility. An interview conducted on 12/08/17 at 11:09 a.m. with Staff Member C, LPN. She stated that during Resident #342's stay, the resident would be in her w/c (wheelchair); she was able to transfer herself into her bed with someone there watching. She would self-propel her w/c, sitting in the wheel chair; I did not see her use a walker while she was here. She stated that on the date of discharge, she went in a car. I took her to the front area. I took her in her wheelchair. She had all her belongings with her. That was the facility wheel chair. The wheel chair did not go with her. Staff Member C confirmed that the resident got into the car, and she did not have a walker with her. Staff Member C stated that the resident did not have a walker at the facility, at home she would have. She stated that one of the aids stood by the resident as she got in the car. Staff Member C stated about the moments of confusion documented on 11/19, just that she would be confused .time of day it would be the afternoon and she would think it was the morning. She would ask what time in the morning it was and I would redirect her to what time of day it was. Staff Member C confirmed that she called ( Family Member #2) on the date of discharge. He answered the phone; told him that she was being discharged back to her apartment. Do you know what time you spoke with him? I do not remember. It was before d/c. The same day. Reviewing the Narrative note, dated 11/19/17, provided materials on community services, Staff Member C was asked what the materials on community services were. Staff Member C stated that means that she got the discharge summary and then separately we print out a list of the medications. And the AHCA (Agency for Health Care Asministration) form, if they were not in agreement with their discharge they could call DCF. Staff member C was asked if it meant Housekeeping services. She stated No and No to a referral for meals on wheels. She said that she could get someone to take her to the store the next day. Staff Member C was asked: Do you know how she was going to get out of the car once she got to her apartment? I do not know. Staff Member C was asked: Do you know how she was going to get up to her apartment? I do not know if there was anyone to assist. An interview was conducted on 12/08/17 at 11:30 a.m. (via phone) with Resident #342's (H, Family Member #2). He was asked if the facility had called him the day that the resident was discharged from the facility. He stated that he did not talk to anyone personally by phone. He stated that he called the SSD after the fact to ask them what happened. He was told by the SSD that Resident #342 was alert and oriented and that even if I had power of attorney, she could make her own decisions. She was at (local hospital) before she was at the nursing home. He stated that (the local hospital) was in contact with him, a (Case Manager) helped coordinate the transition to the nursing home. He stated that I was upset when I talked to SSD, I felt like the hospital recognized that she needed to be in a nursing home or an assisted living facility. I agreed with that. The next thing I know is that I got a call from my (G, Family Member #1) that she (#342) was home (at her apartment). ( Family Member #1) and I were shocked. She was diagnosed with [REDACTED]. It has been a challenge. (After she was discharged to her apartment) she got sick again. I talked to the case manager at the hospital (the one she was admitted to on 11/21), the (case manager), she said that Resident #342 was physically fine, but confused. I worked with the state agency person and located placement at the Assisted Living Facility (ALF).