Every finding on record at Bethea Baptist Healthcare Center

Based on interviews and record reviews, the facility failed to develop comprehensive person-centered care plans related to Advance Directives for 14 of 18 residents (Resident(R)1, R5, R7, R10, R18, R23, R25, R33, R34, R35, R41, R42, R43, and R67) in accordance with their wishes. Findings include: A review of the undated facility policy titled, Residents' Rights Regarding Treatment and Advance Directives revealed the definition of an advance directive and, Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and determine whether the resident would like to formulate an advance directive. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. A review of the undated facility policy titled, Comprehensive Assessment and the Care Delivery Process revealed, Policy Interpretation and Implementation. 1. Comprehensive assessments, care planning, and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. 7. Completed assessments (baseline, comprehensive, MDS, etc.) are maintained in the resident's active record for a minimum of 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan. Review of R1's Advance Directive revealed wishes to remain a full code. The care plans with a review date of 03/26/26 were reviewed and indicated there was no care plan to address the resident's wishes. A review of R5's medical record revealed an advance directive with a code status of Do Not Resuscitate (DNR). A review of R5's care plan dated 02/19/26 revealed there was no care plan to address her advance directive. A review of R7's medical record revealed an advance directive with a code status of DNR. A review of R7's care plan dated 04/09/26 revealed there was no care plan addressing her advance directive. A review of R10's medical record revealed an advance directive with a code status of DNR. A review of R10's care plans dated 11/25/25 when R10 was admitted , and a reviewed and continued date of 03/05/26 revealed there was no care plan addressing her advance directive. Review of R18's Advance Directive revealed wishes for Do Not Resuscitate (DNR). The care plans with a review date of 02/07/26 were reviewed and indicated there was no care plan to address the residents' wishes. Review of R23's Advance Directive revealed wishes for DNR. The care plans with a review date of 04/03/26 were reviewed and indicated there was no care plan to address the resident's wishes. Review of R25's Advance Directive revealed wishes to remain a full code. The care plans with a review date of 04/16/26 were reviewed and indicated there was no care plan to address the resident's wishes. A review of R33's medical record revealed an advance directive with a code status of Full Code. A review of R33's care plans dated 12/01/25 on admission and had a reviewed and continued date of 03/05/26. There was no care plan addressing R33's advance directive. A review of R34's medical record revealed an advance directive with a code status of FULL CODE. A review of R34's care plan dated 02/05/26 revealed there was no care plan addressing her advance directive. A review of R35's medical record revealed an advance directive with a code status of DNR. A review of R35's care plan dated 03/19/26 revealed there was no care plan addressing her advance directive. Review of R41's Advance Directive revealed wishes to remain a full code. The care plans with a review date of 03/23/26 were reviewed and indicated there was no care plan to address the resident's wishes. Review of R42's Advance Directive revealed wishes to remain a full code. The care plans with a review date of 04/19/26 were reviewed and indicated there was no care plan to address the resident's wishes. A review of R43's medical record revealed an advance directive with a code status of full code. A review of R43's care plan dated 03/12/26 revealed there was no care plan addressing her advance directive. Review of R67's Advance Directive revealed wishes to remain a full code. A review of R67's care plan dated 04/16/26 revealed there was no care plan addressing advance directive. During an interview on 04/23/26 at 11:19 AM with the Minimum Data Set (MDS) Coordinator, she stated she does not do Advance Directives care plans. She stated her care plans were developed based on Care Area Assessments (CAAs) identified during the MDS process. She indicated she had not read the policy on comprehensive care plans and was not sure what it says. She also stated that when she was trained, developing an Advance Directives care plan was not taught to her. During an interview on 04/23/26 at 11:34 AM with the Director of Nursing (DON), she stated she was not sure if Advance Directive care plans were supposed to be implemented. She indicated the resident's Advance Directives are discussed during Care Conference Meetings at least quarterly. She confirmed residents did not have an Advance Directive care plan. During an interview on 04/24/26 at 9:10 AM with the Administrator revealed he was unaware resident's Advance Directives needed to be addressed on the care plan.

Number of residents sampled: 21 residents on EBPNumber of residents cited: 1Based on observation, interview, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during two of two observations [Certified Nurse Aide (CNA) BB and Licensed Practical Nurse (LPN) AA] during high-contact resident care activities for one of 21 residents (including 11 supplemental residents) reviewed for precautions (Resident (R)5). This was evidenced by an LPN and a CNA failing to don the required PPE while performing wound care and linen changes. Findings include: A review of the undated facility policy titled, Infection Prevention and Control Program revealed, Policy Explanation and Compliance Guidelines: . 2. All staff are responsible for following all policies and procedures related to the program . 4. Standard Precautions: . c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . 5. Isolation Protocol (Transmission-Based Precautions): . a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection.A review of the undated facility policy titled, Enhanced Barrier Precautions revealed, .Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. 2. Initiation of Enhanced Barrier Precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds. 3. Implementation of Enhanced Barrier Precautions: . b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities . 4. High-contact resident care activities include: . g. Wound care: any skin opening requiring a dressing. A review of the facility policy dated 01/01/25 titled, Personal Protective Equipment revealed, . Personal protective equipment, or PPE, refers to a variety of barriers . to protect mucous membranes, skin, and clothing from contact with infectious agents. It includes gloves, gowns. Policy Explanation and Compliance Guidelines: . 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 7. Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed. A review of the facility policy dated 1/1/25 titled, Handling Soiled Linen revealed, .Definitions: Linen includes sheets, blankets, pillows, towels, washcloths, and similar items from departments such as nursing. Contaminated linen is linen that has been soiled with blood or other potentially infectious materials. The policy did not identify PPE or other procedures for the handling of linen in relation to residents on enhanced barrier precautions. A review of the Centers for Disease Control (CDC) publication dated June 2021 and titled, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, revealed, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities Enhanced Barrier Precautions can be applied . to residents with any of the following: Wounds or indwelling medical devices . Consistent with 2019-2020 CDC EBP interim guidance . examples of high contact resident care activities include . changing linens . and wound care. A review of R5's medical record revealed she had diagnoses of right and left below-the-knee amputations with the most recent being of the left lower extremity on 01/02/26, which continues with a wound at the surgical site. Current physician orders dated [date of the order reviewed] were reviewed and indicated [specific orders as identified in the order, including the specific wound care to be provided]. A review of LPNAA's staff training record revealed that she had completed a course titled, Annual Federal Training Summary which included a course titled, Infection Prevention Control on 10/09/25. Further review revealed that LPNAA completed a training course titled Knowledge Check: Personal Protective Equipment Use on 10/28/25. A review of CNABB's staff training records revealed that she had completed a course titled, Annual Federal Training Summary which included a course titled, Infection Prevention Control on 10/02/25. Further review revealed that CNABB completed a training course titled Knowledge Check: Personal Protective Equipment Use on 10/02/25. An observation on 04/21/26 at 10:35 AM, of a sign posted on the doorframe of R5's room, revealed, a laminated single-page notice in color containing images of two stop signs, and it read, Enhanced Barrier Precautions. Everyone Must: . Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities: . Changing Linens.Wound Care: any skin opening requiring a dressing. An observation on 04/23/26 at 10:35 AM of LPNAA revealed she entered R5's room to perform wound care without donning a gown. LPNAA performed wound care on R5's left below-the-knee amputation surgical site and exited the room. An observation on 04/23/26 at 11:15 AM revealed CNABB changing bed linens in R5's room without wearing a gown or gloves. In an interview on 04/23/26 at 10:55 AM, LPNAA acknowledged the presence of the sign for EBP and explained it was in place for infection prevention related to R5's wound and that wound care was considered direct patient care. She read the sign and stated, I forgot the gown. An interview on 04/23/26 at 11:20 AM with the Director of Nursing (DON) revealed it was her expectation that a gown and gloves be worn during a dressing change for a resident who is on EBP. When asked if a gown and gloves should be worn during linen changes for a resident on EBP, she said, No, not when changing linens only; when the resident is not receiving direct care at the time, this contradicted the instructions on the posted sign and the EBP sign provided for review. An interview on 04/23/26 at 12:55 PM with CNABB revealed she was uncertain if gowns and gloves were required to be used when changing bed linens for a resident on EBP.

Based on facility policy, record reviews and interviews the facility failed to ensure an anticipated discharge for Resident (R)57) was documented and facilitated to ensure a safe and well planned discharge to the community for 1 of 1 residents reviewed for admission transfer and discharge. Specifically R57 was ordered by the physician at discharge, for home health which was not set up prior to discharge by the facility. Findings include: Review of the facility policy titled, Transfer and Discharge. states, Anticipated Discharge, is a discharge that is planned and not due to the resident's death, or an emergency. Policy Explanation and Compliance Guidelines. 2b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so that the resident no longer needs services provided by the facility. 12. Anticipated Discharge to the Community. a. Facility will obtain a physician's order for transfer or discharge instructions or precautions for ongoing care. b. A member of the interdisciplinary team will complete relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to the following: i. A recap of the resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results. ii. A final summary of the resident's status. iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter). iv. A post discharge plan of care that is developed with the participation of the resident, and the resident's representative(s) which will assist the resident to adjust to his or her new living environment. c. Orientation for transfer or discharge will be provided and documented to ensure a safe and orderly transfer or discharge from the facility, in a form and manner that the resident can understand. Depending on the circumstances, this orientation may be provided by various members of the interdisciplinary team. d. Facility will assist with transportation arrangements to the new facility and any other arrangements as needed. e. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge. f. Supporting documentation shall include evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the resident and/or resident representative. Review of the facility policy titled, Documentation in Medical Record, states as the the policy, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The facility admitted R57 on 12/16/2024 with severe protein calorie malnutrition, acute and chronic kidney failure, muscle weakness, need for assistance with personal care, history of a pulmonary embolus and anemia. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview of Mental States) coded as 13 out of 15 indicating no cognitive deficits. Review of the discharge progress note from the physician dated 01/01/2025 states as the discharge orders: 1) Continue medical management. 2) PO (by mouth) diet 3) Tolerating PT and OT 4) OK to D/C (discharge home) with HH (Home Health) The home health order was never carried out, so R57 did not receive home health as ordered by the physician. Review of the Comprehensive Plan of Care for R57 revealed a problem area: Family and resident will discuss discharge options with social worker or designee that will ensure a safe discharge plan for myself. Goal: Resident will be discharged to community with a safe plan in place. Staff will review discharge plans comprehensive assessments only. Interventions: Refer to discharge observation form for final discharge arrangements. Resident will receive assists with referrals to appropriate community agencies. SS will explore options with resident and family for safe discharge planning. Staff will discuss discharge plans with resident and family at time of admission. Review of the last progress note on 04/02/2025 at 2:45 PM is documented as follows: Progress note: Last note: 01/01/2025 at 09:30 AM Resident in bed, alert and verbal, speech clear, able to make wants and needs known. Skin warm and dry to touch. Respirations even and unlabored, no signs of SOB noted. Continent to bowel and bladder. Uses walker for mobility, participates in PT. AM meds taken whole with thin liquids, with no difficulty. Able to feed self after tray setup. Meals taken in room. Bed locked and lowered and call light within reach of resident. Review of the Progress note: Last and only note for Social Services 12/23/2024 at 11:25 AM Resident was addressed as an admission/5day assessment. Resident scored cognitively intact on her BIMS interview (13 of 15). Resident is alert and verbal and able to express her wants and needs. Resident receives assistance from staff in meeting her wants and needs. Resident denied having any mood issues during the mood interview. Resident was encouraged to reach out if needed. Resident had no noted behaviors or refusals during the review period. Resident is a short term rehab patient with plans to return home upon completion of her rehab services. Staff will continue to observe for any changes in resident, and make appropriate staff aware of any changes. Social will continue to monitor as indicated. During an interview on 04/03/2025 at 09:00 AM with the DON she confirmed the progress notes and provided text messages back and forth with the Medical Supply Company, the note read, Good afternoon. Resident is scheduled for discharge on the 2nd. Upon her return home, she will need a shower chair and rolling walker. Therefore, I kindly ask if you could deliver those one day before her discharge date . Thank you for your assistance. Response: Resident is good, is it ok if we deliver it tomorrow while we are already there? We are not open on the 1st. Social Service response: Absolutely, that sounds great! Thank you so much. At this time of the discharge and the setting up of the durable medical equipment, the social service director is on medical leave. An administrative assistant is sending faxes to the medical equipment company using the social service providers emails. During an interview on 04/03/2025 at 11:34 AM with the Social Service Director she confirmed that she was on medical leave starting on 12/26/2024. She stated that the scheduler was handling the discharge. She confirmed that the scheduler had used her email to order the medical equipment for R57 and then confirmed that the home health for R57 was not set up according to the physician's orders. During an interview on 04/03/2025 at 11:50 AM with the Administrator and the Scheduler that was filling in for the Social Worker on 01/01/2025 confirmed that the email for the social worker was used by the scheduler to order the medical equipment and also confirmed that the home health ordered by the physician on 01/01/2025 had not been set up upon discharge home for R57.

Based on observations, interviews, record review and facility policy, the facility failed to administer oxygen according to physician's orders for 1 of 1 residents reviewed for respiratory care, Resident (R)10. Findings include: Review of the facility's policy titled, Oxygen Administration with revision date October 2010 revealed, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Steps in the Procedure: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. Review of R10's face sheet revealed he was admitted to the facility on [DATE] with diagnosis including, but not limited to, type II diabetes, major depressive disorder, hemiplegia, hypertension, dementia and chronic sinusitis. Review of R10's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/28/25 revealed R10 had a Brief Interview of Mental Status (BIMS) score of 10 of 15, indicating that the resident is moderate cognitively impaired. Review of R10's Physicians Orders for months March- April 2025 revealed R10's Oxygen order is, O2 Per 2 L/min continuous R/T resp failure twice a day. Review of R10's Progress Notes dated from 03/07/25 revealed, resident is alert and oriented with confusion @ times. O2 @ 2 liters via nasal cannula. Respirations are even and unlabored. Skin is warm & dry. He takes his medications while with Glucerna. He is incontinent of bowels with incontinence care & turning every 2 hours & as needed. Foley catheter to BSD with adequate output noted. He is able to make his needs known. Call light is within easy reach. Bed is low and locked. Review of R10's Care Plan with a start date of 08/24/23 revealed, resident is at risk for respiratory distress due to obstructive sleep apnea and respiratory failure. I refuse to wear my c-pap. Interventions include administer oxygen as ordered. Maintain oxygen equipment as directed initiated on 07/16/24. During an observation on 04/03/25 at 08:33 AM, R10's oxygen tank was on with an oxygen flow rate of 2L/min via nasal cannula in resident's nose. During an observation on 04/03/25 at 10:30 AM, R10's oxygen machine was not turned on while resident had nasal cannula in his nose. Registered Nurse (RN)1 was present in the resident's room. During an interview on 04/03/25 at 1030 AM, RN1 states that she wasn't aware that the oxygen machine was turned off in the resident's room. R10's nasal cannula was in his nose, and she thought that the oxygen was on. During an interview on 04/03/25 at 2:45 PM, the Director of Nursing (DON) states that her expectation of staff is to follow guidelines for oxygen therapy for the residents and to ensure they are following the physician orders. The DON states that when nurses conduct rounds, they are to check if the resident has oxygen, ensure the oxygen machine is on, and the nasal cannula is in the resident's nose. She also states that the nurses are to assess the resident's respiratory status. The DON states that clinical trainings are conducted on an annual basis.

Based on observations, interviews, and facility policy, the facility failed to ensure that medications belonging to Resident (R)10 were properly stored, secured, and/or administered prior to staff leaving the room for 1 of 1 residents reviewed for medication storage and administration. Findings include: Review of the facility policy titled, Medication Storage, with no revision date revealed, it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines, 1c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of R10's face sheet revealed he was admitted to the facility on [DATE] with diagnosis including, but not limited to, type II diabetes, major depressive disorder, hemiplegia, hypertension, dementia and chronic sinusitis. Review of R10's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 03/28/25 revealed R10 had a Brief Interview of Mental Status (BIMS) score of 10 of 15, indicating that the resident is moderate cognitively impaired. Review of R10's Medication Administration Record (MAR) for April 2025, physician orders for 04/03/25 revealed an administration record for 7:00AM-10:00AM of Aspirin 81mg tab, Amlodipine 10mg tab, Finasteride 5mg tab, Macrodantin 50mg cap, Potassium Chloride 20 mEq cap, Sertraline 25mg tab, Tab-A-Vite 400mcg tab, Tamsulosin 0.4mg cap, and Urecholine 50mg tab. Registered Nurse (RN)1 signed off for administration on 04/03/25 as a late entry for medications at 10:46AM. Medications observed on R10's bedside table at 10:30AM. Review of R10's orders did not include an order for self-administration of medication. During an observation on 04/03/25 at 10:30 AM, R10's room revealed, one clear medicine cup on the overbed table with multiple pills inside. The medication cup was unlabeled as to the medication contents. During an interview on 04/03/25 at 10:30 AM, RN1 states that she verifies the medications on the MAR prior to giving them to the residents. RN1 states she left R10's morning medications at bedside in a medication cup that consist of nine pills. She didn't observe resident take the medications. RN1 states that this isn't her usual practice, and she knows that she isn't supposed to leave the medications at bedside unattended. RN1 states that the resident could have choked or someone else could have taken the medication. During an interview on 04/03/25 at 11:11 AM, the Director of Nursing (DON) states that her expectations for staff are to check the MAR prior to medication administration and to verify the medication card to ensure that the meds are given to the right patient. The DON states that staff stays at bedside while the medication is being administered to ensure the resident takes the medications. The DON states that staff doesn't leave medications unattended in a resident's room. The DON explains that staff are to always follow policy and procedures.

Based on the facility policy, record reviews and interviews, the facility failed to ensure complete and accurate records related to a planned discharge for Resident (R)57). Specifically, there is no documentation in the medical record for R57 pertaining to a discharge home with home health services. Findings include: Review of the facility policy titled, Documentation in Medical Record, states as the the policy, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 4b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 4c. Documentation shall be timely and in chronological order. The facility admitted R57 on 12/16/2024 with severe protein calorie malnutrition, acute and chronic kidney failure, muscle weakness, need for assistance with personal care, history of a pulmonary embolus and anemia. Review of the admission MDS (Minimum Data Set) assessment dated [DATE] indicated a BIMS (Brief Interview of Mental States) coded as 13 out of 15 indicating no cognitive deficits. Review of the discharge progress note from the physician dated 01/01/2025 states as the discharge orders: 1) Continue medical management. 2) PO (by mouth) diet 3) Tolerating PT and OT 4) OK to D/C (discharge home) with HH (Home Health) The home health order was never carried out, so R57 did not receive home health as ordered by the physician. Review of the last progress note on 04/02/2025 at 2:45 PM is documented as follows: Progress note: Last note: 01/01/2025 at 09:30 AM Resident in bed, alert and verbal, speech clear, able to make wants and needs known. Skin warm and dry to touch. Respirations even and unlabored, no signs of SOB noted. Continent to bowel and bladder. Uses walker for mobility, participates in PT. AM meds taken whole with thin liquids, with no difficulty. Able to feed self after tray setup. Meals taken in room. Bed locked and lowered and call light within reach of resident. Review of the Progress note: Last and only note for Social Services 12/23/2024 at 11:25 AM Resident was addressed as an admission/5day assessment. Resident scored cognitively intact on her BIMS interview (13 of 15). Resident is alert and verbal and able to express her wants and needs. Resident receives assistance from staff in meeting her wants and needs. Resident denied having any mood issues during the mood interview. Resident was encouraged to reach out if needed. Resident had no noted behaviors or refusals during the review period. Resident is a short term rehab patient with plans to return home upon completion of her rehab services. Staff will continue to observe for any changes in resident, and make appropriate staff aware of any changes. Social will continue to monitor as indicated. During an interview on 04/03/2025 at 10:48 AM with the Director of Nursing, she acknowledged the missing documentation or lack there of pertaining to the accuracy of the documentation in the medical record for R57. During an interview on 04/03/2025 at 11:34 AM with the Social Service Director she confirmed that she was on medical leave starting on 12/26/2024. She stated that the scheduler was handling the discharge. She confirmed that the scheduler had used her email to order the medical equipment for R57 and then confirmed that the home health for R57 was not set up according to the physician's orders. During an interview on 04/03/2025 at 11:50 AM with the Administrator and the Scheduler that was filling in for the Social Worker on 01/01/2025 confirmed that the email for the social worker was used by the scheduler to order the medical equipment and also confirmed that the home health ordered by the physician on 01/01/2025 had not been set up upon discharge home for R57.

Based on the facility policy, record reviews and interviews, the facility failed to ensure the facility bedhold policy with the bed hold amount was provided to the resident and or the personal representative in a timely manner for Resident (R56) who was discharged to the hospital on [DATE] for 1 of 4 residents reviewed for hospitalizations. Findings include: Review of the facility policy titled, Bed Hold Notice, states, This notice fulfills requirements to remind you of this facility's bed hold policy. Please read carefully and indicate whether or not you wish to reserve your room. I understand that the basic per diem rate is $310.00 per day. The facility admitted R56 on 12/30/2024 with diagnoses including, but not limited to, altered mental status, dementia, need for assistance with personal care, depression and anxiety disorder and chronic pain. Review of the admission minimum data set (MDS) assessment, dated 01/05/2025, revealed section C0500, Brief Interview of Mental Status (BIMS), not scored, indicating severe cognitive deficits. Further review of the, Notice of Resident Transfer, dated 01/11/2025 revealed R56 is not responding verbally, and has difficulty swallowing. Attached to the notice of transfer is a copy of an envelope to indicate that the copy of the bed hold was mailed out to the personal representative on 12/23/2024. R56 was not admitted until 12/30/2024. During an interview on 04/02/2025 at 02:46 PM with the Administrator and the Director of Nursing, they could not confirm that R56 nor her responsible party had received the bedhold policy timely or at all. During the interview, the Administrator stated that, the social worker will make multiple copies of the envelopes at a time, but could not confirm that the resident not the representatives receive the bed hold policy.

Based on observation, record review, interviews, review of the Food and Drug Administration (FDA) Manufacturer' Guidelines, and review of the facility's policy and procedures, the facility and Medical Director failed to ensure that 1 of 3 residents (Resident (R)1) reviewed for falls were free of unnecessary medications. Specifically, an antipsychotic and psychoactive medication were used by the facility without proper medical rationale, proper indication for use, and the lack of behavior and side effect monitoring. Findings include: Review of the facility's undated policy titled Use of Psychotropic Medication Copyright 2024 The Compliance Store, LLC revealed, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s) . The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. Review of the Centers for Medicare and Medicaid Memo Ref 13-35-NH dated May 24, 2013, revealed, .The problematic use of medications, such as antipsychotics, is part of a larger, growing concern. This concern is that nursing homes and other settings (i.e., hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions. When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance it will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, cardiovascular events (cardiovascular accidents and transient ischemic events) and increased risk of death . Review of the FDA's manufacturer's guideline for the use of Seroquel (quetiapine) XR (extended release), revised October 2013, revealed under the section titled, Indications and Usage that Seroquel XR is an atypical antipsychotic indicated for the treatment of Schizophrenia; Bipolar I disorder, manic or mixed episodes; Bipolar disorder, depressive episodes; Major depressive disorder, adjuvant therapy with antidepressants with a Black Box Warning Increased Mortality in Elderly Patients with Dementia related Psychosis.Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel XR is not approved for elderly patients with dementia-related psychosis. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: critical illness myopathy, acute and subacute infective endocarditis and urinary tract infection. Readmissions to the facility from the hospital occurred on 04/17/24, subsequent to a diagnosis of pneumonia and on 05/13/24, subsequent to a mechanical fall from standing position resulting in fracture of the ninth right rib. Both of these readmissions included an order for Seroquel XR 50 mg by mouth at bedtime. Review of R1's Electronic Medical Record (EMR), Physicians Orders and Medication Administration Record (MAR) revealed an open ended order dated 04/24/24 for Seroquel XR 24 hr (hour); 50 mg. Amount to Administer: 1 tab; oral Once An Evening [DX: Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety] for which all doses had been charted as administered. Review of R1's EMR did not reveal and order for behavior monitoring. Review of R1's Care Plan did not reveal a Care Plan for behavior monitoring. However, there was a Care Plan for psychoactive medication and at risk for adverse reactions. Review of Physician progress notes dated 04/04/24, 06/02/24 and 07/03/24, do not comment on the use of Seroquel or behaviors. During an interview on 08/26/24 at approximately 3:39 PM, the Administrator stated he was somewhat familiar with the current regulations and the Assistant Director of Nursing (ADON) stated the use of antipsychotic medication and dementia is discussed on Wednesdays during weekly risk meetings and the Medical Director does not attend but does make rounds on Wednesdays. The ADON acknowledged that Seroquel XR 50mg at bedtime was being administered and stated she would expect a resident on Seroquel XR to have orders for behavioral monitoring. On 08/26/24 at approximately 4:05 PM, the Administrator provided a Consultant Pharmacist record of Psychoactive Utilization report, dated 05/31/24, for R1, which revealed that Quetiapine had been ordered 04/24/24 with a diagnosis of Dem w/beh. and that the next evaluation was due 10/24. During a subsequent telephone interview with the Consultant Pharmacist he stated that he started work at the Facility earlier this year, that he attends the monthly QAA (Quality Assurance) meeting, that the Medical Director does get copies of his recommendations and that he suggests monitoring for potential adverse metabolic effects for antipsychotic medications. On 08/26/24 at approximately 4:54 PM, during a telephone interview, the Medical Director and prescribing Physician stated he makes rounds weekly and was aware FDA prescribing guidelines related to diagnoses for use on Quetiapine and was unsure if behavioral monitoring had been ordered for R1. He did not describe a process to determine if a medication is still needed after hospitalization , but did state according to the nursing staff R1 is more confused, might have sundowners and is unable to sleep. The Medical Director further stated he feels that R1 needs to be on Seroquel because he has a diagnosis of dementia with behaviors which has been overlooked. When asked, he stated R1 does not have schizophrenia or bipolar disorder.

Based on the facility policy titled, Medication Storage, observations and interviews, the facility failed to ensure expired medications and biological's were removed and not stored with medications in use by residents on 3 of 3 units. The findings included: Review of the facility policy titled, Medication Storage, revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. Number 8 under, Policy Explanation and Compliance Guidelines, states: Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy. An observation of the medications drawers on the 2000 Unit revealed the following: On 08/01/2023 at 12:48 PM revealed six (6) capsules of Docusate Sodium 100 milligrams (mgs) expired on 07/20/2023, RX#1211335, Lot #W560033. Fourteen (14) tablets of Levothyroxine 25 micrograms (mcgs) expired on 06/30/2023, RX#1560331, Lot #C230008. Fifty four (54) tablets of Meclizine 25 mgs expired on 07/14/2023, RX#1207941, Lot# BA05422A. During an interview on 08/01/2023 at 12:48 PM, Licensed Practical Nurse #2 (LPN2) confirmed the findings and removed the expired medications from storage with other medications in use by residents. An observation on 08/03/2023 at 7:25 AM of the stored medications and biological's on the 1000 unit revealed one (1) bottle of Sterile Water 100 milliliters (ml's), for single use, was opened and placed back in storage with other biological's in use by residents. LPN1 confirmed the opened bottle of Sterile Water was no longer sterile. An interview on 08/03/2023 at 7:30 AM with LPN1 confirmed the opened bottle of Sterile Water for single use, was no longer sterile once opened, and removed it from storage with other biological's in use by residents. An observation on 08/03/2023 at 12:20 PM of the 4000 Unit revealed one (1) bottle of Sea Clens Wound Cleanser with Lot#8132867 was expired on 07/2023 and remained with other biological's in use by residents. During an interview on 08/03/2023 at 12:25 PM with LPN3, he confirmed the expiration date of 07/2023 and removed the wound cleanser from storage with other biological's in use by residents.

Based on observation, interview, and review of the facility policies and procedures, the facility failed to store, prepare, and serve food under sanitary conditions for 61 out of 61 residents who received food prepared in the kitchen. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all residents. Findings include: Policy review of un-dated policies titled Date Marking for Food Safety, Sanitation Inspection and Kitchen Hood Inspection and Cleaning. Policy: The facility adheres to date marking system to ensure the safety and of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for staffing: 1. Refrigerated, ready-to-eat, perishable food shall be held at a temperature of 41F or less for a maximum of 3 days. Policy: It is the policy of this facility to conduct inspections to ensure food service areas are clean, sanitary, and in compliance with applicable state and federal regulations. Policy Explanation and Compliance Guidelines: 1. All food service area shall be kept clean, free from litter, rubbish and protected from rodents, roaches, flies and other insects. Policy: A safe and healthful work environment will be provided for all employees, residents, and visitors. Pursuant to this end, the kitchen hood exhaust system will be properly cleaned and maintained in order to support the functioning of the kitchen hood fire suppression system. Policy Explanation and compliance Guidelines: 4. The kitchen hood visual inspection will be completed monthly by the Facility Maintenance Director or his designee. 5. If the hood visual inspection system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system will be cleaned by a properly trained, qualified, and certified person (s) acceptable to the authority having jurisdiction. On [DATE] at 10:30 AM, the initial tour of the kitchen accompanied by the Registered Dietitian (RD) revealed the following: One 4 oz carton of milk expired on [DATE]. The door of the reach-in cooler has a stain/smear on the handle and there was food debris at the base of it. There is old-looking trash behind the ice maker. The thermometer outside the reach-in cooler read 54 degrees Fahrenheit and on the inside, it read 50 degrees Fahrenheit. The temperature of a chicken salad inside the reach-in cooler read 46 degrees Fahrenheit. The kitchen salad was discarded. The mixer was not clean, and had dried food and dust on it. The RD stated it has not been used for over a year. There was visible grease on the oven hood and on the outside of the fryers. In the clean dishware storage area were 10 large pans with dried food present and were greasy to the touch. Observation of the walk-in-cooler revealed stainless steel container with cooked food that was unlabeled. There was a wet box containing 4 cartons of liquid eggs, in which one carton was busted open. On [DATE] at 10:32 AM, a follow-up visit was conducted to the kitchenette located between the ,d+[DATE] halls. In the clean dishware storage area were 6 wet nesting pans. One of the reach-in coolers has excess condensation dripping onto food items and onto the floor. There were 2 wet eggs cartons with 3 cracked eggs in them and a large box containing a carton of liquid eggs cartons was wet. A second kitchenette located between the ,d+[DATE] halls had a dishwasher, not in use (not working). The reach-in-cooler had a container with cooked food, undated and unlabeled. There was also old-looking trash behind the stove. There was a large amount of old-looking trash around the dumpster located outside behind the kitchen. The Administrator stated that it was cleaned and pressure washed, after being brought to their attention.

Based on observation, interview, and review of facility policy and procedures, the facility failed to ensure the method of narcotic disposal was documented on the narcotic disposal form. Findings include: Review of facility policy titled Disposal of Medications and Medication-Related Supplies dated ,d+[DATE] revealed C. Schedule II medications remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the director of nursing/administrative nurse and consultant pharmacist; as directed by state laws, regulations, and/or the DEA (Drug Enforcement Administration). D. Schedule III, IV, and V controlled substances are disposed of at the facility by the director of nursing/administrative nurse and the consultant pharmacist, as directed by state law. During an observation on [DATE] at 11:30 AM of the locked narcotics with the Director of Nursing (DON) revealed the narcotics disposal sheet did not contain documentation of the type of disposal method used for destruction of expired and/or medications no longer in use by the residents. During an interview on [DATE] at 11:10 AM with the DON, she stated, Narcotics awaiting disposal are kept in my locked file cabinet and the nurse or another nurse or myself document two signatures on the pharmacy slip. The pharmacist comes monthly for cart checks and she will come anytime that I need her for medication disposal. The last noted time that meds (medications) were disposed was [DATE]. We only use RX (prescription) destroyer to destroy our meds, but the sheets with their sticker and number on it is all that we use. An interview on [DATE] at 11:55 AM with Consultant Pharmacist revealed, Narcotics are disposed by the DON who accepts the meds (medications) from the carts due to death or discharge from the floor nurse. The DON puts the meds in a file cabinet under double lock. I review the narcotic sheet and I sign the narcotic sheets so there should be 3 signatures on the sheets. Then I fill out a narcotics sheet. That sheet is signed by myself, Administrator and the DON. Those sheets are left at the facility with the bundle of narcotic sheets. I come monthly but try to do narc (narcotic)disposal every 3 months. An interview on [DATE] at 12:40 PM with the DON revealed, There is no documentation of the method of disposal used for the narcotics on the disposal sheets.

Based on record reviews and interviews, the facility failed to ensure that a documented injury of unknown origin was reported to the State Agency for 1 of 4 sampled residents. Resident (R) 20 with documented opened areas on right leg was not reported as an injury of unknown origin but it was investigated by the facility. Findings include: The facility admitted R20 on 2/17/16 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an Annual Minimum Data Set (MDS) dated [DATE] indicated R20 was severely, cognitively impaired with no Brief Interview of Mental Status (BIMS) score being given. A review of the medical record on 1/18/22 at 3:02 PM revealed a nursing note dated 11/21/21 that indicated at 8:55 PM, the nurse was approached by Certified Nursing Aide (CNA) staff at 8 PM, stating this nurse should come to the resident's room ASAP. As this nurse walked into resident's room, 2 more CNA staff were standing over resident and showed this nurse open areas on resident's right leg. These wounds were scabbed over and 1 had a PolyMem as of last night, as this nurse also assessed resident's body and he was audited, and last night there were no skin concerns. This was noted as the CNA staff was making rounds, as previous CNA whom had resident was in till 7:15 this evening. Area was cleansed and PolyMem's applied. An interview on 1/20/22 at 10:45 AM with the Administrator revealed the facility interviewed facility staff regarding the injury to the resident's right leg in the 11/21/21 nurse's note. Documentation was provided as Employee Statement Admin & DON were made aware of concern that RP expressed. About residents right leg. Upon interviewing staff and attempting to interview resident. It was determined that resident legs frequently fall off side of bed and the area of concern was caused by the residents legs frequently fall off side of bed and that the area of concern was caused by the residents leg making contact with the side of bed. An interview on 1/20/22 at 12:11 PM with the Director of Nursing (DON) and Administrator revealed the facility did not report the injury of unknown origin but they investigated the incident. The Administrator further stated he did not report the incident because he used 24 hours to investigate the injury and determined it was not unknown. There was no documentation in the nurses notes to indicated the resident frequently left his leg hanging off the side of the bed. The 11/21/21 nurses notes indicate the resident could not be interviewed due to severe cognitive impairments and being non verbal.

Based on interview and record review, the facility failed to ensure collaboration between the facility and the [CONDITION(S)] facility for one of one Resident(R) 359 reviewed for [CONDITION(S)]. Findings include: Review of R359's face sheet dated 01/04/22 revealed R359 was admitted to the facility with the following pertinent Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R359's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Assessment Score (BIMS) of 15 which was consistent for cognitively intact. Review of R359's Care Plan dated 1/19/22 revealed R359, Is receiving [CONDITION(S)] due to CKD (chronic kidney disease) and is at risk for weight fluctations and fluid overload .Weight before [CONDITION(S)] and after returning to facility and record. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Obtain weight after [CONDITION(S)] on these days: Tues, Thurs, Sat . Review of facility [CONDITION(S)] Communication booklet on 1/19/22 at 2:00 PM revealed no documentation of communication sheets and/or [CONDITION(S)] treatment sheets between the facility and the [CONDITION(S)] facility. Review of facility [CONDITION(S)] Communication forms on 1/19/22 at 4:50 PM revealed incomplete documentation by the facility prior to [CONDITION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequently, [CONDITION(S)] treatment sheets obtained from the [CONDITION(S)] center for review during this time. During an interview on 1/19/22 at 2:15 PM with Certified Nursing Assistant (CNA) 1 stated, I am told what time the resident leaves, ensure she receives breakfast and get her ready to go to [CONDITION(S)], and get weights if needed. This information is received from the nurses. She is to have weights done before she goes to [CONDITION(S)] on first shift. The nurses will usually ask us to get them done . During an interview on 1/19/22 at 2:26 PM with Licensed Practical Nurse (LPN) 2 stated, I don't usually weigh her before [CONDITION(S)] because they weigh her there but I do vital signs before and after she returns from [CONDITION(S)]. We use the [CONDITION(S)] communication sheet that is sent with the resident to each treatment (for coordinated care). During an interview on 1/20/22 at 3:30 PM with Director of Nursing (DON) stated, The [CONDITION(S)] staff communicate directly with the nurse who is caring for the resident. During an interview on 1/20/22 at 3:45 PM with the DON a copy of the [CONDITION(S)] contract was requested with none provided prior to exit conference.

Based on observation, interview, and review of facility policy and procedure the facility failed to ensure expired supplies were removed from three of three resident treatment carts and two of two medication refrigerators were monitored daily for acceptable temperature ranges. Findings include: Review of facility policy titled, Storage of Medications dated ,d+[DATE] revealed K. Medications requiring refrigeration or temperatures between 2 (degrees) C (Celsius) (36 degree F (Fahrenheit)) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label .M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .O. Medication storage conditions are monitored on a (monthly) basis and corrective action taken if problems are identified. 1. During an observation on [DATE] at 9:02 AM of Sweetgrass Unit Treatment cart revealed the following expired items: Ten (10) Bleach Sani-cloth disposable wipes expired ,d+[DATE], Forty-nine (49) Steri strips ,d+[DATE] (one fourth) in.(inch) x 3 (three) in. expired ,d+[DATE]. An interview on [DATE] at 9:05 AM with Licensed Practical Nurse (LPN) 3 verified the findings. 2. During an observation on [DATE] at 9:34 AM of [NAME] Unit (4000) Treatment Cart revealed the following expired item: Twelve (12) [MEDICATION(S)] swabs expired [DATE]. An interview on [DATE] at 9:35 AM with LPN 1 verified the findings. 3. During an observation on [DATE] at 10:31 AM of Indigo Unit treatment cart revealed the following expired items: Thirty (30) Steri strips expired ,d+[DATE], One (1) tube [MEDICATION(S)] 0.05% (percent) exp ,d+[DATE]. During an interview on [DATE] at 10:32 AM with LPN 2, she verified the findings. 1. During an observation on [DATE] at 9:56 AM of the medication rooms for [NAME] and Jessimine units, the medication temperature refrigerator log sheets for the month of November was noted with seven of thirty-one days of completed temperatures logged for the month, December was noted with eleven of thirty-one days of completed temperatures logged for the month, and January was noted with seven of twenty days of completed temperatures logged for the month. Further observation of the medication refrigerator revealed the following patient items inside the refrigerator: [MEDICATION(S)] Solution 0.2%/0.5% eye drops, [MEDICATION(S)] Solution 0.005% eye drops, Lorazepamide liquid, Insulin pens- [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] kwikpen, and [MEDICATION(S)] 10 mg (milligram) rectal suppository. During an interview on [DATE] at 10:00 AM with LPN1, she stated that the night shift is responsible for checking the medication refrigerators. 2. During an observation on [DATE] at 10:10 AM of the medication rooms for Sweetgrass and Indigo units, the medication refrigerator temperature log sheet for the month of January was noted with three of twenty days of completed temperatures logged for the month. Further observation of the medication refrigerator revealed the following patient items inside the refrigerator: Lantaprost eye drops, [MEDICATION(S)] solution, acetaminophen rectal suppository 650 mg, [MEDICATION(S)] rectal suppositories, [MEDICATION(S)] insulin, and [MEDICATION(S)] insulin. During an interview on [DATE] at 10:22 AM with LPN 4, she stated, the medication temperature log sheet was incomplete. The night shift nurse is responsible for checking the refrigerators. During an interview on [DATE] at 12:36 PM, the Director of Nursing (DON) stated, The night shift nurse is responsible for checking the medication refrigerator.

Based on record reviews and interviews, the facility failed to ensure that a resident's medical record was accurately documented to reflect an injury of unknown origin, behaviors that could have caused the injury and family notification of the injury and treatment provided for 1 of 1 sampled resident, Resident (R) 20 with documented opened areas on right leg with no documentation of how injury was caused or family notification of injury and treatment provided. Findings include: The facility admitted R20 on 2/17/16 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an Annual Minimum Data Set (MDS) dated [DATE] indicated R20 was severely cognitive impaired with no Brief Interview Mental Status (BIMS) score being given. A review of the medical record on 1/18/22 at 3:02 PM revealed a nursing note dated 11/21/21 that indicated at 8:55 PM the nurse was approached by Certified Nursing Aide (CNA) staff a 8 PM, stating this nurse should come to the resident's room asap. As this nurse walked into resident's room, 2 more CNA staff were standing over resident and showed this nurse open areas on resident's right leg. These wounds were scabbed over and 1 had a PolyMem as of last night, as this nurse also assessed resident's body and audited, and last night there were no skin concerns. This was noted as the CNA staff was making rounds, as the previous CNA whom had the resident was in until 7:15 this evening. Area was cleansed and PolyMem's applied. An interview on 1/20/22 at 10:45 AM with the Administrator revealed the facility interviewed facility staff regarding the injury to the resident's right leg the 11/21/21 nurse's note. A note was provided by the Administrator as Employee Statement Admin & DON were made aware of concern that RP expressed. About residents right leg. Upon interviewing staff and attempting to interview resident. It was determined that resident legs frequently fall off side of bed and the area of concern was caused by the residents legs frequently fall off side of bed and that the area of concern was caused by the residents leg making contact with the side of bed. An interview with the Administrator on 1/20/22 at 11:05 AM revealed per the employee written statement, the responsible party (RP) expressed concerns about the injury to the resident's right leg and brought it to the facility's attention. There was no documentation in the electronic medical record (progress notes) to indicate the responsible party was made aware of the 11/21/21 incident. An interview on 1/20/22 at 12:11 PM with the Director of Nursing (DON) and Administrator revealed the employee statement was incorrect and that the facility spoke with the responsible party on 11/22/21 who was in the room with the resident when the incident was reported to the RP. The DON confirmed there was no documentation in the electronic medical record that indicated the resident's had a behavior of hanging his leg off the side of the bed and provided a second employee statement to indicate the RP was informed resident received a skin tear due to throwing his leg off the side of the bed. The DON stated she could not recall if interventions were put in place to prevent further skin tears.

Based on observations, record reviews and interviews, it was determined the facility failed to ensure PPE (personal protective equipment) was removed and discarded prior to exiting a resident's room (Resident #1) under droplet isolation precautions and prior to leaving the PUI (Person Under Investigation)/COVID-19 positive unit for one of one therapy contract staff (Certified Occupational Therapy Assistant (COTA) #1) observed. This failure occurred during a COVID-19 pandemic. The findings included: A nursing progress note, dated 07/07/20 at 4:00 PM, indicated Resident #1 had been admitted to the facility on COVID-19 quarantine for 14 days related to, the current policy for admission. A care plan, dated 07/07/20, indicated Resident #1 required contact and droplet precautions due to a recent hospital stay and possible exposure to COVID- 19. A nursing progress note, dated 07/08/20 at 8:43 PM, indicated the resident remained on contact/droplet precautions. On 07/10/20 at 1:20 PM, COTA #1 was observed exiting Resident #1's room on the PUI unit wearing a face shield and a white disposable gown. She exited through the glass doors of the PUI/COVID-19 positive unit and proceeded walking down the facility hall, past a nurses' station, and then she turned the corner to the left, down a hall where COVID-19 negative resident rooms were located. Signs posted on the door to Resident #1's room included instructions to, Stop .Staff must .Discard gown before room exit . and Stop .Everyone must .Remove face protection before room exit . Immediately nursing staff in the vicinity were asked who the staff member was who had been observed exiting the unit wearing PPE, and they stated she was a member of the therapy staff. The surveyor proceeded to the therapy office/gym area and was joined by the ADON/IC (Assistant Director of Nurses/Infection Control Preventionist). On 07/10/20 at 1:21 PM, COTA #1 was observed sitting at a work area in the therapy gym wearing a white gown. She was asked if she had just completed therapy with a resident on the PUI unit. She stated Resident #1 had refused therapy because she had not felt well. She was asked if she was still wearing the same gown she had worn in the resident's room, and she said Yes. She was asked if she should have removed her gown and shield prior to leaving the resident's room and the PUI area, and she stated she probably was not a good person to ask because she had only been at the facility, about one week. She was asked if she knew if that resident was COVID-19 positive or negative, and she did not reply. Occupational Therapist, (OT) #1, who was also seated in the working area, stated Resident #1 had tested Negative for COVID-19. They were asked if they knew why Resident #1 was on isolation precautions. COTA #1 did not answer, and OT #1 stated the resident was being watched to see if she became COVID-19 positive. They were asked if there was a policy about removing PPE before leaving a resident's room in the PUI/COVID-19 positive unit, and they both stated they did not know. On 07/10/20 at 1:26 PM, the ADON was asked would it be acceptable for nursing staff to exit a resident's room under droplet isolation precautions or the PUI unit without removing and properly disposing of PPE, and she stated that would not be acceptable. On 07/10/20 at 1:40 PM, the Director of Rehabilitation stated therapy services were supplied by a (named) contract company. She stated COTA #1 was a new employee and had only been at the facility about one week. She stated COTA #1 had reported to her that Resident #1 was not having a good day and had refused therapy. She was asked if she expected COTA #1 to dispose of her PPE before leaving the resident's room, and she stated she would have expected her to remove her shield and gown before leaving the room. She said, Definitely, some education needs to happen. She was asked what kind of education or orientation was done for members of the contract therapy department, and she stated every morning she updated the team about PPE requirements and reminded them to look at the residents' room doors for PPE information. She was asked to provide the employee check off list for COTA #1 including any education about donning and doffing of PPE. On 07/10/20 at 2:25 PM, the Administrator (ADM) was made aware of the situation and acknowledged the concerns. He shook his head and stated, We have worked so hard. On 07/10/20 at 3:08 PM, the Director of Nurses (DON) was asked how the facility knew contracted therapy staff were properly trained to work in the PUI/COVID-19 positive unit, and she stated the Director of Rehabilitation made sure. On 07/10/20 at 3:18 PM, COTA #1 was interviewed a second time. She stated she put on a fresh disposable gown prior to entering Resident #1's room. She stated she did not remove her gown because she had not worked with the resident. She stated she had not touched the resident but had only talked with her. She stated the (named) rehabilitation contract company had provided education on how to work in the facility. Education, On-Boarding and Check-Off documents for COTA #1, provided by the (named) contract company, were reviewed and did not indicate she had been trained on when and how to properly remove PPE. No documentation was provided which indicated the new contract employee was competent for the proper donning and doffing of PPE for use in a PUI/COVID-19 positive unit. During the Infection Control Focused Survey exit conference, on 07/10/20 at 3:30 PM, the ADM stated it would probably be a good idea to have the therapy contract staff complete the facility training.

Based on observation and interview, the facility failed to provide a hands-free disposal method for paper towels used at the kitchen hand washing station. The findings included: During the initial kitchen tour with the Registered Dietitian on 01/14/19 at approximately 10:50 AM, the surveyor observed a large garbage can with a lid that required lifting up to dispose of paper towels used at the handwashing station. The RD stated the hands-free trash can was removed but could be put back. During a follow-up kitchen observation on 01/18/19 at approximately 7:08 PM, no hands-free trash receptacle was available at the kitchen hand washing station. During an interview on 01/18/19 at approximately 7:08 PM, the Director of Dining Services stated the foot activated trash can was not kept by the sink because it gets dirty and has to be washed repeatedly.

Based on random observations and interview, the facility failed to allow residents to state a preference before placing clothing protectors in 1 of 1 dining rooms. The findings included: In a dining observation on 01/14/19 at approximately 12:08 PM Certified Nursing Assistants (CNA's) were observed placing clothing protectors on all residents in the dining room without asking if the resident wanted it. In a dining observation on 01/15/19 at approximately 12:10 PM CNA's were observed placing clothing protectors on all residents in the dining room without asking if the resident wanted it. In an interview on 01/17/19, the Director of Nursing confirmed that a resident's preference could change from day to day and should not be assumed. Review of Facility Policy entitled Promoting/Maintaining Resident Dignity During Mealtimes revealed, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident.

Based on record review and interview, the facility failed to prevent resident to resident abuse for Resident #5, #24, and #11 (3 of 7 residents reviewed for abuse). The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 1/17/19 at 4:04 PM of the nurse's notes dated 11/16/18 revealed an altercation occurred between two residents. The Responsible Party, Director of Nursing, and Supervisor were notified. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Record review on 1/17/19 at 5:29 PM of the nurse's noted dated 10/2/18 revealed an altercation occurred between two residents. The physician and Responsible Party were notified. Further record review revealed Resident #11, whose [DIAGNOSES REDACTED]. Resident #11 had a history of [REDACTED]. During an interview with Licensed Practical Nurse #1 on 1/18/19, s/he confirmed the incident on 11/16/18. During an interview with Rehab Assistant #1 on 1/17/19 at 4:55 PM, s/he confirmed the incident on 10/2/18.

Based on record review and interview, the facility failed to prevent resident to resident abuse for Resident #5 and #24 (2 of 7 residents reviewed for abuse). The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 1/17/19 at 4:04 PM of the nurse's notes dated 11/16/18 revealed an altercation occurred between two residents. The Responsible Party, Director of Nursing, and Supervisor were notified. The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Record review on 1/17/19 at 5:29 PM of the nurse's notes dated 10/2/18 revealed an altercation occurred between two residents. The physician and Responsible Party were notified. During an interview with Licensed Practical Nurse #1 on 1/18/19, s/he confirmed the incident on 11/16/18. During an interview with Rehab Assistant #1 on 1/17/19 at 4:55 PM, s/he confirmed the incident on 10/2/18.