Every finding on record at Arbors at Woodsfield

Based on record review and interview the facility failed to ensure comprehensive assessments were accurate. This affected two residents (Resident #9 and #48) of 12 residents reviewed for accurate assessment. Findings include: 1. Review of Resident #9's medical record revealed an admission date of 08/26/13 with diagnoses including cerebral palsy, major depressive disorder, generalized anxiety disorder, allergic rhinitis, excoriation (skin picking) disorder, irritant contact dermatitis, and candidiasis of the skin. Review of the physician orders revealed to administer hydroxyzine (Vistaril, an anti-histamine medication that is sometimes prescribed to treat anxiety) 50 milligrams (mg) by mouth every eight hours as needed for itching for 90 days written 04/24/25. Further review of the electronic medical record (EMR) revealed no evidence of the resident having received an anti-anxiety medication from 05/01/25 through 05/06/25. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed the MDS reflected the resident had received an anti-anxiety medication during the seven day MDS review period (05/01/25 through 05/07/25). On 06/24/25 at 3:32 P.M., an interview with Corporate Nurse #100 confirmed the resident's annual MDS was not accurately coded to reflect the medications the resident received. She acknowledged the resident was marked on the MDS as having received an anti-anxiety medication when the resident was not receiving one. The Corporate Nurse verified Vistaril was an antihistamine and not an antianxiety medication and should not have been coded as such. 2. Review of Resident #48's medical record revealed an admission date of 04/18/25 with diagnoses including unspecified dementia with psychotic disturbances, post-traumatic stress disorder, type II diabetes, chronic kidney disease- stage III, atrial fibrillation, peripheral vascular disease and generalized anxiety disorder. Review of the physician orders revealed to administer rosuvastatin calcium oral tablet 40 milligrams by mouth at bedtime for hyperlipidemia. Review of the admission MDS dated [DATE] revealed the resident was cognitively intact. The resident's diagnoses (under Section I) did not include the diagnosis of hyperlipidemia despite the resident receiving rosuvastatin calcium every night at bedtime since admission to the facility. On 06/24/25 at 10:05 A.M. interview with the Director of Nursing and Corporate Nurse #100 verified that the resident's admission MDS completed on 04/25/25 was not coded accurately to reflect the resident's diagnosis of hyperlipidemia. Both acknowledged the resident had been receiving rosuvastatin at bedtime for hyperlipidemia since admission to the facility.

Based on record review and interview the facility failed to ensure residents had appropriate indication for use of medications and did not have duplicate medication therapy without appropriate justification. This affected one (Resident #46) of five residents reviewed for medication use. Findings include: Review of Resident #46's medical record revealed an admission date of 01/23/25 with diagnoses that included traumatic brain injury and post-traumatic hydrocephalus. No evidence of any gastro-esophageal reflux disorder (GERD) was identified. Review of the physician's orders revealed the current use of famotidine (medication for treatment of GERD) 20 milligrams (mg) twice daily and protonix (medication for treatment of GERD) 20 mg daily. Further review of the medical record including physician's progress notes and hospital records identified no current or prior diagnosis of GERD or justification for the duplicate medication therapy. Interview with the Director of Nursing on 06/24/25 at 2:35 P.M. verified Resident #46 did not have a diagnosis of GERD and received duplicate medication therapy for GERD.

Based on observation, record review and staff interview the facility failed to ensure residents with reclining wheelchairs were assessed for possible restraint use. This affected two (Resident #12 and #34) of two residents reviewed for possible restraint use. Findings include: 1. Review of the medical record for Resident #12 revealed an admission date of 01/05/21 with diagnoses that included end stage renal disease with hemodialysis, diabetes mellitus and atrial fibrillation. Review of the physician's orders for Resident #12 revealed on 10/17/24 that while resident is up in tilt-in-space wheel chair (wheelchair which can recline for comfort and positioning) to tilt resident back to 30-40 degrees every hour for 5-20 minutes as tolerates to relieve pressure off coccyx and sacrum. No evidence was found in the medical record to determine when the tilt-in-space wheelchair was initiated and no evidence of an assessment to determine if the tilt and space wheelchair was a restraint. Observation of Resident #12 on 06/23/25 at 10:44 A.M. revealed the resident was reclined in a tilt-in-space wheelchair. Interview with the Director of Nursing on 06/23/25 at 3:55 P.M. verified Resident #12 was not assessed for potential use of a restraint with the tilt-in-space wheelchair. The Director of Nursing further indicated the resident had utilized the tilt-in-space wheelchair for a prolonged period. 2. Review of the medical record for Resident #34 revealed an admission date of 04/15/23 with diagnoses that included Alzheimer's disease with dementia, diabetes mellitus and post-traumatic stress disorder. Review of the physician's orders for Resident #34 revealed on 10/17/24 that while resident is up in tilt-in-space wheel chair, to tilt the resident back to 30-40 degrees every hour for 5-20 minutes as tolerates to relieve pressure off coccyx and sacrum. No evidence was found to determine when the tilt-in-space wheelchair use was initiated. Further review of the medical record revealed no assessment was completed to determine if the use of the tilt-in-space wheelchair was a potential treatment. Observation of Resident #34 on 06/23/25 at 1:29 P.M. revealed the resident was reclined in a tilt-in-space wheelchair. Additional observation on 06/23/25 at 3:01 P.M. revealed the resident was reclined in a tilt-in-space wheelchair. Interview with the Director of Nursing on 06/23/25 at 3:55 P.M. verified Resident #34 had not been assessed to determine if the use of a tilt-in-space wheelchair was a potential restraint prior to 06/23/25.

Based on observations, interviews, and policy review, the facility failed to store and prepare foods in a sanitary manner. This had the potential to affect all 55 residents residing in the facility. Findings included: Observations on 04/08/24 between 9:15 A.M. and 9:18 A.M. revealed an eight-quart container of rice crispies in the dry storage room with a use by date of 03/27/24, two dozen hard-boiled eggs in the walk-in refrigerator with an expiration date of 03/10/24, half a white onion with a use by date of 04/04/24, a whole onion with a use by date of 04/06/24, a half a gallon of parmesan cheese with an expiration date of 03/27/24, and a bag of shredded cheddar cheese with an expiration date of 03/27/24. Interview on 04/08/24 at 9:20 A.M. with Dietary Manager (DM) #430 confirmed the above findings. Additional observations of the kitchen on 04/08/24 at 9:26 A.M. revealed food splashes on the prep area walls, food debris and crumbs on the shelving for dishes and pans as well as on the floor below the beverage area, and sticky grime throughout the stainless-steel shelving in the kitchen. DM #430 confirmed findings at the time observations were made. Observation on 04/10/24 at 9:36 A.M. revealed shelving containing spices in the kitchen had a layer of dust, crumbs, and grime; the table with the steamer had a layer of sticky grime on top, the oven and stove had thick layers of grime and debris, two large white containers with flour and sugar had dark brown, sticky grime covering them, the shelf with the microwave had rust, and a container of baking soda was noted with a use by date of 01/10/24. Interview on 04/10/24 at 10 A.M. with DM #430 confirmed above findings. Observation on 04/10/24 at 10:26 A.M. revealed a white carafe on the clean dishes shelf that had dried, brown crust on it and two clear containers with food debris. Interview on 04/10/24 at 10:26 A.M. with Dietary Aide (DA) #410 confirmed findings, removed the white carafe and rinsed it in water before placing it back on the clean dishes shelf. Review of a policy titled Food Receiving and Storage (dated 01/01/22) revealed foods shall be received and stored in a manner that complied with safe food handling practices as outline in the FDA Food Code. Food Services or other staff will maintain clean food storage areas at all times, dry foods that are stored in bins and refrigerated foods stored in the refrigerator will be labeled and dated with an opened on and use by date. Review of a policy titled Food Preparation and Service (dated 01/01/22) revealed food service employees shall prepare and serve food in a manner that complies with safe food handling practices. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. This deficiency represents non-compliance investigated under Complaint Number OH00151791.

Based on medical record review and interview, the facility failed to ensure baseline care plans were developed and/or summaries of the baseline care plan were provided to the residents and their representatives. This affected five residents (#20, #24, #46, #58 and #263) of 23 residents whose care plans were reviewed. Findings include: 1. Review of Resident #58's medical record revealed diagnoses including left artificial shoulder joint, osteoarthritis of the left shoulder, morbid obesity, stage three chronic kidney disease, Stage two (shallow) pressure ulcer of the left heel, hypertension, generalized muscle weakness, difficulty walking, anxiety disorder, depressive disorder, vitamin D deficiency, hyperlipidemia, osteoarthritis of bilateral knees and of the right hip. Review of Resident #58's nursing admission assessment dated [DATE] revealed as needs or risks were identified the facility identified interventions to be implemented. There was no evidence the facility discussed the baseline care plan or provided a summary of it to Resident #58 and/or a representative. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 was able to understand others. Resident #58 was assessed as cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14 (out of 15 possible points). During an interview on 04/10/24 at 4:09 P.M., Social Service Director/Designee (SSD) #126 provided a discharge planning evaluation dated 03/11/24 which she stated was a care plan meeting. The discharge planning evaluation addressed information such as the reason for admission, type of stay, expectations for the stay, discharge plan, a review of types of equipment Resident #58 had available to her upon discharge, and environmental barriers to discharge. The form indicated topics discussed also included activities, activities of daily living/rehab, and mood/behavior. The form contained an area to specify who was provided a copy of the care plan and it indicated it was na (not applicable). SSD #126 verified Resident #58 was not provided with a written summary of the baseline care plan. 2. Review of Resident #263's medical record revealed diagnoses including congestive heart failure (CHF), type two diabetes mellitus, hypertensive heart disease, pressure ulcer of the left heel, hyperlipidemia, depression, peripheral vascular disease, and generalized muscle weakness. Review of nursing admission evaluation dated 03/28/24 revealed interventions were initiated for identified areas of concerns/risks. There was no documentation of Resident #263 receiving a summary of the baseline care plan. On 04/10/24 at 4:09 P.M., SSD #126 provided a Discharge Planning Evaluation dated 03/29/24 which had an area to summarize the discussion of the care plan conference which indicated there was none. The form also indicated a copy of the care plan was not provided to anybody. SSD #126 verified a written summary of the baseline care plan was not provided to Resident #263. 47985 3. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, type II diabetes, acute kidney failure, and major depressive disorder. Review of MDS completed on 01/24/24 revealed Resident #20 had moderately impaired cognition. Record review revealed no evidence a baseline care plan was completed within 48 hours of admission or that a copy was given to Resident #20. Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. SSD #126 stated care conferences could be located in the assessment tab in PointClickCare. Request for baseline care plan was made to Administrator on 04/11/24 at 11:53 A.M. with no response. 4. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hydronephrosis, and cognitive communication deficit. Review of a quarterly MDS completed on 02/06/24 revealed Resident #24 had mildly impaired cognition. Record review revealed no evidence a baseline care plan was completed or given to Resident #24 within 48 hours of admission. Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. SSD #126 stated care conferences could be located in the assessment tab in PointClickCare. Request for baseline care plan was made to Administrator on 04/11/24 at 11:53 A.M. with no response. 5. Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type II diabetes, panic disorder, and post traumatic stress disorder. Review of quarterly MDS completed on 01/17/24 revealed Resident #46 had moderately impaired cognition. Record review revealed no evidence a baseline care plan was completed or given to Resident #46 within 48 hours of admission. Interview on 04/10/24 at 2:29 P.M. with Social Services Director (SSD) #126 revealed care conferences should be completed upon admission, annually, quarterly, and for significant changes. SSD #126 stated after a resident admits, the timing of the care conference depends on family availability but most of the time she meets with the resident to give baseline care plans if they want to have a copy. SSD #126 stated care conferences could be located in the assessment tab in PointClickCare. Request for baseline care plan was made to Administrator on 04/11/24 at 11:53 A.M. with no response. Review of a policy titled Baseline Care Plan (dated 12/28/23) revealed a baseline care plan should be developed within 48 hours of a resident's admission, should include the minimum healthcare information necessary to properly care for a resident including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Pre-Admission Screening recommendations if applicable. The baseline care plan should be used until staff conducts the comprehensive assessment and develop an interdisciplinary comprehensive care plan. The facility should provide the resident and their representative with a summary of the care plan that includes but is not limited to the initial goals of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and any updated information based on the details of the comprehensive care plan as necessary.

Based on observation and interview, the facility failed to ensure all residents received a dignified dining experience when residents seated at a table were not served their meals at the same time. This affected four residents (#2, #8, #47, and #161) of 20 residents observed in the dining room. The facility census was 55. Findings included: Observation on 04/08/24 at 11:09 A.M. revealed Residents #2, #8, #47, and #161 were seated at a table together. Throughout the dining process, the following was observed: -11:09 A.M. Resident #8 received her meal, staff then began to serve other tables. -11:19 A.M. Resident #47 received a bowl of soup. -11:22 A.M. Resident #2 received her tray. -11:26 A.M. Resident #161 received her tray. Interview on 04/08/24 at 11:30 A.M. with Registered Nurse (RN) #135 revealed each table should be served at a time. RN #135 confirmed the above findings. Interview on 04/11/24 at 5:23 P.M. with Resident #47 revealed a lot of times, the residents at lunch tables are not served at the same time. Resident #47 stated it is frustrating and upsetting to be seated at a table with other residents who are eating when she doesn't have her tray because she gets hungry or feels bad when she is served before others. Review of a policy titled Promoting/Maintaining Resident Dignity (dated 10/26/23) revealed it is the policy of the facility to protect and promote resident rights and dignity. All staff members involved in providing care to residents to promote and maintain resident dignity and respect resident rights.

Based on observation, medical record review, review of menus, and interview, the facility failed to ensure food was palatable. This affected four residents (#37, #49, #58 and #263) of six residents reviewed for food concerns and one additional resident (Resident #36). Findings include: 1. Review of Resident #58's medical record revealed diagnoses including heart failure and stage three chronic kidney disease. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58 was cognitively intact and able to make herself understood. On 04/08/24 at 11:54 A.M., Resident #58's lunch was served. Potatoes were dark brown on all sides except two potatoes which had one lighter brown side. Resident #58 tapped her fork on the potatoes and it made a sound as if scraping burned toast. Resident #58 reported the potatoes were hard. As Resident #58 attempted to get one of the potatoes on a fork it and another potato left the plate and landed on the over the bed table. Resident #58 reported the green beans were not seasoned (no evidence of seasoning was noted with observation) according to the meal ticket. Review of the menu for 04/08/24 for lunch revealed menu items included marinated chicken thigh, seasoned green beans, potato wedges, dinner roll/bread, and chocolate cake with peanut butter frosting. On 04/08/24 at 12:00 P.M., Cook #405 stated there were no potatoes or green beans left over to taste. Cook #405 stated she thought the potatoes looked dark but denied they felt hard on the tray line. On 04/08/24 at 12:29 P.M. State tested Nursing Assistant (STNA) #122 was observed picking up trays and stated nobody was really eating the potatoes and stated the potatoes appeared burnt. 2. Review of Resident #36's medical record revealed diagnoses including orthostatic hypotension and history of malignant neoplasm of the kidney. A quarterly MDS dated [DATE] indicated Resident #36 was cognitively intact. On 04/08/24 at 12:21 P.M., Resident #36 reported the potatoes were as hard as rocks and she could not eat them. 3. Review of Resident #37's medical record revealed diagnoses of malignant neoplasm of the right breast and type two diabetes mellitus. A quarterly MDS dated [DATE] revealed Resident #37 was cognitively intact and was usually able to make herself understood. During an interview on 04/09/24 at 8:51 A.M., Resident #37 stated sometimes food was over and under cooked. Resident #37 stated the potatoes served for lunch on 04/08/24 were hard. 4. Review of Resident #263's medical record revealed diagnoses including type two diabetes mellitus and stage three pressure ulcer (significant wound that has penetrated through the top two layers of the skin and reached the fatty tissue beneath) of the left heel. An admission MDS dated [DATE] indicated Resident #263 was cognitively intact. On 04/09/24 at 8:34 A.M., Resident #263 stated he received something on his lunch tray on 04/08/24 which he assumed was supposed to be potatoes that was listed on the meal ticket but they were too hard to eat. 47985 5. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, neoplasm of unspecified behavior of bladder, chronic obstructive pulmonary disease, atrial fibrillation, and type II diabetes. Review of orders revealed Resident #49 received a regular diet with regular textures and thin liquids. Review of a quarterly MDS completed on 02/26/24 revealed Resident #49 required set up help for eating and had no weight concerns. Review of a care plan completed 02/21/24 revealed Resident #49 was at risk for altered nutritional status related to weight loss, advanced age, and medical diagnoses. The goal was for Resident #49 to receive and tolerate diet as ordered and consume adequately to maintain weight with no further weight loss, maintain hydration, and aid in the maintenance of skin integrity through the next review. Interventions included encouraging Resident #49 to attend dining room for meals, provide meals and fluids based on residents food preferences and as ordered, let the resident know where food is located on the tray, and observe percentage of intakes for changes in eating habits. Interview on 04/08/24 at 10:10 A.M. with Resident #49 revealed he thought the food at the facility tasted terrible and was not very warm. Observation on 04/10/24 at 12:11 P.M. revealed State tested Nurse Aide (STNA) #122 walked out of a resident's room after delivering a tray and stated, that pizza is hard as a rock and I can't cut it. STNA #122 retrieved a grilled cheese sandwich for the resident as a substitute. Test tray was completed on 04/10/24 at 12:25 P.M. and revealed the pizza was burnt and black on the bottom, was hard to bite into, and did not maintain an appetizing taste. Interview on 04/10/24 at 2:25 P.M. with Resident #49 revealed the pizza for lunch was not good, the bottom was black and burnt, it was hard to chew and made his teeth hurt to eat. This deficiency represents non-compliance investigated under Complaint Number OH00151791.

Based on record review, observation, and staff interview, the facility failed to implement fall prevention interventions for a resident with a history of falls. This affected one resident (#27) of three residents reviewed for accidents. Findings include: Review of Resident #27's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included a stroke with hemiplegia (paralysis) and hemiparesis (weakness) affecting her left non-dominant side, unspecified convulsions, Alzheimer's disease, vascular dementia, severe intellectual disabilities, muscle weakness, unsteadiness on her feet, and difficulty walking. Review of Resident #27's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. She had a functional limitation in her range of motion on one side of her upper and lower extremity. She had one fall since the prior assessment that was without injury. Review of Resident #27's plan of care revealed she had a care plan in place for being at risk for falls. The interventions included the need for her to be in a low bed when not providing care. That intervention had been revised on 10/12/23. Her physician's orders also included the need for a low bed when not providing care with that order originating on 02/03/23. Review of Resident #27's progress notes revealed her last fall occurred on 01/06/24 at 5:54 A.M. She was found lying on the floor on the mat that was next to her bed. Her bed was indicated to be in its lowest position with no injuries occurring as a result of that fall. On 04/08/24 at 1:40 P.M., an observation of Resident #27 noted her to be lying in bed. Her bed was not noted to be in its lowest position and staff were not in the room providing care. On 04/10/24 at 2:26 P.M., further observation of Resident #27 noted her again in bed with the bed not in it's lowest position. Staff were not in the room providing any care to the resident at the time the observation was made. On 04/10/24 at 2:45 P.M., an observation was made of Resident #27 still in bed with her bed not in its lowest position. The bed frame was off the floor about 12 inches and the resident was on a deep perimeter pressure reduction mattress on top of that. Findings were confirmed with Licensed Practical Nurse (LPN) #107. On 04/10/24 at 2:47 P.M., an interview with LPN #107 confirmed Resident #27's bed should be maintained in its lowest position when not receiving care as per her physician's orders and care plan. She lowered the resident's bed by about six inches so it was closer to the floor. She said she was not able to lower it further due to the bed being able to be moved when it was in its lowest position and the [NAME] wheels were in contact with the floor.

Based on observation and interview, the facility failed to prepare pureed foods to meet the needs of residents requiring a pureed diet. This affected two residents (#5 and #19) of two residents who received a pureed diet. The facility census was 55. Findings included: Observation on 04/10/24 at 9:15 A.M. revealed Cook #420 washed her hands prior to beginning pureed foods. The first pureed food item to be prepared was a vegetable salad with Italian dressing. Cook #420 began by adding 12 ounces of vegetables with dressing already mixed in to the Robocoup machine. Cook #420 ran the machine for approximately 30 seconds, then paused to scrape the sides of the machine before continuing to blend again. She repeated this process 10 times. Cook #420 stated the food was not getting to the appropriate pureed texture and asked Dietary Manager (DM) #430 what to do; DM #430 stated she did not know what to do. Cook #420 stopped pureeing the mixture at 9:27 A.M. to taste, but said it was not ready to serve yet. She started to puree the mixture again for approximately 30 seconds, then stopped to scrape the sides before continuing to puree. Cook #420 stated the food was ready to serve. When tasted, chunks were still visible on tongue which was confirmed by Cook #420 and DM #430 at 9:32 A.M. Cook #420 began to puree the mixture again after adding one more serving of vegetables. After approximately 30 seconds, she paused to scrape the sides with a spatula before pureeing again. She repeated this process five times. At 9:40 A.M., Cook #420 stated the mixture was ready to serve. When tasted, the texture was still gritty with pieces getting stuck on tongue and back of mouth. Cook #420 stated she did not know what else to do to make the texture appropriate for those receiving a pureed diet. Cook #420 then added one tablespoon of Italian dressing to the mixture, pureed for approximately 30 seconds, paused to scrape the sides and added another tablespoon of Italian dressing and repeated this process three more times. Cook #420 used the back of her gloved left hand to wipe her nose, did not remove gloves or wash hands. At 9:49 A.M., she paused to taste the texture again which still had chunks of vegetables. DM #430 called Regional Dietary Manager (RDM) #160 who stated to continue running the machine. At 9:53 A.M., Cook #420 started the machine again. After approximately one minute of pureeing, Cook #420 stopped so she and DM #430 could taste the mixture, which was still gritty in consistency, and discarded their used spoons on the prep table. DM #430 picked up the spoons to throw them in the trash and Cook #420 placed her gloved right hand on the prep table where the spoons had previously been. At approximately 10:00 A.M. Cook #420 discarded the mixture and stated she would cook a different vegetable to puree. Interview on 04/10/24 at 10 A.M. with DM #430 confirmed above findings. Observation on 04/10/24 at 10:28 A.M. revealed Cook #420 added 12 ounces of broccoli to the Robocoupe machine and began to puree. She paused to scrape the sides, added one tablespoon of Italian dressing, then started pureeing again. This process was repeated three times. RDM #160 was present at this time and instructed Cook #420 to add more liquid to the mixture; Cook #420 added a tablespoon of Italian dressing to the mixture. After approximately 30 seconds, mixture was tasted and still not a smooth consistency. Cook #420 added another tablespoon of Italian dressing and scraped sides, then continued pureeing. This process was repeated twice. At 10:40 A.M., RDM #160 took over the pureeing process and added two tablespoons of milk and one tablespoon of thickener to the mixture. At 10:49 A.M., the pureeing process was completed for the broccoli and ready to serve at the appropriate texture. Interview on 04/10/24 at 11:56 A.M. with RDM #160 confirmed all findings. The facility identified Residents #5 and #19 were to receive pureed diets.

Based on medical record review, observation, and interview, the facility failed to provide oral care for a resident who is dependent on staff for personal care. This affected one resident (#46) of two residents reviewed for activities of daily living (ADL). The facility census was 55. Findings included: Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type II diabetes, panic disorder, post traumatic stress disorder, and fibromyalgia. Review of a quarterly minimum data set (MDS) completed on 01/17/24 revealed Resident #46 was dependent on staff for completing all activities of daily living. Review of a care plan dated 10/23/23 revealed Resident #46 had an ADL self-care performance deficit related to Alzheimer's disease, dementia, and a history of falls. Goals included residents ADL needs would be met through the next review with interventions including two person assist for personal hygiene, encouraging participation in daily care and providing positive reinforcement for activities attempted and/or partially achieved, and providing cues and assist as needed to accomplish daily tasks. A dental care plan revealed Resident #46 had potential for dental problems related to age with a goal of having good oral hygiene habits through the next review and intervention including providing medication and/or treatment as ordered. Interview on 04/08/24 at 4:45 P.M. with Resident #46's representative revealed at times, Resident #46 has bad breath and he did not believe her teeth were brushed. Observation on 04/09/24 at 12:46 P.M. revealed Resident #46 was resting in bed. When asked if her teeth had been brushed, Resident #46 shook her head no. When asked to see her teeth, Resident #46 smiled and revealed her teeth had a layer of plaque and grime. Observation on 04/09/25 at 3:13 P.M. revealed Resident #46 was seated in the hallway in her wheelchair. When asked if her teeth had been brushed, Resident #46 shook her head no and showed her teeth which continued to have a layer of plaque and grime. Interview on 04/11/24 at 12:57 P.M. with State tested Nursing Assistant (STNA) #134 revealed oral care should be completed on residents who can't brush their own teeth in the morning, evenings, and as needed. Oral care should be completed daily on residents who are dependent upon staff. STNA #134 stated Resident #46 was dependent upon staff for oral care and hygiene. Interview on 04/11/24 at 1:16 P.M. with STNA #134 confirmed Resident #46's teeth had plaque and build up on them and confirmed Resident #46 shook her head no when asked if oral care had been completed and nodded her head yes when asked if she wanted oral care to be completed. STNA #134 stated even though Resident #46 does not speak often, she is able to accurately answer questions by shaking or nodding her head. A policy for oral care was requested on 04/11/24 at 2:52 P.M. from Administrator but was not received.

Based on medical record review and interview, the facility failed to ensure recommendations for restorative ambulation programs were implemented to maintain a resident's ambulatory status. This affected one resident (#37) of three residents reviewed for activities of daily living. Findings include: During an interview on 04/09/24 at 9:03 A.M., Resident #37 stated she used to ambulate with therapy. However, she had not received assistance with walking for weeks and felt she was getting weaker. Review of Resident #37's medical record revealed diagnoses including degenerative disease of the nervous system, peripheral vascular disease, malignant neoplasm of the right breast, type two diabetes mellitus with neuropathy, osteoporosis, macular degeneration, abnormalities of gait and mobility, difficulty walking and generalized muscle weakness. A Physical Therapy (PT) evaluation dated 11/02/23 indicated Resident #37 was referred to PT due to new onset of falls/fall risk, decrease in functional mobility, functional limitation with ambulation, reduced static balance, reduced dynamic balance, decrease in strength, increased need for assistance from others and reduced activity of daily living (ADL) participation. The PT evaluation Indicated Resident #37 had recently suffered a fall when ambulating to the bathroom with no injuries reported. Resident #37 reported her knee buckled on her while ambulating. At baseline, Resident #37 ambulated 50 feet using a rolling walker and minimal assist. A PT discharge summary dated 12/01/23 indicated Resident #37 met a goal to safely ambulate 100 feet using the most appropriate assistive device and contact guard assistance (CGA). The summary indicated Resident #37 progressed well demonstrating improvements in functional strength and mobility. A restorative ambulation program was established for ambulation 100 feet with upright walker and CGA. Prognosis to maintain her current level of function was excellent with consistent staff support. A Therapy to Restorative Nursing Communication - Resident Status Update form dated 01/05/24 indicated plans for a restorative ambulation program for Resident #37 to ambulate 100 feet with stand by assist and use of an upright walker. A PT evaluation dated 02/06/24 indicated Resident #37 was referred for evaluation and treatment following a fall. The prior level of function when discharged from therapy was ambulating 100 feet with CGA. During the evaluation Resident #37 was able to walk 50 feet with CGA. The evaluation indicated Resident #37 felt unsteady when standing and when walking and was worried about falling. A PT discharge summary dated 03/06/24 indicated Resident #37 met a goal of walking 100 feet with CGA on 02/22/24. The summary indicated Resident #37 progressed well demonstrating improvements in functional strength and mobility. A restorative ambulation program was established for ambulating 100 feet with CGA. A therapy quarterly screen dated 04/08/24 indicated Resident #37 was requesting therapy services to improve strength and balance to improve functional mobility and reduce fall risk. PT was recommended. During an interview on 04/09/24 at 3:00 P.M., Registered Nurse (RN) #132 (restorative nurse) stated she had not received a referral for restorative nursing program for Resident #37 since September 2023. When Resident #37 was placed on therapy caseload for ambulation the restorative ambulation programs were discontinued. During an interview on 04/10/24 at 11:50 A.M., Physical Therapy Assistant (PTA)/rehab manager #400 provided a copy of the restorative referral for an ambulation program dated 01/05/24. PTA #400 stated it was an oversight of therapy not to complete a new referral to restorative nursing when PT ended 03/06/24 but assumed the program recommended 01/05/24 would resume.

Based on record review and interviews, facility failed to conduct care conferences with residents in conjunction with minimum data set (MDS) assessments. This affected two residents (#24 and #49) of three residents reviewed for care planning. The facility census was 55. Findings included: 1. Record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, and cognitive communication deficit. Review of a quarterly MDS revealed Resident #24 had mildly impaired cognition. Record review revealed Resident #24 had a discharge planning meeting with the social worker on 05/24/23, a care conference on 06/02/23, 09/20/23, 11/27/23, and a letter inviting them to a care conference on 01/24/24 but no record of the care conference being completed. Interview on 04/08/24 at 4:08 P.M. with Resident #24 revealed they had not had a care conference or been able to make decisions regarding treatment. Interview on 04/11/24 at 9:50 A.M. with Social Services Director (SSD) #126 revealed the admission care conference should be under an assessment called Discharge Planning Evaluation. SSD #126 confirmed the initial care conference was opened on 05/05/23 but completed on 05/09/23 and the interdisciplinary team was not included in the care conference. 2. Record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including rhabdomyolysis, neoplasm of unspecified behavior of bladder, chronic obstructive pulmonary disease, and atrial fibrillation. Review of a quarterly MDS revealed Resident #49's cognition remained intact. Record review revealed Resident #49 had a care conference on 07/28/23. Review of letters provided by SSD #126 revealed Resident #49 was invited to care conferences for 10/10/23 and 02/26/24 but no evidence was provided to show care conference were completed. Interview on 04/08/24 at 10:14 A.M. with Resident #49 revealed he was not invited to participate in care conferences. Interview on 04/10/24 with SSD #126 revealed care conferences are done upon admission, annually, quarterly, and with significant changes. SSD #126 stated she worked with the MDS nurse on scheduling care conferences who keeps a calendar of when residents are due for quarterly and annual assessments, then would send letters to invite resident and family members to care conferences. SSD #126 stated upon admission, the timing of the admission care conference depended on the availability of family members but the facility would still meet with the resident within the first 48 hours to start discharge planning. SSD #126 stated residents only get copies of care plans if they wanted them. SSD #126 stated Resident #49 should have had a care conference in February 2024 but was not able to find documentation and should have had one in October 2023 as well. Review of a policy titled Comprehensive Care Plans (dated 06/30/22) revealed every effort should be made to schedule a care plan meeting at the best time of the day for the resident and family, and when a resident has no family, the ombudsman may be invited to attend the care plan meeting if desired by the resident.

Based on observation, record review and interview, the facility failed to ensure interventions to prevent pressure ulcers were in place per orders. This affected one resident (#39) of two residents reviewed for pressure ulcers. The facility census was 55. Findings included: Record review revealed Resident #39 admitted to the facility on [DATE] with diagnoses including heart failure, type II diabetes, chronic obstructive pulmonary disease, atrial fibrillation, and dementia. Review of orders revealed Resident #39 had orders in place for an alternating air mattress (01/08/24) and zero gravity boots to bilateral feet while in bed (starting on 02/01/23 and discontinued on 04/08/24). Review of care plan dated 12/31/23 revealed Resident #39 is at risk for impaired skin integrity related to confined to a bed all or most of the time, dementia, diabetes, incontinent of bladder, incontinent of bowel, needs assistance with activities of daily living, palliative care, peripheral vascular disease diagnosis, and skin break down to coccyx. Interventions included skin prep to bilateral heels, turn and reposition as tolerated and preventative treatments as ordered. Review of a quarterly minimum data set completed on 01/25/24 revealed Resident #39 required maximum assistance for bed mobility and had pressure reducing devices in bed. Observation on 04/08/24 at 10:34 A.M. revealed Resident #39 was resting in bed with an alternating air mattress in place and zero gravity boots were noted to be on her dresser. Observation on 04/08/24 at 4:14 P.M. revealed Resident #39 was in bed and her zero gravity boots were on her dresser. Interview on 04/08/24 at 4:15 P.M. with Registered Nurse (RN) #110 verified Resident #39 should have her zero gravity boots on while resting in bed. Review of a policy titled Pressure Ulcer/Skin Breakdown - Clinical Protocol (dated 03/20/24) revealed based on the comprehensive assessment of a resident, a resident receives care consistent with professional standards of practice to percent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. The plan of care for prevention and/or treatment of pressure ulcers will be developed based on the assessments to include but not limited to support surfaces, turning schedule/off-loading, moisture management, incontinence management, nutritional management, pain management, disease effects of perfusion and/or healing, medications that may effect perfusion and/or healing. The physician will authorize pertinent orders related to wound treatments including pressure reduction surfaces.

Based on record review, review of facility infection reports, review of inservice records, staff interview, and policy review, the facility failed to ensure antibiotics were not used unless criteria was met for the treatment of urinary tract infections. This affected one resident (#11) of five residents reviewed for unnecessary medications. Findings include: Review of Resident #11's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included neurogenic disorder withe Lewy bodies, Parkinson's disease, psychotic disorder with delusions, anxiety disorder and chronic kidney disease. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had clear speech and was usually able to make herself understood. Her cognition was moderately impaired. Review of Resident #11's progress notes revealed the resident was straight catheterized on 03/07/24 at 5:05 A.M. for a urinalysis. Preliminary urine results were received on 03/07/24 at 10:33 P.M. and showed the resident's urine to be straw yellow in color and its appearance was turbid. There was a large amount of leukocytes and blood in the urine, but nitrites were negative. Protein was present, white blood cells were too numerous to count and had many bacteria. The physician was notified of the results and instructed the nurse to await the urine culture results. Further review of Resident #11's progress notes revealed a nurse's note dated 03/08/24 at 2:38 P.M. revealed the resident had complaints of burning on urination. The physician was notified and gave an order for Pyridium (an analgesic that could relieve symptoms caused by urinary tract infections and other urinary problems) 200 milligrams (mg) by mouth x six doses. He also ordered Macrobid (an antibiotic used in the treatment of urinary tract infections) 100 mg by mouth twice a day for seven days (14 doses). Further review of Resident #11's progress notes revealed a nurse's note dated 03/09/24 at 12:49 P.M. that indicated the resident's urine culture and sensitivity report was received and reported to the physician. A nurse's note dated 03/10/24 at 11:07 A.M. revealed the physician gave an order to discontinue the resident's Macrobid due to the urine culture and sensitivity report that had been received. The culture and sensitivity report only showed flora. Review of Resident #11's physician's orders revealed resident was started on Macrobid 100 mg by mouth two times a day for 14 administrations until finished. The order had been given on 03/08/24 and was discontinued on 03/10/24. Review of Resident #11's urine culture report for final results resulted on 03/08/24 at 8:52 P.M. revealed the urine culture showed 50,000 CFU/ml of mixed commensal flora. The results were faxed to the physician on 03/09/24, as was hand written on the bottom of the culture report, and informed the physician the resident was currently on Macrobid. A note was added on culture report to stop the Macrobid on 03/10/24. Review of Resident #11's infection report dated 03/08/24 revealed the resident had a symptom onset date of 03/06/24. Symptoms include increased frequency/ urgency and urine having a cloudy appearance. The infection report indicated a urine specimen was collected on 03/07/24. The initial urine showed positive leukocytes, white blood cells, red blood cells, bacteria, protein, and blood. The infection report indicated the culture and sensitivity report was pending and Macrobid 100 mg was ordered to be given by mouth x 14 doses. The report showed the Macrobid was discontinued due to the culture results. Review of Resident #11's medication administration record for March 2024 revealed the resident started receiving the Macrobid with an evening dose on 03/08/24. It was discontinued after the morning dose on 03/10/24. Findings were reviewed with the Director of Nursing (DON) on 04/10/24 at 11:50 A.M. On 04/10/24 at 12:05 P.M., an interview with the DON confirmed Resident #11 received an antibiotic for the treatment of a urinary tract infection that did not meet criteria for treatment. She suspected the physician started the resident on the Macrobid before the final culture results were received based on the resident's complaints of dysuria (burning with urination). She acknowledged the resident had been started on Pyridium to help with the burning with urination before the antibiotic had been started. She further acknowledged increasing fluids with the resident may have provided additional relief of her dysuria until the final culture results were available to see if she had a urinary tract infection that needed treatment. She confirmed the final culture results came back showing mixed commensal flora at 50,000 CFU/ml that did not meet criteria for treatment. She stated she had been having problems getting the resident's physician (also the facility's medical director) to abide by the antibiotic stewardship program and had educated him in the past. She stated the physician did not usually provide a rationale to them when wanting to treat a resident for an infection that did not meet criteria. He was more likely to start an antibiotic if a resident displayed symptoms of an infection or the family wanted the resident started on an antibiotic even before the final culture results were received. She acknowledged the resident received four doses of an antibiotic for symptoms of an infection that did not meet the criteria for treatment before it had been stopped. A review of the facility's policy on Antibiotic Stewardship Program (revised 12/13/23) revealed it was the policy of the facility to implement an antibiotic stewardship program as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The infection preventionist coordinated all antibiotic stewardship activities, maintained documentation, and served as a resource for all clinical staff. The medical director served as the primary medical point of contact for the program and served as a Liaison between the facility and other medical staff members. The antibiotic use protocols included the facility using the McGeer criteria to define infections.

Based on observations, record review, review of a food preference form, and interview, the facility failed to ensure a resident received food according to assessed food preferences/dislikes. This affected one resident (#58) of 24 residents reviewed for food/nutrition. Findings include: During an interview on 04/08/24 at 11:50 A.M., Resident #58 reported she did not like the facility's scrambled eggs so the facility generally prepared and served her fried eggs. Review of Resident #58's medical record revealed diagnoses including morbid obesity, anxiety disorder and depressive disorder. A care plan initiated 03/22/24 indicated Resident #58 was at risk for altered nutritional status related to a baseline care plan indicating obesity and medication diagnoses that included hyperlipidemia, depression, vitamin D deficiency, heart failure, and stage three chronic kidney disease. Interventions included providing meals/fluids based on resident food preferences and updating/honoring resident's food preferences on the tray ticket. On 04/09/24 at 8:19 A.M., Resident #58 was observed in bed with her breakfast tray in front of her. Items served included scrambled eggs. Resident #58 stated she addressed it with one of the girls and was told because her meal ticket indicated scrambled eggs there was nothing she could do to provide an alternate. On 04/09/24 at 8:27 A.M., interview with Dietary District Manager #160 verified Resident #58's food preference list indicated she disliked scrambled eggs. Upon request, Dietary District Manager #160 stated he would prepare fried eggs for Resident #58.

Based on observation, record review, review of medical nutrition therapy recommendations, facility policy and procedure review and interview the facility failed to timely address significant weight loss and/or communicate weight loss recommendations to appropriate staff. Actual Harm occurred on 05/25/22 when Resident #41 was assessed to have a 11.2 pound/11.07% severe weight loss in less than thirty days following her admission on 04/27/22. During this time period, the facility failed to implement timely comprehensive, individualized and effective interventions to prevent the weight loss, promote weight gain, communicate dietary recommendations to the physician and ensure an ordered dietary supplement was being consumed by the resident. This affected three residents (#20, #32 and #41) of six residents reviewed for nutrition/weight loss. The facility identified four residents with significant weight loss. Findings include: 1. Review of Resident #41's medical record revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident's admission weight on 04/27/22 was 101.2 pounds. Review of Resident #41's physician's orders revealed on 04/27/22 she was ordered a regular diet with regular texture and regular fluids of thin consistency. On 04/28/02 the resident was ordered weekly weights for four weeks then monthly. Review of Resident #41's care plan, dated 04/29/22 revealed the resident had a potential for decline in nutritional status related to sub-optimal intake of food/fluids. The goal was for the resident to maintain adequate nutritional status as evidenced by maintaining weight in the range of 100-105 pounds, having no signs or symptoms of malnutrition and consuming at least 50% of at least three meals daily. Interventions were to provide and serve diet as ordered, weigh per facility protocol and report significant weight changes to the registered dietitian, encourage fluid intake and provide a multivitamin and calcium supplement daily. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 05/02/22 revealed the resident was moderately cognitively intact and had poor appetite. The assessment revealed the resident was independent with her eating ability, needed setup help only with meals and was not prescribed a weight-loss regimen. On 05/04/22 the resident weighed 95.0 pounds and on 05/05/22 the resident's weight was 96 pounds which reflected a 5.2 pound weight loss from admission (04/27/22 to 05/05/22). Review of Resident #41's 05/06/22 nutrition and hydration note revealed recommendations to get resident up in wheelchair for meals, allow resident to smoke per facility rules, encourage fluid intake and start Med Plus 2.0 (120 milliliters (ml)) supplement two times per day. Review of a Medical Nutritional Therapy Recommendation form for Resident #41, dated 05/06/22 revealed it included only the recommendation for Med Plus 2.0 (120 ml) two times per day. The recommendations for the resident to be up in wheelchair, encouraging fluid intake and smoking were not included on the form. In addition, there was no evidence the recommendation for the resident to be up in the wheelchair for meals was added to the resident's plan of care. On 05/06/22 a physician order was obtained for Med Plus 2.0 (a dietary supplement) 120 milliliters (ml) two times a day for calorie support. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 8:00 P.M. Staff were to include the percentage of supplement consumed. From 05/06/22 at 8:00 P.M. through 05/13/22 at 8:00 P.M. the resident was only consuming 50 percent (%) of the ordered supplement. There was no evidence the facility re-evaluated the appropriateness of the supplement or effectiveness of this intervention to promote weight gain, prevent additional weight loss during this time period. On 05/14/22 and 05/15/22 the resident consumed only 25% of the 8:00 P.M. Med Plus. On 05/16/22 the resident weighed 92.8 pounds which reflected an additional 3.2 pound weight loss from 05/05/22. There was no evidence the resident was reassessed or evidence of any new dietary interventions being considered/initiated at that time. On 05/16/22 and 05/17/22 the resident did not consume any of the 8:00 A.M. Med Plus supplement. Between 05/18/22 and 05/25/22 the resident consumed between 10% and 60% of the ordered supplement. On 05/25/22 the resident weighed 90 pounds which reflected an additional 2.8 pound weight loss from 05/16/22. From an admission (04/27/22) weight of 101.2 pounds to a current weight on 05/25/22 of 90 pounds the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #41's percentage of meals eaten between 04/29/22 and 05/28/22 revealed she had refused 35 meals and her percentage of meal intake ranged from five percent to 100 percent with the average for 52 meals being 21.7 percent. On 05/24/22 at 12:09 P.M. Resident #41 was observed lying in bed with head of bed (HOB) elevated and her meal tray on her over bed table. The meal consisted of ham, spinach, mashed sweet potatoes, cottage cheese, chocolate ice cream, fresh fruit in pieces and coffee. At 12:25 P.M. Resident #41 remained in bed with the HOB elevated and minimal of meal eaten. A staff member was observed to ask the resident if she would like tray left for additional time to eat and the resident responded, no. On 05/24/22 at 6:00 P.M. Resident #41 was observed lying in bed with the HOB elevated. The resident had ice cream on the meal tray and had eaten some pudding and cookies. The resident had consumed a minimal amount of the total meal. On 05/25/22 at 7:21 A.M. interview with the Director of Nursing (DON) revealed when the dietitian made a recommendation, it was provided to the nursing department and if a physician's order was needed, then the resident's physician was contacted to obtain the order. The DON failed to provide evidence the resident's decreased meal intakes, supplement intakes and continued weight loss were timely reported to the physician/dietitian for re-evaluation or for changes to nutritional interventions to prevent additional weight loss/promote weight gain for the resident. On 05/25/22 at 7:48 A.M. Resident #41 was observed sitting in bed eating breakfast with the HOB elevated. Interview with the resident at the time of the observation revealed she was aware she was losing weight and it was a concern for her family. She reported she doesn't have pain from her previous sacrum fracture and could sit in a chair. On 05/25/22 at 11:40 A.M. interview with Dietitian #206 revealed in general, her recommendations were placed on a Medical Nutritional Therapy Recommendation form and provided to the the DON, dietary manager and nurses working the hall to implement or to be used by nursing to contact the physician for orders, if physician orders were required. On 05/25/22 at 11:56 A.M. interview with State tested Nursing Assistant (STNA) #137 revealed she was not aware of any recommendation to get Resident #41 up in her wheelchair for meals. STNA #137 revealed she does not ask Resident #41 on a regular basis to sit in a chair for meals. She verified she is also not aware of any recommendations related to smoking for the resident. On 05/25/22 at 12:30 P.M. interview with the DON revealed all recommendations from the dietitian were to be put on the Medical Nutritional Therapy Recommendations. The DON revealed if a physician order was needed, then the physician would be contacted for same. If a physician order wasn't needed, then the recommendations would be care planned and would result on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/25/22 at 12:23 P.M. interview with Dietitian #206 verified the electronic health record (EHR) progress note dated 05/06/22, which she wrote, had four recommendations but only one recommendation was included on the Medical Nutritional Therapy Recommendations dated for the same day for Resident #41. Dietitian #206 revealed she doesn't put all the recommendations on the Medical Nutritional Therapy Recommendations form, only the ones that required a physician's order. Dietitian #206 revealed she expected the nursing staff to read her progress notes to be aware of all of the recommendations. On 05/25/22 at 2:26 P.M. a nutrition/hydration note revealed the resident had a significant weight loss since admission to the facility related to sub-optimal caloric intake. The note revealed poor performance at meals continues; not taking Med Plus supplement very well. At this time the dietitian recommended adding the frozen nutritional supplement, magic cup at all meals for calorie support. On 05/26/22 at 7:45 A.M. Resident #41 was observed sitting in bed eating breakfast with the HOB elevated Review of the facility policy titled Nutritional Management, dated 01/01/21 revealed the facility provided care and services to each resident to ensure the resident maintained acceptable parameters of nutritional status in the context of his or her overall condition. It revealed that acceptable parameters of nutritional status referred to factors that reflect that an individual's nutritional status was adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake and pertinent laboratory values. The policy added that a systemic approach was used to optimize each resident's nutritional status by developing and consistently implementing pertinent approaches. In addition, it revealed interventions would be individualized to address the specific needs of the resident. Example included environmental interventions. An example of an environmental intervention would be having the resident sit in a chair during meals. Review of the facility policy titled Comprehensive Care Plans, dated 01/01/21 revealed the comprehensive care plan would be prepared by an Interdisciplinary Team, that included a member of the food and nutrition services staff. Review of the Resident Food Preferences Policy, implemented 01/01/21 revealed nutritional assessments would include an evaluation of individual food preferences. Upon the resident's admission, (the) Dietary Manager or designee would identify a resident's food preferences. When possible, this would be done by direct interview with the resident as soon as possible after admission. The resident's clinical record (orders, care plan, or other appropriate locations) would document the resident's likes and dislikes and special dietary instructions or limitations such as altered food consistency and caloric restrictions. The dietary manager or designee would visit residents periodically to determine if revisions were needed regarding food preferences. The nursing staff would inform the kitchen about resident requests. The Food Services Department would offer food substitutes for individuals who do not want to eat the primary meal. Review of the Weight Monitoring Policy and Procedure, dated 01/01/21 revealed based on the resident's comprehensive assessment, the facility would ensure that all residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte imbalance, unless the resident's clinical condition demonstrates this was not possible or resident preferences indicated otherwise. Weight could be a useful indicator of nutritional status. Interventions would be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule will be developed upon admission for all residents: a. weights should be recorded at the time obtained. b. newly admitted residents- monitor weight weekly for four weeks c. Residents with weight loss- monitor weight weekly d. If clinically indicated- monitor weight daily e. All others- monitor weight monthly Further review of the policy revealed weight analysis, the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in one month (30 days) b. 7.5% change in weight in three months (90 days) c. 10% change in weight in six months (180 days) The physician should be informed of a significant change in weight and may order nutritional interventions. The interdisciplinary plan of care communicates care instructions to the staff. 2. Review of Resident #20's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nutrition data collection/evaluation V2, dated 03/11/22 revealed the resident was on a pureed diet but the resident and family wanted her on a regular diet despite the risks and the resident's food preferences had been updated. The resident was admitted to the facility with a speech therapy recommendation from the hospital for a pureed diet. The resident would not eat the pureed texture, likely contributing to her weight loss. The resident and family requested a regular diet despite education on concerns for safety. The resident's diet was upgraded per physician's orders and the facility speech therapist was notified for consult. Poor oral intakes continued at this time, 33% meal intake since admission. The resident was dependent of staff for eating. The dietician recommended adding Med Pass 2.0 120 milliliters three times a day to provide an additional 720 calories and 30 grams of protein to meet the resident's estimated nutritional needs for weight maintenance. Staff should continue to encourage good oral intakes as tolerated by the resident. The dietician would continue to monitor and follow up as needed. Review of the resident has the potential for nutritional deficits related to advanced age, weight loss and poor oral intake care plan initiated 03/11/22 revealed interventions including administer medications as ordered, monitor/document for side effects and effectiveness, monitor/document/report to nurse/physician as needed for any signs and symptoms of dysphagia (pocketing, choking, coughing, drooling, holding food in your mouth, several attempts at swallowing), monitor/record/report to physician as needed signs and symptoms of malnutrition (emaciation, muscle wasting, significant weight loss (3 pounds in a week; greater than five pounds in a month; greater than 7.5% in 3 months or greater then 10% in six months) and provide and serve diet as ordered, provide and serve supplements as ordered. The care plan revealed the registered dietician was to evaluate and make diet change recommendations as needed and weigh per orders. Review of the nutrition note, dated 03/24/22 revealed the resident weighed 173.8 pounds and had experienced a significant weight loss since admission to the facility. The resident refused to comply with the recommended food texture (pureed) and requested regular textures. The resident was refusing Med Plus 2.0 at times. The resident had continued weight loss despite addition of Med Plus supplement. Poor appetite continues. The resident was fed by staff. Recommendations: add house shake supplement with all meals and consider the start of [MEDICATION(S)] (anti-depressant that can be used for weight gain) or [MEDICATION(S)] (man-made form of cannabis used to treat loss of appetite that causes weight loss). Review of the nutrition note, dated 03/30/22 revealed the resident continued to remain with a significant weight loss. An appetite stimulant was recommended on 03/24/22 and not yet ordered. Please consider an appetite stimulant and house shake supplement to continue. Discontinue the Med Pass 2.0 supplement die to the resident not taking. The resident's physician declined an appetite stimulant. Review of the physician's orders revealed to obtain a monthly weight between the first and the tenth of each month and a regular diet with thin liquids dated 04/01/22. A sippy cup and divided plate with meals was ordered beginning on 04/29/22. Review of the resident's weights revealed the following: 03/05/22 194.8 pounds 03/08/22 188.6 pounds 03/15/22 173.8 pounds 03/29/22 162 pounds 04/02/22 166 pounds 05/06/22 153 pounds 05/09/22 160.9 pounds 05/10/22 159 pounds No further weights were available. Review of the quarterly MDS 3.0 assessment, dated 03/31/22 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating she was cognitively intact. The assessment revealed the resident required total dependence on two staff for bed mobility, transfers, toilet use and personal hygiene. The resident required extensive assistance of one staff member for eating. Lastly, the resident had experienced a weight loss of greater than 5% or more in the last month. Review of the nutrition note, dated 05/06/22 revealed the resident weighed 153.2 pounds with significant weight loss noted. The resident had poor appetite and poor performance with meals even though assisted by family members. The resident was refusing to consume Med Plus 2.0, house shake supplement and nutritional juice supplement. Weight loss related to composition changes (muscle atrophy) and sub-optimal caloric intake. The resident was refusing the nutritional supplements on formulary at the facility. Numerous complaints about meals. Recommendations: discontinue shake supplements with meals and have the dietary manager see the resident for food preferences. The medical record contained no evidence the resident's preferences were assessed/addressed. Review of the resident's meal ticket revealed no evidence of meal preferences. On 05/25/22 at 8:01 A.M. the resident was observed lying in bed with her meal tray covered. The resident was waiting for her family to assist her with her meal. The resident denied anyone asking about her food preferences and stated this would dramatically change how much food she consumed. The resident stated she liked soup but it was not an available option and she could not remember the last time she was provided soup by the facility. On 05/25/22 at 8:12 A.M. interview with Dietary Manager #164 revealed soup was not on the menu replacement/always available items and she currently was not able to order soups. The DM revealed she was unsure if residents requested soups for meals but if I have it, I give it to them The DM denied having small cans of soup available. The DM revealed soups were not currently available to purchase per the budget. Lastly, the DM verified she was unaware Resident #20 had a preference for soup as she was unaware the dietician recommended the dietary manager discuss food preferences with the resident. The DM verified the resident's preferences had not been assessed, even upon her admission to the facility. On 05/25/22 at 8:15 A.M. observation of the dry food storage revealed the facility had one 50 ounce can of chicken noddle soup and four 50 ounce cans of tomato soup. The facility also had nine 50 ounce cans of cream of mushroom soup used for cooking. On 05/25/22 at 11:32 A.M. interview with Dietician #206 verified the resident had experienced an 18.2% weight loss since admission, less than three months ago indicating a significant weight loss. The dietician verified the resident should have been a weekly weight given her weight loss and the dietary manager was to have discussed food preferences with the resident as she had recommended on 05/06/22. The dietician revealed she writes her recommendations on the medical nutritional therapy recommendations log and that was provided to both floor nurses and the dietary manager. The dietician verified the recommendation for the dietary manager to discuss food preferences with the resident was not on the recommendation log, however staff should be reading her progress notes to ensure all recommendations were addressed. 3. Review of Resident #32's medical record revealed a 05/26/19 admission and a 12/03/20 readmission. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 05/14/21 potential for decline in nutritional status related to advanced age, significant weight loss and mechanically altered diet included a goal for the resident to maintain adequate nutritional status as evidenced by maintaining weight with no significant changes, no signs or symptoms of malnutrition and consuming at least 75 percent of at least three meals daily through review date. A 05/14/21 intervention included to weigh per facility policy, monitor, record, report to physician as needed signs and symptoms of malnutrition (emaciation, muscle wasting, significant weight loss of greater than five percent in one month, 7.5 percent in three months or greater than 10 percent in six months). Record review revealed a significant weight loss trend starting 08/04/21 when the resident had a 6.9 pound weight loss of 5.2 percent in 30 days due to decreased calorie intake. The trend continued with the 10/07/21 assessment which included a 8.1 percent weight loss of 10.7 pounds in three months. The weight loss was monitored until the 12/10/21 quarterly nutritional assessment when the resident had a 7.6 percent weight loss of 9.6 pounds in 90 days and 12.1 percent weight loss in 180 days with a 16.2 pound weight loss. The resident had no change in appetite, but meal intake had decreased since lower gum soreness started. The plan was for the resident to have meats chopped and gravy provided to allow for less mastication (not using lower denture), also going to provide ice cream at lunch and dinner meals for caloric support. Review of a physician's order revealed an order, dated 12/10/21 to add ice cream to lunch and dinner tray for weight loss trend. On 01/04/22 an order was obtained for a regular diet, regular texture, regular fluid, thin consistency, no straws/shred lettuce diet; change to chopped meats with gravy and add ice cream (magic cup) to lunch and dinner tray. A 01/10/22 nutrition note included continued weight loss of seven pounds in 30 days for 5.9 percent, 8.9 percent/10.8 pounds in 90 days and 16.2 percent/21.5 pounds in 180 days. The note revealed no change in appetite, but meal intake has decreased to 50 percent since lower gum soreness started. CEA and CA-125 tests to rule out underlying condition that may be cause of weight loss was ordered and was within normal limits. On 01/21/22 an order was received for the supplement, Med Pass 2.0 120 milliliters (ml) three times a day for weight loss. The resident had a 4.2 pound weight gain between 01/04/22 and 02/02/22 then a seven pound 6.07 percent significant weight loss between 02/02/22 and 03/01/22. The resident had a dental clean and check of dentures 03/10/22. A 03/11/22 annual nutritional evaluation revealed the resident was triggering for a significant weight loss of 6.2 percent in 30 days, 8.2 percent in 90 days and 15.2 percent in 90 days. There were no recommendations made at that time. A dietician recommendation, dated 03/30/22 to consider an appetite stimulant for continued weight loss. The physician was notified, however no new orders were received at that time. On 04/02/22 the resident's weight was 103.6 pounds which reflected a 3.8 pound weight loss/3.54 percent between March and April of 2022. There was a 10.23 percent/11.8 pound weight loss in 60 days from 02/02/21 through 04/02/22. There was no evidence of any additional nutritional interventions following the significant weight loss of 11.8 pounds in two months. There was no evidence the facility obtained weekly weights per policy with the trending weight loss starting in August of 2021. Review of the 04/06/22 annual Minimum Data Set (MDS) 3.0 assessment revealed the resident was independent for daily decision making, independent with set up for eating and significant weight loss of greater than 5 percent in 30 days or greater than 10 percent in six months. Review of a 05/06/22 nutrition note revealed the resident had a significant 10.2 percent/11.8 pound unintended weight loss in 90 days and a 15.1 percent/18.4 pound weight loss in 180 days. Caloric intake had declined in past several months related to ill-fitting denture and the resident had a sore in mouth (now resolved). The resident had uncontrolled movement resulting in increased energy expenditure. Facility physician would not order appetite stimulant. The note reflected to consider obtaining a neurological consult for uncontrolled movements. The Med Pass 2.0 supplement for weight loss was discontinued 05/06/22 due to the resident refusal. On 05/23/22 at 10:42 A.M. interview with Resident #32 revealed the resident didn't know know why she is losing weight but indicated she didn't want to (lose weight). The resident did include she liked the ice cream and (magic cup) supplement. On 05/25/22 at 11:59 A.M. interview with Dietician #206 revealed it was the facility policy if there was a resident with a significant weight loss to obtain weekly weights. Dietician #206 revealed she expected nursing staff to initiated the weekly weekly and indicated she didn't write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The dietician revealed she did not know what else to offer the resident. The resident would eat magic cups but she was not a fan of someone living on magic cup. She did not want to put more magic cup or ice cream on the tray because she wanted the resident to eat the regular meal. She did not consider having nursing offer an additional magic cup if the resident did not eat a specified percentage of her meal. She had not considered fortified foods. Review of the Weight Monitoring Policy and Procedure, dated 01/01/21 revealed based on the resident's comprehensive assessment, the facility would ensure all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte imbalance, unless the resident's clinical condition demonstrates this was not possible or resident preferences indicated otherwise. Weight could be a useful indicator of nutritional status. Interventions would be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. A weight monitoring schedule will be developed upon admission for all residents: a. weights should be recorded at the time obtained. b. newly admitted residents- monitor weight weekly for four weeks c. Residents with weight loss- monitor weight weekly d. If clinically indicated- monitor weight daily e. All others- monitor weight monthly Further review of the policy revealed weight analysis: the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in one month (30 days) b. 7.5% change in weight in three months (90 days) c. 10% change in weight in six months (180 days) The physician should be informed of a significant change in weight and may order nutritional interventions. The interdisciplinary plan of care communicated care instructions to the staff.

Based on record review, facility policy and procedure review and interview the facility failed to ensure residents had a monthly resident council meeting and failed to ensure adequate and timely responses to residents' concerns. This affected 13 residents (#1, #4, #5, #9, #14, #21, #23, #31, #32, #37, #44, #45 and #155) of 50 residents residing in the facility who had voiced concerns through resident council. Findings include: Review of facility resident council minutes for the past twelve months revealed there was no meeting conducted in April 2022. Review of facility resident council minutes, dated 08/09/21 revealed Residents #1, #4, #14, #21, #23, #32, #44 and #155 were informed that activities had started in that evening the month of August 2021. Review of facility resident council minutes, dated 01/21/22 revealed Residents #4, #9, #14, #44 and #155 were informed soup being added to the menu was discussed with the kitchen manager and administrator but there was no funding for soup. Review of facility resident council minutes, dated 03/13/22 revealed Residents #1, #4, #5, #9, #21, #23, #31, #32, #37 and #45 were informed the dietary manager was looking into different food items for the men. On 05/26/22 at 11:31 A.M. an interview with the Administrator verified there was no resident council meeting in April 2022 due to not having an activities director. He also verified he did not offer the residents' a meeting opportunity the month of April 2022 with a different staff member. He reported he kept in touch with the president of resident council but a formal meeting was not offered. On 05/26/22 at 12:00 P.M. an interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities and soups to be added to the menu. All four residents revealed they have not received any response as to why they don't have more activities or soup. The residents denied any recall of being told there was no funding for soup. On 05/26/22 at 5:31 P.M. interview with the Administrator revealed the responses regarding resident concerns presented during resident council were discussed verbally during the next resident council meeting. The Administrator revealed there were no written responses provided to the residents of the facility. Review of the facility policy titled Resident Council, dated 08/07/20 revealed the facility supported resident desires to be involved and have input into the operation of the facility. It also revealed council meetings were to be scheduled monthly or more frequently if requested by residents or the Administrator.

Based on review of resident personal fund account records, facility policy and procedure review and interview the facility failed to ensure quarterly bank statements were provided to residents/responsible parties and available for review. This affected 30 resident (#1, #2, #3, #4, #5, #6, #7, #8, #9, #16, #18, #19, #20, #21, #23, #24, #26, #27, #28, #29, #30, #34, #35, #36, #37, #38, #43, #44, #47 and #155) of 30 residents who had personal fund accounts maintained by the facility. The facility census was 50. Findings include: On 05/23/22 at 3:56 P.M. interview with Resident #1 revealed a concern she did not receive a quarterly statement related to her personal fund account. On 05/26/22 at 4:48 P.M. review of the resident personal account fund records with Business Office Manager #126 and Accounts Payable #152 revealed they had no written evidence of providing quarterly statements to all residents and/or the resident's responsible party for whom they managed personal fund accounts for. The staff members indicated they did receive quarterly resident trust fund (RTF) statements mailed to them from National Data Care RFMS banking and do not have electronic copies. They indicated they do send the statements to the responsible party or hand deliver them to each resident BOM #126 indicated if a resident was their own responsible party they would give the resident their quarterly statement in an envelop. If they had a financial responsible party then they would mail the responsible party the statement. If a resident had no responsible party and poor cognition they would file the quarterly statement and did not give it to anyone. The facility does not have the resident sign they received the statement, nor do they have responsible parties acknowledge they received the statement. They do not send them certified. The staff members indicated they do not make a copy of the quarterly statements to keep with the the residents' funds account records. Review of Resident #1's fund records revealed a statement was in her file. Review of Resident's #19 records revealed no quarterly statement was in her file. Resident #6 and Resident #7 had statements in their fund file. Review of the facility Resident Trust Funds Policies and Procedures, implemented 01/01/21 revealed the Resident Trust Funds (RTF) designee would mail quarterly RTF statements and retain a copy either hardcopy or electronically. On 05/26/22 at 4:46 P.M. interview with Business Office Manager #126 and Accounts Payable #152 revealed Resident #6 and Resident #7 do not receive their statement nor does a responsible party, so they were kept in their file. Resident #19's daughter gets her statement so she did not have a statement in her file because they do not make copies. Resident #1 had her first quarter statement in her file. She was her own responsible party and should have received hers in an envelope. Since it was in her file there was no evidence she received it. Business Office Manager #126 and Accounts Payable #152 again verified they do not maintain copies of the quarterly statements. During the interview, Business Office Manager #126 and Accounts Payable #152 revealed there were 30 residents, #1, #2, #3, #4, #5, #6, #7, #8, #9, #16, #18, #19, #20, #21, #23, #24, #26, #27, #28, #29, #30, #34, #35, #36, #37, #38, #43, #44, #47 and #155 for whom the facility managed personal funds for.

Based on record review and interview the facility failed to employ a qualified activity professional as required. This affected four residents (#10, #15, #7 and #6) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting who voiced concerns regarding activities. The facility census was 50. Findings include: 1. Record review revealed the facility former Activity Director (AD), AD #204 who was qualified to function as facility activity director last date worked in the facility on 09/02/21. Activity Director (AD) #203 was hired 09/08/21 and worked until 04/19/22. However, AD #203 was not certified or eligible as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body. AD #203 did not have two years of experience in a social or recreational program within the last five year nor was she a qualified occupational therapist or occupational therapy assistant. AD #203 had not completed a training course approved by the State. Activity Director (AD) #130 was hired on 05/09/22 but did not meet the qualifications for a qualified professional, qualified therapeutic recreation specialist or an activities professional. Activity Assistant (AA) #205 went on leave 02/16/22 through 05/08/22 when she resigned. AA #205 was also not a qualified activity professional. On 05/25/22 at 5:53 P.M. interview with the Director of Nursing verified the facility had not had a qualified activities professional since 09/02/21. 2. On 05/26/22 at 12:00 P.M. a group meeting interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities. All four residents revealed they have not received any response as to why they don't have more activities. During the meeting, the residents present reported there were not enough activities and they felt the facility needed to have more activities on the weekends. The residents indicated there were no activities on the weekends. On 05/26/22 at 5:31 P.M. interview with the Administrator revealed the responses regarding resident concerns presented during resident council were discussed verbally during the next resident council meeting. The Administrator revealed there were no written responses provided to the residents of the facility. Review of the monthly activity calendars revealed the weekends repeated the same activities on Saturday and Sunday. On Saturdays the calendar listed daily chronicle at 2:30 P.M. worksheets, arts, coloring in the activity room and at 5:00 P.M. social hour. On Sundays the calendar listed daily chronicle at 2:30 P.M. bible study in activity room and 5:00 P.M. cards and social in activity room. Monday through Friday activities repeated the same activities each Monday, Tuesday, Wednesday, Thursday and Friday of the week. Each day indicated daily chronicles. Monday, Wednesday and Friday at 1:00 P.M. there was bingo. Every Tuesday and Thursday revealed game/arts and craft. Monday, Wednesday and Fridays at 5:00 P.M. the calendar listed social time and cards. On Tuesday and Thursday at 5:00 P.M. was movie. On 05/26/22 at 5:53 P.M. interview with the Director of Nursing (DON) verified the facility did not have formal activities on the weekends since the part time activity aide went on leave. The facility revealed the former activity assistant, Assistant #205 last worked 02/16/22. The DON revealed staff had been offering some activities through the week. Review of the facility Activities policy, revised 02/06/22 included it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities would be designed to meet the interests of and support the physical, mental and psychosocial well being of each resident, as well as encourage both independence and interaction within the community. Special consideration would be made for developing meaningful activities for residents with dementia and/or special needs. 3. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, [CONDITION(S)] and [CONDITION(S)]. On 05/23/22 at 11:46 A.M. Resident #6 was observed in bed with no activities occurring. On 05/23/22 at 3:46 P.M. the resident was in bed with the television on. On 05/24/22 at 12:31 P.M. the resident was in her room out of bed in a wheelchair with a Hoyer lift pad under her. The television was on. On 05/24/22 at 03:30 P.M. the resident was in her room sitting in a wheelchair. Review of the activity attendance documentation in the facility electronic TASK section revealed the resident did not attend any planned activities in the last 30 days. The daily activities documented in the last 30 days included television and other. There were no refusals of activities documented. The resident was not interviewable. On 05/23/22 at 11:48 A.M. interview with State tested Nursing Assistant (STNA) #108 revealed other on the TASK record could mean the resident was pushed to the nurse's station but stated she was unsure. The STNA revealed Resident #6 spent most of her time in bed or in her room in a wheelchair. On 05/24/22 at 1:07 P.M. interview with Facility Support Advocate #146 revealed she assists with activities in the facility but does not keep track of who attended any particular activity. On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the facility had no paper documentation for activities as all activities were documented in the electronic documentation TASK section for each resident. During the interview, Social Services/Activities (#130) verified there were no activities for Resident #6 other than television and other and she did not know what other meant. There was no plan of care related to activities for Resident #6 and no evidence staff provided any type of one on one activities as the resident was typically in her room. Social Services/Activities #130 verified there was no documentation of activities of choice or an activity plan of care for Resident #6. 4. Review of Resident #7's medical record revealed an admitted d of 02/09/17 with diagnoses including cerebral infarction, chronic obstructive pulmonary disease, unspecified [CONDITION(S)], Alzheimer early onset, delusional disorders, major depressive disorder, vascular dementia and [CONDITION(S)]. Review of the electronic TASK activity documentation for activities revealed no planned activities in the last 30 days had occurred. Daily documented activities were television and other. There were no refusals documented. There was no evidence the resident was provided one on one activities or activities in her room. On 05/23/22 at 10:39 A.M. and 3:47 P.M. and 05/24/22 at 12:31 P.M. and 3:31 P.M. revealed Resident #7 was in her room in bed. The resident's television was noted to be on. On 05/24/22 at 12:59 P.M. interview with Resident #7 revealed she preferred to stay in bed because her back hurt. On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the STNA staff documented in the TASK section to reflect activity participation for Resident #7. Social Services/Activities #130 verified there was no evidence of any planned activities for the resident. On 05/24/22 at 5:09 P.M. interview with STNA #108 revealed Resident #7 watched television and would sometimes come out in the hall for a half hour to an hour then wanted to get back to bed. The STNA revealed the facility had not had any formal activities for a while and indicated she talked to the resident about cats because she knew she had them. 5. Review of Resident #15's medical record revealed a 03/02/22 admission with diagnoses including [CONDITION(S)] of vertebra, sacral and sacrococcygeal region, pressure ulcer of sacral region Stage IV (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer), type 2 diabetes, [CONDITION(S)], dementia, Alzheimer's, abnormal posture, heart failure and dysphagia. Review of the electronic TASK revealed daily routine activities included the resident had visits with family and friends, watched television and other. There was no indication what other meant. There were no planned activities documented for the resident in the last 30 days. On 05/23/22 at 10:35 A.M., 2:54 P.M. and 5:03 P.M., on 05/24/22 at 11:52 A.M., 2:37 P.M. and 5:12 P.M. and on 05/25/22 at 11:48 A.M. and 3:47 P.M. Resident #15 was observed in bed with no activities occurring. On 05/24/22 at 4:27 P.M. interview with Social Service/Activities #130 revealed she had not met the resident as of this date. On 05/24/22 at 05:12 P.M. interview with STNA #113 revealed she had never assisted the resident up out of bed. The STNA revealed the resident liked her stuffed animals and kept them next to her chest and loved ice cream. On 05/24/22 at 5:22 P.M. interview with Social Service/Activities #130 verified there was no evidence of one on one visits or pet visits for the resident. On 05/24/22 at 5:57 P.M. during an interview with the DON, the concern related activities for Resident #15 was discussed. The DON verbalized she figured there would be an issue with activities and stated she did not know of activities being provided to the resident. 6. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses including Alzheimer's disease, dementia with behavioral disturbances and encounter for palliative care. Review of Resident #10's activity log from 04/27/22 through 05/26/22 revealed Resident #10 was provided watching a television as an activity 11 of the last 30 days. Continued review revealed Resident #10 was noted with 19 of 30 days with other documented under the activity section. On 05/26/22 at 4:00 P.M. interview with the DON revealed the facility was currently without a full time qualified activity director and activities were not being provided on a routine basis. When asked what the other activity was for Resident #10, the DON revealed she was not sure.

Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized activity program to meet the total care needs and/or preferences of all residents. This affected four residents (#6, #7, #10 and #15) of four residents reviewed for activities and four additional residents (#4, #5, #9 and #23) present at a resident group meeting during the survey who voiced concerns related to activities. The facility census was 50. Findings include: 1. On 05/26/22 at 12:00 P.M. a group meeting interview with Resident #4, #5, #9, and #23 revealed they had previously requested more activities. All four residents revealed they have not received any response as to why they don't have more activities. During the meeting, the residents present reported there were not enough activities and they felt the facility needed to have more activities on the weekends. The residents indicated there were no activities on the weekends. On 05/26/22 at 5:31 P.M. interview with the Administrator revealed the responses regarding resident concerns presented during resident council were discussed verbally during the next resident council meeting. The Administrator revealed there were no written responses provided to the residents of the facility. Review of the monthly activity calendars revealed the weekends repeated the same activities on Saturday and Sunday. On Saturdays the calendar listed daily chronicle at 2:30 P.M. worksheets, arts, coloring in the activity room and at 5:00 P.M. social hour. On Sundays the calendar listed daily chronicle at 2:30 P.M. bible study in activity room and 5:00 P.M. cards and social in activity room. Monday through Friday activities repeated the same activities each Monday, Tuesday, Wednesday, Thursday and Friday of the week. Each day indicated daily chronicles. Monday, Wednesday and Friday at 1:00 P.M. there was bingo. Every Tuesday and Thursday revealed game/arts and craft. Monday, Wednesday and Fridays at 5:00 P.M. the calendar listed social time and cards. On Tuesday and Thursday at 5:00 P.M. was movie. On 05/26/22 at 5:53 P.M. interview with the Director of Nursing (DON) verified the facility did not have formal activities on the weekends since the part time activity aide went on leave. The facility revealed the former activity assistant, Assistant #205 last worked 02/16/22. The DON revealed staff had been offering some activities through the week. Review of the facility Activities policy, revised 02/06/22 included it was the policy of the facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences of each resident. Facility sponsored group and individual activities and independent activities would be designed to meet the interests of and support the physical, mental and psychosocial well being of each resident, as well as encourage both independence and interaction within the community. Special consideration would be made for developing meaningful activities for residents with dementia and/or special needs. 2. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most current annual activity evaluation was dated 10/30/20. The evaluation revealed the resident enjoyed family/friend visits, parties/social events, religious activities, movies and television and music/talk radio. The 10/08/21 annual Minimum Data Set (MDS) 3.0 assessment revealed under Section F Preferences that it was not very important for the resident to have books, newspapers or magazines, to listen to music, to be around animals and pets, to keep up with the news, to do you things with groups of people, to do to her favorite activities or to go outside in the fresh air when weather was good. The MDS revealed it also wasn't important at all to participate in religious services or practices. The assessment revealed a family member or significant other was the respondent to the questions. Review of the 02/09/22 quarterly MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, required extensive assistance to total dependence from staff for all activities of daily living, was non-ambulatory and had upper extremity impairment on both sides. Review of a 05/10/22 quarterly activity progress note revealed the resident's cognition and communication remained unchanged. The resident enjoyed structured activities and activities of own choosing, chooses activities to do and was at ease interacting with others. She had unclear speech, usually understands, had short term memory impairment and short attention. Her daughter visited once a year. The assessment documented the activity care plan remained appropriate. However, record review revealed the resident had no activity plan of care. On 05/23/22 at 11:46 A.M. Resident #6 was observed in bed with no activities occurring. On 05/23/22 at 3:46 P.M. the resident was in bed with the television on. On 05/24/22 at 12:31 P.M. the resident was in her room out of bed in a wheelchair with a Hoyer lift pad under her. The television was on. On 05/24/22 at 03:30 P.M. the resident was in her room sitting in a wheelchair. Review of the activity attendance documentation in the facility electronic TASK section revealed the resident did not attend any planned activities in the last 30 days. The daily activities documented in the last 30 days included television and other. There were no refusals of activities documented. The resident was not interviewable. On 05/23/22 at 11:48 A.M. interview with State tested Nursing Assistant (STNA) #108 revealed other on the TASK record could mean the resident was pushed to the nurse's station but stated she was unsure. The STNA revealed Resident #6 spent most of her time in bed or in her room in a wheelchair. On 05/24/22 at 1:07 P.M. interview with Facility Support Advocate #146 revealed she assists with activities in the facility but does not keep track of who attended any particular activity. On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the facility had no paper documentation for activities as all activities were documented in the electronic documentation TASK section for each resident. During the interview, Social Services/Activities (#130) verified there were no activities for Resident #6 other than television and other and she did not know what other meant. There was no plan of care related to activities for Resident #6 and no evidence staff provided any type of one on one activities as the resident was typically in her room. Social Services/Activities #130 verified there was no documentation of activities of choice or an activity plan of care for Resident #6. 3. Review of Resident #7's medical record revealed an admitted d of 02/09/17 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 02/10/17 actively plan of care revealed the resident had little or no activity involvement related to decreased activity level. Interventions included to provide an activity calendar, provide items as needed for self-directed activities, remind the resident the resident may leave activities at any time and was not required to stay for the entire activity, respect the resident's preferences for activities and monitor for changes in mood, cognition or medical status that may impact activity involvement. The resident had a 09/19/18 plan of care for exhibiting behaviors, having little or no interest or pleasure in doing activities related to resident's emotional discomfort or strain. An intervention included to provide a program of activities that was of interest and accommodates resident's status. The 02/05/22 activities evaluation revealed the resident finds strength in faith and religion. She enjoyed family and friends visits, movies and television. She enjoyed activities in her own room and one on one in the evenings. The assessment indicated the resident preferred to be in her room in bed, liked to sleep a lot and declined all offered activities. Review of the 02/09/22 annual MDS 3.0 assessment revealed the resident was severely impaired for daily decision making, had no behaviors present and had little interest or pleasure in doing things 12 or 14 days of the review. She was feeling tired and had little energy 12-14 days of the review. The assessment revealed the resident had trouble concentrating on things such as reading or watching television 12 or 14 days of the review. The assessment revealed it was not very important for her to have books, newspaper, magazines, or to listen to music, or to have animals around, or to keep up with the news, or to do things with groups of people. But reflected it was very important for her to do her favorite activities. The assessment revealed it was not important for her to go outside or to participate in religious activities. The assessment revealed the resident required extensive assist of two staff for bed mobility and was not transferred out of bed during the assessment period. Review of the 05/10/22 quarterly activities progress note revealed the resident's cognition and communication was unchanged and she chooses activities to do. The resident was noted to have clear speech and usually understands. She had short term memory impairment and a short attention span. She enjoys activities of her choosing and was pleasant, happy and content. The note revealed the resident was independent in her wheelchair, would not initiate her own activity and her preferred setting for activities were in the day/activity room. Review of the electronic TASK activity documentation for activities revealed no planned activities in the last 30 days had occurred. Daily documented activities were television and other. There were no refusals documented. There was no evidence the resident was provided one on one activities or activities in her room. On 05/23/22 at 10:39 A.M. and 3:47 P.M. and 05/24/22 at 12:31 P.M. and 3:31 P.M. revealed Resident #7 was in her room in bed. The resident's television was noted to be on. On 05/24/22 at 12:59 P.M. interview with Resident #7 revealed she preferred to stay in bed because her back hurt. On 05/24/22 at 4:23 P.M. interview with Social Services/Activities #130 revealed the STNA staff documented in the TASK section to reflect activity participation for Resident #7. Social Services/Activities #130 verified there was no evidence of any planned activities for the resident. On 05/24/22 at 5:09 P.M. interview with STNA #108 revealed Resident #7 watched television and would sometimes come out in the hall for a half hour to an hour then wanted to get back to bed. The STNA revealed the facility had not had any formal activities for a while and indicated she talked to the resident about cats because she knew she had them. 4. Review of Resident #15's medical record revealed a 03/02/22 admission with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's 03/04/22 activity evaluation revealed the location of the resident activities would be in her own room. The resident liked movies, television, music, talk radio, visits with family and friends as well as arts and crafts. She preferred one on one activities. Review of the 03/08/22 admission MDS 3.0 assessment revealed the resident was severely impaired for daily decision, required extensive assist of two staff for bed mobility and transfers, was totally dependent on two staff for dressing, required extensive assist from one staff for eating, was totally dependent on two staff for toilet use and for personal hygiene and was totally dependent on one staff for bathing. Review of the preference section, Section F revealed the resident wanted to have family and close friends involved in decisions for care, to be around animals such as pets, to get fresh air when the weather was good and participate in religious services or practices. The resident activity plan of care, initiated 03/14/22 revealed the resident had little or no activity involvement. Interventions would be pet visits and provide an activity calendar. There was nothing included in the plan of care indicating the resident was going to receive one on one visits as indicated on the 03/04/22 evaluation. Review of the electronic TASK revealed daily routine activities included the resident had visits with family and friends, watched television and other. There was no indication what other meant. There were no planned activities documented for the resident in the last 30 days. On 05/23/22 at 10:35 A.M., 2:54 P.M. and 5:03 P.M., on 05/24/22 at 11:52 A.M., 2:37 P.M. and 5:12 P.M. and on 05/25/22 at 11:48 A.M. and 3:47 P.M. Resident #15 was observed in bed with no activities occurring. On 05/24/22 at 4:27 P.M. interview with Social Service/Activities #130 revealed she had not met the resident as of this date. On 05/24/22 at 05:12 P.M. interview with STNA #113 revealed she had never assisted the resident up out of bed. The STNA revealed the resident liked her stuffed animals and kept them next to her chest and loved ice cream. On 05/24/22 at 5:22 P.M. interview with Social Service/Activities #130 verified there was no evidence of one on one visits or pet visits for the resident. On 05/24/22 at 5:57 P.M. during an interview with the DON, the concern related activities for Resident #15 was discussed. The DON verbalized she figured there would be an issue with activities and stated she did not know of activities being provided to the resident. 5. Review of the medical record for Resident #10 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's activity evaluation, dated 11/18/21 revealed Resident #10 enjoyed movies/television music talk radio, activities in own room, liked one on one and self-recreate and napped during the day. Resident #10 had minimal difficulty/poor hearing, unclear speech and impaired poor vision. The evaluation revealed Resident #10 was pleasant and cooperative and liked to watch television. Review of Resident #10's MDS 3.0 assessment, dated 01/01/22 revealed a Brief Interview for Mental Status (BIMS) score of 06 indicating severely impaired cognition for daily decision making abilities. Resident #10 was noted to enjoy listening to music and religious services. The assessment revealed Resident #10 required total dependence from one staff member for locomotion on and off the unit. Review of the undated plan of care revealed Resident #10 had little or no activity involvement related to decreased activity level. Resident #10 needed encouragement and assistance to activities. Resident #10 preferred church activities, music entertainment and bingo and indicated the resident could be loud and disruptive during activities. Interventions included to provide activity calendar, remind the resident the resident may leave activities at any time and was not required to stay for the entire activity and respect resident preferences for activities. The care plan revealed the resident needed assistance escort to activity functions. Review of Resident #10's activity log from 04/27/22 through 05/26/22 revealed Resident #10 was provided watching a television as an activity 11 of the last 30 days. Continued review revealed Resident #10 was noted with 19 of 30 days with other documented under the activity section. On 05/26/22 at 4:00 P.M. interview with the DON revealed the facility was currently without a full time qualified activity director and activities were not being provided on a routine basis. When asked what the other activity was for Resident #10, the DON revealed she was not sure.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated [DATE], Nursing Home Guidance from the Centers for Disease Control (CDC), review of the facility's policies and procedures, review of the facility's Coronavirus [CONDITION(S)] CoV-2 (Covid-19) outbreak timeline, review of the facility's contact tracing reports, review of employee timesheet reports, review of employee Covid-19 test results, review of staff/ visitor screening logs, review of personal protective equipment (PPE) inventory sheets, review of in-service attendance records regarding specimen collections using point of care (POC) testing, record review, and staff interview, the facility failed to ensure employees did not report to work with symptoms consistent with Covid-19, were properly screened for symptoms of Covid-19 upon entrance into the facility, recognized and reported symptoms of Covid-19 when they were present, and wore appropriate PPE during a Covid-19 outbreak to help reduce the spread of Covid-19 throughout the facility. This resulted in Immediate Jeopardy (IJ) placing residents at risk for the likelihood of harm, complications and/or death on [DATE] when Certified Nursing Assistant (CNA) #3 reported to work on [DATE] at 5:57 A.M. with symptoms consistent with Covid-19, screened herself into the facility through the main entrance, failed to recognize and report her symptoms as possible symptoms of Covid-19, failed to get tested for Covid-19 before entering the facility and remained in the facility for about two and a half hours having direct contact with another employee before she requested to be tested and found to be positive for Covid-19. The employee she had contact with (CNA #10) developed symptoms consistent with Covid-19 on [DATE] and tested positive for Covid-19 on [DATE]. CNA #18, CNA #21, and Registered Nurse (RN) #27 reported to work on [DATE], [DATE] and [DATE], respectively, all having symptoms consistent with Covid-19, screened themselves in through the main entrance, failed to recognize and report their symptoms as possible Covid-19 symptoms, failed to record their symptoms on the visitor/ staff screening logs and worked providing direct resident care while not wearing appropriate PPE recommended for use during Covid-19 outbreaks. The three employees that worked while symptomatic and without proper PPE were on all three of the facility's non-Covid-19 units. It was determined of the facility's 49 residents, 20 residents (Resident #4, #5, #10, #16, #19, #21, #28, #30, #34, #35, #36, #37, #40, #42, #43, #47, #50, #51, #52, and #53) that resided on those units became infected with Covid-19, after the exposures occurred. It was determined of those 20 residents that became infected with Covid-19, three of those residents (Resident #51, #52 and #53) died in the facility despite being previously vaccinated. Only one of those three residents (Resident #52) was considered terminal at that time of their death and under the care and services of hospice. On [DATE] at 3:27 P.M., Administrator in Training #67 and the Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when CNA #3 came into work while showing symptoms consistent of Covid-19. CNA #3 failed to inform the facility she was having those symptoms before she entered the facility, screened herself in, did not recognize and report those symptoms on the screening log as being possible symptoms of Covid-19, and did not seek to be tested for Covid-19 until several hours after her arrival. She had contact with another employee who became symptomatic a few days later and tested positive for Covid-19 five days after her exposure. The facility failed to implement appropriate PPE use amongst the working staff to ensure N95 respirators and eye protection was worn after the Covid-19 outbreak started on [DATE]. Three additional staff (CNA #18, CNA #21, and RN #27) also reported to work while having symptoms consistent with Covid-19 between [DATE] and [DATE]. Those employees also failed to recognize and report their symptoms as possible Covid-19 symptoms, screened themselves into the facility through the main entrance without requesting to be tested and worked providing direct resident contact without wearing proper PPE. Out of the 49 residents that resided in facility, 20 of them became infected with Covid-19 within the appropriate incubation period (,d+[DATE] days) from the date of their exposure. Three of those 20 residents expired, after being infected with Covid-19, with only one of those three being considered terminal and under the care and services of hospice at the time of their death. A total of 10 employees also became infected with Covid-19 during the facility's Covid-19 outbreak. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: · On [DATE] at 4:00 P.M., the facility nurse managers (DON, Staff Development Coordinator, MDS) identified that all residents have the potential to be affected. · On [DATE] at 5:00 P.M., all staff currently working in the facility on [DATE] were re-screened by the Facility Support Advocate to ensure that they did not have any signs or symptoms of COVID-19. No staff members were found to be symptomatic during this re-screening process. · Beginning [DATE] at 5:00 P.M., the Administrator/ Designee will monitor for compliance with the screening process by reviewing the screening logs for accuracy and completeness daily for 7 days. · On [DATE] at 6:30 P.M., the facility staff were re-educated by the nurse managers (DON, SDC, MDS) on the screening process to report any signs or symptoms of COVID-19 during the screening process, to follow the facility policy for staff screening into the facility, the signs and symptoms of COVID-19 with the need to report any of these symptoms during the screening process or if they were to occur at any time during work to their supervisor and follow the facility policy. Additionally, if symptoms occur when at home, the staff were educated to call the facility to report the symptoms and come to the parking lot where a trained staff member would go test them. The facility staff were also re-educated on appropriate usage of personal protective equipment (PPE) per facility policy to include gloves, gown, eye protection, face masks by the facility nurse management. Education began immediately after identification of potential Immediate Jeopardy and was completed by end of day on [DATE]. Total staff educated was 68 and included 9 RN's, 6 LPN's, 25 STNA's, 4 Housekeeper's, 3 Laundry, 1 Maintenance Director, 7 Department Heads, 6 Therapy Staff and 7 Dietary staff. · After [DATE] at 6:30 P.M., no staff will work or be permitted to return to work without first receiving education by one of the facility nurse management team (DON, Staff Development Coordinator, MDS) on the facility's screening process, the need to report the signs and symptoms of COVID-19 during the screening process and wearing appropriate PPE as per the facility's policies/ procedures and CDC guidance. This will include ancillary staff as well. · Beginning [DATE], all new hires will be educated on facility screening process, all Covid-19 Symptoms, and the necessity to report all Covid-19 symptoms to the screener at the time of entry. All new hires will be educated on the proper PPE, and the criteria for use of different face masks and eye protection based on COVID exposures at various times and locations in the facility. · On [DATE] at 7:30 P.M., all Infection Prevention and Control Policies were reviewed by the Administrator, DON and Medical Director and found to be in compliance with CDC guidelines/recommendations. · On [DATE] at 7:30 P.M., survey findings were reviewed by the DON, Administrator and Medical Director during an ad-hoc QAPI meeting. The DON, Administrator, and Medical Director were in agreement with plans, education and audits. · On [DATE] at 8:00 P.M., all 49 residents were assessed for signs and symptoms of COVID-19 by the nurses assigned to the hall. No new residents currently residing in the facility were identified as having the aforementioned. · As of [DATE] at 8:00 P.M., all residents will continue to be monitored/assessed every eight (8) hours by the nurse assigned to each hall, for signs and symptoms of Covid-19 for the duration of the outbreak testing and has been reviewed with Medical Director. · Beginning [DATE] at 8:00 P.M., the Administrator/ designee will interview five (5) staff members working per day for seven (7) days for symptoms of COVID-19 to assure staff are following the screening process. Staff will also be observed to ensure they are wearing proper PPE for the current confirmed and suspected infections. · Beginning [DATE] at 8:00 P.M., the audits on the screening process, interviews with five (5) staff for symptoms of Covid-19 and observations for proper PPE usage will then be completed five (5) times per week for four (4) weeks, then reviewed by the QAPI committee for compliance and further recommendations. Although the Immediate Jeopardy was removed [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1(a.) A review of the facility's Covid-19 outbreak timeline revealed the timeline started when CNA #3 presented with symptoms on [DATE] during morning screening and was tested for Covid-19. POC testing was positive for Covid-19 and the employee was sent home. Contact tracing was indicated to have been completed. A review of the facility's contract tracing report for CNA #3 dated [DATE] revealed she was screened at the front door and showed she was symptomatic. She was tested in the Covid-19 lab by entering through the therapy door and had a positive POC test revealing she had Covid-1. She was indicated to have been in direct contact with another employee that morning. She was then instructed to go home, and the local health department would be reaching out to her. Staff were notified to monitor for signs and symptoms and resident monitoring was to be done every shift for signs and symptoms of Covid-19. A review of staff/ visitor log for [DATE] revealed CNA #3 was the first employee to screen in that day. The screening log initially indicated that she did not have any signs or symptoms of Covid-19 by an N being entered under the symptom column. Someone had then written the word yes over top of the N to indicate the employee did have symptoms. The word test was then written in next to the yes in parenthesis. The symptoms of hoarse, cough and normal temp were added next to the word test to indicate the symptoms CNA #3 had. A review of CNA #3's timesheet for the time period of [DATE] through [DATE] revealed the employee clocked in on [DATE] at 5:57 A.M. and remained in the building until she clocked out at 8:30 A.M. later that same morning. A review of a Covid Test Proof of Testing form revealed CNA #3 was tested for Covid-19 with a POC test on [DATE]. The Proof of Testing form revealed her POC test was positive indicating she was infected with Covid-19. A confirmatory PCR (polymerase chain reaction) test, a test that detects genetic material of the virus, was collected on [DATE] and reported as being positive on [DATE]. On [DATE] at 10:12 A.M., an interview with CNA #3 revealed she came to work on [DATE] and entered through the facility's main entrance. She denied there was another employee there to screen her in and indicated she screened herself in. She confirmed she presented to work with symptoms that morning which included a headache, runny nose, sneezing and hoarseness. She thought they were her normal [MEDICATION(S)] issues she typically got that time of year. She knew what the symptoms of Covid-19 were but did not consider them as possible symptoms of Covid-19 as she was not fevered, was being tested weekly and had been vaccinated. She acknowledged not all people infected with Covid-19 had a fever as a symptom and vaccines did not always prevent you from getting Covid-19 but would lessen the severity of your symptoms if you did become infected. She stated she went to her office, after screening herself in, and did have contact with another employee whom she shared an office with. She was in the facility for a couple of hours before she received a call from a family member, she lived with, that indicated the family member had lost her sense of smell. CNA #3 then requested to be tested for Covid-19 and was found to be positive. She reported at that time, the facility staff were wearing surgical masks when in the facility. On [DATE] at 12:45 P.M., an interview with Administrator in Training (AIT) #67 and the facility's Director of Nursing (DON) confirmed CNA #3 was the first employee to test positive for Covid-19 when the facility's Covid-19 outbreak began on [DATE]. They acknowledged their Covid-19 outbreak timeline and contact tracing report was misleading as it made it sound as if the employee presented with symptoms during the screening process and had been tested for Covid-19 by going through a separate entrance in through the therapy door into the facility's Covid-19 lab. It did not indicate she entered through the front entrance, screened herself in, failed to recognize and report symptoms she had that was consistent of Covid-19 and worked for a couple of hours before requesting to be tested for Covid-19 after it had been made known to her that a family member, she lived with, also had symptoms of Covid-19. The DON denied employees should be screening themselves in. The intent was for the nurse working to screen in the oncoming shift when they reported to work. She acknowledged that was not occurring as intended. The DON also indicated that employees should not be reporting to work with symptoms consistent with Covid-19. They should be calling in ahead of time with any known symptoms to determine if they should report for work or come to the parking lot for testing. They confirmed CNA #3 did have contact with CNA #10, whom she shared an office with, before CNA #3 was sent home. They verified CNA #10 became symptomatic a few days later after she had been sent home and tested positive for Covid-19. 1 (b.) A review of the facility's Covid-19 outbreak timeline for the date of [DATE] revealed CNA #10 was a direct exposure to CNA #3 that morning, so CNA #10 was sent home with instructions to monitor for signs and symptoms of Covid-19. She was indicated to have become symptomatic on [DATE] and tested positive for Covid-19 on [DATE]. The local health department (LHD) was notified, and contact tracing was completed. A review of the contact tracing report for CNA #10 dated [DATE] revealed she was in direct contact with a positive employee that morning. The contact tracing report indicated she was taken to the Covid lab for testing through the therapy door. Her POC test was negative indicating she did not have Covid-19 at that time. She was instructed to monitor for signs and symptoms of Covid-19 and report any that develop. On [DATE], she was indicated to have become symptomatic and tested positive for Covid-19 on that date. Her last date worked was indicated on the report to be [DATE]. A review of CNA #10's timesheets revealed she worked on [DATE] as she clocked in at 7:00 A.M. and did not clock out until 10:38 A.M. after her known exposure. She was off work after she clocked out at 10:38 A.M. until [DATE]. A review of CNA #10's Covid Test Proof of Testing form revealed she had a POC test completed on [DATE]. The test indicated she was positive for Covid-19. A confirmatory PCR test was collected on [DATE] and was reported to be positive for Covid-19 on [DATE]. On [DATE] at 10:00 A.M., an interview with CNA #10 confirmed she was sent home on [DATE] after her exposure to a Covid-19 positive employee. She verified she was in the facility for about four hours or so before being told to go home and monitor herself for signs and symptoms of Covid-19. She confirmed she started to show symptoms of Covid-19 (headache, dizziness, and cough) on [DATE]. She also confirmed she came to the facility on [DATE] and was tested for Covid-19 in the parking lot, which did show she was positive. She confirmed the facility staff were only wearing surgical masks at the time of her exposure due to not having any active Covid-19 cases in the facility between staff or residents at that time. 2. A review of the facility's Covid-19 outbreak timeline for the date of [DATE] revealed State tested Nursing Assistant (STNA) #18 became symptomatic halfway through her shift. She was tested with a POC and found to be positive for Covid-19. She was sent home after her positive Covid-19 test. The LHD was notified, and contact tracing was completed. A review of the contact tracing report regarding STNA #18's positive Covid-19 status revealed she was screened at the front door and was negative for symptoms of Covid-19. Halfway through her shift, she became symptomatic and reported her symptoms to the nurse. A POC test was completed, and she was found to be positive for Covid-19. STNA #18 was sent home. The contact tracing report revealed STNA #18 had reported that she had on a proper mask when she worked on [DATE]. A review of STNA #18's timesheets for the period of [DATE] through [DATE] revealed she clocked in for work at 6:01 P.M. on [DATE]. She remained in the facility until she clocked out at 12:52 A.M. on [DATE]. A review of the facility's screening logs for the time period around when STNA #18 worked the night shift of [DATE] revealed STNA #18 did not report any symptoms when she arrived at work the evening of [DATE]. The column where the staff were to be asked if they had any of the listed symptoms that were consistent with Covid-19 revealed the employee indicated that she did not. The symptoms to be reported included a fever, new onset of a cough, new onset of shortness of breath or difficulty breathing, chills, muscle or body aches, headache, sore throat, new loss of taste or smell, repeated shaking with chills, congestion/ runny nose, nausea, vomiting, diarrhea, new production of sputum or coughing up blood. The symptoms listed were not all inclusive of symptoms that could be associated with Covid-19 as fatigue was not listed as one of those symptoms. A review of a Covid Test Proof of Testing form dated [DATE] revealed STNA #18 was tested for Covid-19 using a POC test. The results indicated she did test positive for Covid-19. On [DATE] at 11:05 A.M., an interview with STNA #18 revealed she did become symptomatic during her shift on [DATE] and tested positive for Covid-19 about seven hours into her 12-hour shift. She was asked when her symptoms started, and she replied she just did not feel right that night even when reporting to work the evening of [DATE] at 6:01 P.M. When asked to describe what she was feeling when she reported she just didn't feel right, STNA #18 replied she was just really tired. She indicated she had screened herself in that night as they typically did when someone was not there to do it for them. She denied she recorded or reported any symptoms of Covid-19 before or upon her arrival at work that night partly because she did not think what she was feeling was a symptom of Covid-19. She did acknowledge fatigue was a symptom associated with Covid-19 and can mean the same thing as being really tired. She was asked what PPE she was wearing during her shift and she indicated she was only wearing a surgical mask. She denied she had a N95 mask on nor did she have eye protection on because there was nothing going on in the building at that time. She also stated, all they had at the front screening area were the surgical masks, so she was under the impression that was what they were supposed to use. She reported she worked on the facility's A hall and B hall. She notified the nurse she was not feeling well around 12:50 A.M. and requested to be tested for Covid-19. Her POC test came back positive for Covid-19 and she was sent home. She reported her duties would have been providing direct care to the residents on that unit who needed assistance from staff for personal care. She would have been in their rooms every couple of hours to provide incontinence care and to assist them with turning and repositioning or to answer call lights if used. She worked closely with STNA #34 that night as they were assigned to the same area and assisted one another with the residents' care. She also reported she had been working on C-hall as well, the previous nights before, when she may have been infectious with Covid-19 (typically two to three days before the onset of symptoms). She denied the facility was wearing N95 masks or eye protection until she returned to work on [DATE], after her extended leave for her isolation period. On [DATE] at 1:06 P.M., an interview with STNA #34 revealed she did work with STNA #18 the night of [DATE]. She confirmed they were both wearing blue surgical masks while working and denied having any eye protection on. She stated N95 masks and eye protection was not initiated until after they started having residents test positive for Covid-19. On [DATE] at 12:45 P.M., an interview with AIT #67 and the facility's DON confirmed STNA #18's contact tracing report was not totally accurate as it indicated she had been screened at the front door and was negative for symptoms. They acknowledged the interview with STNA #18 revealed she screened herself in and was having symptoms that could have been associated with Covid-19 had there been someone that screened her and could have probed for additional information if she reported she just did not feel right. They acknowledged the screening log used that evening did not include fatigue as one of the possible symptoms of Covid-19 even though it was. They were also informed the statement about her reporting she had on the proper mask was not accurate either as her interview revealed she was wearing a surgical mask. They confirmed they were in Covid-19 outbreak testing at that time after two previous employees tested positive for Covid-19 beginning on [DATE]. Again, they reported it was an expectation that staff wear N95 masks and eye protection during that time and while outbreak testing continued. The DON stated if they did not have N95 masks available at the front door all they had to do was call and she would have gotten the masks for them. 3. A review of the facility's Covid-19 outbreak timeline for [DATE] revealed routine testing for both the residents and staff was completed that day. One staff member (STNA #21) and three residents (Resident #37, #47, and #50) tested positive for Covid-19 through use of POC tests that day. The three residents were indicated to have been placed on transmission-based precautions (TBP) and moved to the facility's designated Covid-19 unit, which was D hall. STNA #21 was indicated to have been sent home. Contact tracing was completed and the LHD was notified. 3 (a.) A review of the contact tracing report for STNA #21 dated [DATE] revealed the employee was screened into work the evening of [DATE] and was asymptomatic. She was tested for Covid-19 on [DATE] for outbreak testing in the Covid-19 lab and found to have a positive POC indicating she had Covid-19. She was indicated on the contact tracing report to continue to be asymptomatic. She was notified of the need to monitor for signs and symptoms. A review of STNA #21's timesheets for the time period of [DATE] and [DATE] revealed she clocked in for work at 5:56 P.M. the evening of [DATE]. She did not clock out until 7:00 A.M. on [DATE]. A review of the staff screening logs for [DATE] revealed STNA #21 did not report any symptoms when she arrived at work the evening of [DATE]. Symptoms that should have been recorded and reported included congestion and a runny nose. The screening log was supposed to be signed by the screener but the documentation with the employee's name, vaccination status, exposure to Covid-19, and symptoms of Covid-19 were in a different handwriting than that of the screener's signature. A review of a Covid Test Proof of Testing form dated [DATE] revealed STNA #21 had a POC test for Covid-19 done on that day. The results of that test were indicated to be positive. A confirmatory PCR test for Covid-19 was collected on [DATE] and the results were reported as being positive on [DATE]. On [DATE] at 6:30 P.M., an interview with STNA #21 revealed she was tested on [DATE] as part of the facility's outbreak testing for Covid-19 and was found to be positive for Covid-19. She was asked if she had any symptoms consistent with Covid-19 prior to testing positive for Covid-19 and she initially denied that she did. She was then asked if she developed any symptoms after being tested positive for Covid-19 and reported she initially had nasal congestion then later developed a cough. She was asked again when her initial symptoms had started and replied her nasal congestion actually started before, she was tested on [DATE]. It was after [DATE], that she stated she developed a cough. She was asked about the screening process and indicated there was usually someone out there to screen them in, if not, they did it themselves and just charted it. She denied she was screened in that evening by anyone else. She did not mark the screening log to reflect she had any symptoms of Covid-19 because she was not aware nasal congestion was one of those symptoms she should report. She reported she worked B hall that night and indicated she was wearing a blue (surgical) mask at that time. It was not until she returned to work, after being off for an extended period of time, that they were using N95 masks. On [DATE] at 12:45 P.M., an interview with AIT #67 and the facility's DON revealed STNA #21 did work the night of [DATE] starting at 6:00 P.M. and into [DATE] until 6:00 A.M. They confirmed she was tested as part of the facility's routine testing of the staff as part of their Covid-19 outbreak testing. They also confirmed she tested positive for Covid-19 when tested . They acknowledged the facility's contact tracing report was not accurate as it indicated the employee was asymptomatic when tested . Her interview confirmed she was having nasal congestion when she reported to work the evening of [DATE] and before being tested for Covid-19 at the end of her shift. They also acknowledged her screening log did not indicate she had any symptoms of Covid-19 when she was screened in the evening of [DATE] despite nasal congestion being one of the many symptoms that should be recorded and reported. The employee (CNA #7) that signed the screening logs was the staff member that completed the screens the majority of the time. They confirmed she would not have been there at 6:00 P.M. when the night shift employee arrived, and her signature was just to indicate she reviewed the screening log's entry. The DON confirmed employees should not be screening themselves in and, if symptoms were present, they needed to call into the facility ahead of time to report them. She indicated she lived nearby, and it would not be a problem for her to run over to the facility and test them in the parking lot. 3 (b.) A review of Resident #37's medical record revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #37's census list (a list that identified when a resident was admitted and discharged but also identified any room changes that took place during their stay) revealed he resided on A hall before being tested positive for Covid-19 on [DATE]. Once he had been tested positive for Covid-19, his room was changed to a room on D hall, which was the facility's designated Covid-19 unit. He remained there until the end of his isolation period and was moved back to A hall on [DATE]. A review of a Covid Test Proof of Testing form for Resident #37 revealed a POC test was performed on [DATE]. The results recorded confirmed Resident #37 tested positive for Covid-19. A review of Resident #37's nurses' progress notes revealed a nurse's note dated [DATE] at 10:00 A.M. by Registered Nurse (RN) #80 indicating Resident #37 tested positive for Covid-19. The note also indicated he was moved to the Covid unit into a private room. A review of Resident #37's contact tracing report dated [DATE] revealed Resident #37 was tested for Covid-19 as part of the facility's outbreak testing. He was indicated to be asymptomatic (no symptoms) and was not known to leave his room. His roommate (Resident #50) was also indicated to have been positive for Covid-19. Resident #37 became infected with Covid-19 despite being vaccinated. 3 (c.) A review of Resident #50's medical record revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #50's census list revealed he was admitted to a room on A hall on [DATE]. He did share a room on A hall with Resident #37. He was moved to the facility's Covid-19 unit on the D hall on [DATE] and remained there until his discharge on [DATE]. A review of Resident #50's nurses' progress notes revealed Resident #50 had been going out of the facility at times for his scheduled [CONDITION(S)] appointments. A nurse's progress note dated [DATE] at 10:00 A.M. by RN #80 revealed the resident tested positive for Covid-19. He was placed in TBP and moved to the Covid-19 unit and was placed in a private room. He did not have any complaints at that time and was not showing any symptoms of Covid-19 when he was tested and found to be positive for Covid-19 on [DATE]. His progress notes also included a discharge plan note from Activity Director #73 dated [DATE] at 8:57 P.M. that revealed Resident #50's spouse was also known to have Covid-19 at the same time Resident #50 did. He remained in the facility until his discharge home on [DATE]. A review of a Covid Test Proof of Testing form revealed Resident #50 was tested for Covid-19 on [DATE] by use of a POC test. The test results indicated the resident was positive for Covid-19. A review of a contact tracing report dated [DATE] revealed Resident #50 tested positive for Covid-19 on a POC test as part of the facility's outbreak testing. The contact tracing report indicated the resident does go out of the building for [CONDITION(S)] appointments. The resident was not known to leave his room other than for his scheduled appointments. 3 (d.) A review of Resident #47's medical record revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #47's census list revealed he resided on C hall prior to [DATE]. He was moved to the facility's designated Covid-19 unit on [DATE] where he remained there until he returned to his previous room on [DATE]. A review of Resident #47's nurses' progress notes revealed a nurse's progress note dated [DATE] at 10:01 A.M. by RN #80 that revealed the resident tested positive for Covid-19. The nurse's note indicated the resident was moved to the facility' [TRUNCATED]

Based on record review, investigation review, hydrocollator heating unit user guide review, policy review and staff interview the facility failed to prevent resident burns and failed to ensure fall interventions were in place to prevent falls. This affected two Residents (Resident #2 and #71) of four residents reviewed for accidents. Harm occurred when untrained and unlicensed personnel applied warm moist therapy packs to Resident #2's neck without a physician order [REDACTED]. The burn required topical treatment from 04/11/17 to 07/14/17. Findings include: 1. Review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility. The resident was dependent of two staff members with transfers and personal hygiene and dependent of one staff member with dressing, eating and toilet use. Review of the Nurses' Progress Notes dated 04/01/17 at 12:00 P.M. revealed a two centimeter fluid filled blister with light redness around the blister was noted to the left upper shoulder near the base of the resident's neck. Review of the physician's progress note dated 04/04/17 revealed the resident had a blister to the left shoulder area. The resident had heat being applied to her back and it was most likely a superficial burn. The blister had ruptured and had reactive [DIAGNOSES REDACTED] (redness) at the base. Review revealed treatment orders included Bactroban (topical antibiotic) and gauze and a notation the wound should progressively resolve. No progress notes were available after 04/04/17. Review of the medication administration record (MAR) revealed Bacitracin (topical antibiotic) twice daily every day and night shift until resolved was applied from 04/11/17 to 07/14/17. Review of the quality assessment and assurance investigative report dated 04/03/17 revealed upon investigation a blister was noted to the left upper shoulder near the resident's neck. No pressure or trauma was noted to the area but the resident did lean her head more toward the left side and from sweating the area did become moist from heat. Review revealed hot packs had been applied with restorative therapy but no hot packs were noted at the time the blister was discovered. Restorative documentation revealed restorative therapy worked with the resident after the blister was found on 04/01/17. The physician was notified and ordered to monitor the blister every shift until resolved and if the blister ruptured, apply Bacitracin ointment twice a day until resolved. Review of State tested Nurse Aide (STNA) #39's statement revealed the fluid filled blister was noticed on the resident's left shoulder while giving the resident a shower. Review of the investigation did not identify how the resident received the burn. Review of the Hydrocollator (warm moist therapy) clinical use policy revised 01/18/16 revealed the purpose was to provide warm moist therapy when ordered by the physician. A daily temperature log would be maintained in the therapy department to ensure temperatures were maintained on the range of 160 to 165 degrees Fahrenheit (F). Licensed staff that had been trained in the use of warm moist therapy packs could place warm packs on residents with a physician order. The licensed staff would monitor the use of hot packs and resident's tolerance of such. The licensed staff member was to monitor the skin frequently during treatment for [REDACTED]. Review of the Hydrocollator Heating unit user guide dated 2008 revealed to constantly monitor hot pack application to ensure the skin was not becoming too hot. Individuals with circulatory problems should consult with a physician before using the product. On 07/26/17 at 9:29 A.M. interview with Licensed Practical Nurse (LPN) #67 revealed the resident had a blister from heat applied to her back. LPN #67 revealed the facility determined it was most likely from heat applied to her upper back and not from shear or pressure. On 07/26/17 at 10:10 A.M. interview with Therapy Director (TD) #80 revealed Resident #2 had not been on therapy caseload since 2016. Interview revealed therapy required a physician order [REDACTED]. TD #80 stated the hydrocollator was locked in the therapy gym and kept in the therapy office. The temperature was maintained between 160 to 170 degrees F. TD #80 shared a log was maintained for the unit with an average temperate of 164 degrees F. Lastly, TD #80 shared restorative services were often provided in the therapy gym. On 07/26/17 at 10:15 A.M. STNA #39 was observed with Resident #2 in the therapy gym. Interview with STNA #39 verified Resident #2 used to get hot packs to her neck but no longer got them after the resident obtained a blister at the base of her neck. STNA #39 shared the blister could have been caused by incorrectly applying the hot pack holder to the resident. STNA #39 also shared the hot pack was applied for 15 minutes and a timer was set. Once the timer went off the hot pack would be removed. STNA #39 stated she always told residents to let her know if the pack got too hot but did not do skin checks while the hot pack was in place. Velcro straps were placed around the hot pack and the resident's neck to hold the hot pack in place after being placed in a holder and wrapped in two towels. An additional interview with STNA #39 at 1:00 P.M. revealed heat packs were also applied to Residents #13, #22 and #69 but the STNA was directed on 07/26/17 to stop application immediately. STNA #39 said she was provided education regarding how to apply the packs and which residents received the hot packs from the previous restorative aide no longer working at the facility. STNA #39 said she remembered the residents who received hot packs but a list of these residents was not maintained. STNA #39 said therapy had nothing to do with the application of the hot packs and denied receiving formal education about hot pack use. STNA #39 stated the other restorative aide, STNA #25, instructed her not to apply hot packs to Resident #2's neck after she received the blister but was unable to recall when the information was shared. On 07/26/17 at 1:00 P.M. interview with LPN #67 verified the blister treatment was applied through July stating it took awhile for the blister to completely heal. On 07/26/17 at 4:15 P.M. interview with Registered Nurse (RN) #4 revealed she completed the investigation related to the resident's blister and was unaware restorative was applying hot packs to the resident's neck until the blistered area occurred. RN #4 said when she began the investigation on 04/03/17 the blister was intact and restorative services was provided to Resident #2 after the blister was discovered; however, RN #4 did not know if the hot pack was applied to the resident's neck with the blister. On 07/26/17 at 4:20 P.M. interview with the Director of Nursing (DON) revealed the facility did not feel the blister was related to the use of the hot pack or the entire neck would have been blistered. The DON said the facility did not have information/documentation supporting why they felt the blister was not related to the use of hot packs and the facility did not document weekly skin monitoring for the blister as they would if the area was thought to be a skin alteration due to pressure. The DON verified the resident's primary care physician felt the area was a burn related to the use of heat and also verified the restorative aides were not licensed or trained in application of heat packs and were applying heat to the resident's neck without a physician order. The DON also verified three additional residents were identified to be receiving heat application through restorative services, Residents #13, #22 and #69 and the use of heat packs on these residents was not identified until 07/26/17. On 07/27/17 at 7:50 A.M. an interview with the DON revealed the facility updated the medical director related to the resident's burn and the facility removed the hydrocollator from use and would now be using warm towels for heat therapy. The DON stated all residents were to be assessed to ensure no one had burns. The facility was still investigating to determine how the restorative aides determined which residents needed heat therapy and how the residents were chosen. The DON denied other residents with burns since the last annual survey dated 05/06/16. 2. Medical record review revealed Resident # 71 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 05 indicating she had severe cognitive impairment and was an extensive assist with one person for transfers. Resident #71 had a physician's orders [REDACTED]. Review of the Plan of Care revealed Resident #71 required a sensor alarm and mats to the floor. Review of the progress notes dated 07/19/17 at 3:32 P.M. revealed Resident #71 was yelling out from her room. The nurse and the State tested Nurses Aide(STNA) entered the room and found Resident #71 lying on the floor beside her bed with no injuries. Review of the fall investigation dated 07/19/17 at 2:50 P.M. revealed Resident #71 was found on the floor beside her bed. The resident stated she was getting up to tell the staff her daughter called. The STNA forgot to put the mats and alarm on the resident when she placed her back to bed after lunch. Review of Statement of Witness dated 07/19/17 revealed STNA #5 had put Resident #71 to bed and failed to check the placement of the bed alarm and floor mats. During an interview on 07/27/17 at 1:20 P.M. STNA #5 verified she had put Resident #71 to bed and forgot to turn on her bed alarm and place the mats on the floor.

Based on review of medical records, the facility ' s Cardiopulmonary Resuscitation (CPR) policy, investigation report, emergency medical service (EMS) report, in-service documentation, the Ohio Nurse Practice Act (Chapter 4723, Ohio Revised Code (ORC)) and staff and EMS interviews, the facility failed to initiate CPR or contact emergency medical services (EMS) timely for one full code resident (Resident #1) who was found unresponsive without vital signs. Life threatening harm occurred when Resident #1 did not receive CPR timely, a delay of a minimum of ,[DATE] minutes, and expired at the facility. This resulted in Immediate Jeopardy for one of three residents reviewed for an emergent change in condition. The facility census was 77. On [DATE] at 11:44 A.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] at 2:15 A.M. when Resident #1 was found unresponsive and without vital signs. After finding Resident #1 unresponsive and without vital signs, Licensed Practical Nurse (LPN) #100 delayed initiating CPR or contacting EMS services. LPN #100 sought out Registered Nurse (RN) #101 to verify Resident #1 was without vital signs. LPN#100 then called the DON at home to notify her the resident was unresponsive and without vital signs. LPN #100 was then directed by the DON to check Resident #1 ' s code status. LPN #100 found the resident ' s medical record and code status and identified Resident #1 was a full code. LPN#100 then initiated CPR and notified EMS. LPN #100 ' s actions delayed the initiation of CPR and EMS for at least ,[DATE] minutes after Resident #1 was found unresponsive and without vital signs. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: · On [DATE] at 3:30 A.M. LPN #100 and RN #101 were immediately disciplined (written warnings) by the DON for failure to verify the code status and initiate CPR timely. LPN #100 and RN #101 were also educated by the DON regarding resident rights to choose code status, checking code status, verifying vital signs and what to do when the resident was found without vital signs. · On [DATE] at 3:30 A.M. through [DATE] at 6:00 P.M., the DON completed in-service education on the CPR policy and checking code status for all licensed nursing staff: 11 RNs and 11 LPNs. · On [DATE] through [DATE], the DON completed in-service education on the CPR policy and checking code status for all 48 of 48 STNAs. · On [DATE] at 7:30 A.M. the quality assurance (QA) committee met to review the internal plan of action. Per established QA procedures, audits will be reviewed to determine effectiveness. The Medical Director approved the plan of action and no further recommendation was made at the meeting on [DATE]. · On [DATE] by 10:00 A.M., RN #111 and RN #112 completed audits of all resident charts for correct code status information and verified the information was readily available in the correct location. · On [DATE], the DON (or designee) initiated random code drills to RNs, LPNs and STNAs validating what to do when a resident was found absent of vital signs and where the code status was located in the medical record. The random ongoing code drills are scheduled to continue for four weeks to validate continued recollection of the standard. · On [DATE], RN #114 audited CPR certification of 11 LPNs, 11 RNs, and the DON to ensure CPR certification was current and valid. · On [DATE], interviews with LPN #100 at 7:22 A.M., RN #101 at 7:30 A.M., LPN #102 at 7:50 A.M., STNA #103 at 10:37 A.M., STNA #104 at 12:35 P.M., STNA #105 at 11:17 A.M., STNA #106 at 1:35 P.M., LPN #107 at 1:36 P.M., LPN #108 at 1:37 P.M., STNA #109 at 1:50 P.M., and STNA #110 at 2:10 P.M., revealed staff were knowledgeable about initiating CPR and where to locate residents ' code status. Although the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) as the facility continues to complete random audits to validate knowledge of the standards of locating code status in the medical record and when to initiate CPR. Findings include: Review of Resident #1's closed medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's advance directive dated [DATE] revealed Resident #1 elected code status was full code and required full resuscitative measures. Review of Resident #1 ' s monthly physician orders [REDACTED]. Review of Resident #1 ' s nurse ' s notes dated [DATE] at 12:30 A.M. revealed Resident #1 was noted to have dry heaving and was assisted with care and returned to bed. Resident #1 had denied pain and refused water. At 2:15 A.M. an unidentified STNA notified LPN #100 that Resident #1 was unresponsive, very pale, and cool to touch, fixed stare, mouth gaped opened, and absent of vital signs. At an undetermined time CPR was initiated, and EMS the physician, family, and DON were notified. At 2:52 A.M. CPR was stopped and an emergency medical technician (EMT) pronounced the resident dead. On [DATE] at 7:22 A.M., interview with LPN #100 revealed around 2:00 A.M. on [DATE] two STNAs (unidentified) had reported Resident #1 ' s legs were hanging off the bed. LPN #100 reported the resident was not breathing and an STNA went to get RN #101. LPN #100 reported there was a delay in initiating CPR because she had to check the chart for the resident ' s code status. LPN #100 stated she and RN #101 initiated CPR and continued until the squad arrived. On [DATE] at 7:30 A.M., interview with RN #101 revealed on [DATE] an STNA reported (time unknown) that LPN #100 needed to confirm Resident #1 had expired. RN #101 reported that upon entering the room, Resident #1 was white, cool and the mouth was gaped open. RN #101 reported after checking the resident ' s code status they realized Resident #1 was a full code. RN #101 stated she thought it was approximately 10 minutes before CPR was initiated. On [DATE] at 9:30 A.M., interview with DON verified LPN #100 did not immediately check Resident #1 ' s code status which delayed CPR. The DON could not give an estimated time the CPR was delayed. The DON revealed LPN #100 had called her around 2:15 A.M. to report Resident #1 had expired. The DON reported she asked LPN #100 what Resident #1 ' s code status was and LPN #100 reported she had not checked Resident #1 ' s code status. The DON reported after the code status was verified staff initiated CPR. The DON affirmed she arrived at 2:30 A.M. at the facility to assist with CPR, approximately 10 minutes before the squad had arrived. The DON verified the only place the resident ' s code status was identified was in a specific section of the medical record. On [DATE] at 11:17 A.M., interview with STNA #105 verified around 1:45 A.M. to 2:00 A.M. on [DATE] she found Resident #1 unresponsive. STNA #105 stated she reported her findings to LPN #100 and RN #101. STNA #105 verified there was some time lapse between finding the resident unresponsive and when CPR was initiated. STNA #105 stated she was not present during the entire incident due to assisting other residents. On [DATE] at 1:50 P.M., interview with STNA # 109 affirmed on [DATE] around 12:30 A.M. she had provided incontinence care to Resident #1. STNA #109 reported Resident #1 had some dry heaving but was talking to her. STNA #109 reported that on [DATE] around 2:00 A.M. Resident #1 was found unresponsive and without vital signs. STNA #109 stated CPR was not initiated for ,[DATE] minutes after the resident was discovered. STNA #109 verified staff was not aware Resident #1 was a full code and just assumed the nurse knew the resident ' s code status. On [DATE] at 4:00 P.M., interview with STNA #113 revealed around 2:00 A.M. on [DATE] STNA #105 found Resident #1 unresponsive. STNA #113 stated she was helping STNA #105 care for residents on the hall. STNA #113 confirmed CPR was delayed ,[DATE] minutes due to confusion of the resident ' s code status. Review of the EMS report dated [DATE] revealed the facility called EMS at 2:38 A.M. with report of an unresponsive person. At 2:41 A.M., EMS arrived at the facility. Resident #1 was found unresponsive. Facility staff reported the resident was found approximately 30 minutes prior unresponsive and they had been performing CPR for approximately 20 minutes. Resident #1 was asystole (without a heartbeat) on the heart monitor. A staff RN (unidentified) made the call to end resuscitation measures at 2:50 A.M. On [DATE] at 8:58 A.M., interview with EMT #117 verified the facility called at 2:38 A.M. on [DATE] and reported they had an unresponsive resident and the EMS was on the scene at 2:41 A.M. On [DATE] at 9:00 A.M., interview with EMT #116 revealed the squad was called by the facility for an unresponsive white female. EMT #116 reported Resident #1 was cold, stiff, and was asystole on the monitors when they arrived. On [DATE] at 9:03 A.M., interview with EMT #115 revealed facility staff (unidentified) had reported they had not initiated CPR for ,[DATE] minutes after finding the resident unresponsive due to staff were looking for the resident ' s code status. Review of the facility investigation report dated [DATE] revealed LPN #100 and RN #101 were given a written warning for failure to check code status of Resident #1 who was found absent of vital signs. Review of the facility document titled Critical Behaviors Sheet- AED revealed when a resident is found unresponsive with no vital signs staff is to: activate EMS; direct personnel to obtain code cart and AED; check resident ' s code status; start CPR; when AED arrives stop CPR; resume CPR as prompted and continue until EMS system arrives. Review of QA action plan dated [DATE] at 7:30 A.M. revealed Resident #1 was found without signs of life and the nurse had called the DON before checking code status. Education was provided to all nurses and code drills were initiated on [DATE] with staff. Review of the CPR policy dated August, 2013 revealed the licensed nurse on each shift is responsible for coordinating the rescue effort and directing other team members during the rescue efforts. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advance Life Support (ALS). If an individual is found unresponsive and without a pulse, a licensed staff person who is certified shall initiate CPR unless it is known that do not resuscitate (DNR) or obvious signs of irreversible death (rigor mortis, lividity, decomposition, decapitation, or other circumstances which are incompatible with sustaining life). The following documentation should be recorded in the resident ' s medical record: the condition in which the resident was found or the witnessed event; the sequence of resuscitation efforts, including approximate times, the victim ' s response to CPR, the approximate time that the EMS team took over and the time of death or time the individual was transported. Report the event to the medical director, Administrator, and DON as soon as practical. Review of the Ohio Nurse Practice Act (Chapter 4723, Ohio Revised Code (ORC)) relative to registered nurses effwective [DATE] revealed the authority to determine and pronounce death is limited to those circumstances under which the registered nurse is providing or supervising the individual ' s care through a licensed hospice program or any other entity that provides palliative care. This certification deficiency substantiates Complaint Number OH 871. This certification deficiency is evidence of continued non-compliance from the survey dated [DATE].

Based on observation, medical record review, review of a facility's Self-Reported Incident (SRI), interview with staff, review of facility in-services, review of manufacturer ' s guidelines for use of the sit to stand lift, review of policies and procedures related to notification and falls, the facility failed to ensure Resident #43, who required assistance from staff for transferring, was transferred in a safe manner to prevent a fall. The facility failed to assess the resident for appropriate transfer devices and failed to educate staff on the use of the devices. This resulted in immediate jeopardy with actual harm to Resident #43, when the resident fell from a sit to stand transfer/lift device while staff were attempting to provide incontinence care to the resident and sustained a right spiral femur fracture. This affected one resident who utilized the sit to stand lift for transfers and the likelihood of immediate jeopardy with four additional residents (Resident #15, #33 #76 #85) identified by the facility to use a sit to stand lift. The facility census was 87. On 05/05/16 at 3:50 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on 04/19/16 at 3:30 P.M. when Resident #43 sustained a fall from a sit to stand transfer device while State tested Nurse Aide (STNA) #52 and STNA #20 were performing incontinence care with Resident #43 standing in the device. There was no evidence the sit to stand device was assessed to be appropriate for use with the resident. Following the fall, STNA #20, STNA #63 and STNA #52 lifted the resident from the floor and placed her in a chair without first notifying the nurse prior to moving Resident #43. The resident subsequently complained of increased pain with edema noted to the resident ' s bilateral legs. An x-ray was obtained and on 04/20/16 at 4:45 P.M. (more than 24 hours after the incident) Resident #43 was transferred to the emergency room for evaluation and treatment of [REDACTED]. The Immediate Jeopardy remained ongoing when on 05/04/16 at 3:45 P.M. STNA #63 and Licensed Practical Nurse (LPN) #86 were observed transferring Resident #15 using a sit to stand lift improperly per manufacturer ' s guidelines. The staff members were observed using the lift device to transport the resident from the bathroom to the wheelchair in her room, having to close the base of the device (balance bars) during the transfer process. During the transfer observation, Resident #15 let go of the hand grips on the lift and attempted to sit as the staff were pushing her in the lift, prior to reaching a safe transfer destination. The Immediate Jeopardy was removed on 05/05/16 when the facility removed the sit to stand from service and implemented the following corrective actions: · On 05/05/16 at 4:00 P.M., the two sit to stand lifts available for use were removed from service and from the facility. · On 05/05/16 Residents #15, #33, #76 and #85, who were identified as needing a sit to stand lift, were screened by Physical therapy related to transfers. This included observations of the residents. Therapy and nursing collaborated to change each of these residents from a sit to stand lift transfer to a Hoyer (mechanical) lift transfer. · On 05/05/16 all 87 current residents residing in the facility were assessed for transfer status by Registered Nurse Managers (RN) #67 and #49. · On 05/05/16 Nurse Mangers #67 and #49 audited all resident care cards to ensure they reflected current transfer status. · On 05/05/16 at 7:30 P.M. the Administrative staff held a meeting with the Medical Director ' s on call physician (the Medical Director was unavailable) to review the situation of Immediate Jeopardy and plan of correction to be implemented by the facility. The physician was in agreement with the plan at that time. · On 05/05/16 beginning at 4:30 PM. and concluding on 05/06/16 at 9:30 A.M., 23 licensed nurses and 49 STNAs were educated by the Regional Director of Operations, Executive Director, and RN Education and Training Director on safe transfer and movement of residents ' policy. As of 05/06/16 at 9:30 A.M. the facility identified all licensed and STNA staff had received education. · Additional training for the staff noted above revealed competency testing by administrative staff regarding safe use of a Hoyer (mechanical) lift by the Regional Director of Operations, Executive Director, and RN Education and Training Director . As of 05/06/16 at 9:30 A.M. the facility identified all licensed and STNA staff had received education. · On 05/05/16, 23 licensed nurses and 49 STNAs were interviewed by the Regional Director of Operations, Executive Director, and RN Education and Training Director after being educated and completing return demonstration to ensure understanding of education provided and comfort with work duties. All licensed nurses and STNAs signed acknowledgement statements reflecting understanding and comfort with work duties as related to transferring residents. · On 05/05/16 the facility implemented therapy staff would include direct observation of transfers for residents during the quarterly screening process. · On 05/05/16 the Regional Director of Operations, Executive Director, and RN Education and Training Director educated 23 nurses on proper fall prevention guidelines and assessment. · On 05/06/16 the Executive Director, or designee, implemented a plan to audit five therapy screens per week to ensure they reflected direct observation of transfers was completed. · On 05/06/16 the DON, or designee, implemented a plan to audit five residents per week to ensure current transfer assessments were in place and care plans and resident care cards reflected current transfer status. · On 05/06/16 a plan was implemented for these audits to be completed weekly for four weeks, then monthly for two months. The results of the audits would be reviewed at the quality assurance meetings. · Interview with STNA #5 on 05/06/16 at 12:20 P.M., LPN #77 at 12:24 P.M, RN # 50 at 12:25 P.M., and RN #49 at 12:26 P.M. revealed they had been in-serviced on 05/05/16 and 05/06/16 related to transfers (gait belt and Hoyer lift), notification, assessments, and fall interventions. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility had not fully implemented monitoring and auditing of the proper use of transfer assistive devices. Findings include: Review of Resident #43 ' s medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 had moderate cognitive impairment. Further review of the MDS revealed the resident had physical behavioral symptoms that interfered with her care. The assessment revealed Resident #43 required extensive assistance from two plus staff for transfers, personal hygiene, dressing, bed mobility and toileting. Further review revealed no evidence Resident #43 ' s weight bearing status or need for/use of a lift device for transferring had been assessed. Review of Resident #43 ' s Activities of Daily Living (ADL) care plan, dated 01/05/16 revealed interventions for toileting included extensive assistance with one to two staff participation to use toilet, extensive assistance from one to two staff to move between surfaces and may use lift as needed . The care plan did not specify what type of lift to use or parameters for when staff should use a lift. Review of Resident #43 ' s fall care plan, dated 01/04/16, revealed the resident was at risk for falls. Interventions included assistive device, use lift or stand to pivot and transfer and encourage rest periods as needed to avoid overtiring. Review of a nursing progress note, dated 04/19/16 at 4:30 P.M. and documented by LPN #56 revealed Resident #43 complained of her right knee aching with no edema, redness, or bruising noted. The note indicated the resident stated the girls hurt her knee when transferring her with the lift. The resident was reported to be in bed at the time the nursing note was completed. Review of an Incident/Accident Report, dated 04/20/16, revealed on 04/19/16 at 3:30 P.M. staff were providing hygiene care while Resident #43 was standing in the sit to stand lift. The resident became angry with staff and wanted to get out of the lift. Resident #43 put her arm under the sling and began to slide out of the lift. The resident was assisted to the floor by two staff members. On 04/20/16 (no time noted) the physician was notified and an x-ray was ordered. The x-ray revealed a distal fracture of the right femur and Resident #43 was transferred to the hospital. Review of the facility investigation revealed the DON wrote a statement from information obtained from STNA #52. The statement revealed STNA #52 and a trainee (STNA #20) were providing perineal care for Resident #43 while she was in the sit to stand lift when the resident said I don ' t want in here anymore and pulled her right arm out of the sling and slid down STNA #52 ' s legs to the floor. Review of Situation, Background, Assessment, Request (SBAR) communication form dated 04/20/16 at 10:30 A.M. revealed STNAs reported to the nurse Resident #43 had (1-2 plus) edema noted to her bilateral legs and complaints of right knee pain. The form indicated the pain was worse with touch. Assessment by LPN #83 at that time revealed Resident #43 ' s leg appeared to turn inwards. The physician was notified and orders were received for an x-ray. Review of the right knee x-ray results, dated 04/20/16 revealed a spiral fracture with anterior angulation and displacement as well as proximal overriding. Fracture appears recent. Resident #43 was transferred to the hospital on [DATE] at 4:45 P.M. Resident #43 was re-admitted to the facility on [DATE]. Review of hospital discharge documentation, dated 04/21/16, revealed the resident ' s family requested no surgery and a long leg brace for immobilization and comfort was applied. A note indicated to obtain an orthopedic follow up in four weeks. Record review revealed the facility completed an SRI related to this incident. The SRI, dated 04/20/16 revealed, as a result of the investigation, the facility determined Resident #43 slid out a sit to stand transfer while staff were providing care and was lowered to the floor. As a result of the incident, nursing staff were provided education on proper use of the sit to stand and proper procedure for incident reporting and the proper notification for new onset of pain. On 05/03/16 at 2:04 P.M. Resident #43 was observed in her room in bed. The resident was observed to be non-responsive and did not wake when the surveyor knocked on the door. The resident was observed to have a full length right leg brace in place that extended from her thigh past her knee. Interview with STNA #52 on 05/05/16 at 10:50 A.M. revealed on 04/19/16 at 3:30 P.M. Resident #43 requested to have her brief changed. STNA #52 reported, herself and a trainee (STNA #20) entered the resident ' s room. The resident was seated in a wheelchair. STNA #52 indicated a sling for the sit to stand lift was placed around Resident #43 ' s back and under her arms and connected to the lift. STNA #52 indicated that after assisting Resident #43 to stand, using the lift the resident was attempting to get out of the sling. STNA #52 revealed Resident #43 let go of the hand grips and slid down her legs to the floor. STNA #52 indicated she and two other STNAs (STNA #63 and STNA #20) assisted the resident back into the wheelchair using an arm and leg lift technique and then STNA #63 and LPN #86 assisted the resident back to bed. STNA #52 revealed she reported the incident to the nurse immediately. STNA #52 revealed she had questioned LPN #86 regarding completing an incident report and LPN #86 told her not to worry about it. STNA #52 revealed Resident #43 had complained in the past about the sling hurting her armpits and had behaviors in the past of trying to get out of sling and letting go of the hand grips. STNA #52 reported she had voiced concerns to nursing staff regarding Resident #43 ' s safety in the sit to stand lift and had asked about alterative transfer options and was told the sit to stand lift was the only device that could be used because Resident #43 had refused the Hoyer lift. STNA #52 reported she was trained to attach the blue strap of the sling to the second peg on the sit to stand lift for all residents but was unsure what the different colored straps on the sling indicated. Review of manufacturer ' s guidelines for the sit to stand lift revealed three straps on the sling. The color coded straps could be used to place the resident in various positions. The colors made it easier to connect both sides equally to the sling. The sling was to be attached to the peg based on the height of the resident. Continued interview with STNA #52 reported she had safety concerns with two other residents (Resident #15 and Resident #85) that used the sit to stand lift because the residents frequently wanted to sit and let go of the hand grips before they were lowered to a safe seated position. STNA #52 indicated she had reported these concerns to nursing staff although she could not recall specifically to whom or when they had been reported. Interview with Director of Therapy (DOT) #100 on 05/05/16 at 8:00 A.M. revealed therapy staff did not assess any residents for transfer devices or provide hands on in-services/trainings during quarterly screenings completed for residents. DOT #100 revealed therapy staff attempt to interview staff and observe residents during the screening process. DOT #100 revealed nursing staff had not reported any previous concerns they were experiencing with Resident #43 with regard to transfers. Interview with LPN #56 on 05/05/16 at 10:15 A.M. revealed she was unaware Resident #43 had fallen on 04/19/16 and thought she had just slipped out of the sling. LPN #56 revealed she did not call the physician or file an incident report at the time of the incident. LPN #56 verified STNA #52 had inquired about filling out a statement. LPN #56 indicated she assessed Resident #43 on 04/19/16 at 4:30 P.M. (an hour after the incident) for knee/leg pain and found no abnormal findings. LPN #56 revealed Resident #43 had reported staff was rough with her but would not give her any details. LPN #56 verified Resident #43 had behaviors and would refuse to bear weight on the sit to stand and let go of the hand grips. Interview with the DON on 05/05/16 at 10:20 A.M. revealed Resident #43 was alert and oriented and was not interviewed as part of the facility investigation. The DON also verified STNA #63 and LPN #86 had involvement in the incident regarding Resident #43 on 04/19/16 and were not interviewed as part of the investigation. The DON revealed currently the nursing staff were responsible for determining the type of assistance needed for transferring a resident. The DON verified Resident #43 had a fall from the sit to stand lift that occurred on 04/19/16 around 3:30 P.M. that was not reported until 10:30 A.M. on 04/20/16 when staff reported the resident had increased edema to her bilateral legs and pain. The DON stated the manufacturer ' s guidelines for the sit to stand lift were not readily available for nursing staff to reference. Interview with STNA #63 on 05/05/16 at 10:35 A.M. revealed she was walking by Resident #43 ' s room on 04/19/16 around 3:30 P.M. when she noticed Resident #43 was on the floor and STNA #20 and STNA #52 were trying to assist Resident #43 off the floor. STNA #63 reported she helped the STNAs assist Resident #43 off the floor by using an arm and leg lift technique. STNA #63 revealed after the resident was placed in the chair, she and LPN #86 then transferred the resident by lifting her under her arms and buttocks back to bed. STNA #63 revealed she had previously voiced concerns related to Resident #43 ' s safety using the sit to stand lift and the use of the lift with other residents although she could not recall specifically to whom or when she had reported these concerns. Observation of a sit to stand transfer for Resident #15 on 05/04/16 at 3:45 P.M. revealed STNA #63 and LPN #86 had already applied the sling and were in Resident #15 ' s bathroom attempting to lower the resident onto the toilet upon the surveyors arrival. Resident #15 had removed her hands from the hand grips placing them inside the sling and was attempting to sit before staff had lowered her. After using the toilet, staff had to close the legs of the sit to stand lift to be able to move the resident from the bathroom to the bedroom as the doorway was too narrow and the sit to stand would not fit through unless the legs of the base were closed. The staff members attempted to wheel the resident out of the bathroom and to the other side of the room near the window. STNA #63 and LPN #86 were attempting to open the leg base and Resident #15 was attempting to sit. Resident #15 removed her hands from the hand grip and placed her arms inside the sling. LPN #86 then grabbed the wheelchair and hurriedly placed it under the resident ' s buttocks and STNA # 63 lowered the sit to stand. STNA #63 verified Resident #15 let go of the hand grips and was attempting to sit prior to being lowered to the wheelchair. Review of the sit to stand manufacturer ' s guidelines revealed the legs of the base of the transfer device were for stability when lifting a resident. When transferring a resident, ensure resident ' s arms are outside the sling. Further review revealed not to use the sling in combination with the standup lift as a transport device. It is intended to transfer an individual from one resting surface to another. During transfer, with residents suspended in the sling attached to the lift, do not roll stand up lift over objects such as door frames or uneven surfaces or obstacles that would create an imbalance of the stand-up lift and could cause the standup lift to tip over. Review of the fall policy dated 02/2013 revealed once a fall had occurred it was important to gather as much information as possible including resident statements, staff and responders report and observe for evidence and trauma. Provide emergency care and assessments as indicated. The physician and responsible party should be notified as soon as the resident was stable. Document findings in the resident ' s medial record. An accident/incident report would be completed and forwarded to the DON. Review of the facility policy revised 04/2015 titled Safe Lifting and Movements of Residents revealed staff competency in the use of mechanical lifts shall be assessed at least annually and the transferring needs of residents shall be assessed on an ongoing basis. Resident transferring and lifting needs shall be documented in the care plan. Assessment of the resident ' s transferring needs shall include: Mobility of the resident (degree of dependency), size of the resident, weight bearing ability and cognitive status.