Every finding on record at Belmont Care and Rehabilitation

Based on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours for 3 of 46 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments. Findings include:A review of the Direct Care Staff Daily Reports for 1/31/26 through 3/17/26 revealed the following dates without the required RN coverage:-1/31/26-2/25/26-3/17/26On 8/6/26 at 3:22 PM Staff 1 (Administrator) acknowledged the identified dates without the required RN coverage.

Based on observation and interview it was determined the facility failed to ensure an ice machine had the required air gap for 1 of 1 facility ice and water machine reviewed for kitchen sanitation. This placed residents at risk for cross contamination and foodborne illness. Findings include:On 8/6/26 at 11:00 AM a flexible hose drain line was observed coming into the kitchen through a hole in the wall. The drain hose was resting along the edge of the drain and approximately six inches were coiled around and in contact with the bottom of the kitchen drain. The drain line was discolored with splotchy pink areas observed and was connected to the dual ice and water machine on the other side of the wall.On 8/6/26 at 1:17 PM, Staff 13 (Maintenance Director) was observed working on the dual ice and water machine in the dining room. Staff 13 stated he was the person that provided maintenance to the machine and confirmed there was a flexible drain line that went through the shared wall and drained into a kitchen drain. Staff 8 acknowledged the drain hose was in contact with the drain floor and side wall and there was no airgap present (space between a water pipe sink or drain that prevents dirty water from flowing back into the clean water supply).On 8/6/26 at 1:25 PM Staff 12 (Dietary Manager) was informed of the findings.

Based on observation, interview, and record review it was determined the facility failed to implement appropriate contact precautions for 2 of 3 sampled residents (#s 1 and 32) reviewed for contact precautions. This placed residents at risk for the spread of infection. Findings include1. Resident 1 admitted to the facility in 2024 with diagnoses including urinary tract infection. A 7/29/26 care plan indicated Resident 1 had a multidrug-resistant organism (type of bacteria resistant to multiple antibiotics) urinary tract infection and staff were to follow Contact Precautions.On 8/3/26 at 12:47 PM a Contact Precautions sign was posted by Resident 1's door, which directed staff to wear gloves and a gown each time they entered the room.On 8/6/26 at 12:12 PM Staff 7 (CNA) entered Resident 1's room and delivered a meal to her/him. Staff 7 did not wear a gown and gloves when she delivered the meal to Resident 1. Staff 7 stated PPE was not required when she delivered a meal to Resident 1. On 8/6/26 at 12:15 PM Staff 2 (DNS) stated staff were to wear required PPE each time they entered Resident 1's room.2. Resident 32 admitted to the facility in 4/2026 with diagnoses including Crohn's Disease (inflammatory bowel disease).A 7/24/26 Physician Order revealed Resident 32 had an order for vancomycin (an antibiotic) for C. diff (Clostridium difficile, a bacterium which causes an infection of the colon). On 8/3/26 at 12:08 PM a Contact Enteric Precautions sign was posted by Resident 32's door, which directed staff to wash or gel hands prior to entry, wear a gown and gloves, and use soap and water upon leaving the room.On 8/3/26 at 12:08 PM Staff 10 (CNA) exited Resident 32's room and used hand sanitizer before she exited the room. Staff 10 did not wash her hands with soap and water before she exited Resident 32's room. On 8/4/26 at 12:22 PM Staff 9 (CNA) was observed to remove her gown and gloves then sanitize her hands with hand sanitizer when she left Resident 32's room. Staff 9 then walked to the restroom by the nurses station and washed her hands with soap and water.On 8/4/26 at 12:29 PM Staff 9 stated staff were to wash their hands with soap and water after they were in Resident 32's room. Staff 9 stated they could wash their hands in Resident 32's bathroom, but she washed her hands in the restroom at the nurses station restroom.On 8/4/36 at 1:12 PM Staff 10 stated when she exited Resident 32's room she was to sanitize her hands with alcohol-based hand rub and then go to either the soiled linen room or the restroom by the nurses station to wash her hands.On 8/4/26 at 4:10 PM Staff 2 (DNS) stated Resident 32 was on Contact Precautions due to a diagnosis of C. diff and staff were to wash their hands with soap and water before they exited her/his room.

Based on interview and record review it was determined the facility failed to ensure behavior monitoring was in place related to the use of antipsychotic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary medications. Findings include:Resident 8 was admitted to the facility on [DATE] with diagnoses including depression and delusional disorders.A 3/27/26 physician order revealed Resident 8 was prescribed Olanzapine 5 MG (an antipsychotic medication) once daily for delusions.A review of Resident 8's 7/2026 MAR and 5/2026 care plan revealed no identification or monitoring of targeted behaviors related to antipsychotic use. The record did not include any other behavioral documentation to support the use/effectiveness of the medication.On 8/7/26 at 11:02 AM, Staff 4 (Social Services Director) stated Resident 8 was not on behavior monitoring.On 8/7/26 at 11:19 AM, Staff 2 (DNS) stated residents receiving antipsychotic medications were placed on behavior monitoring and confirmed Resident 8 did not have behavior monitoring in place.

Based on observation, interview, and record review it was determined the facility failed to provide a homelike environment for 1 of 3 sampled residents (#6) reviewed for respiratory care. This placed residents at risk for unsanitary conditions. Findings include: Resident 6 was admitted to the facility in 2022 with diagnoses including dysphagia.Resident 6's 10/25/25 Annual MDS revealed she/he required a feeding tube for nutrition and had a tracheostomy in place.On 8/3/26 at 3:45 PM Resident 6's room was observed to have a small black fan. The small black fan was very dirty and dusty and appeared to not have been cleaned for a long time.On 8/3/26 at 3:57 PM Witness 1 (Family Member) stated the area next to Resident 6's bed was dirty and often had liquid on it from the tube feeding, and it appeared gross.On 8/6/26 at 9:21 AM Resident 6 had a mattress on the floor in her/his room near the bed which appeared dirty with dried clear debris, the oxygen concentrator had dried clear debris and dust on it, the tracheostomy machine had dried white debris all over it, the black fan had dust all over it, and there was a dirty towel on Resident 6's bed.On 8/6/26 at 9:45 AM Staff 3 (LPN Resident Care Manager) observed Resident 6's room, agreed the room was dirty, and needed to be cleaned daily.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received appropriate pain management for 1 of 3 sampled residents (#23) reviewed for pain. This placed residents at risk for uncontrolled pain. Findings include:Resident 23 was admitted to the facility in 12/2025 with diagnoses including idiopathic aseptic necrosis of right femur (a condition where bone tissue dies often causing pain, stiffness, and limited mobility).A review of Resident 23's Physician Orders revealed a 6/19/26 order for PRN oxycodone every four hours for idiopathic aseptic necrosis of right femur.A 6/24/26 Incident Report revealed:Resident 23 last received her/his PRN oxycodone on 6/23/26 at 10:38 PM and was able to receive it again at 2:38 AM. Resident 23 requested pain medication at approximately 3:00 AM on 6/24/26. Staff 14 (Former LPN) was notified by the CNAs, who stated Resident 23's medications were not yet due. At approximately 4:00 AM Resident 23 went to Staff 14's medication cart and again requested pain medication. Resident 23 reported she received the pain medication at about 4:45 AM and was told by Staff 14 she/he did not receive the medication earlier because she/he was asleep. A review of camera data revealed a CNA staff left Resident 23's room at approximately 2:30 AM and went to Staff 14. At 4:30 AM Resident 23 was seen on camera at the nurses station and spoke with Staff 14, Resident 23 then went to her/his room. Staff 14 was observed for an additional 15 minutes at the nurses station and then Resident 23 received medication at 5:02 AM.On 8/4/26 at 9:49 AM Resident 23 stated on 6/24/26 she/he was in pain and Staff 14 did not give her/him pain medications after the CNAs told Staff 14 she/he was in need of the pain medication. Resident 23 stated her/his right hip was in pain at all times and she/he needed to stay on top of the pain and the pain was rated at a seven or eight out of ten. Resident 23 stated she/he went to Staff 14 and asked for the pain medication, and finally received it after 5:00 AM and could have received it around 2:30 AM.On 8/6/26 at 10:23 AM Staff 14 stated Resident 23 requested pain medication too soon and was able to have the medication around 2:30 AM. By the time she offered pain medications Resident 23 was asleep. Staff 14 stated she went into Resident 23's room at approximately 4:00 AM and she/he was asleep.On 8/6/26 at 12:39 PM Staff 2 (DNS) stated the late prn medication concern was investigated and it was determined Staff 14 waited until after an early morning fire drill to provide Resident 23 with her/his pain medication, which resulted in Resident 23 not receiving the PRN pain medication for seven hours when she/he could have them every four hours. Staff 2 stated Resident 23 was in a lot of pain and needed pain medications.On 8/7/26 at 10:54 AM Staff 8 (CNA) stated when Resident 23 complained of pain on 6/24/26 she notified the nurse of the need for pain medication and was told to write the request on a piece of paper. Staff 8 stated she notified the nurse two to three times of the need for pain medications.

Based on interview and record review it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 Resident Council reviewed. This placed residents at risk for lack of timely mail delivery. Findings include: The facility's 5/2017 Mail and Electronic Communication Policy states the following: Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries). Resident 20 was admitted to the facility in 3/2021 with diagnosis of chronic venous hypertension (prolonged high blood pressure in veins of lower extremities) and moderate cognitive impairment. During a Resident Council meeting on 2/26/25 at 10:30 AM, Resident 20 reported she/he did not receive mail on Saturdays. During an interview on 2/26/25 at 3:16 PM, Staff 5 (Social Services Director) was not sure how mail was distributed on Saturdays. During an interview on 2/27/25 at 10:45 AM, Staff 1 (Administrator) confirmed mail arrived at the facility on Saturdays, but mail was not distributed to residents unless residents asked for it.

Based on interview and record review it was determined the facility failed to promptly respond to grievances and complaints from the resident council for 2 of 3 months reviewed. This placed residents at risk for unresolved missing property. Findings include: The facility's 2/2021 Resident Council policy states the following: A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. 1. During a Resident Council meeting on 2/26/25 at 10:30AM, Residents #2, 11, 20, and 24 expressed concerns with unresolved missing clothing. a. A review of Resident Council meeting minutes from 11/19/24 revealed residents voiced concerns regarding missing clothing items in the Housekeeping/Laundry section. A resolution was not filed with the minutes. A review of the Grievance Book revealed no grievances filed for 11/2024 regarding the missing laundry items discussed during Resident Council meeting on 11/19/24. On 2/26/25 at 3:09 PM, Staff 6 (Activities Director) stated when complaints were reported during Resident Council, the process included distribution to each department and each department was responsible for providing resolution within ten days. Staff 1 (Administrator) reviewed and signed off on the resolution and was given back to Staff 6 to file with Resident Council minutes. Staff 6 was not able to locate the resolution regarding missing clothing from Resident Council meeting minutes from 11/19/24. b. A review of Resident Council meeting minutes from 2/5/25 revealed concerns regarding missing clothing. A resolution to the concern included having resident fill out a grievance form for replacement. On 2/26/25 at 8:58 AM, Staff 5 (Social Services Director) reported there were no grievances filed for February 2025. During an interview on 2/27/25 at 10:45 AM, Staff 1 (Administrator) stated the process she expected staff to follow for issues brought up during resident council included for staff to respond to resident issues within ten days and acknowledged the complaints were not addressed promptly.

Based on observation, interview, and record review it was determined the facility failed to provide medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being for 4 of 6 sampled residents (#s 3, 16, 22 and 26) reviewed for abuse and dental. This placed residents at risk for lack of psychosocial needs and decreased dignity. Findings include: The facility's 9/2021 Social Services Policy indicated medically-related social services were provided to maintain or improve each resident's ability to control everyday physical, mental and psychosocial needs. The social worker/social services staff were responsible for the following: -To make referrals and obtain needed services from outside entities. -To provide or arrange for mental and psychosocial counseling services as needed. -To identify and seek ways to support resident needs through the assessment and care planning process. -To identify and promote individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. 1. Resident 3 was admitted to the facility in 1/2022 with diagnoses including anxiety, major depression and substance abuse. Resident 3's 11/8/22 Behavior Management Contract described her/him as verbally aggressive towards staff and Social Services were to meet with the resident weekly if she/he chose to. Resident 3's 1/26/25 Annual MDS assessed her/him to make independent decision about her/his daily life with an ok memory. No evidence was found in Resident 3's clinical record to indicate the resident's mental and psychosocial needs were comprehensively assessed, including an assessment of the resident's trauma and potential trauma triggers. The 2/27/25 care plan identified Resident 3 to experience the following problems and interventions Social Services was to use to address the problem: -Inappropriate behaviors, Resistive to care related to depression, anxiety and insomnia: one-to-one support as needed, flexibility in ADL care routine to accommodate her/his mood. -Ineffective coping characterized by verbal aggression/abuse related to drug/alcohol withdrawal: Provide one-to-one time, discuss any concerns, fears, issues regarding health or other subjects as needed, encourage her/him to express their feelings, provide options of times care can be done and flexibility, Risk Management as needed. On 2/26/25 at 10:58 AM, Staff 5 (Social Services) stated Resident 3 had no indication for potential behavioral triggers in the resident's health record. Staff 5 stated he does not do one-to-one visits with residents and if a resident needed a one-to-one he would make a referral to the mental health consultant. Staff 5 was not able to provide information where behavior monitors were completed or what concise information, he used to assess the residents behaviors. Staff 5 could not identify interventions to assist Resident 3 when she/he experienced stressful behaviors. On 2/28/25 at 9:39 AM, Staff 11 (CNA) stated Resident 3 experienced behaviors almost daily and cursed at staff and refused care often. Staff 11 stated the behavior was not documented to their knowledge. On 2/28/25 at 9:39 AM, Staff 14 (CNA) stated Resident 3had behaviors almost everyday. Staff 14 stated staff reported behavior concerns to the charge nurse and CNAs had not charted behaviors for residents who experienced problematic behaviors. On 2/28/25 at 10:34 AM, Staff 1 (Administrator) stated she expected Resident 3 to have a strong care plan for behaviors. Staff 1 stated behaviors were to be documented, and Staff 5 was expected to provide one-to-one visits as needed. 2. Resident 26 was admitted to the facility in 8/2023 with diagnoses including PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction after a traumatic event or experience), bipolar disorder (extreme mood swings) and substance abuse. Resident 26's 8/24/23 SNF (Skilled Nursing Facility) Social Service History indicated the resident had a military history, experienced several traumas in life and had an unstable medical condition. Resident 26 identified meditation, fresh air, music and visits with family were helpful to cope with anxiety related to her/his trauma experience. Resident 26's 12/1/24 Quarterly MDS revealed the resident was cognitively intact, able to make herself/himself understood and ability to understand others without difficulty. The 12/2/24 SNF Social Services Quarterly Summary for Resident 26 indicated she/he experienced no new trauma and to continue the care plan. No evidence was found in Resident 26's clinical record to indicate the resident's mental and psychosocial needs were comprehensively assessed, including an assessment of the resident's trauma and potential trauma triggers. A 2/21/25 Psychiatric Consultant report revealed Resident 26 was seen for anxiety management and faced challenges with communication with friends and family when she/he were under the influence. The 2/26/25 care plan identified Resident 26 to experience the following problems and interventions Social Services was to use to address the problem: -Inappropriate behaviors, Resistive to care related to depression: one-to-one support as needed, flexibility in ADL care routine to accommodate her/his mood. -Ineffective coping characterized by verbal aggression/abuse related to depression: Provide one-to-one time, refer to mental health as indicated. -Ineffective coping characterized by physical aggression/abusive related to anger: Approach her/him slowly and from the front, be sure to have her/his attention before speaking or touching, provide options for times of care, refer to mental health, if strategies do not work reapproach, keep requests simple. -Ineffective coping, acts sad/depressed related to medical conditions: education for medication, engage in conversation, encourage a change in environment, reach out to family. On 2/26/25 at 10:58 AM, Staff 5 (Social Services) confirmed Resident 26's health records showed no indication of triggers for PTSD, and the helpful tools identified in the initial trauma assessment to aid in coping with anxiety were included in the care plan. Staff 5 stated he does not do one-to-one visits with residents and if a resident needed a one-to-one, he would make a referral to the mental health consultant. Staff 5 could not identify interventions to assist Resident 26 when she/he experienced stressful behaviors. No additional information was provided. On 2/28/25 at 10:34 AM, Staff 1 (Administrator) stated she would expect Resident 26 to have a strong care plan for mental health and for the Staff 5 to provide one-to-one visits as needed. 47000 3. Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). A care conference note dated 11/11/24 and written by Staff 5 (Social Services) indicated Resident 16 was to receive dental care as available. Resident 16's 2/2/25 Annual MDS indicated the resident was in a persistent vegetative state (a condition in which a person is awake but has no awareness of their surroundings or themselves) and she/he had obvious or likely cavity or broken natural teeth. The Dental CAA indicated a referral to a dentist was warranted in order to minimize risks and to maintain her/his current level of functioning. On 2/24/25 at 12:07 PM, Resident 16 was observed in her/his room in bed. The inside of the resident's mouth was unable to be visualized and the resident was unable to answer any questions about her/his oral care. On 2/24/25 at 1:14 PM, Witness 1 (Family Member) stated she made a request to Staff 1 (Administrator) and Staff 5 that Resident 16 be seen by a dentist months ago but she/he had not received any dental treatment. On 2/25/25 at 4:08 PM, Staff 21 (LPN) stated Resident 16 did not have the best teeth and her/his teeth were cracked, broken and missing. Staff 21 further stated she could not remember if the resident had ever been seen by a dentist. On 2/26/25 at 11:39 AM, Staff 5 stated he was responsible for scheduling and tracking resident dental appointments. Staff 5 further stated he had not made a dental referral for Resident 16 following the resident's 2/2/25 Annual MDS. On 2/28/25 at 12:00 PM, Staff 1 (Administrator) stated she expected Staff 5 to schedule dental appointments following the request of a dental referral. 4. Resident 22 was admitted to the facility in 9/2023 with diagnoses including diabetes. Resident 22's 9/16/24 Annual MDS revealed the resident had obvious or likely cavity or broken natural teeth. The Dental CAA indicated a referral to a dentist was warranted in order to minimize risks and to maintain her/his current level of functioning. Resident 22's 9/23/24 Dental Problem Care Plan indicated arrangements for dental care were to be made as needed. Resident 22's 12/17/24 Quarterly MDS revealed the resident was cognitively intact. On 2/24/25 at 10:18 AM, Resident 22 was observed in her/his room in bed and observed to be missing multiple teeth. The resident stated she/he told Staff 5 (Social Services) she/he wanted to see a dentist months ago, but had not not seen a dentist, and never heard back from Staff 5 about a timeframe of when she/he would see a dentist. On 2/26/25 at 10:31 AM, Staff 17 (CNA) stated Resident 22 complained about her/his teeth in 12/2024 and she informed a nurse. Staff 17 stated she did not know if the resident had seen a dentist. On 2/26/25 at 11:35 AM, Staff 5 stated he was responsible for scheduling and tracking resident dental appointments. Staff 5 further stated he had not made a dental referral for Resident 22 following the resident's 9/16/24 Annual MDS. On 2/28/25 at 12:00 PM, Staff 1 (Administrator) stated she expected Staff 5 to schedule dental appointments following the request of a dental referral.

Based on observation, interview and record review it was determined the facility failed to transport clean laundry and failed to transport soiled linens in a manner to prevent cross contamination for 1 of 1 facility reviewed for infection control. This placed residents at risk for cross contamination. Findings include: 1. The CDC's website titled Healthcare-Associated Infections (HAIs) under the heading Appendix D - Linen and laundry management dated 3/19/24 indicated the following: -Clean laundry is to be sorted and transported in designated carts or containers in a manner that prevents the risk of contamination by dust, debris, or soiled linens or other soiled items. The American Healthcare Association's undated website titled Tips for Meeting Linen Requirements in Skilled Nursing Facilities indicated the following: -Clean laundry should be covered to prevent contamination when it is transported to residents. On 2/24/25 at 12:08 PM, Staff 7 (Laundry) was observed delivering laundry on hangers to the residents in room [ROOM NUMBER]. Staff 7 carried the clean laundry from the basement to room [ROOM NUMBER] draped over her bare left arm and the laundry was not covered. When she arrived at room [ROOM NUMBER], Staff 7 was observed to hang the laundry in the residents' closets. On 2/24/25 at 12:12 PM, Staff 7 stated there was no covered cart for delivering clean laundry to residents' closets. Staff 7 stated this was how she delivered clean clothes to residents. On 2/25/25 at 9:59 AM, Staff 7 was observed to carry clean laundry on hangers draped over her bare arm from the basement laundry room to the residents in room [ROOM NUMBER]. The laundry was not covered. On 2/27/25 at 10:47 AM, Staff 8 (Laundry Manager) was observed to carry an uncovered plastic bin which contained clean towels, sheets and clothing protectors upstairs from the basement laundry room and delivered them to the closet opposite the nurses' station. Staff 8 stated the facility had a small covered cart that allowed staff to deliver clean laundry to residents' rooms and linen closets while covered. Staff 8 stated it was difficult to pull the cart up the stairs with laundry in it and was why staff did not use the cart. Staff 8 stated she expected staff to keep laundry covered while delivering clean linen or clothing in order to prevent it from becoming contaminated. On 2/28/25 at 11:06 AM, Staff 2 (DNS) stated she expected residents' laundry and the facility's clean linens to be protected from potential contamination when it was delivered to residents rooms and linen closets. Staff 2 stated the facility had a covered cart but it was awkward and difficult to use so they were working on a solution. 2. The facility's policy titled, Laundry and Bedding, Soiled dated September 2022 indicated the following: -Contaminated laundry is bagged or contained at the point of collection i.e., location where it was used). The CDC's website titled Healthcare-Associated Infections (HAIs) under the heading Appendix D - Linen and laundry management dated 3/19/24 indicated the following: -Soiled linen should be placed in a bag or covered container in the patient care area. -Do not transport soiled linen by hand outside the specific resident care area from where it was removed. On 2/27/25 at 3:42 PM, Staff 16 (CNA) was observed to wheel a reclining shower chair from room [ROOM NUMBER] on the facility's west hall to the shower room on the east hall. A collection of unbagged wet towels and shower sheets were piled on the seat of the chair. On 2/27/25 at 3:46 PM, Staff 16 stated when he completed a shower for Resident 31, he transported the resident back to her/his room on the shower chair. Staff 16 stated Resident 31's family assisted her/him to dry and dress the resident. Staff 16 stated he placed the used towels and shower sheets on the shower chair to transport them to the shower room and placed them in a laundry bag. Staff 16 stated he should have placed the used towels and shower sheets in a plastic bag before taking them down the hall on the shower chair. He acknowledged he did not place the dirty linens in a bag before transporting them. On 2/28/25 at 11:06 AM, Staff 2 (DNS) stated she expected staff to place used linens in a laundry bag before removing them from the area where the care was provided.

Based on interviews and record review it was determined the facility failed to report allegations of verbal abuse within the mandated timeframe for 4 of 4 sampled residents (#s 3, 23, 26 and 41) for 1 of 2 Facility Reported Incident (FRI) reports reviewed for abuse. This placed residents at risk for further abuse. Findings include: The facility's revised 4/2021 Recognizing Signs and Symptoms of Abuse/Neglect revealed it was expected for all personnel to report any signs and symptoms of abuse to their supervisor or the director of nursing services immediately. The facility's revised 9/2022 Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation Policy and Procedures directed staff to report allegations of abuse to the state agency within two hours. On 6/19/24 at 3:52 AM, Staff 10 (LPN) wrote a progress note in Resident 41's health record which revealed on 6/18/24 at about 8:00 PM Resident 41 had been out of the facility and returned to the facility. Resident 41 proceeded to verbally and physically threatened staff, Resident 3, Resident 23 and Resident 26. On 6/20/24 at 11:23 AM, the state agency (SA) received a FRI for the 6/18/24 at 8:00 PM alleged abuse with Resident 41, Resident 3 Resident 23 and Resident 26. On 2/28/25 at 10:13 AM, Staff 2 (DNS) confirmed the FRI for the 6/18/24 allegations of abuse was submitted to the SA late. She stated she expected all allegations of abuse to be reported to the SA within the required two hour reporting time line.

Based on observation, interview and record review it was determined the facility failed to provide a homelike environment for 1 of 1 sampled resident (#16) reviewed for environment. This placed residents at risk for a lack of homelike environment. Findings include: The facility's 2/2021 Homelike Environment Policy indicated residents were provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). Resident 16's 2/2/25 Annual MDS revealed the resident was in a persistent vegetative state (a chronic condition in which a person is awake but unaware of their surroundings). Random observations of Resident 16 from 2/24/25 to 2/27/25 between 8:43 AM through 4:42 PM revealed the resident to be in bed with her/his eyes open at times. The resident shared her/his room with three additional residents, and two of the four barriers she/he shared with her/his roommates were curtains. The other two barriers were walls. The small wall behind the head of the resident's bed revealed a cork board on which hung various papers, including information on aspiration precautions, the resident's case manager and passive range of motion exercises, with very little remaining space left on the wall. A small bedside table, located in between the resident's bed and one of the privacy curtains, had personal hygiene supplies on the surface top. Storage shelves lined the remaining wall in-and-on which were various medical and incontinence supplies, including items which belonged to the resident's roommates. On 2/24/25 at 1:14 PM, Witness 1 (Family Member) stated Resident 16's room looked like a storage room and it was very depressing. Witness 1 further stated she was unable to bring in any personal items for the resident because there was no place to put anything for happiness or wellness. On 2/26/25 at 10:20 AM, Staff 17 (CNA) stated Resident 16's room stored resident supplies for as long as I can remember, and the resident's closet was the only space available in her/his room for personal items. On 2/27/25 12:35 PM, Staff 1 (Administrator) observed Resident 16's room, acknowledged the room lacked space for the resident's personal items and stated the room was not homelike.

Based on observation, interview and record review it was determined the facility failed to make prompt efforts to resolve resident grievances for 2 of 4 sampled residents (#s 2 and 22) reviewed for personal property and Resident Council. This placed residents at risk for unresolved missing property and unaddressed concerns. Findings include: The facility's 6/2023 Grievances/Complaints, Recording and Investigating Policy directed the following: -All grievances and complaints filed with the facility were to be investigated and corrective actions were to be taken to resolve the grievance(s). -The Resident Grievance/Complaint Investigation Report Form was to be filed with the administrator within five working days of the incident. -The resident, or person acting on behalf of the resident, was to be informed of the findings of the investigation, as well as any corrective actions recommended, within five working days of the filing of the grievance or complaint. 1. Resident 22 was admitted to the facility in 9/2023 with diagnoses including diabetes. Resident 22's 12/17/24 Quarterly MDS revealed the resident was cognitively intact. On 2/24/25 at 10:05 AM, Resident 22 was observed in her/his room in bed. Resident 22 stated Witness 2 (Family Member) brought her/him a pair of pants for her/his birthday in 9/2024 and the pants had been missing for about a month and a half. Resident 22 stated she/he mentioned the missing pants to a couple of staff but never received a resolution to her/his complaint. No evidence was found in Resident 22's clinical record or in the facility's 2024 or 2025 Grievance Logs to indicate a grievance had been completed related to Resident 22's complaint of missing pants or an investigation was completed. On 2/26/25 at 2:48 PM, Staff 18 (CNA) stated Witness 2 frequently brought in personal items for Resident 22 without labeling the item with the resident's name or room number. On 2/26/25 at 2:56 PM, Staff 14 (CNA) stated he immediately reported missing resident personal items to the nurse. Staff 14 stated Resident 22 complained a pair of her/his pants were missing on a few occasions a couple of months ago. Staff 14 stated he looked for the resident's pants in the facility's laundry room, could not find them and reported the missing pants to Staff 9 (LPN). On 2/26/25 at 3:34 PM, Staff 9 stated she was unaware Resident 22 was missing a pair of pants. Staff 9 further stated she would have provided the resident with a grievance form had she been aware of her/his complaint. On 2/26/25 at 4:08 PM, Witness 2 (Family Member) stated Resident 22 frequently complained her/his clothing did not come back from the laundry which could be true for sure. Witness 2 further stated she gave the resident a pair of pants for her/his birthday last year. On 2/27/25 at 1:48 PM, Staff 5 (Social Services) stated he was the facility's grievance officer and he was unware Resident 22 complained she/he was missing a pair of pants. On 2/27/25 at 1:54 PM, Staff 1 (Administrator) stated a grievance form should have been completed for Resident 22 regarding her/his missing a pair of pants and a thorough investigation should have been completed. 51846 2. Resident 2 was admitted to the facility in 11/2024 with a diagnosis of congestive heart failure. A review of Resident Council meeting minutes from 2/5/25 revealed Resident 2 reported two pairs of missing pants. The response included for her/him to file a grievance. On 2/25/25 at 12:00 PM, Staff 5 (Social Services) did not have the Grievance Book readily available when requested and stated he had to put it together. A review of the Grievance Book revealed there were no grievances filed for 2/2025. On 2/26/25 at 8:58 AM, Staff 5 stated there were no grievances filed for 2/2025 and Resident 2 did not have a grievance filed for the missing pants. At 9:03 AM, Staff 5 found Resident 2's grievance dated 2/12/25 in his stack of things to do. At 3:16 PM, Staff 5 stated his expectations were to initiate action on a Grievance form within 48 hours. During an interview on 2/27/25 at 10:45 AM, Staff 1 (Administrator) stated expectations included being informed within 24 hours of grievances in order to efficiently provide resolution to residents.

Based on observations, interviews and record review, it was determined the facility failed to protect the residents' right to be free from verbal abuse by a resident for 3 of 4 sampled residents (#s 3, 23 and 26) reviewed for abuse. This placed residents at risk for mental anguish and verbal abuse. Findings include: The facility's revised 4/2021 Recognizing Signs and Symptoms of Abuse/Neglect revealed all types of resident abuse were strictly prohibited. Policy Interpretation defined abuse as willful infliction of injury, intimidation or mental anguish. 1. Resident 41 admitted to the facility in 2020 with diagnosis including Alcohol Abuse with alcohol-Induced Psychotic Disorder (mental disorder characterized by disconnection from reality). Resident 3 admitted to the facility in 2021 with diagnoses including quadriplegia (all four limbs experience partial or complete loss of muscle function) and anxiety. On 6/20/24 at 11:23 AM the state agency received a FRI which alleged resident abuse. On 6/19/24 at 3:52 AM, Staff 10 (LPN) wrote a progress note in Resident 41's health record which revealed on 6/18/24 at 8:00 PM Resident 41 returned to the facility. Resident 41 yelled at staff and residents, including Resident 3. Resident 3 overheard Resident 41 yelling at the staff and Resident 3 came out of her/his room. Resident 41 started to threaten Resident 3 to beat [her/his] fucking ass. Staff 10 got between the residents and asked Resident 3 to return to her/his room. Staff 10 later assisted Resident 3 to complete a grievance form and the resident appeared visibly upset and verbally abused. Resident 3's 1/26/25 Annual MDS assessed her/him to make independent decision about her/his daily life with an ok memory. During the survey from 2/24/25 through 2/28/25 between the hours of 8:00 AM to 4:00 PM Resident 41 had been discharged and was not observed in the facility. Resident 3 was observed with no negative interactions with other residents. On 2/24/25 at 3:57 PM, Resident 3 stated she/he recalled the 6/18/25 incident with Resident 41. Resident 3 stated she/he felt verbally abused by Resident 41 in 6/2024 and felt unsafe at the time of the out of control behavior. On 2/26/25 at 2:56 PM, Staff 5 (Social Services) stated Resident 3 was verbally abused by Resident 41 during the 6/18/24 incident at 8:00 PM. On 2/27/25 at 3:52 PM, Staff 25 (CNA) recalled Resident 41 used abusive language towards staff and other residents, especially when she/he drank alcohol. Staff 25 could not directly recall the 6/18/24 incident. On 2/28/25 at 10:34 AM, Staff 1 (Administrator) confirmed on 6/18/24 Resident 3 was verbally abused by Resident 41. Staff 1 stated she expected all residents to be free from abuse. 2. Resident 41 admitted to the facility in 2020 with diagnosis including Alcohol Abuse with alcohol-Induced Psychotic Disorder (mental disorder characterized by disconnection from reality). Resident 23 admitted to the facility in 2021 with diagnoses including heart failure and major depression. On 6/20/24 at 11:23 AM, the state agency received a FRI which alleged resident abuse. On 6/19/24 at 3:52 AM, Staff 10 (LPN) wrote a progress note in Resident 41's health record which revealed on 6/18/24 at 8:00 PM Resident 41 returned to the facility. Resident 41 yelled at staff and residents, including Resident 23. Resident 41 proceeded to leave the facility and stopped at Resident 23's room door and yelled to Resident 23 you are a fucking murderer and why don't you go murder some more people you fucking creep. Staff 10 later assisted Resident 23 to complete a grievance form and the resident appeared visibly upset and verbally abused. Resident 23's 1/15/25 BIMS indicated Resident was assessed to be cognitively intact. During the survey from 2/24/25 through 2/28/25 between the hours of 8:00 AM to 4:00 PM Resident 41 had been discharged and was not observed in the facility. Resident 23 was observed with no negative interactions with other residents. On 2/25/25 at 12:39 PM, Resident 23 stated she/he recalled the 6/18/25 incident with Resident 41. Resident 23 stated she/he felt verbally abused by Resident 41. On 2/26/25 at 2:56 PM, Staff 5 (Social Services) stated Resident 23 was verbally abused by Resident 41 during the 6/18/24 incident at 8:00 PM. On 2/27/25 at 3:52 PM, Staff 25 (CNA) recalled Resident 41 used abusive language towards staff and other residents, especially when she/he drank alcohol. Staff 25 could not directly recall the 6/18/24 incident. On 2/28/25 at 10:34 AM, Staff 1 (Administrator) confirmed on 6/18/24 Resident 23 was verbally abused by Resident 41. Staff 1 stated she expected all residents to be free from abuse. 3. Resident 41 admitted to the facility in 2020 with diagnosis including Alcohol Abuse with alcohol-Induced Psychotic Disorder (mental disorder characterized by disconnection from reality). Resident 26 admitted to the facility in 2023 with diagnoses including paraplegia (loss of muscle function in lower body) and PTSD (Post-Traumatic Stress Disorder, mental condition with intense emotional and/or physical reaction after a traumatic event or experience). On 6/20/24 at 11:23 AM, the state agency received a FRI which alleged resident abuse. On 6/19/24 at 3:52 AM, Staff 10 (LPN) wrote a progress note in Resident 41's health record which revealed on 6/18/24 at 8:00 PM Resident 41 returned to the facility. Resident 41 yelled at staff and residents, including Resident 26. Resident 26 asked Resident 41 to quiet down and Resident 41 proceeded to yell shut up and go do more heroin bitch. Resident 26 tried to get herself/himself out of bed and Staff 10 calmed Resident 26 enough to stop advancements to the hallway. Resident 41 went to her/his room, obtained her/his grabber stick, returned to Resident 26's doorway and threatened Resident 26 and Staff 10 by swinging the stick and yelling I'll beat you pussies. Come over here. Resident 41 then threw the grabber stick down the hallway and proceeded to leave the facility. Staff 10 later assisted Resident 26 to complete a grievance form and the resident appeared visibly upset and verbally abused. Resident 26's 12/1/24 Quarterly MDS BIMS score of 14, which indicated Resident was assessed to be cognitively intact. During the survey from 2/24/25 through 2/28/25 between the hours of 8:00 AM to 4:00 PM Resident 41 had been discharged and was not observed in the facility. Resident 26 was observed with positive interactions with other residents. On 2/24/25 at 10:21 PM, Resident 26 stated she/he recalled the 6/18/25 incident with Resident 41. Resident 26 stated she/he felt verbally abused by Resident 41. On 2/26/25 at 2:56 PM, Staff 5 (Social Services) stated Resident 26 was verbally abused by Resident 41 during the 6/18/24 incident at 8:00 PM. On 2/27/25 at 3:52 PM, Staff 25 (CNA) recalled Resident 41 used abusive language towards staff and other residents, especially when she/he drank alcohol. Staff 25 could not directly recall the 6/18/24 incident. On 2/28/25 at 10:34 AM, Staff 1 (Administrator) confirmed on 6/18/24 Resident 26 was verbally abused by Resident 41. Staff 1 stated she expected all residents to be free from abuse. 46053 4. Resident 26 was admitted to the facility in 8/2023 with diagnoses including paraplegia, incomplete (a condition involving partial loss of movement and sensation in the lower half of the body due to spinal cord damage) and post-traumatic stress disorder (a mental health condition that can develop after experiencing or witnessing a traumatic event). Resident 26's 8/29/23 Admission MDS and 11/29/23 Quarterly MDS indicated she/he was cognitively intact. A facility investigation completed by Staff 3 (LPN/RCM) indicated on 2/8/24 Resident Resident 41 yelled at Staff 23 (LPN) in a verbally abusive manner which Resident 26 could hear from her/his room. Resident 26 told Resident 41 to stop yelling at Staff 23. Resident 41 entered Resident 26's room and yelled at her/him that she/he was a heroine addict, only had a seventh-grade education and should overdose and die. Staff 23 used a two-way radio to request staff assistance to remove Resident 41 from Resident 26's room. On 2/26/25 at 11:52 AM, Resident 26 stated she/he recalled the incident and stated Resident 41 crossed the threshold to my room and blocked me off. Resident 26 stated, I can't handle being blocked in. Resident 26 stated Resident 41 yelled at her/him using abusive language and with a high level of disregard for anyone's feelings but [her/his] own. On 2/28/25 at 10:49 AM, Staff 14 (CNA) stated Resident 41 yelled at Staff 23 for no reason and Resident 26 stuck up for Staff 23. Staff 14 stated Resident 41 yelled at Resident 26 because Resident 41 didn't like to be told what to do or not to do and was belligerent. Staff 14 stated Resident 41 should not have yelled at Resident 26 the way she/he did. On 2/28/25 at 10:57 AM, Staff 2 (DNS) stated the verbal interaction upset Resident 26. Staff 2 stated Resident 41 used verbally abusive language towards Resident 26 and could not rule out verbal abuse. Staff intervened by positioning themselves between the two residents but were unable to prevent Resident 41 from continuing to use abusive language. Staff 2 stated it was unacceptable for Resident 41 to speak to anyone in such a manner

Based on observation, interview and record review it was determined the facility failed to ensure MDS assessments were accurately assessed for 2 of 7 sampled residents (#s 16 and 23) reviewed for activities and abuse. This placed residents at risk for an inaccurate picture of the resident's status. Findings include: 1. Resident 23 was admitted to the facility in 2021 with diagnoses including heart failure. Resident 23's 10/18/24 Significant Change MDS indicated the resident's BIMS score and the mood interview to screen for depression was not assessed. Resident 23's 1/18/25 Quarterly MDS indicated the resident's BIMS score and the mood interview to screen for depression was not assessed. On 2/2/25 at 12:39 PM, Resident 23 was observed to be alert, oriented and was able to effectually express her/his current and past mood, needs and history. On 2/26/25 at 12:56 PM, Staff 3 (LPN/Resident Care Manager) stated Staff 5 (Social Services) was responsible to complete Sections C (BIMS score), D (mood interview) and E (behaviors). Staff 3 confirmed Resident 23's 10/18/24 Significant Change MDS and 1/18/25 Quarterly MDS was coded as not assessed for her/his cognitive status or for a possible depression score. Staff 3 stated she would expect these areas assessed on the MDS. On 2/26/25 at 2:52 PM, Staff 5 stated he was responsible to complete the cognition and mood sections of the MDS for Resident 23. Staff 5 confirmed Resident 23's 10/18/24 Significant Change MDS and 1/18/25 Quarterly MDS did not reflect the resident's cognition or mood and they were not assessed according to the MDS. 47000 2. Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). Resident 16's 2/2/25 Annual MDS indicated the resident was in a persistent vegetative state (a condition in which a person is awake but has no awareness of their surroundings or themselves). A progress note dated 2/5/25 written by Staff 19 (NP) indicated the resident was in a vegetative state. Resident 16's 2/23/25 Impaired Communication Care Plan revealed the following interventions: -Ask the resident questions that required a one-to-two word response. -Repeat back to the resident what was said to confirm understanding. -Watch the resident's mouth when she/he spoke and encourage enunciation of words. On 2/24/25 at 4:42 PM, Resident 16 was observed in her/his room in bed with her/his eyes closed. Resident 16 opened her/his eyes and smiled at the sound of the state surveyors greeting. Resident 16 moved her/his lips in response to a question posed by the state surveyor but was unable to respond clearly in either words or gestures. On 2/26/25 at 10:12 AM, Staff 19 stated he felt Resident 16 was in a vegetative state because the resident had never responded to any of his questions over the course of multiple visits. Staff 19 stated he was not informed Resident 16 was able to speak, and he would not consider the resident to be in a vegetative state if the resident was able to talk. On 2/26/25 at 10:20 AM, Staff 17 (CNA) stated Resident 16 was able to verbally respond to questions with a quiet yes or no. On 2/26/25 at 10:54 AM, Staff 3 (LPN/RCM) stated Resident 16 was able to say yes, no and fine. Staff 3 stated she did not discuss the resident's verbal abilities with Staff 19 and confirmed the resident's MDS coding was inaccurate.

Based on observation, interview and record review it was determined the facility failed to ensure incidents of suspected resident misappropriation were thoroughly investigated for 1 of 2 sampled residents (#22) reviewed for personal property. This placed residents at risk for abuse. Findings include: The facility's 9/2022 Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating Policy indicated the following: -All reports of resident abuse, including misappropriation of resident property, were thoroughly investigated by facility management. -The administrator was responsible to keep the resident and her/his representative informed of the progress of the investigation. -The individual conducting the investigation was to interview the person who reported the incident, interview any witnesses to the incident, interview staff members (on all shifts) who had contact with the resident during the period of the alleged incident, interview other residents to whom the accused employee provided care or services, review all events that led up to the alleged incident and document the investigation thoroughly and completely. Resident 22 was admitted to the facility in 9/2023 with diagnoses including diabetes. Resident 22's 12/17/24 Quarterly MDS revealed the resident was cognitively intact. A progress note dated 12/20/24 written by Staff 1 (Administrator) revealed the following: -Resident 22 reported $1,500 of her/his personal money was lost or stolen. -Resident 22 reported she/he received the money from Witness 2 (Family Member). -Staff 1 spoke with Witness 2 who confirmed she did provide Resident 22 with an unidentified amount money to use for the facility's vending machines. No evidence was found in Resident 22's clinical record to indicate a thorough investigation of the resident's report of missing money was completed, including interviews with staff members who worked with the resident during this time period. No additional interviews with the resident were completed to determine if she/he received money from other sources outside of Witness 2 and the resident was not offered the opportunity to have her/his room and belongings searched to determine if the money was misplaced. On 2/24/25 at 10:05 AM, Resident 22 was observed in her/his room in bed. Resident 22 stated the $1,500 was kept in her/his closet and came up missing a little over a month and a half ago after Staff 24 assisted her/him to count the money. Resident 22 stated she/he reported the missing money to Staff 5 (Social Services) but nothing was done. On 2/26/25 at 2:55 PM, Staff 18 (CNA) stated she recalled hearing something in passing about some money missing for Resident 22 but did not engage in it because a nurse was involved. On 2/26/25 at 3:30 PM, Staff 21 (LPN) stated Resident 22 reported she/he was missing money, and when she reported the resident's concern regarding the missing money to Staff 5, she was informed the issue had already been addressed. On 2/26/25 at 4:08 PM, Witness 2 stated someone at the facility spoke with her a few months ago about Resident 22's report of her/his money being lost or stolen. Witness 2 recalled she had given Resident 22 approximately $150.00 dollars and was not sure how else the resident could get such a large amount of money unless someone else mailed it to her/him. Witness 2 further stated she thought the resident might still have a bank card. On 2/27/25 at 8:53 AM, Staff 24 stated Resident 22 reported to him about a month or two ago she/he was missing $1,000 dollars. Staff 24 stated he immediately reported this to Staff 1 and Staff 2 (DNS). On 2/27/25 at 1:48 PM, Staff 5 stated he thought Resident 22 had her/his own bank card. Staff 5 stated the resident did leave the facility on occasion to go to the convenience store across the street where the resident could withdraw money from the store's ATM (automated teller machine). Staff 5 stated he did speak with Witness 2 about the resident's report of missing money but he did not interview anyone else, including Staff 24. On 2/27/25 at 1:54 PM, Staff 1 stated she spoke with Witness 2 following Resident 22's report of missing money in 12/2024 and was informed by Witness 2 that she did provide the resident with around $100. Staff 1 stated she asked Staff 24 if he had seen the money and was told by Staff 24 he never saw it and never took it. Staff 1 stated she did not interview any additional staff, and stated the resident's report of missing money should have been investigated more thoroughly, regardless of the amount of money that was missing.

Based on interview and record review it was determined the facility failed to ensure a PASARR Level II (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 1 of 1 sampled resident (# 11) reviewed for PASARR. This placed residents at risk for not receiving specialized services. Findings include: Resident 11 was admitted to the facility in 10/2023 with diagnoses including delusional disorders (a mental health condition characterized by persistent false beliefs that are not based in reality). A review of Resident 11's Pre-Admission Screening/Resident Review (PASRR) Level 1 form completed on 10/19/23 revealed she/he had serious mental illness and was appropriate for further mental health screening upon admission to the facility. No evidence was found in Resident 11's clinical record to indicate the facility referred her/him for further screening related to her/his serious mental illness. On 2/27/25 at 10:04 AM, Staff 5 (Social Services) stated he did not know Resident 11 was not referred for further screening but was appropriate due to her/his serious mental illness. Staff 5 reported a review of residents' PASRR 1's was not completed during regular care conferences but he thought it was a good idea. On 2/27/25 at 12:43 PM Staff 2 (DNS) stated she expected a referral for further evaluation to be completed within a week once it was determined appropriate on a resident's PASARR 1.

Based on interview and record review it was determined the facility failed to ensure a resident-centered care plan was implemented for 1 of 4 sampled residents (#21) reviewed for abuse. This placed residents at risk for not being provided appropriate bed mobility assistance. Findings include: Resident 21 was admitted to the facility in 5/2022 with diagnoses including hepatic encephalopathy (a disorder that occurs when the liver is unable to filter toxins from the blood resulting in their build up in the brain and causing confusion, disorientation and other changes) and a spinal fracture. Resident 21's 1/6/24 Annual MDS indicated she/he was cognitively intact. A review of Resident 21's care plan dated 11/14/2022 revealed she/he required assistance from two staff members for bed mobility and she/he was to receive cares in pairs. A facility investigation created and signed by Staff 2 (DNS) on 2/15/24 indicated Staff 22 (Agency CNA) attempted to reposition Resident 21 by herself by guiding her/his hand to grab the headboard and having her/him pull herself/himself up in bed. Staff 22 was in Resident 21's room without another staff member at the time she attempted to reposition Resident 21. The facility investigation indicated after the interaction, Resident 21 did not want Staff 22 in her/his room again. On 2/28/25 at 9:20 AM, Staff 22 stated she worked with Resident 21 at the time of the reported incident and knew Resident 21 was to receive cares in pairs and required assistance from two staff to reposition her/him in bed. Staff 22 stated she decided to reposition her/him without the assistance of another CNA. Staff 22 stated she asked Resident 21 to reach over her/his head to grab and pull up on the headboard because she/he was not positioned appropriately in the bed. Staff 22 stated Resident 21 could not reach the headboard so she guided her hand to the headboard. On 2/28/25 at 10:41 AM, Staff 2 confirmed Staff 22 did not follow Resident 21's care plan to have two people in her/his room at all times.

Based on observation, interview and record review it was determined the facility failed to ensure residents who were unable to carry out ADLs independently received personal grooming assistance for 1 of 2 sampled residents (#16) reviewed for ADL care. This placed residents at risk for lack of grooming care needs. Findings include: Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). A physician order dated 1/16/25 revealed Resident 16 was to receive a hair removing face cream as needed for facial hair removal. Resident 16's 2/2/25 Annual MDS indicated the resident was in a persistent vegetative state (a condition in which a person is awake but has no awareness of their surroundings or themselves) and was dependent on staff assistance for all of her/his ADL needs. Resident 16's 2/23/25 ADL Self Care Performance Deficit Care Plan revealed the resident required full assistance from one person to shave. On 2/24/25 at 12:07 PM, Resident 16 was observed in her/his room in bed. Facial hair was observed to cover the resident's chin, jawline and parts of her/his neck and cheeks. On 2/24/25 at 1:14 PM, Witness 1 (Family Member) stated Resident 16 would never let people see whiskers on [her/his] chin, and she was disappointed seeing [the resident] with a full beard. Witness 1 stated Resident 16 use to get nasty razor sores when she/he shaved and preferred to use a hair removal cream instead. On 2/25/25 at 3:54 PM, Staff 20 (CNA) stated nurses were responsible to apply the hair removal cream to Resident 16 but she had never seen them use it. On 2/25/25 at 4:08 PM, Staff 21 (LPN) stated Resident 16 had an order for hair removal cream, she was responsible for applying the cream, but she had not used it yet because she was nervous to use it. On 2/25/25 at 4:38 PM, Staff 2 (DNS) observed and acknowledged Resident 16's facial hair and stated the resident was in need of a shave.

Based on observation, interview and record review, it was determined the facility failed to provide an ongoing program to support individual activity interests and preferences for 2 of 3 sampled residents (#s 16 and 27) reviewed for an activity program. This placed residents at risk for a decreased quality of life and social isolation. Findings include: 1. Resident 27 admitted to the facility in 2022 with diagnoses including a stroke and disease of the pharynx (throat). A 10/10/22 Activities Admission Assessment revealed Resident 27 was nonverbal, dependent on staff and needed one-to-one visits. Resident 27 enjoyed hand massages, manicures, to watch television, listen to audio books and music, visits with family, a Pastor and pets. Resident 27's 10/24/24 Annual MDS assessed her/him with memory problems and rarely to never understood her/his ability to talk. Staff assessed Resident 27's leisure and diversional activity preferences as she/he enjoyed to listen to music, animals, to do things with groups of people, to participate in her/his favorite activities and to spend time outdoors. The 1/17/25 SNF (Skilled Nursing Facility) Activity Quarterly Review indicated Resident 27 had not experienced a change in her/his level of activity participation and was dependent on staff for care. The resident liked one-to-one and in-room visits, therapy animal visits, and sensory activities. Resident 27's interests included country and classic rock music, soap operas, murder mysteries, comedies, head and hand massages, her/his nails manicured, visits from the Pastor and her/his family. Resident 27's 2/25/25 care plan revealed she/he was dependent on staff for activities, cognitive stimulation and social interaction related to her/his cognition and immobility. The goal was for her/him to attend two weekly group activities. Staff were directed if she/he was not able to attend activities, the Activity Director would meet with the resident once or twice a week and provide television shows, music, and movies played for her/him while she/he was awake in her/his room. The care plan directed staff to the resident's preferred radio stations which included country and classic rock. Resident 27's preferred activities were head and hand massages, nails manicured, pet visits, family visits, sensory activities, listen to country and classic rock music, Pastor visits, one-to-one visits, to watch preferred television stations with soap operas, murder mysteries and comedies. The Activity Participation records revealed from 1/27/25 through 2/26/25 (30 days) Resident 27 participated in the following activities: -Spiritual Care on 2/6/25 and 2/20/25. -Movie/Video on 2/13/25 and 2/24/25. During the survey from 2/24/25 through 2/28/25 between 8:00 AM to 4:00 PM Resident 27 was not observed out of her/his bed. Observations on 2/25/25 at 9:19 AM,10:46 AM, 12:35 PM, 3:08 PM and on 2/26/25 at 8:47 AM revealed Resident 27 was observed awake in her/his bed with no television or music in the room and no social interactions. On 2/26/25 at 1:49 PM, Resident 27 was observed in her/his bed while the roommate's music played very loud soul music (not her/his preferred music type). On 2/27/25 at 10:29 AM, Staff 14 (CNA) stated Resident 27 sometimes would get out of bed on Tuesday and Thursdays. The CNA's would take her/him to the dining room and she/he looked like she/he enjoyed being around other people. On 2/27/25 at 10:34 AM, Staff 6 (Activity Director) stated Resident 27 was dependent on staff and when time allowed she/he should receive one-to-one visits because he could not get her/him up and out of bed. Staff 6 stated he sometimes completed one-to-one visits with Resident 27 which usually consisted of turning her/his roommate's television on. Staff 6 confirmed Resident 27 could not see the roommate's television. Staff 6 could not identify sensory stimulation type of activities identified to provide in the care plan for Resident 27. Staff 6 could not recall the last time he attempted sensory types of activities. Staff 6 stated he did not provide audio books or music for Resident 27. Staff 6 stated the resident's care plan goal to attend a group activity weekly was based on staff availability to get her/him out of bed. Staff 6 stated he did not invite Resident 27 or request any CNA to assistance to get Resident 27 out of bed to attend any group activity this past week. Staff 6 could not identify Resident 27's activity preferences or recall the last time the resident received a manicure or a hand massage. On 2/27/25 at 11:36 PM, Staff 1 (Administrator) confirmed the lack of activity participation for Resident 27. She stated she expected more opportunities for sensory stimulation and social interactions for Resident 27. 47000 2. Resident 16 was admitted to the facility in 1/2023 with diagnoses including vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain). A care conference note dated 8/6/24 revealed Resident 16 enjoyed to watch television and listen to music in her/his room and she/he had the biggest smile when she/he was out of bed and able to enjoy community activities. Resident 16's 11/4/24 Activity Quarterly Review revealed the resident enjoyed television, music, hand massages and church services. The resident also enjoyed to watch and visit with other residents in the facility's common area during group activities and to listen to people read. Resident 16's 2/2/25 Annual MDS indicated the resident was in a persistent vegetative state (a condition in which a person is awake but has no awareness of their surroundings or themselves). Resident 16's 2/23/25 Activity Care Plan revealed the following: -The resident was to attend a group activity once a week. -The resident was to receive a one-to-one visit from Staff 6 (Activities Director) once a week. -The resident's activity interests included television, manicures, music and visits with her/his pastor. -The resident enjoyed to watch the [NAME] Show on television. The facility's 2/2025 Activity Calendar revealed the following scheduled activities: -2/24/25: 1:30 PM Group Jeopardy Championship Game -2/25/25: 1:30 PM Tabletop Bowling Championship -2/26/25: 2:00 PM Write Around Portland (Writing Group) A review of Resident 16's Activity Task Logs from 1/27/25 through 2/26/25 revealed the resident participated in music and watched a movie on one occasion and participated in spiritual care on two occasions. No evidence was found in Resident 16's clinical record to indicate the resident received one-to-one visits from Staff 6, manicures or hand massages. Random observations of Resident 16 on 2/24/25 from 12:07 PM to 4:42 PM and on 2/25/25 from 8:43 AM to 1:24 PM revealed the resident was in her/his room in bed. No music played. The resident's eyes were open at times and the resident looked toward her/his television, which was turned off. The resident was unable to answer any questions about her/his activity preferences and interests. On 2/24/25 at 1:14 PM, Witness 1 (Family Member) stated Resident 16 enjoyed music, television, pets, children and church, and she had never been interviewed about Resident 16's activity preferences. Witness 1 stated the only thing Resident 16 was able to look at in her/his room was the television and it was often turned off. On 2/25/25 at 4:08 PM, Staff 21 (LPN) stated Resident 16 loved music, especially [NAME] and R&B stuff but was not for certain. Staff 21 stated Resident 16 also enjoyed television, especially the news, soap operas and the [NAME] Show. On 2/26/25 at 10:20 PM, Staff 17 (CNA) stated Witness 1 told her Resident 16 enjoyed soul and Motown music and to watch music videos on television. Staff 17 further stated Witness 1 informed her the resident did not like the [NAME] Show. On 2/27/25 at 10:34 AM, Staff 6 stated residents who were dependent on staff received one-to-one visits, which included Resident 16. Staff 6 stated he completed one-to-one visits with Resident 16 once a week and the visits consisted of turning her/his television on if it was noted to be off. Staff 6 stated he could not recall the last time he attempted a sensory activity, except for one related to smells, and confirmed no additional types of sensory activities were attempted with the resident. Staff 6 stated he knew it was important for Resident 16 to attend weekly church services but he had not interviewed her/his family about additional activity preferences. Staff 6 stated the resident either smiled or slept when in a group activity and stated her/his ability to attend group activities was dependent on staff availability and resident showers. Staff 6 stated the resident's care plan goal of attending a group activity weekly was based on staff availability and not on the resident's preference. Staff 6 stated he did not invite Resident 16 or request any CNA to assist the resident to get out of bed to attend any group activity this week, and could not remember the last time the resident received a manicure or a hand massage. On 2/27/25 at 12:35 PM, Staff 1 (Administrator) stated one-to-one visits needed to consist of more than television, Resident 16's ability to participate in group activities should not be limited by staff availability and the facility needed to offer additional sensory activities to dependent and/or cognitively impaired residents.

Based on interview and record review it was determined the facility failed to ensure resident care equipment was in proper working order to prevent accidents for 1 of 3 sampled residents (#139) reviewed for accidents. This failure resulted in the resident experiencing fractured ribs and increased pain. Findings include: Resident 139 was admitted to the facility in 6/2017 with diagnoses including high blood pressure. Resident 139's ADL Self Care Deficit Care Plan, last revised 12/20/19, indicated the resident was able to move from side to side and sit up while in bed with limited assistance of one person and used the mobility bar to turn from side to side independently. Resident 139's 9/26/21 Quarterly MDS indicated the resident required the assistance of two staff for bed mobility. Resident 139's undated Kardex (tool used by CNAs to direct resident care) directed staff to assure brakes on the bed were locked before transfer, indicated the resident was able to move from side to side and sit up while in bed with limited assistance of one person and used the mobility bar to turn from side to side independently. An 11/27/21 Facility Incident Report specified on 11/27/21, Resident 139 rolled out of bed while Staff 14 (CNA) provided incontinence care. The report detailed that during incontinence care, the bed was in an elevated position, the wheel locks on the bed malfunctioned and the bed shifted. The shift caused the resident to roll off the bed and onto the floor and Staff 14 immediately called Staff 4 (LPN Resident Care Manager). Resident 139 complained of 9 out of 10 pain (measurement of pain scale: 0=none / 10=worst possible pain) in her/his right shoulder, neck and head. Resident 139 was sent to the hospital for evaluation and on 11/27/21 at 9:00 PM, the resident returned to the facility with a diagnosis of right rib fracture and a new prescription for pain medication. Review of Resident 139's health record revealed no 11/27/21 hospital summary documents. Resident 139's 11/2021 MAR revealed the resident did not experience pain and rated her/his pain at 0 daily up until the fall on 11/27/21. After the fall, the resident experienced up to 10/10 pain daily and received PRN oxycodone (opioid medication used to treat moderate to severe pain) to manage her/his pain. Resident 139's 12/2021 MAR revealed the resident experienced up to 10/10 pain daily and received PRN oxycodone to manage her/his pain. Resident 139's 11/2021 and 12/2021 Progress Notes revealed the resident experienced daily pain after the fall and often refused care due to pain. On 5/17/23 at 11:13 AM Staff 19 (CNA) stated on 11/27/21, he provided incontinence care for Resident 139. Staff 19 stated Resident 139 was in her/his bed and the resident used the mobility bars to help roll side to side during care. Staff 19 stated he rolled the resident away from him and towards the window, the bed moved and the resident rolled farther than usual and out of the bed onto the floor. Staff 19 stated he was unsure if the bed's wheel brakes were broken but there was movement even when the brakes were locked. On 5/22/23 at 2:30 PM Staff 2 (DNS) was unable to locate Resident 139's 11/27/21 hospital summary and no additional information was provided. On 5/23/22 at 10:07 AM Staff 4 stated she was the charge nurse at the time of the 11/27/21 incident. Staff 4 stated she did not witness the incident but was called into the room after Resident 139 fell to the floor. Staff 4 stated she assessed Resident 139, the resident complained of right shoulder pain and she arranged to have her/him sent to the hospital for evaluation. Staff 4 stated Resident 139 did not ask for pain medication or experience pain prior to the incident and the resident was pretty painful after the fall. Staff 4 stated at the time of the incident, she believed Resident 139 required the assistance of two staff for bed mobility. Staff 4 reviewed the 9/26/21 Quarterly MDS and acknowledged it indicated the resident required the assistance of two staff for bed mobility. Staff 4 reviewed Resident 139's ADL Self Care Deficit Care Plan and Kardex and agreed it did not correspond with the Quarterly MDS. On 5/23/22 at 11:09 AM Staff 2 and Staff 3 (Regional RN) reviewed the findings of this investigation. Staff 2 and Staff 3 were notified of the MDS and Care Plan discrepancy regarding how the resident was assisted during ADLs and acknowledged the 11/27/21 incident resulted in Resident 139 experiencing severe pain and fractured ribs. 47000 2. Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed and care planned for smoking for 1 of 3 sampled residents (#12) reviewed for accidents. This placed residents at risk for potentially avoidable accidents and unsafe smoking. Findings include: Resident 12 was readmitted to the facility in 1/2023 with diagnoses including cellulitis (a bacterial skin infection). A 1/18/23 SNF Nursing Admission Database Form revealed the following: - Resident 12 was a smoker. - Resident 12's smoking contents were to be locked up. - Resident 12 was to be supervised while smoking until an evaluation was completed. Resident 12's 3/17/23 Quarterly MDS revealed the resident was cognitively intact. No evidence was found in Resident 12's clinical record which indicated a smoking evaluation or care plan was completed. On 5/16/23 at 11:02 AM Resident 12 was observed laying in bed with a lighter on her/his right shoulder. Resident 12 stated she/he normally locked up her/his smoking contents but forgot to do so when she/he came home from being out in the community during the previous night. Resident 12 stated she/he smoked independently. On 5/17/23 at 11:53 AM Staff 27 (CNA) stated he obtained information regarding a resident's smoking status and any assistance needed from the resident's care plan. Staff 27 stated Resident 12 was an independent smoker and she/he independently maintained her/his own smoking supplies. On 5/17/23 at 1:28 PM Staff 15 (CNA) stated residents who were assessed as independent smokers did not need to lock up their smoking contents and were able to keep their cigarettes and lighter on their person or in their room. Staff 15 stated staff were informed of a resident's smoking status by word of mouth. Staff 15 further stated Resident 12 was an independent smoker. On 5/17/23 at 2:04 PM Staff 4 (LPN/Resident Care Manager) stated smoking assessments were completed at the time of a resident's admission to the facility, following a hospitalization and when there was some type of change in the resident. Staff 4 stated she had not completed a smoking assessment for Resident 12, and she would expect a smoking assessment to be completed following Resident 12's re-admission to the facility in 1/2023. Staff 4 reviewed Resident 12's electronic care plan and confirmed a care plan for smoking was not completed and it should have been. On 5/19/23 at 11:15 AM Staff 2 (DNS) stated smoking assessments were completed to determine whether or not a resident was independent with smoking or if they required supervision and were completed along with any significant change in a resident, when a resident readmitted to the facility and on a quarterly basis. Staff 2 stated residents who smoked required a care plan that indicated whether or not they were independent with smoking or if they required supervision. Staff 2 stated Resident 12 was independent with smoking and confirmed she/he was missing a smoking assessment and care plan.

1. Based on observation, interview and record review it was determined the facility failed to implement COVID-19 infection control practices for residents previously exposed to positive or symptomatic COVID-19 residents related to proper resident isolation and PPE (Personal Protective Equipment) usage for 3 of 4 sampled residents (#s 1, 2 and 3) reviewed for Infection Control. This failure, determined to be an immediate jeopardy situation, of not isolating residents who were previously exposed to positive or symptomatic COVID-19 residents, determined to be an immediate jeopardy situation, resulted in the potential for cross-contamination between the suspected COVID-19 residents and transmission to non-COVID-19 residents. Findings include: The 6/25/20 CDC (Centers for Disease Control and Prevention) Preparing For COVID-19 In Nursing Homes guidance included the following instructions for nursing facilities: *All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate). Additionally, more than two temperatures over 99.0F might be a sign of fever in this population. *Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of COVID-19 testing. *While awaiting results of testing, staff should wear N95 respirator, eye protection, gloves and gown when caring for residents. *Have a plan for how roommates, other residents and staff who were potentially exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). *Any reusable PPE (Personal Protective Equipment) must be properly cleaned, decontaminated and maintained after and between uses. The 7/15/20 CDC Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic *Dedicated medical equipment should be used when caring for patients with suspected or confirmed COVID-19 infection. *All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected (after resident use). At the time of survey on 8/4/20 the facility had a resident census of 27. There was one resident on contact and droplet precautions for signs of COVID-19. No other facility residents were on any type of infection control precautions. The following infection control observations, interviews and record review were made: 1. Resident 3 admitted to the facility 3/2020 with [DIAGNOSES REDACTED]. A 8/3/20 Progress Note revealed Resident 3 transferred rooms because her/his roommate had symptoms of COVID-19. On 8/4/20 at 1:02 PM Resident 3 was observed in her/his room without any infection control precautions. (Per CDC Guidelines, Resident 3 was expected to be put on contact and droplet infection control precautions related to her/his potential exposure to COVID-19). Staff 10 (CNA) was observed to walk into Resident 3's room wearing a face mask, face shield and gloves. Staff 10 exited the room without doffing her PPE and proceeded to enter and exit multiple other resident rooms wearing the same face mask and face shield. On 8/4/20 between 12:01 PM and 6:30 PM multiple facility nursing staff were observed to enter and exit resident rooms (which were expected to be on transmission-based precautions per CDC guidelines) wearing the same face masks and face shields and did not disinfect or discard PPE appropriately. 2. Resident 1 admitted to the facility in 2014 with [DIAGNOSES REDACTED]. The following observations were made on 8/4/20: * 1:02 PM Staff 6 (CNA) reported to Staff 5 (LPN) Resident 1 had a fever, cough and malaise. * 1:39 PM Staff were observed to enter Resident 1's room wearing a face shield and face mask only. Resident 1 was not on any infection control precautions. * 3:01 PM Staff 8 (CNA) was observed to enter and exit Resident 1's room wearing a face shield and face mask only. Staff 8 did not doff the face mask or disinfect the face shield after exiting the resident room. * 4:35 PM staff were observed to enter and exit multiple resident rooms when wearing the same face mask and face shield. 3. Resident 2 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. Resident 4's (Resident 2's roommate) 8/3/20 progress note revealed Resident 4 was in the hospital and tested positive for COVID-19. An 8/3/20 progress note revealed Resident 2 had a fever of 100.4F, refused medications, fluids and food. The following observations were made on 8/4/20: * 1:39 PM Resident 2 was observed to not be on contact or droplet infection control precautions. * Resident 2 was observed to independently roam the hallway most of the day with the resident's face mask positioned under her/his chin. * 3:14 PM and 4:51 PM staff were observed to enter Resident 2's room without proper PPE. There were two other residents in the room. * 8:01 PM Resident 2 was pushed down the hallway in a wheelchair to the outside patio by a staff member. Resident 2 was observed to have a moist cough. 4. The following observations and interviews were conducted on 8/4/20 of the single resident room (Resident 6) on contact and droplet precautions: * 1:12 PM Staff 19 (CNA) exited room [ROOM NUMBER] (a transmissions-based precaution room), doffed the PPE gown but left on the gloves, face mask and face shield. Staff, while wearing the contaminated face mask, face shield and gloves proceeded to walk down the hall to the soiled utility room, punch in the access code and enter the soiled utility room. * 3:41 PM Staff 7 (LPN) was observed to exit room [ROOM NUMBER] and place a contaminated thermometer and oximeter on top of the clean PPE cart. Staff 7 was observed to doff the PPE gown outside of room [ROOM NUMBER] and perform hand hygiene. Staff 7 then doffed the contaminated N95 mask and face shield and placed the contaminated face shield on the nursing station counter prior to disinfecting the shield. The nursing station counter was disinfected at the request of the intervening surveyor. Staff 7 then instructed Staff 13 (CNA) to disinfect the thermometer and oximeter. The top of the PPE cart was not disinfected. * 4:38 PM two medics entered Resident 6's room (room [ROOM NUMBER]) wearing only N95 masks. At 4:47 PM both medics stated they were not told the resident exhibited signs of COVID-19 and their policy was to be in full PPE gear if entering a potential COVID-19 positive resident room. On 8/4/20 at 1:39 PM Staff 6 (CNA) stated she was informed of resident updates through the night nurse or secondhand. Staff 6 acknowledged she was unaware which residents were previously exposed to positive or symptomatic COVID-19 residents or had current COVID-19-like symptoms. On 8/4/20 at 3:02 PM Staff 8 (CNA) stated the facility did not communicate with the CNAs which residents were on isolation precautions or residents who were exhibiting signs of COVID-19. Staff 8 stated he received all resident information through rumors. Staff 8 stated he was given one N95 mask to wear throughout the shift and wore the same mask into every room. On 8/4/20 at 2:15 PM Witness 2 (Epidemiologist) stated she visited the facility on 8/3/20 and made several infection control recommendations to the facility Administration which included transferring Resident 3 out of Resident 6's room, placing Resident 3 on COVID-19 infection control precautions and developing cohorting and isolation units. The facility failed to implement COVID-19 infection control practices for residents previously exposed to positive or symptomatic COVID-19 residents which resulted in residents not placed on COVID-19 isolation precautions, improper PPE usage and facility-wide staff and resident exposure to possible COVID-19 infection. On 8/4/20 at 6:30 PM the facility administrative staff including Staff 1 (Administrator) and Staff 4 (Administrator In Training) were informed of the immediate jeopardy (IJ) situation and an immediate plan of correction (POC) was requested. On 8/4/20 at 9:07 PM the facility submitted a plan of correction which was accepted by the survey team. The IJ Removal Plan included: -Resident #s 1, 2 and 3 were appropriately placed on isolation with contact and droplet precautions. Residents 1, 2 and 3 would be placed in a private room to the maximum extent possible until cohorting became necessary due to room availability and capacity. - Staff 1 or designee would complete room changes to separate negative and presumptive positive residents and assign designated staff. - Staff 1 or designee would complete staff screening during business hours and the charge nurse was responsible for screening outside of business hours. -All other residents with roommates who had tested positive or presumptive positive would be placed on isolation with contact and droplet precautions by 8/5/20 at 4:00 PM. -Staff in-servicing would be completed on how to use and complete the COVID-19 TAR, signs and symptoms of COVID-19, timely assessments of changes of condition and notification and would be completed by 8/5/20 at 4:00 PM. -DNS or designee would audit the TAR three times a day (AM, PM, HS) for one week, then daily for one month to ensure any resident who exhibited COVID-19 symptoms would be identified and placed on isolation with contact and droplet precautions. -DNS or designee would audit COVID-19 lab results daily to ensure all roommates of individuals who tested positive were placed on isolation with contact and droplet precautions. DNS or designee would in-service all staff on isolation, upgraded precautions, proper PPE usage and the new screening process. -The results of the audit would be reported by the DNS to the QAA committee monthly or until a lesser frequency was determined appropriate. Appropriate isolation room changes would be completed by 8/5/20 at 4:00 PM. On 8/4/20 at 8:40 PM Staff 9 (LPN) verified she had assessed Residents 1, 2 and 3 for COVID-19 symptoms and a change of condition and notified all the residents' physicians. Staff 9 verified Resident's 1, 2 and 3 were placed on contact and droplet precautions. On 8/5/20 multiple observations were made of Staff 3 (Regional RN) completing the staff in-service per the IJ Plan of correction. On 8/5/20 Staff 5, 6, 7, 8, 10, 11, 13 and 17 all verified they received the staff in-service per POC. On 8/5/20 between 3:30 PM and 3:50 PM multiple observations were made of staff entering and exiting resident rooms, performing appropriate hand hygiene and donning PPE correctly. No infection control concerns were identified. On 8/5/20 at 4:00 PM Staff 3 provided verification that all staff had received the required POC in-servicing, all residents who were positive or presumptive positive for COVID-19 were placed on isolation in private rooms. All residents with roommates who were positive or presumptive positive were placed on isolation. Staff 3 further stated the TAR audits were initiated, the process for screening staff was updated per the POC and the facility had designated staff working with the isolation residents. Staff 3 verified all elements of the POC had been completed. 2. Based on observation, interview and record review it was determined the facility did not implement proper infection control practices for 1 of 1 kitchens reviewed for infection control, 1 of 1 resident (#12) reviewed for COVID-19 CDC screening. This placed residents at risk for possible cross-contamination and COVID-19 infection. Findings include: a. On 8/4/20 at 1:07 PM Staff 16 (Dietary Aide) was observed to turn bowls over with his bare hands and placed his thumbs inside each bowl as he turned the bowl. Staff 15 (Dietary) was observed in the kitchen not wearing a hair restraint. At 1:09 PM Staff 16 stated he was expected to wear gloves and not place his thumbs inside the bowls. Staff 16 then started to dish up fruit slices into one of the bowls. The surveyor stopped Staff 16 and requested the bowls be sanitized. At 1:10 PM Staff 15 verified she did not have on a hair restraint and further stated she forgot. b. On 8/4/20 at 2:15 PM Witness 2 (Epidemiologist) stated she visited the facility on 8/3/20 and made several infection control recommendations to the facility Administration which included disinfecting the food tray cart when it returned to the kitchen. On 8/4/20 at 1:06 PM the food tray cart was observed to be brought into the kitchen without being disinfected. On 8/5/20 at 1:07 PM the food tray cart was left outside the kitchen door. The top of the food tray cart was covered with multiple plastic food lids. Staff 15 (Dietary) disinfected the sides of the food cart but not the top. The surveyor intervened prior to the food cart being brought into the kitchen and requested Staff 3 (Regional RN) to observe the situation. On 8/5/20 at 1:10 PM Staff 3 acknowledged the top of the food cart needed to be cleared and properly disinfected prior to bringing the contaminated cart into the kitchen. c. On 8/5/20 at 11:34 AM an unattended, dirty linen bag was observed on the floor outside of room [ROOM NUMBER]. Staff 10 (CNA) verified the dirty linen bag should not be on the floor, picked the bag up and disposed of the bag appropriately in the Soiled Utility Room. d. On 8/5/20 at 2:39 PM an unattended trash bag was observed on the floor next to the medication cart in the long hall. Staff 13 (CNA) stated an agency nurse did that. Staff 13 proceeded to pick up the trash bag and disposed of the bag appropriately in the Soiled Utility Room. e. The 6/25/20 CDC (Centers for Disease Control and Prevention) Preparing For COVID-19 In Nursing Homes guidance instructed the facility to screen residents entering the facilty for symptoms consistent with COVID-19 or exposure to others with COVID-19 infection and ensure they are [MEDICATION NAME] source control. The guidance further instructed to check the residents temperature. On 8/4/20 at 1:02 PM Staff 6 (CNA) reported Resident 12 and Resident 13 frequently left the facility were not screened upon return. Record review of the COVID-19 Resident Screening forms revealed from 6/26/20 through 8/4/20 the five residents who left the facility routinely were screened six times. Five of the six times the screening process was completed properly. Resident 13 was screened appropriately one of two times when screened. Resident 12 had no completed screening forms. On 8/4/20 at 3:34 PM Resident 12 stated when she/he returned to the facility from being out in the community she/he was not screened and did not get her/his temperature checked. On 8/4/20 at 1:41 PM Staff 1 (Administrator) stated the facility staff did not consistently screen the two residents who routinely left the facility for recreational purposes and enhanced monitoring of the two residents was not in place. On 8/4/20 at 2:59 PM Staff 4 (AIT - Administrator in Training) instructed Staff 14 (Physical Therapy Assistant) facility staff needed to start screening residents when they returned to the facility.

Based on observation, interview and record review it was determined the facility failed to respond appropriately to residents' change of condition related to COVID-19 for 2 of 4 sampled residents (#s 1 and 2) reviewed for infection control. This failure, determined to be an immediate jeopardy situation, and lack of response to perform comprehensive assessments for residents presenting with COVID-19 symptoms delayed placing residents under transmission based precautions and was likely to delay treatment and cause serious harm and/or death. Findings include: The 6/25/20 CDC (Centers for Disease Control and Prevention) Preparing For COVID-19 In Nursing Homes guidance included the following instructions for nursing facilities: *All fevers and symptoms consistent with COVID-19 among admitted patients should be properly managed and evaluated (e.g., place any patient with unexplained fever or symptoms of COVID-19 on appropriate Transmission-Based Precautions and evaluate). Additionally, more than two temperatures over 99.0F might be a sign of fever in this population. *Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of COVID-19 testing. *While awaiting results of testing, staff should wear N95 respirator, eye protection, gloves and gown when caring for residents. *Have a plan for how roommates, other residents and staff who were potentially exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). *Any reusable PPE (Personal Protective Equipment) must be properly cleaned, decontaminated and maintained after and between uses. At the time of survey on 8/4/20 the facility had a resident census of 27. There was one resident on contact and droplet precautions for signs of COVID-19. The remaining residents were tested for COVID-19 on 7/28/20 and pending results. No other facility residents were on any type of infection control precautions. 1. Resident 1 admitted to the facility in 2014 with [DIAGNOSES REDACTED]. On 8/4/20 at 1:02 PM Staff 6 (CNA) was observed to report to Staff 7 (LPN) that Resident 1 had a fever the previous night, a current temperature of 100.9F, appeared to have blush on, a cough and the resident reported she/he did not feel good. On 8/4/20 at 1:39 PM Staff 6 stated she re-checked Resident 1's temperature with a temp dot instead of the same thermometer with a result of 99.8F. Staff 6 stated she reported Resident 1's temperature, cough and the resident's report of not feeling good to Staff 5 (LPN) prior to reporting to Staff 7 and Staff 5 replied, I don't have time to deal with this right now . Review of Resident 1's MAR indicated [REDACTED]. No assessment of Resident 1's change of condition or physician notification was completed. Review of Resident 1's medical record revealed no assessment of Resident 1's symptoms which were consistent with COVID-19. On 8/4/20 at 1:14 PM Staff 5 stated she was too busy to be interviewed. 2. Resident 2 was admitted to the facility in 2019 with [DIAGNOSES REDACTED]. Resident 4's (Resident 2's roommate) 8/3/20 progress note revealed Resident 4 was in the hospital and tested positive for COVID-19. A review of Resident 2's medical record revealed on 8/3/20 at 12:49 PM Resident 2 had a fever of 100.4F and refused medications, fluids and food. On 8/4/20 Resident 2 continued to refuse medications. No assessment of Resident 2's change of condition on 8/3/20 was completed, including the general COVID-19 screening. On 8/4/20 at 6:30 PM the facility administrative staff, including Staff 1 (Administrator) and Staff 4 (Administrator In Training) were informed of the immediate jeopardy (IJ) situation and an immediate plan of correction (POC) was requested. On 8/4/20 at 9:07 PM the facility submitted a plan of correction which was accepted by the survey team. The IJ Removal Plan included: -Resident #s 1 and 2 would be assessed by the licensed nurse on 8/4/20 by 9:30 PM. After the assessment was completed the nurse would contact the physician and follow orders as directed. -CNAs on shift would check temperatures of all facility residents and notify the nurse of any residents with COVID-19 symptoms. For any resident with COVID-19 like symptoms the charge nurse would then perform an assessment. -DNS or designee would audit the TAR three times a day (AM, PM, HS) for 1 week, then daily for one month to ensure any resident showing COVID-19 symptoms would be identified and assessed timely. -DNS or designee would in-service all licensed nurses on how to appropriately fill out the COVID-19 TAR, signs and symptoms of COVID-19, timely assessments of changes of condition and notification would be completed by 8/5/20 at 4:00 PM. -The results of the COVID-19 symptoms TAR audits would be reviewed daily by the NHA (Nursing Home Administrator) and monthly by the QAA committee to ensure that changes of condition were identified and addressed timely. This would continue monthly until a lesser time frame was determined appropriate. Any identified problems would result in a change to the plan of care. On 8/4/20 at 8:40 PM Staff 9 (LPN) verified she had assessed Residents 1 and 2 for COVID-19 symptoms and a change of condition and notified the residents physicians. On 8/5/20 multiple observations were made of Staff 3 (Regional RN) completing the staff in-service per the IJ Plan of correction. On 8/5/20 Staff 5 (LPN) and Staff 7 (LPN) verified they received the staff in-service per POC. On 8/5/20 at 4:00 PM Staff 3 provided verification that all licensed nurses received the required POC in-servicing, Staff 3 further stated the TAR audits were started and all elements of the POC were completed.

Based on observation, interview and record review it was determined the facility failed to ensure resident was free from the of risk aspiration for 1 of 1 sampled resident (#240) reviewed for hydration. As a result, Resident 240 was prescribed not to have thin liquids at bedside due to aspiration precautions and was found to have thin liquids at bedside which exposed the resident to the risk of aspiration and a risk to health and safety, which was determined to be an immediate jeopardy situation. Findings include: Resident 240 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 240's current Clinical Physician order [REDACTED]. - Thin liquids are ONLY to be used on swab sticks. Please DO NOT LEAVE GLASS OF THIN LIQUIDS AT BEDSIDE OR WITHIN REACH; - Regular diet, Pureed texture (food not needed to chew), Honey Thick consistency liquids; - Administer oral suction after each meal to clear oral cavity of any left over, un-swallowed food; - ASPIRATION PRECAUTION: Sit up 90 degrees for ALL eating and drinking. Wait 60 MINUTES after all meals before laying down. Take ONE SMALL bite/sip at a time; swallow hard. Don't talk while eating or drinking. If coughing, choking, sneezing, have wet voice or runny nose/eyes while eating, STOP eating; resume only after cleared. A Speech Therapist (SLP) completed an evaluation on 1/22/19 to assess Resident 240's dysphagia (difficult to swallow), which was faxed to the facility on [DATE] at 10:27 AM, 16 days after completed. The swallowing [DIAGNOSES REDACTED]. Factors included: - Impulsivity; difficult for Resident 240 to execute safe swallow strategies/aspiration precautions; - Poor judgement; lacks insight into swallow safety; while coughing resident will reach for glass and take sips. The same 1/22/19 SLP evaluation assessed the Diet Order for recreational drinking (with trained person at times other than meals) included the following: - Honey thick liquids; exception: THIN liquids such as Water ONLY on A SWAB STICK; - Aspiration precautions; one on one supervision and one on one for all liquids. A 2/6/19 Record review revealed Resident 240 had no comprehensive assessment, comprehensive care plan, in-room care plan or a base line care plan. Observations on 2/4/19 at 12:14 PM Resident 240 sat in her/his wheelchair, which faced the bed in her/his room. Resident 240 had a swab stick in her/his lap, the over bed table to her/his right side with in arms reach and a small clear plastic cup approximately half full with a clear thin liquid. On 2/4/19 at 12:16 PM Staff 17 (Agency LPN) was observed to stand near Resident 240's room door. Staff 17 confirmed he was the Charge Nurse (CN) for Resident 240. Staff 17 stated he was the person who left the water in the clear plastic cup for his use to swab the residents mouth. Surveyor and Staff 17 looked into Resident 240's room and he stated he did not see anything of concern in her/his room. At 2/4/19 at 12:17 PM Staff 8 (CNA) entered Resident 240's room with a meal tray and proceeded to assist her/him with the meal. On 2/4/19 at 1:00 PM Resident 240 was observed in her/his room in wheelchair with the overbed table directly in front of her/him and plastic cup of thin clear liquid with-in reach. On 2/4/19 at 1:03 PM Staff 2 (DNS) confirmed Resident 240's physician order [REDACTED]. Staff 2 stated it was used for the mouth swab and she would educate the CN. Staff 2 removed the thin liquids and was observed to educate the CN. On 2/4/19 at 2:05 PM Resident 240 was observed in her/his room to sit alone with overbed table in front of her/him. As Surveyor walked away, a noise was heard and Surveyor walked back to observed items on the floor from the overbed table. Staff 17 entered the room and was observed picking items up off the floor and placed back on overbed table. On 2/7/19 at 8:54 AM Resident 240 was observed to sit up in her/his bed with pillows for support and the head of bed raised to support the residents right side and her/his feet were off the side of the bed. An overbed table was in front of the resident, slightly to the left and a little more than an arms-reach from the bed. The overbed table had two plastic glasses with lids, one with a thick white substance and another with a thickened pink liquid and a half full small plastic cup with clear thin liquid. No staff were present in the room. On 2/7/19 at 8:54 AM Staff 2 walked with Surveyor to Resident 240's room. Staff 2 confirmed the cup of the clear thin liquid on the bed side table and the two glasses of thickened liquid. Staff 2 stated the cup of thin liquid was water for the mouth swab and the glass with white liquid was milk pudding thick consistency and the pink liquid was honey thick consistency. Staff 2 acknowledged the overbed table with liquids was out of reach but the resident may have been able to stretch to reach and would fall if attempted to reach the liquid. Staff 2 stated she would remove the liquids. On 2/7/19 at 8:58 AM Resident 240 was observed in bed and the pink liquid plastic glass on the overbed table, slightly out of resident's reach. On 2/7/19 at 9:01 AM Staff 2 confirmed the pink liquid plastic glass would stay on Resident 240's overbed table and offered to the resident after she/he woke. On 2/7/19 at 10:44 AM the facility was notified of an immediate jeopardy (IJ) situation related to the facility's failure to keep Resident 240 free from potential accidents with thin liquids left at bedside with aspiration risk and fall risk. This placed all residents at risk for injury. On 2/7/19 at 12:28 PM an accepted facility plan to removed immediate jeopardy situation was submitted by the facility. The plan included the following: - All liquids have been removed from resident's bedside; - All staff members on duty have been in-serviced; - At risk for aspiration care plan and Kardex (in-room care plan) have fluid consistency; - Physician contacted to request change for thicken liquids for mouth swab and no fluids left at bedside; - Identified one other resident with thicken liquid order, no thin liquids at bedside; - DNS or designee will in-service all staff for fluid precautions and no thin liquids at bedside by 2/10/19; - Administrator or designee will complete an audit to ensure no thin liquids left at bedside; - DNS or designee will ensure resident will have a baseline care plan and Kardex that reflect the physician's orders [REDACTED]. - RCM or designee will ensure all residents with upgraded fluid consistencies have a nutrition care plan and Kardex that reflect the physician order [REDACTED]. - DNS or designee will ensure that the nutrition care plan and Kardex are updated each time new fluid consistency orders are received from a physician; - In March, dietitian will audit all diet orders monthly to ensure consistency; audits to continue monthly until lesser frequency is determined appropriate; - Monthly QAPI (Quality Assurance Performance Improvement) meeting review of the audit and QAPI committee will address any ongoing issues as indicated. The plan of care was verified on 2/7/19 by observations of Resident 240 having no thin liquids at bed side and staff interviewed to verfy the inserve for thicken liquids. Comphrensive assessments and care plans had been started. 2. Based on observation, interview and record review it was determined the facility failed to ensure residents' safety by allowing residents (#18 and an unknown resident) to walk with Staff 4 (Activities Director) within proximity of Witness 2 who allegedly threatened Staff 4's life with a gun. This placed residents at risk for harm. Findings include: An undated Plan to Keep Residents Safe from an Active Shooter revealed there was an active shooter threat from Witness 2 (family) to Staff 4. Witness 2 was banned from the facility. The police searched Witness 2 and found no handgun. A 1/28/19 witness statement completed by Staff 1 (Administrator) revealed at approximately 7:30 AM on 1/28/19 it was reported to Staff 1 that Witness 2 possessed a .45 handgun and planned to use it against Staff 4. Staff 1 immediately called 911 and the officers advised Staff 1 to ban Witness 2 from the premises. On 1/28/19 a business letter from Staff 1 to Witness 2 revealed on 1/27/19 Witness 2 made a statement to the residents at the facility that Witness 2 had a .45 caliber handgun and intended to use it against facility staff. Witness 2 had made threatening gestures toward staff members and was no longer welcome on the property. Police were notified of the situation and know Witness 2 was not allowed on the property. On 1/28/19 at approximately 2:35 PM Staff 4 was observed to walk across the street with Resident 18 to the corner store. Staff 4 and Resident 18 returned to the facility. Witness 2 sat on the curb. Staff 4 stated she was in the middle of taking residents to the store and continued to walk residents across the street. On 1/28/19 at approximately 3:15 PM Staff 4 was observed to walk an unidentified resident across the street to the store while Witness 2 was on the curb. On 1/28/19 at 11:04 AM Witness 2 denied having a gun and stated I am not stupid enough to threaten staff and endanger his spouse who lived at the facility. Witness 2 stated he was homeless and lived here (on the public portion of land outside the facility). On 1/28/19 through 2/1/19 there were multiple observations of Witness 2 on the sidewalk and curb near the facility. On 2/1/19 at 11:49 AM Staff 1 stated Staff 4 should not have walked with residents to the store with an active threat against Staff 4's life. Staff 1 stated Staff 4 would not be returning to the facility.

1. Based on observation, interview and record review it was determined the facility failed to ensure the facility's blood glucose monitor (BGM) was approved for multiple resident use and failed to ensure the BGM was cleaned and disinfected according to the Food and Drug Administration (FDA) and manufacturer's guidance. The facility used a single use BGM for multiple residents one of whom had chronic [MEDICAL CONDITION] and the BGM was cleaned with unapproved wipes. This failure had the potential to affect 11 of 11 current diabetic residents and any other residents who required CBG testing, which was determined to be an immediate jeopardy situation. This placed residents at risk for exposure to bloodborne pathogens and communicable diseases. Findings include: The Centers for Disease Control (CDC) guidance included: BGMs are devices that measure blood glucose levels. If BGMs must be shared, the device should be cleaned and disinfected after every use per manufacturer's instructions to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. In coordination with the CDC, the FDA issued the following guidance to manufacturers of BGMs: The primary viruses of concern for bloodborne pathogen transmission between multiple patients are human Human Immunodeficiency Virus ,[MEDICAL CONDITION]., [MEDICAL CONDITION] Virus (HBV), and [MEDICAL CONDITION] Virus (HCV). However, due to its robust nature HBV is the most [MEDICAL CONDITION] in the observed outbreaks to date. During medication pass observations on 1/30/19 at 1:55 PM, Staff 17 (Agency LPN) pointed to a container of hand sanitizing wipes on the treatment cart and stated they were the ones used to clean the BGM between residents. On 1/30/19 at 1:57 PM Staff 16 (RN) confirmed the wipes currently located on the treatment carts were the ones provided by the facility for staff to clean the BGM. Staff 16 and Staff 17 indicated the wipes were kept on both treatment carts and there was currently only one BGM in use. Staff indicated there was no manual available for the facility BGM. On 1/30/19 at 3:31 PM the survey team located the user's manual for the facility BGM via online search. The manual indicated the machine used by the facility was recommended for single user/home use only and was not intended for use in healthcare or long-term care facilities because it was not cleared by the FDA. Manufacturer's product information for the facility's wipes indicated they were antimicrobial and 99.99 percent effective against gram-positive and gram-negative bacteria, fungi and yeast and used for the removal of debris and soil from hands. Review of current facility residents indicated there were 11 who had [DIAGNOSES REDACTED]. One of the 11 diabetic residents also had a [DIAGNOSES REDACTED]. The wipes being used by the facility were not capable of protecting residents against [MEDICAL CONDITION]. On 1/30/19 at 2:35 PM Staff 2 (DNS) stated the facility had no specific policy or procedure book for infection control. Staff 2 was asked for any policies related to cleaning of BGMs and she was unable to locate any documentation. On 1/30/19 at 3:50 PM the facility was notified of an immediate jeopardy (IJ) situation related to the failure to ensure use of the correct type of BGM for CBG checks and failure to ensure approved wipes were used to clean and disinfect BGMs after use. This failure placed diabetic residents at risk for exposure to bloodborne pathogens and communicable diseases. On 1/30/19 at 5:59 PM an accepted facility plan to remove the IJ situation was submitted by the facility. The plan included the following: - Physicians for current diabetic residents will be notified within the next 24 hours of possible cross-contamination due to current CBG cleaning practice. We will follow up as instructed. Medical Director has been notified this evening. We are awaiting her feedback. Residents and their responsible party will also be informed. Facility calibrated the current multi-use CBG machines and they are accurate and now back in use. The single use machines have been removed from the carts. Cleaning wipes have been delivered. Nurses have been instructed to wait for the appropriate cleaning wipes prior to test blood sugars to ensure cross-contamination does not occur. - The facility will notify the physician of any diabetic residents who have discharged since (MONTH) 1, 2019 to inform them within the next 24 hours of the possible cross-contamination affecting their residents. We will audit the [DIAGNOSES REDACTED]. - Nurses will be re-educated on the policy and procedure for obtaining blood sugars, including using the proper cleaning wipes by [DATE]. The facility will order the proper wipes for cleaning CBG machines. The facility will also order additional multi-use CBG machines for back up. - DNS/designee will randomly audit nurses 3 times per week X 4 weeks during med pass to assure proper infection control technique. Should a resident test positive for [MEDICAL CONDITION] a result of this practice, the facility will notify the Health Department within 24 hours. On 1/30/19 the IJ removal plan was verified by insuring the single use BGMs were no longer being used and multi-resident BGMs were implemented and in use. Approved wipes were also purchased and placed on the treatment carts. Staff were interviewed and confirmed they were educated regarding the use of the multi-resident monitors and approved wipes. 2. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene and infection control during meal hall tray delivery for 1 of 3 (Staff 23, CNA) staff. This placed residents at risk for cross-contamination and infection. Findings include: Facility Infection Control Policy for handwashing/hand hygiene revised in (MONTH) (YEAR): Use of an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations such as before and after assisting a resident with meals. During observation of the hall meal tray pass on 1/27/19 at 12:39 PM, Staff 23 was observed to deliver a meal tray to room [ROOM NUMBER]-1. The resident was not in her/his room and had items on the over bed table. Staff 23 held the tray with one arm, removed items from the over bed table and set the tray down. Staff 23 proceeded to retrieve another resident meal tray from the food cart and delivered the tray to room [ROOM NUMBER]-2. Staff 23 was observed to move the resident's TV remote control to make room for the meal tray on the over bed table. Staff 23 assisted the resident in room [ROOM NUMBER]-2 to raise her/his bed with the bed control and adjust bedding. At 12:46 PM Staff 23 was observed to reach into the clean linen closet and retrieved several towels. During an interview on 1/27/19 at 12:49 PM Staff 23 stated she never washes her hands or uses hand sanitizer when passing meal trays or between residents. Staff 23 stated this would take too many gloves. On 1/28/19 at 12:04 PM Staff 2 (DNS) stated she expected staff to hand wash or use hand sanitizer between touching resident items every time. Staff 2 proceeded to complete direct inservice to Staff 23 and staff serving meals.

Based on observation, interview and record review it was determined the facility failed to ensure a resident did not develop a pressure ulcer for 1 of 2 sampled resident (#27) reviewed for pressure ulcers. This failure resulted in Resident 27 acquiring a pressure ulcer that worsened and became infected. This placed residents at risk for complications related to pressure ulcers. Findings include: Resident 27 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. A 12/10/18 progress note (PN) by Staff 2 (DNS) indicated Resident 27 had a brown scabbed broken blister on the inner aspect of the right heel. According to the PN the area was not a pressure area and the physician and RD were notified. A pressure relief boot was placed to the right foot/heel to prevent the site from opening as the blister continued to dry out. Staff 2 documented the site was 1.5 cm x 3.5 cm and there was no depth. Resident 27's medical record revealed no documentation of an assessment or evaluation of the right foot/heel wound other than the 12/10/18 PN. The 12/2018 TAR included no documentation related to the use of the pressure relief boot for treatment of [REDACTED]. On 12/20/18 a Weekly Wound Observation Tool revealed the right foot/heel wound measured 3.2 cm x 1.6 cm x 0.1 cm with a scant amount of serous (clear) drainage present. On 12/20/18 the physician provided orders for wound care to Resident 27's right foot/heel, including cleansing the wound and application of iodosorb (antimicrobial) gel, skin barrier applied to the surrounding tissue and cover with bordered foam dressing daily. Resident 27's medical record revealed no documentation of wound care provided to her/his right foot/heel from 12/20/18 through 12/26/18. On 12/26/18 the physician ordered a change in Resident 27's right foot/heel wound care: cleanse the area and apply bordered gauze every night shift. On 12/29/18 the physician provided orders for Resident 27 to be seen by the wound clinic for the right foot/heel wound. A PN on 12/29/18 indicated wound care for Resident 27's right foot/heel was completed. The PN revealed the wound had a foul odor, eschar (dead tissue) and a small amount of drainage. A 1/6/19 PN revealed Resident 27's wound measured 4 cm x 5 cm with a scant amount of drainage and eschar in the wound bed with no odor detected. On 1/16/19 a PN by the nurse practitioner (NP) noted Resident 27's right foot/heel wound was now 6 cm in length, 5 cm in width with slough (dead tissue) and there was no drainage. The NP documented the resident's right foot/heel wound was surrounded with redness and warmth and antibiotics would be started (for infection). The NP included repeat orders for the resident to be seen by the wound clinic for her/his wound. Resident 27 was first seen by the wound clinic on 1/21/19 (24 days after first ordered) and returned with the following information: the resident's right foot/heel wound was pressure related with diabetic [MEDICAL CONDITION] (nerve damage) a complicating factor. The wound was assessed to be a Stage 3 full thickness wound with slough. On 1/29/19 at 9:42 AM Resident 27 was observed lying in bed without the pressure relief boot on the right foot. The resident was alert and oriented to her/his surroundings and stated the wound on her/his right foot started out as a drying blister and had worsened, increased in size and became infected since it was noted by staff. When asked about the protective boot Resident 27 stated staff frequently forgot to put the boot on her/his right foot. On 1/31/19 at 10:55 AM wound care was provided to Resident 27's right foot/heel wound by Staff 16 (RN) and this RN surveyor observed. The resident's wound was full thickness with an open area approximately the size of a large walnut, with slough observed in the wound bed. There was a small amount of tan drainage noted on the old dressing when it was removed. Staff 16 cleansed the wound and applied clean dressing without difficulty. Staff 16 indicated the resident's right foot/heel wound looked good. On 2/4/19 at 10:35 AM Staff 2 (DNS) stated all documentation for skin and wounds was completed in the electronic health record system and there were no skin tracking sheets or handwritten wound assessments. Staff 2 confirmed there was no Weekly Wound Observation Tool initiated on 12/10/18 when she first noted Resident 27's right foot/heel wound. On 2/8/19 at 10:55 AM Staff 2 indicated she did not think Resident 27's right foot/heel wound was pressure related initially because it was like a flat reabsorbed blister. Staff 2 stated she thought the best intervention was to use a pressure-relief boot to keep the area from worsening. Staff 2 acknowledged the resident frequently was observed without the boot on and no other interventions were attempted to provide pressure relief. Staff 2 further acknowledged the lack of documented wound care or monitoring from 12/10/18 through 12/26/18. When asked about the delay in accessing the wound clinic care for Resident 27 after two requests by the physician and the wound had worsened, Staff 2 indicated the process can take time and she thought the wound care person was unavailable.

Based on observation, interview and record review, it was determined the facility failed to follow physician orders [REDACTED].#s 33 and 240) reviewed for respiratory care. The facility's failure resulted in Resident 240's respiratory distress and oxygen level lessened. This placed residents at risk for respiratory complications and infection. Findings include: 1. Resident 240 admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. The current physician order [REDACTED]. Record review revealed Resident 240 had no assessment or plan of care for her/his respiratory status or care needs. On 1/31/19 at 11:56 PM Resident 240 was observed in the main dining room with a portable O2 tank on the back of her/his wheelchair and the nasal cannula in place. Resident 240's O2 concentrator was observed set at four and a half liters on 2/1/19 at 9:39 PM and 2/4/19 at 12:14 PM. During an interview on 2/05/19 at 11:19 AM Witness 1 (RN) reported she had visited Resident 240 at the facility on 1/31/19 approximately between 1:15 PM and 3:00 PM. Witness 1 reported Resident 240 tried to say something she could not understand and handed the resident a pen and paper to write. Resident 240 dropped the pen twice, then wrote where. Witness 1 mentioned the resident's sister and then Resident 240 pointed to her/his chest. Resident 240 was using the nasal cannula attached to the portable O2 tank on the back of her/his wheelchair. Witness 1 checked the portable O2 tank and the tank was empty. Witness 1 immediately changed Resident 240's oxygen from the portable tank to the O2 concentrator in the room, which was set at four liters. Witness checked Resident 240's O2 saturation, which was at 87%. Witness rechecked Resident 240's O2 saturation approximately in ten minutes at 92% and later in the visit it had dropped to 86%. Witness 1 noted the oxygen order called for five liters and she increased the oxygen immediately on the concentrator from the four liters. During an interview on 2/6/19 at 12:54 PM Staff 2 (DNS) stated she expected the physician orders [REDACTED]. Staff 2 acknowledged the facility had no process to ensure the portable oxygen tanks were not empty and the level of oxygen delivered was set to physician order. She expected the charge nurse to monitor the O2 tanks and level of delivery to the resident. On 2/07/19 at 2:18 PM Staff 25 (LPN) and Staff 11 (CMA) reported the charge nurse was responsible for the portable oxygen tanks. On 2/07/19 at 2:36 PM Staff 18 (Regional Nurse Consultant) stated she expected the charge nurse to monitor the portable O2 tanks but CNAs could assist. Staff 18 was unclear of any documentation to monitor the use of oxygen and was not able to provide any further documentation for the 1/31/19 incident for Resident 240's portable tank on empty and inaccurate oxygen setting on the concentrator. During an interview on 2/07/19 at 3:13 PM Staff 17 (Agency LPN) confirmed the charge nurse was responsible to monitor and change the portable oxygen tanks. Staff 17 acknowledged the responsibility to monitor the amount the oxygen concentrators delivered. Staff 17 acknowledged he was the charge nurse for Resident 240 on 1/31/19 and recalled the tank was empty but they got it fixed. Staff 17 confirmed the oxygen concentrator at times will get changed from five to a lower number and had no reason to explain why this had occurred. 2. Resident 33 was admitted to the facility in 6/2017 with [DIAGNOSES REDACTED]. The current physician order [REDACTED]. Record review of Resident 33's 1/2019 and 2/1/19 to 2/5/19 TAR revealed oxygen saturation levels when taken twice daily ranged from 78% to 98%. Record review of Resident 33's care plan revealed she/he had [MEDICAL CONDITION] and was at risk for impaired oxygenation. The interventions included the following: - Ensure portable tank was available to attend activities; - Monitor for signs and symptoms of acute respiratory insufficiency; - OXYGEN SETTING: O2 via NASAL CANNULA @ 2-3L (liters) CONTINUOUS. On 1/31/19 at 8:15 AM Resident 33 was observed to sit on the edge of her/his bed with the O2 nasal cannula on floor near her/his feet. On 1/31/19 at 8:37 AM Resident 33's was observed with O2 nasal cannula on the floor to the right of her/his bed stand. On 1/31/19 at 12:19 PM Resident 33's O2 nasal canal was observed on the floor. On 1/31/19 at 1:51 PM Resident 33 was observed to lay in her/his bed, the O2 concentration was on set at 3 liters and the nasal cannula was in the garbage can, between her/his bed and dresser. Observations on 2/1/19 at 9:29 AM, 2/4/19 at 8:17 AM and 2:21 PM of Resident 33's O2 concentrator was not on and the nasal cannula was placed over the top to the right of her/his dresser. During multiple observation between 1/31/19 at 8:15 AM through 2/4/19 at 2:21 PM, between 8:00 AM to 5:00 PM, Resident 33 was not observed to have a nasal cannula in place to provide oxygen to the resident. On 2/6/19 at 12:54 PM Staff 2 (DNS) she expected physician orders [REDACTED]. She would expect the nasal cannula to be replaced for infection prevention. Staff 2 reported the facility did not have a process, policy and procedures or system in place to ensure the O2 nasal cannula, O2 tubing or concentrator filters were clean.

Based on interview and record review it was determined the facility failed to ensure a resident maintained acceptable parameters of hydration status for 1 of 1 sampled resident (# 240) reviewed for hydration. This placed residents at risk for dehydration. Findings include: Resident 240 admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. Resident 240's record revealed fluid intake from 1/17/19 to 2/6/19 documented the following amounts of fluids consumed: - 1/17/19 - no fluids, refused once - 1/18/19 - no fluids, marked not applicable twice - 1/19/19 - 120 ml and not applicable twice - 1/20/19 - 20 ml and not available once - 1/21/19 - no fluids, marked not available once - 1/22/19 - no fluids, refused once - 1/23/19 - 145 ml and refused once - 1/24/19 - 160 ml and not applicable once - 1/25/19 - 666 ml and not applicable once - 1/26/19 - 260 ml - 1/27/19 - 780 ml - 1/28/19 - 440 ml - 1/29/19 - 570 ml - 1/30/19 - 900 ml - 1/31/19 - 1,380 ml - 2/1/19 - 320 ml - 2/2/19 - 420 ml and not applicable once - 2/3/19 - 360 ml and refused once - 2/4/19 - 250 ml and refused once - 2/5/19 - 240 ml and refused once, not applicable once - 2/6/18 - no fluids, refused once During an interview on 2/4/19 at 12:16 PM Staff 17 (Agency LPN) stated Resident 240 was thirsty often. Due to the resident's thirst, Staff 17 stated he applied A+D ointment (moisterure barrier) on the residents dry lips and swabbed her/his mouth with a moistened swab. In an interview on 2/5/19 at 11:19 AM Witness 1 (RN) reported she visited Resident 240 on 1/31/19 between 1:15 PM - 2:00 PM. Witness 1 stated during the visit she observed Resident 240's mouth to be dry and her/his skin was observed to be tenting (slow return of the skin to normal position after being pinched) on the hand and clavicle, indicating dehydration. Witness 1 talked with Staff 17 about hydration and he reported the facility was out of mouth swabs. Witness 1 provided swabs and educated facility staff on how to hydrate the resident. During an interview on 2/7/19 at 2:36 PM Staff 18 (Regional Nurse Consultant) stated she expected Resident 240 to have appropriate documentation of fluid intake. She confirmed from 1/17/19 to 1/23/19, Resident 240 only had 285 ml of fluids recorded for the seven days, with multiple days with low intake of fluids. Staff 18 could not provide additional documentation for lack of fluid intake, assessment of hydration needs or risks for dehydration.

Based on observation, interview and record review it was determined the facility failed to obtain and follow physician orders for [MEDICAL CONDITION] (surgical opening in the abdominal wall that provides a way for the end of the small intestine to release stool) care for 1 of 1 sampled residents (#34) reviewed for bladder and bowel . This failure resulted in the Resident 34 developing skin breakdown and unmet [MEDICAL CONDITION] care needs. Findings include: Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 34's 12/2018 Admission MDS revealed the resident had a Brief Interview of Mental Status score of 14 out of 15 (cognitively intact). The 11/12/18 History and Physical Note revealed Resident 34 had an [MEDICAL CONDITION] in place since 1/2018. a. The 12/2018 and 1/2019 Physician Orders revealed Resident 34 had no physician's orders in place for [MEDICAL CONDITION] care from 12/7/18 through 1/10/19, 34 days after admission. The Skin Observation sheet revealed on 1/5/19, 1/6/19 and 1/7/19 the resident had red area (location was not noted). Review of the 1/1/19 through 1/7/19 Progress Notes and clinical record revealed no additional documentation or assessments related to Resident 34's skin. A 1/8/19 Progress Note revealed the resident had an appointment for [MEDICAL CONDITION] management for leaking of the ostomy bag. A 1/8/19 Physician's Telephone Order revealed a referral for wound management and leaking ostomy bag. An undated Kardex Report (in-room care plan) revealed skin problems: cleanse peri-ostomy skin after each episode of [MEDICAL CONDITION] leakage. Apply skin barrier cream. The 1/8/19 Care Plan revealed the resident had pain related to skin irritation surrounding her/his ostomy due to ostomy leakage. Cleanse peri-ostomy skin after each episode of [MEDICAL CONDITION] leakage. Apply skin barrier cream. Refer for wound and ostomy clinic, evaluation and treatment per physician's order. The 1/9/19 Wound Ostomy Clinic report revealed the following: -The resident arrived with no pouch in place. It was reported the pouch was removed on 1/8/19. Gauze was taped over the site. The patient sat in a large puddle of watery stool; -[MEDICATION NAME] (skin around the ostomy site) breakdown around the full circumference of the skin due to stool exposure. It extended approximately 10 cm from the stoma and extended down the right side to the back. It appeared to have a mild yeast component; -There was a high volume of watery stool output during care, approximately 500 ml. Cleansed the resident from knees to back, dressed her/him in a new gown and donated coat; -The resident reported leaking for at least ten days; -The nurse from the facility stated the pouch was off for at least two days (since 1/7/19); -The wound clinic discussed with the facility nurse about masking the pouch with a binder or garments and discussed steps for pouch changes; -Treatment orders: -Empty bag when one-third to one-half full throughout the day. Do not allow to overfill as this could contribute to leaks; -Change pouch every two days or if it leaks until denuded (loss of surface level skin) resolves; -DO NOT LEAVE STOMA EXPOSED as this will only exacerbate the skin breakdown and make pouching even more difficult; -Cleanse site with water and washcloth, do not use soap, alcohol or wipes; -Use tampon to wick drainage during care. Dust denuded skin with anti-fungal powder, brush or blow off excess and seal with Marathon barrier; -Apply Brava [MEDICATION NAME] or Adapt slim barrier ring to the back of the [MEDICATION NAME] 7/8 pre-cut convex pouch; -If needed, apply excess [MEDICATION NAME] powder to stoma to wick drainage during application and setting of pouch; -Ensure skin/pouching surface is very dry. Hairdryer is a great tool for this; -Apply pouch, apply pressure around the pouch for one to two minutes; -Use heat pack or hair dryer to warm pouch to promote adhesion; -Be restful for 20 to 30 minutes to allow bag to settle onto skin well; -Clinic gathered supplies for the facility and faxed the orders, instruction and progress note; -Facility to call to report the need for a follow up if ostomy continues to leak and [MEDICATION NAME] breakdown does not resolve within two weeks. The 1/11/19 physician Order Summary Report revealed new orders to change [MEDICAL CONDITION] pouch every two days or if it leaks and empty bag when it is one-third full to one-half full throughout the day. Do not allow to overfill as this could contribute to leaks. On 1/11/19 the following portion of the above Wound Ostomy Clinic orders were not implemented: -DO NOT LEAVE STOMA EXPOSED as this will only exacerbate the skin breakdown and make pouching even more difficult; -Cleanse site with water and washcloth, do not use soap, alcohol or wipes; -Use tampon to wick drainage during care. Dust denuded skin with anti-fungal powder, brush or blow off excess and seal with Marathon barrier; -Apply Brava [MEDICATION NAME] or Adapt slim barrier ring to the back of the [MEDICATION NAME] 7/8 pre-cut convex pouch; -If needed, apply excess [MEDICATION NAME] powder to stoma to wick drainage during application and setting of pouch; -Ensure skin/pouching surface is very dry. Hairdryer is a great tool for this; -Apply pouch, apply pressure around the pouch for one to two minutes; -Use heat pack or hair dryer to warm pouch to promote adhesion; -Be restful for 20 to 30 minutes to allow bag to settle onto skin well. The 1/12/19 hospital After Visit Summary revealed the resident was seen for ostomy appliance concerns and ostomy wound. The 1/14/19 physician Order Summary Report revealed the remaining Wound Ostomy Clinic orders were implemented: -Every 48 hours. [MEDICAL CONDITION] care, clean skin around stoma with water and washcloth, no soap or wipes. Use tampon to wick drainage during care. Dust denuded (loss of surface level skin) skin with anti-fungal powder, brush off the excess. Seal with marathon barrier and apply Brava [MEDICATION NAME] or adapt slim barrier ring to back of the [MEDICATION NAME] 7/8 pre-cut pouch. Ensure the skin is very dry and then apply pouch. Hold warm hand over and pressure over the site for one to two minutes. Use a heat pack to warm pouch to promote adhesion. Be restful for 20 to 30 minutes. DO NOT LEAVE STOMA EXPOSED. -As needed. [MEDICAL CONDITION] care, clean skin around stoma with water and washcloth, no soap or wipes. Use tampon to wick drainage during care. Dust denuded skin with anti-fungal powder, brush off the excess. Seal with marathon barrier and apply brava [MEDICATION NAME] or adapt slim barrier ring to back of the [MEDICATION NAME] 7/8 pre-cut pouch. Ensure the skin is very dry and then apply pouch. Hold warm hand over and pressure over the site for one to two minutes. Use a heat pack to warm pouch to promote adhesion. Be restful for 20 to 30 minutes. DO NOT LEAVE STOMA EXPOSED. The 1/2019 TAR revealed the following: -empty bag when one-third to one-half full throughout the day. Do not allow to overfill as this could contribute to leaks. The only documented times to check the [MEDICAL CONDITION] were at 6:00 AM and 6:00 PM. -the resident refused ostomy care on 1/20/19, 1/22/19 and 1/24/19. On 1/27/19 at 9:57 AM and 3:20 PM Resident 34 was observed to have ostomy fluid leaking on a towel with the stoma exposed. Resident 34 stated her/his ostomy bag was not on and there was a burn from the feces. Resident 34 stated she/he started refusing placement of the pouch because of skin pain. Resident 34 stated on a pain scale of 1-10 the pain was a 25 at times. Resident 34 stated the pain goes up and down depending on what she/he did and how much ostomy fluid leaked on her/his skin. Resident 34 stated the [MEDICAL CONDITION] was fine when she/he could empty it herself/himself but she/he could no longer do it and relied on facility staff. On 1/27/19 at 10:04 AM and 11:43 AM Resident 34 was observed to have her/his ostomy exposed. Review of Resident 34's clinical record revealed there were no physician notifications the resident refused pouch placement due to skin pain, no additional documentation the resident's [MEDICAL CONDITION] was checked multiple times per shift and no skin assessments. In an interviews on 1/27/19 at 10:26 AM and 3:37 PM and 2/4/19 at 2:45 PM Staff 2 (DNS) stated there were no orders in place for ostomy care until 1/11/19 but should have been. Staff 2 stated she implemented the instructions for [MEDICAL CONDITION] care and use of barrier cream on 1/8/19 without physician's orders. Staff 2 stated the resident should have had a care plan in place for ostomy care since admission but one was not implemented until 1/8/19. Staff 2 was aware the resident refused pouch placement because of skin pain. Staff 2 stated facility staff were having difficulty keeping the ostomy pouch in place because it leaked which caused the reddened area to the resident's skin. Staff 2 stated she expected staff to check the resident's ostomy at least three times per shift but found no documentation to support this occurred. Staff 2 expected staff to complete and document skin assessments at least weekly. Staff 2 stated she did not necessarily expect staff to notify the physician when the resident refused pouch placement which exposed the stoma but further stated she expected physician orders to be followed. In an interview on 1/27/19 at 11:16 AM Staff 21 (LPN) stated when she worked with Resident 34 since 1/23/19 and the resident did not have a pouch in place because she/he refused. Staff 21 stated she spoke to Staff 2 (DNS) because she had concerns about the resident and the orders specified the ostomy should not be exposed. Staff 21 further stated staff should check on the resident's ostomy at least three to four times a shift but did not know if there was documentation this occurred. In an interview on 1/27/19 at 12:09 PM Staff 8 (CNA) stated the resident did not allow him to help her/him often but noticed the difficulty keeping the ostomy pouch in place. Staff 8 stated he tried to check the pouch every hour to hour and a half to keep the bag from overfilling. Staff 8 stated the nurses and care givers did not know much about caring for the resident's [MEDICAL CONDITION]. Staff 8 further stated when the resident's bag was not changed enough by other staff the resident would itch or pull at the site because of skin irritation from the bowel leakage. b. The 12/2018 physician order Summary Report revealed orders on 12/24/18 for [MEDICATION NAME]-[MEDICATION NAME] (anti-diarrhea medication) two times daily for increased liquid in stool from [MEDICAL CONDITION]. The 12/2018 MAR indicated [REDACTED]. In an interviews on 1/27/19 at 10:26 AM and 3:37 PM and 2/4/19 at 2:45 PM Staff 2 (DNS) stated she expected physician's orders be followed.

Based on observation, interview and record review it was determined the facility failed to ensure coordination of services related to [MEDICAL CONDITION] (surgical opening in the abdominal wall that provides a way for the end of the small intestine to release stool) care, failed to ensure appropriate bowel care protocol were implemented, failed to follow physician orders and failed to ensure wound care was provided to professional standards for 3 of 5 sampled residents (34, 28 and 12) reviewed for constipation, bowel and bladder care and skin. The facility's failures resulted in Resident 34 developing skin breakdown and having unmet [MEDICAL CONDITION] care and Resident 28 had bleeding hemorrhoids which required emergency treatment. This placed residents at risk for unmet needs. Findings include: 1. Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 34's 12/2018 Admission MDS revealed the resident had a Brief Interview of Mental Status score of 14 out of 15 (cognitively intact). The 11/12/18 History and Physical Note revealed Resident 34 had an [MEDICAL CONDITION] in place since 1/2018. a. The 12/2018 and 1/2019 Physician Orders revealed Resident 34 had no physician's orders in place for [MEDICAL CONDITION] care from 12/7/18 through 1/10/19, 34 days after admission. The Skin Observation sheet revealed on 1/5/19, 1/6/19 and 1/7/19 the resident had red area (location was not noted). Review of the 1/1/19 through 1/7/19 Progress Notes and clinical record revealed no additional documentation or assessments related to Resident 34's skin. The 1/9/19 Wound Ostomy Clinic report revealed a [MEDICATION NAME] (skin around the ostomy site) breakdown around the full circumference of the skin due to stool exposure. It extended approximately 10 cm from the stoma and extended down the right side to the back. It appeared to have a mild yeast component. The clinic ordered the following treatments: -Empty bag when one-third to one-half full throughout the day. Do not allow to overfill as this could contribute to leaks; -Change pouch every two days or if it leaks until denouement (loss of surface level skin) resolves; -DO NOT LEAVE STOMA EXPOSED as this will only exacerbate the skin breakdown and make pouching even more difficult; -Cleanse site with water and washcloth, do not use soap, alcohol or wipes; -Use tampon to wick drainage during care. Dust denuded skin with anti-fungal powder, brush or blow off excess and seal with Marathon barrier; -Apply Brava [MEDICATION NAME] or Adapt slim barrier ring to the back of the [MEDICATION NAME] 7/8 pre-cut convex pouch; -If needed, apply excess [MEDICATION NAME] powder to stoma to wick drainage during application and setting of pouch; -Ensure skin/pouching surface is very dry. Hairdryer is a great tool for this; -Apply pouch, apply pressure around the pouch for one to two minutes; -Use heat pack or hair dryer to warm pouch to promote adhesion; -Be restful for 20 to 30 minutes to allow bag to settle onto skin well. The 1/11/19 physician Order Summary Report revealed new orders to change [MEDICAL CONDITION] pouch every two days or if it leaks and empty bag when it is one-third to one-half full throughout the day. Do not allow to overfill as this could contribute to leaks. On 1/11/19 the following portion of the Wound Ostomy Clinic orders were not implemented: -DO NOT LEAVE STOMA EXPOSED as this will only exacerbate the skin breakdown and make pouching even more difficult; -Cleanse site with water and washcloth, do not use soap, alcohol or wipes; -Use tampon to wick drainage during care. Dust denuded skin with anti-fungal powder, brush or blow off excess and seal with Marathon barrier; -Apply Brava [MEDICATION NAME] or Adapt slim barrier ring to the back of the [MEDICATION NAME] 7/8 pre-cut convex pouch; -If needed, apply excess [MEDICATION NAME] powder to stoma to wick drainage during application and setting of pouch; -Ensure skin/pouching surface is very dry. Hairdryer is a great tool for this; -Apply pouch, apply pressure around the pouch for one to two minutes; -Use heat pack or hair dryer to warm pouch to promote adhesion; -Be restful for 20 to 30 minutes to allow bag to settle onto skin well. In interviews on 1/27/19 at 10:26 AM and 3:37 PM and 2/4/19 at 2:45 PM Staff 2 (DNS) stated no orders or treatments were in place for [MEDICAL CONDITION] care until 1/11/19 but should have been. Staff 2 stated the facility staff were having difficulty keeping the resident's pouch in place and it leaked. The stool leakage caused a reddened area and the physician was notified of the concern on 1/8/19. Staff 2 expected physician orders to be implemented and followed. b. The 1/14/2019 physician Order Summary Report revealed the following: -Every 48 hours. [MEDICAL CONDITION] care, clean skin around stoma with water and washcloth, no soap or wipes. Use tampon to wick drainage during care. Dust denuded (loss of surface level skin) skin with anti-fungal powder, brush off the excess. Seal with marathon barrier and apply Brava [MEDICATION NAME] or adapt slim barrier ring to back of the [MEDICATION NAME] 7/8 pre-cut pouch. Ensure the skin is very dry and then apply pouch. Hold warm hand over and pressure over the site for one to two minutes. Use a heat pack to warm pouch to promote adhesion. Be restful for 20 to 30 minutes. DO NOT LEAVE STOMA EXPOSED. -As needed. [MEDICAL CONDITION] care, clean skin around stoma with water and washcloth, no soap or wipes. Use tampon to wick drainage during care. Dust denuded skin with anti-fungal powder, brush off the excess. Seal with marathon barrier and apply brava [MEDICATION NAME] or adapt slim barrier ring to back of the [MEDICATION NAME] 7/8 pre-cut pouch. Ensure the skin is very dry and then apply pouch. Hold warm hand over and pressure over the site for one to two minutes. Use a heat pack to warm pouch to promote adhesion. Be restful for 20 to 30 minutes. DO NOT LEAVE STOMA EXPOSED. The 1/2019 TAR revealed the resident refused ostomy care on 1/20/19, 1/22/19 and 1/24/19. On 1/27/19 at 9:57 AM Resident 34 was observed to have ostomy fluid leaking on a towel with the stoma exposed. Resident 34 stated her/his ostomy bag was not on and there was a burn from the feces. Resident 34 stated she/he started refusing placement of the pouch because of skin pain. On 1/27/19 at 10:04 AM and 11:43 AM Resident 34 was observed to have her/his ostomy exposed. Review of Resident 34's clinical record revealed there was no physician notification the resident refused pouch placement due to pain from the skin wound or any skin assessments. In interviews on 1/27/19 at 10:26 AM and 3:37 PM and 2/4/19 at 2:45 PM Staff 2 (DNS) stated she was aware the resident refused pouch placement because of skin pain. Staff 2 stated she did not necessarily expect staff to notify the physician because of the resident's refusals, but further stated she expected physician orders to be followed. Staff 2 expected staff to complete skin assessments at least weekly. c. Resident 34's 12/2018 physician Order Summary Report revealed orders on 12/24/18 for [MEDICATION NAME]-[MEDICATION NAME] (anti-diarrhea medication) two times daily for increased liquid in stool from [MEDICAL CONDITION]. The 12/2018 MAR indicated [REDACTED]. In an interview on 1/27/19 at 10:26 AM and 3:37 PM and 2/4/19 at 2:45 PM Staff 2 (DNS) stated she expected physician's orders to be followed. 2. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/2019 Bowel and Bladder Elimination record and clinical record revealed the resident did not have a documented bowel movement from 1/16/19 through 1/21/19. On 1/22/19 at 5:59 AM a large stool was documented. On 1/20/19 at 11:25 AM a physician's order was received for a mineral oil enema (fast acting constipation relief) as needed, can administer one unit for no bowel movement every two to three days. The 1/2019 MAR indicated [REDACTED] -On 1/16/19 through 1/21/19 milk of magnesia (laxative) as needed for constipation was not administered. -On 1/18/19 [MEDICATION NAME] laxative suppository was administered with no documented response if the laxative was effective. -On 1/20/19 at 12:36 PM a mineral oil enema was administered with no effectiveness noted. Progress Notes revealed the following: On 1/20/19: -the resident became verbally aggressive with a nurse because she/he wanted an enema for her/his constipation; -at 5:01 PM a mineral oil enema was administered and noted as effective; On 1/21/19 at 3:22 AM no bowel movement was reported from the enema and would continue to monitor; On 1/22/19 at 12:34 PM the resident had bleeding hemorrhoids and requested to go to the hospital. The 1/22/19 hospital After Visit Summary revealed the resident was seen in the emergency center for rectal bleeding, was diagnosed with [REDACTED]. The instructions noted You should take a stool softener so you do not become constipated again. In an interview on 1/31/19 at 11:08 AM Resident 28 stated she/he could not recall how long she/he went without a bowel movement, but it was a long time and it hurt. In at interview on 1/31/19 at 11:24 AM Staff 2 (DNS) stated the facility did not have a house bowel protocol in place until 1/28/19. Staff 2 stated going from 1/16/19 through 1/21/19 with no bowel movement could cause serious complications such as an impaction and twisting of the intestines. Staff 2 further stated it was not appropriate for the resident to go more than three days without having a medical intervention such as milk of magnesia or a laxative. Staff 2 stated she expected the physician to be notified when the resident had no bowel movement after three days. 3. Resident 12 admitted to the facility in 7/2018 with [DIAGNOSES REDACTED]. A 8/5/18 Admission MDS revealed Resident 12 had a Brief Interview of Mental Status score of 14 out of 15 (cognitively intact) and wound care for foot. a. A 11/16/18 physician order to cleanse the left foot wound, apply dressing, cover with a pad and wrap every day shift. Review of the 1/2019 and 2/2019 TARs indicated wound care was not completed on the following days: - 1/1/19 - 1/10/19 - 1/22/19 - 1/24/19 - 1/29/19 - 2/5/19 On 1/29/19 at 9:14 AM Resident 12 stated her/his wound dressing to the left foot had not been changed in several days. Resident 12 was observed to not have the wound care dressing with a date, time or initials to indicated when the task had been performed on the following: - 1/29/19 at 9:14 AM - 1/31/19 at 1:49 PM - 2/1/19 at 9:44 AM - 2/6/19 at 9:01 AM On 2/6/19 at 9:16 AM Staff 27 (RNCM) confirmed the TARs were not completed on the five dates in 1/2019 and 2/5/19 per physician order. On 2/6/19 at 9:23 AM Staff 27 confirmed upon observation Resident 12's left foot dressing did not have a date, time or initials written on the wrap to indicate when it had been changed, which she considered a standard of care. Staff 27 stated she expected the date, time and initial to be written on the dressing to indicate when it was changed. b. A 12/15/18 Physician order to assist Resident 12 to put on a cast boot in the morning and take off in the evening daily. Review of the 1/2019 and 2/2019 TARs to put on cast boot in the morning and take off in the evening daily was not completed on the following dates: 1/10/19 and 1/29/19 in mornings. On 2/6/19 at 9:01 AM Resident 12 stated her/his boot was broken for two to three weeks weeks and she/he told the nursing staff it was broken. Resident 12 was observed not wearing a boot on her/his left foot on the following days: - 1/28/19 at 5:28 PM - 1/29/19 at 9:21 AM - 1/31/19 at 9:28 AM - 1/31/19 at 1:49 PM - 2/1/19 at 9:44 AM - 2/6/19 at 9:01 AM On 2/6/19 at 9:04 AM Staff 27 (RNCM) confirmed the physician order to assist Resident 12 with the boot on her/his foot. Staff 27 stated the boot was to protect the wound. Upon observation, Staff 27 confirmed the resident was not wearing a boot and it was broken. On 2/6/19 at 9:13 AM Staff 27 took the boot to the therapy department for repair.

Based on observation, interview and record review it was determined the facility failed to thoroughly investigate the contributing factors to incidents and allegations of verbal, physical, sexual and mental abuse for 4 of 4 sampled residents (#1, 5, 10 and 17) reviewed for abuse. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, the facility did not complete thorough investigations and incident reports for allegations of sexual abuse, physical abuse and mental abuse. Findings include: 1. Resident 1 was admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. The 11/2018 MDS reported she/he has a Brief Mental Status score of 13 of 15 (cognitively intact). A 12/3/18 Nursing Facility Reported Incident Form completed by Staff 2 (DNS) revealed the following: -Resident 1 reported waking up with her/his pants off and was nude from the waist down. Resident 1 believed someone removed her/his clothes and was possibly violated and slept through the event; -No one witnessed the event; -Yes and No were checked to the question has this happened to the same resident(s) or others; A 12/3/18 Investigative Note revealed the following: -On 12/3/18 Resident 1 reported to Staff 1 (Administrator) that she/he woke without pants on and was nude from the waist down but went to bed wearing pants. The resident was uncertain if she/he had been violated overnight; -Staff 1 reviewed the video footage and Staff 27 (CNA) entered the room for approximately five minutes. Staff 27 denied anything unusual going on; -Staff 1 interviewed Staff 26 (RN) and she could not remember anything out of the ordinary that evening. Review of Resident 1's 12/2018 through 1/2019 records revealed no assessment was documented after the alleged possible sexual abuse. In an interview on 1/17/19 at 11:37 AM Staff 1 stated Staff 27 did not do a witness statement, he spoke to Staff 27 and did not want to imply she was being accused of anything. Staff 27 was the only staff who entered the room. Staff 1 did not interview any residents or any additional staff on shift. Staff 1 stated he did not keep the video because he did not know how to download the footage. In an interview on 1/17/19 at 12:37 PM Staff 2 (DNS) stated she did not watch the video, but Staff 1 told her a female housekeeper and Staff 27 entered Resident 1's room. Staff 2 stated the resident should be checked on every two hours and as needed and someone could have taken off her/his pants during care. Staff 2 stated she completed an assessment but was unable to provide documentation an assessment was completed. Staff 2 stated she did not interview any residents or other potential witnesses. 2. Resident 5 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. A 11/23/18 investigation note completed by Staff 1 (Administrator) revealed Resident 5 was agitated and entered the nurse's station. Staff 25 (Agency LPN) asked the resident to leave and Staff 25 physically removed Resident 5. On 1/18/19 at 12:09 PM it was observed on the facility's video that Resident 5 was in the nurses's station standing near Staff 25. Staff 25 and Resident 5 were observed to have a verbal exchange but the video had no audio. Staff 25 got up from his chair and pushed the resident's arms and hands. Staff 25 pushed Resident 5 backwards into a chair and pushed the resident out of the nurses's station. Staff 25 pointed to the floor just outside the nurses station. Resident 5 re-entered the nurses's station and Staff 25 again pushed the resident backwards out of the nurses's station. Staff 6 (CNA) was present during part of the incident. In an interview on 1/23/19 at 11:16 AM Staff 1 stated he did not know if he had any additional interviews or documentation other than the investigative note. Staff 1 stated he did not know the staff member (Staff 6) in the video and further stated he did not interview the staff. In an interview on 1/23/19 at 12:40 PM Staff 2 (DNS) stated she did not complete the investigation but the staff member in the video was Staff 6. 3. Resident 10 was admitted to the facility in 6/2018 with [DIAGNOSES REDACTED]. The 12/2018 MDS reported she/he has a Brief Mental Status score of 14 of 15 (cognitively intact). a. An undated incident summary revealed the following: -On 12/24/18 it was reported to Staff 2 (DNS) at approximately 7:00 PM about an alleged incident of physical abuse; -Staff failed to report the incident until 12/26/18; -On 12/26/18 Resident 10's spouse called in a police report because Staff 4 was still on the premises after an allegation of abuse; -Staff 2 wrote Staff 4 was sent home pending the investigation; -An unidentified resident in the video said she/he witnessed the incident but that was deemed unsubstantiated as she/he was not looking at Resident 10. Staff 4's payroll revealed she did not work on 12/25/18, as scheduled, and worked at the facility on 12/26/18 from 9:34 AM through 5:48 PM. In an interview on 1/28/19 at 2:39 PM Staff 4 stated she worked the entire day on 12/26/18 while Resident 10 was present in the building. In an interview on 1/29/19 at 10:35 AM, Staff 2 stated on 12/24/18 she learned about the allegation Staff 4 hit Resident 10 but failed to report the allegation until 12/26/18 but should have within two hours. Staff 2 stated there were other residents in the common area but she did not interview them. Staff 2 stated she did not interview any other potential witnesses. Staff 2 stated she considered the allegation as unsubstantiated after watching the video on 12/26/18 at approximately 10:00 AM. In an interview on 1/29/19 at 10:35 AM Staff 1 (Administrator) stated he did not keep a copy of the incident on 12/24/18. b. The 1/11/19 Nursing Facility Reported Incident Form revealed on 1/11/19 Resident 10 reported Staff 4 passed her/him in the hall, said nothing but hit the resident on her/his shoulder. The 1/11/19 incident summary revealed Staff 4 did not physically contact Resident 10. Staff 4 walked closely down the hall near Resident 10. Staff 4 was previously told by administration to have a witness present during all interactions with Resident 10 in the dining and resident room. The 1/11/19 video was reviewed by a NFSU Surveyor. Staff 4 did not physically contact Resident 10. Staff 4 was observed to walk very close to Resident 10 in an open hallway where there was adequate space to avoid coming into close proximity to the resident. In an interview on 1/28/19 at 2:17 PM Staff 1 (Administrator) stated there was only a verbal agreement in place and there was no formal interventions in place to ensure Staff 4 and Resident 10 had no continued interactions. In an interview on 1/28/19 at 2:39 PM Staff 4 stated she could not recall walking close to Resident 10. Review of Resident 10's records and investigations revealed no documented interventions were in place to ensure her/his safety from Staff 4. c. On 1/28/19 Resident 10 reported to a NFSU Surveyor that at 10:45 AM Staff 4 walked close to her/him and said happy, happy, happy because the resident's spouse was no longer allowed on the premises. The 1/28/19 video was reviewed by NFSU Surveyor. Staff 4 was observed to walk close to Resident 10 in the hallway near the public restroom. Staff 4 was observed to smile in the resident's direction, walked close behind the resident's wheelchair. Staff 4 was observed to move her mouth three times while directly behind the resident. The video had no audio. In an interview on 1/28/19 at 2:17 PM Staff 1 (Administrator) stated there was only a verbal agreement in place and there was no formal interventions in place to ensure Staff 4 and Resident 10 had no continued interactions. 4. Resident 17 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. A 1/21/19 Nursing Facility Reported Incident Form revealed Resident 17 alleged Staff 15 (LPN) was verbally abusive. In an interview on 1/24/19 at 1:06 PM Staff 1 (Administrator) stated he reviewed the video of the incident to help make an unsubstantiated determination of the allegation of verbal abuse but did not keep a copy. On 1/29/19 at 3:36 PM the facility was notified of an immediate jeopardy (IJ) situation related to facility's failure to thoroughly investigate, prevent and correct incidents of abuse for residents (#s 1, 5, 10 and 17). This failure placed residents at continued risk for abuse, neglect, exploitation or misappropriation of resident property. On 1/29/19 at 6:58 PM an accepted facility plan to remove the immediate jeopardy situation was submitted by the facility. The plan included the following: -Resident 5 is no longer in the facility. Resident 1, Resident 10 and Resident 17 investigations will be reviewed, and further interviews will be conducted with potential witnesses. Activities Director will be suspended pending further investigation. Activities Director will not be permitted to pass Resident 10 in hallway or have any other interactions with Resident 10. -DNS/Administrator will review abuse investigations that occurred in the last 6 months for thorough investigation. Resident interviews will be conducted for satisfaction with care and services. Administrator or designee will follow up as needed. Steps to alleviate the alleged victims emotional or psychological discomfort, i.e., relocation to new room, increased supervision, etc, will be provided as soon as possible. The charge nurse will assess resident the resident to ensure that there is no harm or injury as a result of the alleged incident. This will occur immediately upon report of alleged incident. Findings will be documented in the resident's electronic health record. Administrator will ensure that statements are collected and documented at the time of the alleged incident per abuse investigation policy after every allegation of abuse. -Administrator and Director of Nursing will be reeducated on policy and procedure for thorough abuse investigations. Staff will be reeducated on abuse policy and procedure, including witness statements. -Administrator and Director of Nursing will review incident reports and full investigation for thoroughness. On 1/29/19 the IJ removal plan was verified by ensuring staff were being educated, residents were being interviewed for any care, service and abuse concerns and the activities director was no longer in the building.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from the potential for physical and mental abuse for 3 of 4 sampled residents (#s 5, 10 and 17) reviewed for abuse. As a result, Resident 10 was exposed to multiple incidents of retaliation, intimidation and agitation, which was determined to be an immediate jeopardy situation in the area of CFR 483.12 from Abuse, Neglect and Exploitation. The facility also failed to ensure Resident 5 was free from physical abuse and Resident 17 was free from mental abuse. Finding include: 1. Resident 10 was admitted to the facility in 6/2018 with [DIAGNOSES REDACTED]. A 12/28/18 Significant Change MDS revealed Resident 10 had a Brief Interview of Mental Status sore of 14 out of 15 (cognitively intact). a. An undated incident summary completed by Staff 2 (DNS) revealed the following: -On 12/24/18 at approximately 7:00 PM it was reported to Staff 2 that Resident 10 was getting pickles out of the jar and Staff 4 (Activities Director) smacked her/his hand earlier in the day on 12/24/18 at 2:42 PM; -Staff 2 called Staff 4 and she stated she was not aware of an incident that day and certainly not one that involved her slapping the resident; -Staff 2 failed to report the incident until 12/26/18; -On 12/26/18 Resident 10's spouse called in a police report because Staff 4 was still on the premises after the allegation of abuse; -Staff 4 was sent home pending the investigation; -The video revealed Resident 10 sat behind Staff 4 while Staff 4 cut up fruit and other items. Staff 4 noted Resident 10 reached into the jar with bare hands but there was no audio of the exchange. Immediately after the exchange, Resident 4 propelled her/his wheelchair away from the table; -A resident who stated she/he saw the incident was believed not credible because the video showed the resident was not looking at Resident 10. Staff 4's payroll revealed she was off on 12/25/18 but worked at the facility on 12/26/18 from 9:34 AM through 5:48 PM while Resident 10 was present. In an interview on 1/28/19 at 11:04 AM Resident 10 stated she/he felt Staff 4 was taunting her/him and administration did nothing to protect her/him. Resident 10 tearfully stated administration was putting her/his physical and mental health in jeopardy. In an interview on 1/28/19 at 1:01 PM Resident 12 stated she/he was going across the dayroom when she/he saw Staff 4 setting stuff up for a party. Resident 12 stated she/he saw Resident 10 reach into the pickle jar and saw Staff 4 smack the back of Resident 10's hand. In an interview on 1/28/19 at 2:39 PM Staff 4 stated on 12/24/18 she did not hit Resident 10. Staff 4 stated she was shocked when Resident 10 put her/his hand in the pickle jar and yelled at the resident and shooed the resident out of the dining area. Staff 4 stated she was off on 12/25/18 but worked the entire day on 12/26/18 while Resident 10 was present in the building. In an interview on 1/29/19 at 10:35 AM, Staff 2 stated on 12/24/18 she learned about the allegation Staff 4 hit Resident 10 but failed to report the allegation until 12/26/18 but should have within two hours. Staff 2 stated there were other residents in the common area but she did not interview them. Staff 2 stated she did not interview any other potential witnesses to the event. Staff 2 stated she considered the allegation as unsubstantiated after watching the video on 12/26/18 at approximately 10:00 AM. In an interview on 1/29/19 at 10:35 AM Staff 1 (Administrator) stated he did not keep a copy of the video footage from 12/24/18 and did not interview any additional potential witnesses. In an interview on 1/29/19 at 11:50 AM Staff 7 (CNA) stated she worked with the Resident 10 since 6/2018. Staff 7 stated she noticed a change in Resident 10 since the incident on 12/24/18. Prior to 12/24/18 Resident 10 would joke more but now cried more often and was quicker to escalate her/his behavior. Staff 7 also stated Resident 10 loved Bingo prior to 12/24/18 but now isolated from activities and was less happy. Review of the resident's 12/2018 records revealed no new interventions were implemented to ensure Resident 10 felt safe from Staff 4. b. The 1/11/19 Nursing Facility Reported Incident Form revealed on 1/11/19 Resident 10 reported Staff 4 (Activity Director) passed her/him in the hall, said nothing but hit the resident on her/his shoulder. A 1/11/19 incident summary revealed Staff 1 (Administrator) reviewed the video footage and it showed Staff 4 did not physically contact Resident 10. Staff 4 walked closely down the hall near Resident 10. There were no other witnesses to this event. Staff 4 was previously told by administration to have a witness present during all interactions with Resident 10 in the dining and resident room. The 1/11/19 video was reviewed by a NFSU Surveyor. Staff 4 did not physically contact Resident 10. Staff 4 was observed to walk very close to Resident 10 in an open hallway where there was adequate space to avoid coming into close proximity to the resident. In an interview on 1/28/19 at 2:39 PM Staff 4 stated she could not recall walking close to Resident 10. Review of Resident 10's 1/2019 records and investigations revealed no documented interventions were in place to ensure Resident 10's safety from Staff 4. On 1/11/19 a Notice of Transfer was issued to Resident 10 by Staff 1. The Notice of Transfer action was taken or proposed to be taken because: (check appropriate box(es)). Checked was resident's request as well as other: behavior/harassing employees. In an interview on 1/28/19 at 11:04 AM Resident 10 stated she/he felt Staff 4 was taunting her/him and administration did nothing to protect her/him. Resident 10 tearfully stated administration was putting her/his physical and mental health in jeopardy. In an interview on 1/29/19 at 10:35 AM Staff 1 stated he sat down with Staff 4 and Resident 10 and they agreed not to interact with each other and the facility tried to plan accordingly to avoid contact between the two. Staff 1 stated he did not know if there was any updates to the care plan or documentation to support the intervention. When asked about the notice of transfer, Staff 1 stated he did not necessarily consider Resident 10's behavior harassing, but Resident 10 had cussed him out for not firing Staff 4 and threatened to come after his license. Staff 1 also stated he spoke to Witness 2 (DHS Policy Analyst) and she recommended the notice of transfer. In an interview on 1/29/19 at 1:05 PM Witness 2 stated she spoke with Staff 1 and did not advise him to issue a notice of transfer. Witness 2 stated she suggested Staff 1 to care plan around the issues and follow the Notice of Transfer policies. In an interview on 1/29/19 at 2:45 PM Witness 3 (Ombudsman) stated behavior and harassing employees was not a reasonable rationale to transfer a resident. Witness 3 stated she worked with Resident 10 since 6/2018 and did not experience the resident to have harassing behavior but the resident could become angry. Witness 3 stated Resident 10 felt the notice of transfer was retaliation. c. On 1/28/19 at 11:04 AM Resident 10 reported to a NFSU Surveyor that at approximately 10:45 AM Staff 4 (Activities Director) walked close to her/him and said happy, happy, happy because the resident's spouse was no longer allowed on the premises. Resident 10 stated she/he felt Staff 4 was taunting her/him and administration did nothing to protect her/him. Resident 10 tearfully stated administration was putting her/his physical and mental health in jeopardy. The 1/28/19 video was reviewed by NFSU Surveyors. At 10:44 AM Staff 4 was observed to walk close to Resident 10, smiled in the resident's direction, walked close behind the resident's wheelchair and Staff 4 was observed to have moved her mouth three times while directly behind the resident. The video had no audio. In an interview on 1/28/19 at 2:39 PM Staff 4 stated she did not know what happened at 10:44 AM. Staff 4 stated she did not know why she looked and smiled at the resident and could not recall saying anything to the resident. In an interview on 1/28/19 at 2:17 PM Staff 1 stated there was only a verbal agreement in place and there was no formal interventions in place to ensure Staff 4 and Resident 10 had no continued interactions. 2. Resident 5 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. A 11/23/18 investigation note completed by Staff 1 (Administrator) revealed Resident 5 was agitated and entered the nurse's station. Staff 25 (Agency LPN) asked the resident to leave and Staff 25 physically removed Resident 5. On 1/18/19 at 12:09 PM the facility's video showed Resident 5 was in the nurses's station standing near Staff 25 (Agency LPN). Staff 25 and Resident 5 were observed to have a verbal exchange but the video had no audio. Staff 25 got up from his chair and pushed the resident's arms and hands. Staff 25 pushed Resident 5 backwards into a chair and pushed the resident out of the nurses's station. Staff 25 pointed to the floor just outside the nurses station. Resident 5 re-entered the nurses's station and Staff 25 again pushed the resident backwards out of the nurses's station. Staff 6 (CNA) was present during part of the incident. In an interview on 1/23/19 at 11:16 AM Staff 1 stated he did not know if he completed any additional interviews or documentation other than the investigative note. Staff 1 stated he did not know the staff member (Staff 6) in the video and further stated he did not interview the staff (Staff 6). Staff 1 stated he did not like what he saw on the video and asked the agency not to send Staff 25 back to the facility. In an interview on 1/23/19 at 12:40 PM Staff 2 (DNS) stated she did not complete the investigation but the staff member in the video was Staff 6. In an interview on 1/23/19 at 12:51 PM Staff 6 stated she could not recall what happened and did not recall seeing Staff 25 touch the resident but it was most likely over the resident's cigarettes. In an interview on 1/31/19 at 1:09 PM Staff 25 stated Resident 5 was agitated because she/he could not smoke. Staff 25 stated Resident 5 entered the nurses's station and the resident was pushing Staff 25 backwards and he pushed the resident out of the nursing area. Staff 25 stated he told the resident she/he could not be in the nurses's station. Staff 25 stated he wrote a progress note saying he pushed the resident, but moved him backwards out of the area. Staff 25 denied trying other interventions prior to pushing the resident. 3. Resident 17 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. A 1/21/19 Nursing Facility Reported Incident Form revealed Resident 17 alleged Staff 15 (LPN) was verbally abusive. An undated incident summary revealed the following: -On 1/20/19 at approximately 8:00 AM Resident 17 alleged neglect and verbal abuse. -Resident 17 approached Staff 15 and began to yell. Staff 15 continued to pass medications. -Staff 15 attempted many times to speak with Resident 17 to calm her/him down but was unsuccessful. -Resident 17 wanted an enema but did not have an order. Staff 15 obtained an order and an enema was administered. -911 was called. -Resident 17 stated Staff 15 was an idiot and was going to report her. -The video was reviewed, there was a verbal interaction. -Witness statements revealed the following: -Resident 17 stated she/he pressed the call light and was waiting and screaming for help. The resident self-transferred into the wheelchair and complained to the nurse about the call light. Staff 15 yelled at her/him saying there was nothing she could do about it and was going to call the police. Resident 17 asked for an enema and Staff 15 refused, yelled at her/him more and said she was not going to help her/him. Resident 17 felt threatened because Staff 15 called the police and felt it was abuse. -Staff 15 stated the resident came down the hall yelling and cussing. The resident called her stupid and threatened her and threatened to report her because of a long call light. Resident 17 asked for an enema. Staff 15 stated she could not administer one because she/he did not have an order but would get one. Staff 15 asked the resident not to yell at her and she would help her/him when he calmed down and stopped yelling at her, which did not work. The resident continued to yell and name call so Staff 15 called the police but they would not come because the resident was not being physically aggressive. Staff 15 stated even with the enema administered the resident called her stupid and said she/he would report her. -Staff 6 (CNA) stated she heard the resident arguing with Staff 15. Staff 15 was frustrated and removed herself. The resident was asking Staff 15 for an enema which she provided later in the day. -Staff 14 (CNA) stated she heard the resident threaten and cuss at Staff 15 because she/he wanted an enema. Staff 15 explained there was no order but was working on one. Staff 15 called the police on the resident for the resident's behavior. -Staff 28 (CNA) stated the resident was yelling and screaming because she/he wanted an enema. Staff 28 tried to explain she/he needed an order but the resident continued to cuss. Staff 15 went into the dining room and was able to continue to pass medications. The resident went to her/his room and was calm but angry the rest of the day. In an interview on 1/24/19 at 1:06 PM Staff 1 (Administrator) verified the information contained within the incident summary he completed. Staff 1 stated he reviewed the video of the incident to help make the unsubstantiated allegation of verbal abuse but did not keep a copy of the video. In an interview on 1/30/19 at 10:44 AM Staff 6 stated she witnessed the interaction between Staff 15 and Resident 17. Staff 6 stated Resident 17 asked Staff 15 what was taking so long and was screaming. Staff 15 told Resident 17 to get away really loud. Staff 15 told Resident 17 it was illegal for her/him to be near her during medication pass. Staff 6 stated she never experienced another staff yell or speak to a resident so unprofessionally. Staff 6 stated Staff 15 threatened to call the police with no rationale for the need for police intervention. Staff 6 stated at no time was there a need for Staff 15 to call the police or speak to the resident so unprofessionally. Attempts to contact Staff 15, Staff 14 and Staff 28 were unsuccessful. On 1/29/19 at 3:36 PM the facility was notified of an immediate jeopardy (IJ) situation related to facility's failure to keep Resident 10 free from multiple incidents of retaliation, intimidation and agitation from Staff 4. This failure placed all residents at risk for abuse, neglect, exploitation or misappropriation of resident property. On 1/29/19 at 6:58 PM an accepted facility plan to remove the immediate jeopardy situation was submitted by the facility. The plan included the following: -Resident 10 investigations will be reviewed and further interview will be conducted with staff. The activities director will be suspended pending further investigation. Activities director will not be permitted to pass Resident 10 in the hallway or have any other interactions with Resident 10. -DNS/Administrator will review abuse investigations that occurred in the last six months for thorough investigations. Resident interviews will be conducted for satisfaction with care and services. Administrator or designee will follow up as warranted. -Administrator, DNS or nurse consultant will provide one on one abuse training with current employees at the beginning of every shift for the next seven days or until current employees are educated. Relias learning abuse training will be assigned by 2/9/19. Activities director will be reeducated on how to handle residents with difficult behaviors and the plan for her interactions with Resident 10. -Administrator and DNS will review 24 hour reports three times per week for three months and screen for allegations of abuse. Review actual incidents for thoroughness as they occur. On 1/29/19 the IJ removal plan was verified by ensuring staff were being educated, residents were being interviewed for any care, services and abuse concerns and the activities director was no longer in the building.

Based on observation, interview and record review it was determined the facility failed to implement policies and procedures for the prevention of abuse for 4 of 4 sampled residents (#s 1, 5, 10 and 17) reviewed for abuse. These failures, determined to be an immediate jeopardy situation, resulted in Resident 5 being physically abused, Resident 17 mentally abused and Resident 10 mentally abused and intimidated and Resident 1 placed at risk for sexual abuse. This placed residents at risk for abuse, neglect and exploitation. Findings include: The 2006 Abuse Prevention Program policy used by the facility revealed the following: -The facility was committed to protecting resident from abuse by anyone. -Comprehensive policies and procedures were developed to aid the facility in preventing abuse, neglect or mistreatment. -The abuse prevention program provided policies and procedures that at a minimum ensured the facility: -mandated training on abuse prevention, reporting, stress management, dealing with violent behaviors or catastrophic reactions; -identified occurrences and patterns of potential mistreatment or abuse; -protected the residents during abuse investigations; -developed investigative protocols; -completed timely and thorough investigations of all reports and allegations of abuse; -report and filings of accurate documents relative to incidents of abuse; -ongoing review and analysis of abuse incidents; -implement changes to prevent further occurrences of abuse. The 2014 Abuse Investigations policy used by the facility included the following: -should incidents or suspected incidents of abuse be reported the administrator or designee should investigate the alleged incident; -the investigation will at a minimum be: -reviewed for completed documentation forms; -the resident's medical record would be reviewed to determine if any events lead up to the incident; -interview the person(s) reporting the incident; -interview any witness' to the incident; -interview the resident (as appropriate); -interview staff members on all shifts who had contacts with the resident during the period of the alleged incident; -interview the resident's roommate, family members and visitors; -interview other residents who the accused employee provided care; -witness reports would be obtained in writing by either the staff member or investigator and have the staff sign and date it; -the ombudsman will be notified of the abuse allegation; -employees accused of resident abuse would be suspended immediately pending the outcome of the investigation; -the administrator would provide a written report of the results to the state survey agency, the local police, the ombudsman and others as required within five days of the reported incident. 1. Resident 1 was admitted to the facility in 12/2018 with [DIAGNOSES REDACTED]. A 12/3/18 Nursing Facility Reported Incident Form completed by Staff 2 (DNS) revealed the following: -Resident 1 reported waking up with her/his pants off and was nude from the waist down. Resident 1 believed someone removed her/his clothes and was possibly violated and slept through the event; -No one witnessed the event; -Yes and No were checked to the question has this happened to the same resident(s) or others; A 12/3/18 Investigative Note revealed the following: -On 12/3/18 Resident 1 reported to Staff 1 (Administrator) that she/he woke without pants on and was nude from the waist down but went to bed wearing pants. The resident was uncertain if she/he had been violated overnight. -Staff 1 reviewed the video footage and Staff 27 (CNA) entered the room for approximately five minutes. Staff 27 denied anything unusual going on. -Staff 1 interviewed Staff 26 (RN) and she could not remember anything out of the ordinary that evening. In an interview on 1/17/19 at 11:37 AM Staff 1 stated Staff 27 did not complete a witness statement, he had spoke to Staff 27 and did not want to imply she was being accused of anything. Staff 27 was the only staff who entered the room per Staff 1's video review. Staff 1 did not interview any residents or any additional staff on shift. Staff 1 stated he did not keep the video because he did not know how to download the footage. In an interview on 1/17/19 at 12:37 PM Staff 2 (DNS) stated she did not watch the video, but Staff 1 told her a female housekeeper and Staff 27 entered Resident 1's room. Staff 2 stated the resident should be checked on every two hours and as needed and someone could have taken off her/his pants during care. Staff 2 stated she completed an assessment but was unable to provide documentation an assessment was completed. Staff 2 stated she did not interview any residents or other potential witnesses. 2. Resident 5 was admitted to the facility in 9/2018 with [DIAGNOSES REDACTED]. A 11/23/18 investigation note completed by Staff 1 (Administrator) revealed Resident 5 was agitated and entered the nurse's station. Staff 25 (Agency LPN) asked the resident to leave and Staff 25 physically removed Resident 5. On 1/18/19 at 12:09 PM the facility's video showed Resident 5 was in the nurses's station standing near Staff 25. Staff 25 and Resident 5 were observed to have a verbal exchange but the video had no audio. Staff 25 got up from his chair and pushed the resident's arms and hands. Staff 25 pushed Resident 5 backwards into a chair and pushed the resident out of the nurses's station. Staff 25 pointed to the floor just outside the nurses station. Resident 5 re-entered the nurses's station and Staff 25 again pushed the resident backwards out of the nurses's station. Staff 6 (CNA) was present during part of the incident. In an interview on 1/23/19 at 11:16 AM Staff 1 stated he did not know if he had any additional interviews or documentation other than the investigative note. Staff 1 stated he did not know the staff member (Staff 6) in the video and further stated he did not interview the staff (Staff 6). In an interview on 1/23/19 at 12:40 PM Staff 2 (DNS) stated she did not complete the investigation but the staff member in the video was Staff 6. 3. Resident 10 was admitted to the facility in 6/2018 with [DIAGNOSES REDACTED]. a. An undated incident summary completed by Staff 2 (DNS) revealed the following: -On 12/24/18 at approximately 7:00 PM it was reported to Staff 2 that Resident 10 was getting pickles out of the jar and Staff 4 smacked her/his hand earlier in the day on 12/24/18 at 2:42 PM. -Staff 2 called Staff 4 (Activities Director) and she stated she was not aware of an incident that day and certainly not one that involved her slapping the resident. -Staff 2 failed to report the incident until 12/26/18. -On 12/26/18 Resident 10's spouse called in a police report because Staff 4 was still on the premises after the allegation of abuse. -Staff 4 was sent home pending the investigation. -The video revealed Resident 10 sat behind Staff 4 while Staff 4 cut up fruit and other items. Staff 4 noted Resident 10 reached into the jar with bare hands but there was no audio of the exchange. Immediately after the exchange, Resident 4 propelled herself/himself away from the table. -A resident who stated she/he saw the incident was not believed to be credible because the video showed the resident was not looking at Resident 10. Staff 4's 12/26/18 payroll revealed she worked at the facility on 12/26/18 from 9:34 AM through 5:48 PM. In an interview on 1/28/19 at 2:39 PM Staff 4 stated she worked the entire day on 12/26/18 while Resident 10 was present in the building. In an interview on 1/29/19 at 10:35 AM, Staff 2 stated on 12/24/18 she learned about the allegation Staff 4 hit Resident 10 but failed to report the allegation until 12/26/18 but should of within two hours. Staff 2 stated there were other residents in the common area but she did not interview them. Staff 2 stated she did not interview any other potential witnesses. Staff 2 stated she considered the allegation as unsubstantiated after watching the video on 12/26/18 at approximately 10:00 AM. In an interview on 1/29/19 at 10:35 AM Staff 1 (Administrator) stated he did not keep a copy of the incident on 12/24/18. Staff 1 stated he expected all staff to follow the abuse and investigative protocols. b. The 1/11/19 Nursing Facility Reported Incident Form revealed on 1/11/19 Resident 10 reported Staff 4 (Activities Director) passed her/him in the hall, said nothing but hit the resident on her/his shoulder. The 1/11/19 incident summary revealed Staff 4 did not physically contact Resident 10. Staff 4 walked closely down the hall near Resident 10. Staff 4 was previously told by administration to have a witness present during all interactions with Resident 10 in the dining and resident room. The 1/11/19 video was reviewed by a NFSU Surveyor. Staff 4 did not physically contact Resident 10. Staff 4 was observed to walk very close to Resident 10 in an open hallway where there was adequate space to avoid coming into close proximity to the resident. In an interview on 1/28/19 at 2:39 PM Staff 4 stated she could not recall walking close to Resident 10. In an interview on 1/29/19 at 10:35 AM Staff 1 (Administrator) stated he sat down with Staff 4 and Resident 10 and they agreed not to interact with each other and the facility tried to plan accordingly to avoid contact between the two. Staff 1 stated he did not know if there was any updates to the care plan or documentation to support the intervention. Review of Resident 10's records and investigations revealed no documented interventions were in place to ensure her/his safety from Staff 4. c. On 1/28/19 Resident 10 reported to a NFSU Surveyor that Staff 4 (Activities Director) walked close to her/him and said happy, happy, happy because the resident's spouse was no longer allowed on the premises. The 1/28/19 video was reviewed by NFSU Surveyor. Staff 4 was observed to walk close to the resident, smiled in the resident's direction, walked close behind the resident's wheelchair and Staff 4 was seen saying something while directly behind the resident. The video had no audio. In an interview on 1/28/19 at 2:17 PM Staff 1 (Administrator) stated there was only a verbal agreement in place and there was no formal interventions in place to ensure Staff 4 and Resident 10 had no continued interactions. 4. Resident 17 was admitted to the facility in 1/2019 with [DIAGNOSES REDACTED]. A 1/21/19 Nursing Facility Reported Incident Form revealed Resident 17 alleged Staff 15 (LPN) was verbally abusive. In an interview on 1/24/19 at 1:06 PM Staff 1 (Administrator) stated he reviewed the video of the incident to help make unsubstantiated the allegation of verbal abuse but did not keep a copy of the video. On 1/29/19 at 3:36 PM the facility was notified of an immediate jeopardy situation related to facility's failure to implement policies and procedures to ensure residents (#s 1, 5, 10 and 17) were free from abuse. This failure placed residents at risk for abuse, neglect, exploitation or misappropriation of resident property. On 1/29/19 at 6:58 PM an accepted facility plan to remove the immediate jeopardy situation was submitted by the facility. The plan included the following: -Resident 5 is no longer in the facility. Resident 1, Resident 10 and Resident 17 investigations will be reviewed, and further interviews will be conducted with potential witnesses. Activities Director will be suspended pending further investigation. Activities Director will not be permitted to pass Resident 10 in hallway or have any other interactions with Resident 10. -DNS/administrator will review abuse investigations that occurred in the last six months for thorough investigation. Resident interviews will be conducted for satisfaction with care and services. Administrator or designee will follow up as needed. -Administrator, DNS or nurse consultant will provide one on one abuse training with current employees at the beginning of every shift for the next seven days or until current employees are educated. Relias Learning abuse trainings will be assigned by (MONTH) 9th, 2019. Activities Director will be reeducated on how to handle residents with difficult behaviors and the plan for her interactions with Resident 10. Abuse policy will be reviewed monthly during all-staff meeting for the next six months. -Administrator and DNS will review 24 hour report three times per week for three months and screen for allegations of abuse. Review actual incidents for thoroughness as they occur. On 1/29/19 the IJ removal plan was verified by ensuring staff were being educated, residents were being interviewed for any care, services and abuse concerns and the activities director was no longer in the building. Based on observation, interview and record review it was determined the facility failed to implement policies and procedures to ensure appropriate employee fitness determination was completed for 5 of 5 sampled staff (#s 19, 12, 21, 14 and 20) hired in the last four months. As a result of this deficient practice, which was determined to be an immediate jeopardy situation, all residents were placed at risk for abuse, neglect, exploitation or misappropriation of resident property. Findings include: The 2006 Abuse Prevention Program policy used by the facility revealed the following: -The facility conducted employee background checks and would not willingly employ any individual who had been convicted of abuse, neglect or mistreatment. -The abuse prevention program provided policies and procedures that at a minimum ensured the facility . had protocols for conducting employee background checks. On 1/31/19 at 2:45 PM a record review of 5 of 5 staff personnel records with Staff 22 (Office Manager/Medical Records) found the facility failed to conduct employee fitness screening which included reference, professional licensure and/or criminal background check verifications as follows: - Staff 19 (Dietary Cook) - Incomplete reference check, No criminal background check: - Staff 12 (Dietary Manager) - No references: - Staff 21 (LPN) - Incomplete reference check, No nurse license verification, No criminal background check; - Staff 14 (CNA) - Incomplete reference check; - Staff 20 (CMA/CNA) - Incomplete reference check. In interview on 1/31/19 at 2:45 PM Staff 22 stated various different staff have been responsible to check new staff references and monitor completion of personnel records. In interview on 1/31/19 at 2:54 PM surveyor requested the facility's written policy for screening new staff and active supervision from Staff 1, (Administrator). No information was provided. In interview on 1/31/19 at 3:11 PM Staff 22 stated Staff 21 worked in the facility since 1/10/19 and no references, criminal background or nursing license had been verified. Staff 22 stated she did not have two pieces of identification for Staff 21, so she had not been able to do a criminal background check. Staff 22 stated she had not been trained to perform license verification with the Oregon State Board of Nursing (OSBN) for nursing staff. In interview and record review on 1/31/19 at 3:11 PM Staff 22 stated Staff 19 worked in the facility since 1/3/19 and his criminal background check was pending. The electronic criminal background request for Staff 19 was printed on 1/31/19 (28 days after Staff 19 started work) which stated Finger Prints will be required for this applicant; HIRING ON A PRELIMINARY BASIS NOT ALLOWED. Staff 22 acknowledged Staff 19 was not approved to begin work. In interview on 1/31/19 at 3:58 PM Staff 1 acknowledge staff fitness determinations were incomplete. On 1/31/19 at 3:59 PM record review identified Staff 1 and Staff 22 had an approved QED (Qualified Entity Designee) Certification and were responsibility for staff criminal background check verifications. On 1/31/19 at 4:03 PM Staff 19 was observed to be at work in the facility kitchen. Staff 19 stated he worked in the facility since 1/3/19. On 1/31/19 at 5:37 PM the facility was notified of an immediate jeopardy situation related to facility's failure to implement policies and procedures to ensure appropriate staff fitness determinations were completed for 5 of 5 staff reviewed for fitness determination, including failure to perform references, license nurse verification and criminal background checks for new staff. This failure placed all residents at risk for abuse, neglect, exploitation or misappropriation of resident property. On 1/31/19 at 5:45 PM an accepted facility plan to remove the immediate jeopardy situation was submitted by the facility. The plan indicated the facility would implement the following actions to address the immediate concerns related to staff fitness determinations: - Staff 19 was removed from facility and removed from the facility schedule until criminal background check was approved; - Screening procedures implemented to assure complete personnel records; - Staff training on policies for Background Screening Investigations; - Reference checks would be completed on all current staff; and - QAA Committee will review new employee personnel files monthly for completeness. On 2/1/19 at 9:19 AM the immediate jeopardy removal plan was verified through additional information.

Based on interview and record review it was determined the facility neglected to provide the prescribed diet for 1 of 3 sampled residents (#13) reviewed for Nutrition. This resulted in Resident 13 developing aspiration pneumonia and being admitted to the hospital. Findings include: Resident 13 was admitted to the facility in March 2016 with [DIAGNOSES REDACTED]. Review of Resident 13's Diet order dated 7/18/16 revealed the resident was not to have any ground meat and to cut meat into bite size pieces. Review of a Self Report Form dated 7/26/16 revealed Resident 13 was served the incorrect dietary texture during the noon meal on 7/23/16. Resident 13 was served a meal containing ground meat which resulted in the resident choking. Staff performed back blows and abdominal thrusts on the resident until food was dislodged from her/his throat and choking stopped. The Self Report Form stated the Dietary Manager had prepared the resident's meal and stated she made a mistake. On 9/22/16 at 9:36 am, Staff 2 (LPN-Charge nurse) stated she was the staff who served Resident 13 her/his meal from the kitchen on 7/23/16. Staff 2 stated she checked the meal to assure it was mechanical soft texture but did not check to make sure it did not contain ground meat. Staff 2 stated facility staff have received training post incident to ensure other residents' meals are correct.

Based on interview and record review it was determined the facility neglected to provide the prescribed diet for 1 of 3 sampled residents (#13) reviewed for Nutrition. This resulted in Resident 13 developing aspiration pneumonia and being admitted to the hospital. Findings include: Resident 13 was admitted to the facility in March 2016 with [DIAGNOSES REDACTED]. Review of Resident 13's Diet order dated 7/18/16 revealed the resident was to receive mechanical soft texture-NO GROUND MEATS- assist cutting into small pieces. Review of a Self Report Form dated 7/26/16 revealed Resident 13 was served the incorrect dietary texture during the noon meal on 7/23/16. Resident 13 was served a meal containing ground meat which resulted in the resident choking. Staff performed back blows and abdominal thrusts on the resident until food was dislodged from her/his throat and choking stopped. The Self Report Form stated the Dietary Manager had prepared the resident's meal and stated she made a mistake. A progress note dated 7/25/16 revealed Resident 13 was having increased difficulty with speech, incontinence, increased production of thick, sticky sputum which the resident was unable to clear. Resident 13 was sent out to the hospital the same day. Review of emergency department records dated 7/25/16 reveled Resident 13 was diagnosed with [REDACTED]. On 9/22/16 at 9:20 am, Staff 1 (DNS) stated all staff were to check each meal prior to it being served to a resident. This process was to ensure what was on a resident's plate matched the resident's meal card and prescribed diet. The DNS stated on the day of the incident neither the Dietary Manager nor the nurse who served the meal to Resident 13 ensured the meal and the meal card matched. This resulted in the resident choking which lead to aspiration pneumonia. The DNS stated the Dietary Manger who was working the day of the incident no longer worked at the facility. On 9/22/16 at 9:36 am, Staff 2 (LPN-Charge nurse) stated she was the staff who served Resident 13 her/his meal from the kitchen on 7/23/16. Staff 2 stated she checked the meal to assure it was mechanical soft texture but did not check to make sure it did not contain ground meat. Staff 2 stated facility staff have received training post incident to ensure other residents' meals are correct. Refer to F367.