Every finding on record at Aviata at Emerald Shores

Based on record review, staff interview, and policy review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN, CMS-10055 form) to 1 of 3 sampled residents reviewed for beneficiary notices. The SNF ABN provides information to beneficiaries so they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. (Resident #64) The findings include: Based upon facility documentation, Resident #64 was discharged from a Medicare Part A stay on 2/24/25 and remained in the facility. Review of the Beneficiary Notification review form (CMS 20052) completed by the Business Office Manager (BOM) on 3/18/25 revealed the facility initiated the discharge of Resident #64 from Medicare Part A services when benefit days were not exhausted. The form indicated the SNF ABN (CMS 10055) was not provided to the resident because the resident was not picked up under skilled Medicare Part B services. An interview was conducted with the Administrator on 3/18/25 at 1:11 PM. The Administrator confirmed the notice (SNF ABN) was not served to the resident and agreed if the resident was discharged from Part A and remained in the facility, the resident should have received the SNF ABN notice. Review of the facility policy for SNF Advance Beneficiary Notification (ABN) & Notice of Medicare Provider Non-Coverage (BO-510 revised 5/1/18) revealed that the SNF Advance Beneficiary Notification (SNF ABN) & the Notice of Non-Coverage will be used to properly notify a Medicare Part A resident and/or responsible party of the clinical team decision that the resident, no longer meets the Medicare criteria for daily skilled services. SNF's must provide the Notice of Medicare Provider Non-Coverage and the SNF ABN to Medicare beneficiaries no later than two days before the effective date of the end of the coverage that their Medicare coverage will be ending.

Based on observations, record review, staff interview, and policy review, the facility failed to provide appropriate fingernail care to 1 of 1 sampled residents reviewed for activities of daily living. (Resident #33) The findings include: Observations of Resident #33 were conducted on 3/17/25 at 11:54 AM, 3/18/25 at 11:31 AM, and 3/19/25 at 9:05 AM. During the observations, the resident's left hand was observed to be contracted and 4 of the 5 fingernails (all nails except the thumb nail) on her left hand were long and untrimmed. Further observation of Resident #33's left hand was conducted on 3/19/25 at 10:45 AM with the Director of Nursing (DON). The DON observed the nails on the resident's left hand and confirmed the resident's left hand was contracted. The DON measured the longest nail on the resident's left hand and stated it was 1 cm past the nail bed. The DON confirmed this was not an acceptable length and the resident's nails should be cut short. The DON then spoke with a certified nursing assistant (CNA) and stated the CNA reported she had attempted to trim the resident's fingernails, but they were too thick. The DON confirmed the CNA should have reported this to the nurse or manager. A review of Resident #33's record revealed a significant change minimum data set (MDS) with an assessment reference date of 1/17/25 indicating the resident was dependent for personal hygiene. A review of the last 20 days of progress notes revealed no documented refusals of nail care. Review of the task menu revealed her last documented bath or shower was performed on 3/17/25. A review of the current care plan dated 11/12/24 for Alteration in Usual Functional Performance in self-care related to activity intolerance, fatigue, impaired balance, and limited mobility revealed the resident was dependent for personal hygiene. Review of the facility policy for Bathing/Showering (N-1130 revised 9/1/17) revealed that staff should trim the resident's fingernails during bathing.

Based upon observations, interviews and record reviews, the facility failed to provide proper enteral feedings for 2 of 2 residents observed for enteral feeding. (Resident #1 and #44) The findings include: On 03/17/25 at 11:52 AM, Resident #1 was lying in bed with Glucerna being administered at 55 ml/hr. However, Resident #44's name was written on the tube feeding bottle. Resident #44 was being administered Jevity 1.5 at 45ml/hr but the bottle had Resident #1's name written on the tube feeding bottle. (photographic evidence obtained) As this was observed, Certified Nursing Assistant (CNA) B came into the room. She was asked to identify Resident #1 and #44. The CNA stated Resident #44 was in the B-bed and Resident #1 was in A-bed. The CNA went to get the nurse to assist further with tube feeing concerns An interview with Staff Member A, a Licensed Practical Nurse (LPN) was conducted on 3/17/25 at 12:05 PM. Nurse A was alerted to the switched tube feeding bottles. Staff Member A confirmed that Resident #1's tube feeding was not correct. Resident #1 should have Jevity infusing instead but had Glucerna infusing. Staff Member A confirmed that the tube feeding on Resident #44 was the wrong tube feeding, Resident #44 should have Glucerna infusing not Jevity. A record review on 3/17/25 at 12:30 PM revealed that Resident #1 has a diagnosis of a Cerebrovascular accident (CVA) with hemiplegia affecting the left dominant side, profound intellectual disabilities, Cerebral Palsy, Dysphagia, and Aphasia. The physician's orders states that he is to have Enteral feeding of Jevity 1.5 at 55 ml/hr for 20 hours, off at 10:00 AM, On at 2:00 PM with H20 flush at 55 ml/hr for 20 hours, off at 01:00 AM on at 02:00 AM. an A record review of Resident #44 on 3/17/25 at 12:40 PM revealed that Resident #44 has a diagnosis of cognitive communication deficit, dysphagia following CVA, Type two diabetes, and unspecified severe protein malnutrition. Physician orders state that Resident #44 had an order for Enteral Feed Glucerna 1.5 at 45 ml/hr two times a day with 80 ml/hr flush for 20 hours. On 3/17/25 at 1:00 pm, Resident #1 and Resident #44's tube feedings have been removed from the residents' room at this time. On 3/17/25 at 02:00 PM, facility policy for enteral feeding-enteral nutrition (with effective date of 11/30/2018) states that the nurse administers enteral feeding when volume control is indicated and as ordered by physician; procedure is obtain physician order and identify resident.

Based on observation, record review, staff interviews, and policy review, the facility staff failed to demonstrate competency in skin care during 1 of 1 partial bed bath observations. (Resident #4) The findings include: An observation of a partial bed bath for Resident #4 was observed being performed by Employee A, a Certified Nursing Assistant, on 12/10/24 at 8:40 AM. Employee A explained the procedure to Resident #4. Employee A then obtained one pan of water from the sink in the bathroom and donned gloves. Employee A requested that Resident #4 wash his face with the wet washcloth. Employee A then placed liquid soap in the pan of water, wet the washcloth, and then washed the resident's chest and underarms with the soapy washcloth. Employee A did not rinse the soap from the resident's body. Employee A then placed more liquid soap in the pan of water, wet the washcloth with the soapy water, and washed his back with the soapy washcloth. She did not rinse the soap from the resident's back either. Employee A then placed fresh water in the pan, placed liquid soap on a washcloth, placed the washcloth with soap in the pan of water, then wrung out the washcloth. She then cleansed the resident's genitals and buttocks with the soapy washcloth. She did not rinse the soap from the resident's genitals and buttocks either. Employee A changed the water in the pan again and placed liquid soap in the water. She then washed the resident's feet with the soapy water and did not rinse the resident's feet. A review of Resident #4's electronic medical record revealed an admission minimum data set with an assessment reference date of 12/4/24, indicating that the resident required substantial/maximal assistance of staff to bathe or shower. Review of the resident's comprehensive plan of care dated 12/9/24 for alteration in usual functional performance in self-care indicated the resident required substantial/maximal assistance of one staff for showering/bathing. An interview was conducted with Employee A on 12/10/24 at 9:53 AM. Employee A stated the soap should have been rinsed from the body. She stated she was nervous and forgot the additional pan for rinse water. An interview was conducted with the Director of Nursing (DON) on 12/10/24 at 10:15 AM. The DON stated staff should use 2 pans of water during a bed bath, one for soapy water to cleanse and one for clean water to rinse. She stated the resident should be rinsed with clean water after bathing with soap. Review of the facility policy for Perineal Care (N-1170 revised 9/5/2017) indicated care to include washing, rinsing, and drying of the skin.

Based on observations, staff interview, and policy review, the facility failed to maintain restroom faucets and over bed tables in good condition in 5 of 16 sampled rooms. (Rooms 200, 203, 211, 403, and 405) The findings include: A tour of the 200 and 400 halls was conducted in the presence of the Administrator on 12/20/23 at 3:35 PM. On 12/20/23 at 3:35 PM, it was observed that the sink faucets in rooms 200, 203, 211, 403, and 405 were heavily tarnished. At this time, the Administrator acknowledged that the faucets were tarnished and housekeeping had attempted to clean them, but admitted it may have made the tarnish worse. The Administrator also observed the over bed table in room [ROOM NUMBER] B and confirmed the frame was rusted. (Photographic evidence obtained.) A review of the facility policy Maintenance Plan (effective 11/30/2014) revealed the following: The Company will hire staff or contract for services to ensure the continued maintenance of the Residence. The building and grounds will be maintained in a clean, orderly condition and in good repair either by staff or a contracted landscaper. All equipment and furnishings will be maintained in good condition.

Based on observations, interviews and facility policy review, the facility failed to ensure staff do not administer expired intravenous antibiotics to 1 of 2 sampled residents reviewed for IV antibiotics. (Resident #19) The findings include: On [DATE] at approximately 1:09 PM, an observation was made of Resident #19. During the observation, an intravenous antibiotic bag was observed to be hanging on the intravenous pole. The antibiotic bag displayed three stickers indicating the resident's name, the name of the antibiotic (Ertapenem), and the prescribed dosage (1 gm/100 ml). There was a small, orange square shaped sticker located in the right top corner of the bag indicating an expiration date of [DATE]. On [DATE], a review of Resident #19's Medication Administration Record indicated the intravenous antibiotic was administered on [DATE] at 9:00 AM and signed off as administered by the Infection Preventionist (IP). On [DATE] at approximately 4:01 PM, a phone interview was conducted with the facility's Pharmacist. The Pharmacist was given the prescription number of the expired intravenous antibiotic for validation. The pharmacist indicated the antibiotic was delivered to the facility on [DATE] from the pharmacy. The pharmacist confirmed that the orange sticker indicates the expiration date for the antibiotic and the intravenous fluid the antibiotic was mixed within. On [DATE] at approximately 10:35 AM, an interview was conducted with the Infection Preventionist (IP). The IP confirmed she administered the expired dose of antibiotic. The IP indicated she recalled administering the antibiotic as she was working the floor the morning of [DATE]. The IP indicated she did not notice the expiration date on the intravenous antibiotic bag. On [DATE], a review of the facility's policy entitled Administering Medications (revised [DATE]) indicated, .the expiration/beyond use date on the medication label must be checked prior to administering the medication. On [DATE] at approximately 10:20 AM, an interview was conducted with the Director of Nursing (DON) regarding the expired intravenous antibiotic. The DON indicated the IP should have noticed the expiration sticker located on the intravenous antibiotic bag.

Based on record review, staff interview, and policy review, the facility failed to maintain complete and accurately documented medical records for 1 of 3 sampled residents prescribed antibiotic medications. (Resident #4) The findings include: A review of Resident #4's electronic medical record revealed a physician order dated 5/2/23 for Meropenem intravenous solution 500 mg intravenously every 8 hours for a right hip infection for 11 days. Additional physician orders dated 5/11/23 extended the Meropenem antibiotic usage until 6/24/23. Review of the Medication Administration Record for May 2023 revealed no documentation for the administration of doses due on 5/8/23 at 2:00 PM, 5/8/23 at 10:00 PM, and 5/20/23 at 2:00 PM. An interview was conducted with the Director of Nursing (DON) on 7/13/23 at 8:53 AM. She stated during the facility review, she realized there were 3 doses of the antibiotic not signed off as administered. She interviewed the nurses, and they stated the doses were administered and they forgot to sign the medication record. The DON provided a signed statement dated 5/24/23 stating she interviewed Nurses A, B, C, and D regarding the missing documentation on Resident #4's medication record. Nurse A stated she recalled administering the intravenous medication on 5/8/23 at 2:00 PM but did not recall why she did not document on the medication record. Nurse B stated she recalled getting Nurse C to administer the intravenous medication for the scheduled dose on 5/8/23 at 10:00 PM. Nurse C stated he recalled administering the dose on 5/8/23 but did not document on the medication record. Nurse D recalled administering the intravenous medication on 5/20/23 at 2:00 PM but could not recall why she did not document the dose on the medication record. The facility policy for Clinical/Medical Records (MR-195, revised 8/25/2017) states, The resident's clinical record is readily accessible and systematically organized to facilitate retrieving and compiling information. Required clinical information pertaining to a resident's stay is centralized in the medical record. The facility policy for Administering Medications (revised April 2019) states, .#23 as required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered, the dosage, the route of administration, the injection site (if applicable), any complaints or symptoms for which the drug was administered, any results achieved and when those results where observed, and the signature and title of the person administering the drug.

Based on record review, staff interview, and policy review the facility failed to refer a resident with a mental disorder to the appropriative state-designated authority for a level II PASARR (preadmission screening and resident review) evaluation and determination for 1 of 1 residents sampled for PASARR. (Resident #1) The findings include: Review of resident #1's medical record revealed an admitted [DATE]. Review of resident #1's PASARR dated 6/2/21 and completed by the Director of Nursing (DON) revealed section A. page 2: resident has anxiety disorder and depressive disorder and is currently receiving services for mental illness. Page 5 section 4, indicates no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level II PASARR evaluation not required. The resident record revealed the resident had medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The record did not contain evidence of a level II PASARR. An interview was conducted with the DON on 8/16/22 at approximately 2:04 PM. The DON stated she checked the wrong box on the PASARR and the facility did not request a level II PASARR for the resident. Review of the facility policy for Preadmission Screening and Resident Review (document name SS-402 revised 11/8/21) revealed The center will ensure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting.

Based on personnel record review, policy review and interview, the facility failed to ensure a Certified Nursing Assistant, (CNA), did not work while their license was expired for 1 of 16 personnel records reviewed, (Staff E). The findings include: A review of the CNA licensure for Staff E, was conducted. During the review a license verification document with a note stating, Data as of [DATE] revealed the license status for Staff E was delinquent. The license expiration date was documented as [DATE]. A request was made to the facility Administrator for the most recent license for Staff E, the Administrator provided a document with a note stating, Data as of [DATE]. The second document provided stated that Staff E's CNA license was Clear/Active with an expiration date of [DATE], however the date of the renewal was not provided. On [DATE] at approximately 8:55 AM, an interview was conducted with the Director of Nursing, (DON), who confirmed Staff E was working at the facility as a CNA, during the time her license was expired, between [DATE] and her last day of employment on [DATE]. A review of the time clock punches for Staff E was conducted. The review revealed Staff E worked on [DATE] for 7.55 hours, on [DATE] for 7.97 hours, on ,d+[DATE] for 16.45 hours, and on [DATE] for 9.47 hours. On [DATE] at approximately 9:39 AM, an interview was conducted with the Business Office Manager who confirmed Staff E worked at the facility as a CNA until [DATE]. She confirmed the license for Staff E, as of [DATE] was delinquent with an expiration date of [DATE]. The Business Office Manager confirmed personnel records are reviewed on the employee's anniversary date and stated there is a place in the computer system to add the license number and the expiration date which will send an alert that the license is expired and stated this fell through the cracks. A review of the facility policy titled Nurse Tech I Certified Nursing Assistant, dated [DATE], revealed under the heading Education, A CNA must possess, as a minimum, a high school diploma or GED (General Educational Development) equivalent and be certified/registered in the state of practice.

Based on record review, resident interview, and staff interview the facility failed to implement effective monitoring of bowel activity for 2 of 2 sampled residents receiving routine or as needed medications for constipation. (Resident #1 and #6) The findings include: Review of resident #1's record revealed the resident was admitted to the facility on [DATE]. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic record bowel movement documentation for the last 14 days revealed no bowel movement had been documented from 8/6/22 through 8/16/22. An interview was conducted with resident #1 on 8/16/22 at 3:50 PM. She stated she had not had a bowel movement in 4 days. Review of resident #6's record revealed the resident was admitted to the facility on [DATE]. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic record bowel movement documentation revealed no bowel movement had been documented from 7/28/22 through 8/15/22. The resident was discharged to the hospital on 8/16/22. An interview was conducted with the Director of Nursing (DON) on 8/16/22 at approximately 3:57 PM. The DON stated that staff were expected to document whether or not the resident had a bowel movement every shift in the task menu. She stated nursing was to check the alerts in the electronic record daily to monitor bowel movements.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure staff provided appropriate care and services to promote wound healing and prevent cross contamination of pressure ulcers for 1 of 3 sampled residents with pressure ulcers. (Resident #1) The findings include: An observation of wound care for Resident #1 was conducted with the wound care nurse on 7/28/21 at approximately 12:20 PM. The wound care nurse was observed to apply a dressing to the pressure ulcer on the resident's sacrum. The nurse washed her hands and applied clean gloves, removed the soiled dressing, washed her hands and applied clean gloves, cleansed the wound with saline, then applied the new dressing. The wound care nurse then used the same gloves to apply a [MEDICATION(S)] dressing to the resident's left buttock. The nurse did not wash her hands or change gloves between wound dressings and did not wash her hands and apply clean gloves after cleansing the wound. An interview was conducted with the wound care nurse on 7/28/21 at approximately 12:45 PM. She stated she would normally change gloves between wound dressings, but she was just trying to cover the shear on the resident's buttock with something. An interview was conducted with the Director of Nursing (DON) on 7/28/21 at approximately 1:28 PM. The DON confirmed she would expect staff to, at a minimum, change gloves between dressing changes on different wounds and wash hands/change gloves according to the facility policy during wound care. Review of Resident #1's electronic clinical record revealed physician orders 7/14/21 to clean sacral wound, apply calcium alginate, and dry dressing every day shift and 7/28/21 apply [MEDICATION(S)] dressing to left buttock skin shear and change every 3 days or as needed. The record revealed the resident had an unstageable pressure ulcer to the sacrum. Review of the facility policy Dressing Change (N-1310 revised 12/6/17) revealed a clean dressing will be applied by a nurse to a wound as ordered to promote healing. Procedure: Identify resident. Explain procedure, provide privacy. Assemble equipment as needed for dressing change. Place supplies on prepped work surface. 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. Apply treatment as ordered and clean dressing. Discard gloves and perform hand hygiene.

Based on record review, staff interview, and policy review, the facility failed to maintain a complete record of resident care for 1 of 2 sampled residents with urinary catheters. (Resident #1) The findings include: Review of resident #1's electronic clinical record revealed the resident had a urinary catheter. The record revealed a current physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment record for July 2021 revealed catheter care was not documented on the 7-3 shift on July 19 and 20, nor on 3-11 shift on July 14, 15, 16, 18, 19, 20. An interview was conducted with the Director of Nursing (DON) on 7/28/21 at approximately 3:29 PM. The DON stated she expects catheter care to be documented as completed on the treatment record as ordered. She observed the record and confirmed the documentation for catheter care was not complete. Review of the facility policy Clinical/Medical records (MR-195 revised 8/25/17) revealed clinical records are maintained in accordance with professional practice standards to provide complete and accurate information on each resident for continuity of care. The purpose of the clinical record is to document the course of the resident's plan of care and to provide a medium of communication among health care professionals involved in this care.

Based on observation and staff interview, the facility failed to maintain a clean environment in the food preparation are of the kitchen. Findings include: On 6/2/21 beginning at 9:30 AM, a tour of the kitchen preparation and cooking area was conducted. During the tour it was observed that 4 areas of the kitchen ceiling contained dark dust-like material on the tiles and air vent. These areas were observed over the preparation area where a staff member was observed cutting up raw vegetables, over the oven, and above the area where the tray carts were stored. (Photographic evidence obtained) On 6/2/21 at 9:30 AM, an interview was conducted with the facility Certified Dietary Manager. He indicated the maintenance of the ceiling was the responsibility of the Maintenance Director and he would notify them for a cleaning. Food preparation was ceased at this time while facility staff proceeded to clean the ceiling tiles and air vent.

Based on record review, staff interview and policy review the facility failed to ensure pneumococcal immunizations were offered to 1 of 1 sampled residents who consented to receive the immunization. (Resident #8) The findings include: Review of resident #8's record revealed an admitted [DATE]. The resident signed an informed consent for pneumococcal vaccine indicating she accepted and gave the facility permission to administer the vaccine on 9/28/2020. The record revealed no evidence the vaccine was administered. An interview was conducted with the Director of Nursing (DON) on 5/17/2021 at 1:54 PM. The DON stated the resident consented to the vaccine, but the facility has not administered the vaccine. She stated she would get an order from the physician for the vaccine. The DON reported the individual who completed the consents at that time was only supposed to review influenza consents and she was not aware they completed pneumonia consents as well. Review of the facility policy for Vaccination of Residents revealed all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated.

Based on interview and record review, the facility failed to document a thorough investigation and resolution of grievances involving one staff member (Staff A) for 3 of 3 grievances reviewed. The findings include: On 12/29/2020 a record review of grievances filed in November 2020 was conducted. Record review revealed that a grievance was logged for Resident #2 on 11/5/2020 at 11:00 AM. Review of the concern description revealed a complaint regarding Staff A, a Certified Nursing Assistant (CNA). Further review revealed an allegation that Staff A was rude and used foul language. Review of the Actions Taken revealed that the Executive Director (ED) and Director of Nursing (DON) were made aware and will speak to the CNA about the complaint. Review of the Resolution revealed that the grievance was not confirmed and that the complainant was informed in person of the action taken to address the complaint on 11/11/2020 at the incomplete time of 11:0 AM. The form indicated that no management review had been completed by the Executive Director as of 12/29/2020, the survey date and document's print date. Further review of the November grievances revealed that a grievance was logged for Resident #3 on 11/5/2020 at 15:00 (3:00 PM). Review of the concern description revealed another complaint regarding Staff A treating the resident poorly. Review of the Actions Taken revealed that the ED and DON were made aware of the complaint and DON will meet with and educate the CNA with regards to this concern. The date and time the actions were completed was 11/5/2020 at the incomplete time of 3:0 PM. Review of the Resolution revealed that the grievance was not confirmed and that the complainant was informed in person of the action taken to address the complaint on 11/5/2020 at 3:0 PM. The form indicated that no management review had been completed by the Executive Director as of 12/29/2020, the survey date and document's print date. Further review of the November grievances revealed a grievance was logged for Resident #1 on 11/11/2020 at 10:00 AM. Review of the concern description revealed an allegation of abuse also against Staff A. The Grievance Officer documented that Resident #1 was very sleepy while this worker interviewed him and that Again, he was very sleepy at this time and seemed foggy when answering questions as he was getting ready to leave for [MEDICAL TREATMENT]. The Grievance Officer reported the allegation to the Department of Children and Families (DCF) abuse hotline. Further review of the complaint form revealed under Resolution that the grievance was not confirmed and that the complainant was informed in person of the action taken to address the complaint on 11/11/2020 at 10:30 AM. The form indicated that no management review had been completed by the Executive Director as of 12/29/2020, the survey date and document's print date. On 12/29/2020 a record review of the facility's Complaint/Grievance Policy and Procedure effective 11/30/2014 and revised 8/9/2018 was conducted. Review of the policy revealed The intent of this guideline is to support each resident's right to voice grievances (e.g., those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the center actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution. Further review revealed some of the steps in the process included: -The Grievance Officer/designee shall act on the grievance and begin follow-up of the concern or submit it to the appropriate director for follow-up. -The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. -The findings of the grievance shall be recorded on the Complaint/Grievance Form or electronic equivalent. -Once the follow-up is complete, the results should be forwarded to the Executive Director for review and filing. The Executive Director/designee will log complaints/grievances in Monthly Grievance Log or electronic equivalent. -The individual voicing the grievances shall receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. On 12/29/2020 a record review of the facility's census was conducted. Record review revealed that Resident #1, #2 and #3 were no longer in the facility and therefore were unavailable for interview. On 12/29/2020 at 5:05 PM, an interview was conducted with the Grievance Officer. The surveyor discussed the grievances reviewed for Residents #1, #2, and #3. The surveyor pointed out that the actions taken were primarily written in the future tense and that the received and resolved date and time were nearly the same although the nature of the complaint allegations was serious and involved the same staff member. The surveyor questioned how these cases could be marked as resolved if the involved staff member had not been spoken to and re-educated? The Grievance Officer replied that when she informs the DON of the concerns, the DON usually states that she'll handle it. The surveyor pointed out that the grievance filed on 11/11/2020 was an escalation in allegations regarding the same staff member that two grievances had just been filed against a week earlier. The surveyor questioned if the facility had taken the necessary action to prevent the allegation of abuse filed on 11/11/2020 regarding this staff member and asked if a follow-up was ever conducted with the DON as outlined in the Complaint/Grievance Policy and Procedure. She confirmed that she never followed up with the DON to ensure that the concern was discussed with Staff A. The surveyor then questioned if a thorough investigation was conducted in each case prior to reaching the outcome of not confirmed. The surveyor asked how a grievance could be unsubstantiated if the involved staff member was never spoken to and asked directly if she did or didn't do the things she's alleged to have done and was not provided the opportunity to confirm or deny the allegations. The surveyor further discussed that in the case of Resident #1, his grievance was also marked as not confirmed although review of a telephone statement obtained and transcribed by the DON on 11/11/2020 revealed that Staff A didn't deny handling the resident roughly and confirmed that he is hard to turn in the bed to provide care I was holding him over by pushing him on his side .I don't have time to get help every time, everyone is busy. The Grievance Officer replied that she understood what the surveyor was saying, but did not provide any additional explanation. The surveyor also questioned if a follow-up with Resident #1 may have been necessary prior to closing his complaint in order to ensure a thorough investigation as the resident was preparing to leave for [MEDICAL TREATMENT] and was noted to be very sleepy. She replied that she did return to his room later, but didn't document it anywhere. notes on that visit aren't documented anywhere. On 12/29/2020 at 7:06 PM, a telephone interview was conducted with the DON. The surveyor informed the DON of the concerns reviewed with the Grievance Officer earlier. The DON stated that she spoke to each of the involved residents herself before speaking to Staff A. Upon speaking to Staff A about the residents' concerns, Staff A assured her she did nothing wrong in either scenario. The surveyor asked when the conversation with Staff A took place, as the only documented conversation was on 11/11/2020 and not on 11/5/2020 when two residents filed complaints against her. She stated that she would've addressed it the same day she received the information from social services (11/5/2020). She further stated she did staff education on resident rights and customer service. The surveyor asked if the staff member was in the facility when she was made aware of the allegations. The DON confirmed that Staff A was working at the time and that she should've probably written something down but unfortunately she doesn't recall that she did. She further stated that she reassigned Staff A following receipt of the two grievances on 11/5/2020 and can recognize when a person is reaching the end of their rope and she recognized that in Staff A. The DON explained that Staff A had been working a lot of shifts and so she instructed the Staffing Coordinator not to schedule her for double shifts anymore and informed Staff A of the change as well. The DON also stated that when Staff A was informed that she was suspended pending the outcome of the abuse allegation opened on 11/11/2020, she resigned. Review of the Abuse, Neglect, Exploitation & Misappropriation training referenced by the DON revealed it was provided on 11/13/2020, eight days after the first two complaints were received and two days after the third complaint was received.

Based on observation, interview, and record review the facility failed to ensure timely assistance with Activites of Daily Living (ADL) for 3 of 5 dependent residents (Residents #3, #4, #5) The findings include: On 10/6/20 at approximately 9:50 AM, resident #5 was observed seated in her bed watching television. She was interviewed at this time and noted to be alert and oriented to person, place, and time. Resident #5 stated she had been a resident in the facility for about 3-4 weeks for rehabilitation after having a stroke. She stated she wore an adult brief and required assistance to get to the bathroom in her room to have a bowel movement. She stated sometimes it takes them 30-40 minutes to come and I cannot always hold it, and this happens often. Resident #5 also stated she was concerned about her roommate resident #4 because she has [MEDICAL CONDITION], is an elderly women who needs total care, and that on the previous evening shift resident #4 was left in a chair for over 6 hours without anyone checking on her. Resident #4 was observed at this time and noted to be sitting up in bed, alert but very confused with enteral feeding in progress. On 10/6/20 at approximately 10:10 AM, resident #3 was interviewed and determined to be oriented to person, place and time. She stated the biggest thing is that sometimes they do not answer the call button, so I call my husband to get someone. Resident #3's record was reviewed and revealed resident had poor coordination resulting in difficulty walking, muscle weakness, and urinary incontinence. Resident #4's record was reviewed and revealed resident was dependent for all ADLs and an extensive medical history including [MEDICAL CONDITIONS], generalized muscle weakness, and dysphasia with gastrostomy tube dependency for enteral nutrition. On 10/6/20 at 3:10 PM, staff member F, a Certified Nursing Assistant (CNA) was interviewed regarding resident #4 being in a chair approximately 6 hours. She stated when she arrived for her 3-11 PM shift, resident #4 was already in her chair. The CNA was shown the resident's CNA ADL flow record which required resident check every 2 hours for incontinent needs. The CNA stated she tried to check the resident by looking in the front of the resident's brief but did not put the resident back to bed till around 9 PM utilizing a mechanical lift which she had to operate alone because I couldn't find anyone to help me. She stated she knew that was not right but had no option. When asked why there was no documentation on the CNA flow record of the resident being checked once back in her bed at 9 PM, the CNA stated she was new and did not have access to the computer system for documentation of ADL assistance.

Based on record review and interview the facility failed to develop a comprehensive person-centered care plan that described the mental and psychosocial needs identified in the comprehensive assessment for 1 of 1 resident's sampled for mood and behavior (resident #34). The findings include: On 01/08/20 at approximately 11:36 AM, during review of resident #34's medical record it showed that the resident had been admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] indicated the resident was identified to have depression. On 01/08/20 at approximately 2:42 PM, during record review and interview with staff F, Registered Nurse (RN) and Minimum Data Set (MDS) coordinator, who was responsible for the development of the resident care plans reviewed the resident's care plan dated 11/27/2019 and confirmed it was the most recent and accurate version. Staff F expressed that a [DIAGNOSES REDACTED].#34's plan of care.

Based on observations, record review, staff interviews, and policy review the facility failed to ensure residents with urinary catheters received appropriate care and services in an effort to prevent urinary tract infections for 1 of 1 sampled resident with a urinary catheter. (resident #40) The findings include: Observations of resident #40 were conducted on 1/6/20 at 11:55 AM and 3:49 PM and on 1/8/20 at 12:58 PM. The resident was in bed and the catheter bag was observed to be touching the floor during all observations. An interview was conducted with the north wing unit manager on 1/8/20 at 12:58 PM. She observed the catheter bag touching the floor and stated it should be kept off the floor. Review of the resident's current physician orders revealed an order for [REDACTED]. An observation of catheter care was conducted for resident #40 on 1/9/20 at 9:23 AM, with employee G (certified nursing assistant). Employee G washed hands, donned gloves and began cleansing the resident's penis at the catheter insertion site first using an away from the resident motion then using a back and forth motion. The catheter tubing was observed to be clamped to the bed sheet. When employee G turned the resident on his left side the catheter was observed to be visibly pulled tight to the resident's urinary meatus. No leg strap or other securing device was observed to be in use to secure the catheter to the resident and prevent pulling. An interview was conducted with employee G on 1/9/20 at 9:40 AM. Employee G stated she had cleansed the catheter in a back and forth motion and should have cleansed away from the urinary meatus. She did not know why his catheter was not secured to his leg. An interview was conducted with the north wing unit manager on 1/9/20 at 9:44 AM. She stated the catheter should be secured to the resident's leg to prevent pulling. Review of the facility policy and procedure for Urinary Tract Infections (Catheter- Associated), Guidelines for Preventing (document: IC- 516 review date 9/1/17) reveals the purpose of this procedure is to provide guidelines for the prevention of catheter- associated urinary tract infections. The procedure stated secure the catheter after insertion to prevent movement and do not place the drainage bag on the floor. Review of the facility policy for Urinary Catheter Care (revised 9/5/17) reveals staff should clean the catheter tubing with soap and water, starting close to the urinary meatus, cleaning in circular motion along its length for about 4 inches, moving away from the body.

Based on observation, record review, and interview the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 1 residents sampled for mood and behavior (resident#34). The findings include: On 01/06/20 at approximately 3:33 PM, during interview with the resident's representative the representative expressed that the resident's mood had been depressed significantly since she had been residing at the facility and described the resident's normal mood as friendly and full of laughter. The representative expressed concern that the resident was depressed and just sits in a chair now. On 01/07/20 at approximately 1:36 PM, during observation of resident #34 in her room, the resident had her arms crossed and was notably frowning, when asked how the resident was, she responded not well, I don't want to be here. When questioned more the resident denied more questions and shrugged without making eye contact. On 01/07/20 at approximately 2:41 PM, during observation of resident #34 she was observed seated in her wheelchair in the hall in front of her room. There were several staff passing, one staff briefly said hey to the resident and continued walking. The resident looked to see who had talked to her, but the staff was already passed the resident. On 01/08/20 at approximately 9:41 AM, during observation of resident #34, she was sitting in her wheelchair at her bedside table notably frowning. When asked how she was the resident shrugged and stated not good when questioned further she stated I don't want to just sit here for the rest of my life. The resident would not answer more questions at that time. On 01/08/20 at approximately 11:36 AM, during review of resident #34's medical record it showed that the resident had been admitted [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's care plan dated 11/15/2019 identified that the resident had the potential for impaired or inappropriate behaviors related to cognitive loss with interventions listed to provide physical and verbal cues to alleviate anxiety, and to give positive feedback. Additionally, the care plan identified that the resident had the potential for loss of independence due to impaired cognition with interventions listed to introduce self frequently, add validation, use visual cues and gestures, to speak slowly and distinctly, to identify yourself at each interaction and face the resident and make eye contact when communicating. On 01/08/20 during observation of resident #34 at approximately 11:45 AM, the resident was observed sitting in her wheelchair in front of the nurse's station on the hall her room was located. The resident had begun falling asleep and was visibly nodding her head. At approximately 12:11 PM an unidentified direct care staff member walked up to the resident and abruptly started moving the resident's wheelchair without saying anything to the resident. The resident looked visibly startled. The staff member proceeded to propel the resident's wheelchair into an activities room adjacent to the nurse's station. In the activities room were three staff, two unidentified direct care staff and staff E, Certified Nursing Assistant (CNA) and activities coordinator. There was no meaningful engagement with the resident during that time. One of the unidentified staff members was observed using a cell phone, the other came in and out of the room talking to the other staff and staff E, CNA was painting another resident's fingernails. At approximately 12:26 PM staff [NAME] was observed to finish painting the other resident's nails and then observed to use a cellphone before packing the nail painting supplies up. Resident #34 was observed during this time unengaged by any of the staff. Staff E, CNA, engaged several times with the other resident in the room but did not interact with resident #34 before leaving the activities room propelling the other resident out in her wheelchair. Resident #34 remained in the room alone. The observation continued for another approximate 10 minutes with resident #34 sitting in her wheelchair in the activities room by herself. On 01/08/20 at approximately 12:50 PM, during observation of resident #34 she was seated in her wheelchair at the bedside table eating in her room alone. When asked how she was doing she stated, not good, when questioned more she would not answer and began tapping her beverage cup on the table without making eye contact. On 01/08/20 at approximately 01:37 PM, during interview with resident #34's CNA, staff D, when asked about resident #34's mood she stated she is mean when asked to describe how the resident was mean the CNA expressed because of the way the resident looks and that she will try to swat at her when providing care. When questioned about what interventions the CNA uses to calm or redirect the resident, she stated if she gets too bad, we just leave her alone. On 01/08/20 at approximately 1:45 PM, during interview with staff E, CNA and activities coordinator, when asked to describe resident #34's mood, expressed that the resident was not very friendly but that if she had a visitor it makes her day. When asked what kind of goals the resident had in activities the CNA stated, I don't know, she's content watching a movie, and she loves her little snacks.

Based on observation, staff interview, and policy review the facility failed to provide a sanitary homelike environment by failing to implement their infection prevention program to ensure staff performed hand hygiene after providing resident care for 2 of 3 resident care observations (resident # 40), to ensure isolation precautions are being followed for 1 of 2 sampled residents for transmission-based precautions (resident #9), to ensure staff demonstrated proper use of Personal Protective Equipment (PPE) and to ensure staff followed standard precautions during the performance of routine housekeeping duties for 1 of 2 sampled residents for isolation precautions (resident #27). The findings include: An observation of catheter care was conducted for resident #40 on 1/9/20 at 9:23 AM, with employee G (certified nursing assistant). Employee G washed hands, donned gloves and began cleansing the resident's penis at the catheter insertion site first using an away from the resident motion then using a back and forth motion. Employee G then removed gloves and left the room to obtain linen. She did not wash her hands prior to leaving the room. An interview was conducted with employee G on 1/9/20 at 9:40 AM. Employee G confirmed she should have washed her hands before leaving the resident's room. Review of the facility policy for Hand Hygiene (revised 5/10/19 N-1530) reveals hand hygiene should be performed before and after patient care and after glove removal. On 01/06/20 at approximately 2:11 PM, during observation and interview the door to resident #9's room had personal protective equipment attached and a sign stating to see nurse before entering. The nurse on the unit stated that the resident was on isolation precautions for [MEDICAL CONDITIONS] or [DIAGNOSES REDACTED]. (a bacterial infection that causes inflammation to the colon and can spread from person to person by contact with spores). On 01/07/20 at approximately 3:27 PM, during observation of resident #9 receiving therapy in the facility therapy room, the resident was observed among a row of 5 other residents seated in wheelchairs with walkers in front of them. Staff C, Physical Therapy Assistant (PTA), was observed assisting the residents with exercises. Staff C provided resident #9 with a bin of bean bags that were set on a rolling overbed table. Staff C assisted resident #9 to stand using the walker and to toss the bean bags into a bin a few feet in front of the walker. Staff C was not wearing gloves or any other personal protective equipment and was observed touching the resident's wheelchair, clothing and person while assisting resident #9. After resident #9 had thrown all of the bags, staff C, placed the walker the resident had been using in a stack of other walkers along a wall and assisted the resident in his wheelchair out of the room. Staff C was not observed to perform handwashing or hand hygiene before assisting the next resident. Staff C was not observed to sanitize the equipment that resident #9 had used in any way before giving it to the next resident to use. No observations of staff C performing hand hygiene or sanitizing the equipment were made as observation continued for the therapy for the other 5 residents which involved touching their clothing, wheelchairs, person, and therapy equipment. On 01/07/20 at approximately 3:46 PM, during record review of resident #9's medical record it was noted that the resident had been admitted from the hospital with the [DIAGNOSES REDACTED]. on 12/27/2019 and was currently receiving treatment at the facility for the infection. On 01/07/20 at approximately 4:24 PM, during interview with resident #9's medication nurse, staff B, Licensed Practical Nurse (LPN), she confirmed that the resident was on precautions for [DIAGNOSES REDACTED]. and stated that the resident was still symptomatic and posed a risk of transmission to other residents. On 01/08/20 at approximately 10:35 AM, during interview with staff C, PTA, he expressed that when someone is on isolation precautions and requires therapy if the condition and precautions permit residents are brought to the therapy room and staff keep an adequate record of which surfaces they have touched so as to ensure they are sanitized after use. Staff C expressed that he did not know that resident #9 was on precautions for [DIAGNOSES REDACTED]. and stated he thought it was due to a urinary infection. Staff C expressed that things the resident touch in the therapy room should be disinfected after the resident uses them. Staff C, confirmed that he had not disinfected the bean bags, rolling table, or bin prior to use by the next resident and confirmed hand hygiene was not performed and stated that hand hygiene, wearing gloves, and disinfecting the equipment should have happened. On 01/08/20 at approximately 11:00 AM, review of facility policy titled [MEDICAL CONDITION] dated 9/1/2017 stated that the primary reservoirs for [DIAGNOSES REDACTED] are infected people and surfaces and that spores can persist on resident-care items and surfaces for months while being resistant to common cleaning and disinfecting methods. Steps listed to assist in prevention of transmission included disinfecting potentially contaminated surfaces and frequent hand washing. Additionally, record review of the facility policy titled Hand Hygiene dated 5/10/2019, that hand washing should be performed after contact with inanimate objects in the immediate vicinity of a patient and before and after patient care. An observation was made on 1/8/2020 at approximately 9:52 AM, of housekeeper, (staff member A) who entered resident #27 room without donning PPE. An isolation box with PPE (gowns and gloves) and a sign which read, please see a nurse before entering was observed hanging on the door to resident #27's room. An interview was conducted on 1/8/2020 at approximately 9:54 AM, with staff member A who reveled she would see the nurse prior to entering the room if there was a sign on the door. Staff member A stated there was no sign on the door. Staff member A revealed only gloves are needed when cleaning isolation rooms. Staff member A revealed she changes the mop head and water every two rooms and had clean mop water and a clean mop head to mop resident #27's room. Staff member A revealed she would mop the room across the hallway after cleaning resident 27's room, then she would change the water and mop head. An interview was conducted on 1/8/2020 at approximately 10:35 AM, with Staff member H, environmental supervisor who confirmed housekeeping staff are expected to don PPE prior to entering any isolation room and confirmed the mop water and mop head should be changed after cleaning an isolation room. Staff member H confirmed isolation rooms should be cleaned last. A review of the policy entitled, Cleaning Procedures with effective date 1/07 revealed under section 3, A: for daily isolation room cleaning, use all PPE required in our Infection Control Guidelines.

Based on record review, staff interview, and review of the facility's policy, the facility failed to demostrate that the use of an indwelling [MEDICATION NAME] was necessary for 1 of 1 resident sampled (#474). The facility also failed to ensure implementation of interventions to minimize complications of the resident's indwelling urinary [MEDICATION NAME], which resulted in the resident (#474) being transferred to a higher level of care for treatment of [REDACTED]. The findings were: A record review conducted for resident #474 revealed a physician order [REDACTED]. Another physician order [REDACTED]. The treatment record (TAR) dated October 2017 revealed an order for [REDACTED]. There was no recording that the resident received any catheter care for 10/16/2017 or 10/17/2017. A review of the nurses notes revealed an entry dated 10/11/17 at 4:00pm that stated 16 French indwelling foley catheter inserted to promote wound healing. At this time, clear yellow urine return. Another nurses note dated 10/12/17 stated foley catheter patent with clear yellow urine noted. The nurses notes reviewed from the dates of 10/13/17 - 10/16/17 revealed no further documentation of the assessment of the resident's urine. On 10/17/17 the form titled Situation, Background, Appearance, Review and Notify (SBAR) was completed with a note under the [MEDICAL CONDITION]/urine evaluation section that stated cloudy/pus in urine noted in foley catheter bag. A nurses note dated 10/17/17 at 6:30pm stated admitted to Bay Medical Center (BMC) with urinary tract infection [MEDICAL CONDITIONS]. A hospital consult was observed in the medical record from Bay Medical Center dated 10/18/17 with the assessment [MEDICAL CONDITION], secondary to urinary tract infection . The resident remained in the hospital from 10/17/18 until 11/10/17. A review of the plan of care for resident #474 revealed a care plan for altered bladder elimination that included an intervention for catheter care as ordered and as needed. According to the physician order [REDACTED]. During review of the treatment record where catheter care was recorded, there were multiple shifts that catheter care was not performed as noted above. The plan of care also failed to have the intervention to monitor and report to medical doctor (MD) as needed for signs and symptoms of urinary tract infection [MEDICAL CONDITION] marked as an active intervention. On 12/20/17 at 2:00pm, an interview was conducted with the Director of Nurses (DON). She stated when a resident has an indwelling catheter, a physician's orders [REDACTED].A. completed the catheter care. The October 2017 treatment record was shown to the DON for catheter care for resident #474 and she stated the nursing staff work 8 hour shifts and confirmed the catheter care was not signed off as completed for the dates and shifts listed above. She discussed resident #474 and his history of UTI's during his stay at the facility when he required an indwelling catheter. She confirmed resident #474 did not have the indwelling catheter from 8/8/17 until it was inserted on 10/11/17. She further stated he did not have any issues during this time frame with UTI's. She explained the physician ordered the indwelling catheter to be inserted due to the decubitus ulcer on his coccyx that was not healing. The facility's policy and procedure titled Urinary Tract Infections (catheter associated) Guidelines for Preventing, updated on 9/01/17, was reviewed. Steps in the procedure for catheter associated urinary tract infections (CAUTI) prevention strategies for clinical staff stated in procedure 2.a. to conduct ongoing assessments and monitoring of residents with indwelling catheters to establish continued need. It also stated to document every 24 hours or per facility protocol. The DON had stated in her interview on 12/20/17 at 2:00pm that it was the expectation of a nurse to monitor and document during their shift the urine appearance and observe for signs and symptoms of a UTI for a resident with an indwelling catheter.