Every finding on record at Avante at Ormond Beach, Inc

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety, by failing to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility failed to ensure that the dietary staff practiced proper procedures for hand hygiene, disposable glove use, and proper sanitation practices when cleaning the meat slicer in the kitchen. Appropriate hand hygiene, food handling, and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial kitchen tour on 03/17/2025 at 10:44 AM, the dish machine was observed with the Certified Dietary Manager (CDM). Dietary Aide G tested the machine with a test strip. The dish machine was a high-temperature machine. The machine was operated through both cycles four times, and the temperature gauge for the rinse cycle did not reach 180' F (Fahrenheit) during any of the cycles. The wash cycle temperature was 160' F. The rinse cycle only reached 173' F. Dietary Aide G stated the required temperature should be 180' F. During an interview with the CDM at 10:50 AM, she stated the dish machine was working fine this morning, and she did not understand why it was not reaching the required temperature now. She confirmed the rinse cycle should reach 180' F. During a second tour of the kitchen on 03/19/2025 at 11:20 AM, the lunch meal service was observed. From 11:20 AM to 11:40 AM, Dietary [NAME] E, the evening cook, was observed washing the meat slicer off with soapy water and a rag. She did not remove any parts of the slicer. She finished cleaning it, wiped it off, and covered it with a plastic bag. She then rolled it into the dry storage room and returned to the kitchen to assist with the lunch meal service. On 03/19/2025 at 12:00 PM, Dietary [NAME] E was observed changing gloves without washing her hands. She was preparing pureed food in a blender. During an interview with Dietary [NAME] E on 03/19/2025 at 1:43 PM, she expressed that she would need to use the translator on her phone because her first language was Russian. She used a translator to understand the questions she was being asked. She stated she remembered changing gloves when she was preparing the pureed beef in the blender. She confirmed that she did not wash her hands in between. She confirmed she had been trained to wash her hands between glove changes. The CDM was standing nearby and nodded her head in agreement. On 03/19/2025 at 12:10 PM, Dietary [NAME] F was observed changing gloves without washing her hands. During an interview with Dietary [NAME] F on 03/19/2025 at 1:38 PM, she stated she had gravy dripping off of her glove. She did not want to walk all the way across the kitchen to take her gloves off and wash her hands, so she just took the dirty glove off, discarded it and donned a new pair of gloves. She did not want to leave the tray line to go wash her hands, so she just continued serving the meals. On 03/19/2025 from 1:20 PM to 1:41 PM, observations of the dish washing operations were made. Dietary Aide G was observed donning gloves and then began washing off dirty dishes and stacking them in dish machine racks. She loaded the trays into the dish machine and ran them through. She then pulled the tray of clean dishes out of the machine and went back over to the dirty side of the dish room and continued to rinse dirty dishes from the lunch meal service. At 1:24 PM, she went to the clean side of the dish room and pulled the trays out of the dish machine. She did not change gloves in between or wash her hands. She then proceeded to unload the clean dishes from the racks placing them on a cart with other clean dishes. After she finished unloading the clean dishes, she returned to the dirty dishes and continued to rinse and load them in racks. Another aide brought over two large orange trays and asked her to run them through the machine. She took them and ran them through. She then removed them from the machine with the same gloves on and put them up against the wall to drip dry. She returned to the dirty side and continued to rinse and rack the dirty dishes. At 1:28 PM, she returned to the clean side and pulled a rack of clean dishes out of the machine. She continued to wash the dishes going back and forth between the clean and dirty side without changing gloves or washing her hands. During an interview with the CDM on 03/19/2025 at 1:38 PM, she observed Dietary Aide G washing dishes without stopping to change her contaminated gloves and wash her hands. The CDM confirmed that the aide should not be going back and forth between the dirty and clean side without washing her hands and changing her gloves. She was then asked to observed the meat slicer in the dry storage room. She went to the meat slicer and removed the plastic cover. The food support plate and underside of the blade were encrusted with food debris. (Photographic evidence obtained) The CDM confirmed that the meat slicer was still not clean. At 1:51 PM, the CDM provided the policy and procedure and trainings for the dietary staff on hand washing and glove use. She was informed of the observations during the lunch meal service of Dietary [NAME] F not changing gloves when required (moving from one task to another) without washing hands in between. She confirmed that she should wash her hands between glove changes. A review of the Food and Nutrition Services In-Services sign-in sheet revealed that Dietary Cooks E and F, and Dietary Aide G received training on 12/02/2024 on hand hygiene. (Copy obtained) A review of the manufacturer's specifications for cleaning the meat slicer revealed: Cleaning and Sanitizing the Slicer: 3. Use a clean cloth to remove all coarse residual food and liquids from the slicer surfaces. Sanitize all the removable parts and the slicer. 10. In a clean basin or sink, in a solution of clean warm water and correctly diluted sanitizing solution, soak and wash the removable parts. Remove the parts form the basin or sink and allow them to air dry. 11. Wipe the slicer with correctly diluted sanitizing solution. The slicer shall be cleaned and sanitized at intervals to comply with national state and/or local health codes. (Copy obtained) A review of the facility's procedure for properly cleaning a food slicer (Undated) revealed: To properly clean a food slicer, disassemble it, wash all parts with hot, soapy water, rinse thoroughly, and sanitize with a food-safe solution, then dry all components before reassembling. 2. Disassembly: Remove removable parts: Disassemble the slicer by removing the blade, carriage, food pusher, and any other removable parts. 3. Cleaning: Wash with hot, soapy water: Wash all disassembled parts with hot soapy water, using a soft-bristled brush to remove any stubborn food particles. Clean the blade thoroughly, paying attention to both sides and any crevices. Ensure the carriage is thoroughly cleaned to remove any residue or buildup. After washing, sanitize all parts with a food-safe sanitizer according to the manufacture's instructions. Rinse all parts thoroughly with clean water to remove any sanitizer residue. Dry all parts thoroughly. Clean after each use. Regularly clean the slicer after each use to prevent food buildup and bacterial growth. (Copy obtained) A review of the facility's policy and procedure titled Infection Control - Food Handling (issued 03/02/2019, revised 03/02/2019) revealed: 1. Food staff are to wash hands when: before putting on gloves; when changing tasks, after handling soiled dishes, utensils and equipment. 4. Single use gloves are not to be used for more than one task. Change gloves and perform hand hygiene between tasks. (Copy obtained)

Based on observations, interviews, and reviews of the facility's Infection Control Program and Hand Hygiene policies, the facility's staff failed to offer or assist residents with hand hygiene before meals for five (Residents #66, #63, #102, #57, #29) of five residents who received meal trays and were unable to perform hand hygiene independently in a manner to prevent cross contamination. The findings include: On 03/17/2025 at 12:20 PM, an observation was made of lunch meals served in the south dining room. The staff was observed using hand hygiene before serving trays to residents but none of the residents were offered hand hygiene before their meal was served. On 03/19/2025 at 12:14 PM, an interview was conducted with Resident #66. When asked, she stated she was not offered hand hygiene before meals. Her roommate, Resident #102, a new admission on 03/18/2025, stated she was not offered hand hygiene either. On 03/19/2025 at 12:18 PM, an observation was made of lunch meals served in the north dining room. The staff was observed using hand hygiene before serving trays to residents but none of the residents were offered hand hygiene before their meal was served. On 03/20/2025 at 12:10 PM, Resident #57 was asked whether she was offered hand hygiene before meals. She stated it had never been offered. On 03/20/2025 at 12:12 PM, Resident #29 was asked whther she was offered hand hygiene before meals. She stated hand hygiene had not been offered to her before any meal. On 03/20/25 at 12:21 PM, Certified Nursing Assistant (CNA) A was interviewed. When asked about resident hand hygiene before meals, she stated she did ask the residents about hand hygiene before mealtime most of the time. On 03/20/25 at 12:26 PM, Therapist B was interviewed. When asked about hand hygiene for residents before meals, she stated it was not offered but should be. On 03/20/25 at 12:27 PM, CNA C was interviewed. When asked about hand hygiene for residents before meals, she stated she would usually wash the residents' hands before serving them. On 03/20/2025 at 12:32 PM, a hand hygiene policy for residents was requested from the Director of Nursing. On 03/20/2025 at 1:46 PM, a hand hygiene policy for residents was requested from the Administrator. On 03/20/2025 at 2:40 PM, Resident #63 was asked if she was offered hand hygiene before her meals. She stated no, she could not do it herself and needed assistance with the task. On 03/20/2025 at 2:45 PM, the facility's policy and procedure titled Activities of Daily Living (ADLs) - Maintain Abilities (issued: 3/2/19, revised: 3/2/19) was provided for review. It contained no specific language for resident hand hygiene before meals; however, paragraph number three read: The facility will provide care and services for the following activities of daily living: a: Hygiene - bathing, dressing, grooming, oral care, and hand hygiene. (Photographic evidence obtained) On 03/20/2025 at 3:09 PM, an interview was conducted with the Director of Nursing (DON) regarding hand hygiene for residents before meals. When asked about the process for hand hygiene before meals, she stated the ADL (activities of daily living) policy was what they used for this procedure; there was no separate policy for mealtime hand hygiene. She stated, Staff is expected to offer the resident hand hygiene and assist dependent residents with hand hygiene before meals. When asked if she completed any surveillance for hand hygiene for residents, she stated she had not.

Based on observations, resident and staff interviews, and a review of policies and procedures, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable living environment, by failing to 1) Keep resident care equipment functioning for one resident (#8) whose bed controls did not work, and 2) Keep the rooms clean for four (Residents #54 #39, #302, #59) of five residents receiving enteral nutrition, in a total survey sample of 36 residents and a facility census of 102. The facility failed to clean and maintain the enteral nutrition (tube feeding) pumps and poles, walls, floors and floor boards surrounding the air conditioning (AC) units and the AC units themselves in four resident rooms. These concerns could negatively impact residents' enjoyment of their environment. A clean living environment is necessary to reduce the spread of infection and promote the highest well-being of the facility's residents. The findings include: A tour of the facility was conducted on 03/18/2025 at 10:30 AM with the following findings: In room [ROOM NUMBER]C, Resident #54's enteral nutrition pump and pole were observed with dried-on enteral food product on them. (Photographic evidence obtained) In room [ROOM NUMBER]A, Resident #83's floor had a large rust stain on the tile floor under the AC. (Photographic evidence obtained) At 10:43 AM, Resident #8 stated her bed did not rise when the remote control was pressed. She was asked to press the button on the remote control and nothing happened. In room [ROOM NUMBER]C, Resident #52's wall around the AC unit was in disrepair. The paint had bubbled up and cracked around the unit. (Photographic evidence obtained) In room [ROOM NUMBER], Resident #30's AC unit had dirt and black biological growth on the vent and a small pile of sand under the AC unit. The unit cover was broken and hanging away from the wall. (Photographic evidence obtained) In room [ROOM NUMBER], Resident #78's AC unit had black biological growth under the AC unit. (Photographic evidence obtained) In rooms 210B and 102A and B, Residents #39, #302, and #59's enteral nutrition pumps and poles were observed with dried-on, encrusted enteral food product on them. (Photographic evidence obtained) A review of Resident #54's 03/20/2025 physician's order revealed: Enteral Feed Order every shift. Isosource 1.5, 45 ml (milliliters)/hour (hr.) x 20 hours. On at 2:00 PM, off at 10:00 AM. (Copy obtained) A review of Resident #39's 03/20/2025 physician's order revealed: Enteral Feed Order every shift. DiabetiSource 1.2 at 45 ml/hr. x 20 hours. On at 2:00 PM, off at 10:00 AM. (Copy obtained) A review of Resident #302's 03/20/2025 physician's order revealed: Enteral Feed Order every shift for nutrition. DiabetiSource 1.2 at 70 ml/hr. continuous. (Copy obtained) A review of Resident #59's 03/20/2025 physician's order revealed: Enteral Feed Order every shift. Isosource 1.5 at 60 ml/hr. x 24 hours. (Copy obtained) During a follow-up tour on 03/20/2025 at 10:33 AM with the Maintenance Director, he stated the staff were trained to enter work orders into the electronic building management system the facility used to track maintenance requests and work orders. The following observations were made: In room [ROOM NUMBER]C, Resident #54's enteral nutrition pump and pole were observed with dried-on enteral nutrition product on them. In room [ROOM NUMBER]A, Resident #83's floor had a large rust stain on the floor under the AC unit. Resident #83 stated when it rained, the ceiling leaked in her room. The maintenance director stated sometimes the drip pan on the AC unit would leak, and the pan was rusty so the water was a brown color that stained the floor. Resident #8's bed did not rise when the remote control was pressed. The maintenance director laid down on the floor, so he could see under the bed. He tried to fix the problem, but then stated he would have to take the bed out of the room to work on it. In room [ROOM NUMBER]C, Resident #52's wall around the AC unit was in disrepair. The paint had bubbled up and cracked around the unit. In room [ROOM NUMBER], Resident #30's AC unit had dirt and black biological growth on the vent and a small pile of sand under the AC unit. The unit cover was broken and hanging away from the wall. The Maintenance Director took the cover and re-attached it to the unit. In room [ROOM NUMBER], Resident #78's AC unit had black biological growth underneath of it. In rooms 210B and 102A and B, Residents #39, #302, and #59's enteral nutrition pumps and poles were observed with dried-on, encrusted enteral food product on them. All of the above identified concerns were confirmed with the Maintenance Director during the follow-up tour. He reviewed the work orders in the electronic building management system on his phone and stated he had not been notified of any of the problems identified. He confirmed that any staff member could enter a work order in the system. During an interview with the Supervisor of Housekeeping on 03/20/2025 at 11:02 AM, she was informed of the above identified concerns for housekeeping. She left the interview to inspect the rooms. She returned to the interview at 12:10 PM and confirmed that the enteral nutrition product had been stuck to the poles and pumps for some time. She stated, It's like glue. I have to scrape it off when it dries on. She confirmed it was the responsibility of the housekeeping department to clean the enteral food product off the poles when it spilled/splattered. During an interview with the Administrator at 03/20/2025 at 11:20 AM, she stated the maintenance of the AC units and the repair of the walls around them should be done. There was a plan for building renovations to begin in May 2025, but the ongoing maintenance should still be done. The staff were to enter the identified problems in the electronic building management system so the Maintenance Director would see that there was a work order that needed to be completed. A review of the facility's policy and procedure titled Preventative Maintenance Program (implemented 2016, revised 01/05/2024) revealed: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance is required. Required preventative maintenance may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years. (Copy obtained) A review of the facility's policy and procedures titled Routine Cleaning and Disinfection (Undated), revealed: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high tough areas to include: IV poles. 13. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. (Copy obtained)

Based on record review and interviews, the facility failed to develop a discharge plan that addressed all of the resident's needs post discharge, by failing to reconcile medication after discharge for one (Resident #1) of three residents reviewed for discharges, from a total sample of 8 residents. The findings include: A review of Resident #1's medical record revealed an admitted [DATE], and the resident was discharged home on 10/24/24. The resident's medical diagnoses included Nonrheumatic mitral valve insufficiency, Fibromyalgia, Chronic Systolic (congestive) Heart Failure, and Major depressive disorder. An admission Minimum Data Set (MDS) assessment, dated 10/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. A review of Resident #1's physician orders dated 10/16/24 revealed the following medications Apixaban (Eliquis) 5 milligrams (mg) two times a day (BID) for cardiac arrhythmia, Furosemide (Lasix) 20 mg every day (QD) for cardiac Arrythmia, Metoprolol 25 mg BID for blood pressure, Sertraline 50 mg QD for depression, Celecoxib 100 mg BID for pain, and Amiodarone 200 mg BID for cardiac Arrythmia. A review of the Resident #1's Interdisciplinary discharge summary note dated 10/24/24 included a statement that read, medications were released to family per state regulations. (Photographic evidence obtained) Per the discharge orders, the resident was to go home without medications and the pharmacy for ordering medications was listed. (Photographic evidence obtained) Medications were not sent home with resident. A signed copy of the last page of the medication list was in the medical record (Photographic evidence obtained). Further record review for Resident #1 found no documentation that a discharge meeting was held with the resident. On 12/19/2024 at 1:32 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She was asked to explain the facility's process for reconciliation of post-discharge medications. She stated that during the discharge process, the nurse will educate the resident/family on discharge medications, use of equipment, and making sure they call their primary physician for follow-up. During this time, the nurse will also answer any questions they may have. The discharge paperwork is printed out by the nurse and given to the resident on the day of discharge. The nurses go over their medications and how to take them, each department will go over their part of the discharge. Nurses will call the resident's pharmacy to order any prescriptions they may need. The physician's discharge orders are reviewed by the nurse, to determine if the resident has orders to go home with medications, prescriptions or just a medication list. The nursing staff also check to see if home health services needs to be set up and they will call the residents' provider of choice if they have one. Finally, the nurse will put a note in the resident electronic record that the discharge has been completed, questions answered, and paperwork is given to the resident. On 12/19/2024 at 2:40 PM, an interview was conducted with the Social Services Director (SSD) regarding the discharge process. She stated that discharge planning starts on admission. She is usually made aware of the possibility of long-term or short-term residents. Upon receiving the projection discharge, the date is put on the discharge calendar, and the interdisciplinary team (IDT) is notified during clinical meeting. The clinical team (Nurses) and provider manage the discharged medications. The residents are told they cannot be discharged with controlled substances. The residents do not get a copy of the discharge order, but they get a copy of the IDT discharge summary. The nurse completes the discharge and has the resident sign the IDT discharge summary. The resident receives a signed copy and then a copy will be uploaded by the nurse into the record. She explained that Medicare residents will have their left-over medication sent back to the pharmacy and medications will be called into their pharmacy of choice. If a person is on Medicaid, usually the resident will go home with left over medications. Social services coordinates contacting providers for services and the residents can ask to use their preferred provider. Should the resident have a question after going home, they can call the social services here for assistance. The SSD stated she did not document in the medical record her conversations with the resident post discharge. On 12/19/2024 at 3:30 PM, an interview was conducted with Director of Nursing (DON). The DON stated that she had been in the position less than a month. When asked about medications and discharges, the DON stated the facility will send narcotics home with residents along with regular medications according to what insurance they currently have. They go by Medicare and Medicaid guidelines. She stated the nurse discharging the resident should explain discharge instructions, go over the medication list, inform the residents of any medical equipment that was ordered, and review any home health needs that were ordered. The nurse should also answer all the residents' or resident representative questions before they leave the building. She confirmed that Resident #1 was not sent home with the medication because of the type of insurance resident had and was not sure how she would verify if the orders were sent to the pharmacy. When asked what the facility protocol was for ensuring that residents who were discharged without the medication received the medication at home. She said she was not sure and would have to follow up. On 12/19/24 at 4:48 PM, a follow up interview was conducted with the DON. She explained that she spoke with Resident #1's physician who told her that no orders were sent to the pharmacy because the resident was not on narcotics. The DON confirmed that there was no process in place for residents that were discharged home without medication. On 12/19/2024 at 5:00 PM, an interview was conducted with the Administrator. She was asked to explain the facility process for discharge medications. She stated that they are identified in the discharge paperwork. She explained that if the resident or family member asked them, they would contact the residents' physician on discharge for him to call in the needed prescriptions for the residents. She acknowledged that they do not document their attempts to contact the physician, and do not have a means to ensure the prescriptions were called in for the resident. The facility policy titled Transfer and Discharge Requirements revised 3/2/19. The Policy indicated that the facility would ensure residents are treated equally regarding transfer, discharge and the provision of services, regardless of their payment source in accordance to state and federal regulations. The policy indicated that 3. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident; b. Resident representative information including contact information; c. Advance Directive information; d. All special instructions or precautions for ongoing care, as appropriate; e. Comprehensive care plan goals; f. All other necessary information, including a copy of the resident's discharge summer and any other documentation, as applicable, to ensure a safe and effective transition of care. (Photographic evidence obtained) 50369

Based on observations, interviews, and record review, the facility failed to ensure three (Resident #6, #7, and #8) of eight sampled residents had access to the call light while in bed. The findings include: 1. On 2/22/24 at 12:45 PM, Resident #6 was observed in bed with head of bed elevated, resident did not speak but nodded his head after greeting the resident. The call light was clipped to itself on the wall. (Photographic evidence obtained). When asked if he could get to his call light, the resident shook his head in a no response. A review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses that included gastrostomy status, aphasia following cerebral infarction, hemiplegia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. A review of the resident's most recent minimum data set (MDS) assessment dated [DATE] revealed, severe hearing impairment with a cochlear implant, impaired vision but can see large print, is rarely understood but understands simple commands and responds appropriately, not comatose; unable to assess Brief Interview for Mental Status (BIMS) due to verbal difficulties. On 2/23/24 at 9:45 AM, Resident #6 was observed lying in bed, eyes open. His call light was observed clipped to itself on the wall behind his bed, out of his reach. When asked if he could reach his call light if he needed to call for help. He did not answer verbally, he was observed to shake his head in a no response. 2. On 2/22/24 at 12:42 PM, Resident #7 was observed in bed, eyes closed; lips were dry and crusted, call light button was lying on the floor, clipped to the top sheet (Photographic evidence obtained). The resident did not respond to verbal stimuli. A review of the medical record for Resident #7 revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dysphagia, oropharyngeal phase, and aphasia. A review of the most recent MDS assessment dated [DATE], revealed unclear/garbled speech, usually understands and is sometimes understood, not comatose, unable to conduct BIMS due to garbled speech. On 2/22/24 at 3:45 PM, an interview was attempted with Resident #7 in his room. After greeting the resident, he attempted to speak. His speech was garbled, but he was able to indicate that he was not able to reach/find his call light. The call light remained on the floor. (Photographic evidence obtained). 3. On 2/22/24 at 10:50 AM, an interview was conducted with Certified Nursing Assistant (CNA) A regarding call lights. She explained that CNAs are to supposed to make sure the residents have their call lights within reach every time they go into the room. On 2/22/24 at 12:35 PM, Resident #8 was observed in her bed. The call light was draped over the night stand not within reach (Photographic evidence obtained) When the resident was asked where her call light was, she pointed to night stand and stated, They always forget to give it back to me. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a brief interview for mental status (BIMS) score 15 of 15, indicating cognitively intact. On 2/22/24 at 1:45 PM, a joint interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) regarding call lights. During the interview, they stated that all staff should make sure the resident has access to their call light. On 2/22/24 at 2:40 PM, during an interview with Licensed Practical Nurse (LPN) B, she stated that it was everyone's responsibility to make sure call lights were within the residents' reach. On 2/22/24 at 3:00 PM, during an interview with CNA B, she stated that anytime a staff member goes into the residents room, they are supposed to check to see that the call light is withing the residents reach. On 2/22/24 at 3:27 PM, CNA C was asked who is responsible to make sure call lights are within reach, she replied All of us. On 2/22/24 at 4:30 PM, an interview was conducted with the administrator regarding the call light Performance Improvement Project (PIP) initiated in January 2024. The administrator was asked to provide a copy of plan, he replied, he would need to look for it. The PIP was received on 2/22/24 at 10:56 PM. After reviewing the document, the plan did not include a plan for education/in-service to staff or how deficiencies would be addressed. A review of facility Performance Improvement Project: Call lights: Initiated on 1/15/24 revealed: Objective and Goal: Staff responsiveness to patient -initiated call lights is highly important 2. Call light audits will be reviewed for and within the residents reach for safety (Ongoing)

Based on observations and interview, the facility failed to ensure current and accurate nurse staffing information was posted (facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift) on a daily basis at the beginning of each shift. The findings include: On 2/22/24 at 9:00 AM, the posted nurse staffing information was observed displayed on a table across from the reception desk. The staffing information was dated 2/21/24 with a census of 99. (Photographic evidence obtained) On 2/22/24 at 10:05 AM, a second observation of the posted staffing information (in the same area) located across from the reception desk was dated 2/21/24 with a census of 99. On 2/23/24 at 9:15 AM, the posted staffing information was observed displayed on the reception desk. The staffing information was dated 2/22/24 with a census of 94. (Photographic evidence obtained) On 2/23/24 at 9:54 AM, the posted staffing information was observed to have been moved from the reception desk to the table across from desk. The form was dated 2/22/24 with a census of 94. On 2/23/24 at 10:40 AM, the posted staffing information observed for a second time on table across from reception desk. The form was observed dated 2/22/24 with a census of 94. On 2/23/24 at 11:00 AM, an interview was conducted with the Administrator. When asked what the current census was for the day, he stated, 96. When asked who updates the daily posted staffing, he stated, The staffing coordinator does. When asked when the daily staffing should be posted/updated. He stated early morning, Before our morning meeting, which is held at 9:00 AM. It should be updated around 7:45-8:00 AM, then we can discuss it during morning meeting and make any updates if necessary.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure enteral tube syringes were replaced daily for four (Residents #4, #8, #6, and #7) of five residents receiving enteral tube feedings (TF) and failed to ensure the enteral feeding bag for one (Resident #7) resident receiving enteral TF was dated/timed to reflect contents were less than or up to 24 hours old for residents, from a total sample of 8 residents. This could result in the residents not receiving appropriate care and/or clinical complications. The findings include: 1. On 2/22/24 at 10:25 AM, Resident #4 was observed supine in bed, with head of bed (HOB) elevated between 30 and 45 degrees. Her TF syringe was on an overbed table, not dated. (Photographic evidence obtained) A review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses that included anoxic brain damage, diabetes type 2, tracheostomy, and gastrostomy. Resident's enteral feed order dated 2/1/24, revealed every shift Diabetisource 1.2 @ 65 ml/hr. x20 hrs. on at 1400, off at 1000. A review of the most recent minimum data set (MDS) assessment, dated 2/6/24, revealed the resident was comatose and totally dependent for all care. Physician's order dated 1/1/24 revealed change enteral syringe every 24 hours and as needed. (Copy obtained) During an interview with Licensed Practical Nurse (LPN) A on 2/22/24 at 11:05 AM, she was asked who was responsible for changing TF supplies. She replied, the 11-7 shift was responsible to change out the TF bags/solution and syringe, and they are supposed to be dated. 2. On 2/22/24 at 12:35 PM, Resident #8 was observed in bed with eyes closed. Her TF was dated 2/22/24. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. Resident's enteral feed order dated 12/18/23, revealed every shift recommend Diabetisource 1.2 @ 100 ml/hr. x20 hrs., on at 12 pm, off at 8 am flush 50 ml/hr. every 4 hr. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a brief interview for mental status (BIMS) score of 15 out of 15, indicating cognitively intact. Physician's order dated 2/3/24 revealed change enteral syringe every night shift. (Copy obtained) 3. On 2/22/24 at 12:45 PM, Resident #6 was observed in bed with HOB elevated. His TF syringe was on an overbed table, not dated. (Photographic evidence obtained). A review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses that included gastrostomy status, aphasia following cerebral infarction, hemiplegia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. Resident's enteral feed order dated 9/11/23, revealed every shift Diabetisource 1.2 at 45ml/hr. x 20 hrs., on at 2 pm, off at 10 am. Resident's review of the most recent MDS assessment, dated 1/9/24, revealed the resident had severe hearing impairment but has a cochlear implant, impaired vision but can see large print, is rarely understood but understands simple commands and responds appropriately, not comatose; unable to assess BIMS due to verbal difficulties. Physician's order dated 2/10/24, revealed change enteral syringe every night shift. (Copy obtained) 4. On 2/22/24 at 12:50 PM, Resident #7 was observed in bed, eyes closed; lips were dry and crusted, TF pump was off, Isosource bag was dated 2/21/24 (photo), resident did not respond to verbal stimuli. His TF syringe was on an overbed table, not dated. (Photographic evidence obtained). A review of the medical record for Resident #7 revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dysphagia, oropharyngeal phase, and aphasia. Resident's enteral feed order dated 5/9/23, revealed every shift Isosource 1.5 at 65 ml/hr. x 20 hrs. off 1000, on 1400. A review of the most recent MDS assessment dated [DATE], unclear/garbled speech, usually understands and is sometimes understood, not comatose, unable to conduct BIMS due to garbled speech. Physician's order dated 2/9/24, revealed change enteral syringe every night shift. (Copy obtained) On 2/22/24 at 3:56 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC revealed that the tube feeding was a closed system. The bags are prefilled and are usually changed out on the night shift. When asked why the TF would be dated with yesterday's date, she replied, most likely because the 24 hours wasn't up. When asked how anyone would know if the bags did not have a time hung on them. She stated, the bags can actually be hung for 36 hours and would be changed out by then. When asked how they could be sure, the RNC did not respond. A review of the facility's policies and procedures titled: Quality of Care (revised 3/2/19), revealed the following: Page 3-4, Item 10. Tube feeding Management/Restore Eating Skills. The facility will ensure that a resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including by not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (Copy obtained)

Based on observations, interviews, and medical record review, the facility failed to ensure tracheostomy/respiratory care was provided to two (Residents #4 and #8) of two resident reviewed for respiratory care, by failing to follow physician orders for tracheostomy care, suction and/or oxygen tubing. This could result in the residents not receiving appropriate care and/or clinical complications. The findings include: 1. A review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses that included anoxic brain damage, diabetes type 2, tracheostomy, and gastrostomy. A review of the most recent minimum data set (MDS) assessment, dated 2/6/24, revealed the resident was comatose and totally dependent for all care and unable to assess Brief Interview for Mental Status (BIMS). On 2/22/24 at 10:25 AM, Resident #4 was observed supine in bed (lying on her back), with head of bed elevated between 30 and 45 degrees. A tracheostomy collar was in place with oxygen (O2) flow set at 12 liter per minute (LPM). The tracheostomy collar was humidified and corrugated tubing with drain bag attached to the bed frame higher than the tubing causing excess water to pool in tubing rather than drain bag (and was not dated). The suction setup located on bedside table revealed the tubing was open to air, was not bagged and was dated 2/7/24. The sterile water bottle on overbed table at foot of bed was open to air and was not dated. One time use cardboard with plastic liner suction container was observed on overbed table with clear fluid. (Photographic evidence obtained) Review of Resident #4's physician's orders revealed the following: 1/1/24-Trach-resident has 8.5 trach; obtain O2 sats every shift, notify Medical Doctor of (oxygen) saturations <90%; humidified oxygen 28%/ 5 liters per minute via trach collar; may suction every 2 hours as needed. 1/6/24-Change corrugated tubing and trach mask weekly every Saturday night shift. 1/6/24-Change humidity bottle weekly every Saturday night shift. 1/1/24-Change internal cannula daily. 1/1/24-Change nebulizer set-up weekly every Saturday night shift. 1/6/24-Change O2 tubing connecting to O2 concentrator every Saturday night shift. 1/6/24-Change suction cannister and tubing weekly every Saturday night shift. 1/6/24-Change yanker suction weekly every Saturday night shift. On 2/22/24 at 11:05 AM, an interview was conducted with Licensed Practical Nurse (LPN A). She stated that trach collars are changed weekly, and inner cannula are changed daily. She explained that she performed this task when she first comes on duty. The bedside suction machine with tubing is changed weekly at night but cannister is only changed when full. The suction kits are for one-time use only and the sterile water is to be dated after being opened. The trach collar is to be at 28% or 8 LPM; is humidified with tubing changed weekly with tubing to be at lowest point of gravity. 2. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a BIMS score 15 of 15, indicating cognitively intact. On 2/22/24 at 12:35 PM, Resident #8 was observed in bed, eyes closed, roused to verbal stimuli; nasal cannula in place; O2 tubing not dated, O2 set at 2.5 LPM. (Photographic evidence obtained) Review of Resident #8's physician's orders revealed the following: 12/9/23-Change oxygen set up and bag weekly, every Sunday night shift, place in labeled O2 bag and tie to handle of O2 concentrator. 1/25/24-Oxygen continuous at 2 LPM via nasal cannula. On 2/22/24 at 1:45 PM, a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). They explained the O2 tubing is changed weekly by nurses on the night shift and is to be dated. Nurses are responsible to check liter flow every shift and certified nursing assistants (CNA) are not allowed to adjust liter flow. A review of the facility's policies and procedures titled: Quality of Care (revised 3/2/19), revealed the following: Page 4, Item 12. Respiratory/Tracheostomy Care and Suctioning, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provide such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. (Copy obtained) .

Based on interviews, medical record review, and facility policy and procedure review, the facility failed to ensure residents were free from any significant medication errors, by failing to administer medications within the specified timeframe based on physician's scheduling orders for ten (Residents #1, #3, #4, #5, #9, #10, #11, #12, #13, and #14) of fourteen sampled residents, from a total census of 101. Failure to administer medications in a timely manner can result in a resident's inability to maintain the proper level of medication in the bloodstream to be effective; reduced functional ability; lower quality of life; hospitalization , disease progression, and/or death. The findings include: On 1/9/24 at 9:30 AM, the administrator was requested to provide a copy of current Quality Assurance and Performance Improve (QAPI)/Performance Improvement Project (PIP) being conducted at the facility. On 1/9/24 at 11:01 AM, the administrator was again requested to provide just a list of the current PIPs. On 1/9/24 at 11:20 AM, the administrator provided a list of the QAPI/PIPs that were either initiated or in the process since October 2023. The list did not contain any PIPs to address medication administration. (Copy obtained) On 1/9/24 at 12:25 PM, an interview was conducted with Director of Nursing (DON). The DON stated that an ad hoc PIP had been initiated in December for medication administration. When she was asked why it was not on the list, she said, because it was an ad hoc PIP and had not gone to QAPI in December. 1. A review of Resident #1's medical record revealed an admitted [DATE] and discharge date of [DATE] with diagnoses that included hemiplegia/hemiparesis following CVA affecting left non-dominant side, facial weakness, muscle weakness, difficulty walking with lack of coordination, dysphagia and gastrostomy. On 1/10/24 at 9:00 AM, the Director of Nursing (DON) was requested to provide Resident #1's Medication Administration Audit (MAA) report for the period 11/1/23 through 11/30/23. The 79-page report was received at 9:25 AM. (Copy obtained) A review of Resident #1's MAA Report from 11/1/23 through 11/26/23, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 21 of 30 days as follows: On 11/1/23, the medication Gabapentin (pain) was scheduled for 8 AM, it was administered at 9:34 AM. On 11/4/23, Gabapentin was scheduled for 8 AM, it was administered at 10:31 AM. The following medications were scheduled for 9 AM, they were administered between 10:32 and 10:36 AM: Escitalopram Oxalate (depression), Carbidopa-Levodopa (Parkinsons), Cholecalciferol (deficiency), Ascorbic Acid Tablet (deficiency), Lorazepam (anxiety), Lisinopril (hypertension), Rivaroxaban (Cerebrovascular Accident -CVA), and Famotidine (Gastroesophageal reflux disease-GERD). On 11/5/23, Gabapentin was scheduled for 8 AM, it was administered at 11:34 AM. The following medications were scheduled for 9 AM, they were administered between 11:34 and 11:37 AM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid Tablet, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. On 11/6/23, Gabapentin was scheduled for 8 AM, it was administered at 9:59 AM. On 11/8/23, Gabapentin was scheduled for 8 AM, it was administered at 9:14 AM. On 11/9/23, Gabapentin was scheduled for 8 AM, it was administered at 9:32 AM and was scheduled for 20:00 PM, it was administered at 22:34 PM. Famotidine was scheduled for 21:00 PM, it was administered at 22:36 PM. On 11/10/23, Gabapentin was scheduled for 8 AM, it was administered at 14:04 PM; it was scheduled again for 20:00 PM and was administered at 21:40 PM. The following medications were scheduled for 9 AM, they were administered at 14:04 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 18:00 PM, it was administered at 21:40 PM. On 11/11/23, Gabapentin was scheduled for 8 AM, it was administered at 9:38 AM. On 11/12/23, Gabapentin was scheduled for 8 AM, it was administered at 9:33 AM. On 11/13/23, Gabapentin was scheduled for 8 AM, it was administered at 16:32 PM. The following medications were scheduled for 9 AM, they were administered between 16:32 and 16:41 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril Rivaroxaban, and Famotidine. On 11/14/23, Gabapentin was scheduled for 8 AM, it was administered at 9:34 AM. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:51 PM. On 11/16/23, Gabapentin was scheduled for 8 AM, it was administered at 9:37 AM. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:54 PM. On 11/17/23, Gabapentin was scheduled for 8 AM, it was administered at 9:01 AM; it was scheduled again at 20:00 PM and was administered at 22:24 PM. The following medications were scheduled for 21:00 PM, they were administered at 22:24 PM: Mirtazapine, Lorazepam, and Famotidine. On 11/18/23, Gabapentin was scheduled for 8 AM, it was administered at 13:25 PM. The following medications were scheduled for 9 AM, they were administered between 13:25 and 13:45 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:44 PM On 11/19/23, Gabapentin was scheduled for 8 AM, it was administered at 12:32 PM. The following medications were scheduled for 9 AM, they were administered at 12:32 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:50 PM On 11/20/23, Gabapentin was scheduled for 8 AM, it was administered at 9:25 AM. On 11/21/23, Gabapentin was scheduled for 8 AM, it was administered at 10:58 AM. The following medications were scheduled for 9 AM, they were administered between 10:58 and 11:09 AM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:09 PM On 11/22/23, Gabapentin was scheduled for 8 AM, it was administered at 10:16 AM. The following medications were scheduled for 9 AM, they were administered between 10:19 and 10:27 AM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. On 11/23/23, Gabapentin was scheduled for 8 AM, it was administered at 9:28 AM; it was scheduled again at 20:00 PM and was administered at 21:11 PM. On 11/24/23, Gabapentin was scheduled for 8 AM, it was administered at 9:12 AM. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 19:18 PM On 11/26/23, Gabapentin was scheduled for 8 AM, it was administered at 9:04 AM. (Copy obtained) 2. A review of Resident #3's medical record revealed an admitted [DATE] and discharge date of ,d+[DATE]//23 with diagnoses that included hepatic encephalopathy, depression, anxiety, persistent mood disorder. On 1/10/24, the DON was requested to provide Resident #3's MAA Report for the period 11/1/23 through 11/30/23. The 48-page report was received at 9:31 AM. (Copy obtained) A review of Resident #3's MAA Report from 11/2/23 through 11/17/23, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 14 of 16 days as follows: On 11/2/23, the following medications were scheduled for 21:00 PM, they were administered between 22:25 PM and 22:26 PM: Propranolol HCI (htn), Magnesium Oxide (deficiency), Pantoprazole Sodium (Gerd) and Rifaximin (liver cirrhosis). On 11/3/23, Lactulose (hepatic encephalopathy) was scheduled for 12:00 PM, it was administered at 13:43 PM. On 11/4/23, the following medications were scheduled for 9 AM, they were administered between 10:41 and 10:43 AM: Furosemide (chronic obstructive pulmonary disease-COPD), Clonazepam (anxiety), Rifaximin, Propranolol HCI, and Pantoprazole Sodium. On 11/5/23, Lactulose was scheduled for 8:00 AM, it was administered at 11:30 AM. The following medications were scheduled for 9 AM, they were administered at 11:32 AM: Furosemide, Rifaximin, Propranolol HCI, and Pantoprazole Sodium. On 11/6/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:51 AM. The medication was scheduled again for 12:00 PM, it was administered at 14:59 PM. On 11/8/23, Lactulose was scheduled for 12:00 PM, it was administered at 13:42 PM. On 11/9/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:21 AM. Prednisone (Thrombocytopenia) was scheduled for 8:00 AM, it was administered on 9:19 AM. Rifaximin was scheduled for 21:00 PM, it was administered at 22:31 PM. On 11/10/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:49 AM. The medication was scheduled again for 12:00 PM, it was administered at 14:03 PM. Prednisone was scheduled for 8:00 AM, it was administered on 9:48 AM. The following medications were scheduled for 21:00 PM, they were administered at 22:34 PM: Propranolol HCI, Magnesium Oxide, and Pantoprazole Sodium. On 11/11/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:13 AM. Prednisone was scheduled for 8:00 AM, it was administered on 9:10 AM. On 11/12/23, Lactulose was scheduled for 12:00 PM, it was administered at 13:17 PM. On 11/13/23, Prednisone was scheduled for 8:00 AM, it was administered on 10:30 AM. Rifaximin was scheduled for 9:00 AM, it was administered on 16:26 PM. Lactulose was scheduled for 12:00 PM, it was administered at 16:27 PM. On 11/14/23, Rifaximin was scheduled for 9:00 AM, it was administered on 13:14 PM. Lactulose was scheduled for 12:00 PM, it was administered at 13:14 PM On 11/15/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:02 AM. Prednisone was scheduled for 8:00 AM, it was administered on 9:05 AM. On 11/17/23, Furosemide was scheduled for 9:00 AM, it was administered at 14:08 PM. Lactulose was scheduled for 17:00 PM, it was administered at 23:59 PM. (Copy obtained) 3. A review of Resident #4's medical record revealed an admitted [DATE] with diagnoses that included intracerebral Hemorrhage, cirrhosis of liver, weakness, difficulty walking, muscle wasting, cognitive communication deficit, Anemia, alcohol dependence, falls, ascites, nicotine dependence, unspecified dementia, hypotension, hypokalemia On 1/10/24, the DON was requested to provide Resident #4's MAA Report for the period 12/1/23 through 12/31/23. The 65-page report was received at 9:26 AM. (Copy obtained) A review of Resident #4's MAA Report from 12/1/23 through 12/31/23, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 9 of 31 days as follows: On 12/2/23, the following medications were scheduled for 21:00 PM, they were administered between 22:29 PM and 22:30 PM: Levetiracetam (seizures) and Memantine HCI (dementia). On 12/8/23, Melatonin was scheduled for 22:00 PM, it was administered at 23:06 PM On 12/11/23, the following medications were scheduled for 9:00 AM, they were administered between 13:31 PM and 13:32 PM: Furosemide, Metoprolol Succinate (htn), Levetiracetam (seizures), Thiamine HCI (supplement), Spironolactone (diuretic), Folic Acid (supplement), Memantine HCI (dementia), and Ferrous Sulfate (supplementation). On 12/14/23, the following medications were scheduled for 9:00 AM, they were administered between 13:54 PM and 13:59 PM: Furosemide, Levetiracetam, Metoprolol Succinate, Thiamine HCI, Spironolactone, Folic Acid, Memantine HCI, Ferrous Sulfate, and Andro Gel Transdermal (testosterone). On 12/16/23, the following medications were scheduled for 21:00 PM, they were administered at 22:05 PM: Levetiracetam and Memantine HCI. On 12/18/23, the following medications were scheduled for 21:00 PM, they were administered at 22:49 PM: Levetiracetam and Memantine HCI. On 12/21/23, Memantine HCI was scheduled for 9:00 AM, it was administered at 10:29 AM. On 12/26/23, the following medications were scheduled for 9:00 AM, they were administered between 11:43 AM and 11:49 AM: Furosemide, Levetiracetam, Metoprolol Succinate, Thiamine HCI, Spironolactone, Folic Acid, Memantine HCI, Ferrous Sulfate, and AndroGel Transdermal. On 12/29/23, the following medications were scheduled for 9:00 AM, they were administered between 10:36 AM and 13:12 PM: Furosemide, Levetiracetam, Metoprolol Succinate, Thiamine HCI, Spironolactone, Folic Acid, Memantine HCI, Ferrous Sulfate), and Andro Gel Transdermal. (Copy obtained) 4. On 1/10/24, the DON was requested to provide Resident #5's MAA Report for the period 12/14/23. The 12-page report was received at 9:31 AM. (Copy obtained) A review of Resident #5's MAA Report on 12/14/23, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) as follows: On 12/14/23, Metformin HCI (diabetes) was scheduled for 8:00 AM, it was administered at 10:25 AM. The following medications were scheduled for 9:00 AM, they were administered between 10:29 AM and 10:40 AM: Scopolamine Base Patch (tracheal secretions), Potassium Chloride Liquid (hypokalemia), Carvedilol (htn), Sacubitril-Valsartan (htn), and Insulin Glargine Subcutaneous Solution (type 2 diabetes mellitus). Humalog Injection Solution (diabetes) was scheduled for 11:30 AM, it was administered at 12:54 PM. (Copy obtained) 5. On 1/10/24, the DON was requested to provide Resident #9's MAA Report for the period 1/1/24 through 1/7/24. The 28-page report was received at 11:51 AM. (Copy obtained) A review of Resident #9's MAA Report from 1/1/24 thru 1/7/24, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 3 of 7 days as follows: On 1/1/24, Gabapentin was scheduled for 17:00 PM, it was administered at 22:08 PM. Melatonin was scheduled for 20:00 PM, it was administered 22:08 PM. Clonazepam, Sennosides-Docusate Sodium (constipation), and Hydralazine HCI (hypertension) were scheduled for 21:00 PM, they were administered at 22:08 PM. On 1/2/24, Melatonin was scheduled for 20:00 PM, it was administered at 23:22 PM. Clonazepam, Sennosides-Docusate Sodium, and Hydralazine HCI were scheduled for 21:00 PM, they were administered at 23:22 PM. On 1/5/24, Cyanocobalamin (VitB 12) was scheduled for 10 AM, it was administered at 11:24 AM. (Copy obtained) 6. On 1/10/24, the DON was requested to provide Resident #10's MAA Report for the period 1/1/24 through 1/7/24. The 40-page report was received at 11:49 AM. (Copy obtained) A review of Resident #10's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 6 of 7 days as follows: On 1/1/24, Gabapentin was scheduled for 16:00 PM, it was administered at 17:17 PM. Apixaban was scheduled for 21:00 PM, it was administered at 22:35 PM. On 1/2/24, Gabapentin was scheduled for 16:00 PM, it was administered at 17:17 PM. On 1/3/24, Gabapentin was scheduled for 8:00 AM, it was administered at 9:36 AM. Invega Sustenna Intramuscular Suspension (Schizoaffective disorder) was scheduled for 9:00 AM, it was administered at 11:44 AM. The following medications were scheduled for 17:00 PM, they were administered at 22:18 PM: Lamotrigine (mood), Calorically Dense Oral Supplement, and Mirtazapine. On 1/4/24, Gabapentin was scheduled for 16:00 PM, it was administered at 17:28 PM On 1/5/24, Gabapentin was scheduled for 8:00 AM, it was administered at 11:40 AM and scheduled again for 16:00 PM, it was administered at 17:36 PM. The following medications were scheduled for 9:00 AM, they were administered between 11:39 AM and 11:40 AM: Magnesium Oxide (deficiency), Apixaban, Topiramate (brain injury), Ferrous Sulfate, Mirtazapine, Bupropion HCI ER (depression). On 1/7/24, Gabapentin was scheduled for 8:00 AM, it was administered at 9:13 AM, and was scheduled again at 12:00 PM, it was administered at 13:07 PM. (Copy obtained) 7. On 1/10/24, the DON was requested to provide Resident #11's MAA Report for the period 1/1/24 through 1/7/24. The 29-page report was received at 11:50 AM. (Copy obtained) A review of Resident #11's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/2/24, the following medications were scheduled for 8:00 AM, they were administered at 9:04 AM: Phenytoin Sodium Extended (seizure disorder), Famotidine (indigestion), and Memantine HCI (anxiety). On 1/3/24, the following medications were scheduled for 20:00 PM, they were administered at 22:22 PM: Phenytoin Sodium Extended, Ropinirole Hydrochloride (multiple sclerosis), Famotidine, and Levetiracetam (epilepsy). On 1/4/24, the following medications were scheduled for 8:00 AM, they were administered between 9:17 AM and 9:19 AM: Phenytoin Sodium Extended, Levetiracetam Famotidine, and Memantine HCI. On 1/5/24, the following medications were scheduled for 8:00 AM, they were administered at 11:04 AM: Phenytoin Sodium Extended, Levetiracetam, Famotidine, and Memantine HCI. Escitalopram Oxalate scheduled for 9:00 AM, it was administered at 11:04 AM. On 1/7/24, the following medications were scheduled for 8:00 AM, they were administered at 10:23 AM: Phenytoin Sodium Extended, Levetiracetam, Famotidine, and Memantine HCI. Escitalopram Oxalate scheduled for 9:00 AM, it was administered at 10:23 AM. (Copy obtained) 8. On 1/10/24, the DON was requested to provide Resident #12's MAA Report for the period 1/1/24 through 1/7/24. The 33-page report was received at 11:56 AM. (Copy obtained) A review of Resident #12's MAA Report from 1/1/24 thru 1/7/24, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/1/24, Fluoxetine HCI (depression) was scheduled for 9:00 AM, it was administered at 10:52 AM. The following medications were scheduled for 21:00 PM, they were administered at 22:04 PM: Arginine (supplement), Apixaban (blood thinner), Sennosides-Docusate Sodium (constipation), Ferrous Sulfate (supplementation), and Trazodone HCI (depression). On 1/2/24, Acetaminiphen-Codeine (pain) was scheduled for 0:00 AM, it was administered at 3:25 AM On 1/5/24, the following medications were scheduled for 9:00 AM, they were administered at 15:02 PM: Ferrous Sulfate, Apixaban, Fluoxetine HCI, ProHeal (nutritional supplement), and Acetaminiphen-Codeine. ProHeal was scheduled again at 13:00 PM, it was administered at 15:02 PM. On 1/6/24, ProHeal was scheduled for 17:00 PM, it was administered at 18:22 PM. Ascorbic Acid was scheduled at 20:00 PM, it was administered at 21:29 PM. On 1/7/24, Acetaminiphen-Codeine was scheduled at 0:00 AM, it was administered at 2:04 AM. (Copy obtained) 9. On 1/10/24, the DON was requested to provide Resident #13's MAA Report for the period 1/1/24 through 1/7/24. The 31-page report was received at 11:57 AM. (Copy obtained) A review of Resident #13's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/1/24, Percocet (pain) was scheduled for 8:00 AM, it was administered at 9:03 AM. On 1/2/24, Percocet was scheduled for 0:00 AM, it was administered at 1:07 AM On 1/3/24, Percocet was scheduled for 8:00 AM, it was administered at 9:33 AM. Hydralazine HCI was scheduled for 8 AM, it was administered at 9:26 AM. Rosuvastatin Calcium (hyperlipidemia) was scheduled at 17:00 PM, it was administered at 19:05 PM. On 1/4/24, Percocet was scheduled for 8:00 AM, it was administered at 9:05 AM. Percocet was scheduled for 12:00 PM, it was administered at 13:26 PM. Percocet was scheduled for 16:00 PM, it was administered at 17:36 PM. Hydralazine HCI was scheduled for 8 AM, it was administered at 9:06 AM. Hydralazine HCI was scheduled for 12 PM, it was administered at 13:25 PM. Hydralazine HCI was scheduled for 16:00 PM, it was administered at 17:35 PM. On 1/5/24, Percocet was scheduled for 20:00 PM, it was administered at 21:19 PM. (Copy obtained) 10. On 1/10/24, the DON was requested to provide Resident #14's MAA Report for the period 1/1/24 through 1/7/24. The 41-page report was received at 11:57 AM. (Copy obtained) A review of Resident #14's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/2/24, Sucralfate was scheduled for 16:30 PM, it was administered at 17:53 PM. On 1/3/24, Linaclotide (constipation) and Amlodipine Besylate (htn) were scheduled for 8:00 AM, they were administered at 12:15 PM. The following medications were scheduled for 9:00 AM, they were administered between 12:15 PM and 12:21 PM: Calorically Dense Supplement, Sennosides-Docusate Sodium, and Apixaban. Sucralfate was scheduled for 16:30 PM, it was administered at 17:37 PM. On 1/4/24, Linaclotide and Amlodipine Besylate were scheduled for 8:00 AM, they were administered at 9:11 AM. Sucralfate was scheduled for 11:30 AM, it was administered at 15:24 PM. Calorically Dense Supplement was scheduled for 13:00 PM, it was administered at 15:23 PM. On 1/6/24, Linaclotide and Amlodipine Besylate were scheduled for 8:00 AM, they were administered at 9:17 AM. Mirtazapine and Melatonin were scheduled for 22:00 PM, they were administered at 1:26 AM. Apixaban was scheduled for 21:00 PM, it was administered at 23:39 PM. On 1/7/24, Linaclotide was scheduled for 8:00 AM, it was administered at 9:18 AM. (Copy obtained) On 1/10/24 at 9:30 AM, the Medication Administration Audits for Residents #1, #3, #4, #5, #9, #10, #11, #12, #13, and #14 were reviewed with the DON. The audits revealed repeated medication administration errors (timeliness of administration) for Residents #1, #3, #4, #5, #9, #10, #11, #12, #13, and #14. On 1/10/24 at 12:40 PM, an interview was conducted with Licensed Practical Nurse D, regarding medication administration. She stated that nurses are to document medication administration at the time of administration. She explained that the facility protocol states medication administration can be given one hour before to one hour after the scheduled time and if administration is late to call the physician and document in Electronic Medical Records (EMR). On 1/10/24 at 12:50 PM, an interview was conducted with LPN I, regarding medication administration. She explained that nurses can give medication one hour before or one hour after the scheduled time and if given late they call the physician and family and document it in EMR. She stated that medication administration documentation is to be done at time of administration. A review of the facility's policy titled, 6.0 General Dose Preparation and Medication Administration (1/2022) revealed the following: Page 2, item 5.4 Administer medications within time frames specified by Facility policy or manufacturer's information. (Photographic evidence obtained)

Based on observations, interviews, and record review, the facility failed to accurately inform resident representatives, and families of those residing in the facility of the current COVID-19 status for 4 of 5 sampled residents (Residents #1, #2, #4 and #5) out of a total of 103 residents in the facility. On 6/23/23, the facility communicated to resident representatives/family members there were no staff or residents positive for COVID-19 at the facility, when in fact there were residents in the facility who were COVID-19 positive. The findings include: During an entrance conference with the Administrator and the Infection Preventionist (IP) on 6/26/23 at 9:05 am, the IP reported there was an active COVID-19 outbreak in the building. Positive residents were cohorting on the south wing. Six residents were coming off isolation today and there were a total of 15 positive residents at this time. A line listing was requested for all positive residents identified during the outbreak. Census at the time was 103 residents. Review of the COVID-19 resident line list revealed on 6/6/23, the first 6 resident tested positive for COVID-19. Between 6/8/23 and 6/23/23 an additional 28 residents tested positive for COVID-19; fifteen of those residents within the past 10 days. A tour of the facility was conducted on 6/26/23 at 9:35 am. The south wing was toured first and revealed multiple resident rooms with signage and personal protective equipment (PPE) for droplet and contact isolation. Housekeeping was in one room wiping down the room and the doorknob. She had full PPE on. A second staff was observed outside another room donning full PPE prior to entering. Licensed Practical Nurse (LPN) A was interviewed at 9:45 am. She said, The COVID positive residents are mostly on this one side of the unit, but there are residents everywhere and that is why the COVID keeps spreading. Certified Nursing Assistant (CNA) A was interviewed on 6/26/23 at 10:05 am. She said the COVID-19 outbreak started about 3 weeks ago and quite a few staff had also tested positive. An interview was conducted with Resident #1 on 6/26/23 at 10:15 am. She and Resident #3 were outside smoking on the south end of the front patio. There were multiple residents also smoking on the north side of the patio, approximately 50 to 60 feet away. Resident #1 introduced herself and said everyone caught COVID because one resident who was admitted with COVID wouldn't stay in her room. Resident #1 tested positive herself last Sunday. She is allowed to come to this side of the patio to smoke but must wear a mask in the halls. Resident #1 stated she comes off isolation tomorrow. She concluded by stating the facility called her brother to report the COVID status of the building and told him there were no positive cases, and he could visit. But they still have positive cases in the building! Resident #3 was interviewed on 6/26/23 at 10:30 am and reported she had tested positive for COVID-19 but felt fine. She is allowed to come outside and smoke away from the general population as long as she wears a masks in the halls. She showed me her N95 mask on which she had drawn a smiley face. Before she got sick. she had been wearing a mask and staying away from people, but still caught it and tested positive Sunday. A review of Resident #1's electronic medical record (EMR) found she was admitted to the facility on [DATE] and had diagnoses including COVID-19 (diagnosed [DATE]). A review of her Admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had a brief interview for mental status score of 15, indicating she was cognitively intact. Resident #1 had a physician's orders dated 6/18/23 for contact and droplet precautions for COVID-19 for 10 days, ending 6/28/23. Resident #1's electronic Cliniconex Message Board transcripts (a blast messaging program that notifies the next of kin or resident representative of the COVID-19 facility status upon activation by a user) were reviewed. The text message and phone calls dated 6/23/23 to Resident #1's emergency contact announced: We are calling to inform you that there are no staff or residents positive for COVID-19 at the facility. Our center is following the recommendations of the CDC (Centers for Disease Control) on prevention steps. Visitation is still open at this time. The notifications were sent by the Administrator. (Photographic evidence obtained) Resident #3's EMR was reviewed and revealed she was admitted on [DATE] and readmitted [DATE]. She had diagnoses including COVID-19 (diagnosed [DATE]). Her Cliniconex Message Board transcripts revealed the last message was sent to her emergency contact on 6/16/23 and reported 1 or more individuals in the building were positive for COVID-19. There was no message sent on 6/23/23, the day of her readmission. Additional residents were reviewed including Resident #4 (admitted [DATE]), Resident #2 (admitted [DATE]) and Resident #5 (admitted [DATE]). All 3 residents Cliniconex messages sent by the Administrator on 6/23/23 to their emergency contacts announced no COVID-19 in the building. (Photographic evidence obtained) The Administrator was interviewed on 6/26/23 at 11:50 am. She was asked about the Cliniconex notifications sent on 6/23/23. The Administrator confirmed on 6/23/23, she had sent a blast message to all resident contacts all at once. When advised the message reported no COVID-19 in the building despite having 15 active cases that day per the resident line list, she said that was a mistake. She reviewed the electronic site and showed the notification status selection buttons were right next to each other, that she must have selected the wrong message button. She had no idea that message had gone out. The Administrator confirmed the same message went out to all resident's contacts in a batch, stating she would correct it right now. The messages are sent every week. The facility's COVID-19 Preparedness Plan 2023 stated under Section IX states: Residents and families are provided weekly updates on outbreak status. (Photographic evidence obtained)

Based on observation and interviews, the facility failed to post the following Nurse Staffing information on a daily basis as required: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. During a tour of the facility on 4/24/23 at 11:13 a.m., the Daily Staffing Projection posted in a shadow box near the entrance of the facility was observed. The date of the Nurse Staffing information was 3/20/23. (Photographic evidence obtained) During an interview with Workforce Coordinator F on 4/27/23 at 10:19 a.m., she stated she had been performing her duties since October 2022. She stated she was responsible for posting the daily staffing projection, and in her absence, the Senior Human Resource Manager was responsible for ensuring the information was updated. She was advised of the 4/24/23 observation of the out-of-date posted staffing information and she acknowledged it was out of date. She stated she had been on leave starting the day after that information was posted, she recently returned to work, and the staffing information had since been corrected. During an interview with the Senior Human Resources Manager on 4/27/23 at 10:36 a.m., he stated he was aware of the requirement for the daily posted staffing. He confirmed that Workforce Coordinator F was responsible for updating the daily posted staffing and that he served as a back-up in her absence. He stated she had been out on leave and he was not aware that the staffing had not been changed.

Based on observations, medical record review, interviews, and a review of the facility's policy and procedure for pressure ulcers, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, by failing to apply physician-ordered bilateral heel protectors for one (Resident #88) of two residents selected for a review of pressure ulcers, out of nine residents with pressure ulcers, from a total sample of 43 residents. The findings include: An observation of Resident #88 was made on 4/24/23 at 11:57 a.m. He was in is his room. A family member was at bedside and was interviewed concerning the resident's care. She stated the resident had dressings on both heels for pressure ulcers and was receiving hospice services. His dressings were always done and the wound care physician saw him. The family member's concern was that Resident #88 had two sets of booties/heel protectors for his feet and they had both disappeared. They have been missing for at least three weeks. She stated she had searched the room numerous times. Dressings were observed on both heels, but there were no heel protectors applied. Resident #88 was observed on 4/25/23 at 8:30 a.m. lying in his bed. Dressings were observed on both heels, however, no booties/heel protectors were applied, nor was a pillow under his ankles to offload the pressure to his heels. Resident #88 was observed on 4/26/23 at 8:49 a.m. lying in his bed. Dressings were observed on both heels, however, no booties/heel protectors were applied, nor was a pillow under his ankles to offload the pressure to his heels. His right foot was hanging off the side of the bed. The resident's family member was interviewed again on 4/26/23 at 12:00 p.m. She stated again that Resident #88 had not had his booties/heel protectors for several weeks and there were two pairs that were ordered by the hospice provider. She stated, He does not have them on again today. A review of Resident #88's medical record revealed an admitted [DATE] with diagnoses including cerebrovascular accident (CVA - stroke), hemiplegia (weakness/immobility on one side), and diabetes mellitus. The resident was noted with an acquired pressure ulcer on his right heel on 8/12/22, and his left heel on 10/5/22. Wound dressings were ordered and dated 4/25/23. A review of the resident's active physician's orders revealed an order for bilateral heel booties every shift for heel protection, dated 8/16/22. A new order was placed on the chart on 4/27/23, instructing staff to 'Float heels using either prevention boots or other offloading boots or pillows being sure the patient's heels are not touching the pillow or directly on the mattress while in bed.' A review of a Wound Progress note, dated 4/25/23, revealed a right heel wound, Stage IV, with bone exposed and a left heel wound, Stage III. The right heel was improving but the left heel was not improving, it was staying the same. An interview was conducted with Certified Nursing Assistant (CNA) B on 4/26/23 at 2:02 PM. She stated the resident used a mechanical lift to transfer, he did not stand, and he required total assistacen from staff for transfers and toileting. He could feed himself. She stated he did have pressure ulcers on his heels, and his heels should be offloaded. He did take his feet off of the pillow when she tried to use one. She reported she was not aware of booties/heel protectors having been ordered for this resident. If he is turned on one side, he will turn right onto his back. I have been trying to offload his heels, but he likes to have one foot off the bed. She reported not seeing any boots/booties/heel protectors for his feet. An interview was conducted with Licensed Practical Nurse (LPN) C on 4/26/23 at 2:07 PM. She reported being unable to find any booties/heel protectors in the resident's room, and that the CNA just asked her about the resident's heel booties. The LPN stated the booties would have to be ordered. The Central Supply clerk came by and reported that heel booties were available in supply. LPN C stated, He (Resident #88) is supposed to have heel protectors on, and I will put them on as soon as I receive them. The LPN confirmed he was not currently wearing the booties to protect his heels. A review of the facility's policy and procedure for Treatment Services to Prevent/Heal Pressure Ulcers (Revised 3/2/19), read: The facility will ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing.

Based on observations, medical record review, and interviews, the facility failed to ensure that three (Residents #42, #8, and #18) of 12 residents receiving oxygen, from a total sample of 43 residents, had physicians' orders for the oxygen (Resident #42), and received oxygen at the flow rate ordered by the physician (Residents #8, and #18). The findings include: 1. On 4/24/23 at 2:45 p.m., Resident #42 was observed lying in bed wearing a nasal cannula. His oxygen concentrator was located at bedside, and the oxygen flow rate was set at 3 LPM. (Photographic evidence obtained) A review of Resident #42's physician's orders revealed no order for oxygen. (Photographic evidence and copy obtained) A medical record review revealed that Resident #42 was admitted to the facility on [DATE] and then readmitted on [DATE]. His diagnoses included COPD with (acute) exacerbation; dependence on supplemental oxygen; shortness of breath; generalized anxiety disorder, and major depressive disorder. A review of the April 2023 Medication Administration Record (MAR) revealed no oxygen monitoring. (Copy obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 3/29/23, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating Resident #42 was cognitively intact. The assessment also documented that he was receiving oxygen therapy. A review of Resident #42's care plan, with a revision date of 1/17/23, revealed he had oxygen therapy related to COPD and shortness of breath (SOB). Interventions included administration of medications as ordered by the physician. Monitor/document side effects and effectiveness. Oxygen settings. Oxygen via nasal cannula per Medical Doctor (MD) orders. On 4/27/23 at 11:11 a.m., LPN D reported that nursing was responsible for ongoing monitoring of oxygen therapy, ensuring the resident was provided the correct flow rate and weekly oxygen tube changes. Correct oxygen settings were identified on the order in the electronic medical record. Correct oxygen settings were communicated from one staff person to another in shift change reports. When asked what happened when there were discrepancies found in residents' physicians' orders, he replied, Call the nurse practitioner and clarify the order, review what the order states, review changes that need to be made, and correct the order. On 4/27/23 at 11:22 a.m., the Director of Nursing (DON) confirmed that Resident #42's correct oxygen flow rate settings were identified in the physician's order in [the electronic medical record]. 2. On 4/24/23 at 1:58 p.m., an observation was made of Resident #8 lying in bed with oxygen being provided via nasal cannula. The oxygen flow rate was set at 3 Liters per minute (LPM). When the resident was asked what her flow rate setting should be, she was unsure. (Photographic evidence obtained) An observation was made of the resident lying in her bed on 4/25/23 at 8:30 a.m. Her oxygen flow rate was still set at 3 LPM. (Photographic evidence obtained) An observation was made of the resident lying in her bed on 4/26/23 at 8:33 a.m. Her oxygen flow rate was still set at 3 LPM. At 9:55 a.m. on 4/26/23, her oxygen flow rate was set at 2 LPM. (Photographic evidence obtained) A medical record review was conducted, which noted an admitted [DATE] with a readmission on 7/13/22. The resident's diagnoses included chronic obstructive pulmonary disease (COPD) and hypoxemia. A 3/16/23 physician's order noted the resident's oxygen flow rate was to be set at 2 LPM via nasal cannula. The resident's care plan, updated on 2/20/23, revealed a focus area for emphysema and COPD. Oxygen was to be administered as ordered by the physician. An interview was conducted with Licensed Practical Nurse (LPN) A on 4/26/23 at 10:00 a.m. The LPN reviewed Resident #8's oxygen order in the electronic medical record and reported the oxygen should be infusing at 2 LPM. She stated she hadn't changed the oxygen setting this morning. She entered the resident's room and checked the oxygen concentrator to ensure that the oxygen flow rate was set at 2 LPM. When she was shown the photographs of the resident's oxygen setting over the last three days (3 LPM), she stated the oxygen setting in the photographs was inaccurate and the staff must not be getting at eye level when setting the flow rate. A review of the facility's policy and procedure for Respiratory/Tracheostomy Care and Suctioning (Revised 3/26/21), read: The facility will ensure residents who need respiratory care are provided such care consistent with professional standards of practice, the comprehensive person centered care plan, and resident goals and preferences. Under number 4 was written: Based upon the resident assessment attending physicians orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. 3. A review of the medical record revealed that Resident # 18 was admitted to the facility on [DATE], with diagnoses including COPD with acute exacerbation, generalized anxiety disorder, and major depressive disorder. On 4/24/23 at 11:39 a.m., the resident's oxygen concentrator was observed to be set at a flow rate of 4 LPM. The resident verbalized the flow rate should be set at 2 LPM and expressed she did not adjust the flow rate herself. She reported she was not physically capable of reaching the dial to adjust the flow rate. On 4/25/23 at 10:30 a.m., the resident's oxygen flow rate was observed to be set at 4 LPM. On 4/26/23 at 11:47 a.m., the resident's oxygen flow rate was observed to be set at 3 LPM. On 4/26/23 at 2:46 p.m., the resident's oxygen flow rate was observed to be set at 2 LPM. On 4/27/23 at 1:52 p.m., LPN E explained that the resident's oxygen was ordered at 2 LPM PRN (as needed) and was administered for low oxygen saturation. She reviewed the resident's record and verified the record documented an oxygen order for a flow rate of 2 LPM PRN and for oxygen saturations below 90. She expressed she was not aware that the resident's oxygen was set at a flow rate of 3 or 4 LPM, and explained that CNAs did not adjust flow rates, as oxygen was considered a medication and CNAs did not administer medications. If a CNA observed an oxygen flow rate set outside of the prescribed amount, they should report it to the nurse. Nurses should be checking oxygen flow rates during medication passes. A review of Resident #18's physician's orders revealed an order written on 3/28/23 for oxygen at two liters per minute via nasal cannula PRN for shortness of breath and oxygen saturations below 90. An order written on 4/25/23 required oxygen saturations to be taken every shift and PRN. Call medical doctor (MD) if saturations are below 90. 45153 28892

Based on clinical record review, interviews and facility policy and procedure review, the facility failed to provide written notice of the facility bed hold policy to one (Resident #5) of two sampled residents. The findings include: A review of the clinical record for Resident #5 revealed he was admitted to the facility on [DATE] and then transferred to the hospital on 2/13/22 for shortness of breath. No evidence was found in the resident's record of information regarding bed hold policy prior to the transfer/discharge to the hospital. A review of Resident #5's Quarterly Minimum Data Set (MDS) assessment, dated 2/13/22 revealed he had a brief interview for mental status (BIMS) score of 15 out of 15, indicating cognitively intact. During a telephone interview with Resident #5 on 2/23/22 at 1:07 PM, he confirmed, he had not received any bed hold information from the facility. On 2/23/22 at 1:20 PM, an interview was conducted with the Director of Nursing (DON) and Employee A, Admission Coordinator (AC). After reviewing the transfer/discharge paperwork for Resident #5, they confirmed that he was only provided SNF/NF to Hospital Transfer Form and did not receive any bed hold policy information. During an interview with Employee C, Corporate Nurse on 2/23/22 at 1:49 PM, she confirmed that Resident #5 did not receive any bed hold policy information. A review of the facility's policy and procedure entitled Transfer and Discharge requirements, revised on 3/2/19, reads under Policy the following: It is the facility policy to ensure residents are treated equally regarding transfer, discharge, and the provision of services, regardless of payment source in accordance to state and federal regulations. Procedure under section 1. The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: (e.) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. g. The facility will not transfer or discharge the resident while the appeal is pending, pursuant to statute 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to statute 431.220 (a) (3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

Based on observations and interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety, by failing to maintain the kitchen in a safe and sanitary manner for the 102 residents who were currently residing in the facility. The findings include: During a visit to the kitchen on 8/30/21 at 10:25 AM, an observation of three air conditioner (AC) vents was found to be dirty and have a black substance on them. The ceiling around each vent was also found to have a black substance. One of the AC vents was near the steam table where food is served. During an interview with Employee A, Certified Dietary Manager at the time of the observation, he confirmed the findings and stated, he would talk with maintenance about it. (Photographic evidence obtained) During a second visit to the kitchen on 8/31/21 at 3:35 PM, two of the three AC vents remained dirty with black substance on them. The ceiling around each vent continued to have a black substance. During an interview with Employee C, Regional Certified Dietary Manager at the time of the observation, he confirmed the vents were not clean and the ceiling needed to be repaired. (Photographic evidence obtained) On 8/31/21 at 3:38 PM, the Administrator entered the kitchen and stated the maintenance staff came in last night and cleaned them. He was shown the vents and confirmed they could be cleaned better. On 9/1/21 at 11:45 AM, the three AC vents were observed dripping water near the serving line, near the food cart and over the dishwashing area. During an interview with Employee B, Dietician at the time of the observation, he confirmed the AC vents were dripping water. (Photographic evidence obtained) On 9/2/21 at 1:30 PM, a follow up visit to the kitchen was conducted with Employee C, Regional Certified Dietary Manager and Administrator. The Administrator stated repairs were made to the air conditioning and ventilation system which appeared to eliminate the dripping condensation from the vents. Administrator also stated, they had plans to make repairs to the ceiling area in the kitchen.

Based on observations, interview and record review, the facility failed to maintain a medication error rate of less than five percent. During the medication administration observations, there were three errors and a total of thirty-five opportunities, resulting in an error rate of 8.57%. The findings include: On [DATE] at 9:19 AM, an observation of medication administration was conducted with Employee H, Licensed Practical Nurse (LPN). While trying to obtain one loratidine 10 milligram (mg) tablet, three tablets poured into the medication cup. The nurse then used a spoon to separate one pill and disposed the other two loratidine tablets in a trash container attached to the medication cart. During this observation, three residents were close to where the nurse threw out the pills. On [DATE] at 9:30 AM, during an interview with Employee H, LPN, she confirmed the disposal of two loratidine tablets into the garbage container. She stated that since the medication was not a narcotic it was not an issue. When she was asked about the facility policy on medication disposal, she stated that narcotics are disposed in a solution for destroying medication and should be signed off by two nurses. She added, she was not sure about the process for non-controlled medication and that she had always disposed the medication in the garbage bag. On [DATE] at 10:00 AM, an observation of medication administration was conducted for Resident #4 with Employee E, LPN. Resident #4 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Employee E, LPN administered one capsule of [MEDICATION(S)] 667 mg to Resident #4, while the resident was in the hallway awaiting transportation to the [CONDITION(S)] center. On [DATE] at 10:06 AM, Employee E, LPN was observed entering room [ROOM NUMBER]-A to administer medication and left the cart unlocked. On [DATE] on 12:50 PM, an interview was conducted with Employee E, LPN. She acknowledged only one [MEDICATION(S)] 667 mg capsule was administered to Resident #4, instead of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When she was asked about the administration time for the medication, she did not see anything wrong with the time. After reviewing the medication administration record (MAR) for Resident #4, the nurse confirmed the medication was not administered with his breakfast. On [DATE] at 1:45 PM, an interview was conducted with the Director of Nursing (DON) regarding the findings of the medication administration observations. She stated that nurses were required to enter medication orders as they are prescribed to the MAR and if something is not clear, they should consult the physician for order clarification. When she was asked about the orders for Resident #4, she stated, he was to receive [MEDICATION(S)] 667 mg ([MEDICATION(S)] binder) 2 capsules two times a day on [CONDITION(S)] day and three times a day for non-[CONDITION(S)] days. When asked about the time for administration, she confirmed that the medication should be offered with meals. She stated that since the direction to administer with meals were at the end of the order it was not clear if it was to be administered with meals on non-[CONDITION(S)] day. She added, she would get the nurse practitioner to clarify the order and add breakfast and dinner to the order. When she was asked what the facility policy on medication destruction was, she stated all medication should be disposed in the medication destruction solution. Controlled medication destruction should be witnessed by two nurses and documented. She mentioned that the nurse observed during medication observation thought that only narcotics needed to be destroyed with the medication destruction solution and therefore, an in-service was conducted. A review of the facility's policy and procedure titled, Disposal/Destruction of Expired of Discontinued Medication, last revised on [DATE], read: 13. Wasted medications are defined as medication contaminated or refused that require disposal. Facility should not place wasted medications back in the original containers. 13.2. Wasted single doses of medication for disposal should be disposed of in a manner that limits access to them by authorized personnel or residents. 13.3 wasted single doses of medication may be flushed or placed in public sewage only if permitted by applicable law. (In Florida: A single dose of wasted medication should be secured until the dose is flushes or placed in public sewage.) A review of the facility's policy and procedure titled, Infection Control- Medication Administration, revised [DATE], read: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulation and national guidelines. 4. Verify medication is being provided at the right time per physician orders/medication administration record (MAR), verify dosage, and verify route of administration (i.e., orally, intravenous, or subcutaneous). 5. Verify medication is being provided at the right time per physician orders/ medication administration record. (Copies obtained)

Based on interviews, record review and facility policy and procedures, the facility failed to provide assistance with showers for one (Resident #12) of five sampled residents reviewed for activities of daily living (ADLs), out of a total sample of 33 residents. The findings include: An interview was conducted with Resident #12 in room [ROOM NUMBER]A on 8/30/21 at 2:26 PM. He stated the only concern he had with the facility was with showers. He had only received a shower seven times since he moved into the facility. He was supposed to get one twice weekly, but the last time he got a shower was around August 3rd. Review of the shower schedule for the north hallway revealed Resident #12 was scheduled for showers on Tuesday and Friday during 3-11 PM shift. (Photographic evidence obtained) A record review for Resident #12 revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly minimum data set (MDS) assessment, dated 8/25/21, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. The assessment also documented his need for total dependence with toilet use and bathing with one-person physical assist. Resident #12 was care planned on 12/11/20 for ADL self-care performance deficits related to limited mobility and musculoskeletal impairment. Approaches included bathing/showering: avoid scrubbing and pat dry sensitive skin, provide sponge bath when a full bath or shower cannot be tolerated, resident is totally dependent on one staff to provide bath/shower per request, schedule, and as necessary. A review of Resident #12's Kardex dated 9/1/21 revealed: Shower - provide sponge bath when a full bath or shower cannot be tolerated. Resident is totally dependent on one staff to provide bath/shower per request, schedule, and as necessary. (Photographic evidence obtained) Review of the certified nursing assistant (CNA) task documentation revealed Resident #12 received a shower four times between 7/1/21 and 8/31/21. (Photographic evidence obtained) On 9/1/21 at 10:55 AM, Resident #12 was outside his room. He was asked if the staff had given him a shower or bath today, he replied, the last time I got a shower was around August 3rd. When he was asked if he refuses to take a shower, he replied, No, I do not. On 9/1/21 at 2:48 PM, an interview was conducted with Employee D, Certified Nursing Assistant who was assigned to take care of Resident #12. She stated, Resident #12 gets a bed bath each day and as needed. He is scheduled to get a shower on Tuesday and Friday during the 3-11 PM shift. If a resident refuses a shower, then we are supposed to document it in the computer and on the shower sheet. On 9/1/21 at 03:28 PM, an interview was conducted with Employee E, LPN/North Wing Unit Manager. She reviewed the north wing shower schedule book and confirmed that Resident #12 was scheduled for Tuesday and Friday during the 3-11 PM shift. She reviewed the completed shower task documentation on the computer and confirmed that for the past thirty days, Resident #12 had only received a shower on 8/17/21, 8/18/21 and 8/26/21. When she was asked if there was any documentation, he refused to take a shower in the past thirty days, she said, Yes, once on 8/17/21. Employee E, LPN stated the aides should be documenting all showers in the computer and confirmed the documentation for Resident #12 was not sufficient to confirm that showers were being provided as scheduled. On 9/2/21 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). She stated that Resident #12 is usually outside smoking until later in the evening and when he comes in, he doesn't want to take a shower. When she was asked what should happen if a resident refuses to take a shower, she stated, staff should document the refusal in the computer and on the shower sheet. The DON reviewed Resident #12's completed shower task documentation sheets for July and August 2021 and confirmed that showers were not being provided as scheduled and there was no documentation that he was refusing them. Review of the facility's Policy and Procedure for Activities of Daily Living (ADLs), revised on 3/2/19, revealed the facility will provide care and services for the following activities of daily living: a. Hygiene - bathing, dressing, grooming, and oral care. (Photocopy obtained)

Based on observation, interview, record reviews and a review of the policy and procedure for respiratory care, the facility failed to ensure that one (Resident # 89) of seven residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 33 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: On 8/30/21 at 2:20 PM, Resident #89 was observed lying in bed with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 2.5 liters/minute (LPM). A review of Resident #89's medical record noted an admitted [DATE] and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] <92% every 8 hours as needed for SOB. On 9/1/21 at 11:30 AM, Resident #89 was observed lying in bed with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 3 LPM. (Photographic evidence obtained) On 9/1/21 at 4:09 PM, Resident #89 was observed for a third time in his room with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 3 LPM. An interview was conducted with Employee G, Licensed Practical Nurse (LPN), and Resident #89's assigned nurse on 9/1/21 at 4:11 PM. When she was asked to check the oxygen setting on Resident #89's oxygen concentrator, she reported it was set at 3 LPM. When she was asked how many LPM the resident was supposed to receive, she replied, 2 LPM and adjusted the oxygen level to 2 LPM. When she was asked who is responsible for checking the oxygen setup, she said, the nurses are responsible for ensuring the correct settings, but she had been off for the last 3 days. A review of the quarterly minimum data set (MDS) assessment, dated 8/10/21, revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The assessment also documented he was receiving oxygen and hospice care. A review of Resident #89's care plan revealed, he has oxygen therapy related to [CONDITION(S)], history of respiratory failure, congestive heart failure (CHF), and SOB. Interventions included: change residents position every 2 hours to facilitate lung secretion movement and drainage. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Observe for signs or symptoms of respiratory distress and report to physician PRN. Oxygen settings: Oxygen via nasal cannula per physician orders. A review of the Respiratory/[CONDITION(S)] Care and Suctioning policies and procedures with revised date of 3/2/19, read: The intent of this policy is that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan, and the resident's choice. The facility will ensure that a resident, who needs respiratory care, including [CONDITION(S)] care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. (Copy obtained)

Based on observation, interview and record review, the facility failed to ensure infection prevention and sanitary administration of a breathing treatment for one (Resident #13) of one resident sampled for observation of medication administration. The findings include: A medication pass observation was conducted on 09/30/20 at 12:13 p.m. Registered Nurse (RN) A dropped the plastic cover to the nebulizer mouthpiece cup into the resident's bedside trash can. RN A then reached into the trash can with a gloved hand, replaced the cap on the breathing treatment delivery system, and handed the unit to Resident #13. Resident #13 took the disposable breathing treatment mouthpiece from RN A with bare hands, and proceeded to move the unit toward her mouth. The treatment was interrupted at that time, and RN A was asked to explain what transpired and what should be done. RN A stated, The lid fell into the trash but landed in a cup. The nurse asked what she should do now. She stated, I will just replace the whole thing. She removed the entire unit with the plastic tubing and retrieved a new disposable mouthpiece. (Photographic evidence obtained) On 09/30/20 at 12:16 p.m., an observation was made of the trash can next to Resident #13's bed. An adult brief was observed in the can along with other trash at the time the nurse dropped the plastic cover in the can, retrieved the mouthpiece cover, and proceeded to hand it to Resident #13. RN A was interviewed on 09/30/20 at 12:16 p.m. and stated, That was (Resident #13's) adult brief. (Photographic evidence obtained) An interview was conducted with RN B, Infection Control Nurse, on 09/30/20 at 12:25 p.m. RN B stated if a staff member dropped anything into the trash can related to patient care, especially related to medication administration, the staff member was expected to replace the item immediately. RN B stated he would provide 1:1 education and then facility-wide staff education on medication administration and infection control related to dropping an item in the trash can. He confirmed that nothing should come out of the trash can and then be handed to a resident. A review of Resident #13's September 2020 Medication Administration Record [REDACTED] Policies and Procedures were reviewed for Infection Control-Medication Administration (revised on 03/02/19). The policy text read, It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure included at line 10: If the sterility of the medication is compromised, or suspected of being compromised, the medication is discarded. A review of RN A's personnel file revealed education related to infection control precautions, infection prevention and control for all staff, medication administration, medication storage and labeling were all documented as having been completed on 03/06/20. A review of Policy 6.0, General Dose Preparation and Medication Administration, included documented at line 3.5: If a medication which is not in a protective container is dropped, facility staff should discard it according to facility policy. .

Based on resident interview, clinical record review, staff interview, and facility policy and procedure review, the facility failed to ensure one resident (#1) out of three sampled residents was not involuntarily secluded from his room against his will when he wanted to be put back in his bed instead of staying up in his wheelchair during lunch. Facility staff confirmed that Resident #1 requested three times to be assisted back to bed; Employee B was directed by assigned floor nurse to make sure Resident #1 did not go into his room; Employee B positioned herself so as to stop Resident #1 from accessing his room. This was during the lunch meal service when staff were passing meal trays. Resident #1 required a mechanical lift to be transferred back into his bed. Staff confirmed, as a matter of staff convenience, they told the resident to wait until they got done passing meal trays and could get two staff to use the mechanical lift to put him in his bed. The findings include: During an interview with Resident #1 on 11/12/2019 at 1:40 PM, he hesitated for few seconds to answer any questions. He asked if he was in trouble. When assured he was not, he stated he does not have good enough recall to say something like what was described happened. He then said he thought it did happen, but cannot remember well enough to tell this surveyor what happened. He stated, I think it really did happen. I couldn't say it in a court of law, though. He stated he did not want anyone to get in trouble. He stated he did not know how to file a grievance or that he should report any problem with how staff treated him. He apologized for not being able to help this surveyor. When informed that an investigation would still be conducted, he appeared to be concerned and asked why. When explained, he stated that it was not necessary, and he was fine. Review of the clinical record for Resident #1 revealed he was admitted to the facility on [DATE], readmitted on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as having adequate hearing and vision. His speech was clear. He made himself understood and understands others. His Brief Interview of Mental Status (BIMS) score was 12 out of a possible 15, indicating little cognitive impairment. He had no disorganized thinking, inattention or signs of altered mental status. He had no behaviors toward self or others. He did not reject care. He had mild depressive symptoms of feeling down or depressed and tired/fatigued. He required extensive assistance of one for bed mobility, locomotion off the unit, dressing and personal hygiene. Limited assistance of one for transfers. Total dependence of one for bathing. No impairment in upper extremities. Impairment in both lower extremities. He was always incontinent of bowel and bladder. He reported no pain. Did not receive pain medications. Was not treated for [REDACTED]. He experienced two or more falls with no injury since his last admission. He had no skin conditions and was at risk for pressure ulcers. No restraints were used. Review of Resident #1's Care Plan last revised 09/24/2019, revealed a Focus area: Resident has potential to demonstrate verbally abusive behaviors related to ineffective coping skills, mental/emotional illness. Makes inappropriate remarks and name calling with peers. Has history of making fabricated statements of mistreatment from roommates. The interventions included: Give resident as many choices as possible about care and activities. Intervene before agitation escalates, guide away from sources of distress. Engage calmly in conversation. Focus area: Resident is dependent on staff for meeting emotional, intellectual, physical and social needs related to immobility. Dependent with mobility and some activities of daily living (ADLs) . Interventions included: Modify daily schedule, treatment plan as needed to accommodate activity participation as requested by the resident. Focus area: Resident has an ADLs self-care performance deficit related to activity intolerance, fatigue. He requires limited to extensive assistance with his ADLs. Transfer: The resident is able to transfer with extensive assist of 2 staff members, use mechanical lift when uncooperative or feeling weak. Focus area: Resident has a behavior problem related to possible attention seeking behaviors of placing himself on the floor in the presence of female staff members. Interventions included: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Focus area: Resident has had actual fall related to poor balance, unsteady gait and potential behaviors of attention seeking. Resident states I slide out of my wheelchair so the nurses can come in and touch me. Interventions: Remind resident to ask and wait for assistance from staff. Focus area : Resident is at risk for alteration in comfort related to [MEDICAL CONDITION]. Interventions included: Offer repositioning, pillows, to get out of bed or to return to bed to increase comfort. Provide a calm quiet atmosphere. Focus area: Resident has a psychosocial well-being need (preference for certain CNAs to provide care). Interventions included: Continue to provide support as needed. Provide opportunities for the resident to participate in care. Review of the nursing progress notes dated 11/01/2019 revealed no documentation indicating Resident #1 wanted to lie down prior to lunch or was not feeling well or did not want to eat his lunch. No documentation of an incident with staff. During an interview with the Administrator and the Director of Nursing (DON) on 11/12/2019 at 12:20 PM in North Wing atrium, the Administrator stated that he had not had any abuse allegations reported to him in the last 2 weeks. He seemed surprised and stated No, no one has reported anything. The DON agreed. During an interview with Employee B on 11/12/2019 at 2:42 PM, she stated she has worked at this facility six months. She has [AGE] years' experience as a Certified Nursing Assistant (CNA). She remembers on 11/01/2019 that when they first got Resident #1 up, they told him that they would put him back in bed after lunch. He agreed to be put back to bed after lunch. She went to lunch and when she got back, she was told that he had wanted to go to bed, so they put him back in bed prior to him having his lunch. The nurse told her to get him up that morning because he is always in bed. She thinks it was Employee A, LPN. Employee C, the transportation CNA assisted Employee A with putting him back in bed. Prior to her leaving for lunch, she saw Employee A and Employee C take him into his room and put him in bed. She stated he did not have his lunch prior to her leaving for her lunch break. She works with him a lot. She received abuse prohibition training during orientation and again about three months ago. She was trained to know the different types of abuse. She was trained to identify the abuse when it is happening. She was trained to report to Unit Manager. She was trained to intervene immediately. She stated she would report it. She would have squealed on it. She stated she has had the Resident Rights training and the resident has the right to get back in bed if he want to. During an interview with Employee K, Housekeeping, on 11/12/2019 at 3:02 PM, she stated she has worked at this facility for [AGE] years. She was not sure if she worked on 11/01/2019 or not. When asked if she has ever witnessed the nursing staff keep someone out of their room when they want to go get back in bed she stated, They do that all the time. They tell them that they have to stay up and each their lunch. She could not recall having training on involuntary seclusion or the obligation to report if she observed or became aware of abuse. During a telephone interview with Employee C, CNA on 11/12/2019 at 3:20 PM she stated she also provides transportation when residents need to go out. She recalled coming to work on 11/01/2019. She did not work the floor that day. She clocked in at 12:30 PM. She went to the North Wing and saw Resident #1 up in his wheelchair. She stated He was trying to get back in his bed. They kept telling him he couldn't go back to bed because he had just gotten up. (Employee B) was standing in his door and telling him couldn't go back to bed. (Employee B) would redirect him and grab his wheelchair and turn him around and tell him 'No you're not going to get in bed yet. Employee A asked her to assist her to put Resident #1 back into his bed. She did not know where Employee B went. She stated, According to my training, he should have been allowed to go back to bed. I didn't know it was something that needed to be reported because it was the nurse that was telling him he had to stay up. After I helped Employee A put him back to bed, I left to take another resident to an appointment. During a telephone interview with Employee A, Licensed Practical Nurse (LPN) on 11/12/2019 at 3:40 PM she stated We got him (Resident #1) up for lunch and had him sit by the table. He wanted to go back to bed. We kind of moved him back to the table. Employee B was telling him he couldn't go back to his room. She was standing in his door. She kept telling him '(Resident #1) you have to go back. We can't put you in bed yet. Not right now. We were passing trays. It was the start of the meal. She stated she brought him in his wheelchair back to the table. (Employee B) was at his door. She did not remember Employee B pushing him in his chair. (Employee C) helped me put him in bed. (Employee B) was passing trays. She did not go to lunch. I don't recall (Employee B) leaving the floor for lunch break. She did not remember when she had abuse training last. She has had training on resident rights. She stated that the resident should have the right to go back to bed if he wants. She stated It was for his own safety. We just got him up for the meal. He didn't want the food and rolled back toward his room. She asked him to go back to the table. I'm sure it sounds stupid and there are times when it would be appropriate for us to stop and put him back in bed. She does not recall Employee B pushing him in the chest or yelling at him. She thinks the interaction was appropriate except for not allowing him to go into his room. She thought it was a good idea for Resident #1 to stay up for a while. He got up and didn't resist. He requires a (mechanical lift) for transfers and we didn't have the staff at that time to transfer him into bed because they were passing the meal trays. She thought he had not been up long before lunch was served. When his tray was placed in front of him, he looked at the food he said he's not eating that slop. She asked him again to stay in the atrium and eat his lunch. Employee B was sitting in the chair by his door. She was right there with her cart and could see that Employee B did not push him. When asked to clarify where the chair Employee B was sitting in was positioned, she stated that Employee B was blocking the door and the chair she was sitting in was in the door frame of Resident #1's room. She confirmed that he was not able to go around Employee B in his wheelchair and gain access to his room and that she instructed Employee B to sit at his door and not let him into his room. She again stated that it was for his own safety. At the request of the Administrator a second interview was conducted with Employee B on 11/13/2019 at 9:22 AM. She stated the chair she was seated in was never put in front of the door the nurse was able to go into the room and pass the medications. The nurse and her coworker put him in bed. She asked him if he could wait until the lunch trays could be passed and he said no. Employee A asked her to redirect him to go into the room because he is a fall risk and the trays were coming and she was passing medications. She told him that it would be safer for him to stay in the atrium so he would be safe and could be watched. She stated He has a habit of going into his room and ends up on the floor. He tells the staff he is trying to get in bed when they find him on the floor. I sat in a chair next to the door of the resident's room. He attempted to enter his room three times. When he attempted to come in, she asked him if he could wait to be assisted to be put in bed and he told her no. He told her I want to go to bed. When she redirected him, he sighed and slumped in his chair. When he wheeled himself to the door, she would talk to him and he stopped. She did not put her hands on his wheelchair or on him physically. When this was happening, the other CNAs were passing trays. Employee A asked Employee C to assist her to put him in the bed. She observed Employee C roll him into his room and Employee A wheeled the mechanical lift into the room and the door was shut. She then went to lunch. Employee A directed her to keep redirecting him. This has happened on other occasions. The nurse is always directing them to redirect him so he won't go in his room and slide out of his chair and end up on the floor. She stated she sat in the chair until Employee A brought the mechanical lift and they (Employee A and Employee C) went into the room to put him in bed. She then got up and passed the rest of the lunch trays. She believed the purpose was to keep him out of his room so he would stay safe if he tried to get back in bed. She denies trying to belittle him or embarrass him. She did not yell at him or physically touch him. During an interview with Employee L, RN on 11/13/2019 at 1:30 PM, he stated he did see Employee B sitting in a chair near Resident #1's door on 11/01/2019. He could not say for sure whether she was sitting in the doorway or not. He stated he tries to stay focused on the medications he is passing and not pay too much attention to all the activity on the unit. He stated he did not see Employee B take hold of Resident #1's wheelchair and redirect him, but he was not watching the whole interaction. He thought it last about 15 minutes before they took him into his room and put him in bed. He stated he has had the abuse prohibition and resident rights training. He feels he is able to identify the different types of abuse and knows he is obligated to report it. He stated that Resident #1 should have been able to access his room. Review of the facility policy and procedure entitled Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) issued 03/02/2019 read: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and or chemical restraints. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Involuntary Seclusion is defined as separation of resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will or the will of the resident's legal representative.

Based on observations, staff interviews, review of the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) Reference Manual, the facility's Infection Control policy and procedure for Cleaning and Disinfecting Blood Glucose Meters, and review of the Centers for Disease Control and Prevention guidelines, the facility failed to maintain an infection prevention and control program to prevent the transmission of blood borne pathogens by failing to ensure that glucometers were cleaned and disinfected between residents. During observations of Blood Glucose Monitoring (BGM) testing via fingerstick, three (3) of three (3) Licensed Practical Nurses (Employees DDD, XXX, NNN), failed to clean and disinfect glucometers (a device used to measure blood glucose) between each resident's use for six (6) of seven (7) residents observed (Residents #49, #58, #235, #27, #284 and #79), out of a total of 27 residents who required blood glucose monitoring. This failure placed the residents at risk for transmission of potentially infectious blood borne pathogens. On 4/24/18 at 4:15 PM, Immediate Jeopardy (IJ) was determined to exist. On 4/25/18 at 1:55 PM, the Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 4/25/18 at 8:00 AM, the facility presented a Credible Allegation of Compliance (A[NAME]). The A[NAME] was revised during the survey, with a final A[NAME] presented on 4/27/18 at 1:20 PM, which was accepted. On 4/27/18 at 7:45 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME]. The findings include: 1. During a 4/24/18 observation on the South Wing at 5:18 PM, Employee DDD, Licensed Practical Nurse (LPN), was observed walking away from a resident and approaching her medication cart with a blood glucometer in her hand. The nurse placed the glucometer on the top of her medication cart, but did not clean it. An interview was conducted with the LPN at that time. When asked whether she had more blood glucose testing to complete, she replied, Yes, I'm just finishing one for (Resident # 49), and now I need to do one for (Resident # 58). Employee DDD was observed on 4/24/18 at 5:20 PM as she walked over to Resident #58 at the dining room table with the same glucometer and single use lancet. She proceeded to clean the resident's finger and obtain a blood glucose reading without first cleaning/disinfecting the blood glucose meter. She returned to her cart with the BGM; disposed of her supplies, and did not clean the glucometer. The nurse stated that she needed to obtain a blood glucose reading for Resident #235. She placed the glucometer (without cleaning it first) into a blue plastic container, which housed single-use lancets, alcohol wipes, and a bottle of glucometer test strips. As Employee DDD entered Resident #235's room, she was asked when she should clean the glucometer. Employee DDD stated, I clean it after use, if it touches a resident's bed. She proceeded to wash her hands, and without cleaning/disinfecting the machine, she obtained the resident's blood glucose reading. As she was exiting the room, she was again asked whether she should now clean the machine. She replied, Yes, I should clean it after every use, and I just forgot. She was asked why she obtained a blood sugar reading for Resident #235 without first cleaning/disinfecting the glucometer, and she replied, I just forgot. An observation was made on 4/24/18 at 5:25 PM with Employee DDD of the two (2) blood glucose meters housed in the medication high cart for the south wing. There were multiple dry, red/brown colored areas observed on the outer surface of both of the glucometers. The nurse confirmed the stains on the glucometers and cleaned both of the the machines. (Photographic evidence obtained) 2. During an observation of blood glucose testing for Resident #27 on 4/24/18 at 4:15 PM, LPN/Employee NNN retrieved a blue basket containing a Blood Glucose Monitor (BGM); a bottle of test strips, lancets, and alcohol wipes from the drawer of her medication cart. She placed it on a Styrofoam tray, then took it to Resident #27's room and placed it on the bedside table. Employee NNN donned gloves, placed a test strip into the BGM, cleansed the resident's finger with an alcohol wipe, and obtained the resident's blood glucose reading. The nurse returned the basket containing the BGM and all other supplies to the draw in her cart. She did not clean/disinfect the BGM. At 5:36 PM, Employee NNN removed the basket containing the BGM (the only one on the cart), lancets, and a bottle of test strips. She placed the items on a Styrofoam tray, took the basket into Resident #284's room, and obtained the resident's blood glucose reading. She returned all items to the cart without cleaning/disinfecting the BGM. During an interview on 4/24/18 at 5:38 PM, LPN/Employee NNN was asked about cleaning/disinfecting the BGM. LPN/Employee NNN stated, My Procedure is to clean the machine every shift, or when I think it is necessary. On 4/24/18 at 5:43 PM, an observation of the third medication cart on this unit revealed two (2) BGMs with a dry, red/brown substance observed on both BGMs. (Photographic evidence obtained) 3. During an observation of LPN/Employee XXX on 4/26/18 at 11:45 AM, she was preparing to complete blood glucose testing for Resident #79. LPN/Employee XXX was observed removing the blood glucose meter (BGM), a lancet, a test strip bottle, and alcohol wipes from her medication cart. As the nurse approached the resident's room, signage (See Nurse) was posted on the door, and personal protective equipment (PPE) was observed. When asked about Resident #79's isolation status, the nurse replied, She is not on isolation; that is the other room., as she entered the resident's room without donning the Personal Protective Equipment (PPE). The surveyors watched from the resident's doorway while the nurse entered the room, washed her hands, donned gloves and placed the glucometer on the bedside table without a barrier. She wiped the resident's left index finger with the alcohol wipe, obtained a blood droplet; then reached into the test strip bottle with the gloved hand just used to obtain a blood droplet, in order to get a clean test strip. She obtained the resident's blood sugar reading, removed her gloves, washed her hands, and returned to the cart. She placed the glucometer on the top of her cart with the bottle of test strips (no barrier on cart). She wiped the glucometer off with a disinfectant wipe, and placed it on top of the cart without a barrier. At that time, she was asked again about Resident #79's isolation status, and she stated, Oops, that is a ding. I did not realize she was on isolation, and no one told me that in report; only about the other resident being on isolation. Employee XXX was asked about providing a clean barrier when using equipment, and stated that she was not aware that she was supposed to do that. During an interview with LPN/Employee DDD on 4/24/18 at 8:51 PM, she was asked whether she had been trained on cleaning/disinfecting of the blood glucose meters. She stated that she could not remember having received this training at this facility. During an interview with LPN/Employee NNN on 4/24/18 at 9:00 PM, she stated she had recently been trained on how to properly clean and disinfect the blood glucose meters. She could not remember who performed the in-service or what was covered, but said she knew, due to her years of experience, that blood glucometers were cleaned once a shift, or if she thought they needed it. On 4/24/2018 at 6:40 PM, the Director of Nursing (DON) and Minimum Data Set Coordinator B were asked for the facility's policy and procedure for cleaning/disinfecting blood glucose machines. The DON stated, We don't have a specific policy and procedure for cleaning the glucometers. We just go by the manufacturer's insert. On 4/24/2018 at 6:49 PM, the DON entered the conference room stating that she looked on the Portal, and found an infection control policy and procedure for cleaning and disinfecting blood glucose meters. She provided the policy. (Photographic evidence obtained) During an interview with the Administrator on 4/24/18 at 8:45 PM, he was asked what process was in place, and what expectations he had, for the cleaning and disinfecting of the BGMs. He stated he knew the staff needed to clean them between each resident. When asked what training for staff was in place for orientation and cleaning of the meters, he responded that there was no staff developer in the facility; that responsibility would fall under the DON or Assistant DON (ADON, who quit approximately 2 weeks ago). Agency staff were trained in competencies through their own agencies, and received the facility's orientation packet, but not the skills training packet. The skills training packet was more like on-the-job training. He was asked if there was any guarantee that new agency nurses were coming to the floor with necessary skills to perform needed tasks prior to working on the floor. He replied that new agency nurses came with a lot of documentation, but he would have to ask Human Resources exactly what came with them. He believed the documentation included items such as their licenses and background screenings. An interview with the DON on 4/24/18 at 8:50 PM, revealed that training was completed in (MONTH) (YEAR) related to the cleaning/disinfection of BGMs. 'About nine (9) nurses received the training. The facility hasn't trained the agency nurses. Some have since been trained, but not all of them. We have documentation of the training. There were also competencies in the employee files. We are down a lot of staff. There are maybe only 10 or 12 facility nurses. We have orientation training, but the BGM training is on-the-floor training. This is for our staff. We do not have preceptor training for agency staff.' She stated that she expected agency nurses to know essential nursing functions. She was not aware that the staff were not cleaning/disinfecting the meters between resident use, or that any were visibly soiled with what appeared to be blood. The DON confirmed there were no audits in place for the oversight of BGM cleaning/disinfecting, and nobody was assigned to conduct them. She stated they were following the manufacturer's instructions for cleaning and disinfecting. During an interview with the DON on 4/27/18 at 3:38 PM, she confirmed that she was functioning as the facility's infection control nurse since the ADON left two weeks earlier. 'We track our infections through line listing and mapping/color coding per infection. We meet every morning in morning clinical meetings, and we track in the computer system on the clinical dashboard. It gives us an alert when a stop date is needed for antibiotics. It stays on the dashboard until completed. We do our training through a dedicated piece of the orientation training, which now includes glucometers, PPE, and isolation rooms. We track and trend monthly through an analysis, and if we recognize a pattern, we approach it by going out to do education or through physician follow up. For suspected scabies, [MEDICAL CONDITIONS], lice, etc., we implement precautions and notify staff on the spot, and then through report. We provide signage on doors as an alert.' A review of the facility's Infection Control policy and procedure on Cleaning and Disinfecting Blood Glucose Meters (not dated) revealed the following: It is the policy of the facility to clean and disinfect blood glucose meters that are shared between residents. Indirect contact transmission - Patient care devices . may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients. If a glucometer that has been used for one resident must be reused for another resident, the device must be cleaned and disinfected before it can be used for another resident. Procedures included the following: .8. Thoroughly clean all visible soil or organic material (e.g. blood) from glucometer prior to disinfection. 9. Using gloves as indicated, wash with disinfectant and allow for drying time as indicated per manufacturer . .11. Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters . A review of the 'Assure Platinum Blood Glucose Monitoring system QA/QC Reference Manual' revealed in section B, Performing a Blood Glucose Test: All components that come into contact with blood samples should be considered to be biohazardous and capable of transmitting [MEDICAL CONDITION] diseases between patients and healthcare professionals. -A new pair of clean gloves should be worn by the user before testing each patient. -Wash hands thoroughly . -Use only an auto-disabling, single-lancet device for each patient. -The meter should be cleaned and disinfected after use on each patient. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. .whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. .Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 4/25/18 at 1:55 PM, the Nursing Home Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy. Information was shared regarding LPNs DDD, XXX, and NNN for not cleaning or disinfecting the glucometers between each resident during BGM observations beginning on 4/24/18 at 4:15 PM. The facility presented a Credible Allegation of Compliance (A[NAME]) on 4/25/18 at 8:00 AM. Revisions to the A[NAME] were made during the survey, with a final A[NAME] presented on 4/27/18 at 1:20 PM. The team accepted the A[NAME] and lifted the Immediate Jeopardy at 7:45 PM on 4/27/18, after validation of the implementation of the A[NAME]. Validation was made through observations, staff interviews, and facility record reviews by the survey team, including: An interview with the DON and Administrator which revealed that all existing blood glucometers had been disposed of. New glucometers (2 per cart) were obtained from on-site central supply, and distributed immediately. Nursing staff confirmed receipt of new glucometers through interview(s). Survey team members observed individual and group trainings of nurses on the cleaning/disinfecting of blood glucometers, and the use of personal protective equipment (PPE). The survey team reviewed documentation of those (ongoing) trainings, including certified competencies, in-service training materials, and staff sign-in sheets as the DON provided them. Interviews with nurses confirmed they had been not only re-trained in proper cleaning/disinfection of glucometers, but had also demonstrated competency as part of the re-training. Nurses interviewed were successfully able to explain proper procedures and steps for cleaning and disinfecting glucometers per the manufacturer's instructions and the newly implemented policy and procedure. Observation throughout the remainder of the survey confirmed proper cleaning/disinfecting of shared glucometers. The Director of Nursing and Administrator stated that the DON and designee(s) would perform daily audits/observations to ensure continued compliance. The team agreed that the A[NAME] had been successfully implemented, and a system was in place to ensure compliance, therefore the Immediate Jeopardy was lifted. The facility remained out of compliance at a lower scope and severity of E, potential for more than minimal harm, for all residents with a [DIAGNOSES REDACTED].

Based on observation, interview, clinical and facility records review the facility failed to thoroughly investigate and report an alleged abuse for 1 (Resident #2) of 4 sampled residents. The failure of the facility to thoroughly investigate an allegation of abuse, failure to report the alleged abuse, and the initial inaction of the facility placed all residents residing in the facility at risk for abuse and resulted in immediate jeopardy. The findings include: Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] and left the facility against medical advice on 01/21/12. The resident was assigned to room [ROOM NUMBER]B. The listed [DIAGNOSES REDACTED]. Review of the nurse's note dated 01/20/12 at 3:00 p.m. in Resident #1's clinical record revealed the resident was admitted at 12:30 p.m. via transport wheelchair. The nurse indicated the resident was alert and oriented to person, place and time, had no complaints and revealed no signs or symptoms of distress. Review of the nurse's note dated 01/21/12 at 8:20 a.m. in Resident #1's clinical record revealed the writer was "called to room by RN #1 - husband at bedside assisting wife with belongings. Husband stated, "I am going to take her home now." I asked the husband "why" in presence of RN #1. Resident #1 stated, "That black man with the foreign accent climbed into bed 3 or 4 times with my roommate. I told both resident and family that this matter would definitely be investigated but I find that behavior very hard to believe." The note revealed a call was placed to Resident #1's physician, and to the facility's Director of Nursing (DON) (name removed). The nurse also documented in the note that a call was received from the physician with an order received to discharge Resident #1 home without medications. The note revealed the DON, Admissions and the on-call Registered Nurse (RN) were made aware of the situation. Review of the nurse's note dated 01/21/12 at 8:30 a.m. in Resident #1's clinical record revealed, "Husband came in saying he was taking his wife out of facility. I ran and got a supervisor RN #2. We both entered room. RN #2 ask resident why she wanted to leave. Resident stated a tall black man with an accent climbed into bed with Resident #2 several times last night. RN #2 offered to change resident's room with no male aides. Resident and husband said no. I just want to take my wife home. I can take better care of her at home. Dr. of resident was notified and gave discharge orders. DON was notified and RN #2 tried to get resident and husband to sign AMA (against medical advice) form but they walked out of facility. " Review of the physicians progress note dated 01/21/12 revealed the physician did not see Resident #1 because she was not happy at rehab and was discharged home before he could see her. The physician reported in the progress note that the nurse advised him the resident wanted to leave due to problems. Review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE]. The resident was assigned to room [ROOM NUMBER]A. The [DIAGNOSES REDACTED]. The Resident Assessment and Care Screening with an assessment reference date of 12/23/11 revealed the resident did not have any hearing or visual difficulty, was able to understand and speak English, and was continent of bowel and bladder. The functional status of the resident listed in Section G revealed the resident required extensive assistance of one person for bed mobility, transfers, walking, toilet use and personal hygiene. The functional status of Resident #2 listed in Section G revealed the resident was totally dependent, requiring the assistance of one person to get dressed. Review of Resident #2's Daily Skilled Nurses Note dated 01/20/12 revealed the resident was assessed by the nurses assigned to her on the night and day shifts. Both shifts indicated that Resident #2's emotional status was alert and confused; both nurses indicated that Resident #2's orientation was confused and forgetful. Review of Resident #2's Daily Skilled Nurses Note dated 01/21/12 revealed the resident was assessed by the nurses assigned to her on the night and day shifts. Both shifts indicated that Resident #2's emotional status was alert and confused; both nurses indicated that Resident #2's orientation was confused and forgetful. On 01/25/12 at 12:45 p.m. an interview with the Nursing Home Administrator (NHA) and DON revealed that the facility had one Adverse Incident in November 2011, one in December 2011 and none for January 2012. The NHA revealed he was the Risk Manager for this facility. When asked if the incident reported by Resident #1 had been investigated he indicated it had. The NHA left the office and returned with 5 hand written witness statements. The statements read as follows: 1. I, LPN #1, received in report about 11:15 p.m. 1-20-12 that theres (punctuation noted) a new admission in room [ROOM NUMBER]B. About 12:15 a.m. 1-21-12 this writer did rounds. Resident in bed 134B in bed resting with eyes closed oxygen at 2 liters/minute via nasal cannula. Resp even and unlabored. No c/o pain, no s/o distress noted at this time. About 5:30 a.m. 1/21/12 this writer entered 134 to administer med to 134A, 134B was up out of bed at this time in bathroom. At this time I asked resident is everything ok, and introduced myself as the 11-7 nurse. Resident responded, yes I'm fine just trying to empty bedside commode (BSC) pail. Alerted resident that CNA (certified nursing assistant) is in next room, we will take care of that for you. Resident acknowledge and walk back to bed. I then left, and re-entered room to take BGM (blood glucose monitor) of 134B, she was sitting on side of bed, BGM within normal limits, no further concerns from resident, reported to on-coming nurse that resident is self-care with B&B (bowel and bladder), have CNA (certified nursing assistant) check BSC frequently. (Signed by LPN #1; no date or time of statement revealed.) 2. After RN #1 made me aware of the situation with Resident #1 I entered room [ROOM NUMBER] I saw the resident's husband putting items from her nightstand in a bag. I approached the couple introduced myself and asked "What is the issue?" The husband responded "I am taking her home." I asked them why and resident stated "You need to check your night staff." She then elaborated when I questioned her she said "That tall black man climbed into bed with her" and she pointed to assigned roommate. I asked the couple "Do you think that there might be some confusion with the new environment change?" The husband stated, "No that is not it." I asked the couple to wait a minute and allow me to call her MD. I left the room, put a call out to (the resident's doctor) service and DON (name removed). At that time the resident and husband were already at the desk. I had asked the couple 2 times to please sit in atrium and give me a few minutes for the MD and DON to call back. I asked the couple if they would go sit in atrium. He said "The next place I go is out the door." A few minutes lapsed and (name removed) DON called back and asked me to ask him to leave the vicinity of the nurse's station. He then angrily pushed his wife down the hall. I spoke with (name removed) again and ran behind the couple asking to sign the AMA papers at the front gate. When I returned to South Unit the MD covering for (the resident's physician) was on the phone and order to discharge obtained. (Signed by RN #2 on 1/22/12; no time of signature revealed.) 3. I did not go to south wing I did not go to the patient's room, I think theirs (spelling noted) some confusion. I was assigned to north wing and that where I stay. (Signed by CNA #1 on 01/21/12; no time of signature revealed.) 4. I, CNA #2, didn't get in the bed with (Resident #2). I CNA #2 helped her to the bathroom when she needed help thats it. (Signed by CNA #2 on 01/21/12; no time of signature revealed.) 5. There is no one got into bed bed (duplicate wording noted) with me last night. (Signed by Resident #2 on 01/21/12; no time of signature revealed.) An interview with the NHA on 01/25/11 at 1:10 p.m. revealed that the first thing that was done when this was reported was to ask Resident #2 "because she would tell us. We then asked the staff what happened and that was it." When asked if the alleged incident had been reported he stated, "What would I report? Nothing happened." On 1/25/12 at 1:32 p.m. an interview with Social Services Director (SSD) revealed she was the facility's Abuse Coordinator. When asked what the procedure was for the facility when abuse is reported she stated, "If abuse is reported we immediately suspend pending investigation. Start the investigation, check on the resident to determine if safe, head to toe assessment if physically abused, notify the responsible family member and physician. A mini mental is done on the resident." Per the SSD she revealed she completes the Immediate Report for abuse and then the Risk Manager completes the investigation and the rest of the reports. When the SSD was asked what is considered to need an Immediate report she replied, "If a resident was hit by a staff member, verbal abuse, sexual abuse, exploitation." Per the SSD she was unaware of any occurrence that took place in the facility on 01/21/12. The SSD stated, "I don't know anything about that. I was not working that day. I am only a phone call away, and they are supposed to call me for something like that." The SSD stated, "Even if the resident denied that someone got into her bed it should have been reported." On 01/25/12 at 1:50 p.m. an interview with the DON revealed that she was first made aware of the allegation as the husband was rolling Resident #1 out of the building. Per the DON the husband would not speak with her. The DON revealed she then spoke with the RN supervisor and "I immediately told them to go talk with Resident #2." The DON revealed that Resident #2 denied that anyone had climbed in bed with her. Per the DON "those males on that shift were contacted to come in and do a statement." When the DON was asked about her knowledge of the regulation related to abuse she stated, "You ask the resident that is alleged to be abused if the incident happened and if they say it did you have to report it. When the resident denies anything happened, and she was not confused, then I would go by the first-hand information from the resident." Per the DON, "Typically when there is an allegation of abuse, immediately maintain the safety of the resident and a One Day report is filed and let the abuse coordinator know. The staff involved is suspended pending an investigation." A telephone interview on 01/25/12 at 2:40 p.m. was conducted with an Adult Protection Investigator (API) with the Department of Children and Families to discuss the allegation and the facility's response to the allegation. Per the API the allegation "should have been reported and let the folks that determine the allegation is not substantiated do their job. This resident may possibly be fearful of retaliation." On 01/25/12 at 3:05 p.m. an interview with RN #1, the nurse assigned to Resident #1 and #2 on the day shift of 1/21/12, revealed that Resident #1's husband told her "I am taking my wife out. I got the supervisor and we went to the room and that is when she stated those things. Resident #2 was in the room and at first she didn't say anything, but then later she wrote her own statement. It was just the two of them in the room." Per RN #1 she had worked with Resident #2 since November 2011. RN #1 revealed she worked in the facility as a floater and had worked with Resident #2 off and on. RN #1 revealed that Resident #2 had "good and bad days", and was alert and oriented to person, place and situation. On 01/25/12 at 3:12 p.m. an interview with RN #2 revealed that on 01/21/12 she came in around 6:45 a.m. that day and around 8:30 a.m. or 9:00 a.m. the nurse informed her of the allegation. "I questioned Resident #1, and spoke with the staff that were there, the staff members that worked that night and spoke with Resident #2." Per RN #2 she had known Resident #2 since she was admitted to the facility. RN #2 revealed that Resident #2 had intermittent confusion, but could make her needs known. Per RN #2 she found out who was assigned to Resident #2 and reported it to the DON and the nurse on-call. On 01/25/12 at 4:37 p.m. an interview with the NHA, in the presence of the DON and the Regional Vice President of Operations (RVPO), revealed the police were not notified of the abuse allegation, the allegation was not reported, and no employee was suspended because Resident #2, per the NHA, was "alert and oriented and would know if something happened. Nobody was suspended. What was I supposed to suspend anybody for?" On 1/25/12 at 5:37 p.m. the NHA requested to speak with this surveyor. The NHA stated, "I screwed up. I should have reported this." The NHA administrator revealed he would "take care of it now." On 1/26/12 at 5:56 p.m. a telephone conversation with LPN #1 revealed that around midnight "I do a walk around. Both were sleeping around 12 - 2:30 p.m. About 5:30 a.m. I went to give Resident #2 her meds and Resident #1 was emptying her BSC." Per LPN #1 he offered to empty the BSC for her and she sat on the bed and started brushing her hair. "I went to get the things for her blood sugar and it was normal. She laid back down. She denied pain, didn't act afraid; she seemed normal. LPN #1 revealed that the curtain was closed between the two residents. LPN #1 revealed that the residents in room [ROOM NUMBER] had a black male CNA the night of the alleged incident. Per LPN #1 Resident #2 "will cut the light on if she needs to get up. She needs assistance to and from the toilet. I woke her up about 5:30 a.m. to give her meds. Resident #2 is alert and oriented usually. First thing in the morning she is a little confused. She does have a urinary tract infection, but generally a straight on conversation with you." On 01/26/12 at 6:00 p.m. an interview with CNA #1 revealed he "was working on the north wing not the south wing. I was nowhere in the region on the assignment. Never worked with her. The thing is that there is allegations against someone else." On 01/26/12 at 6:19 p.m. an interview with CNA #2 revealed "Friday night I was the CNA and I went in to help her (Resident #2) go to the bathroom. I helped her about 3 times. She goes pretty regular. There was no lights on in the room. I left 134B (Resident #1) a towel and washcloth, and she said she did not need any help. She did not act startled or afraid or anything like that. I have worked with Resident #2 since she came here. Honestly, I think Resident #2 is forgetful and she will just stand there, and I have to remind her why she was in the bathroom. I think she still recognizes certain people. I think she has a short memory. I am pretty sure she knows me. She does not call me by name." On 1/26/12 at 6:20 p.m. a telephone interview with Resident #2's physician revealed he was not aware of the 01/21/12 alleged incident until the evening of 01/25/12. Resident #2's physician revealed that when he was informed on 01/25/12 of the allegation he came directly to the facility to assess Resident #2. On 01/27/12 at 9:16 a.m. the NHA stated, "I will always err on the side of caution. It is my duty to protect the residents and myself. I made a wrong decision. I will bring everything to the QA (Quality Assurance) meeting. I will to do some teaching. I will tell them my thought process, and what I did was wrong. I should have followed the process. I didn't follow what I had in place." Per the NHA he revealed he tried to contact Resident #1, but she or her husband would not speak with him. On 1/27/12 at 2:00 p.m. the NHA, DON, RVPO were informed that Immediate Jeopardy existed and was ongoing until there was evidence that training/re-training of staff was provided. The NHA stated, "You're kidding; why?" The NHA was advised that the facility failed to investigate and report an allegation of abuse. On 01/27/12 at 4:32 p.m. the NHA requested to speak with this surveyor, and said, "Would it make any difference that DCF came in to speak with Resident #2 Monday morning?" The NHA revealed that the DCF investigator informed him what she was there for, and why she needed to speak with Resident #2. The NHA then stated, "I should have put two and two together then, shouldn't I have?" Review of the facility's Abuse and Neglect policy approved on 11-06-08 revealed the following statements: POLICY: It is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, physical, sexual and mental abuse, corporal punishment and involuntary seclusion by facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse also includes those practices and omissions, neglect and misappropriation of resident property that left unchecked, lead to abuse. DEFINITIONS: Incident means alleged occurrences or episodes of staff misconduct and injuries of unknown origin. Staff means any employee, volunteer or contractor of the facility such as facility administrator, administrative staff, physicians, RNs, LPNs, nurse aides, podiatrists, dentists, vocational therapists, beauticians, housekeepers, dietary, laundry, maintenance staff and laboratory personnel. Staff misconduct means alleged (i) mistreatment of [REDACTED]. Abuse by definition is the willful (non-accidental) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psycho social well-being. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory words to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Sexual Abuse includes but is not limited to sexual assault, sexual coercion and sexual harassment. Physical Abuse includes, but is not limited to, threats of punishment, humiliation, harassment or deprivation. Mental Abuse includes, but is not limited to, threats of punishment, humiliation, harassment or deprivation. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This facility prohibits mistreatment, neglect and abuse of residents and misappropriation of resident's property and although we cannot guarantee that a resident will not be abused we can only assure that the facility will take steps necessary to prevent abuse. Such steps include, but are not limited to, pre-employment screening of all employees, staff education and ongoing in-servicing of resident's rights, monitoring and investigation of incident and accidents. INVESTIGATION AND REPORTING PROCEDURE: 5. All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to: ? The Director of Nursing ? The Administrator or the designated representative ? Director of Social Services or Abuse Officer ? Regional Director of Clinical Operations ? Regional VP of Operations ? The resident ' s attending physician - obtain order for treatment if needed ? The resident's family/responsible party ? Long-term care Ombudsman ? Police, if appropriate ? Follow Local and State guidelines for reporting and always report to State survey and certification agency. ? Follow Federal Guidelines for Reporting. No State law timeframe can override the Federal reporting timeframe. A. Report immediately via fax, to the appropriate agency. a) Immediately means as soon as possible but out not exceed 24 hours after discovery of the incident, in the absence of a shorter state timeframe requirement. 6. The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the investigation is in progress. TRAINING PROCEDURE: 4. Begin the internal investigation immediately after notifying the Administrator and appropriate parties and agencies. A thorough investigation should include, but is not limited to: a. Examining the alleged victim promptly and documenting findings, if any as part of the investigation report; b. Collecting and preserving physical and documentary evidence; c. Protecting the alleged victim from further abuse by identifying removing the cause of the danger; d. Interviews of victims and witnesses; e. collecting other corroborating/disproving evidence; f. Involvement of other regulatory authorities who can assist; g. Documentation of each step taken during the internal investigation; h. The Administrator will oversee all necessary corrective actions depending on the results of the investigation; f. The Director of Nursing will utilize an Incident Report, Report Log to analyze patterns and trends and analyze the data to determine what, if any, changes are needed to policies and procedures, staffing and facility systems to prevent additional occurrences. Reports should be made quarterly at Quality Assurance Committee meetings. However, changes in policy may be implemented immediately by Administration. The facility did not conduct a thorough investigation and failed to report the abuse allegation to Resident #2's physician, the State and Federal reporting guidelines were not followed and the facility failed to protect the residents residing in the facility by failing to suspend the potential perpetrator(s) pending a thorough investigation. On 01/27/12 at 6:50 p.m. the facility provided evidence that 139 or it's 146 employees had received in-service and training of the Abuse Policy that was approved on 11/06/08. The information provided by the NHA revealed that no employee would be allowed to report on duty until the in-service training had been completed. The NHA, DON and the Vice-President of Operations were informed at 7:00 p.m. the IJ was removed. The facility took action including suspending an employee pending investigation, conducting & completing their own internal investigation, notifying the appropriate authorities, and providing training to staff. The IJ was removed on 1/27/12. At the time of exit the deficiency remained out of compliance at S/S=F. .

Based on observation, interview, and clinical and facility records review the facility failed to implement their written policies and procedures regarding an alleged abuse for 1 (Resident #2) of 4 sampled residents. The failure of the facility to implement their policy and procedure related to alleged abuse placed all residents residing in the facility at risk for abuse and resulted in immediate jeopardy (IJ). The findings include: Review of Resident #1's clinical record revealed the resident was admitted to the facility on [DATE] and left the facility against medical advice on 01/21/12. The resident was assigned to room [ROOM NUMBER]B. The listed [DIAGNOSES REDACTED]. Review of the nurse's note dated 01/20/12 at 3:00 p.m. in Resident #1's clinical record revealed the resident was admitted at 12:30 p.m. via transport wheelchair. The nurse indicated the resident was alert and oriented to person, place and time, had no complaints and revealed no signs or symptoms of distress. Review of the nurse's note dated 01/21/12 at 8:20 a.m. in Resident #1's clinical record revealed the writer was "called to room by RN #1 - husband at bedside assisting wife with belongings. Husband stated, "I am going to take her home now." I asked the husband "why" in presence of RN #1. Resident #1 stated, "That black man with the foreign accent climbed into bed 3 or 4 times with my roommate. I told both resident and family that this matter would definitely be investigated but I find that behavior very hard to believe." The note revealed a call was placed to Resident #1's physician, and to the facility's Director of Nursing (DON) (name removed). The nurse also documented in the note that a call was received from the physician with an order received to discharge Resident #1 home without medications. The note revealed the DON, Admissions and the on-call Registered Nurse (RN) were made aware of the situation. Review of the nurse's note dated 01/21/12 at 8:30 a.m. in Resident #1's clinical record revealed, "Husband came in saying he was taking his wife out of facility. I ran and got a supervisor RN #2. We both entered room. RN #2 ask resident why she wanted to leave. Resident stated a tall black man with an accent climbed into bed with Resident #2 several times last night. RN #2 offered to change resident's room with no male aides. Resident and husband said no. I just want to take my wife home. I can take better care of her at home. Dr. of resident was notified and gave discharge orders. DON was notified and RN #2 tried to get resident and husband to sign AMA (against medical advice) form but they walked out of facility. " Review of the physicians progress note dated 01/21/12 revealed the physician did not see Resident #1 because she was not happy at rehab and was discharged home before he could see her. The physician reported in the progress note that the nurse advised him the resident wanted to leave due to problems. Review of Resident #2's clinical record revealed the resident was admitted to the facility on [DATE]. The resident was assigned to room [ROOM NUMBER]A. The [DIAGNOSES REDACTED]. The Resident Assessment and Care Screening with an assessment reference date of 12/23/11 revealed the resident did not have any hearing or visual difficulty, was able to understand and speak English, and was continent of bowel and bladder. The functional status of the resident listed in Section G revealed the resident required extensive assistance of one person for bed mobility, transfers, walking, toilet use and personal hygiene. The functional status of Resident #2 listed in Section G revealed the resident was totally dependent, requiring the assistance of one person to get dressed. Review of Resident #2's Daily Skilled Nurses Note dated 01/20/12 revealed the resident was assessed by the nurses assigned to her on the night and day shifts. Both shifts indicated that Resident #2's emotional status was alert and confused; both nurses indicated that Resident #2's orientation was confused and forgetful. Review of Resident #2's Daily Skilled Nurses Note dated 01/21/12 revealed the resident was assessed by the nurses assigned to her on the night and day shifts. Both shifts indicated that Resident #2's emotional status was alert and confused; both nurses indicated that Resident #2's orientation was confused and forgetful. On 01/25/12 at 12:45 p.m. an interview with the Nursing Home Administrator (NHA) and DON revealed that the facility had one Adverse Incident in November 2011, one in December 2011 and none for January 2012. The NHA revealed he was the Risk Manager for this facility. When asked if the incident reported by Resident #1 had been investigated he indicated it had. The NHA left the office and returned with 5 hand written witness statements. The statements read as follows: 1. I, LPN #1, received in report about 11:15 p.m. 1-20-12 that theres (punctuation noted) a new admission in room [ROOM NUMBER]B. About 12:15 a.m. 1-21-12 this writer did rounds. Resident in bed 134B in bed resting with eyes closed oxygen at 2 liters/minute via nasal cannula. Resp even and unlabored. No c/o pain, no s/o distress noted at this time. About 5:30 a.m. 1/21/12 this writer entered 134 to administer med to 134A, 134B was up out of bed at this time in bathroom. At this time I asked resident is everything ok, and introduced myself as the 11-7 nurse. Resident responded, yes I'm fine just trying to empty bedside commode (BSC) pail. Alerted resident that CNA (certified nursing assistant) is in next room, we will take care of that for you. Resident acknowledge and walk back to bed. I then left, and re-entered room to take BGM (blood glucose monitor) of 134B, she was sitting on side of bed, BGM within normal limits, no further concerns from resident, reported to on-coming nurse that resident is self-care with B&B (bowel and bladder), have CNA (certified nursing assistant) check BSC frequently. (Signed by LPN #1; no date or time of statement revealed.) 2. After RN #1 made me aware of the situation with Resident #1 I entered room [ROOM NUMBER] I saw the resident's husband putting items from her nightstand in a bag. I approached the couple introduced myself and asked "What is the issue?" The husband responded "I am taking her home." I asked them why and resident stated "You need to check your night staff." She then elaborated when I questioned her she said "That tall black man climbed into bed with her" and she pointed to assigned roommate. I asked the couple "Do you think that there might be some confusion with the new environment change?" The husband stated, "No that is not it." I asked the couple to wait a minute and allow me to call her MD. I left the room, put a call out to (the resident's doctor) service and DON (name removed). At that time the resident and husband were already at the desk. I had asked the couple 2 times to please sit in atrium and give me a few minutes for the MD and DON to call back. I asked the couple if they would go sit in atrium. He said "The next place I go is out the door." A few minutes lapsed and (name removed) DON called back and asked me to ask him to leave the vicinity of the nurse's station. He then angrily pushed his wife down the hall. I spoke with (name removed) again and ran behind the couple asking to sign the AMA papers at the front gate. When I returned to South Unit the MD covering for (the resident's physician) was on the phone and order to discharge obtained. (Signed by RN #2 on 1/22/12; no time of signature revealed.) 3. I did not go to south wing I did not go to the patient's room, I think theirs (spelling noted) some confusion. I was assigned to north wing and that where I stay. (Signed by CNA #1 on 01/21/12; no time of signature revealed.) 4. I, CNA #2, didn't get in the bed with (Resident #2). I CNA #2 helped her to the bathroom when she needed help thats it. (Signed by CNA #2 on 01/21/12; no time of signature revealed.) 5. There is no one got into bed bed (duplicate wording noted) with me last night. (Signed by Resident #2 on 01/21/12; no time of signature revealed.) An interview with the NHA on 01/25/11 at 1:10 p.m. revealed that the first thing that was done when this was reported was to ask Resident #2 "because she would tell us. We then asked the staff what happened and that was it." When asked if the alleged incident had been reported he stated, "What would I report? Nothing happened." On 1/25/12 at 1:32 p.m. an interview with Social Services Director (SSD) revealed she was the facility's Abuse Coordinator. When asked what the procedure was for the facility when abuse is reported she stated, "If abuse is reported we immediately suspend pending investigation. Start the investigation, check on the resident to determine if safe, head to toe assessment if physically abused, notify the responsible family member and physician. A mini mental is done on the resident." Per the SSD she revealed she completes the Immediate Report for abuse and then the Risk Manager completes the investigation and the rest of the reports. When the SSD was asked what is considered to need an Immediate report she replied, "If a resident was hit by a staff member, verbal abuse, sexual abuse, exploitation." Per the SSD she was unaware of any occurrence that took place in the facility on 01/21/12. The SSD stated, "I don't know anything about that. I was not working that day. I am only a phone call away, and they are supposed to call me for something like that." The SSD stated, "Even if the resident denied that someone got into her bed it should have been reported." On 01/25/12 at 1:50 p.m. an interview with the DON revealed that she was first made aware of the allegation as the husband was rolling Resident #1 out of the building. Per the DON the husband would not speak with her. The DON revealed she then spoke with the RN supervisor and "I immediately told them to go talk with Resident #2." The DON revealed that Resident #2 denied that anyone had climbed in bed with her. Per the DON "those males on that shift were contacted to come in and do a statement." When the DON was asked about her knowledge of the regulation related to abuse she stated, "You ask the resident that is alleged to be abused if the incident happened and if they say it did you have to report it. When the resident denies anything happened, and she was not confused, then I would go by the first-hand information from the resident." Per the DON, "Typically when there is an allegation of abuse, immediately maintain the safety of the resident and a One Day report is filed and let the abuse coordinator know. The staff involved is suspended pending an investigation." A telephone interview on 01/25/12 at 2:40 p.m. was conducted with an Adult Protection Investigator (API) with the Department of Children and Families to discuss the allegation and the facility's response to the allegation. Per the API the allegation "should have been reported and let the folks that determine the allegation is not substantiated do their job. This resident may possibly be fearful of retaliation." On 01/25/12 at 3:05 p.m. an interview with RN #1, the nurse assigned to Resident #1 and #2 on the day shift of 1/21/12, revealed that Resident #1's husband told her "I am taking my wife out. I got the supervisor and we went to the room and that is when she stated those things. Resident #2 was in the room and at first she didn't say anything, but then later she wrote her own statement. It was just the two of them in the room." Per RN #1 she had worked with Resident #2 since November 2011. RN #1 revealed she worked in the facility as a floater and had worked with Resident #2 off and on. RN #1 revealed that Resident #2 had "good and bad days", and was alert and oriented to person, place and situation. On 01/25/12 at 3:12 p.m. an interview with RN #2 revealed that on 01/21/12 she came in around 6:45 a.m. that day and around 8:30 a.m. or 9:00 a.m. the nurse informed her of the allegation. "I questioned Resident #1, and spoke with the staff that were there, the staff members that worked that night and spoke with Resident #2." Per RN #2 she had known Resident #2 since she was admitted to the facility. RN #2 revealed that Resident #2 had intermittent confusion, but could make her needs known. Per RN #2 she found out who was assigned to Resident #2 and reported it to the DON and the nurse on-call. On 01/25/12 at 4:37 p.m. an interview with the NHA, in the presence of the DON and the Regional Vice President of Operations (RVPO), revealed the police were not notified of the abuse allegation, the allegation was not reported, and no employee was suspended because Resident #2, per the NHA, was "alert and oriented and would know if something happened. Nobody was suspended. What was I supposed to suspend anybody for?" On 1/25/12 at 5:37 p.m. the NHA requested to speak with this surveyor. The NHA stated, "I screwed up. I should have reported this." The NHA administrator revealed he would "take care of it now." On 1/26/12 at 5:56 p.m. a telephone conversation with LPN #1 revealed that around midnight "I do a walk around. Both were sleeping around 12 - 2:30 p.m. About 5:30 a.m. I went to give Resident #2 her meds and Resident #1 was emptying her BSC." Per LPN #1 he offered to empty the BSC for her and she sat on the bed and started brushing her hair. "I went to get the things for her blood sugar and it was normal. She laid back down. She denied pain, didn't act afraid; she seemed normal. LPN #1 revealed that the curtain was closed between the two residents. LPN #1 revealed that the residents in room [ROOM NUMBER] had a black male CNA the night of the alleged incident. Per LPN #1 Resident #2 "will cut the light on if she needs to get up. She needs assistance to and from the toilet. I woke her up about 5:30 a.m. to give her meds. Resident #2 is alert and oriented usually. First thing in the morning she is a little confused. She does have a urinary tract infection, but generally a straight on conversation with you." On 01/26/12 at 6:00 p.m. an interview with CNA #1 revealed he "was working on the north wing not the south wing. I was nowhere in the region on the assignment. Never worked with her. The thing is that there is allegations against someone else." On 01/26/12 at 6:19 p.m. an interview with CNA #2 revealed "Friday night I was the CNA and I went in to help her (Resident #2) go to the bathroom. I helped her about 3 times. She goes pretty regular. There was no lights on in the room. I left 134B (Resident #1) a towel and washcloth, and she said she did not need any help. She did not act startled or afraid or anything like that. I have worked with Resident #2 since she came here. Honestly, I think Resident #2 is forgetful and she will just stand there, and I have to remind her why she was in the bathroom. I think she still recognizes certain people. I think she has a short memory. I am pretty sure she knows me. She does not call me by name." On 1/26/12 at 6:20 p.m. a telephone interview with Resident #2's physician revealed he was not aware of the 01/21/12 alleged incident until the evening of 01/25/12. Resident #2's physician revealed that when he was informed on 01/25/12 of the allegation he came directly to the facility to assess Resident #2. On 01/27/12 at 9:16 a.m. the NHA stated, "I will always err on the side of caution. It is my duty to protect the residents and myself. I made a wrong decision. I will bring everything to the QA (Quality Assurance) meeting. I will to do some teaching. I will tell them my thought process, and what I did was wrong. I should have followed the process. I didn't follow what I had in place." Per the NHA he revealed he tried to contact Resident #1, but she or her husband would not speak with him. On 1/27/12 at 2:00 p.m. the NHA, DON, RVPO were informed that Immediate Jeopardy existed and was ongoing until there was evidence that training/re-training of staff was provided. The NHA stated, "You're kidding; why?" The NHA was advised that the facility failed to investigate and report an allegation of abuse. On 01/27/12 at 4:32 p.m. the NHA requested to speak with this surveyor, and said, "Would it make any difference that DCF came in to speak with Resident #2 Monday morning?" The NHA revealed that the DCF investigator informed him what she was there for, and why she needed to speak with Resident #2. The NHA then stated, "I should have put two and two together then, shouldn't I have?" Review of the facility's Abuse and Neglect policy approved on 11-06-08 revealed the following statements: POLICY: It is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, physical, sexual and mental abuse, corporal punishment and involuntary seclusion by facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse also includes those practices and omissions, neglect and misappropriation of resident property that left unchecked, lead to abuse. DEFINITIONS: Incident means alleged occurrences or episodes of staff misconduct and injuries of unknown origin. Staff means any employee, volunteer or contractor of the facility such as facility administrator, administrative staff, physicians, RNs, LPNs, nurse aides, podiatrists, dentists, vocational therapists, beauticians, housekeepers, dietary, laundry, maintenance staff and laboratory personnel. Staff misconduct means alleged (i) mistreatment of [REDACTED]. Abuse by definition is the willful (non-accidental) infliction of injury, unreasonable confinement, intimidation, or punishment resulting in harm, pain, mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psycho social well-being. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory words to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Sexual Abuse includes but is not limited to sexual assault, sexual coercion and sexual harassment. Physical Abuse includes, but is not limited to, threats of punishment, humiliation, harassment or deprivation. Mental Abuse includes, but is not limited to, threats of punishment, humiliation, harassment or deprivation. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. This facility prohibits mistreatment, neglect and abuse of residents and misappropriation of resident's property and although we cannot guarantee that a resident will not be abused we can only assure that the facility will take steps necessary to prevent abuse. Such steps include, but are not limited to, pre-employment screening of all employees, staff education and ongoing in-servicing of resident's rights, monitoring and investigation of incident and accidents. INVESTIGATION AND REPORTING PROCEDURE: 5. All alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to: ? The Director of Nursing ? The Administrator or the designated representative ? Director of Social Services or Abuse Officer ? Regional Director of Clinical Operations ? Regional VP of Operations ? The resident ' s attending physician - obtain order for treatment if needed ? The resident's family/responsible party ? Long-term care Ombudsman ? Police, if appropriate ? Follow Local and State guidelines for reporting and always report to State survey and certification agency. ? Follow Federal Guidelines for Reporting. No State law timeframe can override the Federal reporting timeframe. A. Report immediately via fax, to the appropriate agency. a) Immediately means as soon as possible but out not exceed 24 hours after discovery of the incident, in the absence of a shorter state timeframe requirement. 6. The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the investigation is in progress. TRAINING PROCEDURE: 4. Begin the internal investigation immediately after notifying the Administrator and appropriate parties and agencies. A thorough investigation should include, but is not limited to: a. Examining the alleged victim promptly and documenting findings, if any as part of the investigation report; b. Collecting and preserving physical and documentary evidence; c. Protecting the alleged victim from further abuse by identifying removing the cause of the danger; d. Interviews of victims and witnesses; e. collecting other corroborating/disproving evidence; f. Involvement of other regulatory authorities who can assist; g. Documentation of each step taken during the internal investigation; h. The Administrator will oversee all necessary corrective actions depending on the results of the investigation; f. The Director of Nursing will utilize an Incident Report, Report Log to analyze patterns and trends and analyze the data to determine what, if any, changes are needed to policies and procedures, staffing and facility systems to prevent additional occurrences. Reports should be made quarterly at Quality Assurance Committee meetings. However, changes in policy may be implemented immediately by Administration. The facility did not implement the policy and procedure set forth regarding abuse allegations. The facility did not conduct a thorough investigation and failed to report the abuse allegation to Resident #2's physician, the State and Federal reporting guidelines were not followed and the facility failed to protect the residents residing in the facility by failing to suspend the potential perpetrator(s) pending a thorough investigation. On 01/27/12 at 6:50 p.m. the facility provided evidence that 139 or it's 146 employees had received in-service and training of the Abuse Policy that was approved on 11/06/08. The information provided by the NHA revealed that no employee would be allowed to report on duty until the in-service training had been completed. The NHA, DON and the Vice-President of Operations were informed at 7:00 p.m. the IJ was removed. The facility took action including suspending an employee pending investigation, conducting & completing their own internal investigation, notifying the appropriate authorities, and providing training to staff. The IJ was removed on 1/27/12. At the time of exit the deficiency remained out of compliance at S/S=F. .