Every finding on record at Aviata at Brentwood

Based on observation, record review, and interview, the facility failed to ensure a resident-centered care plan was developed for 1 of 6 residents reviewed (Resident #6).Findings include: Review of Resident #6's admission record showed the resident was admitted on [DATE] with diagnoses to include diabetes mellitus, dysphagia, major depressive disorder, Parkinsonism, Alzheimer's disease, obstructive sleep apnea, and gastro-esophageal reflux disease without esophagitis.Review of Resident #6's physician order dated 3/31/2026 read, Nothing by Mouth diet NPO [nothing by mouth] texture, NPO Consistency.During an observation on 7/9/2026 at approximately 10:00 AM, Resident #6 was sitting up in bed. There was a large Styrofoam glass of ice cubes on the resident's bedside table.During an interview on 7/9/2026 at 10:00 AM, Resident #6 stated, I have been having ice chips for months. I let them melt in my mouth.Review of Resident #6's nursing note dated 7/9/2026 at 1:39 PM authored by the Director of Nursing (DON) read, Evaluation for ice at bedside by Speech Therapy. DON nursing request to therapy screen request to observe resident with ice at bedside.Review of Resident #6's care plan did not show any focus for the resident's non-compliance with the NPO order.During an interview on 6/9/2026 at 3:35 PM, the DON stated, There is no care plan for resident's non-compliance with NPO order.During an interview on 6/9/2026 at 6:06 PM, Regional Nurse Consultant stated, The care plan did not address ice chips or ice cubes nor the resident's refusal to address physician order for NPO.Review of the facility policy and procedure titled Plans of Care with the last review date of 1/26/2026, read, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or residence representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and social needs that are identified in the comprehensive assessment. Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS [Omnibus Budget Reconciliation Act Minimum Data Set] assessment (except discharge assessment), and as needed.

Based on observation, record review, and interview, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) for contact precautions for 1 resident who was on transmission-based precautions (Resident #5) to prevent the possible spread of infection and communicable diseases.Findings include:During an observation on 7/8/2026 at 9:30 AM, there was a signage for transmission-based precautions posted on the Resident #5's door that read, Contact Precautions. Stop. All family and visitors: Please report to nurses station or see staff before entering room. Everyone Must: Performa hand hygiene with alcohol-based hand rib (ABHR) or soap and water before entering and exiting. Wear gown before entering and remove upon exiting. Wear gloves before entering and remove upon exiting. The room door also had PPE supplies to include gown and gloves. The Social Services Director, Staff B, Certified Nursing Assistant (CNA), and a family member were in Resident #5's room. They did not have any PPE on.Review of Resident #5's physician order dated 7/8/2026 read, Isolation type- Contact D/T [due to] MRSA [methicillin-resistant Staphylococcus aureus] in urine.During an interview on 7/8/2026 at 9:30 AM, Staff B, CNA, stated, I did not see the sign before entering the room and that was the reason why I didn't have on the PPE.During an interview on 7/8/2026 at 9:32 AM, the Social Services Director stated, I have forgotten to put on PPE before entering the room.Review of the facility policy and procedures titled Isolation- Categories of Transmission-Based Precautions with the last review date of 2/2026 read, Policy Statement: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other resident. Policy Interpretation and Implementation: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs staff of the type of CDC [Centers for Disease Control and Prevention] precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions: 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on record review and interview, the facility failed to ensure the resident representative was notified of a sustained fall for 1 of 3 residents reviewed, Resident #129.Findings include:Review of Resident #129's SBAR (Situation, Background, Assessment, and Recommendation) Communication form showed the resident had a fall on 1/25/2025. Further review of the form showed it documented, [Resident #129's representative's name] she is emergency contact and there is no number for her and daughter as well but no numbers to call family. The form was signed by Staff E, Licensed Practical Nurse (LPN).During an interview on 12/9/2025 at 9:36 AM, Resident #129's Granddaughter stated, No one notified of the fall when it happened. I came into the facility and saw my grandmother's knees were a bloodbath. I called the unit manager on facetime and showed her what my grandmother looked like. She had me hold and that is when [Staff B, LPN's name] told me of the fall. During an interview on 12/9/2025 at 1:38 PM, Staff B, Licensed Practical Nurse (LPN), stated, [Resident #129' name's] granddaughter called me on a facetime. She was concerned with bruising. I asked her to let me see what she was talking about. I did not know at the time of the fall, when I checked the computer, I informed her of the fall. The nurse did call and could not reach her. If they had called me, I perhaps gotten a hold of her. At that time, I was the unit manager and was on call that day [1/25/2025] the fall happened. During an interview on 12/9/2025 at 3:00 PM, Staff E, LPN, stated, I cannot remember if I contacted the family or not.Review of the facility policy and procedure titled Notification of Change in Condition with the last review date of 5/20/2025 read, Policy: The Center to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is a(an): Accidents.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services under restorative nursing program as recommended by therapy department for 2 of 6 residents reviewed for restorative services, Residents #62, and #109. Findings include: 1) Review of Resident #62's occupational therapy discharge summary, dates of service 10/23/2025 to 11/8/2025, read, Discharge Recommendations: Restorative nursing plan. Restorative Program Established/Trained= Restorative Bed Mobility Program. Bed Mobility Program Established/Trained: rolling, sitting at EOB [Edge of Bed]. Prognosis: Prognosis to Maintain CLOF [Current Level of Functioning] = Good with consistent staff follow-through. Review of Resident #62's clinical records revealed no documentation indicating the resident received restorative nursing as recommended by the occupational therapist. During an interview on 12/10/2025 at 12:40 PM, the Director of Nursing confirmed Resident #62's clinical record did not include documentation indicating the facility had provided restorative nursing to Resident #62 as recommended by the occupational therapist. She confirmed the facility did not have a restorative nursing program. During an interview on 12/12/2025 at 8:30 AM, the Director of Nursing was unable to explain why the facility did not have a restorative nursing program and could not provide a date on which restorative program ended. 2) During an interview on 12/12/2025 at 8:40 AM, Resident #109 stated she had not had therapy for a while and would like to have therapy if it was offered to her. Review of Resident #109's physical therapy discharge summary, date of service 6/7/2025 to 9/12/2025 read, Progress & Response to Treatment: Pt [patient] has made good progress towards all goal areas with decreased assistance with bed mobs, transfers and gait. Patient does fluxuate [Sic.] with respiratory deficits requiring frequent rest periods. Patient also presents with occasional knee bucking in standing making patient at continue risk for falls. Patient discharged at this time with RNP [Restorative Nursing Program]. During an interview on 12/11/2025 at 10:44 AM, the Rehabilitation Director stated, [Resident #109's name] was responsive she was discharged with supervision when ambulating. She was discharged because she met her maximum potential and recommend to go to the restorative program. I was not aware the facility does not have a restorative program. During an interview on 12/12/2025 at 9:50 AM, the Director of Nursing stated that the facility had not had a restorative program for a couple of months. Review of the facility policy and procedures titled Restorative Nursing Services with the last review date of 5/20/2025 read, Policy: The center provides restorative nursing to encourage and enable residents to be as independent as possible based on their individual condition, and goals. Restorative nursing programs are considered for residents who: Are not a candidate for rehab services. Benefit from restorative along with rehab services.

Based on record review and interview, the facility failed to take action on the results of laboratory testing in a timely manner for 1 of 3 residents reviewed for laboratory services, Resident #129.Findings include: Review of Resident #129's admission record documented the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia, anemia, long term (current) use of insulin, and chronic kidney disease.Review of physician initial encounter note dated 12/9/2024 read, HPI [History of Present Illness] [Resident #129's name] is an [AGE] year-old female who presented to Aspire Brentwood after evaluation at a local hospital for urinary retention and altered mental status. She was found to have a urinary tract infection and was started on intravenous antibiotics; the infection was likely responsible for her altered mental status. She was dehydrated and received intravenous fluids. Her diabetes was uncontrolled and was managed with insulin. During her hospital stay, she improved and participated in physical and occupational therapy. Due to her weakness and overall medical condition, it was determined she would benefit from continued medical and therapy care at a rehabilitation facility. Plan: Cont. [continue] meds [medications] for DM-II [type 2 diabetes mellitus]- Glipizide, Pioglitazone, Accuchecks AC/HS [blood sugar checks before meals and at bed time], Sliding scale insulin.Review of Resident #129's physician orders showed a lab order dated 12/9/2024 that included Hemoglobin A1C (measures the average blood sugar (glucose) levels over the past two to three months).Review of Resident #129's Lab Results Report with the reported date of 12/11/2024 showed the hemoglobin A1C of 10.8.Review of Resident #129's nursing progress notes revealed no notification of the reported results to the physician.Review of Resident #129's physician order dated 12/21/2024 read, Lantus Subcutaneous Solution 100 unit/ml [milliliter] (Insulin Glargine), Inject 10 unit subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia, Hold if BS [blood sugar] less than 126.Review of Resident #129's physician order dated 12/21/2024 read, Insulin Lispro Injection Solution (Insulin Lispro), Inject as per sliding scale: if 0-150= 0; 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units; 401-499= 12 units, Call MD [Medical Doctor], subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with hyperglycemia.During an interview on 12/9/2025 at approximately 2:00 PM, the Director of Nursing (DON) stated, The physician should have been notified of these results.During an interview on 12/10/2025 at 2:30 PM, Resident #129's physician stated, Vaguely remember the resident, cannot say that the facility has a history of not reporting lab results or problems. It could simply be an oversight. It was so long ago, cannot answer with any certainty if they report results to me.

Based on record review and interview, the facility failed to ensure accuracy of minimum data set assessments for 1 of 3 residents reviewed for dialysis (Resident #6).Findings include:Review of Resident #6's physician order dated 4/29/2025 read, Hemodialysis- Tuesday, Thursday and Saturday- [Address and Phone number of Dialysis Center].Review of Resident #6's quarterly Minimum Data Set assessment dated [DATE] showed dialysis was not checked under Section O- Special Treatments, Procedures and Programs.During an interview on 11/4/2025 at 12:44 PM, the Director of Nursing stated, [Resident #6's name] is a dialysis patient.During an interview on 11/4/2025 at 12:47 PM, the Minimum Data Set Registered Nurse stated, [Resident #6's name] is a dialysis patient. Section O would need to be corrected. We follow the RAI [Resident Assessment Instrument] manual.

Based on observation, interview, and record review, the facility failed to ensure residents received blood pressure medications as ordered for 1 of 3 residents reviewed for medication management (Resident #6).Findings include: Review of Resident #6's physician order dated 10/9/2025 read, Midodrine HCl Oral Tablet 5 MG [milligram] (Midodrine HCl), Give 5 mg by mouth every 12 hours as needed for hypotension. Give for Systolic BP [Blood Pressure] less than 110 and diastolic BP less than 60.Review of Resident #6's Weights and Vitals Summary showed the blood pressure of 105/54 mmHg [millimeters of mercury] on 10/11/2025 at 5:04 PM and 102/50 mmHg on 10/11/2025 at 11:19 PM.Review of Resident #6's Medication Administration Record (MAR) for October 2025 for administration of Midodrine HCl 5 mg showed no documentation on 10/11/2025.During an interview on 11/5/2025 at 9:55 AM, the Advanced Practice Registered Nurse #1 stated, On 10/11/2025, the on call notes did not mention anything about blood pressure, but Midodrine was already at hand. Parameters are ordered for a reason. [Resident #6's name] blood pressure some days was through the roof and some days was lower than normal. Not sure if the staff had checked her blood pressure and then rechecked the blood pressure and it had recovered.During an interview on 11/5/2025 at 10:42 AM, Staff A, Licensed Practical Nurse (LPN), stated, On 10/11/2025, I was checking on [Resident #6's name] and she had no signs of distress throughout the day. I don't recall why the medication is not marked as given. I always look at parameters. If I would have given the medication, I would have documented on the MAR.During an interview on 11/5/2025 at 12:08 PM, the Director of Nursing stated, Midodrine should have been given and parameters should have been followed.Review of the facility policy and procedure titled Medication- Oral Administration of with an effective date of 11/30/2014 read, Procedure. Review physician's order.

Based on record review and interview, the facility failed to ensure medical records were accurate for 3 of 10 sampled residents (Residents #3, #4, and #5).Findings include: 1) Review of Resident #3's clinical record revealed an incident report dated 10/17/2025 that documented, At approximately 1645 [4:45 PM] [Resident #3's Name] was found lying on the floor on the left side of his bed lying on his right side. The right side of his forehead had a large actively bleeding laceration, as well as a skin tear on the right knee and right hand. His right eye was swollen shut and has a hematoma near the eyebrow. Other info: Attempted to climb out of bed on his own and unaware of his limitations. Review of Resident #3's hospital Discharge summary dated [DATE] read, Patient is a [AGE] year old male who presented in a c-collar [cervical collar] and not on a backboard as a level 1 trauma alert by air after a ground level fall. Per EMS [Emergency Medical Services] report, patient came from assisted living facility [Sic.] after a fall. It was reported that patient fell forward and onto his head and face. Patient was found to have the following injuries: - Nondisplaced fracture of the right orbital floor. No herniation of intraconal fat. - Nondisplaced fracture of the anterior wall the right maxillary sinus. - Comminuted, minimally displaced fracture of the lateral wall of the right maxillary sinus. - Right forehead scalp laceration and subcutaneous hematoma. - Right preseptal soft tissue swelling. - Small right frontoparietal subdural hematoma measuring up to 2 mm [millimeters]. Review of Resident #3's fall risk evaluation dated 10/31/2025 read, History of falling (Immediate or previous [within the last 6 months])? No. The fall risk evaluation documented Resident #3's fall risk score as 35 with a category assignment of Low Risk. During an interview on 11/4/2025 at 12:40 PM, the Director of Nursing stated, Well that's [Resident #3's fall risk assessment dated [DATE]] incorrect. 2) Review of Resident #4's physician order dated 9/18/2025 read, Wound Care: Sacrum-Cleanse with NS [Normal Saline]- pat dry- apply collagen and calcium alginate- skin prep periwound- cover with superabsorb every day shift. Review of Resident #4's Treatment Administration Record (TAR) for October 2025 for wound care of sacrum cleansing with normal saline and applying collagen and calcium alginate showed no entry documented on 10/3/2025. Review of Resident #4's physician order dated 10/3/2025 read, Wound Care: Sacrum- Cleanse with NS- pat dry- gently pack with collagen sheet and calcium alginate- skin prep periwound-cover with superabsorb dressing every day shift. Review of Resident #4's TAR for October 2025 for wound care of sacrum cleansing with normal saline and gently packing with collagen sheet and calcium alginate showed no entries documented on 10/5/2025 and 10/9/2025. Review of Resident #4's physician order dated 10/3/2025 read, Wound Care- (R) [Right] Lateral thigh- cleanse with N/S, cover with hydrocolloid dressing, every day shift. Review of Resident #4's TAR for October 2025 for wound care for the right lateral thigh showed no entry documented on 10/5/2025. Review of Resident #4's physician order dated 10/20/2025 read, Wound Care: Sacrum- Cleanse with Dakins- pat dry- apply Dakins Moistened Kerlix packing- cover with a superabsorbent every day shift. Review of Resident #4's TAR for October 2025 wound care of sacrum cleansing with Dakins and applying Dakins moistened kerlix showed no entry documented on 10/29/2025. Review of Resident #4 TAR for November 2025 for wound care of the sacrum cleansing with Dakins and applying Dakins moistened kerlix showed no entry documented on 11/1/2025. During an interview on 11/5/2025 at 11:23 AM, the Wound Care Nurse stated, Resident #4's name] will refuse care at times depending on her mood. She would refuse wound care from floor nurses. Since I have been doing her care, she has not refused. I don't know why her wound care treatment record has blanks. Maybe she has been hospitalized . A lot of times wound care would fall on the nurse on the cart to do the wound care, not sure why there are blanks. During an interview on 11/5/2025 at 12:08 PM, the Director of Nursing (DON) stated, The treatment record should not have any blanks. The nurses are to document accurately the treatment provided and if resident refused should document accordingly. 3) Review of Resident #5's Medication Administration Record (MAR) for September 2025 for administration of Aspirin 81 Oral Tablet Chewable (Aspirin), Give 1 tablet by mouth one time a day for preventative showed code 8 (nausea/vomiting) documented on 9/25/2025 at 9:00 AM. Review of Resident #5's progress note dated 9/25/2025 read, Nausea reported. New admit medication not on hand. will contact MD [Medical Doctor] regarding nausea. During an interview on 11/5/2025 at 8:04 AM, the Director of Nursing stated, Per the nurse [Staff B's name], she said he [Resident #5] was nauseous and she held the mediation. She mentions she would contact the provider and then circle back to the resident and later it resolved and the provider did come and see him shortly after and no complaints of nausea. Per [Staff B's name] he was refusing medication because he was nauseous. During an interview on 11/5/2025 at 11:58 AM, Staff B, Registered Nurse (RN), stated, The provider came to see him [Resident #5]. I went in. He was nauseous. I didn't contact the provider because I when back to check on him when I finished my med pass and he was fine. I don't remember, I don't want to misspeak. It should be documented. During an interview on 11/5/2025 at 1:26 PM, the Advanced Practice Registered Nurse (APRN) #2 stated, I really cannot say if not having that medication could affect him. I don't recall if they notified me about the medications. [Resident #5's name] had no alarming vitals that would concern me that were documented. During an interview on 11/5/2025 at 2:06 PM, the DON stated, The nurse should have documented her action when she circled back with the resident to have a better understanding of what happened. During an interview on 11/5/2025 at 12:07 PM, the Regional Nurse Consultant stated, We do not have a documentation policy.

Based on record review and interview, the facility failed to implement the discharge policy developed to ensure follow up with discharged residents for 1 resident (Resident #2) of 3 residents reviewed for discharge.Findings include: Review of Resident #2's admission record showed the resident was admitted with diagnoses that included sepsis, acute respiratory failure with hypoxia, type 2 diabetes mellitus with ketoacidosis and hyperglycemia without coma, acquired absence of right leg below knee, encounter for orthopedic aftercare, acquired absence of right great toe, morbid severe obesity due to excess calories and encounter for surgical aftercare, and discharged on 6/17/2025. During an interview on 6/30/2025 beginning at 10:44 AM, Staff A, Case Manager, stated, [Resident #2's name] elected to discharge home from the facility on 6/17/2025 after his insurance company discontinued payments for skilled services. I called [Resident #2's name] insurance company and they told me to set up home health care with their parent company. The insurance company would set up day of discharge home health care and gave me a reference number for the home health services. I found out on 6/20/2025 that home health services have not been to [Resident #2's name] home. I contacted [Resident #2's name] parent insurance company that told home health services have not been set up for [Resident #2's name] because of the limitations of his plan. I do not know why [Resident #2's name] parent insurance company has provided a reference number for home health services. I did not follow up with [Resident #2's name] to verify home health services are being provided to [Resident #2's name]. I did not do a follow up call. I just forgot to give him a follow-up call. I have not talked to him. During an interview on 6/30/2025 at 10:48 AM, the Director of Nursing stated, My expectation is that a follow-up call is made to discharged residents to check on them. During an interview on 6/30/2025 at 11:12 AM, the Administrator stated, [Resident #2's name] discharged from the facility on 6/17/2025 due to his insurance company declining to pay for additional skilled services. I was notified by adult protective services on 6/20/2025 that [Resident #2's name] was not receiving home health services. Review of the facility policy and procedures titled Discharge Planning last reviewed on 5/22/2025 read, Procedure. 6. Within twenty-four (24) to forty-eight (48) hours (or next day) after discharge to home, another nursing facility or to another type of residential facility such as a board-and-care home, a follow up phone call, or if necessary, home visit will be made to ascertain that community services/referrals are indeed being provided according to the discharge plan.

Based on observation, record review, and interviews, the facility failed to ensure care and services were provided for a PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 (Resident #1) of 3 Residents reviewed with a PICC access device. Findings include: Review of Resident #1's clinical record documented re-admission to the facility on [DATE] with diagnosis that included intraspinal abscess and granuloma (cluster of white blood cells), osteomyelitis (infection of the bone), and urinary tract infection. During an observation on 2/24/2025 at 09:45 AM Resident #1 was lying in bed with a PICC noted in the upper right arm. There was a transparent dressing cover the top of the PICC. The transparent dressing was dated 2/9/2025. (Photographic evidence obtained) During an interview on 2/24/2025 at 09:45 AM Resident #1 stated, I came into the facility with the catheter from the hospital and the dressing was changed once since then. It has not been changed since then. During an interview on 2/24/2025 at 10:08 AM Staff A, LPN (Licensed Practical Nurse) stated, The dressing should have been changed on the evening shift after seven days. I administered Vancomycin through the line and did not pay attention to the date of 2/9/2025 on the dressing, I should have changed it. During an interview on 2/24/2025 at 10:20 AM Staff B, LPN Unit Manager confirmed the transparent dressing to Resident #1's upper right arm was dated 2/9/2025 and stated, The PICC dressing is dated 2/9/2025. It was not changed and should have been changed every seven days. Review of Resident #1's physician orders dated 2/9/2025 read, Change Dressing on admission or 24 hours after insertion and weekly thereafter and PRN [as needed]. Review of Resident #1's Treatment Administration Record for February 2025 documented that PICC dressing change was not completed every seven days as ordered. During an interview on 2/24/2025 at 3:59 PM the Director of Nursing stated, My expectation is for the PICC line dressing to be changed within 24 hours after admission and then every seven days and as needed, if the dressing is soiled. The PICC line dressing should have been changed on the 17th, but it was not and has not been changed since 2/9/2025.

Based on observation, interview, and record review, the facility failed to follow safe smoking practices for 4 of 5 residents reviewed for accidents, Resident #3, #15, #35, and #61. Findings include: 1. During an observation on 8/12/2024 at 8:49 AM, there was a pink device with mouth piece on top of drawer in Resident #3 room. Review of Resident #3's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #3's care plan initiated on 5/3/2024 showed it read, Focus: The resident smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. During an observation on 8/13/2024 at 2:55 PM, with Staff G, Licensed Practical Nurse (LPN) Unit Manager, the smoking box located in the nursing station did not contain any vaping devices. During an interview on 8/13/2024 at 2:55 PM, Staff G, LPN Unit Manager, stated, It is not smoking time. The vapes should be in the box stored away. I do not see any vapes in the box, not sure where they could be. The staff scheduled for supervising the smoking break is responsible for collecting the vapes when it is the end of the smoking break. 2. During an observation on 8/13/2024 at 3:13 PM, Resident #35 was sitting up in his bed with a black vaping device on top of the resident's bedside table in front of him. During an interview on 8/13/2024 at 3:13 PM, Resident #35 stated, We were told we could have our vapes with us. I do not go outside to use it. I vape in my room. You cannot smell it. The staff and doctors have seen me and have not said anything to me. Review of Resident #35's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #35's care plan initiated on 5/3/2024 showed it read, Focus: [Resident #35's name] smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 3. During an observation on 8/13/2024 at 3:21 PM, Resident #15 had a vaping device on top of his bed. Resident #15 handed the vape to the Director of Nursing (DON). During an interview on 8/13/2024 at 3:21 PM, Resident #15 stated, I always have my vape with me, but you can take it. Review of Resident #15's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #15's care plan initiated on 5/3/2024 showed it read, Focus: The resident smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 4. During an observation on 8/13/2024 at 3:23 PM, Resident #61 was sitting up in his bed. When the DON requested the vape device, the resident refused. After the DON explained the policy, Resident #61 top out vape device from inside a bed pan on top of his bedside table and gave it to the DON. During an interview on 8/13/2024 at 3:23 PM, Resident #61 stated, It is my right to have my vape. I am not a prisoner. I have never signed a policy stating I am not able to have the vape with me. Review of Resident #61's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #61's care plan initiated on 5/3/2024 showed it read, Focus: The resident smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. During an interview on 8/13/2024 at 3:30 PM, with the DON stated, I have been here in the facility for two months and we know this is a problem and we are working towards addressing the compliance of turning in the vapes at the end of the smoking times. [Resident #3's name] did have it in her room and we removed the vaping device form her room. Review of the facility policy and procedure titled Smoking-Supervised with the last review date of 1/23/2024 showed it read, Policy: The center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times . Procedure . 8. Electronic cigarettes are permitted, but only in facility designated smoking areas. a. The same rules that apply to regular tobaccos cigarettes also apply to electronic smoking materials. b. Electronic cigarettes and materials, including the liquids, will be retained and stored by nursing staff.

Based on record review and interview, the facility failed to ensure 2 of 3 residents reviewed for preadmission screening and resident review (PASRR), Resident #38 and Resident #22, were referred to the appropriate state designated authority for Level II PASRR evaluation and determination. Findings include: Review of Resident #38's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis not due to a substance or known physiological condition (onset date 1/5/2022). Review of Resident #38's psychiatry progress note, date of service 6/24/2024, revealed the resident had diagnoses that included brief psychotic disorder. Review of Resident #38's Level I PASRR completed by the facility staff on 3/27/2024 failed to reveal documentation in Section 1: PASRR Screen Decision-Making A. MI [Mental Illness] or suspected MI (check all that apply) that Resident #38 had a diagnosis of psychotic disorder. Review of Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following) showed it read, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #22's admission record revealed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included pseudobulbar affect (onset date 7/9/2021), delusional disorders (onset date 5/11/2021) and unspecified psychosis not due to a substance or known physiological condition (onset date 1/14/2021). Review of Resident #22's psychiatry care plan note, date of service 6/10/2024, revealed the resident had diagnoses that included brief psychotic disorder and pseudobulbar affect. Review of Resident #22's Level I PASRR completed by the facility staff on 3/27/2024 failed to reveal documentation in Section 1: PASRR Screen Decision-Making A. MI or suspected MI (check all that apply) that Resident #2 had diagnoses of pseudobulbar affect, delusional disorders and psychotic disorder. Review of Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following) showed it read, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. During an interview on 8/14/2204 at 12:35 PM, the Director of Nursing stated Resident #38's and Resident #22's PASRRs were not accurate, should include the residents' psychiatric diagnoses and needed to be corrected.

Based on observation, interview, and record review, the facility failed to maintain a clean and homelike environment in one hall out of three main front hallways. Findings include: During an interview on 8/12/2024 at 11:09 AM, Resident #58 stated, Did you see the black stuff in the hallway on the ceiling, over there where they do Bingo. It should be cleaned off. During an observation on 8/12/2024 at 2:20 PM, the hallway between main dining room and 400 Hall had a water leak in a ceiling tile and black substance on upper support header. (Photographic evidence obtained) During an interview on 8/12/2024 at 2:45 PM, the Maintenance Director confirmed there was a leak in the roof above the hallway and stated it had been an issue for a while. During an interview on 8/13/2024 at 3:30 PM, Resident #35, Resident Council President, stated that Resident Council has reported concerns to management with water leaking and mold on the ceiling in the hallway outside of the main dining room for a long time. Review of the facility policy and procedure titled Maintenance dated 11/30/2014 and reviewed on 1/23/2024 showed it read, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/ items in need of repair. Procedure . The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper condition.

Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents reviewed for discharge status (Resident #102), 1 of 4 residents reviewed for nutrition (Resident #2), and 1 of 5 residents reviewed for falls (Resident #10). Findings include: 1. Review of Resident #102's admission record showed the resident was admitted to the facility on [DATE] and discharged on [DATE] to an Assisted Living Facility. Review of Resident #102's MDS (Minimum Data Set) discharge return not anticipated assessment dated [DATE] showed Section A2105- Discharge Status documented the resident was discharged to a short-term general hospital. Review of Resident #102's progress note titled Discharge Summary and dated 6/25/2024 showed it read, Pt [Patient] discharged to ALF [Assisted Living Facility]. Pick up with ALF staff via wheelchair. discharged with personal belongings, discharge papers and remaining prednisolone eye drops and insulin pen. During an interview on 8/13/2024 at 12:27 PM, Staff A, MDS Coordinator, verified that Resident #102 was coded as discharging to short-term general hospital. 46523 2. Review of Resident #2's physician order dated 2/26/2024 showed it read, CCD NAS [Controlled Carbohydrate Diet No Added Salt] diet, Regular Texture, regular/thin liquids consistency, all meats chopped. Review of Resident #2's quarterly MDS dated [DATE] showed it read, K0520. Nutritional Approaches . C. Mechanically altered diet require change in texture of food or liquids (e.g. pureed food, thickened liquids) . 3. While a Resident: No. During an interview on 8/14/2024 at 10:25 AM, Staff A, MDS Coordinator, stated, [Resident #2's name] had orders for all meats chopped. The mechanically altered diet should have been coded yes. 3. Review of Resident #10's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including other lack of coordination, unspecified dementia, muscle weakness, difficulty in walking, other seizures, restlessness and agitation, and cognitive communication deficit. During an observation on 8/13/2024 at 8:24 AM, Resident #10 was lying in bed with bed position at the lowest level and a sign on the closet door that read, call don't fall. Review of Resident #10's annual MDS dated [DATE] showed the resident did not have any falls since admission or prior to assessment under Section J1800. Review of Resident #10's progress note dated 4/25/2024 showed it read, Discussed fall that occurred on 4/24/2024 @ 515PM [at 5:15 PM]. Resident was found on the floor in her room. Resident stated that she was getting up to walk and fell . Bump noted to top of scalp. MD [Medical Doctor] and family notified. New intervention for lab review for AMS [Altered Mental Status]. Review of Resident #10's Change in Condition form dated 4/24/2024 showed it read, Situation: Fall without injury. Review of Resident #10's care plan initiated on 5/24/2022 showed it read, [Resident #10's name] is at risk for falls r/t [related to] lack of coordination, other symptoms and signs involving cognitive functions and awareness and need for assistance with personal care. Review of Resident #10's care plan initiated on 12/11/2023 showed it read, [Resident #10's name] has actual fall-poor balance, unsteady gait r/t unspecified dementia, unspecify severity without behavioral, psychotic or mood disturbance, and anxiety, altered mental status, other lack of coordination, other symptoms and signs involving cognitive functions and awareness and need for assistance with personal care. During an interview on 8/14/2024 at 10:20 AM, Staff A, MDS Coordinator, stated, [Resident #10's name] is coded incorrectly. She did have fall prior to the assessment. Review of the facility policy and procedure titled MDS with the last review date of 1/23/2024 showed it read, Policy: The center conducts initial and periodic standardized, comprehensive and reproductive assessment no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weakness, and preferences using the federal and/or state required RAI. Procedure . Each person completing a section or portion of a section of the MDS signs the attestation statement indicating its accuracy.

Based on observation, interview, and record review, the facility failed to ensure that residents received wound care treatment in accordance with professional standards of practice for 1 of 5 residents reviewed for skin conditions, Resident #85. Findings include: During an observation on 8/12/2024 at 8:55 AM, Resident #85 had a bandage placed over her forehead dated for 8/10/2024 with unreadable initials under the date. The bandage was not adhered to the head with all adhesive not touching the skin. The bandage was being held on with dried blood from the wound the bandage was covering. During an observation on 8/13/2024 at 10:15 AM, Resident #85 had a bandage placed over her forehead dated for 8/10/2024 with unreadable initials under the date. The bandage was not adhered to the head with all adhesive not touching the skin. The bandage was being held on with dried blood from the wound the bandage was covering. Review of Resident #85's physician order dated 1/2/2024 showed it read, Woundcare [Sic]-forehead open area cleanse with NS [Normal Saline], pat dry, cover with DPD [Dry Protectant Dressing] change daily and PRN [as needed]. Review of Resident #85's Treatment Administration Record (TAR) for August 2024 for wound care of the forehead showed no entry documented on 8/11/2024. During an interview on 8/14/2024 at 2:20 PM, the Director of Nursing (DON) stated, All physician orders need to be followed and if the nurse feels the order is not appropriate for the resident, she would be expected to contact the ordering physician to inform and obtain new orders for the wound care. During an interview on 8/14/2024 at 2:46 PM, Staff E, Wound Care Licensed Practical Nurse (LPN), stated, The dressing was not changed for the resident on 8/12/24. The wound care order would stay yellow on the charting system, and the nurse would know that the wound did not get the dressing changed and they would be obligated to complete the order. Review of the facility policy and procedure titled Dressing Change with the last review date of 1/23/2024 read, Policy: A clean dressing will applied [Sic] by a nurse to a wound as ordered to promote healing . Procedure . Apply treatment as order [Sic] and clean dressing.

Based on record review and interview, the facility failed to ensure medical records were accurate for 1 of 5 residents reviewed for skin conditions, Resident #10, and 1 of 6 residents reviewed for medication administration, Resident #20. Findings include: 1. Review of Resident #10's physician order dated 6/19/2024 read, Woundcare [Sic]- sacrum apply house barrier cream three times a day and prn [as needed] . Order Status: Active . Start Date: 06/19/2024. Review of Resident #10's Medication Administration Record (MAR) for June 2024 for administration of house barrier cream on sacral wound showed no entries documented on 6/20/20204, 6/23/2024 and 6/24/2024 at 5:00 AM. Review of Resident #10's MAR for July 2024 for administration of house barrier cream on sacral wound showed no entries documented on 7/3/2024 at 1:00 PM, and on 7/7/2024, 7/10/2024, 7/13/2024, 7/21/2024, 7/24/2024, and 7/27/2024 at 5:00 AM. Review of Resident #10's MAR for August 2024 for administration of house barrier cream on sacral wound showed no entries documented on 8/1/2024, 8/4/2024, 8/7/2024, and 8/10/2024 at 5:00 AM. During an interview on 8/14/2024 at 1:45 PM, the Director of Nursing stated, The application of the barrier cream is being done, but the staff is not documenting it in the MAR. If the order is on the MAR, staff is expected to accurately document in the system. 2. Review of Resident #20's physician order dated 8/7/2024 showed it read, Midodrine HCl Oral Tablet 5 mg [milligram] (Midodrine HCl), Give 1 tablet by mouth every 8 hours related to orthostatic hypotension hold for BP >110 (blood pressure greater than 110). Do not administer past 6 PM. Review of Resident #20's MAR for August 2024 showed Midodrine HCl 5 mg was administered at 10:00 PM on 8/8/2024, 8/9/2024, 8/10/2024, and 8/13/2024. During an interview on 8/13/2024 at 9:42 AM, the Director of Nursing stated, [Resident #20's name] order was a transcription error. It will be updated. Review of the facility policy and procedure titled Documentation of Progress with the last review date of 1/23/2024 showed it read, Policy: Documentation of a resident's condition will provide an accurate and timely record of their progress taking into consideration their acuity and length of stay. Review of the facility policy and procedure titled Physician Orders with the last review date of 1/23/2024 showed it read, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing wound care, failed to implement enhanced barrier precautions, and failed to ensure staff used appropriate personal protective equipment while providing high contact care to the residents on enhanced barrier precautions to prevent possible spread of infection and communicable diseases. Findings include: 1. During an interview on 8/13/2024 at 8:45 AM, Staff E, Wound Care Licensed Practical Nurse (LPN), stated, [Resident #36's name] has a surgical wound on her abdomen and a pressure ulcer in her coccyx area, which she acquired during her last hospital stay. During an observation on 8/13/2024 at 9:03 AM, Staff E, Wound Care LPN, and Staff F, Certified Nursing Assistant (CNA), entered Resident #36's room. There was no enhanced barrier precautions sign or personal protective equipment outside of the resident room. Staff E and Staff F performed hand hygiene and donned gloves but did not don a gown. Staff F assisted Staff E with positioning Resident #36. The resident was turned on her side and a hydrocolloid dressing dated 8/10/2024 was observed. Staff E removed the dressing from coccyx and performed hand hygiene. Staff E prepared all wound care supplies and donned gloves and placed a barrier on the back of the resident's buttocks area. Staff E cleaned the open wound located in Resident #36's coccyx with gauze and normal saline. Without performing hand hygiene, Staff E patted dry the wound. Then, Staff E removed her gloves and performed hand hygiene. Staff E donned new pair of gloves and applied dressing to the coccyx area. Staff E and Staff F adjusted and placed briefs back on Resident #36. Without performing hand hygiene or removing the gloves used to dress the coccyx wound, Staff E continued to remove dressing located in the center of Resident #36's abdomen. Staff E removed gloves and washed her hands. Staff E donned new pair of gloves and applied iodine to Resident #36's surgical incision. Staff E preformed hand hygiene and donned new pair of gloves. Staff E applied new dressing to abdominal incision and readjusted Resident #36's briefs. Without performing hand hygiene or removing the gloves used to apply dressing to the abdominal incision, Staff E lifted Resident #36's left foot and applied skin prep to the left heel deep tissue injury wound. Review of Resident #36's physician orders dated 8/13/2024 showed it read, Isolation type-Enhanced Barrier Precautions d/t [due to] open wounds. 2. During an observation on 8/13/2024 at 10:14 AM, Staff E, Wound Care LPN, and Staff F, CNA, donned gloves and gown before entering Resident #3's room. Staff E preformed hand hygiene and removed old dressing and removed gloves. Without performing hand hygiene started to open the packets of gauze. Staff E donned new pair of gloves without hand hygiene and cleansed the wound in sacrum area with normal saline. Without performing hand hygiene, Staff E patted dry the cleaned area. Staff E removed gloves and performed hand hygiene and donned new pair of gloves. Staff E applied treatment and dressing to the sacral area. Staff E removed her gloves and performed hand hygiene and cleansed the wound on the right posterior thigh, which was not covered by a dressing. Staff E cleaned the wound and without hand hygiene, patted dry the area. Staff E removed her gloves and performed hand hygiene and applied dressing to the right posterior thigh. Review of Resident #3's physician orders dated 8/13/2024 showed it read, Isolation type-Enhanced Barrier d/t wounds. During an interview on 8/13/2024 at 10:42 AM, Staff E, Wound Care LPN, stated, I should have done hand hygiene after cleaning the wound and when I removed my gloves [for Residents #3 and #36]. [Resident #36 name] does not have orders for enhanced barrier precaution that is why I didn't gown. I should have performed hand hygiene after cleaning the wound and also when removed the abdominal dressing after touching the briefs with the gloves. During an interview on 8/14/2024 at 11:04 AM, the Director of Nursing (DON) stated, Staff are expected to don gloves and gown when providing direct care to the residents who are on enhanced barrier precautions. [Resident #36's name] has enhanced barrier precautions due to her open wounds. Staff are expected to perform hand hygiene after cleaning a wound and moving onto another step and once they remove their gloves, they should perform hand hygiene before donning new set of gloves. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/23/2024 showed it read, Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities. Definitions . High contact care activity- provide opportunities for transfer of MDRO to staff hands and clothing. High contact care activities include: dressing, bathing/showering, transferring, providing hygiene, such as brushing teeth, combing hair and shaving, changing linens, incontinent care, toileting, device care or use, such as central line, urinary catheter, feeding tube, tracheostomy or ventilator, wound care. Enhanced Barrier Precautions (EBP): the infection control process that reduces the spread of MDROs by using gloves and gowns for high contact care activities . Procedure: 1. Identify residents who are appropriate for EBP including . b. Resident who have a wound and/or indwelling medical devices. Review of the facility policy and procedure titled Dressing Change with the last review date of 1/23/2024 showed it read, Policy: A clean dressing will applied [Sic] by a nurse to a wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Procedure . Perform hand hygiene, Apply gloves, Remove and dispose of soiled dressing, Remove gloves, Perform hand hygiene, Apply gloves, Evaluate wound for type, color, amount of drainage, Cleanse wound as ordered, dispose of gauze, Remove gloves and perform hand hygiene. Review of the facility's Skills Competency Assessment: Clean Dressing Change with the last review date of 1/23/2024 showed it read, The employee demonstrates skills and competence in the following . 10. Place supplies on prepped work surface and position wastebasket/bag in accessible area for dressing disposal per universal precautions. 11. Perform hand hygiene (soap and water or hand sanitizer) and apply gloves. 12. Open dressing packaging, Write date, time and nurse initials on cover of dressing or pre-cut tape. wipe scissors before and after use with alcohol pad. 13. Remove gloves. perform hand hygiene (soap and water or hand sanitizer). 14. Apply glove. Provide privacy and position resident comfortably and appropriately. Monitor pain level prior to beginning and during dressing change. 15. Place a clean barrier under area to be dressed. 16. Remove soiled dressing and dispose of as per policy. 17. Remove gloves. Performed hand hygiene. 18. Apply gloves. Assess wound for type, color, amount of drainage. Obtain wound culture if indicated. 19. Cleanse wound as ordered . 21. Remove gloves. Perform hand hygiene. 22. Don gloves and applies [Sic] treatment as ordered. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 1/23/2024 showed it read, Overview: The CDC [Centers for Disease Control and Prevention] defines hand hygiene as cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e. alcohol-based sanitizer including foam or gel) . Process: Hand hygiene should be performed . After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wounds dressings.

Based on record review and interview, the facility failed to ensure the nurse staffing information was posted on a daily basis (Photographic evidence obtained). Findings include: Review of the displayed nurse staffing information document on Monday, 8/12/2024 at 5:59 AM, showed the nurse staffing information for Friday, 8/9/2024, was posted in the front lobby area of the facility. During an interview on 8/12/2024 at 7:00 AM, the Director of Nursing confirmed the posted nurse staffing information was not updated daily. He stated that the weekend supervisor was responsible to ensure the nurse staffing information was posted daily. During an interview on 8/14/2024 at 12:02 PM, the Director of Nursing stated the facility did not have a policy related to posting nurse staffing information. He stated the facility followed the federal regulation.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 12 of 13 residents reviewed, Residents #6, #11, #12, #28, #44, #58, #59, #68, #70, #97, #98, and #204. Findings include: 1. Review of Resident #28's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, other pulmonary embolism without acute Cor Pulmonale (a condition that causes the right side of the heart to fail), essential (primary) hypertension, congenital pneumonia, sleep apnea, and longstanding persistent atrial fibrillation. During an observation on 4/3/2023 at 9:38 AM, Resident #28 was lying in bed, receiving oxygen via nasal cannula at 2 liters per minute. During an interview on 4/3/2023 at 9:38 AM, Resident #28 stated, I use 2 liters of oxygen. During an observation on 4/4/2023 at 9:52 AM, Resident #28 was lying in bed, receiving oxygen via nasal cannula at 2 liters per minute. Review of Resident #28's physician orders revealed no order for oxygen administration. During an interview on 4/4/2023 at 2:34 PM, Staff C, Licensed Practical Nurse (LPN), stated, [Resident #28's name] does not have a current order or a care plan for oxygen. They are currently being administered oxygen and have an oxygen concentrator in their room. 2. Review of Resident #6's medical records revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with the diagnoses including essential (primary) hypertension, heart failure, unspecified atrial fibrillation, and wheezing. During an observation on 4/3/2023 at 10:05 AM, Resident #6 was in bed, wearing a nasal cannula with oxygen being administered at 2 liters per minute. During an interview on 4/3/2023 at 10:05 AM, Resident #6 stated, My oxygen should be set to 2 liters per minute. On 4/4/2023 at 10:28 AM, Resident #6 was in bed, wearing a nasal cannula with oxygen being administered at 2 liters per minute. Review of Resident #6's physician orders revealed no order for oxygen administration. During an interview on 4/4/2023 at 2:36 PM, Staff C, LPN, stated, [Resident #6's name] does not have a current order or a care plan for oxygen. During an interview on 4/4/2023 at 3:03 PM, the Director of Nursing (DON) stated, My expectation is that anyone in the building receiving oxygen should have an order before we administer oxygen. During an interview on 4/4/2023 at 3:23 PM, the Executive Director stated, It is my expectation that anyone receiving oxygen continuously or PRN should have a physician order. 45576 3. Review of Resident #12's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, angina, and heart failure. During an observation on 4/3/2023 at 10:18 AM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. There was no date on the tubing. The nebulizer tubing was lying on the side table not covered and tubing was not dated. During an observation on 4/3/2023 at 3:22 PM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. Nebulizer tubing was lying on the side table not covered and the tubing was not dated. During an observation on 4/4/2023 at 8:34 AM, Resident #12 was receiving oxygen at 2 liters via nasal cannula. There was no date on the tubing for nasal cannula or nebulizer tubing. The nebulizer was lying on the table not covered. Review of Resident #12's physician order dated 2/9/2023 reads, O2 [oxygen] at 2 Liters as needed for O2 sat [saturation] below 92%. Resident #12's physician orders included no order for changing oxygen tubing or rate of oxygen flow. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, Minimum Data Set (MDS) Coordinator, stated, I have visually seen her with oxygen and seen her take it off. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. 4. Review of Resident #44's medical records revealed the resident was admitted on [DATE] with diagnoses including asthma, shortness of breath, anemia, heart failure, and atherosclerotic heart disease. Review of Resident #44's physician orders revealed no orders for oxygen administration and no orders for oxygen tubing to be changed. During an observation on 4/3/2023 at 10:46 AM, Resident #44 was lying on his back with oxygen being administered at 2 liters per minute via nasal cannula, with no date on the tubing. During an interview on 4/3/2023 at 10:46 AM, Resident #44 stated, I am always on oxygen. During an observation on 4/3/2023 at 3:27 PM, Resident #44 was being administered oxygen at 2 liters per minute via nasal cannula, and the oxygen tubing was not dated. During an observation on 4/4/2023 at 8:36 AM, Staff A, LPN, North Wing Manager, confirmed that oxygen was being delivered at 2 liters per minute via nasal cannula and there was no date on the nasal cannula oxygen tubing. 5. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pulmonary edema, anemia and anxiety. Review of Resident #70's physician order dated 6/20/2022 reads, Oxygen as needed PRN [as needed] at 2 L [Liter] via nasal cannula as needed for shortness of breath. During an observation on 4/3/2023 at 10:40 AM, Resident #70's oxygen tubing had no date. During an observation on 4/3/2023 at 3:33 PM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. Nasal cannula tubing was not dated. During an observation on 4/4/2023 at 9:00 AM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date or time noted on the tubing. During an interview on 4/4/2023 at 9:00 AM, Staff A, LPN, North Wing Manager, stated, The oxygen tubing is not dated. I had the staff go through the department last night and label a plastic bag and hang the bag on all concentrators. 6. Review of Resident #58's medical records revealed the resident was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and atrial fibrillation. Review of Resident #58's physician orders reads, Order Summary: Respiratory: Oxygen @ [at] 2 L [liters] via n/c [nasal cannula] continuous . Start Date: 06/28/2021 . Order Summary: Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene . Start Date: 06/28/2023 . Order Summary: Resident tolerance of nebulizer treatment (Add corresponding code in supplementary documentation. Good= G, Fair= F, Poor= P every 6 hours as needed. Start Date: 07/08/2021. During an observation on 4/3/2023 at 10:23 AM, Resident #58 was sitting in a wheelchair in the hall with oxygen being administered via nasal cannula from portable oxygen tank set at 1 liter per minute. Nasal cannula tubing was not labeled. The nebulizer mask and tubing were lying on the table, not dated and not covered. During an observation on 4/3/2023 at 2:10 PM, Resident #58 was receiving oxygen at 1 liter per minute via nasal cannula on portable tank. There was no date on the oxygen tubing. Nebulizer mask and tubing were lying on the table, not dated and not covered. During an observation on 4/3/2023 at 3.22 PM, Resident #58 was receiving oxygen from concentrator via nasal cannula at 1 liter per minute. The tubing was not dated. The nebulizer mask and tubing were lying on the table, not dated and not covered. During an interview on 4/4/2023 at 8:34 AM, Staff A, LPN, North Wing Manager, confirmed that the oxygen rate was set at 1 liter, there was no date on the tubing for nasal cannula or nebulizer, and the nebulizer was not covered. During an interview on 4/4/2023 at 8:52 AM, Staff A, LPN, North Wing Manager, stated, The tubing was not changed and was not labeled as ordered. I had the night shift change all the tubing and place the clear bag with the date on it, last night. They were supposed to change all the nebulizer mask and place them in a bag. They missed this one. Oxygen tubing changes are done on night shift normally on Friday night. CNAs [Certified Nursing Assistants] or PCAs [Personal Care Attendants] change tubing and date the bag. 7. Review of Resident #68's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, arrhythmias, atherosclerosis, heart failure, obstructive sleep apnea, cardiomegaly, anxiety, and anemia. Review of Resident #68's physician order dated 6/20/2022 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed . Oxygen @ 3 L via n/c Cont. [continuously] every shift. During an observation on 4/3/2023 at 9:56 AM, Resident #68 was lying in bed with oxygen being administered at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an interview on 4/3/2023 at 9:56 AM, Resident #68 stated, I think the setting is 3. I don't change it. I can't get out of bed myself. The oxygen tubing is only changed if needed. It's not changed weekly. During an observation on 4/3/2023 at 3:16 PM, Resident #68 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an observation on 4/4/2023 at 7:48 AM, Resident #68 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an interview on 4/4/2023 at 8:08 AM, Staff F, LPN, stated, Oxygen is checked by the nurse during medication administration for rate. Only the nurses adjust the oxygen. Aids can change the tubing. Oxygen tubing is changed normally Thursday or Saturday nights. During an interview on 4/4/2023 at 8:32 AM, Staff A, LPN, North Wing Manager, confirmed that the oxygen rate was at 2 liters per minute. 8. Review of Resident #59's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of Resident #59's physician orders dated 4/3/2023 reads, Respiratory oxygen 2-3 L continuous NC [Nasal Cannula]. During an observation on 4/3/2023 at 10:28 AM, Resident #59 was lying in bed with nasal cannula prongs lying on the resident's left side of his cheek, not in nares. Oxygen was being delivered via nasal cannula at 1.5 liters per minute. The nebulizer was lying on table, not covered and not dated. During an interview on 4/3/2023 at 10:28 AM, Resident #59 stated, I use oxygen all the time. Tubing is changed when it starts to bother me, or it gets dirty. During an observation on 4/3/2023 at 3:27 PM, Resident #59 was being administered oxygen at 1.5 liters per minute via nasal cannula. The tubing was not dated, and the nebulizer was lying on table, not covered and not dated. During an interview on 4/4/2023 at 8:34 AM, Staff A, LPN, North Wing Manager, confirmed that Resident #59's oxygen rate was at 1.5 liters per minute and there was no date on tubing for nasal cannula or nebulizer tubing. During an interview on 4/4/2023 at 8:52 AM, Staff A, LPN, North Wing Manager, confirmed that the tubing was not changed and was not dated per facility policy for Resident #12, Resident #44, Resident #58, Resident #70, Resident #68 and Resident #59. Staff A confirmed that there were no orders for oxygen tubing to be changed for Resident #12 and Resident #59. During an interview on 4/5/2023 at 1:52 PM, Staff E, LPN, MDS Coordinator, stated that the residents that were using oxygen required a physician order. During an interview on 4/5/2023 at 4:24 PM, the DON stated, My expectation is that orders are followed at the rate of flow ordered and that tubing is changed on Friday nights and all tubing is dated at that time. All Residents receiving oxygen therapy need a physician order for oxygen and rate of delivery. Also, an order for oxygen tubing to be changed weekly and as needed is required for all residents receiving nebulizer treatments. 39371 9. Review of Resident #11's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and acute respiratory failure. During an observation on 4/3/2023 at 11:09 AM, Resident #11 was sitting in a wheelchair, wearing nasal cannula and receiving oxygen via condenser. The setting on the oxygen condenser was between 2.5-3.0 liters per minute. Oxygen tubing was not dated (photographic evidence obtained). During an observation on 4/3/2023 at 3:29 PM, Resident #11 was sitting on the side of the bed, wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an interview on 4/3/2023 at 3:30 PM, Resident #11 stated, I do not touch the settings. I just turn the condenser on/off. During an observation on 4/4/2023 at 8:30 AM, Resident #11 was wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an observation on 4/5/2023 at 1:31 PM, Resident #11 was eating lunch, wearing nasal cannula and receiving oxygen via condenser. The setting was at 3 liters per minute. Review of Resident #11's physician order dated 7/6/2022 reads, Respiratory: Oxygen - Continuous 2 L nc to maintain O2 stats above 92%. Review of Resident #11's physician order dated 7/6/2022 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/6/2023 at approximately 3:30 PM, the DON confirmed stated that the oxygen setting was 3 liter per minute. 40559 10. Review of Resident #97's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation, memory deficit following cerebral infarction, major depressive and anxiety disorder. During an observation on 4/3/2023 at 11:46 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. During an observation on 4/4/2023 at 8:14 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. Review of Resident #97's physician order dated 2/24/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #97's oxygen tubing and concentrator was not labeled or dated. 11. Review of Resident #98's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hypertension, major depressive disorder, and encounter for screening for respiratory tuberculosis. During an observation on 4/3/2023 at 11:01 AM, Resident #98 was sitting on the side of his bed with oxygen being administered at 3 liters per minute via nasal cannula with no label or date on the tubing. During an observation on 4/4/2023 at 8:48 AM, Resident #98 was lying in bed with oxygen being administered at 3 liters per minute via nasal cannula with no label or date on the tubing. Review of Resident #98's physician order dated 3/2/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #98's oxygen tubing and concentrator were not labeled or dated. 12. Review of Resident #204's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, dysphagia, type II diabetes mellitus, bipolar disorder, major depressive disorder, anxiety disorder, restless leg syndrome, and hypotension. During an observation on 4/3/2023 at 11:57 AM, Resident #204 was lying in bed with oxygen running at 3 liters per minute, with no date or label on the tubing. During an observation on 4/4/2023 at 8:35 AM, Resident #204 was lying in bed, being administered oxygen via nasal cannula at 3 liters per minute, with no label or date on the tubing. Review of Resident #204's physician order dated 3/29/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #98's oxygen tubing and concentrator were not labeled or dated. Review of the facility policy and procedure titled Oxygen Therapy reads, Procedure: Physician's order for oxygen therapy shall include: Administration modality, FiO2 [the concentration of oxygen in the gas mixture] or liter flow, Continuous or PRN [as needed], PRN orders must include specific guidelines as to when the resident is to use oxygen. Documentation shall include . Start O2 [oxygen] flowrate at the prescribed liter flow or appropriate flow for administration device . Label tubing and humidifier with date and time.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary homelike environment (photographic evidence obtained). Findings include: During an observation on 4/3/2023 at 11:33 AM, Resident #39's room had a tube feeding pole that had formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an observation on 4/3/2023 at 3:32 PM, Resident #39's room had a tube feeding pole with formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an observation on 4/4/2023 at 10:51 AM, Resident #39's room had a tube feeding pole with formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an interview on 4/4/2023 at approximately 3:00 PM, the Administrator stated, This should not be. I think nursing is supposed to clean the pole. I expect the housekeepers to clean the rooms every day. During an interview on 4/4/2023 at approximately 4:00 PM, the Director of Nursing (DON) stated, I see the formula on the pole. Housekeeping will not touch any medical equipment. The pole is medical equipment. Nurses only have wipes. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment revised in September 2022 reads, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation . 1 . c. Non-critical items are those that come in contact with intact skin but not mucus membranes. (1) Non-critical resident care items include bedpans, blood pressure cuffs, crutches, and computers . (3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufactures' instructions. Review of the facility policy and procedure titled Daily Patient Room Cleaning revised in 6/2016, reads, Timing & Method . 5) Damp mop floor with germicide solution damp mop floor working from back corner to door, Use Wet Floor sign when finished . Additional Information . The goal of cleaning is Infection Control.

Based on record review and staff interview, the facility failed honor a resident's full code status by not initiating cardio-pulmonary resuscitation (CPR) for 1 of 4 residents reviewed. (Resident #1) The facility failed to honor Resident #1's expressed and written wishes to have cardio-pulmonary resuscitation (CPR) implemented in the event of respiratory/cardiac failure. The facility nursing staff failed to provide basic life support, including immediate CPR, to a resident who was found unresponsive and absent of life, and the resident died . This failure resulted in immediate jeopardy. Findings: A Nursing Progress note, dated [DATE] at 1:04 AM, read Certified Nursing Assistance (CNA) asked RN (Staff A) to come look at patient, CNA thinks he has expired, RN (Staff A) auscultated lung and heart sounds, no pulse, no respiration noted at this time. A telephone interview was conducted with Staff A, Registered Nurse (RN), on [DATE] at 11:45 AM. Staff A, RN, related she touched Resident #1 and he was cold. She knew he had expired. Staff A further said that she knew Resident #1 was full code. She was given that information on report and she did not call Emergency Medical Service (EMS). An interview was conducted on [DATE] at 1:20 PM with the medical director. He stated the nurse (Staff A, RN) did call him in the middle of the night and reported to him the passing of Resident #1. He recalled that the nurse stated that she had not initiated CPR, due to finding him cold. He understood Resident #1's wishes were to be a full code. The medical director's expectation was for the nurse to initiate CPR. An interview was conducted on [DATE] at 12:50 PM with the administrator. She stated, None of the nurses were ever told if a patient is cold to withhold CPR. That is not our policy. Full code is full code, you do CPR regardless. An interview was conducted on [DATE] at 12:55 PM with the DON. She said, 'While interviewing nurses, we asked if they found a person unresponsive and cold what would that mean. Noting they would still proceed if the person was a full code to provide CPR. I would not instruct any nurse to withhold CPR if cold. A record review of the facility Policy and Procedure, titled Cardio [MEDICAL CONDITION] Resuscitation (CPR), read, Policy: CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a valid Do Not Resuscitate (DNR) order. The facility removed the immediacy on (MONTH) 5, 2019, as evidenced by: 1) A record review on [DATE] of 6 months of deaths in the facility showed three residents expired with hospice services. There were no similar facility deaths due to withholding CPR. 2) An interview was conducted on [DATE] at 9:30 AM with the administrator. She stated all resident charts were audited and found no discrepancy with Advanced Directives in the computer and in charts compared to doctor's orders. She further stated that three mock drills and several in-services have been completed since yesterday. Resident #1 was at the facility for only seven hours when he passed. The administrator demonstrated documentation of a QA meeting on [DATE] at 9:00 AM with medical director, administrator, DON and ADON attending. Mock drills and in-services will be ongoing until the entire nursing staff has been re-educated. The conclusion of QA root cause analysis was the nurse chose not to follow facility policy. 3) An interview was conducted on [DATE] at 10:42 AM with the DON. She stated, The nurse will be terminated. She is on suspension at this moment and we will report her to the DOH. 4) An interview was conducted on [DATE] at 1:20 PM with the medical director. He stated, An ad hoc QAPI was conducted the same morning, [DATE], to review and analyze the situation. 5) An interview was conducted on [DATE] at 12:50 PM with the administrator. She stated, None of the nurses were ever told if a patient is cold to withhold CPR. That is not our policy. Full code is full code, you do CPR regardless. 6) An interview was conducted on [DATE] at 12:55 PM with the DON. She said, 'While interviewing nurses, we asked if they found a person unresponsive and cold what would that mean. Noting they would still proceed if the person was a full code to provide CPR. I would not instruct any nurse to withhold CPR if cold. 7) An interview was conducted on [DATE] at 9:45 AM with Staff C, RN. She stated she attended a [DATE] mock code drill, completed the posttest, and attended an in-service on the [DATE]. The in-service dealt with the importance of CPR/Advanced Directives and resident's right to be have that choice. A follow-up interview conducted on [DATE] at 1:00 PM with Staff C. She stated, A resident feeling cold would not determine if I do CPR, the code status does and that is policy. 8) An interview was conducted on [DATE] at 10:00 AM with Staff F, CN[NAME] She attended an in-service on the [DATE] and did a mock drill on [DATE]. She stated, We discussed and reviewed our policies on DNR, CPR, and patients right to choose on their own. 9) An interview was conducted on [DATE] at 10:20 AM with Staff G, CN[NAME] She attended a mock drill and in-service on [DATE]. She stated, .in-service went over P & P of CPR, DNRs and residents' right to have their wishes honored. 10) An interview was conducted on [DATE] at 10:30 AM with Staff H, CN[NAME] She attended an in-service on [DATE]. The in-service covered CPR, advanced directives, and residents' right to have them honored. 11) An interview was conducted on [DATE] at 11:00 AM with Staff I, CN[NAME] She attended both an in-service and a mock drill on [DATE]. The in-service included CPR, DNRs and residents' rights. 12) An interview was conducted on [DATE] at 11:10 AM with Staff J, LPN. She attended an in-service and a mock drill. She stated, she was an EMT prior to becoming a nurse. The in-service was detailed, and the mock was good practice for her and the other staff who did not have experience in codes. 13) An interview was conducted on [DATE] at 11:22 AM with Staff K, CN[NAME] She attended a mock drill on [DATE]. 14) A mock code blue demonstration was observed on [DATE] at 4:00 PM in the activity room. The code blue was announced over the facility speaker. In less than one minute two nurses (one came with crash cart) and one CNA arrived. The nurse who called code sent one nurse to check the code status and the other to call 911. The resident was identified as a full code and cycles of compression and breaths began. The nurse who called the code had a nurse begin the paperwork in anticipation of EMS arrival for transport. Nurses took turns with compression and breaths. At the end there was a paper test handed out to participants. The mock code was analyzed by DON and ADON, looking for times and flow of code. 15) An interview was conducted on [DATE] at 1:10 PM with Staff J, LPN. She stated, the coldness of a resident does not mean to hold CPR. The policy is we do CPR if the resident is a full code. 16) An interview was conducted on [DATE] at 1:15 PM with Staff M, RN. She stated, she attended a mock code drill this AM. With full code status, you do CPR period, coldness of a resident is not a factor in CPR the code of resident is. 17) An interview was conducted on [DATE] at 1:17 PM with Staff N, LPN. She stated, she had been off the last two days and attended an in-service. She further stated, she had not been instructed to withhold CPR if a resident is cold, the only time you withhold CPR is if they are a DNR. 18) An interview was conducted on [DATE] at 4:20 PM with Staff O, LPN, she related she had attended both a mock drill and an in-service, We reviewed our policies on DNR, CPR and patients' rights. She stated that the only time CPR is withheld is when the code status is a DNR, The coldness of a person is not an indicator to withhold CPR. 19) An interview was conducted on [DATE] at 4:35 PM with Staff P, LPN. She stated, The only time to withhold CPR is with a DNR. (At the) in-service we reviewed our policies on DNR, CPR and patients' rights. She also stated, CPR is initiated immediately and continued until EMS arrives, that's the policy. 20) A record review was conducted on [DATE] of the in-services conducted. 21) A record review was conducted on [DATE] of the facility's CPR policy. It read, CPR will be provided to all residents who are identified to be in [MEDICAL CONDITION] unless such resident has a valid Do Not Resuscitate (DNR) order. Procedure:1. In the event of [MEDICAL CONDITION], immediately call for assistance. 2. Two licensed nurses verify: resident identity, current code status. 3. Use paging system and call Code Blue to room # or location 3 times. 4. In the absence of physician's order for DNR will begin CPR. 5. Center staff will continue performing CPR until EMS assume responsibility for CPR, or if resident responds. 6. Notify physician and resident representative. 7. Document in the medical record.

Based on interviews, and record reviews, the facility staff failed to immediately report to the state certification agency and other state officials in accordance with state law, protect residents, and conduct a thorough investigation after family members reported to facility staff an allegation of sexual abuse/fondling by an unknown male for 1 of 1 (Resident #66) residents. Failure to immediately report, protect residents after an allegation of abuse, and conduct a thorough investigation of the allegation of sexual abuse/fondling placed facility residents at a serious and immediate threat to their health, safety, and well-being. Immediate Jeopardy was determined to exist beginning on [DATE] and removed and corrected as of [DATE]. Findings: 1 .Review of the medical record for resident #66 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed in Section C- Cognitive Status that the resident is rarely/never understood. The resident was assessed to have short and long term memory loss, and moderately impaired- decisions poor cues/supervision required. Section E- Behavior indicates for E0100Z: [MEDICAL CONDITION] is checked. Review of the resident's care plan implemented [DATE] revealed resident displayed exit seeking behaviors and was confused. The Cognitive Care Plan dated [DATE] revealed the resident had both long and short term memory loss, is not able to make needs known, and wanders on unit. Staff interventions include to observe whereabouts. 2. Telephone interview on [DATE] at 1:45 PM with resident #66's daughter revealed last Sunday evening ([DATE]) resident #66 told her that a man had recently fondled her. The daughter stated that she told the white haired nurse, (Nurse #1), about the incident. When asked if the facility had followed up on the allegation, the daughter stated that they have not. 3. Follow-up interview on [DATE] at 4:10 PM with the daughter of resident #66 revealed that she was told by resident #66 that a man had gotten in bed with her and "got fresh" with her. The daughter stated that she was addressing the need for a telephone to be in her mother's room with Certified Nursing Assistant (CNA) #1 when the both of them walked to the nursing station where her husband and the nurse (Nurse #1) were talking about the resident's allegation of being fondled. She stated that CNA#1 overheard the conversation with her, the nurse, and her husband about the incident. The daughter stated that Nurse #1 asked if the resident had a history of [REDACTED]. The nurse also stated that the resident is experiencing an increase in confusion. During the interview, the daughter stated that the allegation of sexual abuse/fondling was "out of character " for the resident. 4. Interview with CNA #1 on [DATE] at 2:33 PM revealed that she was approached by resident #66's son-in-law on Sunday, [DATE]. At this time, he reported to her that resident #66 told him a man came into the resident's room and tried to get "fresh" with her. The CNA stated that she, along with the son-in-law, went to nurse #1 and told her what the son-in-law told her. The CNA stated that resident #66 had never expressed any concerns related to males being "fresh" with her before. 5. Interview with the Director of Nursing (DON) on [DATE] at approximately 3:00 PM revealed that she was not aware that the daughter had expressed a concern to nurse #1 relating to resident #66's allegation of being fondled. 6. Interview on [DATE] at approximately 5:30 PM with the nurse #1 revealed that the family of resident #66 did approach her last Sunday and reported that the resident had told them that a male had been "fresh" with her. Nurse #1 stated that she asked the family if the resident had a history of [REDACTED]. She also stated that she told the family that the resident's behaviors have increased recently. During continued interview at this time, nurse #1 stated that she was dealing with three concerns related to the resident #66. The concerns were the allegation of fondling, the family wanting a telephone put in the resident's room, and the resident's exit seeking behavior. Nurse #1 stated that she focused on the exit seeking behavior as her priority and did not follow-up on the allegation. When asked if she had completed an incident report related to the allegation she stated that she had not. 7. Interview with the Administrator on [DATE] at approximately 5:00 PM revealed that she had interviewed resident #66 and that she felt that her confusion and mental status made her allegations not credible. She stated that staff interviews were conducted and did not indicate that the resident was a victim of abuse. She stated that the staff, 24 members, received in-service education on Abuse Definition and Policies and Procedures on [DATE] at 4:40 PM. 8. Review of the in-service records for [DATE] revealed that 2 of the 6 CNAs on who work on the north hall where resident #66 resides received the in-service training. The remaining staff of the north hall was in-serviced by telephone on [DATE]. The administrator stated that nurse #1 was placed on leave on [DATE]. Review of the facility staffing did not reveal that she had worked in the facility after Sunday [DATE]. 9. Interview with the Administrator on [DATE] at approximately 2:00 PM confirmed that the facility had not reported the incident to the state certification Agency (Agency for Health Care Administration), Local Law Enforcement or to the other state agencies required by state law (Department of Children and Families-Adult Protective Services) as of this time. Again, the administrator stated that that their investigation did not reveal that the allegation was credible. 10. Interview with the Director of Social Services (DSS) on [DATE] at approximately 9:30 AM revealed that the administrator directed her to perform a mini-mental exam on resident #66. The Social Services Director stated that she performed the exam, (Brief Interview for Mental Status or BIMS), on [DATE]. The BIMS score was noted as 9 (moderately impaired). She stated that that was the first time that she spoke to the resident following the allegation. She was not asked to be present on any of the interviews conducted on [DATE]. 11.) Review of the facility's policy and procedure N-1265 RESIDENT ABUSE (Effective [DATE] with a revision date of [DATE]) revealed under Procedure #9 Investigation of Abuse #2 Investigations will be accomplished in the following manner. I. Preliminary investigation. 1. Immediately upon report of an incident to the individual in charge, the suspect(s) shall be segregate from the resident. The factual basis for the credibility of the allegation shall be ascertained, and the Abuse Coordinator shall be notified. The Abuse Coordinator shall notify the Director of Clinical Services (and the suspect(s) Department Director when applicable. 2. If the charge appears on its face to be credible, and then the suspect(s) shall be suspended without pay pending an investigation. 3. The Clinical Nurse in charge or Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. 4. An incident report shall be filled by the individual in charge who revived the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion. 12.) Review of the facility ' s policy and procedure N-1265 RESIDENT ABUSE revealed under Procedure #9 Investigation of Abuse 1. The Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. A social Services representative shall be present in the role of resident advocate during any questioning or interviewing of residents. Corrective Action taken by facility: Immediate Jeopardy removed and corrected on [DATE] On [DATE], the facility provided to the surveyors and implemented a " Four Point Action Plan " dated [DATE] with the Objective & Goal identified as: Staff will appropriately report any allegation of neglect and abuse. The Initiative included: 1. Immediate corrections to ensure safety of affected residents. 2. Identification of any other residents who may be affected or at risk. 3. Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. The facility took the following Action Steps which were confirmed as being completed by the surveyors: 1. Immediate corrections to ensure safety of affected residents: a.) On [DATE], CNA #1 and Nurse#1 were suspended pending investigation. b.) On [DATE], every (Q) 15 minute safety checks initiated for resident #66 c.)On [DATE] at 5:00PM, facility notified DCF/APS (State Agency required by state law to be notified of abuse) d.) On [DATE], Citrus County Sheriff's Department notified of allegation. Deputy onsite at 10:00 PM on [DATE] e.) State Certification Agency (Agency for Health Care Administration)-1 day Immediate Federal report submitted on [DATE] f.) On [DATE], Facility policy implemented indicating that "any and all suspected or reported abuse" is to be reported to the Abuse Coordinator. g.)On [DATE], Resident #66 was assessed by licensed nurse and no indications of harm or negative findings were observed. Resident's physician was notified on [DATE] of statement, assessment , and plan to monitor with frequent safety checks. h.) On [DATE] @ 9:00 AM, facility re-interviewed resident regarding incident, she has no recollection of any incident involving a man. Resident (Brief Interview for Mental Status) BIMS score assessed on [DATE] as 9 (moderately impaired) and resident remained confused during interview. 2. Identification of any other residents who may be affected or at risk. All alert and oriented residents will be interviewed to assess if all feel safe in their living environment. a.) Total facility census 115. Interviews with 88 of 88 alert and oriented residents were completed by management staff between 7:00 AM & 9:00 PM on [DATE] using the resident interview and observation abuse form from the Quality Indicator Survey (QIS) manual with no negative responses identified. 27 of 27 residents that are not alert and oriented had interviews attempted and they were reviewed for indications of negative events. None were identified. 124 facility staff and 13 contracted staff interviewed for indications of any negative events. None identified. 3. Interventions put into place to prevent the incident from occurring again. a.) 137 of 137 facility and contracted staff in-serviced on abuse and proper reporting of abuse completed by [DATE]. b.) Resident education session about definition of abuse and reporting completed by Executive Director (ED) with alert and oriented residents (88 of 88) completed at 11:15 AM on [DATE]. 4. Plan for future follow up to ensure that interventions are working. a.) Department staff will do resident interviews weekly for 4 weeks; then monthly for 3 months; then quarterly through next review. Report results to the Quality Assurance (QA) Committee b.) On [DATE], Department managers received schedule of residents to be interviewed weekly and copies of forms to be used. On [DATE], surveyors verified the completion of the Q15 minute checks for resident #66 from copies of the checks completed by facility personnel, signed off with time and initialed by the staff member since [DATE] at 6:00PM. Checks were still in progress on [DATE]. Checks did not indicate any negative effects or changes in the resident. Interview with the corporate nurse, on [DATE] at 9:00 AM, revealed that the 15 minute checks would continue for 72 hours. After the 72 hour time frame, the administrator/executive director would decide when the 15 minute checks could be discontinued based on the resident 66's status. On [DATE], surveyors verified the in-servicing on the definition of abuse and abuse reporting with the 124 facility staff and 13 contracted personnel. A comparison of the staffing list,with the in-services sign-in sheets was completed by the team. All 137 staff were verified to have been trained. Interview was conducted with the Administrator/ED and the Director of Nursing, on [DATE] at 10:30 AM which confirmed all in-servicing had been completed with the staff. An interview was conducted with the Corporate Nurse, on [DATE] at 3:00 PM, which confirmed that the full staff in-servicing was complete to include the contracted personnel. Random interviews with staff 22 staff on [DATE] and [DATE] revealed that staff were able to articulate the facility policy to include the reporting of any and all suspected incidents of abuse to the Abuse Coordinator, as well as the definition of abuse, and to identify the Abuse Coordinator. Random interviews with 24 residents on [DATE]-[DATE] revealed that they knew how to report abuse and they denied being abused or witnessing abuse. Random interviews with 8 family members on [DATE]-[DATE] revealed that they knew how to report abuse and denied that their family member in the facility had been abused. Surveyors verified the background screening for 25 of the 137 facility and contracted staff to include Nurse #1 and CNA #1. All were identified to have clear background screenings.

Based on interviews, record reviews, and review of facility policies, the facility failed to implement their policies and procedures related to abuse and failed to develop a policy that ensured all allegations of abuse were investigated and reported for 1 of 1 (Resident #66) residents. Resident #66's family members reported to facility staff that the resident had been sexually abused/fondled. The facility staff failed to report this allegation to administration. After notification of facility administration, administration failed to immediately report to the state certification agency, local law enforcement or other state agencies as they determined that the resident's allegation was not credible. Review of the facility's policies and procedures revealed that only an allegation which appears "on its face to be credible" is investigated further and reported. Failure to immediately report all allegations of abuse, protect residents after an allegation of abuse, and conduct a thorough investigation of the allegations placed facility residents at a serious and immediate threat to their health, safety, and well-being. Immediate Jeopardy was determined to exist beginning on [DATE] and removed and corrected as of [DATE]. Findings: 1 .Review of the medical record for resident #66 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed in Section C- Cognitive Status that the resident is rarely/never understood. The resident was assessed to have short and long term memory loss, and moderately impaired- decisions poor cues/supervision required. Section E- Behavior indicates for E0100Z: [MEDICAL CONDITION] is checked. Review of the resident's care plan implemented [DATE] revealed resident displayed exit seeking behaviors and was confused. The Cognitive Care Plan dated [DATE] revealed the resident had both long and short term memory loss, is not able to make needs known, and wanders on unit. Staff interventions include to observe whereabouts. 2. Telephone interview on [DATE] at 1:45 PM with resident #66's daughter revealed last Sunday evening ([DATE]) resident #66 told her that a man had recently fondled her. The daughter stated that she told the white haired nurse, (Nurse #1), about the incident. When asked if the facility had followed up on the allegation, the daughter stated that they have not. 3. Follow-up interview on [DATE] at 4:10 PM with the daughter of resident #66 revealed that she was told by resident #66 that a man had gotten in bed with her and "got fresh" with her. The daughter stated that she was addressing the need for a telephone to be in her mother's room with Certified Nursing Assistant (CNA) #1 when the both of them walked to the nursing station where her husband and the nurse (Nurse #1) were talking about the resident's allegation of being fondled. She stated that CNA#1 overheard the conversation with her, the nurse, and her husband about the incident. The daughter stated that Nurse #1 asked if the resident had a history of [REDACTED]. The nurse also stated that the resident is experiencing an increase in confusion. During the interview, the daughter stated that the allegation of sexual abuse/fondling was "out of character " for the resident. 4. Interview with CNA #1 on [DATE] at 2:33 PM revealed that she was approached by resident #66's son-in-law on Sunday, [DATE]. At this time, he reported to her that resident #66 told him a man came into the resident's room and tried to get "fresh" with her. The CNA stated that she, along with the son-in-law, went to nurse #1 and told her what the son-in-law told her. The CNA stated that resident #66 had never expressed any concerns related to males being "fresh" with her before. 5. Interview with the Director of Nursing (DON) on [DATE] at approximately 3:00 PM revealed that she was not aware that the daughter had expressed a concern to nurse #1 relating to resident #66's allegation of being fondled. 6. Interview on [DATE] at approximately 5:30 PM with the nurse #1 revealed that the family of resident #66 did approach her last Sunday and reported that the resident had told them that a male had been "fresh" with her. Nurse #1 stated that she asked the family if the resident had a history of [REDACTED]. She also stated that she told the family that the resident's behaviors have increased recently. During continued interview at this time, nurse #1 stated that she was dealing with three concerns related to the resident #66. The concerns were the allegation of fondling, the family wanting a telephone put in the resident's room, and the resident's exit seeking behavior. Nurse #1 stated that she focused on the exit seeking behavior as her priority and did not follow-up on the allegation. When asked if she had completed an incident report related to the allegation she stated that she had not. 7. Interview with the Administrator on [DATE] at approximately 5:00 PM revealed that she had interviewed resident #66 and that she felt that her confusion and mental status made her allegations not credible. She stated that staff interviews were conducted and did not indicate that the resident was a victim of abuse. She stated that the staff, 24 members, received in-service education on Abuse Definition and Policies and Procedures on [DATE] at 4:40 PM. 8. Review of the in-service records for [DATE] revealed that 2 of the 6 CNAs on who work on the north hall where resident #66 resides received the in-service training. The remaining staff of the north hall was in-serviced by telephone on [DATE]. The administrator stated that nurse #1 was placed on leave on [DATE]. Review of the facility staffing did not reveal that she had worked in the facility after Sunday [DATE]. 9. Interview with the Administrator on [DATE] at approximately 2:00 PM confirmed that the facility had not reported the incident to the state certification Agency (Agency for Health Care Administration), Local Law Enforcement or to the other state agencies required by state law (Department of Children and Families-Adult Protective Services) as of this time. Again, the administrator stated that that their investigation did not reveal that the allegation was credible. 10. Interview with the Director of Social Services (DSS) on [DATE] at approximately 9:30 AM revealed that the administrator directed her to perform a mini-mental exam on resident #66. The Social Services Director stated that she performed the exam, (Brief Interview for Mental Status or BIMS), on [DATE]. The BIMS score was noted as 9 (moderately impaired). She stated that that was the first time that she spoke to the resident following the allegation. She was not asked to be present on any of the interviews conducted on [DATE]. 11.) Review of the facility's policy and procedure N-1265 RESIDENT ABUSE (Effective [DATE] with a revision date of [DATE]) revealed under Procedure #9 Investigation of Abuse #2 Investigations will be accomplished in the following manner. I. Preliminary investigation. 1. Immediately upon report of an incident to the individual in charge, the suspect(s) shall be segregate from the resident. The factual basis for the credibility of the allegation shall be ascertained, and the Abuse Coordinator shall be notified. The Abuse Coordinator shall notify the Director of Clinical Services (and the suspect(s) Department Director when applicable. 2. If the charge appears on its face to be credible, and then the suspect(s) shall be suspended without pay pending an investigation. 3. The Clinical Nurse in charge or Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. 4. An incident report shall be filled by the individual in charge who revived the report in conjunction with the person who reported the abuse. This report shall be filed as soon as possible in order to provide the most accurate information in a timely fashion. 12.) Review of the facility ' s policy and procedure N-1265 RESIDENT ABUSE revealed under Procedure #9 Investigation of Abuse 1. The Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. A social Services representative shall be present in the role of resident advocate during any questioning or interviewing of residents. Corrective Action taken by facility: Immediate Jeopardy removed and corrected on [DATE] On [DATE], the facility provided to the surveyors and implemented a " Four Point Action Plan " dated [DATE] with the Objective & Goal identified as: Staff will appropriately report any allegation of neglect and abuse. The Initiative included: 1. Immediate corrections to ensure safety of affected residents. 2. Identification of any other residents who may be affected or at risk. 3. Interventions put into place to prevent the incident from occurring again. 4. Plan for future follow up to ensure that interventions are working. The facility took the following Action Steps which were confirmed as being completed by the surveyors: 1. Immediate corrections to ensure safety of affected residents: a.) On [DATE], CNA #1 and Nurse#1 were suspended pending investigation. b.) On [DATE], every (Q) 15 minute safety checks initiated for resident #66 c.)On [DATE] at 5:00PM, facility notified DCF/APS (State Agency required by state law to be notified of abuse) d.) On [DATE], Citrus County Sheriff's Department notified of allegation. Deputy onsite at 10:00 PM on [DATE] e.) State Certification Agency (Agency for Health Care Administration)-1 day Immediate Federal report submitted on [DATE] f.) On [DATE], Facility policy implemented indicating that "any and all suspected or reported abuse" is to be reported to the Abuse Coordinator. g.)On [DATE], Resident #66 was assessed by licensed nurse and no indications of harm or negative findings were observed. Resident's physician was notified on [DATE] of statement, assessment , and plan to monitor with frequent safety checks. h.) On [DATE] @ 9:00 AM, facility re-interviewed resident regarding incident, she has no recollection of any incident involving a man. Resident (Brief Interview for Mental Status) BIMS score assessed on [DATE] as 9 (moderately impaired) and resident remained confused during interview. 2. Identification of any other residents who may be affected or at risk. All alert and oriented residents will be interviewed to assess if all feel safe in their living environment. a.) Total facility census 115. Interviews with 88 of 88 alert and oriented residents were completed by management staff between 7:00 AM & 9:00 PM on [DATE] using the resident interview and observation abuse form from the Quality Indicator Survey (QIS) manual with no negative responses identified. 27 of 27 residents that are not alert and oriented had interviews attempted and they were reviewed for indications of negative events. None were identified. 124 facility staff and 13 contracted staff interviewed for indications of any negative events. None identified. 3. Interventions put into place to prevent the incident from occurring again. a.) 137 of 137 facility and contracted staff in-serviced on abuse and proper reporting of abuse completed by [DATE]. b.) Resident education session about definition of abuse and reporting completed by Executive Director (ED) with alert and oriented residents (88 of 88) completed at 11:15 AM on [DATE]. 4. Plan for future follow up to ensure that interventions are working. a.) Department staff will do resident interviews weekly for 4 weeks; then monthly for 3 months; then quarterly through next review. Report results to the Quality Assurance (QA) Committee b.) On [DATE], Department managers received schedule of residents to be interviewed weekly and copies of forms to be used. On [DATE], surveyors verified the completion of the Q15 minute checks for resident #66 from copies of the checks completed by facility personnel, signed off with time and initialed by the staff member since [DATE] at 6:00PM. Checks were still in progress on [DATE]. Checks did not indicate any negative effects or changes in the resident. Interview with the corporate nurse, on [DATE] at 9:00 AM, revealed that the 15 minute checks would continue for 72 hours. After the 72 hour time frame, the administrator/executive director would decide when the 15 minute checks could be discontinued based on the resident 66's status. On [DATE], surveyors verified the in-servicing on the definition of abuse and abuse reporting with the 124 facility staff and 13 contracted personnel. A comparison of the staffing list,with the in-services sign-in sheets was completed by the team. All 137 staff were verified to have been trained. Interview was conducted with the Administrator/ED and the Director of Nursing, on [DATE] at 10:30 AM which confirmed all in-servicing had been completed with the staff. An interview was conducted with the Corporate Nurse, on [DATE] at 3:00 PM, which confirmed that the full staff in-servicing was complete to include the contracted personnel. Random interviews with staff 22 staff on [DATE] and [DATE] revealed that staff were able to articulate the facility policy to include the reporting of any and all suspected incidents of abuse to the Abuse Coordinator, as well as the definition of abuse, and to identify the Abuse Coordinator. Random interviews with 24 residents on [DATE]-[DATE] revealed that they knew how to report abuse and they denied being abused or witnessing abuse. Random interviews with 8 family members on [DATE]-[DATE] revealed that they knew how to report abuse and denied that their family member in the facility had been abused. Surveyors verified the background screening for 25 of the 137 facility and contracted staff to include Nurse #1 and CNA #1. All were identified to have clear background screenings.