Every finding on record at Care Center of Aberdeen

Based on record review, staff and family interviews, and facility policy review, the facility failed to ensure the Resident Representative (RR) was notified timely of a significant change in condition requiring the initiation of treatment for one (1) of four (4) sampled residents. Resident #1. This failure resulted in the resident representative not being informed that the resident developed three (3) new Stage II pressure injuries and that treatment had been initiated. Findings Include: Record review of facility policy titled Change In Resident Medical Status with review date of 3/26 revealed .A facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s), when there is - . A need to alter treatment significantly (that is a need to discontinue or change an existing treatment due to adverse consequences, or to commence a new form of treatment) .During an interview on 7/20/2026 at 3:00 PM, the Treatment Nurse stated nursing staff reported skin concerns on 5/7/2026 with Resident #1. She stated she assessed Resident #1, identified and staged three (3) Stage II pressure injuries, and initiated treatment. She further stated that she did not notify the RR of the newly developed pressure injuries or treatment because she believed the Nursing Supervisor was responsible for notifying the RR. During an interview on 7/20/2026 at 3:10 PM, the Nursing Supervisor stated she did not notify Resident #1's RR of the newly developed pressure injuries or treatment because she believed the Treatment Nurse was responsible for notifying the RR of treatment-related orders.During an interview on 7/20/2026 at 3:39 PM, the Director of Nursing (DON) stated it was the facility's expectation that the RR be notified whenever a resident experiences a change in condition. He confirmed the RR should have been notified when Resident #1 developed the Stage II pressure injuries and treatment was initiated.During a telephone interview on 7/21/2026 at 8:47 AM the RR stated that she did not receive a phone call or any other notification informing her that Resident #1 had developed pressure injuries or that treatment had been initiated.Record review of a Progress Note - Skin Issues with effective date of 5/7/2026 revealed nursing documentation of 3 new in-house Stage II pressure injuries located on the coccyx, right rear thigh, and right gluteus. The documentation included wound measurements and treatment orders for each wound. Record review revealed no documentation that Resident #1's representative was notified of the newly developed pressure injuries or initiation of treatment.Record review of Face Sheet revealed Resident #1 was admitted to the facility on [DATE] with a medical diagnosis of Unspecified Intracranial Injury with Loss of Consciousness of Unspecified Duration, Initial Encounter.Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/12/2026 revealed a blank Brief Interview for Mental Status (BIMS) summary score indicating the resident does not have the ability to be interviewed.

Based on observation, staff interview, and facility policy review, the facility failed to ensure food items in the kitchen were properly labeled and dated after opening and failed to maintain a clean refrigerator to prevent cross-contamination of stored foods during one (1) of two (2) kitchen tours. Findings Include:Review of the facility policy titled Cleaning and Sanitizing Equipment, revised 5/18, revealed under Policy: All equipment is kept clean and food contact surfaces are cleaned and sanitized.Review of the facility policy titled Food Storage Labeling, revised 8/12, revealed under Policy: The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedures. Also revealed under Procedure 1. Labelinga. All temperature-controlled foods and ready-to-eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the food, Date of storage.Observations on 5/4/26 at 5:25 PM during the initial kitchen tour revealed Refrigerator #1 contained:- One (1) 5-pound container of open and undated pimento cheese spread- One (1) open package of boiled eggs containing five (5) eggs that was undated- One (1) open and undated carton of liquid whole eggsAn observation of Freezer #1 revealed frozen fish fillets stored in a clear gallon zip-lock bag that was undated. An observation of the kitchen pantry revealed one (1) open five (5)-pound bag of Quick Grits that was unlabeled and not secured in a storage bag. An observation of Refrigerator #3 revealed numerous small circular black spots scattered throughout the interior back portion of the refrigerator, the left inner side panel, and three (3) refrigerator racks. The black spots varied in size and had a fuzzy texture. Also observed inside the refrigerator was a silver metal square container covered in aluminum foil that contained sliced onions without a label to determine the date of storage.An observation and interview with Dietary Staff #1 on 5/4/26 at 6:05 PM confirmed the black substance inside Refrigerator #3 and stated, It looks like mold. She stated the substance could contaminate the food and make a resident or staff member sick. She revealed the Dietary Manager was responsible for cleaning out the refrigerator. Dietary Staff #1 confirmed the undated items in the refrigerator, freezer, and pantry and stated the items should be discarded because there was no way to determine how long they had been stored. She stated the grits should have been secured in a bag in the storage room. She explained that any opened food items stored in the refrigerators, freezers, or pantry must be dated and stored appropriately to maintain freshness and food safety and to prevent illness.An observation and interview with the Dietary Manager (DM) on 5/4/26 at 6:40 PM confirmed the black substance inside Refrigerator #3. He stated it was the dietary aides' responsibility to clean the refrigerator. He confirmed the refrigerator was not clean and stated the substance could contaminate food items stored inside. He further confirmed all foods stored in the refrigerator, freezer, and pantry should be labeled and dated to ensure safe food consumption and prevent foodborne illness.An interview with the Administrator on 5/6/26 at 7:55 AM revealed opened food items in the kitchen should be labeled, dated, and stored appropriately and kitchen equipment should remain clean according to the equipment cleaning schedule to ensure food safety and prevent residents from becoming ill. She revealed it was the DM's responsibility to ensure this was done.

Based on staff interviews, record review, and facility policy review the facility failed to accurately complete the Minimum Data Set (MDS) assessment, as evidenced by incorrectly coding during the 7-day observation look-back period for three (3) of nineteen sampled residents. Residents #3, Resident #7, and Resident #53 Findings Include: Record review of the facility policy titled, Minimum Data Set Charting Documentation Guidelines, dated 11/25, revealed, To have an accurate assessment of the residents, information must be gathered on the residents while in the observation period for the MDS. This information must come from resident assessment and documented information in the residents' chart within the time frames set forth on the MDS. To ensure that information is in the chart to validate information on the MDS the Charting Documentation guidelines should be utilized . Record review of the facility policy titled, MDS Process revealed, The Resident Assessment Instrument (RAI) Manual shall serve as the primary reference for MDS coding guidelines, scheduling requirements, and regulatory compliance. Resident #3 Record review of Resident #3's January 2026 Medication Administration Record (MAR) revealed an active order for Rivaroxaban Oral Tablet 20 milligrams (MG), give 1 tablet by mouth in the evening, with a start date of 10/16/2025. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/26 revealed under Section N, Resident #3's anticoagulant medication was not coded. An interview with the MDS Nurse on 5/05/2026 at 3:40 PM, confirmed Resident #3 was on an anticoagulant and his quarterly MDS Assessment that was done on 01/12/26 was not coded correctly to reflect the anticoagulant he is receiving. Record review of the Face Sheet revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included Paroxysmal Atrial Fibrillation and Presence of a Cardiac Pacemaker. Record review of the MDS with an Assessment Reference Date (ARD) of 01/12/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #3 was cognitively intact. Resident #7 Record review of Resident #7's Order Summary Report revealed an order dated 08/05/2025, Admit to Hospice Services DX (diagnosis): COPD (Chronic Obstructive Pulmonary Disease) Record review of the MDS with an ARD of 04/07/26, revealed under Section O, Resident #7 Hospice Care was not coded. An interview with the MDS Nurse on 5/06/2026 at 9:40 AM, confirmed Resident #7 was on hospice services and his quarterly MDS Assessment that was done on 4/7/2026 was not coded correctly to reflect the hospice services he is receiving. Record review of the Face Sheet revealed Resident #7 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder. Record review of the MDS with an ARD of 04/07/26 revealed a BIMS score of 15 which indicated Resident #7 was cognitively intact. Resident #53 Record review revealed Resident #53's MDS with ARD of 04/08/26 Section N - Medications was marked seven (7) of 7 days for anticoagulant. Interview on 05/06/26 at 9:00 PM with the MDS nurse confirmed that the resident was not taking an anticoagulant medication and it was incorrectly coded for an anticoagulant. She stated that the resident was taking an antiplatelet and it was incorrectly coded as an anticoagulant. Record review of Resident #53's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension and Cardiac Murmur. Record review of Resident #53's MDS with an ARD of 04/08/26 revealed a BIMS score of 03 indicating severe cognitive impairment.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the feeding tube care plan was implemented for Resident #5 and an Activities of Daily Living (ADL) care plan was implemented for Resident #17 for two (2) of nineteen care plans reviewed. Resident #5 and #17. Findings Include: Review of the facility policy titled Care Plan Process with a revision date of 12/24, revealed Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to several specified areas (e.g., customary routine, vision, and continence). Resident #5 Record review of Resident #5's Care Plan Report revealed The resident requires tube feeding related to (r/t) resisting eating . Interventions . Diabetasource @ 59 ml(milliliters)/hr(hour) for 24 hours . with a revision date of 2/23/2026. Record review of the Order Summary revealed an order dated 02/23/2026 for Enteral Feed Order . Diabetasource @ 59 ml(milliliters)/hr(hour) for 24 hours to include 1700 kcals (kilocalories), 88 grams of protein, and 1189 ml of fluid. On 5/04/2026 at 5:36 PM an observation revealed Resident #5's enteral feeding pump was paused and actively beeping. On 5/04/2026 at 5:45 PM, during an observation and interview Certified Nurse Aide (CNA) #1 was observed feeding Resident #5 a mechanically chopped meal. CNA #1 revealed the resident receives pleasure trays, which was why the feeding pump had been turned off. CNA #1 further revealed she did not know how long the feeding had been off. On 5/06/2026 at 1:30 PM, Resident #5 was observed sitting in the front foyer without his tube feeding infusing. A subsequent observation on 5/06/2026 at 1:52 PM again revealed Resident #5 sitting in the front foyer without the enteral feeding pump infusing. During an interview on 5/6/2026 at 3:55 PM, the Minimum Data Set (MDS) Nurse confirmed Resident #5's care plan and physician's order were for his enteral feedings to be continuously infusing and further revealed if he was not getting his feedings then his plan of care was not being followed and it should have been. Record review of the Face Sheet revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Encounter for Attention to Gastrostomy, Type 2 Diabetes Mellitus, and Unspecified Sequelae of Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated Resident #5 was severely cognitively impaired. Resident #17 Record review of the Care Plan Report for Resident #17 revealed Resident needs assist with ADLs.Interventions.Bathing: Observe nail length, clean on bath day and as needed.Personal Hygiene: The resident is dependent on staff for personal hygiene. Nail Care-clean, cut and file nails. Date Initiated 11/19/2024. Observations on 5/4/2026 at 5:48 PM, 5/5/2026 at 8:47 AM, and again on 5/6/2026 at 8:26 AM of Resident #17 revealed her fingernails were approximately one (1) inch in length with jagged edges and contained a dark brown/black substance underneath the nails. On 5/6/2026 at 8:30 AM during an observation and interview, Licensed Practical Nurse (LPN) #1 confirmed Resident #17's fingernails were long, jagged, and contained a dark brown/black substance underneath. She stated the resident's fingernails should have been trimmed during bathing or showering. She further stated long, jagged fingernails placed Resident #17 at risk for skin tears or scratches that could lead to infection. During an interview on 5/6/2026 at 10:04 AM, the MDS Nurse confirmed the ADL care plan for Resident #17 had been developed appropriately; however, the interventions were not implemented by facility staff. Record review of the Face Sheet indicated Resident #17 was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease. Record review of the MDS, with an ARD of 3/3/2026, revealed under Section C that a BIMS was not conducted because Resident #17 was rarely or never understood.

Based on staff interview and record review the facility failed to ensure blood sugar monitoring was provided in accordance with professional standards of practice for one (1) of five (5) residents who were reviewed for medication monitoring. Resident #94Findings Include: Review of a statement typed on facility letterhead dated 5/6/26 and signed by the Administrator revealed, The facility does not have a policy on insulin/glucose monitoring. Record review of Resident #94's Medication Administration Record (MAR) with order date of 04/28/2026, revealed Novolin 70/30 Flex Pen Subcutaneous Suspension Pen-Injector (70-30) 100 Unit/ml (milliliter) (Insulin NPH Isophane & Reg (Human) Inject eight (8) units subcutaneously two times a day. Record review of Resident #94's Medication Administration Record revealed no documentation of monitoring blood sugar. Record review of Blood Sugar Summary revealed Resident #94's blood sugar was checked on 4/28/2026 and 4/29/2026. On 5/6/2026 at 10:45 AM an interview with the Director of Nursing (DON) confirmed that blood sugars should be monitored when a resident has an order for insulin. The DON revealed the house supervisor is responsible for putting in admission orders. He stated when entering an order, there was a place to add a supplementary task to check the blood sugar. The DON confirmed that the house supervisor failed to add the supplementary task when the insulin order was entered. Record review of the Face Sheet revealed the facility admitted Resident #94 on 4/28/2026 with medical diagnoses including Diabetes Mellitus Due To Underlying Condition with Diabetic Neuropathy. Record review of Interviews - V 4 dated 4/28/26 revealed a Brief Interview for Mental Status (BIMS) summary score of 10 which indicated Resident #94 was moderately cognitively impaired.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care necessary to maintain personal hygiene for one (1) of 89 residents observed. Resident #17Findings include:Review of the facility policy titled Activities of Daily Living, with a review date of 9/2025, revealed, .ADLs shall include, but are not limited to personal hygiene, bathing, voiding, toileting, repositioning, and meals offered.On 5/4/2026 at 5:48 PM, 5/5/2026 at 8:47 AM, and again on 5/6/2026 at 8:26 AM, observations of Resident #17 revealed her fingernails were approximately one (1) inch in length with jagged edges and contained a dark brown/black substance underneath the nails.During an observation and interview on 5/6/2026 at 8:30 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #17's fingernails were long, jagged, and contained a dark brown/black substance underneath. She stated the resident's fingernails should have been trimmed during bathing or showering. She further stated long, jagged fingernails placed Resident #17 at risk for skin tears or scratches that could lead to infection.During an interview on 5/6/2026 at 8:45 AM, the Director of Nursing (DON) stated all residents' fingernails should be kept trimmed and clean. He stated fingernails should be checked during bathing or showering but may be trimmed whenever needed. He further stated long, jagged fingernails could easily cause skin tears, which could lead to infection.Record review of the admission Record indicated Resident #17 was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease.Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/3/2026, revealed under Section C that a Brief Interview for Mental Status (BIMS) was not conducted because Resident #17 was rarely or never understood.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure physician-ordered continuous enteral feedings were consistently administered for one (1) of two (2) residents reviewed for tube feeding management. Resident #5Findings Include:Review of the facility policy titled Tube Feedings with a revision date of 12/15 revealed, 1. All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders .Record review of the Order Summary revealed an order dated 02/23/2026 for Enteral Feed Order.Diabetasource at 59 ml (milliliters) /hr (hour) for 24 hours to include 1700 kcals (kilocalories), 88 grams of protein, and 1189 ml of fluid.An observation on 5/04/2026 at 5:36 PM revealed Resident #5's enteral feeding pump was paused and actively beeping.During an observation and interview on 5/04/2026 at 5:45 PM, Certified Nurse Aide (CNA) #1 was observed feeding Resident #5 a mechanically chopped meal. CNA #2 revealed the resident receives pleasure trays, which was why the feeding pump had been turned off. CNA #1 further revealed she did not know how long the feeding pump had been off.During an observation on 5/06/2026 at 1:30 PM, Resident #5 was observed sitting in the front foyer without his tube feeding infusing. A subsequent observation on 5/06/2026 at 1:52 PM again revealed Resident #5 sitting in the front foyer without the enteral feeding pump infusing.During an interview on 5/06/2026 at 1:57 PM, Licensed Practical Nurse (LPN) #2 revealed Resident #5 received Diabetisource at 59 ML per hour through his Percutaneous Endoscopic Gastrostomy (PEG) tube and also received pleasure trays for all meals. LPN #2 stated the resident frequently preferred to sit in the front foyer and revealed she was unsure whether the feeding pump should be brought into the foyer due to the amount of foot traffic through the area. LPN #2 confirmed the resident had a physician's order for continuous tube feeding and acknowledged that the resident's nutritional needs were not being met as ordered when the feeding was not infusing.During an interview on 5/06/2026 at 2:45 PM, the Director of Nursing (DON) revealed Resident #5 had gained three pounds from January to February, and the Registered Dietitian had recommended changing the resident's continuous feeding to bolus feedings four times daily; however, the physician declined the recommendation and ordered the resident to remain on continuous feedings in addition to pleasure trays. The DON confirmed Resident #5 should have remained connected to the feeding pump regardless of his location within the facility and acknowledged that failure to administer the feeding as ordered placed the resident at risk for weight loss and inadequate nutritional intake.Record review of the Face Sheet revealed Resident #5 was admitted to the facility on [DATE] with diagnoses that included Encounter for Attention to Gastrostomy, Type 2 Diabetes Mellitus, and Unspecified Sequelae of Cerebral Infarction. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/11/26 revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated Resident #7 was severely cognitively impaired.

Based on observation, record review, staff and representative interviews, and facility policy review, the facility failed to ensure residents were free from the use of chemical restraints for one (1) of three (3) residents reviewed for chemical restraints (Resident #5), when the facility administered psychotropic medications without obtaining the required consent to inform the resident or representative of the risks, benefits, and alternatives of the medication prior to use. Findings include:Review of a facility policy titled Anti-Psychotics - Use of Anti-Psychotics, last revised 02/25, revealed consent for anti-psychotic and psychoactive medication treatment shall be completed.A phone interview with Resident #5's representative on 12/2/25 at 12:30 PM related to a complaint that she had reported, revealed she had requested a list of all of her mom's medications so she could review them. She stated she found that her mom was taking Haldol, an antipsychotic medication that has a black box warning. She stated she was unaware that her mom was on that and never signed a consent for any medications. She stated she had to make the facility take the resident off the Haldol in October.Review of the September Medication Record for Resident #5 revealed Haldol 0.5 mg give one tablet daily, ordered 8/31/24 and discontinued 9/22/25. Haldol 0.5 mg give 1/2 tablet daily at bedtime, ordered 9/22/25.Review of the October Medication Record for Resident #5 revealed Haldol 0.5 mg give 1/2 tablet daily at bedtime, ordered 9/22/25 and discontinued 10/8/25.Review of the December Medication Record for Resident #5 revealed Sertraline 25 mg give one tablet daily for depression, ordered 7/20/25 with no stop date.An interview with the Director of Nursing (DON) on 12/3/25 at 1:30 PM revealed he was unable to find any consent for Resident #5's psychotropic medications Haldol or Sertraline. He stated the purpose of the consent form is to inform the residents/representative of the potential risks and benefits of the use of the medication and allow them to make an informed decision.Review of the admission Record revealed Resident #5 was admitted on [DATE] with a diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbances.Review of the Brief Interview for Mental Status (BIMS) dated 9/23/25 revealed a score of 3, indicating Resident #5 was severely cognitively impaired.Review of Section N: Medications of the Minimum Data Set (MDS) for Resident #5 dated 9/23/25 revealed antipsychotic and antidepressant medications marked as taking.

Based on staff interviews, record review, and facility policy review, the facility failed to honor the resident's right to receive written notification, including the reason for the change, before the resident's room in the facility was changed for one (1) of three (3) residents reviewed. Resident #1Findings include:Record review of facility policy titled, Room Changes dated 11/17, revealed, The Social Service Designee/Social Worker, in conjunction with the DON (Director of Nursing), will facilitate that each resident is assigned a room suited to his/her needs.4. The resident or resident representative, when applicable, will receive written notice to include the reason for the change before the resident's room or roommate in the facility is changed.During an interview on 7/28/25 at 2:45 PM, the Social Service Director stated that she and Resident #1's representative had discussed moving the resident closer to the nurses' station and this was done in August 2024. When another room became available in September 2024, she moved the resident and did not notify the resident's representative. She confirmed it was her responsibility to notify the resident and/or representative about room changes, and she failed to provide the notification for that move. An interview with the Administrator on 7/29/25 at 10:50 AM, revealed that it was each resident's right to be informed of a room change and a reason for the room change. She confirmed the facility failed to notify Resident #1's representative of the room change and the reason for the room change in September 2024. Record review of admission Record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included Dementia.Record review of Resident #1's Minimum Data Set (MDS) Section C dated 6/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had a severe cognitive impairment.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to protect a resident's safety and prevent an accident when staff failed to use a wheelchair lift safety belt to secure a resident's wheelchair on the lift gate during the lift procedure to place the resident into the back of the van. This resulted in the resident rolling backwards in the wheelchair and flipping off the lift gate when it was lifted around four (4) feet high in the air and the resident hit backwards onto the concrete injuring her head and received a three (3) centimeter (cm) laceration to the back of her head. This was for one (1) of two (2) residents incidents reviewed. Resident #37 Findings Include: Review of the facility policy titled Policies for Company Owned Vehicle with a revision date of 5/18 revealed under, 3. Seatbelts: The driver and all passengers in the company/facility owned vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts, and is responsible for ensuring that all person(s) in the vehicle are safely seat belted . An interview with Resident #37 on 5/12/25 at 2:15 PM revealed she goes to dialysis three times a week and requires the use of the facility transport van. She revealed that she had a recent fall from the van and indicated her wheelchair rolled off the wheelchair lift while loading onto the van. Record review of Resident #37's Witnessed Fall dated 3/14/25 revealed, This nurse was notified that resident rolled off lift and fell backwards while being loaded to be transported to dialysis. Resident lying on flat concrete. Resident able to sit up. Resident has laceration to back of head and complained of right side pain. Resident stated, I fell backwards out of my chair and hit my head. Additionally, the facility started neurological checks, physician was contacted, and the resident was transported to the hospital via ambulance. Record review of Resident #37's Progress Notes' dated 3/14/25 revealed, Abrasion to the back of head is 3 cm by 3 cm - dry with no active bleeding. Record review of the Emergency Department Records dated 3/14/25 revealed, Resident #37 had a computed Tomography scan (CT) of head and cervical spine and an X-ray of the right shoulder with no acute findings. Record review of the written witness statement dated 3/14/25 revealed, I was loading Resident #37 on the bus when the lift remote stopped working. I locked her wheelchair and went on the inside of the bus to manually pump the lift. I instructed her to keep the chair locked. Once I got the lift up, I told Resident #37 to wait for me to unlock her chair. She proceeded to unlock it and before I could catch her chair, she rolled off the lift and fell backwards and was signed by Certified Nurse Aide (CNA) #1. A telephone interview with CNA #1 on 5/14/25 at 8:18 AM revealed she was transporting Resident #37 to dialysis on the day she fell from the van. She explained that she was loading the resident onto the van by herself using the wheelchair lift, and the lift remote control messed up and would not rise. She stated she told the resident not to unlock her wheelchair brakes, and she went inside the back of the van to manually work the van lift. CNA #1 revealed the resident rolled back off the van lift and fell backward onto the pavement. She stated, I was later informed by the Director of Nursing that I should have been using a strap (safety belt) when lifting the resident on the lift gate. CNA #1 revealed that she had never been told to use the strap, and confirmed she did not apply it that day. She additionally added, I was told that we had to have 2 people with van transfers, but nobody was out there with me. She explained that she had been trained on the old transport bus and had only ridden on the newer bus and did not get training. An interview with the Director of Nursing (DON) on 5/14/25 at 8:40 AM revealed staff called her to report Resident #37's fall from the van. She stated the resident was sent to the hospital, was evaluated, and had X-rays, which were all okay. She explained the fall was caused by the resident unlocking the wheelchair brakes, which caused her to roll back off the lift. The DON admitted that CNA #1 reported to her that she did not use the safety wheelchair strap during lift use and stated, I believe she would have fallen off the lift regardless of using the strap, but I know the belt is there for a reason. She confirmed the belt should have been used. She stated, After the fall, I started retraining and called corporate and suspended CNA #1. She explained that CNA #1 resigned after the incident and never returned to work. The DON revealed the aide was new to the transport position and had been working for less than 2 weeks when the event occurred. She revealed the aide had training and checkoffs before driving the van and knew the safety strap was required. She explained the facility only used one staff member for transport unless the resident had dementia (poor cognition) or was an amputee and stated, Really, it's a case-by-case basis on using one versus two staff members. An interview with the Administrator (ADM) on 5/14/25 at 9:10 AM revealed CNA #1 hired in and worked for a while and then decided to become the backup van driver. She confirmed the aide trained for more than 2 weeks and had check offs prior to starting the position. She acknowledged she reviewed and signed off on the incident report for Resident #37's fall and explained that she was off during that time and the DON handled the investigation. The ADM revealed the aide had no prior write ups or concerns with the care she provided to the residents. Record review of the Employee Warning Report dated 3/14/25 revealed, Elder rolled off the back of the van lift- elder unlocked w/c (wheelchair). It rolled back off lift. Lift safety belt was not latched. Certified Nurse Aide #1 was suspended and signed acknowledgment of receipt. Record review of the Company Owned Vehicle Driver Inservice Checklist dated 2/28/25 revealed under, Patient/Passenger Safety & (and) Special Equipment: The proper and safe operation of the wheelchair lift was initialed by Certified Nurse Aide #1 as completed. Further review revealed she signed the Vehicle Lift Operations Proficiency Checklist dated 2/28/25. On 5/15/25 at 8:11 AM, during a follow up telephone interview with CNA #1, she revealed she did train with CNA #2 and CNA #3 and stated neither told her nor showed her to use the safety belt with the wheelchair lift. She confirmed she signed the training record and stated, That's my fault; I should have paid more attention when I signed it. CNA #1 confirmed she knew the strap was there and it would make sense to use it for the residents' safety and acknowledge this would have prevented the fall. An interview with CNA #2 on 5/15/25 at 8:24 AM revealed that she trained CNA #1 on the newer van for a total of five days. She stated, I explained to her about the safety belt and how to use it. An interview with CNA #3 on 5/15/25 at 9:05 AM revealed that she trained CNA #1 on the transport van and fully explained to her that she had to use the safety belt on the wheelchair lift. She revealed CNA #1 had more than 2 weeks of training on the safety of transportation and using seat belts and safety straps. An interview with the Administrator with the DON in attendance on 5/15/25 at 9:21 AM confirmed the investigation into Resident #37's fall revealed CNA #1 did not use the safety belt during the van lift process, which resulted in the resident's fall backwards in her wheelchair from the lift gate which was lifted around four feet high, to the concrete below. The DON stated the aide admitted she did not use the strap and acknowledged she was trained to utilize the wheelchair strap when lifting residents on the lift gate. A record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/02/25, revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident #37 was cognitively intact. A record review of the Admission Record revealed that the facility admitted Resident #37 on 11/15/16 with a medical diagnosis that included End Stage Renal Disease.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to label and store food properly and maintain the kitchen and the equipment in a clean and sanitary condition for two (2) of three (3) kitchen tours. Findings included: Review of the facility's policy titled, Food Storage Labeling, with revised date ,d+[DATE] revealed, Policy: The facility will ensure the safety and quality of food by following good food storage labeling procedures . Review of the facility's policy titled, Cleaning Schedule, with revised date ,d+[DATE] revealed, .Procedure: .All equipment and work areas are cleaned after each use, or, on a routine basis .A cleaning schedule is established by the Director of Food and Nutrition Services .The Director of Food and Nutrition Services checks routinely to see that the task is completed according to standards . During the initial kitchen tour with the Dietary Manager (DM) on [DATE] at 10:24 AM several observations were made regarding food storage practices. In produce refrigerator number one (1), several items, including mashed potatoes, spam, applesauce, orange juice, apple juice, cranberry juice, and a sliced onion were present without dates indicating when they were opened or when they expired. Similarly, in produce refrigerator number two (2), several items, such as pimento cheese, sweet and sour sauce, BBQ sauce, mayonnaise, and potato salad, were also opened and undated. The dry storage room revealed more of the same concerning practices, with items like creamy peanut butter, powdered sugar, brown sugar, key lime sauce, teriyaki sauce, Worcestershire sauce, and grits lacking appropriate dating with opened containers. During an interview on [DATE] at 10:50 AM with the DM, he confirmed that no open food items should be stored without an open date. He further emphasized that this practice is unacceptable as it could lead to food-borne illnesses. During an interview on [DATE] at 11:15 AM with the Administrator, she confirmed that the facility policy requires that open food items be labeled with an open date, underscoring the importance of adherence to safety protocols. During an observation and interview on [DATE] at 11:05 AM with the Production Supervisor, she confirmed that the roll-up food service window located directly above the steam table was heavily covered across the top and down the sides with large accumulations of dust and grease. Additionally, other dirt and dust particles were in each individual slat. The steam tables also had old grease drippings on the bottom shelf. When questioned about the responsibility for cleaning the roll-up service window, she expressed uncertainty, stating, I'm not sure who is responsible for cleaning the roll-up service window, whether it's dietary or maintenance. During an interview on [DATE] at 11:08 AM with the DM, he revealed that both he and the Maintenance Supervisor were responsible for cleaning the roll-up service window. However, he acknowledged that it had not been cleaned in quite some time and was in a dirty state, indicating a need for immediate attention. He further expressed concern that the accumulation of dirt and dust could fall into the food as the roll-up window was opened for service. Additionally, he confirmed that this situation could cause the food to become contaminated and that proper cleaning protocols should be enforced to ensure the safety of the residents.

Based on staff and resident interviews, record review, and facility policy review, the facility failed to ensure cognitive residents' right to determine their end-of-life care for three (3) of 24 residents reviewed. Resident #37, #73, and #75 Findings Include: Review of the facility policy titled Advance Directives with a revision date of ,d+[DATE], revealed under, Policy: The facility recognizes that all adults have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. It is the policy of the facility to encourage residents and their family/caregivers to participate in decisions regarding care and treatment . Resident #37 During an interview with Resident #37 on [DATE] at 3:26 PM, the resident stated she wanted to make her own healthcare decisions while she was able. She reported that no one from the facility had spoken to her about her end-of-life preferences. When asked whether she wanted the facility to do everything possible to resuscitate her if she stopped breathing or her heart stopped, she responded, Yes, I want everything done. A review of the Resident/Family Consent for Cardiopulmonary Resuscitation (CPR) form, dated [DATE], indicated that CPR should not be performed and was signed by a family member. In an interview with Social Services (SS) #1 on [DATE] at 3:36 PM, she confirmed that Resident #37 was cognitively intact and capable of making her own healthcare decisions. She explained that she was unsure why the resident had not been allowed to sign her own code status form, explaining that she was not employed at the facility when the resident was admitted . She further stated it was the resident's right to make her own healthcare decisions, and the facility should have honored that. During an interview with the Administrator on [DATE] at 8:50 AM, she confirmed that Resident #37 was cognitively intact and that advance directives should have been discussed with her. She stated the resident should have been given the opportunity to sign her own paperwork. A record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 14, indicating that Resident #37 was cognitively intact. A record review of the Admission Record revealed that the facility admitted Resident #37 on [DATE] with a medical diagnosis that included End Stage Renal Disease. 41878 Resident #73 During an interview on [DATE] at 2:25 PM, Resident #73 stated he had a family member that helped him with his financial information, but he would like to make his medical decisions. He revealed if he stopped breathing, he wanted to receive measures to be revived. During an interview on [DATE] at 2:50 PM, the Director of Nursing (DON) revealed each cognitive resident had the right to determine their end-of-life care to be followed by the facility. She confirmed the facility failed to verify and document Resident #73's wishes and to ensure his preference for end-of-life care was honored. During an interview on [DATE] at 2:55 PM, the Admission Coordinator revealed she was responsible for completing the Advance Directive forms on admission. She confirmed Resident #73 was cognitive, therefore, it was his right to determine his choice for end of life care. Record review of Resident #73's Order Summary Report revealed an order dated [DATE] for full code status. Record review of Resident #73's Durable Power of Attorney, dated and signed by resident on [DATE], revealed, If I become unconscious, incapacitated, or need for any reason to make a decision regarding termination of life support, when in the opinion of medical experts or opinions, and there is not reasonable expectation of my recovery, they I specifically authorize my attorney-in-fact to determine when to terminate life support. Record review of Resident #73's Resident/Family Consent for Cardiopulmonary Resuscitation, dated and signed by resident's representative on [DATE]. The form indicated, I understand that CPR constitutes an extraordinary measure and should be done on this resident in the case of extreme emergency. Record review of Resident #73's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included Schizophrenia, Epilepsy, and Major Depressive Disorder. Record review of Resident #73's MDS Section C dated [DATE], revealed a BIMS score of 14 which indicated the resident was cognitively intact. Resident #75 During an interview on [DATE] at 11:00 AM, Resident #75 revealed he was able to make decisions about his health care and when something happened to him, he did not want to be resuscitated. During an interview on [DATE] at 2:50 PM, the DON confirmed the facility failed to verify and document Resident #75's wishes for end-of-life care to ensure his preference was honored. During an interview on [DATE] at 2:55 PM, the Admission Coordinator confirmed Resident #75 was cognitive, therefore, it was his right to determine his choice for end-of-life care. A record review of the electronic Order Summary Report revealed a Do Not Resuscitate DNR order dated [DATE]. Record review of Resident/Family Consent for Cardiopulmonary Resuscitation dated [DATE], revealed Resident #75's representative signed this form as the representative that has legal authority to act on behalf of the resident and chose I understand that CPR constitutes an extraordinary measure and should not be done on this resident . Record review of Resident #75's General Durable Power of Attorney revealed the person listed was authorized .to make any and all health care decisions for me if I be unable to give informed consent with respect to any given health care decision . Record review of Resident #75's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included Type 1 Diabetes Mellitus, Depression, and Hypertension. Record review of Resident #75's MDS Section C dated [DATE], revealed a BIMS score of 13 which indicated the resident was intact cognitively.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to address and resolve a resident grievance related to timely Activities of Daily Living (ADL) care for one (1) of 20 sampled residents. Resident #247 Findings include: Review of the facility policy titled Grievances-Resident with a revision date of 05/24 revealed, All residents are to be encouraged and assisted (if necessary) in filing grievances to include those with respect to care and treatment, the behavior of staff . The Administrator or Designee has been appointed as the Grievance official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigation by the facility .Upon receipt of a grievance/complaint the staff receiving the complaint will report to their supervisor, grievance official, or will initiate the Grievance/Complaint Form NS-795. Resident #247 Record review of Grievance/Complaint with an effective date of 03/24/2025, 3. Name of Staff who received this Complaint. (Name of Social Worker/Internet Review left by family member) revealed under Explanation/Nature of Complaint, .Well my sister (Resident 247) had an issue a little while back when she came to visit. I cut my call light on and asked to be changed when she (Name of CNA)(Certified Nursing Assistant) came in. CNA responded, You'll have to wait til I get back from my lunch. Her sister responded, So she's just supposed to sit in this while you go to lunch and then she got changed. On 5/12/25 at 11:00 AM, an interview with Resident #247 revealed she feels like it takes too long to be changed when she has had a bowel movement, and she has reported it at least three times and it is still not resolved. During an interview on 5/15/25 at 8:20 AM, the Licensed Social Worker (LSW) revealed the resident has complained before about CNAs not answering the call light promptly and leaving her soiled for a long period. She revealed the resident has complained to me at least 3 times about this issue, and it could be more, and the Director of Nursing (DON) is aware of it as well. She confirmed she had not opened additional grievances each time the resident complained, but would report it to the DON, and if she were instructed to open a grievance, she would have done it. An interview on 5/15/25 at 10:12 AM, Resident #247 revealed she had a good day yesterday until her sister brought her in from the outside activities. She revealed, I saw my aide in the hallway, and I told him that I had a bowel movement and needed to be changed. He said ok, let me finish passing this ice and get my vital signs, and then I'll be right in there. My sister pushed me into my room, and I waited about an hour and a half. I have always reported it to the social worker (SW), and I called her yesterday and reported it to her again. An interview on 5/15/25 at 10:30 AM, the DON revealed that she was aware of a grievance that the resident had on 3/24/25 that an aide had told her she was going to lunch and couldn't change her brief. She revealed we did address that grievance and thought we had a resolution and confirmed that she was unaware that it was still an ongoing concern and grievance for the resident. During an interview on 5/15/25 at 10:45 AM, the Administrator (ADM) revealed she is the grievance officer, and she or the social worker usually opens a grievance form for any issue to be investigated. She confirmed that she was unaware of any other grievances voiced regarding Resident #247 not getting her care in a timely manner until yesterday. She revealed that a grievance form should have been opened if additional complaints were voiced to the social worker or any staff member. Then it would have been investigated correctly and followed through with a resolution and a follow-up. A review of the Admission Record revealed the facility admitted Resident #247 on 2/3/25 with medical diagnoses that included Paranoid schizophrenia and Encephalopathy. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/8/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated Resident #247 was cognitively intact.

Based on staff interviews, record review and facility policy review, the facility failed to submit a change in status referral for a Level II PASRR (Pre-admission Screening and Resident Review) for a resident with a new mental diagnosis for one (1) of four (4) PASRR's reviewed. Resident #5. Findings Include: Review of the Facility Policy Pre-Admission Screening (PAS)/PASRR with latest revision date of 08/24 documented A change in status referral for Level II Resident Review Evaluations Is Also Required for Individuals Who May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: *A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42CFR (Code of Federal Regulations) 483.100 (where dementia is not the primary diagnosis) . Record review of Resident 5's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Depression and Unspecified Psychosis. Record review of Resident #5's Initial Behavioral Medicine/Psychiatric assessment dated [DATE] revealed that he had a new diagnosis of Mood d/o (disorder) with Psychosis and the assessment was signed by Mental Health Nurse Practitioner. Record review of Resident #5's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/10/25 under Section I - Active Diagnoses revealed that he had a Psychotic Disorder. Section N revealed that he was taking antipsychotic medication. An interview on 05/13/25 at 9:00 AM with Admissions Coordinator revealed that she completed a Level I PAS on Resident #5 prior to his admission and he did not trigger for a Level II. She revealed that they went by the hospital history and physical and this documentation did not indicate a diagnosis that would trigger a Level II. Admissions Coordinator revealed that anytime a resident received a new mental health diagnosis or had a new or discontinued antipsychotic medication, they were supposed to submit a status change. On 05/13/25 at 1:35 PM an interview with Licensed Social Worker (LSW), revealed that a change in status was required to be submitted with any new diagnosis and with any new antipsychotic medication addition or discontinuation. LSW revealed that she reviewed Resident #5's records and could not find in the hospital transfer where he had the Psychosis diagnosis when he admitted to the facility. She revealed that Resident #5 was admitted to the facility on [DATE] and she confirmed that he did not have the Psychosis diagnosis at that time. A phone interview on 05/15/25 at 8:50 AM with Mental Health Nurse Practitioner (MHNP), revealed that she assessed Resident #5 on 03/11/25 due to paranoid behaviors and because he was feeling like all the staff were against him. MHNP revealed that Resident #5 was admitted to the facility on antipsychotic medications and on 03/11/25, she diagnosed him with Mood Disorder with Psychosis. An interview on 05/15/25 at 9:28 AM, the LSW revealed she was responsible for submitting the change of status forms for a Level II PASRR. She revealed that she was aware that with any new mental illness diagnosis, she was required to submit a new change of status form for a Level II PASRR. She revealed that she did not submit the change of status form on Resident #5 because she wasn't aware of the new diagnosis. LSW revealed that the purpose of the Level II evaluation was to make sure the resident received the proper psychiatric care that they may need. She revealed that while searching through Resident #5's medical records they found that the Mental Health Nurse Practitioner had diagnosed him with Psychosis on 03/11/25. LSW confirmed that the new diagnosis was missed and that a Level II change in status had not been completed and should have been. An interview on 05/15/25 at 11:15 AM with the Director of Nursing (DON), revealed that she received and reviewed the Physician and Nurse Practitioner Progress Notes when completed and that she just missed the new diagnosis for Resident #5. DON revealed that she received Resident #5's assessment dated [DATE] that was completed by the Mental Health Nurse Practitioner and confirmed that she did not realize that the Psychosis diagnosis was new for him.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for Activity of Daily Living (ADL) related to nail care for two (2) of 20 sampled residents. Resident #63 and #75 Findings include: Record review of facility policy titled Care Plan Process dated 12/24, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care. The facility staff shall follow the care plan. Resident #63 A review of Resident #63's ADL care plan revised 4/3/25 indicated: Resident needs assist with ADLs .Interventions: .Nail care - cut and file weekly and as needed . Observations and an interview with Resident #63, on 5/12/25 at 11:49 AM and again on 5/13/25 at 10:45 AM, revealed that his fingernails were one (1) inch in length, jagged and had a brown substance underneath and Resident #63 expressed a desire to have his nails trimmed. On 5/13/25 at 10:50 AM, during an interview and observation Registered Nurse (RN) #1 confirmed Resident #63's fingernails were very long and needed trimming. She noted that the resident could scratch and make wounds due to the length and condition of the nails. An interview on 5/15/25 at 11:16 AM with the Minimum Data Set (MDS) Coordinator revealed staff were not following the established plan of care for Resident #63. She further confirmed there was no documentation indicating a refusal of nail care by the resident. Review of the Admission Record indicated that the facility admitted Resident #63 on 2/10/2020 with a medical diagnosis that included Hemiplegia, Unspecified Affecting Right Dominant Side. A review of the MDS with an Assessment Reference Date (ARD) of 4/4/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 14 which indicated Resident #63 was cognitively intact. 41878 Resident #75 Record review of Resident #75's care plan revised 2/5/25 revealed Resident needs assist with ADLs. Interventions included to Assist ADLs as needed. Bathing: observe nail length, clean on bath day and as needed . During an interview and observation on 5/12/25 at 10:55 AM, Resident #75's fingernails were long and overgrown with a brown substance noted underneath his nails. He confirmed he wanted his fingernails trimmed. During an interview and observation of Resident #75's nails on 5/13/25 at 11:10 AM, the Director of Nursing (DON) acknowledged the resident's nails were long with a brown substance under the nails. She acknowledged that the care plan was a guide for each resident's care, and she confirmed the facility failed to implement the care plan related to nail care. An interview with the MDS Coordinator on 5/13/25 at 2:20 PM, revealed she was responsible for developing and updating the care plans. She revealed the care plan was an individualized guide for each resident's care and preferences and confirmed the facility failed to follow Resident #75's developed care plan for ADLs related to nail care. Record review of Resident #75's Admission Record revealed the facility admitted the resident on 8/30/23 with diagnoses that included Type 1 Diabetes Mellitus, Depression, and Hypertension. Record review of Resident #75's MDS Section C dated 4/29/25, revealed a BIMS score of 13 which indicated the resident was intact cognitively.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for two (2) of 20 sampled residents. Resident #63 and #75. Findings include: Record review of facility policy titled, Resident Quality of Care, dated 8/24, revealed, Each resident shall receive optimal care to attain and/or maintain the highest possible mental and physical functional status as determined by the comprehensive assessment and person-centered plan of care. Each resident's care is tailored to the functional status and needs they may have. At the time of the bath, all residents shall also receive, if applicable, nail care. Record review of facility policy titled, Nail Care, dated 1/24, revealed, Purpose - to promote cleanliness, safety, and a neat appearance. Resident #63 On 5/12/25 at 11:49 AM and again on 5/13/25 at 10:45 AM, an observation and interview of Resident #63 revealed that his fingernails were one (1) inch in length, jagged and had a brown substance underneath and the resident expressed a desire to have his nails trimmed. During an interview of the observations on 5/13/25 at 10:50 AM, Registered Nurse (RN) #1 confirmed Resident # 63's fingernails were very long and needed trimming. She noted that the resident could scratch and make wounds due to the length and condition of the nails. During an interview on 5/14/25 at 1:46 PM with the Administrator, it was confirmed that a resident with long, jagged fingernails could potentially cause a skin tear. Record review of the Admission Record indicated that the facility admitted Resident #63 on 2/10/2020 with a medical diagnosis that included Hemiplegia, Unspecified Affecting Right Dominant Side. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/25 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 14 which indicated Resident #63 was cognitively intact. 41878 Resident #75 During an interview and observation on 5/12/25 at 10:55 AM, Resident #75 revealed he wanted his fingernails trimmed. His fingernails were observed to be slightly long with a brown substance noted under nails. During an interview and observation of Resident #75's nails on 5/13/25 at 11:10 AM, the Director of Nursing (DON) observed the long nails with the brown substance under the nails. The resident informed the DON that he preferred his nails to be shorter than they were. She acknowledged it was important to keep the nails clean and trimmed to protect the resident from skin concerns and infections. She confirmed the facility failed to maintain the resident's nails at a length he preferred and failed to keep the nails clean. Record review of Resident #75's Admission Record revealed the facility admitted the resident on 8/30/23 with diagnoses that included Type 1 Diabetes Mellitus, Depression, and Hypertension. Record review of Resident #75's MDS Section C dated 4/29/25, revealed a BIMS score of 13 which indicated the resident was intact cognitively.

Based on observation, staff, resident and resident family interviews, record review, and facility policy review, the facility failed to ensure a clean environment as evidenced by dirty wheelchairs and strong, offensive odors for three (3) of seven (7) sampled residents reviewed. Resident #6, Resident #7, and Resident #8. Findings Include: Record review of the facility policy titled, Policy for General Cleaning and Maintenance of Equipment with latest review date of 08/21 revealed, It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident .Equipment is first cleaned of surface soil with soap and water or facility disinfectant . Record review of Statement typed on facility letterhead dated 10/24/24 and signed by the Administrator (ADM) revealed that the Facility does not have a policy to include odor free environment. However, the goal of the facility includes: To provide a safe, sanitary and odor free environment for all patients, employees and visitors at the facility. An observation and interview on 10/23/24 at 8:40 AM, revealed a strong, pungent odor in Resident #6's room on the 400 hall and a puddle of liquid on the floor in the bathroom at the base of and in front of the commode. The bathroom tile was dark, and the color of the liquid substance was difficult to determine. The wet area on the bathroom floor measured about one and one-half by two feet and had a foul odor. There was also a yellow liquid splattered on the commode seat. Resident #6 was sitting up in a chair in his room and he said that he didn't notice a foul odor and stated, When you stay in here so long, you get used to it. An observation on 10/23/24 at 11:15 AM, in Resident #6's room and bathroom revealed a foul odor and a liquid substance on the floor of the bathroom in front of the commode. An observation and interview on 10/23/24 at 12:10 PM, in Resident #6's room with the ADM, confirmed the strong, foul odor in the room and bathroom and confirmed the liquid substance on the floor in the bathroom. ADM revealed that the liquid on the floor in the bathroom looked and smelled like urine and she would address that issue. She also agreed that they should provide a clean, odor free environment for the residents because this was their home. An observation and interview on 10/23/24 at 9:12 AM, revealed Resident #8 sitting in her wheelchair in the small dining room on the 400 hall with her husband at her side. Resident #8's husband revealed that she had been at the facility since the end of January of this year and she had Dementia and could no longer take care of herself. He revealed that his only concern with the facility was that he had noticed that her wheelchair was nasty, and he didn't think it had been cleaned since she was admitted to the facility. He revealed that there was junk spilled on it, there was lots of grit, grime, dust, and hair stuck to the wheelchair frame. He stated, It's nasty, and they let it go. Resident #8's husband revealed that he had not mentioned it to anyone, but he shouldn't have to. An observation revealed a grayish brown substance on the wheelchair frame and on the spokes of the two large wheels. On 10/23/24 at 10:26 AM, an observation revealed Resident #7 sitting in his wheelchair in the small dining room on the 400-hall. His wheelchair was dirty with white and brown food crumbs in the chair between the cushion and arm rest on both sides and there was a gray and brown substance covering the frame of the wheelchair bilaterally. Resident #7 was alert but was observed as non-verbal. An interview on 10/23/24 at 11:55 AM with the Director of Nursing (DON) revealed that resident wheelchairs were assigned to be cleaned by the Certified Nursing Assistants (CNAs) on the third shift, 10 P - 6 A, on Sunday nights. She revealed that they had a CNA Sunday Assignment sheet posted in a binder at the desk and the aides knew that cleaning the wheelchairs was their responsibility to complete. The DON revealed that they divided up the residents between six CNAs and they were required to clean the wheelchairs of the residents who were assigned to them on that shift. She revealed that they did not have a sign-off sheet and didn't have anything in place to make sure the wheelchairs were cleaned. The DON revealed that if any staff member observed that a wheelchair needed to be cleaned at any time, they should take care of it right then and not wait until the scheduled Sunday night shift for someone else to do. She revealed that they had Sani-clothes also available on the carts and anyone could wipe a wheelchair down if it needed to be cleaned. An observation and interview on 10/23/24 at 12:05 PM, with the ADM confirmed that Resident #7 and Resident #8's wheelchairs were dirty and needed to be cleaned. She revealed that they had a place out back where they took the dirty wheelchairs, and pressure washed them. ADM confirmed that the wheelchairs didn't look like they had been cleaned in a while and should have been taken care of and stated, We are going to correct it now and there's nothing else I can say except they are dirty. A phone interview on 10/23/24 at 12:35 PM with Complainant revealed that she came to the facility often and visited her dad. She revealed that the room her dad was previously in on the 400 hall had a pungent urine odor and stated, It always smelled like pee. She revealed that they had moved her dad into another room and there was no issue with the odor in his room now. The Complainant revealed that during her visits with her dad, she had witnessed a lot of filthy wheelchairs, and she revealed that the facility still smelled of urine sometimes. The Complainant revealed that the urine odor was bad, and she felt sorry for the residents who could not speak for themselves and stated, They deserve better. The Complainant revealed that she had talked to the staff, reported dirty wheelchairs and the odors and there hadn't been much change. She stated, The wheelchairs are never clean. An interview on 10/24/24 at 8:15 AM, with CNA #1, revealed that the aides on the 10 P-6 A shift were responsible for cleaning the wheelchairs. She revealed that if any staff member noticed anything spilled on the wheelchair or noticed that the wheelchairs were dirty any other time, they should clean them right then and not wait on the night shift to do it. CNA #1 revealed that they could use soap and water or use the Sani -Wipes to clean them. An interview on 10/24/24 at 8:20 AM, with the DON revealed that they should have noticed the dirty wheelchairs, cleaned them, or at least wiped them down with Sani-Wipes which were readily available. She revealed that each CNA was responsible for the wheelchairs of the residents who were assigned to them on Sunday nights on the 10 P to 6 A shift. The DON confirmed that they had a sheet they were supposed to go by, but they didn't document anything about the cleaning of the wheelchairs. The DON revealed that they knew they had an issue and confirmed that they did not have an effective plan in place to ensure they were being cleaned. Record review of the facility CNA Sunday Assignment sheet, revealed that on the 10 PM - 6 AM shift every Sunday night the CNA assignments included .Clean and Disinfect all vital sign equipment and wheelchairs . Record review of Resident #6's Admission Record revealed an admitted [DATE] and that he had diagnoses that included Chronic Obstructive Pulmonary Disease, Epilepsy, and Osteoarthritis. Record review of Resident #6's MDS with ARD of 09/11/24 under Section C revealed a BIMS Score of 10 which indicated that he had mild cognitive deficits. Section GG revealed that he required supervision or touching assistance with toileting hygiene. Record review of Resident #7's Admission Record revealed an admitted [DATE] with diagnoses that included Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction, Aphasia, and Dependence on Wheelchair. Record review of Resident #7's MDS with ARD of 08/09/24 revealed that the Brief Interview for Mental Status (BIMS) should not be conducted due to resident is rarely or never understood. Record review of Resident #8'sAdmission Record revealed an admitted [DATE] and that she had diagnoses that included Unspecified Dementia and Epilepsy. Record review of Resident #8's MDS with ARD of 10/09/24 under Section C revealed that a Brief Interview for Mental Status should not be conducted due to resident is rarely or never understood.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to honor a resident's choice to smoke cigarettes for one (1) of 17 smokers residing in the facility. Resident #45. Findings Include: Record review of the facility policy titled Resident's Rights Policy with a revision date of 11/23 revealed, Every resident in this facility has the right to: . 22. Use tobacco in accordance with applicable policies, rules, and laws . An observation with interview on 11/13/23 at 3:30 PM, with Resident # 45, revealed him standing in the day room waiting to go outdoors to smoke. The resident revealed that the facility was punishing him because he was caught smoking in his bathroom. He stated they took his cigarettes away as punishment, and he was only allowed to use a vape pen. An interview with Resident # 45 on 11/14/23 at 8:35 AM revealed he was caught by staff smoking in his room. He stated, I feel it's a punishment to take my cigarettes away. The resident stated, You just don't know how hard it is to smoke all your life and then be told you can't. The resident voiced he desired to smoke, and he had told multiple staff members, but they will not allow it. An observation on 11/14/23 at 1:30 PM of the supervised scheduled smoke break revealed Resident #45 was provided a vape pen while all other residents were allowed to smoke cigarettes. An interview on 11/14/23 at 1:58 PM with the Director of Nursing (DON) revealed that Resident #45's smoking privileges had been taken away because he refused to follow the facilities rules related to the smoking policy. She stated that he was caught with cigarette butts and a lighter in his room on 7/14/23 and later was caught smoking in his room on 8/14/23. The DON revealed that Resident # 45 was told at that time that he could no longer smoke, since he could not follow the facility policy for smoking. She revealed that he was offered a nicotine patch, which he refused. She revealed the facility also offered to transfer him to another facility, but he wished to stay. The DON revealed she spoke with the resident on multiple occasions and explained that he could no longer smoke cigarettes due to not following the rules. She stated the facility decided the vape pen was the best option and to her knowledge he had been okay with not smoking. An interview with Resident #45 on 11/15/23 at 2:40 PM revealed it was not fair to allow other residents to smoke but not him. He revealed that the Director of Nursing (DON) told him he could work toward regaining his smoking privileges back, and he had done everything they had asked and still could not smoke. He revealed that the DON suggested he use the vape pen, but that had not curbed his need to smoke cigarettes. An interview with the Administrator (ADM) on 11/15/23 at 4:35 PM revealed they are a smoking facility and confirmed that Resident #45 was admitted to the facility as a smoker. The ADM confirmed that they had not tried any other interventions apart from revoking the resident's smoking privileges. An interview on 11/16/23 at 8:03 AM with the Director of Nursing (DON) confirmed the facility had not done everything they could to honor Resident # 45's right to smoke cigarettes. Record review of the Departmental Notes for Resident # 45 dated 8/14/23 revealed, Resident has not followed the policy for smoking and will not be allowed to smoke . Record review of the Departmental Notes for Resident # 45 dated 9/20/23 revealed, Resident has been asking frequently to go out to smoke. He cannot smoke due to not following the policy . Record review of the Face Sheet revealed Resident # 45 was admitted to the facility on [DATE] with medical diagnosis that included Heart Failure, Bipolar Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, and Anxiety Disorder. Record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/23 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicates Resident #45 was cognitively intact.

Based on staff interviews, record review and facility policy review, the facility failed to submit a change in status referral for a level 2 PASRR (Pre-admission Screening and Resident Review) on a resident with a new mental diagnosis, new antipsychotic medication, and an inpatient psychiatric stay for one (1) of three (3) PASRRs reviewed. Resident #24. Findings include: Review of the Facility Policy Pre-Admission Screening PAS/PASRR (Pre-admission Screening/Pre-admission Screening and Resident Review) with latest revision date of 09/23, revealed .A change in status referral for Level II Resident Review Evaluations Is Also Required for Individuals Who May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: . *A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42CFR (Code of Federal Regulations) 483.100 (where dementia is not the primary diagnosis). * A resident whose intellectual disability as defined under 42 CFR 483.100, or related condition as defined under 42 CFR 435.1010 was not previously identified and evaluated through PASRR. * A resident transferred, admitted , or readmitted to a NF (Nursing Facility) following an inpatient psychiatric stay or equally intensive treatment . Record review of Resident #24's Diagnosis list revealed a diagnosis of Major depressive disorder, recurrent, severe with psychotic symptoms with an onset date of 06/28/2022. Record review of Physician Order List of Resident #24 revealed an order dated 06/14/2022, Evaluate and admit to Behavioral Health as indicated and an order dated 06/28/2022, Risperidone 0.5 mg tablet by mouth @ (at) bedtime. Record review of Resident #24's November 2023 Physician Orders revealed orders dated 06/28/22, Bupropion HCL XL 150 mg tablet by mouth daily and Cymbalta 60 mg capsule by mouth twice daily. On 11/14/23 at 2:25 PM, an interview with Social Services, revealed that she was responsible for completing the Level II Change in Status Request forms and submitting them to (Proper Name for state designated authority) for any resident who went out to inpatient behavioral health and then (Proper Name for state designated authority) would let them know if it triggered for a Level 2 PASRR. She revealed that she failed to submit the status change information on Resident #24. On 11/14/23 at 2:40 PM, an interview with Administrator confirmed that Resident #24 had a new diagnosis of Depression with Psychosis, had been to behavioral health and that the Status Change Form should have been submitted. The Administrator revealed that after this information was submitted, (Proper Name for the state designated authority) would have gotten back to the facility for further recommendations for services needed. On 11/15/23 at 10:10 AM, an interview with Director of Nursing (DON) revealed that when a resident was sent out for behavioral health, a change of status form should be filled out and submitted. She revealed that this form should also be submitted if a resident had an order for a new or changed antipsychotic medication. The DON confirmed that Resident #24 had been sent out to behavioral health and came back with antipsychotic medications ordered and there had not been a change in status form submitted. Record review of Resident #24's Face Sheet revealed an admitted [DATE] with diagnoses including Metabolic Encephalopathy, and Major Depressive Disorder, recurrent, Severe with Psychiatric Symptoms. Record review of Resident #24's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/22/23 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide adequate supervision during smoke breaks to prevent residents from obtaining smoking paraphernalia and to maintain resident safety during smoke breaks for one (1) of 15 residents who smoke. Resident #45. Findings Include: Record review of the facility policy titled Smoking Policies and Regulations with a revision date of 10/22 revealed, .Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurse stations. The facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking. These areas will be monitored by designated staff . Resident #45 An observation and interview on 11/13/23 at 3:30 PM, with Resident # 45, revealed him standing in the day room waiting to go outdoors to smoke. An interview with Resident # 45 on 11/14/23 at 8:35 AM, revealed he was caught by staff smoking in his room with cigarettes' butts and a lighter that he had confiscated during a supervised smoke break. An observation on 11/14/23 at 1:30 PM, of the supervised scheduled smoke break revealed two (2) staff members that dispensed the residents' cigarettes and provided assist with lighting for fourteen residents while leaving the smoke box open on the outdoor table. All outdoor tables had small, shallow circular ashtrays. An interview with Registered Nurse #1 on 11/14/23 at 1:50 PM, revealed they usually have two (2) staff members to supervise the smokers. She revealed that Resident # 45 had been caught smoking in his room a couple of times. An interview on 11/14/23 at 1:58 PM, with the Director of Nursing (DON) revealed that Resident #45 was safe with independent smoking when he was admitted to the facility, which meant he could smoke anytime in the designated area. She stated that he was caught with cigarette butts and a lighter in his room on 7/14/23 and was caught smoking in his bathroom on 8/14/23, despite receiving supervised smoke breaks. She revealed Resident #45 confirmed that he took the cigarette butts during the supervised smoke break and stole a lighter out of the box that held the smoking supplies when the staff member turned her head. An interview with the Director of Nursing (DON) on 11/15/23 at 9:20 AM, revealed the facility had 15 residents that required smoking supervision. She revealed that they have two (2) staff members that supervise the residents' smoke breaks and stated they have adequate supervision. The Survey Agent inquired how Resident #45 could have got cigarette butts and a lighter inside the facility if he was adequately supervised, and she replied, He waits until they turn their heads and sneaks and takes it. She confirmed that she had not tried any other interventions. She denied trying any one-on-one measures or staff education. She acknowledged, without adequate supervision, the resident could still potentially sneak a lighter or cigarette butts during the smoking times. An interview with Social Services on 11/15/23 at 4:20 PM, revealed that Resident #45 had been caught smoking in his room twice and he had been caught stealing used cigarette butts. An interview with the Administrator (ADM) on 11/15/23 at 4:35 PM, revealed they are a smoking facility and confirmed that Resident #45 was admitted to the facility as a smoker. She revealed they have adequate staff members outside with the resident to supervise during the smoking process. She revealed the facility had implemented increased monitoring during smoke breaks since Resident #45 was caught smoking in his room. She revealed that increased monitoring was defined as increased awareness by the staff since the smoking incident occurred. Record review of the Resident Incident Report for Resident # 45 dated 7/14/23 revealed, Resident was found to be taking cigarette butts and lighter in his pocket-He stated that he was going to smoke in his bathroom until he was caught. Resident is able to smoke independently at this time. Record review of the Resident Incident Report for Resident #45 dated 8/14/23 revealed, Staff reports that residents room smelled of smoke. I went in and elder has been smoking in his bathroom. He had butts in his pocket. He stated he stole the lighter when the nurse had turned her head, he took the lighter. He also stated that he wanted to smoke independently so I smoked in my room. Record review of the Face Sheet revealed Resident # 45 was admitted to the facility on [DATE] with medical diagnosis that included Heart Failure, Bipolar Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease, and Anxiety Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/05/23 revealed under Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicates Resident #45 was cognitively intact.

CI MS # Based on facility policy reviews, record reviews, observations, and interviews, the facility failed to supervise and to secure the seat belts to a bilateral [CONDITION(S)] resident while riding in the facility van/bus. Resident #1 fell from the unsecured wheelchair and received injuries of fractures to his hand and fractures to three (3) fingers, a head injury requiring three (3) stitches, and a trip via ambulance to the emergency room (ER) for treatment of injuries. Resident #1 was one (1) of five (5) residents reviewed for supervision and prevention of accidents hazards. FINDINGS INCLUDE: Review of the facility policy titled Policies for Company Owned Vehicle, latest review date 4/22; revealed 3. Seatbelts The driver and all passengers in the company/facility owned vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts, and is responsible for ensuring that all person(s) in the vehicle are safely belted, and remain safely belted until the vehicle reaches its assigned destination. Review of the facility policy titled Accident Prevention (F-558, F-689, F700), latest revision 11/17 revealed, Each resident shall receive supervision and assistive devices to prevent accidents. Interview on 05/17/2022 at 1:30 PM, with the Director of Nursing (DON) revealed that Resident #1 was placed on the van/bus by the facility van/bus driver (Driver #1). The DON stated that Driver #1 was no longer driving the facility van/bus but was currently a Nurse Aide (NA) on the 11:00 PM to 7:00 AM night shift at the facility. Driver #1 has not driven the facility van/bus since the incident occurred on 1/26/2022. The DON confirmed that the Resident # 1 was injured from the fall in the van/bus and was transported to the emergency room (ER) via ambulance for treatment. The DON and the facility Administrator (ADM) completed an investigation and found no abuse and no neglect of Resident #1. Resident #1 was treated and released from the ER with three (3) stitches to his forehead and a splint applied to his hand due to fractures. The DON confirmed that Resident #1 was a bilateral [CONDITION(S)]. DON stated that Resident #1 was a difficult resident and had complained that the seat belt was too tight and that he did not want to wear the seat belt. DON stated that the resident was cognitive and had a Brief Interview for Mental Status (BIMS) score of 15 which confirmed that he was cognitively intact. DON stated that the Driver #1 was the only staff on the bus when Resident #1 fell from his wheelchair. DON stated that Driver #1 called 911 and had the resident transported to the ER via ambulance. DON stated that the resident was a [CONDITION(S)] resident, and he rode the van/bus three (3) times per week to [CONDITION(S)]. DON confirmed that the resident remained in the facility for over a month after the incident of 1/26/2022 and was discharged to his brother's home, to live with his brother and sister-in-law, in February 2022. Interview on 05/18/2022 at 9:00 AM, with the van/bus Driver #2 revealed that she had been working at the facility for [AGE] years and had been the backup driver for over one year. Driver #2 stated that she and all drivers were trained on how to properly secure the seat belts and to supervise the residents riding on the van/bus. (Driver #2) stated that they had regular in-services/training on van/bus safety and on the proper way to secure the seat belts. (Driver #2) stated that the maintenance man had trained them on how to operate the wheelchair lift and how to secure the wheelchairs in the van/bus. Driver #2 stated that she had transported the resident in the facility van/bus on several occasions to [CONDITION(S)] and to other appointments and she had never had any problems with him refusing to wear the seat belts. Driver #2 stated that they had been trained/educated that if a resident was difficult or was having problems that they were to get a second person to ride the van/bus with the driver to ensure safety of the residents. Interview on 05/18/2022 at 11:00 AM, with the former Social Services Designee (SSD #1) Marketing Director confirmed that she was supervisor of the van/bus drivers when the fall of Resident #1 occurred on 1/26/2022. SSD #1 stated that Driver #1 called her to report that there was a van/bus accident involving Resident #1 falling from his wheelchair out on to the floor of the van/bus. SSD #1 stated that Driver #1 had not called 911 prior to calling her. SSD #1 told Driver #1 to hang up the phone and to call 911 immediately. SSD #1 stated that the accident occurred on Chestnut Street (the street that ran in front of the facility) not far from the ER. SSD #1 stated that Driver #1 had told her that Resident #1 was bleeding from a head injury, and she needed help. SSD #1 informed Driver #1 to call 911 and not to move the resident. SSD #1 confirmed that none of the staff from the facility went to the scene of the accident to assist. SSD #1 stated that Resident #1 was a [CONDITION(S)] resident and went to [CONDITION(S)] three (3) times per week. Resident #1 was a demanding resident but was not a problem. Resident #1 was discharged on [DATE] to the home of his brother and did receive injuries of a fracture to his hand and three (3) fingers and had received three (3) stitches to his head from the fall in the facility van/bus. Interview on 05/18/2022 at 12:40 PM, with Driver #1 revealed that on the day of 1/26/2022, she had driven the van/bus approximately six (6) miles from the facility when (Res #1) fell out of his wheelchair. Driver #1 stated that she put on the brakes and that Resident #1 fell to the floor of the van/bus. Driver #1 stated that she had secured the seat belts on Resident #1 prior to leaving the facility, and that he had complained that the seat belts were too tight and he did not want the seat belt on him. Driver #1 secured the seat belt and drove away in the van/bus with the resident. There were no other residents or staff on the van/bus at the time of the incident on 1/26/2022. Driver #1 was transporting the resident to an out-of-town doctor's appointment in another city approximately 30 miles away. Driver #1 stated that she was driving safely and slowly and had softly put on the brakes when the resident fell out of his wheelchair on to the floor. Driver #1 stated that she immediately pulled the van/bus over to the side of the road and called 911 and then called the facility office and talked to the facility switchboard operator. Driver #1 stated that the resident was bleeding on his head and that she applied pressure to his head until the ambulance arrived approximately 20 minutes later. The ambulance picked up the resident and transported him to the ER for treatment. Driver #1 stated that she did not use the first aide kit she used napkins to put pressure on the resident's head and to wipe the blood. Driver #1 changed her account of the accident events and stated that she did use bandages from the first aide kit located on the van/bus to the head of the resident. Driver #1 stated that she no longer would drive the facility van/bus. Driver #1 stated that she did not see the resident remove the seat belt but he must have taken it off when she was driving the van/bus, causing him to fall to the floor when she put on the brakes. Driver #1 stated that she had secured the seat belt on the resident prior to leaving the facility. (Driver #1) confirmed that no staff from the facility came to the scene of the accident to assist. Interview on 05/19/2022 at 9:20 A.M. with the facility Medical Director (MD) revealed that he was also the ER physician on 1/26/2022 when the ambulance was called to pick up the resident after he fell in the facility van/bus. MD stated that he treated the resident in theER on [DATE] and placed three (3) stitches to the cut on his head. MD stated that he then x-rayed the resident's hand and fingers and placed a splint on the hand and fingers due to multiple fractures. MD made a consult referral to an orthopedic surgeon for evaluation after release from theER on [DATE]. MD stated that the resident received superficial injuries from the fall in the facility van/bus. MD stated that the ambulance picked up resident quickly after the 911 call was placed and that it was not 20 minutes after the 911 call was placed. MD stated that after the call was made to 911 until the time the resident arrived in the ER was no more than 10 minutes. MD stated that the van/bus was pulled over with the injured resident less than a block from the ER. Record review of the Face Sheet for Resident #1 revealed that he had been admitted to the facility on [DATE] and was discharged from the facility on 02/11/2022. Resident #1 had diagnoses of Acquired absence of right leg above the knee and Acquired absence of left leg above the knee; End Stage renal disease; Type 2 diabetes; Essential Hypertension; Unspecific fracture to right forearm; among other diagnoses. Record review revealed a facility Accident and Incident Report (A&I) dated 1/28/2022 revealed the resident involved was Resident #1 with documentation of a fall with head injury laceration-superficial, fractures, abrasions in facility vehicle. The facility (A&I) revealed Elder was being transported by facility van to MD appointment in Tupelo. (Driver #1) stated that she went to apply her brake due to a car turning in front of her, elder slid from his wheelchair (W/C) onto the floor. (Driver #1) called 911 and the ambulance transported him (Res #1) to the ER. (MD) was present in the ER. Computerized Tomography (CT) and x-rays performed. CT negative -xrays revealed fracture to Right index finger and possible fracture to middle finger. Elder was transported back to the facility. Rt (right) (right) arm and hand in splint -3 sutures to forehead. Record review of the radiology report x-ray right hand dated 1/26/2022 at 10:59 AM, revealed that Resident #1 had fracture of the proximal phalanx, right fourth finger with probable essentially nondisplaced fractures of the third and fifth finger proximal phalanges. Advanced arteriosclerosis of the visible distal right forearm and hand. The CT Head without contrast report dated 1/26/2022 at 10:58 A.M. revealed that there is evidence of a scalp laceration overlying the frontal scalp.

Based on observation, staff interview, and facility policy review, the facility failed to follow the COVID -19 Infection Control Guidelines to prevent the spread of the [MEDICAL CONDITION] which likely led to the death of four (4) of 32 residents who had not been outside the facility, Resident #1, #2, #3, and #4; as evidenced by the facility's failure to change gloves and wash hands or use hand sanitizer between rooms, failure to practice social distancing, and failure to remove contaminated personal protective equipment (PPE) when exiting the dedicated COVID-19 unit. On [DATE], the State Agency (SA) surveyor made observations of the facility staff not social distancing while eating lunch in the dining room, failing to perform hand hygiene between contact with residents, and failing to properly use personal protective equipment. Record review revealed the facility had a total of nine (9) COVID-19 related deaths in the facility with four (4) of those being residents who had not been out of the facility. The Immediate Jeopardy (IJ) was determined to exist on [DATE], when the first death of a resident, who had not left the building, occurred due to, or as a consequence of COVID-19. The facility's failure to follow appropriate COVID-19 infection control guidelines for social distancing, handwashing, and proper use of personal protective equipment, had caused, or likely to cause serious injury, harm, impairment or death to residents who tested positive for the COVID -19 virus while residing solely in the facility. This affected four (4) of 32 Covid-19 positive residents who had not been out of the facility. Resident #1, #2, #3, and #4 expired due to, or as consequence of COVID-19 as indicated on the certificates of death. Findings include: Review of the facility's Hand Hygiene policy and procedure, with a revision date of ,[DATE], revealed: Purpose is to cleanse hands to prevent transmission of infection and other conditions and to provide clean health environment for residents, staff, and visitors. The procedure for indications for handwashing included: hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room, and before and after applying gloves. Wearing gloves does not replace the need to perform hand hygiene. Review of the facility's policy Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), revised ,[DATE], revealed: It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to transmission based precautions, including the use of eye protection. The policy indicated, to prevent the spread of respiratory germs within your facility, ensure employees clean their hands according to Centers for Disease Control and Prevention (CDC) guidelines including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment. The policy further revealed, to identify dedicated employees to care for COVID-19 patients. An observation, on [DATE] at 11:25 AM, revealed, staff members sitting together at tables in the dining room eating lunch. The staff members were not socially distanced from each other and were not wearing masks. The staff members were laughing and talking loudly. During the observation, one of the Certified Nursing Assistants (CNA) was helping another CNA take her gown off. Neither of them had a mask on. An observation and interview on [DATE] at 11:35 AM, with the Administrator, confirmed the staff were not socially distancing. The Administrator stated the staff should not be sitting together at the dining room tables. She identified the staff at the tables as CNA #1, CNA #2, CNA #3 and Sunshine Aide #1. The Administrator stated that they knew better. She stated that this could lead to the spread of infection. An observation, on [DATE] at 11:50 AM, revealed, CNA #1 walked out of the Social Services office wearing gloves. She closed the door with her gloved hand and walked into room [ROOM NUMBER] and adjusted the air conditioner. CNA #1 did not remove her gloves and wash her hands. CNA #1 then entered room [ROOM NUMBER] and leaned on the foot board of the bed with her gloved hands. On [DATE] at 11:52 AM, an observation revealed, CNA #2 adjusted the mask for the resident in room [ROOM NUMBER]. CNA #2 left the room without washing her hands or removing her gloves. She entered room [ROOM NUMBER]without removing her gloves or washing her hands, picked the call light up from the floor, and placed it on the bed for the resident. CNA #2 then entered room [ROOM NUMBER]A with the same gloves on and did not wash her hands or use hand sanitizer. An observation, on [DATE] at 12:00 PM, revealed, lunch meal trays were being served on the 400 Hall. CNA #1 delivered and set up trays in rooms [ROOM NUMBER] without washing her hands or using hand sanitizer between the rooms. During an interview, on [DATE] at 12:08 PM, Registered Nurse (RN) #2, confirmed staff should use hand sanitizers or wash their hands when they change their gloves and any time they go in and out of a room. She stated the facility's Infection Control Preventionist was out on medical leave, and she was covering that position. RN #2 stated they have put extra hand sanitizers on the halls for the staff to use. RN #2 stated it was her responsibility to monitor staff for wearing proper protective equipment and to make sure they were maintaining proper infection control practices. She stated that she had done an in-service on proper protective equipment (PPE), donning and doffing PPE and changing equipment with each resident. RN #2 stated she was also responsible for calling residents' families and updating them on resident conditions affected by COVID-19. An interview with the Administrator (ADM) and Director of Nursing (DON), on [DATE] at 12:40 PM, revealed their first COVID case was around the first of May. The DON stated she felt it was brought into the facility by a [MEDICAL TREATMENT] resident. The DON confirmed that residents going out of the facility wear masks and are screened when they come back in. The DON stated she felt they were doing everything they could to take care of their residents. The ADM stated she was aware they had problems, and they were going to work on it. During an interview, on [DATE] at 1:15 PM, Resident #5 revealed, staff put on gloves in the room and when they finish, they take their gloves off and go out. An observation, on [DATE] at 1:25 PM, revealed Licensed Practical Nurse (LPN) #1 exited the 200 Hall (COVID) doors fully dressed out in personal protective equipment (PPE). She walked to the nurse's desk and attempted to open the door to the lounge/bathroom area, bumping into another staff member who was coming out of the area. LPN #1 then turned around and removed her gloves and disposed of them in the garbage can under the nurse's desk. LPN #1 walked back to a garbage can, sitting outside the door to the COVID hall, removed her gown, and placed it in the garbage can. She then left the area without removing her shoe covers. An interview with LPN #2, on [DATE] at 1:35 PM, revealed, she works the ,[DATE] shift giving medications. LPN #2 stated that she was working the 100 Hall today, but she has had to work the 200 Hall (COVID unit) and other floors giving medications during the same shift. LPN #2 stated that at times, the medication cart had been taken onto the COVID unit, but it was sprayed down when brought out. An observation, on [DATE] at 2:35 PM, revealed, CNA #4 exited the COVID unit and walked to the nurse's desk, and went into the lounge/bathroom without removing her PPE. On [DATE] at 2:55 PM, during an interview with CNA #1, revealed, she has had COVID in-services. CNA #1 confirmed she sat at the table with CNA #3 during lunch. CNA #1 confirmed they were not six (6) feet apart and did not have a mask on, because they were eating. She stated that social distancing meant that you are at least six (6) feet apart. She confirmed that the COVID-19 virus could be spread by not wearing a mask and social distancing. CNA #1 stated she was told to wear gloves. She stated she felt that she only had to change her gloves if she had contact with the residents. CNA #1 stated she knew that she was not supposed to wear gloves in the hall, but the staff was limited, and they were trying to get everything done. She stated that not changing her gloves could cross-contaminate everything. During an interview, on [DATE] at 3:15 PM, LPN #1 confirmed she exited the COVID unit without removing her PPE. She confirmed she came off the unit contaminated. LPN #1 stated she did not realize she had not taken her shoe covers off. She stated not removing her shoe covers could cause contamination to any other areas that you go to. LPN #1 stated she thought she was supposed to undress outside the doors. She stated that she did not notice the cans inside the door. An interview with CNA #2, on [DATE] at 3:17 PM, confirmed she ate lunch in the dining room with a Sunshine Aide #1. She stated she knew that they should be six (6) feet apart, but she just didn't think anything about it. CNA #2 confirmed she did not follow the facility's policy. She stated that she had been in-serviced on social distancing. During an interview, on [DATE] at 3:30 PM, with Sunshine Aide #1, she stated that she had been working at the facility since the end of May. Sunshine Aide #1 stated she had training during orientation about social distancing and about wearing a mask, gloves, face shield and shoe covers. She stated they (PPE equipment) should be removed when the resident's care was finished to prevent spreading germs to someone else. An observation and interview, on [DATE] at 11:43 AM, with the DON and the Maintenance Supervisor, revealed, during actual measuring, that the distance from the doors of the COVID unit to the nurse's desk was 20 feet. The DON confirmed staff leaving the COVID unit without removing their PPE, would be considered contaminated. The measurements taken in the dining by the Maintenance Supervisor, in the presence of the DON, revealed the dining room tables were 42 inches wide (3 feet and 6 inches). The Maintenance Director and the DON confirmed, with staff sitting together at the tables, they were not socially distanced as they should be and could be at risk to spread the [MEDICAL CONDITION]. On [DATE] at 3:32 PM, an interview with the Administrator (ADM), confirmed the facility had a dedicated COVID unit. She stated Nurses and CNAs are assigned to the unit. The ADM confirmed they are not dedicated staff. She stated the medication nurse should put all her of PPE on when she enters to administer the medications and should remove all her PPE before coming out through the door when finished. An interview with CNA #3, on [DATE] at 4:00 PM, revealed, she confirmed that she ate lunch in the dining room and sat at the table with CNA #1. CNA #3 stated that social distancing meant that you are 6 feet apart. She stated they have red X(s) on the floor to mark six (6) foot distancing. She confirmed they were not following that today. CNA #3 also confirmed she did not have a mask on when she assisted CNA #1 with removing her PPE. She stated she had been to in-services and knew that she should wear a mask and wash her hands between residents and when going from one room to another. An interview, on [DATE] at 4:39 PM, with CNA #4, revealed, she knew that she was supposed to take her PPE off when she left the unit. CNA #4 stated she guessed that she looked out the window and saw everybody else out there with gowns on and just went out. CNA #4 stated she knew that she was supposed to take her PPE off, because that is the correct way. She stated she made a mistake and that it would spread germs. CNA #4 confirmed she has had in-services concerning proper use of PPE. During an interview, on [DATE] at 10:35 AM, with the ADM concerning staff failure to follow infection control protocols, she stated that obviously they have room for improvement. The ADM stated that staff were aware of the policies and procedures and what they were doing was not the right practice. Record review revealed Licensed Practical Nurse (LPN) #1 attended in-service training that addressed COVID-19 and Infection Control on [DATE], [DATE], [DATE], and [DATE]. Record review revealed LPN #2 attended in-service training that addressed COVID-19 and Infection Control on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Record review revealed CNA #1 attended in-service training that addressed COVID-19 and Infection Control on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review revealed CNA #2 attended in-service training that addressed COVID-19 and Infection Control on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review revealed CNA #3 attended in-service training that addressed COVID-19 and Infection Control on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review revealed CNA #4 attended in-service training that addressed COVID-19 and Infection Control on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 9:30 AM, during an interview with the DON, she stated that she did not feel they (staff) caused the outbreak. The DON stated they had not been lax, and she felt like this virus was in the air. She stated that they had a drop in staff and were down seven (7) nurses at one time and didn't have a choice about medication administration. The DON stated the medication cart was sprayed down if used on the COVID hall, but sometimes people take things upon themselves. An interview with the ADM, on [DATE] at 9:45 AM, revealed, they had 21 residents on the COVID unit at this time, and now have dedicated staff consisting of one (1) nurse and two (2) CNAs each shift, and a medication cart dedicated to that unit. The ADM confirmed the outbreak was not isolated but was widespread with residents testing positive on each hall. She confirmed the facility had four (4) residents, who had not been out of the facility that tested positive for the [MEDICAL CONDITION] and expired. She stated these residents were on the 100, 300, and 400 Halls when they tested positive. The ADM confirmed these residents were negative on the initial facility wide testing and later converted to positive. Review of a typed statement on the facility's letterhead, unsigned and undated, revealed, facility wide resident testing was conducted on [DATE] and [DATE]. Resident #1 Record review of the facility's Face Sheet for Resident #1, revealed, Resident #1 was admitted by the facility on [DATE], with an admission [DIAGNOSES REDACTED]. Resident #1 resided on the 400 Hall in the facility. A review of the laboratory results for Resident #1, revealed, a nasal swab was performed to test for Coronavirus on [DATE], with results that indicated Negative results for the Coronavirus COVID-19. Resident #1 was retested on [DATE] and had converted to a positive result. Review of Resident #1's Certificate of Death, revealed, the resident's date of death documented as [DATE]. The immediate cause of his death was listed as [DIAGNOSES REDACTED] with the underlying cause that initiated and resulted in his death, was due to, or a consequence of COVID-19. Resident #2 Record review Resident #2's Face Sheet, revealed, Resident #2 was admitted by the facility on [DATE], with an admission [DIAGNOSES REDACTED]. Resident #2 resided on the 100 Hall in the facility. A review of laboratory results, revealed, a nasal swab for Coronavirus COVID-19 was collected on [DATE] for Resident #2, which indicated Negative results. Resident #2 was retested on [DATE] and had converted to a positive result for Coronavirus COVID-19. Review of Resident #2's Certificate of Death, revealed, Resident #2's date of death was [DATE]. The immediate cause of his death was [DIAGNOSES REDACTED] with the underlying cause that initiated and resulted in his death as being COVID-19. Resident #3 Review of the facility's Face Sheet for Resident #3, revealed, Resident #3 was admitted by the facility on [DATE], with an admission [DIAGNOSES REDACTED]. Resident #3 resided on the 300 Hall in the facility. Review of Resident #3's laboratory results, revealed, a nasal swab for for the Coronavirus COVID-19 was collected on [DATE] and indicated Negative results. Resident #3 was retested on [DATE] and had converted to a positive result. A review of Resident #3's Certificate of Death, revealed, his date of death to be [DATE]. The immediate cause of his death was listed as [DIAGNOSES REDACTED], with the disease or injury that initiated the events resulting in his death as being COVID-19. Resident #4 Record review of Resident #4's Face Sheet, revealed, the facility admitted Resident #4 on [DATE], with an admission [DIAGNOSES REDACTED]. Resident #4 resided on the 300 Hall in the facility. Review of Resident #4's laboratory results for a nasal swab collected for the Coronavirus COVID-19 test, on [DATE], revealed, Negative results. Resident #4 was retested on [DATE] and had converted to a positive result. Review of Resident #4's Certificate of Death, revealed, the resident's date of death was [DATE]. The immediate cause of Resident #4's death was listed as [DIAGNOSES REDACTED], with the underlying cause that initiated events which resulted in his death, as being COVID-19. During an interview, on [DATE] at 2:05 PM, the ADM confirmed Resident #1, Resident #2, Resident #3, and Resident #4 had not been outside of the facility since their initial negative Coronavirus COVID-19 test on [DATE]. The facility submitted an acceptable Removal Plan on [DATE] for the Immediate Jeopardy. Review of the facility's Removal Plan revealed the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE], during four observations on the day shift, Certified Nursing Assistant (CNA) #1 and CNA #2 failed to perform proper hand hygiene between entering residents rooms and one Licensed Practical Nurse (LPN) #1 and CNA #4 were observed exiting the COVID unit without removing their PPE prior to exit. Director of Nursing (DON) and Nursing Facility Administrator (NFA) were notified on [DATE], at approximately 12:30PM, of observations related to Infection Prevention and Control noncompliance. 2. DON immediately initiated in-services on [DATE], at 12:30PM, on policies for Infection Control latest revision ,[DATE], Hand Hygiene latest revision ,[DATE] and Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) latest revision ,[DATE]. In-services were initiated on [DATE], at 2:00PM, by Registered Nurse #1 (RN) to include all staff consisting of Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants, Dietary, Housekeeping, Laundry, Therapy, Maintenance, Administration and contract staff. No staff will be allowed to work until participation of the in-services for Infection Control latest revision ,[DATE], Hand Hygiene latest revision ,[DATE], Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) latest revision ,[DATE], and Donning PPE and Removing PPE latest revision N/A. 3. DON began visual inspections every two hours on [DATE]. 2020, at 1:00PM, to end on [DATE], at 1:00 PM, to prevent noncompliance related to Infection Prevention and Control. Proper hand hygiene and safe donning and removal of PPE was monitored by unit nurses on each shift by observations and return demonstrations on [DATE]. DON and unit nurses began visual inspections every 2 hours on [DATE], at 1:00 PM, to end on [DATE], monitoring housekeeping for appropriate cleaning of environment, resident restrooms, nurse stations and community restrooms. No Negative findings were identified during the observation and return demonstrations. 4. On [DATE], at approximately 5:30 PM, all residents were reassessed for signs and symptoms related to COVID-19 by RN #1, #2, Infection Preventionist, RN #3 and DON. Assessments were completed with no new identified signs or symptoms of COVID-19. 5. DON initiated disciplinary action and education on [DATE], at 3:00 PM, to CNA #1, CNA #2, CNA #4 and LPN #1. 6. Facility Quality Assurance Committee Meeting was held on Tuesday, [DATE], at 7:00 PM, with the committee consisting of facility DON, NFA, Medical Director, #2 Infection Preventionist, RN #3, Housekeeping/Laundry Supervisor, Medical Director, Activity Director. Topics discussed increase in COVID positive cases, assessing residents for signs and symptoms related to COVID-19, educating staff on Interim COVID-19 Policy and Infection Control latest revision ,[DATE], tracking and trending infection, dedicated staff and supplies for COVID-19 hall and admissions. Facility Quality Assurance Committee Meeting was held on Wednesday, [DATE], at approximately 1:30 PM, with the committee consisting of facility DON, NFA, Medical Director, #2 Infection Preventionist, RN #3, and Activity Director. Topics discussed, results of survey, increase in COVID positive cases, assessing residents for signs and symptoms related to COVID-19, educating all staff to include the following departments, dietary, Housekeeping, Laundry, therapy, maintenance, administration, direct care on interim COVID-19 policy and Infection Control, tracking and trending infection, dedicated staff and supplies for COVID-19 hall and admissions. 7. Facility wide retesting of residents and staff has been scheduled with the local hospital. 8. Facility alleges that all corrective actions have been completed on [DATE]. 9. No staff will be allowed to work until in-serviced. The Survey Team validated the facility's Corrective Actions through observation, interview, record review, and review of sign-in sheets. 1. The SA validated through observations that no further issues noted with staff not performing hand hygiene measures and removal of PPE when exiting the COVID-19 unit on the 200 Hall. 2. The SA validated through interviews and review of in-service sign-in sheets that in-service education was provided by the facility in the form of lectures and films. 3. The SA validated through interviews and review of monitoring tools utilized to perform visual inspections of nursing staff for proper hand hygiene and PPE use, and housekeeping for cleaning of the environment. 4. The SA validated through record review that all residents in the facility were assessed for signs and symptoms of COVID-19. 5. The SA validated through interview and record review that disciplinary actions and education was provided to CNA #1, #2, #4 and LPN #1. 6. The SA validated a Quality Assessment and Assurance Committee meeting was held on Tuesday, [DATE] and Wednesday [DATE] by interview and review of the sign-in sheet. 7. The SA validated facility wide testing for staff and resident through observation and review of correspondence via e-mail with the Chief Executive Officer of the local hospital. 8. The SA validated that all corrective actions listed were accomplished by [DATE]. 9. The SA validated through interviews and record review that staff were not allowed to work until in-serviced. The SA validated that all corrective actions were completed as of [DATE], and the IJ was removed prior to exit on [DATE].