Every finding on record at Chattanooga Health and Rehab Center

Based on facility policy review, observations, and interviews, the facility failed to ensure the kitchen equipment was maintained in a sanitary working condition. The findings include:Review of the facility's Nutritional Services policy titled, Sanitation Inspection, dated 9/1/2021, revealed .All food service areas shall be kept clean, sanitary .The department shall establish a sanitation program for food services .Sanitation inspections will be conducted .The dietary manager shall develop and provide food service personnel with standard operating procedures .During an observation and interview of the kitchen during the initial tour on 8/4/2025 at 10:50 AM, with the Lead [NAME] (LC) revealed on inspection of the cook-top stove / oven, the splash plate behind the stove top eyes was noted to have smeared, dried, dark brown food debris present. The doors of the unit had dried, multi-colored food debris on the top of both oven doors. The 3/4 inch gap at the bottom face plate of the unit was harboring diced potato pieces in different degrees of color from tan to charred black. Further observation revealed an electrical box located to the left of the cook-top stove appeared to be covered with a sticky tan substance with granular food debris present.During an interview on 8/4/2025 at 11:53 AM, the LC stated the kitchen equipment was cleaned (deep) weekly, the LC confirmed the cook-top oven was in need of a thorough cleaning. During an interview on 8/4/2025 at 11:53 AM, the Assistant Director of Nursing (ADON) confirmed the cook-top oven was in need of cleaning.During an interview on 8/6/2025 at 11:00 AM, the Dietary Manager (DM) stated he was aware of the observations of the cook top stove. The DM confirmed the cook-top stove after the initial tour of the kitchen on 8/4/2025 was not in a clean condition and was in need of cleaning. The DM could not produce a cleaning schedule when asked, he stated the facility did not have the documentation.

Based on facility policy review, medical record review, and interview, the facility failed to provide 2 of 3 residents (Resident #30, and Resident #38) an NOMNC (a notice of non-coverage) after therapy services were discontinued, the resident remained in the facility for long-term care services, or was discharged from the facility. The facility's failure resulted in residents not being informed of the cost of therapy services if continued therapy services were desired which did not allow the residents to have an informed choice. The findings include:Review of the facility policy titled, Advance Beneficiary Notices/ NOMNC, dated 9/01/2021, revealed .A notice of Medicare Non-Coverage (NMNC) .shall be issued to the resident/representative when Medicare covered services are ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident how to request an appeal .Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Aorta, Anemia, Cardiomegaly, and Muscle Weakness.Review of facility documentation revealed Resident #30 last covered Part A skilled services day was 6/18/2025. Continued review revealed no documentation a NOMNC was provided to Resident #30 which did not allow the resident/resident representative to make an informed decision or file an appeal.Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, History of Falling, Age related Physical Debility, and Hypertension.Review of facility documentation revealed Resident #38 last covered Part A skilled services day was 5/22/2025. Continued review revealed no documentation a NOMNC was provided to Resident #3 which did not allow the resident/resident representative to make an informed decision or file an appeal.During an interview on 8/6/2025 at 11:10 Am, the [NAME] President of Clinical Reimbursement confirmed Resident #30 and Resident #38 were not given notices explaining their informed choice prior to discharge form skilled Services.

Based on facility policy review, medical record review, and interview the facility failed to ensure the Physician reviewed and acted upon irregularities identified by the Consultant Pharmacist for 1 resident (Resident #4) of 5 residents reviewed for unnecessary medications.The finding include: Review of the facility policy titled, Medication Regimen Review and Reporting, revised 9/2018 revealed .In accordance with state regulations, the consultant pharmacist .works with the nursing care center staff .findings are communicated to the director of nursing or designee and the medical director .these findings are documented and filed with other consultant pharmacist recommendations .recommendations and findings are documented and acted upon by the nursing care center and/ or physician . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Schizoaffective Disorder, Chronic Kidney Disease, and Delusional Disorders. Review of a Consultant Report for Resident #4 dated 12/2024 revealed .hydroxyzine [mediation to treat anxiety] 25 mg [milligrams] QHS [every night at bedtime] .consider trial decrease to 10 mg QHS . Continued review revealed the Physician had not signed or documented a response to the Consultant Pharmacist Recommendation. Review of a Consultant Report for Resident #4 dated 1/2025 revealed .clonazepam [medication to treat anxiety] 0.5 mg BID [twice a day] .consider trial decrease to 0.5 mg Q day [everyday] . Continued review revealed the Physician had not signed or documented a response to the Consultant Pharmacist Recommendation. Review of a Consultant Report for Resident #4 dated 6/2025 revealed .hydroxyzine 25 mg QHS .consider trial decrease to 10 mg QHS . Continued review revealed the Physician had not signed or documented a response to the Consultant Pharmacist Recommendation. Review of a Consultant Report for Resident #4 dated 7/2025 revealed .clonazepam 0.5 mg BID .consider trial decrease to 0.5 mg Q day . Continued review revealed the Physician had not signed or documented a response to the Consultant Pharmacist Recommendation. During an interview on 8/6/2025 at 9:42 AM, the Director of Nursing (DON) confirmed the Physician was in the facility at least monthly to review reports. The DON confirmed the Consultant Pharmacist recommendations were not acted upon by the physician.

Based on observation and interview the facility failed to ensure expired intravenous supplies were discarded and not available for resident use in 1 of 2 medication storage rooms observed for medication storage. The findings include: During an observation in the 100-hall medication storage room on [DATE] at 3:01 PM, with the Director of Nursing (DON), revealed the following concerns: (nine) 20-gauge intravenous (IV) catheters with an expiration date of [DATE], (one) 22-gauge IV catheter with an expiration date of [DATE], and (one) 25-gauge needle with an expiration date of [DATE]. During an interview on [DATE] at 3:10 PM, the DON stated the IV supplies stored in the medication room were available for immediate resident use, was expired, and should be discarded.

Based on facility policy review, observations, and interviews, the facility failed to ensure the dumpster area and refuse contents were maintained in a clean and sanitary order. The findings include:Review of the facility's Nutritional Services policy titled, Sanitation Inspection, dated 9/1/2021, revealed .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other issues .The department shall establish a sanitation program for food services .Sanitation inspections will be conducted .The dietary manager shall develop and provide food service personnel with standard operating procedures .During an observation of the outside dumpster area on 8/4/2025 at 10:53 AM, with the Assistant Director of Nursing (ADON) revealed 2 dumpsters for waste disposal. Observation of the ground surrounding the dumpster area revealed cardboard, multiple plastic bags with unknown content, and multiple cardboard boxes atop the dumpsters. Further observation revealed neither dumpster had a drain plug in place.During an interview on 8/4/2025 at 10:54 AM, the ADON confirmed the dumpster area was not maintained properly.

Based on facility policy review, observations, and interviews, the facility failed to ensure kitchen equipment of 1 gas cook top oven was maintained in good working condition.The findings include:Review of the facility's policy titled, Sanitation Inspection, dated 9/1/2021, revealed .All food service areas shall be kept clean, sanitary .The department shall establish a sanitation program for food services .Sanitation inspections will be conducted .The dietary manager shall develop and provide food service personnel with standard operating procedures .During an observation and interview of the kitchen during the initial tour on 8/4/2025 at 10:50 AM, with the Lead [NAME] (LC) revealed on inspection of the cook-top stove / oven, the door on the right side of the unit, upon slight touch would open and drop forcefully. The door was observed to be heavy and had the potential to fall forward and injure kitchen staff while in use. Continued observation revealed the bottom metal face plate, just below the oven doors appeared to have a wrinkle in the metal and was not attached to the frame of the unit. The metal plate not being affixed appropriately created a 3/4 inch gap which retained burnt food pieces and other food residue. When asked the LC confirmed the stove had been in operation in this condition for Months.During an interview on 8/4/2025 at 11:53 AM, the Assistant Director of Nursing (ADON) confirmed the cook-top oven was in need of professional repair. During an interview on 8/6/2025 at 11:00 AM, the Dietary Manager (DM) stated he was aware of the observations of the cook top stove door and bottom face plate. The DM confirmed the cook-top stove after the initial tour of the kitchen on 8/4/2025 was in need of professional repair.

Based on facility policy review, observations, and interview, the facility failed to ensure food items were sealed properly and failed to ensure the kitchen cooking equipment was maintained in a sanitary condition which had the potential to affect 48 of 49 residents. The findings include: Review of the facility's undated policy titled, Food Storage, revealed .all open products .will be sealed .rolled closed .lid closed .to ensure quality and prevent contamination against pests or rodents . Observation of the food preparation area on 5/20/2024 at 10:45 AM, with the Certified Dietary Manager (CDM) revealed the following: 15-ounce (oz) bottle of ground cinnamon was not sealed 14-oz bottle of cayenne pepper was not sealed 32-oz bag of brown sugar (1/4 full) was not sealed Toaster oven had crusty, brown food debris present to the delivery chute with dried, brownish-black residue present to 3 temperature dials Observation of the cooking area on 5/20/2024 at 10:50 AM, with the CDM revealed a thick, brownish-yellow residue to the front panel of the deep fryer. During an interview on 5/20/2024 at 11:25 AM, the CDM confirmed the dried food items (brown sugar, cinnamon, and cayenne pepper) were not sealed appropriately and the kitchen equipment (toaster and deep fryer) had not been maintained in a sanitary condition.

Based on facility policy review, medical record review, and interview, the facility failed to refer 1 resident (Resident #36) identified with possible serious mental disorders to the state-designated authority for a Level II Pre-Admission Screening and Resident Review (PASRR) evaluation of 14 residents reviewed for PASRR. The findings include: Review of the facility's policy titled, PASRR Program Policy, revised 5/2024, revealed .Any resident who exhibits .evident or possible serious mental health disorder .will be referred promptly to the state mental health or intellectual disability authority for a level 2 resident review . Review of a Pre-Admission PASRR screening dated 3/18/2022, revealed Resident #36 had no mental health disorder. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Major Depression, Delusional Disorder, Restlessness, and Agitation. During an interview on 5/22/2024 at 10:10 AM, the Social Service Director confirmed Resident #36 was not referred to the state-designated authority for a Level II PASRR screening after a new mental health diagnosis.

Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plan to include hospice services for 1 resident (Resident #28) and code status for 1 resident (Resident #31) of 21 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plan Revisions Upon Status Change, revised 5/2024, revealed .The comprehensive care plan will be .revised as necessary .when a resident experiences a status change .care plan will be updated with new or modified interventions . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Chronic Obstructive Pulmonary Disease (COPD), and Diabetes Mellitus. Review of the Physician's Orders for Resident #28 dated 4/20/2024, revealed admit to hospice services. Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and received hospice care. Review of a comprehensive care plan dated 4/20/2024, revealed Resident #28's code status was Do Not Resuscitate (DNR). The comprehensive care plan had not included hospice services for Resident #28. During an interview on 5/21/2024 at 4:05 PM, the Assistant Director of Nursing (ADON) confirmed Resident #28's care plan was not revised to include hospice services. 49786 Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, COPD, Type 2 Diabetes, and Major Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #31 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Review of a comprehensive care plan dated 9/14/2023, revealed Resident #31 .has a full code status . Review of the POLST (Physician Orders for Scope of Treatment) form for resident #31 dated 12/11/2023, revealed Resident #31 had a DNR status. Review of the Physician's Orders for Resident #31 dated 1/19/2024, revealed .DNR . During an interview on 5/22/2024 at 10:20AM, the Director of Nursing confirmed Resident #31's comprehensive care plan was not revised to reflect the residents DNR status.

Based on facility policy review, medical record review, observation, and interview, the facility failed to properly secure medications for 1 resident (Resident #25) of 8 residents screened for accidents and hazards. The findings include: Review of the facility's policy titled, Medication Administration, revised 5/2024, revealed .Medications are administered by licensed nurses .Administer medication as ordered in accordance with manufacturer specifications .observe resident consumption of medication . Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Spinal Stenosis, and Dementia. Review of the Physician's Orders for Resident #25 dated 7/14/2023, revealed .Miralax [laxative] 17 GM [Grams] .Give 1 packet by mouth one time a day for Constipation .mix with 4-6 ounces [oz] of fluid . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation on 5/20/2024 at 11:00 AM, in Resident #25's room, revealed the resident was not in the room, and an 8 oz cup containing a disposable spoon, no water, and approximately 1 oz of an unidentified white powder was observed on Resident #25's bedside table. During an observation on 5/20/2024 at 1:00 PM, in Resident #25's room, revealed the resident was not in the room, and an 8 oz cup containing a disposable spoon, no water, and approximately 1 oz of an unidentified white powder was observed on Resident #25's bedside table. During an observation and interview on 5/20/2024 at 3:00 PM, in Resident #25's room with Licensed Practical Nurse (LPN) C, revealed the resident was not in the room, and an 8 oz cup containing a disposable spoon, no water, and approximately 1 oz of an unidentified white powder was observed on Resident #25's bedside table. LPN C stated the resident had a Physician's Order for Miralax and confirmed the unidentified white powder in the 8 oz cup left at the bedside unsecured was Miralax. During an interview on 5/20/2024 at 3:05 PM, Resident #25 stated the white powder in the cup at her bedside was Miralax, the resident also stated she did not take the medication this morning, .I will take it later today . Review of the medication administration record for Resident #25 dated 5/20/2024, revealed the resident was administered Miralax 17 GM. During an interview on 5/22/2024 at 11:11 AM, the Director of Nursing stated Resident #25 had not been assessed for self-administration of medication, and confirmed medications were left unsecured at the bedside.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 1 of 2 dumpsters (dumpster B). The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 5/1/2024, revealed .garbage should not accumulate or be left outside the dumpster . Observation of the outside dumpster area on 5/20/2024 at 11:15 AM, with the Certified Dietary Manager (CDM), revealed 2 dumpsters for waste disposal. Further observation revealed the area around the dumpster B had 1 trash bag of unknown contents (3/4 full), 4 used disposable gloves, and multiple pieces of paper debris (various sizes) present on the ground. During an interview on 5/20/2024 at 11:26 AM, the CDM confirmed the dumpster area had not been maintained in a sanitary condition.

Based on facility policy review, observation, and interviews the facility failed to ensure practices to prevent the potential spread of infection were followed while delivering meal trays to residents on 1 hallway of 3 hallways observed. The findings include: Review of facility policy titled, Hand Hygiene, revised 5/2024, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to .residents .Alcohol-based hand rub .is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty .The use of gloves does not replace hand hygiene .perform hand hygiene prior to donning [applying] gloves, and immediately after removing gloves . During an observation on 5/20/2024 at 1:38 PM, Certified Nursing Assistant (CNA) A entered room [ROOM NUMBER] A with gloved hands, served/set up the meal tray, removed the gloves, and exited the room without washing or sanitizing the hands. CNA A rolled the meal cart down the hallway, stopped to donn a new pair of gloves, continued to roll the meal cart down the hallway, retrieved a tray from the cart, entered room [ROOM NUMBER] B, served/set up the meal tray, removed the gloves, and exited the room without washing or sanitizing the hands. Further observation revealed CNA A entered room [ROOM NUMBER] A, retrieved a helmet, and placed the helmet on the resident's head. CNA A donned a pair of gloves without washing or sanitizing the hands, returned to the meal cart, retrieved a tray, entered room [ROOM NUMBER] B, served/set up the meal tray, removed the gloves, and exited the room without washing or sanitizing the hands. During an observation on 5/20/2024 at 1:45 PM, CNA B entered room [ROOM NUMBER] A with gloved hands, served/set up the meal tray, exited the room with the gloved hands, and retrieved a towel from the clean linen cart. CNA B re-entered room [ROOM NUMBER] A with the same gloved hands, cut the residents meat using silverware, exited the room, the gloves were not removed, and the hands were not washed or sanitized. Continued observation revealed CNA B retrieved a meal tray from the meal cart, entered room [ROOM NUMBER] B, served/set up the meal tray, removed the gloves, and sanitized the hands. During an interview on 5/20/2024 at 1:46 PM, CNA A confirmed she failed to wash or sanitize the hands during meal service. During an interview on 5/20/2024 at 1:47 PM, CNA B confirmed she failed to wash or sanitize the hands during meal service. During an interview on 5/22/2024 at 11:05 AM, the Director of Nursing confirmed the facility failed to ensure practices to prevent the potential spread of infection were followed while delivering meal trays on 5/20/2024.

Based on financial record reviews and interviews, the facility failed in their fiduciary responsibility in holding, safeguarding, managing and accounting for the deposited personal funds for 9 of 27 residents with Resident Trust Accounts (#7, # 9, #14, #15, # 16, #17, #18, #19 and #20). The findings include: Review of the Resident Trust Account for Resident #7, dated 9/05/2023, revealed he was over the allowed limit of $2,000 ($341.17). Resident #17's balance dated 9/06/2023 showed $2,057.17, ($57.17 over the limit). Review of the Resident Trust Account for Resident #14, [AGE] years old, revealed she was over the allowed limit of $2,000. Resident #14s balance dated 9/06/2023, showed $3,792.43, ($1,792.43 over the limit). Review of the Resident Trust Account for Resident #15 revealed he was over the allowed limit of $2,000. Resident #15's balance dated 9/06/2023, showed $3,653.58, ($1,653.58 over the limit). Review of the Resident Trust Account for Resident #16 revealed he was over the allowed limit of $2,000. Resident #16's balance dated 9/06/2023, showed $4, 286.40, ($2,286.40 over the limit). Review of the Resident Trust Account for Resident #19 revealed he was over the allowed limit of $2,000. Resident #19's balance dated 9/06/2023, showed $6,171.20 ($4,171.20 over the limit). The accounts were over the allowable amounts which would affect the residents qualification for Medicaid. During an interview with the Business Office Manager (BOM) on 9/21/23 at 2:30 pm, the BOM stated, Resident # 19 has an outstanding child support balance of $25,883.36 and the last check was sent out on 2/2/23 for $4,239.64 for back child support. When asked by surveyors what the plan is to pay his outstanding judgement for back child support. The BOM stated, I will cut a check for $5000 to get him under resource limit and continue to do that if his funds approach resource limit. The BOM provided a signed and dated statement to the same. Continued interview with the BOM in the conference room on 9/21/23 at 2:40 pm, revealed the BOM plan to spend down Resident #16's overage is to work with the son to bring her below the allowable Medicaid limit. However, there was no definite plan for Resident #14 or Resident # 15 other than, will have to transition to private pay for a short amount of time to spend down to Medicaid allowable. The BOM provided signed and dated statement to the same. According to the BOM, regarding Resident #17, I have been given instructions from [name of accounting firm] on how to remedy this issue and get balances correct. The BOM did not provide any definite plans or actions for Resident #7's overage. Interview with the Business Office Manager (BOM) on 9/21/23 at 1:10 pm in the conference room revealed Resident #17 had been receiving the pension/retirement check belonging to Resident #20 for 10 months. The BOM provided a signed and written statement dated 9/21/23, revealing the same. The BOM revealed to the surveyors, We didn't know until you [the surveyors] started asking about the accounts. The BOM provided the surveyors with an email from [named of facility's accounting company] dated 9/21/2023, revealing details on how to correct the accounts between Residents #17 and #20. The BOM stated she was in the process of reconciling the accounts. Review of statement from the BOM dated 9/21/23, revealed Resident #17 recently married another facility resident and the facility used some of Resident #17's funds for the wedding. Interview with the BOM in the conference room on 9/21/23 at 1:20 pm revealed, we didn't realize we used some of Resident #20's money for Resident #17's wedding because we didn't realize we had debited Resident #20's pension/retirement check to help fund the wedding. Continued interview revealed the facility was assisting Resident #17 to spend down funds that actually belonged to Resident #20 and we didn't realize until you [surveyors] started asking us about the Resident Trust Funds. Review of Resident #9's Trial Balance account revealed a negative balance in the amount of -$3648.80. Interview with BOM on 9/21/23 at 1:30 pm in the conference room revealed Resident #9 had a direct debit being taken from two sources. Per interview with BOM, being taken out by corporate and myself with the mistake being done in August 2023. A signed and dated statement by the BOM revealed a refund check had been sent on 9/21/23 to bring the account current. Review of a copy of a check in the amount of $3648.80 was presented by the BOM to the surveyors in the conference room on 9/21/23 at 1:35 pm. The check was dated 8/29/23 and when the BOM was asked by the surveyors as to the discrepancies in the dates, the BOM acknowledged the check was backdated to August 29th. When the BOM was asked why the check was backdated, she stated, I don't know that's what they gave me. When asked to clarify who was they, the BOM stated, Corporate. No specific name was provided. Review of Resident #18's Trial Balance account revealed a negative balance in the amount of-$1778.00. Interview with BOM on 9/21/23 at 1:40 pm in the conference room revealed Resident #18 had a direct debit being taken from two sources. Per interview with BOM, being taken out by corporate and myself with the mistake being done in August 2023. A signed and dated statement by the BOM revealed a refund check had been sent on 9/21/23 to bring the account current. Review of a copy of a check in the amount of $1778.00 was presented by the BOM to the surveyors in the conference room on 9/21/23 at 1:45 pm. The check was dated 8/29/23 and when the BOM was asked by the surveyors as to the discrepancies in the dates, the BOM acknowledged the check was backdated to August 29th. When the BOM was asked why the check was backdated, she stated, I don't know that's what they gave me. When asked to clarify who was they, the BOM stated, corporate. No specific name was provided. Surveyors asked the BOM and Administrator how the facility communicated with the corporate accounting firm. The BOM replied via email. Surveyors asked if there was any communication with the corporate accounting firm in regard to the negative balance for Resident #18. The BOM presented a printed copy of an email at 2 pm to the surveyors in the conference room dated 8/10/23. The email stated, [name of recipient] the [name of accounting firm] direct debit for [name of resident] rejected due to insufficient funds. This is one of the duplicate pulls we discussed on our call. I am not sure on how we proceed with that or how we get that corrected. She is showing a negative balance in [name of accounting firm] where she had a negative balance before at all. The surveyors replied, this email was in August and it is now September, is there a reason nothing has been done prior to now to reconcile this resident's account? The BOM replied, I don't know. The Administrator stated, Corporate is not as transparent as I am accustomed to.

Based on facility's Resident Trust documentation review and interviews, the facility failed to maintain each resident's personal entrusted funds to the facility were full and complete for 4 of 4 residents (# 9, #17, #18 and #20) reviewed. The facility failed to ensure the appropriate Care Cost deductions were debited from Resident #9 and Resident #18's accounts. The facility failed to ensure Resident #20 received a pension/retirement funds as was entrusted to the facility. The findings include: Interview with the Business Office Manager (BOM) on 9/21/23 at 1:10 pm in the conference room revealed Resident #17 had been receiving the pension/retirement check belonging to Resident #20 for 10 months. The BOM provided a signed and written statement dated 9/21/23, revealing the same. The BOM revealed to the surveyors, We didn't know until you [the surveyors] started asking about the accounts. The BOM provided the surveyors with an email from [named of facility's accounting company] dated 9/21/2023, revealing details on how to correct the accounts between Residents #17 and #20. The BOM stated she was in the process of reconciling the accounts. Review of statement from the BOM dated 9/21/23, revealed Resident #17 recently married another facility resident and the facility used some of Resident #17's funds for the wedding. Interview with the BOM in the conference room on 9/21/23 at 1:20 pm revealed, we didn't realize we used some of Resident #20's money for Resident #17's wedding because we didn't realize we had debited Resident #20's pension/retirement check to help fund the wedding. Continued interview with the BOM revealed the facility, was assisting Resident #17 to spend down funds that actually belonged to Resident #20 and we didn't realize until you [surveyors] started asking us about the Resident Trust Funds. Review of Resident #9's Trial Balance account revealed a negative balance in the amount of -$3648.80. Interview with BOM on 9/21/23 at 1:30 pm in the conference room revealed Resident #9 had a direct debit being taken from two sources. Per interview with BOM, being taken out by corporate and myself with the mistake being done in August 2023. A signed and dated statement by the BOM revealed a refund check had been sent on 9/21/23 to bring the account current. Review of a copy of a check in the amount of $3648.80 was presented by the BOM to the surveyors in the conference room on 9/21/23 at 1:35 pm. The check was dated 8/29/23 and when the BOM was asked by the surveyors as to the discrepancies in the dates, the BOM acknowledged the check was backdated to August 29th. When the BOM was asked why the check was backdated, she stated, I don't know, that's what they gave me. When asked to clarify who was they, the BOM stated, Corporate. No specific name was provided. Review of Resident #18's Trial Balance account revealed a negative balance in the amount of -$1778.00. Interview with BOM on 9/21/23 at 1:40 pm in the conference room revealed Resident #18 had a direct debit being taken from two sources. Per interview with BOM, being taken out by corporate and myself with the mistake being done in August 2023. A signed and dated statement by the BOM revealed a refund check had been sent on 9/21/23 to bring the account current. Review of a copy of a check in the amount of $1778.00 was presented by the BOM to the surveyors in the conference room on 9/21/23 at 1:45 pm. The check was dated 8/29/23 and when the BOM was asked by the surveyors as to the discrepancies in the dates. The BOM acknowledged the check was backdated to August 29th. When the BOM was asked why the check was backdated, she stated, I don't know that's what they gave me. When asked to clarify who was they, the BOM stated, Corporate. No specific name was provided. Surveyors asked the BOM and Administrator how the facility communicated with the corporate accounting firm. The BOM replied via email. Surveyors asked if there was any communication with the corporate accounting firm in regard to the negative balance for Resident #18. The BOM presented a printed copy of an email at 2 pm to the surveyors in the conference room dated 8/10/23. The email stated, [name of recipient] the [name of accounting firm] direct debit for [name of resident] rejected due to insufficient funds. This is one of the duplicate pulls we discussed on our call. I am not sure on how we proceed with that or how we get that corrected. She is showing a negative balance in [name of accounting firm] where she had a negative balance before at all. The surveyors replied, this email was in August and it is now September, is there a reason nothing has been done prior to now to reconcile this resident's account? The BOM replied, I don't know. The Administrator stated, Corporate is not as transparent as I am accustomed to. Interview with the BOM on 10/02/23 at 4:00 pm in the conference room revealed residents nor their responsible parties have received quarterly statements since April 2023. The BOM provided a signed and written statement dated 10/02/23, revealing the same. The BOM revealed to the surveyors, I guess I didn't look into that (quarterly statements) that wasn't my highest priority, I am so sorry. When surveyors asked for copies of the April 2023 quarterly statements for all the residents with Resident Trust accounts, the BOM stated, I was told when I asked the previous BOM about that, she said she did not make any copies for the statements that were sent out, so we don't have any copies. The surveyors clarified, So, you have no copies of any quarterly statements you can provide? The BOM response, she shook her head, no and responded, no.

Based on record review and interviews, the facility failed to manage Resident Trust Accounts for 6 out of 27 residents (#7, #14, # 15, # 16, #17 and #19) to ensure they did not exceed the allowable Medicaid limit of $2000. The findings include: Review of the Resident Trust Account for Resident #7 revealed he was over the allowed limit of $2,000. Resident #17's balance showed $2,057.17, ($57.17 over the limit). Review of the Resident Trust Account for Resident #14 revealed she was over the allowed limit of $2,000. Resident #14s balance showed $3,792.43, ($1,792.43 over the limit). Review of the Resident Trust Account for Resident #15 revealed he was over the allowed limit of $2,000. Resident #15's balance showed $3,653.58, ($1,653.58 over the limit). Review of the Resident Trust Account for Resident #16 revealed he was over the allowed limit of $2,000. Resident #16's balance showed $4, 286.40, ($1,286.40 over the limit). Review of the Resident Trust Account for Resident #17 revealed he was over the allowed limit of $2,000. Resident #17's balance showed $3,653.58, ($2,653.58 over the limit). Review of the Resident Trust Account for Resident #19 revealed he was over the allowed limit of $2,000. Resident #19's balance showed $6,171.20 ($4,171.20 over the limit). The accounts were over the allowable amounts which would affect the residents qualification for Medicaid. During an interview with the Business Office Manager (BOM) on 9/21/23 at 2:30 pm, the BOM stated, Resident # 19 has an outstanding child support balance of $25,883.36 and the last check was sent out on 2/2/23 for $4,239.64 for back child support. When asked by surveyors what the plan is to pay his outstanding judgement for back child support. The BOM stated, I will cut a check for $5000 to get him under resource limit and continue to do that if his funds approach resource limit. The BOM provided a signed and dated statement to the same. Continued interview with the BOM in the conference room on 9/21/23 at 2:40 pm, revealed the BOM plan to spend down Resident #16's overage is to work with the son to bring her below the allowable Medicaid limit. However, there was no definite plan for Resident #14 or Resident # 15 other than, will have to transition to private pay for a short amount of time to spend down to Medicaid allowable. The BOM provided signed and dated statement to the same. According to the BOM, regarding Resident #17, I have been given instructions from [name of accounting firm] on how to remedy this issue and get balances correct. The BOM did not provide any definite plans or actions for Resident #7's overage.

Based on financial record reviews and interviews, the facility's governing body failed to honor monetary contractual agreements of vendor services and failed ensure effective management of its financial resources to ensure invoices were paid timely per agreements which had the potential for disruption in essential services and created a situation which had the potential to be detrimental to the health, safety, and welfare of all residents in the facility. The facility failed to manage residents financial accounts entrusted to the facility for 9 (#7, # 9, #14, #15, # 16, #17, #18, #19 and #20) of 27 residents. The findings include: Interview with the Administrator and the Business Office Manager (BOM) on 9/21/23 at 3 pm in the conference room, revealed when asked directly by the surveyors if the facility had any legal documents or any threats of legal action for non-payment or any outstanding invoices, the BOM replied, I get calls all the time and I forward them to Corporate and they are supposed to take care of it, it is out of my hands. I don't know what else to tell them [referring to creditors]. The Administrator informed the surveyors, she was subpoenaed for a deposition that occurred on August 24, 2023. The Administrator provided a copy of the subpoena when asked by the surveyors. The subpoena requested production of documentary evidence of financial records and deposition of the Administrator. The Administrator stated. This happened before I came a few months ago and Corporate would not go and made me go because they said I represented the facility. When asked by the surveyors if the facility has any past due invoices or invoices in collection, the Administrator provided the following documents: Review of outstanding invoices provided by the BOM and the Administrator revealed an outstanding invoice from a durable medical equipment company, 4th [NAME] notice for supplies purchased since September 2022 to March 2023 in the total amount of $15,416.24. Review of an email provided by the BOM and Administrator regarding past due payments stated, I have reached out to you on several occasions in an effort to resolve the above past commercial account with our client [ named company] however the balance still remains unpaid. The email was from a janitorial and housekeeping supply company with an outstanding balance of $4,727.31 Review of invoice provided by the BOM and Administrator revealed outstanding balance of $13,487.82 for Maintenance supplies dated back from February 2023 to July 2023. Review of an invoice for food equipment provided by the BOM and Administrator revealed outstanding balance of $11, 392.88. Review of a letter requesting refund for overpayment to the facility for services paid in error from a health insurance company in the amount of $192,704.19. The Administrator stated, I don't know what this is about. Further interview with the Administrator revealed there were numerous times the Administrator paid for nursing supplies and food when needed for the residents. Further interview revealed the facility was not provided with enough funds for operating accounts from the corporate office. The Administrator stated, in order for them (residents) to get what they needed, I did what I had to do by paying out of my pocket. I even had to put the landscaper on payroll to make sure he got paid because we had issues with him getting paid. The Administrator stated multiple times during the interviews over the course of the investigation, I am used to knowing the budget of a facility but it is not transparent here and I don't know if we have a budget with this company or what it is, we send the invoices to corporate and its out of our hands. Refer to F567, F568 and F569

Based on review of the facility's policy, medical record review, facility documentation review and interview, the facility failed to protect 1 resident (Resident #1) from verbal abuse of 3 residents reviewed for verbal abuse. The findings include: Review of the facility's policy Abuse, Neglect and Exploitation dated 2020, showed .Verbal Abuse means the use of oral .communication .that willfully includes disparaging and derogatory terms to residents . Resident #1 was admitted to the facility on [DATE] from an acute hospital stay with diagnoses including Infection of Left Femur Internal Fixation Device, Post Op Removal of Left Internal Fixation Device, Chronic Obstructive Pulmonary Disease, History of Drug Abuse and Endocarditis. Review of facility documentation, dated 4/11/2023, showed Resident #1 reported an incident of verbal abuse to the Wound Care Nurse on 4/11/2023 at 10:20 AM. Review showed Resident #1 stated at about 5:00 AM the night shift Certified Nurse Aide (CNA) #1 came into her room. Review showed the Wound Care Nurse recorded Resident #1's retelling of the incident as follows: .Slept sitting up on side of bed .wheelchair was blocking the walkway .woke up by [CNA #1] saying .you can't put that wheelchair there I have to get through' .[Resident #1] .I've got to get my [profanity word used] legs on the bed [CNA #1] said .Yeah that's why you are here . [Resident #1] .cursing at [CNA #1] .[Resident #1] said [CNA #1] told my roommate .Don't pay her any attention .She's got a bad attitude .At least, I have teeth and when I talk you can't see down my throat .[Resident #1] then said this is [profanity word used] nuts .[CNA #1] said .Yeah, you an addict, you an addict. I can tell because you can't control yourself The document revealed Resident #1 told the Wound Care Nurse, CNA #1 continued to talk to the roommate about Resident #1 walked by Resident #1 to the bathroom and CNA #1 stated .At least I can walk . The document revealed Resident #1 stated CNA #1 then walked out of the room, into the hall and she could hear the CNA talking about her with the door closed. Resident #1 stated she could hear CNA #1 saying she had a bad attitude and something about her wheelchair placement. Review of facility documentation dated 4/11/2023 at 1:30 PM, with Resident #1's roommate, conducted by the DON the roommate stated she witnessed CNA #1 state to Resident #1 .you're an addict and you can't control yourself .at least I can walk . During an interview on 4/24/2023 at 2:20 PM, the DON revealed CNA #1's derogatory comments were confirmed by Resident #1's roommate and by the video recorded in the hall on the morning of 4/11/2023. The DON stated the CNA was terminated for verbal abuse on 4/12/2023 related to the incident with Resident #1 on 4/11/2023. During an interview on 4/24/2023 at 3:00 PM, with the facility Administrator, revealed CNA #1 had verbally abused Resident #1. During a telephone interview on 4/25/2023 at 4:00 PM, with Resident #1, she stated .it was about 5:00 AM . The resident stated she was asleep when CNA #1 woke her, speaking in a scolding manner about the wheelchair being in the way. Resident #1 stated at first, she was confused about what was being said and why. Resident #1 stated she lashed out at CNA #1 because the rudeness was .uncalled for . She stated the CNA went to her roommate's bedside and spoke in a derogatory way about her. Resident #1 stated the CNA went outside her door and repeated her displeasure with her (Resident #1) and repeated the derogatory remarks. Resident #1 stated CNA #1's had an inappropriate verbal outburst directed at her on 4/11/2023.

Based on observations and interviews, the facility failed to permit in-room visitation for residents who desired it, for 2 of 4 residents (Residents #4 and #6) of 4 residents reviewed for resident rights. The facility required all resident visitation occur in designated areas off the clinical units, after COVID 19 visitation restrictions were lifted. The findings included: Observations of the facility on both shifts on 2/15/22 and 2/16/22 showed no evidence resident visitation occurred in resident rooms. All visits observed by the surveyor occurred in the front common dining area adjacent to the lobby. No visitors were noted present on the clinical floor just beyond the lobby throughout the survey. Interview with the Ombudsman on 2/15/22 at 4:38 PM by telephone revealed she had received complaints related to quality of life at the facility, which included allegations the facility did not permit family visitation on the clinical units in resident rooms, despite requests of residents to have private visitation in their rooms. The Ombudsman reported residents were informed by staff, visitation was not permitted outside areas designated by the facility, due to COVID 19 restrictions. Interview with Resident #4 on 2/16/22 at 2:11 PM in the resident's room revealed she reported the facility prohibited family visitation in resident rooms and had been doing so for months due to COVID 19, instead requiring visits to happen in common areas in the front dining room, which she had complained about to clinical staff, who told her they could not do anything about it. Resident #4 reported she sought a meeting with the Ombudsman to address the issue on 2/15/22 after requests for in-room visits by her family were denied by clinical staff who informed her family their instructions per facility Administration were not to allow visitation to occur in resident rooms on the clinical floor due to COVID 19 restrictions. Interview with Resident #6 on 2/16/22 at 3:12 PM, in the resident's room revealed she was alert and oriented in all spheres. Resident #6 also reported visitation was limited to common areas and not allowed in resident rooms which she felt was inappropriate and limited privacy. Resident #6 reported she complained to the clinical staff about the matter and was told it was facility policy due to COVID 19. Resident #6 reported she also complained to the Ombudsman's office about the matter, and her family at her request, had started to pursue alternate placement for her related to the policy. Interview with Employee (E) #4 on 2/16/22 at 3:55 PM on the 100 hallway unit adjacent to the nursing station, revealed they were a clinical employee contracted to the facility by a travel agency. E #4 reported she had been instructed by the facility that no visitation was permitted on the clinical unit in resident rooms due to COVID 19 restrictions and all visitation was to occur in designated areas off the unit supervised by staff. Interview with E #5 on 2/16/22 at 4:09 PM near the nursing station, revealed they were a travel agency clinical staff member. E #5 reported she was instructed by facility staff members that per facility policy no visitation was permitted in resident rooms due to COVID 19. E#5 reported she directed all visitors to designated spaces off the unit where residents were to meet with them. Interview with E #8 on 2/16/22 at 4:16 PM on the back hallway, revealed she was an employee of the facility. E #8 reported family visitation was only permitted in designated areas off the unit due to COVID 19 restrictions which had been in place for several months. E #8 could not recall when the facility last permitted resident visitation in their rooms. Interview with the Administrator on 2/16/22 at 4:41 PM, in the conference room confirmed the facility had restricted resident visitation to designated safe areas off the clinical unit in response to a COVID 19 outbreak in January 2022, and the facility was off outbreak status with no new positive cases since 1/20/22. The Administrator confirmed all visitors were screened prior to entry. The Administrator confirmed the facility continued to restrict visitation to designated safe areas off the clinical unit and confirmed in room visitation for residents had not been allowed.

Based on review of facility policy, review of the facility February 2020 Activity Calendar, observation, and interview, the facility failed to provide an ongoing activities program to support residents in their choice of activities for 4 residents (Residents #7, #4, #6 and #5) of 9 residents reviewed for activities. The findings included: Review of the facility policy, Preparation for Activities (revised June 2018), revealed .The activity Director/Coordinator is responsible for the scheduling of all activity functions .A list of activities scheduled for the month is posted in a location that is visible and easily accessible .schedules are provided individually to residents who cannot access .posted schedule .all lists/calendars are current .when changes are made the schedule is updated .activities start on time as stated .on the calendar .if an activity is delayed or cancelled an alternative, similar type of program is provided at the same time in place of the cancelled event . Review of the February 2020 Activity Calendar showed 3 to 4 days weekly entries which read .independent activities . or .1 to 1 activities . listed as the only activities on the calendar. Only one activity was scheduled on the weekends (Superbowl activity on 2/13/2020) and no activities appeared scheduled later than 2:30 PM daily. The bottom of the calendar read in bold print .Tentative Calendar based on availability of Social Services and other staff as there is no Activities Department Staff . Observations of the facility conducted on 2/15/2022 and 2/16/2022 on both shifts showed the facility activity room was locked and not accessible to residents. No group or 1 to 1 activities were observed between staff or residents at the scheduled times (1:00 PM both days) or at other times. Throughout the survey, residents were observed in the lobby as they watched television or seated in the dining area or hallways near the nursing station. Residents observed in their rooms were observed to mostly watch television. No activities staff were observed providing 1 to 1 activities as outlined on the facility calendar. Interview with Employee (E) #18 on 2/15/2022 at 2:50 PM, in the facility, revealed the Activities Director resigned sometime in the late summer of 2021 and had not been replaced, and those duties had been assigned to the floor clinical staff and Social Services Department. E #18 reported floor staff (Licensed Nurses and Certified Nurse Aides) struggled to meet the expectation to provide clinical care and activities to residents. Interview with the Ombudsman on 2/15/22 at 4:38 PM, by telephone, revealed she had received complaints related to quality of life at the facility, which included allegations the facility did not provide regular activities for residents, and allegations the facility did not have an Activities Director on staff since July or August of 2021, and the Ombudsman confirmed those allegations when she investigated. Interview with Employee #1 on 2/15/22 revealed since the former Activities Director left, responsibility for managing resident activities had been handed off to the social services worker and clinical staff, which included Certified Nurse Aides (CNAs) and the licensed nursing staff. E #1 reported when this was announced, she questioned the decision and expressed concerns clinical staff were already fully engaged in resident care and could not realistically be expected to supervise/manage all resident activities. E #1 suggested the surveyor speak to Residents #4, #5 and #7 as they were alert and oriented persons who could provide accurate information and stated she was aware Resident #4 had spoken to the Ombudsman. E #1 stated .we buy things out of our pockets for them all the time .but we can't do it all, because we have to take care of them first .and it takes all our time to do that .and we can't work overtime here .they won't let us . Interview with Resident #7 on 2/15/22 at 5:15 PM, in her room, revealed the resident was alert and oriented. Resident #7 reported she had limited mobility and required assistance with group activity participation and liked to cross stitch in her room when alone. Resident #7 stated the last time she was provided materials for her hobby was sometime in the fall of 2020 (several months prior when a member of the rehabilitation staff brought to her a small cross stitch kit purchased for her out of the staff member's personal funds). Resident #7 stated she used to enjoy bingo games at the facility held at least once weekly where she would win small prizes and she missed that the most. Resident #7 stated in the past, activities staff would always bring a daily meal menu to the room, offer an activity, chat, as they helped with the menus, and once per month would give every resident a calendar of events to review and make sure residents attended activities they were interested in. Resident #7 stated recently the facility held holiday gatherings at Christmas and Valentine's Day, but only the Social Worker and somebody she did not recognize were there to tend to around 20 persons (she estimated) who attended. Outside that, CNAs or nurses tried to help with activities, but did not have time due to their clinical duties. Resident #7 reported the Social Services department issued a calendar each month, however most of the activities never occurred as they had to be canceled due to other duties of the social services and clinical staff. Resident #7 reported when scheduled activities were canceled, they were never replaced with other things to do. Interview with Employees E #2 and E #3 on 2/15/22 at the facility, revealed both confirmed for several months responsibility for activities for residents had been assigned to the clinical staff and Social Worker. E #3 reported she spoke to the former DON more than once and stated she was told .we still had to do it, so make time for it, or she would find somebody who could . E #3 confirmed the facility activities room was rarely used anymore, and most of the time, alert residents coordinated things amongst themselves. But those less capable were dependent upon the Social Worker or clinical staff. E #2 stated . we try to help with it, but we are paid to keep these people safe, clean, turned, fed, toileted, dressed, deal with their behaviors sometimes, and everything else we do .the Social Worker tries her best, but she has things to do too .we can't do it all . Interview with E #11 on 2/16/2022, revealed in their role at the facility they had multiple duties including activities. E #11 reported when the former Activities Director left, those duties were assigned to the clinical floor staff and social services department. E #11 reported residents were given activities calendars once per month, but that was stopped when the clinical staff and social services departments could not provide the activities on the calendar due to time constraints, and to their knowledge no March 2022 activity calendar was completed at the time. E #11 reported residents were warned when calendars were issued that everything on them was tentative, based upon availability of social services staff to do them, and confirmed frequently activities listed on the calendar were cancelled and not replaced due to lack of clinical or social services staff to supervise them. E #11 reported recent holiday activities at the facility included Halloween, Thanksgiving and Christmas activities. E #11 reported a volunteer from one of the local hospice providers assisted the social worker with managing the activities, however, there were only those two persons to supervise snacks for an estimated 19 or more residents who participated. E #11 reported several of the residents needed direct assistance and monitoring with the activities to maintain safety. E #11 reported when activities were cancelled due to lack of staff to supervise them, some residents expressed disappointment, but they stated they understood. E #11 stated they felt it negatively impacted quality of life for residents and they had expressed that to the Ombudsman recently. E #11 reported when responsibility for activities was initially shifted to the clinical staff and social services department several months beforehand, clinical staff made good faith efforts to assist with them. However, over time clinical staff participation declined. Interview with Resident #4 on 2/16/22 at 2:11 PM, in the resident's room, revealed she was a retired social worker. Resident #4 reported her mobility was limited and she was mostly bedfast. Resident #4 reported the facility staff or social services worker provided her puzzle books, reading materials etc. but outside that, her access to activities was limited. Resident #4 reported she rarely received an activities calendar and when she did, events on it were frequently canceled due to lack of time or availability of clinical persons or the Social Services Director (SSD) to supervise the activity. Resident #4 reported she would like to participate in more group activities if they were available and staff were available to assist her getting to them in her wheelchair. Resident #4 reported if more opportunities for activities were available to her, she would feel better about her placement in long term care in the first place and she would feel less bored. Interview with Resident #6 on 2/16/22 at 3:12 PM, in the resident's room revealed she was alert and oriented. Resident #6 confirmed a lack of daily activities in the facility as well. Resident #6 reported she entertained herself mostly by watching television. Resident #6 stated she had not received an individual activities calendar anytime during her stay at the facility and reported activities only happened on holidays. Resident #6 reported most of the time, activities listed on the activity calendar posted at the front of the building, did not occur anyway, so she rarely inspected it. Interview with Resident #5 on 2/16/22 at 3:40 PM, revealed the resident was alert and oriented. Resident #5 stated they participated in card games amongst friends in the facility but those were not organized by staff. Resident #5 reported since the prior activities person left, the activities room was rarely used. Resident #5 reported .the CNAs try to help with things to do .but they are so busy they don't have time for that . Resident #5 reported they missed having bingo games, going to the activity room, socializing while doing crafts etc., and doing other activities at the facility, like going outside when it was warm and having ice cream, and having church services which used to occur there. Resident #5 stated if those activities were made available once again, they would participate every day. Resident #5 reported they were informed by a former Director of Nursing (DON) the facility could not open the activity room unless staff were there to supervise it, and there were no activity staff available for that. Resident #5 reported after that, they did not complain about activities anymore, as they believed it would not help, and with peers, began to plan card games etc. amongst themselves. Interview with E #4 on 2/16/22 at 3:55 PM in the 100 Unit hallway, revealed they were a clinical employee contracted to the facility by a travel agency. E #4 reported in the three weeks she had staffed the facility she had not seen group activities in progress during her assigned shifts. E #4 reported she was not aware she was expected to provide activities to residents and stated her role was clinical. E #4 appeared unaware the facility had an activities room. E #4 did not know if the facility had an activity department and did not recall observing 1 to 1 activities provided to residents as outlined on the calendar. Interview with E #5 on 2/16/22 at 4:09 PM, near the nursing station, revealed they were a travel agency clinical staff member. E #5 reported she had not noticed any activities staff or group activities in progress during her shifts at the facility and reported she was never told nursing was expected to perform resident activities in addition to clinical care. E #5 reported she was not sure if the facility had an activities department and had not noticed one if it did. Interview with the Administrator on 2/16/22 at 4:41 PM, in the conference room, revealed issues with activities were identified over the Christmas holidays when they became more apparent, but did not elaborate. The Administrator confirmed the facility had failed to provide scheduled activities in accordance with its activity calendar, due to lack of an Activity Director and activity staff.

Based on review of facility policy, review of the facility February 2020 Activity Calendar, observation, and interview, the facility failed to have a qualified activity professional to provide an ongoing activities program to support residents in their choice of activities for 4 residents (Residents #7, #4, #6 and #5) of 9 residents reviewed for activities. The findings included: Review of the facility policy, Preparation for Activities (revised June 2018), revealed .The activity Director/Coordinator is responsible for the scheduling of all activity functions .A list of activities scheduled for the month is posted in a location that is visible and easily accessible .schedules are provided individually to residents who cannot access .posted schedule .all lists/calendars are current .when changes are made the schedule is updated .activities start on time as stated .on the calendar .if an activity is delayed or cancelled an alternative, similar type of program is provided at the same time in place of the cancelled event . Review of the February 2020 Activity Calendar showed 3 to 4 days weekly entries which read .independent activities . or .1 to 1 activities . listed as the only activities on the calendar. Only one activity was scheduled on the weekends (Superbowl activity on 2/13/2020) and no activities appeared scheduled later than 2:30 PM daily. The bottom of the calendar read in bold print .Tentative Calendar based on availability of Social Services and other staff as there is no Activities Department Staff . Observations of the facility conducted on 2/15/2022 and 2/16/2022 on both shifts showed the facility activity room was locked and not accessible to residents. No group or 1 to 1 activities were observed between staff or residents at the schedule times (1:00 PM both days) or at other times. Throughout the survey residents were observed in the lobby as they watched television, or seated in the dining area or hallways near the nursing station. Residents observed in their rooms were observed to mostly watch television. No activities staff were observed providing 1 to 1 activities as outlined on the facility calendar. Interview with Employee (E) #18 on 2/15/2022 at 2:50 PM in the facility revealed the facility had not employed an Activities Director in nearly one year. E #18 reported several positions at the facility had been eliminated or open positions went unfilled due to budget cuts at the facility and duties of the eliminated or open positions were shifted to other staff at the facility. E #18 reported the Activities Director resigned sometime in the late summer of 2021 and had not been replaced, and those duties had been assigned to the floor clinical staff and Social Services Department. E #18 reported floor staff (Licensed Nurses and Certified Nurse Aides) struggled to meet the expectation to provide clinical care and activities to residents. Interview with the Ombudsman on 2/15/22 at 4:38 PM, by telephone, revealed she had received complaints related to quality of life at the facility, which included allegations the facility did not provide regular activities for residents, and allegations the facility did not have an Activities Director on staff since July or August of 2021, which she confirmed when she investigated. Interview with Employee #1 on 2/15/22, revealed the Activities Director position had not been filled for several months. E #1 reported since the former Activities Director left abruptly to pursue other employment, responsibility for managing resident activities had been handed off to the social services worker and clinical staff, which included Certified Nurse Aides (CNAs) and the licensed nursing staff. Interview with Resident #7 on 2/15/22 at 5:15 PM, in her room, revealed the resident was alert and oriented. Resident #7 reported she had limited mobility and required assistance with group activity participation and liked to cross stitch in her room when alone. Resident #7 stated the last time she was provided materials for her hobby was sometime in the fall of 2020 (several months prior when a member of the rehabilitation staff brought to her a small cross stitch kit purchased for her out of the staff member's personal funds). Resident #7 stated she used to enjoy bingo games at the facility held at least once weekly where she would win small prizes and she missed that the most. Resident #7 stated in the past, activities staff would always bring a daily meal menu to the room, offer an activity, chat as they helped with the menus, and once per month would give every resident a calendar of events to review and make sure residents attended activities they were interested in. Resident #7 stated recently the facility held holiday gatherings at Christmas and Valentine's Day, but only the Social Worker and somebody she did not recognize, were there to tend to around 20 persons (she estimated) who attended. Outside that, CNAs or nurses tried to help with activities, but did not have time due to their clinical duties. Resident #7 reported the Social Services department issued a Calendar each month, however most of the activities never occurred as they had to be canceled due to other duties of the social services and clinical staff. Resident #7 reported when scheduled activities were canceled, they were never replaced with other things to do. Interview with Employees #2 and #3 on 2/15/22 at the facility, revealed both confirmed for several months responsibility for activities for residents had been assigned to the clinical staff and Social Worker. Both reported the facility had not had an activities person since the last Activities Director quit and had not been replaced. E #3 confirmed the facility activities room was rarely used anymore, and most of the time alert residents coordinated things amongst themselves. But those less capable were dependent upon the Social Worker or clinical staff. Interview with E #11 on 2/16/2022, revealed in their role at the facility, they had multiple duties including activities. E #11 reported the facility had not employed an Activities Director in nearly a year. E #11 reported when the former Activities Director left, the position was left unfilled deliberately due to budget concerns and those duties were assigned to the clinical floor staff and social services department. E #11 reported residents were given activities calendars once per month, but that was stopped when the clinical staff and social services departments could not provide the activities on the calendar due to time constraints, and to their knowledge no March 2022 activity calendar was completed at the time. E #11 reported activities listed on the calendar were cancelled and not replaced due to lack of clinical or social services staff to supervise them. E #11 reported when activities were cancelled due to lack of staff to supervise them, some residents expressed disappointment, but they stated they understood. E #11 stated they felt it negatively impacted quality of life for residents and they had expressed that to the Ombudsman recently. E #11 reported multiple staff members, including the social services department and clinical staff, had expressed concerns to administration about the need for an activities department, overseen by an activity director, for several months. Interview with Resident #4 on 2/16/22 at 2:11 PM, in the resident's room, revealed she was a retired social worker. Resident #4 reported her mobility was limited and she was mostly bedfast. Resident #4 reported the facility staff or social services worker provided her puzzle books, reading materials etc. But outside that, her access to activities was limited. Resident #4 reported she rarely received an activities calendar and when she did, events on it were frequently canceled. Resident #4 reported she would like to participate in more group activities if they were available and staff were available to assist her getting to them in her wheelchair. Interview with Resident #6 on 2/16/22 at 3:12 PM, in the resident's room, revealed she was alert and oriented. Resident #6 confirmed a lack of daily activities in the facility as well. Resident #6 reported she entertained herself mostly by watching television. Resident #6 stated she had not received an individual activities calendar anytime during her stay at the facility and reported activities only happened on holidays. Resident #6 reported most of the time activities listed on the activity calendar posted at the front of the building did not occur. Interview with Resident #5 on 2/16/22 at 3:40 PM, revealed the resident was alert and oriented. Resident #5 stated they participated in card games amongst friends in the facility, but those were not organized by staff. Resident #5 reported the facility had no Activities Director for . a long time . Resident #5 reported since the prior activities person left, the activities room was rarely used. Resident #5 reported they missed having bingo games, going to the activity room, socializing while doing crafts, going outside when it was warm and having ice cream, and having church services, which used to occur. Resident #5 stated if those activities were made available once again, they would participate every day. Resident #5 reported they were informed by a former Director of Nursing (DON) the facility could not open the activity room unless staff were there to supervise it, and there were no activity staff available for that. Interview with E #4 on 2/16/22 at 3:55 PM, in the 100 Unit hallway, revealed she was a clinical employee contracted to the facility by a travel agency. E #4 reported in the three weeks she had staffed the facility, she had not seen group activities in progress during her assigned shifts. E #4 did not know if the facility had an activity department and did not recall observing 1 to 1 activities provided to residents as outlined on the calendar. Interview with E #5 on 2/16/22 at 4:09 PM, near the nursing station, revealed she was a travel agency clinical staff member. E #5 reported she had not noticed any activities staff or group activities in progress during her shifts at the facility. E #5 reported she was not sure if the facility had an activities department and had not noticed one if it did. Interview with the Administrator on 2/16/22 at 4:41 PM, in the conference room, confirmed the facility had not employed an Activity Director in the past year. The Administrator confirmed the facility had failed to provide scheduled activities in accordance with its activity calendar, due to lack of an Activity Director and activity staff.

Based on facility policy review, medical record review, and interview, the facility failed to complete weekly monitoring and documentation of pressure ulcers and failed to provide physician ordered wound treatment for 1 resident (Resident #6) of 3 residents reviewed for pressure ulcers. The facility's failure to monitor and provide treatment resulted in worsening of a pressure ulcer and Harm for Resident #6. The findings include: Review of the facility policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised 4/2018, showed .the nurses shall describe and document/report the following .Full assessment of pressure sore (pressure ulcer, an injury to the skin resulting from prolonged pressure) including location, stage (severity of the pressure ulcer), length, width and depth, presence of exudates (fluid drainage) or necrotic tissue (dead tissue) .The physician will order pertinent wound treatments, including .dressings .and application of topical agents (medications applied to the skin) . Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Order Summary Report revealed Resident #6 had wound care orders dated 11/29/2019 for Dakins Solution 0.25% (a wound care medication to prevent infection) to be applied to the wounds on the resident's legs topically every 24 hours as needed for wound care. There was no documentation of any other wound treatment orders. Medical record review revealed Resident #6 was treated for [REDACTED]. Review of the medical record showed the facility had not maintained copies of the wound care clinic notes or wound care clinic orders in Resident #6's medical record. The wound care clinic notes were obtained from the clinic at the request of the surveyor. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #6 was cognitively intact, required extensive assistance of 2 staff members with bed mobility, had impaired range of motion to both legs, and had pressure ulcers present on admission to the facility. Review of Resident #6's wound care clinic progress note dated 12/9/2019, showed the resident had pressure ulcers to the right calf, left calf, left heel, and sacrum. Wound descriptions were as follows: right calf 13.5 centimeters (cm) (length) by (x) 3.5 cm (width); left calf 10.5 cm x 2.0 cm; left heel 2.5 cm x 3.0 cm; and sacrum 1.5 cm x 1.0 cm x 2.0 cm (depth of wound). The treatment completed by the wound care clinic was .Sorbact (type of wound dressing used to remove bacteria) to wound beds, covered with [MEDICATION NAME] (foam wound dressing), secured with Kerlix (type of gauze dressing) . Medical record review of Resident #6's Treatment Administration Record (TAR) revealed a treatment with a start date of 12/11/2019 for Sorbact to wound beds, cover with [MEDICATION NAME], and change daily. Review of the medical record showed the last date the facility nurses completed any weekly monitoring, measurements, or description of Resident #6's pressure ulcers was on 12/13/2019. Review of the care plan dated 12/14/2019 showed Resident #6 had pressure ulcers to the sacrum, buttock, and both calves. Interventions included: administer medications as ordered, assess/record wound healing weekly, and weekly treatment documentation to include the measurements and tissue type of the wound. Review of the wound care clinic note dated 12/19/2019 showed the following pressure ulcer descriptions: right calf 19.6 cm x 2.6 cm x 1.9 cm; left calf 16.2 cm x 5.6 cm x 2.1 cm; left heel 7.0 cm x 6.5 cm x 0.6 cm with undermining (wound tunneling); sacrum 2.1 cm diameter and 1.6 cm depth. All of the wounds had copious amount of purulent drainage and a strong foul odor. Resident #6 was ordered antibiotics and the wound care clinic treatment was [MEDICATION NAME] (antimicrobial silver dressing) applied to all wound beds. Resident #6 was to return to the wound clinic in 3 - 5 days. Review of Resident #6's wound care clinic progress note dated 12/23/2019 showed the following pressure ulcer descriptions: right calf 35 cm x 2.1 cm x 1 cm, and a strong foul odor; left calf 4 cm x 2 cm; left heel 3 cm x 2.4 cm; and sacrum 2.4 cm diameter and 1 millimeter (mm) depth, moderate thick yellow drainage with a foul odor. The progress noted stated .Very concerned about the right calf. Is extremely wet and the wound personnel (nursing staff in the nursing home) has been putting wet silver over it, which is causing it to become macerated (overly wet for prolonged period of time). Changing plan of care to do daily Dakin's full-strength wet-to-dry dressing changes in an effort to kill the bacterial load as well as dry these areas up .orders were .faxed to the nursing home. They are to call the office if she has worsening signs and symptoms of infection, otherwise follow-up with me in 1 week . Review of the Physician Orders from the wound care clinic dated 12/23/2019 revealed the facility was to wash the lower leg wounds with [MEDICATION NAME] (antimicrobial skin cleanser) or a like product; Dakins full strength wet to dry dressing daily to the lower leg wounds, secured with Kerlix from the base of the toes to the bend of the knee; and the wound to the sacrum was to be packed daily with Sorbact, with no substitutions for the Sorbact, and cover with [MEDICATION NAME]. Review of the Treatment Administration Record (TAR) dated 12/1/2019-12/31/2019 showed the following: 1. Order start date 11/29/2019 - Dakins solution 0.25% apply to legs every 24 hours as needed for wound care. There was no documentation the treatment was completed on any day in December. 2. Order start date 11/30/2019 - Cleanse with [MEDICATION NAME], cover with [MEDICATION NAME], and [MEDICATION NAME], cover the entire leg with Kerlix every day. The TAR documentation showed the treatment was not completed on 12/1, 12/4 - 12/8, 12/10, 12/13 - 12/15, 12/17 - 12/19, 12/21, 12/23, 12/24, 12/28, and 12/29. 3. Order start date 12/11/2019 - [MEDICATION NAME] wash (or like product) to all wounds. Both lower leg wounds and the left heel were to have Sorbact to wound beds, cover with [MEDICATION NAME] (or like product), and change daily. The TAR documentation showed the treatment was not completed on 12/13 - 12/15, 12/17 - 12/19, 12/21, 12/23, 12/28, and 12/29. Review of the TAR and the Order Summary Report revealed the wound clinic physician orders dated 12/23/2019 were not on the TAR or the summary report. Review of a Physician's order from the wound care clinic dated 12/31/2019, showed the facility was to wash the bilateral lower legs and sacral wounds with [MEDICATION NAME], use a Dakins compress for 15 minutes to the right lower leg wound, and pack all 3 wounds with Sorbact and cover with [MEDICATION NAME]. The lower leg wounds were to be wraped with Kerlix. Review of the TAR and the Order Summary Report revealed the wound clinic physician orders dated 12/31/2019 were not on the TAR or the summary report. Review of Resident #6's wound care clinic progress note dated 1/6/2020, showed .She and her mom state the nursing home has told her that they (nursing home staff) have ordered the Sorbact multiple times, however it has not been delivered yet. They (nursing home staff) have been applying 'some silver gel' . The pressure ulcer descriptions were as follows: right calf 17.0 cm x 4.2 cm x 0.6 cm; left calf 4 mm; left heel 4.0 cm x 3.2 cm; sacrum was stable with no change in size; and there was a new stage 1 pressure ulcer to the entire left buttock with a new stage 2 pressure ulcer to the center of the left buttock. The wound care clinic treatment was [MEDICATION NAME] to the left buttock and both legs. The progress note stated .Very concerned about the right lateral calf .Since the nursing home has been unable to obtain the Sorbact, change her back to [MEDICATION NAME]. They (nursing home staff) are to leave the leg dressings on this week without changing them until such time they can get the [MEDICATION NAME] .follow-up with me in 1 week . Review of a Physician's order from the wound care clinic dated 1/6/2020, showed the facility was to leave to leg dressings on until the next wound care clinic visit. Review of Resident #6's wound care clinic progress note dated 1/13/2020 showed the following pressure ulcer descriptions: right calf 13.0 cm x 3.8 cm x 0.7 cm; left calf almost closed; left heel pressure ulcer 2.5 cm x 2.0 cm; and the sacrum remained the same. [MEDICATION NAME] was applied to all wounds. Review of a Physician's order from the wound care clinic dated 1/13/2020, showed the facility was to change the dressings to the sacrum daily and as needed, but to leave the lower leg dressings on until the next wound clinic visit. Review of Resident #6's Order Summary revealed a physician's order dated 1/15/2020, to ensure the dressings placed by the wound care clinic to lower leg pressure ulcers remained in place and dry. Review of the TAR dated 1/1/2020-1/31/2020 showed the following: 1. Order start date 11/29/2019 - Dakins solution 0.25% apply to legs every 24 hours as needed for wound care. There was no documentation the treatment was completed on any day in January. 2. Order start date 11/30/2019 and stop dated of 1/7/2020 - Cleanse with [MEDICATION NAME], cover with [MEDICATION NAME], and [MEDICATION NAME], cover the entire leg with Kerlix every day. The TAR documentation showed the treatment was completed as ordered. 3. Order start date 12/11/2019 and a stop date of 1/15/2020 - [MEDICATION NAME] wash (or like product) to all wounds. Both lower leg wounds and the left heel were to have Sorbact to wound beds, cover with [MEDICATION NAME] (or like product), and change daily. The TAR documentation showed the treatment was not completed on 1/7 - 1/9, 1/11, and 1/14. 4. Start date 1/15/2020 - [MEDICATION NAME] wash (or like product) to sacral wounds, Sorbact to wound beds, cover with [MEDICATION NAME] (or like product), change daily and as needed. The TAR documentation showed the treatment was not completed on 1/15, 1/16, 1/19 - 1/23, 1/25 - 1/28, and 1/30. 5. Start date 1/15/2020 - ensure dressings applied to both lower leg wounds remained in place and dry. The dressings were to be checked every shift. The TAR documentation showed the dressings were not checked for 32 of 48 shifts, with no documentation the dressings were checked for the entire day on 1/16, 1/19, 1/21 - 1/23, 1/27, and 1/28. During an interview on 2/23/2020 at 11:39 AM, Resident #6 stated she had wounds to both of her legs and on her sacrum that had developed at another facility. She stated she went to the wound care clinic once per week. The wound clinic staff had been providing the dressing changes to her legs because the facility had been unable to get the dressing the wound clinic had ordered to be used. During an interview on 2/25/2020 at 8:21 AM, Licensed Practical Nurse (LPN) #3 stated she was unsure why the TAR documentation was incomplete. The wound care nurse had been sick and had frequent absences from work and was unavailable at the time of the survey. The floor nurses were to provide wound care to the residents when the wound care nurse was absent. During a phone interview with the wound care clinic Nurse Practitioner (NP #2) on 2/25/2020 at 1:43 PM, NP #2 stated the resident had been seen in the clinic on 2/24/2020 with the wound on the right calf measuring 18.5 cm by 4.7 cm by 0.6 cm. NP #2 also stated on 12/31/2019, the clinic changed the dressing to the resident's right calf and the nursing home staff was not to change the dressing until the resident was seen again at the clinic on 1/6/2020. After the nursing home had been unable to provide the Sorbact for 2 weeks, the clinic took over the dressing changes on 1/6/2020. The wound on the right calf had worsened due to the .burden of infection . in the wound. NP #2 stated the treatment needed to be provided 3 times weekly and the clinic was unable to see the resident 3 times per week. The facility's inability to provide the ordered wound care dressing and change it 3 times weekly had contributed to the continuing infection and worsening of the wound. During an interview on 2/25/2020 at 2:43 PM, Licensed Practical Nurse (LPN) #1 stated the wound care clinic had ordered Sorbact to be used for Resident #6's wound to the right calf. The facility had been unable to obtain the dressing from their supplier or their pharmacy. The LPN had not contacted the wound care clinic regarding the facility's inability to obtain the dressing and the LPN was unsure what discussions the wound care nurse (who was unavailable during the time of the survey) had with the wound care clinic in regards to the facility's inability to obtain the dressing. During a phone interview on 2/26/2020 at 9:44 AM, the facility's NP (NP #1) stated she was not aware of the facility's inability to obtain an ordered wound care dressing for Resident #6, requiring the wound care clinic to provide the dressing changes. During an interview on 2/26/2020 at 3:05 PM, the Director of Nursing confirmed the facility's nursing staff did not complete weekly monitoring, measuring, and documentation for Resident #6's wounds.

Based on medical record review, review of facility investigations, interview, and observations, the facility failed to implement the care plan interventions for prevention of falls for 1 resident (#1) of 5 residents reviewed for falls, of 45 sampled residents, resulting in a [MEDICAL CONDITION] requiring sutures (harm) for Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, which indicated moderate cognitive impairment. Continued review revealed the resident required extensive assistance of one person for all activities of daily living. Medical record review of the care plan dated 7/1/16 revealed .Safety .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .W/C (wheelchair) alarm . Medical record review of a nurse's note dated 9/10/16 at 7:50 PM, revealed .found lying on the floor in front of her W/C with a laceration in the center of her head . Medical record review of a nurse's note dated 9/11/16 at 3:35 AM, revealed .Returned to facility via EMS (Emergency Medical Services) .stitches to forehead covered with drsg (dressing) . Review of a facility investigation dated 9/13/16 revealed .Date of Occurrence 9/10/16 .Locomotion Status: W/C (wheel chair) bound .Transfer status: extensive assist .sitting in W/C in her room .Summary: Resident sent to ER (emergency room ) status [REDACTED]. Further review of the investigation revealed the resident was supposed to have a pressure alarm in place in the wheelchair at the time of the fall, as care planned 7/1/16. Telephone interview with Certified Nursing Assistant (CNA) #8 on 1/12/17 at 10:35 AM, who was with Resident #1 after the fall on 9/10/16, confirmed Resident #1 did not have a pressure alarm in the wheelchair at the time of the fall and CNA #8 could not recall if the call light was within reach. Interview with Licensed Practical Nurse #7 on 1/17/17 at 12:30 PM, in the conference room, confirmed Resident #1's care plan at the time of the fall on 9/10/16 identified the need for interventions to prevent falls, which included the need of a pressure alarm in the wheelchair. The failure to ensure the care plan interventions were implemented to prevent falls resulted in a fall with a [MEDICAL CONDITION] requiring sutures for Resident #1. Refer to F323

Based on medical record review, review of a facility investigation, interviews, and observations, the facility failed to ensure assistive devices were in place to prevent falls for 2 residents (#1, #48) of 5 residents reviewed for falls, of 45 sampled residents, resulting in a head laceration which required sutures (harm) for Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored a 8 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance with all activities of daily living with 1 staff person to assist. Medical record review of the care plan dated 7/1/16 revealed .Safety .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed .W/C (wheelchair) alarm . Medical record review of the nurses note dated 9/10/16 at 7:50 PM, revealed .found lying on the floor in front of her W/C with a laceration in the center of her head . Medical record review of a hospital emergency department record dated 9/10/16 at 23:13 (11:13 PM) revealed .Laceration-Single Repair .subcutaneous fascia closed .3 sutures, Skin layer closed, greater than 10 sutures interrupted . Medical record review of a nurse note dated 9/11/16 at 3:35 AM, revealed .Returned to facility via EMS (Emergency Medical Services) transferred into bed .stitches to forehead covered with drsg (dressing) . Review of a facility investigation dated 9/13/16 revealed .Date of Occurrence 9/10/16 .Locomotion Status: W/C (wheelchair) bound .Transfer status: extensive assist .call bell .Alarm in use .pressure alarm .(indicating interventions that should have been in place at the time of the fall were a call bell and pressure alarm) .What activity, event, environment .was resident engaged in prior to the fall or at time of fall? .sitting in W/C in her room .Summary: Resident sent to ER (emergency room ) status [REDACTED]. Telephone interview with Certified Nurse Aide (CNA) #8 on 1/12/17 at 10:35 AM, who was the CNA with the resident after the fall on 9/10/16, confirmed Resident #1 did not have a pressure alarm in the wheelchair at the time of the fall, and CNA #8 could not recall if the call light was within reach at the time of the fall. Interview with Licensed Practical Nurse (LPN) #7 on 1/17/17 at 12:30 PM, in the conference room, confirmed Resident #1 was supposed to have a pressure alarm in her wheelchair to prevent falls at the time of the fall on 9/10/16. The failure to ensure assistive devices to prevent falls were in place resulted in a fall with a head laceration requiring sutures for Resident #1. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #48's quarterly MDS dated [DATE] revealed the resident had severe cognitive impairment. Continued review revealed the resident was totally dependent for transfers, dressing, eating, personal hygiene and bathing with 1-2 person assist. Review of a facility investigtion dated 12/9/16 revealed the resident had fallen from his wheelchair and no injuries were sustained from the fall. Continued review revealed, to prevent further falls, the intervention implemented after this fall was to place a dycem in the seat of the wheelchair. Medical record review revealed Resident #48's care plan was updated to reflect the new intervention for fall prevention, .Safety .dycem (non slip surface) to W/C (wheel chair) seat . Interview with CNA #3 on 1/11/17 at 10:40 AM, on the 200 hallway, revealed .not sure if he (Resident #48) is supposed to have anything in his wheelchair seat or not . Observation of Resident #48 with the Director of Nursing (DON) on 1/11/17 at 2:05 PM, in the resident's room, confirmed there was no dycem in the resident's wheelchair seat. Interview with the DON on 1/18/17 at 8:35 AM, in her office, confirmed the facility failed to ensure safety devices were in place at the time of the fall for Resident #1 which resulted in a fall with a head laceration requiring stitches (harm) for Resident #1, and failed to ensure safety devices were in place for Resident #48. Refer to F282

Based on review of Provider History Profile, medical record review, and interview, the facility failed to ensure an effective Quality Assurance (QA) program that recognized an ongoing concern with preventing falls and accurate medical records. The QA committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns. The facility failed to ensure the QA program was effective in preventing repeat deficiencies at F-323 and F-514. The facility failed to prevent accidents, which resulted in a fall with a [MEDICAL CONDITION] (Harm) for Resident #1. The findings included: Review of the Provider History Profile dated 12/12/16 revealed the facility was cited F-323 during the annual Recertification survey on 1/27/16 for failure to ensure interventions were in place to prevent falls. Continued review revealed F-514 was cited during the annual Recertification surveys on 12/9/14 and 1/27/16, for failure to maintain a complete and accurate medical record. During the annual Recertification survey conducted from 1/8/17 through 1/19/17, the facility's QA Committee failed to ensure a system for management of safety devices resulting in 1 resident (#1) receiving a fall with injury, 1 resident (#48) with an observation of a safety device not in place, and 2 residents (#36, #134) not having accurate documentation in the medical record, of 45 residents reviewed during stage 2. Interview with the Regional Director of Clinical Services and the Administrator on 1/19/17 at 11:15 AM, in the conference room, confirmed the QA committee had not identified a problem with falls and safety devices not being in place and had not identified incomplete documentation in the medical record as areas to be addressed with corrective actions. Refer to F282, F323, F514

Based on medical record review, and interview, the facility failed to notify the physician of the presence of pressure ulcers for one resident (#14) of three residents reviewed for pressure ulcers. The facility's failure to notify the physician of the presence of the pressure ulcers resulted in Actual Harm to resident #14. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse's note signed and dated on August 25, 2014, at 12:00 p.m. by Licensed Practical Nurse (LPN) #2 revealed, "...Res's (resident's) heels broke down. On R (right) heel stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) measuring at 1 cm (centimeter) x (times) 1 cm without bleeding/odor. On L (left) heel stage 2 measuring at 0.50 cm x 0.50 cm without bleeding/odor...Heels to be elevated when in bed. Will continue with POC (Plan of Care) per M.D.'s (medical doctor) orders..." Continued review revealed no documentation the physician had been notified of the pressure ulcers. Medical record review of Weekly Skin Integrity Reviews dated September 3, 10, 17, and 24, 2014; October 5, 11, 24, 2014; November 5, and 12, 2014 (skin assessments for November 19 and 26 were blank); and December 3, 2014, all documented the presence of pressure ulcers to the resident's right and left heels. Continued review revealed no documentation the physician had been notified of the pressure ulcers. Medical record review of Weekly Nursing Progress Notes dated September 17 and 24, 2014; October 11 and 24, and November 12, 2014, all documented the presence of pressure ulcers on the resident's heels. Continued review revealed no documentation the physician had been notified of the pressure ulcers. Medical record review of Physician's orders from August 2014, through November 2014, revealed no physician's orders for the treatment of [REDACTED]. Medical record review of the Physician's progress notes revealed no documentation indicating the physician or nurse practictioner had been notified of the resident's pressure ulcers. Medical record review of a Nurse's note signed and dated on December 5, 2014, by the Wound Care Nurse revealed, "...2. Unstg (unstageable) slough and or eschar (non-living tissue , slough may be soft and moist, eschar may be soft or hard and may appear scab-like)-noted to L heel 3 x 2.9 cm 100 percent necrotic (non-living tissue covering ulcer) with zero drainage or odor noted. 3. Unstg noted to R heel. Area measures 9 cm x 10 cm. 100 percent necrotic with zero drainage or odor. Both areas tx (treatment) orders received and noted. Family and NP (Nurse Practictioner) aware..." Interview with the Director of Nursing (DON) on December 9, 2014, at 1:35 p.m., in the Conference Room, confirmed the DON had not been made aware of the presence of the pressure ulcers until December 5, 2014. Continued interview confirmed neither the nurse practitioner nor the physician had been notified of the pressure ulcers from August 25, 2014, until December 5, 2014. Further interview with the DON confirmed the pressure ulcers had increased in size and stage since initially identified in August. Interview with LPN #2 on December 9, 2014, at 3:20 p.m., in the Wound Care Nurse's office, confirmed the LPN had identified the presence of pressure ulcers on the resident's heels on August 25, 2014. Continued interview confirmed LPN #2 had "...forgot..." to notify the Wound Care Nurse or physician of the presence of the pressure ulcers. The facility's failure to notify the physician of the presence of the pressure ulcers resulted in Actual Harm to resident #14.

Based on medical record review and interview, the facility failed to assess the presence of pressure ulcers on the Minimum Data Set (MDS) for one resident (#14) of three residents reviewed for pressure ulcers of 34 sampled residents. The facility's failure to assess the presence of pressure ulcers resulted in Actual Harm to resident #14. The findings included: Medical record review of resident #14's Care Plan dated February 12, 2014, revealed the resident was at risk for the development of pressure ulcers related to cognitive status and fragile skin. Medical record review of a Nurse's note signed and dated on August 25, 2014, at 12:00 p.m. by Licensed Practical Nurse (LPN) #2 revealed, "...Res's (resident's) heels broke down. On R (right) heel stage 2 (partial thickness loss of skin presenting as a shallow open ulcer with a red or pink wound bed) measuring at 1 cm (centimeter) x (times) 1 cm without bleeding/odor. On L (left) heel stage 2 measuring at 0.50 cm x 0.50 cm without bleeding/odor...Heels to be elevated when in bed. Will continue with POC (Plan of Care) per M.D.'s (medical doctor) orders..." Medical record review of Weekly Skin Integrity Reviews dated September 3, 10, 17, and 24, 2014; October 5, 11, 24, 2014; November 5, and 12, 2014 (skin assessments for November 19 and 26 were blank); and December 3, 2014, all documented the presence of pressure ulcers to the resident's right and left heels. Medical record review of Weekly Nursing Progress Notes dated September 17 and 24, 2014; October 11 and 24, and November 12, 2014, all documented the presence of pressure ulcers on the resident's heels. Medical record review of the most recent Quarterly MDS dated [DATE], revealed the resident was at risk for the development of pressure ulcers, and had no documentation of the presence of pressure ulcers. Medical record review of a Nurse's note signed and dated on December 5, 2014, by the Wound Care Nurse revealed, "...2. Unstg (unstageable) slough and or eschar (non-living tissue , slough may be soft and moist, eschar may be soft or hard and may appear scab-like)-noted to L heel 3 x 2.9 cm 100 percent necrotic with zero drainage or odor noted. 3. Unstg noted to R heel. Area measures 9 cm x 10 cm. 100 percent necrotic (non-living tissue covering ulcer) with zero drainage or odor..." Interview with the MDS Nurse on December 9, 2014, at 2:23 p.m., in the Conference Room, revealed the MDS Nurse was not aware of the presence of pressure ulcers on resident #14's heels. Continued interview revealed the MDS Nurse used the weekly wound reports, not the Weekly Skin Integrity reviews or weekly Nursing progress Notes, to assess if a resident had any pressure ulcers. Further interview revealed the MDS Nurse was not aware of the nurse's notes which documented the presence of the pressure ulcers. Continued interview confirmed the last Quarterly MDS was inaccurate and did not document the presence of pressure ulcers on the resident's heels. The facility's failure to assess the presence of pressure ulcers resulted in Actual Harm to resident #14.

Based on medical record review, observation and interview, the facility failed to identify and initiate treatment of [REDACTED].#14) of three residents reviewed for pressure ulcers. The facility's failure to identify and treat the pressure ulcers resulted in unstageable pressure ulcers and Actual Harm to resident #14. The findings included: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's Care Plan dated February 12, 2014, revealed the resident was at risk for the development of pressure ulcers related to cognitive status and fragile skin. Continued review of the resident's care plan revealed interventions to include "...document change in skin color, turgor...weekly skin checks by licensed nurse...report any red areas to nurse immediately...heel protectors in place while in bed..." Medical record review of a Nurse's note signed and dated on August 25, 2014, at 12:00 p.m. by Licensed Practical Nurse (LPN) #2 revealed, "...Res's (resident's) heels broke down. On R (right) heel stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a pink wound bed without slough) measuring at 1 cm (centimeter) x (by) 1 cm without bleeding/odor. On L (left) heel stage 2 measuring at 0.50 cm x 0.50 cm without bleeding/odor...Heels to be elevated when in bed. Will continue with POC (Plan of Care) per M.D.'s (medical doctor) orders..." Medical record review of Weekly Skin Integrity Reviews dated September 3, 10, 17, and 24, 2014; October 5, 11, 24, 2014; November 5, and 12, 2014 (skin assessments for November 19 and 26 were blank); and December 3, 2014, all documented the presence of pressure ulcers to the resident's right and left heels, and no description or measrements of the ulcers. Medical record review of Weekly Nursing Progress Notes dated September 17 and 24, 2014; October 11 and 24, 2014, and November 12, 2014, all documented the presence of pressure ulcers on the resident's heels, and no treatment for [REDACTED]. Medical record review of Treatment Records from August 2014, through November 2014, revealed no treatment for [REDACTED]. Medical record review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired, was totally dependent for all Activities of Daily Living, was at risk for the development of pressure ulcers, and had no documentation of the presence of pressure ulcers. Medical record review of physician's orders from August 2014, through November 2014, revealed no physician's orders for the treatment of [REDACTED]. Medical record review of Physician's progress notes revealed no documentation the physician was aware of resident #14's pressure ulcers. Medical record review of a Nurse's note signed and dated on December 5, 2014, by the Wound Care Nurse revealed, "...2. Unstg (unstageable) slough and or eschar (non-living tissue , slough may be soft and moist, eschar may be soft or hard and may appear scab-like)- known but not stageable due to coverage of wound bed by slough and or eschar)noted to L heel 3 x 2.9 cm 100 percent necrotic (non-living tissue covering ulcer) with zero drainage or odor noted. 3. Unstg noted to R heel. Area measures 9 cm x 10 cm. 100 percent necrotic with zero drainage or odor. Both areas tx (treatment) orders received and noted. Family and NP (Nurse Practictioner) aware..." Medical record review of a physician telephone order dated december 5, 2014, revealed "...skin prep...to R (right) heel Q (every) day and prn (as needed)..." and "...skin prep to L (left) heel Q day and prn..." Review of the resident's Care Plan dated December 5, 2014, revealed the presence of unstageable pressure ulcers to both the right and left heels. Observation of resident #14 on December 9, 2014, in the resident's room, at approximately 4:00 p.m., with the Wound Care Nurse, revealed the presence of pressure ulcers to both the right and left heels. Continued observation of the resident confirmed the presence of the pressure ulcers which now had the appearance of Stage 2 ulcers, which had increased in size from the initial measurements as documented on August 25, 2014. Interview with the Wound Care Nurse on December 9, 2014, at 10:33 a.m., in the Conference Room, revealed the Wound Care Nurse had not been notified of the presence of the pressure ulcers until December 5, 2014, and confirmed had not been assessing, monitoring or treating the wounds. Continued interview confirmed the Wound Care Nurse was not aware of the documentation of the pressure ulcers on Weekly Skin Assessments, and confirmed the pressure ulcers had increased in size and stage since the wounds were initially identified on August 25, 2014. Continued interview revealed all residents with pressure ulcers are to be ordered a protein supplement to aid in wound healing. Continued interview confirmed the Wound Care Nurse had not ordered a protein supplement for the resident because the nurse was not aware of the presence of the pressure ulcers. Interview with the Director of Nursing (DON) on December 9, 2014, at 1:35 p.m., in the Conference Room, confirmed the DON was not made aware of the presence of the pressure ulcers until December 5, 2014. Continued interview confirmed the Nurse Practitioner nor the physician had been notified of the pressure ulcers. Further interview with the DON confirmed the pressure ulcers had increased in size and stage since initially documented in August. Interview with LPN #2 on December 9, 2014, at 3:20 p.m., in the Wound Care Nurse's office, confirmed LPN #2 had identified the presence of pressure ulcers on resident #14's heels on August 25, 2014. Continued interview confirmed LPN #2 had "...forgot..." to notify the Wound Care Nurse or physician of the presence of the pressure ulcers. The facility's failure to identify and treat the pressure ulcers resulted in Actual Harm to resident #14.