Every finding on record at Bellbrook

Based on observation, interview and record review the facility failed to ensure a level I PASARR (Preadmission Screening and Resident Review) screening was completed for one (R6) of one resident reviewed for PASARR's. Findings include:On 2/17/26 at 9:22 AM, R6 was observed in their bedroom sitting in their wheelchair. R6 was interviewed at that time.A review of the medical record revealed R6 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder and received Abilify (an antipsychotic medication)15 milligrams daily.A review of the medical record revealed a Level I Screening Hospital Exemption Discharge to have been completed on 11/11/24, for a prior admission [DATE] to 12/13/24).Further review of the medical record revealed no evidence of a Level I screening to have been completed for the current admission.On 2/17/26 at 3:08 PM, Social Worker (SW) A was interviewed and asked to provide R6's most recent Level I PASARR screening. SW A stated they would look into it and follow back up.Shortly after SW A provided the 2024 Level I PASARR screening for review.On 2/18/26 at 9:25 AM, SW A was recalled for a second interview. The provided 2024 PASARR Level I screening was reviewed. SW A stated a new one should have been done for the current admission. SW A stated they would review the record and follow back up. At 9:52 AM, SW A returned and stated a Level I PASARR screening was not conducted for R6. SW A stated they were following up on it now.On 2/18/26 at 9:58 AM, the Administrator stated the facility did not have a policy regarding PASARR and noted the facility would follow the current regulations.No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake: MI00148291. Based on interview and record reviews the facility failed to timely notify the Physician and/or practitioner of an identified change of condition and failed to monitor/assess the resident once the change of condition was identified for one (R140) of one resident reviewed for a change of condition, resulting in a delayed notification to the physician and delayed interventions and care/treatment. Findings include: A review of a complaint submitted to the State Agency (SA) included concerns of the facility staff to have failed to properly assess and seek appropriate treatment following a change in R140's condition. Review of the medical record revealed R140 was initially admitted to the facility on [DATE] with diagnoses that included dementia and the need for personal care assistance. Review of the progress notes documented the following: On [DATE] at 10:43 AM, a Nursing note documented in part . had episode at breakfast this am (morning)- took spoonful of oatmeal and started to cough was able to spit oatmeal out with encouragement and took some orange juice. Vss (vital signs stable) and lungs are clear-elder is in no distress. Will monitor . On [DATE] at 10:17 PM, a Nursing note documented in part . appetite poor for supper, drank approx. 50% of ensure . On [DATE] at 2:21 PM, a Nursing note documented in part . seen by speech therapist- no coughing episodes noted ate few bites of oatmeal and little bit of orange juice. No appetite for lunch . On [DATE] at 1:39 PM, a Nursing note documented in part . Patient asleep most of the shift. Patient not able to arouse during meals ate 0% of breakfast and lunch. Medication not given due to the patient not being able to awake throughout the shift . The above note was modified twice. The first modification of the [DATE] Nursing note completed at 2:44 PM, inserted the following . Patient family has been aware of moms condition today bp (blood pressure) ,d+[DATE], [NAME] <sic> 96.8, spo2 (oxygen saturation level) 96%, hr (heart rate) 94, resp (respirations) 14 . The second modification of the [DATE] Nursing note completed at 2:51 PM, changed the previous respiration rate of 14 to 20. The [DATE] note was documented and modified by Licensed Practical Nurse (LPN) I. Review of the medical record revealed no documented time the above vitals were obtained on [DATE] and no documentation of additional vitals obtained or monitoring conducted after the identified change of condition for R140. Further review of the medical record revealed no immediate notification to the physician or practitioner regarding the identified change of condition for R140. Review of a facility policy titled Change in Resident's Condition updated [DATE], documented in part . The community will promptly notify the resident, his/her attending physician . of changes in the resident's medical/mental condition and/or status . The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been . a significant change in condition: physical/emotional/mental . refusal of treatment or medications (two consecutive times) . a need to transfer the resident to a hospital/treatment center . The nurse caregiver will record pertinent changes in the resident's medical record and whom was contacted to these changes . A Nursing note dated [DATE] at 3:29 PM, documented in part . Physician contacted with elders status change. Physician ordered stat (immediate) chest x-ray, stat cbc (complete blood count) and bmp (basic metabolic panel) and to monitor vitals. Blood drawn from left antecubital with no adverse effects noted . labs call in stat for pick up . A Nursing note dated [DATE] at 3:56 PM, documented in part . Elder noted with absence of breath sounds and heartbeat at 16:40 (4:40 PM) . Both of the notes above was documented by Unit Manager (UM) F. This indicated LPN I failed to notify the physician/practitioner timely after the identification of the change of condition for R140. As documented by LPN I of not being able to awake the resident throughout their shift, unable to arouse resident for breakfast and lunch and unable to administer the resident's medications throughout their shift. This revealed hours in the delay of notification to the physician and a delay in timely care. Review of a Physician Discharge Summary dated [DATE], documented in part . Rapid decline with decrease po (by mouth) intake, lethargy x 1 day - CBC, BMP, C-XRY (chest x-ray) ordered STAT . Patient expired before results obtained . Review of the cbc and bmp labs with the collection date of [DATE], revealed the following abnormal levels: Sodium 156 H (high) - Range ,d+[DATE] Chloride 114 H - Range ,d+[DATE] BUN (blood urea nitrogen) 71 H - Range ,d+[DATE] Creatinine 2.88 H - Range 0.60 - 1.20 eGFR (estimated glomerular filtration) 15 L (low) - Range >60 WBC (white blood cell) 15.5 H - Range 3XXX,d+[DATE].0 Hematocrit 46.9 H- Range 35XXX,d+[DATE].0 Review of a chest x-ray dated [DATE], documented in part . IMPRESSION . early interstitial infiltrates in the right lung base . On [DATE] at 1:42 PM, LPN I was interviewed via telephone and asked about R140's change of condition documented on [DATE]. LPN I was asked why they modified their note twice and why the respirations were changed from 14 to 20 in the final modification. LPN I stated they go back to their notes throughout their shift and make changes. LPN I stated they were unsure but the wrong vitals could have been noted and they went back to correct it. LPN I was asked why there were no additional vitals obtained or additional monitoring of R140 after the identified change of condition. LPN I replied they had checked on R140 throughout the day but was unsure of the documentation of the additional vitals obtained or any noted documentation of the monitoring conducted. LPN I was asked what exactly did check on mean when monitoring R140 and LPN I stated there were moments that R140 did not want to eat or take medications in the past. LPN I was asked was it normal that the resident could not be awakened for an entire shift and could not be aroused to eat or take their medications for an entire shift? And LPN I did not respond. LPN I was asked why there was a delay in notification to the physician after an entire shift of an identified change of condition with R140 and LPN I replied they did notify UM F and the physician. On [DATE] at 2:22 PM, UM F was interviewed and asked about the change of condition identified for R140 on [DATE]. UM F stated they were informed by LPN I that the resident did not eat breakfast. UM F stated R140 was up that morning because they were the one that put the resident back to bed after breakfast. UM F was asked if R140's eyes were opened and UM F confirmed they were not. UM F stated at that time LPN I was taking R140's vitals and UM F went to their morning meeting. UM F stated they had meetings scheduled for most of that day. UM F stated after their meetings they assisted LPN I with obtaining the vitals for R140. UM F was unable to recall the value of each vital, however stated the vitals were normal for R140. UM F stated after obtaining the vitals they were the one to notify the Physician of R140's change of condition and the Physician ordered the STAT labs and chest x-ray. UM F stated soon after they pronounced the death of R140. The Director of Nursing (DON) who was employed with the facility on [DATE], was no longer employed with the facility at the time of the survey. On [DATE] at 4:42 PM, the Administrator and [NAME] President of Operations (VPO) J was interviewed and informed of the concern of the delay in addressing an identified change of condition. No further explanation or documentation was received by the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 12/15/24 between 8:50-9:35 AM, during an initial tour of the kitchen, the following items were observed: In the walk-in cooler, there was a pan of cooked corned beef, uncovered and undated. The Internal temperature of the corned beef ranged from 99-102 degrees Fahrenheit. When queried at that time, Dietary Staff C stated the corned beef had been cooked sometime this morning. When queried about a cooling log, Dietary Staff C checked the log and stated that the corned beef had not been placed on the cooling log. No explanation was given for why the cooling log had not been utilized. According to the 2017 FDA Food Code section 3-501.14 Cooling, 1. (A) Cooked POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be cooled: 1. (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); P and 2. (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. There were 6 cans of various food items on the floor behind the can racks. According to the 2017 FDA Food Code section 3-305.11 Food Storage, 1. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: 1. (1) In a clean, dry location; 2. (2) Where it is not exposed to splash, dust, or other contamination; and 3. (3) At least 15 cm (6 inches) above the floor. In the dry storage room, there were crumbs, food debris, packages of crackers and condiment packages on the floor underneath the racks. The floor underneath the dish machine was observed with standing water, and a slimy surface. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) Physical facilities shall be cleaned as often as necessary to keep them clean. There was a red sanitizer bucket in the main kitchen area. The concentration of the sanitizer solution was tested with a smart power test strip. The strip did not change color to detect any level of sanitizer. According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114; There was a bin of thickener with the scoop stored inside, and the handle was resting in the thickener powder. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour, or cinnamon; On 12/15/25 at 10:00 AM, DM B was queried about the corned beef not being logged on the cooling log. DM B confirmed the corned beef should have have documented on the cooling log. DM B was also queried about the housekeeping concerns in the dry storage area and underneath the dish machine, and stated that on weekends they don't have their strongest porters on the schedule.

Based on observation, interview and record review the facility failed to thoroughly and accurately investigate allegation(s) of staff to resident physical/verbal abuse for one (R91) of two residents reviewed for abuse. Findings include: On 12/16/24 at approximately 11:02 AM, R91 was observed sitting in a wheelchair in their room. The resident was alert and able to answer questions asked. R91 noted that they were at the facility to obtain physical therapy following a fall at their assisted living home located on the same property as the facility. R91 reported that they wanted to get back to their assisted living home and was not happy at the facility. They noted that a male staff member (herein after Certified Nursing Assistant/CNA D) was very rude, disrespectful and grabbed their wrist. R91 noted that the incident happened about two weeks ago, possibly the first week in December. When asked if they reported the incident to any staff members, R91 reported that they had talked with the Administrator/Abuse Coordinator and pulled out a piece of paper that noted CNA D's first name and also the name of the Administrator. A review of R91's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: fracture of left femur and history of falls. A review of resident Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 (cognitively intact cognition). *It should be noted that there were no documents in the resident's clinical record that addressed any allegations regarding rough and/or rude treatment. A request for all IA (investigation/accident) reports and/or grievances was made on 12/16/24 at approximately 3:38 PM. On 12/16/24 at approximately 3:58 PM, the facility responded with two grievances and two IAs. Neither mentioned anything regarding the allegation pertaining to CNA D being rude, disrespectful and grabbing R91's wrist. Nothing else was provided on 12/16/24. On 12/17/24 at approximately 2:35 PM, an interview was conducted with the Administrator/Abuse Coordinator. The Administrator was asked again if there were any additional IA/Grievances pertaining to R91. They responded No. At that time the Surveyor reported that R91 had made an allegation that CNA D was rude, disrespectful and grabbed their wrist. It was also reported to the Administrator that R91 had a piece of paper that noted CNA Ds name as well as their signature. Again, the Administrator noted that they did not recall the actual incident and noted that perhaps they missed a concern form. The Administrator could only recall that at times R91 makes inappropriate racial slurs. On 12/17/24 at approximately 3:36 PM, the Administrator provided an additional Grievance/Complaint report that documented, in part, the following: Date received: 12/5/24 .Resident name (R91) .Grievance/complaint reported to .Administrator . other: Clinical Coordinator (CC)A . Describe grievance/complaint: Customer service/care concerns with CNA D .Documentation of follow-up by CC A: Date assigned: 12/5/24 .What actions was/were taken to resolve grievance/complaint (be specific) .Removal of CNA from care of elder per elder request .Resolution: CNA A removed from elder care per elder request .Form completed by: CC A and Grievance officer/ Administrator on 12/5/24. On 12/17/24 at approximately 3:49 PM, an interview was conducted with Clinical Coordinator A regarding the grievance noted above, what was alleged by R91 and what Customer service/care concerns referred to. CC A reported that they recalled talking to R91 who noted that CNA D did not have a good attitude and was rough and rude. CC A could not recall as to the specifics regarding rough and rude. CC A did note that R91 asked that CNA D not work with them. CC A noted that they spoke with CNA D who did not recall any issues with R91 on or about 12/5/24 but noted that the CNA noted that R91 made rude comments to them, and they did not like it. CNA Ds personnel record was reviewed there was no indication in the record that detailed R91's allegation, no documents that noted they should not work with R91 or further education regarding Customer/Service Care. The facility schedule for the month of December 2024 noted that CNA D worked on 12/6/24 the day after the allegation. An attempt to contact CNA D was made on 12/17/24 at approximately 5:43 PM. A voice message was left. No return call was made prior to the end of the Survey. The facility policy titled Abuse, Neglect (Revised August 2022) was reviewed and documented, in part, the following: .Policy: This Community will not tolerate verbal .physical, or mental abuse .Any resident .may file a complaint with this Community's Administrator .or with any other officials .Alleged Violation .is a situation or occurrence that is observed or reported by staff, resident .but has not been investigated .Identification of inappropriate behavior of staff, such as derogatory language, rough handling .Protection: .The Community will take all action necessary to prevent the abuse .while it is conducting its investigation of the incident .if Staff is accused or suspected: immediately remove from the Community and the work schedule pending the outcome of the investigation .Investigation .The investigation shall be completed, whenever possible, within twenty-four (24) hours after the Administrator has knowledge of the incident, but the investigation should not take longer than five (5) working days .

Based on observation, interview and record reviews the facility failed to ensure an Annual Resident Review (ARR) level I screening was completed and submitted annually for a level II OBRA (Omnibus Budget Reconciliation Act of 1993) evaluation for one (R2) of one resident reviewed for PASARR's (Preadmission Screening Annual Resident Review). Findings include: On 12/15/24 at 10:08 AM, R2 was observed sitting in their wheelchair sleeping. With verbal stimuli R2 was easily awakened. A brief interview was attempted with the resident at that time. A review of the medical record revealed R2 was admitted to the facility on [DATE], with diagnoses that included: dementia, dysthymic disorder, anxiety disorder, psychotic disorder with delusions, major depressive disorder, adjustment disorder and hoarding disorder. Further review of the medical record contained a Level I Screening (ARR) dated 7/26/2023. A Level II screening exemption criteria document was noted with the physician electronic signature and dated 7/26/2023. The medical record did not contain a completed and submitted Level I or Level II screening for the year of 2024. On 12/17/2024 at 9:10 AM, Social Worker Technician (SWT) G and Social Worker Helper (SWH) H was interviewed and asked to provide the Level I and Level II PASARR screening for R2. SWH H stated they had a bunch of PASARR's that needed to be scanned in the resident charts. SWH H stated they would look through the pile and provide R2's PASARR's for review. At 11:36 AM, the Level I and Level II exemption documents from 2023 was provided by the Administrator and Director of Nursing (DON). At 11:51 AM, the Administration team (Administrator and DON) was asked if they had any Level I or Level II PASARR screening for the year of 2024. At 12:44 PM, the Administrator stated R2's annual was submitted to OBRA and the facility had not received a response for the Level II determination. At this time the Administrator was asked to provide the Level I (annual) screening submitted. Review of a Level I screening dated 12/17/2024 was provided. This indicated the facility failed to ensure a Level I screening was completed timely and before being requested by the surveyor. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview and record reviews the facility failed to implement a resident centered care plan with individualized interventions that identified behaviors and/or mood concerns for one (R13) of five residents reviewed for unnecessary medications. Findings include: On 12/15/24 at 10:11 AM, R13 was observed laying on their back in bed. During a brief interview conducted with the resident, R13 was asked if they had any concerns with their care at the facility and R13 responded in part . I'm not sure. I can't really remember things . A review of the medical record revealed R13 was initially admitted to the facility in June 2024 with a readmitted [DATE] with diagnoses that included: dementia without behavioral, psychotic or mood disturbances, Alzheimer's disease and anxiety disorder. Review of the physician orders and Medication Administration Record (MAR) revealed the following medications: Sertraline 25 mg (milligram) tablet, one time daily for depression. Trazodone 50 mg tablet, at hour of sleep for depression. Memantine 5 mg tablet, one time daily for Alzheimer's disease. A review of the behavioral consultations noted the following: 6/21/24 consultation documented in part . According to pt (patient), resident has had depression over 1-2 years . pt (patient) has C/O (complaints of) depression with emotional distraught due to medical change and, get worse due to debility . pt look alert and verbal response, sadness with tearful when talking about his depression a+o x 2-3 (alert and oriented times two/three) . + (positive) Anxious; +Depressed; +Sad . Generalized anxiety disorder . (chronic) . Psychosocial support, Monitor mood change . Adjustment disorder with mixed anxiety and depressed mood . (acute) . Dysthymic disorder . (chronic) . 11/25/24 consultation documented in part . Dx (diagnosis) of anxiety depression stay with Desyrel Zoloft as well as Namenda HX (history) of Remeron, and monitor today any mood change and medication evaluated for benefit vs risk . pt seen in his room pt look alert and verbal response, there are no c/o medication after a trial of Desyrel but pt still with confused . pt's psychotropic medication has change pt has taken Namenda and Zoloft and Seroquel now . Mood: +Anxious; +Depressed; +Sad . Affect: +Flat . Delirium: +Present . Generalized anxiety disorder . stay with Desyrel for anxiety depression insomnia . stay Zoloft for depression, Stay Namenda for dementia to delay progression of cognitive . Psychosocial support, Monitor mood change . Dysthymic disorder . Dementia . moderate, with psychotic disturbance . pt's Namenda and Desyrel benefit to pt . A review of the care plans revealed no individualized behaviors, mood or stressors identified for the resident or person centered interventions implemented. Further review of the care plans revealed no implementation of resident specific non-pharmacological interventions noted. Review of the medical record revealed no documentation of identified behaviors or specific mood changes identified. Further review of the medical record revealed no documentation for the monitoring of the residents identified behaviors or specific mood changes. A review of a facility policy titled Behavior Monitoring/Management revised July 2018, documented in part . Outline and Best Practice Suggestions for the Behavior team would be the following . What behavior(s) is the resident exhibiting? (Review target behaviors) . Is there documented behavior monitoring in place that identifies the following criteria . target behavior, specific and individualized interventions to decrease or eliminate behavior, method of determined outcome if interventions were successful . A care plan is in place to demonstrate the target behavior, interventions that are most successful and goals . On 12/17/24 at 12:20 PM, Unit Managers (UM) - UM F and Clinical Coordinator (CC) CC A was interviewed and asked what the targeted behaviors and/or identified mood concerns were for R13. UM F and CC A was also asked to provide documentation of identified behaviors or mood concerns for R13. UM F and CC A stated they would look into it and follow back up. No additional explanation or documentation was provided that identified targeted behaviors or mood concerns for R13.

Based on interview and record review the facility failed to timely transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion for two (R311 and R333) of three residents reviewed for resident assessments. Findings include: According to the CMS (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual v1. 17.1, effective 10/1/2019, .Submission files are transmitted to the QIES (Quality Improvement and Evaluation System) ASAP (Assessment and Submission and Processing) system using the CMS wide area network .Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirement .must be submitted with 14 days of the MDS Completion Date (Z0500B + 14 days) .For each file submitted, the submitter will receive confirmation that the file was received for processing and editing by the QIES ASAP system. This confirmation information includes the files submission identification number (ID), the date and time the file was received for processing as well as the file name . The facility reported there was no actual policy for MDS transmitting. Review of R311's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included: Atrial Fibrillation and diabetes type II. The resident was discharged from the facility on 8/13/24. Review of the MDS dated [DATE] documented sections C, D, E, Q and Z had not been completed and the MDS was 120 days overdue. Review of R333's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included: acute fracture and Atrial Fibrillation. Review of the MDS dated [DATE] revealed section Z was not signed/completed. On 12/17/24 at approximately 6:40 PM, the facility MDS Nurse E, was interviewed and asked why R311 and R333 MDS was not completed and submitted to CMS in a timely manner. MDS Nurse E noted that with respect to R311, Social Services failed to complete their portions of the MDS and for R333 there was a failure to sign and submit.

This citation pertains to Intake Number(s): MI00141179. Based on interview and record review, the facility failed to permit readmission into the facility after a hospitalization for one (R61) of three residents reviewed for closed records. Findings include: Review of a complaint submitted to the State Survey Agency revealed an allegation that the facility denied R61's admission back to the facility because they said they could not accommodate his needs which were oxygen, suctioning, and a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically inserted into the stomach to aid in delivery of nutrition). Review of R61's clinical record revealed the following: R61 was admitted into the facility on [DATE] and discharged to the hospital on 11/10/23 with diagnoses that included: acute respiratory failure with hypoxia, dysphagia (difficulty swallowing), gastrostomy status (PEG tube), and Parkinson's disease. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R61 had intact cognition, was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity) for all self-care, transfers, and wheelchair mobility, received oxygen therapy, and had an indwelling urinary catheter. Review of R61's progress notes revealed the following: On 10/26/23, R61 was discharged to the hospital. R61 was readmitted on [DATE]. Review of a progress note written on 10/31/23 revealed, .readmitted to facility this afternoon .post respiratory failure. Elder has own suction machine and demonstrates proper use .has PEG tube and is NPO (nothing by mouth) at this time .Alert and able to make needs known . On 11/7/23, the following was documented in a progress note, .Elder suctioned with suction machine with small amount of secretions noted . On 1/7/23 at 5:20 PM, the following was documented in a progress note, Elder observed with productive cough but refusing to be suctioned .appeared uncomfortable but unable to verbalize what was wrong .ordered .to be sent to .hospital . Review of a Discharge MDS assessment dated [DATE] revealed R61 was discharged to the hospital and was anticipated to return. Further review of R61's clinical record revealed R61 did not return to the facility. On 1/10/24 at approximately 11:30 AM, an interview was conducted with Admissions Coordinator 'A'. When queried about the readmission process when a resident was referred back to the facility after a hospitalization , Admissions Coordinator 'A' reported the hospital sent a referral to the facility which was reviewed by the interdisciplinary team (IDT) prior to readmission. Admissions Coordinator 'A' reported the facility maintained documentation of referrals. The referral for readmission sent from the hospital after R61's hospitalization (discharged from the facility to the hospital on 11/7/23) was requested at that time. When queried about why R61 was not permitted to readmit into the facility after the hospitalization , Admissions Coordinator 'A' reported she would look into it. On 1/10/24 at 12:22 PM, the Administrator was asked to provide the electronic referral from R61's last hospital admission for readmission into the facility. The Administrator reported if the resident did not return to the facility, the referral was not available to print. At that time, it was requested to review the referral via the electronic referral system used to communicate between the hospital and the facility. On 1/10/24 at 12:55 PM, a second interview was conducted with Admissions Coordinator 'A'. When queried about whether the hospital referred R61 for readmission after discharge from the hospital, Admissions Coordinator 'A' reported a referral was made. When queried about why R61 did not return to the facility, Admissions Coordinator 'A' reported the facility was unable to meet the resident needs due to the resident possibly getting a trach (tracheostomy - a tube surgically placed into the windpipe to assist with breathing) and the facility was not able to care for residents with trachs. Admissions Coordinator 'A' explained R61 did not have a trach at the time of discharge from the hospital. Review of the electronic referral system mentioned above revealed only communication made by the facility. Admissions Coordinator 'A' explained that once a resident did not come back to the facility, the hospital's communication was unable to be viewed. The following was documented and explained as communication made from the facility to the hospital at the time of referral: It was documented on 11/13/23 at 10:21 AM by former Admissions Coordinator 'F', .spoke with sister and niece .last week plan to continue 'treating aggressively including going back to the hospital multiple times. We do not think we can meet his need at (facility) .' Review of a Facility Assessment Tool provided by the facility on 1/8/24 at 12:15 PM revealed the assessment was reviewed on October 2023 and documented, .Patient referrals are reviewed by clinical liaison and admissions team utilizing RED, YELLOW, GREEN documents. Residents that need additional review are discussed with DON (Director of Nursing) to ensure clinical capability and staffing is adequate to meet patient needs . On 1/10/24 at 1:11 PM, an interview was conducted with the Director of Nursing (DON). When queried about who decided if a resident was permitted to readmit into the facility after a hospitalization , the DON reported it was a decision made by the IDT. When queried about why R61 was not readmitted into the facility after his hospitalization which began on 11/7/23, the DON stated, We could not meet his needs. When queried about what needs the facility could not meet, the DON explained it was due to R61's disease process and what potentially could happen with his condition. The DON reported R61 was a hospice candidate, but he wanted to receive all treatments possible. The DON explained R61 required suctioning and his family reported he might have to go back out to the hospital for a trach, but R61 did not have a trach at the time of discharge from the hospital. When queried about R61 receiving suctioning prior to the hospitalization , the DON did not offer a response. The DON reported when R61 was a resident, he had multiple episodes of aspiration and if he were to be readmitted he would likely continue to require hospitalization s. When asked to provide the facility's documentation in R61's clinical record that noted what specific needs the facility was not able to meet, the DON reported there was no documentation because R61 was not discharged from the facility, he went to the hospital. On 1/10/24 at 1:38 PM, an interview was conducted with the Administrator. The Administrator reported the IDT discussed readmissions which included the physicians to decide whether or not to readmit a resident from the hospital. When queried about R61, the Administrator reported the IDT determined R61 required more care than what the facility could provide and would likely need to transition to long term care. The Administrator reported the facility did not have a long term care bed at the time the referral was made. At that time, the census of available beds on 11/13/23 was requested, as well as a policy regarding readmissions and discharges to the hospital. On 1/10/23 at 2:42 PM, the Administrator emailed the following information: .We did not initiate a facility discharge as he was in the hospital, and at the time the family canceled the bed hold to pursue a higher level of care. We did receive the referral again, our admissions person (Admissions Coordinator 'F', spoke w (with)/the family and his desire for care remained aggressive, his care needs were leaning towards needing a trach and LTC, therefore we do not have the clinical capability to manage for trachs on site. I am including our clinical skills inventory that should have accompanied the Healthcare Assessment (Facility Assessment Tool). Review of the facility census on 11/13/23 revealed there were three empty beds available in the facility. On 1/10/24 at 2:40 PM, the Administrator provided a document titled, Clinical Skills Inventory and explained it should have been attached to the Facility Assessment Tool provided on 1/8/23. Review of the Clinical Skills Inventory revealed services that the facility can provide which were marked green, services the facility requires more staff education, equipment/supplies, or information prior to acceptance. The center has capability to provide the service, but may be at a saturation point for case mix which were marked yellow, and services the facility cannot provide which were marked red. The form indicated the facility was able to provide oral suctioning which was marked green. It was documented the facility was not able to provide tracheal suctioning or tracheostomy care, however it was reported R61 did not have a tracheostomy at the time he was being referred back to the facility. The form was reviewed by the DON and Administrator on 11/9/23. Review of a facility policy titled, Bed Hold and Return to Facility dated August 2022, revealed, in part, the following: .Residents are permitted to return to the facility after hospitalization or therapeutic leave if their needs can be met by the facility, they require the services provided by the facility and they are eligible for Medicaid or Medicare covered services or services covered by another payor .Resident not permitted to return following hospitalization or therapeutic leave constitutes a facility-initiated discharge. A facility must not discharge a resident unless .the facility cannot meet the residents needs .

Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene and glove use during wound care for one resident, (R9) of one resident reviewed for infection control during wound care, resulting in the potential for the spread of infection. Findings include: On 1/9/23 at 11:10 AM, an observation of R9's right heel pressure ulcer dressing change was observed being performed by Nurse 'B'. Nurse 'B' began by donning gloves and removing the soft heel boot from R9's right foot. R9, then removed their gloves and put on a clean pair, they were not observed to perform hand hygiene in between glove changes. After donning clean gloves, Nurse 'B' removed the old dressing from R9's right heel. The wound was approximately 5 centimeters in length by 6 centimeters in width with small areas of necrotic tissue and slough at the bottom of the wound. It was further observed the wound had a slight, foul odor. Nurse 'B' then soaked a gauze in Dakin's solution (a wound care treatment) and applied the gauze to the wound per the physician's orders and waited to appropriate time to have the solution applied to the wound. While the gauze was applied to the wound for the prescribed time, Nurse 'B' was not observed to remove their gloves. While waiting the time, nurse 'B' but moved about R9's room touching various things in the environment including the medication storage area on the wall, the bedside table, and their computer workstation. After approximately five minutes into the ten minute time required for the wound to be soaked with Dakin's Nurse 'B' removed their gloves, but did not perform hand hygiene. Nurse 'B' continued for the remaining five minutes to move about the room straightening up and having contact with items in R9's environment. When the time was up, Nurse 'B' donned a clean pair of gloves without performing hand hygiene applied santyl (wound care treatment product) to their gloved finger and applied the santyl to the wound. After the santyl was applied, Nurse 'B' covered the wound and wrapped it in bulky dressing. Nurse 'B' then discarded their gloves, performed hand hygiene and exited the room. On 1/9/23 at 11:35 AM, an interview was conducted with Nurse 'B' regarding their hand hygiene and glove use technique, not performing hand hygiene in between glove changes, and using contaminated gloves to touch things around the environment. Nurse 'B' indicated they should have performed hand hygiene in between glove use and not had contact with the environment with contaminated gloves. A review of a facility provided document from their infection control policies was conducted and read, .Hand Hygiene .Perform hand hygiene immediately before gloves are applied and after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments .

Based on observation, interview, and record review, the facility failed to ensure personal cell phones were not stored in the food preparation area, failed to ensure food items were discarded after the use-by dates, and failed to maintain kitchen equipment per the manufacturer's recommendations. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include: During an initial tour of the kitchen on 12/12/22 between 8:30 AM-9:15 AM with Certified Dietary Manager (CDM) A, the following observations were made: There were 2 cell phones and chargers on the food preparation counter across from the ovens. CDM A stated that staff sometimes use their phones as a timer while cooking. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. According to the 2017 FDA food code, Section 7-209.11 Storage, Except as specified under SS 7-207.12 and 7-208.11, Employees shall store their personal care items in facilities as specified under 6-305.11(B), and Section 6-403.11 Designated Areas, .(B) Lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single-service and single use articles cannot occur. In the walk-in cooler, there was 1 opened 5-pound container of cottage cheese dated as opened 11/9 with a use by date of 11/25, 1 unopened 5-pound containers of cottage cheese with a manufacturer's best by date of 12/8, and 5 unopened 5-pound containers of cottage with a manufacturer's best by date of 12/10. CDM A confirmed the containers should all be discarded. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. CDM B was queried about the cleaning schedule for the ice machine in the kitchen, as well as the schedule for changing the water filter. CDM B stated that an outside company performed these services, but was unable to provide a date for when they had last been completed. The water filter had a hand written date noting: Installed 9/23/21, Replace 3/23/22, and the sticker on the ice machine for documenting the cleaning dates had not been updated. The documentation for the cleaning of the ice machines was requested from the Administrator, and from the provided information, the following was noted: Service Agreement: Three (3) ice machines to be cleaned and sanitized twice a year Work Order: 3/29/22 Performed preventative maintenance of ice machine in kitchen .also installed a new filter. Per the Administrator via an email sent on 12/13/22 at 10:58 AM, the ice machines were going to be cleaned on 12/13/22 (9 months from the date they were last cleaned).

This citation pertains to Intake MI00130893 Based on interview and record review, the facility failed to prevent a significant medication error for one (R189) of one resident reviewed for cardiac medications resulting in R189 missing five consecutive doses of an antiarrhythmic medication. Findings include: Review of the closed record revealed R189 was admitted into the facility on [DATE] with diagnoses that included: atrial fibrillation, heart failure and arthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R189 was cognitively intact and required the extensive assistance of staff for activities of daily living (ADL's). Review of R189's hospital discharge instructions dated 12/29/21 revealed in part, .Your primary diagnosis was: Paroxysmal atrial fibrillation . Medications: Propafenone HCL 225 MG Cp12 Commonly known as: RYTHMOL SR take 1 Cap by mouth every 12 hours. For diagnoses: Persistent atrial fibrillation . Reduce your risk for stroke by: .After discharge, ensure you take all your medications as prescribed . Review of R189's January 2022 Medication Administration Record (MAR) revealed: The order for propafenone ER 225 mg two times a day was Not Administered, not available on: 1/15/22 prior to bed 1/16/22 upon rising 1/16/22 prior to bed 1/17/22 upon rising 1/17/22 prior to bed On 12/13/22 at 10:28 AM, Dr. F, R189's physician, was interviewed by phone and asked if she had ever been contacted that R189's propafenone medication was not available and had not been given. Dr. F explained she had not been notified. When asked if she should have been notified about propafenone not being available, Dr. F explained she soul be notified because as an antiarrhythmic it is being used to keep the heart in a normal rhythm. On 12/13/22 at 1:59 PM, the Director of Nursing (DON) was interviewed and asked when a medication should be reordered. The DON explained any medication should be reordered a couple days before they are gone so they do no run out. When asked how long it takes to get a medication from the pharmacy, the DON explained it usually would come the next day. The DON was asked why R189 missed five consecutive doses of propafenone because they were not available. The DON explained the medication ran out, it was not one kept in their backup supply, and they had a difficult time getting more from the pharmacy. The DON was asked if Dr. F should have been notified that the medication was not available. The DON explained the physician should always be notified of missed medication doses. When informed Dr. F said she had not been notified, the DON had no answer. Review of a facility policy titled, Medication-Related Errors revised 5/1/10 read in part, .Medication Errors. If a medication reaches a resident in error. Facility should: 1. Notify Pharmacy of any possible dispensing occurrence; and 2. Notify Physician/Prescriber and obtain further instructions and/or orders . Omission error: Facility fails to administer an ordered dose to the resident, unless refused by the resident or not administered because of recognized contraindication .

This citation pertains to Intake MI00130893 Based on interview and record review, the facility failed to ensure cardiac medications were ordered and given in a resident centered manner for one (R189) of one resident reviewed for cardiac medications resulting in blanket parameters placed on metoprolol (beta blocker) and not having propafenone (antiarrhythmic) available. Findings include: A complaint was filed with the State Agency that alleged in part, (R189) was in [Hospital] with atrial fibrillation (afib) that converted with medication, allowing her to be released for physical therapy . At times during (R189's) stay at [Facility], some of her medicines for afib were not given (metoprolol and propafenone) . (R189) needed to be on metoprolol or (R189) would go back into afib which could possibly cause a stroke . (R189) started to complain about chest pains and not feeling good 1-18-22 . These were the same symptoms (R189) had with afib previously, and her heart rate was documented as 119 . (R189) moved into independent living at [Facility] the next morning 1-19-22 approximately at 10 am. That same evening I went to her apartment and while talking to her she had a massive stroke . Review of the closed record revealed R189 was admitted into the facility on [DATE] with diagnoses that included: atrial fibrillation, heart failure and arthritis. According to the Minimum Data Set (MDS) assessment dated [DATE], R189 was cognitively intact and required the extensive assistance of staff for activities of daily living (ADL's). Review of R189's hospital discharge instructions dated 12/29/21 revealed in part, .Your primary diagnosis was: Paroxysmal atrial fibrillation . Medications: .Change: metoprolol 50 MG (milligrams) Tabs Commonly known as : Lopressor take 1 Tablet by mouth every 12 hours . What changed: medication strength, how much to take, when to take this . Propafenone HCL 225 MG Cp12 Commonly known as: RYTHMOL SR take 1 Cap by mouth every 12 hours. For diagnoses: Persistent atrial fibrillation . Reduce your risk for stroke by: .After discharge, ensure you take all your medications as prescribed . It should be noted the hospital records did not have parameters on the metoprolol. Review of R189's December 2021 Medication Administration Record (MAR) revealed metoprolol 50 mg two times a day was Not Administered (Outside of Order Parameter) on 12/31/22 prior to bed. The vitals were documented as: blood pressure (BP) 95/50 and pulse 90. Review of R189's January 2022 MAR revealed metoprolol 50 mg was Not Administered (Outside of Order Parameter) on: 1/1/22 upon rising, BP 106/43, pulse 89 1/2/22 prior to bed, BP 106/56, pulse 91 1/4/22 upon rising, BP 102/58, pulse 62 1/4/22 prior to bed, BP 100/61, pulse 72 1/6/22 prior to bed, BP 97/55, pulse 71 1/10/22, upon rising, BP 92/52, pulse 80 1/11/22 upon rising, BP 101/61, pulse 74 1/12/22 upon rising, BP 102/57, pulse 75 The physician order for metoprolol was changed on 1/12/22 to include new parameters: BP and/or Pulse Hold: Systolic Blood Pressure < (less than) 100 Hold; Pulse <60 Hold. Continued review of R189's January 2022 MAR revealed: The order for metoprolol 50 mg was held due to parameters on: 1/12/22 prior to bed, BP 105/70, pulse 88 1/14/22 upon rising, BP 94/51, pulse 66 1/14/22 prior to bed, BP 90/50, pulse 76 1/18/22 upon rising, BP 95/52, pulse 90 The order for propafenone ER 225 mg two times a day was Not Administered, not available on: 1/15/22 prior to bed 1/16/22 upon rising 1/16/22 prior to bed 1/17/22 upon rising 1/17/22 prior to bed Review of a physician progress note by Dr. F dated 1/7/22 read in part, .Diagnosis/Status Update/Treatment/Plan: .Afib with RVR (rapid ventricular rate). no AC (anticoagulant) 2/2 (secondary to) advance age and pt (patient) fall risk. On metoprolol, rhythmol (for) afib . On 12/13/22 at approximately 10:00 AM, the Director of Nursing (DON) was interviewed and asked about why R189's metoprolol was held for outside of parameters prior to 1/12/22 when parameters were listed on the MAR. The DON explained Dr. F, R189's attending physician had standing parameters for metoprolol, it was to hold the medication if the systolic blood pressure was less than 110. When asked why have parameters on blood pressure if the medication was being used to keep R189 out of afib, the DON explained Dr F never ordered metoprolol without parameters. On 12/13/22 at 10:28 AM, Dr. F was interviewed by phone and asked why R189 had blood pressure parameters on her metoprolol when it was being used for afib. Dr. F explained she used the same parameters on all residents, but would sometimes lower the parameter to less than 100 systolic, but did not go below that because she did not want residents to get dizzy and fall while in therapy. When asked if she had ever been notified R189 had been light headed or dizzy when her BP was low, Dr. F explained she had not. Dr. F was asked if the same parameters for every resident was truly appropriate when metoprolol was being used for afib in someone that was asymptomatic when her systolic blood pressure was less than 100. Dr. F had no answer. Dr. F was asked about R189 not getting her propafenone. Dr. F explained there were never parameters on propafenone and R189 should have received all doses of that medication. When asked if the nurses had contacted her that R189 was not getting metoprolol or propafenone, Dr. F explained she had not been notified. Review of R189's progress notes revealed: A nursing note dated 1/18/22 at 4:23 PM read in part, Resident complains of right sided rib, breast, shoulder and neck pain this AM. No skin issues noted to area. VS (vital signs): 138/74, pulse 95 . After lunch, resident complains of same pain. Pain sharp with inspiration . NP (Nurse Practitioner) to assess resident. (Dr. F) made aware, received order for metoprolol x 1 dose this afternoon. VS prior to administration pulse 100-120s . Medication administered, BP 116/67, pulse 101 . Resident states no relief of pain . A clinical note dated 1/18/22 at 5:15 by NP G read in part, .Subjective: Patient reports Rt (right) sided pain goes into shoulder upper back, started this am, Worse with deep breath, denies c/p (chest pain)- b/p meds had been held secondary low b/p this am . A nursing note dated 1/19/22 at 2:45 AM read in part, Resident c/o (complained of) midsternal chest discomfort earlier this PM . A nursing note dated 1/19/22 at 11:02 AM read in part, Resident discharged to IL (independent living) apartment this AM at approximately 10:15am . On 12/14/22 at 12:04 PM, NP G was interviewed by phone. NP G was asked about R189's complaint of right sided chest pain. NP G explained she was the Physical Medicine and Rehabilitation (PM&R) NP that was at the facility that day. She was informed that R189 was having chest pain so she assessed her and reported to Dr. F her findings. NP G was asked if she had been informed R189 had not received her metoprolol or had not received propafenone for two and a half days prior to her chest pain. NP G explained she did not look at R189's medications and had not been told about the missing doses of either medication. Review of R189's hospital records dated 1/19/22 read in part, .History of Present Illness: .female with a significant past medical history of paroxysmal atrial fibrillation status post cardioversion not on anticoagulation . multiple other comorbidities who presented to the ER (emergency room ) due to left-sided weakness and dysarthria (slurred speech) . The patient was recently discharged from [Hospital] due to atrial fibrillation with RVR . She was not started on anticoagulation as it was contraindicated due to her age and fall risk, however she was discharged with an increased dose of her Lopressor to 50 mg twice daily from 25 mg twice daily. From [Hospital], the patient was discharged to [Facility] . her Lopressor doses were held due to hyppotension . The patient did complain of bilateral chest pain that was nonradiating that resolved spontaneously . it is likely due to her atrial fibrillation. Around 8:15 in the evening, the patient's (family member) was talking [sic] into her bed and noticed that the patient was drooling on one side of her face, specifically at the left side with a facial droop. She immediately felt she had a stroke, and called 911 . During her neurological assessment by the EMS (emergency medical services), she demonstrated significant weakness of the left upper and lower extremity . Impression and Plan: .presented to the ER due to left-sided weakness and dysarthria. She was found to have a right MCA (middle cerebral artery) stroke, was started on tPA (tissue plasminogen activator - clot buster) and was urgently taken for a mechanical thrombectomy (surgical removal of blood clot) with neuro endovascular. The patient was transferred to the ICU (intensive care unit) for closer neurological monitoring and ventilator management . Review of a facility policy titled, Resident Centered Medication Program revised 10/27/08 read in part, .Medication therapy is personalized to meet the residents' needs .

Based on interview and record review the facility failed to maintain the treatment preferences and determination wishes for one R38 of two residents reviewed for advance directives. Findings include: Review of the medical record revealed R38 was admitted to the facility on [DATE] with diagnoses that included: chronic atrial fibrillation, diastolic heart failure and an abnormal coagulation profile. Review of a Treatment Preferences And Determination Of Resident's Wishes documented the following in part, . The capacitated resident . has requested the following Code Status . Code C . I do not want hospitalization , unless needed for my comfort only . No cardiopulmonary resuscitation (CPR) . Provide me with all care and services that are available in the long-term care facility, that my physician feels are appropriate. Services such as (but not limited to) Intravenous therapy and antibiotics . This document was signed by R38 on the date of admission on [DATE]. Review of an Admission Nursing note dated [DATE] at 10:08 AM, documented in part . arrived via stretcher ambulance . is alert and oriented X ,d+[DATE] very soft spoken. Signed Code C for advance directives . Denies any pain or discomfort at this time . Review of an Admission Social Services note dated [DATE] at 2:57 PM, documented in part . Resident admitted for rehab/tx (treatment) post hospital stay, resident is adjusting to many changes in medical/physical health status and need for rehab/tx placement. Resident is alert and oriented with some forgetfulness periods, but active in own poc (plan of care)/choices . Resident was independent in self care and lifestyle prior to hospitalization . Review of a Physician Progress note documented by a Nurse Practitioner (NP) on [DATE] at 11:54 AM, documented in part . Very limited ROS (Review of Systems) due to significant decline in patient function overnight. DIL (Daughter In Law name) at bedside. She states that her and her husband are aware of significant decline and have been expecting this decline. Decision has been made to do comfort care here at facility. DIL has signed for patient to be code D . Patient has been placed on comfort care, Morphine sulfate 5 mg (milligram) q (every) 4 hours prn (as needed) has been instituted . Review of the facility document Treatment Preferences And Determination Of Resident's Wishes documented a Code D as . Comfort measures only. No Cardiopulmonary resuscitation (CPR). No artificial nutrition and hydration . Review of a Treatment Preferences And Determination Of Resident's Wishes dated [DATE], documented the facility staff allowed R38's daughter in law to sign the resident as Code D on [DATE]. The daughter in law signed as the residents DPOA (Durable Power Of Attorney). Review of a Change of Condition note dated [DATE] at 12:31 PM, documented in part . Writer called to room to pronounce patient death . Patient pronounced at 8:41 AM . Review of the medical record revealed R38 was their own responsible party. Further review of the medical record revealed no documentation of a competency evaluation to have been completed. The DPOA was not active. On [DATE] at 12:04 PM, Social Worker (SW) C was interviewed and asked to review their records and R38's medical record and provide all competency evaluations and DPOA documents. At 1:58 PM, SW C returned and stated the resident did not have a competency evaluation completed and provided a copy of R38's DPOA. When asked if the resident was not deemed incompetent how the resident Treatment Preferences And Determination Of Resident's Wishes was changed from a CODE C to a CODE D eight days later when the DPOA was not effective, and the SW C replied the nurse had the family sign the code status change. The SW C stated that is not the correct protocol being that the DPOA was not active.

Based on observation, interview and record review, the facility failed to ensure adequate infection control practices including, 1) appropriate screening of visitors and staff; 2) properly utilize personal protective equipment (PPE); and 3) implement proper hand hygiene per Centers for Disease Control and Prevention (CDC) guidance for R15. This deficient practice had the ability to affect all 34 residents in the facility. Findings include: On 9/12/21 at 9:59 AM, an isolation cart with three drawers was observed in the hallway outside a room with a sign that read in part, - STOP - Full PPE Required beyond this point: 14-Day Isolation . Preferred PPE - Use N95 or Higher Respirator . The top drawer contained yellow isolation gowns, the middle drawer contained surgical masks and gloves, the bottom drawer contained face shields and goggles. On 9/12/21 at 9:59 AM, Certified Nursing Assistant (CNA) A was observed wearing a face shield and a black surgical mask. CNA A was observed to put on an isolation gown and gloves and enter the isolation room with the same surgical mask. Upon exiting the room, CNA A was observed to remove the isolation gown and gloves, but did not change her surgical mask, nor was there an observation of cleaning of the face shield. After exiting the room, CNA A was observed to walk across the hall and enter another resident's room that was not on isolation. It should be noted CNA A was wearing the same black mask upon going into an isolation room and going into a non-isolation room. On 9/12/21 at 10:17 AM, Dietary Aide E was observed entering the isolation room wearing an isolation gown, surgical mask, and face shield. Upon exiting to the isolation room, Dietary Aide E was observed removing the isolation gown and gloves but was not observed to clean her face shield and continued wearing the same surgical mask and face shield to enter multiple non-isolation resident rooms. On 9/12/21 at 12:38 AM, CNA A was observed exiting the isolation room with the same black surgical mask and face shield she had been wearing before entering the room and walk into the dining room where multiple residents were eating their lunch. On 9/13/21 at 9:29 AM, Dietary Aide F was observed in the isolation room wearing a gown, surgical mask, and face shield. Upon exiting the room, Dietary Aide F was observed to remove the gown but continue to wear the surgical mask and face shield. Dietary Aide F was then observed to walk into the dining room to prepare the food for lunch. On 9/13/21 at approximately 12:00 PM, Dietary Aide F was observed preparing all the resident's plates for lunch wearing the same surgical mask and face shield worn while in the isolation room. On 9/14/21 at 1:05 PM, Physical Therapist (PT) J was observed wearing a surgical mask and face shield, put on a gown and gloves and enter the isolation room. It should be noted PT J was continuously in the isolation room with his surgical mask until he exited the room at 1:48 PM. On 9/14/21 at 1:18 PM, CNA I was observed wearing a KN95 mask. It should be noted KN95 masks are not a National Institute for Occupational Safety & Health (NIOSH) approved respirator. CNA I was asked what PPE was required for the isolation room. CNA I explained a gown and gloves were required when in the room. When asked about what mask was required, CNA I explained she could wear the same mask and face shield all day. On 9/14/21 at 1:44 PM, Dietary Aids F and G were interviewed and asked about what PPE was required when in the isolation rooms. Both Dietary Aids F and G explained they could wear the same mask and face shields all day, both in and out of the isolation rooms. On 9/14/21 at 1:48 PM, PT J was observed exiting the isolation room he had entered at 1:05 PM. PT J was asked what PPE was required in the isolation room. PT J explained a gown, gloves, a mask, and face shield. When asked what type of mask, PT J explained he wore a surgical mask but changed it when coming out of the room to a new surgical mask. It should be noted PT J was then observed to enter the therapy room where other residents were having therapy. On approximately 9/12/21 at 12:21 PM, CNA A observed entering a room to deliver a tray with a black surgical mask and face shield. CNA A was then observed going back into food prep area with same PPE. On 09/12/21 at 12:38 PM, CNA C entered isolation room (room number redacted) with a face shield, surgical mask, yellow gown, and gloves. When asked, CNA C stated they wear a surgical mask with face shield, gown, and gloves to enter an isolation room. On 9/14/21 at 1:50 PM, the Director of Nursing (DON) was interviewed and asked about PPE use in isolation rooms. The DON explained staff should be wearing a gown, mask, eye protection and gloves. When asked about what type of mask should be used, the DON explained she had instructed the staff they could wear the same surgical mask all day unless it became soiled or contaminated. The DON further explained the staff only needed a N95 mask if they were going to be face-to-face, providing direct patient care for longer than fifteen minutes. The DON was informed of the observations of staff wearing the same mask worn from the isolation room to a non-isolation room. The DON explained she had never told the staff they had to change their mask; they could wear the same mask all day. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 9/10/21 read in part, .Source control options for HCP (Healthcare Provider) include: A NIOSH-approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators (note: these should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated) . If they are used during the care of a patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator during the care of a patient with [CONDITION(S)]-CoV-2 infection, facemask during a surgical procedure or during the care of a patient on Droplet Precautions), they should be remove and discarded after the patient care encounter and a new one should be donned. The CDC definition of Close contact is defined as, being within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period with someone with [CONDITION(S)]-CoV-2 infection. Review of a facility policy titled, Infection Prevention and Control Manual Coronavirus (COVID-19) undated read in part, .All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator . Full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19 per CDC guidance . A face mask for source control does not replace the need to wear an N95 or equivalent or higher-level respirator (or other recommended PPE) when indicated, including when caring for patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection . On 9/12/21 at 8:04 AM, upon entry into the facility a cart was observed in the facility's entrance foyer. The cart contained a log sheet, thermometer, and masks. There was no facility staff present to screen, monitor, or to ensure the four surveyors completed the screening and met the criteria to enter the facility. On 9/12/21 at 8:09 AM, Registered Nurse (RN) K was observed walking down the stairs towards the exit. When asked if visitors and incoming staff are supposed to screen themselves, RN K replied yes, for afterhours the staff are expected to screen themselves. On 9/12/21 at 8:27 AM, another surveyor entered the building unaware that they were expected to screen themselves and proceeded to the conference room to join the surveyor team. There was no facility staff present to screen the surveyor in the facility. The facility staff was unaware that the surveyor entered the facility without being screened, temperature monitored, or educated on the facility infection control practices and protocols. Review of a Centers for Medicare & Medicaid Services (CMS) Memorandum (Ref: QSO-20-39-NH) Revised 4/27/21 documented in part, . Nursing homes have been severely impacted by COVID-19, with outbreaks causing high rates of infection, morbidity, and mortality. The vulnerable nature of the nursing home population combined with the inherent risks of congregate living in a healthcare setting have required aggressive efforts to limit COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes . Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission . Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor's vaccination status) . These core principles are consistent with the Centers for Disease Control and Prevention for nursing homes, and should be adhered to at all times . On 9/14/21 at 12:51 PM, the Director of Nursing (DON) was interviewed and asked about the after-hour screening of staff and visitors and acknowledged that the facility had recently changed their protocol for the after-hour screening and had reviewed several options and was still trying to figure out the best way to handle the after-hour screening. The DON stated the Administrator was in charge of this and to talk further with them. On 9/14/21 at 2:24 PM, the Administrator was interviewed regarding the after-hour screening of visitors and staff and acknowledged that the facility spent many hours on coming up with a plan for screening after hours. When asked about the concern of visitors and staff accurately documenting their temperatures and ensuring every person that walked in the door after hours actually screened themselves to enter the building, the Administrator acknowledged the concern. Review of a facility policy titled Infection Prevention and Control Manual Coronavirus (COVID-19) chapter 13 (no date noted) documented in part, . Screening . The long-term care facility must screen the visitor for COVID-19 symptoms and check their temperature. Any individuals with symptoms of COVID-19 infection (fever equal to or greater than 100.0 F, cough, headache, shortness of breath, fatigue, sore throat, myalgia, chills, nausea, diarrhea, vomiting or new onset loss of smell or taste) will not be permitted to visit . Facilities must maintain a screening log of visitors in case an individual becomes ill and case investigation and contact tracing are necessary . On 9/13/21 at 12:28 p.m., R15 was escorted to the dining room by Certified Nursing Assistant (CNA) 'L'. R15 was assisted with feeding by CNA 'L'. At that time, CNA 'L' was observed with long artificial fingernails that were pointed in shape, and approximately one inch long in length. On 9/14/21 at 12:15 p.m., CNA 'L' was observed with long artificial fingernails. When asked how long they had worked at the facility, CNA 'L' stated that they were a float pool CNA that was allowed to work at any of the (Corporation Name Redacted) facilities where help was needed. CNA 'L' was asked how long they had been working at the current facility and stated it would be a year in a couple of days. CNA 'L' was asked if anyone had talked to her about appropriate nail length when caring for residents and stated, No, . I was off for a little bit of a time. When asked how they would know how long their fingernails should be when providing resident care, CNA 'L' stated, No one has ever said anything. When asked if long artificial fingernails were discussed during orientation upon hire, CNA 'L' stated, Not to my recollection. At that time, CNA 'L' was asked what type of care they provided for the residents at the facility. CNA 'L' stated, I provide all care that has to do with daily living. On 9/14/21 at 12:25 p.m., during an interview, the Director of Nursing (DON)/Infection Control Preventionist, was asked when staff/CNAs are hired at the facility if fingernail length was discussed during orientation for staff providing activities of daily living. The DON stated, I don't know. I have to talk with the person who does new hires. During an interview on 9/14/21 at 12:30 p.m., when asked about staff having long artificial fingernails, Human Rersources Staff Member 'N' stated, We go over the dress code. I'm not sure we go over the nail length with them. Staff Member 'N' was asked what the facility's expectation regarding nail length and hand hygiene for staff was providing resident care. Staff Member 'N' stated, To be short, natural length, and clean. They (staff) are discouraged from wearing acrylic nails. On 9/14/21 at 1:35 p.m., during an interview with the DON)/infection Control Preventionist, stated, Certainly, long nails are not appropriate; through the times, things have changed. We were desperate for staff, so I didn't pay much attention to it. The DON/Infection Control Preventionist stated, Nails need not be long that they could cause injury. Review of the facility's policy titled Dress [NAME] Policy - Applies to All Colleague . revised 2/1/2020 read as follows, . Grooming . Due to documented infection control risks, acrylic nails, extensions, tips or applications are discouraged when providing direct patient care. Colleagues working in dining services and other auxiliary departments are not permitted to wear acrylic nails, extensions, tips or applications unless wearing intact latex free gloves. Further review of the CDC (Centers for Disease Control and Prevention) Guidelines for Skin and Nail Care reviewed January 8, 2021, the following was reported, Fingernail Care . Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients . Keep natural nail tips less than ¼ inch long. Some studies have shown that skin underneath rings contains more germs than comparable areas of skin on fingers without rings .

Based on observation, record review and interview of staff the facility failed to ensure that one resident (R337) was evaluated for the ability to self-administer medications at bedside safely. Findings include: Review of the medical record revealed R337 was admitted to the facility on [DATE]. Review of the most recent Minimum Data Set assessment revealed R337 was cognitively intact and required extensive assistance for most Activities of Daily Living. On 09/12/21 at approximately 9:45 AM, (R337) was observed in his room with [MEDICATION(S)] nasal spray sitting at bedside. (R337) stated that he takes it once per day. On 09/12/21 at approximately 10:59 AM, 3:15 PM and 4:25 PM [MEDICATION(S)] was observed at bedside. On 09/12/21 at approximately 4:30 PM an interview was conducted with Registered Nurse (RN) D. RN D was asked what the policy is for self-administration of medication. She explained residents need to be assessed and educated on how to administer their medications. RN D reviewed the medical record and could not locate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Next the DON arrived and asked (R337) how long he had been using this medication. (R337) claimed he had been using it for two weeks. DON asked where it was from. (R337) replied look at the label. Review of the facility policy titled .Self Administration of Medications Dated 12/01/07 Stating, 2. Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition .

Based on interview and record review, the facility failed to justify the use of antibiotics for one resident (R286) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse side effects. Findings include: Review of the Center for Disease Control and Prevention (CDC) The Core Elements of Antibiotic Stewardship for Nursing Homes dated 2015, documented in part . Improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . CDC also recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. Antibiotics are among the most frequently prescribed medication in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics . studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from [CONDITION(S)], increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic -resistant organisms . Infection prevention coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria . during the evaluation and management of treated infections and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. When infection prevention coordinators have training, dedicated time, and resources to collect and analyze infection surveillance data, this information can be used to monitor and support antibiotic stewardship . Review of the facility's July 2021 Infection log revealed R286 was prescribed [MEDICATION(S)] for a [CONDITION(S)] with no documented signs or symptoms, urinalysis or cultures completed. On 9/14/21 at 12:45 PM, the Director of Nursing (DON) who also serves as the the Infection Preventionist was interviewed and confirmed the facility utilization of the McGreer's criteria. The DON was asked about the [MEDICATION(S)] order for R286 not meeting criteria and the DON stated they would look into it. On 9/14/21 at 3:12 PM, the DON stated R286 son took the resident to their private doctor and a dip stick was done and the resident was prescribed antibiotics for a [CONDITION(S)]. When clarified with the DON that the medication was filled by the facility and administered by the facility staff, the DON confirmed that it was. When asked about the antibiotic being administered despite it not meeting criteria, the DON did not have a response. A facility policy titled Chapter 7 Surveillance documented in part . Antibiotic Stewardship . Antibiotic stewardship programs are initiatives aimed at improving antimicrobial/antibiotic use in healthcare settings. Recommendations and interventions of an effective antibiotic stewardship program are designed to ensure that residents who meet the criteria for infection receive the right antibiotic, at the right dose, at the right time, and for the right duration. Some studies show that the appropriate use of antimicrobial/antibiotics has the potential to limit antibiotic resistance in long term care settings .

Based on observation, interview and record review, the facility failed to institute and operationalize appropriate infection control principles and practices per the Centers for Disease Control and Prevention (CDC) guidelines including the failure to ensure precautionary safety measures to prevent the exposure of residents to 2019 Novel Coronavirus (COVID-19) for six (R#s: 701, 702, 703, 704, 705 and 706) of eight residents reviewed for cohorting (sharing a room) with COVID-19 positive or presumed positive residents, resulting in the potential for transmission of COVID-19 from a positive or presumed positive roommate to a negative roommate many of whom were at high risk due to age and co-morbidities to be exposed and/or develop COVID-19. Findings Include: A review of CDC guidance for Long-Term Care Facilities read in part, . Isolate symptomatic patients as soon as possible . place patients with suspected or confirmed COVID-19 in private rooms with the door closed and with private bathrooms (as possible) . Residents #701 and #702 Review of the census record revealed R#701 and R#702 had shared a room beginning on 4/21/20. Review of the clinical record revealed R#701 was originally admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R#701 scored 13/15 on the Brief Interview for Mental Status (BIMS) Exam, indicating intact cognition. The MDS assessment also indicated R#701 required the assistance of staff for Activities of Daily Living (ADL's). Review of R#701's progress notes revealed: An Admission note dated 3/27/20 at 4:27 PM read in part, .Wheezing noted at the bases BL (bilaterally). Elder expressed very mild shortness of breath . A Nursing note dated 3/29/20 at 3:26 PM read in part, .Resident noted with labored breathing and audible wheezing. BP (blood pressure): 150/86 P (pulse): 98 T (temperature): 97.3 R (respirations): 24 SPO2 (oxygen saturation levels): 76% (normal range 94-100%) 3L (liter) O2 (oxygen) via nc (nasal cannula). HOB (head of bed) elevated and oxygen increased to 4L via nc . SPO2 93% 4L O2 via nc. Labored breathing and audible wheezing still noted . A Nursing note dated 3/31/20 at 3:08 PM read in part, .Pulse ox (pulse oximeter - SPO2) 25%, elder answers to name and arousable . Non rebreather mask with hi flow oxygen administered 75% pulse ox with 101 HR RR (respiratory rate) 22 . 911 called and elder taken to (Name Redacted - local hospital) . An Admission note dated 4/8/20 at 9:36 PM read in part, . was sent to the hospital for cough and shortness of breath. (R#701 was diagnosed and treated for [REDACTED]. Review of (Name Redacted) Hospital records revealed R#701 was tested for COVID-19 on admission to the hospital on [DATE] and was negative for COVID-19. A Social Services note dated 4/21/20 at 3:49 PM read, Elder moved to room (number redacted). Staff moved all of elders belongings and introduced to new roommate. It is noted the new roommate was R#702. A Nursing note dated 4/23/20 at 4:54 PM read in part, .facility testing all residents for Covid-19 virus . Review of a facility provided report revealed R#701 was tested for COVID-19 on 4/24/20 and the results were reported at NOTDETECTED, indicating R#701 was negative for COVID-19. Resident #702 Review of the clinical record revealed R#702 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent annual MDS assessment dated [DATE], R#702 scored 11/15 on the BIMS exam, indicating mild cognitive impairment. The MDS assessment also R#702 required the minimal assistance of staff for ADL's. Review of a Nursing progress note dated 4/4/20 at 11:42 read in part, Writer spoke with (R#702) about moving to room (number redacted) in attempt to cohort resident under investigation for covid-19 to one hall and asymptomatic resident to another. (R#702) currently is asymptomatic . Review of vital signs for R#702 revealed: On 4/16/20 at 6:04 PM, Temperature (Degrees) 99.00 Oral On 4/20/20 at 8:17 AM, Pulse Oximeter (%) 91.00 Room Air On 4/20/20 at 6:06 PM, Pulse Oximeter (%) 91.00 Nonrebreather On 4/21/20 at 7:41 AM, Pulse Oximeter (%) 92.00 Room Air A Nursing progress note dated 4/23/20 at 4:54 PM read in part, .facility testing all resident for Covid-19 virus . Review of a facility provided report revealed R#702 was tested for COVID-19 on 4/24/20 and the results were reported at DETECTED, indicating R#702 was positive for COVID-19. Review of a Resident Roster list dated 5/1/20 revealed R#701 and R#702 continued to share a room at the facility on a COVID-19 positive hall. Residents #703 and #704 On 5/4/20 at 11:15 a.m., R#703 was observed in bed resting and R#704 was observed in a chair in their room. Resident #703 Review of the census record revealed R#703 moved into the same room as R#704 on 5/14/19, where they remained together as of 5/4/20. A review of the clinical record revealed R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 2 out of 15 which indicated R#703 had impaired cognition and required limited assistance with one-person physical assist for ADL's. Further review of R#703's clinical record vital signs (VS) revealed the following: Temperatures: 3/26/20 @ (at) 9:08pm - 98.7 3/27/20 @ 6:22pm - 99.9 4/4/20 @ 12:39pm - 101.5 4/5/20 @ 3:44pm - 101.0 4/5/20 @ 4:24pm - 100.6 4/7/20 @ 9:04pm - 98.8 4/8/20 @ 10:05pm - 98.7 4/13/20 @ 7:56pm - 98.8 4/19/20 @ 4:10pm - 99.0 5/02/20 @ 8:28pm - 99.4 A review of the Clinical Notes in part revealed the following: 4/5/20 @ 3:44pm - SpO2 - 80% O2 applied. 4/5/20 @ 11:26pm - Resident lethargic during the beginning of shift; PRN (as needed) Tylenol received; PO2 88% RA (room air) 2 L O2 via NC received . 4/6/20 @ 3:59am - . Resident SpO2 86% on room air . Resident repositioned and nasal cannula replaced, SpO2 91% on 2L . 4/11/20 @ 3:02am - . SpO2 90% on room air . 4/13/20 @ 12:35pm - poor appetite . SpO2 95% on 2L per nasal cannula . 4/13/20 @ 2:25pm - Pulse ox 88 percent on room air. 93 percent on 2L oxygen. 4/15/20 @ 12:46pm - Resident is non-compliant with keeping NC on. SpO2 maintained about 92% RA. 4/15/20 @ 10:44pm - At dinner appetite poor . 92% on 2 liters O2 per nasal cannula . 4/21/20 @ 1:41pm - Ate 25% yogurt at BF (breakfast), not eating at lunch. Dr./Family aware of appetite changes. 4/23/20 @ 4:47pm - Resident received Covid 19 nasal swab test. 4/24/20 @ 4:42pm - Resident results of Covid received as positive via lab. Family notified of result, along with plan of care for the unit . 4/28/20 @ 11:39pm - . SpO2 94% on RA . Ate 50% of meal . 4/29/20 @ 2:40pm - . Elder continues to be on droplet precautions . 4/30/20 @ 2:48am - Isolation- airborne precautions in place . Resident #704 A review of the clinical record revealed R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 8 out of 15 which indicated R#704 had moderately impaired cognition and required extensive to total care with two to three-person physical assist for ADL's. Further review of R#704's clinical record vital signs revealed the following: Temperatures: 4/8/20 @ 9:26am - 99.0 4/13/20 @ 7:57pm - 100.0 5/2/20 @ 8:28pm - 99.2 5/3/20 @ 9:36pm - 99.3 5/4/20 @ 8:19am - 99.0 A review of the Clinical Notes in part revealed the following: 4/5/20 @ 11:32pm - .Decrease in appetite . 4/10/20 @ 5:30pm - MDS Notes: 1135 waiver is in place for this elder. She is showing a change in condition due COVID-19 outbreak with social distancing and isolation as evidenced by cough, holding food, and difficulty swallowing. Skilled services is necessary . 4/12/20 @ 4:25pm - .BF ate yogurt 25%, lunch 25% plus yogurt 4/13/20 @ 2:03am - .Isolation precautions continues . 4/13/20 @ 6:19pm - Resident ate. 25% of dinner . 4/15/20 @ 12:36pm - Resident is refusing to eat or drink fluids . 4/15/20 @ 10:50pm - resident refused dinner- after multiple attempts from staff, drink very little fluids -VS 97.7, 18, 93% on RA - no noted SOB SpO2 93% on RA . 4/18/20 @ 8:21pm - c/o (complaint of) tiredness . C/O of hunger but refuses to eat . 4/19/20 @ 9:40pm - .Ate poorly states she is hungry but pushes food away . Droplet precautions remained . 4/23/20 @ 10:47am - Resident alert with confusion . appetite remains poor, consumes 30% of breakfast this AM with cueing . Pulse ox 95% on ra, temp: 97.9. 4/23/20 @ 3:54pm - Her PHQ-9 (Patient Health Questionnaire-9 - screen for depression) Test Score has changed since the COVID-19 pandemic, due to some reports of feeling down, feeling anxious, and also having a decrease appetite . 4/27/20 @ 12:59pm - Writer spoke with residents daughter (name redacted) about potential room change for mom 2/2 (sic) neg (negative) covid test. Discussed risk vs (versa) benefit including emotional room change. Family would like mom to remain in current room at this time. 4/27/20 @ 2:03pm - Resident received covid 19 nasal swab test. Left message with family to notify writer with update. Will F/U (follow-up) with results once received. Residents #703 and #704 continued to share the same room despite R#703's fever, lethargy, abnormal SpO2, loss of appetite, contact and droplet isolation per physician's orders [REDACTED]. those at high-risk for severe illness from COVID-19 are: People [AGE] years and older . who live in a nursing home or long-term care facility . underlying medical conditions . On 5/4/20 at 11:20 a.m., during a interview, when asked about R#703 and R704 sharing the same room, Registered Nurse (RN) 'E' stated, R#704 is negative. About 3 ½ weeks ago, she (R#704) had a fever, but then it went away .When asked about roommate R#703, RN 'E' stated, She (R#703) had a low grade fever, loss of appetite ., but not at the same time as (name) R#704. They were at different times. An interview was conducted with the Director of Nursing (DON) on 5/4/20 at 12:45 p.m. when queried about R#703 (tested positive for COVID-19) and R#704 (tested negative for COVID-19) cohorting in the same room, the DON stated, (name) R#704 looked like roommate (R#703) so we left her in there (room). The DON further stated, We talked to the family and they did not want her to move. Residents #705 and #706 Review of the census record revealed R#705 and R#706 had shared a room beginning on 7/18/19. R#705 Review of the clinical record revealed R#705 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly MDS dated [DATE], R#705 scored 13/15 on the BIMS exam, indicating intact cognition. The MDS assessment also indicated R#705 required the assistance of staff for ADL's. Review of progress notes for R#705 revealed: A Dietary note dated 4/9/20 at 11:29 AM read in part, .Last weight 123.7# (pound) . Resident typically does not have much of an appetite for breakfast however, recently has not been eating much lunch either . Unintended wt (weight) loss r/t (related to) decreased intake . A Dietary note dated 4/23/20 at 3:23 PM read in part, .Last weight 120# indicating slight weight loss over the last 2 weeks. Resident reported a good appetite overall despite weight loss . A Nursing note dated 4/23/20 at 4:30 PM read in part, Resident received Covid 19 nasal swab test . Review of a facility provided report revealed R#705 was tested for COVID-19 on 4/24/20 and the results were reported at NOTDETECTED, indicating R#701 was negative for COVID-19. R#706 A review of the clinical record revealed R#706 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6 out of 15 which indicated R#706 had impaired cognition and required extensive assistance with one-person physical assist for ADL's. Further review of R#706's clinical record vital signs revealed the following: Temperatures: 3/24/20 @ 10:08am - 99.4 4/6/20 @ 4:08pm - 99.0 4/9/20 @ 4:15pm - 99.0 4/17/20 @ 4:47pm - 99.0 4/24/20 @ 9:56pm - 98.9 4/28/20 @ 7:55pm - 98.8 4/30/20 @ 7:56pm - 98.7 A review of the Clinical Notes in part revealed the following: 4/7/20 @ 7:52am - resident noted with productive cough and congestion in lung fields, Temp 97.7. Resident SpO2 95% on room air . 4/8/20 @ 11:34am - Resident noted to have possible significant weight loss this week . Resident reported an ok appetite however per staff and writer observation intake decrease. Resident refused breakfast yesterday . Resident noted to have recent cough and congestion likely impacted appetite, [MEDICATION NAME] in place . initiate FAR (Food Acceptance Record) through the month of April . 4/8/20 @ 10:46pm - .Occasional cough noted . 4/11/20 @ 3:23am - Temp 97.0 Productive cough noted . 4/12/20 @ 2:31am - Resident continue with occasional cough . Temp 97.7 4/12/20 @ 12:20pm - Temp 98.0, mild cough noted . 4/18/20 @ 1:50pm - .Resident T 96.3. Resident SpO2 92% on room air . 4/23/20 @ 4:32pm - Resident received COVID-19 nasal swab test . 4/27/20 @ 2:15pm - Resident results of Covid received as positive via lab . 4/28/20 @ 1:32pm - .temp 97.1, SpO2 93% .; 4/28/20 @ 4:58pm - Update resident's daughter of results of Covid testing . Residents #705 and #706 continued to share the same room despite R#706's fever, productive cough and congestion in lung fields, abnormal SpO2, and decreased food intake. On 5/4/20 at 12:43 PM, the DON was interviewed and queried about cohorting positive and negative COVID-19 residents. The DON explained the facility kept roommates together because the negative roommate was already exposed to [MEDICAL CONDITION]. The DON was asked about CDC guidelines for the cohorting of residents. The DON explained the facility were following guidelines that came out in March 2020, early on about keeping roommates together to not expose other residents in the facility. The DON was asked to provide the guidance and date it was issued. The DON was unable to locate the document at that time. On 5/4/20 at 1:52 PM, the Administrator was interviewed and queried about R#701 and R#702 sharing a room after confirming R#701 was negative and R#702 was positive. The Administrator explained since R#701 had been very symptomatic and hospitalized , R#701 more than likely had [MEDICAL CONDITION] already and R#702 had been asymptomatic and it was a surprise when R#702 had tested positive, so it was decided to keep the residents together so as not to expose any other residents. On 5/5/20 at 2:37 PM, the Administrator and DON were interviewed concurrently by phone. The DON explained there was a percentage of false negative tests, and they presumed R#701 had been positive for COVID-19 and falsely tested negative. The Administrator and DON were asked to confirm R#701 had two negative COVID-19 tests, one at the hospital on [DATE] and one at the facility on 4/24/20. The Administrator and DON both confirmed Yes. On 5/5/20 at 3:49 PM, an email from the Administrator provided the CDC guidance the facility was following regarding cohorting residents. The Administrator indicated the document was dated 4/19/20 and the only part highlighted read, Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed resident into a shared space with them. Review of the CDC guidance titled, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes dated 4/15/19 read in part, Dedicate space in the facility to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort resident with COVID-19 . Have a plan for how resident in the facility who develop COVID-19 will be handled (e.g., transfer to single room, prioritize for testing, transfer to COVID-19 unit if positive). Closely monitor roommates and other residents who may have been exposed to an individual with COVID-19 and, if possible, avoid placing unexposed residents into a shared space with them . Indicating a resident who was positive should have been moved to a COVID-19 hall and their negative roommate should have been monitored in a separate room. Review of the facility's policies titled Limiting transmission of COVID-19 dated 3/5/2020 documented in part the following: . Immediate actions if COVID-19 is suspected: 1. Mask the patient as soon as identified 2. Place the patient in a private room with the door closed . However, the facility's policy did not address cohorting of positive or presumed positive roommates with negative roommates.

Based on observation, interview, and record review, the facility failed to provide backflow prevention on 3 of 3 shower wand assemblies within the Sanctuary East Spa effecting 61 residents, resulting in the increased likelihood of cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 10/22/19 at 03:00 P.M., An environmental tour of the facility was conducted by this surveyor. The following item was noted: 3 of 3 shower wand assemblies within the Sanctuary East Spa were observed missing atmospheric vacuum breakers, increasing the likelihood of cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. On 10/23/19 at 09:45 [NAME]M., An interview was conducted with Director of Environmental Services A regarding a specific Policy/Procedure for identifying and correcting maintenance concerns. Director of Environmental Services A indicated daily maintenance rounds were conducted by his staff and noted concerns were recorded in the WorksHub software system. On 10/23/19 at 10:48 [NAME]M., Record review of the Policy/Procedure entitled: Resident Equipment dated 12/01/2008 revealed under Purpose: To create a safe and secure home for the residents. Record review of the Policy/Procedure entitled: Resident Equipment dated 12/01/2008 further revealed under Policy/Procedure: All resident equipment is to be checked on a monthly basis for proper and safe operation. The maintenance department is responsible for checking all equipment to include but not limited to: Shower Equipment.

Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner for two residents (R#53 and R#55) of three residents reviewed for dignity, resulting in the potential for diminished feelings of self-worth. Findings include: Resident #55 On [DATE] at 9:47 AM R#55 was observed in their room and was queried in regard to how they were treated at the facility. R#55 expressed feelings of being not wanted, and also expressed concerns with being treated in a respectful manner. R#55 explained the facility was their home. Review of the clinical record for R#55 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission minimum data set (MDS) assessment dated [DATE], it was revealed the resident scored 15 out of 15 on a BIMS assessment, which indicated the resident was cogntively intact. Review of a grievance form for R#55 dated [DATE] documented the following concern: Elder expressed concerns regarding staff verbalizing frustration outside of room. Review of action taken to resolve the concern documented, cena (certified nursing assistant) one to one discussion written with cena. It was documented that the actions taken were effective, and that there were no further concerns. Review of a Documentation of Discussion form dated [DATE] with former staff member Certified Nursing Assistant (CNA) 'G' dated [DATE] documented the following: Both, Resident(s) and Associates reported that conversation overheard that was not Customer Service appropriate. Resident perception that approach was rude and did not take into consideration what she was requesting. Not being respectful of resident requests of when they request to retire. Stating in common area the reason why residents should be readied for bed prior to 1900 (7:00PM). Stating that pager should be turned off after 1900 In future be mindful to: Honor resident requests Be mindful how you respond to residents and their requests and how and where comments are made. Resident #53 R#53 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#53 as cognitively intact. R#53 required a two-person assistance for bed mobility, transfer and toilet use. On [DATE] at 4:21PM, observed R#53 sitting in a wheelchair next to their bed watching television. When asked R#53 stated There was this younger aide that didn't treat me with respect. I did tell someone and they (the facility) did an investigation. They were going back and forth on who was going to take care of me . A Resident Interview Summary for R#53 provided by the facility dated [DATE] documented in part, . Has any staff member presented themselves in unprofessional manner or provided poor service? One is not quit <sic> as nice as the others, like she has a chip on her shoulder and I hear a lot of staff complaining about their jobs . there was a heated argument about whose job it was to help me. It was said that You know your job and I know my job, it's not my to do your job. They were talking about who was to help me get changed, I need two people to move. My therapist (Physical Therapist PT F identified) and Certified Nursing Aide (CNA) G were the ones. You stated, a heated discussion, was there yelling or foul language? No, I would say just a loud voice, she was really hot. A statement provided by the facility with CNA G dated [DATE] at 8:52 AM, documented in part, . I was not the aggressor, he was . I was coming down the hall, he flagged me down and said, hey are you on this hall? I did not know yet. I had worked all day shift on another hallway. I came over to the other hall and everyone was soaked, the beds were all wet . I asked the Therapist to step out of the room so I could do her sugars. He said he would just hang out. I said, you know she did not go to the bathroom until I put her on the toilet and you could have put her on the toilet and I could have taken her off. She was a one-person assist. After that, he said that is not my job to clean them. I did say to him if it was not for my job, you would not have a job. I said, oh really. He said, it is your job. I asked him to leave for the third time so I could provide patient care, and he said no he was not going to leave . A statement provided by the facility with PT F dated [DATE] documented in part, . The resident had soiled herself when we started working. She mentioned that the same thing had happened earlier. I took her back to her room, and left her just outside her door . I informed that resident that I had told her nurse and CNA G. After a half an hour, I come back and the patient was in a gown . I told the resident we would just walk in the room because she was wearing a gown . CNA G then come up to me and says, You could have done this yourself. I said, no I could not have done it, she is a two-person assist, I couldn't have assisted her. Then she needed to get her blood sugar. I said okay- then she kept saying over and over, you could have just done it. I said please do not tell me my job. The she started yelling at me. I left the room-When I came back the resident said the CENA (CNA G) was nasty while I was gone while she was changing the sheets . On [DATE] at 11:59 AM, PT F was queried regarding the incident with CNA G that took place in front of R#53. PT F stated in part, . I was working with the resident in the therapy gym and she was having episodes of diarrhea in the morning, she felt like she had to go back and couldn't wait. I put her outside of her door because housekeeping had just cleaned her room and had a sign on her door. It was during shift change, so I waited to see who the aide and nurse was. I saw CNA G and let her know that I am putting the resident here and she was two-person transfer and I let them know that she was having diarrhea, I saw the resident and asked her was she cleaned and she said that she was. so, they resident agreed to work in the room with PT due to the diarrhea. The aide (CNA G) said you could have done this by yourself, you could have cleaned her up yourself. she said don't tell me what my job is, I know what my job is. I didn't want to keep doing this in front of the resident. I left and told the nurse and my manager. I went back to check on the resident to see how she was doing and she said ever since the aide came on duty, she was nasty to her. I didn't want to prolong the conversation and put the resident on the spot . On [DATE] at 12:24 PM, the Director of Nursing (DON) was queried on the incident involving CNA G and PT F that took place in front of R#53 and the DON stated in part, Any personal conversation/frustration should not take place in a patient care area, they should go to a Non-patient care area. I was called that evening by a nurse, informing me there was a louder tone conversation going on. She was upset that she had to work a different unit. HR interviewed the therapist and employee and she was given a final written warning. She decided to quit at that time without sufficient notice. On [DATE] at 1:20 PM, the Administrator was queried regarding the situation with CNA G and PT F that took place in front of R#53 and the Administrator acknowledged that incident occurred and felt the facility followed the proper protocol. A dignity policy was requested by the Administrator and the Resident Rights was provided. Review of an undated document titled, FEDERAL RESIDENT RIGHTS & FACILITY RESPONSIBILITIES revealed, in part, the following: Residents Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an enviornment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident .

Based on observation, interview and record review the Facility failed to report to the State Agency allegations of Resident to Resident abuse for four Residents (R#17, R#27, R#40 and R#365) out of four Residents reviewed for abuse, resulting in the increased potential for unidentified and/or continued abuse. Findings include: Resident #40 On 10/21/19 the medical record for R#40 was reviewed and revealed the following: R#40 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. An IDT (interdisciplinary team) clinical note dated 7/9/19 revealed the following: .Elder has extensive history of inappropriate sexual behaviors, impulsivity and physical behaviors . A nursing note dated 7/13/19 at 11:00 AM was reviewed and revealed the following: Resident observed by therapy having a physical behavior. RN (Registered Nurse) notified by therapy of the behavior. Resident was escorted back to his room, where he is currently resting. Family and management notified. Will continue to monitor. no other behaviors observed. An addendum nursing note dated 7/13/19 at 11:27 AM revealed the following: Resident observed by therapy having a physical behavior. RN notified by therapy of the behavior. Resident was escorted back to his room, where he is currently resting. family and management notified. Message left for social work for follow up with psych (psychiatric) eval (evaluation). Will continue to monitor. A nursing note dated 7/16/19 revealed the following: Elder having physical and sexual behaviors towards female staff . A nursing note dated 7/29/19 revealed the following: .Resident observed having physical behaviors with staff. Resident taken to room, in less stimulation and explained that behavior is in inappropriate . Resident #365 On 10/21/19 the medical record for R#365 revealed the following: R#365 was initially admitted to the facility on [DATE] and was discharged on [DATE]. A review of R#365's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/18/19 revealed R#365 needed limited assistance with most of their activities of daily living. R#365's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A review of an initial investigation report dated 7/13/19 pertaining to R#40 and R#365 revealed the following: Alleged incident on- 7/13/19 .Description of alleged violation: Elder (R#40) made contact with elder (R#365) while in the therapy gym .Brief Description of the alleged incident in the words of the person who reported/informed: Elder (R#40) made contact with elder (R#365) while she was riding on the bike in the therapy gym .Notification Tracking-Incident regarding: (R#40) made contact with (R#365) while in therapy gym. Date and time of occurrence: 7/13/19 10:55. Notified Director of Nursing (yes) On: Date/Time: 7/13/19 11:10 AM .Notified Administrator (yes) On: Date/Time: 7/13/19 11:10 AM . A review of a report titled Disruptive Behavior Event pertaining to R#40 and R#365 on 7/13/19 revealed the following: Details of the event-Specific event type:-Sexual Behavior .Brief Factual Description-RN was notified by therapy that resident entered therapy gym and went to to a female resident and made contact with her midsection . A witness statement by staff member B pertaining to R#40's allegation on 7/13/19 revealed the following: Summary of interview-I observed (R#40) make contact with (R#365) while she was riding on the bike. (R#40) was redirected and escorted out of the therapy gym. I informed .Nurse 'C' staff nurses . A witness statement by R#365 pertaining to the incident with R#40 revealed the following: Summary of interview-An elderly man was wheeling toward me in his wheelchair while I was sitting on the therapy bike and made contact with her midsection. The therapist immediately remove the man from the therapy gym . A review of an initial investigation report dated 7/29/19 pertaining to R#40 and R#365 revealed the following: Alleged incident on-7/29/19 .Description of alleged violation: Resident (R#365) stated she was standing outside of the oxygen tank room, when elder (R#40) wheeled himself passed her on her buttocks made contact .Incident regarding: Resident stated elder (R#40) tapped her bottom when passing by in wheelchair. Date and time of occurrence: 7/29/19. Notified Director of Nursing (yes) Date/Time: 11:00 AM. Notified Administrator (no) On: Date/Time: N/A . Further review of the facility investigation for the allegation between R#40 and R#365 on 3/29/19 revealed the following: Brief description of the alleged in the words of the person who reported/informed: Resident (R#365) expressed concerns to OT (occupational therapist) that the elder (R#40) made contact with her buttocks while self-propelling by her while she was standing in west hall waiting on oxygen . A witness statement from staff member D pertaining to the allegation between R#40 and R#365 on 7/29/19 revealed the following: Resident reported to me that while she was standing in West hallway waiting for her oxygen tank to be changed, the elder (R#40) was self-propelling down the hall and touched her backside while passing by. A witness statement from staff member [NAME] pertaining to the allegation between R#40 and R#365 on 7/29/19 revealed the following: I was in west hallway changing resident oxygen tank out and observed the elder (R#40) make contact with resident (R#365) buttocks while passing by using his hands and feet to move. On 10/23/19 at approximately 2:28 p.m., staff member B was queried via phone regarding the allegation on 7/13/19 of R#40 making contact with R#365's 'midsection' while they were in the therapy room, on the bike. Staff member B stated the following: I had by back turned when (R#40) came into the therapy room. When I turned around I saw (R#40)'s hand on R#365's abdomen. (R#365) told me that R#40 had lifted up her shirt and exposed her breast. We took R#40 out of the gym. Staff member B was queried if they notified anyone that R#40 had lifted up R#365's shirt and exposed them and they indicated that they did notify R#40's nurse. On 10/23/19 at approximately 3:56 p.m., Nurse C was queried regarding the allegation between R#40 and R#365 on 7/13/19. Nurse C indicated that on 7/13/19 she was made aware by a therapist that R#40 had gone into the therapy gym and lifted up R#365's shirt. Nurse C was queried if R#40 had a history of [REDACTED]. Nurse C was queried what R#40 does that is sexually inappropriate and they indicated that R#40 will go down the hallway and try to touch females backsides. On 10/23/19 at approximately 3:28 p.m., the facility Administrator was queried if they had reported the allegations that R#40 had touched R#365's midsection in therapy gym on 7/13/19 and the allegation that R#40 had touched R#365's buttocks in the hallway on 7/29/19. The Administrator indicated that they had not reported either allegation to the state agency for review. The Administrator was queried why the two allegations were not reported to the State Agency and they indicated that though their investigation of the allegations they had concluded that no abuse occurred. Resident's #17and #27 R#27 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#27 required a two-person assistance for most activities of daily living. R#17 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented a Brief Mental Status (BIMS) of 11 indicating moderately impaired cognition. R#17 required a one-person physical assistance for most activities of daily living. On 10/23/19 at 11:23 AM, when R#17 was queried regarding a few documented incident's with R#27, R#17 stated in part, . I've known him for years . I am very close to his family, see (pointing to pictures on the wall) his family took me out on their boat. In a way it was tough (being their roommate), he would hit his family as well. I knew him for years. He doesn't recognize me anymore. He was so sick and I wanted to move. He would try to take my food off of my plate and after he couldn't take my stuff anymore, he would go for other people's stuff . His wife come and visit sometimes. He doesn't recognize her anymore either. He tried kicking her in the stomach a few time and I had to intervene and help. When he was well, he was the nicest person that you ever met until the Dementia. When queried on how R#17 felt since the room change and no longer residing in the room with R#27, R#17 stated, I do feel relief, I don't have to prevent him from hitting anyone anymore and I am getting more sleep now that I am not his roommate. Sometimes in the middle of the night it would take five staff members to help control him. It used to wake me up all of the time. A facility's Proof of Internal Investigation Report dated 4/11/19 documented in part, . Resident (R#27 name redacted) demonstrates physical behaviors towards a staff member. Resident (R#17's name redacted) attempted to intervene by placing hands on R#27's upper arms . A facility's Proof of Internal Investigation Report dated 7/31/19 documented in part, . While repositioning self in dining room elder (R#27's initials redacted) made contact with (R#17's initials redacted) . (R#27's initials redacted) became frustrated at inability to maneuver around chair and began moving rapidly making contact with (R# 17's name redacted) torso . A CENA (Certified Nurse Assistant) statement documented in part, . Overheard elders (R#17 and R#27 names redacted) having an escalated conversation upon visualizing elders R#17 stated R#27 made contact with his torso while attempting to self-propel around his WC (wheelchair) to get out the dining room. R#17 states R#27 kept bumping into his WC. R#27 appeared frustrated . Staff member separated elders immediately after incident . A facility's Proof of Internal Investigation Report dated 10/17/19 documented in part, . (R#27 name redacted) reached over to take something off of R#17's plate, R#17 verbally responded, R#27 flailed his arms and one made contact with Doug's forearm-right side . A Voice report provided by the Administrator (the facility's Incident and Accident reporting system) dated 10/22/19 documented in part, . Event date 10/17/19 . Description of Disruptive behavior- Outburst of Anger . Elders separated to different tables where they finished their meals with no further altercation . On 10/23/19 at 12:51 PM, the Administrator (who also identified themselves as the Abuse Coordinator) was queried on the above incidents and stated in part, . (regarding the (MONTH) 2019 incident) After a thorough investigation there were no signs or symptoms of any ill intent. (R#17 name redacted) knew that (R#27 name redacted) had cognitive deficits. On the (MONTH) incident there was no ill intent, (R#27's name redacted) was attempting to go around (R#17 name redacted). (R#17 name redacted) stated that he felt safe and that he understand the resident has cognitive deficits. In (MONTH) out investigation showed no ill intent and no malice in (R#27's) actions. When asked why the same typed verbiage was utilized in all of the investigations documentation and signed by the staff member, instead of the staff (that witnessed the incidents) documenting or typing their own statements the Administrator stated, Because we are interviewing them and we have the questions of the investigation and we ask them those questions. The Administrator was asked how they monitored for potential or actual reported allegations of abuse? The Administrator stated, I think it's important to say that since then he (R#17) had a room change since. We are out there every day with our residents asking questions and we have a wonderful social services department that follow's up thoroughly on everything. The Administrator was asked if any of these incidents were reported to the State Agency and the Administrator stated, No, because after the investigation there were no signs/symptoms that abuse had ever occurred. A facility policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property and Exploitation Prohibition (dated June, 1 2007 with a revision date of (MONTH) (YEAR)) documented in part, . Purpose: to outline and maintain the Community's procedures as it relates to . protection of residents, prevention and identification of abuse, investigation and reporting of allegation or witnessed abuse/neglect . Allegations, suspicion, and substantiated findings of abuse, neglect . will be reported according to the State-specific guidelines for reporting . Incidents and/or alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator/designee, but not later than 2 hours after the allegation is made . The Administrator or his/her designee will notify the State Agency of alleged violations involving abuse . as soon as possible, but not later than 2 hours after the allegation is made .