Every finding on record at Birchwood Park Rehabilitation

Based on interview, clinical record review and facility documentation the facility staff failed to ensure that Residents are treated resident with respect and dignity for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility staff failed to ensure that Resident #111 was treated with respect and dignity during ADL incontinence care. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress notes: 3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above. 3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA. On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111. The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). A review of the Grievance Form filled out by the Unit Manager dated 3-24-25 read as follows: [Resident #111 name redacted] Date: 3-24-25 Grievance / Concern Received by: Daughter & Resident. Reported To: [Unit Manager name redacted] Summary of Grievance: CNA rude and spraying . Resolution: CNA counseled. On the afternoon of 4/3/25 an interview with CNA #1 was conducted and she was asked if she had taken care of Resident #111, and she stated that she had. When asked about the interaction she had with Resident #111, and she stated that he had to be changed, and she admitted to spraying air freshener in the room when she was changing him. She also stated that she was singing while she was changing him. She denied slamming things, she denied being rude or disrespectful. When asked if it could be perceived as rude to be spraying air freshener while cleaning up a resident, she stated that she did not feel it was rude. When asked if she thought it was unprofessional to be singing while caring for a resident, she stated that she Always Sings. A review of the personnel file for CNA #1 revealed the following excerpts from the Counseling Form related to this incident: Reason for action: Report of [CNA name redacted] spraying air freshener and mumbling under her breath after providing care to a resident that had a BM [bowel movement], causing the resident to feel embarrassed and uncomfortable Goals specifically related to employee's recent job performance: 1. Maintain professionalism 2. Remain sensitive to resident's perception 3. Maintain dignity. A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts: Definitions: Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation . On 4/3/25, during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to implement the abuse policy for reporting allegations of abuse for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility staff failed to follow abuse reporting guidelines set forth in the State Operations Manual and the facility abuse policy. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress notes: 3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above. 3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA. On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111's unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111.The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed for possible abuse the Social Worker stated that they were not. The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked if that is the correct order in which to proceed after an abuse allegation, according to the SOM and facility policy, and he stated that the SOM and facility policy indicate reporting should be done immediately but no later than 2 hours after an allegation of abuse is made. When asked was this done in this case, he stated that it was not. A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts: Page 1 Definitions: Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation . Page 5 Paragraph 2 VII. Reporting / Response The company will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury On 4/3/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility policy the facility staff failed to report allegations of abuse in a timely manner for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility did not report allegations of abuse in the required timeframe of no later than 2 hours after the allegation is made. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress notes: 3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above. 3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA. On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111. The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed for possible abuse the Social Worker stated that they were not. The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked if that is the correct order in which to proceed after an abuse allegation, according to the SOM and facility policy, and he stated that the SOM and facility policy indicate reporting should be done immediately but no later than 2 hours after an allegation of abuse is made. When asked was this done in this case, he stated that it was not. A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts: Definitions: Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation . Page 5 Paragraph 2 VII. Reporting / Response The company will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury On 4/3/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure allegations of abuse and neglect are thoroughly investigated for 1 Resident (#111) in a survey sample of 29 Residents. The findings included: For Resident #111 the facility failed to thoroughly investigate allegations of abuse. Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. On 4/1/25 a review of the clinical record revealed the following progress notes: 3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above. 3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA. On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111. The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed, she stated that they were not. When asked about the interview with the Resident she stated that the Resident complained of the CNA spraying air freshener and mumbling under the breath. The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked what steps were taken to protect Residents while the investigation was ongoing, and the Administrator stated that they filled out a grievance form and, interviewed CNA #1 and wrote up a counseling statement for her as they did not feel this was abuse. A review of the Grievance Form filled out by the Unit Manager dated 3-24-25 read as follows: [Resident #111 name redacted] Date: 3-24-25 Grievance / Concern Received by: Daughter & Resident. Reported To: [Unit Manager name redacted] Summary of Grievance: CNA rude and spraying . Resolution: CNA counseled. On the afternoon of 4/3/25 an interview with CNA #1 was conducted and she was asked if she had taken care of Resident #111, and she stated that she had. When asked about the interaction she had with Resident #111, and she stated that he had to be changed, and she admitted to spraying air freshener in the room when she was changing him. She also stated that she was singing while she was changing him. She denied slamming things, she denied being rude or disrespectful. When asked if it could be perceived as rude to be spraying air freshener while cleaning up a resident, she stated that she did not feel it was rude. When asked if she thought it was unprofessional to be singing while caring for a resident, she stated that she Always Sings. A review of the personnel file for CNA #1 revealed the following excerpts from the Counseling Form related to this incident: Reason for action: Report of [CNA name redacted] spraying air freshener and mumbling under her breath after providing care to a resident that had a BM [bowel movement], causing the resident to feel embarrassed and uncomfortable Goals specifically related to employee's recent job performance: 1. Maintain professionalism 2. Remain sensitive to resident's perception 3. Maintain dignity. A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts: Definitions: Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation . On 4/3/25, during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observations, resident interviews, staff interview, and clinical record review the facility staff failed to provide needed oral care to a dependent resident receiving enteral feedings for 1 of 29 residents (Resident #123), in the survey sample. The findings included: The facility staff failed to provide needed oral care to a dependent resident receiving enteral feedings, Resident #123. Resident #123 was originally admitted to the facility 6/10/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia causing pulmonary aspiration, enteral feedings are required. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. Resident # 128's care plan with a revision dated of 3/20/25 stated (name of resident) has an ADL self-care performance deficit related to a CVA with hemiparesis. The goal stated (name of resident) will improve current level of function in ADLs through the review date, 6/29/25. The intervention dated 7/20/22 stated, oral care routine (AM, PC, HS) brush (name of resident) teeth, rinse dentures, clean gums with toothette, and rinse mouth with wash. An observation was made of Resident #123 on 4/1/25 at approximately 1:31 PM. The resident was in bed at a 60-degree position. The resident was attempting to make a need known but experienced much difficulty because his difficulty with speech and the hygiene of his oral cavity. The resident's lips were covered with very dry and stringy mucus, while the inside of his mouth and his tongue was with a large amount of dry and whitish mucus. On 4/3/25 at approximately 4:05 PM another observation was made of Resident #123 while he was in bed. The resident inner mouth and his lips were with a large amount of dried which made it difficult for him to open and close his mouth. The resident cleared his throat and moved his head to stated that his lips and mouth were dry and uncomfortable. On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the Director of Nursing stated the resident had received oral care and going forward they would stay on top of his oral care needs.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for 2 of 29 residents (Resident 126 and Resident #128), in the survey sample. The findings included: 1.Resident #126 was originally admitted to the facility 6/25/24. The current diagnoses included end stage renal disease requiring dialysis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/2/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #126's cognitive abilities for daily decision making were intact A review of the Resident #126's dialysis communication book revealed no communications notes from the dialysis center on 3/24/25 and 3/26/25. An interview was conducted with the Resident #126 on 4/3/25 at 4:35 PM. The resident stated she received dialysis services on Mondays, Wednesdays and Fridays, and she attended dialysis on 3/24/25. The resident further stated that she missed dialysis on 3/26/25 because she had a dermatology appointment, regarding the underarm irritation. The person-centered care plan dated 6/27/24 had a problem which stated (name of the resident) needs hemodialysis related to renal failure. The goal read (name of the resident) will have no signs or symptoms of complications from dialysis through the review date, 7/6/25. The interventions included Coordinate plan of care with dialysis as needed but it failed to include ongoing communication, coordination and collaboration between the nursing home and the dialysis center. An interview was conducted with the Licensed Practical Nurse (LPN) #3 at approximately 4:30 PM. LPN #3 stated there were no dialysis communication notes in the book for 3/24/25 or 3/26/25, but she had spoken with the Unit Manager to determine if they had been removed to be uploaded to the electronic record by medical records. On 4/3/25 at approximately 5:05 PM the Unit Manager stated they were unable to locate dialysis communications which were not in the communication's book. On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the facility's Team offered no comments and voiced no concerns.2. Resident #128 was originally admitted to the facility 01/02/24 and readmitted on [DATE]. The facility staff failed to maintain ongoing records of communication between the facility and the dialysis center. The current diagnoses included end stage renal disease requiring dialysis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/09/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #128's cognitive abilities for daily decision making were intact A review of the Resident #128's dialysis communication book revealed no communications notes from the dialysis center for last week of February. An interview was conducted with the Resident #128 on 4/03/25 at 1:30 PM. The resident stated that he received dialysis services Monday through Friday and carries the communication book from the his unit to the dialysis Monday through Friday. The person-centered care plan dated 2/16/24 reads Resident #128 has End Stage Renal Disease (ESRD) and does require Dialysis interventions at this time - conducted inhouse with Dialyze Direct Mon - Fri. The goal read the resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. The interventions included Dialysis Communication Record is sent to the dialysis center with each appointment, and return of form is ensured after appointment is completed and to Dialyze Direct in-house dialysis m-f. An interview was conducted with the Licensed Practical Nurse (LPN) #3 at approximately 3:45 PM. LPN #3 stated there were no dialysis communication notes in the book for the last 2 weeks of February 2025 (excluding Saturday and Sunday) because the medical records staff need to upload them in electronic medical records (EMR). On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and Corporate Consultants. The above information was reviewed. No further information was given.

Based on observations, Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff involuntarily secluded one (1) Resident (Resident #226) in a survey sample of 74 Residents, resulting in psychosocial harm. The findings included: For Resident #226, who refused a transfer to the locked memory care unit (for residents with dementia and behaviors), the facility staff failed to honor the resident's request. The staff moved him against his will, into the secured unit with no access codes to afford him independent egress. The resident did not meet the criteria for the move as no criteria was ever derived in the facility by way of policy or procedure, which resulted in a move for staff convenience. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. Three MDS (minimum data set) federal assessments were reviewed since the resident's admission through the time of survey on 12-10-24. Those follow below: 1. The first MDS admission assessment was dated 6-10-24 and indicated the resident had a Brief Interview for Mental Status BIMs score of 8 of a possible 15 points upon admission after Acute hospitalization for encephalopathy from a fall and missing hemodialysis. He was coded in the document as able to understand and be understood, no aberrant behaviors, needed only limited assistance with most (activities of daily living) ADLs such as toileting, ambulating, hygiene, transferring, and bed mobility, and was dependant on staff only for bathing, however needed only tray set up and clean up for meals. 2. The second MDS was a quarterly assessment dated [DATE] which indicated the Resident had a Brief Interview for Mental Status BIMs score of 11 of a possible 15 points after a rehospitalization for septic shock due to hypovolemia, as no infection was found to support septic shock, nor sedation as narcan had no effect. He was coded in the document as able to understand and be understood, no aberrant behaviors, and functional abilities were not coded. 3. The third MDS was a quarterly assessment dated [DATE] indicated the Resident had a Brief Interview for Mental Status BIMs score of 10 of a possible 15 points. He was coded in the document as able to understand and be understood, no aberrant behaviors, needed only set up and clean up for bathing, otherwise, was completely independent for all (activities of daily living) ADLs such as toileting, ambulating, hygiene, transferring, and bed mobility, and eating. On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the Resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the Resident's brother agreed to the room change even though these individuals were only emergency contacts and the Resident refused and was his own responsible party. The reason given for the move, was elopement risk. The Resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the Resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner. During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The Resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do. The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here? Immediately following the shower room observation the Resident's room was examined. The Resident's room was shared with a second Resident. Resident #226's room tour included but was not limited to the following environmental observations: Broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit. The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms. The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere. Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The bed divider curtain had brown stains and smeared feces on it. The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall. The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's room. There were no televisions in any room, and no water to drink in any room. There was also noted in the hallway the air conditioning main vent in the ceiling and air return on the wall were so dusty that they had the appearance of brown fur coating them. The walls were marked and smeared and had paint scraped off in places It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole 150 bed facility. Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response. The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him. On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged . On 12-12-24 the Social worker's license and curriculum vitae were requested for verification and vetting as part of the employee records review for competency of staff. It was noted that the required course work and degree required by state and federal regulation for this employee was not sufficient for the role. The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit. On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the Resident's move, nor was a request made for assessment and told that the Resident wished to discharge. On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them. Resident #226 refused the move to the secured unit and was moved against his will. Resident #226 was unable to bathe in a safe, clean environment, and his room was not a safe, clean environment. The room was cold with the heating unit out of the wall. The Residents personal items and clothing were missing and not available to him. Confused Residents wandered in and out of his room affording him no private space. The Resident was unable to sleep as his roommate called out all night for water to drink, and food was found to be insufficient. The Resident kept a jar of peanut butter by his bed and a loaf of bread so that I can eat something when they forget my tray like they do my roommate's tray. The Resident repeatedly told staff he wanted to be let out of the unit and wanted to be discharged . There were no activities being held on the unit, and there was no television for any of the Residents. Resident #226 received no care planning by an interdisciplinary team, no social work for room moves or discharge assistance, and he received no psychosocial support. The Resident stated no one listened to him, he felt locked in, unable to walk or go outside, and he felt like a prisoner that was going crazy with nothing to do but stare at the walls. On 12-12-24, during the end of day debriefing meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that the Resident had requested to stay in his room, and to be planned for discharge, which was denied and there was no evidence that the physician was notified of this request. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, and culminated in the withholding of a resident's rights, and involuntary seclusion resulting in psychosocial harm. On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his roommate had been moved back onto regular units last night (12-18-24). This indicated that the involuntary seclusion was borne out by the fact that the day before survey exit the Resident was moved back to a regular unit. At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from accidents, hazards receive adequate supervision and assistance devices to prevent accidents, resulting in harm for two (2) Residents (#78 & 56) in a survey sample of 74 Residents. 1. For Resident #78 the facility staff failed to implement fall precautions for a Resident known to be a high fall risk resulting in Resident #78 sustaining a fractured hip after a fall from her wheelchair, this is harm. On 12/11/24 a review of the clinical record revealed that Resident #78 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, dysphagia, muscle weakness, dementia, severe without behavioral disturbance, psychotic mood disturbance and anxiety, abnormalities of gait and mobility, hypertension, hx (history) of renal cancer, and hx of repeated falls. Resident #78 had a BIMS (Brief Interview of Mental Status) score of 13/15 on admission indicating mild cognitive impairment. On 2/13/24 (one month prior to falls) Resident #78 BIMS was assessed at 5/15 indicating severe cognitive impairment. A review of the clinical record revealed that Resident #78 had 6 falls from 3/23/24 through 11/24/24 (3/23/24, 3/30/24, 7/1/24, 8/2/24, 11/23/24 and 11/24/24). Each of those aforementioned falls had a Post Fall Review Sheet attached in the clinical record with the exception of the 3/23/24 fall. The progress notes for the fall on 3/23/24 read: 3/23/2024 4:53 p.m. - Note Text: Entered resident room at 4:12 pm noted resident laying on right-side head-on flood large amount of blood on floor surrounding head area. when spoke to resident she responded by saying help me, did not move resident due to large amount of blood, 911 called at 4:13pm and reported incident EMT response team arrived at 4:20pm, Place call to MD on call message left to return. received return call and they were made aware of the injury and okay to send to ER. Resident was assess [sic] by EMT and they transported resident to [Hospital name redacted] with Head Laceration. Call place to family member and spoke with family member. Call place to [Hospital name redacted] report given RN [Nurse name redacted]. Bed hole [sic] sent with paperwork. The clinical record revealed that Resident #78 returned to the facility on [DATE] the progress note read as follows: 3/25/24 4:16 p.m. - Note Text: At 2:58pm resident arrived from [Hospital name redacted] via stretcher. family member in room with resident. Resident back with diagnosis of hip fracture 1. Left valgus impacted femoral neck fracture. Alert and verbally responsive, skin warm and dry [sic], respiration even no distress noted. No complain [sic] or facial expression of pain or discomfort. Old dry wound to forehead no drainage or s/s of infection observed. Peripheral IV assess to right arm antecubital. Meds verified by NP. [Nurse Practitioner name redacted]. V/S 96.9, 99%,18,96/56,77. Fall precautions in place, bed in the lowest position, call light within reach. Will continue to monitor. A review of Resident #78's complete care plan revealed that on admission the Resident was identified as being a high fall risk as evidenced by the following entry on admission, dated 4/30/23: FOCUS: [Resident #78 name redacted] is High, risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs Date Initiated: 04/30/2023 Created on: 04/30/2023 GOAL: [Resident #78 name redacted] will be free of falls through the review date. Date Initiated: 03/05/2024 Revision on: 04/18/2024 Target Date: 10/09/2024 INTERVENTION: Anticipate and meet her needs. Date Initiated: 04/30/2023 Created on: 04/30/2023 Be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 04/30/2023 Created on: 04/30/2023 Follow facility fall protocol. Date Initiated: 04/30/2023 Created on: 04/30/2023 Pt evaluate and treat as ordered or PRN. Date Initiated: 04/30/2023 Created on: 04/30/2023. The care plan update was not updated reviewed and revised after the fall with major injury on 3/23/24. The following revision to the care plan was made after the fall on 8/5/24. FOCUS: [Resident #78 name redacted] has had an actual fall with no injury, R/T Poor communication/comprehension Date Initiated: 08/05/2024 Created on: 08/05/2024 GOAL: [Resident #78 name redacted] will resume usual activities without further incident through the review date. Date Initiated: 08/05/2024 Revision on: 08/05/2024 INTERVENTIONS: Continue interventions on the at-risk plan. Low bed, Rt & Lt fall mats, repositioning every shift Date Initiated: 08/05/2024 Created on: 08/05/2024 Observe and report PRN to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 08/05/2024 Created on: 08/05/2024 Neuro checks per protocol. Date Initiated: 08/05/2024 Created on: 08/05/2024. On 12/18/24 an interview with LPN 1 (Unit Manager), who was asked what the expectation is for nursing staff after a fall occurs and she stated that Nurses are expected to assess the Resident for injuries, notify physician and family, follow any new orders from physician pertaining to the incident, and document the fall as well as the post fall follow up, and the care plan should be updated to add new interventions after a fall. When asked if this was done after each fall, she stated that it was not. On 12/18/24 a review of the facility FALL POLICY revealed the following excerpts: 9. When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a Post fall review and a Post fall follow up note in PCC [the electronic health record] c. Complete an incident report in PCC d. Notify physician and family. e. Review the resident's care plan and update as indicated f. Document all assessments and actions g. Obtain witness statements in the case of injury h. If there are signs of serious injury or there are concerns about the circumstances of the fall notify the Director of Nursing and or the Administrator. i. Begin neurologic assessment using Neurological Record assessment tool in PCC On 12/18/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 40711 2. The facility's staff failed to provide supervision and implement interventions to reduce environmental hazards for a resident who was burned after heating up her coffee in a microwave located in a communal dining room on Unit 2, resulting in harm. Resident #56 was originally admitted to the facility 08/22/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Unsteadiness on feet and Impulsiveness, Burn of first degree of left forearm, initial encounter. Burn of unspecified degree of single right finger (nail) except thumb, initial encounter. Unspecified dementia without behavioral disturbance. Unsteadiness on feet. Impulsiveness. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities and Goals) the resident was coded as independent with eating, oral care, toileting hygiene, personal hygiene, bathing/showering self. Sub section: GG0120 coded resident as using a walker as a Mobility Device. The care plan focus dated 10/14/24 read that Resident #56 has actual impairment to skin integrity of the left third finger and right forearm burn r/t impaired safety awareness. The Goal was that resident will have no complications r/t burn of the right forearm and left third finger through the review date. The interventions: Encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. During the initial rounds on 12/11/24 at approximately 10:27 AM., an interview was conducted with another resident, Resident #5 concerning warming her foods. Resident #5 mentioned We had a communal microwave in the break room. They took it away after a lady burned herself. Resident #5 also said that she didn't know the resident but after she was burned the microwave was removed and they could no longer warm their foods. A review of the Synopsis of the event: Date of incident: 6/03/24. Time: 6:00 PM. Location: Dining Area., Type of Injury: Burn to include redness, swelling and pain. Assessment: Redness, blistering, and swelling noted to left forearm, and right middle finger. Description of event: Resident was heating up coffee in a microwave in the unit 2 dining area. When attempting to pick coffee up, resident spilled hot coffee on her hand. According to the investigative document, Resident #56 was interviewed by staff at 10:00 AM., by then Unit 2 manager, now currently, the Infection Preventionist (IP) OSM #5. The resident stated the above mentioned had occurred. According to the staff interview, the resident was heard yelling out from the dining room. The June Treatment Administration Record (TAR). Right 3rd finger treatment. Clean area with durable wound cleanser (dwc), apply xeroform and cover with band aide everyday shift for wound care -Start Date- 06/06/2024. Discontinued Date-06/07/2024. Right Hand 3rd Digit. Cleanse with wound cleanser, apply bacitracin and cover with dry bandage every day shift for wound care -Start Date- 06/08/2024 0700 -Discontinued Date- 06/19/2024. Left Forearm. Apply Skin Prep and LOA every day and evening shift for Blister -Start Date- 06/07/2024 1500 -Discontinued Date- 06/12/2024. A review of the June 2024 TAR revealed daily wound care of the Right-Hand 3rd Digit. Cleanse with wound cleanser, apply bacitracin and cover with dry bandage every day shift for wound care -Start Date= 06/08/2024 0700. Discontinue Date =06/19/2024. Apply Skin Prep and LOA to Left Forearm every day and evening shift for Blister. Start Date= 06/07/2024 3:00 PM. discharge date =06/12/2024. A review of the Nurse Practitioner's Skin and Wound note on 06/05/2024 at 12:46 PM., read: Patient being evaluated for new left dorsal forearm burn and right middle finger burn secondary to coffee spill by the patient. Right middle finger with pink epithelial tissue and left dorsal forearm with intact blister. Recommend skin prep to forearm and bacitracin to right middle finger. WOUND ASSESSMENTS: Date wounds were acquired: 6/03/24 6/05/24- Wound #1 Location: right middle finger, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: New, Odor Post Cleansing: None, Size: 2.2 cm x 0.9 cm x 0.1 cm. Calculated area is 1.98 sq cm. Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: Scant amount of Serosanguineous, Wound Pain at Rest: 6. Wound: 2=6/04/24 Location: left forearm, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: New, Odor Post Cleansing: None, Size: 1.2 cm x 1.1 cm x 0.1 cm. Calculated area is 1.32 sq cm., Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: None amount of None, Wound Pain at Rest: 5. PLAN: Wound #1 right middle finger Burn Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Bacitracin ointment to base of the wound. 3. secure with Bordered gauze. 4. change BID, and PRN. PLAN: Wound #2 left forearm Burn. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Skin Prep to base of the wound. 3. secure with Leave open to air. 4. change BID. PLAN: Wound #1=6/12/24 Location: right middle finger Burn, Partial Thickness, Improving without complications. Size: 1.0 cm x 0.20 cm x 0.10. 100% epithelial, wound edges attached, peri wound intact, scant exudate, serosanguinous, no odor. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Bacitracin ointment to base of the wound. 3. secure with Bordered gauze. 4. change Daily and PRN. PLAN: Wound #2=6/12/24-24 Location: left forearm, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: Improving without complications: None, Size: 1.2 cm x 0.60 cm x 0.10 cm. Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: scant, serosanguineous, no odor. Treatment recommendations: Change dressing daily, Cleanse with wound Cleanser, apply bacitracin ointment use bordered gauze. PLAN: Wound #1=6/19/24 Location: right middle finger Burn. Wound Resolved. PLAN: Wound #2=6/19/24-24 Location: left forearm. Wound Resolved. On 12/12/24 at approximately 5:00 PM., during the end of day meeting. The Director of Nursing (DON), the Administrator and Corporate Staff #2., were asked if they had a Communal Microwave on Unit 2 and requested accident hazard reports on residents receiving burns. The DON said that she remembered an accident that took place months ago. The DON was asked if the microwave was still in the communal dining room. The DON said that the microwave had been removed, but she doesn't remember when the microwave was removed. On 12/13/24 at approximately 10:10 AM., the DON and Corporate Staff #1 informed surveyor of resident #56 receiving a coffee burn months ago. Documents of the incident were given to the survey staff. On 12/13/24 at approximately 3:55 PM., Resident not available to interview. Staff states resident was on Leave of Absence with activities. On 12/17/24 at approximately 11:15 AM., Resident not available to interview. Staff states resident was at an appointment. On 12/17/24 at approximately, 11:15 AM., an interview was conducted with Other Staff Member (OSM) #5. OSM #5 said that the room was for staff to heat up food, but the residents would use the microwave also. OSM #2 said that she took the microwave off the unit to keep everyone safe after the resident was burned. OSM #2 said they provided First aide to Resident #56. The forearm looked red and was swollen. Nurse didn't physically see the resident as she was warming up her coffee who used a walker for mobility on and off the unit. On 12/17/24 at approximately 3:25 PM., an interview was conducted with Certified Nursing Assistant (CNA) #11. CNA #11 said that she heard about the incident but didn't witness it. CNA #11 also mentioned that the incident occurred in the dining room on Unit 2. CNA #11 also said that initially a resident had the microwave in his room, but it was removed and put in the dining room. Licensed Practical Nurse (LPN) #7 wrapped her hand. On 12/17/24 at approximately 4:25 PM., an interview was conducted with Resident #56 concerning her incident. Resident #56 said that after she heated and removed her cup of coffee from the microwave, she spilled it on her hand and arm as she was using her walker. On 12/19/24 at approximately 5:55 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided prior to survey exit.

Based on a resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 74 residents (Resident #280), in the survey sample which resulted in harm. The findings included: Resident #280 was originally admitted to the facility 12/3/24 after an acute care hospital stay. The resident's current diagnoses included a TIA, migraines, chronic pain of the back and neck, fibromyalgia, and Raynaud's phenomena. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 12/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #280's cognitive abilities for daily decision making were moderately impaired. On 12/13/24 at approximately 12:55 PM an interview was conducted with Resident #280. The resident stated she arrived at the facility on 12/3/24 after 5:00 PM and she was experiencing significant neck and back pain at the time of her arrival. The resident stated she informed the nurses of her pain and her desire to be medicated before it became severe, but it was 2-3 hours before she received the pain medication, Hydromorphone 2 mg (Scheduled II narcotic). The resident stated she did not receive her routine Morphine (Schedued II narcotic) the night of admission or at all the next day 12/4/24. She stated on 12/5/24 she began receiving a liquid Morphine, not the tablet she received in the hospital or what she took at home. Resident #280 stated she gave up hope of ever getting her pain under control while in the facility, until the liquid Morphine was started on 12/5/24. The resident also stated by the time she received the liquid Morphine she was experiencing such excruiating pain that she was unable to lie down or sit up without wanting to scream. The resident also stated she could not participate in her care or eat. The resident further stated the first few doses of the liquid Morphine did not have the same effect as the tablets but she was grateful to finally start getting routine pain medication. Resident #280 reiterated that no one informed her why she was not receiving the Morphine tablets or told her to request the Hydromorphone when needed. The resident stated the nurses allowed her pain to become debilitating by only administering the Hydromorphone once when the scheduled Morphine was not available. Resident #280 was discharged from the acute care hospital to the rehabilitation facility on Morphine SR 15 milligram(mg) tablet - take one tablet by mouth every 12 hours, Gabapentin 300 mg - take two tablets by mouth three times each day, and Hydromorphone 2 mg, 1-2 tablets by mouth every three hours as needed for pain, maximum daily dose 16 tablets. The physician order summary revealed the following pain medications, Gabapentin Capsule 300 MG - Give 1 capsule by mouth three times a day for pain (This is half of what she was discharged on ) start on 12/4/24, Morphine SR 15 milligram(mg) tablet - take one tablet by mouth every 12 hours (this was discontinued on 12/4/24), Morphine Sulfate (Concentrate) Solution 20 MG/ML - Give 10 mg by mouth three times a day for pain was ordered to start on 12/5/24, and Hydromorphone tablet 2 mg - Give 1 tablet by mouth every 4 hours as needed for Pain give 1-2 tabs every 3 hours for pain, start on 12/3/24. The person-centered care plan had a problem dated 12/12/24 which stated at risk for alteration in comfort related to pain, Raynaud's syndrome, asthma with SOB while lying flat, GERD, HTN, Hypothyroidism, HF, PVD, Depression, osteoporosis, spinal stenosis, and B&B incontinence. The goals included will alert staff to need for pain medication through next review date, Will have pain/discomfort recognized and controlled by next review date, and Will verbalize relief from discomfort through next review date, 03/12/2025. The interventions included Medicate as ordered, obtain resident rating of the pain scale face/verbal descriptor and document, and offer repositioning, pillows, to get out of bed or to return to bed to increase comfort. A review of the Medication Administration Record revealed on 12/3/24 the resident received no pain medication even after complaining of pain of 5 out of 10 upon arriving to the facility. On12/4/24, resident #280 received Hydromorphone tablet 2 mg at 8:41 PM for pain rated as 8 out of 10. The Hydromorphone tablet 2 mg was not administered again during the resident's stay at the facility although it was available for administration as needed. The resident only received one-half of the dose of Gabapentin (300 mg three times daily for pain management) the acute care hospital discharged her to receive, and the Morphine SR was discontinued on 12/4/24 at 8:04 PM because it was on backorder from the pharmacy and Morphine Concentrate was ordered on 12/4/24 at 4:54 PM to start on 12/5/24. On 12/19/24 at approximately 11:34 AM an interview was conducted with the Manager for Unit 4 regarding Resident #280 pain management. The Manager stated We could have done a better job managing her pain. On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings. Opioids have been regarded for millennia as among the most effective drugs for the treatment of pain. Their use in the management of acute severe pain and chronic pain related to advanced medical illness is considered the standard of care in most of the world (https://pmc.ncbi.nlm.nih.gov/articles/PMC2711509/). Hydromorphone belongs to the opioid class of medications and is utilized to effectively manage and treat moderate-to-severe acute pain and severe chronic pain in patients. The drug exerts its analgesic effects by interacting with the mu-opioid receptors (https://pubmed.ncbi.nlm.nih.gov/29261877/). FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain (https://pubmed.ncbi.nlm.nih.gov/30252371/). Gabapentin is an anticonvulsive medication that is beneficial in managing certain types of neural pain and psychiatric disorders(https://www.ncbi.nlm.nih.gov/books/NBK493228/). Gabapentin at doses of 1800 mg to 3600 mg daily (1200 mg to 3600 mg gabapentin encarbil) can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy (https://pubmed.ncbi.nlm.nih.gov/28597471/).

Based on interview clinical record review and facility documentation the facility staff failed to ensure residents receive treatment and care in accordance with professional standards of practice for one (1) Resident (#376) in a survey sample of 74 Residents, which resulted in harm. The findings included: For Resident # 376 the facility staff failed to ensure follow up on lab work which led to the resident having to be hospitalized for a blood glucose of over 900, this is harm. On 12/13/24 a review of the clinical record revealed that Resident #376 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dialysis dependent end stage renal disease, myocardial infarction, hemiplegia / hemiparesis following CVA (Cerebral Vascular Accident), hypertension and generalized muscle weakness. Resident #376's most admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/11/22 coded Resident #376 as having a BIMS (Brief Interview of Mental Status) score of 13 / 15 indicating mild cognitive impairment. A review of the clinical record revealed that there were discrepancies in the discharge orders from the hospital. The following excerpts are from the physician progress notes: 10/6/22 1:00 p.m. - Clarification with nurse: d/c [discharge] med list has pt on Lokelma weekly, [Electronic Health Record name redacted] med list does not have pt on Lokelma weekly also calcium acetate missing from PCC orders, also metoprolol is 50 mg on d/c med list but 25 mg in [EHR name redacted] (d/w nursing so corrections can be made). 10/10/22 1:00 p.m. - Chief Complaint / Nature of Presenting Problem: Patient reports a diabetic patient reports receiving insulin and blood sugar checks throughout the day. History Of Present Illness: [AGE] year-old male seen per staff request indicated he is a diabetic blood sugars throughout the day as well as insulin. On arrival patient was sitting. Discussed with patient regarding his concerns. Reviewed hospital charts information indicating patient was a diabetic. Patient indicated he was insulin dependent. 10/16/22 7:30 p.m. - patient has some cognitive impairment however indicated he received insulin in the past will obtain hemoglobin A1c Plan: Patient indicated that the mail he received was in correct concerns for other following underlying conditions will obtain lab overview patient indicated he was a diabetic was taken other medication 1 he was homeless. Patient indicated he was on insulin however he was homeless and indicated that he moved from New York. Patient does have some cognitive impairment for further overview will obtain labs to establish baseline 10/17/22 1:00 p.m. - Patient reported that he was a diabetic however unable to identify hemoglobin A1c any labs indicating that patient is diabetic. Labs were ordered multiplications however patient refused because he receives dialysis receives labs at the dialysis unit. Discussed with patient additional labs are needed to determine his overall health and chronic disease. He verbalized understanding and agreed to receive lab work. Discussed with dialysis unit regarding patient's labs and asked him to add additional labs to help reduce with invasive treatment for patient she verbalized understanding nursing staff printed out labs and provided to staff. Patient denies any further complaints or concerns at this time we will continue to monitor patient closely he continues to progress with physical and Occupational Therapy further evaluation conducted he has not required any rehospitalization or any antibiotic course since his rehabilitation stay, he has a good nutritional intake we will continue to monitor. 10/25/22 1:00 p.m. Patient has some concerns regarding diabetes his hemoglobin A1c was obtained waiting for results from dialysis. The blood sugars remained stable 100 he denies any further complaints or concerns at this time no increased pain or discomfort. Tolerating dialysis. Further evaluation conducted. 1/8/23 3:15.m.- Note Text: @ 1445 can noted resident's speech unclear,& trying to eat but is drooling from right side of mouth, full body check completed resident lungs clear, BS hyperactive, resident noted w/ loose stools, eyes dilated, BP 180/88, 92,20, 98.8, O2 sat 94%, resident continue to try to communicate verbally, but speech unclear, Rt side face droop, On- call NP notified gave N/O to send resident to ER 911 for eval. Transfer summary, care plan, bed hold, med list sent w/ emt's, resident skin dry & intact, but confused upon exiting this facility, emergency contact (friend) notified no answer. On 12/11/24 a review of the clinical record revealed that on admission to the facility the Resident discharge paperwork from the hospital did not list diabetes as a diagnosis. The progress notes, however, did reflect the Resident telling the nurse and the Nurse Practitioner on several occasions that he was diabetic and took Lantus and Metformin daily. The Nurse Practitioner ordered labs including an HgbA1C on 10/11/22. A review of the clinical record revealed that there were no A1C lab results scanned into the record. A request was made to obtain the lab results from the on-site dialysis center. The results were obtained on 12/15/24 and revealed an A1C abnormal. On 12/15/24 at approximately 2:00 p.m. an interview was conducted with the DON who was asked if the nurses follow up on the labs and she stated that when the labs come in the doctor or NP usually sees them and signs off on them. She further said that if the nurses are made aware of a lab that is abnormal or critical value, they will notify the physician or NP. When asked why this abnormal A1C lab was not followed up on, she stated that the results were not received from the dialysis center. The surveyor requested medical records from the hospital and on 12/17 /24 the records received from the hospital revealed that Resident #378 did indeed have a diagnosis of diabetes since 2008. The Resident was sent out from the facility unresponsive via rescue squad on 1/8/24 and when arrived at the ER the Resident's blood sugar was over 900. On the afternoon of 12/18/24 an interview was held with the Nurse Practitioner currently at the facility who stated that all the NP and physicians have access to the local Hospital's electronic health record. When asked if they could view a Resident record from an inpatient stay, she indicated that they could. When asked if the Resident's A1C lab was showing up in the system and she stated that she could not find it. She then stated she would get in touch with the onsite dialysis center to obtain the lab. She looked in the record and found that Resident #376 did have a diagnosis of diabetes and was admitted to the hospital from the facility on 1/8/23 through 1/18/23 with admitting diagnoses of hyperosmolar hyperglycemic state. The Resident did not return to the facility after his stay in the hospital. On 12/19/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent, assess, identify timely, and treat avoidable pressure ulcers resulting in harm for two Residents, (Resident #117, and Resident #379) in a survey sample of 74 Residents. The findings included: 1. For Resident #117, the facility staff did not assess, nor identify an avoidable sacral pressure ulcer prior to it becoming a stage 3 full thickness ulcer with 80 % slough (dead stringy yellow tissue) in the wound bed, first identified during survey on [DATE]. The Resident was also suffering from significant weight loss, malnutrition, and meals were not provided, which would impact his skin and ability to heal. The Resident did not receive timely ADL care, did not receive preventative skin care and pressure reduction devices, and was not gotten out of bed during the entire 2 week survey. Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on [DATE] for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records. The Resident was again sent out to the hospital on [DATE] through [DATE] for a severe urinary tract infection causing sepsis and septic shock, and acute kidney injury which was reversed successfully in the hospital with IV (intravenous) fluids for dehydration and IV antibiotics. Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease. Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of [DATE]. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet. The only previous MDS assessment to the [DATE] MDS was dated [DATE], and was the Resident's admission assessment. This MDS had not been signed as completed until [DATE], and submitted late. The document revealed the Resident's weight at that time to be 139 pounds. This indicated a greater than 10% weight loss in the previous 2 months. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on [DATE]. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record. Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, thin consistency. On [DATE] mighty shakes 4 ounces was ordered at bedtime for a supplement. No other diet changes nor supplements were ever ordered during the Resident's stay. The Resident was observed during initial tour of the facility on [DATE] immediately following a shower room observation with Resident #117's room mate. The room tour revealed a dirty and unsafe room environment which included but was not limited to the following being observed; broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit. Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The bed divider curtain had brown stains and smeared feces on it. The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. Resident #117's bed was pushed against the PTAC unit holding it in place so it would not completely fall out of the hole in the outside facing wall. Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. The fitted bed sheet under the Resident had a yellow halo around the Resident which appeared to be dried urine with a strong odor. The Residents incontinence brief was obviously soaked with urine and wrinkled down at the waist with the heaviness of the liquid it contained. The Residents hair was matted to his head, greasy, dandruff lay in his bed and on his pillow, and body odor/sweat could be clearly smelled. During the entire survey Resident #117 was never observed during the day shift out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry, and his eyes were sunken. His skin was flaking and dry and when the skin on his hand was examined it tented when pulled gently in an upward fashion and stayed that way. His mucus membranes were sticky and when he spoke his lips would stick together with thick saliva briefly. He constantly complained my butt hurts, my butt hurts. Staff were made aware that the Resident was thirsty, and complaining of butt pain. Staff stated they would have the NP look at him. On [DATE] the Resident was assessed by the Registered Nurse Practitioner (NP) and found to have a stage 3 sacral pressure sore. Each day of survey the Resident was visited and observed to be in bed lying on his back or right side facing the window. No pressure reduction support devices and repositioning was ever observed. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #117's room. There were no televisions in any room, no personal items, and no water to drink in any room. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents. Staff on the memory care unit were interviewed and asked why Resident #117 was not clean, they stated well, he refuses a lot, and (name) Resident #117 is hospice now and doesn't like to be moved much. Staff were taken to the Residents' room and #117 was asked if he would like a shower or bath, and he simply shook his head yes. ADL (activities of daily living) care records were reviewed for Resident #117 and revealed that the Resident was totally dependant on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed every day during survey and found to be dirty and unkempt with flaking skin, dandruff, greasy hair, and in a soiled bed with soiled linens. At times the Resident was found wearing only an incontinence brief, and at other times wearing a white stained T-shirt and also an incontinence brief. The Resident was never seen out of bed during daytime hours for the entire survey. On [DATE] A Certified Nursing Assistant (CNA) was found in the hallway after Resident #117 was found begging for water. The CNA brought in 120 milliliters of tea for the Resident, and was again told he asked for water. She stated oh he just wants to drink, not eat. The CNA was asked if she was aware that the caffeine in tea was a diuretic and could further dehydrate the Resident. She did not respond. On [DATE] the Kitchen manager was interviewed and stated that they did not keep track of percentages of meals and fluids consumed, and stated that the nursing staff were responsible for that. She was asked if she had decaffeinated tea on hand, and she stated she had decaf coffee but not tea. On [DATE] A CNA was interviewed and stated, he (Resident #117) went out to the hospital with altered mental status, low blood pressure, dehydration and a UTI (urinary tract infection), and when he came back he went on hospice. He's been in bed now since then. The Resident had actually returned on [DATE], and was not placed on hospice until [DATE] (one month later). The CNA was asked for his hospice notes, and she went to the LPN (Licensed Practical Nurse) unit manager with the surveyor accompanying her and asked for the notes. The LPN stated I will look for them, and later stated I don't have any. The entire clinical record was reviewed and no hospice notes were in the clinical record. Staff were then asked if hard copy notes could be located in a binder, and they stated they had no such binder. There was an observed notice taped to the Resident's closet door from the new social worker addressed to the hospice staff. The document instructed that the Resident's hospice supplies had been found in the general supply closet in the facility with normal inventory. The document instructed hospice staff to inform the nurses on the unit when hospice supplies were brought in for the Resident. It appeared that the facility staff and hospice staff were not communicating. On [DATE] from 11:30 AM until 1:00 PM a second surveyor was observing lunch service on the memory care secured unit until the meal was finished. Resident #117 was never fed, and his tray was removed from his room. The tray was placed back on the tray cart to return to the kitchen for disposal, untouched. The CNA was asked why he was not fed, and she replied oh he's hospice he don't want it. The Resident received no food, and no fluids from 9:00 AM breakfast to 5:00 PM dinner (8 hours). No water was in any Resident room on the secured unit during the entire survey. Resident #117's clinical record was reviewed. Weight documents all completed by chair scale revealed the following; [DATE] - 145.3 pounds on admission. [DATE] - 143.0 pounds out to hospital on [DATE] with bleeding, returned [DATE]. [DATE] - 139.0 pounds [DATE] - 139.0 pounds [DATE] - 123.0 pounds [DATE] - 122.6 pounds No further weights were being recorded as staff stated well, he's hospice now, so no need really. The Resident was not placed on hospice until [DATE], (2 weeks later with no weights completed) and remained a Full Code CPR status. The Registered Dietician (RD) was called via cellular phone for interview and was unable to be contacted. A message was left on voicemail, however, surveyors received no call back. No RD notes were found in the clinical record, however, on [DATE] at 12:11 PM, the Administrator and Director of Nursing (DON) supplied one note they had received from the RD dated [DATE]. The RD note was reviewed and revealed continued weight loss and the following 4 recommendations, none of which were followed: 1. Consider benefit of appetite stimulant medication due to poor oral intake. 2. when poor oral intake less than 50% offer alternate meal options. 3. weekly weights for one month due to readmit. 4. RD to monitor for significant changes in weight poor oral intake or skin integrity and follow up as needed. Weekly Skin Review assessments were reviewed and were only completed on (5) weekly occasions during the Resident's 3.25 month stay equaling (13) weekly opportunities, and (8) missed weekly opportunities. The weekly skin checks were only completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. No wounds were identified in any of the documents. All Nursing and physician progress notes, and a care plan meeting note from [DATE] were reviewed and revealed no identification of a wound on the Resident until [DATE], when the Registered Nurse Practitioner (NP) assessed the Resident. On [DATE] the NP documented on a Wound Assessment Report location sacrum, 14 centimeter (cm) length x width total measurement of the wound, 0.1 cm deep date acquired [DATE] in house, wound status new, stage/severity Full Thickness, 20% granulation, 80% slough, Erythema peri wound (red and inflamed), exposed tissue Epithelium, Dermis. Treatment daily and as needed cleanse with wound cleanser, hydrogel primary treatment, dressing bordered gauze. The report documented as an etiology skin failure at end of life. While this is a chronologically correct description, it is not a diagnosis of the causation of the skin failure, which was a pressure ulcer/skin failure. The Resident was experiencing no other skin failure/breakdown anywhere else on his body. This included his face and nose having undergone treatment for cancer, and no tissue there was failing nor open. The only skin failure for this Resident with a known high risk for skin breakdown, who suffered from incontinence of bowel and bladder was the pressure ulcer wound over a bony prominence. The Resident wore incontinence briefs and was found to be lacking adequate ADL care timely. Resident #117 was also not fed meals culminating in significant weight loss, nor given fluids adequately, culminating in dehydration and urinary tract infection with sepsis and hospitalization . He was afforded no preventive measures in place to relieve pressure while being bed ridden for 2 months per staff interview since his return from the hospital on [DATE]. Staff were interviewed on [DATE] and asked what interventions could be offered to a Resident to prevent pressure sores. The Director of Nursing (DON) provided a policy on Pressure Injury Prevention and Management that documented basic or routine care interventions which could include but were not limited to the following 4 items for prevention in one who was at risk for developing pressure sores. No other items were named specifically in the policy for prevention of pressure sores, and none of the 4 on the policy were followed; 1. Redistribute pressure (such as repositioning/protecting offloading) 2. Minimize exposure to moisture, and keep skin clean, especially of fecal contamination. 3. Provide appropriate pressure redistributing, support surfaces. 4. Maintain or improve nutrition and hydration status, where feasible. The DON was asked if Foley catheters were available to those who were bed ridden with incontinence to prevent pressure sores, and she stated yes. She was asked if supplements, fluids, diet changes, and moisture barrier creams, and positioning devices were available, and she stated yes. She was asked if she was aware that the mattress for Resident #117 was the same as the ones used for the ambulatory residents on the memory care unit, and she stated she was not aware of that. None of the above prevention strategies were afforded Resident #117 for prevention of the pressure sore indicating this ulcer was potentially avoidable. On [DATE] a redistribution air mattress was ordered for the Resident, however did not arrive until after his move to another unit on [DATE] (7 days after identification of the stage 3 pressure sore. The professional nationally recognized experts in pressure ulcer staging, identification, and care are NUPAP. The National Pressure Injury Advisory Panel. In their reference guidance literature, it documents that this wound to be a stage 3 full thickness tissue loss at identification. On [DATE] a Weekly Non-pressure Wound Observation Tool document was completed by the LPN during wound rounds with the NP for the Resident and documented that the wound was first observed on [DATE], (even though there is no information nor documentation to support this) and the LPN documented that on [DATE] no inflammation was noted (in error) even though the NP documented there was Erythema (red and inflamed) by definition. The Wound Observation Tool note completed by the LPN went on to document that the Interdisciplinary Care Planning Team (IDT) and Responsible Party (RP) were notified at that time (on [DATE]). The IDT that was mentioned in the document was also documented in nursing progress notes and described the team as consisting only of the unit manager LPN and the new social worker which does not constitute an interdisciplinary team. The new Social worker was also found during survey not to be qualified for the position. The Wound Observation Tool document describes that the LPN writing the note was with the NP during the observation. The Care plan was reviewed and included focuses, goals and interventions for potential for pressure ulcer development created on [DATE] related to Dementia and bowel and bladder incontinence. A new care plan entry was created on [DATE] which identified the first actual impairment to skin integrity with interventions for the 3 following items; 1. Follow facility protocols for treatment of injury. 2. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands to avoid striking any sharp or hard surface. 3. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations. The care plan was not Resident specific and did not specify treatments, moisture barrier creams, nor devices, supplements, diet changes, nor any measures/interventions to be instituted to prevent new pressure sores, and to prevent this new pressure sore from worsening, as an interdisciplinary care plan team would be expected to produce. On [DATE] Review and copy of Physician's orders was conducted, and on [DATE] The Medication Administration Record (MAR) was copied, which is an exact copy of the physician orders. The MAR is used to document nursing signatures to show the orders are recorded as completed. Both revealed the 2 current orders for wounds; 1. Cleanse sacrum with wound cleanser, apply hydrogel and cover with dry dressing every day start date [DATE]. 2. Cleanse right buttock (MASD) moisture associated skin damage with wound cleanser and apply triad paste every day and evening shift start date [DATE], which was not identified in the NP assessment. It is unknown why the [DATE] orders were derived as skin assessment documents clearly denote no wounds for this Resident until [DATE], and the right buttock was never mentioned in any assessments, even by the NP on [DATE]. No documentation of wounds existed prior to [DATE], and the Resident's skin was documented as intact with no wounds up to [DATE]. No formal assessment was never completed and documented of wounds until [DATE]. This information indicates that there may have been further wounds that existed and were not documented prior to the identification of the full thickness sacral wound found on [DATE]. Only one supplement was ordered for the Resident, and it follows below; 1. Mighty shake 4 ounces at bedtime ordered [DATE]. The Might Shake was not given on the following nights, with no reason documented as to why it was withheld; October - [DATE], [DATE]. November - [DATE], [DATE], [DATE], [DATE]. December - [DATE], [DATE], [DATE]. Resident #117 experienced a potentially avoidable pressure ulcer injury which was not assessed nor identified until it became a full thickness wound with dead yellow slough tissue obscuring the base of the wound by 80%. The Resident was at risk for skin breakdown after being continuously bed ridden for months, was experiencing continued significant weight loss, and was hospitalized for fecal impaction with hemorrhage, and hospitalized for a urinary tract infection, dehydration, and severe sepsis while in the facility. No interventions were in place for a moisture barrier cream after incontinence, which was recommended in the NP note yet never ordered. The NP also recommended an air mattress which was ordered on [DATE], however, did not arrive until the Resident was moved a week after the identification of a stage 3 pressure sore. The pressure sore injury should have been identified during ADL care of the Resident, and no preventive interventions were ever care planned for this Resident until he exhibited a stage 3 pressure sore. On [DATE] at 11:15 a.m., the Administrator, Director of Nursing, and Corporate Nurse were notified that the survey team was considering a harm level deficiency. The facility staff was given the opportunity to provide any further information or explanation. They stated they had no further information to provide. On [DATE], and [DATE] during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns which could constitute harm for this Resident. Furthermore they were made aware that Residents were not being bathed and given hygiene timely, nor as often as needed, as this was the observation on days during the survey with multiple Residents being soiled and unkempt, in a dirty room with dirty linens and clothing. They were made aware that Resident #117 was not afforded preventive measures that were available such as; moisture barrier creams, Foley catheters, oral fluid increases, air mattress, protein and vitamin supplements, and alternate meal offerings. On [DATE], prior to the survey exit the Director of Nursing informed surveyors that Resident #117 and his room mate had been moved back onto regular units last night ([DATE]). At the time of survey exit on [DATE] the facility Administrator, and Director of Nursing stated they had nothing further to provide. 40026 2. For Resident #379 the facility staff failed to ensure Resident had weekly skin assessments and interventions in place to prevent the development of pressure injury, resulting in the development of four (4) pressure ulcers. On [DATE] a review of the clinical record revealed that Resident #379 was admitted to the facility on [DATE] with diagnoses that included but was not limited to sepsis, metabolic encephalopathy, protein-calorie malnutrition, acute kidney failure, atherosclerotic heart disease, hypothyroidism, Alzheimer's disease, dementia, anxiety disorder hypertension, dysphagia, g-tube dependence, instability of gait and mobility and insomnia. Upon admission the Admission Screening form was completed. The admission screening form dated [DATE] section C states that the skin turgor is normal, skin temp is warm and there are no wounds or open areas documented on the form. A review of the clinical record revealed that the care plan for Resident #379 read as follows: FOCUS: [Resident name redacted] has DTI [Deep Tissue Injury] pressure ulcer to left hell [sic], left lateral ankle, right later ankle pressure or potential for pressure ulcer and potential for skin breakdown development r/t Dehydration, disease process, incontinence, Hx of ulcers, Immobility. Date Initiated: [DATE] Created on: [DATE]. GOAL: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: [DATE] Target Date: [DATE]. INTERVENTIONS: Administer medications as ordered. Observe/document for side effects and effectiveness. Date Initiated: [DATE] Created on: [DATE]. Administer treatments as ordered and observe for effectiveness. [duplicate] Date Initiated: [DATE] Created on: [DATE] Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: [DATE] Created on: [DATE] If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: [DATE] Created on: [DATE] Inform the resident/family/caregivers of any new area of skin breakdown Date Initiated: [DATE] Created on: [DATE]. On [DATE] a review of Policy entitled Pressure Injury Prevention and Management revealed the following excerpt: 3. Assessment of Pressure Injury Risk a. Licensed nurses will conduct a pressure injury risk assessment using the Braden Scale, on admission/readmission, weekly x four weeks, then quarterly or whenever the residents condition changes significantly. c. Licensed nurses will conduct a full body skin assessment weekly and after any newly identified pressure injury Findings will be documented in the medical record. 4. Interventions for Prevention and to Promote Healing c. Evidence based interventions for prevention will be implemented for all resident who are assessed at risk or who have a pressure injury present. Basic or routine care could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and or offloading heels, etc.) ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination. iii. Provide appropriate pressure-redistributing support surfaces iv Maintain or improve nutrition and hydration status where feasible. A review of the clinical record revealed the following: [DATE] - Weekly Skin assessment not filled out entire document left blank. [DATE] - Weekly skin assessment all questions left unanswered, and one comment was placed in the wound section Right heel - sdti [suspected deep tissue injury] right lateral ankle - sdti left heel - sdti left lateral ankle - sdti [DATE] - Weekly Skin Assessment all questions left unanswered and one comment in the wound section read: Left big toenail bleeding during morning hygiene. Weekly Wound Assessments: [DATE] - Wound #1 Location - Left heel SDTI (Suspected Deep Tissue Injury) 3a. SDTI 5a. Overall Impression -First observed 8a. Wound Measurements Length 7 cm Width 5.5 cm Depth 0.1 cm [DATE] Wound #2 1.Location - Left Lateral Ankle 3a. SDTI 5a. Overall Impression - First observed 8a. Length 2.0 cm Width 2.0 cm Depth 0.1 cm [DATE] - Wound #3 Right Lateral Ankle 3a. SDTI 5a. Overall Impression - First observed 8a. Length 3.0 cm Width 2.5 cm Depth 0.1 cm [DATE] - Wound #4 Right Lateral Foot 3a. SDTI 5a. Overall Impression - First observed 8a. Length 3.5 cm Width 1.5 cm Depth 0.1 cm On [DATE] at approximately 1:00 p.m. an interview was conducted with the DON who was asked when interventions should be put in place for prevention of pressure ulcers, she stated that they should be done on admission. When asked if this was done in Resident #379's case she stated that it was not. When asked when the care plan should be updated after the development of a new pressure area, and she stated that the care plan should be updated immediately following a change in the condition of the Resident to include development of pressure areas treatment and any new interventions. When asked if that was done in this case, she stated it was not updated when the pressure areas were discovered on [DATE], and the care plan was not updated until a week later. When asked if the Resident received repositioning devices, booties, an air mattress or any specific turning and repositioning schedule to prevent or aid in healing of the pressure wounds, she stated, There is no evidence of these interventions in the chart. On [DATE] the during the end of day debreifing meeting, the Administrator was made aware of the findings and no further information was provided.

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain a safe, clean comfortable homelike environment for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of five Residents (Resident #226, #117, #91, #69, and #280) in a survey sample of 74 Residents, resulting in a Substandard Quality of Care. The findings included: 1. For Resident #226, the entire memory care unit was dirty, in disrepair, was not safe, not clean, nor homelike. 2. For Resident #117, the entire memory care unit was dirty, in disrepair, was not safe, not clean, nor homelike. 1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226. During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do. The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here? Immediately following the shower room observation the Resident's room was examined. The Resident's room was shared with a second Resident. The room tour included but was not limited to the following being observed; broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit. The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms. The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere. Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The bed divider curtain had brown stains and smeared feces on it. The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed (#117) was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall. Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. During the entire survey Resident #117 was never observed during the day out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry. The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. The same number of clothing articles were found for Resident #117. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's room. There were no televisions in any room, and no water to drink in any room. There was also noted in the hallway the air conditioning main vent in the ceiling and air return on the wall were so dusty that they had the appearance of brown fur coating them. The walls were marked and smeared and had paint scraped off in places. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents. On 12-13-24 the Director of Maintenance and Director of Environmental Services (house keeping) were interviewed and agreed that staffing for the 2 departments had been tight. Environmental services had 13 total employees. That number was responsible for house keeping, laundry and floor machine technicians. This number culminated in daily staffing dispersal of 3 staff in laundry, and 1 floor tech, which left 1 housekeeper on each of the 4 nursing units, and 1 housekeeper in common areas such as dining rooms on each unit, the main kitchen, activities, offices, therapy, bathrooms, conference rooms, the dialysis center, and main hallways/entrances. The added 4 staff positions would be trade outs for the other staff members days off during a seven day schedule. With 123 resident rooms total each of the nursing units housed approximately 20 to 35 Resident rooms for one house keeper to clean each day in an 8 hour shift allowing for 16 minutes to clean each room. Two of the 3 dryers in the laundry had been broken since June 2024, so linens and privacy curtains and resident personal laundry was not being washed and returned timely even though the staff was washing and drying around the clock. The only working dryer was being operated 24 hours per day. The dirty linen storage on the units was backed up as a result, and creating some of the pervasive urine and feces odors in the facility. Linens, bedding, and privacy curtains were not being changed as often as necessary due to the inability to have enough on hand to change them out more frequently. The maintenance Director stated they were starting to get some priorities taken care of in the facility now as staffing had improved just recently, and he began painting the memory unit and new cabinets began to be installed on 12-13-24. On 12-12-24, and 12-13-24 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that the entire memory care unit was not safe, clean and comfortable. On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24). At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide. 34894 3. For Resident # 91 residing on Unit 1, the facility staff failed to ensure bugs/insect/gnats were not in sandwiches stored on top of the light fixture over the bed. There were no sheets on the mattress nor linens on the bed during the entire survey. Resident # 91 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction, Hypertension, Anxiety Disorder, Hemiplegia and Vascular Dementia. The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 91's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Resident # 91 required assistance with Activities of Daily Living. Review of the clinical record was conducted on 12/10/2024-12/19/2024. On 12/10/2024 during the initial tour of Unit 1, clutter was observed in Resident # 91's room. There were several items on the nightstand, on the window sill and clutter around the bed. There were 4 sandwiches wrapped individually in sandwich bags lying on top of the ledge of the light fixture above the bed. Numerous bugs/insects were observed swarming in one of the sandwich bags. There were dozens of bugs/insects in the sandwich bag. Closer observation of the room revealed there were bugs/insects flying in the room. The Facility Administrator came into the room while the surveyor was inspecting the area. The Administrator picked up the four sandwiches and noticed the bugs/insects. The Administrator stated the insects they might have been black gnats. She stated that was unacceptable and that insects should not be in residents rooms. She stated she was going to take care of the problem. The Administrator took all four sandwiches to the soiled utility room at the end of the hall. The Administrator returned to Resident # 91's room and asked why he had so many sandwiched. Resident # 91 stated he was keeping them to eat later. The Administrator informed Resident # 91 that he could not keep several sandwiches at the bedside because they were attracting bugs/insects. The Administrator told Resident # 91 stated the Dietary Staff would provide sandwiches whenever he requested them. On 12/10/2024 at 2:30 p.m., an interview was conducted with CNA (Certified Nursing Assistant)-1 who stated that Resident # 91 liked to keep snacks at the bedside and did not want staff members to remove them. CNA-1 stated bugs/insects should not be in residents rooms. On 12/11/2024 at 9:15 a.m., black insects were noted in Resident # 91's room near the sink at the entrance to the room and on items on Resident # 91's side of the room. Resident # 91 was sitting on the side of the bed. On 12/11/2024 at 9:45 a.m an interview was conducted with the Dietary Manager who stated the sandwiches were placed on each meal tray as requested by the resident. The Dietary Manager stated she was not aware that Resident # 91 was collecting the sandwiches and not eating them. The Dietary Manager stated she was not aware that bug/insects were in the sandwiches at the bedside. On 12/11/2024 at 12:40 p.m. an interview was conducted with the DON (Director of Nursing) who stated bugs/insects should not be in residents rooms. Review of the facility policy entitled Resident Environmental Quality, implemented 11/1/2020, revised 12/1/2022 revealed a policy statement which read The facility should be designed, constructed, equipped and maintained to Provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The policy explanation and guidance included the following excerpts: 5. The facility must provide each resident with a. A separate bed of proper and height and size for the convenience of the resident b. A clean comfortable mattress c. Bedding appropriate to the weather and climate . During all of the days of the survey, there were observations of no sheet on the mattress at any time. Resident # 91 was observed lying in the bed with no sheet or bedding covering the mattress. The resident was lying on the uncovered vinyl mattress. On 12/17/2024, at approximately 03:45 PM, Resident #91 was observed walking into his room. Bed observed unmade no sheets. Air condition unit set at 62 degrees. Resident states I don't want sheets on my bed its too hot. Everyone here knows not to put sheets on my bed and to keep my curtain drawn. On 12/18/2024 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings of failure to provide a clean, comfortable, homelike environment. There was no documentation that the resident refused to allow the staff to provide bedding for the mattress No further information was provided. 34306 Upon walking up the sidewalk into the facility on [DATE] at approximately 11:15 AM, an observation was made of a large mat along the walkway leading to the front door entrance. Viewable at the corners of the mat were many broken and loose tiles in the sidewalk. Overhead under the awning were large pieces of plaster missing and hanging plaster about to fall. As the Team was escorted to the conference room through the corridor of Unit 1, unpleasant lingering odors reeked to the end of the corridor and much debris and clutter was observed. Immediately upon getting seated in the conference room several windows had sections of missing blinds on Unit 3, observable from the conference room. Residents and staff were viewable through the broken blinds. 4. Resident #69 was originally admitted to the facility 1/2/2024. The current diagnoses included end stage renal disease requiring hemodialysis, and a history of strokes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/23/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #69's cognitive abilities for daily decision making were intact. On 12/10/24 at approximately 2:39 PM an interview was conducted with Resident 69. Resident #69 stated he was dissatisfied with his room primarily because of episodes of water dripping from the ceiling onto his head and face. The resident pointed out many water-stained ceiling tiles. The resident further stated that the light over the sink has been extremely dim for months, and he had reported it to several staff but, no one would replace it. Resident #69 also stated that his room floor is not mopped consistently, and the sink is usually soiled, and the bathroom was not clean because of lack of general cleaning. Resident #69 adamantly stated he refuses to go to the shower room because it is not clean or homelike. The resident also stated there are not always towels and washcloths for bathing and his soiled clothes were running over in his room because of problems in the laundry. He stated the environment saddens him and he would like to move but, he does not have a place to live outside the facility. On 12/10/24 at 2:39 PM observations were made of the concerns the resident identified, it was validated that the bathroom did not have a freshness and there were multiple stained ceiling tiles overhead, as well as the light over the sink was barely projecting light. It was also identified that the floor lacked gloss and had a stickiness to it, the sink was with multiple items and lacked cleanliness. The trash can was without a liner and used gloves were observed on the floor next to it and soiled laundry was over in the corner beneath the television. On 12/19/24 at approximately 4:45 PM the above information was shared with the Environmental Services Director and Maintenance. At approximately 5:00 PM four staff were observed in Resident #69's room, one was on a ladder working on the ceiling tiles, the dim light bulb had been removed from over the sink and a super bright light was in place. On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings. 5. Resident #280 was originally admitted to the facility 12/3/24 after an acute care hospital stay. The resident's current diagnoses included a possible TIA, chronic pain fibromyalgia, and Raynaud's phenomena. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 12/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #280's cognitive abilities for daily decision making were moderately impaired. On 12/13/24 at approximately 12:55 PM an interview was conducted with Resident #280. The resident stated she was not satisfied with the cleanliness of the room. She stated the floors may appear clean, but she sees how black her socks are when she gets in the bed. The resident stated that she was in the room most of the time and she had not seen anyone clean the floors or the bathroom, but they had removed the trash daily. Resident #280 also stated there was a dead bug in the floor near the door for two days before a nurse decided to sweep it up. Resident #280 stated her focus was to be discharged home very soon because nothing was going well in the facility. On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings. 40711 6. On 12/13/24 at approximately 12:30 PM., an observation of Unit 3 was made on the Memory Care Unit. Fourteen residents were observed sitting, standing and or walking around in the dining room. Some residents were observed leaving from out of the dining room near a metal door plate that was separating in an outward position from the door approximately 1 inch. Staff were also observed coming and going from the dining area. On 12/19/24 at approximately 11:35 AM.,an observation was made on unit 3, to the dining room area. The metal door plate was still extending outward from the door leading into the dining room. On 12/19/24 at approximately 1:07 PM., an observation was made on Unit 2, room [ROOM NUMBER]. Buckling ceiling tiles, a hole in the ceiling and a brown substance was noticed on the privacy curtain (32-A). Resident #88 was resting quietly in her bed. Her Brief Interview for Mental Status (BIMS) score was a 3 out of a possible 15. This indicated Resident #88 cognitive abilities for daily decision making were severely impaired. Resident #88 was not able to respond to questions asked concerning the condition of her room. On 12/19/24 at 12:25 PM., an interview was conducted with the Maintenance Assistant/Other Staff Member (OSM) #11, concerning the ceiling tiles, and hole in the ceiling in room [ROOM NUMBER] on unit 2. OSM #11 said, The new ceiling tiles came in today. The privacy curtain was observed visible soiled with a brown substance. On 12/19/24 at approximately 1:00 PM., an interview was conducted with the IP concerning the brown substance observed on the privacy curtain on unit 2, room [ROOM NUMBER]. The IP said that she had spoken to the Environmental Services Department (ESD) and said, It's an infection control issue. On 12/19/24 at approximately 5:30 PM., an interview was conducted with the Administrator and with OSM #8 concerning the privacy curtain room, the ceiling tiles and the hole present in the ceiling in room [ROOM NUMBER]. On 12/19/24 at approximately 5:45 PM., OSM #8 informed surveyor that he was replacing the privacy curtain (32-A), and confirmed that it looked like Bowel Movement (BM) smeared on it. On 12/19/24 at approximately 5:55 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 40026 7. For the facility, the facility staff failed to ensure clean comfortable and sanitary environment for Residents, staff and the public. The following observations were made during the course of the survey: Hallway bathroom on Unit 2 cove base pulled off wall since survey started on 12/10/24, not repaired. Strong urine odor on hall Unit 1 noticed on the morning of 12-10-24, 12-16-24 and 12-17-24. On 12/18/24 8:47 AM used glove noted outside of room [ROOM NUMBER] and linens in floor. Soiled linens were observed on the floor in room [ROOM NUMBER]. Shower room Unit 1 - used pull ups, gloves and plastic cups on the floor, 1st shower stall floor was dirty and used washcloth left on railing. Shower stall 2 - dirty washcloth on floor as well as one on handrail. Hoyer lift in middle of the room blocking the shower stalls chair scale had resident clothing and soiled brief laid across it. On 12/18/24 10:00 AM - room [ROOM NUMBER] soiled linens observed on the floor. On 12/18/24 at approximately 10:10 a.m. an interview conducted with LPN #2 (Unit Manager) who was asked if it was an acceptable practice to place soiled linens on the floor, she stated, It is not ok to have soiled linens on the floor and it is an infection control risk to leave soiled linens on the floor. On 12/18/24 10:20 a.m. Shower room Unit 2 - toilet unflushed with urine and feces, bathroom smelled of urine, Cove base peeling off of the shower room walls, shower stall dirty and soiled linen in shower room floor. The resident council minutes dated 8/14, 9/26 and 10/24/24 reflected complaints of needing more linens, (towels, sheets), as well as dirty bathrooms. On 12/18/24 an interview was conducted with Other Employee #1 stated that they have had issues with linens being available due to 2 of the 3 dryers being broken and unavailable for use. When asked if this has impacted the staff she stated that they did not have enough clean linens to bathe the residents. They stated they had to cut towels to make wash cloths. Other Employee #1 stated that the facility would no longer allow them to use disposable wipes so they have to use the linens for incontinent care. Review of the facility policy entitled Resident Environmental Quality revealed the following excerpts: The facility should be designed, constructed, equipped and maintained to Provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. 5. The facility must provide each resident with: a. A separate bed of proper and height and size for the convenience of the resident b. A clean comfortable mattress c. Bedding appropriate to the weather and climate . On 12/19/24 during the end of day debriefing meeting the Administrator was made aware of the findings and no further information was provided.

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an activities program to meet the needs and preferences of each resident to include the entire locked memory care unit and for four individual Residents (Resident #226, #117, #77, and #105) in a survey sample of 74 Residents, resulting in a Substandard Quality of care. The findings included: 1. For Resident #226, the entire memory care unit was without a television, or activities from the commencement of survey on 12-10-24 through 12-18-24, and some activity planning did occur on 12-19-24 just prior to exit. 2. For Resident #117, the entire memory care unit was without a television, or activities from the commencement of survey on 12-10-24 through 12-18-24, and some activity planning did occur on 12-19-24 just prior to exit. 1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226. During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do. An observation the Resident's room was conducted. The Resident's room was shared with a second Resident (Resident #117). The room tour included but was not limited to the following being observed; broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit. The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms. The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere. Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The bed divider curtain had brown stains and smeared feces on it. The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed (#117) was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall. Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. During the entire survey Resident #117 was never observed during the day out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry. The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. The same number of clothing articles were found for Resident #117. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's and #117's room. There were no televisions in any room, and no water to drink in any room. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents. It is notable to mention that no activities were noted to be conducted during day shift in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole 150 bed facility. Observations continued daily with multiple surveyors taking turns continuously and it was found that from 10:00 AM until 4:00 PM every day from 12-10-24 until 12-18-24 that no activities were noted to be conducted in the secured unit. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole facility, and if we let them have TV's they will just pull them off the wall. When asked which Residents had done this none could attest that they had actually seen this in practice, it had simply been assumed. Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response. On 12-18-24, during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the concerns that the entire memory care unit was not receiving any activity programming, and that the calendar of events document that had been received as requested from staff, had not been observed happening on the unit as was written on the calendar. On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24). At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide. 34306 3. The Activity Directors (AD) failed to conduct activity assessments for Resident #77 from 11/15/23 through 9/18/24 and after the assessment was completed the resident's preferences were not incorporated in the person-centered care plan. Resident #77 was originally admitted to the facility 11/3/23 and she was readmitted [DATE] after an acute care hospital stay. The current diagnoses included Epilepsy, ESRD requiring dialysis, depression, and behavior problems with hallucinations and fabricating stories. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/27/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #77's cognitive abilities for daily decision making were moderately impaired. On 12/19/24 at 2:49 PM an interview was conducted with Resident #77. The resident stated she does not attend activities, and she did not remember a choir coming to her room to sing Christmas carols. The resident stated she would have enjoyed the singing because she loves music. A review of the resident's activity assessments revealed assessments were conducted on 11/14/23 for her initial admission, 9/19/24 after return to the facility from a hospital stay and on 10/30/24 with the annual MDS assessment. This indicated activity assessment were only conducted for this resident upon admission/readmission and annually. The 10/30/24 activity assessment revealed that it was very important to the resident to listen to music she likes, to be around animals such as pets, to keep up with the news and to participate in religious services or practices, yet the information was not incorporated in the person-centered care plan A person-centered care plan was developed for resident #77 initially on 10/21/24 and the problem read, (name of resident) has no group activity involvement related to immobility and physical limitations. She enjoys reading and coloring in her room. The goal read, the resident will participate in 1:1 activities of choice such as talking and receiving new materials 2-3 times per week by review date 2/3/25. The interventions included establish and record the resident's prior level of activity involvement and interest by talking with the resident, caregivers, and family on admission and as necessary. The resident can color large print pictures. The resident's preferred activities are art and movies. The above-mentioned preferred activities were not documented on the 10/30/24 activity assessment. On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings. 4. The Activity Directors (AD) failed to conduct activity assessments for Resident #105 from 12/27/23 through 12/19/24 and the preferences included on the activities assessment dated [DATE] were not incorporated in the person-centered care plan. Resident #105 was originally admitted to the facility 10/27/23 and he was readmitted [DATE] after an acute care hospital stay. The current diagnoses included a major neurocognitive disorder with Lewy Bodies dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making were severely impaired. The person-centered care plan was developed for resident #105 initially on 7/31/24 and the problem read, (name of resident) has little or no activity involvement related to cognitive deficits, chronic health conditions. The goal read, (name of resident) will express satisfaction with type of activities and level of activity involvement when asked through the review date 1/24/25. The interventions included explain to (name of the resident) the importance of social interaction, leisure activity time. Remind (name of the resident) that he may leave activities at any time and is not required to stay for entire activity. The person-centered care plan also included activity interventions for behaviors; 11/1/23 Distract (name of the resident) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 7/31/24 Provide a program of activities that is of interest and accommodates the resident's status. On 12/13/24 at 12:55 PM an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated Resident #105 does not communicate in English and prior to his decline could not focused, remain seated or concentrate long enough to participate in group activities. On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings.

Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in Substandard Quality of Care. The findings included: During a recertification survey conducted 12/10/24 through 12/13/24 and 12/16/24 through 12/19/24 residents were identified who could benefit from meaningful and individualized activity programs. A further review of the activities program revealed that the current Director of Activities (AD) had been employed at the facility since July 23, 2024, and her previous experience in a similar role was with an assisted living community, (assisted living facilities are not classified as health care settings). An interview was conducted with the current AD on 12/12/24 at approximately 4:50 PM. The AD stated she had a special love for enrichment through various activities and it was her desire to become an Activities Director Certified not an Activities Professional. The facility's AD stated she was not completing the activity section of the comprehensive Minimum Data Set Assessment, but she was developing the care plan goals. The facility's AD further stated she obtained a degree in gerontology and had worked greater than 700 hours in an activities program, therefore she had contacted a representative with the National Certification Council for Activity Professionals (NCCAP) about the Professional Equivalency Track for certification as an ADC. A review of the correspondence between the AD and the representative revealed the representative requested that the facility's AD proceed to upload specific documents for review. The facility's AD stated NCCAP requirements were for her to complete and pass two test which cost $60.00 each, then she would be allowed to pay $80.00 to take the test for certification as an Activities Director. On 12/13/24 at approximately 1:10 PM the Regional [NAME] President requested additional information and provided the surveyors with a copy of the state and federal regulations regarding the qualifications of an AD. She asked if she was reading the regulation correctly because the current AD had years of experience. On 12/13/24 at approximately 12:45 PM, the Human Resource Director (HRD) stated the activity department had three employees, the Director and two assistants and neither was certified as an AD or AP. The HRD provided a summation of the facility's AD from 8/15/2023 to current. The findings revealed all the ADs between 8/15/2023 and 12/19/2024 were unqualified based upon the facility's job description below: The facility's Activities Director job requirements dated December 2018 stated the Activities Director must meet at least one (1) of the following criteria: Degree and certification as a therapeutic recreation specialist; or Certified Activity Director by the National Certification Council for Activity Professionals; or two (2) years' experience in a social or recreational program within the past five (5) years, in which one (1) year was full time in a resident activities program in a health care setting; or prior completion of a state approved training course. The Activities Director job requirements also stated that the individual must have one (1) to two (2) years management/supervisory experience, effective verbal and written English communication skills, excellent creative and communication skills and skill at working with individuals who have cognitive, physical or sensory disabilities. The Activities Director job requirements further stated that the individual must have practical knowledge of how an Activity Department functions in a nursing facility. General knowledge of regulatory requirements for an activity program in a long-term care facility, outstanding interpersonal skills with a high level of energy and enthusiasm, experience in working with volunteers and the ability to organize and develop a volunteer program. On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings.

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to employ a full time professional necessary to carry out the provisions of a licensed or certified Social worker in a 220 bed facility impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents. The findings included: For Resident #226, who refused a transfer to the locked memory care unit (for Residents with dementia and behaviors), the facility staff failed to honor the Resident's request. The staff moved him against his will, and did not afford him the services of a Social worker to plan care and discharge, per his wishes. He was involuntarily secluded. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the Resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the Resident's brother agreed to the room change even though these individuals were only emergency contacts and the Resident refused and was his own responsible party. The reason given for the move, was elopement risk. The Resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the Resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner. During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The Resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and crys all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do. The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole facility. Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response. The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him. On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged . On 12-12-24 the Social worker's license and curriculum vitae were requested for verification and vetting as part of the employee records review for competency of staff. It was noted that the required course work and degree required by state and federal regulation for this employee was not sufficient for the role. The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit. On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the Resident's move, nor was a request made for assessment and told that the Resident wished to discharge. On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them. On 12-12-24, during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the lack of Social Work services for 5.5 months which continued through survey, and that the Resident had requested to stay in his room, and to be planned for discharge. The discharge request was ignored. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, which culminated in the withholding of a resident's rights, and involuntary seclusion. On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24). At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an infection prevention and control program to include environmental concerns for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of four Residents (Resident #226, #117, #105, and #87) in a survey sample of 74 Residents. The findings included: 1. For Resident #226, the entire memory care unit was dirty, in disrepair, had bodily fluids on surfaces, and there were no paper towels nor soap to wash staff hands in any resident room. 2. For Resident #117, the entire memory care unit was dirty, in disrepair, had bodily fluids on surfaces, and there were no paper towels nor soap to wash staff hands in any resident room. 1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117. 2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226. During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do. The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here? Immediately following the shower room observation the Resident's room was examined. The Resident's room was shared with a second Resident. The room tour included but was not limited to the following being observed; broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit. The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms. The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere. Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor. The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The bed divider curtain had brown stains and smeared feces on it. The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed (#117) was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall. The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's room. There were no televisions in any room, and no water to drink in any room. There was also noted in the hallway the air conditioning main vent in the ceiling and air return on the wall were so dusty that they had the appearance of brown fur coating them. The walls were marked and smeared and had paint scraped off in places. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents. On 12-13-24 the Director of Maintenance and Director of Environmental Services (house keeping) were interviewed and agreed that staffing for the 2 departments had been tight. Environmental services had 13 total employees. That number was responsible for house keeping, laundry and floor machine technicians. This number culminated in daily staffing dispersal of 3 staff in laundry, and 1 floor tech, which left 1 housekeeper on each of the 4 nursing units, and 1 housekeeper in common areas such as dining rooms on each unit, the main kitchen, activities, offices, therapy, bathrooms, conference rooms, the dialysis center, and main hallways/entrances. The added 4 staff positions would be trade outs for the other staff members days off during a seven day schedule. With 123 resident rooms total each of the nursing units housed approximately 20 to 35 Resident rooms for one house keeper to clean each day in an 8 hour shift allowing for 16 minutes to clean each room. Two of the 3 dryers in the laundry had been broken since June 2024, so linens and privacy curtains and resident personal laundry was not being washed and returned timely even though the staff was washing and drying around the clock. The only working dryer was being operated 24 hours per day. The dirty linen storage on the units was backed up as a result, and creating some of the pervasive urine and feces odors in the facility. Linens, bedding, and privacy curtains were not being changed as often as necessary due to the inability to have enough on hand to change them out more frequently. The maintenance Director stated they were starting to get some priorities taken care of in the facility now as staffing had improved just recently, and he began painting the memory unit and new cabinets began to be installed on 12-13-24. On 12-12-24, and 12-13-24 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that the entire memory care unit was not safe, clean and comfortable. On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24). At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide. 34306 3. The facility's staff failed to have soap and towels available for use in Resident #105's room. Resident #105 was originally admitted to the facility 10/27/23 and he was readmitted [DATE] after an acute care hospital stay. The current diagnoses included a major neurocognitive disorder with Lewy Bodies dementia. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making were severely impaired. A review of Resident #105's person-centered care plan dated 1024/24 failed to reveal an intervention not to have soap or a towel at the sink for use. On 12/11/24 at approximately 12:10 PM Resident #105 was observed in his room as the lunch meal was being served. At the sink it was identified there was no means of washing the resident's or staff's hands for there was no soap or towels for use. The room across the hall was also observed without soap or towels for use. The staff did not perform hand hygiene for Resident #105 before serving the lunch meal. On 12/13/24 at 12:45 PM, an observation was also made of Resident #105 prior to serving of the lunch meal and after the meal. Again, there were no soap or towels available to be used and the resident had no hand hygiene before or after lunch. On 12/13/24 at 12:55 PM an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated Resident #105 does not communicate in English and is unable to wash his own hands therefore the staff provides hygienic services to the resident. On 12/13/24 at approximately 2:50 P.M., a final interview was conducted with the Administrator, Director of Nursing, and three Corporate Nurse Consultants. The above information was conveyed to the administrative staff, they all looked at each other but voiced no comments/concerns regarding the above findings. 40711 4. The facility staff failed to ensure her hands were washed with soap and dried with paper towels before providing Activity of Daily Living (ADL) care for a dependent care Resident. Resident #87 was originally admitted to the facility 03/06/23 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Difficulty in walking, not elsewhere classified. The Minimum Data Set (MDS) assessment with discharge assessment reference date (ARD) of 10/20/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for short term memory problems as well as severely impaired for daily decision making. In sectionGG(Functional Abilities Goals) the resident was coded as dependent oral hygiene, toileting hygiene, showering/bathing, personal hygiene, requiring set-up eating. The care plan dated 9/20/24 read that Resident #87 has an ADL self-care performance deficit r/t Activity Intolerance, Aggressive Behavior, Confusion, Dementia, Impaired balance and Stroke. The goal was resident will maintain current level of function in ADLs through the review date 10/29/2024. The interventions are the following: Resident requires limited to extensive assistance by 1 staff with bathing/showering and Provide sponge bath when a full bath or shower cannot be tolerated. On 12/19/24 at approximately 11:00 AM., a Full bed bath observation was conducted on Resident #87 with Certified Nursing Assistant (CNA) #14 was observed washing her hands with water and with dripping wet hands she placed them inside of her gloves and began to provide a full bed bath to Resident #87. License Practical Nurse (LPN) #8 was also present. An observation was made of the resident's room, no soap dispenser or paper towels were seen. On 12/19/24 at approximately 11:40 AM., an interview was conducted with CNA #14 concerning Resident #87. CNA #14 said that she was not able to use soap because the rooms don't have soap or paper towels in them. CNA #14 also said that she needs soap and paper towels to wash her hands and the resident hands. About Handwashing: Many diseases and conditions are spread by not washing hands with soap and clean, running water. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Follow these five steps every time. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Rinse your hands well under clean, running water. Dry your hands using a clean towel or an air dryer. https://www.cdc.gov/clean-hands/about/index.html On 12/19/24 at approximately 5:55 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to maintain a qualified Social Worker in a 220 bed facility resulting in a Substandard Level of Care impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents. The findings included: For Resident #226, who refused a transfer to the locked memory care unit (for Residents with dementia and behaviors), the facility staff failed to honor the Resident's request. The staff moved him against his will, and did not afford him the services of a Social worker to plan care and discharge, per his wishes. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the Resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the Resident's brother agreed to the room change even though these individuals were emergency contacts and the Resident refused and was his own responsible party. The reason given for the move, was elopement risk. The Resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the Resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner. During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The Resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and crys all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do. The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole facility. Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response. The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him. On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged . On 12-12-24 the Social worker's license and curriculum vitae were requested for verification and vetting as part of the employee records review for competency of staff. It was noted that the required course work and degree required by state and federal regulation for this employee was not sufficient for the role. The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit. On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the Resident's move, nor was a request made for assessment and told that the Resident wished to discharge. On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them. On 12-12-24, during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the lack of Social Work services for 5.5 months which continued through survey, and that the Resident had requested to stay in his room, and to be planned for discharge. The discharge request was ignored. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, which culminated in the withholding of a resident's rights, and involuntary seclusion. On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24). At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.

Based a clinical record review and staff interview the facility staff failed to accurately code the Minimum Data Set (MDS) assessment and trackings for 1 of 29 residents (Resident #123), in the survey sample. The findings included: Resident #123 was originally admitted to the facility 6/10/2022 and was last readmitted to the facility 11/10/2024 after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia requiring enteral feedings. The quarterly MDS assessment with an assessment reference date (ARD) of 3/28/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. An interview was conducted with the Business Office Manager (BOM) on 4/1/25 at approximately 1:38 PM. The BOM revealed the resident had resided in the facility since 6/10/2022 except for short stays in the acute care hospital. A review of the resident's MDS assessment with an ARD of 3/28/25 was coded at A1900 that the resident's admitted (date this episode of care in this facility began) was 12/15/2023 instead of 6/10/2022. A further review of the resident MDS history revealed the resident was discharged return not anticipated to a local acute care hospital 3/10/2024 and returned to the facility 3/12/2024. The entry tracking record was coded at A1700 (Type of Entry) as a reentry. Also when the resident was discharged return not anticipated to a local acute care hospital 12/5/2023 upon his return to the facility the entry tracking record dated 12/15/2023 was coded at A1700 (Type of Entry) as an admission not a reentry, yet an admission MDS assessment was not conducted. The requirements for a resident discharged Return not Anticipated according to the CMS RAI Version 3.0 Manual dated October 2023, stated in Chapter 2 page 2-37 to use the following coding for Entry Trackings: 07. Entry Tracking Record (Item A0310F = 01) There are two types of entries - admission and reentry. Admission (Item A1700 = 1) Entry tracking record is coded an Admission every time a resident: - is admitted for the first time to this facility; or - is readmitted after a discharge return not anticipated; or - is readmitted after a discharge return anticipated when return was not within 30 days of discharge. The CMS RAI Version 3.0 Manual dated October 2023, stated in Chapter 2 page 2-8 and 2-9: 2.5 Completion of an OBRA Admission assessment must occur in any of the following admission situations: - when the resident has never been admitted to this facility before; OR -when the resident has been in this facility previously and was discharged return not anticipated; OR when the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge (see Discharge assessment below). On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the facility's Team voiced no concerns.

Based a clinical record review and staff interview the facility staff failed to accurately code the Minimum Data Set (MDS) assessment and trackings for 1 of 29 residents (Resident #123), in the survey sample. The findings included: Resident #123 was originally admitted to the facility 6/10/2022 and was last readmitted to the facility 11/10/2024 after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia requiring enteral feedings. The quarterly MDS assessment with an assessment reference date (ARD) of 3/28/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact. An interview was conducted with the Business Office Manager (BOM) on 4/1/25 at approximately 1:38 PM. The BOM revealed the resident had resided in the facility since 6/10/2022 except for short stays in the acute care hospital. A review of the resident's MDS assessment with an ARD of 3/28/25 was coded at A1900 that the resident's admission date (date this episode of care in this facility began) was 12/15/2023 instead of 6/10/2022. A further review of the resident MDS history revealed the resident was discharged return not anticipated to a local acute care hospital 3/10/2024 and returned to the facility 3/12/2024. The entry tracking record was coded at A1700 (Type of Entry) as a reentry. Also when the resident was discharged return not anticipated to a local acute care hospital 12/5/2023 upon his return to the facility the entry tracking record dated 12/15/2023 was coded at A1700 (Type of Entry) as an admission not a reentry, yet an admission MDS assessment was not conducted. The requirements for a resident discharged Return not Anticipated according to the CMS RAI Version 3.0 Manual dated October 2023, stated in Chapter 2 page 2-37 to use the following coding for Entry Trackings: 07. Entry Tracking Record (Item A0310F = 01) There are two types of entries - admission and reentry. admission (Item A1700 = 1) Entry tracking record is coded an admission every time a resident: - is admitted for the first time to this facility; or - is readmitted after a discharge return not anticipated; or - is readmitted after a discharge return anticipated when return was not within 30 days of discharge. The CMS RAI Version 3.0 Manual dated October 2023, stated in Chapter 2 page 2-8 and 2-9: 2.5 Completion of an OBRA admission assessment must occur in any of the following admission situations: - when the resident has never been admitted to this facility before; OR -when the resident has been in this facility previously and was discharged return not anticipated; OR when the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge (see Discharge assessment below). On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the facility's Team voiced no concerns.

Based on interview, observation, and facility documentation the facility staff failed to promptly act upon the grievances and recommendations of regularly attending Resident council members. The findings included: The facility staff failed to promptly address the concerns brought forth by the Resident council group members. On 12/11/24 at 3 p.m. a Resident Council meeting was held with the Resident Council President and 6 other members who regularly attended. During the meeting it was discussed that the facility fails to act, in a timely manner, on suggestions, or concerns brought forth by the Resident Council. On 12/12/24 a review of the Resident council minutes revealed that several issues were repeatedly brought up in Resident council. Excerpts from the Resident council minutes revealed the following: On 8/14/24, 9/26/24, and 10/24/24 - Resident council minutes reflected complaints of needing more linens, (towels, sheets), long turnaround time for getting laundry back from housekeeping, and personal items missing from laundry, as well as bathrooms needing to be cleaner (unclean bathrooms / shower rooms were also noted during survey). On 8/14/24 and 9/26/24 - Resident council minutes reflected complaints that there were no clocks in the hallway or the activity room (identified during the survey). On 10/24/24 and 11/25/24 - Resident council minutes reflect that Nursing staff make Residents feel as if they are In the way. Complaints of Unit 4 included staff not giving medications on night shift, and Nursing staff are on the cell phones. Resident council also claimed Nursing staff Talking about other Residents in common areas where others can hear them. Resident council also complained that Administration is not following up or following through on grievances. On 12/17/24 at approximately 2:00 p.m. an interview was conducted with Other Employee #4 who stated that there has been a Turn over in Activity Staff as well as the Social Worker so this slowed things down a bit. On 12/19/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observations, resident interviews and staff interviews on all four resident living areas, and review of facility documentation, the facility's staff failed to follow Centers for Disease Control and Prevention (CDC) guidance to establish an infection control program to ensure [CONDITION(S)]-CoV-2 infection control measures/practices were in place during a major [CONDITION(S)]-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalization s and deaths which constituted immediate jeopardy at F880 (L) in the following specific areas: The facility failed to provide accurate documentation of their COVID-19 surveillance and data analysis including line listings of infections and vaccination status of resident and HCP; which was necessary for early detection to enable a response to a [CONDITION(S)]-CoV-2 outbreak and to report [CONDITION(S)]-CoV-2 infections information to Public Health Authorities. The facility failed to post visual signs at the entrance and/or in strategic places with instructions about current Infection Prevention Control recommendations related to [CONDITION(S)]-CoV-2. The facility failed to adhere to the CDC recommended screening process to identify anyone entering the facility who was positive for [CONDITION(S)]-CoV-2 or with symptoms of COVID-19. The facility failed to quarantine residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection including new admissions and re-admissions during an outbreak for 6 residents (Resident #21, #73, #90, #53, #16, and #65) of 42 residents in the survey sample. The facility staff failed to ensure facemasks were well-fitting and worn to cover the nose and mouth, and ensure that HCP caring for [CONDITION(S)]-CoV-2 positive residents are using full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). On [DATE] at 8:37 p.m., the facility Administrator, Director of Nursing and three Corporate Consultants were informed that the above non-compliance constituted Immediate Jeopardy at F-880; Infection Prevention and Control Program secondary to an outbreak of [CONDITION(S)]-CoV-2 infections within the facility at a scope and severity level 4 widespread (L) which constituted Substandard Quality of Care. The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on [DATE] at 4:25 p.m. The deficient practice was decreased to an F (potential for more than minimal consequence). The facility's final cumulative of data provided on [DATE] disclosed from [DATE] through [DATE]; there were fifty-three [CONDITION(S)]-CoV-2 positive residents, nineteen were hospitalized , one remained in the hospital and nine died . The cumulative of [CONDITION(S)]-CoV-2 positive staff was six, one staff was hospitalized and died , four staff returned to work and no staff was still in quarantine. The facility stated they felt this was accurate but was unable to attest it was one hundred percent accurate. The findings included: 1A. The facility staff failed to provide accurate documentation of their COVID-19 surveillance and data analysis including line listings of infections and vaccination status of resident and HCP; which was necessary for early detection to enable a response to a [CONDITION(S)]-CoV-2 outbreak. Multiple times on [DATE] interviews were attempted with the Infection Preventionist (IP) to review the line listing of [CONDITION(S)]-CoV-2 cases in the facility including residents and staff. Each time the IP would leave for she desired to review the documents on her computer. Even after bringing in the computer to review the line listing she was unable to definitely provide the requested numbers. She stated the cases are not adding up correctly. The IP stated the outbreak began [DATE] when an alert and oriented resident (Resident #90) tested positive after a Rapid test. She was not certain of the symptoms the resident presented with prior to the test but she stated the resident was symptomatic and a PCR test was performed as a result of the positive Rapid test. The PCR test results were also positive. Another interview was attempted with the IP on [DATE] at approximately 10:10 a.m., to obtain a cumulative of [CONDITION(S)]-CoV-2 cases since the beginning of the pandemic was requested as well as the number of cases in-house on [DATE], when the survey team entered the facility. The IP stated she thought there were 36 in-house cases on [DATE] but the numbers still weren't adding up therefore; she needed to review the line listing to get an official count. The IP was also asked to provide the number of hospitalized residents/staff, number of deceased residents/staff, and the number/name of residents/staff who were vaccinated. On [DATE] at approximately 3:15 p.m., the IP stated she believed there were 19 [CONDITION(S)]-CoV-2 cases in the facility when the survey team arrived on [DATE] but she still wasn't sure of the cumulative since the pandemic began. At approximately 4:15 p.m., the Regional Clinical Reimbursement Consultant (RCRC) stated the IP wasn't able to assist further with the [CONDITION(S)]-CoV-2 statistics because she would be rendering direct care therefore; she would be calculating the numbers. On [DATE] at approximately 11:20 a.m., the RCRC provided the following numbers as an accurate cumulative of the facility [CONDITION(S)]-CoV-2 cases and the disposition of the affected residents/staff. The cumulative of Residents who tested positive for [CONDITION(S)]-CoV-2 was forty-eight. Seven of the forty-eight resident died including one in the facility, seventeen of the cumulative residents were admitted to the hospital, three of the cumulative residents remained in the hospital and thirty-six of the cumulative residents were quarantined in the facility. The cumulative of staff who tested positive for [CONDITION(S)]-CoV-2 was eight, one staff died , one staff was hospitalized , no staff remained in the hospital, one staff remained quarantined and six staff had returned to work. On [DATE] at approximately 3:15 p.m., the facility stated they had made additional changes to the cumulative number of residents and staff to account for all affected since the outbreak beginning [DATE]. The cumulative of [CONDITION(S)]-CoV-2 positive residents was fifty-three, nineteen were hospitalized , one remained in the hospital and nine died . Six new resident cases were identified [DATE] - [DATE]. The cumulative of [CONDITION(S)]-CoV-2 positive staff was six, one staff was hospitalized and died , four staff returned to work and no staff were still in quarantine. Three pages of emails were provided to the survey team along with documentation of the cumulative data and line listings. An email dated [DATE] at 6:02 a.m., stated; we have eight more staff and two staff members who tested positive for [CONDITION(S)]-CoV-2. At 7:47 a.m., an email read; another one just tested positive. Its nine now. Another email dated [DATE] read; we have two more residents who tested positive for COVID today. An email dated [DATE] read; we have two COVID positive residents who expired at the hospital. We also have some new residents who tested positive. I will send an updated line listing later this evening. Another email dated [DATE] at 6:04 p.m. read; Attached is a copy of the COVID-19 line list. It seems like 75% of my September positives are residents who are vaccinated. On [DATE] an email read A COVID positive staff death at (name of the facility). Have you done the Occupational Safety and Health Administration investigation to determine work relatedness? We need to document thoroughly. B. The facility staff failed to report [CONDITION(S)]-CoV-2 infections information to Public Health Authorities. The three pages of email chains above revealed the facility staff had a situation too overwhelming for then to manage, yet they failed to notify the health department promptly of the first positive case of [CONDITION(S)]-CoV-2, each suspected or confirmed [CONDITION(S)]-CoV-2 infection and of additional cases, including residents with severe respiratory infection resulting in hospitalization or death, three residents or HCP with acute illness compatible with COVID-19 with onset within a 72-hour period.An interview was conducted with the Infection Preventionist on [DATE] at approximately 3:20 p.m. The Infection Preventionist stated she had not contacted the local Health Department and/or the Epidemiologist in reference to the facility's outbreak or to ask for assistance in managing their rapid increasing number of [CONDITION(S)]-CoV-2 positive cases. The Infection Preventionist further stated approximately one week ago the Local Health Department came in on their own to conduct a site visit and offer assistance. 2. The facility failure to post visual signs at the entrance and/or in strategic places with instructions about current Infection Prevention Control recommendations related to [CONDITION(S)]-CoV-2. On [DATE] at approximately 7:05 p.m., upon arriving to the facility the only signage at the visitor's entrance read face mask required at all times. This signage was located to the sides of the door and at a low position. There was no entrance door signage with clear information/alerts to visitors. Review of other visitor entrances (kitchen, construction unit and the laundry door connecting with Unit 1) also disclosed no signage. CDC had recommended that long term care facilities developed a written COVID-19 plan which included; Facilities should encourage visitors to be aware of signs and symptoms of acute respiratory illness consistent with COVID-19 and not enter the facility if they have such signs and symptoms. Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms. Signage should include signs and symptoms of COVID-19 and who to notify if visitors/staff/vendors have symptoms. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/hcf-visitors.html). 3. The facility staff further failed to adhere to the CDC recommended screening process to identify anyone entering the facility who was positive for [CONDITION(S)]-CoV-2 or with symptoms of COVID-19. On [DATE] at approximately 7:05 p.m., after ringing the doorbell the survey team was allowed to enter the first set of doors where visitors and staff were screened. The staff member stated screening was a self-performed task but assisted us to obtain our temperatures. After multiple days of reviewing the screening logs the team was unable to account for many on duty staff therefore a review of the screening logs for [DATE] - [DATE] were reviewed with the staffing coordinator on [DATE]. The review of [DATE] confirmed eleven direct care staff were not signed in as screened. The review of [DATE] confirmed there were seven direct care staff who did not sign in as screened. On [DATE] - [DATE] many support staff wasn't verified. Another screening review was conducted of the facility's personnel on duty [DATE]. The review disclosed seven direct care staff and eleven support staff had not signed in as screened. Many of the facility Healthcare Personnel (HCP) were foregoing the screening process by entering and exiting the facility through various doors. The outcome of foregoing the screening resulted in a breach in the infection prevention and control (IPC) protocol as evidenced by continuous newly diagnosed residents with [CONDITION(S)]-CoV-2 infections, some resulting in hospitalization s and/or death. After this was brought to the facility staff attention on [DATE], staff was assigned to carryout screening. According to the [DATE], Centers for Medicare and Medicaid Services (CMS) Memo QSO,d+[DATE]-NH, Guidance for Infection Control and Prevention of COVID-19, nursing homes should follow the Core Principles of COVID-19 Infection Prevention. One of the Core Principles read; Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor's vaccination status). HCP should not work while acutely ill, even if [CONDITION(S)]-CoV-2 testing is negative, in order to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. All visitors should sign in and out on a visitor's log. 4. The facility staff failed to manage residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection including new admissions and re-admissions during an outbreak, and to manage staffing of HCP who worked a COVID positive unit and immediately afterward worked a Well unit. A. On [DATE] at approximately 4:00 p.m., a review of resident readmissions/admission was conducted with the DON. The DON stated Resident #21 was readmitted to the facility from the hospital [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated they elected not to quarantine Resident #21 an unvaccinated resident, after an eight day hospital stay because of the negative [CONDITION(S)]-CoV-2 test and for resident safety related to impaired cognition, gait problems and behaviors. Resident #21 was readmitted to the Memory Unit. The DON further stated they didn't have a quarantine unit for residents who resided on the Memory Unit. B. On [DATE] at approximately 8:30 a.m., Resident #73 was observed sitting in a wheelchair in his doorway. Resident #73 was originally admitted to the facility [DATE] and had never been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #73's cognitive abilities for daily decision making were intact. The resident stated he was moving off the COVID-19 positive unit that day. Resident #73 stated he was vaccinated and had never tested positive for [CONDITION(S)]-CoV-2. The resident further stated he was admitted to the room in August and he was told [DATE] that he no longer needed to quarantine and he would be moved. Review of the resident's clinical record revealed he was admitted to the facility [DATE]. Resident #73 a fully vaccinated had resided on a COVID-19 positive unit from [DATE] - [DATE]. On [DATE] at approximately 4:00 p.m., a review of Resident #73's admission was conducted with the Director of Nursing (DON). The DON stated Resident #73 was admitted to the room on the Admitting Unit prior to the outbreak of [CONDITION(S)]-CoV-2 cases and he remained there to complete his period of quarantine. On day one of the survey, the survey team made observations to determine how the facility was managing admissions/re-admission of residents. Designated rooms for quarantine were not identified for residents returning to the facility after hospitalization or for pending and newly confirmed positive resident within the facility. On [DATE] at approximately 1:55 p.m., the survey team addressed this concern with the facility's team including five corporate consultants. Corporate Consultant #4 stated there was a designated quarantine unit and ask what happened to it. The Administrator stated the positive cases resulted in them outgrowing the COVID-19 positive unit therefore; they didn't have quarantine rooms and new admissions would not be accepted because of the vast number of [CONDITION(S)]-CoV-2 positive cases. An email dated [DATE] in reference to the first positive resident case of [CONDITION(S)]-CoV-2 read; do you have a COVID unit set up? What will you do if the PCR is positive? Please let us know the results when you know them. The facility COVID-19 Action Plan dated [DATE], read there would be three units set-up for the resident population in accordance with CDC Guidelines. The Units were described as a Well/Cool Unit, a Quarantine/Warm Unit for new admission and readmissions and an Isolation/Hot Unit for COVID-19 positive residents. The facility only had one general well unit, one well memory unit, one COVID-19 positive memory unit and one full COVID-19 positive unit. Facilities should create a plan for managing new admissions and readmissions. In general, all new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Exceptions include residents within 3 months of a [CONDITION(S)]-CoV-2 infection and fully vaccinated residents. (https://www.vdh.virginia.gov/content/uploads/sites/[DATE]/VDH-COVID-19-Guidance-for-Nursing-Homes.pdf) C. Resident #90 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay, returning to the facility [DATE]. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview was coded for intact long and short term memory as well as modified independence with daily decision making. A physician's progress note dated [DATE] at 10:15 a.m., read; Evaluation following positive COVID-19 test. Resident #90 is seen today for follow-up after a positive COVID-19 test. The resident is currently symptomatic with low grade fevers, positive for Shortness of Breath/Cough, Oxygen saturation at 85% on Room Air. Chest X-Ray shows a Left Lower Lobe pneumonia. Facility unable to obtain the monoclonal antibody infusion from Maryland. Advised nursing to send to Emergency Department for infusion. Resident was subsequently admitted for COVID-19 pneumonia. The resident was readmitted to the facility [DATE]. Upon entering Resident # 90's room on [DATE] at approximately 9:45 a.m., a sheet was observed on the floor and on top of the sheet were elimination saturated towels, a gown and used gloves. Resident #90; a [CONDITION(S)]-CoV-2 infected resident; was in bed uncovered and without clothing. The resident stated he no longer felt sick and presented without shortness of breath, cough, diaphoresis or fatigue. Shortly afterwards the wound care Nurse Practitioner and LPN #3 entered the resident's room to assess the resident's impaired skin. After the wound care Nurse Practitioner completed her assessment she stepped on the sheet and soiled linen, proceeded out the room and off the unit with the same dirty shoe protectors on. D. Observation of multiple resident room on the COVID-19 positive unit revealed no trash bags in the trash cans in most rooms, the hallway was with dried brownish spill areas, paper, used gloves and other debris. There were no clean gowns on the unit to be utilized by the staff, the clean linen cart cover was up exposing all the linen and stacks of what appeared to be clean linen was observed in chairs and sitting on top of furniture in rooms in approximately five rooms. An interview was conducted with the DON on the COVID-19 positive unit on [DATE] at approximately 10:05 a.m. The DON stated she didn't agree with the manner the staff allowed Resident #90 to handle his soiled linen but it was the practice. The DON also stated she would have Environmental Services to come immediately to clean the unit and add liners to the trash cans. As the DON walked the hallway she instructed staff to cover the clean linen and remove linen from resident rooms. E. Review of staff scheduling revealed on [DATE], LPN #7 worked a COVID-19 positive Unit from 11:00 - 7:30 a.m., afterwards working from 7:30 a.m. - 3:30 p.m., on a Well Unit. An interview was conducted with LPN #7 on [DATE] at approximately 10:25 a.m. LPN #7 stated she knew it appeared she hadn't been home but she works sixteen hours most days on the same unit and is off for eight hours. LPN #7 didn't say anything about working a positive unit before working a negative unit. The facility COVID-19 Action Plan update [DATE] read; Staff have been assigned to work only on COVID or quarantined or non-affected units/wings/rooms. Staff assignments are documented and time reconciled daily. An interview was conducted with the DON on [DATE] at approximately 4:45 p.m. The DON stated staff are scheduled to remain on the COVID positive unit if they worked the COVID positive unit their first shift and they are working a double shift. She further stated if a staff worked the Well unit the first shift they may work the COVID positive unit the second shift. An interview was conducted with the Medical Director on [DATE] at 11:20 a.m. The Medical Director stated the facility staff informed him of the Immediate Jeopardy status on [DATE] and they conducted a Quality Assurance meeting [DATE] to discuss the [CONDITION(S)]-CoV-2 status and means to improve infection control practices in the facility. The Medical Director stated he was aware of the outbreak but he wasn't aware of the cumulative data since the outbreak occurred. He assured us he was notified of cases as they occur but not as cumulative data. The Medical Director stated [CONDITION(S)]-CoV-2 infections can be deadly and following CDC guidelines were the expectation of all staff in the facility. The Medical Director further stated education of the staff would be the most effective method to achieve compliance and he would assure regardless of the consequences including disciplinary action that all non-compliance be eradicated. 5. The facility staff failed the implement source control, in accordance with CDC guidance and FDA guidance. A. On [DATE], after the screening process, the team was allowed to enter the second set of doors into the reception area of the facility. The team was met by the Director of Nursing who stated the personal protective equipment (PPE) facility wide included an N-95 mask. The Director of Nursing of Nursing was observed wearing an N-95 below her nose at that time and during most interactions with her. Various types of mask were observed donned by the facility staff but regardless of the types of mask, worn most were not appropriately positioned to cover the nose and mouth. B. On [DATE] at approximately 8:05 p.m., LPN # 6 was observed exiting from the zipped wall of the COVID-19 positive unit wearing an N-95 mask not completely covering the nose and she was observed adjusting it. C. On [DATE] at approximately 10:35 a.m., CNA #5 was observed in the hallway wearing an N-95 mask which wasn't well-fitting and clearly without a tight seal. D. On [DATE] at approximately 10:25 a.m., LPN #7 was observed seated at the nursing station on a COVID positive unit with the facemask around her neck leaving her nose and mouth completely uncovered. E. On [DATE] at approximately 10:27 a.m., CNA #9 was observed in the Dayroom on a COVID positive unit talking to another CNA; five residents were present and CNA #9's facemask was off exposing her nose and mouth. CNA #9 stated I can't breathe when wearing this mask. An emailed dated [DATE] was sent to the facility's Administrator from a Consultant. It read; during a Huddle call (name of the staff member) reminded that all staff must be masked. Meaning over the nose. (Name of the staff member) witnessed staff during rounds and nurses sitting at the desk without mask. F. On [DATE] at approximately 8:45 a.m., on a COVID-19 positive Unit CNA #3 was observed putting her gown on the handrail in the hallway. CNA #3 proceeded in the hallway with a water pitcher in hand which was brought off of a [CONDITION(S)]-CoV-2 infected resident's room (Resident #47). After filling the water pitcher with ice CNA #3 proceeded back into the resident's room without a gown on (it was still hanging on the handrail). CNA #3 stood in front of the [CONDITION(S)]-CoV-2 infected resident and assisted him to drink water afterwards; the resident began to cough weakly. CNA #3 left the resident's bedside washed her hands, picked up a bag of soiled linen from the floor and proceeded into the next room with the soiled linen. An interview was conducted with CNA #3, on [DATE] at approximately 8:55 a.m., she stated she was fully vaccinated and had never tested positive for [CONDITION(S)]-CoV-2. CNA #3 stated she had the gown on but forgot to put it back on when she went in to get Resident #47's water pitcher. CNA #3 removed the gown from the handrail and said here it is. An interview was conducted with Resident #47 on [DATE] at approximately 9:00 a.m. Resident #47 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The resident was discharged again from the facility [DATE] to an acute care hospital for respiratory distress and wet lungs. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. Resident #47 was very short of breath, diaphoretic and constantly requesting water. Observation of the indwelling catheter system revealed a very soiled and coiled catheter leg strap and a catheter drainage bag with approximately 200 milliliters of dark yellow urine. An interview was conducted with LPN #7 on [DATE] at approximately 9:13 a.m., regarding the resident's weak state. LPN #7 stated since the resident was diagnosed with a [CONDITION(S)]-CoV-2 infection, the resident's physically abilities had declined to the point he was unable to hold his water pitcher. On [DATE] at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, and Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. The Regional Director of Clinical Services stated corrective action had started and compliance of the facility Infection Control COVID-19 policies in accordance with the CDC and the Virginia Department of Health would include ongoing monitoring by the Administrator. 6. The facility staff failed to move Resident #53 a COVID-19 positive resident from a non-COVID unit to a COVID positive unit timely (2 days later). Resident #53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] included [CONDITION(S)], [CONDITION(S)], type 2 diabetes, major depression, convulsions, [CONDITION(S)], cerebral infarction, cognitive impairment and contracture of left hand. In the area of Cognitive Patterns Brief Interview for Mental Status (BIMS) this resident was coded as a 15. A Care Plan dated [DATE] indicated: Focus- COVID- 19 active diagnosis. Resident #53 was identified as able to move around using a wheelchair. Resident #53, who resided on a non-COVID-19 unit, was observed on [DATE] at 7:53 P.M. and [DATE] at 9:43 A.M. seated in a wheelchair in her room (#25) door way. Resident #53 was also observed using the bathroom in her room that was shared with her roommate at 11:15 A.M. on [DATE] who was COVID-19 negative at time. Resident #53 was observed without a mask. On [DATE] Resident #53 was identified as COVID-19 positive. Resident #53 was observed moving in and out of her room with the door open. There was no signage observed on the outside door of this room indicating infection control measures and practices were in place. Resident #53 remained in her room (#25) for two days before moved on [DATE] across the hall to room [ROOM NUMBER] as the only resident in a semi-private room (#26), but still on the non-COVID unit. Resident #53's bed linen, personal items, unfinished orange juice and food container were observed in room [ROOM NUMBER] until [DATE]. Resident #53's previous roommate (Resident #65) was identified as COVID-19 positive on [DATE]. 7. The facility staff failed to move Resident #16, who was COVID-19 Positive and living on a non-COVID unit to a COVID unit in a timely manner (3 days later). Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] included [CONDITION(S)] disorder, cervical spinal cord sequela, spinal stenosis, chronic pain, hypertension, dysphasia and mood disorder. Resident #16 was identified as COVID-19 positive on [DATE]. Resident #16 was living on Unit II, a non-COVID Unit in room [ROOM NUMBER]. Resident #16 was not transferred out of bedroom [ROOM NUMBER] until [DATE]. Resident #16's bed linen, personal items and food container remained in his room until [DATE]. Resident #16's floor, bed and other areas of the room remained un-sanitized and not cleaned. There was no signage observed on the outside door of this room indicating infection control measures and practices were in place. 8. The facility staff failed to move Resident #65, a COVID-19 positive resident, from a non-COVID unit to a COVID unit in a timely manner (2-days). Resident #65 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] included dementia, [CONDITION(S)], cerebral infarction, depression, dysphasia, and hypertension. A Quarterly Minimum Data Set (MDS) coded this resident in the area of Cognitive Patterns - with a BIMS score of 13. Resident #65 was assessed in the area of ADLs as being able to walk and transfer with one person physical assist. This resident was assessed as steady at all times when walking. A Care Plan dated [DATE] indicated: Focus- The resident is an elopement risk/wander due to impaired awareness; Goal- The resident's safety will be maintained through the review date. Interventions- Distract resident from wandering by offering pleasant diversions, activities, food, conversation, television, book. Resident #65 was identified as COVID-19 positive on [DATE]. Resident #65's Roommate, Resident #53, was identified as COVID-19 positive on [DATE]. Resident #53 remained in the room with Resident #65 for two days after testing positive for COVID-19. Resident #65 was observed moving in and out of her room with the door open at 9:43 A.M. on [DATE] and at 2:43 P.M. and [DATE]. Staff were observed on [DATE] at 9:15 A.M. assisting Resident #65 with removal of her breakfast tray. Staff were not wearing PPE. Resident #65 was observed walking around in the room on several occasions. There was no signage observed on the outside door of this room indicating infection control measures and practices were in place. 9. The facility staff failed to ensure infections control measures were consistently implemented to prevent the development and/or transmission of a communicable disease (COVID-19), and other infectious diseases by not wearing the required N95 masks or improperly wearing the required facial coverings. A. On [DATE] at approximately 7:05 p.m., upon facility entrance Dietary Staff member #3 was observed sitting in a chair in the dining room with no facial covering on. Sitting less than four feet near him was dietary staff member #4 with no facial covering. They appeared to be playing a video game. The surveyor was screened at the entrance then entered into the dining area where the two facility staff were seen. She asked Dietary staff member #4 where was his mask. He stated, that he didn't think he needed to wear his mask because he wasn't around residents. B. On [DATE] at approximately 10:10 AM. FSD/OSM (Food Service Director/Other Staff Member) #5 was seen wearing his N95 mask with his nose exposed on several occasions during the kitchen inspection. C. On [DATE] at approximately 12:00 PM, District Dietary Manager (OSM) #6 was interviewed concer

Based on observations, resident interviews, staff interviews and review of facility documentation, the facility's staff failed to adhere to the following Centers for Disease Control and Prevention (CDC) guidance to have an established and effective COVID-19 testing program in place during a major [CONDITION(S)]-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalization s and deaths which constituted Immediate Jeapardy at a scope and severity level of 4 widespread (L): The facility failed to ascertain the vaccination status of all Healthcare Personnel (HCP) to determine who was unvaccinated and required expanded screening testing and the facility failed to conduct unvaccinated HCP testing for [CONDITION(S)]-CoV-2 infection based on the level of community transmission (high/Red). The facility was broad based testing two times a week. The facility failed to have documentation that the required testing of the results of unvaccinated HCP including contractors, agencies and vendors was completed and corresponded to the facility's testing frequency. On [DATE] at 8:37 p.m., the facility Administrator, Director of Nursing and three Corporate Consultants were informed of the above Immediate Jeopardy concerns at F-886; COVID-19 Testing; during an outbreak of [CONDITION(S)]-CoV-2 infections within the facility which was cited at a scope and severity level of 4 widespread (L) which constituted Substandard Quality of Care. The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on [DATE] at 4:25 p.m. The deficient practice was decreased to an F (potential for more than minimum consequence). During this non-compliance the facility was subject to a major [CONDITION(S)]-CoV-2 outbreak with increased transmission of COVID-19, hospitalization s and death. The following cumulative data was provided by the facility on [DATE]. From [DATE] to [DATE], there were fifty-three [CONDITION(S)]-CoV-2 positive residents, nineteen were hospitalized , one remained in the hospital and nine died . The cumulative of [CONDITION(S)]-CoV-2 positive staff was six, one staff was hospitalized and died , four staff returned to work and no staff was still in quarantine. The facility stated they felt this was accurate but was unable to attest it was one hundred percent accurate. The findings included: 1. The facility failed to ascertain the vaccination status of all Healthcare Personnel (HCP) to determine who was unvaccinated and required expanded screening testing and the facility failed to conduct unvaccinated HCP testing for [CONDITION(S)]-CoV-2 infection based on the level of community transmission. Interviews with many of the HCP revealed based on CDC guidelines they met the requirements to be tested (they were unvaccinated) but were not tested based on the level of community transmission for they lacked knowledge related to the testing requirements. On [DATE], the level of community transmission was reviewed for the facility's city's level data. The level was HIGH and the community had been at that level during our review period of [DATE] - [DATE]. The guidance stated when the level of community transmission is HIGH unvaccinated staff must be tested two times each week. Many of the facility HCP interviewed [DATE] - [DATE] stated they were unvaccinated and had not tested two times per week from [DATE] - [DATE] for various reasons (specifics for each individual). An interview was conducted with Certified Nursing Assistant (CNA) #4 on [DATE] at 2:27 p.m., CNA #4 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and she usually tested approximately one time each week. An interview was conducted with Physical Therapist Assistant (PTA) #4 on [DATE] at 2:33 p.m., PTA #2 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and she had not recently tested but she only worked at the facility as needed. An interview was conducted with Certified Nursing Assistant (CNA) #6 on [DATE] at 10:00 a.m., CNA #6 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and she usually test approximately one time each week. CNA #6 stated she thinks she was lasted tested [DATE] by the IP. An interview was conducted with Dietary staff #15 on [DATE] at approximately 12:20 p.m., Dietary staff #15 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and was last tested approximately one week ago because the facility administration doesn't want them walking through the building to get tested . An interview was conducted with LPN #11 on [DATE] at 10:04 a.m., LPN #11 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and she usually tested on e to two time each week and she was lasted [DATE] at a CVS pharmacy and prior to that [DATE] but no one at the facility had ever asked her to provide documentation of testing. An interview was conducted with Certified Nursing Assistant (CNA) #13 on [DATE] at 10:19 a.m., CNA #13 stated she was unvaccinated, had tested positive for [CONDITION(S)]-CoV-2 February 2021 and she tested [DATE] and prior to that she hadn't tested for over a week. An interview was conducted with LPN #10 on [DATE] at 10:27 a.m., LPN #10 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and she was last tested approximately [DATE] and hadn't tested since then. An interview was conducted with Certified Nursing Assistant (CNA) #8 on [DATE] at 10:30 a.m., CNA #8 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and she was tested [DATE] when she arrived for her shift but prior to that she hadn't been tested since approximately [DATE]. An interview was conducted with Dietary staff #20 on [DATE] at approximately 10:55 a.m. The Dietary staff #20 stated she was unvaccinated, had tested positive for [CONDITION(S)]-CoV-2, [DATE] and was last tested approximately six weeks ago for another. Dietary staff #20 stated the facility had never asked about the vaccination or requested testing status. An interview was conducted with Dietary staff #19 on [DATE] at approximately 11:05 a.m. The Dietary staff #19 stated she was unvaccinated, had never tested positive for [CONDITION(S)]-CoV-2 and was last tested approximately two weeks ago for another entity. Dietary staff #19 stated the facility had never asked about her vaccination or requested testing status. 2. The facility failed to have documentation that the required testing of the results of unvaccinated HCP was completed and corresponded to the facility's testing frequency. On [DATE] at approximately 10:25 a.m., HCP testing was observed and the documentation of the testing was reviewed. A review of those listed as tested revealed the HCP name/signature only, no documentation of their test results. An interview was conducted with the Infection Preventionist (IP) on [DATE] at approximately 3:20 p.m., the Infection Preventionist stated testing for HCP was two times weekly (Tuesday and Thursday) based on the level of community transmission and that an undocumented test result indicated the result was negative. The tested HCP results for [DATE] remained undocumented throughout the survey. During an interview with the IP on [DATE] at approximately 3:20 p.m., the IP stated all staff testing isn't documented because the licensed nurses who performs the testing often test direct care HCP during their shift and solely provide the HCP with the result. The IP had no documentation indicating which HCP should have been tested , if they had been tested based on the level of community transmission from [DATE] - [DATE], or documentation the testing was completed along with the results. The IP stated she never followed-up with the licensed nurses to gleam information of HCP testing and results except if a staff member tested positive. An interview was conducted with Licensed Practical Nurse (LPN) #3 on [DATE] at 12:04 p.m., LPN #3 stated the Rapid test (The BinaxNOW COVID-19 Ag Card) are used for staff testing and if there is a positive result it is followed-up with a polymerase chain reaction (PCR) test. LPN #3 also stated that the current practice for staff testing is to delegate it to licensed nurses on various shifts and only the Director of Nursing and IP knows where the results are documented for the prior system of documentation was discontinued for the computerized line listing method. On [DATE] at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, and Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. The Regional Director of Operations stated beginning [DATE] staff testing and results of unvaccinated employees will be tracked on COVID testing logs. The IP will provide a weekly updated vaccination list to the Administrator/designee who will audit testing three times each week for eight weeks to ensure all unvaccinated staff are in compliance with routine testing according to the level of community transmission 3. The facility staff failed to ensure that 3 Independent Contracted Construction Workers and 1 child who were observed on Unit 4 on [DATE] working, who admitted to working in the building on [DATE] and 30 days prior were tested for Covid-19 based on the facility's testing frequency to coincide with the level of community transmission (HIGH/RED) twice a week. On [DATE] at 10:45 a.m. a walk-through was conducted on Unit 4. Unit 4 was empty due to a facility refurbishment in progress. During the walk-through 3 construction workers and 1 child was observed on Unit 4. In the dining room two of the construction workers and the child were observed painting. The third construction worker was down the short hall installing ceiling tiles. All 4 individuals were observed without facemasks. On [DATE] at 10:55 a.m., Construction Worker #10 who was on the short hall was asked if he had ever been tested for Covid-19 by anyone at the facility. Construction Worker #10 stated, No English. Construction Worker #10 opened his phone, and was able to speak using a Spanish to English translator application. Construction Worker #10 stated, No tested , no vaccine. On [DATE] at 11:05 a.m., Construction Worker #11 and Construction Worker #9 who were painting in the Unit 4 dining room with the child were asked if they had completed the Covid-19 screening log when they entered the facility today. Construction Worker #9 stated, We forgot to sign in yesterday and today. We just came back yesterday, we haven't been in the building for 30 days. Construction Worker #9 was asked if the 3 of them were vaccinated and if anyone in the facility had informed them that the building was experiencing a Covid -19 outbreak and that facemask's were required. Construction Worker #9 stated, No one is vaccinated. We have masks but no one from the facility told us to wear the masks or anything about the covid. Construction Worker #9 was asked if anyone in the facility had ever tested them for Covid-10. Construction Worker #9 stated, No, we have not been tested . On [DATE] at approximately 1:30 p.m., the Infection Preventionist was asked if she has any documentation to show that the 3 construction workers or the 1 child had been tested when they were in the facility 30 days ago or any results that they had been tested on [DATE] or [DATE] prior to working. The Infection Preventionist was unable to provide the information that was requested. On [DATE] at approximately 4:30 p.m., the Administrator, the Regional Director of Clinical Services and the Regional Director of Operations were made aware of the above observations. The Regional Director of Operations stated, All construction was supposed to be stopped at the end of August when the outbreak started. There should not be anyone back there at all. On [DATE] at approximately 3:30 p.m., the Regional Director of Clinical Services stated, We have place signage at the side construction entrance of the facility indicating to vendors that the facility is in a Covid-19 outbreak status and visitation is restricted as of [DATE]. Signage in Spanish was also placed on the construction door prohibiting entrance until further notice. The construction supervisor was notified a second time that all construction must stop and workers are not authorized to be in the building until further notice. Also the Administrator will walk the construction unit twice daily to assure workers do not enter. The Regional Director of Operations stated, Beginning [DATE] all staff including contracted employees and vendors reporting to work will be required to submit to routine testing per community transmission rates, provide proof of recent testing (within 3 days), provide proof of vaccination status, or get tested on their scheduled shift. The facility policy titled Novel Coronavirus Prevention and Response dated ,d+[DATE] was reviewed and is documented in part, as follows: Policy: The facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus. Policy Explanation and Compliance Guidelines: 4. Considerations/priorities for testing. c. Testing for COVID-19 will occur for staff or residents with signs and symptoms of COVID-19, outbreaks within the facility and routinely following the frequency guidance according to the facility's level of community transmission. On [DATE] at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared. An Immediate Jeopardy Abatement Plan for F-tag 886 signed by the Administrator on [DATE] was provided to the survey team. 1. The facility performed staff testing of scheduled employees and agency staff [DATE]-[DATE]. It was discovered that two unvaccinated dietary staff members did not follow policy for testing and screening and worked on [DATE]. Both employees had received education on [DATE] and one employee received an additional test reminder on [DATE] by the regional director of dining services. Both employees were subsequently tested on [DATE] with negative results. Reeducation on policy for testing and screening was provided to dietary staff members on [DATE]. All staff including contracted employees and vendors reporting to work as of [DATE] will be required to submit to routine testing per community transmission rates, provide proof of recent testing (within 3 days), provide proof of vaccination status, or get tested on their scheduled shift. Per CMS guidelines, vaccinated staff members will not be required to submit to routine testing. 2. There was a cumulative total of 53 resident who have tested positive for Covid-19. 9 residents died , 1 died while still at the facility. 19 residents were hospitalized . 1 resident remains hospitalized . 6 staff tested positive for Covid-19. 1 staff member was hospitalized and passed. 4 staff have returned to work, none are on quarantine. Residents on this list who remain in the facility will continue to be monitored and treated under current COVID protocols until their cases have resolved. The center conducted facility wide rapid testing of negative residents [DATE] -[DATE] and six new resident cases were identified. All six residents currently reside on the COVID unit. All residents of the facility have the potential to be affected by the this practice. 3. Staff education was provided on [DATE] to employees in the following departments; nursing, environmental services, dietary, maintenance, and administrative staff. Staff education included CMS guidelines regarding frequency of testing for unvaccinated employees based on level of community transmission. Beginning [DATE] no employees will be allowed to return to work until the training has been completed. Training will be provided by the SDC in person or by phone. Staffing coordinator will ensure proof of vaccination status or a recent negative test (within three days) for all agency employees prior to scheduling them to work. Unvaccinated agency staff who have not had a recent test must be tested on their scheduled shift in order to be able to work. Scheduled staff testing will be held Monday and Thursday, however a nurse will be assigned to conduct testing seven days a week for all staff in order to remain in compliance with the testing guidelines. The frequency of scheduled staff will be adjusted to reflect current community transmission rates. 4. Beginning [DATE] staff testing and results for unvaccinated employees will be tracked on COVID testing log. Infection preventionist will provide a weekly updated vaccinated staff list to Administrator or designee who will audit testing log 3 x per week for 8 weeks to ensure all unvaccinated facility staff and unvaccinated contracted staff are in compliance with routine testing according to community transmission rates. Any identified concerns will be immediately corrected. Additional education and disciplinary actions will be taken as appropriate. Results of audits will be summarized and submitted by the Nursing Home Administrator to the QAPI committee for oversight and additional recommendations to this plan. The next QAPI meeting is scheduled for [DATE] and will continue monthly x 6 months to assure ongoing compliance. 5. Medical Director was notified on [DATE] of the Immediate Jeopardy status of the facility and actions taken to abate. The facility conducted an AdHoc QAPI meeting on [DATE] reviewing and approving the Allegation of Compliance and corrective actions. Facility alleges compliance as of [DATE], signed by the Administrator. The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on [DATE] at 4:25 p.m. The deficient practice was decreased to an F (Potential for more than minimal consequence).

Based on a complaint investigation, medical record review, staff interviews and facility document review the facility staff failed to obtain a Cardiopulmonary Resuscitation Status upon admission on [DATE] and failed to initiate Cardiopulmonary Resuscitation on [DATE] at 6:50 A.M. for 1 (Resident #117) of 22 residents in the survey sample, when the resident was assessed and found to be absent of vital signs. The finding included: Resident #117 was a [AGE] year old male admitted to the facility on [DATE] at 7:00 P.M. for a respite only stay. Resident #117 [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for Resident #117 was a Discharge Assessment with an Assessment Reference Date (ARD) of [DATE]. Under Section A0310F Entry/discharge reporting Resident #117 was coded as 12 out of 15 which indicated moderate cognitive impairment. Death in facility record. Under Section A1900 admitted Resident #117 was coded as [DATE]. Under Section A2000 discharge date Resident #117 was coded as [DATE]. Under Section A2100 Discharge Status Resident #117 was coded as 8. deceased . On [DATE] at approximately 10:30 A.M., the MDS Coordinator was asked for the baseline/initial care plan. The MDS Coordinator stated, There is no baseline care plan I can't find it. A copy of the Facility's Resident Baseline Care Plan was reviewed and included an area for code status. Resident #117's Nurse's Notes were reviewed and are documented in part, as follows: [DATE] 11 P.M.: Resident arrived today from Name (Local hospital) for a respite stay of 5 days under the care of Name (Physician), resident is on hospice with Name (Hospice Company). Alert and oriented times three, continent of bladder, incontinent of bowel, takes meds (medications) whole, able to feed self, regular diet with thin liquids, total care with activities of daily living., extensive assist with positioning, confined to bed. Lungs clear, bowel sounds present in all 4 quadrants, skin warm and dry to touch, oxygen at 2 liters per minute via nasal cannula. Orders were verified with MD (Medical Doctor). Currently no complaint of pain, no distress noted. Vital Signs: ,[DATE] (blood pressure), 77 (pulse), 98.2 (temperature), 14 (respirations), 95% (oxygen saturation). [DATE] 12:00 A.M.: Resident in bed at present resting with eyes closed. O2 (oxygen) at 2 liters per minute denies pain and discomfort at present. ,[DATE] (blood pressure), 56 (pulse), 12 (respirations), 91% (oxygen saturation), no signs of distress noted. HOB (head of bed) elevated for comfort. Will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 2:00 A.M.: Resident resting comfortable, no signs of distress noted. Brief changed and repositioned. Responded to name being called. O2 90%, incontinent of bowels and bladder. Call light within reach, bed in lowest position. Will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 4:00 A.M.: Resident shows no signs of distress, unlabored respirations, no sob (shortness of breath) noted, reposition, HOB elevated for comfort, will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 5:00 A.M.: CNA (Certified Nursing Assistant) reported a change in Resident breathing, upon assessment resident had ,[DATE] breaths per minute. O2 increased to 4 Liters per minute with HOB elevated at 45% will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 5:30 A.M.: Resident resting with eyes open at present. Labored resp. (respirations) noted. No signs of distress or discomfort noted. Hospice notified of change in condition. O2 4 Liters per minute in place will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] Late Entry: Hospice nurse was notified of missing paper work upon change of status. Name (RN (Registered Nurse) #1 the hospice on call nurse stated that patient had a DNR (Do Not Resuscitate) status on his discharge note and in his file. I asked for a copy of resident DNR status on which the nurse stated that the patient had one on file and he saw it on the discharge paper, but he will bring one in. Patient was observed breathing ,[DATE] breaths per minute on 4 liters of O2. HOB elevated. Hospice nurse arrived and was given a brief description of resident condition. Hospice nurse then proceeded to resident's room. The nurse then came to nurse station and stated that resident has passed and he pronounced him at 6:50 A.M. The hospice nurse then called the doctor for said patient in which the nurse came back to the nurse station and stated to call 911 for patient did not has a DNR and the hospice nurse stated he was trying to get an order from the doctor. 911 was called. The Hospice Plan of Care/Comprehensive assessment dated [DATE] for Resident #117 was reviewed with no Cardiopulmonary Resuscitation Status addressed. Resident #117's facility admission orders [REDACTED]. Resident #117's facility Medication Administration Record [REDACTED]. Also a Medication Book Insert sheet was reviewed and is documented in part, as follows: Name: Resident #117 allergies [REDACTED]. Code Status: (Blank) Diagnosis: [REDACTED]. Meds Taken: Whole Diet: Regular. The Hospice Company's Discharge Summary document dated [DATE] was reviewed and is documented in part, as follows: Summary of Care: patient was admitted to Name (facility) about ten hours ago with [MEDICAL CONDITION]. Upon arrival he had a tuck in visit and his family was present. The family did not bring his medications as requested and Name (Physician) faxed scripts to the pharmacy so the patient would have medications tonight. Nurse (LPN #2) was present during the admission and she was aware that there was no DNR and discharge paperwork from the hospital did not arrive with the patient. Assessment or observation of death: AT 5:45 A.M. this morning I received a call from the facility stating that the patient's condition had changed and they would like to have someone out to assess the patient. I arrived at 6:45 a.m. and spoke with the nurse on the unit. She stated that his respirations had changed and he didn't look good. There were no respirations and his apical pulse was absent after one full minute. Returned to the nurses desk and informed the nurse the patient has expired. She stated that she did not have a copy of his DNR. Name (Physician) notified and instructed to call 911. On [DATE] at 3:43 P.M. a phone interview was conducted with Hospice Nurse RN (Registered Nurse) #1. RN #1 was asked to explain what happened on [DATE] when Resident #117 expired and if he knew the code status. RN #1 stated, I got a call from the facility around 5:45 a.m. and was told the resident had a change of condition was asked if I could come in to take a look at him. I was never asked about the resident's code status over the phone and I didn't know the code status when I went into the resident's room. When I got to the facility the nurse told me the resident was breathing funny. I went down to check the resident and there was no pulse or respiration. I went and asked the nurse for the DNR papers and she said we don't have one. I don't go into a facility assuming a resident has a DNR. The nurse was scrambling around looking for a DNR and I got on the phone with out medical director and told her there was a change in condition and there was no DNR, the physician said we need to call 911. If I do not have a DNR in hand I assume the resident is a Full Code. RN #1 was asked if the facility initiated CPR (Cardiopulmonary Resuscitation) after it was determined the resident was a full code and were instructed to call 911. RN #1 stated, No I never saw anyone initiate CPR. No one was in a panic or nothing. I don't work for the facility but I would have expected for them to at least start CPR. LPN #1's CPR Certification was reviewed and was current at the time Resident #117 was under her care. Resident #117's Hospital Inpatient Palliative Care Medicine Consult Note dated [DATE] was reviewed and is documented in part, as follows: PLAN: *Code Status: DNR/DNI (do not intubate). A durable DNR was not completed. His POST was not completed. Resident #117's Hospital Code Status History was reviewed and indicated 9 admissions since [DATE] with the resident having a Full Code Status. On [DATE] at approximately 5:15 P.M. the Virginia Department of Health Office of Licensure and Certification was called where two Supervisors were made aware of the above information and facility Immediate Jeopardy was questioned. After reviewing the information the Supervisors instructed the Survey Team to call Immediate Jeopardy in the facility. The Administrator, the Director of Nursing (DON) and the Regional Quality Specialist were called into the conference room and the above information was shared. At 5:29 P.M. Immediate Jeopardy was called in the facility for citation F-678 and the Administrative Team was made aware we would need a Plan of Correction to abate the immediacy of the Immediate Jeopardy. On [DATE] at 8:45 P.M. the following Plan of Correction was accepted by the State Agency and the immediacy of the Immediate Jeopardy was removed and is documented in part, as follows: Beacon Shores Nursing & Rehabilitation CEO (Chief Operating Officer), DON and Nurse Consultant were made aware at 5:29 pm on [DATE] of an Immediate Jeopardy for F678. We were made aware that Name (Resident #117) has no code status, he was a Full Code, and CPR was not started for the absence of vital signs. There (sic) chart was reviewed and confirmed this information. The Statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the center has taken or is planning to take actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been or are to be corrected by the date or dates indicated. F 678 It is the practice of this facility personnel to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED]. On or before (MONTH) 23, 2019 Licensed Nurses and Certified Nurses Assistance will attend an in-service. The in-service will be conducted by the Director of Nursing or Designee and will include: -Review of Regulation -Review of the Statement of Deficiencies -Review of the Plan of Correction -Review of Abuse Policy (1) How the corrective actions will be accomplished for those residents found to have been affected by the deficient practice. a. Resident #117 expired on [DATE] and cannot be corrected. Nurse Name (LPN #1) resigned on [DATE] from employment at this facility. Director of Nursing was terminated on [DATE] for poor Standards of Care that resulted in an Immediate Jeopardy and responsibility for repeat deficiencies. (2) How the facility will identify other residents having the potential to be affected by the same deficient practice. a. Facility completed a 100% chart audit of all residents in the facility immediately for code status on (MONTH) 23, 2019. b. 52 residents are full codes and have the potential to be affected. c. 65 residents are Do Not Resuscitate and have the potential to be affected. (3) What measures will be put in place or systemic change made to ensure that the deficient practice will not recur. Beginning (MONTH) 23, 2019 Licensed Nurses and Certified Nurses Assistance will attend an in-service that will end on (MONTH) 24, 2019. The in-service will be conducted by the Director of Nursing or Designee and will include: -Review of Regulation -Review of the Statement of Deficiencies -Review of the Plan of Correction - All licensed nurses who are currently CPR certified will be educated on how to interpret code status and what to do in the event they find a resident without vital signs, heart rate, or respiration. a. Any resident found to not have a code status will be considered a full code. d. On admission, resident's orders and code status will be verified by the admitting nurse with the attending physician. If the physician is unavailable when called and until he returns the call, the resident will be considered a full code. e. On admission, the charge nurse will verify code status with an alert and oriented resident and if the resident is cognitively impaired, the family and/or Power of Attorney may verify code status. f. An order is written for DNR or Full Code status and signed by the physician. g. Code status is verified with the family and/or resident by the Social Services Director after receiving baseline care plan. A POST or DNR directive form is signed at that time if they have elected a DNR status. h. An AD Hoc meeting held to review Code Status policies on [DATE]. The Executive Director, Assistant Director of Nursing, Regional Team, and Medical Director, as well as the Administrator were in attendance at the meeting. On [DATE] at 11:10 A.M. an interview was conducted with the facility Medical Director. The Medical Director was made aware of the information that had been gather and was asked what he would have expected. The Medical Director stated, I am shocked and upset this has happened first. A resident is always considered a full code unless there is an order for [REDACTED]. After several attempts to reach LPN #1 by phone a return call was received on [DATE] at 9:30 A.M LPN #1 was asked to describe what happened with Resident #117 on [DATE] into [DATE], if CPR was ever initiated and if the Director of Nursing was aware of the situation. LPN #1 stated, He (Resident #117) was my patient that night. During report I was never told his code status. The CNA told me around 5:30 that he had a change and his breathing was different. I called the supervisor and she said to call the hospice on-call nurse. I called the hospice nurse and he said he would come in to see him. The hospice nurse arrived around 6:30 and I gave him a report them he with down to the resident's room. He came back up and said the resident had no vitals and asked for the DNR papers. I told him we didn't have any DNR papers. He got on the phone with the hospice doctor and told me to call 911. I called 911. Myself or anyone else never went down and started CPR, we waited for 911 to come. The police came as well. The supervisor did come over after it was all over and say we should have started CPR. The DON was aware because when she came in she took me into the medication room and told me his death was all my fault and I was going to lose my license. She also said my nurse's notes were terrible. I was so upset she was yelling and cursing at me. After I finished my work I went to HR (human resources) and resigned. I thought since he was hospice he was a no code. On [DATE] at 1:00 P.M. an interview was conducted with LPN #4 who was the supervisor on [DATE] into [DATE] when Resident #117 expired. LPN #4 was asked if LPN #1 had told her that Resident #117 condition had worsened and if she had made the comment after the resident had expired that the staff should have started CPR. LPN #4 stated, Yes she (LPN #1) did call me and told me he wasn't doing well and I told her to call the hospice nurse so they could come in an assess him. I did say later in the shift that they should have started CPR after they called 911. The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised (MONTH) 2011 was reviewed and is documented in part, as follows: Policy Statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation in victims of sudden [MEDICAL CONDITION]. Policy Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS (Basic Life Support) includes recognizing the atypical presentation of sudden [MEDICAL CONDITION]. 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support. 8. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: a It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual. The facility policy titled Advance Directives revised (MONTH) (YEAR) was reviewed and is documented in part, as follows: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. After the facility notified the Survey team that all Licensed Staff had received the Plan of Correction training, team members went to each unit and validated that the staff were knowledgeable on the Plan of Correction training in order for the Immediate Jeopardy to be abated. Staff members were able to verbalize understanding of the Plan of Correction training and the Immediate Jeopardy was fully abated at 4:15 P.M. on [DATE] and the deficiency was lowered to a level 2 isolated. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on a complaint investigation, medical record review, staff interviews and facility document review the facility staff failed to obtain a Cardiopulmonary Resuscitation Status upon admission on [DATE] and failed to initiate Cardiopulmonary Resuscitation on [DATE] at 6:50 A.M. for 1 (Resident #117) of 22 residents in the survey sample, when the resident was assessed and found to be absent of vital signs. The finding included: Resident #117 was a [AGE] year old male admitted to the facility on [DATE] at 7:00 P.M. for a respite only stay. Resident #117 [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for Resident #117 was a Discharge Assessment with an Assessment Reference Date (ARD) of [DATE]. Under Section A0310F Entry/discharge reporting Resident #117 was coded as 12 out of 15 which indicated moderate cognitive impairment. Death in facility record. Under Section A1900 admitted Resident #117 was coded as [DATE]. Under Section A2000 discharge date Resident #117 was coded as [DATE]. Under Section A2100 Discharge Status Resident #117 was coded as 8. deceased . On [DATE] at approximately 10:30 A.M., the MDS Coordinator was asked for the baseline/initial care plan. The MDS Coordinator stated, There is no baseline care plan I can't find it. A copy of the Facility's Resident Baseline Care Plan was reviewed and included an area for code status. Resident #117's Nurse's Notes were reviewed and are documented in part, as follows: [DATE] 11 P.M.: Resident arrived today from Name (Local hospital) for a respite stay of 5 days under the care of Name (Physician), resident is on hospice with Name (Hospice Company). Alert and oriented times three, continent of bladder, incontinent of bowel, takes meds (medications) whole, able to feed self, regular diet with thin liquids, total care with activities of daily living., extensive assist with positioning, confined to bed. Lungs clear, bowel sounds present in all 4 quadrants, skin warm and dry to touch, oxygen at 2 liters per minute via nasal cannula. Orders were verified with MD (Medical Doctor). Currently no complaint of pain, no distress noted. Vital Signs: ,[DATE] (blood pressure), 77 (pulse), 98.2 (temperature), 14 (respirations), 95% (oxygen saturation). [DATE] 12:00 A.M.: Resident in bed at present resting with eyes closed. O2 (oxygen) at 2 liters per minute denies pain and discomfort at present. ,[DATE] (blood pressure), 56 (pulse), 12 (respirations), 91% (oxygen saturation), no signs of distress noted. HOB (head of bed) elevated for comfort. Will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 2:00 A.M.: Resident resting comfortable, no signs of distress noted. Brief changed and repositioned. Responded to name being called. O2 90%, incontinent of bowels and bladder. Call light within reach, bed in lowest position. Will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 4:00 A.M.: Resident shows no signs of distress, unlabored respirations, no sob (shortness of breath) noted, reposition, HOB elevated for comfort, will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 5:00 A.M.: CNA (Certified Nursing Assistant) reported a change in Resident breathing, upon assessment resident had ,[DATE] breaths per minute. O2 increased to 4 Liters per minute with HOB elevated at 45% will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 5:30 A.M.: Resident resting with eyes open at present. Labored resp. (respirations) noted. No signs of distress or discomfort noted. Hospice notified of change in condition. O2 4 Liters per minute in place will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] Late Entry: Hospice nurse was notified of missing paper work upon change of status. Name (RN (Registered Nurse) #1 the hospice on call nurse stated that patient had a DNR (Do Not Resuscitate) status on his discharge note and in his file. I asked for a copy of resident DNR status on which the nurse stated that the patient had one on file and he saw it on the discharge paper, but he will bring one in. Patient was observed breathing ,[DATE] breaths per minute on 4 liters of O2. HOB elevated. Hospice nurse arrived and was given a brief description of resident condition. Hospice nurse then proceeded to resident's room. The nurse then came to nurse station and stated that resident has passed and he pronounced him at 6:50 A.M. The hospice nurse then called the doctor for said patient in which the nurse came back to the nurse station and stated to call 911 for patient did not has a DNR and the hospice nurse stated he was trying to get an order from the doctor. 911 was called. The Hospice Plan of Care/Comprehensive assessment dated [DATE] for Resident #117 was reviewed with no Cardiopulmonary Resuscitation Status addressed. Resident #117's facility admission orders [REDACTED]. Resident #117's facility Medication Administration Record [REDACTED]. Also a Medication Book Insert sheet was reviewed and is documented in part, as follows: Name: Resident #117 allergies [REDACTED]. Code Status: (Blank) Diagnosis: [REDACTED]. Meds Taken: Whole Diet: Regular. The Hospice Company's Discharge Summary document dated [DATE] was reviewed and is documented in part, as follows: Summary of Care: patient was admitted to Name (facility) about ten hours ago with [MEDICAL CONDITION]. Upon arrival he had a tuck in visit and his family was present. The family did not bring his medications as requested and Name (Physician) faxed scripts to the pharmacy so the patient would have medications tonight. Nurse (LPN #2) was present during the admission and she was aware that there was no DNR and discharge paperwork from the hospital did not arrive with the patient. Assessment or observation of death: AT 5:45 A.M. this morning I received a call from the facility stating that the patient's condition had changed and they would like to have someone out to assess the patient. I arrived at 6:45 a.m. and spoke with the nurse on the unit. She stated that his respirations had changed and he didn't look good. There were no respirations and his apical pulse was absent after one full minute. Returned to the nurses desk and informed the nurse the patient has expired. She stated that she did not have a copy of his DNR. Name (Physician) notified and instructed to call 911. On [DATE] at 3:43 P.M. a phone interview was conducted with Hospice Nurse RN (Registered Nurse) #1. RN #1 was asked to explain what happened on [DATE] when Resident #117 expired and if he knew the code status. RN #1 stated, I got a call from the facility around 5:45 a.m. and was told the resident had a change of condition was asked if I could come in to take a look at him. I was never asked about the resident's code status over the phone and I didn't know the code status when I went into the resident's room. When I got to the facility the nurse told me the resident was breathing funny. I went down to check the resident and there was no pulse or respiration. I went and asked the nurse for the DNR papers and she said we don't have one. I don't go into a facility assuming a resident has a DNR. The nurse was scrambling around looking for a DNR and I got on the phone with out medical director and told her there was a change in condition and there was no DNR, the physician said we need to call 911. If I do not have a DNR in hand I assume the resident is a Full Code. RN #1 was asked if the facility initiated CPR (Cardiopulmonary Resuscitation) after it was determined the resident was a full code and were instructed to call 911. RN #1 stated, No I never saw anyone initiate CPR. No one was in a panic or nothing. I don't work for the facility but I would have expected for them to at least start CPR. LPN #1's CPR Certification was reviewed and was current at the time Resident #117 was under her care. Resident #117's Hospital Inpatient Palliative Care Medicine Consult Note dated [DATE] was reviewed and is documented in part, as follows: PLAN: *Code Status: DNR/DNI (do not intubate). A durable DNR was not completed. His POST was not completed. Resident #117's Hospital Code Status History was reviewed and indicated 9 admissions since [DATE] with the resident having a Full Code Status. On [DATE] at approximately 5:15 P.M. the Virginia Department of Health Office of Licensure and Certification was called where two Supervisors were made aware of the above information and facility Immediate Jeopardy was questioned. After reviewing the information the Supervisors instructed the Survey Team to call Immediate Jeopardy in the facility. The Administrator, the Director of Nursing (DON) and the Regional Quality Specialist were called into the conference room and the above information was shared. At 5:29 P.M. Immediate Jeopardy was called in the facility for citation F-678 and the Administrative Team was made aware we would need a Plan of Correction to abate the immediacy of the Immediate Jeopardy. On [DATE] at 8:45 P.M. the following Plan of Correction was accepted by the State Agency and the immediacy of the Immediate Jeopardy was removed and is documented in part, as follows: Beacon Shores Nursing & Rehabilitation CEO (Chief Operating Officer), DON and Nurse Consultant were made aware at 5:29 pm on [DATE] of an Immediate Jeopardy for F678. We were made aware that Name (Resident #117) has no code status, he was a Full Code, and CPR was not started for the absence of vital signs. There (sic) chart was reviewed and confirmed this information. The Statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the center has taken or is planning to take actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been or are to be corrected by the date or dates indicated. F 678 It is the practice of this facility personnel to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED]. On or before [DATE] Licensed Nurses and Certified Nurses Assistance will attend an in-service. The in-service will be conducted by the Director of Nursing or Designee and will include: -Review of Regulation -Review of the Statement of Deficiencies -Review of the Plan of Correction -Review of Abuse Policy (1) How the corrective actions will be accomplished for those residents found to have been affected by the deficient practice. a. Resident #117 expired on [DATE] and cannot be corrected. Nurse Name (LPN #1) resigned on [DATE] from employment at this facility. Director of Nursing was terminated on [DATE] for poor Standards of Care that resulted in an Immediate Jeopardy and responsibility for repeat deficiencies. (2) How the facility will identify other residents having the potential to be affected by the same deficient practice. a. Facility completed a 100% chart audit of all residents in the facility immediately for code status on [DATE]. b. 52 residents are full codes and have the potential to be affected. c. 65 residents are Do Not Resuscitate and have the potential to be affected. (3) What measures will be put in place or systemic change made to ensure that the deficient practice will not recur. Beginning [DATE] Licensed Nurses and Certified Nurses Assistance will attend an in-service that will end on [DATE]. The in-service will be conducted by the Director of Nursing or Designee and will include: -Review of Regulation -Review of the Statement of Deficiencies -Review of the Plan of Correction - All licensed nurses who are currently CPR certified will be educated on how to interpret code status and what to do in the event they find a resident without vital signs, heart rate, or respiration. a. Any resident found to not have a code status will be considered a full code. d. On admission, resident's orders and code status will be verified by the admitting nurse with the attending physician. If the physician is unavailable when called and until he returns the call, the resident will be considered a full code. e. On admission, the charge nurse will verify code status with an alert and oriented resident and if the resident is cognitively impaired, the family and/or Power of Attorney may verify code status. f. An order is written for DNR or Full Code status and signed by the physician. g. Code status is verified with the family and/or resident by the Social Services Director after receiving baseline care plan. A POST or DNR directive form is signed at that time if they have elected a DNR status. h. An AD Hoc meeting held to review Code Status policies on [DATE]. The Executive Director, Assistant Director of Nursing, Regional Team, and Medical Director, as well as the Administrator were in attendance at the meeting. On [DATE] at 11:10 A.M. an interview was conducted with the facility Medical Director. The Medical Director was made aware of the information that had been gather and was asked what he would have expected. The Medical Director stated, I am shocked and upset this has happened first. A resident is always considered a full code unless there is an order for [REDACTED]. After several attempts to reach LPN #1 by phone a return call was received on [DATE] at 9:30 A.M LPN #1 was asked to describe what happened with Resident #117 on [DATE] into [DATE], if CPR was ever initiated and if the Director of Nursing was aware of the situation. LPN #1 stated, He (Resident #117) was my patient that night. During report I was never told his code status. The CNA told me around 5:30 that he had a change and his breathing was different. I called the supervisor and she said to call the hospice on-call nurse. I called the hospice nurse and he said he would come in to see him. The hospice nurse arrived around 6:30 and I gave him a report them he with down to the resident's room. He came back up and said the resident had no vitals and asked for the DNR papers. I told him we didn't have any DNR papers. He got on the phone with the hospice doctor and told me to call 911. I called 911. Myself or anyone else never went down and started CPR, we waited for 911 to come. The police came as well. The supervisor did come over after it was all over and say we should have started CPR. The DON was aware because when she came in she took me into the medication room and told me his death was all my fault and I was going to lose my license. She also said my nurse's notes were terrible. I was so upset she was yelling and cursing at me. After I finished my work I went to HR (human resources) and resigned. I thought since he was hospice he was a no code. On [DATE] at 1:00 P.M. an interview was conducted with LPN #4 who was the supervisor on [DATE] into [DATE] when Resident #117 expired. LPN #4 was asked if LPN #1 had told her that Resident #117 condition had worsened and if she had made the comment after the resident had expired that the staff should have started CPR. LPN #4 stated, Yes she (LPN #1) did call me and told me he wasn't doing well and I told her to call the hospice nurse so they could come in an assess him. I did say later in the shift that they should have started CPR after they called 911. The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised [DATE] was reviewed and is documented in part, as follows: Policy Statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation in victims of sudden [MEDICAL CONDITION]. Policy Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS (Basic Life Support) includes recognizing the atypical presentation of sudden [MEDICAL CONDITION]. 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support. 8. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: a It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual. The facility policy titled Advance Directives revised [DATE] was reviewed and is documented in part, as follows: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. After the facility notified the Survey team that all Licensed Staff had received the Plan of Correction training, team members went to each unit and validated that the staff were knowledgeable on the Plan of Correction training in order for the Immediate Jeopardy to be abated. Staff members were able to verbalize understanding of the Plan of Correction training and the Immediate Jeopardy was fully abated at 4:15 P.M. on [DATE] and the deficiency was lowered to a level 2 isolated. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on a complaint investigation, medical record review, staff interviews and facility document review the facility staff failed to obtain a Cardiopulmonary Resuscitation Status upon admission on [DATE] and failed to initiate Cardiopulmonary Resuscitation on [DATE] at 6:50 A.M. for 1 (Resident #117) of 22 residents in the survey sample, when the resident was assessed and found to be absent of vital signs. The finding included: Resident #117 was a [AGE] year old male admitted to the facility on [DATE] at 7:00 P.M. for a respite only stay. Resident #117 [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) for Resident #117 was a Discharge Assessment with an Assessment Reference Date (ARD) of [DATE]. Under Section A0310F Entry/discharge reporting Resident #117 was coded as 12 out of 15 which indicated moderate cognitive impairment. Death in facility record. Under Section A1900 admitted Resident #117 was coded as [DATE]. Under Section A2000 discharge date Resident #117 was coded as [DATE]. Under Section A2100 Discharge Status Resident #117 was coded as 8. deceased . On [DATE] at approximately 10:30 A.M., the MDS Coordinator was asked for the baseline/initial care plan. The MDS Coordinator stated, There is no baseline care plan I can't find it. A copy of the Facility's Resident Baseline Care Plan was reviewed and included an area for code status. Resident #117's Nurse's Notes were reviewed and are documented in part, as follows: [DATE] 11 P.M.: Resident arrived today from Name (Local hospital) for a respite stay of 5 days under the care of Name (Physician), resident is on hospice with Name (Hospice Company). Alert and oriented times three, continent of bladder, incontinent of bowel, takes meds (medications) whole, able to feed self, regular diet with thin liquids, total care with activities of daily living., extensive assist with positioning, confined to bed. Lungs clear, bowel sounds present in all 4 quadrants, skin warm and dry to touch, oxygen at 2 liters per minute via nasal cannula. Orders were verified with MD (Medical Doctor). Currently no complaint of pain, no distress noted. Vital Signs: ,[DATE] (blood pressure), 77 (pulse), 98.2 (temperature), 14 (respirations), 95% (oxygen saturation). [DATE] 12:00 A.M.: Resident in bed at present resting with eyes closed. O2 (oxygen) at 2 liters per minute denies pain and discomfort at present. ,[DATE] (blood pressure), 56 (pulse), 12 (respirations), 91% (oxygen saturation), no signs of distress noted. HOB (head of bed) elevated for comfort. Will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 2:00 A.M.: Resident resting comfortable, no signs of distress noted. Brief changed and repositioned. Responded to name being called. O2 90%, incontinent of bowels and bladder. Call light within reach, bed in lowest position. Will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 4:00 A.M.: Resident shows no signs of distress, unlabored respirations, no sob (shortness of breath) noted, reposition, HOB elevated for comfort, will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 5:00 A.M.: CNA (Certified Nursing Assistant) reported a change in Resident breathing, upon assessment resident had ,[DATE] breaths per minute. O2 increased to 4 Liters per minute with HOB elevated at 45% will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] 5:30 A.M.: Resident resting with eyes open at present. Labored resp. (respirations) noted. No signs of distress or discomfort noted. Hospice notified of change in condition. O2 4 Liters per minute in place will continue to monitor. Signed By LPN (Licensed Practical Nurse) #5. [DATE] Late Entry: Hospice nurse was notified of missing paper work upon change of status. Name (RN (Registered Nurse) #1 the hospice on call nurse stated that patient had a DNR (Do Not Resuscitate) status on his discharge note and in his file. I asked for a copy of resident DNR status on which the nurse stated that the patient had one on file and he saw it on the discharge paper, but he will bring one in. Patient was observed breathing ,[DATE] breaths per minute on 4 liters of O2. HOB elevated. Hospice nurse arrived and was given a brief description of resident condition. Hospice nurse then proceeded to resident's room. The nurse then came to nurse station and stated that resident has passed and he pronounced him at 6:50 A.M. The hospice nurse then called the doctor for said patient in which the nurse came back to the nurse station and stated to call 911 for patient did not has a DNR and the hospice nurse stated he was trying to get an order from the doctor. 911 was called. The Hospice Plan of Care/Comprehensive assessment dated [DATE] for Resident #117 was reviewed with no Cardiopulmonary Resuscitation Status addressed. Resident #117's facility admission orders [REDACTED]. Resident #117's facility Medication Administration Record [REDACTED]. Also a Medication Book Insert sheet was reviewed and is documented in part, as follows: Name: Resident #117 allergies [REDACTED]. Code Status: (Blank) Diagnosis: [REDACTED]. Meds Taken: Whole Diet: Regular. The Hospice Company's Discharge Summary document dated [DATE] was reviewed and is documented in part, as follows: Summary of Care: patient was admitted to Name (facility) about ten hours ago with [MEDICAL CONDITION]. Upon arrival he had a tuck in visit and his family was present. The family did not bring his medications as requested and Name (Physician) faxed scripts to the pharmacy so the patient would have medications tonight. Nurse (LPN #2) was present during the admission and she was aware that there was no DNR and discharge paperwork from the hospital did not arrive with the patient. Assessment or observation of death: AT 5:45 A.M. this morning I received a call from the facility stating that the patient's condition had changed and they would like to have someone out to assess the patient. I arrived at 6:45 a.m. and spoke with the nurse on the unit. She stated that his respirations had changed and he didn't look good. There were no respirations and his apical pulse was absent after one full minute. Returned to the nurses desk and informed the nurse the patient has expired. She stated that she did not have a copy of his DNR. Name (Physician) notified and instructed to call 911. On [DATE] at 3:43 P.M. a phone interview was conducted with Hospice Nurse RN (Registered Nurse) #1. RN #1 was asked to explain what happened on [DATE] when Resident #117 expired and if he knew the code status. RN #1 stated, I got a call from the facility around 5:45 a.m. and was told the resident had a change of condition was asked if I could come in to take a look at him. I was never asked about the resident's code status over the phone and I didn't know the code status when I went into the resident's room. When I got to the facility the nurse told me the resident was breathing funny. I went down to check the resident and there was no pulse or respiration. I went and asked the nurse for the DNR papers and she said we don't have one. I don't go into a facility assuming a resident has a DNR. The nurse was scrambling around looking for a DNR and I got on the phone with out medical director and told her there was a change in condition and there was no DNR, the physician said we need to call 911. If I do not have a DNR in hand I assume the resident is a Full Code. RN #1 was asked if the facility initiated CPR (Cardiopulmonary Resuscitation) after it was determined the resident was a full code and were instructed to call 911. RN #1 stated, No I never saw anyone initiate CPR. No one was in a panic or nothing. I don't work for the facility but I would have expected for them to at least start CPR. LPN #1's CPR Certification was reviewed and was current at the time Resident #117 was under her care. Resident #117's Hospital Inpatient Palliative Care Medicine Consult Note dated [DATE] was reviewed and is documented in part, as follows: PLAN: *Code Status: DNR/DNI (do not intubate). A durable DNR was not completed. His POST was not completed. Resident #117's Hospital Code Status History was reviewed and indicated 9 admissions since [DATE] with the resident having a Full Code Status. On [DATE] at approximately 5:15 P.M. the Virginia Department of Health Office of Licensure and Certification was called where two Supervisors were made aware of the above information and facility Immediate Jeopardy was questioned. After reviewing the information the Supervisors instructed the Survey Team to call Immediate Jeopardy in the facility. The Administrator, the Director of Nursing (DON) and the Regional Quality Specialist were called into the conference room and the above information was shared. At 5:29 P.M. Immediate Jeopardy was called in the facility for citation F-678 and the Administrative Team was made aware we would need a Plan of Correction to abate the immediacy of the Immediate Jeopardy. On [DATE] at 8:45 P.M. the following Plan of Correction was accepted by the State Agency and the immediacy of the Immediate Jeopardy was removed and is documented in part, as follows: Beacon Shores Nursing & Rehabilitation CEO (Chief Operating Officer), DON and Nurse Consultant were made aware at 5:29 pm on [DATE] of an Immediate Jeopardy for F678. We were made aware that Name (Resident #117) has no code status, he was a Full Code, and CPR was not started for the absence of vital signs. There (sic) chart was reviewed and confirmed this information. The Statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the center has taken or is planning to take actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been or are to be corrected by the date or dates indicated. F 678 It is the practice of this facility personnel to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders [REDACTED]. On or before (MONTH) 23, 2019 Licensed Nurses and Certified Nurses Assistance will attend an in-service. The in-service will be conducted by the Director of Nursing or Designee and will include: -Review of Regulation -Review of the Statement of Deficiencies -Review of the Plan of Correction -Review of Abuse Policy (1) How the corrective actions will be accomplished for those residents found to have been affected by the deficient practice. a. Resident #117 expired on [DATE] and cannot be corrected. Nurse Name (LPN #1) resigned on [DATE] from employment at this facility. Director of Nursing was terminated on [DATE] for poor Standards of Care that resulted in an Immediate Jeopardy and responsibility for repeat deficiencies. (2) How the facility will identify other residents having the potential to be affected by the same deficient practice. a. Facility completed a 100% chart audit of all residents in the facility immediately for code status on (MONTH) 23, 2019. b. 52 residents are full codes and have the potential to be affected. c. 65 residents are Do Not Resuscitate and have the potential to be affected. (3) What measures will be put in place or systemic change made to ensure that the deficient practice will not recur. Beginning (MONTH) 23, 2019 Licensed Nurses and Certified Nurses Assistance will attend an in-service that will end on (MONTH) 24, 2019. The in-service will be conducted by the Director of Nursing or Designee and will include: -Review of Regulation -Review of the Statement of Deficiencies -Review of the Plan of Correction - All licensed nurses who are currently CPR certified will be educated on how to interpret code status and what to do in the event they find a resident without vital signs, heart rate, or respiration. a. Any resident found to not have a code status will be considered a full code. d. On admission, resident's orders and code status will be verified by the admitting nurse with the attending physician. If the physician is unavailable when called and until he returns the call, the resident will be considered a full code. e. On admission, the charge nurse will verify code status with an alert and oriented resident and if the resident is cognitively impaired, the family and/or Power of Attorney may verify code status. f. An order is written for DNR or Full Code status and signed by the physician. g. Code status is verified with the family and/or resident by the Social Services Director after receiving baseline care plan. A POST or DNR directive form is signed at that time if they have elected a DNR status. h. An AD Hoc meeting held to review Code Status policies on [DATE]. The Executive Director, Assistant Director of Nursing, Regional Team, and Medical Director, as well as the Administrator were in attendance at the meeting. On [DATE] at 11:10 A.M. an interview was conducted with the facility Medical Director. The Medical Director was made aware of the information that had been gather and was asked what he would have expected. The Medical Director stated, I am shocked and upset this has happened first. A resident is always considered a full code unless there is an order for [REDACTED]. After several attempts to reach LPN #1 by phone a return call was received on [DATE] at 9:30 A.M LPN #1 was asked to describe what happened with Resident #117 on [DATE] into [DATE], if CPR was ever initiated and if the Director of Nursing was aware of the situation. LPN #1 stated, He (Resident #117) was my patient that night. During report I was never told his code status. The CNA told me around 5:30 that he had a change and his breathing was different. I called the supervisor and she said to call the hospice on-call nurse. I called the hospice nurse and he said he would come in to see him. The hospice nurse arrived around 6:30 and I gave him a report them he with down to the resident's room. He came back up and said the resident had no vitals and asked for the DNR papers. I told him we didn't have any DNR papers. He got on the phone with the hospice doctor and told me to call 911. I called 911. Myself or anyone else never went down and started CPR, we waited for 911 to come. The police came as well. The supervisor did come over after it was all over and say we should have started CPR. The DON was aware because when she came in she took me into the medication room and told me his death was all my fault and I was going to lose my license. She also said my nurse's notes were terrible. I was so upset she was yelling and cursing at me. After I finished my work I went to HR (human resources) and resigned. I thought since he was hospice he was a no code. On [DATE] at 1:00 P.M. an interview was conducted with LPN #4 who was the supervisor on [DATE] into [DATE] when Resident #117 expired. LPN #4 was asked if LPN #1 had told her that Resident #117 condition had worsened and if she had made the comment after the resident had expired that the staff should have started CPR. LPN #4 stated, Yes she (LPN #1) did call me and told me he wasn't doing well and I told her to call the hospice nurse so they could come in an assess him. I did say later in the shift that they should have started CPR after they called 911. The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised (MONTH) 2011 was reviewed and is documented in part, as follows: Policy Statement: Personnel have completed training on the initiation of Cardiopulmonary Resuscitation in victims of sudden [MEDICAL CONDITION]. Policy Interpretation and Implementation: 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness). 2. Sudden [MEDICAL CONDITION] is a leading cause of death in adults. 3. Victims of [MEDICAL CONDITION] may initially have gasping respirations or may even appear to be having a [MEDICAL CONDITION]. Training in BLS (Basic Life Support) includes recognizing the atypical presentation of sudden [MEDICAL CONDITION]. 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support. 8. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: a It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exist for that individual. The facility policy titled Advance Directives revised (MONTH) (YEAR) was reviewed and is documented in part, as follows: Policy Statement: Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. After the facility notified the Survey team that all Licensed Staff had received the Plan of Correction training, team members went to each unit and validated that the staff were knowledgeable on the Plan of Correction training in order for the Immediate Jeopardy to be abated. Staff members were able to verbalize understanding of the Plan of Correction training and the Immediate Jeopardy was fully abated at 4:15 P.M. on [DATE] and the deficiency was lowered to a level 2 isolated. Prior to exit no further information was shared. This is a Complaint Deficiency.

Based on a complaint investigation, clinical record review, staff and resident interviews and facility documentation review, the facility staff failed to accurately assess areas of skin breakdown and provide appropriate interventions, care and treatment which constituted harm for one resident (Resident #369) in the survey sample. 1. The facility staff failed to accurately assess Resident #369 for a sacral pressure ulcer. Upon assessment in the local ER, the resident was assessed to have an unstageable sacral pressure ulcer 9.5 centimeters (cm) x 8.5 cm x 0.0 depth with yellow slough wound bed, which constituted harm. The findings included: Resident #369 was admitted to the nursing facility on 2/6/18 with [DIAGNOSES REDACTED]. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Resident #369's Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded the resident with a 9 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was moderately impaired in the skills needed for daily decision making. The residents was assessed to require extensive assistance of two staff for bed mobility, transfers, toilet use and bathing. The resident was not able to stabilize himself without staff assistance to ambulate and used a wheelchair for main mode of mobility. The resident was coded to be at risk for the development of pressure ulcers, but had none upon admission to the nursing facility. The assessment was coded for other skin problems as well as wound infections other than feet. Resident #369 was assessed always incontinent of bowel and bladder. The care plan dated 2/19/18 identified the resident had a potential for pressure ulcers and alteration in skin integrity other than pressure ulcers. The goal the staff set for the resident was that his skin would remain intact by the next review, 5/19/18. Some of the approaches the staff would implement to accomplish this goal included use proper technique when lifting and repositioning, do not pull or slide resident in bed, dietary to ensure necessary calories and call physician for any treatment orders. This care plan problem listed a right buttock boil and treatment as ordered to include an oral antibiotic, but there was no date to indicate when the boil originated. A care plan dated 6/28/18 identified an actual skin alteration-right buttock abscess. The goal set by the staff for the resident was to maintain intact skin by the next review. Some of the approaches the staff would implement to accomplish this goal included if wound had drainage to report to the physician, administered treatments as ordered by the physician and document, use pillows, supportive, protective devices with positioning. The Braden scale dated 6/21/18 and 9/18/18 assessed the resident was at risk for the development of pressure ulcers. The clinical record revealed the following regarding alterations in skin integrity: -6/14/18 at 2:30 p.m. (Nurse's notes) First indication of an area on the right buttock as reported by a Certified Nursing Assistant (CNA) brief had an unknown substance in it that was not BM or urine. Upon inspection of skin, there was no obvious open areas, but when palpating across right buttock, large amount of serosanquinous purulent drainage noted from a pin-point open area to the skin. Opening measured 0.1 x (by) 0.1 x 0.0. Drainage is foul smelling. Skin surrounding area is firm and warm to touch .long term care physician contacted x (times) 2 to report findings. Will notify oncoming shift. Dry dressing applied over site for protection . -6/15/18 at 12:00 p.m. (Nurse's notes) LTC physician contacted again regarding previously documented area on right buttock condition. Site remains unchanged . -6/15/18 at 6:00 p.m. (physician's orders [REDACTED]. Keflex (oral antibiotic) 500 milligrams (mg) QID (4 x a day) x 7 days. -6/21/18 (Nurse Practitioner's progress notes) culture from abscess to right buttock revealed 2 different organisms at this time, proteus mirabilis and positive [MEDICAL CONDITIONS]. To start [MEDICATION NAME] IM (intramuscular) x 7 days with pharmacy dose. Contact Isolation [MEDICAL CONDITION]. -6/22/18 at 4:00 p.m. (Medication Administration Record [REDACTED] -Nurse's notes continue to document right buttock abscess on 6/23/18 at 9:15 p.m., 6/24/18 at 1:00 p.m. and 6/26/18 at 9:00 p.m. No measurements or descriptions documented for any of the above dates. -Nurse's notes documentation on 6/27/18 at 8:00 p.m. and 6/29/18 at 2:42 a.m. the nurses notes document right buttock wound-no measurements or description. -Nurse's notes documentation dated 6/30/18 at 9:00 p.m. indicate right buttock wound-no measurements and no description. -Nurse's notes dated 7/1/18 at 2:17 a.m. and 10:00 a.m. changed to indicate a left buttock wound-no measurements and no description. -Nurses notes dated 7/2/18 at 1:00 p.m. documented the following: .mild [MEDICAL CONDITION] to skin surrounding the right hip abscess, but non-pitting. Area looks puffy. Right gluteal appears symmetrical to the left gluteal . This documentation indicated skin integrity issues to both right and left gluteal areas, but further description, measurements or follow-up for treatment orders. No treatment orders for wound care. The next skin assessment was on 7/6/18 that notated-skin intact. -Nurse's notes dated 7/2/18 at 3:00 a.m. and 9:00 p.m. indicated right buttock wound and that resident was still on contact precautions [MEDICAL CONDITION]. -Nurse's notes dated 7/5/18 at 9:00 p.m. indicated contact precautions [MEDICAL CONDITION] were discontinued. -The skin assessment flow sheets indicated the residents skin was intact until 6/15/18 and an existing area on 6/29/18. The skin assessment sheets do do document any further or existing areas until 9/28/18. The Licensed Practical Nurse (LPN) #7 was interviewed on 4/2/19 and stated that he entered all of these entries with the exception of 3/2/18 and 3/9/18. He stated skin assessments were completed on the 3/11 shift and when entering information on the Skin Inspection Report it reflected the skin status with a notation of either skin intact (nothing anywhere) or Skin Not Intact-existing or new. He stated he could not recall the resident well, but knew he had some areas on his sacral and buttocks with an infection that he gave antibiotics for along with transmission precautions. -Nurse's notes dated 9/24/18 at 9:00 p.m. indicated the following: Resident has skin breakdown to right buttock. He has several open areas, appears to be from moisture. Physician orders [REDACTED].*hydrogel applied and covered with dry dressing daily. MD made aware . No measurements or descriptions documented regarding the several open areas. *Hydrogel is made up of about 90 percent water that is suspended in a gel base, and assists in providing the appropriate amount of moisture to assist the wound with healing. This can help the tissues debride, granulate and eventually heal fully (https://advancedtissue.com/2014/03/hydrogel-dressing-basics/). -Nurse's notes dated 9/25/18 at 2:50 p.m. indicated physician's orders [REDACTED]. daily, zinc 220 mg daily and protein 30 ml twice a day. Hydrogel with dry dressing continued. -Nurse's notes dated 10/2/18 indicated .dressing intact to buttocks . -Nurse's notes dated 10/3/18 indicated Resident #369 was transferred to the local hospital via 911 for vomiting episodes. From the review of the clinical record, the only physician orders [REDACTED]. There were no treatment orders presented to this surveyor for wound care/dressings the right buttock when first identified on 6/14/18. The nurses documented dry dressings applied over site for protection. The Director of Nursing (DON) was interviewed on 4/3/19 at 12:30 p.m. She stated what ever was in the record was all she could locate about Resident #369's skin integrity issues. She stated she was not sure if the abscess had ever healed or that there were new areas that developed. She stated they had standards of care meetings and daily meeting to discuss all resident care areas to include any wounds pressure and non-pressure related. She stated the only information about the resident's wounds were in the nurse's notes, no wound tracking forms were initiated which should have been for pressure and/ or non-pressure to clearly tract all wounds. The nurse's notes dated 10/3/18 at 7:30 p.m., indicated the paramedics arrived to transfer Resident #369 via 911 to the local hospital ER for evaluation due to vomiting. The hospital ER notes indicated Resident #369 arrived to theER on [DATE] at 8:13 p.m. Review of the hospital's ER records revealed *unstageable sacral decubitus (same as pressure ulcers), 9.5 centimeters (cm) x 8.5 cm x 0.0 yellow slough wound bed. Other open areas were described as a bleeding area on posterior scrotum and a second open red area also on the scrotum. *Unstageable*Category/ Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed (National Pressure Ulcer Advisory Panel/NPUAP www.npuap.org). On 4/3/19 at 1:30 p.m., an interview was conducted with the MDS Coordinator. She stated from review of the clinical record, she could only find the 9/24/18 order that addressed any wound care to the right buttock. She also stated from her review of the documentation, she did not believe the right buttock had healed and it worsened in addition to a left buttock wound to incorporate the sacrum. She stated the staff should have initiated a Wound Assessment Report that would have identified the type of wound, tracked the wound, weekly assessment findings, cause, drainage, pain, measurements, any cultures, symptoms of infection, pulses if applicable, nutritional review, weight, physician contacts, responsible party contacted and the date when the wound resolved. She stated from the nurses notes documentation she coded the resident with a [MEDICAL CONDITION], not pressure. She said she does not do an eyes on assessment and depends on the nurses to document what they see during their assessments of the residents. She stated this type of document was started in the facility in 2012 and she did not know why Resident #369 did not have one. She stated the resident was on the standard mattress issued to all facility residents which was a pressure injury prevention mattress. She stated if the resident had multiple *Stage II pressure areas or greater, he should have been placed on a low air loss alternating pressure mattress. *Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Bruising indicates deep tissue injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/) On 4/4/19 at 3:30 p.m., the Regional Quality Specialist (RQS) stated that upon her review of the clinical record, she thought the right buttock abscess had revolved and a new area started on 9/24/18 because the weekly Skin Inspection Report indicated the skin was intact from 7/6/18 through 9/21/18 and the isolation precautions were discontinued on 7/2/18. She stated it was not until 9/28/18 that there was documentation on this report to indicate skin not intact-existing, but could not explain why LPN #7 did not document new for a newly identified area instead of existing which LPN #7 explained was how he documented areas on the Skin Inspection Report for areas already present. She stated it was her impression the areas on the Resident #369's sacral and or buttocks were from moisture and not pressure related. However, the RQC stated it was not plausible that a resident could leave the nursing facility on 10/3/18 at 7:30 p.m. without an unstageable sacral pressure ulcer and be assessed for one upon arrival in theER on [DATE] at 8:13 p.m. She said the wounds may have merged into one that encompassed both the sacral and buttocks based on the assessed size presented in the ER. She stated all wounds were to be tracked via the Wound Assessment Report which would have clearly shown when a wound either resolved or worsened, as well as treatments and physician orders. On 4/4/19 at 6:05 p.m., during a debriefing with the Administrator, DON and RQC, they stated they should recognize and discuss any and all changes with the residents durung the standards of care meeting. The DON stated she expected that the nursing staff conduct accurate assessments and treatment for [REDACTED]. On 4/4/19 at 6:30 p.m. during further interview with the Administrator and the RQC, the RQC restated the nursing staff should have identified a pressure ulcer at an earlier stage and not first identified as unstageable. The RQC stated she clearly understood there were problems with inaccurate assessments or lack of them for Resident #369's skin, along with proper treatments. She stated, I am going to do a sweep of the building to make sure accurate assessments are being done and bring this issue around 360 degrees. A telephone interview was conducted with the Resident Representative who was also the complainant on 4/4/19 at 1:10 p.m. She stated, on 10/2/18, the day before the resident was transferred to the hospital, she called a nurse down to change the resident because he had soiled himself. She stated that was the first time she saw the condition of the resident's bottom when the aide turned the resident on his side. She said, I was not told about the extent of his wound. It was a large discolored, eaten away area. That is the only way I know how to describe it. I thought it was a little spot, that is what they would tell me. Complaint Deficiency.

Based on observation, staff interviews, clinical record review, and review of the facility's policy the facility staff failed to ensure the necessary treatment, care and services were provided to prevent development of a pressure ulcer for 1 of 24 residents (Resident #7), in the survey sample resulting in harm. Resident #7 developed a facility acquired pressure ulcer to the right heel which was first assessed at an advanced stage (with eschar). The findings included: Resident #7 was originally admitted to the facility 8/1/11 and readmitted [DATE] after an acute hospital visit. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/30/16 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as moderately impaired for daily decision making. The resident was also coded for not being able to speak and rarely to never understanding what's communicated to him and rarely to never capable of making himself understood. The resident was also coded as not exhibiting mood or behavior problems. Resident #7 required extensive assistance of 2 person with bed mobility and transfers, extensive assistance of 1 with dressing, eating, and toileting, total care of 1 with personal hygiene and total care of 2 with bathing. The resident was coded totally incontinent of bowels and bladder. In section M (Skin conditions) of the 8/30/16 MDS assessment Resident #7 was coded as at risk of developing pressure ulcers at M0150. Resident #7 was also coded as not having venous or arterial ulcers, but having an open lesion other than a pressure ulcer on the foot. The resident was coded for having a pressure reducing device to the chair and bed, being on a turning/repositioning program, receiving nutrition or hydration interventions to manage skin problems, applications of ointments/medications other than to feet and application of dressings to the feet at M1200I. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. The Braden scale dated 9/6/16 revealed Resident #7 had a high risk for skin breakdown. The Braden score was 12. The predicting tool revealed the resident was with very limited ability to respond to pressure related discomfort, the skin is occasionally exposed to moisture, the resident is chair fast, completely immobile, and receives nutrition by tube feedings. Resident #7 had undated physician orders [REDACTED]. Pressure ulcer prevention requires assessment of the resident's risk factors and development of a plan to reduce or eliminate the risk factors. These include constant monitoring as care is rendered for redden areas especially over bony prominences, protecting the skin from incontinence episodes, lifting the resident off surfaces use of a draw sheet, limiting elevation of the head to 30 degrees, establishing and implementing an individualized turn schedule, notifying appropriate staff of changes identified in the skin.(Pottery & Perry 7th edition, chapter 48 page 1303) The clinical record revealed a nurse's note dated 9/23/16 at 2:00 p.m. which read; Resident has an opened wound noted to the right foot/heel. Applied wet-to-dry dressing to wound and applied Kerlix (woven gauze). No signs/symptoms of distress noted. Will continue to monitor. The clinical record did not reveal the physician was notified neither was a physician's orders [REDACTED]. On 9/24/16 at 2:30 p.m., a nurse's note read; writer informed by Unit Manager to follow-up with (name of the physician) regarding the right heel wound and treatment. Writer assessed right heel and noted open area measured 5.5 centimeter by 5.0 centimeters by 0.3 centimeters, wound bed pink, beefy with a moderate amount of bloody drainage. Surrounding tissue soft; small eschar to edge. No odor noted. Patient's heels elevated, turned and repositioned as tolerated. (name of the physician) notified with new order to cleanse site with Dermal Wound Cleanser and apply Exuderm every 3 days and as needed. Writer also called to notify next of kin with no YR (sic). Writer also noted multiple small blisters to right arm, intact fluid filled, new order skin prep every shift. Eschar is dead tissue that sheds or falls off from healthy skin. It's caused [MEDICAL CONDITION] also occurs in pressure wounds (bedsores). Eschar is typically tan, brown, or black, and may be crusty. (http://www.healthline.com/symptom/eschar) Exuderm dressings are sterile [MEDICATION NAME] wound dressings designed for all stages of wounds. Exuderm dressings create a moist environment to encourage wounds to heal.(https://www.medline.com/product/Exuderm-Thin-[MEDICATION NAME]/[MEDICATION NAME]-Dressings/Z05-PF ) Skin Prep is a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films. (http://www.smith-nephew.com/professional/products/advanced-wound-management/skin-prep/) Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermisPartial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) Stage 3 Pressure Injury: Full-thickness skin lossFull-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/) Resident #7 had an undated physician's orders [REDACTED]. Resident #7's skin assessment report revealed no entries on 8/23/16 and 8/25/16. The 9/1/16 entry read; skin not intact - existing, 9/8/16 entry read; skin intact, 9/15/16 entry read; skin not intact - existing, 9/22/16 entry read; skin not intact - new. There was no corresponding documentation explaining what the existing or new skin areas were or their locations. An interview was conducted with the Director of Nursing (DON) on 9/28/16 at approximately 3:45 p.m. The DON stated they had not investigated the wound to Resident #7's right inner heel but they believed it was a result of vascular problems and heat produced by use of the prevalon boots. Prevalon boots give patients the most advanced protection against heel pressure ulcers and foot drop. Prevalon helps minimize pressure, friction and shear on your patient's feet, heels and ankles. By elevating the foot and separating the heel from the mattress, it delivers total heel pressure relief (http://www.sageproductsglobal.com/en/prevalon.cfm). An interview was conducted with LPN #4 on 9/29/16 at approximately 6:05 p.m., LPN #4 documented the skin assessments results on 9/1/16, 9/8/16, and 9/15/16. LPN #4 stated she never inspected Resident #7's skin but she did document the information provided to her by LPN #7. LPN #4 stated she documented for LPN #7 because she told her she did not have a password to use the skin assessment report software. An interview was conducted with LPN #7 by telephone on 9/29/16 at approximately 6:45 p.m. LPN #7 stated she was responsible to perform skin assessments on Resident #7 and she did complete them and told another nurse by mouth the results to document. LPN #7 stated on 9/22/16 the resident had open areas to the top of the left foot and the heel of the right foot and she was supposed to document in the chart the description of the open areas and measure them but she failed to do that. LPN #7 stated it's my fault for not documenting, if you didn't document you didn't do it. Resident #7's care plan dated 9/24/16 read: Alteration in skin integrity Stage II pressure injury to right lateral foot. The goals were; no further breakdown until next review. Nutrition support to be given until next review. Will not have an impact on socialization until next review. The interventions were: Medications and treatments as ordered. Notify physician of any changes. Weekly skin assessments by nurse. Certified Nursing Assistant (CNA) to check skin daily when changing and bathing resident and notify nurse. Provide pain medication as scheduled and as needed. Educate resident on skin integrity, nutrition and prevention measures. Monitor dressing to ensure clean and dry every shift. change as needed and as ordered. Encourage socialization. See dietary care plan (The Nutrition care plan had been updated since the resident acquired the right foot pressure ulcer). Resident #7 was observed in bed on 9/28/16 at approximately 11:05 a.m. The resident was lying on the left side on a low air loss replacement mattress. Contractures were noted of all extremities and blue Prevalon boots were on bilateral lower extremities. Licensed Practical Nurse (LPN) #1 entered the room to provided wound care to Resident #7's right heel including the inner foot pressure ulcer. CNA #10 stated she had positioned Resident #7 on the left side when she came in to work with the resident. Positioning the resident on the left side prevented LPN #1 from having a direct view of the pressure ulcer. CNA #10 held Resident #7's right leg up and LPN #1 removed an Exuderm dressing dated 9/27/16 3 - 11 p.m. and the wound began to bleed from the wound bed. LPN #1 had to look under and up to see the pressure ulcer and render care. LPN #1 sprayed the pressure ulcer with wound cleanser and wiped the wound with 4 by 4 gauze and proceeded to dry the wound. Using a cotton tip applicator, LPN #1 applied Hydrogel wound gel to the wound, applied 4 by 4 gauze and wrapped the wound in kling roll gauze and tape with the date on it to hold it all together. The right inner heel pressure ulcer was observed with dark tissue around the edges from approximately 10 o'clock to 2 o'clock. Hydrogel is ideal for dry-to-moist clean wounds. Helps create a moist wound environment. Balanced formulation Easy irrigation Indications: pressure ulcers, partial and full-thickness wounds, leg ulcers, surgical wounds, lacerations, abrasions and skin tears, and first- and second-[MEDICAL CONDITION](www.medline.com/product/[MEDICATION NAME]-Hydrogel/Gel/Z05-PF ). The facility's policy titled Pressure Ulcer Risk Assessment with a revision date of October 2010 under Assessment: skin assessments will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Monitoring: staff will maintain a skin alert performing routine skin inspections daily or every other day as needed. Nurses are to be notified to inspect the skin if changes are identified. Under Prevention of Pressure Ulcers General Guidelines: The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. The primary physician came to the facility 9/29/16 and wrote a progress note. There was no time documented on the progress note. It read; (name of resident) developed a right medial beneath the malleolus and extending to the bottom of the foot on 9/24/16. Measurement 5.5 centimeter by 5.0 centimeters by 0.3 centimeters, initial treatment Dermal Wound Cleanser and apply Exuderm but later changed to Hydrogel and cover with Border gauze. He has a flexion contracture and pushes his leg against his booties. He had a previous Peripheral Vascular Laboratory (PVL) 4/2015 with arterial disease of his distal common femoral artery left and right consistent with mild [MEDICAL CONDITION] disease. Repeat study today shows continued arterial disease with mild [MEDICAL CONDITION] disease. He has a decreased dorsalis pedis pulse and a posterior tibial pulse that is more weak. Impression flexion contracture with [MEDICAL CONDITION] disease exacerbating a medial stage II malleolus and sole of foot ulcer. The DON stated no staff member could confirm the physician assessed Resident #7's pressure ulcer while in the facility on 9/29/16 or only viewed nurse's notes and requested PVL reports. The physician did not describe the type of tissue identified in the pressure ulcer during the assessment on 9/29/16 and the same measurements were documented in both assessments. The physician stated the resident pushes against the booties but no action was taken regarding the Prevalon boots. The above findings were shared with the Administrator, Director of Nursing and the Corporate Quality Assurance Nurse by telephone on 9/29/16 at approximately 7:35 p.m. for the pre-exit conference. The Corporate Quality Assurance Nurse stated prevention of pressure injuries is first priority and healing pressure injuries if one develops. The Corporate Quality Assurance Nurse stated it is also the facility's expectation for skin assessments to be completed and documentation of findings of open areas including location, description, tissue type, measurements, drainage, indication of pain, notification of physician and responsible party. The Corporate Quality Assurance Nurse also stated first identification of pressure ulcers with eschar is not desirable. The Corporate Quality Assurance Nurse stated there was a system failure with this resident and the interventions are to train the nurses, use a weekly wound log, identify the cause of the pressure, keep the physician informed and for the physician to assess and help identify interventionsfor pressure injury prevention and management.

Based on clinical record review, observation, facility staff interview, and facility document review, facility staff failed to provide adequate supervision for 3 of 24 residents in the survey sample, (Resident #12, Resident #16, and Resident #17), and failed to provide devices to prevent accidents for 2 of 24 residents in the survey sample, (Resident #7 and Resident #10). 1. Resident #12 sustained a wrist fracture and pelvic fractures after sustaining a fall during a resident to resident altercation after wandering into another resident's room. 2. Resident #16 and Resident #17 were observed in a resident to resident altercation with lack of supervision. 3. The facility staff failed to ensure the safety device to prevent accidents was functioning for Resident #7, the bed alarm. 4. The facility staff failed to ensure the safety devices to prevent accidents was in place for Resident #10, the bed and chair alarm. The findings included: 1. Resident #12 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set - an assessment tool), a quarterly, with an ARD (Assessment Reference Date) of 6/1/15, assessed the resident as moderately cognitively impaired, poor cues, and supervision required. During the survey period, Resident #12 was observed wandering up and down the halls, and into other resident's rooms, but no residents were in the rooms at the time observed. On 8/6/15 a FRI (Facility Reported Incidence - a report that the facility gives to the State Agency when an incident occurs) sent on 1/20/15 was reviewed. The FRI indicated that on 1/16/15 a resident to resident altercation with injury occurred between two residents that lived on the same secured memory unit. The FRI indicated that Resident #12 wandered into Resident #11's room, and Resident #11's pushed Resident #12 which caused a fall. A Resident Incident Report was dated for 1/16/15 at 6:15 p.m The Incident Report read as follows: Incident type: Found on floor Type of Injury: Sprain Location: Resident Room Incident Level: Non-witnessed Property Involved: Other resident Activity at time: Other Incident Reported By: CNA #30 Report prepared by: LPN #30 Narrative of incident and description of injuries: Resident was ambulating in another resident room and was pushed to the floor. Right leg hurts Immediate Action Taken: Ordered X-ray of right knee Resident #12 resided on the Memory Unit, Unit #5. The 'as worked' schedule/assignment sheet for Memory Unit (Unit #5) on the day of the incident, 1/16/15, was reviewed. The assignment sheet indicated that LPN #30 worked on the 3PM-11PM and one CNA worked on the 3PM-11PM shift. The census sheet for 1/16/15 indicated that Unit #5 had 15 residents at the time of the incident. The Risk of Elopement/Wandering Review sheet was reviewed. Resident #12 was assessed for the risk of elopement/wandering on 12/9/14. The assessment noted that Resident #12 ambulated independently, with or without the use of an assistive device (including a wheelchair). The assessment noted that Resident #12 wandered aimlessly or was non-goal-directed (i.e. confused, moves without purpose, may enter others's rooms and explores other's belongings). The assessment noted that Resident #12 had a behavior pattern, goal-directed, or routine that was tied to the resident's past (i.e. worked 3rd shift, taking long walks, or seeking someone they can't find). The clinical record was reviewed and evidenced the following: Resident #12's Physician Recertification report, with a date of examination of 1/16/15, read as follows: Chief Complaint: (Resident #12's name) is a male who is developing dementia and is unable to care for himself. He is admitted at this time for continuing care. He is seen at this time for recertification. HPI (History of Present Illness): The resident is sent for evaluation and monitoring of acute and chronic disease. He has developed impaired cognition and is unable to care for himself. He is apparently had recent behavioral disturbances and continues to wander. There is dementia of unknown etiology, major depression, Vitamin D deficiency, osteoarthritis, and degenerative joint disease. For the interval between November and January 2015, he has developed more agitation. He has an X-ray pending from slipping and falling in (Resident #11's) room and complaining of left leg hurting. The nurse's notes for 1/16/15 read as follows: Resident was pushed by another resident in room, Resident removed and taken to his room. X-ray done on right hip. Tech. (technician) said he could do the right hip, femur, and knee. Call made to Responsible Party, Physician #30, and supervisor notified. A late entry nurse's note dated on 1/20/15 (for 1/16/15) read as follows: Late Entry: Resident was pushed by another resident in room, in which he fell to the floor. Resident in the room said this resident came into his room and he did not want him there. Said he pushed resident and he tripped. (Certified Nurse Assistant) CNA #30 found resident on the floor. Resident is able to walk. Called made to Responsible Party. Emailed Physician #30 and another call made to X-ray company. Assessment made and resident is in no pain. X-ray tech. said he could X-ray the right hip, femur, and right knee. Resident denied vital signs. Resident put in a wheelchair and transferred to bed. Resident showed no abnormal behavior. The X-ray results showed questionable right iliopubic junction fracture and a new order was obtained 1/17/15 to send to the ER (emergency room ). The nurse's note for 1/17/15 read as follows: Resident came back from hospital R/T (related to) fall and c/o (complaints of) pain at 3:30 p.m., BP (blood pressure) at time 138/64, 87- pulse, 18 respirations, continuous BP checks, Q15 (every 15 minutes) vital signs and neurological checks. No new orders from hospital, pelvis complete (X-ray). No acute abnormalities, tolerated schedule medications, ate meal 100%, no ambulation on shift, remain in bed, notice bruising on right hand/arm r/t fall, no c/o of pain. Continuous monitoring for swelling, changed in bed, clean brief, sheets changed, call bell within reach. Physician #30 emailed of final results, and RP notified. The nurse's note for 1/19/15 read as follows: Resident sitting up in wheelchair, alert and orient times 1. Resident's right hand swollen and warm to touch. Resident s/p (status [REDACTED]. MD made aware of right hand swelling, new orders to send resident to ER (emergency room ) for CT (computerized tomography scan) and evaluation. Very difficult to assess for pain at this time, the resident is unable to respond when asked about pain. Resident showed no expressions of pain at this time. RP made aware of sending to ER. The resident was sent to the ER 1/19/15 for right hand swelling. The nurse's note for 1/19/15 at 10:00 p.m., read as follows: Pt. (patient) returned from hospital, CT performed with ABN (abnormal) values, X-ray of right wrist noted sm. (small) fx. (fracture), soft cast applied. Circulation checks WNL (Within Normal Limits) to right hand. N.O. (new order) written to check placement of soft cast and circulation to right hand each shift and prn (as needed), MD emailed and RP aware. The E.D. (Emergency Department) notes, with a visit date of 1/19/15, read as follows: 1/19/15, 16:01 (4:01 p.m.), Patient arrives via transport service from facility with report of fall, seen here recently for same and discharged . Facility staff request CT's as patient is baseline ambulatory with assist and has not been able to ambulate since the fall. Also reports right wrist swelling. 1/19/15, 16:30 (4:30 p.m.), Assumed care of patient from EMS (Emergency Medical Services), patient given busy apron, orders placed on patient, X-ray to the bedside 1/19/15, 18:27 (6:27 p.m.), emergency room Physician has seen and evaluated patient, Ortho cart to bedside for splint. 1/19/15, 18:27 (6:27 p.m.), Patient back to CT. 1/19/15 18:37 (6:37 p.m.), Splint (a device to hold the wrist in place) done and placed on the right wrist. The Emergency Physician's notes/ED Follow Up notes, dated for 1/19/15 at 20:12 (8:12 p.m.), read as follows: Assessment/Differential Diagnosis: [REDACTED]. ED Course/Medical Decision Making: Wrist splinted. Chief Complaint: Patient presents with fall and wrist injury. (Resident #12's name) with PMH (Past Medical History) of advanced dementia who presents to the ED from the facility for reevaluation s/p fall 2 days ago, as he was pushed down by another resident. Per record review, Pt. (patient) was seen here and had a negative pelvic X-Ray). The nursing home has been concerned because pt. usually ambulated with assistance but has not walked since the fall. It is unclear as to whether Pt. fell again today or sustained head trauma with the fall. The history is provided by the nursing home and medical records. The history is limited by the condition of the patient. No language interpreter was used. Physical Exam: Ecchymoses (bruising) to Rt. (right) inner wrist and forearm. Good ROM (Range of Motion) of bilateral hips, flexion, extension, rotation without pain. Pt. is active, mumbles to verbal stimuli, moves all extremities times 4.CT Wrist Complete Right Final Result. Impression: 1. impacted fracture of the distal radius as described above. 2. Widening of the scapholunate space suggesting ligament injury. 3. Severe degenerative change at the first metacarpal joint. Discharge instructions included information about wrist fracture. A splint was applied to the right wrist on 1/19/15 at 6:30 p.m. in the ED with no immediate complications. On 1/26/15 the resident was sent to the ER for CT scans of lower extremties. The nurses note dated for 1/26/15 indicated that the Resident was sent to the ED to have a CT scan completed of the lower extremities. The ED notes dated for 1/26/15 included the following discharge instructions: He has multiple small fractures in his pelvis. He needs to be NO weight bearing and follow up with orthopedics in 2-3 weeks, he can transfer with assistance from bed to chair only. The resident was diagnosed with [REDACTED]. The nurse's notes from the nursing facility, dated for 1/26/15 at 1:00 pm, read as follows: Resident return from hospital at 10:30 p.m. for CT scan, has pelvic fracture, ordered bed rest and slight weight bearing. New order for Tylenol (pain reliever) 325 mg (milligrams) times 2 for pain, emailed Physician, no new orders or response. The Physician's Progress note, with an exam date of 1/27/15 read as follows: S: (Resident #12's name) is a white male who had a fall January 16 and was complaining of left leg pain with difficulty walking. He had X-rays done in-house which showed a right normal knee, right femur, and lateral hip x-ray with no fracture and a right hip x-ray suggesting a ilipubic area suprapubic ramus fracture. He was sent to the emergency room the next day where an x-ray revealed no evidence of a pelvic fracture. He came back to the unit and on the 19th developed a swollen right wrist with continuing leg pain and difficulty ambulating. He was sent back to the ER where he was found to have a swollen right wrist and a right wrist fracture. He was placed in a soft cast and referred to an orthopedic in 1 week. He continued to have difficulty and a CT scan was ordered. As he continued to have pain and inability to walk he was sent back to the emergency roiagnom on [DATE] where a CT scan showed multiple small pelvic fractures at which time he has been referred to an orthopedic in 2 weeks. O (Observation): Lower extremities tender unable to bear weight, Right soft wrist cast with fractured right wrist. A (Assessment): Multiple fractures with small pelvic fractures confirmed by CT scan, Right wrist fracture, Secondary to fall. P (Plan): Continue with orthopedic follow-up, continue with pain control. Further evaluation as necessary. Physical Therapy once able. The clinical record evidenced that Resident #12 had to be transferred using the hoyer lift, since he could not bear weight on his legs. The TAR (Treatment Administration Record) for the month of February 2015 read as follows: 2/1/15 Non-weight bearing, transfer with hoyer lift only to recliner char/Geri chair as tolerated each shift, dx. (diagnosis) hip fracture. The Administration furnished the fall investigation report. The fall investigation report indicated that Resident #12 was hit by Resident #11. The investigation report included an employee/witness statement given by CNA #30. The Employee/Witness statement read as follows: Date 1/16/15, Time: 6:15 p.m., Location of incident: Resident #11 room Statement of Incident/Witness of Incident/Investigators Summary: (Should include when, where, how, why): Walking down the hallway notice the pt. on floor. Study (sic) by the door waiting on the nurse to come back. Pt. set up and then study (sic.) up and try to walk, and I notice something was wrong with his left leg, so I set he (sic) down in the chair until the came and then I got a wheelchair and took him in his room so she could look at him. The investigation report did not include a statement by (Licensed Practical Nurse) LPN #30 that worked the memory unit during that shift. The Administration indicated that the LPN #30 no longer worked there. The investigation report did include a statement from CNA #30. On 8/5/15 at approximately 6:10 p.m., CNA #30 was interviewed. CNA #30 stated, I don't work in locked units often. The surveyor asked if she could could recall anything about the incident that happened on 1/16/15 between the two residents. CNA #30 indicated that it had been so long ago that she did not remember. CNA #30 stated, They usually have one nurse and one CNA, and sometimes a split CNA scheduled. A split CNA works from 3pm-5pm, so that would make it one nurse and two CNAs. The surveyor asked CNA #30, what kind of residents are on this unit? CNA #30 stated, Ones that try to leave, dementia residents. It gets busy, they do a lot of walking, when there's just one CNA, it's kind of hard. There should be at least two CNAs back there, you would need more eyes to supervise. The residents go into other people's stuff. The surveyor asked CNA #30, what if a resident went into another resident's room, and pinched someone's nose, or pulled their hair, and you were in one room and the nurse is in another would you know, and what would you do in that situation? CNA #30 stated, No one would know, unless they would tell you, some could tell you, others couldn't, and I would separate them.? Since the incident, Resident #11 has been moved to another memory unit. Resident #12's care plan was reviewed. The care plan read as follows: Date: 9/16/14, Problem: Inappropriate behavior, resident urinates and defecates in rooms, corners, aggressive behavior, and eating feces. Goals: Resident should have decreased episodes through next review. Approach/Plan: Monitor and intervene to ensure safety as needed, Redirected when noted behaviors. Date: 9/16/14, Problem: Decreased attention span secondary to dementia which limits his participation in activities. Resident wanders around the secured unit in/out of activities, Goal: Resident will be encouraged to attend activity of choice each day and remain at activity for at least 10 minutes as tolerated through next review. Approaches: Give cues and redirection when he is distracted. Date: 9/16/14, Problem: Dementia, Goal: residents wants, needs, and safety will be met while maintaining dignity, Approaches: permit common behaviors, such as hoarding objects or wandering, as long as they are conducted in a safe environment. Problem: Wandering with potential for elopement. Goal: Resident should remain safe with decreased incidence of elopement through next 90 days. Approaches: Allow resident to wander but monitor closely. Date: 3/27/14, Problem: At risk for abuse: Wandering, poor safety awareness, confusion, disorientation, inability to recognize danger. Goals: Resident will remain self. Resident will not infringe on the rights of other residents while exhibiting behaviors (this goal was crossed out on the care plan). Approach/Plan: Monitor resident to ensure that his/her rights are protected, attempt to redirect as needed, ensure that resident has appropriate activities and socialization opportunities. Date: 1/27/15, Problem: Fracture of pelvis, multiple small fracture, Goals: Resident will have no complaints daily and fracture will continue to heal through the next review. Hoyer transfer to geri char only was included but was discontinued. The Administration was made aware of the findings. The administration furnished the Memory Care Unit description. The description read as follows: Admission Criteria: Admission of an individual to the Memory Care Unit will be a comprehensive process. Placement is based upon the [DIAGNOSES REDACTED]. Only those person's diagnosed with [REDACTED]. This [DIAGNOSES REDACTED]. Memory Care: Our committed staff, 100% dedicated to the memory unit, is focused on increasing and maintaining quality of life by minimizing the challenges of daily living. Our unit is small and intimate, allowing our team to work closely with each resident on a personal level. Resident feels, safe, secure, and loved, freeing them from worries and allowing them to live life to the fullest. Standards for Nursing Homes: An up-to-date staffing pattern and staff ratios for the unit is recorded on a daily basis. The staffing pattern will ensure that there is a minimum of one (1) attendant, awake, on duty, and physically located on the unit twenty-four (24) hours per day, seven (7) days per week at all times. 2. Resident #16 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set - an assessment tool), a quarterly, with an ARD (Assessment Reference Date) of 7/9/15, assessed the resident's BIMS (Brief Interview for Mental Status) score as a 6 out of a possible 15 indicating severe cognitive impairment. The MDS assessed the resident as having behaviors present, fluctuates (comes and goes changes in severity). Resident #17 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set - an assessment tool), a quarterly, with an ARD (Assessment Reference Date) of 7/9/15, assessed the resident's BIMS (Brief Interview for Mental Status) score as a 2 out of a possible 15, which means the resident was cognitively impaired. The MDS assessed the resident as having signs of delirium with inattention, and disorganized thinking, with behaviors present, fluctuates (comes and goes changes in severity). On 8/5/15 at 5:00 p.m., one surveyor, one LPN, and one CNA were on the Memory Unit, Unit #5. LPN #31 was in a resident's room, passing medications with the door shut, and CNA #31 was in another resident's room at the other end of the hall. Resident #16 and Resident #17 are roommates. On 8/5/15 at approximately 1:00 p.m., Resident #17 was observed in bed on her back. Two surveyors observed the following: Resident #16 tugged on Resident #17's shirt. Resident #16 tried to sit on Resident #17's bed. Resident #16 pulled on Resident #17's arm, and Resident #17 hit Resident #16 on the back. One surveyor notified CNA #33, and the CNA removed Resident #16 from the room. On 8/5/15, The surveyor observed the following from 5:00 p.m.- 5:15 p.m.: Resident #16 was in the bed on her left side facing the door. Resident #17 was trying to sit on Resident #16's bed. Resident #17 took a phone cord (with no telephone connected, with a frayed end), which was located at the side of the bed, picked it up, proceeded to put it near Resident #17's neck, and then dropped it. Resident #16 pulled on Resident #17's shirt. Resident #17 stated, You have to sit down. Resident #16 pinched Resident #17's nose. Resident #17 put her hand on Resident #16's neck, and then let go, Resident #16 stated, You're choking me (female name). Resident #16 tugged on Resident #17's hair, Resident #17 hit Resident 16's hands. CNA #31 saw Resident #16 near Resident #17, removed the resident, took her to the activity room located across the hall, and gave her a coloring book. CNA #31 was notified of the incident. The surveyor asked CNA #31, where's the other CNA? CNA #31 stated, The other CNA goes to the other unit at 5 p.m. You see the residents are very busy. Resident #16 and Resident #17 are just roommates, and Resident #16 does drift to Resident #17, but I have not observed anything like that before between them. Having more people supervising would help. The surveyor asked CNA #31, If someone is giving medications, and an aide is helping someone else, you wouldn't know if something happened? CNA #31 stated, You're right. LPN #31 was notified of the incident. LPN #31 stated, Usually they do have two CNAs and 1 nurse most of the time back here. It's usually busy between 3-5 p.m., but after dinner they get better. The 'as worked' schedule was reviewed for 8/5/15. One LPN (LPN #31) and one CNA (CNA #31) were on the schedule for the 3-11 p.m. shift. On 8/6/15 at approximately 6:00 p.m., LPN #32 was interviewed. LPN #32 indicated that having more staffing in that unit would definitely help. LPN #32 stated she never observed any negative interactions between Resident #16 and Resident #17. LPN #32 indicated that Resident #16 will display other behaviors when she is agitated such as picking at the material on the doors. On 8/6/15 at approximately 6:00 p.m., the Administration was made aware of the findings. 3. The facility staff failed to ensure the safety device to prevent accidents was functioning for Resident #7, the bed alarm. Resident #7 was a [AGE] year old admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The current MDS a quarterly (Minimum Data Set) with an assessment reference date of 7/21/15 coded the resident as scoring a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severely impaired decision making skills. The resident was wheelchair bound. Resident #7 required extensive assistance of one staff for bed mobility and two staff for transfers. The clinical record evidenced the resident had a history of [REDACTED]. Review of the clinical record evidenced a physician order [REDACTED]. This order was also noted on the treatment administration record (TAR). On 8/4/15 at 4:00 pm, 8/5/15 at 9:15 am, and 8/6/15 at 3:30 pm, the resident was observed asleep in bed. During each of these observations the bed sensor alarm box was in the off position. The unit manager was asked to examine this finding on 8/6/15 at 3:30 pm. She entered the resident's room and stated, It was in the off position .the battery probably needs replacement or the positioning of the sensor pad needs to be adjusted .I usually round every morning to make sure all the fall equipment is working. The evening shift nurse initialed on the TAR for 8/4/15 that the bed sensor alarm was on the bed, and that placement and function of the sensor alarm were checked that shift. The above findings was shared with the administrator, the interim DON and the corporate nurse during the pre-exit meeting held on 8/6/15. No additional information was provided for review prior to exit. 4. The facility staff failed to ensure the safety devices to prevent accidents were in place for Resident #10, the bed alarm and chair alarm. Resident #10 a [AGE] year old was re-admitted to the facility on [DATE] with a hip fracture status [REDACTED]. refers to a surgical procedure to fix a severe bone fracture, or break) after rolling out of bed at the facility on 2/15/15. The quarterly MDS (Minimum Data Set) with an assessment reference date of 3/9/15 coded the resident as scoring a 00 out of a possible 15 on the Brief Interview for Mental Status (BIMS), this indicated the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility and transfers. The clinical record evidenced physician admission orders [REDACTED]. There was no order in the clinical record to discontinue either the chair or bed alarm when reviewed on 8/6/15. The above orders were noted on the August 2015 TAR (treatment administration record). The TAR evidenced initialed documentation by the nurses on day shift, evening shift and night shift that from 8/4/15 through 8/6/15 the bed and chair sensor alarms were in place and checked. During the survey days of 8/4/15 at 4:15 pm, 8/5/15 at 9:30 am, 10:15 am, 6:15 pm and 8/6/15 at 9:25 am, the resident was observed either in bed or in the geri-chair at various locations such as the resident room and activity room. A sensor pad was observed under the bottom sheet on the resident's bed each day of survey. There was no attached alarm box. Each of the above observations failed to evidence a sensor alarm was in place to either the bed or chair as ordered. On 8/6/15 the licensed practical nurse (nurse #21) and the certified nurse aide (CNA #20) assigned to care for Resident #10 were interviewed at 9:25 am. The nurse was asked if the resident was to have a bed sensor alarm and chair alarm in use. She stated, He/she no longer needs the chair alarm. She indicated the resident was to have a bed alarm. While in the resident room the nurse and aide both looked for the bed sensor alarm. The bed sensor pad was noted but the alarm box was not found. The CNA indicated there was a care plan for each resident for the aides to review that would have what safety devices where to be in place. A review of this document evidenced the resident was to have both the bed and chair alarms in place. The comprehensive plan of care originated on 3/11/5 and revised on 6/4/15 identified the resident was at risk for falls. The goal was the resident falls should decrease through the next review. Approaches to obtain and maintain the goal was for a bed alarm. The chair alarm was not included as an approach. On 8/6/15 at 9:55 am, the unit one manager was interviewed. The above findings was shared. She indicated it was the CNA and nurses responsibility each shift to ensure the safety devices were in place, stating,I depend on the nurses and CNAs to make sure they are in place. In response to the nurses signing that these safety devices were in place when in fact they were not, she stated, If the nurses are signing it's there .the expectation is that they are there. The above findings was shared with the administrator, the interim DON and the corporate nurse during the pre-exit meeting held on 8/6/15. No additional information was provided for review prior to exit.

Based on staff interviews, clinical record review and facility staff record reviews the facility staff failed to recognize the advance directives for 1 of 24 residents in the survey sample, Resident #24, and failed to ensure there were CPR (cardiopulmonary resuscitation) certified staff on duty for each shift. 1. Resident #24's closed record review evidenced an Advanced Directives Discussion Document dated [DATE]. The document indicated Resident #24's wishes were for cardiopulmonary resuscitation (CPR) in the event of respiratory or [MEDICAL CONDITION]. The resident was found not breathing and without a pulse on [DATE] at 6 am. The staff did not initiate CPR. 2. The facility failed to ensure there were CPR certified staff on duty for each shift. The findings included: 1. Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. The resident continued to have some respiratory distress and low oxygen levels secondary to [MEDICAL CONDITIONS] (fluid in the lungs) and was treated with [MEDICATION NAME] (a diuretic). The resident stabilized and was discharged back to the facility on [DATE]. The significant change MDS with an assessment reference date of [DATE] assessed the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident's cognition was intact. The Advanced Directives Discussion Document dated [DATE], evidenced Resident #24's wishes were for cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The admission physician orders [REDACTED]. The physician History and Physical (H&P) conducted on [DATE] also documented the resident was a Full Code. Inside the closed record was a Yellow Durable Do Not Resuscitate Order dated [DATE], that preceded the current code status. Nurses Notes dated [DATE] read, @ 0600 (at 6:00 am) went into patient's room to do accu (check sign) (blood sugar check) pt (patient) found not breathing. CNA (certified nurse aide) last (sign for changed) pt @ 4 am. Brother notified & will call facility back with funeral home info (information). MD notified (physician name) on call. The interim director of nursing (DON) was interviewed on [DATE] at 12:25 pm. She was asked to review Resident #24's closed record and determine the resident's code status. After reviewing documents she stated, It's conflicting .I have a DNR order signed for 2011, there is an Advanced Directive signed in 2013, the H&P (history and physical) and the physician order [REDACTED]. He/she was a full code. She stated the yellow DNR sheet should have been removed from the resident's record once the resident's code status changed. This action would have clearly communicated to the nursing staff the resident's current code status. After reviewing the nurses notes for [DATE] the DON recognized that CPR was not performed. When asked should CPR have been performed? She stated, Yes. The previous months medication administration records (MAR's) clearly listed on the bottom of each page that the resident was a Full Code. Further review evidenced there was no pronouncing of death by a registered nurse (RN) in the record for Resident #24. The nurse (licensed practical nurse #20) who was assigned to care for Resident #24 on [DATE] was interviewed on [DATE] at 1:00 pm via a phone conversation. She was asked to state the event on [DATE] surrounding Resident #24's death. She stated she went to the resident's room to obtain a blood sugar at 6 am. She noted the resident was not breathing. She stated, I tried to wake (him/her) up, I shook (him/her) and called (his/her) name, (he/she) was expired. He/she was a no code (DNR). The nurse stated, He/she did not have a pulse, I checked his/her jugular (neck artery). When asked, How did you know the resident was a DNR? She replied, I remembered he/she was a DNR from making copies of his records for doctor appointments and seeing the yellow (DNR) form. A second interview was conducted in person with LPN #20 later in the day at 2:20 pm. The nurse reiterated the resident was a DNR. She stated that she was very familiar with Resident #24's clinical record as she reviewed it frequently during nightly chart checks. The nurse was shown the Advance Directives Discussion Document dated [DATE], along with the physician order [REDACTED]. She stated the yellow DNR form should have been discarded when the resident's code status was revised. When asked, What would you have done differently? She stated, I would have started CPR. LPN #20 stated she called and informed the RN (registered nurse) supervisor, and asked the RN floor nurse to assess the resident. There was no documentation of the assessment or pronouncement of death in the clinical record from the RN supervisor or RN #2 floor nurse. During both interviews with LPN #20 and RN #2 did not indicate there was evidence of obvious signs of irreversible death (e.g rigor mortis) for Resident #24 during her initial finding/ assessment of the resident at 6 am. The facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised 2011 read, in part: 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 8. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; or b. There is obvious signs of irreversible death (e.g rigor mortis). Rigor Mortis-At the time of death, a condition called primary flaccidity occurs. Following this, the muscles stiffen in rigor mortis. All muscles in the body are affected. Starting between two to six hours following death, rigor mortis begins with the eyelids, neck, and jaw. The sequence may be due to different lactic acid levels among different muscles, which is directly related to the difference in glycogen levels and different types of muscle fibers. Rigor mortis then spreads to the other muscles within the next four to six hours, including the internal organs. The onset of rigor mortis is affected by the individual's age, sex, physical condition, and muscular build. www.nih.gov The Record of Death was incomplete and read: date of death : February 22, 2015 Time: 0600 am. Principle Cause of Death: [MEDICAL CONDITION]. Death Certificate signed by: blank. The line and date for the physicians signature was blank. The section for the nursing staff indicating who transcribed the information was also blank. The above findings was shared with the administrator, the interim DON and the corporate nurse during the pre-exit meeting held on [DATE]. No additional information was provided for review prior to exit. 2 . During the review of the most recent two week 'as worked' schedule ([DATE] through [DATE]) a comparison was made between the schedule and the staffing of CPR (cardiopulmonary resuscitation) certified staff for each shift. The day shift (7 am to 3 pm) did not have CPR certified staff for [DATE] and [DATE]. The evening shift (3 pm to 11 pm) did not have CPR certified staff for [DATE], [DATE], [DATE] and [DATE]. The night shift (11 pm to 7 am) did not have CPR coverage for [DATE], [DATE], [DATE], and [DATE] through [DATE]. This information was provided to the facility Administrator and acting Director of Nursing on [DATE] at 5:30 pm. They were requested to provide any additional information none was provided for review prior to exit.

Based on staff interviews, clinical record review and facility document review the facility staff failed to provide CPR for 1 of 24 residents in the survey sample during an acute change in condition, Resident #24. Resident #24's closed record review evidenced an Advanced Directives Discussion Document dated [DATE]. The document evidenced Resident #24's wishes were for cardiopulmonary resuscitation (CPR). The resident was found not breathing and without a pulse on [DATE] at 6 am. The staff did not initiate CPR. The findings included: Resident #24 was [AGE] year old readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. The resident continued to have some respiratory distress and low oxygen levels secondary to [MEDICAL CONDITIONS] (fluid in the lungs) and was treated with [MEDICATION NAME] (a diuretic). The resident stabilized and was discharged back to the facility on [DATE]. The significant change MDS with an assessment reference date of [DATE] assessed the resident as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident's cognition was intact. An Advanced Directives Discussion Document dated [DATE], evidenced Resident #24's wishes were for cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The admission physician orders [REDACTED]. The physician History and Physical (H&P) conducted on [DATE] also documented the resident was a Full Code. Inside the closed record was a Yellow Durable Do Not Resuscitate Order dated [DATE], that preceded the current code status. Nurses Notes dated [DATE] read, @ 0600 (at 6:00 am) went into patient's room to do accu (check sign) (blood sugar check) pt (patient) found not breathing. CNA (certified nurse aide) last (sign for changed) pt @ 4 am. Brother notified & will call facility back with funeral home info (information). MD notified (physician name) on call. The interim director of nursing (DON) was interviewed on [DATE] at 12:25 pm. She was asked to review Resident #24's closed record and determine the resident's code status. After reviewing documents she stated, It's conflicting .I have a DNR order signed for 2011, there is an Advanced Directives signed in 2013, the H&P (history and physical) and the physician order [REDACTED].She stated the yellow DNR sheet should have been removed from the resident's record once the resident's code status changed. Stating this action would have clearly communicated to the nursing staff the resident's current code status. After reviewing the nurses notes for [DATE] the DON recognized that CPR was not performed. When asked should CPR have been performed? She stated, Yes. The previous months medication administration records (MARs) clearly listed on the bottom of each page that the resident was a Full Code. Further review evidenced there was no assessment or pronouncement of death by a registered nurse (RN) in the record for Resident #24. The nurse (licensed practical nurse #20) who was assigned to care for Resident #24 on [DATE] was interviewed on [DATE] at 1:00 pm via a phone conversation. She was asked to state the event on [DATE] surrounding Resident #24's death. She stated she went to the resident's room to obtain a blood sugar at 6 am. She noted the resident was not breathing. She stated, I tried to wake (him/her) up, I shook (him/her) and called (his/her) name, (he/she) was expired. He/she was a no code (DNR). The nurse stated, He/she did not have a pulse, I checked his/her jugular (neck artery). When asked, How did you know the resident was a DNR? She replied, I remembered he/she was a DNR from making copies of his records for doctor appointments and seeing the yellow (DNR) form. A second interview was conducted in person with LPN #20 at 2:20 pm. The nurse reiterated the resident was a DNR. She stated that she was very familiar with Resident #24's clinical record as she reviewed it frequently during nightly chart checks. The nurse was shown the Advance Directives Discussion Document dated [DATE], along with the physician order [REDACTED]. She stated the yellow DNR form should have been discarded when the resident's code status was revised. When asked, What would you have done differently? She stated, I would have started CPR. LPN #20 stated she called and informed the RN (registered nurse) supervisor, and asked the RN floor nurse to assess the resident. There was no documentation of the assessment or pronouncement of death in the clinical record from the RN supervisor or RN #2 floor nurse. Both interviews with LPN #20 and RN #2 failed to indicate there was evidence of obvious signs of irreversible death (e.g. rigor mortis) for Resident #24 during her initial finding/ assessment of the resident at 6 am. The facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised 2011 read, in part: 2. Sudden [MEDICAL CONDITION] (SCA) is a leading cause of death in adults. 5. Depending on the underlying cause, the chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. 7. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 8. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (basic life support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and /or external defibrillation exists for that individual; or b. There is obvious signs of irreversible death (e.g. rigor mortis). Rigor Mortis-At the time of death, a condition called primary flaccidity occurs. Following this, the muscles stiffen in rigor mortis. All muscles in the body are affected. Starting between two to six hours following death, rigor mortis begins with the eyelids, neck, and jaw. The sequence may be due to different lactic acid levels among different muscles, which is directly related to the difference in glycogen levels and different types of muscle fibers. Rigor mortis then spreads to the other muscles within the next four to six hours, including the internal organs. The onset of rigor mortis is affected by the individual's age, sex, physical condition, and muscular build. www.nih.gov The Record of Death was incomplete and read: date of death [DATE] Time: 0600 am. Principle Cause of Death: [MEDICAL CONDITION]. Death Certificate signed by: blank. The line and date for the physicians signature was blank. The section for the nursing staff indicating who transcribed the information was also blank. The above findings was shared with the administrator, the interim DON and the corporate nurse during the pre-exit meeting held on [DATE]. No additional information was provided for review prior to exit.

Based on observations, clinical record review, staff and resident interview and facility documentation, the facility failed to ensure assistance needs and safe practices were implemented during a transfer to prevent accidents for 1 of 24 residents (Resident #1) in the survey sample. Resident #1 was not transferred with the necessary staff assistance, nor was safety precautions implemented to prevent a fracture. The findings include: Resident #1 was admitted to the nursing facility on 2/12/14 with status [REDACTED].A.C. (a device that promotes wound healing through Negative Pressure Wound Therapy*), abnormal gait, carbuncle of foot, history of [DIAGNOSES REDACTED], high blood pressure, diabetes mellitus (DM), coronary artery disease (CAD) and right hip arthritis. The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 with a score of 15 (cognitively intact with the skills needed for daily decision making) and no problems with communication to include hearing and speech. She was not coded with any mood or behavioral symptoms. She was assessed to require extensive assistance from two staff for bed mobility, transfers from one surface to another. She was not able to balance herself without staff assistance. The resident was coded with Range of Motion limitation in lower extremity on one side. There were no coded impairments in the bilateral upper extremities. Resident #1 was coded always incontinent of bowel and bladder. She was coded with fall history 2-6 months before admission. The resident was assessed with [REDACTED].** upon admission, two unstageable pressure ulcers ** with necrotic tissue. The care plan dated 3/4/14 identified Resident #1 with a potential for fractures and falls related to osteoporosis. The goal the staff set for the resident was that she would have no complications related to osteoporosis. Some of the interventions the staff set for the resident to accomplish this goal included assist with Activities of Daily Living (ADL) and transfers as needed, avoid jarring and pulling movements. The care plan did not specify two staff were needed to safely transfer the resident with a mechanical lift. The care plan also identified the resident had pressure ulcers to the left heel and a surgical debridement to left anterior foot with a wound V.A.C., suspected deep tissue injury to left bunion. The care plan indicated boots were applied to bilateral heels. The Fall Risk Evaluation dated 2/13/14 scored Resident #1 with an 18 (high risk for falls=10 or greater). On 7/15/14 at 11:30 AM, Resident #1 was observed in bed watching television. A fracture boot secured with Velcro straps was observed on the left leg that encompassed the portion of the leg below the knee and included the foot, heel and ankle. A closer look revealed the leg was padded with ABD (abdominal) pads inside the boot. A Prevalon (brand name) soft boot secured with Velcro straps was observed on the right leg that encompassed the portion of the leg below the knee that included the foot, heel and ankle. On 7/15/14 at 1:30 PM, an interview was conducted Resident #1. She stated she had fallen at home in October 2013, and lay on the floor for three days and developed a pressure ulcer on the top of her left foot. She also suffered a femur fracture of the left leg which was surgically repaired and had successfully healed. She said prior to the fall she lived on her own and ambulated using a walker or a cane. She also drove a car to and from the store. She stated she was at another nursing facility to convalesce after the fall and developed a left heel ulcer. She stated, "I came here for wound healing of the top of my left foot and the heel. I was to go home after that, but since I fractured the lower part of the left leg that will delay me for my discharge home." The resident had physician's orders [REDACTED].A.C. to left ankle and to protect heels from pressure. On 2/27/14 there were physician's orders [REDACTED]. During the aforementioned interview with Resident #1, she was asked how she obtained the recent fracture of her left leg, to which she stated, "Sometime during the first part of March of this year, the aide came in to transfer me by herself to the wheelchair from the bed and kept the boots on both feet. Now know that I also had a wound machine with tubing and a pump attached to the top of my left leg. She didn't even worry about that, but dragged it along during the transfer. I wasn't able to plant my good side (right side) on the floor because she kept the boot on my right foot. I could not help her at all. She did not even use the blue belt around my body that time. When we moved from the bed to the chair, the Velcro from one of the boots attached itself to the other boot and twisted my leg and she (the aide) roughly slung me over into the chair. I am very small and she took me by the waist and under my arm and fully moved me; it hurt too. As she (the aide) did that, my leg also hit the bed frame or something hard on the way. I said a curse word because the pain of that hit was excruciating!" When asked how she was being transferred prior to the incident; she said, "They were transferring me with one staff, but used the blue belt around my waist. They would take the boots off so I would not slip. They needed two people to move me because I am not steady and I had that apparatus on my left leg (referring to the wound V.A.C. and pump). It was an accident waiting to happen. Everyone is on a schedule and have to hurry and get everything done." An incident report dated 3/6/14 indicated the staff reported the resident complained of pain to the left lower leg and knee after transfer by Certified Nursing Assistant (CNA#3) from the bed to the wheelchair on the same day at 1:30 PM. The report indicated upon assessment, swelling and pain was noted to the left lower extremity. The supervisor, physician and responsible party (RP) were notified. The physician ordered an X-ray of the left extremity and to have the resident sent out to the Emergency Department (ED) for further evaluation. The ED evaluation and X-Ray results dated 3/6/14 revealed "Acute (new and sudden) non-displaced (broken, but still in place) and incomplete fracture at the anterior (top) tibial (shinbone-larger of the two bones of leg below the knee) metaphysis (wide portion near growth plates)." When the resident arrived at the ED on 3/6/14 at 9:03 PM, she told the ED staff she was being transferred earlier that day by a single man transport when her leg was banged. According to the ED records, the wound V.A.C. was in place on the left leg. The left lower leg was positive for bruising and swelling and the resident was unable to move it. The CNA (#3) that improperly transferred the resident on 3/6/14 was no longer an employee of the nursing facility since June 2014. On 7/16/14 at 10:00 AM, an interview was conducted with Unit II Nurse Manager. She stated that the facility was a "No Lift" facility which meant the residents are able to ambulate and transfer with or without assistance by not physically lifting them; otherwise they use a mechanical lift for total lifting or utilize the Sit-to-stand lift. She said Resident #1 should be total with 2 person assist totally lifted with the mechanical lift for her safety. She stated the Certified Nursing Assistant (CNA) care sheet indicated the resident was a Hoya lift for transfers with the assistance of 2. On 7/16/14 at 10:55 AM, an interview was conducted with the Wound Care Nurse. She stated Resident #1 was admitted with the wound V.A.C. on the top of her left foot and an unstageable heel ulcer. She said the wound V.A.C. was discontinued on 5/2/14 and the anterior ulcer on the top of the left foot was completely healed. She said Prevalon boots were applied to both feet shortly after the resident's admission. She said the resident did not stand for her and was non weight bearing on the left side completely. She stated she would find it difficult for anyone to transfer her in and out of bed with a wound V.A.C., the V.A.C. pump and bilateral boots on her feet unless they used the total mechanical lift. She stated it was the facility's policy to not lift residents totally, but to use the mechanical lift or the sit-to-stand. She stated a minimum of two people are required at all times if a total lift was used for transfers. The Rehabilitation Director and Occupational Therapist (OT) were interviewed on 7/16/14 at 11:25 AM. They stated when the resident was admitted she was non weight bearing on the left extremity. They stated the facility was a "Non lift facility" and the safest way to transfer the resident was with the total lift and 2 person assist. They stated one person would hold the leg and any equipment, wound V.A.C. and pump when the resident had one, and one person would operate the lift. They said, "We don't know how one person could have safely transferred the resident." They stated since the wound V.A.C. was discontinued, the resident still required 2 person assist using the mechanical lift; one person holding the resident and her leg and the other person operating the lift. During the interview, the Rehabilitation Director and the OT said the resident fractured her leg in March 2014 during an improper transfer from one staff and currently had a fracture boot on the left leg, but the wound V.A.C. was gone and the resident had a Prevalon boot in place on the right heel/foot. They stated the therapy department removed the right Prevalon boot only to stand the resident and pivot her between the parallel bars for support with two therapy staff persons; the left fracture boot remained in place during sessions. They stated since 6/18/14 they (therapy department) also transferred the resident with the sliding board to the wheelchair and back to take her to therapy late afternoons and she is not lifted. They stated she was able to propel herself in the wheelchair. On 7/16/14 at 12:00 PM, an interview was conducted with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON). They verified the resident was admitted with a wound V.A.C. on the left anterior foot and had orders for Prevalon boots shortly after being admitted to the facility. They also stated the resident was non weight bearing on the left lower extremity due to the heel ulcer and the anterior wound with wound V.A.C. and pump. They stated on 3/6/14 Resident #1 got tangled up with the wound V.A.C. and the Velcro straps during a transfer by one staff from the bed to the chair, hit her leg and sustained a tibial fracture. The Administrator stated the facility was a "Non-lift" facility which meant, "People are not transferred, when there is a need to totally lift them, without mechanical devices." The Rehabilitation Director joined the aforementioned interview at 12:30 PM. She stated her professional opinion was that the safest way to have transferred the resident was with 2 person assist and the mechanical lift. She stated, "You would never ever transfer anyone without a transfer belt". Resident #1 had current orders for the total lift for transfers as a safety order. The DON stated, "Looking back in retrospect, the safest way to have transferred the resident was with two staff and the Hoya (mechanical lift) lift. It is also our policy to use two staff when using the Hoya." The DON stated she had at least four C.N.A.'s that could describe how they transferred the resident. As each one entered the room, they all stated they had never transferred the resident. C.N.A. #1 stated she did not get the resident up on her shift because the therapy staff got her up to take her to therapy late afternoon and she was up until sometime after dinner, if she chose to stay up. She stated the therapy department was using the sliding board now, but if she had to get the resident up she would use the Hoya lift and another nursing staff. The ADON stated she did some random training on transfers after the incident occurred on 3/7/14, but did not make the training mandatory for all licensed and certified staff. The CNA (#3) that transferred the resident on 3/6/14 was the last name on the inservice sign in sheet. The employee signature was visibly different than on some of her signed employee documents in her employee file. On 7/17/14 at 10:00 AM, the DON stated CNA #3's name was last on the list because she personally trained her in her office. She stated during the training CNA #3 had a family emergency and had to leave suddenly and did not sign the inservice sign sheet, so she signed for her, which explained why the signatures were different. When asked why she did not sign when she returned, the DON stated, "Honestly, I forgot to ask her." On 7/17/14 at 10:30 AM, the Administrator stated the legal procedure was to indicate on the education sign in sheet, the person's name and indicate you signed for the person. The problem with improper transfers was not monitored throughout the nursing units, nor was it addressed through the Quality Assurance process, in addition the facility failed to make the transfer training mandatory by all nursing staff. One of the Unit II charge nurses, LPN (licensed practical nurse) #4 was interviewed on 7/17/14 at 2:25 PM. She stated she would have never transferred any resident without a transfer belt, or one that had a wound V.A.C on their leg and Prevalon boots to both of them. She stated, "That is ridiculous, you just set yourself up for an accident. Get the assistance and or the lift device you need and do it right!" On 7/16/14 at 1:45 PM, the MDS Coordinator was interviewed about the residents MDS assessments dated: 3/14/14, a 30 day assessment, 3/21/14 change of therapy assessment and 3/31/14 end of therapy assessment and the most recent quarterly MDS assessment dated [DATE]. All of these assessments coded the resident to require extensive assistance from 1 staff for transfers. Based on the orders to use the Hoya Lift for transfers that required 2 persons per facility policy, these assessments were inaccurate. The MDS Coordinator stated she obtained her information from the Activities of Daily Living TheraStat Data sheets that the CNAs fill out for the time period of the aforementioned assessments. She stated they were filled out incorrectly or the staff was actually transferring the resident using one person. She said the facility policy for Hoya transfers required 2 person assist. The CNA care sheet indicated the resident was a Hoya lift with the assist of 2 staff. There were specific orders dated 3/6/14 to current for Hoya lift with all transfers. The Treatment Administration Record (TAR) from 3/6/14 to current indicated the staff was signing off on the 7/3, 3/11 and 11/7 shift they were using the Hoya lift. The MDS coordinator stated she would have to do some corrections. The facility's policy and procedure entitled: Safe lifting and Movement of Residents dated 2/2013 indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Staff will documents resident transferring and lifting need in the care plan. The facility's policy and procedure entitled Lifting Machine, using a portable dated 2/2014 indicated the care plan would be reviewed to assess for any special needs of the resident. Two (2) nursing assistants are required to perform lifting with a manual lifting device. Complaint deficiency References: * V.A.C. Therapy promotes wound healing through Negative Pressure Wound Therapy (NPWT). By delivering negative pressure (a vacuum) at the wound site through a patented dressing, this helps draw wound edges together, remove infectious materials and actively promote granulation. (www.kci1.com/KCI1/vactherapy). ** Stage II pressure ulcer is Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Unstageable pressure ulcer: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. This information was obtained from the website: <http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/>