Every finding on record at Aria at Villa Pines

Number of residents sampled:Number of residents cited:Based on observation, interview and record review, the facility did no establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infection. This has potential to affect the census of 33 residents. The facility did not add the residents with COVID infection during an outbreak to the January infection Control Rates. CNA F (Certified Nursing Assistant) had a breach in infection control when performing pericare (cleansing of the genital area) and catheter care (cleansing of the catheter tubing). Evidenced by: Facility policy Management of Covid-19, Influenza, and other ARI Outbreak, revised 11/11/25 states in part: .7. The Infection Preventionist/Designee will intitiate tracking log/line lists. Facility policy Infection Prevention and Control-Surveillance of Infections, revised 11/11/25 states, in part: .11. Outbreak Resolution d. Complete all section of log. e. Complete the monthly rate and analysis for the month. Example 1 Surveyor reviewed January 2026 resident line list. The line list showed 11 residents with COVID-19 during a facility outbreak. Surveyor reviewed January 2026 Monthly infection control record which had 3 residents with lower respiratory infections. The 11 residents with COVID were not on the infection control record for January. Of note, the infection control rates for January 2026 will not be accurate with the 11 residents left off the list. On 4/22/26 at 1:15 PM surveyor interviewed DON/IP B. Surveyor asked DON/IP B what is included on the monthly surveillance DON/IP B stated Infection log, maps, graphs, and staff/resident illnesses. Surveyor asked should all infections including COVID-19 be on the monthly infection control record. DON B stated yes, otherwise our infection rates are not going to be correct. Surveyor asked DON /IP B should you have added the COVID-19 positive residents during the outbreak to the January infection control record. Yes, I should have. DON/IP B stated I will add them and resubmit with correct infection rates. Example 2 The facility's Infection Control – Standard and Transmission Precautions, dated 4/1/25, states, in part: It is the facility's policy to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable diseases and infections in accordance with State and Federal Regulations and national guidelines.1. All staff are to adhere to Standard Precautions. The facility's Infection Control-Indwelling Catheter Care policy, dated 4/4/25, states, in part: The facility's policy is to ensure that the residents receive care and services to prevent urinary tract infections in those residents with an indwelling catheter, per standards of practice.13. Secure catheter tubing with non-dominant hand and with a single downward, cleansing stroke cleanse catheter tubing from labia or meatus.16. Discard supplies, remove gloves and perform hand hygiene. The facility's Perineal Care policy, dated 4/8/25, states in part: .9. Cleanse. 10. Remove gloves, perform hand hygiene and apply new gloves prior to continuing care. On 4/22/26 at 8:11 AM Surveyor observed CNA F perform pericare / catheter care for R7. CNA F applied gown and gloves and then cleansed, rinsed, and dried the perineal area and catheter tubing. Without removal of gloves and hand hygiene, CNA F then adjusted R7's bedding, repositioned the catheter drainage bag and assisted R7 with application of clean undergarments. Surveyor interviewed CNA F and asked about infection control when moving from dirty to clean tasks. CNA F stated you need to wash your hands. Surveyor asked if peri care / catheter care is considered a dirty task. CNA F stated yes. Surveyor asked if hand hygiene needs to be performed prior to assisting with clean clothing and bedding. CNA F stated yes, I should've washed my hands. On 4/22/26 at 8:37 AM, Surveyor interviewed DON B (Director of Nursing) and asked if gloves are considered contaminated after pericare/catheter care. DON B stated yes, I expect gloves to be changed after cleansing, prior to touching resident bedding and new clothing.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 33 residents who reside in the facility.Surveyor observed the stove hood to have dust directly above the food preparation area and attached to the light fixtures, the sprinklers, the 5-foot shelving, and a metal box.Surveyor observed the facility's stand mixer to be stored with a plastic covering. When staff removed the plastic covering, Surveyor observed food particles on the undercarriage. Surveyor observed one dented can in circulation.Evidenced by:Example 1Facility policy, titled Cleaning Instructions: Hoods and Filters, includes: . To clean the interior and exterior of the hood, use a cloth soaked in soapy detergent water. Rinse thoroughly and air dry. A more abrasive cleaning agent may be needed in some cases. A cleaning agent that can handle grease may be needed. Hoods and filters should be cleaned professionally at least yearly.On 4/20/26 at 9:43 AM, Surveyor and DM J (Dietary Manager) observed the facility's stove hood to have dust on the filter, the sprinklers, the light fixtures, a metal box and a 5-foot shelf. The dust was directly above the food preparation area.On 4/20/26 at 9:43 AM, DM J indicated the stove hood needed to be cleaned and there is potential for the dust to dislodge and fall into the food being prepared directly underneath. DM J indicated the Maintenance department are responsible for cleaning the stove hood.On 4/22/26 at 10:37 AM, Surveyor and [NAME] I observed the stove hood, noting the metal box is still covered with dust. [NAME] I indicated the Maintenance Man was supposed to clean it, but he missed this section. [NAME] I indicated there is potential for the dust to dislodge and fall into food being prepared under the dust covered box in the facility's stove hood.Example 2On 4/20/26 at 9:43 AM, during initial tour of the kitchen, Surveyor observed 1 dented can on the shelf in the dry storage unit.On 4/20/26 at 9:43 AM, DM J indicated the can should be removed from the shelf and sent back to the supplier for credit.Example 3Facility policy, titled Food Preparation Appliances, undated, includes: Small appliances such as mixers. will be cleaned and sanitized after each use.On 4/20/26 at 9:43 AM, DM J indicated the stand mixer is clean and stored under a plastic covering. Surveyor asked DM J to uncover the stand mixer for observation. DM J and Surveyor observed food particles to be hardened on the undercarriage.On 4/20/26 at 9:43 AM, DM J indicated the mixer was not cleaned thoroughly before being stored and it should have been.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors out of 25 opportunities with an error rate of 8%. R 21 received isosorbide mononitrate ER (extended release) 30 mg tab crushed.R15 received 24-hour metoprolol succinate 25 mg ER tablet crushed. Evidenced by:Facility policy titled Medication Administration-General Guidelines dated Dec. 2019 states in part: .Orders to crush medications should not be applied to medications which, if crushed, present a risk to the resident. For example: 1. Long-acting or enteric-coated dosage forms should not be crushed. An alternative should be sought. Example 1 R21's physician order states Isosorbide Mononitrate ER Oral Tablet Extended Release 24-hour 30 mg. (Isosorbide Mononitrate). Give 60 mg by mouth one time a day for essential HTN. R21's Medication Administration Record (MAR) for 4/21/26, shows: Isosorbide Mononitrate ER oral Tablet Extended Release 24 hour 30 MG (Isosorbide Mononitrate) Give 60 mg by mouth one time a day for essential hypertension. HTN. On 4/21/26 at 7:31 AM, surveyor observed MT H (Medication Technician) administer two tablets of Isosorbide Mononitrate ER Oral Tablet Extended Release crushed in applesauce to R21. Example 2 R15's physician order states Metoprolol Succinate ER Oral Tablet Extended Release 24-hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth one time a day for Ventricular rate control in A-Fib. R 15's MAR for 4/21/26 states Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth one time a day. On 4/21/26 at 7:50 AM surveyor observed MT H (Medication Technician) administer Metoprolol Succinate ER Oral Tablet Extended Release 24-hour tab crushed in apple sauce to R15 On 4/22/26 at 7:23 AM, surveyor interviewed MT H. Surveyor asked if there is anything special you need to do with an extended-release medication. MT H responded you are not supposed to crush it. Surveyor asked if Isosorbide ER and metoprolol ER be crushed. MT H stated no. Surveyor asked during med pass with this surveyor did you crush these medications. MT H stated yes. I should have known that they couldn't be crushed. On 4/22/26 at 10:00 AM, surveyor interviewed DON B. Surveyor asked DON B should extended-release medication be crushed. DON B (Director of Nursing) stated no. Surveyor asked DON B would you expect your staff not to crush extended-release medications. DON B stated yes.

Based on interview and record review, the facility did not immediately notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 15 Residents (R16) reviewed for notification of change in condition.R16 had weight gains or losses greater than three pounds in one day and a physician was not notified as ordered.This is evidenced by: The facility's policy, titled Change of Condition Process, effective 3/1/21, states in part: Policy Statement: The purpose of this policy is to promptly implement a system for a resident having a change in condition. A change in condition is defined as an improvement or decline in their physical, mental, or psychosocial status. Procedure: Change of Condition: 1. When a change of condition or change from baseline is observed and reported, the licensed nurse is responsible for evaluating the Resident's condition. Examples of a condition change are as follows, but not limited to: a. Weight loss, gain or change in appetite. 3. The physician will be notified.R16 was admitted to the facility on [DATE] with diagnosis that include pulmonary hypertension (high blood pressure in the lung arteries), acute respiratory failure with hypercapnia (respiratory failure due to too much carbon dioxide in the blood), and chronic kidney disease - stage 3 (mild to moderate kidney impairment).R16's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/23/26 indicates R16 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating she is cognitively intact. R16's physician orders include the following:-Bumetanide (loop diuretic used to treat excess fluid retention) oral tablet 2 mg - Give 2 tablets by mouth two times a day for edema. Take in the morning and late afternoon. Start date: 3/17/26.-Daily weights: Call MD (medical doctor) if 3 # (pound) change overnight or 5 # change [per week] - Every day shift for weight monitoring due to diuretic. Start date: 3/18/26.R16's Medication Administration Records (MAR) for March and April 2026 document the following weight gains or losses greater than three pounds in one day without a physician notification: -3/18/26: 152.6 lbs (pounds)-3/19/26: 145.8 lbs [change of -6.8 lbs] -3/22/26: 144.8 lbs-3/23/26: 141 lbs [change of -3.8 lbs] -4/1/26: 136.2 lbs -4/2/26: 139.7 lbs [change of +3.5 lbs] -4/3/26: 139.9 lbs-4/4/26: 132 lbs [change of -7.9 lbs] -4/10/26: 133.9 lbs-4/11/26: 129.2 lbs [change of -4.7 lbs]-4/12/26: 135.2 lbs [change of +6 lbs] On 4/21/26 at 2:50 PM, Surveyor spoke with R16. R16 indicated she gets weighed early every morning before she eats breakfast. On 4/22/26 at 11:18 AM, Surveyor interviewed RN D (Registered Nurse) and asked how physicians are notified about resident changes, such as weight loss. RN D indicated nurses can communicate directly with physicians via a secure messaging app called Hucu. RN D logged into the app and pulled up the physician messaging history for R16. There was a message in March letting a physician know about weight loss, but RN D indicated there were no notifications regarding weight loss changes of three pounds in a day.On 4/22/26 at 12:02 PM, Surveyor spoke with DON B (Director of Nursing B) regarding R16's order to notify a physician of any weight loss changes of three pounds in a day. DON B told surveyor to speak with ADON C (Assistant Director of Nursing) about this. ADON C reviewed messages on the Hucu app for R16. On 3/18, there was a general notification about R16 being admitted to the facility. On 3/26, weight loss was reported. On 4/15, there was an additional notification regarding weight.ADON C indicated the facility tries to establish a baseline weight for the first three days a resident is admitted to the facility. Notifications regarding weights would be made via Hucu. ADON C indicated whether a physician is notified depends on when weights are taken. They should be taken right away in the morning to be consistent. Sometimes the resident refuses in the morning and they are done later in the day, so that may not be an accurate change. ADON C indicated she would look to see if she could find any other notifications for R16.On 4/22/26 at 2:40 PM, NHA A (Nursing Home Administrator) indicated a physician has been in the building to see R16 and has reviewed her weights.On 4/22/26 at 3:58 PM, Surveyor spoke with NHA A and DON B regarding R16. NHA A indicated ADON C was still looking through notifications to see if they corresponded to the weight changes. Surveyor let NHA A and DON B know that if the order to notify the physician isn't being followed, this is a concern- especially since nurses can easily send a message to the physician using the Hucu app. On 4/22/26 at 4:30 PM, NHA A indicated she would send over the physician notifications that she could find regarding R16's weight changes. NHA A indicated sometimes physicians include generic orders like this for residents, but R16 is being seen by doctors on a weekly basis, and they review her weights and vitals. Surveyor reviewed documentation provided by NHA A. Nursing staff notified a physician on 3/26/26 of R16's weight loss since admission. Nursing staff also notified a physician of R16's weight gain from 4/11/26 to 4/15/26 via the Hucu app on 4/15/26 and was asked if R16 had any signs or symptoms of fluid overload. R16 had provider visits on the following dates: 3/18/26, 3/25/26, 4/6/26, 4/8/26, 4/15/26, and 4/20/26.There is no documentation that a physician was notified of weight changes on the following dates: 3/19/26, 3/23/26, 4/2/26, 4/4/26, 4/11/26, and 4/12/26.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 incidents reviewed, affecting 1 of 2 residents (R34).R34 had a potential allegation of abuse and the facility did not submit a report to the State Agency (SA).Evidenced by:The facility's Abuse Prevention Program, undated, states, in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and secure environment. The purpose of this policy is to assure that the facility is going all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: . *filing accurate and timely investigative reports.R34 admitted to the facility on [DATE] and had diagnoses that include, in part: chronic obstructive pulmonary disease (a progressive lung disease causing breathing difficulty); chronic combined systolic and diastolic heart failure (a complex heart condition that presents with symptoms like fatigue and uncomfortable or difficult breathing); muscle wasting and atrophy (loss of muscle mass and reduction in size of muscle, often leading to reduced strength); weakness; cognitive communication deficit (a communication impairment stemming from cognitive issues such as memory, attention, or executive dysfunction-inability to regulate emotions, thoughts, actions-, rather than a language deficit); need for assist with personal care.R34's Progress Notes include:*3/12/26 11:53 AM BIMS (Brief Interview for Mental Status) Evaluation: Brief Interview of Mental Status should not be conducted. (Resident is rarely/never understood). Complete staff assessment for mental status. Resident was unable to complete Brief Interview for Mental Status. Seems or appears to recall after 5 minutes: Memory Problem. Seems or appears to recall long past: Memory problem. Resident can identify current seaseon. Resident is able to recall he or she is in a nursing home/hospital swing bed. Resident made decisions regarding tasks of daily life: Moderately impaired.*3/12/26 1:48 PM Resident requested suppository for constipation. Writer and CNA (Certified Nursing Assistant) repositioned resident on left side writer inserted suppository. While inserting suppository resident screamed loudly stop, stop you are elbowing me.On 4/22/26 at 10:53 AM, Surveyor interviewed DON B (Director of Nursing) and asked what about if a resident says, Stop, stop you're elbowing me. DON B stated, stop, apologize, get another person to assist, report to the nurse. Surveyor asked if a nurse is involved, is this to be reported. DON B stated yes. Surveyor and DON B reviewed R24's progress note and DON B stated I don't recall this situation, but I feel I would've followed up on this; would've updated NHA A (Nursing Home Administrator) and we would start an investigation.On 4/22/26 at 11:43 AM, Surveyor interviewed NHA A stated I was in at the time of the incident. I spoke with the staff and the resident. Surveyor asked to review documentation of the interviews. NHA A stated there was no documentation. Surveyor asked if the incident was reported. NHA A stated no. Important to note: a facility report was not submitted to the state agency following the incident.

Based on interview and record review, the facility did not complete a thorough investigation in response to allegations of abuse for 1 of 3 incidents reviewed affecting 1 of 2 residents (R34).On 3/12/26, the facility became aware of an alleged violation of abuse for R34. The facility did not interview other residents and staff about the allegation.Evidenced by:The facility's Abuse Prevention Program, undated, states, in part: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and secure environment. The purpose of this policy is to assure that the facility is going all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. This will be done by: . *implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, misappropriation of property and mistreatment, and making the necessary changes to prevent future occurrences; . VI. Internal Investigation 1. All incidents will be documented, whether or not abuse neglect, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect, exploitation, mistreatment or misappropriation of resident property will result in investigation.4. Investigation Procedures. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Resident whom the accused has regularly provided care, and the employees with whom the accused has regularly worked, will be interviewed.R34 admitted to the facility on [DATE] and had diagnoses that include, in part: chronic obstructive pulmonary disease (a progressive lung disease causing breathing difficulty); chronic combined systolic and diastolic heart failure (a complex heart condition that presents with symptoms like fatigue and uncomfortable or difficult breathing); muscle wasting and atrophy (loss of muscle mass and reduction in size of muscle, often leading to reduced strength); weakness; cognitive communication deficit (a communication impairment stemming from cognitive issues such as memory, attention, or executive dysfunction-inability to regulate emotions, thoughts, actions-, rather than a language deficit); need for assist with personal careR34's Progress Notes include:*3/12/26 11:53 AM BIMS (Brief Interview for Mental Status) Evaluation: Brief Interview of Mental Status should not be conducted. (Resident is rarely/never understood). Complete staff assessment for mental status. Resident was unable to complete Brief Interview for Mental Status. Seems or appears to recall after 5 minutes: Memory Problem. Seems or appears to recall long past: Memory problem. Resident can identify current season. Resident is able to recall he or she is in a nursing home/hospital swing bed. Resident made decisions regarding tasks of daily life: Moderately impaired.*3/12/26 1:48 PM Resident requested suppository for constipation. Writer and CNA (Certified Nursing Assistant) repositioned resident on left side writer inserted suppository (medication for constipation inserted rectally). While inserting suppository resident screamed loudly stop, stop you are elbowing me.On 4/22/26 at 10:41 AM, Surveyor interviewed RN E (Registered Nurse) and asked what staff does if a resident says stop. RN E stated you stop and ensure safety. Surveyor asked about R34. RN E stated R34 called out a lot for many things. In this situation, the resident has been many days without a bowel movement and it was mid insertion (of the suppository). A CNA (Certified Nursing Assistant) was with me to assist with positioning. R34's family had a camera in the room and they were listening to us. The family could've thought that we were abusing her, I wanted to document to show that we weren't. Surveyor asked if the incident was reported. RN E stated I'm certain that I told DON B (Director of Nursing) because this could sound abusive.On 4/22/26 at 10:53 AM, Surveyor interviewed DON B and asked what about if a resident says Stop, stop you're elbowing me. DON B stated, stop, apologize, get another person to assist, report to the nurse. Surveyor asked if a nurse is involved, is this to be reported. DON B stated yes. Surveyor and DON B reviewed R24's progress note and DON B stated I don't recall this situation, but I feel I would've followed up on this; would've updated NHA A (Nursing Home Administrator) and we would start an investigation.On 4/22/26 at 11:43 AM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated I was in at the time of the incident. RN E stopped me and said R34 said we were elbowing her and we weren't. I spoke with CNA G and asked if the resident was elbowed; CNA G said no, I think it I was holding him/her with my hands. NHA A stated I went to see R34 to see how R34 was doing. R34 has some cognitive issues; sometimes was spot on, other times might not respond or could take a bit for response. I asked if there was anything wrong. R34 said no. Surveyor asked if other residents under the care of RN E and CNA G were conducted. NHA A stated no. Surveyor asked to review documentation of the interview with RN E, CNA G and R34. NHA A stated there was no documentation. Surveyor asked if there was a complete investigation of the incident. NHA A stated I talked with the staff involved and the resident. The staff stated there was no elbowing. Surveyor asked if holding a resident, without use of elbows, could be hurting a resident. NHA A stated it is possible. Surveyor asked if it is important to interview other residents regarding their care as part of an investigation. NHA A stated, I get that.

Based on observation, interview, and record review, the facility did not ensure adequate interventions were in place for safety to prevent accidents from occurring for 1 of 1 resident (R25) reviewed for elopement. The facility did not ensure that R25 was wearing a WanderGuard each shift from 12/23/25 to present. Evidenced by: The facility policy entitled Elopement Prevention and Missing Resident Policy, revised on 10/10/25. Policy states in part: .Residents who are at risk for elopement shall be provided with at least one of the following safety precautions. 1. A WanderGuard device that will notify facility staff when the resident has left the building without supervision. All WanderGuard safety devices and door alarms should be placed appropriately and maintained and tested per the manufacturer's instructions as part of the facilities Prevention Maintenance Program. The regular testing of all Wander Guard safety devices shall be documented and included as part of the Preventative Maintenance Program. R25 was admitted to the facility on [DATE] with diagnoses that include dementia (decline in brain function that severely affects memory, thinking, and daily activities), anxiety disorder, and depression (mood disorder including persistent sadness, loss of interest in activities, and fatigue). R25's Minimum Data Set (MDS) assessment, dated 6/24/2026, indicated a Brief Interview for Mental Status (BIMS) of 3 which indicates severe cognitive impairment. R25's physician order states as follows: Check Wanderguard function and placement every shift. Expires 11/13/26. Order Date 12/23/25 Start Date 12/23/26. (Of note, the order start date was entered as 12/23/26 instead of 12/23/25.) R25 has an Elopement risk assessment dated [DATE]. Conclusion: At risk for elopement. Plan: Wander Guard in place. R25's Treatment Administration Record (TAR) from admission on 6/2025 to 12/23/25 states as follows: Check Wander Guard function and placement every shift. Expires 12/23/25. Starting 12/23/25 to 4/22/26 there is no order in TAR for checking the Wander Guard. On 4/20/26 at 3:06 PM surveyor observed resident with WanderGuard on his L (left) wrist. On 4/22/26 at 11:03 AM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E what is your process when someone has a WanderGuard. RN E responded they get an assessment first, then activate the WanderGuard which has an expiration date, chart each shift after testing the WanderGuard. We also have a binder which a picture of each resident in the nurse's station. Surveyor asked RN E where is the WanderGuard check documented. RN E stated in the TAR. Surveyor asked RN E if R25 had a WanderGuard. RN E stated oh yes. Surveyor asked if RN E could show this surveyor the documentation in the TAR. RN E looked in the TAR and stated that she did not have any documentation in the TAR. On 4/22/26 at 11:20 AM, surveyor interviewed DON B. Surveyor asked where documentation with a WanderGuard would be found. DON B stated in the TAR every shift. Surveyor asked if DON B could look up R25's TAR for WanderGuard documentation. DON B was not able to find documentation on WanderGuards in the TAR. Surveyor showed DON B the physician order, and DON B stated that she wrote the wrong start date for the order, it was supposed to be 12/23/25 and it was written 12/23/26. DON B states I just put the wrong year for the start date. Surveyor asked DON B would you expect your nursing staff to document on the WanderGuard residents every shift. DON B stated yes.

Based on observation, interview, and record review the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 of 1 Residents (R7) reviewed for oxygen.R7 did not have oxygen tubing changed on a weekly basis.Evidenced by:The facility's Oxygen Tubing Change Procedure policy, undated, states, in part: Purpose: To ensure safe, sanitary, and effective delivery of oxygen therapy while minimizing the risk of infection and equipment malfunction. Policy Statement: Oxygen delivery devices (including cannulas, masks, and tubing) will be changed routinely and as needed based on resident condition, infection control standards, and manufacturer recommendations. Procedure 1. Routine Tubing Change Frequency- Oxygen tubing and delivery devices shall be changed: . *Every 14 days if humidification is in use. *Per manufacturer recommendations if more stringent .R7 admitted to the facility on [DATE] and has diagnoses that include, in part: acute on chronic diastolic (congestive) heart failure (a heart condition with symptoms including severe shortness of breath and fatigue); interstitial pulmonary disease (a group of lung disorders characterized by inflammation or scarring of the lung tissue, making if difficult to breathe and absorb oxygen); chronic respiratory failure (a long term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen levels)R7's Physician Orders include: change oxygen tubing weekly Friday. Change oxygen supplies including cannula, tubing, humidifier bottles / wash filter on concentrator at this time. Initial and Date supplies.Start date 11/14/25On 4/20/26 at 10:34 AM, Surveyor observed R7 in his/her room, wearing an oxygen nasal cannula that was attached to an oxygen concentrator with humidification, running at 3 LPM (liters per minute). A green tag on the tubing was labeled with Change-Tuesday Date 3/31. On 4/20/26 at 10:53 AM, Surveyor interviewed CNA F (Certified Nursing Assistant) and asked about oxygen tubing. CNA F stated the tubing is changed weekly. Surveyor asked CNA F when R7's tubing was changed. CNA F looked at the label on R7's tubing and stated the date is 3/31.On 4/22/26 at 7:49 AM, Surveyor interviewed DON B (Director of Nursing) and asked about oxygen tubing. DON B stated it needs to be changed weekly, and we missed that for R7.

Based on interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This affected 1 of 1 sampled residents (R8) reviewed for medication errors.R8 was given morphine sulfate oral solution (an opioid prescribed to relieve pain) after the printed expiration date on the medication card.This is evidenced by:The facility's policy, titled Medication Storage in the Facility, revised 1/18, states in part: Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Procedures:. H. Outdated, contaminated, or deteriorated medications.are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists.Expiration Dating (Beyond-use dating): A. Expiration dated (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. E. The nurse will check the expiration date of each medication before administering it. F. No expired medications will be administered to a resident. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner.R8 was admitted to the facility on [DATE] and is currently enrolled in hospice services with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right-sided paralysis and weakness following a stroke) and chronic pain. R8's physician orders include the following: 11/20/25: Morphine sulfate (concentrate) oral solution 20 mg/mL - Give 0.25 mL by mouth every 4 hours as needed for dyspnea (shortness of breath) / moderate to severe pain. Dose is 5 mg.On 4/22/26 at 12:09 PM, Surveyor observed the medication cart for the 300 wing with RN D (Registered Nurse). Surveyor noted that R8's morphine sulfate oral solution (20 mg/mL) had an expiration date of 12/28/25 with 5 syringes remaining in the bag. RN D confirmed the expiration date, pulled the syringes from the cart, and indicated that she was surprised they were still in the medication cart. On 4/22/26 at 12:20 PM, RN E entered the medication room and Surveyor asked her to verify the expiration date on R8's morphine sulfate oral solution. RN E confirmed the expiration date of 12/28/25. RN D verified the expiration date in the narcotic count binder as well. RN D asked RN E to dispose of the expired syringes with her. R8's Medication Administration Record (MAR) for February 2026 indicates the morphine sulfate oral solution was administered to R8 on 2/9/26 at 6:10 AM. R8's MAR for April 2026 indicates the morphine sulfate oral solution was administered to R8 on 4/1/26 at 3:15 AM and on 4/19/26 at 3:22 PM. On 4/22/26 at 2:42 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated medication carts should be gone through often to look for expired medications; in a perfect world, they would be gone through every shift. Surveyor informed DON B about R8's expired morphine sulfate being in the medication cart and having been administered in February and April. DON B indicated she would expect the morphine sulfate to be discarded and not used past the expiration date.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 3 residents reviewed for grievances (R2). R2 voiced a grievance to the facility, and the facility did not complete appropriate interviews or provide follow up with the complainant after the conclusion of the investigation. Evidenced by: The facility's policy titled Grievance Policy dated 4/1/25 states in part .4. The Grievance Officer will route the grievance to the appropriate department head related to the grievance filed, and an investigation of the grievance will be conducted. Based on the nature of the grievance, the Grievance Officer will initiate any additional interventions that are indicated at that time.When indicated, a review of the resident's medical record to obtain information regarding the resident's clinical condition will be completed.5. After thorough research has been conducted, the Department Head and/ or Grievance officer will work with staff identified as key individuals critical to problem resolution for the specifically identified concern.7. The resident will be provided with a verbal follow- up to their grievance, including the following information: a. The name of the Department Head conducting the investigation. b. The steps are taken to investigate the grievance. c. The final results of the grievance- a. Signature by resident or representative on grievance document. R2 was admitted to the facility on [DATE] with diagnoses that include fracture of left pubis (a break in the pubic bone (pelvis)), type 2 diabetes mellitus, major depressive disorder, and chronic pain. R2's most recent MDS (Minimum Data Set) dated 8/26/25 states that R2 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R2 is cognitively intact. R2's physician orders state in part: Hydrocodone- acetaminophen 10/325mg (milligrams) Give 2 tablets by mouth 6 times a day for pain. On 8/21/25, R2 reported to facility staff that she had concerns regarding a specific nurse and not getting the correct medications. The facility filed a grievance. The facility's document titled Grievance Form states in part Date grievance submitted: 8/21/25.Grievance Information: Nurse [Nurse's Name] gave medications on the night shift she was unsure of.Requested Grievance Resolution: Resident had no request immediately then informed [SSD (Social Services Director) Name] that she wanted it looked into.Summary of Investigation Findings/Conclusion: [R2] recognized a medication on 8/21 by [Nurse's Name] that she was not aware of She did not care for interaction with - see [SSD Name] attached. Was the grievance substantiated? Yes. The facility took the following corrective action: Med count was correct and accurate. [Nurse's Name] was called on 8/21/25 by [NHA (Nursing Home Administrator) Name] and [DON (Director of Nursing) Name] staff member was written up via verbal conversation on 8/21/25.The attached documentation mentioned above from SSD C states in part .The resident reported that she had an experience with the night nurse [Nurse's Name] she felt unsettled about. Resident stated on the NOC (night) shift the night before our conversation on 8/21/25 the nurse brought her medications to her room, and the resident requested that the meds be handed to her and not given directly from med cup.When she looked at the 3 medications in her cup, she recognized 2 of the medications but one of them looked different. When the resident questioned the nurse, [Nurse's Name] took the medications to the hall where the med cart was and returned within a reasonable amount of time with the correct medication. It is important to note that the grievance investigation does not have documentation of staff or resident interviews, other than SSD C's interview with R2. Additionally, the facility does not have documentation that the resolution of the grievance was communicated, in writing, with the resident. On 9/16/25 at 12:22 PM, Surveyor interviewed R2. Surveyor asked R2 to explain the incident, R2 reported that the nurse came into her room to administer her medications and attempted to pour the medications into her mouth, instead of handing them to her. R2 stated that she requested the medications to be placed into her hand and then realized that she did not have the correct medications, stating that she has taken these medications for 15 years and knows what they look like. R2 reported that the nurse then went back to the med cart and brought in the correct medications. Surveyor asked R2 who she reported her concerns to, R2 stated SSD C. Surveyor asked R2 if the facility followed up with her regarding a resolution, R2 stated no. On 9/16/25 at 12:30 PM, Surveyor interviewed SSD C. Surveyor asked SSD C what the process is once a resident expresses a grievance, SSD C stated that the facility initiates an investigation. Surveyor asked SSD C if facility staff follow- up with residents to discuss the resolution once the grievance has been fully investigated, SSD C stated that they follow- up with residents or their representatives verbally and it is signed off on the bottom of the grievance form by facility staff. Surveyor asked SSD C if they obtain a signature from the resident or their representative indicating that they agree or disagree with the resolution, SSD C stated no. Surveyor asked SSD C if they met with R2 to discuss the outcome of her grievance, SSD C stated that she met with R2 the following day and gave her a verbal update, indicating to R2 that facility staff identified that the nurse was attempting to give her Tylenol, and that the nurse was educated.It is important to note that R2 did not have an order for Tylenol/ acetaminophen. On 9/16/25 at 1:25 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if they asked the nurse why she was attempting to give R2 Tylenol instead of her scheduled hydrocodone- acetaminophen 10/325mg, NHA A reported that the nurse needed to get the medication from their contingency (back-up) supply, but the nurse decided to administer the Tylenol instead. Surveyor asked NHA A if R2 had an order for Tylenol, NHA A stated that she would have to look. Surveyor asked NHA A if they interviewed other residents about not getting the correct medications, NHA A stated no. NHA A reported that she did come in on a night shift to make observations of the nurse and spoke with the CNA (Certified Nursing Assistant) regarding another grievance but did not have any staff interviews regarding R2's grievance. On 9/16/25 at 2:25 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she asked the nurse why she was attempting to give R2 Tylenol instead of her scheduled pain medication, DON B stated that the nurse reported that R2's scheduled pain medication was not available, so she attempted to administer the Tylenol. Surveyor asked DON B if R2 had an order for Tylenol, DON B stated that she would have to check. The facility failed to conduct a complete investigation into R2's grievance and provide adequate follow- up with R2 regarding the resolution of the grievance.

Based on observation, interview, and record review, the facility did not ensure for 2 of 7 residents (R2 and R5), each resident received food with at a palatable temperature. An anonymous complainant voiced concerns regarding food temperatures. R2 and R5 voiced concern related to cold food. Test tray found food was not served at appropriate temperatures. In addition, the cauliflower/broccoli was mushy. Evidenced byFacility policy, Food Temperatures, undated, states, as follows: Procedure: All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F (Fahrenheit). All cold food items must be stored and served at a temperature of 41 degrees F or below. Food preparation and service areas will follow these methods: Hold foods at or below 41 degrees F for cold foods and at or above 135 degrees F for hot foods (to keep food out of the temperature danger zone.)The facility serves the halls in the following order: 300, 100, 200. Surveyor requested a room test tray after all the residents on the 200 wing were served lunch.On 8/5/25 at 11:50 AM, Surveyors observed staff begin tray line. At 12:40 PM, the food cart was brought to the 200 wing (the last wing served). At 12:46 PM, Surveyor was provided with a test tray after the last person on the 200 wing was served lunch. The food temperatures were as follows: Chicken Tetrazzini 128.7 F (Fahrenheit), Cauliflower /Broccoli 130.5 F, Milk 50.5 F. The food was cold and not palatable. The cauliflower/broccoli was mushy and not palatable. On 8/5/25 at 9:43 AM, Surveyor spoke with R2. R2 stated, half the times her eggs are cold. On 8/5/25 at 10:00 AM, Surveyor spoke with R5. R5 stated, the food is not always hot enough.On 8/5/25 at 2:10 PM, Surveyor spoke with DM C (Dietary Manager). DM C stated, staff were running late for tray line today. DM C stated, staff usually start tray line at 11:50 AM and are done at 12:10 PM. DM C added, there is a new staff member in training in the kitchen and that may have slowed the tray line process. Surveyor asked DM C, what temperature should food be when it's served to residents. DM C stated, we do not want food to be under 140 degrees F (Fahrenheit) when it reaches the residents. DM C stated, cold foods should not be served less than 40 degrees F. Surveyor stated, Chicken Tetrazzini on the Test Tray was 128.7 degrees F. DM C stated, that is cold, it should be at least 140 degrees F. DM C stated, she has not had complaints regarding cold food just the food items themselves. Surveyor shared the milk was 50.5 degrees. DM C stated, the milk needs to be at 40 degrees F or below. Surveyor shared with DM C the food was not palatable due to the temperature of the foods and the broccoli/cauliflower being overcooked and mushy.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 26 residents. Surveyor observed Cook J use single use alcohol pads multiple times. Cook J did not allow thermometer to air dry before using it in different dishes. Surveyor observed 3 utensils to have pieces missing from them and in circulation. Surveyor observed food to be removed from original container, undated, and not closed properly in freezer. Surveyor observed food in refrigerator past the use by date. Evidenced by: Example 1 Manufacturer's recommendations for use of Medline Large Alcohol Prep Pad, 70% isopropyl alcohol, dated ., includes: Sterile pads are packaged in single-use packs for convenience . This product is intended for use on the body only. Safety Data Sheet for Medline Large Alcohol Prep Pad, revised 1/5/24, includes: . May be harmful if swallowed . Wash thoroughly with soap and water after handling and before eating . If ingested, seek medical advice immediately and show the container or the label . Ingestion: If swallowed, call a physician immediately. Rinse mouth and throat thoroughly with water. Do not induce vomiting unless directed to do so by a physician. On 2/15/24 at 11:44 AM, Surveyor observed Cook J pulling hot food out of the oven and setting it up to take the temperature. Cook J used a single use alcohol prep pad to wipe the thermometer and then stuck it in chicken drumsticks. Cook J did not allow the thermometer to air dry before sticking it in the chicken drumsticks. Cook J then used the same single use alcohol wipe to wipe the thermometer. Cook J stuck the thermometer in the next food (potatoes) without allowing it to air dry. Cook J repeated this practice with the following foods: chicken, potatoes, carrots, pureed meat, mechanical soft meat, gravy, soup, and beef patties. On 2/15/24 at 11:54 AM, during an interview, Cook J indicated she did not know the surface contact time for the alcohol prep pads she was using. Cook J indicated she did not allow the thermometer to air dry before putting it into food. Cook J and Surveyor observed and reviewed the packaging for the alcohol prep wipes, noting the package states: for removal of oils and residue from skin, . discard after single use, . if accidentally swallowed seek medical assistance or contact Poison Control Center right away ., intended for use on the body only . Cook J indicated she should not use the wipe with more than one food or she could cross contaminate the foods and the wipe is intended for one time use only. Cook J indicated she was unaware the product was not for surface cleaning and was for use on skin. Example 2 On 2/13/24 at 9:57 AM, during initial tour of the facility's kitchen, Surveyor observed 2 spatulas to have chips and cracks in the rubber with pieces missing. Surveyor also observed a pancake [NAME] to have been melted and still in circulation. On 2/13/24 at 9:57 AM, during initial tour, Cook K indicated these pieces could have broken off into the food and could continue to chip off into food if they are not discarded. Cook K indicated when the utensils are damaged, they need to be removed. Example 3 On 2/13/24 at 9:57 AM during initial tour, Surveyor observed French toast in the facility's freezer to be removed from the original container and without an open date or use by date. Surveyor also observed the food to be exposed as the plastic around it was not closed properly. Cook K indicated the French toast should be covered and it should be marked with a use by date and/or the manufacturer's expiration date. Example 4 On 2/13/24 at 9:57 AM, during initial tour, Surveyor observed biscuits in the facility's refrigerator with the date of 2/3/24. Cook K indicated the biscuits should have been tossed out within 5 to 7 days.

Based on observation, interview, and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 6 residents reviewed for accidents (R12 and R14). Surveyor observed R14 to be seated next to a charging electric power wheelchair in a common tv room. R12 is at risk for aspiration pneumonia and Surveyor observed CNA L (Certified Nursing Assistant) assisting R12 with his meal in a reclining position in bed and not upright. Surveyor observed CNA L to be organizing R12's room instead of supervising him and assisting him with his meal. CNA L did not use the care planned adaptive equipment, a plastic spoon. CNA L did not assist R12 in putting 1/2 teaspoon sized bites on his spoon. R12 had seven (7) coughing episodes during observation. Example 1 Facility policy, entitled Electric Power Wheelchair, reviewed October 2023, includes, in part: charging of electric wheelchairs will be done in a designated area . R14 admitted to the facility on [DATE]. R14's most recent Minimum Data Set, with Assessment Reference Date of 1/7/24, indicates R14 is impaired on one of his upper extremities and both of his lower extremities and is fully dependent on staff to wheel him in his wheelchair. On 2/13/24 at 11:27 AM, Surveyor observed R14 to be sitting at a table watching TV in a visiting area. Surveyor observed a power wheelchair charging next to R14. (It is important to note the electric/power wheelchair did not belong to R14, but R14 was put at risk as he was positioned next to the charging power wheelchair.) On 2/13/24 at 11:31 AM, CNA H (Certified Nursing Assistant) indicated the staff normally charge the power wheelchairs here and she was unaware of the risk of the resident injury due to the battery exploding and that the power chair should be charging behind a fire safe door. On 2/13/24 at 11:34 AM, Activity Director I and CNA L indicated they charge two power wheelchairs in this area and residents often sit in the area as well. Activity Director I and CNA L indicated they were not aware the power chair should be charging behind a fire safe door. On 2/13/24 at 11:41 AM, NHA A (Nursing Home Administrator) indicated staff charge two power chairs in this area and not behind a fire safe door. NHA A also indicated R14 tends to spend a lot of time watching TV in this area while chairs are charging. NHA A indicated she thought the facility had to charge power chairs in a public area and not in a resident room due to being told they could catch on fire. Surveyor asked if the power chair could catch on fire in the current location with R14 sitting right next to it. NHA A indicated this is possible and the power chairs should be charging behind a fire safe door to prevent resident injury. Surveyor observed staff unplugging power wheelchair and moving it to a safe location to charge. Example 2 Facility policy, entitled Meal Supervision and Assistance, reviewed 11/23, includes: the facility will develop and implement an individualized care plan based on the resident assessment to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time. The resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position . When assisting resident with eating staff should remain seated next to the resident so they are at the resident's level not standing over resident . Be careful to provide portions of food easy for the residents to chew . Wipe the resident's mouth as needed . encourage the resident to participate with his or her meal as much as possible . Report any swallowing difficulties and refer to the speech therapy department. R12 admitted to the facility on [DATE] with diagnoses including dysphagia, autistic disorder, dementia, hemiplegia, and hemiparesis following cerebral infarction affecting left non-dominant side, vision loss in both eyes, contracture of left hand, personality and behavior disorder, deaf, and non-speaking. R12's Comprehensive Care Plan, initiated 9/23/2019, includes, in part: 5/16/23- Focus-R12 is at risk for aspiration pneumonia related to mechanically altered diet. 5/16/23- Goal- the resident will be free of signs and symptoms of aspiration pneumonia through the next review date . 5/16/23- Approach- Encourage good fluid intake as well as good nutrition and adequate rest. 11/15/21- Approach- Consult with Registered Dietician and change diet if chewing/swallowing problems are noted . 5/16/23- Approach- Monitor/document/report to Medical Doctor as needed for the following signs and symptoms of aspiration pneumonia: fever but no chills, pink, frothy foul-smelling sputum, cyanosis . 2/5/24- Goal- Resident will be able to feed self with supervision, set-up, and assistance as needed . 1/30/24 Approach- Monitor/document for physical/nonverbal indicators of discomfort or distress, hitting self, and follow up as needed . 4/18/23 Focus- R12 has a mechanically altered diet . is nutritional at risk related to . cerebral infarction, speech and language deficit, dementia without behaviors, visual loss, anxiety disorder, dysphagia, autistic, pain, and deaf . 3/8/23- Approach- Encourage to dine in wing lounge for meals. Position upright for all intake by mouth food- 1/2 spoonful's, one on one assist with meals, one on one supervision for self-feeding of snacks . assist resident to scoop food onto plastic teaspoon . alternate food and drinks . adaptive equipment- plastic teaspoon, two handled cups with lids for liquids . On 2/13/24 at 12:13 PM, Surveyor observed CNA L (Certified Nursing Assistant) assisting R12 with his lunch meal. CNA L was wearing gloves throughout the observation. CNA L went from assisting R12 with eating to rearranging items and touching dirty linens in his room to assisting him again, without washing hands and donning new gloves in between. CNA L stood over R12 when she was assisting him. R12 was slouched down in his bed and leaning to his left. He was not upright. Surveyor observed R12 throwing bed pillows and a neck pillow behind himself as he attempted to readjust himself. Surveyor observed R12 scoop large heaping spoonful's of food to his mouth, dropping some on his neck napkin. Surveyor observed R12 experience difficulty in swallowing and coughing 7 times during the observation. R12 lifted his chin to the right, lifted his chin to the left, and R12 tucked his chin in to his neck trying to swallow his food. After bites some of his food ran out of his mouth, down his chin to his neck napkin and after other bites R12 pocketed his food in his mouth. Surveyor observed R12 startle when CNA L put the metal spoon in his hand without notice from his left side and when she put his cup into his hand without notice from his right side. CNA L was approaching R12 from both sides while standing and in between straightening his room out. Surveyor observed R12 hit himself in the head several times with an open hand and make grunting noises as if he was frustrated. When interviewed, CNA L indicated R12 was deaf and blind. CNA L indicated she was assisting R12 and allowing him to do as much as he can for himself. CNA L indicated she also was organizing his room in between assisting R12. CNA L indicated R12 eats all his meals in his bed. On 2/15/24 at 8:29 AM, Surveyor observed CNA H assisting R12 with his meal. During an interview, CNA H indicated R12 is blind, deaf, and non-verbal. CNA H indicated she makes her presence known by lightly touching R12 on the back of his hand on the side she will be on. CNA H indicated she sits next to R12 at his eye level to assist him and she does not move about the room or complete other tasks while assisting R12 with his meal. CNA H explained, This way he knows I am here and ready to assist. CNA H indicated R12 is to be upright in a 90-degree position for meals and for an hour after meals, so he does not aspirate. CNA H indicated when R12 hits his head with an open hand it means he is mad or frustrated. CNA H indicated R12 is to have a plastic spoon and he is to take small bites like the size of half of the spoon and that is why she spreads his food out on the plate, so he does not get heaping spoonful's when he self feeds. On 2/15/24 at 9:10 AM, Med Tech D indicated R12 is to be upright at a 90-degree angle for meals and for at least 20 minutes after eating. Med Tech D indicated R12 is to have a plastic spoon and cups with two handles and a lid to minimize his risk of aspiration or other accidents. Med Tech D indicated staff are to be seated next to R12, offering assistance, and supervising R12 while eating, and not working on other tasks throughout his room. Med Tech D indicated staff are to report to the floor nurse when R12 is having difficulty with swallowing or experiencing coughing while eating.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R23 and R12) of 5 opportunities and 1 (R10) of 1 supplemental for hand hygiene for sampled residents. Surveyor had an observation of multiple breaks in appropriate infection control practice for handwashing and catheter care for R23. Surveyor had an observation of a break in appropriate infection practice by not wearing gloves when administering R10's eye drops. Surveyor observed CNA L (Certified Nursing Assistant) wearing gloves assisting R12 with his meal and touching dirty linens and other things around R12's room without removing gloves and without handwashing. This is evidenced by: The facility's policy, entitled Hand Hygiene, dated 6/23, states, in part . Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Hand Hygiene Table . After handling contaminated objects . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . After assistance with personal body functions ( . elimination .) Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) . The facility's policy, entitled Administration of Eye Drops or Ointments, dated 10/23, states, in part . 3. Wash hands or utilize alcohol-based hand rub and apply gloves . Example 1 R23 was admitted to the facility on [DATE] and has diagnoses that include neuromuscular dysfunction of the bladder, unspecified, (a person lacks bladder control due to brain, spinal cord, or nerve problems), and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms. On 2/15/24 at 1:22 PM, Surveyor observed CNA E (Certified Nursing Assistant) empty R23's catheter bag. CNA E performed hand hygiene, donning a gown, and gloves applied. CNA E obtained alcohol wipes from R23's cabinet and a clear plastic bag that had a graduate cylinder inside the bag. CNA E removed the graduate from the clear plastic bag and used the plastic bag as a barrier by placing it on the floor. CNA E placed the graduate on top of the plastic bag. CNA E continued to perform cares by wiping the catheter spout with an alcohol pad, unclamped the spout, emptied the urine contents into the graduate, then clamped and wiped the catheter spout with an alcohol pad. CNA E proceeded to R23's bathroom, read the amount of urine, emptied the contents into the toilet, obtained a paper towel, and placed it into the graduate (note: the graduate was not rinsed nor washed out). CNA E came back to R23 and placed the graduate in the same plastic bag from the floor, opened R23's cabinet, and returned the plastic bag to the cabinet. On 2/15/24 at 1:40 PM, Surveyor interviewed CNA E. CNA E reviewed the process of emptying a catheter bag with the Surveyor. CNA E indicated that after she put the paper towels inside the graduate, she forgot to change her gloves. Surveyor asked CNA E if she should perform hand hygiene before touching a resident's personal belonging after handling a contaminated graduate, she indicated she did not and that she usually changes her gloves and should have performed hand hygiene. Surveyor asked CNA E if she rinsed out the graduate after emptying the contents, she indicated she does not and she rinses them out every other day. CNA E further indicated that the second shift rinses the graduates out. On 2/19/24 at 10:33 AM, Surveyor interviewed CNA F. CNA F explained the process of emptying a catheter. CNA F indicated that she uses a paper towel from the bathroom as a barrier and does not use the plastic bag as a barrier. The plastic bag goes into the resident's drawer in their room. CNA F further indicated that after emptying the graduate into the toilet, she rinses the graduate with hot soapy water. Surveyor asked CNA F if she would perform hand hygiene after handling bodily fluids, she indicated she would remove her gloves and perform hand hygiene prior to touching any resident's belongings. On 2/19/24 at 1:38 PM, Surveyor interviewed DON B (Director of Nursing). DON B explained the process of emptying a catheter bag. Surveyor shared the observation of R23's catheter bag emptied by CNA E. DON B indicated the graduate should have been rinsed out, hand hygiene should have been performed after handling bodily fluids and a paper towel should have been used a barrier. Example 2 R10 was admitted to the facility on [DATE] and has diagnoses that include unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and combined forms of age-related cataract, bilateral. R10's Physician Order states, in part Artificial Tears solution . instill 1 drop in both eyes two times a day for dry eyes . Order date 8/25/21. On 2/15/24 at 8:34 AM, Surveyor observed MT D (Medication Technician) administering eye drops to R10. MT D performed hand hygiene, obtained a tissue, administered an eye drop into each eye, and performed hand hygiene. On 2/15/24 at 9:03 AM, Surveyor interviewed MT D. MT D indicated she did not wear gloves when administering R10's eye drops, and she should have. On 2/15/24 at 9:53 AM, Surveyor interviewed DON B. DON B indicated she was advised of the eye drop administration by MT D, and she should have worn gloves. On 2/19/24 at 1:30 PM, Surveyor interviewed LPN G (Licensed Practical Nurse). LPN G explained the process for administering eye drops. LPN G indicated that gloves should be always worn when administering eye drops. On 2/19/24 at 1:38 PM, Surveyor interviewed DON B again. Surveyor updated on LPN G's interview. DON B indicated that gloves should have been worn when administering eye drops. 38882 Example 3 R12 admitted to the facility on [DATE] with diagnoses including dysphagia, autistic disorder, dementia, hemiplegia, and hemiparesis following cerebral infarction affecting left non-dominant side, vision loss in both eyes, contracture of left hand, personality and behavior disorder, deaf, and non-speaking. On 2/13/24 at 12:13 PM, Surveyor observed CNA L (Certified Nursing Assistant) holding R12's spoon handle assisting him with his lunch. CNA L had gloves on both hands. CNA L walked around R12's room picking items up and touching dirty linens. CNA L then went back to assisting R12 with his meal. CNA L did not wash her hands or remove her gloves after touching things around the room and before assisting R12 with his meal. On 2/15/24 at 8:29 AM, CNA H indicated she does not wear gloves to assist with feeding R12 and if she were to touch dirty linens or other things around in R12's room she would wash her hands before assisting him with his meal. On 2/15/24 at 9:10 AM, Med Tech D (Medication Technician) indicated staff are to wash hands before assisting residents with meals. Med Tech D indicated if staff stop assisting a resident with a meal to fold linens or to organize items in the room, they should wash their hands before beginning to assist with meal again. On 2/15/24 at 9:49 AM, DON B (Director of Nursing) indicated staff so not need to wear gloves to assist residents with their meal unless they intend to touch the food. DON B indicated staff are to remove gloves and wash hands after touching dirty linens and items and before assisting residents with meals.

Based on observation, interview, and record review, the facility did not ensure that nursing staffing information was accurate and current. This has the potential to affect all 26 residents in the facility. The facility's nursing staff information postings were not updated daily. This is evidenced by: Division of Quality Assurance (DQA) memo 12-020 titled, Clarification Concerning Posting Requirements for Nurse Staffing documents: Required Staffing Information .Nursing homes must post information about the number of staff directly responsible for resident care on each shift. This information must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift . The information that is posted must include the following . 1. Facility name. 2. The current date. 3. The total number of staff directly responsible for resident care per shift for each of the following categories: licensed (RNs (Registered Nurse), LPNs (Licensed Practical Nurse), and unlicensed (CNAs (Certified Nursing Assistant)). (For example, 1 RN, 2 LPNs, and 4.5 CNAs.) The number of RNs must be separate from the number of LPNs. 4. The actual hours worked per shift for each of the following categories: licensed (RNs, LPNs), and unlicensed (CNAs). 5. Resident census. Timing: Information is to be posted daily and must be present at the start of each shift. Nursing homes can choose to post staffing information for the entire day or for the current shift. Nursing homes are required to update the posted staffing if any changes arise, for example, if a nursing assistant calls in sick or goes home sick and is not replaced. The facility policy entitled, Nurse Staffing Posting Information dated 10/23, states in part, . 1. The Nurse Staffing Sheet will be posted on a daily basis . 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift . On 2/13/24 at 9:30 AM, Surveyor observed the nursing staff information posting dated 2/12/24. On 2/13/24 at 1:10 PM, Surveyor observed the nursing staff information posting dated 2/12/24. On 2/14/24 at 8:05 AM, Surveyor observed the nursing staff information posting dated 2/12/24. On 2/14/24 at 12:28 PM, Surveyor observed the nursing staff information posting dated 2/12/24. On 2/15/24 at 7:55 AM, Surveyor observed the nursing staff information posting dated 2/12/24. On 2/15/24 at 9:53 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who is responsible for the staff information posting, she indicated the scheduler or the NHA (Nursing Home Administrator). On 2/15/24 at 9:53 AM, Surveyor interviewed RO C (Regional Operations). RO C indicated she noticed the staff information posting was not updated and she had changed it. RO C reported that the scheduler is out ill and indicated that the staff information posting was missed. On 2/19/24 at 8:51 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A indicated that the staff information posting should be changed daily as changes occur.

Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for 2 of 48 residents (R2 and R3) as staff observed R1 inappropriately touching R3's private area and observed R1 with his hands moving under sheets by R2's private area. The facility failed to: 1. Implement a policy on one to one monitoring/supervision and educate all staff on one to one supervision/monitoring. 2. Staff did not provide adequate supervision to keep further abuse from occurring. 3. Staff did not ensure R1's sexual behaviors were captured in behavior tracking documentation. 4. Staff did not update R3's care plans with intervention to ensure his safety. Using the concept of a reasonable person, women and men don't want to be touched by strangers and would feel threatened, unsafe and vulnerable if unable to defend themselves from unwanted sexual advances. R2 and R3 are vulnerable and unable to protect themselves. The facility's failure to keep residents free from sexual abuse created a finding of Immediate Jeopardy (IJ), beginning on 3/31/20. On 7/29/20 at 12:30 PM, NHA A (Nursing Home Administrator) was informed of the IJ. The facility removed the jeopardy on 8/6/20; however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. Evidenced by: The facility's Abuse policy, revision date of 9/16/17, includes, in part: . sexual abuse is non-consensual sexual contact of any type with a resident. Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation .includes verbal abuse, sexual abuse, physical abuse, and mental abuse . The facility will make all efforts to protect all residents after alleged abuse, neglect, and/or exploitation .Temporary separation from other residents if resident's behavior poses a threat of abuse . Temporary or permanent room change . involve family members to sit with resident . Temporary one-on-one supervision . R1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R1 has an APOAHC (Activated Power of Attorney for Health Care) in place. R1's most recent MDS (Minimum Data Set), with ARD (Assessment Reference Date) of 5/20/20, indicates he ambulates and toilets independently. It also indicates R1 is cognitively intact with a BIMS (Brief Interview for Mental Status) score of 14 out of 15. R1's Comprehensive Care Plan, initiated on 1/9/20, includes, in part: . 1/9/20 targeted behaviors: difficulty sleeping, difficulty falling asleep, verbalizes sadness, crying, impulsive, restless, and exit seeking . R1's Nurse Note, dated 3/12/20, indicates at 10:10 PM R1 was found in an adjoining room, sitting on R3's bed. During an interview on 7/28/20 at 4:30 PM, RN C indicated CNA D reported the incident to her and when she went in to the room, R3 was asleep and R1 was back in his room. DON B was notified and spoke to RN C. DON B indicated during an interview she decided to not investigate further due to no contact being observed by staff. (It is important to note CNA D is no longer employed by the facility and the facility's contact information for her was not current.) Incident 1. R1's Nurse Notes, dated 3/31/20, indicate there is an ongoing investigation as R1 was witnessed in (R2)'s room that visually looked like he was touching (R2's) crotch . R1 placed on one-on-one as of 3:35 PM. R2 was admitted to the facility on [DATE]. His MDS, dated [DATE], indicated R2's cognition was severely impaired with a BIMS score of 00 out of 15. Investigation, dated 3/31/20, includes, in part: CNA E statement: I was walking in the hallway going pass R2's room and I seen (R1) in R2's room. R1 was bent over by R2 with his hands by his crotch and moving his hands around down there by crotch area. I said (resident name) and startled him. R1 was coming out of the room and he said he needs to be covered up. I told R1 he needs to go sit down. I checked on R2 and covered him up to make sure he was safe and went to my supervisor to let her know what happened. DON B statement: CNA E came to my office stating she found R1 in R2's room. R2 was in bed. She found R1 bent over R2 and R1's hands were near R2's crotch. I asked her if R1 touched R2's skin and she stated she did not see that R1 touched his skin. One-on-one began immediately . R1's statement: Just trying to cover him up. R1 indicated he saw R2 trying to play with himself and he went to cover R2 with a sheet so his private area could not be seen from the door. R1 denied touching R2 inappropriately. Conclusion: On 3/31/20 CNA E was walking down the hall . and noted R1 was in room of R2. Both residents reside on the (same) wing. She observed that R2 was in bed and R1 was leaning over and his hand was near R2's crotch area. CNA E did not actually see R1's hand on R2 but saw the movement of the sheet. R2 is unable to articulate and his BIMS of 0 . We were unable to substantiate or not substantiate that there was any inappropriate action. For safety of all residents R1 will continue to be on one-on-one observation. On 7/29/20 at 2:30 PM during an interview with Surveyor, CNA E indicated on 3/31/20 around 3:30 PM she was walking pass R2's room and observed R1 was in R2's room. CNA E indicated she observed R1 was standing bent over R2 who was lying in his bed. CNA E stated, R1 was fondling down there. No skin on skin, but I could see sheets moving down there. CNA E indicated R2's brief was on, but opened and he also had on a gown. CNA E indicated R1's hand was in sheets and they were moving up and down by R2's private area. CNA E removed R1 and reported this immediately. R1's Nurses Notes, dated 4/1/20, include, in part: R1 found lying in bed on his left side with no shirt on and with his pants and underwear pulled down to his knees masturbating. Resident was allowed privacy and instructed to inform staff when it is ok to return to room. R1's Nurses Notes, dated 4/18/20, include, in part: R1 was walking in hall with supervision. Reported R1 kept putting his hand down his pants .Writer stopped R1 from touching R2. Again writer reminded R1 of social distance and no touching other residents. R1 then went to his room and proceeded to cat call [MEDICATION NAME] at staff for about 30 minutes. R1's Fall Report, dated 5/4/20, indicates R1 had an unwitnessed fall on 5/3/20 at 7:00 PM. Review of post fall findings, in this report, include, in part: . Describe new fall prevention interventions to be implemented as a result of the assessment: closer observation with one-on-one staff . List suggestions of referrals to be made as a result of the fall: closer observation of staff, also if resident felt dizzy he should sit back down and use call light for assistance. Always have call light close by. On 7/28/20 at 4:10 PM during an interview with Surveyor, CNA F stated, I left to break in the breakroom. I told CNA G to watch him. He fell while I was on break. On 7/28/20 at 4:20 PM, Surveyor interviewed CNA G stated, I remember the fall. I was in a resident's room and heard a noise. I came out and found R1 on the floor by the kiosk machine, in hall. CNA F, the unit helper was one-on-one with R1. She was warming up her food in the break room. I was watching him to the best of my ability. CNA G indicated she was not one-on-one with R1, because she had other residents to care for on that hall. Progress Notes, dated 5/6/20, indicate the Interdisciplinary Team met and discussed R1's fall. They suggest to continue one-on-one supervision. (It is important to note there was no one-on-one with R1 at the time of his fall. R1 was care planned to have one to one supervision related to his sexual behavior toward others.) Incident 2. Progress Notes, dated 5/11/20, include, in part: Call placed to R1's power of attorney and medical doctor to update incident of inappropriate touching of R3. Notified medical doctor of psych consult and new orders. This resident will be moved to room [ROOM NUMBER] with a private bathroom today. Of note R1 had a shared bathroom with R3. R3 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. R3's MDS, with ARD of 3/10/20, indicates R3 is moderately cognitively impaired with a score of 12 out of 15. R3's MDS also indicates he requires limited assistance by one staff member for toileting and transferring. R1's Incident Report, dated 5/11/20, includes, in part: Housekeeper H's statement: Around 9:45-10:00 AM I was cleaning in R3's room when R3 went into his bathroom. R1 went into his room (they share a bathroom), then R1 closed his door. I heard the door handle on R1's side. I checked on R3 and caught R1 with his hand moving towards R3's privates. R1 was seen leaning on the toilet riser bar with one hand and the other hand on R3's lower abdomen, reaching, for the unknown. R1 was eye level with R3. R1's clothing was intact. I watched for maybe just a couple of seconds, then I yelled, (Resident Name) what are you doing, you don't touch him there. R1 said he was helping him. R3 was already on the toilet so I don't know what he would have been helping him with. I told R1 to get out of the bathroom. R1 left right away and went back to his room. I told UH I (Unit Helper) to keep an eye on him and I ran to get or tell DON B. UH I's statement: .an incident happened with patient, R1, around 10:20 AM. R1 went to his room around 10:19 AM after visiting with this writer. R1 shut his door as usual. As I was sitting at my post when the housekeeper, Housekeeper H, went in R3's room. About thirty seconds later I heard yelling coming from R3's room, I walked in. All I seen was the housekeeper standing there and R3 sitting on the toilet. That is when the housekeeper told me she heard something in the bathroom when opening the door. She seen R1 playing with himself in front of R3. But I did not hear a thing such as yelling or screaming, not even an alarm, until then. I did not witness R1 in there. (It is important to note UH I is assigned to be one-on-one with R1 at the time of this incident.) Police report, dated 5/11/20, includes, in part: . Housekeeper H stated she witnessed R3 go into the bathroom in his room. She stated R1 and R3 share a bathroom . but have their respective rooms. She stated after R3 went into the bathroom, she noticed R1 go into his room and close the door. Housekeeper I stated she was concerned with R1's behavior at that point and decided to stay in the area and continue to clean. She stated just a few moments later she heard another door click, the sound of latching, in R1's room. She stated she found this to be suspicious and went to check on R3. She stated as she entered R3's room, the bathroom door was cracked approximately one to two inches. She stated she asked R3 if he was okay and received no response. She stated she then entered the room and observed R3 seated on the toilet with his pants and diaper down to the ground and R1 standing above him with his hand in the groin area of R3. Housekeeper H stated she immediately asked R1 what was going on. She stated he replied with he was helping him use the restroom. Housekeeper H stated she never observed any staff members assisting R3 using the restroom and believed R1 was not being truthful about why he was in the bathroom with R3. I asked Housekeeper H to explain to me more about R1's hand positioning while he was in the restroom with R3. She explained R1's hand was touching the private parts of R3 while he was seated on the toilet. She states R1 was moving his hands up and down . She stated R1 usually liked his door closed and she believed this was the reason why he always wants the door closed . I asked Housekeeper H if R1 was saying anything to R3 when he was touching him. Housekeeper H stated she believed R1 was saying something to him, however, she could not determine what he was saying . A short time later . A following is a list of questions followed by R3's response to each question: . Were you in the bathroom this morning? Yes. Do you need help going to the bathroom? Yes, need help changing the diaper. Were you touched on your private parts? No. One man tries to touch. Who? One of the nurses touched himself. I have to slap his hands away. R3 commented that he has noticed a lot of gay men in this town . Do you trust that man? No. R3 stated that he will have to live in a home for the rest of his life because he can't take care of himself. Is there anyone you trust here? Not really. R3 commented the lady nurses touch him as well, but implied for cleaning purposes. Why does the man touch your privates? Homosexual Does he leave? Sometimes. Can the man walk on his own? Yeah. Would you recognize the man again? R3 responded that he doesn't want to get the man in trouble but he doesn't want him around his family. Does he talk to you when he is touching you? Tries to. How many times has he touched you? I don't know. Has he done anything else besides touching? No, look at me. I'm not a kid. Sometimes I have to say no more than once. Then my voice changes and I tell him to knock it off, then he stops. On 7/28/20 at 1:30 PM during an interview with Surveyor, Housekeeper H indicated she was mopping R3's floor when he walked into his bathroom. Housekeeper H indicated she walked out of the room to give R3 privacy to go to the bathroom and on her way out of room, Housekeeper H shut door, leaving it open a crack. Housekeeper H indicated she stood in the hallway, outside of R3's room and UH I was sitting in a chair in hallway. Housekeeper H stated, R1 was in hallway walking and he saw R3 going into his bathroom. R1 then B lined into his own room and shut the door. Housekeeper H indicated this is when she suspected something was not right. Housekeeper H told UH I to go check on the two men, but UH I did not move. Housekeeper H then heard a sound of a latching bathroom door from R1's room. Housekeeper H stated, UH I didn't go. He stayed on his post so I did it myself. Housekeeper H indicated she entered R3's room and called through the bathroom door, Is everything ok? She did not receive a response so she opened the door. Housekeeper H indicated R3 was seated on the toilet with his pants and brief on the floor and R1 was bent over at eye level facing R3. Housekeeper H stated, His hand was down under and going. Housekeeper H stated she watched for a couple seconds and then yelled at R3 to stop what he was doing. On 7/28/20 at 1:50 PM during an interview with Surveyor, UH I indicated he does not have physical contact with residents in his position. UH I indicated he was assigned to one-on-one supervision of R1 and this means UH I sits outside of R1's room and waits for him to come out. Then UH I walks with R1 and makes sure he doesn't get too close with others. UH I stated on 5/11/20 he saw R3 go into his bathroom while Housekeeper H was mopping in his room. UH I stated when the doors were open, he could see into both rooms (R1 and R3's) from his post/chair in hallway. UH I indicated R1 went into his room to take a nap and he didn't worry about him. Then he heard Housekeeper H yelling. When UH I entered the shared bathroom, R1 was in his own room, R3 was on the toilet, and Housekeeper H said to him R1 was touching himself. UH I indicated Housekeeper told him to stay there and R3 and she was going to report it. The facility did not have a policy on what one-to-one supervision entailed, and staff had different understanding of what it meant. On 7/28/20 at 2:00 PM during an interview, DON B indicated the facility did not have a policy of what one-on-one supervision meant. DON B indicated one-on-one supervision means in line of sight when outside of room. Surveyor asked about R1 in his room. DON B indicated the facility staff respect R1's privacy. DON B indicated R3's door was to remain open at all times. Surveyor asked if this was care planned. DON B and Surveyor reviewed care plan and DON B stated, It isn't but it should have been. On 7/28/20 at 2:10PM during an interview NHA A indicated the facility does not have a policy on one-on-one supervision and to her it meant eyes on at all times. NHA A indicated UH I should have made sure R1 was not behind closed doors with another resident, in this case, R3. On 7/28/20 at 11:22 AM during an interview Business Officer Manager K (BOM K) indicated one-on-one supervision is to watch R1 while he is in the hallway and it is ok for him to have the door shut while he is in his room. On 7/28/20 at 4:10 PM CNA F indicated one-on-one supervision means to watch R1 and make sure he is safe and not misbehaving, because he is inappropriate with female staff and other residents. On 7/28/20 at 4:20 PM CNA G indicated one-on-one supervision means to watch resident at all times and know where he is, but she was not able to do this at all times due to other resident's on hallway needing assistance too. R1's Psych Initial Visit Note, dated 5/11/20, includes, in part: . R1 is requiring one-on-one supervision due to his impulsivity and sexual inappropriateness. He had been reported to have touched two other residents inappropriately .R1 exhibits the following moderate symptoms: Sexually inappropriate behavior has occurred. Poor judgement is creating safety issues when left alone. The facility's failure to protect R2 and R3 from sexual abuse by R1 created a situation of IJ. The jeopardy was removed on 8/6/20 by which time the facility had implemented the following action plan: Plan of Removal: The facility immediately moved R1 to a different hallway to a private room with a private bathroom on 5/11/20. Care plan was updated to show resident moved to a private room with a private bathroom. Immediate education will be provided to all staff before their next working shift on what one-on-one observation entails. Meaning, I will have eyes on R1 at all times. R1 will be allowed privacy with door shut, with one-on-one staff member outside the door at all times when in room. When R1 is out of room, R1 will have one-on-one with eyes on him at all times. The facility reviewed the care plan for appropriate interventions. The facility will provide all staff education on abuse/neglect/exploitation, audits will be completed to ensure this will not happen again. The facility did educate all staff on the types of abuse, what to do if suspect abuse, who to report abuse to and procedures on 5/12/20. The facility will ensure behavior charting is complete and accurate for R1 and if R1 would have been behaviors what interventions would be in place. The facility will review and update all resident care plans for potential sexual tendency [DIAGNOSES REDACTED]. The facility will do spot-check audits on one-on-one observation three times a week for two months or until substantial compliance is met. The facility will develop a one-on-one policy and all staff will be educated on the policy. The results of the audit will be reviewed at Quality Assurance Performance Improvement meetings.

Based on observation, interview and record review the facility did not ensure it maintained an infection prevention and control program designed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19 affect 19 of 48 resident who reside at the facility. The facility did not ensure staff donned gowns upon entering resident rooms who were newly admitted to the facility and on isolation precautions for observation of COVID-19. LPN C had potential to work with any resident that resided in the facility on the day of the survey. Evidenced by: Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memo revised 3/13/20 QSO 20-14 includes: Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room). Current CDC (Centers for Disease Control) Guidelines (Website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) note in part: . Considerations for new admissions or readmissions to the facility . A patient hospitalized for [REDACTED]. However, to ensure they are not infected, nursing homes should place them in Transmission-based Precautions in a separate observation area or in a single-person room until 14 days have elapsed since admission Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Reference QSO-20-29 dated 5/6/20 includes: Critical Element (5/8/20) COVID-19 Focused Survey for Nursing Homes: Page 4 Transmission-Based Precautions . For a resident on Contact Precautions: staff don gloves and isolation gown before contact with the resident and/or his/her environment; For a resident on Droplet Precautions: staff don a facemask within six feet of a resident; . For a resident with known or suspected COVID-19: staff wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available. A facemask is an acceptable alternative if a respirator is not available . The facility policy titled Isolation - Categories of Transmission-Based Precautions updated 3/2020 includes under Contact precautions Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room to avoid touching potentially contaminated surfaces with clothing after gown is removed. R1 was admitted to the facility on [DATE]. On 6/30/20 between 9:00 AM and 9:20 AM Surveyor observed LPN C enter R1's room to administer a [MEDICATION NAME] shot. The sign on R1's door stated that Mask and shield only LPN C did enter with a facemask, face shield, and gloves but did not put on a gown. Upon exiting R1's room Surveyor asked LPN C why she did not wear a gown. She explained that after a resident is admitted they are on precautions for 14 days. After the first week we don't need to wear a gown. Surveyor asked her if the facility had been short on PPE. LPN C stated that she was not aware they had ever been short of PPE. At 11:10 AM Surveyor asked LPN C where she was working today. LPN C stated she worked on the 300 and 400 wings. Surveyor asked if she would be on the other units and LPN C agreed if she was needed she would work on any of the units. Of note CDC guidance states nursing homes should place new admissions or readmissions in Transmission-based Precautions in a separate observation area or in a single-person room on droplet and contact precautions for 14 days. This requires the use of the following PPE use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Not following appropriate TBP places increases the risk of exposure to the healthcare provider with potential to spread communicable disease, COVID 19, to facility residents and staff. On 6/30/20 at approximately 12:00 PM Surveyor spoke with (DON) Director of Nursing B, who is also the facility's Infection Preventionist, who stated the facility had changed the PPE required for new admissions after 7 days and follow only droplet precautions after 7 days. When Surveyor asked if new admissions were also on contact and droplet precautions initially upon admission to the facility DON B agreed.

Based on observation, interview, and record review the facility did not store and prepare food in accordance with professional standards of food safety. This has the potential to affect all 63 residents. The facility left dumpsters uncovered, stored dented cans, left a scoop in the thickener powder, had pasteurized eggs with no use by date, had multiple cartons of expired milk, had multiple food items uncovered in the refrigerators, did not cool down leftovers yet served items to residents, and did not check food temperatures of cold food items such as juice, salads, and desserts. This is evidenced by: On [DATE] at 10:25 a.m., Surveyor began the initial kitchen tour with the DM (Dietary Manager). Surveyor noted there were 3 dumpsters outside of the building at the end of the driveway. Two out of the 3 dumpsters were open and left uncovered. The DM stated dumpsters are to be closed to help control pests entering the facility. Surveyor noted 2 cans in the dry storage room. Both cans had large dents on the top of the can affecting the rim and seal of the products. One can contained 105 ounces of dried beets and the other can contained 4 pounds of chunk light tuna. The dents measured approximately 3 inches and caused the rim of both cans to be rough. The DM stated any dented can was to be returned to vendor. Surveyor noted a square plastic container of thickener powder with a blue scoop in the container. The DM stated scoops are not allowed in containers because the handle is considered dirty and should not touch the contents of the container. The DM removed the scoop but did not dispose of the thickener powder. Surveyor entered the walk in refrigerator and noted a tray of salad dressings (ranch, french, 1000 island, and italian) uncovered. The DM stated the salad dressings were prepoured for the lunch meal and were never covered. In addition, there was a square plastic container of shredded cheddar cheese on the top shelf of the refrigerator that was also uncovered. The DM instructed a staff person to cover the salad dressings. On [DATE], Surveyor also noted in the walk in refrigerator a half full crate of fat free milk that had expired on [DATE]. Surveyor asked Cook-I if leftovers were kept. Cook-I stated sometimes leftovers were kept and reheated the next day. Cook-I stated some residents will ask for certain food items to be served the next meal or next day. The food item would be plated, covered, and labeled for that specific resident. Surveyor then opened the reach in refrigerator which also contained a gray tub of milk including the expired fat free milk. Cook- I stated the milk in the gray tub was for breakfast and lunch today. During the initial kitchen tour, overall the kitchen was dirty and cluttered. The refrigerator handles were dirty. There were 3 plastic tubs of oatmeal, sugar, and flour. The lids on the 3 plastic tubs were covered in grease and grime. There were 3 carts in the walk in refrigerator and 4 carts [DIAGNOSES REDACTED] the work area of kitchen staff. On [DATE] at 10:15 a.m., Surveyor noted 127 pasteurized eggs were in a cardboard rack but there was no use by date posted on the eggs. The DM stated staff was suppose to write the use by date on the egg holders but confirmed this was not done. Surveyor asked the DM to review the cooling log. The DM stated the only item on the cooling log was a pork roast cooked and cooled in July. Cook-G stated the facility cooked pork and beef roasts at least a few times per month. Cook-G stated the cooling process was completed on the second shift. Cook-G stated the roasts are reheated and served the next day. Cook-G stated pork and beef roasts are on the menus a few times per month. Surveyor requested the cooling logs for the past 6 months from the DM. The DM did not provide any cooling logs by the end of survey. The Surveyor asked the DM how leftovers were cooled and the DM stated the leftover food items were labeled and dated but staff did not check cooling temperatures and follow the facility cooling process. The DM stated some residents would request for food items to be saved and reheated for the next meal or the next day. The DM stated leftovers are never kept beyond 3 days. On [DATE] at 11:20 a.m., Surveyor observed DA (Dietary Aide)-H set up a cart of beverages. On the cart were hot items such as coffee and water plus cold items such as milk and juices. DA-H did not check the temperature of any item on the cart except for the milk. Cook-G checked the temperature of the milk. At 11:35 a.m., Cook-G served the dining room cold lettuce salads and fruit. Cook-G did not check the temperature of these cold items. Surveyor asked Cook-G if anyone checked the temperature of cold food items and Cook-G stated the cold food items such as juices, desserts, salads, or fruit are never checked for proper serving temperature.

Based on interview and record review the facility did not ensure that a comprehensive person centered care plan was developed for 2 of 19 sampled residents (R49 and R22). R49 has a history of falls. The facility did not develop a care plan related to falls. R22was readmitted to the facility after right hip repair after a fall. The facility had no care plan in place to address R22's post surgical pain. This is evidenced by: Example 1: R49 was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. A Fall Risk Assessment was completed on admission indicating that R49 was at risk for falls and has had a history of [REDACTED]. R49 was working with therapy for strength to return home. Review of R49's medical recored revealed a fall occured on 07/02/19 at approximately 7:00AM. Nurse progress notes and a fall report state that a CNA (Certified Nursing Assistant) had witnessed the resident transferring from wheelchair to bed and bed slipped out from under R49 when sitting down. R49 sat on the floor. No injury noted. Intervention that was put in place at that time was to monitor for bed breaks to be on at all times. Review of R49's comprehensive care plan and CNA kardex revealed no focus area on falls before or after this fall. The post fall intervention to monitor for bed breaks on at all times was not documented on R49's care plan. On 08/13/19 at 7:56AM Surveyor interviewed R49 who had stated there was a fall recently where R49's bed slipped out from under resident and resident ended up sitting on the floor. On 08/14/19 at approximately 2:30 PM Surveyor interviewed NHA (Nursing Home Administrator) and DON (Director of Nursing) regarding how care plans are updated. After an incident, like a fall, happens the nurse working at that time will create a progress note and an incident report if needed. If there is an intervention put in place at that time the nurses can update the care plan either by hand writting the intervention on the paper care plan in the hard chart or make the update in the computer system. The Interdisciplinary Team (IDT) will review the incident at their next meeting and determine if they agree with the intervention and if other interventions can be put in place. They will update the care plan if needed. On 08/15/19 at approximately 10:15AM Surveyor interviewed RN-E (Registered Nurse) regarding how care plans are updated. RN-E stated that after an incident, like a fall, the nurse will create a progress note and an incident report. RN-E was not sure if the nurses themselve could update the plan of care in the computer system. If there are interventions that need to be monitored there is a clinical board that the info is written on to be passed along to the following shifts staff until the IDT can meet to review the incident and update the care plan. At approximately 11:15AM RN-E spoke with Surveyor again to clarify that any of the nurses can update the care plans at any time. Example 2: R22 was readmitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. Review of the MAR (medication administration record) for (MONTH) 2019 did show a physician order [REDACTED]. There was an order also for [MEDICATION NAME]-[MEDICATION NAME] tablet 5-325 mg to give 1 tablet by mouth every 4 hours as needed for moderate pain. This was given nine times in the month of May. Review of pain evaluation from 5/2/2019 rated R22 pain level at a 9 out of 10 (10 being the worst pain) in the right hip that radiated to the groin. R22 pain was described as frequent and throbbing. Review of most recent comprehensive care plan provided by the facility had no focus on pain. Review of the CNA care plan for R22 did not include any pain interventions. Surveyor interviewed R22 on 8/12/2019, when asked about pain R22 stated R22 had pain down the leg and hip. A pain pill was given for this but it did not always help. Surveyor interviewed MDS (minimum data set) coordinator on 8/14/19 regarding R22's care plan. MDS coordinator confirmed that R22 had pain noted on the MDS as well as pain assessments, however no care plan was developed. On 8/15/2019 surveyor requested any other information the facility might have regarding R22 and pain. Surveyor interviewed NHA. The NHA stated that when R22 arrived back in the facility after surgery for [REDACTED].

Based on observation, interview, and record review the facility did not provide care and services to promote the healing of pressure injuries for 1 of 6 residents (R22) reviewed for pressure injuries. R22 developed bilateral pressure injuries to the heels. The pressure injury to the left has healed, while the right remains. R22 was observed with pressure interventions not in place on 2 separate occasions. This is evidenced by: R22 was admitted to the facility on [DATE] . R22 had multiple hospitalization s for infections, exacerbation of [MEDICAL CONDITION], and a fall which resulted in a [MEDICAL CONDITION] and repair. R22 returned to the facility on [DATE] following the right [MEDICAL CONDITION] and repair. Review of the CNA (Certified Nursing Assistant) care plan indicated R22 was to float both heels when in bed or recliner and use off loading boots at all times. Review of the comprehensive care plan noted R22 had current skin integrity concerns related to a right heel injury due to friction and shearing. The care plan intervention included to float both heels with pillows when in bed or recliner and to wear off loading boots instead of shoes. Review of the nurses notes indicated R22 developed a right heel injury that measured 1.5 cm (centimeters) by 1.1 cm by 0.1 cm deep. The right heel injury was described as open, red, and no drainage. Review of the nurses notes indicated R22 also developed a left heel injury that measured 0.4 cm by 0.3 cm by unknown. The left heel injury was described as a small brown scab with no drainage. The nurses noted reported R22 stated the heel injuries developed due to both feet rubbing on the recliner foot rest. On 07/24/19 the left heel injury was resolved. The right heel injury was improved and measured 0.9 cm by 0.5 cm by unknown depth and was described as a red scab with no drainage. On 08/14/19 the right heel injury measured 0.6 cm by 0.4 cm by unknown and was described as a brown scab. On 08/12/19 at approximately 2:00 p.m., Surveyor observed R22 was resting in the recliner with no off loading boots or pillows to float both heels. Both heels were resting on the foot rest of the recliner. On 08/13/19 at 7:30 a.m., Surveyor again observed R22 lying in bed with no off loading boots or pillows to float heels. The left foot was bare and the right foot had a gripper sock on. Both heels were observed in contact with the bed mattress. Surveyor asked R22 why his boots were not on and he stated staff did not put them on last night. R22 confirmed he had not worn the off loading boots or had pillows to float heels during the night of 08/12/19 through 08/13/19. On 08/13/19 at 7:40 a.m., Surveyor observed R22's left heel. The skin was intact and there was no evidence of any injury. On 08/14/19 at 8:04 a.m., Surveyor asked CNA-F to assist Surveyor in observing R22's right heel. CNA-F removed R22's off loading boot and socks then raised R22's foot. Surveyor observed a small brown firmly adhered eschar on the right heel. The observation was consistent with the most recent facility assessment of R22's right heel injury. On 08/13/19 at 12:18 p.m., Surveyor interviewed CNA-F regarding R22's skin care. CNA-F stated R22 was to wear the off loading boots on both feet at all times. On 08/13/19 at 9:07 a.m., Surveyor interviewed RN (Registered Nurse)-E regarding R22's care plan. RN-E stated the CNA care plan was unclear. RN-E stated the off loading boots should be worn when R22 was up and heels should be floated using pillows when in bed or recliner. RN-E stated she clarified the CNA care plan and also educated staff on duty.

Based on record review and interview the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, advanced directives and court order for 1 of 12 residents (Resident 1). Resident 1's Advance Directives indicate Resident 1's wished to be a full code/receive CPR (Cardiopulmonary Resuscitation). Resident 1's plan of care indicated that he was to be a full code. Resident 1 had a court order to be a full code. When Resident 1 was found not breathing on [DATE], LPN I did not provide CPR to Resident 1. The facility failed to provide Resident 1 with CPR. This created a situation of immediate jeopardy beginning on [DATE]. The Nursing Home Administrator was informed of the immediate jeopardy situation on [DATE] at 2:06 PM and removed the jeopardy the same day ([DATE]). The deficient practice continues at a scope/severity level E (potential for harm that is not immediate jeopardy/pattern) as the facility continues to implement its action plan for the 21 residents who are full-code. This is evidenced by the following: Centers for Medicare and Medicaid Services S&C memo ,[DATE]-NH, revised [DATE] indicates: Initiation of CPR-Prior to the arrival of emergency medical services, nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advanced directives or in the absence of advanced directives or a Do Not Resuscitate order. CPR-certified staff must be available at all times. If a resident experiences [MEDICAL CONDITION] facility staff must provide basic life support, including CPR prior to the arrival of emergency medical services, and : · in accordance with the resident's advanced directives, or · in the absence of advance directives or a Do Not Resuscitate order, and · if the resident does not show obvious signs of clinical death. (rigor mortis, dependent lividity, decapitation, transection or decomposition). At the time of the survey the facility census was 58 residents. Of those 58 residents 21 requested to receive CPR. The facility's policy Cardiopulmonary Resuscitation, revision date [DATE], includes the following: Policy: Prior to the arrival of emergency medical services (EMS), this facility provides basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] in accordance with that resident's advance directives or in the absence of advances directives or a Do Not Resuscitate (DNR) order. This policy does not allow for implementation of requiring that an arrest is witnessed in order to follow a resident's choice for treatment with CPR. Procedure: 3. Each resident's choice regarding CPR or DNR code status is readily available for quick identification. 4. CPR certified staff are available at all times to provide CPR if/when needed. 5. Direct staff initiate CPR when [MEDICAL CONDITION] occurs for resident in the following circumstances: a. Residents who have requested CPR Code Blue protocol: -Resident/staff/visitor is found pulseless and or not breathing -CPR initiated/code blue announced -911 called -Equipment brought to location of code Note: The policy indicates to do CPR if the resident is a full code; there are no interventions listed regarding not to do CPR. The facility uses the American Heart Association standard of practice for CPR. The manual for 1 rescuer adult CPR sequence: 1. Assess the victim for a response. If no response, shout for help. 2. If you are alone, activate the emergency response system and get an AED if available. 3. Open the victim's airway and check breathing (take at least 5 seconds and no more than 10). 4. If no adequate breathing, give 2 breaths. 5. Check the victim's pulse (take at least 5 seconds and no more than 10 seconds). 6. If you do not definitely feel a pulse, perform 5 cycles of compressions and ventilations (30:2 ratio). Positioning the Victim: The victim should be in a faceup position and on a hard surface before you begin CPR. If an unresponsive victim is not faceup, roll the victim to a faceup position. If a victim is not on a hard surface (for example, if the victim is in bed), place a board or other rigid surface between the victim and the bed. If one is not available, move the victim to the floor. Resident 1 was initially admitted to the facility on [DATE]. Prior to admission to this facility Resident 1 resided in another nursing home for more than [AGE] years and moved to this facility following tracheotomy placement. Resident 1 was [AGE] years old. Resident 1's [DIAGNOSES REDACTED]. Resident 1 has a court appointed guardian. Resident 1's hospital History and Physical, admitted [DATE], indicates Neurologic: Resident 1 withdraws to painful stimuli. Resident 1 has severe contractures of the hands and upper extremities, noted foot drop with muscle wasting. Resident 1 is a full code. Code can only be changed if guardian pursues such plan of care with the court system. During this hospital stay Resident 1 had a tracheotomy placed, was on mechanical ventilation and was eventually weaned off before discharge to the facility on [DATE]. Resident 1's nursing note on [DATE] includes: Resident 1 was non-responsive with dialated pupils with fixed gaze, staff opened eyes manually. Did respond with facial twitching to tactile stimuli. Resident 1 has noted contractures to bilateral legs and upper extremities. Resident 1 is a full code status. On [DATE] Resident 1 was sent to the emergency room for breathing difficulties. From there Resident 1 was sent to another hospital on [DATE] for weaning from the mechanical ventilation. The History and Physical states Resident 1 did have one episode of possible vasovagal event. At the time he did have a rectal tube in place. He was found to have a pulseless electrical activity/bradycardic arrest and did receive a short period of cardiopulmonary resuscitation before return of spontaneous circulation. During the hospital stay Resident 1 was treated for [REDACTED]. The hospital discharge summary, dated [DATE], indicates Resident 1 has had a decline in his overall condition in the context of being in a persistent vegetative state for [AGE] years. Resident 1 is approaching the end of his life. Conversations were had with Resident 1's guardian, she requested he remain a full code status based on judge's statement on court order assigning her as guardian and stated No life termination decisions without further order of the court. Resident 1 was readmitted to the facility on [DATE]. Resident 1's nursing notes, dated [DATE], Resident 1 is unresponsive to verbal/tactile stimulation, respirations labored, irregular. Contractures of upper extremities and bilateral feet. On [DATE], Resident 1 was sent to the emergency room for respiratory distress. Resident 1 remained in the hospital until he was readmitted to the facility on [DATE]. Resident 1's social service note, dated [DATE], preparation for admit scheduled [DATE]. Guardian reports court date set for [DATE] for courts to reverse full code status per doctors recommendation. Upon readmission on [DATE], Resident 1's guardian signed the CPR Preference form and checked Yes: I want Cardiopulmonary resuscitations (CPR) attempts. On [DATE], Resident 1's guardian also signed the facility's care and treatment guidelines indicating she wanted Acute Treatment transfer to hospital for sudden, critical changes in health status. Resident 1's care plan, dated [DATE], indicates Resident 1 is a full code and will have a red dot on name plate outside of room to alert staff that he is a full code. The facility documentation indicates Licensed Practical Nurse (LPN) I received CPR training in [DATE]. Resident 1's nursing notes: [DATE] at 10:00 PM, Resident 1 resting in vegetative state. Has tracheotomy with tracheotomy mask with humidified air. Resident 1 breathing with ease. [DATE] at 3:00 AM, cares completed by staff. No resp (respiratory) distress charted by LPN I. [DATE] at 4:30 AM, Res (resident) skin cool not breathing. 911 called for immediate assistance charted by LPN I. 4:35 AM, EMT's (emergency medical technician) arrived, airway was clear Res not breathing, EMT instructed writer to call (Physician J). 0450-(Physician J) notified order rec (received) to release body to funeral home of choice per Guardian . charted by LPN I. [DATE]: addendum at 0430, CNA (certified nursing assistant) called for assistance, she stated Res was not breathing. Writer immediately to bedside, sharp sternal rub given with no response, chest compressions initiated directed CNA to call 911, EMTs arrived approx (approximately) 3 min (minutes) later stated Res was flat lined and to call his MD, (Physician J) notified and gave orders to release body at 0450 . charted by LPN I. Other than skin is cool and Resident 1 not breathing, LPN I did not document any visual characteristics or vital signs indicating obvious signs of death, such as dependent lividity or rigor mortis. On the 911 voice recording the following occurred. There was no date/time stamp on the recording: 911 Operator - Adam's county 911 LPN I - Yeah hi this is (LPN I) at (facility), ah we have a patient that's already expired, but he is a full code, and we have nobody here, so I don't know if you are supposed to send anybody over here, or what you are supposed to do. 911 Operator - Well you need to tell me, do you need an ambulance? LPN I- Well yes, like I said he is DOA (dead on arrival), I'm sure of that, we just talked about him about an hour ago and he wasn't in any respiratory distress. 911 Operator - Ok can you (LPN I) was your name? LPN I- Yes. 911 Operator - Okay and who is the patient? LPN I- (gave and spelled name of Resident 1). 911 Operator - Okay, all right what wing? LPN I- Ah 100 wing clear down at the end of the hall. 911 Operator - Okay alrighty but um probably just take him out as ah just as unresponsive then. LPN I- Ah yes ah not breathing you know what else can I say. 911 Operator - Okay all right. LPN I- I can't say that he's dead, but I'm sure he is. 911 Operator - Okay LPN I- Okay 911 Operator - All right good bye. On [DATE], at 4:10 AM, the survey team arrived unannounced at the facility to investigate an anonymous complaint regarding staffing on the night shift and an incident related to CPR for Resident 1 that did not go well due to lack of staffing. The doors were locked and the survey team needed to ring a bell and wait for CNA S to answer the door to let the survey team in the facility. On [DATE], at 4:42 AM, Surveyor interviewed LPN G. LPN G stated resident code status is identified by a red dot by their name on the door for a full code and it is also in the front of the chart. LPN G stated if someone who was a full code was found not breathing she would take the backboard to the room, start CPR and have the CNA call 911. LPN G stated on the night shift there is typically only one nurse with 3 CNAs. On [DATE], at 7:55 AM, Surveyor interviewed CNA H via the phone. Surveyor asked if this was an okay time as CNA H had been working the pervious night shift and CNA H stated it was fine. CNA H confirmed she was working on [DATE] when Resident 1 expired. CNA H stated she and CNA L were in Resident 1's room and changed him and repositioned him. CNA H and CNA L returned about an hour later to check on Resident 1 and he was not with us anymore. CNA L stayed in the room while CNA H went to tell the nurse (LPN I). LPN I went to Resident 1's room, pushed on his chest a couple of times but was not able to revive Resident 1. LPN I then left the room to call 911. Surveyor asked why CNA H did not go to call 911. CNA H stated we/CNAs are not allowed to call 911. CNA H then left Resident 1's room to assist other residents and was not present in the room when the EMTs arrived. CNA H stated she did not remember seeing LPN I bag Resident 1 or doing any breathing for him. CNA H stated the night of [DATE] there were 3 CNAs and LPN I working in the building. When the facility interviewed CNA H and had her write a statement on [DATE], CNA H stated Resident 1 was a purplish color, mottled and stiff. CNA H did not indicate any of that to Surveyor during the above conversation nor did the facility ask CNA H to clarify what mottled and stiff looked like to her. On [DATE], at 11:27 AM, CNA L returned Surveyor 's phone call. CNA L stated when they did their rounds on Resident 1 he was gone. CNA H went to get LPN I right away. LPN I came in and did a couple of compressions then LPN I left the room and called the EMTs. LPN I was the only nurse working and she did not ask CNA L or H to go call 911. LPN I then returned to Resident 1's room and waited for the EMTs. CNA L was in Resident 1's room the entire time. The EMTs came in and hooked Resident 1 up to a machine. CNA L confirmed she is not CPR certified but she used to be. Surveyor asked if any equipment was brought into the room prior to the EMTs arrival. CNA L stated there was no equipment brought in except LPN I did have her stethoscope to check for a pulse. The crash cart is in the storage room with the suction machine and they were not brought into the room. CNA L also stated that the couple of compressions LPN I did were done in the bed without a hard surface under Resident 1. LPN I did not use the ambu bag or attempt to use the suction machine on Resident 1. On [DATE], at 8:56 AM, Surveyor left a message for CNA T to call back when available. CNA T never returned the phone call. On [DATE], at 8:58 AM, LPN I returned Surveyor 's phone call. Surveyor asked LPN I to recall the events of [DATE] with Resident 1. LPN I stated CNA L came and got her stating Resident 1 was not breathing. LPN I went to Resident 1's room and did a sternal rub and did not get a response. LPN I sent CNA H to call 911 and LPN I began chest compressions. When the EMTs arrived they put on the wires and there was no reading. Surveyor asked if LPN I did any bagging while doing chest compressions. LPN I stated No she did not do any bagging and I knew he was dead. LPN I confirmed she did not suction his tracheotomy or do anything to check his airway. Surveyor asked what Resident 1's code status was. LPN I stated he was a full code but they are supposed to go to court to get it changed. LPN I stated she did not feel Resident 1 should have been accepted back to the facility until the advance directives were changed to a DNR as he was brain dead. LPN I stated she performed CPR for ,[DATE] minutes and she did not leave Resident 1 to call 911 she sent the CNA. LPN I stated the CPR stopped when the EMTs arrived as they had spoken with the doctor. Surveyor asked who gave the order to stop and LPN I stated she did not know exactly who, it was the doctor the EMTs were on the phone with. LPN I stated she was the only CPR certified staff in the building because the CNAs are not certified. Surveyor asked if CNAs can call 911 and she stated yes they can. Surveyor then informed LPN I that CNA H stated she did not call 911 and that they are not allowed to. LPN I stated she thought it was CNA H but maybe it was CNA L who called 911. LPN I stated they are short staffed and need 2 nurses at night. LPN I stated the night with Resident 1 she was stuck. Surveyor asked her to clarify what that meant. LPN I said there should have been two nurses so one could do CPR and one could make the calls. LPN I stated following the coding of Resident 1 she was not talked to by anyone and there was no follow up report completed. LPN I also stated they used to do CPR run throughs but they do not do them and could not remember when the last one was done. On [DATE], at 10:34 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated in the case of a [MEDICAL CONDITION] the CNA should immediately get the nurse and all nurses are CPR certified. DON B then stated she was not CPR certified however, the nurse is to check the code status which is indicated by a red dot on the door name plate for residents who wish to be a full code. Then the nurse should check for a response, breathing, and pulse and if needed start compressions. DON B stated while this is occurring the CNA or other staff should call 911. DON B stated the facility has a crash cart that contains ambu bags and an AED (automated external defibrillator). Once the EMTs arrive they are to take over. Surveyor asked when should staff stop CPR. DON B stated they can't make that call. It has to be decided by the doctor to stop CPR. DON B stated the morning of [DATE] following Resident 1's death she spoke with LPN I who stated she initiated CPR but she did not ask for details of the event. DON B stated she would have expected the CNA to get the crash cart and LPN I to use the ambu bag with Resident 1. The EMTs Prehospital Care Report for [DATE] includes the following: Summary of events- dispatched to facility for unresponsive male, not breathing. We arrived on scene. A RN (referring to LPN I) reports to us the patient is last seen normal at 3:00 AM. The RN stated He's gone. The patient is a vent patient. Humidified oxygen is being administered. The patient is unresponsive to the touch, skin is cool, patient pale in color, stiffness in the arms and legs noted. We are unable to palpate a carotid pulse, patient not breathing. RN reports the patient is a full code. The RN reports no chest compressions has been done on the patient. The EKG monitor is placed and shows asystole in 2 leads. The RN at facility is informed of our findings. The coroner is called. Ambulance dispatched at 4:29 AM, arrived at scene at 4:31 AM, arrived at patient at 4:33 AM, and departed at 4:41 AM. On [DATE], at 10:45 AM, Surveyor interviewed EMT M. EMT M stated it was after hours when they arrived at the facility and the doors were locked. They had to ring the door bell and wait for staff to come let them in. EMT M stated the nurse was not doing CPR on their arrival. EMT M stated she did not call the physician and she did not know who did. EMT M stated it is the ambulance protocol that if the person is down a short time they will do CPR. EMT M stated nobody was doing CPR so they did not initiate per their protocol, but if it had been initiated by the facility they would have continued it. EMT M stated it was the first time they arrived since January that the facility was not doing CPR on arrival when someone was a full code. At 12:40 PM, Surveyor spoke with EMT N, the other paramedic on scene, who stated they were let in the facility by a person with a deep voice, short and curly hair (this describes LPN I) and she said, He is gone, he is gone. She (LPN I) did not do CPR on him. EMT N stated they did not call the physician. EMT N stated they hooked him up to the machine and could not find a pulse. Note: The EMTs the facility stated they interviewed on [DATE] were not the responding EMTs per the Prehospital Care Report. On [DATE], at 11:12 AM, Surveyor interviewed Physician J, Resident 1's physician. Physician J stated she received a call from the facility which indicated they wanted to stop CPR on (Resident 1) and gave the order to stop CPR as it was her understanding that Resident 1 was a DNR (do not resuscitate). (It is important to note that at this time the facility was not doing CPR on Resident 1.) Physician J stated it was her understanding that the facility had received the court order for Resident 1 to be a DNR the day or two before the incident. Surveyor stated there was no documentation that Resident 1 was a DNR. Physician J then asked Was I misinformed? Physician J again stated she gave the order to stop CPR as she thought he was a DNR. (Of note, the nurse did not indicate to the Physician that Resident 1 was a full code status.) On [DATE], at 11:21 AM, Surveyor interviewed Social Services (SS) K. SS K stated there was no change to Resident 1's code status, he was still a full code. SS K stated there was a court date set to review the code status but Resident 1 passed away before the court date happened. On [DATE], at 11:41 AM, Surveyor interviewed LPN I again via phone for clarifications. Surveyor asked LPN I about the CPR as others stated it was not performed. LPN I stated she walked into Resident 1's room and struck him on the chest three times then after that she did it very few times. When asked about previous statements LPN I stated she could not remember who called the EMTs or who or when a physician was called to stop CPR. Surveyor asked LPN I to review the CPR process she was trained to do. LPN I stated she did not know what to answer and would need to think about it awhile then stated airway, breathing, heart tones, start ambu bag and compressions. LPN I stated there is an ambu bag on the crash cart in the closet across from the nurses station. LPN I then stated it should be easier to access not in a locked closet. (Note upon other interviews the closet is opened by a general key that all staff have and the bathroom keys sitting at the nurses station.) LPN I then stated that night ([DATE]) CNA L yelled up the hall for her and she went to the room and did chest compressions. She then stated the EMTs can't get in at night so someone had to go let them in. LPN I did not have the crash cart in Resident 1's room during the incident. After the survey team left on [DATE] the facility began to interview the staff on duty on [DATE]. On [DATE] the facility interviewed LPN I and asked her to write a statement. LPN I's statement wrote: Observed Resident 1 had overall color pale and with purplish hue, pupils were dilated and fixed, no audible heart tones, extremities were all stiff, writer unable to move them. Skin was very cool to touch. Skin dry, no perspiration observed on skin. I then attempted to move lower jaw line to [MEDICAL CONDITION] not obstructed and he had a clear airway, jaw line was immovable due to stiffness. Next completed sternal rub times 2, no response from Resident 1. Chest compressions began ,[DATE] times to no avail. Resident continued with obvious signs of death, 911 was called. EMTs arrived, placed EKG leads on Resident 1, no response, resident continues death status. At 4:50 AM, nurse called Physician J, notified her of no results of above procedures, Physician J gave order to release body to funeral home. LPN I knew Resident 1 was full code for CPR. She was unsure of the situation because Resident 1 had obvious signs of death. State worker called me between ,[DATE] AM, I was awakened from sound sleep, as per usual I work night shift all the time and usually do not sleep until ,[DATE] AM. I was very tired and unsure of her questions. When state representative talked via phone with me, I do not believe she asked me patients appearance at that time only if I initiated CPR. I believe my clinical record or nurses note is 100% accurate. In reference to why the crash cart or AED was not present in the room or nearby, the resident already had obvious signs of death. -Note: The facility policy and procedures do not indicate not to start CPR based on appearance of death. Resident 1's medical record also indicates chronic severe contractures of arms and legs (which could explain the resident's stiffness, dilated pupils and fixed gaze, all related to persistent vegetative state. During neither interview with surveyor did LPN I state she did not perform CPR due to obvious signs of death; and she initially stated and documented in the nursing notes that she performed CPR for Resident 1. Resident 1's Advance Directives indicate Resident 1's wished to be a full code/receive CPR (Cardiopulmonary Resuscitation). When Resident 1 was found not breathing on [DATE] LPN I did not provide CPR to Resident 1. The facility denied Resident 1 the only chance he had for living. Regardless of the small chance for a positive outcome, there was virtually no chance for a positive outcome from failing to attempt CPR. According to the American Heart Association's Chain of Survival, the chances for survival decrease ,[DATE]% for each minute that CPR is delayed following a sudden [MEDICAL CONDITION]. Brain damage can occur within ,[DATE] minutes. After 10 minutes of delay, few attempts at resuscitation succeed. <http://www.chainofsurvival.com/cos/Timing_detail.asp> The facility removed the immediate jeopardy on [DATE] when they began immediate re-educating nursing staff on proper CPR policy and procedure, accurate documentation, communication of code status to the physician, and resident rights. They also instituted that any future code situation will have a full investigation, Code Blue/CPR drills will be conducted and they are pursuing CPR certification of additional night staff.

Based on interview and record review the facility did not ensure that each resident was free from mental abuse (humiliation) for 1 resident out of 5 reviewed (Resident 1). Resident 1 had a picture of him posted to social media with the words "Jerk!" typed across the picture. This picture was taken without Resident 1's consent or knowledge. In addition, it was alleged by the complainant and a staff person that a video was also taken of Resident 1 while he was agitated and swearing. Someone was kicking his wheelchair and he was kicking back. Laughing was heard in the background. Family Member (FM) - E stated that his father would be humiliated and very angry about this if he did not have dementia. FM E stated that his father would have been mortified if he knew that someone felt that he was a "Jerk." Findings as follows: Surveyor asked for the the facility's social media privacy policy for the facility. The survey team was handed the "Employee Handbook" dated 2013. Page 17 states, "HIPPA (Health Insurance Portability and Accountability) and Privacy Laws-...The use of pictures of "Facility name" resident in websites or email is prohibited without the express written consent of the facility and the resident and or the resident guardian if applicable. In addition the personal public use of information about resident in any form including Internet blogs and other social media may violate law and is strictly prohibited by "facility name." "Consent-Individuals who receive e-mail, text messages, links, information, files, and/or data that may violate the terms of this policy are expected to see that such behavior stops immediately. "Social Media, Blogging and Online Communication-..Personal use of social media during work hours is not permitted. 1. Do not post or display comments about co-workers, managers, customers or the Company that are vulgar, obscene, threatening intimidating, harassing...6. Do not share any information about any (Facility name) resident on any social media forum. In general this means that an employee may not use a resident's name, provide any information which would personally identify the resident or blog or post about (facility name) resident. Do not post pictures of any (facility name) residents. Do not post any HIPPA protected information..." The facility's policy for cell phone use from the handbook states, "...Unless employees are required to carry a cell phone as part of their jobs cell phones must be shut off and kept out of designated work areas." The facility's policy for abuse dated 2011 states that the federal definition of Abuse -Willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Mental abuse-includes but is not limited to humiliation, harassment, threats of punishment, and deprivation. Neglect-failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness... Resident 1 was recently admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident 1 has an activated Power of Attorney for health care decisions. Resident 1's MDS dated [DATE] indicates that he is 2 out of 15 on his BIMS (brief interview of mental status). The BIMS score indicates Resident 1 is severely cognitively impaired (Short term and long term memory). Resident 1's care plan dated 6/19/14 indicates he is at risk for behaviors related to his dementia. The goal is to maintain safety of resident and others. Interventions included: redirection and diversion with activities of interest, (pet visits, music watching listening to TV, outside group activities, men ' s club, one to one, and visiting with staff and others). Monitor for behaviors of: wandering exit seeking, increased anxiety, restlessness, verbally inappropriate, striking throwing objects-Validate. On 7/22/14 the Southern Regional Office received an allegation from a confidential complainant stating that she received a "Snapchat" (Social Media) picture and video of a resident who has one leg, sitting in a wheelchair. Across the picture of the resident was the word "Jerk!" written on it. The video shows someone kicking the resident's wheelchair and the resident kicking back with laughter in the back ground. The video was taken on the 300 wing and the complainant did not know who the resident was. The "Snapchat" came from CNA C and allegedly the "Snapchat" was sent to several people including CNA D who was specifically named. The complainant stated that she received the snapchat video about 2-3 weeks ago on a weekend day shift. The complainant stated that CNA D was on the friends list on snapchat that is why she received it. The complainant thought that the person kicking the wheelchair was a staff member because the person wore black capri scrub pants. Surveyor observed the photo from Snapchat and it is a resident with one leg and has the word "Jerk" written across it. On 7/24/14 at 8:00 AM Surveyor interviewed DON B regarding having any information regarding the allegation of Resident 1 "Snapchat" video and picture. DON B stated that she was unaware of any information regarding "Snapchat" videos or pictures. DON B stated that cell phones are not allowed on the units. On 7/24/14 the survey team interviewed several staff members regarding having any information of Resident 1 and a "Snapchat" video or picture. Only 2 staff had any information regarding Resident 1 and the pictures and or videos. On 7/24/04 at 9:10 AM, Surveyor interviewed CNA D regarding Resident 1. Surveyor asked CNA D if she had any knowledge of a video or a picture of Resident 1 about a month ago, around the 4th of July. CNA D stated that she was unaware of any such video or picture with Resident 1 in it but was not 100% sure and would call back if she remembered any additional info. CNA D added that they are not supposed to have cell phones on the floor while working. On 7/24/14 at 9:20 AM Surveyor received a call back from CNA D regarding additional information. CNA D stated, "I spoke with my family member as we share a phone and the family member remembers getting a video from CNA C which had a resident in it with one leg. The resident was saying obscene things and he was kicking out. A caption on the video stated "this guy is an ass". My family member did not tell me at the time about the video and it was not saved. She (CNA C) is my friend away from work, but this is wrong and if I had seen the video I would have reported it. I do not know anything about a picture." On 7/24/14 at 10:50 AM, Surveyor interviewed CNA C regarding any "Snapchat" picture or video that may have been taken around the first weekend in July. CNA C stated that the last day she worked in the facility was July 4th. CNA C denied taking any video or picture of Resident 1. Surveyor asked CNA C several times about Resident 1 and the "Snapchat " pictures and video and how could it have come from her phone if she didn't take it. CNA C then stated, "Well maybe I did take a video, but I don't remember any picture." Surveyor asked to describe the day when she came to work when she took the video. CNA C stated, "I came in at 12:00 PM and as soon as I got here Resident 1 was falling and I ran to help the staff helping him, then I sat at the table to fill out paperwork. I had my phone on me as I didn't get time to put it away at that point. He (Resident 1) was at the table where I was filling out the paperwork and he was agitated and swearing. He (Resident 1) was kicking out at staff stepping on their foot stating 'does that hurt' and when they said 'no' he then (Resident 1) did it harder." Surveyor asked CNA C why she took the video. CNA C stated, "I took the video to show what his behaviors were. I sent them to friends. I know this was really bad and I shouldn't have done this. I'm sorry." Resident 1 was unable to be interviewed as he was not at the facility. No other staff interviewed having any knowledge of the incident with Resident 1. On July 29th at 5:09 PM Surveyor received a call from Family Member E (FM) regarding his father's picture and video that was sent via social media. FM E stated that he was very upset that this happened to his father and that his father would be humiliated and very angry if he did not have dementia. FM E stated that his father would have been mortified if he knew that someone felt that he was a "Jerk." FM E also stated that he is angry that staff did not report this to stop it, as obviously there were people laughing and he was allegedly being kicked and was mad enough to kick back. FM E stated that he felt that maybe this is why he was having behaviors or why he was given behavior medication if the staff were abusing him. FN E stated that he felt this was abusive to his father and worries that this may have occurred with other residents too. Surveyor received the police report case # 14-4580 which in part states, "(CNA Name) (CNA C) she remembered sending a video message to people via snap chat but did not recall sending a picture. She stated she did not remember who she sent the message to. She did not recall what the caption on the screen was. The officer asked what the video was of. She (CNA C) stated it was a male patient who was kicking at someone. She (CNA C) stated she did not remember who. (CNA C) stated no one was kicking at the patient. CNA C stated that she knew she had made a bad decision but at the time thought it was funny..." The facility staff willfully used social media to send abusive, degrading, humiliating pictures of Resident 1 to other people. CNA C was also neglectful for not providing goods and services to protect this resident from abuse.

Based on observation, interview and record review, the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents for 4 of 12 residents reviewed for falls (Residents 1, 2, 9 and 10). The facility did not consistently assess behavior trends and identify root causes for unwanted self-transfers, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. Resident 1 was assessed to be at risk for falls upon admission. Resident 1 fell 21 times while at the facility. Resident 1 had 14 falls after which the facility did not assess Resident 1's behavior trends and identify root causes for unwanted self-transfers and falls, did not consistently implement new interventions to prevent falls when past interventions had proven ineffective, and did not consistently implement care-planned approaches for preventing falls. Resident 1 had 7 falls involving trying to get to the toilet, was incontinent, or voided when toileted after the fall. The facility did not identify this as a cause or change her 2 hour toileting schedule. The facility continued to remind Resident 1 to use the call light or to ask for assistance before attempting to transfer independently, but numerous nursing notes document this was ineffective because the resident did not remember. The failure to provide appropriate supervision and assistive devices to prevent falls created a finding of immediate jeopardy, which began 3/26/12. The administrator and Corporate RN were notified of this finding at 10:50 AM on 7/11/12. The facility removed the immediate jeopardy on 7/11/12; however, the deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) because the facility has yet to fully implement and evaulate its action plan and based on the following examples: Resident 2 has fallen 5 times since he was admitted on [DATE]. The facility did not put new interventions in place after 2 of those falls to keep him safe. Resident 9 sustained a fall and and the facility did not place appropriate interventions to prevent additional falls but, instead, developed an approach that was already supposed to be in place. During survey, Resident 9 was not transferred in accordance with his plan of care. Resident 9 was left sitting on the bed, which was not in a low position. He was then transferred without the care-planned grippy socks. Resident 10 sustained falls at the facility. The facility did not place preventative measures to prevent additional falls from occurring. As evidenced by: The facility policy with revision date of 4/09 titled Accidents/Falls states: Policy: The facility strives to promote safety, dignity, and overall quality of life for residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Procedure: ...7. Any episode of a fall or other incident/accident should be documented on the incident accident report. The information should be recorded in factual observed detail ... Each incident/accident or fall must be investigated and/or assessed to determine the cause of the episode to prevent any further injury ... The administrator should have knowledge of all reports, and the interdisciplinary (IDT) team should review all incident/accident reports whenever possible. 9. A post-fall assessment will be conducted following any fall episode within 24 hours post fall. The completed post-fall assessment will be maintained in the resident's medical record. 10. The resident's individualized care plan is to be updated with any charges or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented. 11. Post fall/incident/accidents will have continued follow-up on the 24 hour report/alert charting for 48-72 hours so as to continue assessment for possible injuries as well as to further evaluate the interventions put into place. Example 1 Resident 1 was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Resident 1 was her own person on admission, however her power of attorney was activated on 1/31/12. Resident 1's admission Minimum Data Set ((MDS) dated [DATE] states Resident 1 scored a 3 on her Brief Interview for Mental Status assessment indicating she has severe cognitive impairment. Resident 1's MDS in Section G indicates she requires limited assistance of 1 staff for transferring, bed mobility, walking in her room and corridor. Resident 1's quarterly MDS dated [DATE] indicates no change in cognition, transferring, bed mobility, or walking in her room and corridor. Resident 1's MDS Care Area assessment dated [DATE] indicates she has the following risk factors for falls: wandering, balance problems during transition, history of falls - 1 in a month prior to admission, has fallen once since admission, takes diuretics, and has osteoporosis. The CAA states the rationale for care planning is: Resident will not sustain serious injury with a fall. Resident 1's initial Falls Risk assessment dated [DATE] states she is at risk for falls as Resident 1 hurries when she wants to go somewhere which leads her to fall. Resident 1's initial care plan dated 12/19/11 fall interventions put in place are: educate resident, call light within reach, gripper socks at night was added on 12/20/11, and chair & bed alarm added on 12/21/11 but removed as Resident 1 refused the alarms on 12/28/11. Resident 1 also had in place the intervention for bladder and bowel incontinence to toilet every 2 hours until a pattern is established by her 3 day tracking tool. It is important to note that Resident 1's care plan dated 12/30/11 indicates she requires a 4 wheeled walker and 1 staff to assist her to toilet, transfer, and for mobility. 1. The facility accident/incident report dated 12/20/11 for Resident 1 indicates she fell with the call light in reach and bed in lowest position at the time of the fall. The facility add the intervention of gripper socks at night and reviewed safety and call light use with Resident 1. Resident 1's nurses notes (NN) dated 12/21/11 at 3:30 AM states she was up walking in the hall per herself and was taken back to her room by staff. 2. The facility accident/incident report dated 1/3/12 for Resident 1 indicates she was found on the bathroom floor with a large hematoma to the left side of her head and bruising to her coccyx. The facility put the following interventions in place after the fall: cue to toilet every 2 hours, grab bars to the toilet and anti-skid strips in front of the toilet. The 2 witness statements attached to the accident/incident report for Resident 1's 1/3/12 fall were not completed for when she was last toileted and last repositioned. 3. The facility accident/incident report dated 1/19/12 for Resident 1 indicates she fell from her stationary chair and was found at her bedside. Resident 1 had stated that she wanted to lie down. The facility added the intervention of anti-skid strips in front of Resident 1's bed on 1/20/12. 4. The facility accident/incident report dated 2/12/12 for Resident 1 indicates she fell from her stationary chair and was trying to get into bed. Resident 1 had stated that she wanted to lie down. The facility added the intervention of offering Resident 1 to lay down for naps on 2/12/12. The witness statement attached to the accident/incident report for Resident 1's 2/12/12 fall was not completed for when she was last toileted and last repositioned. Resident 1's NN dated 2/26/12 at 11:20 AM states Resident 1 was up independently with her walker saying she is tired of sitting and wants to go out. Resident 1's NN dated 3/11/12 at 6:00 PM states Resident 1 attempted to exit the facility during the shift. 5. The facility accident/incident report dated 3/21/12 for Resident 1 indicates she fell from her bed and was trying to get her pull up brief off as it was too tight. Resident 1 also stated she would get up on her own again. The witness statement attached to the accident/incident report for Resident 1's 3/21/12 fall states that Resident 1 had been incontinent on the floor. The facility evaluated and changed Resident 1's brief size. 6. The facility accident/incident report dated 3/26/12 for Resident 1 indicates she fell at 1:15 PM trying to get to the toilet. The report indicates Resident 1 was toileted "prior to the fall" but does not give a time. Resident 1 sustained a reddened area to her left dorsal hand and tiny skin tear not bleeding, also found 2 elongated streaks dorsally to her left underside of her elbow with intact skin. The post fall risk assessment dated [DATE] indicates that a dycem was in place at the time of the fall. The report indicates a new bowel and bladder diary is to be started as an intervention and continue close observance when Resident 1 is up wandering the hall with her walker. It is important to note that Resident 1's care plan indicates she requires a 4 wheeled walker and 1 staff to assist her for transferring and mobility and no new intervention was put in place while the bowel and bladder diary was started to keep Resident 1 safe. On 7/10/12 at 5:00 PM Surveyor interviewed Corporate RN I who stated that the bowel and bladder diaries are not kept as part of a Resident's medical record so Resident 1's was not provided for 3/26/12. No changes were made to Resident 1's care plan with respect to Resident 1's toileting schedule. Resident 1's NN dated 3/26/12 at 6:40 PM states Resident 1 continues to attempt to toilet herself and staff intercept her when they see her up independently with her 4 wheeled walker. 7. The facility accident/incident report dated 3/27/12 for Resident 1 states she was found on the bathroom floor at 8:50 AM. She had independently gone to the bathroom to have a bowel movement and was found incontinent. Resident 1 stated she hit her head and received a bump to the upper occipital area of her head. The 2 witness statements attached to the report indicate Resident 1 was last toileted at 7:30 AM. The post fall risk assessment dated [DATE] states that Resident (1) will not request help even though frequently re-educated and call light is in reach. The report indicates the facility implemented a new intervention: Resident 1's walker is to be near her at all times with reasoning that Resident 1 will get up even if her walker is not next to her. The facility also added bed and chair alarms on 3/27/12 but they were also discontinued on the same date due to refusal by the POA . Resident 1's NN dated 3/28/12 at 12:00 PM states she "needs constant reminders to wait for assistance..." The Facility Bowel and Bladder Functional Evaluation tool dated 4/5/12 states, "Resident (1) exhibits functional and urge urinary incontinence. Attempts to toilet self often. Staff assist with toileting and pericare. Wears briefs." It is important to note that no changes were made to Resident 1's care plan. On 7/11/12 at 10:50 AM Surveyor interviewed Corporate RN I who stated that the facility did not change Resident 1's toilet schedule or add any new interventions after the 4/5/12 bowel and bladder assessment. 8. The facility accident/incident report dated 4/6/12 for Resident 1 states she was found on the floor at 4:10 PM. The report did not state where she had been prior to falling. Resident 1 stated that her left hip hurt after the fall. The report states that a 24 hour trial of hourly checks will be done to assess Resident 1's needs. The post fall risk assessment dated [DATE] is blank by the question "What was the resident doing prior to the fall, if known?" Resident 1's NN dated 4/7/12 at 9:00 AM states, Resident (1) is non-compliant with safety instructions and re-direction. Up several times independently in her room without using her walker or assistance, call light attached to upper edge of bed bar in close proximity to left hand of Resident (1). She understands its use, but forgets quickly. Gait is shuffled and slow with Resident (1) stretching out her arms and partially bent forward. Resident 1's NN dated 4/9/12 at 3:00 AM states Resident 1 does not use the call light for assistance. And at 11:00 AM, Resident 1 is developing bruising to her posterior left thigh. 9. The facility accident/incident report dated 4/12/12 for Resident 1 states she was found on the floor at 2:45 AM and stated she did not know where she was going. The report Resident was sleeping in her bed at 2:00 AM. The report also states that Resident 1 was taken to the bathroom after the fall and voided. The witness statement attached states she was last toileted at 11:55 PM. Resident 1's bruising to her left hip/thigh continues. The facility notes that staff education was provided and to ensure her walker is by her at all times. On 7/10/12 at 5:40 PM Surveyor interviewed Corporate RN I who stated that Resident 1's walker was not in place at the time of her fall on 4/12/12. 10. The facility accident/incident report dated 4/14/12 for Resident 1 states she was found on the floor at 8:10 PM and stated she fell because no one was in her room. The witness statement attached states she was last toileted at 7:15 PM. The report states Resident 1's power of attorney will decide about a psychological consult in May and Resident 1 well be assessed for the restorative program. It is important to note that a physician's telephone order dated 5/17/12 indicates Resident 1 could have a psychological consult and the consult was completed on 6/7/12. Resident 1 started a restorative program for ambulation on 4/17/12. Resident 1's Fall Risk Assessment quarterly review dated 4/24/12 states she is a high risk for falls with multiple recent falls. On 7/11/12 at 10:50 AM Surveyor interviewed Corporate RN I who stated Resident 1's Fall Risk Assessment quarterly review dated 4/24/12 was a little late. 11. The facility accident/incident report dated 5/10/12 for Resident 1 states she was found on the floor at 4:35 AM. The witness statement attached states she was last toileted at 2:45 AM and was last seen sleeping in her bed. The post fall risk assessment dated [DATE] indicates Resident 1's bed was in the low position when she fell and that the new intervention is her bed is to be in the lowest position. It is important to note that this intervention is also documented in place when Resident 1 fell on [DATE]. Resident 1's NN dated 5/10/12 at 11:45 AM states Resident 1 required a great deal of reminding to ask for assistance. Resident 1's NN dated 5/11/12 at 5:00 PM states, Frequent reminders to have assistance but with impaired cognition does not retain or understand need for assistance. Resident 1's NN dated 5/18/12 at 11:00 AM states ...education to have Resident (1) ask for assist has been ineffective... 12. The facility accident/incident report dated 5/22/12 for Resident 1 states she was found on the floor at 4:20 PM. Resident 1 fell from a chair in the lounge. The report states that Resident 1 was to have a physical therapy (PT) screen (competed on 5/31/12), suggest an activity box, and was referred to occupational therapy (OT) for cognition. It is important to note that no documentation was provided that the activity box or OT referral were completed for Resident 1 for this fall intervention. Resident 1's NN dated 5/24/12 at 11:00 AM states ...still requires assistance with ambulation but needs numerous reminders to ask for assistance. As intervention OT will be screening with potentially developing a memory book... Resident 1's PT screen dated 5/31/12 states she is not appropriate for PT. Resident 1's Fall Risk Assessment quarterly review dated 6/4/12 states she continues to be high risk for falls with multiple recent falls. The Facility Bowel and Bladder Functional Evaluation tool quarterly review dated 6/4/12 states, "Resident (1) experiences urgency with urination it does dribble or has occasional small amount of urinary incontinence. She wears pull ups (briefs) for this issue. Remains continent of bowel." Despite knowing that Resident 1 can have urgent needs to use the bathroom, no changes were made to the resident's toileting schedule. There was no consultation with the physician and POA with respect to a possible medication change. Resident 1's NN dated 6/9/12 no time written for this entry (after 11:30 AM note and before 9:00 PM note) states Resident 1 had increased behaviors and had chosen to lie down. This was effective for less than 10 minutes and Resident 1 began yelling/calling out ... she was attempting to self-transfer in her room so she was brought out into the lobby on the unit. Resident 1 was found on the floor and had managed to remove the dycem. ...when asked why she did not ask for assistance Resident 1 stated "I didn't want to"... 13. The facility accident/incident report dated 6/9/12 for Resident 1 states she was found on the floor at 10:22 AM from a chair in the 200 hall lounge due to yelling out/behaviors was in a supervised area. As an intervention Resident 1 was instructed to ask for assistance and stressed the importance of the dycem placed in her chair. Also noted is OT could screen Resident 1 to develop a memory book... It is important to note that the OT screen to develop a memory book was not done until 6/22/12. Resident 1's NN dated 6/9/12 at 9:00 PM states Resident 1 ambulating with walker unwilling to ask for assistance... Resident 1's NN dated 6/10/12 at 1:45 PM states she attempted to self-transfer 3 times during the shift. Resident 1's NN dated 6/11/12 at 11:40 AM states Psychological dictation was received and Resident 1's power of attorney (POA) agreed with starting Zoloft. NN at 8:00 PM states Resident 1 was up with her walker independently and staff intervened as needed. 14. The facility accident/incident report dated 6/12/12 for Resident 1 states she was found on the floor at 4:05 PM in the bathroom by her toilet. Resident 1 was last toileted at 3:30 PM. The report states Resident 1's wheelchair was in the bathroom and Resident 1 may have tripped on it. The report noted that Resident 1 started Zoloft on 6/12/12 and that staff were educated regarding not leaving her roommate's wheelchair in the bathroom and to start 1 hour checks during waking hours to assess her needs. Resident 1's NN dated 6/13/12 AM (no exact time noted) states Resident 1 up as usual with walker, forgetful in use of call light... The facility OT report dated 6/13/12 indicates a referral was made to make a life story (memory book) to decrease behaviors. It is important to note that this was an intervention for Resident 1's fall on 6/9/12. Resident 1's NN dated 6/19/12 at 11:45 AM states a request was sent to the physician's office to request an OT evaluation and treatment orders to develop a memory book ... It is important to note that this intervention was for the fall on 6/9/12. Resident 1's OT evaluation/treatment sheet dated 6/22/12 state she was seen to develop a life story (memory) book. 15. The facility accident/incident report dated 6/23/12 for Resident 1 states she was found on the floor at 7:00 PM near her bed. Resident 1 was last toileted at before supper (no exact time was indicated). Resident 1 sustained a small abrasion to her left elbow. The report notes that she will continue on hourly checks but does not state any new intervention was added to keep Resident 1 safe. 16. The facility accident/incident report dated 6/24/12 for Resident 1 states she was found on the bathroom floor at 10:20 AM. Resident 1 was found with her left cheek and forehead pressed against the wall with her glasses pressing into her face. Resident 1 sustained bruising to her left temporal area, 2 separate lacerations which required cleansing, pronounced elevation to cheek and left lateral posterior scalp, and bruising to her left hip and buttocks. Resident 1 was sent to the emergency room to be evaluated. The report notes that she will continue on hourly checks. The facility Falls Risk Post-Fall assessment dated [DATE] states possible placement of alarming floor mat was discussed with Resident 1's POA, but was not put in place due to increasing Resident 1's agitation. It does not state any new intervention put in place to keep Resident 1 safe. The hospital report dated 6/24/12 states Resident 1 sustained a concussion with no loss of consciousness. Resident 1's NN dated 6/25/12 AM (no exact time indicated) states ...Resident 1 continues to attempt being up without assistance... 17. The facility accident/incident report dated 6/26/12 for Resident 1 states she was found on the floor at 6:55 PM by her roommate's bed. Resident 1 stated she hit her head and sustained a small amount of redness on the right side of her head. The report states as an intervention of a psychological placement would be discussed and Resident 1 continues on hourly checks. It does not state any immediate new intervention put in place to keep Resident 1 safe. 18. The facility accident/incident report dated 7/2/12 for Resident 1 states she was found on the floor at 6:40 PM in her room. Resident 1 sustained a contusion to the back of her head. Her walker was noted to be on the other side of her room. The report states as an intervention that further lab workup and a request for a pharmacy consult would be done. It does not state any new immediate intervention was put in place to keep Resident 1 safe. Resident 1's NN dated 7/2/12 6:45 PM states the family did not want her sent to the emergency room . 19. The facility accident/incident report dated 7/2/12 for Resident 1 states she was found on the floor at 10:15 PM next to her bed. Resident 1 was noted to have a contusion to the back of her head from the previous fall, her left elbow was red and slightly swollen, and had a 7 inch abrasion over her lower left ribs. The report states as an intervention that further lab workup and a request for a pharmacy consult would be done. Resident 1 was taken to the nurses' station after this fall for 1:1, but did not indicate how long the 1:1 was in place. Resident 1's care plan dated 6/18/12 indicates activity staff to use life story book (memory book) was added on 7/3/12. It is important to note that this intervention was to be added after Resident 1's 6/9/12 fall. Resident 1's NN dated 7/3/12 10:30 AM states ... Resident 1 continues to self-transfer and education is generally ineffective... 20. Resident 1's NN dated 7/4/12 6:45 PM states Resident 1 was found on the floor in her room at 3:30 PM. No new interventions were noted after this fall. Resident 1's NN dated 7/5/12 9:30 AM states IDT met to discuss fall. It is important to note that no new interventions were identified to keep Resident 1 safe. Resident 1's NN dated 7/7/12 1:45 PM states she ...did self-transfer three times today with reminders provided. 21. Resident 1's NN dated 7/8/12 3:30 PM states she was found on the floor lying on her back. The family is noted to have stated that if found unresponsive Resident 1 may be sent to the emergency room . It is important to note that no new interventions were put in place to keep Resident 1 safe. Resident 1's NN dated 7/9/12 1:15 PM states Resident 1 is noted to have elevation to her posterior scalp... Resident 1's NN dated 7/10/12 11:15 AM states Resident 1 ...is impulsive and will get up frequently to ambulate, not easily redirected by staff. Resident 1's care plan dated 6/18/12 indicates 1:1 for 24 hours to assess needs was added on 7/10/12. On 7/10/12 at 8:55 AM Surveyor observed Resident 1 ambulating with her 4 wheeled walker independently in the 200 hall and no staff were assisting her. At 9:13 AM Surveyor observed Resident 1 standing in the 200 hall just outside her door. She was standing holding onto the hand rail without staff assistance. On 7/10/12 at 3:10 PM Surveyor interviewed Director of Nursing (DON) B who stated that the nurse on duty reviews the resident fall initially and she would expect an intervention to be put in place after the fall. DON B explained that the IDT also reviews falls the next day after the fall or if a resident falls on a weekend those falls would be reviewed by IDT on Mondays. On 7/11/12 at 7:05 AM Surveyor interviewed DON B who stated that the facility utilizes the dycem as a standard protocol with almost every alarm or cushion. DON B stated she did not have the bowel and bladder diaries for Resident 1 with start date of 3/26 or hourly checks started on 4/6 because these are not kept as a part of a resident's permanent record. DON B stated that she did not know if Resident 1's toileting schedule had been looked at as an intervention and provided no evidence that it had been considered even though 7 of Resident 1's falls involved trying to void/get to the bathroom. DON B stated that all facility staff was educated on 4/19/12 about following the resident care plan as part of the intervention from Resident 1's fall on 4/12/12. She stated that Resident 1 did not see OT for cognition as the intervention from Resident 1's fall on 5/22/12. DON B agreed there was no new intervention for Resident 1 after her fall on 6/23/12. On 7/11/12 at 12:40 PM Surveyor interviewed Nursing Home Administrator (NHA) A and Corporate RN I. NHA stated that Resident 1 will be reassessed for fall reviewing the root cause for the falls and will receive 1:1 observation for 48 hours to assess her schedule and needs. NHA A stated Resident 1 will now be prompted to void every hour as well. The failure to provide appropriate supervision and assistive devices to prevent falls created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 7/11/12, the noncompliance at a lower level of scope/severity of E (potential for harm that is not immediate jeopardy/pattern) is evidenced by: Resident 1 was reassessed for falls on 7/11/12 The IDT met on 7/11/12 to discuss Resident 1's previous falls, interventions, and has reviewed the new fall assessment to identify the root cause analysis. Based off the IDT discussions and the root cause analysis the following interventions have been put into place for Resident 1: Resident was put on direct 1:1 supervision as of 7/10/12 to ensure safety, staff will document the resident's routine, including toileting needs. This documentation will be reviewed after 24 hours of completiont to summarize findings. Based off of the findings, new interventions will be put into place if needed. An individualized fall log for the Resident has been created and will continue to be utilized to monitor for patterns and trending. Resident was care planned to prompt to void every one hour, staff will document if the resident voids or is wet. Resident was immediately re-assessed for pain. All staff will be re-educated on teh policy and procedure for accidents and incidents and how to determine root cause analysis, prior to working their next shift. Example 2 Resident 2 was admitted to the facility on [DATE] from home. He has current [DIAGNOSES REDACTED]. Resident 2's guardianship was put in place on 5/22/12. Resident 2's admission Minimum Data Set ((MDS) dated [DATE] states Resident 2 scored a 3 on his Brief Interview for Mental Status assessment indicating he has severe cognitive impairment. Resident 2's MDS in Section G indicates he requires extensive assistance of 1 staff for transferring and bed mobility, and limited assistance of 1 staff walking in his room. Resident 2's MDS Care Area assessment dated [DATE] indicates he has the following risk factors for falls: difficulty maintaining sitting balance, impaired balance during transitions, diuretics, cardiac dysrhythmias, incontinence, visual impairment, hearing impairment, wandering, cognitive impairment, and Alzheimer's disease. The CAA states the rationale for care planning is not completed. Resident 2's initial Falls Risk assessment dated [DATE] indicates he is at risk for falls. Resident 2's care plan dated 6/5/12 indicates he requires 1 staff to assist him with transfers and toileting. He has the following interventions in place for falls: bed in lowest position, anti-roll back bars on wheelchair, chair alarm when out of bed, floor mat alarm at bedside (on 7/11/12 changed to connected to nurse call light system), assist with 4 wheeled walker for toileting every 2 hours, added 7/6/12 gripper socks when shoes are off, and added 7/6/12 dycem on and under wheelchair cushion. Resident 2's nurses notes (NN) dated 5/12/12 at 10:20 AM states Resident 2 ...has attempted to self-transfer 3 times this shift ... Required frequent reminder to ask for assistance... The facility accident/incident report dated 6/4/12 for Resident 2 indicates he was found at 10:55 PM sitting on the alarm mat stating he was trying to shut off the alarming mat when he slid out of bed. 1. The Falls Risk Post-Fall assessment dated [DATE] states Resident 2 wants to sit on the side of the bed at times but mat alarm goes off which angers/irritates Resident 2. It is important to note that no new interventions were added to keep Resident 2 safe. 2. The Falls Risk Post-Fall assessment dated [DATE] states Resident 2 was seated in the lobby in his wheelchair. He made an attempt to self-transfer at 9:45 AM without asking for assistance. A staff was able to assist Resident 2 to the floor. It indicates the interventions put in place were to educate Resident 2 to ask for assistance, ask activity staff for activities/ideas to keep Resident 2 content, and Occupational Therapy (OT) is working on his life story. Resident 2's OT treatment sheet dated 6/25/12 with entry on 6/19/12 stating "completed parts of life story." 3. The Falls Risk Post-Fall assessment dated [DATE] states Resident 2 was found by his bathroom door at 6:45 PM stating he had to go to the bathroom. He was last toileted at 5:15 PM. It is important to note that no new interventions were put in place to keep Resident 2 safe. Resident 2's NN dated 6/23/12 at 9:45 AM states Resident 2 ...requires reminders regarding self-transfers and verbalizes "yeah, yeah" ... 4. The Falls Risk Post-Fall assessment dated [DATE] states Resident 2 was found at 6:00 PM sitting on the floor mat with only his socks on. Resident 2 stated he was trying to get up from bed and slid to the floor. The facility added to his care plan gripper socks when his shoes are off. On 7/10/12 at 9:11 AM Surveyor observed Resident 2 enter room 208's bathroom (not his room) and self-transferred to the toilet with his chair alarm sounding. CNA L entered room 208 and transferred Resident 2 back to his wheelchair. 5. The Falls Risk Post-Fall assessment dated [DATE] states Resident 2 was found at 2:10 PM on the floor. Resident 2 had attempted to self-transfer from his bed to his wheelchair. The facility's new interventions were to offer naps, evaluate his bowel and bladder, and connect his floor mat to the nurse call system. On 7/10/12 at 3:45 PM Surveyor interviewed Resident 2's Family Member (FM) M who stated her only concern was that Resident 2 self-transfers and she is afraid he will hurt himself if he falls. FM M stated she visits almost every day and Resident 2 won't use his call light for assistance and is up and around before the staff can get to him. On 7/10/12 at 3:10 PM Surveyor interviewed Director of Nursing (DON) B who stated that the nurse on duty reviews the resident fall initially and she would expect an intervention to be put in place after the fall. Example 3 According to "[DIAGNOSES REDACTED]. The facility completed a "Falls Risk Assessment-HGDR" on 6/8/12. This assessment indicates that Resident 9 is unsteady but is not at risk for falls. This document also indicates that Resident 9 has no history of falls. Resident 9 sustained three falls in the facility since December, 2011. The facility completed an incident report that