Every finding on record at Bridgeport Medical Lodge

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 (rooms [ROOM NUMBERS]) of 9 rooms reviewed for resident rights: The ceiling vents in rooms [ROOM NUMBERS] had a black solid wet substance on them. These failures placed residents at risk for an unsafe environment and could place residents at risk for decreased quality of life. Findings Included:Observation on 08/06/26 at 1:15 PM revealed a black solid wet substance on the air vents in rooms [ROOM NUMBERS]. Residents were unable to be interviewed due to disease process and cognition level. Interview on 08/06/26 at 2:08 PM with The Maintenance Director revealed that he knew the air vents in rooms [ROOM NUMBERS] had a black solid wet substance on them and needed to be cleaned. He stated that he was behind on cleaning the vents because he had been without a maintenance assistant for about three weeks. The Maintenance Director also revealed that he cleaned the air vents in residents' rooms about once a month normally. The Maintenance Director stated that he did not keep a cleaning schedule on the vents in the facility. He stated that he had not received any complaints about the residents' vents. The Maintenance Director stated that if the air vents were not cleaned regularly, it could affect the quality of the air that the residents breathe. He stated that if he fell behind in cleaning the vents or observed cigarette butts on the ground, he should report it to the Administrator. An interview on 08/06/26 at 3:45 PM with LVN A, who was one of the two nurses who worked the 6:00 AM to 6:00 PM shift, revealed t that she had not noticed the ceiling vents in rooms [ROOM NUMBERS] had a black substance on them. LVN A stated that she thought it was housekeeping's responsibility to clean the vents. LVN A stated she had not reported the vents to housekeeping or maintenance to be cleaned. LVN A stated it was everyone's responsibility to report unsanitary conditions in residents' rooms. LVN A stated that the black solid wet substance on the ceiling air vents should be cleaned to prevent respiratory issues for residents. An interview on 08/06/26 at 4:03 PM with the Administrator by telephone revealed that it was all the staff's responsibility to report unsanitary conditions to him or their department head. The Administrator also revealed that the vents should be cleaned regularly throughout the building by maintenance to prevent bacteria growth in them and ensure that they do not turn into black mold that could cause sickness and disease. The Administrator also stated that the vents should be cleaned because something could get loose and fall to the ground. The Administrator stated that no one had reported dirty vents to him. Record Review of Departmental (Maintenance) - Plumbing, HVAC and Related Systems, revised 06/11, reflected: The purpose of this procedure is to guide the sanitary handling of the plumbing, heating, ventilation, air conditioning, and related systems within the facility:.14. Clean air vents and air handling units at least annually.

Based on observation, interview, and record review, the facility failed to establish policies regarding smoking areas, and smoking safety for 1 of 2 smoking areas. The non-smoking sitting area outside the secured unit had 2 cigarette butts on the plastic trash can lid and one cigarette butt lying on the ground immediately outside the door to the secured unit. These failures could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment and possible fires at the facility.Observation on 08/06/26 at 1:08 PM revealed an outside sitting area that was accessible to the secured unit. The outside sitting area was also observed to be accessible from another hallway that was not the secured unit by other residents and staff. This outside seating area had a No Smoking sign posted and was visible outside the door and hanging on the building. Observation of the trash can in the sitting area revealed two cigarette butts that were extinguished on the plastic lid of the trash can and one cigarette butt lying on the ground outside the door to the secured unit. Observation and interview on 08/06/26 at 2:08 PM with the Maintenance Director revealed two cigarette butts on the plastic trash can lid outside the secured unit's door and another cigarette butt on the ground outside the door. The Maintenance Director stated that he changed the trash can liners every two days because not many people used the trash can. The Maintenance Director stated that they could have only been there since the previous day. The Maintenance Director revealed that there were two outside sitting areas. He stated there was one smoking area and this a non-smoking area. The Maintenance Director stated no one should smoke in that area per the facility's smoking policy. He also revealed he had not seen any residents on the secured unit smoke in the area, he was unaware this had occurred in the last two days, and he had not witnessed any employees smoking in the non-smoking area while he was working. He stated if residents were smoking in this area, it meant that they were possibly unsupervised and this was against the facility's smoking policy. He stated if residents, staff, or families disposed of cigarettes improperly, they could possibly catch something on fire. An interview on 08/06/26 at 3:45 PM with LVN A, who was one of the two nurses who work the 6:00 AM to 6:00 PM shift, revealed there were no smokers in the secured unit at the facility. LVN A stated that she had not witnessed any residents or staff smoking in the sitting area (non-smoking area) outside the secured unit. LVN A stated that if she saw a resident smoking in the non-smoking sitting area, she would report it to their nurse. LVN A also stated if she saw a staff member smoking in the non-smoking outside sitting area, she would report it to the ADON. LVN A stated that the facility policy stated to only smoke in the designated outside smoking area. LVN A also revealed that it was everyone's responsibility to ensure the policy was followed and reported it to the Administrator if they saw someone not following the facility policy. LVN A stated if the facility policy was not followed, the facility could have accidental fires and residents could accidentally burn themselves. An interview on 08/06/26 at 4:03 PM with the Administrator by telephone revealed that it was his responsibility to ensure that facility policies were followed. The Administrator stated he was unsure who was responsible for the cigarette butts in the non-smoking area, and no one had reported seeing someone smoking in the non-smoking area to him. He stated however, he felt it was probably the temporary nurse staffing agency because the facility staff and residents knew the smoking policy. The Administrator revealed the facility smoking policy stated that residents should only smoke in the smoking area at the designated times to ensure that they were supervised to prevent residents from being burned and ensure that they do not throw their cigarette butts on the ground which could cause a fire that would harm the whole facility. Record Review of Smoking Policy - Residents, revised date 03/08/23, reflected: This facility should establish and maintain safe resident smoking practices:.2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building.

Based on observation, interview and record review, the facility failed to provide safe and secured storage of drugs and biologicals by not keeping medication in locked compartments, for 2 of 8 carts reviewed for medication storage. The facility also failed to label drugs and biologicals in accordance with currently accepted professional principle by not labeling opened dates on 22 of 25 insulin pens reviewed for medication labeling. _LVN A failed to lock medication cart when the cart was not in use. _Treatment cart was left unlocked when not in use._22 of 25 insulin pens were not labeled with an open date.These failures could result in drug diversion, medication ineffectiveness, adverse reactions to residents, and overdosing to residents. Findings includedAn observation on [DATE] at 5:30AM revealed medication cart for the 200 hall was left unattended and unlocked at the nurses' station. There was also a treatment cart that was left unattended and unlocked, out of view, behind the nurses' station. There were 3 residents sitting by the nurses' station. Inside 200 hall medication cart were 7 insulin pens. They were not labeled with an open date. There were labels on the pen caps instructing to discard after 28 days.An observation on [DATE] at 5:48AM revealed 9 insulin pens in the 500 hall medication cart were not dated with an open date, 4 insulin pens in 600 hall medication cart without an open date. All insulin pens were labeled with instruction to discard after 28 days of opening.An observation on [DATE] at 6:00AM revealed 2 out of 3 insulin pens in the 100 hall medication cart were not dated with an open date. All insulin pens were labeled with instruction to discard after 28 days of opening. In an interview on [DATE] at 5:35AM with LVN A, he stated that he was in charge of 200 hall medication cart. He stated he left briefly to change the trash bag of another cart he had. He stated all carts should remain locked when they were not in use and they were out of sight. He stated the risk of carts being left unlocked included residents getting ahold of medications which could cause adverse reactions or overdosing. LVN A also identified an insulin pen he used to administer insulin to Resident #1 in 200 hall medication cart. He stated he was unsure why the insulin pens were not labeled. He stated once an insulin pen was opened, it could be used for 28 days before it had to be discarded. He stated he forgot to check for opened dates on the insulin pens. He stated the risk of administering insulin without knowing an opened date included ineffectiveness, hyperglycemia (high blood sugar). In an interview with LVN B on [DATE] at 5:48AM, she stated she had 500 and 600 hall medication carts. She stated all carts should be always locked when they were not in use. She stated the treatment cart was shared among night shift nurses and she was unsure who left it unlocked. She stated she was not aware it was left unlocked. She stated residents could get ahold of medications which could result in allergic reactions, overdosing. She stated she used 1 out of 9 pens to administer insulin to Resident #2. She stated she did not check for opened dates on the pens. She stated the risk of giving insulin without an opened date included potentially giving expired insulin to residents which could result in ineffectiveness of medication. She stated all undated insulin should be disposed. In an interview with RN C on [DATE] at 6:00AM, she stated she had the 100 hall medication cart. She stated she did not notice 2 of 3 insulin pens were not labeled. She stated the risk of giving insulin without knowing the opened date included ineffectiveness of medication. She also stated all medication and treatment carts should always be kept locked when not in use to prevent unauthorized access to medication.In an interview with the DON on [DATE] at 6:44AM, she stated she expected her staff to label insulin pens with an opened date when they were in use. She stated the nurses had a checklist they needed to complete daily which included dating insulin pens. She stated the risk of not dating insulin pens included medication ineffectiveness which could result in hyperglycemia. The last in-service regarding labeling medication was done on [DATE]. The DON also stated all nurses should lock carts when they were not in use. She stated regardless of the shifts, all carts should always be kept locked when they were unattended. She reminded all nurses daily to lock their carts and if she saw an unlocked cart she would lock it and reminded the nurse in charge of the cart.Record review of Daily nursing charting requirements checklist, unknown date, revealed the checklist included ensure all inhalers, insulin, breathing treatment, . are dated when opened and stored appropriately.Record review of Pharmacy in-service, dated [DATE], conducted by the facility's pharmacy provider, Medication Therapy Solution, revealed the in-service included the topic of med cart checklist. It mentioned all insulin vials/pens must be labeled with unrefrigerated/date opened. Record review of Security of Medication cart policy, dated [DATE], revealed the policy stated Medication carts must be securely locked at all times when out of the nurse's view. When medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observations, interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and exploitation for one (Resident #1) of 3 residents reviewed for abuse. The facility failed to protect Resident #1 from being abused by CNA A, who, through video-footage, was observed to be physically rough with Resident #1 during incontinent care, was verbally aggressive, and had struck Resident #1 across the forehead. The noncompliance was identified as PNC. The PNC began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the investigation began. This failure could result in resident abuse, psychosocial harm, and physical injuries.Findings included:Record review of Resident #1's admission record dated [DATE] revealed an 82- year-old female with an Initial admission Date of [DATE] and re-admission date of [DATE]. Resident #1 had the following diagnoses: Other Lack of Coordination (primary diagnosis), Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, Alzheimer's disease, anxiety disorder, and need for assistance with personal care. Advance Directive; DNR. Record Review of Resident #1's Care Plan undated revealed: Admit to SNF D/T self care deficit, will optimize the autonomy and independence of this resident to safely preform self care activities. assist as needed in aspects of self care that are problematic to resident. Electronic Monitoring Electronic Monitoring /Camera in room per resident and family request - managed by family R/T resident dignity will be maintained and protected through next AEB no documented or reported breach to provision of resident dignity. care will be met and uninterrupted via camera use. keep sign posted at all times on door of room regarding electronic monitoring. Resident has an ADL self-care performance deficit r/t Dementia, BATHING: Resident requires assistance with bathingBED MOBILITY: Resident requires assistance with bed mobility.DRESSING: Resident requires assistance with dressing.Record review of Quarterly Minimum Data Set, dated [DATE] revealed; BIMS score of 99 (resident was unable to completed the interview). Section GG- Functional Abilities E- Shower/bathe self- Substantial/maximal assistance F. upper body dressing-Substantial/maximal assistance; G Lower body dressing- Mobility: A. Roll left and right-Dependent-Helper doe ALL of the effort. Substantial/Maximal assistance Record review of resident #1's order Summary Report dated [DATE]-[DATE] revealed; Skull 3v/ Hand Rt 2v sent for imaging [DATE] 12:12 PM CT one time only related to Pain Unspecified wi/c patient. Psychological Services, ordered [DATE]. Review of the facility's provider investigation report, dated [DATE], revealed Resident #1's family member witnessed CNA A, the alleged perpetrator, striking Resident #1 in the face while providing ADL care. Resident was found with bruising on right hand measuring 4.6 x 2.5 x 0.1 cm. There was mild swelling to the left side of the face. Results of x-ray for left side of the face came back cleared. CNA A was removed from the facility and the agency company was contacted. Safe rounds were performed on all residents under CNA A's care. All residents reported feeling safe. The family, physician, ombudsman, and police were all notified. Review of in-room video, undated, revealed a 40 second clip which showed Resident #1 lying in bed with mechanical lift sling under her body, CNA A standing next to the bed. CNA A rolled Resident #1 away from her (Resident #1 is on her left side) toward the wall and adjusted her pants. CNA A then rolled Resident #1 back towards her (Resident #1 is being rolled back to her right side) grabbed her wrist and pulled her over. At 0:13 seconds CNA A was heard saying Save those fake-ass tears, you weren't trying to cry before you hit me. CNA A was observed lifting Resident #1's head up and adjusting the nightgown. At 0:21 seconds, Resident #1 was lying in bed with top part of her body exposed, CNA A used a body wipe to clean under the right armpit and crossed over Resident #1's body to wipe left armpit area. At 0:33 seconds, CNA A lifted Resident #1's head to place shirt over head when Resident #1 used her left hand to hit CNA A on her right forearm. CNA A then used her right hand and hit Resident #1 on the left side of her forehead (audible sound of hand making contact with flesh) and said Stop. Video ends at 0:40 seconds. Interview with Resident #1 could not be conducted. Resident #1 had expired, unrelated to the incident, on [DATE].Attempted interview on [DATE] at 2:14 PM, with CNA A revealed no answer to phone call to last known number, voicemail left with call back number. Interview on [DATE] at 2:18 PM, the Agency Director revealed, CNA A was not an employee but an independent contractor with his agency. Her access to the platform was removed on [DATE]. She was disqualified from accepting any positions. Background checks and abuse/neglect training was verified by agency. Interview on [DATE] at 4:10 PM, the DON revealed she was notified of the alleged abuse of Resident #1 via a call from the resident's family member. The family member informed both the Administrator and the DON on [DATE] that when he reviewed the footage from the electronic monitor in Resident #1's room, he observed CNA A strike Resident #1 in the face while providing assistance with ADL care. The DON stated that CNA A was scheduled to work on [DATE] from 6:00 AM-2:00 PM but clocked out early stating she had stomach issues and became incontinent at work. There was no prior care concerns related to CNA A. She stated the facility then started an abuse investigation that resulted in a confirmed finding. Safe rounds was performed on all residents under CNA A's care along with abuse in-service of staff. The Administrator and DON provided in-services related to employee burn out and stress. The DON said on Monday's and Friday's she checks in with staff to inquire if they are feeling overwhelmed. She stated that once a week, spot checks are conducted. The facility initiated a stop and watch form that allows staff members to fill out and report to administration. If they feel, a coworker is suspected of abuse or neglect.Interview on [DATE] at 10:00 AM, the Administrator revealed CNA A was an agency staff without any prior resident complaints or concerns. He stated he became aware of the incident when notified by Resident #1's family member. Staff member CNA A exited the building prior to knowledge of the incident, facility investigation initiated responsible parties were notified, in-service staff for abuse and staff burnout were initiated. Administrator conducted a meeting with agency director to ensure that future agency staff members come highly recommended.Interview on [DATE] at 2:38 PM, CNA B revealed she worked with CNA A and did not suspect abuse of any residents. She stated that CNA A had family issues with her grandchildren and had to finically provide for them. She stated that if she suspected abuse or neglect, she would report it to the administrator immediately. Interview on [DATE] at 1:27 PM with agency CNA C revealed she had a cheat sheet that helps with the resident's care: Report abuse to the nurse or administrator immediately. She stated she had worked a lot of shifts and had been trained on abuse and neglect. She was able to name the types of neglect and abuse. Interview on [DATE] at 2:33 PM with agency LVN D revealed she was trained on abuse and neglect. She stated if she suspected abuse or neglect go and report it to the administrator.it has to be investigated. Today ([DATE]) was her first day working in this building. Interview on [DATE] at 3:06 with LVN E revealed he had worked with CNA A before and did not suspect abuse or neglect. He was able to name types of abuse and signs of neglect. Interview on [DATE] at 2:58 PM- with CNA A revealed she did not call prior because she was waiting on the advice of her lawyer. She stated this was a last-minute shift, the day of the incident. She stated she was at the hospital with her grandson who was on a ventilator and that her husband was dead and she was the only one responsible for her bills, so she took the last-minute shift because she needed the money. She stated she had stomach issues, maybe something she ate prior to coming to work and she had diarrhea. CNA A stated she had worked with Resident #1 before. She stated Resident #1 was swinging at her and CNA A stated she just blacked out. CNA A stated she knew Resident #1 had a camera, due to the sign outside. CNA A stated she looked up and saw the camera and freaked out. She stated she just panicked and unplugged the camera and then plugged it back in. She stated she left afterwards and told the staffing coordinator that she messed her clothes and left. CNA A stated she knew it was wrong, but she needed the money. She stated she never had issues before and she stated she had been interviewed by the state before regarding abuse and neglect but not related to anything she did. CNA A stated she had received abuse training from both the agency and the facility. She was able to name the different types of abuse and stated suspicion of abuse was to be reported to the Administrator immediately. Record Review of Portable X-Ray dated [DATE] revealed; SKULL 3V Findings; AP oblique and lateral views of the skull demonstrate a diffuse osteoporosis. No skull fracture is present the bilateral orbits are intact. The soft tissues are unremarkable. There is no radiopaque foreign body. Right Hand Rt 2V; AP, lateral and oblique views of the right hand are submitted. The bones are osteoporotic. No acute dislocation or fracture is visualized. There is no bony erosion or destruction. The mild-to-moderate osteoarthritis is visualized in the 1st carpometacarpal joint. The soft tissues are unremarkable without radiopaque foreign body. Record review of Criminal History Conviction Name Search Result dated [DATE] revealed, no matching records for CNA A. Record review of Provider Detail Public Search dated [DATE] revealed CNA A's NA Certification Status Active, Certificate Issue Date [DATE]. Initial Certificate Issue Date [DATE]. Certificate Expires [DATE] Record review of Employability Status Check Search Results dated [DATE] CNA A revealed; Unemployable? NO. NAR Status Active. NAR; Active, Unemployable NO. MAR: Active Unemployable NO. Record review of CNA A's Staffing Agency Training dated [DATE] revealed Test Name: Abuse and Neglect (Child, Domestic, Elder) and Human Trafficking. Score 80% Record review of Agency Facility orientation dated [DATE] revealed As an agency staff member, I understand and acknowledge that it is my responsibility to provide quality of care consistent with resident's needs. Signed by CNA A.Record review of a document titled, Other dated [DATE] at 12:44 PM revealed; Person Preparing Report: ADON obtained a statement from CNA A I came in the morning not feeling well. As you can see in the video my pants were already messed. I was not feeling well but I had already started getting her dressed so I figured I should finish. I was frustrated and burnt out and needed a break. I lashed out on her and hit her then noticed the camera and I unplugged it. I know I shouldn't have done it but I did and can not deny it ADON asked CNA A Did you reach out to another CNA or charge nurse for support? CNA A stated no. I was ready to go home I was sick. Record review of a document titled Other prepared by the ADON dated [DATE] at 12:44 PM revealed, at 12:47 PM family notified facility regarding findings on the in-room security camera. Purple bruising noted to top of right hand measuring 4.6cm X 2.5cm. Also noted 0.1x0.5x0.1 open area above bruising. Resident unable to give description. Incident was not witnessed. Full skin assessment completed. ROM WNL to right hand with no c/o or s/s of pain or discomfort noted to area. XRAY FACE AND RIGHT HAND. Record review of Progress Notes authored by ADON dated [DATE] at 3:57 PM revealed, at 12:47 PM family notified facility regarding findings on the in-room security camera. Purple bruising noted to top of right hand measuring 4.6cm x 2.5cm. Also noted 0.1 x 0.5x.0.1 open area above bruising. Area cleansed with NS and steristrip applied. Physician informed. Will continue to monitor areas. Record review of Trauma informed Care Assessment-PTSD dated [DATE] revealed, a PTSD Screening with no probable cause findings for Resident #1.Record review of New Patient Referral Form dated [DATE] revealed, referral for psychology was submitted for Resident #1. Record review of Root Cause Analysis undated revealed, On September19, 2025, facility video surveillance captured a CNA striking a resident in the head. This action constitutes abuse and violates the residents' rights, facility policies, and federal/state regulations. Staff Action: CNA had already left for the day and then removed from the reminder of her shifts immediately following discovery. Corrective Actions: Staff Action: Immediate removal of CNA from duty. Disciplinary process initiated, including termination and reporting to the Contract Nurse Agency and law enforcement. EDUCATION; Facility wide re-education on: Abuse/neglect policies. Resident rights and staff burn out. Leadership Oversight: DON/Administrator to conduct unannounced rounds on all shifts for two weeks. Random staff/resident interviews conducted to validate awareness of abuse prevention practices. Culture & Prevention: Re-incorporation of anger management, stress-de-escalation, and conflict resolution resources into orientation and annual training. Leadership rounding to reinforce zero-tolerance culture and provide staff support. Record review of Inservice and Training dated [DATE] revealed, Topic: abuse and neglect. Trainer was the ADON. Record review of in-service training report dated [DATE] revealed, Subject Stress Reduction/Potential Burnout conducted by DON. Review of Abuse and Neglect -Clinical protocol revised [DATE] revealed; The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse.

Based on interviews and record reviews, the facility failed to keep the environment as free from accident hazards for 1 (Resident #1) of 4 residents reviewed for accidents. The facility failed to ensure Resident #1's environment was free from accidents and hazards when being pushed by another resident, with her permission, from a smoke break. While going up the ramps towards the entrance to the door, Resident#1's wheelchair got stuck on the ramp on 300 hall, as the ramp does not cover the length of the doorway, and she fell face first on 10/27/25. On 10/29/2025 at 5:22pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/29/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of accidents, hazards and a decline in quality of care. Findings included:Record review of Resident #1's face sheet, dated 10/29/25, reflected a [AGE] year-old female, admitted [DATE] and readmitted [DATE], diagnosed with but not limited to: traumatic subdural hemorrhage without loss of consciousness (a condition where a collection of blood (hematoma) forms between the brain and its outer covering (dura mater) after a head injury, without the person experiencing a loss of consciousness) -onset 10/28/25, unspecified sequelae (a condition which is the consequence of a previous disease or injury)of cerebral infarction (long-term complications or after effects of a stroke (cerebral infarction) that cannot be specifically identified or classified), type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema (high blood sugar levels over time can damage the blood vessels in the retina. This damage can lead to the formation of small, leaky blood vessels.), bilateral, morbid (severe) obesity due to excess calories, anxiety disorder unspecified, depression unspecified, hemiplegia and hemiparesis (weakness on half of the body) following (body mass index (BMI) of 40 or higher, or a BMI of 35 or higher) cerebral infarction affecting right dominant side ((stroke) affecting the right dominant side of the brain would cause symptoms on the left side of the body, such as weakness or paralysis (left hemiparesis or hemiplegia), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (person has experienced weakness (hemiparesis) or paralysis (hemiplegia) on their left side due to damage to the right side of their brain),acquired absence of right and left leg below knee (double below-knee amputation). Record review of Resident #1's BIMS Evaluation, dated 10/28/25, reflected her BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, dated 10/28/25, reflected at risk for falls r/tdeconditioning, incontinence, psychoactive drug use, unaware of safety needs, Biliteral BKA, Bilateral Hemiplegia, Hx of CVA, dialysis, and was non-compliant with her POC. [Resident#1] goal reflected [Resident#1] will not sustain serious injury. [Resident#1] interventions reflected: [Resident #1] to be given frequent reminders to not lean forward or over the side while in wheelchair as she will fall r/t having bilateral lower amputations and is morbidly obese with poor balance. Record review of Resident #1's weight, dated 10/28/25, reflected 271 pounds. Record review of Resident #1's care plan, dated 07/15/25 reflected, an ADL self-care performance deficit r/t limited mobility and hemiplegia. Resident #1's goal was to maintain current level of function. Resident #1's intervention included bed mobility extensive with one person assist and transfer extensive with two-person assist. Record review of Resident #1's weight, dated 10/28/25, reflected 271 pounds. Record review of Resident #1's care plan, dated 07/15/25 reflected, an ADL self-care performance deficit r/t limited mobility and hemiplegia. Resident #1's goal was to maintain current level of function. Resident #1's intervention included bed mobility extensive with one person assist and transfer extensive with two-person assist. Record review of Resident #1's progress notes, dated 10/27/25 to 10/29/25, reflected: 10/27/25 [Resident#1] witnessed fall and hospital transfer written by LVN A. 10/27/25 LVN A contacted by local ER nurse. Nurse stated cranial bleed (Involve bleeding in or around the brain) confirmed, transferred to another hospital. Trauma care pending. ER nurse stated resident was requesting to leave AMA to return to facility. LVN A informed ER nurse per facility admin resident was unable to return d/t [sic] current diagnoses. ER nurse reports resident was no longer seeking AMA and would continue to receive treatment. LVN A will continue f/u with ER on resident's condition. 10/28/25 [Resident#1] returned back to facility.Educated on staff only pushing wheelchair. Record review of Resident #1's hospital record, dated 10/28/25, reflected: diagnosed with Traumatic subdural hemorrhage without loss of consciousness, initial encounter. Record review of Resident #2's face sheet, dated 10/30/25, reflected a [AGE] year-old male, admitted [DATE], diagnosed with but not limited to: lack of coordination, pain in right shoulder, pain in right hip, adjustment disorder and history of falling. Record review of Resident #2's MDS, dated [DATE], reflected her BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #2's care plan, undated, reflected at risk for behavior problem. Resident#2 goal reflected no evidence of behavior problems. Resident#2's interventions included Intervene as necessary to protect the rights and safety of other residents During an interview on 10/29/25 at 10:00 am, the DON stated Resident #2 pushed Resident #1 around the facility and out for smoke breaks. The DON stated Residents #1 wanted Resident #2 to push her and it was her right to allow him to do so. The DON stated since the incident Resident #1, Resident #2 and staff were educated to only allow staff to push Resident#2 The DON stated the facility rehab looked for Resident #1 a self-propelling wheelchair because she was a double amputee. During an interview on 10/29/25 at 10:20 a.m., Resident #2 stated he was the Resident Council President, and he tried to help everyone. Resident #2 stated he always pushed Resident #1 around the facility with her permission. Resident #2 stated he was pushing Resident #1 in from smoke break and she fell out of the wheelchair in the entry way. Resident#2 stated since the incident he does not push the residents anymore.During an interview on 10/29/25 at 10:35 a.m., Resident #1 stated Resident #2 was pushing her back into the building with her permission from smoke break and her wheelchair got stuck in the doorway on the ramp. Resident#1 stated she took a nosedive and fell face first and was bleeding. Resident #1 stated that she was educated not to let other residents push her after the accident. Resident #1 stated, because both her legs were gone, it was easier for her to fall out of her wheelchair. During an observation and interview at on 10/29/2511:05 a.m., laundry Aide C showed surveyor where in the doorway Resident#1 fell. Surveyor observed a small, sliver metal ramp and a door with scratches. Laundry Aide C stated she witnessed Resident#1 fall out her wheelchair. Laundry Aide C stated Resident #1 was hard to push because she was a heavier lady. Laundry aide C stated Resident #2 always pushed her. Laundry Aide C stated Resident #2 pushed Resident #1 and could not get her over the ramp hump. Laundry Aide C stated it looked like Resident #2 lost his balance and Resident #1 fell out of the wheelchair. During an interview at 11:45 am on 10/29/25, the Maintenance Director stated the ramp was added because the residents asked for another ramp during resident council meeting. The Maintenance Director stated residents prefer not to use the ramp on 200 hall because of the slope. The Maintenance Director was told by the Regional Maintenance Director that it was ok to add the ramp. The Maintence Director he added the ramp to 300 hall. The Maintenance Director stated there was a 2-inch drop and the ramp made for a smooth transition from inside to outside.During an interview on 10/29/25 at 1:20 p.m., the Admin stated the Regional Maintenance Director was no longer with the company. The Admin stated the Regional Maintenance Director got the okay from life safety to install the ramp. During an interview on 10/29/25 at 1:30 p.m., the Surveyor requested the Regional Maintenance Director's telephone number from the Admin. The telephone number was not provided before exit. During an observation on 10/29/25 at 2:00 p.m., the surveyor observed residents out on smoke break with two staff supervising them (Laundry aide C and wound care nurse). Staff were observed assisting residents back into the building using the ramp on 300 hall which included Resident1 and Resident#2. Record review on 10/29/25 of the Life Safety Director's email to surveyor reflected, the ramp does not cover the width of the door; therefore, it is wrong. It does not look like it needed a ramp in the first place. (Life Safety Director) would say they added something they should not have added and created a hazard. Record review on 10/29/25, Admin email reflected, the ramp was put up on 08/19/2025 by the Maintenance Director. During an interview on 10/29/25 laundry aide D stated two staff go out with residents to smoke. Laundry aide D stated it was hard to push Resident #1 to smoke break. Laundry aide D stated since the incident Resident #2 had not pushed her and only staff can. This was determined to be an Immediate Jeopardy (IJ) on 10/29/25 at 5:22pm. The Administrator were notified. The Administrator was provide with the IJ template on 10/30/25 at 4:07 pm.The following Plan of Removal submitted by the facility was accepted on 10/30/24 at 4:07 pm: Plan of Removal - F689Tag: F689 - Free of Accident Hazards/Supervision/DevicesFacility: Resident Involved: Resident #1Date of Incident: 10/27/25Date of Return to Facility: 10/28/25Immediate Jeopardy Template Submitted: 10/29/25 Corrective Action Taken for Resident #1Upon return from the hospital, Resident #1 was immediately assessed by nursing staff for injury and pain.A new care plan was developed and implemented addressing supervision and transport needs.Resident #1 was educated on safety awareness, including not allowing other residents to push her wheelchair.The resident's responsible party and physician were notified of the incident and updated on the new interventions.Resident #1's wheelchair was inspected for mechanical safety and replaced with a facility-provided wheelchair with safety locks and anti-tippers.Environmental Services completed a review of ramps and thresholds to ensure proper coverage and safe transition between surfaces.Environmental Correction: Maintenance has removed the ramp on 10/29/25.o On 10/30/25 The previous exit door on 300 hall was temporarily closed, two exit strategies still available at the end of hall 300 all/both are 150 feet from the furthest door. o On 10/30/25- Contractor on site for exit site that is temporarily closed with expected completion of 11/5/25.Education:DON/ADON in-serviced staff on Abuse and Neglect completed on 10/28/25.o DON/ADON in-serviced staff on Falls on completed on 10/28/25. o All areas of egress were evaluated and no other areas noted to be of concern on 10/29/25.o On 10/29/25, the Administrator and DON educated staff on immediate reporting of environmental hazards.o On 10/29/25, Administrator and DON educated staff and residents on new exit; on egress for smokers no hazards were identified.o Regional VP of Operations in-serviced the Administrator on 10/29/25 on proper egress and ramps for door exits.o On 10/29/25 Administrator In serviced the Maintenance Director/assistant on appropriate egress and hazards. o Facility had in-serviced staff on accident, prevention, supervision, and resident transport safety completed on 10/30/25. During an observation on 10/29/25 at 5:45 pm, the DON immediately went and removed the sliver, metal ramp on 300 hall and brought it back into the building. During an observation and interview on 10/30/25 at 12:30 p.m., the Maintence Director measured the 300-hall ramp and it was 34 inches in length, and the doorway entrance was 44 inches in length. Surveyor asked Maintenance Director to call Life Safety Directors to get a understanding on how to make the ramp be in compliance. During an observation on 10/30/25 at 12:52 pm surveyor heard Maintence Director, the Admin and the contractor talking with Life Safety Director about ramp regulations. The admin stated he could see how the ramp could be a hazard. During an interview on 10/30/25 at 1:00 p.m., the Director of Rehabilitation stated Resident #1 was now using a custom 20 x 20-inch self-propelling wheelchair with tilt in space frame in a low-profile model. It has a custom molded cushion to relieve pressure on sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) and ischial tuberosities (the paired bony prominences of the lower pelvis). The low profile assists with increased weight distribution within base of support, and it has bilateral trunk (both sides of the torso) supports to assist with positioning and decrease lateral lean in upright posture. During an observation and interview on 10/30/25 at 1:20 p.m., Resident #1 stated she was so happy that she had a new wheelchair. Surveyor observed Resident #1 self-propelling herself in the therapy room. During an observation and interview at 2:00 p.m., surveyor observed Laundry Aide C, Wound Care Nurse and Maintenance Director assisted residents down the 200-hall ramp one at a time. Observed Wound Care Nurse in serviced residents only use 200 hall door for smoke breaks. Wound Care Nurse explained 300 hall door was for exiting the facility. During an observation at 4:15 pm the 300-hall door had caution tape and closed sign blocking anyone from using it on both sides. During interviews between 4:20 pm and 5:00 pm, LVN E, LVN F, CNA G and CNA H revealed staff were knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:00 pm Laundry Aide D revealed she was knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:10 pm wound Care Nurse revealed she was knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:15 pm ADON, revealed she was knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:20 pm Dietary aide and Dietary supervisor stated no one was to exit out 300 hall door, no residents should be pushing other residents, report hazards immediately to Maintenance Director and Admin at anytime. During an interview on 10/30/25 at 5:40 p.m., the Admin stated he had a meeting with the Maintenance Director, and they went over Long-term care (LTC) egress ramps in Texas must follow the Texas Accessibility Standards ([NAME]) and the Texas Building and Life Safety Code, which are based on ADA guidelines. Key rules included a maximum slope of 1:12 for accessible routes, a minimum clear width of 36 inches, handrails for ramps with a rise greater than 6 inches, and level landings at the top and bottom of each run. General slope and surface requirements Running slope: No steeper than 1:12 (1 inch of rise for every 12 inches of horizontal run). Cross slope: No steeper than 1:48. Changes in level: Any abrupt change greater than (1/4) inch must be beveled and changes greater than (1/2) inch must be addressed with a ramp or stair. Admin stated the contractor should have ramp completed for 300 hall by 11/05/25 During an interview on 10/30/25 at 5:50 pm, the DON stated staff did a clean sweep to make sure residents did not have hazards in their room and around the facility. DON stated management will be doing extra rounds to assist staff and residents with wheelchair transport. The DON was knowledgeable about new smoking procedures and fall policy. DON stated there was nothing the facility could have done to prevent this incident from happening. The DON stated the facility had not had issues with the ramp and the past, and residents pushing other residents. During an observation and interview at 10/30/25 at 6:00 pm, surveyor observed Quality Assurance Nurse and Wound Care Nurse taking residents one by one down the 200-hall ramp. Resident #1, Resident #2, Resident #3, and Resident #4 were knowledgeable about not using 200 hall door and residents not pushing each other. During an over-the-phone interview at 10/30/25 at 6:05 pm the V.P. of Operations stated he went over the state requirements and regulations for the ramp with the Administrator . During an interview between 6:10 pm to 6:30 pm, LVN J, LVN K and CNA L revealed staff were knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. Record review of a Resident Smoking in-service, dated 10/29/25, with nursing staff reflected: Residents are to enter building and exit building from door across from therapy using concrete ramp [200 hall] 300 hall exit door is an emergency exit only. The in-services additionally covered facility policy and procedures titled, Smoking Policy-Residents, dated 03/2023, reflected, .This facility should establish and maintain safe resident smoking practices. Record review of accident prevention, supervision, and resident transport safety in-service dated 10/29/25 reflected: the class covered facility policy titled, Accidents and Incidents-Investigating and Reporting revised 11/2024, reflected: .All accidents or incidents involving residents, employees, visitors, venders, etc. occurring on [facility] premises shall be investigated and reported to the Administrator . Record review of Immediate reporting of environmental hazards and unsafe resident behaviors class dated 10/29/25 covered facility policy, Hazardous Areas, Devices and Equipment revised 07/2017 reflected: All hazardous area, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.Identification of hazards.A. hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: E. Irregular floor surfaces Assessments and Analysis of Hazards.2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.Interventions.10. Interventions will be accompanied by communication with staff and leadership, residents, family and visitors.12.Training on safety and interventions to reduce hazard risks will be ongoing.Monitoring to ensure that recommendations are implemented consistently and correctly will be a component of the safety and accident prevention program. Record review of construction quote, dated 10/30/25 reflected, a description of concrete with slope, concrete includes fiber mesh and material reinforcement, slab to be finished with a gradual slope for drainage, price includes materials, equipment, and labor, client responsible for providing clear access to site and adequate water/power supply. Quote accepted and signed on 10/30/25 by contractor and facility The Administrator was informed the Immediate Jeopardy was removed on 10/30/25 at 6:30 pm. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolation due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 (Resident #39 and #29) reviewed for infection control. 1.The facility failed to ensure LVN A wore gloves before opening capsule medication Depakote and administering it to Resident #39 via g-tube (a g-tube is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have difficulty swallowing). 2.The facility failed to ensure LVN B wore PPE for Enhanced Barrier Precautions while providing care for Resident #29 and failed to ensure LVN B did not use her finger to mix several medications in medication cups with water before administering medications to Resident #29 via g-tube. The failures could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: 1. Review of Resident #39's face sheet dated 11/20/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #39 had diagnoses which included Parkinson's disease with dyskinesia (a progressive nervous system disorder, which affects the ability to move muscles and inability to control involuntary jerks and shakiness), unspecified open wound to the left middle finger with damage to nail, unspecified fever, shortness of breath, gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), bipolar disorder (this is a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and viral Hepatitis (this is a liver inflammation due to a viral infection). Review of Resident #39's quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was 0, indicating he was unable to be assessed for cognitive status. The MDS Assessment reflected Resident #39 was usually unable to be understood by others. Further review revealed Resident #39 was dependent on staff for all ADL's and required a feeding tube to obtain 51 % or more nutrition. The MDS reflected Resident #39 was dependent on staff for all upper and lower bed mobility including turning and repositioning in bed. Review of Resident #39's care plan initiated 07/17/24, revealed Resident #39 required enteral feeding via G-tube, he relied on enteral feedings for all nutritional and hydration needs, and could not have anything to eat or drink by his mouth. The goal was Resident #39 would be free of preventable aspiration (choking) through the review date. The interventions included nursing to administer resident with tube feeding and water flushes, to discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. To follow current enteral feeding orders per MD for nutritional/hydration support, to monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, self-extubating (process of removing a tube), tube dysfunction or malfunction, Abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, Nausea/vomiting, dehydration, to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, for RD to evaluate quarterly and PRN, to monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed, ST evaluation and treatment as ordered, to always wear abdominal binder, may remove for showers, check skin under binder every shift. The Care plan further revealed Resident #39 had liver disease r/t Hepatitis C (viral infection that affects the liver and can cause acute or chronic illness). The goal was Resident #39 would be free from s/sx of liver complications, including Infection, abnormal or unexplained bleeding, malnutrition, anemia, cognitive decline, or mental status changes through review date. Interventions reflected to give anti-emetics (drug that treats nausea and vomiting) as ordered for any nausea and vomiting, to monitor/document side effects and effectiveness. The interventions were to give medications as ordered, to monitor/document effectiveness and side effects, and to monitor vital signs and notify MD of significant abnormalities. Review of Resident #39's active orders reflected Depakote Sprinkles Oral Capsule Delayed Release. Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule via G-Tube three times a day related to bipolar disorder, unspecified. Review of Resident #39's November 2024 MAR dated 11/19/24 reflected Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium). Give 1 capsule via G-Tube three times a day related to bipolar disorder was administered by LVN A. Observation on 11/19/24 at 1:59 PM revealed LVN A removed medication Depakote capsule from the medication bubble card and into a medication cup. LVN A then picked up the Depakote capsule with her bare hands, without sanitizing, and opened the capsule and sprinkled/emptied the medication into the medication cup to administer to Resident #39 via G tube. LVN A did not wear gloves to open the medication. In an interview with LVN A on 11/19/24 at 2:15 PM, she stated she thought it was ok to touch the capsule with her bare hands because the medication was inside. She stated she may have reacted without thinking because she was nervous being watched, that's why she forgot to wear gloves before opening the capsule medication with her bare hands. She stated the expectation was to wear gloves before touching any medication or applying medication or administering any medication that required touching skin. She stated the risk to the resident was contamination of the medication she touched with her bare hands, and she also risked exposing herself to the medication which was used for bipolar for Resident #39. 2. Review of Resident #29's face sheet dated 11/20/24 revealed a [AGE] year-old male who readmitted to the facility on [DATE], with an initial admission of 08/14/15. Resident #29 had diagnoses which included vascular dementia without other behaviors (this is brain damage that is caused by multiple strokes causes memory loss and cognitive decline), high blood pressure, dysphagia following stroke (difficulty swallowing), unspecified cough, depression, cognitive communication difficulty (difficulty communicating), chronic kidney diseases, hemiplegia and hemiparesis on left side following stroke (muscle weakness and paralysis on one side) and, gastrostomy status (g-tube) (surgical procedure that creates an opening into the stomach). Review of Resident #29's quarterly MDS assessment dated [DATE], reflected a BIMS of 99 indicating Resident #29 was cognitively impaired to complete the assessment. Resident #29 had impaired range of motion on his left upper and left lower body and was completely dependent on staff to set up and clean up following activity. Resident #39 was always incontinent of bowel and bladder. The document reflected Resident #39 had a feeding tube and received 51% or more of his nutrition through the feeding tube. Review of Resident #29's Care Plan initiated 02/02/24 revealed Resident #29 was on Enhanced Barrier precautions related to feeding tube. The care plan did not reflect interventions. Care plan also revealed Resident #29 required tube feeding related to swallowing problems. The goal was for Resident #29 to maintain adequate nutritional and hydration status as evidenced by weight stable no signs and symptoms of malnutrition or dehydration the thorough the review date. The interventions were to keep head of bed elevated to 45 degrees during and thirty minutes after tube feeds, to follow current enteral feeding orders per MD for nutritional/hydration support, to monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubating, tube dysfunction or malfunction, Abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, Nausea/vomiting, dehydration, to obtain and monitor lab/diagnostic work as ordered. Review of Resident #29's active orders on 11/19/24 reflected: - Implement and maintain enhanced barrier precautions when performing high contact care activities. Every shift for g-tube. - Acetaminophen oral tablet 325 mg (acetaminophen). give 2 tablets via g-tube two times a day related to pain, unspecified. Give 2 tablets to equal 650 mg total; not to exceed 3gm of acetaminophen in 24hrs from all sources. - Enteral feed orders every shift enteral: crush or open capsules and dilute each medication with 5 to 10 ml of water if indicated. - Enteral feed orders every shift enteral: Flush feeding tube with 30 to 60 ml of water before and after each - Lisinopril oral tablet 10 mg (lisinopril) give 1 tablet via g-tube one time a day related to essential (primary) hypertension, hold if sbp<110, - Memantine HCL 10 mg tablet. Give 1 tablet via G-tube two times a day related to vascular dementia. - Provera oral tablet 5 mg (medroxyprogesterone acetate), give 1 tablet via g-tube one time a day related to abnormal level of hormones in specimens from other organs, systems and tissues. - Valproic acid oral solution 250 mg/5ml (valproate sodium). Give 5 ml via g-tube two times a day related to vascular dementia, unspecified severity, with other behavioral disturbance. - Zoloft oral tablet 50 mg (Sertraline hcl). Give 1 tablet via g-tube one time a day related to other recurrent depressive disorders. - Zyrtec allergy oral tablet 10 MG (Cetirizine HCL) Give 1 tablet via G-Tube one time a day related to cough. Observation of medication administration via g-tube on 11/20/24 at 06:39 AM, revealed Resident #29's door signage reflected . STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as; central lines, urinary catheter, feeding tube, tracheostomy (surgical procedure that creates an opening in the neck to provide an airway and remove secretions from the lungs). Wound care: any skin opening requiring dressing. LVN B did not wear her gown for Enhanced Barrier Precautions for Resident #29 with a g-tube during medication administration. LVN B left Resident #29's room to get more medication after it spilled, and reentered Resident #29's room to administer the medication and she did not put on PPE again for g-tube medication administration and for reconnecting Resident #29's feeding. LVN B placed each medication (Acetaminophen, lisinopril, Memantine, medroxyprogesterone, Zoloft, and Zyrtec) in separate medication bags, crushed them and placed them in individual medication cups. The Valproic acid solution was measured into an individual cup as well. LVN B put on gloves and went into Resident #29's room and placed the medication tray with the individual medication cups onto the prepared clean bed side table and went into the resident's bathroom with two cylinders and filled them with water. After listening to G-tube the resident's bed with the bed remote LVN B put some water in the individual crushed medication cups of Acetaminophen, lisinopril, Memantine, medroxyprogesterone, Zoloft, and Zyrtec. LVN B flushed Resident #29's g-tube with 30 ml of water, then she picked up one of the medication cups and swirled it to try and mix the crushed medication with water but failed to dissolve/mix, therefore LVN B used her right pointer finger to mix the medication and water before pouring the medication mixture into Resident #29's g-tube. She then administered 30 ml of water after medication administration. LVN B continued this process of mixing each individual medication with her finger before administering it via the tube of Resident #29. LVN B did not change her gloves before starting to administer Resident #29's medications via g-tube and she did not use a spoon, straw, or other acceptable device to dissolve the medications in with the water. LVN B's last medication to administer was 5ml of Valproic acid solution. LVN B stated she would get some more to finish the medication administration. In an interview on 11/20/24 at 06:55 AM, LVN B was asked if she saw the signage on Resident #29's doorway and what it meant, and she yelled ooh No! She stated she was upset with herself for forgetting to put on her gown for PPE. LVN B stated she had been in-serviced on EBP which was to prevent infection of MDRO's for residents that had internal tubing. LVN B stated that not following the proper way of g-tube care and not wearing PPE for EBP could cause residents to be at risk for infection. She stated it was her responsibility as a nurse to follow infection precautions. LVN B stated she was upset with herself for forgetting to get something to use to dissolve and mix the medication, something like a spoon or steerer. She stated she used her finger to improvise for not having a spoon. LVN B stated that was unacceptable procedure and she should have stopped and went and gotten a spoon or straw on her medication cart. She stated she was knowledgeable of g-tubes but was nervous being watched and forgot to follow the proper way of dissolving and mixing the medication before administration via g-tube. LVN B stated that not following the proper way of g-tube care could cause residents to be at risk for contamination of the medication and at risk for infection. In an interview with the ADON on 11/21/24 at 01:58 PM she stated she had taken over as the infection control preventionist three weeks ago. She stated she had not done any in-service on enhance barrier precautions yet. She stated the expectation was for nursing staff to use PPE for g-tube medication administration. The ADON stated It was an extra layer of protection between the staff and the patient, and for anyone who had any type of opening. She stated staff had to gown up to make beds, to touch the patient, and any direct care with the resident, on Enhanced Barrier Precaution to prevent MDRO infections. The ADON stated it was ultimately her responsibility to monitor and follow up that staff were following infection control, but each staff was responsible to prevent spread of infection. In an interview with the DON on 11/21/24 at 02:31 pm, she stated she had been at the facility for three months as the DON. The DON stated the nurses should follow the proper way of administering medication through the g-tube which meant also wearing PPE for EBP. The DON stated nurses were responsible for making sure that they followed the policy for g-tube and preventing spread of infection and the ADON monitored infection control, and she was overall responsible for all nursing staff. She stated both LVN A and LVN B were really upset with not following proper aseptic technique (this is a set of practice and procedure that healthcare providers use to prevent spread of infection causing germs) for g-tube and she had completed 1:1 check off and in-service with them. She stated the nurses should follow the proper way of administering medication through the g-tube and LVN A should have worn gloves before touching the capsule to open it and LVN B should have used something else like a spoon or the wooden steer to mix the medication with the water and not use her finger. The DON stated nurses were responsible for making sure that they follow the g-tube policy to prevent adverse effects and infections. In an interview with the Administrator on 11/21/24 at 3:31 PM, he stated he expected staff to follow all infection control, enhanced barrier precautions, and for the department heads to do monthly in services and audits to draw attention to problem areas of staff not following the signage outside the doors and not following the facility policies. The Administrator stated he had a new DON now and they are working together to get training and 1:1 with different staff members so everyone can be on the same page. The Administrator stated it was not an excuse, but people tend to mess up when they are being watched and he was like that himself, but as a team, they are working on that so that they do it the correct way all the time and not mess up even if someone was watching them. He stated the expectation was that they learned from their mistake. Review of the facility's Implementation of Standard and Transmission-Based Precautions policy, dated 03/24, revealed, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use . Review of facility policy titled Administering Medication through an Enteral Tube revision date 07/05/19, reflected . the purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube Assemble the equipment and supplies as needed .personal protective equipment (e.g., gown, gloves, mask, etc., as needed) .dilute the crushed or split medication with 5-15 ml water (or as prescribed), administer the medication by gravity flow . Review of undated policy Enteral Nutrition for Closed System Nasogastric, Naso intestinal, Gastric and Jejunal feeding tubes reflected Enteral nutrition therapy will be performed in a safe manner by qualified licensed nurses according to standard practice guidelines . Review of the facility's policy dated August 2016, and titled Standard Precautions revealed .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .hand hygiene is performed with soap (anti-microbial or non-antimicrobial) or alcohol-based hand rub before and after contact with the resident .

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 2 of 15 residents reviewed for clinical records (Resident #23 and Resident #36) in that: The facility failed to ensure Resident #23's and #36's use of bed rails/grab bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Record Review of Resident #23's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #23 had relevant diagnoses of personal history of traumatic brain injury, other reduced mobility, generalized muscle weakness, other muscle spasm, unspecified depression, myopathy (disease that affects the skeletal muscles that control voluntary movement), heart failure, other insomnia, other lack of coordination, gout (type of arthritis that causes recurring episodes of pain, swelling, redness and tenderness in the joints), generalized edema (severe condition that occurs when fluid builds up in the body's tissue), unspecified anxiety disorder, unspecified sleep disorder, type 2 diabetes mellitus without complications (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels), chronic peripheral venous insufficiency (condition that occurs when veins in the legs or arms have difficulty returning blood to the heart), severe obesity, and shortness of breath. Record Review of Resident #23's Quarterly MDS, dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Resident #23's functional limitations in range of motion were listed as no impairment for upper or lower extremities. Resident #23 was noted to use a wheelchair for mobility. Resident #23 was noted to need moderate assistance for self-care categories of toileting, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #23 was noted to need moderate assistance in the mobility categories of sit to stand, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer. Observation of Resident #23's room and bed on 11/19/2024 at 9:45 AM revealed grab bars on the bed in a raised position. The resident was not in room at the time. Observation on 11/20/2024 at 8:08 AM revealed the grab bars in a raised position. Attempts to interview Resident #23 were declined by the resident on 11/19/2024 at 12:55pm and on 11/20/2024 at 8:10am. Record review of Resident #23's Care Plan, last updated on 8/22/2024, reflected a focus area of ADL self-care performance deficit with interventions of Bed Mobility-resident independent with bed mobility, no assistance required. There was no mention of bed rails/grab bars. Record review of Resident #36's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #36 had relevant diagnoses of mild dementia with mood disturbance in other diseases classified elsewhere (mild symptoms of dementia, or a decline in mental abilities that effect a person's daily life, in other diseases with mood disturbance such as depression or apathy), Parkinson's disease without dyskinesia and without mention of fluctuation (a chronic condition that can be managed with medications to help control symptoms such as tremors, slow movement, stiffness, and loss of balance), bilateral angular blepharoconjunctivitis (eye condition that causes redness, irritation, scaling, and fissuring in the inner or outer corner of the eyelid of both eyes), unspecified anxiety disorder, type 2 diabetes mellitus without complications (chronic condition where the body does not use insulin properly resulting in unusual blood sugar levels), unspecified schizoaffective disorder (mental illness that combines symptoms of schizophrenia (chronic mental disorder affecting thoughts, perceptions, emotions, and social interactions) and a mood disorder but does not meet the criteria for either alone), bipolar disorder (serious mental illness that causes mood swings, along with changes in energy, thinking, behavior, and sleep), metabolic encephalopathy (brain disorder that occurs when a chemical imbalance in the blood affects the brain), other reduced mobility, history of falling, unspecified polyneuropathy (disease that causes widespread nerve damage which can lead to impaired sensory and motor function), moderate stage primary open-angle glaucoma of right eye (moderate level of damage to the optic nerve in the right eye along with visual field loss of the peripheral vision but not yet significantly affecting the central vision), and essential tremor. Record review of Resident #36's Quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated a severe cognitive impact. The Quarterly MDS also showed that Resident #36 had no functional limitations in range of motion by upper or lower body impairments, utilized a wheelchair for mobility; was dependent for lower body dressing, showering/bathing, putting on/taking off footwear; required moderate assistance with tub/shower/toiler transfers, sit to stand, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfers. Observation on 11/19/2024 at 9:55AM of Resident #36 room area and bed revealed that the bed had a half-length bed rail raised on the left-hand side of the bed along the wall and a grab bar raised on the right-hand side. The resident was in the room sitting in a manual wheelchair and dressed for the day. The bed rail and grab bar were observed again on 11/20/2024 at 8:10 AM in same positions. Interview on 11/19/2024 at 9:55 AM with Resident #36 revealed is the resident felt she was well taken care of by staff, had no concerns for safety in the facility, and that she intended to be a long-term resident. Resident #36 did not remember if she had been evaluated for having bed rails or grab bars on her bed and did not mind them on the bed. Resident #36 did not remember if the grab bar or bed rail were used frequently or not. Resident #36 was unsure why or when the grab bar or bed rail was placed on the bed. Record review of Resident #36's Care Plan, last updated on 10/24/2024, reflected that Resident had ADL self-care performance deficits and required interventions of: a Hoyer lift with 2 staff for transferring, assistance with personal hygiene, assistance with bathing, assistance with bed mobility, and assistance with dressing. The Care Plan had no mention of bed rails or grab bars as an intervention or focus for Resident #36. Interview on 11/21/2024 at 2:15PM with the ADON revealed that the facility procedure for bed rails or grab bars was to care plan the reason for the items to be on the resident bed with the IDT, document what had been tried before, and give reason the bed rail/grab bar was needed or what it would provide for the resident in specifics. The ADON stated there was no exception to the bed rails/grab bars being included in the care plan and was the standard for the facility. The ADON stated that if a resident were found to have bed rails/grab bars on their bed staff should be verifying the devices were care planned, the resident was assessed for safety, a signed consent form is in place, and that the ADON over that part of the building was consulted to the missing part of the process. The ADON stated it was important for bed rails/grab bars to be care planned so that staff know why they were being used, to ensure residents were assessed safe to use them, and to be able to reference back in the event somethings happens to be able to verify why they were in place. The ADON was not familiar with reasons specific to Resident #23 or #36 having bed rails or grab bars on their beds as the ADON was assigned to a different area of the facility; the ADON who was assigned to these residents was involved in care plan meetings on this day. The ADON stated that the grab bars/bed rails were typically used to promote residence independence and ability to turn in bed while the risks were that if not care planned staff would not know why they were in place, staff would not know the resident was safe to use them, and residents would be at risk with bed rails for potential injuries or entrapment. Interview on 11/21/2024 at 2:53 PM with the ADM revealed that care plans were expected for all residents to be updated as conditions changed, for staff to document concerns and issues that a family member or resident had and to document interventions. The ADM stated he expected staff to be truthful and to make sure to document more than less in care plans so resident needs and limitations were clear to anyone reading the care plan for the first time. The ADM stated that grab bars/bed rails were expected to be documented clearly. The ADM stated that Resident #23's care had been talked about last week during the IDT meeting and thought the care plan was updated at that time. The ADM stated that Resident #36 had utilized the grab bars/bed rail for some time and was unsure why they were not already on the care plan. Interview on 11/21/2024 at 3:20 PM with the DON revealed that care plans were to be updated based on the care plan meeting with the resident, family/responsible party, and IDT , and preferably in real time. The DON stated that grab bars/bed rails were to be updated within the care plan review period. The DON stated that risks to the resident for grab bars/bed rails not being on a bed when they should be could range from loss of independence or mobility; if not in the care plan could have had a result of CNA or other nursing staff not having awareness for what the resident was using the rails for. Bed rails/grab bars could be documented by anyone clinical who was in the IDT meeting where the bed rails/grab bars were discussed and approved. The DON stated that if a resident requested grab bars/bed rails then nursing staff will initiate the assessment and obtain consent from the resident or their responsible party, then the IDT will review for further assessment by therapy, for request to maintenance to add to the bed if not already, and the care plan to be updated. Record Review of the facility's Proper Use of Side Rails policy (C)2001 MED-PASS, Inc. (Revised August 2024) pertinent sections state: Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: 5. The resident's care plan will reflect the use of side rails and updated as necessary. Record Review of the facility's Care Plans, Comprehensive Person-Centered (C)2001 MED-PASS, Inc. (Revised December 2016) pertinent sections state: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 2. Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program . 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.

Based on observations, interviews, and record review, the facility failed to accommodate residents' food preferences and allergies for 2 of 6 (Residents #1 and Resident#2) residents reviewed for food preferences and allergies. 1. The facility failed to provide Resident #1 with a strawberry (preference) or vanilla house shake, when she had listed that she disliked the chocolate house shake. 2. The facility failed to ensure Resident #2 did not receive a chocolate house shake, which was listed as a food allergy in her medical record. These failures could cause an allergic reaction, a decrease in resident choices, a diminished interest in meals, placing them at risk for contributing to poor intake and/or weight loss. Findings included: Record review of Resident #1's admission record revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified protein-calorie malnutrition (imbalance between the nutrients your body needs and the nutrients it gets), deficiency of other vitamins (lacking any of the 13 essential vitamins that your body needs in small amounts to work optimally), and gastro-esophageal reflux disease without esophagitis (common digestive disorder- reflux of stomach acid into the esophagus). Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident#1 had a BIMS score of 12 which indicated a moderate cognitive impairment . Record review of Resident #1's care plan dated 02/28/24 revealed Resident#1 had GERD (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). Resident#1 Goal was for Resident#1 to remain free from discomfort, complications related to GERD Resident#1 interventions revealed avoid food or beverages that tend to irritate esophageal lining .alcohol, chocolate, caffeine . Record review of Resident #1's order dated 05/17/24 revealed the following: house shake 40 oz two times a day for weight loss. Interview on 07/18/24 at 9:42 AM with the Ombudsmen revealed Resident #1 had not received her preference flavor of the house shake. The ombudsmen revealed resident #1 would throw up the chocolate house shake. The Ombudsmen revealed Resident #1 could deal with the vanilla shakes but preferred strawberry house shakes. The Ombudsmen revealed she was in the building on 07/14/24 and the facility only had chocolate house shakes for the residents. Interview on 07/18/24 at 11:25 AM with Resident #1 revealed she had not had a house shake since Monday because the kitchen only had chocolate. Resident #1 revealed she had informed the dietary staff (unknown) that she could not drink the chocolate house shakes. Resident #1 revealed that she cannot have the chocolate ones because they made her stomach hurt. Resident #1 stated that it irritated and upset her that she was not able to get the strawberry house shake but she would drink the vanilla. Observation and interview on 07/18/24 at 12:50 PM with Resident #1 revealed she did not have a house shake on her lunch tray. Observation of the lunch tray ticket revealed a notation that read chocolate shake only. Interview with Resident #1 revealed she did not have a house shake for lunch. Interview on 07/18/24 at 12:56 PM with the Dietary Manager revealed the facility met the Residents need for nutrition. The Dietary Manager revealed she ordered twice a week and enough house shakes are ordered. The Dietary Manager revealed she was aware that Resident #1 preferred the strawberry house shakes over the vanilla and chocolate. The Dietary Manager revealed the dietary staff put aside certain flavors for each resident that want certain flavors. The Dietary Manager revealed the Dietary Aide was responsible for putting the house shakes on trays and to follow the instructions on the ticket tray. The Dietary Manager met with residents and documented their preferences. The Dietary Manager revealed residents had the right to refuse the house shakes . Dietary Manager revealed Resident#1 could have an upset stomach. Observation and interview on 07/22/24 at 8:20 AM revealed Resident #1 did not have a house shake on her breakfast tray. Observation of Resident #1's tray ticket revealed a written notation that read chocolate shake only. Interview with Resident #1 revealed she did not have her house shakes because the facility only had chocolate house shakes available. Observation on 07/22/24 at 8:57 AM of the facility kitchen revealed chocolate house shakes in the reach in refrigerator. Observation of the walk-in refrigerator revealed an open box of chocolate house shakes. Observation of the walk-in freezer revealed an unopened box of vanilla house shakes on the bottom shelf in the back of the walk-in freezer. Interview with Dietary Manager07/22/24 at 9:00 AM revealed the vanilla house shakes could have been taken out and thawed out. The Dietary Manager revealed the Dietary Aides knew the house shake was in the freezer and it would have taken fifteen minutes to thaw the shakes. Interview with Dietary Aide on 07/22/24 at 10:00 AM revealed the chocolate house shakes were the only ones in the refrigerator and she wrote on the tray ticket chocolate shake only to let Resident#1 know that was the only flavor available. Dietary aide revealed the Dietary aides are responsible for the tray set up. Record review of Resident #2's Admission Record revealed, she was a [AGE] year-old female admitted to the facility initially on 04/10/22 and readmitted on [DATE]. Resident#2 was diagnosed with vomiting, unspecified, unspecified diarrhea, diverticulosis of large intestine without perforation (small pockets on the inside of the colon) or abscess without bleeding, and gastro-esophageal reflux disease without esophageal reflux disease without esophagitis (common digestive disorder- reflux of stomach acid into the esophagus). Record review of Resident#2's admission Record revealed Resident#2 had an allergy to chocolate. Record review of Resident #2 quarterly MDS dated [DATE] revealed her BIMS score was 15 which indicated she was cognitively intact. Record review of Resident# 2's orders dated 09/25/23 revealed the following: House supplement 2.0 three times a day 90 CC .Please open . Record review of Resident #2's miscellaneous note created by the Dietary Manager and dated 08/31/22 revealed Resident #2 had an allergy to chocolate, severity unknown and reaction noted on admission. Observation of Resident #2 on 07/22/24 at 8:00 AM revealed her to be eating breakfast in the dining hall. Interview with Resident #2 revealed she was allergic to chocolate, and she gave her house shake to her neighbor. Observation of Resident#2 tray ticket revealed she was allergic to chocolate. Interview on 07/22/24 with the Dietary Manager at 9:00 AM revealed Resident #1 should not have gotten a chocolate house shake and the dietary aide would be written up. The Dietary Manager revealed she would need to check with nursing to see if she has an allergy to chocolate or if it was a dislike of chocolate. Resident could end up with an upset stomach if this was a true allergy. Interview with the ADON on 07/22/24 at 9:12 AM revealed if the residents did not receive their house shakes, they could experience weight loss. Resident #2 has an intolerance to chocolate and would have an upset stomach and possibly diarrhea. Interview over the phone at 07/22/24 at 9:38 AM with the Registered Dietitian revealed the nursing staff and the Dietary Manager went over the recommendations for residents with weight loss. The Registered Dietitian revealed the Dietary Manager met with the residents upon admission and throughout their stay to document residents' preferences . Registered Dietitian revealed Resident could experience weight loss. Interview with Dietary Aide on 07/22/24 at 10:00 AM revealed the aides were responsible for setting up the resident's tray. The Dietary Aide revealed she was rushed to get breakfast out and put the chocolate shake on Resident#2 tray. The Dietary Aide revealed the chocolate house shakes were the only ones in the refrigerator. Interview on 07/22/24 at1:35 PM with Administrator revealed Resident #2 has asked for chocolate cake in the past and may be at risk for an upset stomach . Record review of the facility policy, Food Preference , dated 07/2017, reflected, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team .10. The food service department will offer a variety of foods at each scheduled meal .

Based on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided, consistent with professional standards of practice for 2 of 2 residents (Resident #1 and Resident #2) reviewed for respiratory care and services. The facility failed to ensure Resident #1's oxygen tubing was dated. The facility failed to ensure Resident #2's oxygen tubing was dated and properly stored when not in use. These failures could place residents at risk for respiratory infections. Findings included: Record review of Resident #1's admission record, dated 04/25/2024, revealed a [AGE] year-old female with an original admitted [DATE] and readmitted on [DATE] with diagnoses that included heart failure, shortness of breath, obstructive sleep apnea, and chronic obstructive pulmonary disease. Record review of Resident #1's most recent MDS assessment, dated 03/15/2024, revealed a BIMS score of 12 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #1 received oxygen therapy while not a resident and while a resident. Record review of Resident #1's care plan, revised on 03/21/2024, revealed the resident has oxygen therapy r/t CHF, ineffective gas exchange, and CPAP r/t to sleep apnea. Record review of Resident #1's physician orders, dated 03/04/2024, revealed Oxygen: Change Mask, O2 tubing, water bottle, and clean concentrator filter every night shift every Sun Initial & date tubing & bottle. Record review of Resident #2's admission record, dated 05/03/2024, revealed an [AGE] year-old female with an original admitted [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's Disease, heart failure, and chronic obstructive pulmonary disease. Record review of Resident #2's quarterly MDS assessment, dated 04/16/2024, revealed a BIMS score of 10, indicating moderate cognitive impairment. Further review of the MDS revealed Resident #2 did not receive oxygen therapy while a resident. Record review of Resident #2's physician orders, dated 05/03/2024, revealed Oxygen: Change Mask, O2 tubing, water bottle, and clean concentrator filter every night shift every Sun for SOB related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Observation on 04/25/2024 at 3:47 PM revealed Resident #1 was observed in her room sitting in a recliner with blanket on and O2 on via nasal cannula. The concentrator was running at 2.5 LPM and the tubing and humidifier were undated. A CPAP machine was on the table next to the bed. No storage bag for tubing was observed near the CPAP or concentrator. Observation on 04/25/2024 at 4:20 PM revealed contact isolation signage posted on Resident #2's door. Resident #2 was lying in bed. A concentrator was near the bed, turned off, with O2 tubing lying on the floor and not stored in a bag. The humidifier and tubing were undated. Interview on 04/25/2024 at approximately 4:20 PM, CNA A stated the tubing and humidifier should be dated and thought it should have been changed on Sunday. She stated dating allows them to know when it was last changed. CNA A stated when the tubing was not in use it should be kept in a bag to keep it clean, and so it will not be contaminated. Interview on 04/25/2024 at 4:31 PM, LVN B stated tubing should be in a bag to keep it clean and should be dated to see how old it was. She stated the tubing was to be changed every week on the night shift on Sunday evening. LVN B stated if tubing was not stored properly, it could collect dust particles and be contaminated. Interview on 04/25/2024 at 4:49 PM, the ADON stated her expectation was that O2 tubing be changed every Sunday with a fresh bag by night shift. She stated staff should also change out the water bottle and the filter. The ADON stated the end of the tubing, and the humidifier should be dated. She said this was done to keep the tubing clean and sanitary. She stated the nurses were responsible and she was responsible to ensure the policy was followed. Interview on 04/25/2024 at 5:30 PM, the Operations Manager stated his expectations were for staff to know and follow the Oxygen policy. He stated ultimately, he was responsible to ensure staff followed facility policy. He stated the risk could be germs. He stated the DON and the ADON usually spot check those tanks and ensure they were following regulation. He stated he had met with the clinical team to begin staff in-services to ensure if they see something not labeled then they were to alert one of the clinical team. Review of facility policy titled Oxygen Administration revised October 2010, reflected, in part: Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 4 (Hall 100, 300, 500, and 600) of 4 halls reviewed for pests, and the main dining room. The facility failed to ensure an effective pest control program was implemented to prevent the presence of flies and water bugs within the facility. This failure placed residents at risk for foodborne illness and/or disease spread by pests. Findings included: An observation and interview on 10/17/23 at 9:30 AM in room [ROOM NUMBER] revealed flies were observed in the room during incontinent care. Following care, Resident #17 described the flies as a nuisance. An observation on 10/17/23 at 9:55 AM revealed flies were observed in the hallway on Hall 500. An observation on 10/17/23 at 10:18 AM in room [ROOM NUMBER] revealed multiple flies were observed in the room. Observation and interviews on 10/17/23 at 10:25 AM in room [ROOM NUMBER] revealed numerous flies were in the room, landing on residents and tables. Resident #71 stated the flies had been bad as long as she had been there, for 3-4 months. Resident #91 stated the flies were terrible. An observation on 10/17/23 at 10:50 AM in room [ROOM NUMBER] revealed multiple flies were observed in the room. Observation and interview on 10/17/23 at 10:53 AM in room [ROOM NUMBER] revealed there were multiple flies in the room. Resident #59 stated the flies were bad. Resident #59 stated she had been seeing those large water bugs as well. She said she had one crawl out of the top drawer of her nightstand recently. She stated she believed they were coming out of the door in her bathroom, there were holes in the door and she had seen them crawling out of the door and around her toilet. Observation in the bathroom revealed the inside of her bathroom door had six various sized holes in the lower portion if her door. There was a live water bug approximately one inch long on her bathroom floor behind her toilet. Resident #59 stated she had reported it in the past to a CNA or two but did not remember the names of the CNAs. She stated the nursing staff had come in and try to kill them for her. She did not recall ever seeing anyone from maintenance or a pest control company treat her room. An observation and interview on 10/17/23 at 11:30 AM in room [ROOM NUMBER] revealed there were multiple flies were observed in the room. Resident #78 stated the flies come and go. An observation and interview on 10/17/23 at 11:35 AM in room [ROOM NUMBER] revealed there were multiple flies were in the room. Resident #58 stated the flies had been there for years. An observation on 10/17/2023 at 11:35 AM revealed multiple flies in Residents #81 and #76's room. A fly swatter was observed on the dresser. Interviews on 10/17/2023 at 11:35 AM with Residents #81 and #76 revealed the flies were in their room for a while. Resident #81 said he was not sure why there were so many flies in their room, but they were bothersome. In an interview on 10/17/2023 at 11:43 AM, in the doorway to Residents #81 and #76's room, ADON G said saw all the flies and they should not be in the room. She said the facility wanted to ensure the rooms were clean and free of pests to ensure residents' comfort. She said the fly swatter in the room indicated to her that the flies had been in the room for some time. An observation on 10/17/23 at 11:45 AM revealed flies were seen in the hallway on Hall 600. During an interview on 10/17/23 at 11:53 AM , Resident #92 stated he had not had a problem with flies in his room but did see them often when he is out in the facility. Observation and interview on 10/17/23 at 12:00 PM in room [ROOM NUMBER] revealed multiple flies were observed in the room. Resident #12 stated they had been there for a long time. An observation on 10/17/23 at 1:25 PM in room [ROOM NUMBER] revealed there were multiple flies observed in the room, many were landing on Resident #68's bedside table. Resident #68 stated the flies had been a problem for a while. He stated he was waving them away from his breakfast tray that morning and had one land in his milk. He stated the staff brought him another glass of milk. Resident #68 stated the staff had tried to help and had come in occasionally with a fly swatter. He stated he also saw water bugs in his room on occasion and the staff had come in and stomped on them. An observation on 10/17/23 at 1:48 PM revealed multiple flies were observed in the main dining room. Observation and interview on 10/18/23 at 7:10 AM revealed there were still multiple flies in room [ROOM NUMBER]. During an interview, LVN D acknowledged the flies were bad. She stated they were worse over the past summer and the nurses had purchased some natural fly traps to use at the nurse's station. She stated there was a maintenance log and pest control log at the nurse's station for reporting, but it had been an ongoing issue. LVN D denied seeing any water bugs recently. During an interview on 10/18/23 at 9:00 AM, LVN C stated she had seen the flies around the facility and in the resident's rooms and they entered through the doors. She stated she had only seen one water bug and had killed it herself. LVN C stated they had a bug book at the nursing station where they were supposed to document any pests seen. During an interview on 10/19/23 at 10:10 AM, ADON A stated department heads were assigned rooms and made rounds daily. Any maintenance issues or pest control issues should be logged in the books at the nurse's station as a best practice. Observation and interview with the Maintenance Supervisor on 10/19/23 at 10:15 AM revealed he was aware of the problem with flies in the building. He stated he was not responsible for pest control in the building as they had a company to handle the task. He was not aware of an issue with water bugs in the building. The Maintenance Supervisor stated he only learned the day before that flies were not included in the pest control company's contract as he had no access to it. He stated it was added yesterday and the company had already come out to begin addressing the issue. He stated the company representative believed the source was the outside dumpster . He stated he would see the pest control representatives within the facility frequently and they would mention the flies to each other. He stated he believed each one thought the other was handling the issue and is glad the problem was getting addressed. When shown the bathroom door in room [ROOM NUMBER], the Maintenance Supervisor stated he was not previously aware of the problem, or he would have taken care of it quickly. He stated he depended on the nursing staff to enter any maintenance issues they find in the maintenance logbook at the nursing station, and he checks it every day. He stated the staff would sometimes catch him in the hall and verbally report a problem, but he really needed them to use the book. When asked about the window screens, he stated he was responsible for checking those and was aware there were some that needed replacement. He stated he was working on some higher priority issues at that time and planned to get to the screens as soon as he could. He was not aware of any residents who like to open their windows and did not feel it was contributing to the problem with the flies. Observation and interview on 10/19/23 at 10:39 AM in room [ROOM NUMBER] revealed CNA E was normally assigned to the 500 Hall but had not noticed the holes in the bathroom door. She stated she would document the issue in the maintenance log. She stated she was aware of the flies in the rooms but did not recall seeing water bugs in the resident's rooms. She stated she would kill them and document them in the pest control log if she had seen any. During an interview on 10/19/23 at 10:50 AM, the Operations Manager stated he was unaware until 10/18/23 that flies were not part of the facility's pest control contract. He stated the previous Administrator was there until mid-September. He stated he did not know the maintenance supervisor was also previously unaware flies were not being treated by their pest control company. He stated he had met with housekeeping and maintenance the day before as well as the pest control company. The Operation Manager stated flies were added to the contract. He stated flies could carry disease and were very annoying to the residents and their goal was the elimination of them from the facility. Record review of the facility's pest control contract titled, Commercial Pest Control Proposal and Annual Service Agreement dated 1/30/2015 revealed: [Pest control company name] will perform regular service twice monthly for the control of Roaches, Rats, Mice, Fire Ants. Record review of the facility's current pest control log revealed there were no entries related to flies in 2023. The most recent entries reflecting roaches/water bugs occurred on 10/9/23 in room [ROOM NUMBER] and 5/11/23 in room [ROOM NUMBER]. Record review of the facility's policy titled, Pest Control, dated Revised 9/22/23 reflected, Our facility shall maintain an effective pest control program .1. This facility maintains an on-going pest control program for insects and rodents .3. Windows are screened to assist with insect and rodent entry .6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure foods were dated and stored properly. These failures could place residents at risk for food borne illness. Findings included: An observation of the facility's only kitchen on 10/17/23 beginning at 8:15AM revealed the following: -three opened bags of cereal which were undated (not identifying the expiration date or the date in which the food was received/opened) and placed on a shelf for dry food storage -one opened cardboard box with a package of ground beef in it, sitting on the floor of the walk-in freezer During an interview with Dietary Aid J on 10/17/23 at 8:20AM, she confirmed the three bags of cereal were undated (not identifying the expiration date or the date in which the food was received/opened). She stated items should be labeled and dated by whomever opened the food items. She also confirmed the opened cardboard box, which contained a package of ground beef, was sitting on the floor in the walk-in freezer. She stated the box should have been placed on one of the storage shelves in the freezer. Review of the facility's Food Receiving and Storage policy, dated 07/2014, reflected, .Foods shall be received and stored in a manner that complies with safe food handling practices . The Food and Drug Administration Food Code dated 2017 reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety The Food and Drug Administration Food Code dated 2022 reflected, .3-305.11 Food Storage (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor .

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for four (Residents #12, #59, #76, and #81) of twenty-one residents reviewed for resident rights. 1. The facility failed to ensure Residents #81 and #76's room did not have stained and soiled carpeting and multiple flies. 2. The facility failed to ensure Resident #59's room did not have six various sized holes in her bathroom door, multiple flies and a water bug in her room. 3. The facility failed to ensure Resident #12's room did not have a large hole in the window screen and multiple flies in his room. These deficient practices could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment. Findings included: Observation and interview on 10/17/23 at 10:53 AM in Resident #59's room revealed she was sitting up in a chair in her room. Multiple flies were observed in her room . Resident #59 stated she had seen large water bugs as well. She stated she had seen them crawling out of the holes in her bathroom door. Observation of her bathroom door revealed 6 holes of various size in the lower half of her door. No bugs were seen exiting the holes, but a water bug was observed on her bathroom floor behind the toilet. Resident #59 stated she had reported it in the past to a CNA or two but did not remember the names of the CNAs. She stated the nursing staff had come in and try to kill them for her. She did not recall ever seeing anyone from maintenance or a pest control company come by to treat her room. An observation on 10/17/2023 at 11:35 AM revealed multiple flies in room residents #81 and #76's room. A fly swatter was observed on the dresser. The carpeting in their room was visibly stained, had food crumbs, and sticky when walked on. Interviews on 10/17/2023 at 11:35 AM with Residents #81 and #76 revealed the flies were in their room for a while. Resident #81 said he was not sure why there were so many flies in their room, but they were bothersome. Observation and interview on 10/17/23 at 12:00 PM in Resident #12's room revealed him sitting on his bed. Multiple flies were observed in the room. Resident #12 stated they had been there for a long time. The window blinds were open revealing a bird feeder just outside the window. The window was closed. A large hole was observed in the window screen approximately 12 inches in diameter. Resident #12 stated the hole had been there for a while and he did not open his window. He did not know if staff were aware and had not previously complained about it. In an interview on 10/17/2023 at 11:43 AM, in the doorway to Residents #81 and #76's room, ADON G said she saw all the flies and they should not be in the room. She said the facility wanted to ensure the rooms were clean and free of pests to ensure residents' comfort. She said the fly swatter in the room indicated to her that the flies had been in the room for some time. In an interview on 10/17/2023 at 12:14 PM, the Housekeeping Supervisor stated management performed daily rounds to check for cleaning issues, but he had not done so that day. He said the floors should not be stained and dirty and housekeeping was responsible to ensure rooms were cleaned properly. He said files in the room posed a risk of spreading disease and residents should not have to deal with them. He said the room needed to be deep cleaned. During an interview on 10/18/23 at 7:10 AM, LVN D stated she was the charge nurse on the 500 Hall. She stated there was a maintenance log and pest control log at the nurse's station for reporting pest or maintenance issues. LVN D denied seeing any water bugs recently and was not aware of the holes in the bathroom door in Resident #59's room. During an interview on 10/19/23 at 10:10 AM, ADON A stated department heads were assigned rooms and made rounds daily. Any maintenance issues or pest control issues should be logged in the books at the nurse's station as a best practice. She was unaware of the issues in Resident #59 or #12's rooms. Observation and interview with the Maintenance Supervisor on 10/19/23 at 10:15 AM revealed he was aware of the problem with flies in the building. He stated he was not responsible for pest control in the building as they had a company to handle the task . When shown the bathroom door in Resident #59's room, the Maintenance Supervisor stated he was not previously aware of the problem, or he would have taken care of it quickly. He stated he depended on the nursing staff to enter any maintenance issues they find in the maintenance logbook at the nursing station. He stated he checked it every day. The Maintenance Supervisor stated the staff would sometimes catch him in the hall and verbally report a problem, but he really needed them to use the book. When asked about the window screens, he stated he was responsible for checking those and was aware there were some that needed replacement. He stated he was working on some higher priority issues at that time and planned to get to the screens as soon as he could. He was not aware of any residents who liked to open their windows and did not feel it was contributing to the problem with the flies. Observation and interview on 10/19/23 at 10:39 AM in Resident #59's room revealed CNA E was normally assigned to the 500 Hall but had not noticed the holes in the bathroom door. She stated she would document the issue in the maintenance log. She stated she was aware of the flies in the rooms but did not recall seeing water bugs in the resident's rooms. She stated she would kill them and document them in the pest control log if she had seen any. Record review of in-service records titled, Room rounding - inspecting rooms for foul odors, cleanliness, dated 3/8/23 and 4/20/23. Record review of the facility's Maintenance Request logs for the past three months revealed there was no entry related to the bathroom door in Resident #59 or the window screen in Resident #12's room. Record review of the facility's current pest control log revealed there were no entries related to flies in 2023. The most recent entries reflecting roaches/water bugs occurred on 10/9/23 in room [ROOM NUMBER] and 5/11/23 in room [ROOM NUMBER]. Record review of the facility's policy titled, Pest Control, dated Revised 9/22/23 reflected, Our facility shall maintain an effective pest control program .1. This facility maintains an on-going pest control program for insects and rodents .3. Windows are screened to assist with insect and rodent entry .6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Record review of the facility's policy titled, Quality of Life - Homelike Environment, revised May 2017, reflected, Residents are provided with a safe, clean, comfortable, and homelike environment .The facility staff and management shall, maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary and orderly environment .

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices were put into place to prevent accidents for one (Resident #81) of eight residents reviewed for quality of care. The facility failed ensure Resident #81's call light was placed where the resident could reach it, to prevent potential fall and injury. This failure could place the resident who require supervision assistance due at risk for falls with injuries, hospitalization , and a decreased quality of life. Findings included: Review of Resident #81's Face sheet dated 10/19/2023 reflected and [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included: Prophylactic surgery (surgery whose purpose is to minimize or prevent the risk of developing cancer in an organ or gland that has yet to develop cancer, hypertension (the pressure in your blood vessels is too high ), hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), cognitive communication deficit Attention and communication difficulties), moderate dementia (forgetful of recent events), anxiety disorder (persistent and excessive worry that interferes with daily activities), hypothyroidism (thyroid doesn't create and release enough thyroid hormone into your bloodstream), type 2 diabetes (cells don't respond normally to insulin; this is called insulin resistance.) Review of Resident #81's quarterly MDS assessment, dated 8/7/2023 reflected severely impaired cognition and daily decision making. Resident #81 was a one-person limited assist for bed mobility, transfers, extensive assist with dressing, toileting, and personal hygiene. Review of Resident #81's care plan dated 4/8/2023 and updated 6/9/2023 falls, with goals not to have major falls / poor safety awareness and interventions of that included encourage call light use and bed in low position and keep walker within reach. The care plan was updated again on 10/18/2023 with an intervention of signage call don't fall, and again on 10/19/2023 - PT and OT screen. A review of Resident #81's nursing notes dated 10/18/2023 at 11:28 PM revealed, Resident on post fall 2/3, no delayed injury noted, resident was sent to ER earlier today due to recent fall and was sent right back, no abnormal findings, continue neuro checks. An observation and interview on 10/19/2023 at 9:20 AM in Resident #81's room revealed him sat in his wheelchair by the window. Resident #81's call light was on the floor between A and B beds in the room, on the opposite side of Resident #81's bed from where he was siting. The call light clip was missing. Resident #81 said he was always reminded by staff to use his call light if he needed assistance. He said he was not sure where the call light was but when it was pointed out to him he was able to recognize it. In an interview on 10/18/2023 at 8:30 AM, Resident #81's family member said Resident #81 slid out of his wheelchair last night. Resident #81's family member stated Resident #81 would often get up, forgetting he was not strong enough to stand. In an interview on 10/18/2023 at 11:40 AM, RN F said Resident #81 slid out of his wheelchair onto his butt at 7:00 PM on 10/17/2023. She said she received the information in the report that morning. She stated Resident #81 was assessed with no injuries or pain. She said when she came on shift morning, his vitals had dropped and after consulting the physician, she sent him to the hospital. She said Resident #81 was a fall risk and his call light should have been placed to allow him to call for assistance when needed. In an interview on 10/18/2023 at 11:50 AM, ADON G said when Resident #81 fell , she assessed him. She said he was on his butt on the left side of the bed. She said he did not have any injuries and did not complain of any pain. She said Resident #81 said he was trying to get into him bed. She said Resident #81's call light should always be placed where he could reach it. In an interview on 10/19/2023 at 9:30 AM, LVN H said Resident #81 returned from the hospital with no injuries or follow up. She stated Resident #81's call light should have been within his reach to enable him to call for assistance as needed especially since he fell yesterday. She said the call light was on the floor in Resident #81's room and the clip was missing. She said she replaced the clip and placed it within reach of Resident #81. She said staff knew to remind him to call for assistance. In an interview on 10/19/2023 at 10:05 AM, the Administrator said Resident #81 was a fall risk and interventions for him included call light in reach and reminders to use it. He said the call light should not have been on the floor because it placed resident #81 at risk of accidentally falling if he did not have access to it. In an interview on 10/19/2023 at 1:31 PM, with CNA I revealed Resident #81 liked to move around a lot so she checked on him often. She said he needed reminders to use his call light. She said she had left the call light on Resident #81's bed but he may have put it on the floor. She said no matter what, the call light needed to be accessible to Resident #81 to allow him to call for assistance and minimize his risk of falling. Record review of the facility's policy titled, Resident call light system, revised 6/2023, reflected The purpose of this procedure is to respond to the resident's requests and needs. Ensure the call light is easily reachable by the resident.

Based on interview and record review, the facility failed conduct an initial Comprehensive Assessment within 14 calendar days after admission for 2 of 22 residents (Resident #254 and Resident #255) reviewed for Comprehensive Assessments and timing. The facility failed to ensure Comprehensive MDS Assessments for Resident #254 and Resident #255 were completed within 14 days after their admissions to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Review of Resident #254's Face Sheet, dated 10/19/23, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high), and hypertension (high blood pressure). Review of Resident #254's electronic health records on 10/19/23 revealed that an initial MDS Assessment had not been completed and submitted by the facility as required. Review of Resident #255's Face Sheet, dated 10/19/23, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), bipolar disorder (mental illness that causes unusual shifts in mood, ranging from extreme highs to extreme lows), and legal blindness. Review of Resident #255's electronic health records on 10/19/23 revealed that an initial MDS Assessment had not been completed and submitted by the facility as required. During an interview with the MDS Coordinator on 10/19/23 at 2:15PM, she stated she was responsible for completing Comprehensive MDS Assessments within 14 days of each resident's admission to the facility. She confirmed that Resident #254 and Resident #255's Comprehensive MDS Assessments had not been fully completed and submitted within the required timeframe, based on their admitted s. She stated she did not feel as though this posed a risk to resident care, but there could be a risk of delayed payment to the facility due to the Comprehensive MDS Assessments not being submitted within the required timeframes. Review of the facility's MDS Completion and Submission Timeframes policy, dated 07/2017, reflected, .Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 34 opportunities, resulting in an 5% percent medication error rate involving 1 (Resident #31) of 3 residents reviewed for pharmaceutical services. The facility failed to ensure LVN B did not crush and attempt to administer two medications, Metoprolol Succinate ER (extended-release, given for blood pressure) and potassium chloride ER (extended-release potassium supplement), which should not have been crushed. This failure could place the resident at risk for not receiving the therapeutic effect of their medication or cause a drug intended for slow release to be absorbed all at once resulting in potentially harmful side-effects. Findings included: Record review of Resident #31's Face Sheet dated 10/19/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including hypokalemia [low potassium level in the blood], and essential primary hypertension [high blood pressure]. Record review of Resident #31's MDS assessment dated [DATE] revealed she had a BIMS score of 10, indicating she had moderately impaired cognition, and had no swallowing disorders. Record review of Resident #31's Active Orders dated 10/18/23 revealed the following entries: .May crush crushable medication Dated 9/28/23. Potassium Chloride ER oral tablet Extended release 10 mEq Give 1 tablet by mouth four times a day related. to hypokalemia. Start date 10/03/2023. Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG give 1 tablet by mouth one time a day related to essential primary hypertension. Start date 10/03/2023. Observation and interviews on 10/18/23 at 7:34 AM revealed LVN B prepared multiple medications for administration for Resident #31 which included a potassium chloride ER 10 mEq tablet, and a metoprolol succinate ER 25 mg tablet. When the medications were brought into Resident #31's room, she informed LVN B she was getting her medications crushed and mixed in pudding at that time so she would not have to swallow so many pills. She told him there were a few she could swallow but wanted the others crushed. LVN B returned to his medication cart with the medications and stated he was confused because he had cared for this resident before and she did not get her medications crushed then. He explained he was not her usual charge nurse and was helping out that morning. LVN B stated he would check the orders to see which medications could be crushed. He utilized the computer on his cart and began checking her medication administration record. LVN C approached and was identified as the usual Charge Nurse for the hall and had arrived late that morning. The two LVNs discussed Resident #31 and LVN C confirmed she had been crushing medications for her and stated there was an order on her record. The order was pulled up which reflected May crush crushable medications. When asked how they determined which medications were crushable, LVN C stated she looked them up. She named a few of Resident #31's medications she knew should not be crushed but stated she did not have the list in front of her to know them all (the medications named did not include metoprolol or potassium). LVN C was observed walking away. LVN B was observed sorting the pills and removing only the medications named by LVN C and placing them in a separate medication cup. LVN B began crushing the other medications including the metoprolol ER and potassium ER tablets. He combined all the crushed medications and mixed them pudding for administration. LVN B administered the pills identified by LVN C as not crushable, Resident #31 swallowed them without difficulty. He was asked by this surveyor to stop before administering the crushed medications. Interview with LVN B revealed he knew ER meant extended-release and was a that type of medication that should not be crushed. He acknowledged he had crushed the metoprolol and potassium in error. He discarded the crushed medications. LVN B pulled new medications from the cart, checked them, then administered them appropriately. An interview with the DON on 10/18/23 at 8:41 AM revealed the facility had a list of medications that could not be crushed available to the nurses to help them determine if a medication could or could not be crushed. The DON stated, if there was any confusion at all, the nurses should have contacted the pharmacist or physician prior to administering the medications. She stated the staff had been trained on utilizing the lists. During an interview with the DON on 10/19/23 at 8:34 AM, the medication error rate was discussed. The interview revealed additional in-service trainings were being conducted with all nurses related to use of the Do Not Crush list. She ensured the list was available on all medication carts. The DON stated the risks associated with crushing extended-release medications included possible decrease in therapeutic effect and adverse outcomes for the resident as it could affect the rate of absorption of the medication. Interview with LVN B on 10/19/23 at 10:40 AM revealed he had received additional in-service training. He stated the risk of crushing extended-release medications included decreased therapeutic effect and the resident could receive too much medication all at once and cause harm. Record review of the facility's Medications Not To Be Crushed list dated 2002, rev 02/17 revealed the following medications were included: Metoprolol (extended release) tablet Reason: Time release formulation Potassium Chloride tablet Reason: Time release formulation Record review of the facility's policy, Medication Crushing Guidelines dated 2001 revealed: Medications that Should not be Crushed or Chewed-When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc.), the nurse administering the medication should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form, if possible. The rationale for not crushing some medications includes: .D. Timed Release Tablets are designed to release medication over a sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case, the medication should not be crushed

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 4 (Residents #1, #2, #3, and #4) of 12 residents reviewed for infection control. The facility failed to ensure LVN A and LVN B sanitized their hands and the blood pressure cuff between uses on Residents #1, #2, #3, and #4. This failure could place residents at risk of infectious disease. The findings included: Continuous observations on 05/04/2023 between at 10:09AM and 10:30AM revealed LVN A took the blood pressure cuff from the top of the medication card and placed it on Resident #1's wrist in 100 Hall. After taking the blood pressure reading, LVN A removed the cuff and placed it on top of the medication cart. LVN A then dispensed and administered Resident #1's medications. LVN A then took the blood pressure cuff and went to Resident #2's room and placed it on Resident #2's wrist. After taking the blood pressure reading, LVN A removed the cuff and placed it on top of the medication cart. LVN A then dispensed and administered Resident #2's medications. LVN A then went to Resident #3's room, took the blood pressure cuff from the top of the medication cart and placed it on Resident #3's wrist. After taking the blood pressure reading, LVN A removed the cuff and placed it on top of the medication cart. LVN A then dispensed and administered Resident #3's medications. LVN A did not sanitize his hands or the blood pressure cuff between care of Residents #1, #2, or #3. An observation on 05/04/2023 at 10:18AM revealed LVN B walking down 100 Hall with a blood pressure cuff on her right wrist. LVN B went to Resident #4's room and placed the same blood pressure cuff on Resident #4's wrist. After taking the blood pressure reading, LVN B removed the cuff and returned to the hall. LVN B did not sanitize her hands or the blood pressure cuff after taking it off her wrist and placing it on Resident #4's wrist. An interview on 05/04/2023 at 10:23AM with LVN B revealed she was taking resident #4's blood pressure. She stated she had the blood pressure cuff on her own wrist when she entered Resident #4's room. She said that she usually kept the cuff in her bag but had not brought the bag today. She stated she was assigned to 600 Hall and part of 100 Hall and came over to 100 Hall to take Resident #4's blood pressure. She said she had not sanitized the cuff or her hands after she removed the cuff from her wrist and before she placed it on Resident #4's wrist. She said the cuff would not be considered sanitized since she took it from her own wrist and placed it directly onto Resident #4. She said the cuff should be sanitized for use between residents to minimize the risk of cross-contamination or spreading infection. An interview on 05/04/2023 at 10:36AM with LVN A revealed he was assigned to 200 Hall and part of 100 hall. He said he did not sanitize his hands between dispensing and administration medications to Residents #1, #2, and #3. He stated he did not sanitize the blood pressure cuff or his hands between uses on Residents #1, #2, and #3. He stated the cuff should be sanitized between use on residents to prevent spreading infections. He said he should wash or sanitze his hands between providing care to residents. He said he had been trained in infection control practices but sanitizing the cuff was a standard precaution that should always be done. An interview on 05/04/2023 at 12:47PM with the ADON revealed staff should know to sanitize their hands and blood pressure cuffs between residents. She said this was important to limit the possible spread of infection. She stated good infection control practices were of particular importance because the facility had two residents on contact precautions with ESBL (Extended spectrum beta-lactamase). She said this was a difficult to treat bacteria. She said the facility also had one resident who was positive for COVID-19. She said although there was one resindent with ESBL on 100 Hall, they were not Resident #1, #2, #3, or #4. An interview on 05/04/2023 at 2:27PM with the Administrator revealed his expectation was that staff make every effort to minimize the spread of infections. He said he expected staff to follow the facility's policy which was to sanitize equipment between resident use and their hands. He said this was in place to limit a risk cross-contamination. He said he expected nurse management to ensure staff were trained in infection control policies and practice. An interview on 05/04/2023 at 3:05PM with the DON/IP revealed she expected staff to sanitize all equipment and their hands before and after contact with any resident to minimize the transmission of infections. She said this was the policy. She stated she had in-serviced staff on infection control in the past and they should know this. She said as the IP, she provides regular training to staff, and they were monitored the ADONs and charge nurses. She stated the facility had residents who were on both contact and droplet precautions making it more important for staff to understand proper infection control practices. Review of in-service records revealed staff were last in-service on Infection control standards on 03/09/2023. Review of the facility's policy dated September 2022 and titled Cleaning and Disinfecting of Resident-Care Items and Equipment revealed .Reusable items are cleaned and disinfected or sterilized between residents (e.g. stethoscopes, durable medical equipment) . Review of the facility's policy dated November 9, 2022, and titled Standard Precautions revealed .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .hand hygiene is performed with soap (anti-microbial or non-antimicrobial) or alcohol-based hand rub before and after contact with the resident .Resident-Care Equipment: reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed .

Based on observations, interviews and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of four halls reviewed for infection control. 1. Facility failed to ensure that visitors who visited a COVID-19 positive room were aware of the COVID-19 status and had appropriate PPE available and hand washing and doffing station available. 2. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination between residents' positive with COVID-19 and residents who were not positive for the virus. 3. The facility failed to ensure residents, especially those residents positive for COVID-19, were practicing social distancing and wearing appropriate PPE to help prevent the spread of COVID-19 to residents who were negative for COVID-19. 4. Facility allowed residents who were COVID-19 positive to comingle with residents who were COVID-19 negative on the memory care unit. These failures placed residents and staff at risk of contracting COVID-19 and increased infections which could decrease their psycho-social well-being and quality of life. An Immediate Jeopardy (IJ) was identified on 1/23/23 at 2:30 PM and the IJ template was provided to the facility Administrator on 1/23/23 at 3:30 PM. While the immediate jeopardy was lifted on 1/24/23 at 4:00 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Findings included: Review of face sheet of Resident #1 dated 1/24/23 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Dysphagia (difficulty swallowing); Hypertension (high blood pressure); Alzheimer's disease; COVID-19 (diagnosed on [DATE]). Resident #1 resides on the Facility's Memory Care Unit. Review of Face Sheet of Resident #2 dated 1/24/23 revealed she was an 83- year-old female who was admitted to the facility on [DATE] with diagnoses Cognitive Communication Deficit; Chronic Kidney Disease; Type 2 Diabetes Mellitus; Dehydration; COVID-19 (diagnosed on [DATE]). Review of Excel spreadsheet provided by Infection Preventionist, the DON (no date) with list of resident names and the date that each tested COVID-19 positive, along with the date of the last day of isolation. Included on the list was Resident #1 who tested COVID-19 positive on 1/16/23 and Resident #2 who tested COVID-19 positive on 1/14/23. The list contained 43 names of Facility residents who had tested COVID-19 positive from dates: 1/4/23 through 1/18/23. Observation on 1/23/23 at 8:35 AM revealed LVN B and CNA C were in the hallway of the memory care and four residents (unknown COVID-19 status) were walking in the hallway. None of the 4 residents in the hallway had masks on. LVN B and CNA C were not donned in full PPE. LVN B had her masks (KN95 on top of a surgical mask) below her nose. CNA C had a N95 mask on as she walked a resident to the dining room by holding her arm. Observation on 1/23/23 at 9:18 AM Family Member exited the room of a COVID-19 positive resident (Resident #2) who was not on the Memory Care Unit, family member removed his PPE in the hallway and then asked surveyor where he was supposed to throw the PPE away at. Family Member walked to the nurses' station with used PPE in hand and handed it to LVN C. LVN C asked him if he had washed his hands before leaving the room and he replied no. Family Member then exited the facility. Observation and interview on 1/23/23 at 10:00 AM of a Family Member at the memory care unit doors wearing a surgical mask below her nose. Family Member entered the memory care unit and did not don full PPE proceeded to the dining room where her family member (Resident #1) was sitting at a table with other residents. Family Member overheard surveyor and LVN B discussing who was COVID positive in which family member (pushing Resident #1 down the hallway) asked if her family member (Resident #1) was COVID positive and LVN B stated yes. Observation and interview on 1/23/23 at 10:05 AM LVN B located in the hallway of the Memory Care Unit wearing a KN95 mask (loose fitting) over a surgical mask (both below her nose). LVN B stated when she came in at 6:00 AM there were no isolation carts on the Memory Care Unit; then someone (unknown) had brought over the isolation carts a little bit ago, by then she (LVN B) had already been exposed so no reason to don PPE at that point. Observation and interview on 1/23/23 at 10:15 AM revealed there was no doffing station or hand washing area prior to exiting the memory care unit. CNA C stated that surveyor could doff her PPE and wash her hands in there (she pointed to a locked door at the end of the memory care unit). LVN B overheard and unlocked the door and stated that the Surveyor could doff her PPE and wash her hands in the sink in the room. This room appeared to be a hopper room with 3 barrels (2 dirty clothes/linen and 1 trash). Interview on 1/23/23 at 10:16 AM with LVN B and CNA C who stated they each wash their hands in the same locked room and when they have to exit the memory care unit, they do so through the main doors which exits into the main section of the facility (cold halls). CNA C stated that when she removed dirty linen or trash from the memory care unit, she would exit through the main memory care doors into the facility and exit the door at the end of hall 300 (cold hall). CNA C stated that she thought it would be easier and better to exit the memory care unit to the outside so she would not have to go through the cold halls. Review of a Provider investigation Report, facility in-service (training) dated 1/5/23 reflected, Topic: PPE requirements in the facility. Summary of in-service: Full PPE (N95 mask, gloves, gown, eye protection) is required in all HOT (COVID-19 positive rooms) and warm (Covid-19 suspected rooms). There were no staff signatures on the in-service. Facility Policy attached to in-service page 31 revealed Full PPE is required for healthcare personnel working inside the Isolation (COVID-19 positive) zone and Quarantine (unknown COVID-19) zone CDC Guidance. KN95respirators should not be used as part of the PPE while working in Isolation or Quarantine zones. Observation on 1/23/23 at 10:10 AM revealed 2 female residents walking in the hallway of the memory care unit neither were wearing a mask. There were no residents in their rooms, the remaining residents were seated in the dining room / common area. Residents were seated within 1-2 feet of each other while at the tables. Interview on 1/23/23 at 10:12 AM LVN B and CNA C stated they were unsure which residents were COVID-19 positive on the memory care unit and that they did not have PPE isolation carts on the memory care hallway until after 9 something this morning (1/23/23). Interview on 1/23/23 at 10:18 AM Administrator stated the Central Supply person was responsible for restocking isolation carts in the facility. Interview on 1/23/23 at 9:57 AM Wound Care Nurse stated she has gone to the memory care unit every day but did not know who on the unit was COVID-19 positive; just that there were positive residents on the memory care unit. The Wound Care Nurse stated that staff and visitors should don their PPE at the door of the resident they are going in to see. Interview on 1/23/23 at 11:02 AM the Receptionist stated she did not ask who the visitor was going to see as that was a HIPAA violation. The Receptionist stated that she made sure every visitor was screened in and that they take their temperature. The Receptionist said that she received a list every day that had the residents who were COVID-19 positive. The Receptionist showed the Surveyor a list which revealed the residents on the rehab hall were all COVID positive but none on the memory care were listed as COVID-19 positive. Review of Facility's COVID-19 Implementation and Guidance Policy page 2 reflected Prevention of spreading germs within the facilities: Isolation: Post signs on each resident door of what type of precautions they are on and to see the nurse prior to entering the room PPE outside of resident rooms to include facemasks, eye protection, gowns, and gloves (as indicated) Position trash cans with red bags (two) one for linen and one for trash in the resident's room. Review of the Facility policy on Isolation-Initiating Transmission-Based Precautions, with a revision date of August 2019, revealed, Policy Interpretation and Implementation reflected, When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee): a. Clearly identified the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used. b. Explains to the resident (or representative) the reason(s) for the precautions. c. Provides and/or oversees the education of the resident . d. Determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. 1. The signage informs the staff of the type of CDC precautions(s), instructions for use of PPE, and/or instructions to see the nurse before entering the room. e. Ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. Review of COVID-19 Implementation and Guidance facility policy page 2 (no date) Prevention of spreading of germs within the facilities: Isolation: Post signs on each resident door of what type of precautions they are on and to the nurse prior to entering the room. PPE outside of resident rooms to include facemask, eye protection, gowns, and gloves (as indicated) Position trash cans with red bags (tow0 one for linen and one for trash in the resident's room. Review of the CDC website accessed on 2/7/22 revealed that for Personal Protective Equipment: HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the CDC website accessed on 2/7/22 revealed that in regards to visitation of a resident with confirmed COVID-19, Visitation For the safety of the visitor, in general, patients should be encouraged to limit in-person visitation while they are infectious. However, facilities should adhere to local, territorial, tribal, state, and federal regulations related to visitation. o Counsel patients and their visitor(s) about the risks of an in-person visit. o Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets, when appropriate. Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. Visitors should be instructed to only visit the patient room. They should minimize their time spent in other locations in the facility. On 1/23/23 at 3:30 PM, The Administrator was notified that an Immediate Jeopardy had been identified and a Plan of Removal was requested. The Facility's Plan of Removal (as followed) was accepted 1/24/23 at 11:50 AM. *Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. The response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance. 3. 1. The facility which was in COVID-19 outbreak 43 residents of 106 and 17 of 93 staff members had a positive COVID-19 status failed to ensure postings were on the front door alerting facility had COVID positive in the facility. Facility Postings were added to the front door of the facility which read We are experiencing active Covid-19 throughout our facility. Please screen and wear the proper PPE. For further questions you may reach out to our staff. This process will be overseen by Administrator/Designee. This plan of removal will be completed by 1/23/23. 2. Facility failed to ensure that visitors who visited a COVID positive room were aware of the COVID + status and had appropriate PPE available and hand washing and doffing station available. Facility ensured proper signage was in place on resident room doors alerting visitors of isolation rooms as well as to don/doff proper PPE before entering/exiting rooms. The Administrator/Designee will oversee this process. This plan of removal will be completed by 1/23/23 3. Facility failed to have PPE/ isolation carts outside rooms of COVID positive residents on the memory care unit. PPE/Isolation carts were moved outside of the memory care unit to allow staff/visitors to don PPE prior to entering the memory care unit. The Administrator/Designee will oversee this process to ensure that isolation carts are available to don PPE prior to entering the Covid-19 positive unit. This plan of removal will be completed by 1/23/23 4. Facility failed to ensure staff who were assigned to work with COVID positive residents knew who was positive and had PPE available. Staff were not wearing masks appropriately by wearing KN95/surgical mask under their nose. In-services were completed with all nursing staff regarding Proper Reporting to Oncoming shift Regarding Covid (+) Residents. As well as all staff in-servicing on Proper Mask Placement with all staff. The DON/Designee will conduct in-servicing. The Administrator/designee will ensure all staff in-servicing is completed. All 24-hour reports were reviewed and updated to reflect Covid (+) residents. This plan of removal will be completed by 1/23/23 5. Facility failed to isolate or attempt to isolate residents who were COVID positive on the memory care unit. Staff were in-serviced on separating Covid-19 positive residents from non-covid 19 positive residents. Staff were instructed to frequently educate and redirect residents to remain separated from other residents. The DON/Designee will conduct in-servicing. The Administrator/designee will ensure all staff in-servicing is completed. This plan of removal will be completed by 1/23/23 6. Facility allowed residents who were COVID positive to comingle with residents who were COVID negative on the memory care unit. Staff in-servicing was completed to attempt to keep residents isolated in their rooms away from each other. Staff were instructed to frequently educate and redirect residents to remain separated to not comingle. The DON/Designee will conduct in-servicing. The Administrator/designee will ensure all staff in-servicing is completed. This plan of removal will be completed by 1/23/23. Monitoring following IJ: Interview on 1/24/23 at 1:18 PM the Administrator revealed that the receptionist was asking visitors who they were to see and informing them if that resident was COVID-19 positive and if so then she (The Receptionist) would be advising them to wear PPE and wash their hands. The Administrator stated that he was reviewing all the in-services(training) on Isolation and PPE and ensuring that all staff had signed them. He stated he did not think the redirection of residents on the Memory Care unit would be 100% effective but more effective than no redirection at all. Interview on 1/24/23 at 1:28 PM the Receptionist stated she had been in-serviced (trained) on doing a thorough screening of visitors to the facility. She stated that she reiterated handwashing protocols when someone was visiting a COVID positive resident. The Receptionist stated that when a visitor was visiting a resident that they might see signage on the door to see the nurse. They were told that they should wear appropriate PPE that was supplied next to the residents' door. Observation on 1/24/23 at 1:34 PM revealed 7 rooms on the Rehab Hall which residents reside who were COVID-19 positive. There was signage on each door reflecting Please see nurse and PPE. There was an isolation/PPE cart located beside each of the 7 doors on the Rehab Hall. Interviews on 1/24/22 9 nurses and 13 CNAs from shifts 6:00 AM-2:00 PM and 2:00 PM-10:00 PM who stated that they had been in-serviced (trained) on the correct PPE to wear in a HOT (COVID-19 positive) area of the facility. The staff stated that they knew to notify visitors of COVID positive residents and what PPE they should wear and the hand washing protocols when exiting a COVID positive area. The staff on the Memory Care unit stated that they were taught (in serviced/trained) to assist in redirecting the residents and attempted to social distance the residents. The nurses and CNAs were taught to complete a shift- to- shift report so that all staff knew what residents COVID-19 positive and which residents were COVID-19 negative. An Immediate Jeopardy (IJ) was identified on 1/23/23 at 2:30 PM and provided to the facility Administrator on 1/23/23 at 3:30 PM. While the immediate jeopardy was lifted on 1/24/23 at 4:00 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for one of 5 residents (Resident #1) reviewed for changes in condition . LVN A failed to notify Resident #1's physician of her change in condition on [DATE] when she was identified as having a high blood sugar of 411. Glucose builds up in the blood if there is not enough insulin to move glucose into your cells. During an episode of ketoacidosis, it is common for blood sugar to rise to a level over 400 milligrams per deciliter. When blood sugar levels are so high, some sugar overflows into the urine which can become a medical emergency.) This failure could place residents at risk of their physician not being aware of incidents involving a change in their medical condition. Findings include: Record review of Resident #1's MDS assessment, dated [DATE], reflected the resident was an [AGE] year-old-female with an admitted to the facility of [DATE]. Her diagnoses included diabetes and hip fracture. Her cognitive status was not impaired. Record review of Resident #1's Care Plan, dated [DATE], reflected: Resident has a diagnosis of diabetes. Facility interventions included monitor for hypo/hyperglycemia (low and high blood sugar), diaphoresis (sweating), excessive thirst, seizures, and altered mental status. Notify Physician as needed. Record review of Resident #1's Physician Orders, dated [DATE], reflected: Fingerstick Blood Sugar every morning at 7:00 AM. There were no ordered parameters for physician notification of blood sugars. Glipizide (medication to treat diabetes) 5 milligrams daily Farxiga (medication to treat diabetes) 10 milligrams daily Record review of Resident #1's MARs, dated [DATE], reflected: Fingerstick Blood Sugar every morning at 7:00 AM [DATE] Blood sugar 120 [DATE] Blood sugar 122 [DATE] Blood sugar 411 Record review of Resident #1's progress notes reflected the following: On [DATE] at 10:58 AM Blood pressure ,d+[DATE], pulse 90, Temperature 97.7 degrees Fahrenheit. Resident is alert and continues yelling help. Resident does not verbalize what kind of help is needed. Reposition/distraction provided with some positive effect. Finger stick blood sugar of 411 this AM. Physician was notified . Pending response. Resident remains resting in bed at this time with no apparent signs of distress. Call light within reach. - written by LVN A. Record review of Resident #1's Hospital Notes, dated [DATE], reflected: [AGE] year-old female recently admitted and was unresponsive when brought to the emergency room . Evaluation revealed sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death) and a blood glucose of about 400. On [DATE] at 3:56 AM Resident not breathing, no vital signs, on-call ADON notified. Hospice notified. Time of death pronounced by Hospice. - Written by LVN E. Record review of websitehttps://www.cdc.gov/diabetes/basics/getting-tested .htmon [DATE] reflected: A fasting blood sugar level of 99 mg/dL or lower is normal, 100 to 125 mg/dL indicates you have prediabetes, and 126 mg/dL or higher indicates you have diabetes. An interview with LVN A on [DATE] at 12:45 PM revealed she notified the physician of the resident's blood sugar of 411 the morning of [DATE] . She said she never received a response and did not attempt to contact him again regarding the blood sugar. LVN A said later in the afternoon she notified the physician and sent the resident to the hospital because the resident was not as responsive as usual. She said there was not a policy that told her how long she was supposed to wait to get a physician response before trying to contact them again for a change in condition. She said she did not remember who the physician was . An interview on [DATE] at 2:00 PM with ADON B revealed on [DATE] Resident #1 had high blood sugars and was sent out to the hospital for lethargy. She said the physician should have been notified for the resident's blood sugar level of 411 at 7:00 AM on [DATE] and a nurse should not wait for more than ,d+[DATE] minutes to get a response back especially if the resident continued to decline . An interview on [DATE] at 2:00 PM with ADON C revealed she did not work on [DATE]. She said if a resident had a blood sugar of 411, the physician was supposed to be contacted . ADON C said the physician for Resident #1 always responded pretty fast. An interview on [DATE] at 3:18 PM with the Physician revealed he did not receive a message on [DATE] for Resident #1's blood sugar of 411. He said he was not contacted until 4:50 PM on [DATE] when the resident was sent to the hospital for unresponsiveness, a low blood pressure (,d+[DATE]), and a high pulse rate (114). He said he was supposed to be notified for changes in condition. He said he was more concernced about the resident's unstable vital signs than the elevated blood sugar. An interview on [DATE] at 1:38 PM with the DON revealed Resident #1 was sent to the hospital and expired on Hospice at the facility. She said she did not know the resident had a blood sugar of 411 the morning of [DATE]. She said the physician should have been contacted and a reasonable time to wait for a physician response was ,d+[DATE] minutes. Record review of the facility's Policy and Procedure for, change in a Resident's Condition or status, dated [DATE], reflected: 2. A. A 'significant change ' of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions [is not self-limiting] Record review of the facility's Guidelines for Notifying Physicians of Clinical Problems, dated [DATE], reflected: These guidelines are intended to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and that 2) all significant changes in resident/patient status are assessed and documented in the medical record .Immediate Notification (Acute) Problem .3. Sudden in onset or a marked change compared to usual [baseline status] status and are b. unrelieved by measures which have already been prescribed and/or attempted.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 residents (Residents #1) reviewed in that: The facility failed to allow Resident #1 The right to retain and use personal possessions, .including clothing This failure could place residents at risk of emotional distress, feelings of disrespect and lack of dignity. Findings included: Review of Resident #1's face sheet dated 9/21/22 revealed she was a [AGE] year-old female who was admitted to the facility memory care unit on 5/10/22 with diagnoses of asthma (illness that affects the movement of air through the lungs); Alzheimer's disease (disease that affects the memory); low back pain; pain in the right foot; Gastroesophageal Reflux Disease (stomach contents backing up into the tube that flows from mouth to stomach; Dysuria (painful urination); Hallucinations (perception that something is seen that is not present). Review of Resident #1's care plan dated 9/21/22 revealed Problem/Need: Resident has a DX of Alzheimer's and is on medications and requires assistance with decision making; Goal: Resident will be assisted with decision making as needed and will have no serious side effects; Approaches: Assist with decision making as needed, allow choices whenever possible. Review of Resident #1's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 99; indicative of unable to complete the exam due to severe cognition deficit. Section G bullet G. of MDS under Activities of Daily Living Resident #1 scored 2 indicative of needing one-person physical assist for dressing. Observation on 9/21/22 at 12:09 PM Resident #1's room contained a bed and a small bedside table. There were no articles of clothing in the drawers of the table and there were no articles of clothing in Resident #1's closet. Interview with ADON A on 9/21/22 at 12:12 PM revealed that facility staff remove all of Resident #1's clothes from her room and place them in a locked office due to Resident #1 having had issues with putting on all of her clothes and then the facility staff could not determine what articles of clothing were clean and which were dirty. [Resident #1] puts on the clothes then takes them off and throws them in the floor; so, they (facility staff) are just trying to make sure she had some clean clothes. She said that there are usually a couple of sets of clothes in her room. ADON A stated that there are no other residents that their personal belongings such as clothes have been removed from their room. She said that Resident #1's Family Member told the facility to leave a few sets in her room. ADON A said she is unsure why Resident #1 did not have any clothes in her room on the morning of 9/21/22. Observation and interview on 9/21/22 at 12:24 PM, of the closet off the dining room in the memory care unit. The closet door was locked and ADON A unlocked the closet with a key in which there were several shirts and pants hanging on hooks on the walls. ADON A stated that all of the clothes in the closet belonged to Resident #1. Interview with DON on 9/21/22 at 12:28 PM revealed she recalled a conversation with Resident #1's Family Member regarding Resident #1 not having access to her clothing. DON stated that she had told Resident #1's Family Member had complained about Resident #1 not having a change of clothes in her closet, in which the DON told her that the clothes are readily available in a locked closet in the memory care unit. DON said that after the conversation with Resident #1's granddaughter that the facility would ensure there were a couple of sets of clothes in the closet for Resident #1 to change into if she wanted. DON said the problem with leaving all the clothes in Resident #'1 closet is that she would try to put several outfits on at one time. Interview with Resident #1's Family Member on 9/21/22 at 1:20 PM, who stated that when she had come to visit Resident #1 on 9/04/22, Resident #1 was soiled from blood due to her fall on 9/03/22. The Family member cleaned Resident #1 then had to ask for a change of clothes as there were none in the room. She said she was told by the facility staff (unknown name of aide) that the reason her clothes were removed from her room was because she would just change her clothes all the time. The staff that were working on that day 9/4/22 said that they did not know where her clothes were kept. Resident #1's Family Member stated that she did nott think it was a problem for Resident #1 to continually change her clothes as it kept her content and happy, as it was her entertainment. She said that she thought Resident #1 could spend hours changing her clothes. Facility staff had told her that they (facility staff) could not keep up with what was clean and what was dirty. Resident #1's Family Member said that if this was the case then she never minded doing all of Resident #1's laundry if she had clothes to put on. Resident #'s Family Member said that she thought that Resident #1 could spends hours changing clothes, she would sometimes lay clothing that she had taken off on her bed but then would put it back on a bit later. She had never been told that Resident #1 would wear several shirts or pants causing a fall risk; just that she changes so often, and they could keep up with what was clean and dirty. Resident #1's Family Member stated that she was not aware of where to locate Resident Rights in the facility; but she does think Resident #1's rights are not being observed because she enjoyed changing clothes. Review of Facility Grievance dated 9/5/22 filed by Resident #1's Family Member and received by DON. Resident #1's Family Member filed a grievance with one of the concerns regarding why Resident #1's clothes were not available in her room. Actions taken to resolve the grievance: 8. Resident will have a change of clothes in her closet. The clothes had been in the office of the secured unit, as resident would frequently change clothes and/or try to put on multiple items at the same time. This grievance was marked as resolved on 9/9/22 by DON and ADON A. Interview with Administrator on 9/21/22 at 2:31 PM who stated that he had reviewed the grievance field by Resident #1's Family Member. He said that he had heard that Resident #1 had tried to put on multiple clothes and that would be a safety concern. Administrator said that Resident #1's clothes were kept somewhere on the memory care unit so that the staff would have access to them as needed. He said that if the resident were just changing clothes frequently that would be fine, but if she was putting on multiple clothes at one time, this could have impeded her gait and it could be a fall risk. Administrator stated that any behaviors such as Resident #1 had with changing clothes frequently should be care planned. Interview on 9/21/22 at 3:37 PM with Social Worker who said that he did not recall ever having conversations during care plan meetings regarding Resident #1's clothes. He said that he does think it is the Resident's right to have her clothes and to change them frequently if she chose to do so. Interview with ADON A on 9/21/22 at 4:20 PM who stated that Resident #1 urinates in her clothes then would throw the dirty clothes on the floor or the bed and then facility staff would not know which clothes were clean and which were dirty. ADON A said that she thought Resident #1 had anxiety and this would be the reason she changed clothes frequently. She said there was no harm in Resident #1 changing clothes frequently, only that Resident #1 would run out of clothes due to the clothes going to the laundry and not have had time to wash and return the clothes. ADON A stated that it is the resident's right to have clothes and change them frequently, but it was also the resident's right to not wear wet clothes or a hospital gown. She said that she thought it was a fixation by Resident #1 changing clothes often. ADON A said, once clothes are on the floor staff would not know if they were clean or dirty. She said she didn't think it was a problem with Resident #1 layering her clothes sine she had not had a fall due to her layering her clothes. ADON A said that she tried to use the same agency staff on the memory care unit and that way they (agency staff) knew where Resident #1's clothes were being kept. Interview with CNA B on 9/21/22 at 4:48 PM who stated that she worked the memory care unit at the facility. She said that she was very familiar with Resident #1. She said that Resident #1 likes to go into other resident's room and get their clothes and put them on. CNA B said that Resident #1 had recently had a urinary tract infection and that her clothes used to be in her closet until she got the infection then her clothes were moved out of her closet. CNA B said that Resident #1 would put clean clothes on and take them off them put them back on and that it would be a problem due to her infection. She said that it would be a problem because her dirty clothes would be mixed with her clean clothes. CNA B said about a month ago she saw that [Resident #1]'s clothes had been moved to a closet on the memory unit; she said she had been told by the off-going CNA that Resident #1's clothes were removed from her room because facility staff couldn't determine what was clean and what was dirty because she (Resident #1) would change clothes so often. Interview on 9/21/22 at 5:48 PM with Resident #1's RP. He stated that he was aware that Resident #1's clothes had been taken out of her room. He said that he was told that her clothes had been removed because she was constantly changing clothes. Resident #1's RP said that he didn't not think it hurt anything for Resident #1 to change her clothes all the time. Resident #1's RP said he thought it was Resident #1's right to have her clothes in her room if she so desires. Review of Resident #1's progress notes dated 9/01/22 through 9/21/22 and there was no mention of Resident #1 exhibiting behaviors of changing clothes frequently. Review of facility's Resident Rights policy with a revision date of December 2016 titled Resident Rights Policy Interpretation and Implementation page 1 bullet point ee. Retain and use personal possessions to the maximum extent that space and safety permit.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for one (Resident #1) of 6 residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #1's behaviors (changing clothes frequently). This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident #1's face sheet dated 9/21/22 revealed she was a [AGE] year-old female who was admitted to the facility memory care unit on 5/10/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's care plan dated 9/21/22 revealed Problem/Need: Resident has a DX of Alzheimer's and is om medications and ma require assistance with decision making; Goal: Resident will be assisted with decision making as needed and will have no serious side effects; Approaches: Assist with decision making as needed, allow choices whenever possible. Review of Resident #1's MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 99; indicative of unable to complete the exam due to severe cognition deficit. Section G bullet G. of MDS under Activities of Daily Living Resident #1 scored 2 indicative of needing one-person physical assist for dressing. Observation on 9/21/22 at 12:09 PM Resident #1's room contained a bed and a small bedside table. There were no articles of clothing in the drawers of thetable and there were no articles of clothing in Resident #1's closet. Interview with ADON A on 9/21/22 at 12:12 PM revealed that facility staff remove all of Resident #1's clothes from her room and place them in a locked office due to Resident #1 having had issues with putting on all of her clothes and then the facility staff could not determine what articles of clothing were clean and which were dirty. [Resident #1] puts on the clothes then takes them off and throws them in the floor; so, they (facility staff) are just trying to make sure she had some clean clothes. She said that there are usually a couple of sets of clothes in her room. ADON A stated that there are no other residents that their personal belongings such as clothes have been removed from their room. She said that Resident #1's Family Member told the facility to leave a few sets in her room. ADON A said she is unsure why Resident #1 did not have any clothes in her room on the morning of 9/21/22. Observation and interview on 9/21/22 at 12:24 PM, closet off of the dining room in the memory care unit. The closet door was locked and ADON A unlocked the closet with a key in which there were several shirts and pants hanging on hooks on the walls. ADON A stated that all the clothes in the closet belonged to Resident #1. Interview with DON on 9/21/22 at 12:28 PM revealed she recalled a conversation with Resident #1's Family Member regarding Resident #1 not having access to her clothing. DON stated that she had told Resident #1's Family Member had complained about Resident #1 not having a change of clothes in her closet, in which the DON told her that the clothes are readily available in a locked closet in the memory care unit. DON said that after the conversation with Resident #1's Family Member that the facility would ensure there were a couple of sets of clothes in the closet for Resident #1 to change into if she wanted. DON said the problem with leaving all the clothes in Resident #'1 closet is that she would try to put several outfits on at one time. Interview with Resident #1's Family Member on 9/21/22 at 1:20 PM, who stated that when she had come to visit Resident #1 on 9/4/22, Resident #1 was soiled from blood due to her fall on 9/3/22. The Family Member cleaned Resident #1 then had to ask for a change of clothes as there were none in the room. She said she was told by the facility staff (unknown name of aide) that the reason her clothes were removed from her room was because she would just change her clothes all the time. The staff that were working on that day 9/4/22 said that they did not know where her clothes were kept. Resident #1's Family Member stated that she didn't think it was a problem for Resident #1 to continually change her clothes as it kept her content and happy, as it was her entertainment. She said that she thought Resident #1 could spend hours changing her clothes. Facility staff had told her that they (facility staff) could not keep up with what was clean and what was dirty. Resident #1's Family Member said that if this was the case then she never minded doing all of Resident #1's laundry if she had clothes to put on. Resident #'s 1 Family Member said that she thought that Resident #1 could spends hours changing clothes, she would sometimes lay clothing that she had taken off on her bed but then would put it back on a bit later. She had never been told that Resident #1 would wear several shirts or pants causing a fall risk; just that she changes so often, and they could keep up with what was clean and dirty. Resident #1's Family Member stated that she was not aware of where to locate Resident Rights in the facility; but she does think Resident #1's rights are not being observed because she enjoyed changing clothes. Review of Facility Grievance dated 9/5/22 filed by Resident #1's Family Member and received by DON. Resident #1's Family Member filed a grievance with one of the concerns regarding why Resident #1's clothes were not available not her room. Actions taken to resolve the grievance: 8. Resident will have a change of clothes in her closet. The clothes had been in the office of the secured unit, as resident would frequently change clothes and/or try to put on multiple items at the same time. This grievance was marked as resolved on 9/9/22 by DON and ADON A. Interview with Administrator on 9/21/22 at 2:31 PM who stated that he had reviewed the grievance field by Resident #1's Family Member. He said that he had heard that Resident #1 had tried to put on multiple clothes and that would be a safety concern. Administrator said that Resident #1's clothes were kept somewhere on the memory care unit so that the staff would have access to them as needed. He said that if the resident were just changing clothes frequently but if she was putting on multiple clothes at one time, he could impede her gait and it could be a fall risk. Administrator stated that any behaviors such as Resident #1 had with changing clothes frequently should be care planned. Interview on 9/21/22 at 3:37 PM with Social Worker who said that he did not recall ever having conversations during care plan meetings regarding Resident #1's clothes. She said he does think it is the Resident's right to have her clothes and to change them frequently if she chose to do so. Interview with ADON A on 9/21/22 at 4:20 PM who stated that Resident #1 urinates in her clothes then she would them on the floor or the bed and then facility staff would not know which clothes were clean and which were dirty. ADON A said that she thought Resident #1 had anxiety and this would be the reason she changed clothes frequently. She said there was no harm in Resident #1 changing clothes frequently, only that Resident #1 would run out of clothes due to the clothes going to the laundry and not have had time to wash and return the clothes. ADON A stated that it is the resident's right to have clothes and change them frequently, but it was also the resident's right to not wear wet clothes or a hospital gown. She said that she thought it was a fixation by Resident #1 changing clothes often. ADON A said, once clothes are on the floor staff would not know if they were clean or dirty. She said she didn't think it was a problem with Resident #1 layering her clothes sine she had not had a fall due to her layering her clothes. ADON A said that she tried to use the same agency staff on the memory care unit and that way they (agency staff) knew where Resident #1's clothes were being kept. Interview with CNA B on 9/21/22 at 4:48 PM who stated that she worked the memory care unit at the facility. She said that she was very familiar with Resident #1. She said that Resident #1 likes to go into other resident's room and get their clothes and put them on. CNA B said that Resident #1 had recently had a urinary tract infection and that her clothes used to be in her closet until she got the infection then her clothes were moved out of her closet. CNA B said that Resident #1 would put clean clothes on and take them off them put them back on and that it would be a problem due to her infection. She said that it would be a problem because her clean clothes would be mixed with her clean clothes. CNA B said about a month ago she saw that [Resident #1]'s clothes had been moved to a closet on the memory unit; she said she had been told by the off-going CNA that Resident #1's clothes were removed from her room because facility staff couldn't determine what was clean and what was dirty because she (Resident #1) would change clothes so often. Interview on 9/21/22 at 4:36 PM with MDS C who stated she was responsible for ensuring Resident #1's care plan was up to date. She also stated that they (facility) had just had a care plan earlier in the day (9/21/22). MDS C said that she updates care plans at least quarterly or PRN for all residents who are skilled. MDS C said that Resident #1 was a skilled resident. She said that she had become aware today (9/21/22) of Resident #1 putting on a bunch of clothes at one time. She was told to put it on the care plane today (9/21/22) by Administrator. MDS C said that Resident #1 should not have her clothes removed from her room at all times; except when she is exhibiting behaviors such as putting on several clothes at one time. She stated that when a care plan was updated it would have the updated dated on the care plan. She was unsure why the behavior of Resident #1 was not included in the latest care plan. Interview on 9/21/22 at 5:48 PM with Resident #1's RP. He stated that he was aware that Resident #1's clothes had been taken out of her room. He said that he was told that her clothes had been removed because she was constantly changing clothes. Resident #1's husband said that he didn't not think it hurt anything for Resident #1 to change her clothes all the time. Resident #1's husband said he thought it was Resident #1's right to have her clothes in her room if she so desires. He said that he had attended two care plan meetings but had no attended the care plan meeting on 9/21/22. Resident #1's husband said that she had never had a care plan meeting about her clothes; and that he also had never received a copy of her care plan. Review of Facility policy titled Care Plans - Baseline dated June 16, 2022, revealed 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; d. Any updated information based on the details of the comprehensive care plan. Review of Facility policy titled Care Plans Comprehensive Person Centered dated December 2016; Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practices for one (Resident #49) of one resident reviewed for [CONDITION(S)] care who was providing her own [CONDITION(S)] care, and 3 of 3 (LVN C, LVN D, LVN E) staff members reviewed for [CONDITION(S)] care were not aware of how to perform [CONDITION(S)] care and suctioning. 1. The facility failed to ensure emergency respiratory interventions for Resident # 49 with a [CONDITION(S)] were at Resident #49's bedside; oxygen, suction and replacement cannula. As a result, Resident #49 went into respiratory distress on 08/16/2022 at 1:30 PM. 2. The facility failed to complete respiratory equipment maintenance. 3. On 08/16/2022 at 1:30 PM, LVN C failed to assess Resident #49's respiratory system while the resident was in respiratory distress. An Immediate Jeopardy (IJ) was found on 08/16/2022. While the IJ was removed on 08/18/2022, the facility remained out of compliance at a severity level of the potential for more than minimal harm, and a scope of isolated due to the facility's need to monitor the effectiveness of the corrective systems. These failures could affect residents with a [CONDITION(S)] by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. Findings included: Review of Resident #49's face sheet, dated 08/16/2022, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It causes weakness, problems with muscle control, and muscle stiffness. The degree of [CONDITION(S)] symptoms vary depending on the location and extent of the injury), unspecified cough, dyspnea (difficult or labored breathing), [CONDITION(S)] (a chronic [CONDITION(S)] lung disease that causes obstructed airflow from the lungs). and hyperventilation (rapid or deep breathing, usually caused by anxiety or panic). Review of website https://medlineplus.gov/ency/article/ 5.htm reflected, A [CONDITION(S)] is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a [CONDITION(S)] tube or [CONDITION(S)] tube. (Retrieved on 08/26/2022). Review of Resident #49's annual MDS assessment, dated 06/23/2022, reflected Resident #49 had a [CONDITION(S)]. The BIMS score was 15 indicating Resident #49 was cognitively intact. The resident was clearly understood by others and had a clear understanding of others communicating with her verbally. Review of Resident #49's Care Plan, dated 07/22/2022, reflected Resident #49 had a [CONDITION(S)] and was at increased risk for upper respiratory infections. The care plan indicated At time resident will manipulate her oxygen concentrator to the setting she thinks she needs, order for 2-4 continuous. Nurse to be present during [CONDITION(S)] care to monitor and redirect as needed. EMS supplies are to be assessed every shift---Ambu bag and mask at bedside, spare, and stepdown trachs, suction tuning, [CONDITION(S)] kits, sterile water and [MEDICATION(S)], saline bullets, suction catheters, and [MEDICATION(S)], and any other supplies needed at bedside. Full [CONDITION(S)] assessment to be done every shift: secure and patent, document any breakdowns or red areas. Change [CONDITION(S)] every month and PRN for airway maintenance, assist pt with [CONDITION(S)] care as needed. Vital signs qshift and prn, include 02 sats and lung sounds, administer medication as ordered, administer respiratory treatments as ordered, concentrator filters to be changed weekly, notify MD as needed. Review of Resident #49's February 2022 Physician' Order Sheet with an order date of 02/21/22, reflected to provide [CONDITION(S)] care daily. Observation on 08/16/22 at 1:00 PM revealed Resident #49 was sitting on the side of her bed with a [CONDITION(S)] in place. There were no inner cannulas at the bedside, and the suction machine was on the floor, at the foot of the resident's bed, unplugged. An emergency replacement inner cannula was not inside the resident's room. The preventative maintenance on the concentrator was due in March 2017. The oxygen concentrator was set at 2 liters per minute (LPM). An Interview on 8/16/22 at 1:30 PM revealed Resident #49 performed her own [CONDITION(S)] care, and had experienced shortness of breath continuously while coughing, a throbbing headache, and occasionally felt like she would pass out after coughing. Resident # 49 said she felt dizzy, but she had not informed the staff because she was unsure of the cause. Resident # 49 said she felt dizzy when the oxygen was at 2 LPM. Resident #49 said at least 4 LPM would prevent symptoms such as dizziness. Resident #49 said she had not been educated on proper [CONDITION(S)] care and the worst outcome that had occurred due to lack of [CONDITION(S)] care was respiratory failure twice recently at the facility since she had been admitted 1.5 years ago. Resident #49 said she had not been assessed by a respiratory therapist since she was admitted to the facility on [DATE]. Resident # 49 said the staff at the facility had not been involved with her [CONDITION(S)] care because they had not been trained. Resident #49 said the [CONDITION(S)] had been placed approximately 9 years ago. Resident #49 began to experience respiratory distress during the interview to include her face turning red, coughing extensively and her upper torso thrusting in attempt to gasp for more air. Resident # 49 pushed the call light for assistance, and LVN C entered the room and checked her oxygen level with a pulse oximeter. LVN C assessed the oxygen concentrator, determined it was not working properly, and switched it off/on. LVN C put the pulse oximeter on the finger of the resident and said the pulse oximeter on the resident said it was low at 92. LVN C left the room. Immediately afterwards, the resident began coughing, was unable to speak and held her neck. LVN C returned to Resident # 49's room, checked the concentrator, the tubing, and checked the oxygen level on the pulse oximeter, which was at 93%. No further treatment or intervention was offered by LVN C. Resident # 49 continued to look as though she wasn't getting enough oxygen. Resident # 49 said she had experienced respiratory failure before, and nothing was done when she notified the staff about her difficulty breathing. Resident # 49 provided her own tracheotomy care because she felt the staff were not competent. Resident # 49 stabilized without intervention prior to the end of the interview. An interview on 08/16/2022 at 2:50 PM with LVN C revealed she administered nebulizer treatments and was sometimes assigned to care for Resident # 49 and her [CONDITION(S)] and suctioning needs. LVN C said the emergency equipment available for Resident # 49 was a suction machine that was in her room but was not set up beside Resident # 49. The suction machine was kept at the foot of her bed, unplugged. Additionally, an ambu-bag, and an extra cannula was required. LVN C said these pieces of equipment were not in the resident's room and there was no reason why it was not kept at the bedside. LVN C said the tubing connected to the [CONDITION(S)] was replaced on the weekend night shift. The worst-case scenario if the resident does not have what she needed would be death. LVN C said she would start with obtaining vital signs, next she would check on medications that were ordered as needed, and notify the physician if a resident experienced respiratory distress. LVN C said she would perform interventions to increase Resident # 49 's oxygenation status. LVN C said the documentation related to [CONDITION(S)] care was a yes or no indicating whether they were or were not in the room at the time the resident was providing care An interview on 08/16/2022 3:00 PM with LVN E revealed she worked with Resident # 49 as an agency nurse. LVN E revealed the emergency equipment required for a [CONDITION(S)] resident included a suction machine and an extra cannula. LVE E said the DON was responsible for ensuring the emergency equipment was available for Resident # 49. LVN E said there was no reason why the emergency cannula was not kept at the bedside. LVN E said she did not notice the overdue preventative maintenance label on the concentrator. LVN E said if the concentrator wasn't working properly, it could cause the resident to not receive oxygen or an infection. LVN E said she was told by a CNA (unidentified) that the resident was having trouble breathing earlier (time was not provided). LVN E said she had checked Resident #49's oxygen level but did not listen to her lungs. LVN E said she had not received training from this facility on [CONDITION(S)] care and suctioning and did not know if she needed training to work with Resident # 49 as she cared for her own [CONDITION(S)]. LVN E said she did not complete a full respiratory assessment because I don't know why. LVN E said death could occur if the resident did not have what she needed for her [CONDITION(S)]. An interview on 08/16/22 at 3:00 PM with LVN D revealed the emergency measures required for a resident with a [CONDITION(S)] were a suction machine, oxygen, and a bag-valve-mask. LVN D said she did not look at the oxygen concentrator in Resident # 49's room. LVN D said neither the facility nor the agency had checked her competencies on [CONDITION(S)] care and suctioning. An interview on 08/16/2022 at 3:15 PM with ADON A revealed the agency checked the staff competencies on [CONDITION(S)] care and suctioning but the facility did not conduct their own training. There was no reason provided as to why the facility staff were not trained on [CONDITION(S)] care and suction competencies. The ADON said the DON was responsible for ensuring emergency equipment was available and accessible to the staff. An interview on 08/16/2022 at 3:30 PM with the DON regarding Resident #49 revealed she did not know about the emergency inner cannula not being at the bedside nor the suction machine not being plugged in and accessible. The DON said she did not know about the maintenance due on the respiratory equipment. The DON did not provide information related as to who was responsible for routine equipment maintenance. The DON said a respiratory therapist was not on call and the facility did not have an agreement for respiratory services. The DON said she was responsible for the competency training of the nursing staff. The DON said the nurse should have completed a respiratory assessment on Resident #49 during her respiratory distress. The DON was unaware of Resident # 49's prior hospitalization s related to respiratory infections. Interview on 08/16/2022 at 3:45 PM with LVN E revealed the emergency supplies required for a resident with a [CONDITION(S)] include a replacement [CONDITION(S)], a suction cannister with suction catheter, [MEDICATION(S)], and oxygen. LVN E did not know why the emergency inner cannula was not in Resident #49's room and why the suction machine was unplugged on the floor. LVN E did not know the concentrator was due for maintenance. LVN E did not know of a respiratory therapist being available to assess Resident #49. LVN E verbalized the details of a complete respiratory assessment. LVN E said an inner cannula change in a [CONDITION(S)] was a sterile procedure. LVN E said if the resident performed her own [CONDITION(S)] care, this was no longer a sterile procedure and results in an increased risk for infection. LVN E said Resident #49's respiratory status should be assessed by a nurse, specifically oxygen saturation, and lung sounds. An interview was not completed with a Respiratory Therapist. An interview was not completed with the Medical Director. Reviews of facility in-services from 03/01/2022 to 08/16/2022 revealed no-in services on [CONDITION(S)] care, suctioning , respiratory care, or change in condition. Record Review of nursing [CONDITION(S)] competencies attempted from the nurse agency but the facility failed to produce these requested at 08/16/2022 at 3:30 PM. Record Review of nurse's progress notes for Resident # 49 related to the details of a supervised [CONDITION(S)] care was not found. Record Review of the facility's physician communication notes revealed there was no documentation of the nurse communicating Resident # 49's respiratory distress to the physician on 08/16/2022. Record review of facility policy related to care from a Respiratory Therapist was not provided requested at 08/16/2022 at 3:31 PM. Record Review dated 05/17/2022 of the facility infection log revealed Resident # 49 had an upper respiratory infection. Record Review requested at 08/16/2022 at 3:45 P M of respiratory evaluations or procedure in the event of an emergency and were not provided. Record Review dated 04/21/2021 of the Physicians Order revealed orders for oxygen were 2-4LPM. Record Review (no date indicated) of the facility policy on [CONDITION(S)] care and suctioning revealed the nurse is to suction available check physician order, explain the procedure to the resident, assess, measure oxygen saturation, listen to the lungs with stethoscope, observe for asymmetrical chest expansion, and sterile technique. Record Review dated 02/21/2022 of Resident #49's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Taber's Cyclopedic Medical Dictionary 21st Edition (no date available) reflected the following on page 2348, An emergency [CONDITION(S)] kit is kept at the bedside at all times Record Review of recent hospital records related to upper respiratory infections were attempted, but were not obtained. Record Review of the facility's communication notes was attempted. There was no documentation present that indicated that the physician was notified during Resident# 49's respiratory distress on 08/16/2022. Record Review of facility documents related to changes in condition, staff awareness of policies and procedures related to [CONDITION(S)] care, training on respiratory assessment and emergency interventions and equipment, communication related to the resident's condition and equipment issues was attempted but these were not provided. Record Review was attempted on facility competency trainings related to [CONDITION(S)] care and suctioning, but these were not provided. Record review of Fundamentals of Nursing Seventh Edition by Potter and Perry , (no date available) reflected the following on page 948, Critical Decision Point: Keep [CONDITION(S)] obturator at bedside with a fresh [CONDITION(S)] to facilitate reinsertion of the inner cannula, if dislodged. Keep an additional [CONDITION(S)] tube of the same size and shape on hand for emergency replacement An IJ was identified 08/16/2022 at 2:34 PM. The IJ template was provided to the facility on [DATE] at 4:48 PM. The DON was notified of the IJ, and a plan of removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 08/17/2022 at 4:24 PM. Record review of the Plan of Removal reflected: DON/ADON/Nurse Managers conducted in-service with all facility nurses, and agency nurses in facility beginning 8/16/2022, regarding [CONDITION(S)] care, suctioning, respiratory assessments, S/S or respiratory distress with notification to NP/PA/MD and competencies completed with return demonstration. In-services and competencies will be completed by 8/17/2022. Clinical nurses will not be allowed to work until all competencies and in-servicing is completed. QI RN will ensure competencies of DON is reviewed by 8/17/22. New hire nurses and agency nurses that have not been trained will not be allowed to start a shift prior to receiving. New hire nurses will receive orientation and skills check offs upon hire. In-servicing will be conducted for agency staff by DON/designee. Administrator/designee will ensure all staff in-services are completed. We will continue to complete in- servicing for agency nurses and new hire employees ongoing. This will be monitored daily by DON/Designee and will be brought to clinical meeting for review. Emergency equipment was provided for [Resident #49] to include [CONDITION(S)] cannulas, suction machine with [MEDICATION(S)] and soft tip suction catheters, and ambu-bag. All equipment to be located at bedside. Plan of Removal from the facility related to in-service training: DON/ADON/Nurse managers conducted in-services with all facility nurses, and agency nurses in facility beginning 8/16/2022, regarding having proper equipment for emergency situations. In-services will be completed by 8/17/2022. Facility nurses will not be allowed to work until all competencies and in-servicing is completed. All trained and competent nurses will perform [CONDITION(S)] care. Any and all [CONDITION(S)] care will not be performed by residents or patients. [Resident #49] was educated on 8/17/22 about no longer being able to perform self-[CONDITION(S)] care. Emergency equipment will be noted on MAR/TAR Q shift to ensure equipment is present. DON/designee will monitor daily to ensure compliance and report findings to QA committee. The facility has purchased new oxygen concentrators. [Resident #49's] concentrator was changed. Facility has purchased 11 new concentrators for resident use. These concentrators will be maintained and have routine inspections through a qualified individual per manufacturers recommendations. Any concentrators with mechanical failures will be immediately removed and sent to a qualified repair facility to be repaired per manufacturer specifications. Inspections will be completed quarterly and as needed with findings of inspections reported to QA committee. Administrator/designee will be responsible for overseeing this process. Nursing staff will be in-serviced and educated on tag out procedures for oxygen concentrators. Administrator will obtain an as needed (PRN) contract for respiratory services by 8/18/2022. Nursing staff will be in-serviced on RT resource and availability. DON/designee will notify RT as a resource for any residents who may require RT consultation. MD/PA/NP will also consult per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These findings will be reported to QA committee. As of 08/18/2022, there was a vendor agreement for respiratory therapy to provide services at the facility. Monitoring of the Plan of Removal (POR) reflected: Monitors were ADON's A and B, were trained regarding accurate documentation and verification that a [CONDITION(S)] tube with inner cannula sets must be present at bedside of each patient with a [CONDITION(S)]. Monitors completed documentation regarding verification of supply availability, staff competency regarding [CONDITION(S)] sets at bedside, accurate documentation regarding [CONDITION(S)] sets. The DON and designee(s) were trained regarding documentation of [CONDITION(S)] supplies at bedside and on skills proficiency training check off document. Review of in-services dated, 08/17/2022, reflected in-services by the DON for nursing staff across all shifts concerning principles of [CONDITION(S)] care and [CONDITION(S)] suctioning/bagging of [CONDITION(S)] patient, and suctioning/[CONDITION(S)] care checklist, documentation, and reporting. An Interview on 8/17/22 at 4:55 PM with LVN B revealed Resident #49 was told she was not able to do her own [CONDITION(S)] care. Interview dated 8/17/2022 at 5:25 PM with LVN A revealed she had an in-service 08/16/2022 on [CONDITION(S)] care and suctioning by ADON A and the DON. The training included return demonstration, reading the paperwork on [CONDITION(S)] care, suctioning, check the bedside equipment, and [CONDITION(S)] cleaning, checking the supplies in the room, ensuring a sterile procedure, and performing a respiratory assessment. An Interview on 8/18/2022 at PM at 5:00 PM with ADON A revealed she had an in-service on 08/16/2022 provided by the DON on [CONDITION(S)] care and suctioning. The training included return demonstration, reading the paperwork on [CONDITION(S)] care, suctioning, checking the bedside equipment, [CONDITION(S)] cleaning, checking the supplies in the room, ensuring a sterile procedure, and performing a respiratory assessment. If a resident experienced signs and symptoms of distress, nurses would attempt to stabilize the resident and notify the physician. An Interview on 8/18/2022 at PM at 6:00 PM with ADON B revealed she had an in-service on 08/16/2022 provided by the DON on [CONDITION(S)] care and suctioning. The training included return demonstration, reading the paperwork on [CONDITION(S)] care, suctioning, check the bedside equipment, and [CONDITION(S)] cleaning, checking the supplies in the room, ensuring a sterile procedure, and performing a respiratory assessment. If a resident experienced signs and symptoms of distress, nurses would attempt to stabilize the resident and notify the physician. Observations on 08/18/2022 at 4:00 PM revealed Resident #49 had all emergency [CONDITION(S)] supplies in her room. ADON A was observed performing competent [CONDITION(S)] care. The oxygen concentrator had been switched to another one. Resident # 49 understood that she would be receiving competent [CONDITION(S)] care and suctioning. Staff had started caring for her by 08/18/2022. An Immediate Jeopardy (IJ) was found on 08/16/2022. While the IJ was removed on 08/18/2022, the facility remained out of compliance at a severity level of the potential for more than minimal harm, and a scope of isolated due to the facility's need to monitor the effectiveness of the corrective systems.

Based on observation, record review and interviews the facility failed to ensure each resident received adequate transfer assistance to prevent accidents for 1 of 3 residents (Resident #41) reviewed for accidents, hazards, and supervision. PCA K failed to have assistance from another staff member when she completed transfers on Resident #41 potentially causing rib fractures. This failure place residents who require 2 person assist for transfers at risk for accidents and injuries. Findings included: Review of Resident #41's face sheet dated 8/17/22 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of unspecified atherosclerosis (buildup of fats on the artery walls) of right leg; Right leg amputee; Muscle weakness; unsteadiness on feet; age related [CONDITION(S)] (porous bones). Review of Resident #41's MDS dated [DATE] revealed that Resident #41 was a 2 person assist for transfers and also had a BIMS (Brief Interview for Mental Status) score of 13 indicating she was cognitively intact. Interview with LVN D on 8/17/22at 5:30 PM revealed she was told by the resident (unknown time) approximately 8/9/22 that her ribs hurt, and she said that a girl that came in the other night was rough with her and squeezed her too tight while putting down on the toilet. The resident could not remember who the girl was. LVN D said she assessed the resident and palpated (felt around her abdomen while applying a small amount of pressure) her and didn't find anything unusual so she thought the resident was confused or had been dreaming. She stated she didn't report it right away since she again thought the resident was just confused. She stated she reported it the next day (unknown exact date) when the resident continued to complain of the pain. She stated she reported it to the ADON B. LVN D stated she knew she should report abuse immediately but assumed that Resident #41 was being confused and had dreamed about it. Review of Nurses notes dated 8/11/22 at 11:42 PM, note typed by LVN D reflected, 10:45 AM-resi also c/o left side rib pain. [Physician E] notified, new order for left side rib x-ray, STAT XRAY notified, awaiting arrival. Review of Resident #41's x-ray exam date 8/11/22 revealed the x-ray was completed on her left ribs (2 view). The results reflected, Impression: Acute nondisplaced (nothing out of place) fracture of the 7th rib posterior laterally. Nondisplaced rib fracture of the 8th rib posterior laterally noted. Bones are osteoporotic. Interview on 8/18/22 at 8:36 AM Resident #41 stated she had called for the nurse ( a few nights ago) because she needed to go to the bathroom. She said the girl came in and when she started to put her on the commode, the toilet hit her ribs. She stated she did holler ouch when the incident occurred. She also stated the 'girl did not use a gait belt, instead she placed her hands on the resident's ribs and lifted her with both hands for all transfers. Interview on 8/28/33 at 9:46 AM with ADON B revealed she became aware of the incident involving Resident #41 when LVN D came to her and said the resident complained of rib pain (unknown date and time). LVN D state she told her that she wanted to get an x-ray of Resident #41's ribs due to the complaint of pain. She stated when the x-ray results came back showing a fracture she notified the nursing leadership team (DON and ADON A) and ADON B advised LVN D to complete an incident report. She stated she had assumed the DON completed a self-report and reported it to the abuse coordinator. Interview with the DON on 8/18/22 at 10:10 AM revealed she stated she had become aware of the incident on 08/11/2022, when she received a text message with the results of the x-ray that had been ordered. The DON stated the text was from ADON B who said an x-ray had been completed on Resident #41 because she had been complaining of rib pain. The DON stated she was not made aware of an allegation of abuse; she was also told that it could have possibly happened during a transfer. She stated she is unsure of the date and time that she learned of the possibility of injury during a transfer. She said she completed a self-report on 8/12/22 at 11:50 AM and she had received the x-ray results the day before (8/11/22) at 6:00 PM. She said the reason she did not report it when she first learned of it was because there was nothing mentioned about abuse. She stated abuse should be reported immediately no matter what the resident's mental status is. Interview on 8/18/22@ 6:02 PM PCA K, she stated that she is not a CNA she has completed a most of the CNA training but has not tested yet so she is currently a Hospitality Aide. She stated that she knew she was not supposed to be assisting residents until she is certified but has been told to do it anyways. She stated that she had not cared for Resident #41 for over a week; she stated that the last time she worked was on 8/9/22 and she was not assigned to work with Resident #41. She said that she worked night shift and when she would work with Resident #41 the resident would already be asleep when she came on shift and that Resident #41 does not get up during the night to go to the bathroom. Review of facility in-service dated 8/12/22 led by therapy. Topic was: Safe transfer techniques, and was presented to CNA's from 200 hall; there were a total of 21 staff members signatures on the in-service sheet.

Based on interview, and record review the facility failed to ensure services were provided using proper safety techniques to prevent accidents for 2 of 6 residents (Resident # 1 and Resident #2) reviewed for accidents. The facility failed to use a 2 person assist when transferring Resident #1 from her wheelchair to the bed, which resulted in a fracture to her right leg. This failure was determined to be Past Non-Compliance, identified on 01/06/22 and removed on 01/07/22, due to the facility having implemented actions which corrected the non-compliance prior to the beginning of the investigation on 02/28/2022. This failure placed Residents at risk for improper care, injury, pain, and decreased quality of life. Record review of Resident #1's face sheet, dated 03/01/22, revealed she was a [AGE] year-old female who admitted to the facility on [DATE], and had the following diagnoses: Unspecified disorders of bone density and structure; Unspecified fracture of shaft of right tibia; Unspecified fracture of right fibula; Muscle weakness; Difficulty in walking, History of falling; Unsteadiness on feet; and Cognitive communication deficit. Record review of Resident #1's MDS, dated [DATE], revealed she had a BIMS of 03, which indicated severe cognitive impairment. Further review revealed Resident #1 required extensive assistance (Resident involved in activity, staff provide wight-bearing support) with Two+ persons physical assistant for transfers. Record review of Resident #1's Care Plan, undated, revealed Resident #1 required a level of support to complete bed mobility, transferring, walking, and locomotion needs every shift, as of 09/12/19. Record review of Resident #1's Lift/Transfer Assessment, dated 11/22/21, revealed she required 2-person manual assist, does not have upper extremity strength to support weight during transfer, and her lift/transfer plan included no mechanical lift required handheld or manual assist x2. Record review of Resident #1's Progress Notes, dated 01/06/22, revealed RN B documented the following Resident c/o pain to RT ankle/foot with c/o pain. CNA reported to this nurse that during a transfer with the Resident that the CNA heard a sound and then Resident c/o in pain. Upon assessment no other injury noted, Resident is calm without change to usual cognition. [MD] notified and new order received for x-ray of Rt ankle/foot. Xray ordered at this time. ADON made aware of change of condition. RP notified at the time. In an interview on 02/28/22 at 10:54 AM, LVN C stated she had worked at the facility since October 2021, and she was very familiar with Resident #1's care needs because Resident #1 is was on her assigned hall. LVN C stated she did not work the day Resident #1 obtained the fracture. She stated she was told the fracture occurred when Resident #1 was transferred from her wheelchair to the bed . LVN C stated CNA A transferred Resident #1 by himself, but Resident #1 was a 2 person assist. LVN C stated she did not know if CNA A always transferred Resident #1 by himself and she had never witnessed him transferring Resident #1 by himself. She stated CNA A occasionally worked on her hall (500 hall) but believed he primarily worked on the 200 hall. LVN C stated the CNA's who primarily worked on the 500 hall always transferred Resident #1 using a 2 person assist. She stated if CNAs did not know how a Resident should be transferred, then they could look up on the computer or ask the charge nurse. In a phone interview on 02/28/22 at 3:37 PM, RN B stated on 01/06/22 CNA A told her he transferred Resident #1 from her wheelchair to the bed and as he was sitting her on the bed, he heard a popping noise. RN B stated Resident #1 was a 2 person assist and did not know why CNA A transferred her alone and she did not ask him. RN B stated she did not know if CNA A always transferred Resident #1 by himself or if other staff did one person assist because was PRN and worked at the facility approximately once every 1 to 2 weeks. RN B stated she had never transferred Resident #1. RN B stated she assessed Resident #1's right leg and saw swelling and slight bruising around her ankle. RN B stated she contacted the doctor and he ordered x-rays of the ankle and foot . RN B stated she notified the family. In a phone interview on 03/01/22 at 8:40 AM, CNA A stated he no longer worked at the facility . He stated he put in a two weeks' notice and he believed his last day was 01/06/22. CNA A stated on his last day he transferred Resident #1 from her wheelchair to bed and as he placed her on the bed, he heard a pop noise come from her leg. CNA A stated he called for a nurse and a nurse assessed Resident #1 (didn't recall a name). CNA A stated Resident #1 was a one person assist because of CNA A's size. He stated he always transferred Resident #1 by himself. CNA A stated he did not just base the one person assist on his size. He stated he confirmed Resident #1 was a one person assist with the other CNAs. CNA A stated he could not recall which CNAs told him Resident #1 was a one person assist. He stated he never saw other CNAs transferring Resident #1 using a one person assist, but it was only because the other CNAs were female and due to their size, it required two of them to transfer Resident #1. CNA A stated he worked 4 different halls and he knew if Resident were a one or two person assist. He stated if he did not know how a Resident should be transferred, then he would ask the other CNAs, but due to his size, he was able to transfer most Residents by himself. CNA A stated he would get help if a Resident was too big for him to transfer alone. He stated he did get trained on how to transfer Residents, but he could not recall the exact date. CNA A stated he was trained to ask other staff, if he didn't know how a Resident should be transferred. In an interview on 03/01/22 at 9:30 AM, CNA D stated she primarily worked on Resident #1's hall and she was a 2-person assist. She stated she did not work the day Resident #1 was injured. CNA D stated she worked the following day and was told by the charge nurse CNA A transferred Resident #1 by himself and broke her leg. She stated she does not remember which charge nurse was on duty that day. CNA D stated anytime a Resident was injured, the charge nurse would educate the CNAs at the beginning of their shift. CNA D stated CNA A had helped her transfer Resident #1 before, and she had never witnessed him doing it by himself. She stated CNA A primarily worked on another hall. CNA D stated she had witnessed CNA A assist many Residents by himself, but she didn't know if they were 1 or 2 persons assist. CNA D stated she was in-serviced that day (01/07/22) on lift and transfers. In an interview on 03/01/22 at 10:49 AM, the Administrator stated Resident #1 was a two person assist and he was unaware CNA A was transferring Resident #1 by himself. He stated this incident happened on CNA A's last day, so he did not speak to him about the incident to know the details of why he transferred Resident #1 by himself. He stated staff were expected to look on Smart Chart to get familiar with the Resident's transfer status and/or talk to a charge nurse if there was a question about the Resident's status. He stated on the side of caution, staff should always use two persons assist if status is unknown. The Administrator stated he did in-service staff on Lifts/Transfers the day after the incident occurred. He stated he consistently in-serviced staff on proper transfers to avoid the risks of injuries and falls. The facility implemented the following interventions to address the non-compliance: Review of the facility's provider investigation report for Intake # 3 revealed the facility self-reported Resident #1's incident with major injury from the facility on 1/08/22. The Provider Investigation Response revealed: -MD Notified -RP Notified -HHSC Notified -Hospice Notified -In-Services on Transfer Training Completed -Resident received orders for [MEDICATION(S)] Q 2 hours for any uncontrolled pain (she already had orders for [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]) -R. Lower extremity immobilizer applied for protection of injured R. Lower Leg -Appointment Scheduled with Orthopedist. The Provider Action Taken Post-Investigation: - Follow up Ortho Appointment Scheduled -In-services on Transfer Training Completed. Record review of the facility's staff rooster revealed CNA A was no longer employed at the facility as of 01/06/22. Record review of an in-service dated 01/07/22 and titled Safe Lifting and Movement of Residents revealed staff were educated on the facility's appropriate techniques and devices to lift and move Resident. Record review of an in-service dated 01/07/22 and titled Safe Lifting and Movement of Residents revealed staff were educated on the facility's appropriate techniques and devices to lift and move Resident. Record review of an in-service dated 01/26/22 and titled Safe Lifting and Movement of Residents revealed staff were educated on the facility's appropriate techniques and devices to lift and move Resident and safe lifting procedures, sit to stands, 2-person patient transfer, stand pivot transfer, and use of gait belt for safety. Interviews were conducted between 02/28/22 and 03/01/22 with 5 CNAs, 3 LVNs and 1 RN, which work multiple shifts (6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM) stated they were aware Resident #1 is a two-person assist and was in-serviced on 2-person assist transfers, safe lifting and transferring Residents.

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection for all 74 residents for the COVID-19 virus. 1. The facility failed to prevent the transmission of COVID-19 by allowing staff who documented or displayed signs and symptoms of COVID-19 to continue to provide care to residents. 2. The facility failed to train staff on completing the COVID-19 employee/visitor screening tool, taking their temperature, or appropriate temperature ranges. The tool was not available in staff's native language when they were unable to read the tool in English and they were unable to accurate complete the tool to reflect signs, symptoms, and possible exposure to COVID-19. 3. The facility failed to track the spread of the COVID-19 infection in the facility and contact sick staff to determine who they worked with or provided care to in order to track residents' possible exposure to COVID-19. An Immediate Jeopardy/Immediate Threat was identified on 11/09/20. While the Immediate Jeopardy was removed on 11/12/20, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 11/09/20. These failures placed residents at risk of exposure to COVID-19, which could result in serious illness, hospitalization , or even death. Findings included: Review of the facility line listing (document designed to be used as a line list template for investigations of outbreaks of unexplained respiratory illness), received on 11/06/20, reflected the facility had staff and residents who were positive for COVID-19. The line listing was not in order and staff and residents were mixed together on the form. The line listing did not provide any information on contact tracing (fundamental activities that involve working with a patient (symptomatic and asymptomatic) who has been diagnosed with [REDACTED]. The line listing only provided addresses, phone numbers, and indicated the persons on the form were COVID-19 positive. An interview on 11/06/20 at 3:00 PM with the DON revealed her first date of employment with the facility was on 10/26/20. She said she had an occasional cough that started on 11/06/20 but she thought it was related to allergies and a recent surgery she had. She said she tested negative for COVID-19 on 11/06/20. She said the facility currently had 40 residents who were COVID-19 positive and 34 residents who were not COVID-19 positive. She said two staff members, Dietary Aide A and CNA B were the first staff in the facility to test positive for COVID-19. She said both staff tested positive for COVID-19 during weekly testing conducted by the facility on 10/19/20. The DON stated all the residents were tested on [DATE] for COVID-19 and were negative. She said when all residents and staff were tested again the week of 10/26/20, multiple residents and staff were positive. She said she did not know if the staff members had been questioned regarding contact tracing, but thought the Administrator was monitoring the infection in the building. She said the MDS Nurse (currently out sick) and she were the Infection Preventionist for the facility. Record review of the updated facility line listing, received on 11/09/20, revealed the facility had staff and residents who were COVID-19 positive. The line listing had staff and residents separated. It did not reflect symptoms, symptom onset date, test date, or information to determine how the infection had spread throughout the facility. The line listing contained the dates when positive results were received. The line listing reflected the following: Week of 10/25/20: 12 staff tested positive and 24 residents tested positive. Week of 11/01/20: 19 staff tested positive and 24 residents tested positive . (It is unclear if these were newly positive residents or not.) Week of 11/08/20: 1 staff tested positive and 1 resident tested positive. An interview on 11/09/20 at 1:30 PM with Dietary Aide A revealed she was one of the first staff members at the facility to become ill with the COVID-19 virus. She said she worked in the facility kitchen preparing meals for the residents . Dietary Aide A said on 10/18/20 she realized she could not smell or taste (symptom of COVID-19) and was feeling ill. She said she filled out the facility COVID-19 screening form and documented that she had a change in taste and smell. She said she notified a nurse, unknown name, and asked if she was supposed to stay at work. The nurse asked if she had allergies and she told her yes. Dietary Aide A said the nurse provided her with an allergy pill and a vitamin C supplement and told her it was okay for her to work. She said she was tested for COVID-19 by the facility on 10/19/20 and was notified at 6:00 AM on 10/20/20 that she had tested positive. Her last day worked was 10/19/20. Dietary Aide A said the facility did not have any COVID-19 cases at that time and she was wearing a surgical mask and gloves when she worked. Record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, dated 10/18/20, for Dietary Aide A revealed she had marked on the form that she had a new loss of taste/smell. The form had an area for a Nurse/Administrator to sign, but it was blank. An interview on 11/09/20 at 1:45 PM with CNA B revealed she was currently ill at home with COVID-19. She said her symptoms started on 10/17/20 and she wanted to call-in sick to work because her joints hurt, and she ached all over. She said she notified LVN C who told her they were short on staff and that she needed to work and should call-in the next day, but she did not notify anyone else. CNA B said she went ahead and worked on 10/17/20 and 10/18/20 even though she felt ill. She said she was scheduled to be off work on 10/19/20. She said she was tested for COVID-19 on 10/19/20 and was notified on 10/20/20 that she had tested positive. She said no one from the facility had contacted her after she was notified that she had tested positive. She said she felt upset because she had worked with Resident #1. She said she told the resident she did not feel well and was concerned she had COVID-19. She said she found out a week later that Resident #1 had tested positive for COVID-19. CNA B did not document her signs and symptoms on the Facility COVID-19 Visitor/Employee Assessment Questionnaire. An interview on 11/09/20 at 2:00 PM with the ADON and Human Resources Staff revealed a nurse or receptionist was supposed to screen employees for COVID-19 when they arrived to work. They said they did not know Dietary Aide A and CNA B were allowed to work with COVID-19 signs and symptoms. They said they did not contact either staff member to investigate if they had signs or symptoms of COVID-19 or who they may have exposed to COVID-19 because they thought the Administrator was supposed to. An interview on 11/11/20 at 10:55 AM with LVN D revealed she remembered giving Dietary Aide A Vitamin C but did not remember her reporting she was sick. She said she did not review the employee's COVID-19 screening form that day and did not know who was responsible for reviewing the employee COVID-19 screening forms. An interview on 11/11/20 at 12:50 pm with LVN C revealed she was at home because she had tested positive for COVID-19 on 11/03/20. She said employees were responsible for screening themselves for COVID-19 when they arrived to work and documenting their temperature and screening questions on the screening form. She said on approximately 06/01/20, the facility stopped having staff available to screen employees. She said she did not remember CNA B ever notifying her to tell her she was sick. An interview and record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, dated 11/01/20, on 11/11/20 at 11:30 AM with Housekeeper E revealed she documented she had a temperature of 93.1 degrees Fahrenheit on 11/01/20. She said she was never in-serviced on how to fill out the Facility COVID-19 Visitor/Employee Assessment Questionnaire and was not in-serviced on how to take her temperature or what the appropriate temperature ranges were. She said she was supposed to write down whatever the thermometer read. She said she did not notify anyone about her abnormal temperature reading and said it was cold outside that day. She said a fell ow staff member (she would not provide the staff's name) and she reported to their Housekeeping Supervisor that they had sore throats on 11/05/20. They were instructed to work anyway. She said her co-worker tested positive for COVID-19, unknown date. She said she did not document that she had a sore throat on the screening form because she knew she had to work even if she was sick. An interview and record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, dated 11/01/20, on 11/11/20 at 11:45 AM with Dietary Aide F and Housekeeper E (translator for Dietary Aide F who only spoke Spanish) revealed Dietary Aide F documented she had a temperature of 93.1 degrees Fahrenheit on 11/01/20. Dietary Aide F said she was not able to read the form in English and tried to fill it out. She said she documented whatever Housekeeper E told her to. An interview and record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, date unknown, on 11/11/20 at 12:00 PM with Housekeeper G and Housekeeper E (translator for Housekeeper G who only spoke Spanish) revealed Housekeeper G did not date her screening form, but documented she had a temperature of 89.6 degrees Fahrenheit in October 2020. She said employees had to screen themselves and she would just copy what the staff in front of her had documented on her screening form. She said she was never in-serviced on how to fill out the form and could not read it. She said she was never in-serviced on how to take her temperature or what appropriate temperature ranges were. An interview and record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, dated 10/25/20, on 11/11/20 at 2:10 PM with Housekeeper H revealed she documented she had a temperature of 94.8 degrees Fahrenheit on 10/25/20. She only spoke Spanish and her family member translated the state surveyor's questions for her. Housekeeper H said she was responsible for screening herself when she got to work but could not read the form. She said she was not in-serviced on how to fill out the form and self-taught herself to take her temperature. An interview and record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, dated 11/01/20, on 11/11/20 at 2:20 PM with Housekeeper I revealed she documented she had a temperature of 94.8 degrees Fahrenheit on 11/01/20 and documented she had traveled internationally within the last 14 days to countries with sustained COVID-19 community transmission. She only spoke Spanish, so her family member translated the state surveyor's questions for her. Housekeeper I said she found out she was COVID-19 positive on 11/05/20 but started having symptoms (her nasal passages were burning) on 11/04/20. She said she did not report her symptoms because she did not think much about them and could not read the questions on the form which included questions regarding new on-set symptoms. She said she would screen herself and write whatever the employee in front of her had written. She said she never received an in-service on how to complete the form or take her temperature. An interview and record review of the Facility COVID-19 Visitor/Employee Assessment Questionnaire, dated 11/03/20, on 11/11/20 at 2:30 PM with CNA J revealed she documented she had a headache, fatigue, and muscle or body aches on 11/03/20 but continued to work her shift. She said she did not report her symptoms at the time. She said she completed her weekly testing for COVID-19 the week of 11/09/20 and she was negative. She said employees filled out the COVID-19 Visitor/Employee Assessment Questionnaire when they arrived to work, and no one asked her about her symptoms on 11/03/20. She said the facility in-serviced her on how to fill out the form and take her temperature, but she did not remember when. An interview on 11/11/20 at 8:03 PM with CNA K revealed she tested positive for COVID-19. She said her last day at work was 11/03/20 because that was the day she tested positive for COVID, but she started having symptoms on 11/01/20. She said she was sick, but just assumed she had a sinus infection that was not contagious and worked anyway . She did not document her symptoms on her COVID-19 Visitor/Employee Assessment Questionnaire. She said the facility did not in-service her on how to fill out the form and take her temperature. An interview on 11/10/20 at 12:22 PM with LVN L revealed she was sick with COVID-19. She said she started feeling ill while at work on 11/04/20. She said she had a sore throat but decided to stay at work and not report her symptoms because she knew she was scheduled to be off work the next day. She said she found out she tested positive for COVID-19 on 11/05/20. She said the facility in-serviced her on how to fill out the form and take her temperature, but she did not remember when. An interview on 11/12/20 at 10:30 AM with the Business Office Staff Member revealed she tested positive for COVID-19 on 11/03/20. She said she started having symptoms on 11/02/20 with a runny nose but was not concerned about it and decided to work anyway. She said she did not report her symptoms to anyone. She said she was notified at work on 11/03/20 that she had tested positive for COVID-19. An interview on 11/10/20 at 12:15 PM with the Staffing Coordinator revealed she was at home sick with COVID-19. She said she started feeling ill on 11/03/20 after she assisted with moving residents, who were COVID-19 positive, to the COVID-19 building. She said she had congestion and notified the ADON. The ADON did not give her any instructions. She said she remained at work and she monitored her symptoms. She said she started having a low-grade fever that night and called in sick on 11/04/20. She said she was tested for COVID-19 and found out she tested positive on 11/05/20. An interview on 11/12/20 at 11:00 AM with the Housekeeping Supervisor revealed two of his housekeeping staff resigned after they were diagnosed with [REDACTED]. He said he did not know the Spanish-speaking staff did not know how to read the COVID-19 screening form. He said Administrative staff had talked with him about his screening forms because he would just draw a line through all of the questions instead of answering yes or no. An interview on 11/09/20 at 3:25 PM with the Regional Administrator and ADON revealed staff were supposed to screen themselves when they arrived to work and fill out the COVID-19 Visitor/Employee Assessment Questionnaire in order to assess for signs and symptoms of COVID-19. They said sometimes the front desk had a person available to screen staff. They were not aware that staff had documented international travel, abnormally low temperature checks, and signs and symptoms of COVID-19 on their forms. They said staff who were ill were not supposed to be at work and they did not know if staff had been in-serviced on how to take their temperature or what appropriate temperature ranges were. The ADON said staff were in-serviced on filling out the screening form in August 2020. Review of the in-service received from the ADON at the time of the interview reflected the print was not dark enough to read, but it was dated for August 2020. An interview on 11/10/20 at 11:40 AM with the Administrator revealed he was at home sick with COVID-19. He said he first had symptoms on 11/04/20, felt a little groggy, and that while at work on 11/05/20, he was told he was COVID-19 positive. He said he did not speak with Dietary Aide A or CNA B after they tested positive for COVID-19 because the Human Resources Staff was supposed to. The Administrator said the Human Resources Staff was also responsible for reviewing and auditing the questionnaires daily. He said he was not aware Dietary Aide A and CNA B both worked while they were sick and he did not review the COVID-19 Visitor/Employee Assessment Questionnaires. He said he was hired in August 2020 and thought the facility had provided an in-service to employees about how to fill out the form in April 2020. He said he was not aware of any in-services regarding the form after August 2020. He said if staff had signs and symptoms of COVID-19, they were supposed to notify the DON and Administrator and go home to quarantine for 14 days. He said an MDS Nurse was the Infection Preventionist at the facility (out with COVID-19) and the DON would be trained on the position once she returned to work. He said he did not know if they had been in-serviced on how to do root cause analysis (process of discovering the root causes of problems in order to identify appropriate solutions) and contact tracing to review and monitor the infection spread in the facility. An interview on 11/10/20 at 12:35 PM with the DON revealed she was home sick with COVID-19. She said she first started having symptoms on 11/07/20 and that she only came into contact with the ADON that day. She said she received her positive test results on 11/08/20. She said she never spoke with Dietary Aide A or CNA B because she was not employed at the time of their infection. She did not review the daily COVID-19 Visitor/Employee Assessment Questionnaires and did not know who was responsible for reviewing them. She said the bottom of the form reflected the DON or Administrator would review them. She said she did not complete any root cause analysis or contact tracing on the infection at the facility, but she did complete CDC infection control training in April 2020. She said she did not receive training on root cause analysis or contact tracing from the facility. She said she did not know if facility staff were in-serviced on how to fill out the screening form, appropriate temperature ranges, or how take their temperature. She said the CNAs would have learned how to take their temperature in their CNA class to receive their certification. An interview on 11/10/20 at 1:40 PM with the Corporate Quality Improvement Nurse revealed she completed an in-service with the DON regarding COVID-19 facility policies and procedures on 11/04/20. Review of the in-service completed with the DON by the Corporate Quality Improvement Nurse revealed the DON was trained on the COVID-19 facility policies and procedures on 11/04/20. An interview on 11/11/20 at 12:10 PM with the ADON revealed the facility did not have a Spanish COVID-19 Visitor/Employee Assessment Questionnaire and she was not aware the Spanish-speaking staff did not know how to read it. An interview on 11/11/20 at 1:50 PM with the Human Resource Staff revealed employees were supposed to screen themselves for COVID-19. She said she had never received an in-service on how to fill out the form or take her temperature. She said she thought the person working at the front desk was responsible for reviewing the screening forms. An interview with the Administrator on 11/12/20 at 12:55 PM revealed he was not aware that the Spanish-speaking staff could not read the COVID-19 Visitor/Employee Assessment Questionnaire. An interview on 11/10/20 at 4:45 PM with the Medical Director revealed he was not aware the facility allowed staff to work even if they were ill. He said the facility should have been paying attention and sent sick staff home because they were likely shedding the COVID-19 virus at the time of their symptoms in the facility. Record review of the updated facility line listing, received on 11/10/20, revealed the facility had staff and residents who had the COVID-19 virus. The line listing had staff and residents separated. It reflected the following COVID-19 exposures: -Dietary Aide A exposed 3 kitchen staff and had no known exposure with residents. (The dietary aide prepared meals for all of the residents) -CNA B exposed 1-20 residents to COVID-19 . -LVN C exposed 1-20 residents and one staff member to COVID-19. -Housekeeper I did not expose any residents or staff to COVID-19. -CNA K exposed an unknown number of residents and 4 staff to COVID-19. -LVN L exposed 1-20 residents. The list did not identify which staff she had exposed to COVID-19. -Business Office Staff Member did not expose any residents or staff to the COVID-19 virus. -The Staffing Coordinator worked with residents who were already COVID-19 positive. She exposed 6 staff members to COVID-19. -The DON did not expose any residents or staff to COVID-19. -The Administrator did not expose any residents or staff to COVID-19. Review of the facility policy and procedure, Infection Prevention and Control Program, revised August 2016, revealed, the infection prevention and control program was coordinated and overseen by an Iinfection Preventionist. Surveillance tools were used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, and monitoring employee infections. Outbreak management was a process that consisted of: determining the presence of an outbreak, managing the affected residents, preventing the spread to other residents, and documenting information about the outbreak. Review of the facility policy and procedure, Surveillance for Infections, revised September 2017, revealed, the Infection Preventionist would conduct ongoing surveillance for healthcare associated infections and other epidemiologically significant infections that had substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Review of the facility policy and procedure, Isolation - Initiating transmission-based precautions, revised August 2019, revealed, COVID-19 Pandemic: staff will be screened every shift or at the beginning of the shift for signs and symptoms including a temperature prior to reporting to work. If any questions are answered yes on the COVID-19 Visitor/Employee Assessment Questionnaire, then the employee will be sent home and the Criteria to Return to Work Policy will be utilized. An Immediate Jeopardy/Immediate Threat was identified on 11/09/20. The Regional Administrator and DON were notified of the Immediate Jeopardy on 11/09/20 at 5:25 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 11/11/20 at 10:25 AM and reflected the following: Immediate Actions Taken: Staff screening logs for 11/9/20 were immediately reviewed and no staff reported feeling symptoms on the screening logs for 11/9/20. One staff member reported they had travelled internationally in the last 14 days. It was confirmed that the staff member did not travel internationally in the last 14 days and had selected that line in error. A. Staff in the facility at the time were immediately questioned and no staff reported feeling unwell or symptomatic. B. Staff in-services on how to complete the screening logs were commenced. C. Staff in-services on how to take temperature were commenced. D. Root cause analysis/contact tracing was commenced. Actions Taken/Systems put in place to reduce risk of future occurrence include: The facility has trained the assigned screeners at the front door to ensure they take the temperature of the staff member and that after the form is filled out the screener will review the form completely to ensure that it is filled out completely. Any form where a symptom is marked, or they respond affirmatively to international travel and/or exposure or have a temperature of greater than 100.0°F will not be allowed entry into the facility and the administrator and/or DON will be notified. This training was started on 11/9/20 and will be completed on 11/10/20. This in-service is titled: Screening COVID-19 Staff/Visitor and is included at the end of this document. Going forward any new screening staff will be trained prior to being allowed to be a screener. The screeners will be trained by the ADON under the supervision of the Corporate Quality Improvement Nurse. The two nurses that allegedly allowed staff reporting symptoms to work have been given written disciplinary corrective actions and will be trained one-on-one regarding removing staff immediately from the facility if they have signs/symptoms of COVID. This training is titled: Reportable Illness - one on one in-service and is included at the end of this document. The training will be conducted by the ADON under the supervision of the Corporate Quality Improvement Nurse. All staff, including all charge nurses, will be in-serviced on immediately excusing any staff member from the facility if they report symptoms and to notify the administrator or DON immediately. This in-service will be completed by 11/11/20. This in-service is titled: Reportable Illness and is included at the end of this document. Any staff member not completing the in-service by 11/11/20 will not be allowed to work until the training is complete. The in-service will be conducted by the ADON under the supervision of the Corporate Quality Improvement Nurse. The DON and/or designee will monitor this process weekly for the duration of the emergency pandemic declaration to ensure maintained compliance. An in-service on how to complete the screening logs will be given to all staff starting on 11/9/20 and finished by 11/11/20. This in-service is titled: COVID Screening Process and is included at the end of this document. Any staff member not trained by that date will not be allowed to work until the training is completed. The in-service will be conducted by the ADON under the supervision of the Corporate Quality Improvement Nurse. An in-service on how to take temperature will be given to all staff starting on 11/09/20 and finished by 11/11/20. This in-service is titled: Temperature and is included at the end of this document. Any staff member not in-serviced by that date will not be allowed to work until the training is completed. The in-service will be conducted by the ADON under the supervision of the Corporate Quality Improvement Nurse. The administrator and/or DON will review the Screening Forms (questionnaires) daily for the duration of the emergency pandemic declaration to ensure that the forms were filled out correctly, completely, and that any staff member reporting symptoms, fever, international travel, or exposure were excluded from entering the facility or until evidence can be presented to the administrator, DON, and/or designee that the symptom has been shown to be related to a non-COVID and non-communicable disease diagnosis. The administrator, DON, and/or designee will also confirm that the screenings were conducted by a staff member trained in the screening process. The facility will complete the contact tracing by 9:00 am on 11/10/20 and any future staff and/or residents that test positive for COVID will have contact tracing/root cause analysis done. This will be monitored by the DON and/or designee daily for any future positive results. To ensure the staff retain the knowledge from the in-services, the facility will re-inservice on the four topics listed above every two weeks for the next two months. The Administrator reviewed this plan on 11/10/20 and will be responsible for on-going monitoring daily for the duration of the emergency pandemic. Any findings will be reported to QAPI. Monitoring of the facility's Plan of Removal included the following: Interviews and observations were conducted on 11/11/20 starting at 9:20 AM and continued through 11/12/20 at 2:00 PM with 25 staff members from various shifts. The in-services included a Spanish and English version of the COVID-19 Visitor/Employee Assessment Questionnaire, training for designated screening staff, training on how to fill out the form and take a temperature with appropriate identification of temperature ranges, training for employees that instructed them not to go to work if they were sick, and training for staff to know what to do if a fell ow staff member reported illness to them. The staff members were able to: Understand how to read and answer the questions on the COVID-19 Visitor/Employee Assessment Questionnaire. Understand the process of taking a temperature and appropriate temperature ranges. Understand their responsibility to not go to work if they were ill. Verbalize the communication that needed to occur if a staff member reported they were ill. Interviews and record reviews revealed staff were being screened by designated staff and were not working ill. Interviewed staff members and shifts were: LVN D - worked 6:00 AM to 2:00 PM PTA M- worked day shift Housekeeper E - worked day shift Dietary Aide F - worked day shift Housekeeper G - worked day shift LVN C - worked 6:00 AM to 2:00 PM Housekeeper H - worked day shift CNA J - worked 6:00 AM to 2:00 PM Dietary Aide N - worked day shift CNA K - worked 6:00 AM to 2:00 PM LVN O - worked 6:00 AM to 2:00 PM Activity Director - worked day shift Housekeeper P - worked day shift LVN Q - worked day and evening shift LVN R - worked 6:00 AM to 2:00 PM CNA S - worked day and evening shift CNA T - worked all shifts Business Office Staff - worked day shift CNA U - worked all shifts Housekeeping Supervisor - worked day shift Physical Therapy Director - worked day shift Dietary Aide V - worked day shift Dietary Aide W - worked day shift PTA X - worked day shift PT Y - worked day shift Interviews on 11/12/20 at 1:05 PM and 1:20 PM with the Administrator and DON revealed the facility had designated trained staff to screen visitors and employees. If staff answered yes to any of the questions or had abnormal temperatures, they would be reported to the Administrator or DON. Staff who were ill were not supposed to go to work and if staff reported they were ill to fell ow staff, the DON or Administrator would be notified. He or the DON/designee would be responsible for reviewing the screening forms daily. The DON was the Infection Preventionist and was responsible for conducting contact tracing on the facility infection. An Immediate Jeopardy/Immediate Threat was identified on 11/09/20. While the Immediate Jeopardy was removed on 11/12/20, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility was provided the Immediate Jeopardy template on 11/09/20.

Based on observation, interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit the mistreatment, neglect, and abuse of three (Residents #15, #16, and #18) of twenty-one residents, who were reviewed for abuse/neglect concerns. The facility failed to protect Residents #15 and #16, who both had severe cognitive impairment, from sexual abuse by Resident #18 and failed to develop and implement measures to address Resident #18's sexually inappropriate behaviors. On 06/09/15, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/11/15 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures resulted in Residents #15 and #16 experiencing sexual abuse and had the potential to affect all 14 female residents identified with cognitive impairment by placing them at risk for abuse and neglect. Findings included: The facility's current, undated Abuse Policy and Procedure reflected: Each resident has the right to be free from abuse. Residents will not be subjected to abuse by anyone including but not limited to, facility staff and other residents. Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences. Investigation: All staff in the nursing facility and all residents, responsible parties, and or legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully. The administrator or his/her designee will repot this allegation of abuse immediately to the state agency (DADS) and to the proper local authorities. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing. The director of nursing will ensure that facility completes the appropriate investigative forms and forwards a copy of the investigation to DADS within 5 working days. Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will imitate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. When an abuse identifies perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility, pending outcome of he investigation. Reporting/Response: Upon completion of an investigation, the director of nurses and the administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences. Resident #18's MDS assessment, dated 04/16/15, reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE] with a re-admission on 04/02/15. His [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. The assessment did not reflect the presence of any behavioral symptoms. The resident was able to walk on and off the unit with only supervision and setup help. Resident #18's Care Plan, dated 03/22/15, reflected the resident displayed socially inappropriate behavior by kissing another resident (Resident #15) and placing his hand down her shirt. The care planned approaches were as follows: - Social Services to evaluate and visit as needed - Activities staff to visit and provide diversional activities - Monitor and document behavior - Elicit family input for best approach(es) - Administer behavior medications as ordered by physician - Talk in calm voice when behavior is disruptive - Encourage family/responsible party to visit - 5/3/15 - Resident was kissing and touching a female resident, he was re-directed - 4/30/2015 - SC (standards of care) done CPOC (continue plan of care) next 90 days - 5/24/15 - Resident was being sexually inappropriate with female resident,SW to assist with finding placement to assist with behaviors. There was no documentation reflecting specific interventions were developed or implemented to monitor or prevent Resident #18's sexual behaviors towards female residents. An observation on 06/07/15 at 10:08 a.m. revealed Resident #18 was alert and able to transfer and ambulate independently. An interview at that time with ADON BB revealed Resident #18 had a history of [REDACTED]. ADON BB stated as an intervention, the nursing staff was monitoring the resident's whereabouts in the facility on an on-going basis. Resident #18's Nursing Department Notes written by LVN OO, dated 03/22/15 at 4:00 p.m., reflected: Resident was seen on hall 2 standing near another resident, housekeeper witnessed him leaning over to kiss her on the lips and then again and then put his hand down her shirt, nurse was notified and nurse spoke with resident telling him that (his) behavior was not appropriate, resident voiced understanding. The note was co-signed by ADON CC on 04/22/15 at 5:34 a.m. A Resident Incident Report, dated 03/22/15, reflected on 03/22/15 at 11:45 a.m. the following incident transpired: Housekeeper (Housekeeper AA) came and reported that this Resident (Resident #15) was sitting in gerichair in (the) hallway and a male resident (Resident #18) came up and kissed her on the lips. Kissed her again a second time and witness stated he (Resident #18) put his hand down her (Resident #15) shirt. When male resident saw housekeeper he pulled his hand out. Witness went and told nurse. Spoke with male resident that it is not appropriate behavior to do that and he voiced understanding. Called DON and reported what happened. Male resident is on q (every) 15 minute checks. Will cont (continue) to monitor. This report was prepared, signed, and dated by ADON BB on 03/22/15. An interview on 06/10/15 at 11:10 a.m. with Housekeeper PP revealed she witnessed Resident #18 in the hallway kissing Resident #15 on the mouth. She stated she then saw him put his hand inside of Resident #15's, and he touched her breast. She stated when Resident #18 saw her looking he pulled his hand out of Resident #15's shirt. She stated she reported the incident right away. There was no documentation reflecting the facility conducted every 15 minute checks on Resident #18 following the incident on 03/22/15. Resident #15's MDS assessment, dated 01/16/15, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 02/27/14. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with both short-term and long-term memory problems and no behavioral symptoms. The resident required extensive assistance with her ADLs and was totally dependent upon staff for locomotion on and off the unit. Resident #15's Care Plan, updated and continued on 06/09/15, reflected the resident had short-term and long-term memory problems and difficulty making herself understood. A Care Plan, initiated on 03/22/15, reflected the resident was approached by a male resident, and the male resident kissed her and placed his hand down her shirt. An observation on 06/07/15 at 10:52 a.m. of Resident #15 revealed she was non-ambulatory, she was bed and geri-chair bound. Resident #15 was transferred via a Hoyer lift with the assistance of two staff, she was alert but confused, she was totally dependent on staff for all her ADLs, and she was incontinent of bowel and bladder. An attempt was made to interview Resident #15 on 06/09/15 at 9:00 a.m.; however, due to the resident's cognitive deficits she was unable to engage in any meaningful conversation. An interview on 06/09/15 at 9:45 a.m. with the DON revealed she did not consider Resident #18 kissing Resident #15 as sexually inappropriate behaviors. After this incident, the DON stated she spoke with Resident #18's family member, and the family member informed her that the resident had been sexually inappropriate with the family member before his admission to the facility. The DON stated Resident #18 was referred to psychological services on 03/25/15, and he had been receiving psychological services since April 2015. She stated they tried to refer Resident #18 to a psychiatric hospital, but they would not accept the resident due to funding issues. The DON further explained that due to the resident's cardiac status and the fact that it has deteriorated the other hospitals would not accept him. The DON stated the staff was monitoring Resident #18's whereabouts, and they were aware he was not supposed to be left alone in the dining room or the rotunda at all. She stated he was supposed to be redirected back to his room in the afternoon, and every shift was aware if Resident #18 was in the rotunda then a nurse must be at the nurses' station. A telephone interview on 06/09/15 at 5:04 p.m. with Resident #15's responsible party revealed another family member received the call from the facility and was told about Resident #18 kissing Resident #15. The responsible party stated he/she was not told about Resident #18 putting his hands down Resident #15's shirt. Resident #18's Nursing Departmental Notes written by ADON BB on 05/03/15 5:58 p.m. reflected: Resident kissing and touching another residents (sic) breasts (Resident #16). Witnessed twice. Separated both times. Talked with resident (Resident #18) about not touching other residents. That it is not acceptable. Called DON and (Social Worker). (Social Worker) stated he will come and talk to him (Resident #18). He (Resident #18) denied touching her. Will cont to monitor. This note was co-signed by ADON CC on 05/04/15 at 5:35 a.m. A Resident Incident Report, dated 05/03/15, reflected Resident #18 was observed kissing Resident #16 twice on that date. It was also noted that Resident #18 was touching Resident #16's breasts. The DON and Social Worker were immediately notified of the incident. This report was prepared/signed by ADON BB and signed by the DON and Administrator on 05/03/15. An Incident Witness Statement, prepared by MA QQ, reflected on 05/03/15 at 4:00 p.m. she walked into the dining room and observed Resident #18 with his hands underneath Resident #16's shirt, and he was touching her breasts. She noted that she asked Resident #16 to go with her, and she notified the charge nurse of the incident. An interview on 06/09/15 at 11:10 a.m. with MA QQ revealed she saw Resident #18 kiss Resident #16 on her mouth two times with his hand under her shirt touching her breast. MA QQ stated she intervened by asking Resident #18 to come with her, and the resident pulled his hand out from under Resident #16's shirt. MA QQ revealed she immediately reported the incident to the nurse. Resident #18's Nursing Departmental Notes written by LVN BBB, dated 05/24/15 at 2:43 p.m., reflected: Noted to have had his hand down a female's (Resident #16) pants and being sexually inappropriate with same female resident. Explained to resident that he can not act sexually inappropriately like that with female residents. Currently sitting in the dining room at this time. Female resident across the room at this time. The note was co-signed by ADON BB on 05/26/15 at 5:20 p.m. A Resident Incident Report, dated 05/24/15, reflected dietary employees observed Resident #18 with his hands down a female's (Resident #16) pants. Resident #18 was noted to be acting sexually inappropriate. The report was prepared/signed by LVN OO and signed by the DON and Administrator on 05/24/15. An interview on 06/09/15 at 11:50 a.m with the DON revealed she denied having any knowledge of Resident #18 touching female residents. An Incident Witness Statement, prepared by Dietary Aide RR, reflected on 05/24/15 at 3:30 p.m. she observed (Resident #18) was sucking on (Resident #16) breast and had his hand between her legs, inside her. An Incident Witness Statement, prepared by Dietary Aide SS, reflected she observed Resident #18 with his mouth on Resident #16's breast and his hands down her pants in the dining room. Resident #16's Nursing Departmental Notes written by LVN AAA, dated 05/24/15 at 4:45 p.m., reflected: Reported to nursing that this resident (Resident #16) had been sexually fondled in the dining room by a male resident (Resident #18). It was told to nursing that a male resident had his hands down her pants and was sucking on her breast. This resident (Resident #16) when questioned had no recollection of events. This nurse contacted this residents (sic) RP (responsible party) and reported that a male resident had been sexually inappropriate towards (his/her) family member. (Family member) stated (he/she) was upset but he sort of understood. This nurse assured him that the resident (Resident #16) was not harmed and that she had no memory of the incident. He states he feels that administration will know what to do. This nurse spoke with male resident (Resident #18) and he denied having touched any residents. This nurse.told him he would have to eat (in) his room until this was resolved. He expressed understanding at this time. This note was co-signed by ADON BB on 05/26/15 at 5:19 p.m. The facility's incident reports for the incidents involving Resident #18 and #16 reflected both incidents occurred in open common areas of the facility to include the dining room and rotunda. Resident #16's MDS assessment, dated 04/01/15, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 12/10/09. Her [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. The resident did not have the presence of behavioral symptoms. The resident required limited assistance with transfers and was independent with ambulation on/off the unit. Resident #16's Care Plan, updated and continued on 04/15/15, reflected the resident had difficulty participating in social conversation with the potential for alteration in activities related to her disease process and cognitive limitations. An attempt on 06/09/15 at 3:30 p.m. to interview Resident #16 revealed the resident was not interviewable due to severe cognitive deficits. An interview on 06/08/15 at 3:30 p.m. with ADON BB revealed she was aware Resident #16 had been kissed on the lips and had been touched on her breast by Resident #18 on two different occasions. She stated the DON was informed and both the physician and family had been notified of the incident. ADON BB stated the staff were aware of Resident #18's behaviors, and they tried to monitor him closely. She stated she was aware of three separate incidents involving Resident #18 being sexually inappropriate with two female residents (Resident #15 and Resident #16) by kissing and touching the women. An interview on 06/09/15 at 8:55 a.m. with CNA GG revealed she witnessed Resident #18 kiss Resident #16 on the lips in the dining room several weeks ago. She stated she intervened and told Resident #18 it was inappropriate behavior. The residents were separated, and Resident #18 was redirected. CNA GG stated she immediately reported the incident to the charge nurse. An interview on 06/09/15 at 9:18 a.m. with Physician TT revealed he was well acquainted with Resident #18, and he was aware of the resident's sexually inappropriate behaviors. When asked about the communication document dated 05/20/15 from ADON CC asking about the possible use of Depo-[MEDICATION NAME] to alleviate Resident #18's symptoms, Physician TT stated he did not want to order the Depo-[MEDICATION NAME] until Resident #18 had been evaluated by a psychologist. Physician TT stated he also wanted the resident's family involved prior to moving forward with treatment of [REDACTED]. An interview on 06/09/15 at 11:00 a.m. with LVN LL revealed she was aware Resident #18 had a history of [REDACTED]. When asked what interventions have been implemented to address Resident #18's behaviors, LVN LL stated they tried to keep track of where the resident was. An interview on 06/09/15 at 11:30 a.m. with LVN AAA revealed she was aware of the incident involving Resident #18 and Resident #16 on 05/24/15. She stated she assessed Resident #16 following the incident. LVN AAA stated Resident #16 did not have the capacity to consent to what happened nor the ability to process what Resident #18 did to her. She stated Resident #16 had no memory of the incident. She further explained Resident #16 was very susceptible to suggestion; for example, if someone motioned to the resident to come the resident would do so without any safety awareness. An interview on 06/09/15 at 1:50 p.m. with Dietary Aide RR revealed on 05/24/15 in the dining room a Dishwasher got her attention. Dietary Aide RR stated she saw Resident #16 standing with her pants partly down with Resident #18's hand between her legs inside of her vagina. Dietary Aide RR revealed Resident #18 had his mouth on her bare breast sucking it, and Resident #16 looked confused. She stated she sent someone to get a nurse, and the nurses came right away and separated the residents. An interview on 06/09/15 at 1:55 p.m. with Dietary Aide SS, who worked as a Dishwasher, revealed on 05/24/15 she saw Resident #16 walking around the dining room, and she thought something was said but she could not hear what. She stated Resident #18 walked up to Resident #16, pulled the front of her pants down, and he put his hand between her legs. Dietary Aide SS then pulled up Resident #16's shirt, and he began sucking on the resident's breast. Dietary Aide SS revealed Resident #16 looked confused. She stated a co-worker sent for a nurse who intervened. Dietary Aide SS said she had not seen any other incidents like that between residents. An interview on 06/10/15 at 11:25 a.m. with the Social Worker revealed he counseled Resident #18 following the incident on 05/24/15. The Social Worker stated he explained to Resident #18 that he could not engage in any type of non-consensual sexual behaviors. He stated Resident #18 verbalized understanding, and the resident denied any of the incidents. The Social Worker stated he spoke with Resident #18's family member, and the family member informed him that Resident #18 exhibited sexual behaviors toward the family member prior to his admission at the facility. The Social Worker was asked what the plan was for Resident #18. He stated several other facilities have been contacted, and he was just waiting for a phone call. The Social Worker stated he did not think Resident #18 was aware of his behavior. He stated all staff including himself were monitoring Resident #18's behaviors. On 06/09/15 at 11:50 a.m., the Administrator and DON were notified that an IJ was identified. On 06/10/15 at 3:55 p.m., the facility submitted an acceptable Plan of Removal. The Plan of Removal reflected: The Plan of Removal was accepted on 06/10/15 and reflected Resident #18 was identified by the attending physician on 06/08/15 to be a threat to others. A physician order [REDACTED]. Resident #18 and his responsible party were issued an immediate discharge letter due to this threat. Resident #18 was placed on one-on-one monitoring until he leaves the facility. Resident #15 ' s care has been reviewed and there are no lingering effects such as emotional distress or sign or symptoms of anxiety, fear, or agitation from her incident with Resident #18 in March 2015. Further monitoring by each charge nurse on each shift of Resident #15 will continue for the next 30 days. Resident #16 ' s care has been reviewed and there are no lingering effects, such as emotional distress or sign or symptoms of anxiety, fear or agitation, from her incident with Resident #18 in in May 2015. Further monitoring by each charge nurse on each shift of Resident #16 will continue for the next 30 days. The facility's Plan of Removal also reflected the Administrator was in-serviced by the corporate nurse on the understanding of abuse prohibition components to include identifying, reporting, investigating and protecting. From this date forward, all incidents of alleged abuse will be reviewed immediately and findings reported to the State agency and the local authority. Any incidents concerning alleged abuses will be investigated, the perpetrator will be placed on one on one monitoring during the investigation and until the threat has resolved or the resident has been discharged from the facility. During this process all other residents will be protected and monitored to ensure their health and safety. An immediate in-service training will be conducted and completed by the corporate nurse, for all facility staff on 06/09/15. The in-services cover the following: Any staff member who witnesses a resident inappropriately touch another resident, or have any type of sexual contact with a resident, without that residents ' consent, will be placed on one on one monitoring immediately. A member of management will be notified immediately. The resident who is the aggressor will remain under one on one monitoring, either by a staff member or a member of the resident ' s family until the facility has determined that the threat of reoccurrence has resolved, or until that resident has discharged from the facility. Evidence of the in-service training will include content and sign-in sheets to verify what and when staff was trained on. An additional in-service will be completed on 6/10/15 by the Corporate Nurse with all licensed nurses regarding policy and procedure for completion of incident reports, documentation and notification of incidents, and for identifying, reporting, investigation, protecting residents when an allegation of abuse or neglect is reported. The Plan of Removal reflected other residents in the facility were assessed and interviewed regarding possible abuse. Fourteen interviewable female residents were selected on all halls which resulted in the findings that no other female residents reported sexual contact by male residents. In addition 14 confused female residents were assessed by licensed facility staff for signs of fear or anxiety. A system has been implemented to ensure during the abuse prohibition process that any allegations of abuse will incorporate the interviewing of all alert and oriented residents affected and assessment of cognitively impaired residents for signs and symptoms of abuse or neglect. To further identify other residents with behaviors that affect others to include residents that have sexually inappropriate behaviors a roster sample matrix was used to identify residents with behaviors. Five residents were identified as having behavioral issues that need to be monitored, and they were placed on behavior monitoring flow sheets to be completed every shift for two weeks. If, behaviors are identified and affects others, individual plans to address each behavior will be developed to manage the behavior. An interview on 06/09/15 at 3:50 p.m. with the Medical Director revealed he had no previous knowledge of the situation regarding Resident #18. An interview on 06/09/15 at 3:58 p.m. Physician TT explained the Administrator's plan was to discharge Resident #18 to the hospital for evaluation and treatment. An interview on 06/09/15 at 4:15 p.m. with DON revealed she should have done more prevention in the manner of preventing incidents. The DON explained that funding was an issue for Resident #18, but he now had an appointment with a psychiatrist on 06/17/15. The DON acknowledged that staff monitoring was not enough to protect all of the residents. The DON was asked if any other residents had been identified as having inappropriate sexual behaviors in the facility, and she stated there were not any others. Beginning on 06/11/15 at 8:00 a.m. until 2:00 p.m. interviews were conducted with the Dietary Manager, Dietary Aide A, Dietary Aide B, Dietary Aide C, CNA D, CNA E, LVN F, LVN J, CNA K, CNA L, LVN M, Van Driver, CNA O, RN P, CNA R, Dietary Aide S, CNA T, CNA U, CMA V, CNA Y, ADON BB, ADON CC, Human Resources Director, CNA GG, CNA HH, CNA II, Housekeeper JJ, CNA KK, LVN LL, CNA MM, Housekeeper NN, Housekeeping Supervisor, Dietary Aide VV, CNA WW, CNA XX, and CNA ZZ. The interviews revealed the employees received in-service training related to residents with sexually inappropriate behaviors. The facility staff were able to correctly answer questions about abuse including sexual abuse, signs and symptoms of sexual abuse, reporting of inappropriate sexual behaviors, what actions to take if you observe or suspect sexual abuse and monitoring residents with sexual behaviors. The IJ was removed on 06/11/15. On 06/11/15 at 4:24 p.m., the Administrator and DON were notified the IJ was removed. While the IJ was removed on 06/11/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Plan of Removal, dated 06/10/15, reflected there were 14 female residents with cognitive impairment.

Based on observation, interview and record review, it was determined the facility failed to implement its written policies and procedures that prohibit the mistreatment, neglect, and abuse of three (Residents #15, #16, and #18) of twenty-one residents, who were reviewed for abuse/neglect concerns. The facility failed to protect Residents #15 and #16, who both had severe cognitive impairment, from sexual abuse by Resident #18 and failed to develop and implement measures to address Resident #18's sexually inappropriate behaviors. On 06/09/15, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/11/15 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures resulted in Residents #15 and #16 experiencing sexual abuse and had the potential to affect all 14 female residents identified with cognitive impairment by placing them at risk for abuse and neglect. Findings included: Resident #18's MDS assessment, dated 04/16/15, reflected he was a [AGE] year-old male, who was admitted to the facility on [DATE] with a re-admission on 04/02/15. His [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. The assessment did not reflect the presence of any behavioral symptoms. The resident was able to walk on and off the unit with only supervision and setup help. Resident #18's Care Plan, dated 03/22/15, reflected the resident displayed socially inappropriate behavior by kissing another resident (Resident #15) and placing his hand down her shirt. The care planned approaches were as follows: - Social Services to evaluate and visit as needed - Activities staff to visit and provide diversional activities - Monitor and document behavior - Elicit family input for best approach(es) - Administer behavior medications as ordered by physician - Talk in calm voice when behavior is disruptive - Encourage family/responsible party to visit - 5/3/15 - Resident was kissing and touching a female resident, he was re-directed - 4/30/2015 - SC (standards of care) done CPOC (continue plan of care) next 90 days - 5/24/15 - Resident was being sexually inappropriate with female resident,SW to assist with finding placement to assist with behaviors. There was no documentation reflecting specific interventions were developed or implemented to monitor or prevent Resident #18's sexual behaviors towards female residents. An observation on 06/07/15 at 10:08 a.m. revealed Resident #18 was alert and able to transfer and ambulate independently. An interview at that time with ADON BB revealed Resident #18 had a history of [REDACTED]. ADON BB stated as an intervention, the nursing staff was monitoring the resident's whereabouts in the facility on an on-going basis. Resident #18's Nursing Department Notes written by LVN OO, dated 03/22/15 at 4:00 p.m., reflected: Resident was seen on hall 2 standing near another resident, housekeeper witnessed him leaning over to kiss her on the lips and then again and then put his hand down her shirt, nurse was notified and nurse spoke with resident telling him that (his) behavior was not appropriate, resident voiced understanding. The note was co-signed by ADON CC on 04/22/15 at 5:34 a.m. A Resident Incident Report, dated 03/22/15, reflected on 03/22/15 at 11:45 a.m. the following incident transpired: Housekeeper (Housekeeper AA) came and reported that this Resident (Resident #15) was sitting in gerichair in (the) hallway and a male resident (Resident #18) came up and kissed her on the lips. Kissed her again a second time and witness stated he (Resident #18) put his hand down her (Resident #15) shirt. When male resident saw housekeeper he pulled his hand out. Witness went and told nurse. Spoke with male resident that it is not appropriate behavior to do that and he voiced understanding. Called DON and reported what happened. Male resident is on q (every) 15 minute checks. Will cont (continue) to monitor. This report was prepared, signed, and dated by ADON BB on 03/22/15. An interview on 06/10/15 at 11:10 a.m. with Housekeeper PP revealed she witnessed Resident #18 in the hallway kissing Resident #15 on the mouth. She stated she then saw him put his hand inside of Resident #15's, and he touched her breast. She stated when Resident #18 saw her looking he pulled his hand out of Resident #15's shirt. She stated she reported the incident right away. There was no documentation reflecting the facility conducted every 15 minute checks on Resident #18 following the incident on 03/22/15. Resident #15's MDS assessment, dated 01/16/15, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 02/27/14. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with both short-term and long-term memory problems and no behavioral symptoms. The resident required extensive assistance with her ADLs and was totally dependent upon staff for locomotion on and off the unit. Resident #15's Care Plan, updated and continued on 06/09/15, reflected the resident had short-term and long-term memory problems and difficulty making herself understood. A Care Plan, initiated on 03/22/15, reflected the resident was approached by a male resident, and the male resident kissed her and placed his hand down her shirt. An observation on 06/07/15 at 10:52 a.m. of Resident #15 revealed she was non-ambulatory, she was bed and geri-chair bound. Resident #15 was transferred via a Hoyer lift with the assistance of two staff, she was alert but confused, she was totally dependent on staff for all her ADLs, and she was incontinent of bowel and bladder. An attempt was made to interview Resident #15 on 06/09/15 at 9:00 a.m.; however, due to the resident's cognitive deficits she was unable to engage in any meaningful conversation. An interview on 06/09/15 at 9:45 a.m. with the DON revealed she did not consider Resident #18 kissing Resident #15 as sexually inappropriate behaviors. After this incident, the DON stated she spoke with Resident #18's family member, and the family member informed her that the resident had been sexually inappropriate with the family member before his admission to the facility. The DON stated Resident #18 was referred to psychological services on 03/25/15, and he had been receiving psychological services since April 2015. She stated they tried to refer Resident #18 to a psychiatric hospital, but they would not accept the resident due to funding issues. The DON further explained that due to the resident's cardiac status and the fact that it has deteriorated the other hospitals would not accept him. The DON stated the staff was monitoring Resident #18's whereabouts, and they were aware he was not supposed to be left alone in the dining room or the rotunda at all. She stated he was supposed to be redirected back to his room in the afternoon, and every shift was aware if Resident #18 was in the rotunda then a nurse must be at the nurses' station. A telephone interview on 06/09/15 at 5:04 p.m. with Resident #15's responsible party revealed another family member received the call from the facility and was told about Resident #18 kissing Resident #15. The responsible party stated he/she was not told about Resident #18 putting his hands down Resident #15's shirt. Resident #18's Nursing Departmental Notes written by ADON BB on 05/03/15 5:58 p.m. reflected: Resident kissing and touching another residents (sic) breasts (Resident #16). Witnessed twice. Separated both times. Talked with resident (Resident #18) about not touching other residents. That it is not acceptable. Called DON and (Social Worker). (Social Worker) stated he will come and talk to him (Resident #18). He (Resident #18) denied touching her. Will cont to monitor. This note was co-signed by ADON CC on 05/04/15 at 5:35 a.m. A Resident Incident Report, dated 05/03/15, reflected Resident #18 was observed kissing Resident #16 twice on that date. It was also noted that Resident #18 was touching Resident #16's breasts. The DON and Social Worker were immediately notified of the incident. This report was prepared/signed by ADON BB and signed by the DON and Administrator on 05/03/15. An Incident Witness Statement, prepared by MA QQ, reflected on 05/03/15 at 4:00 p.m. she walked into the dining room and observed Resident #18 with his hands underneath Resident #16's shirt, and he was touching her breasts. She noted that she asked Resident #16 to go with her, and she notified the charge nurse of the incident. An interview on 06/09/15 at 11:10 a.m. with MA QQ revealed she saw Resident #18 kiss Resident #16 on her mouth two times with his hand under her shirt touching her breast. MA QQ stated she intervened by asking Resident #18 to come with her, and the resident pulled his hand out from under Resident #16's shirt. MA QQ revealed she immediately reported the incident to the nurse. Resident #18's Nursing Departmental Notes written by LVN BBB, dated 05/24/15 at 2:43 p.m., reflected: Noted to have had his hand down a female's (Resident #16) pants and being sexually inappropriate with same female resident. Explained to resident that he can not act sexually inappropriately like that with female residents. Currently sitting in the dining room at this time. Female resident across the room at this time. The note was co-signed by ADON BB on 05/26/15 at 5:20 p.m. A Resident Incident Report, dated 05/24/15, reflected dietary employees observed Resident #18 with his hands down a female's (Resident #16) pants. Resident #18 was noted to be acting sexually inappropriate. The report was prepared/signed by LVN OO and signed by the DON and Administrator on 05/24/15. An interview on 06/09/15 at 11:50 a.m with the DON revealed she denied having any knowledge of Resident #18 touching female residents. An Incident Witness Statement, prepared by Dietary Aide RR, reflected on 05/24/15 at 3:30 p.m. she observed (Resident #18) was sucking on (Resident #16) breast and had his hand between her legs, inside her. An Incident Witness Statement, prepared by Dietary Aide SS, reflected she observed Resident #18 with his mouth on Resident #16's breast and his hands down her pants in the dining room. Resident #16's Nursing Departmental Notes written by LVN AAA, dated 05/24/15 at 4:45 p.m., reflected: Reported to nursing that this resident (Resident #16) had been sexually fondled in the dining room by a male resident (Resident #18). It was told to nursing that a male resident had his hands down her pants and was sucking on her breast. This resident (Resident #16) when questioned had no recollection of events. This nurse contacted this residents (sic) RP (responsible party) and reported that a male resident had been sexually inappropriate towards (his/her) family member. (Family member) stated (he/she) was upset but he sort of understood. This nurse assured him that the resident (Resident #16) was not harmed and that she had no memory of the incident. He states he feels that administration will know what to do. This nurse spoke with male resident (Resident #18) and he denied having touched any residents. This nurse.told him he would have to eat (in) his room until this was resolved. He expressed understanding at this time. This note was co-signed by ADON BB on 05/26/15 at 5:19 p.m. The facility's incident reports for the incidents involving Resident #18 and #16 reflected both incidents occurred in open common areas of the facility to include the dining room and rotunda. Resident #16's MDS assessment, dated 04/01/15, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE] with a re-admission on 12/10/09. Her [DIAGNOSES REDACTED]. The resident had severe cognitive impairment with inattention and disorganized thinking. The resident did not have the presence of behavioral symptoms. The resident required limited assistance with transfers and was independent with ambulation on/off the unit. Resident #16's Care Plan, updated and continued on 04/15/15, reflected the resident had difficulty participating in social conversation with the potential for alteration in activities related to her disease process and cognitive limitations. An attempt on 06/09/15 at 3:30 p.m. to interview Resident #16 revealed the resident was not interviewable due to severe cognitive deficits. An interview on 06/08/15 at 3:30 p.m. with ADON BB revealed she was aware Resident #16 had been kissed on the lips and had been touched on her breast by Resident #18 on two different occasions. She stated the DON was informed and both the physician and family had been notified of the incident. ADON BB stated the staff were aware of Resident #18's behaviors, and they tried to monitor him closely. She stated she was aware of three separate incidents involving Resident #18 being sexually inappropriate with two female residents (Resident #15 and Resident #16) by kissing and touching the women. An interview on 06/09/15 at 8:55 a.m. with CNA GG revealed she witnessed Resident #18 kiss Resident #16 on the lips in the dining room several weeks ago. She stated she intervened and told Resident #18 it was inappropriate behavior. The residents were separated, and Resident #18 was redirected. CNA GG stated she immediately reported the incident to the charge nurse. An interview on 06/09/15 at 9:18 a.m. with Physician TT revealed he was well acquainted with Resident #18, and he was aware of the resident's sexually inappropriate behaviors. When asked about the communication document dated 05/20/15 from ADON CC asking about the possible use of Depo-[MEDICATION NAME] to alleviate Resident #18's symptoms, Physician TT stated he did not want to order the Depo-[MEDICATION NAME] until Resident #18 had been evaluated by a psychologist. Physician TT stated he also wanted the resident's family involved prior to moving forward with treatment of [REDACTED]. An interview on 06/09/15 at 11:00 a.m. with LVN LL revealed she was aware Resident #18 had a history of [REDACTED]. When asked what interventions have been implemented to address Resident #18's behaviors, LVN LL stated they tried to keep track of where the resident was. An interview on 06/09/15 at 11:30 a.m. with LVN AAA revealed she was aware of the incident involving Resident #18 and Resident #16 on 05/24/15. She stated she assessed Resident #16 following the incident. LVN AAA stated Resident #16 did not have the capacity to consent to what happened nor the ability to process what Resident #18 did to her. She stated Resident #16 had no memory of the incident. She further explained Resident #16 was very susceptible to suggestion; for example, if someone motioned to the resident to come the resident would do so without any safety awareness. An interview on 06/09/15 at 1:50 p.m. with Dietary Aide RR revealed on 05/24/15 in the dining room a Dishwasher got her attention. Dietary Aide RR stated she saw Resident #16 standing with her pants partly down with Resident #18's hand between her legs inside of her vagina. Dietary Aide RR revealed Resident #18 had his mouth on her bare breast sucking it, and Resident #16 looked confused. She stated she sent someone to get a nurse, and the nurses came right away and separated the residents. An interview on 06/09/15 at 1:55 p.m. with Dietary Aide SS, who worked as a Dishwasher, revealed on 05/24/15 she saw Resident #16 walking around the dining room, and she thought something was said but she could not hear what. She stated Resident #18 walked up to Resident #16, pulled the front of her pants down, and he put his hand between her legs. Dietary Aide SS then pulled up Resident #16's shirt, and he began sucking on the resident's breast. Dietary Aide SS revealed Resident #16 looked confused. She stated a co-worker sent for a nurse who intervened. Dietary Aide SS said she had not seen any other incidents like that between residents. An interview on 06/10/15 at 11:25 a.m. with the Social Worker revealed he counseled Resident #18 following the incident on 05/24/15. The Social Worker stated he explained to Resident #18 that he could not engage in any type of non-consensual sexual behaviors. He stated Resident #18 verbalized understanding, and the resident denied any of the incidents. The Social Worker stated he spoke with Resident #18's family member, and the family member informed him that Resident #18 exhibited sexual behaviors toward the family member prior to his admission at the facility. The Social Worker was asked what the plan was for Resident #18. He stated several other facilities have been contacted, and he was just waiting for a phone call. The Social Worker stated he did not think Resident #18 was aware of his behavior. He stated all staff including himself were monitoring Resident #18's behaviors. The facility's current, undated Abuse Policy and Procedure reflected: Each resident has the right to be free from abuse. Residents will not be subjected to abuse by anyone including but not limited to, facility staff and other residents. Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents' whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis. The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences. Investigation: All staff in the nursing facility and all residents, responsible parties, and or legal representatives has been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully. The administrator or his/her designee will repot this allegation of abuse immediately to the state agency (DADS) and to the proper local authorities. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing. The director of nursing will ensure that facility completes the appropriate investigative forms and forwards a copy of the investigation to DADS within 5 working days. Protection: It is the up most importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigative process. The facility will imitate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. When an abuse identifies perpetrator that is identified by an eyewitness, the facility will immediately remove the perpetrator from the facility, pending outcome of he investigation. Reporting/Response: Upon completion of an investigation, the director of nurses and the administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences. On 06/09/15 at 11:50 a.m., the Administrator and DON were notified that an IJ was identified. On 06/10/15 at 3:55 p.m., the facility submitted an acceptable Plan of Removal. The Plan of Removal reflected: The Plan of Removal was accepted on 06/10/15 and reflected Resident #18 was identified by the attending physician on 06/08/15 to be a threat to others. A physician order [REDACTED]. Resident #18 and his responsible party were issued an immediate discharge letter due to this threat. Resident #18 was placed on one-on-one monitoring until he leaves the facility. Resident #15 ' s care has been reviewed and there are no lingering effects such as emotional distress or sign or symptoms of anxiety, fear, or agitation from her incident with Resident #18 in March 2015. Further monitoring by each charge nurse on each shift of Resident #15 will continue for the next 30 days. Resident #16 ' s care has been reviewed and there are no lingering effects, such as emotional distress or sign or symptoms of anxiety, fear or agitation, from her incident with Resident #18 in in May 2015. Further monitoring by each charge nurse on each shift of Resident #16 will continue for the next 30 days. The facility's Plan of Removal also reflected the Administrator was in-serviced by the corporate nurse on the understanding of abuse prohibition components to include identifying, reporting, investigating and protecting. From this date forward, all incidents of alleged abuse will be reviewed immediately and findings reported to the State agency and the local authority. Any incidents concerning alleged abuses will be investigated, the perpetrator will be placed on one on one monitoring during the investigation and until the threat has resolved or the resident has been discharged from the facility. During this process all other residents will be protected and monitored to ensure their health and safety. An immediate in-service training will be conducted and completed by the corporate nurse, for all facility staff on 06/09/15. The in-services cover the following: Any staff member who witnesses a resident inappropriately touch another resident, or have any type of sexual contact with a resident, without that residents ' consent, will be placed on one on one monitoring immediately. A member of management will be notified immediately. The resident who is the aggressor will remain under one on one monitoring, either by a staff member or a member of the resident ' s family until the facility has determined that the threat of reoccurrence has resolved, or until that resident has discharged from the facility. Evidence of the in-service training will include content and sign-in sheets to verify what and when staff was trained on. An additional in-service will be completed on 6/10/15 by the Corporate Nurse with all licensed nurses regarding policy and procedure for completion of incident reports, documentation and notification of incidents, and for identifying, reporting, investigation, protecting residents when an allegation of abuse or neglect is reported. The Plan of Removal reflected other residents in the facility were assessed and interviewed regarding possible abuse. Fourteen interviewable female residents were selected on all halls which resulted in the findings that no other female residents reported sexual contact by male residents. In addition 14 confused female residents were assessed by licensed facility staff for signs of fear or anxiety. A system has been implemented to ensure during the abuse prohibition process that any allegations of abuse will incorporate the interviewing of all alert and oriented residents affected and assessment of cognitively impaired residents for signs and symptoms of abuse or neglect. To further identify other residents with behaviors that affect others to include residents that have sexually inappropriate behaviors a roster sample matrix was used to identify residents with behaviors. Five residents were identified as having behavioral issues that need to be monitored, and they were placed on behavior monitoring flow sheets to be completed every shift for two weeks. If, behaviors are identified and affects others, individual plans to address each behavior will be developed to manage the behavior. An interview on 06/09/15 at 3:50 p.m. with the Medical Director revealed he had no previous knowledge of the situation regarding Resident #18. An interview on 06/09/15 at 3:58 p.m. Physician TT explained the Administrator's plan was to discharge Resident #18 to the hospital for evaluation and treatment. An interview on 06/09/15 at 4:15 p.m. with DON revealed she should have done more prevention in the manner of preventing incidents. The DON explained that funding was an issue for Resident #18, but he now had an appointment with a psychiatrist on 06/17/15. The DON acknowledged that staff monitoring was not enough to protect all of the residents. The DON was asked if any other residents had been identified as having inappropriate sexual behaviors in the facility, and she stated there were not any others. Beginning on 06/11/15 at 8:00 a.m. until 2:00 p.m. interviews were conducted with the Dietary Manager, Dietary Aide A, Dietary Aide B, Dietary Aide C, CNA D, CNA E, LVN F, LVN J, CNA K, CNA L, LVN M, Van Driver, CNA O, RN P, CNA R, Dietary Aide S, CNA T, CNA U, CMA V, CNA Y, ADON BB, ADON CC, Human Resources Director, CNA GG, CNA HH, CNA II, Housekeeper JJ, CNA KK, LVN LL, CNA MM, Housekeeper NN, Housekeeping Supervisor, Dietary Aide VV, CNA WW, CNA XX, and CNA ZZ. The interviews revealed the employees received in-service training related to residents with sexually inappropriate behaviors. The facility staff were able to correctly answer questions about abuse including sexual abuse, signs and symptoms of sexual abuse, reporting of inappropriate sexual behaviors, what actions to take if you observe or suspect sexual abuse and monitoring residents with sexual behaviors. The IJ was removed on 06/11/15. On 06/11/15 at 4:24 p.m., the Administrator and DON were notified the IJ was removed. While the IJ was removed on 06/11/15, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern, because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's Plan of Removal, dated 06/10/15, reflected there were 14 female residents with cognitive impairment.

Based on observation, interview and record review, the Administrator and the DON failed to effectively and efficiently manage facility resources to attain or maintain the highest practicable physical well-being for two (Residents #1 and #2) of of three residents reviewed for weight loss, whose clinical conditions did not demonstrate weight loss was unavoidable. The Administrator failed to supervise the DON to ensure: a) RA A was supervised and monitored to ensure residents were weighed as ordered and weights were accurate. Thirty of 106 residents were re-weighed on 10/01/10 and found to have a 3% difference from their previous weights. Residents #1 and #2 sustained severe weight loss. b) licensed nursing staff were supervised and monitored to ensure the RD was notified of weight loss and recommendations from the RD were followed up and implemented. The RD was not notified of Resident #1's and #2's weight loss. The RD recommended a change in enteral formula for Resident #2, which was not implemented. c) licensed nursing staff were supervised and monitored to ensure residents were receiving the benefit of health supplements, vitamins and minerals when residents were identified as being at risk for weight loss. Resident #1 was not receiving any health supplements, vitamins or minerals. c) the RD was supervised and monitored to ensure dietary recommendations met the residents' caloric and protein requirements. Resident #1 was not recommended adequate amounts of enteral formula to meet his protein and caloric needs. Resident #1 had severe weight loss and a low [MEDICATION NAME] (protein) level. On 10/01/10, these findings resulted in an Immediate Jeopardy (IJ) situation in the area of Administration for Resident #1, Resident #2 and the 30 residents, whose weights differed a minimum of 3% from 09/25/10 to 10/01/10. While the IJ was removed on 10/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of a "pattern" due to continued monitoring to ensure staff were implementing the training received and addressing the residents' significant/severe weight loss. These failures could affect the facility's 106 residents, including Residents #1 and #2, and placed them at risk for significant weight loss, [MEDICAL CONDITION], development of pressure ulcers and an overall decline in condition. Findings included: 1) Resident #1, according to physician orders [REDACTED]. The resident's diet order was "Resident is NPO (nothing by mouth) for [DEVICE] only...Give enteral formula: Ensure Plus 1 can 4 times a day via [MEDICATION NAME]." No orders to weigh the resident were noted. No dietary supplements or vitamins were noted as ordered. Resident #1's Braden scale assessment for predicting pressure ulcers dated 07/12/10 reflected he was at high risk for breakdown and indicated his nutrition was "probably inadequate." Resident #1's MDS assessment dated [DATE] reflected the resident was severely impaired cognitively, was non-verbal and required the total assistance of 1-2 staff members for all activities of daily living. Resident #1's care plan dated 07/22/10 reflected the resident was at risk for weight loss, with a plan including weighing the resident as ordered, reporting significant weight loss to the physician and consulting the Dietician quarterly and as needed. According to the facility weight log, undated but provided by the DON on 10/01/10, Resident #1's weights were as follows: July 2010 - 127 lbs, August 2010 - 128 lbs, September 2010 - 126 lbs and on 09/25/10 after the scale was re-calibrated the resident weighed - 124 lbs. Resident #1's dietary evaluations were as follows: 07/13/10 - [AGE] year-old, 60.0 inches tall weighing 128 pounds. Daily calorie requirements of 1485.0 cal/day, receiving 1440.0 cal/day, difference -45.0 cal/day. Daily protein requirements 58.2 grams (gm), receiving 52.8 gm/day, difference - 5.4 gm/day. 08/11/10 - [AGE] year-old, 60.0 inches tall, weighing 128 pounds. Daily calorie requirements of 1485.0 cal/day, receiving 1440.0 cal/day, difference -45.0 cal/day. Daily protein requirements 58.2 grams (gm), receiving 52.8 gm/day, difference - 5.4 gm/day. No evidence of a dietary evaluation was found for Resident #1 for September 2010 despite a documented weight loss of four lbs. On 10/01/10 at 12:00 PM, in an interview with the Dietician, she stated regarding Resident #1, "His BMI (body mass index) is normal high, his weight loss is not significant. I can raise him another can (of enteral formula) but I don't want him to get chubby. He's bedfast and his BMI like I said is normal high. I just don't think ___ (Resident #1) weight loss is significant" On 10/01/10 at 2:20 PM, Resident #1 was weighed by Restorative Aide (RA) A. The resident was in his bed and observed with contractures of his legs. He appeared taller than his measured height (60 inches) and was very thin. Resident #1 weighed 107 pounds. RA A was asked what she would normally do when there was weight loss, and she stated she would go get the charge nurse or DON. RA A left the room and returned with the DON. Resident #1 was re-weighed, and again the results were 107 pounds, reflecting a severe weight loss of 21 lbs (16%) in two months. (128 lbs in August 2010 to 107 lbs on 10/01/10) An unidentified Hospice Aide present in the room, who normally cared for Resident #1, stated, "He has lost weight. I can't say it was 20 pounds, but he has lost weight." On 10/01/10 at 2:35 PM, in an interview, the DON stated she was concerned RA A had not actually been weighing the residents and was just making them up, because the weights she recorded one week earlier were so different. The DON also stated they had just had the scales re-calibrated the previous week prior to the 09/25/10 weights. "I talked to her (RA A) already and I told her I had to know if she was making up the weights," said the DON. "She said she was was not." Because of the extreme weight difference for Resident #1, the facility staff decided to check the scale for accuracy. The scale was checked on 10/01/10 at 2:35 PM. The RAs, in the presence of the DON, placed 20 lbs of hand weights on the scale, and it weighed accurately (20 lbs). An interview with Resident #1's family member was conducted on 10/01/10 at 6:30 PM. The family member stated Resident #1 weighed 122 lbs in the hospital just prior to his admission to the facility on [DATE]. The family member stated he/she was concerned, because he/she thought the resident had lost weight. laboratory results dated [DATE] reflected Resident #1's [MEDICATION NAME] level was low at 3.0 grams/deciliter (reference range 3.4-5.0 grams/deciliter). 2) Resident #2, according to physician orders [REDACTED]. His [DEVICE] diet order was as follows, "NPO with Boost @ 60 cc/hr for 23 hours/day." Supplements included, Resource [MEDICATION NAME] one packet twice a day, and a Multivitamin/Mineral Liquid 15 milliliters every day, A hospital rounding report dated 06/25/10 reflected Resident #2's weight as 237.7 pounds and he was 70 inches tall. Resident #2's MDS assessment dated [DATE] reflected the resident was severely impaired cognitively and required extensive assistance by 1-2 staff for all activities of daily living. Resident #2's Assessment of Nutritional Risk dated 7/30/10 reflected the resident at high nutritional risk. On 10/01/10 at 12:00 PM, the Dietician was interviewed about Resident #2. When asked about Resident #2's documented weight loss from 256 pounds on re-admission to 235 pounds at the end of September (2010), she stated, "That can't be right. I have 241 (pounds)." She further stated she knew he had been having problems tolerating his enteral formula, and she had made a recommendation to change the formula, but did not know why it was not done. When asked what other formula options were available, she stated, "We could try 2.0 calorie HTN." The Dietician was asked if she was notified of the latest weight and she stated, "I should have been notified. I don't want tube feeders to ever lose weight." According to the facility weight log, undated but provided by the DON on 10/01/10, Resident #2's weights were as follows: July 2010 - 256 lbs, August 2010 - 254 lbs, September 2010 - 241 lbs and on 09/25/10 after the scale re-calibration the resident weighed - 235 lbs. Resident #2's dietary evaluations were as follows: 09/09/10 - [AGE] year-old man weighing 241 pounds and 70 inches tall. Daily calorie requirements of 2408.4 cal/day, receiving 1393.8 cal/day, difference -1014.6 cal/day. Daily protein requirements 109.5 grams (gm), receiving 13.8 gm/day, difference -95.7 gm/day. "Alb ([MEDICATION NAME]) has improved to 3.2 (g/dL) (reference range 3.4-5.0 g/dL)" On 10/01/10 at 2:30 PM, Resident #2 was weighed by RA A with the DON present. Observation revealed Resident #2 was awake and alert, and he had no skin breakdown. Resident #2 weighed 201.7 lbs, reflecting a 54.3 lb (2l%) weight loss in three months (256 lbs in July 2010 to 201.7 lbs on 10/01/10). 3) Review of the Facility Weight Loss Protocol, undated, but provided by the DON on 10/01/10 as current revealed the following: "Purpose 1. To carefully observe and monitor weight changes in residents. 2. To address weight changes to determine appropriate and timely actions that should be implemented. Procedure 1. Address weight changes for residents losing 5% in one month or 7.5% in three months... 4. Notify the physician and family of weight loss. 5. Obtain orders for lab work if indicated... 8. Place resident on weekly weights... 9. Be sure resident is on a multivitamin... 10. Place weight loss assessment in a folder at the nurses station labeled, ASSESSMENTS FOR DIETICIAN...If severe, fax weight loss assessment to dietician...." No notation was made for ensuring weight data was correct. 4) On 10/01/10 at 3:30 PM, these facility failures placed Resident #1, Resident #2 and the 30 residents, whose weights differed a minimum of 3% from 09/25/10 to 10/01/10, in an IJ situation in the area of Administration. The ADM and DON were notified of the IJ situation. 5) The facility's Plan of Removal was accepted on 10/02/10. The Plan of Removal reflected the following: a. The facility would verify the accuracy of the scales. b. Assessments were conducted of Residents #1 and #2, including new weights, a head-to-toe assessment along with labs and a dietary assessment. c. Re-weigh and evaluate all other residents for possible weight loss. Residents suspected of having a weight loss of 3% or more would have a dietary assessment and labs including CMP (Complete Metabolic Panel), Pre-[MEDICATION NAME], and CBC (Complete Blood Count). d. Change in personnel and the procedure for weighing residents. e. In-services conducted for charge nurses and restorative staff responsible for obtaining weights. f. Over-site by the Administrator and monitoring through the facility's QA&A Committee. 6) After verifying the accuracy of the scales, re-weighs of the facility's residents were conducted on 10/01/10. The results revealed 30 of 106 residents (one refused) had weights, which differed 3% or greater from the weight recorded by RA A seven days before. Each of those residents with a 3% or greater weight loss had labs drawn and dietary evaluations conducted by the next day 10/02/10. Resident #1's dietary evaluation dated 10/01/10 reflected the following changes: "[AGE] year-old, 60.0 inches tall weighing 107 pounds. Daily calorie requirements of 1328.1 cal/day, receiving 1800.0 cal/day, difference +471.9 cal/day. Daily protein requirements 48.6 grams (gm), receiving 66.0 gm/day, difference +17.4 gm/day." Resident #2's dietary evaluation dated 10/01/10 reflected the following changes: "[AGE] year-old man weighing 200 lbs and 70.0 inches tall. Daily calorie requirements of 2093.8 cal/day, receiving 2300.0 cal/day, difference +206.2 cal/day. Daily protein requirements 90.9 grams (gm), receiving 103.5 gm/day, difference +12.6 gm/day. Recommend Resource 2.0 at 50 cc/hour for 23 hours/day." A review of the facility in-service entitled Weight Loss Protocol/Assessment of Weight revealed the in-service was conducted on 10/01/10 and all, "Managers and Restorative Nursing Aides verbalized understanding of the material." An interview was conducted with RA B on 10/03/10 at 2:00 PM. She stated she would be responsible for weighing the residents from now on. She stated she had received training on weighing the residents in the last 24 hours and she was instructed to weigh the residents with a charge nurse present and to report any weight changes to the DON. On 10/03/10 at 3:15 PM, CNA C was interviewed. She stated she was told she would be the back-up for RA B. She stated she had received training in the last 24 hours. CNA C also stated she was instructed to weigh the residents with a charge nurse present and to report any weight changes to the DON. On 10/03/10 at 4:30 PM, during an interview, RA A denied falsifying the residents' weights. When RA A was asked why the weights could be so different she stated, "I have no idea." On 10/03/10 at 2:30 PM, the DON was asked what she thought happened to cause the problem with the residents' weight loss, which resulted in an IJ. The DON responded, "I trusted my staff." When asked who was responsible for supervising the restorative aide and ensuring her weights were accurate, she stated, "No one was really in charge." Lastly, the DON was asked about the Dietician's recommendations for less than the daily requirements of calories and protein, and she stated, "All weights will come through me, and I will question the diets." The DON was asked if the residents' physicians had been notified, and she stated the Medical Director had been notified and he had taken responsibility to order all the labs on the residents. The residents' physician would be notified during the work week. On 10/03/10 at 3:05 PM, the ADM was interviewed regarding the problems discovered with the accuracy of weights and weight loss, which resulted in an IJ. The ADM stated the issue had occurred due to a staff member falsifying records. He stated in the past when they were discussing weights, he should have asked how they assured they were accurate. The ADM was asked who was responsible for assuring the weights were correct, and he stated the aide had, "no specific over-site." 7) While the IJ was removed on 10/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of a "pattern" due to continued monitoring to ensure staff were implementing the training received and addressing the residents' significant/severe weight loss. The ADM and DON were notified the IJ was removed on 10/03/10 at 5:00 PM. 8) Upon entrance to the facility on [DATE] at 8:40 AM, the ADM reported the census as 106.

Based on observation, interview and record review, it was determined the facility failed to ensure acceptable parameters of nutritional status including body weight and/or [MEDICATION NAME] levels were maintained for two (Residents #1 and #2) of three residents reviewed for weight loss, whose clinical conditions did not demonstrate weight loss was unavoidable. 1) Resident #1 experienced severe weight loss when he lost 21 lbs (16%) from August 2010 through 10/01/10. The facility had identified the resident was at risk for weight loss. Documented weights were inaccurate. Dietary supplements and vitamins were not ordered. Nutritional evaluations on 07/13/10 and 08/11/10 failed to provide the resident with sufficient calories and protein recommendations on a daily basis. His [MEDICATION NAME] level was below normal on 10/03/10. 2) Resident #2 experienced severe weight loss when he lost 54.3 lbs (21%) in three months from July 2010 to 10/01/10. The facility had identified the resident as being at risk nutritionally. Documented weights were inaccurate. The resident did not tolerate the enteral formula he was given, but recommendations for a change in the formula from the RD were not followed. The RD was not notified of the resident's weight loss in August and September 2010. On 10/01/10, these findings resulted in an Immediate Jeopardy (IJ) situation in the area of Quality of Care with Substandard Quality of Care (SQC) for Resident #1, Resident #2 and the 30 residents, whose weights differed a minimum of 3% from 09/25/10 to 10/01/10. While the IJ was removed on 10/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of a "pattern" due to continued monitoring to ensure staff were implementing the training received and addressing the residents' significant/severe weight loss. These failures could affect the facility's 106 residents, including Residents #1 and #2, and placed them at risk for severe/significant weight loss, [MEDICAL CONDITION], development of pressure ulcers and an overall decline in their health and well-being. Findings included: 1) Resident #1, according to physician orders [REDACTED]. The resident's diet order was "Resident is NPO (nothing by mouth) for [DEVICE] only...Give enteral formula: Ensure Plus 1 can 4 times a day via [MEDICATION NAME]." No orders to weigh the resident were noted. No dietary supplements or vitamins were noted as ordered. Resident #1's Braden scale assessment for predicting pressure ulcers dated 07/12/10 reflected he was at high risk for breakdown and indicated his nutrition was "probably inadequate." Resident #1's MDS assessment dated [DATE] reflected the resident was severely impaired cognitively, was non-verbal and required the total assistance of 1-2 staff members for all activities of daily living. Resident #1's care plan dated 07/22/10 reflected the resident was at risk for weight loss, with a plan including weighing the resident as ordered, reporting significant weight loss to the physician and consulting the Dietician quarterly and as needed. According to the facility weight log, undated but provided by the DON on 10/01/10, Resident #1's weights were as follows: July 2010 - 127 lbs, August 2010 - 128 lbs, September 2010 - 126 lbs and on 09/25/10 after the scale was re-calibrated the resident weighed - 124 lbs. Resident #1's dietary evaluations were as follows: 07/13/10 - [AGE] year-old, 60.0 inches tall weighing 128 pounds. Daily calorie requirements of 1485.0 cal/day, receiving 1440.0 cal/day, difference -45.0 cal/day. Daily protein requirements 58.2 grams (gm), receiving 52.8 gm/day, difference - 5.4 gm/day. 08/11/10 - [AGE] year-old, 60.0 inches tall, weighing 128 pounds. Daily calorie requirements of 1485.0 cal/day, receiving 1440.0 cal/day, difference -45.0 cal/day. Daily protein requirements 58.2 grams (gm), receiving 52.8 gm/day, difference - 5.4 gm/day. No evidence of a dietary evaluation was found for Resident #1 for September 2010 despite a documented weight loss of four lbs. On 10/01/10 at 12:00 PM, in an interview with the Dietician, she stated regarding Resident #1, "His BMI (body mass index) is normal high, his weight loss is not significant. I can raise him another can (of enteral formula) but I don't want him to get chubby. He's bedfast and his BMI like I said is normal high. I just don't think ___ (Resident #1) weight loss is significant" On 10/01/10 at 2:20 PM, Resident #1 was weighed by Restorative Aide (RA) A. The resident was in his bed and observed with contractures of his legs. He appeared taller than his measured height (60 inches) and was very thin. Resident #1 weighed 107 pounds. RA A was asked what she would normally do when there was weight loss, and she stated she would go get the charge nurse or DON. RA A left the room and returned with the DON. Resident #1 was re-weighed, and again the results were 107 pounds, reflecting a severe weight loss of 21 lbs (16%) in two months. (128 lbs in August 2010 to 107 lbs on 10/01/10) An unidentified Hospice Aide present in the room, who normally cared for Resident #1, stated, "He has lost weight. I can't say it was 20 pounds, but he has lost weight." On 10/01/10 at 2:35 PM, in an interview, the DON stated she was concerned RA A had not actually been weighing the residents and was just making them up, because the weights she recorded one week earlier were so different. The DON also stated they had just had the scales re-calibrated the previous week prior to the 09/25/10 weights. "I talked to her (RA A) already and I told her I had to know if she was making up the weights," said the DON. "She said she was was not." Because of the extreme weight difference for Resident #1, the facility staff decided to check the scale for accuracy. The scale was checked on 10/01/10 at 2:35 PM. The RAs, in the presence of the DON, placed 20 lbs of hand weights on the scale, and it weighed accurately (20 lbs). An interview with Resident #1's family member was conducted on 10/01/10 at 6:30 PM. The family member stated Resident #1 weighed 122 lbs in the hospital just prior to his admission to the facility on [DATE]. The family member stated he/she was concerned, because he/she thought the resident had lost weight. laboratory results dated [DATE] reflected Resident #1's [MEDICATION NAME] level was low at 3.0 grams/deciliter (reference range 3.4-5.0 grams/deciliter). 2) Resident #2, according to physician orders [REDACTED]. His [DEVICE] diet order was as follows, "NPO with Boost @ 60 cc/hr for 23 hours/day." Supplements included, Resource [MEDICATION NAME] one packet twice a day, and a Multivitamin/Mineral Liquid 15 milliliters every day, A hospital rounding report dated 06/25/10 reflected Resident #2's weight as 237.7 pounds and he was 70 inches tall. Resident #2's MDS assessment dated [DATE] reflected the resident was severely impaired cognitively and required extensive assistance by 1-2 staff for all activities of daily living. Resident #2's Assessment of Nutritional Risk dated 7/30/10 reflected the resident at high nutritional risk. On 10/01/10 at 12:00 PM, the Dietician was interviewed about Resident #2. When asked about Resident #2's documented weight loss from 256 pounds on re-admission to 235 pounds at the end of September (2010), she stated, "That can't be right. I have 241 (pounds)." She further stated she knew he had been having problems tolerating his enteral formula, and she had made a recommendation to change the formula, but did not know why it was not done. When asked what other formula options were available, she stated, "We could try 2.0 calorie HTN." The Dietician was asked if she was notified of the latest weight and she stated, "I should have been notified. I don't want tube feeders to ever lose weight." According to the facility weight log, undated but provided by the DON on 10/01/10, Resident #2's weights were as follows: July 2010 - 256 lbs, August 2010 - 254 lbs, September 2010 - 241 lbs and on 09/25/10 after the scale re-calibration the resident weighed - 235 lbs. Resident #2's dietary evaluations were as follows: 09/09/10 - [AGE] year-old man weighing 241 pounds and 70 inches tall. Daily calorie requirements of 2408.4 cal/day, receiving 1393.8 cal/day, difference -1014.6 cal/day. Daily protein requirements 109.5 grams (gm), receiving 13.8 gm/day, difference -95.7 gm/day. "Alb ([MEDICATION NAME]) has improved to 3.2 (g/dL) (reference range 3.4-5.0 g/dL)" On 10/01/10 at 2:30 PM, Resident #2 was weighed by RA A with the DON present. Observation revealed Resident #2 was awake and alert, and he had no skin breakdown. Resident #2 weighed 201.7 lbs, reflecting a 54.3 lb (2l%) weight loss in three months (256 lbs in July 2010 to 201.7 lbs on 10/01/10). 3) Review of the Facility Weight Loss Protocol, undated, but provided by the DON on 10/01/10 as current revealed the following: "Purpose 1. To carefully observe and monitor weight changes in residents. 2. To address weight changes to determine appropriate and timely actions that should be implemented. Procedure 1. Address weight changes for residents losing 5% in one month or 7.5% in three months... 4. Notify the physician and family of weight loss. 5. Obtain orders for lab work if indicated... 8. Place resident on weekly weights... 9. Be sure resident is on a multivitamin... 10. Place weight loss assessment in a folder at the nurses station labeled, ASSESSMENTS FOR DIETICIAN...If severe, fax weight loss assessment to dietician...." No notation was made for ensuring weight data was correct. 4) On 10/01/10 at 3:30 PM, these findings resulted in an Immediate Jeopardy (IJ) situation in the area of Quality of Care with Substandard Quality of Care (SQC) for Resident #1, Resident #2 and 30 residents, whose weights differed a minimum of 3% from 09/25/10 to 10/01/10. The ADM and DON were notified of the IJ situation. 5) The facility's Plan of Removal was accepted on 10/02/10. The Plan of Removal reflected the following: a. The facility would verify the accuracy of the scales. b. Assessments were conducted of Residents #1 and #2, including new weights, a head-to-toe assessment along with labs and a dietary assessment. c. Re-weigh and evaluate all other residents for possible weight loss. Residents suspected of having a weight loss of 3% or more would have a dietary assessment and labs including CMP (Complete Metabolic Panel), Pre-[MEDICATION NAME], and CBC (Complete Blood Count). d. Change in personnel and the procedure for weighing residents. e. In-services conducted for charge nurses and restorative staff responsible for obtaining weights. f. Over-site by the Administrator and monitoring through the facility's QA&A Committee. 6) After verifying the accuracy of the scales, re-weighs of the facility's residents were conducted on 10/01/10. The results revealed 30 of 106 residents (one refused) had weights, which differed 3% or greater from the weight recorded by RA A seven days before. Each of those residents with a 3% or greater weight loss had labs drawn and dietary evaluations conducted by the next day 10/02/10. Resident #1's dietary evaluation dated 10/01/10 reflected the following changes: "[AGE] year-old, 60.0 inches tall weighing 107 pounds. Daily calorie requirements of 1328.1 cal/day, receiving 1800.0 cal/day, difference +471.9 cal/day. Daily protein requirements 48.6 grams (gm), receiving 66.0 gm/day, difference +17.4 gm/day." Resident #2's dietary evaluation dated 10/01/10 reflected the following changes: "[AGE] year-old man weighing 200 lbs and 70.0 inches tall. Daily calorie requirements of 2093.8 cal/day, receiving 2300.0 cal/day, difference +206.2 cal/day. Daily protein requirements 90.9 grams (gm), receiving 103.5 gm/day, difference +12.6 gm/day. Recommend Resource 2.0 at 50 cc/hour for 23 hours/day." A review of the facility in-service entitled Weight Loss Protocol/Assessment of Weight revealed the in-service was conducted on 10/01/10 and all, "Managers and Restorative Nursing Aides verbalized understanding of the material." An interview was conducted with RA B on 10/03/10 at 2:00 PM. She stated she would be responsible for weighing the residents from now on. She stated she had received training on weighing the residents in the last 24 hours and she was instructed to weigh the residents with a charge nurse present and to report any weight changes to the DON. On 10/03/10 at 3:15 PM, CNA C was interviewed. She stated she was told she would be the back-up for RA B. She stated she had received training in the last 24 hours. CNA C also stated she was instructed to weigh the residents with a charge nurse present and to report any weight changes to the DON. On 10/03/10 at 4:30 PM, during an interview, RA A denied falsifying the residents' weights. When RA A was asked why the weights could be so different she stated, "I have no idea." 7) While the IJ was removed on 10/03/10, the facility remained out of compliance at a severity level of "No actual harm with potential for more than minimal harm, that is not immediate jeopardy" and a scope of a "pattern" due to continued monitoring to ensure staff were implementing the training received and addressing the residents' significant/severe weight loss. The ADM and DON were notified the IJ was lowered on 10/03/10 at 5:00 PM. 8) Upon entrance to the facility on [DATE] at 8:40 AM, the ADM reported the census as 106.

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of four sampled residents was assessed for injury following a fall, which resulted in a fractured shoulder and pelvis. When Resident #1 fell , LVN B assessed the resident for rotation of her hips. She did not assess the resident any further and did not administer anything for the resident's pain, despite the resident's moaning in pain. LVN B did not notify the physician or the resident's family member the resident had fallen. The resident was lifted to a sofa, where she sat for four-and-a-half hours, because she could not get up from the sofa. She ate her dinner there. LVN B returned to reassess the resident three hours later, only because the CNA had requested her to do so. LVN B notified the physician and received orders for an x-ray. LVN B then instructed the Medication Aide to administer pain medication to the resident. The resident was then sent to the hospital per the family's request. These failures could affect the facility's 107 residents, including Resident #1, and placed them at risk for not being adequately assessed or being administered pain medication when the resident experienced a change in condition. This could result in unidentified injuries or pain not being treated in a timely manner resulting in the residents' continued discomfort and unrelieved pain. Findings included: Resident #1, according to physician orders [REDACTED]. A history and physical for Resident #1 dated 03/01/10 reflected the following, "Pleasantly confused." Review of Resident #1's hospital records revealed a History and Physical dated 09/16/10. It reflected: "fell [DATE] ...Proximal right humeral fracture, fractured inferior and posterior pubic rami." On 09/22/10 at 2:30 PM, an interview was conducted with CNA A. In the interview, CNA A stated she was in the dining room of the facility's only secured unit at 2:00 PM on 09/14/10. She stated Resident #1 was ambulating and was refusing to sit down or use her walker. CNA A stated she saw Resident #1 loose her balance, but was not able to get to her before she fell . CNA A stated she called for LVN B, and with the assistance of LVN B and a second CNA, they lifted Resident #1 to the sofa. CNA A stated Resident #1 had no complaints of pain at the time. CNA A continued by stating at approximately 5:00 PM, she and a second CNA attempted to get Resident #1 up from the sofa for dinner but Resident #1 could not get up to eat dinner, would not stand and was moaning. CNA A stated she sent for LVN B, but did not see her assess Resident #1, because she was passing trays. CNA A stated Resident #1 stayed on the sofa through dinner. Resident #1's family member was present. At approximately 7:30 PM, Resident #1 stated she needed to go to the bathroom. When the staff assisted her to the wheelchair, she urinated on herself. Resident #1 was taken to her room and stayed in her wheelchair since the x-ray technicians had arrived. On 09/22/10 at 3:00 PM, LVN B was interviewed. LVN B stated she was called to the secured unit on 09/14/10 at approximately 3:00 PM. She stated Resident #1 was on the floor, and she was moaning but "not yelling out." LVN B was asked if moaning was normal for Resident #1, and she responded, "She would moan when she was in pain." LVN B was asked about her assessment of Resident #1. The LVN stated she bent Resident #1's legs up and looked for external rotation, and there was none. She stated she did not do any assessment of the resident's upper extremities, ribs or pelvis. LVN B stated she and two CNAs moved Resident #1 to the sofa, where she sat, because the CNAs were unable to get her up for dinner at approximately 5:30 PM. LVN B was asked how many times she came to check on Resident #1 post fall between the time she was placed on the sofa until 5:30 PM, and she stated she did not check on Resident #1. LVN B stated it was at approximately 6:00 PM when she called the physician for the first time regarding the resident's fall and obtained an order for [REDACTED]. When asked why she did not medicate the resident earlier if she thought she was in pain, LVN B stated she really did not think she had injured herself in the fall and was "surprised" to find out about the fractures. The LVN stated Resident #1 was fed dinner while seated on the sofa. At approximately 6:30 PM, she was again called to Resident #1 when her family member stated the resident was unable to use her arm. LVN B said, when the resident attempted to reach for something, she grimaced. LVN B stated she then sent the resident to the hospital at the family's request. LVN B was asked to clarify Resident #1's moaning. LVN B confirmed Resident #1 moaned the whole time she was on the floor and sitting on the sofa. LVN B confirmed she recognized Resident #1's moaning as a sign of pain. Review of the facility's current policy entitled Change of Condition provided by the DON on 09/22/10 revealed the following: "Procedure 1. When a resident's condition changes, the charge nurse will complete the following form and give it to the care plan coordinator to insure proper documentation of the care plan and MDS (Minimum Data Set). 2. This form does not resolve the charge nurse of her responsibilities of assessing, intervening, notifying the family and physician, appropriate follow-up and proper documentation in the clinical record...." Review of the facility resident roster dated 09/21/10, and confirmed as current by the Administrator, revealed the census was 107.