Every finding on record at Covenant Post Acute

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) were free from physical restraints when Resident 3 had a position change alarm (bed/chair alarm-alerting device intended to monitor a resident's movement that emits an audible loud sound when the resident moves) put in place for staff convenience, without the resident or responsible party's (RP) consent, medical justification or assessment to evaluate the affect the alarm had on the resident. This failure resulted in Resident 3's movement being restricted because the alarm would sound with small movements which made the resident to feel embarrassed and her privacy was violated causing her to lie in the same position for extended periods of time to prevent the alarm from sounding.During a concurrent observation and interview on 4/7/26 at 10:16 a.m. with Resident 3, in Resident 3's room, Resident 3 was lying in bed flat on her back with discoloration under her right eye. Resident 3 stated she had fallen in the bathroom recently causing her to have a black eye. Resident 3 stated, after the last fall they put this stupid pad under me and an alarm goes off if I move too much. Resident 3 was alert and oriented. Resident 3 stated, I did not want this alarm on my bed. It is loud and I am scared to move.During a review of Resident 3's admission Record, undated, the admission record indicated, Resident 3 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia (chronic disorder involving widespread body pain), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), muscle weakness, abnormalities of gait (a person's manner of walking) and mobility (ability to move) and repeated falls.During a review of Residents 3's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 3's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 13 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 3's cognition was not impaired.During a concurrent interview and record review on 4/7/26 at 11:03 a.m. with LVN 1, Resident 3's Order Summary Repot, dated 4/7/26 was reviewed and indicated, .Monitor bed alarm for placement and functionality every shift when in bed or up in wheelchair . LVN 1 stated the bed alarm was ordered on 2/27/26 after her last fall. Resident 3's progress notes were reviewed, LVN 3 stated she was unable to find documentation Resident 3's RP was notified the bed alarm intervention was put into place or that consent was received to use the alarm. LVN 1 stated Resident 3 was alert and oriented, was able to make her needs known, but could be forgetful. LVN 1 stated the bed alarm worked by the resident's weight staying on the pad, and the alarm would sound loudly if the body weight was shifted. LVN 1 stated when the resident moved it could easily set the alarm off. LVN 1 stated she did not know a position alarm could be considered a restraint and did not believe it restricted the resident's movement even if the resident was scared to move because she did not want to set the alarm off. During a concurrent observation and interview on 4/8/26 at 1:02 p.m. with Resident 3, in Resident 3's room, Resident 3 was lying flat on her back in bed. Resident 3 stated the pad alarm sounds if she moved was still under her. Resident 3 stated she stayed in the same position on her back because she did not want to set off the alarm because it embarrassed her. Resident 3 stated, this thing [the alarm] invades my privacy, I cannot move or get up on my own, it bothers everyone because it is really loud.During an interview on 4/8/26 at 1:45 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 3 had a position alarm on her bed, and the alarm would sound loud if the resident moved or lifted her body weight. CNA 4 the alarm was really loud so everyone could hear it. CNA 4 stated Resident 3 had the alarm to prevent her from getting out of bed without supervision and to prevent falls. CNA 4 stated Resident 3 would go to the restroom by herself and was not supposed to, so the alarm was placed to notify staff if the resident tried to get up.During a concurrent interview and record review on 4/8/26 at 2:26 p.m. with LVN 2, LVN 2 stated Resident 3 was very impulsive and would get up without assistance. Resident 3's IDT-Accident/Fall (IDT-team from different healthcare disciplines who work together to provide comprehensive patient care), dated 2/25/26 was reviewed and indicated, . Root Cause Analysis: Resident experienced an unwitnessed fall in her room restroom. Resident reported she attempted to get off the toilet without waiting for assistance. Resident remains at very high fall risk due to multiple intrinsic factors. Resident remains at extremely high risk for serious injury with future falls. IDT reinforces that high-risk residents are not to be left unattended during toileting. Due to h/o [history of] multiple falls at home and co-morbidities IDT determined to implement Bed Alarm/Chair Alarm. Purpose: Alert staff of unassisted transfer attempts, Alarm use is strictly for fall prevention and early staff response. Resident retains full freedom of movement. LVN 2 stated the IDT met to review resident falls and determine new interventions to put into place. LVN 2 stated the bed alarm was initiated because other interventions had failed. Resident 3's fall risk care plan, dated 2/18/26, was reviewed, the care plan indicated, . Is At Risk For Falls Related to: Generalized weakness. Unwitnessed [fall] 2/27/26. unwitnessed 3/3/26. Unwitnessed 3/27/26. Witnessed fall 4/2/26. Bed alarm, placement. Purpose: Alert staff of unassisted transfer attempts, Alarm use is strictly for fall prevention and early staff response. Resident retains full freedom of movement. 2/27/26. LVN 2 stated she did not consider the bed alarm a restraint because the resident was able to move, even though the alarm would go off. LVN 2 stated if there was a potential for the alarm to be considered a restraint the facility would need to get informed consent (a process where a medical provider educates a patient about the risks, benefits and alternatives to treatment) from the resident or RP. LVN 2 stated the facility had not gotten informed consent for Resident 3's position change alarm.During an observation on 4/8/26 at 3:15 p.m. with Resident 3, in Resident 3's room, Resident 3 continued to lie flat on her back in bed. Resident 3 stated she did not like the bed alarm.During a concurrent interview and record review on 4/8/26 at 3:30 p.m. with the Director of Nursing (DON), the DON stated when other fall prevention interventions were failing the IDT would determine if a bed alarm was an appropriate intervention. The DON stated the bed alarms were to prevent injury from repeated falls by notifying the staff when the resident got up without assistance. The DON stated Resident 3 had multiple fall interventions in place and continued to fall, but the facility had not attempted one on one supervision for her. The DON stated the facility had not considered the bed alarm a restraint and they had not gotten informed consent from Resident 3 or her RP. The DON stated the nurse would call to notify the RP when a position change alarm was put into place. The DON stated the resident could still get up but it was possible to restrict movement if the resident had a fear of setting the alarm off. The DON stated she was unaware Resident 3 was not moving in bed for fear of setting off the alarm or that the resident did not want the alarm. The DON stated Resident 3's bed alarm was not used to restrain her. The DON stated Resident 3 was alert and oriented with periods of forgetfulness. The DON stated the nurse had spoken to Resident 3's RP and not Resident 3 even though her BIMS showed no cognitive impairment, because she had intermittent confusion.During an interview on 4/8/26 at 3:57 p.m. with the Administrator (ADM), the ADM stated the facility did not have a process in place for bed alarm consents. The ADM stated it was important to get consent for the bed alarms to make sure the RP, and residents understood the risks and benefits of the alarm. The ADM stated if a resident could not make their own decision regarding the bed alarm due to cognition they would defer to the RP for consent. The ADM stated Resident 3 had fall interventions in place which included moving her closer to the nurse's station but he did not recall if one on one supervision had been attempted.During a review of the facility's policy and procedure (P&P) titled Use of Restraints, dated 4/2017, the P&P indicated, . Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement. If the resident cannot remove a device in the same manner in which the staff applied it. and this restricts his/her typical ability to change position. that device is considered a restraint. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative.During a review of the facility's P&P titled Resident Alarms, dated 9/2/2022, the P&P indicated, . It is the policy of this facility to utilize residents alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences. an alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected. The use of alarms does not eliminate the need for adequate supervision . Types of alarms include. Bed alarms-including devices such as a sensor pad on the bed. When alarms are used, the interdisciplinary team shall determine whether the alarm meets the definition of a restraint . The resident's assessment to determine whether the alarm meets the definition of a restraint shall be documented.

Based on interview and record review, the facility failed to ensure a physician (PHY) was notified promptly of a change in condition for one of three sampled residents (Resident 1) when Resident 1 sustained a fall on 3/23/26 at 9:00 p.m. and the resident's mental status declined from alert to unresponsive within one hour of the fall. The resident was sent out to the acute care hospital at 10:45 p.m.This failure resulted in Resident 1's delayed transfer to the acute care hospital (ACH) due to the change in mental status and placed the resident at risk of death from delayed treatment. During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities), chronic kidney disease (kidneys are damaged and cannot properly filter waste and extra fluid from the body), hypertensive heart disease (heart damage caused by long-term, unmanaged high blood pressure), and osteoarthritis of the hip (progressive disorder of the joints, caused by gradual loss of cartilage).During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental Status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 03 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was severely cognitively impaired.During a concurrent interview and record review on 4/7/26 at 11:03 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was at high risk for falls because he would try to self-transfer. Resident 1's Progress Note (PN), dated 3/23/26 at 9:00 p.m. the PN indicated, . at approx [approximately] 2100 [9:00 p.m.] writer was called to room and noted resident on floor in bathroom. Resident was alert and responsive. VS [vital signs] as time of fall was 145/92 @ [at] 2115. [9:15 p.m.] @2130. [9:30 p.m.] 135/92 . @ 2145 [9:45 p.m.] 97/49. @2200 [10:00 p.m.] writer was called back to room to note resident was unresponsive VS [blood pressure] 60/42. [physician's name] gave order to sent to [name of ACH]. EMS [emergency medical service] arrived @2200 and left with resident @2245 [10:45 p.m.]. LVN 1 stated Resident 1 was sent out to the hospital on 3/23/26 because he had a change in mental status and when he returned to the facility he was admitted to hospice (care for individuals with a terminal illness for end of life treatment).During a concurrent interview and record review on 4/8/26 at 2:26 p.m. with LVN 2, Resident 1's SBAR Summary for Providers (SBAR-Situation, Background, Assessment and Recommendation is a tool used to communicate critical information with healthcare providers), dated 3/23/26 at 10:15 p.m., was reviewed. The SBAR indicated, . Mental Status Evaluation: Unresponsiveness. Resident has unwitness fall in the resident bathroom approx. 2100 [9:00 p.m.] assessment done by writer, no visible injury noted.resident was responsive at the time of fall.resident on neuro checks [a neurological exam by healthcare professionals to evaluate a patient's brain and nervous system function].at time of fall. @2200 [10:00 [p.m.] writer was called back to room to note resident was unresponsive VS [blood pressure] 60/42. [name of physician] notified and gave order to send resident to [name of acute care hospital rt [related to] unwitnessed fall. LVN 2 stated Resident 1 was a high fall risk and had a history of trying to get up unassisted. LVN 2 stated Resident 1 had an unwitnessed fall on 3/23/26 and was sent to the ACH due to a change in condition. Resident 1's neuro check sheet dated 3/23/26 was reviewed and indicated, . date 3/23 [2026]. 9:00 [p.m.] . BP [blood pressure] . 145/92. Consciousness. Orient [checked] . Response to. Name [checked]. pain [checked]. Environment [checked]. 9:15 [p.m.]. BP 149/102 . Consciousness. Consciousness. Orient [checked] . Response to. Name [checked]. pain [checked]. Environment [checked]. 9:30 [p.m.] BP 135/92 . Consciousness. Orient [marked 0]. Disorient [checked] . Drowsiness [checked]. Response to . Name [marked 0]. Pain [marked 0] Environment [marked 0]. Unresponsive [checked]. 9:45 [p.m.] BP 97/49 . Consciousness. Orient [marked 0]. Disorient [checked] . Drowsiness [checked]. Response to . Name [marked 0]. Pain [marked 0] Environment [marked 0]. Unresponsive [checked]. 10:00 [p.m.] BP 60/42 . Consciousness. Orient [marked 0]. Disorient [checked] . Drowsiness [checked]. Response to . Name [marked 0]. Pain [marked 0] Environment [marked 0]. Unresponsive [checked]. LVN 2 stated Resident 1's blood pressure had dropped between the fall at 9:00 p.m. and 9:30 p.m. and his level of consciousness changed at 9:30 p.m. LVN 2 stated the physician should have been contacted immediately when the resident's mental status changed from alert to drowsy and unresponsive at 9:30 p.m. LVN 2 stated Resident 1 had an unwitnessed fall and the change in mental status could indicate a potential head injury and he would need a medical evaluation. LVN 2 stated there was a half hour lapse in the change of consciousness and the physician notification which was not caught timely.During an interview on 4/8/26 at 3:30 p.m. with the Director of Nursing (DON), the DON stated the LVN notified the Physician, the Nurse Practitioner and herself after the resident fell. The DON stated LVN 3 had started neuro checks. Resident 1's neuro check sheet was reviewed, the resident's blood pressure started to decline started to decline at 9:30 p.m. and level of consciousness decreased. The DON stated the LVN had notified the providers but did not document it. The DON stated the providers recommended monitoring the resident, but if the notification and order were not documented they were considered not done. The DON stated Resident 1's fall happened during the LVN's medication pass and she had checked the resident then continued to pass medications. The DON stated the physician was documented as notified at 10:00 p.m. and the LVN received an order to send the resident to the hospital.During a telephone interview on 4/8/26 at 3:47 p.m. with the Nurse Practitioner (NP), the NP stated he was not aware Resident 1 had a fall on 3/23/26. The NP stated he does not remember speaking to the LVN on 3/23/26 regarding Resident 1's fall or change in condition and the physician was normally on call after 8:00 p.m. The NP stated any resident who had a fall and had a change in the level of consciousness would need to be sent to Emergency Department (ED) as soon as possible because it was a red flag that something was wrong. The NP stated any time a resident falls and there was new disorientation (state of confusion), drowsiness or a significant drop in blood pressure, he would send the resident to the ED because that was a significant change in condition after a fall.During an interview on 4/8/26 at 3:57 p.m. with the Administrator (ADM), the ADM stated the IDT (Interdisciplinary Team- involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident) IDT-team from different healthcare disciplines who work together to provide comprehensive patient care) had met and discussed Resident 1's fall. The ADM stated if a resident had a fall and the level of consciousness changed the physician would need to be notified promptly and their orders would need to be followed.During a review of Resident 1's History & Physical (H&P) from the ACH dated 3/23/26, the H&P indicated, . found on floor next to toilet at skilled nursing facility at 2100. EMS found the patient hypotensive and patient was transported to [name of ACH] for further care . patient found to be hypotensive. acute kidney injury. left sided pneumonia and patient admitted to the ICU due to upgoing pressor requirement. history of dementia and chronic kidney disease brought in for AMS [altered mental status] s/p [status post] unwitnessed fall at skilled nursing facility. Admit to ICU [intensive care unit-specialized hospital department providing life support for patients with severe or life threatening illnesses].During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, . Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician on call when there has been. accident or incident involving the resident. significant change in the resident's physical/emotional/mental condition. need to transfer the resident to a hospital. A significant change of condition is a major decline or improvement in the residents status that. will not normally resolve itself without intervention. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview and record review, the facility failed to implement their written policy and procedure when Resident 1 had a unwitnessed fall on 3/4/26 that resulted in a hip fracture and required surgical intervention and the facility did not report the injury until 3/18/26 (14 days later) for one of three sampled residents.This failure resulted in a delay in investigating the unwitnessed fall with severe injury and the potential for abuse to go undetected.During a concurrent observation and interview on 3/24/26 at 10:55 a.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1's bed was empty without out linen with a call light sitting on top. CNA 1 stated Resident 1 was not currently in the facility.During an interview on 3/24/26 at 1:17 p.m. with Licensed Vocation Nurse (LVN) 2, LVN 2 stated, while a CNA was caring for Resident 1's roommate, Resident 1 touched the CNA, and when the CNA checked on Resident 1 she was on the floor. LVN 2 stated she went right away to the room and Resident 1 told her she turned and fell. LVN 2 stated she assessed Resident 1 and documented assessment in Resident 1's progress notes. LVN 2 stated Resident 1 reported she had pain in her back. LVN 2 stated she did not move Resident 1 back to her bed. LVN 2 stated she called 911 for ambulance to the hospital. LVN 2 stated Resident 1 had not returned to the facility.During a review of Resident 1's Progress Notes (PN) dated 3/4/26, the PN indicated, . At around of 0530 [5:30 a.m.] writer [LVN 2] was called . CNA said she was attending roommate (to change) when she fell, cna felt something hit on her back. When CNA turned around she noted the resident was on the floor already, the CNA was not able to see, what happened exactly because the curtain was pulled to give privacy to the roommate resident was around. Writer, was immediately called for the help while writer was passing the meds. Upon entering in the room noted resident was laid between the bed A and bed B . Writer immediately initiated the eval [evaluation], asked the resident what happened resident said she fell and she wants to go to her bed. Resident stated I fell but I don't know how happened. noted that she said she turned and she was already on the floor. writer evaluated the resident for any injuries or skin tears, not noted any skin tear or any visible injuries, but she complain of pain on her lower back and Left hip. Facial grimacing noted . writer ask the resident if she was able to move her legs she can not do it because of the pain . Writer kept the resident in same position, avoided any further movement of the extremities. She was kept on the floor. MD [doctor name] was contacted via phone an orders to send to acute [hospital] further evaluation and tx [treatment] if indicated. Writer immediately called 911. paramedics arrive around 0538 .During an interview on 3/24/26 at 2:11 p.m. with the Director of Nursing (DON), the DON stated the facility had received documents from the hospital indicating Resident 1 had a hip fracture on 3/17/26. The DON stated Resident 1's fall with hip fracture was reported to California Department of Public health (CDPH) on 3/18/26. The DON stated the facility's Director of Business Development (DBD) called the hospital and was notified Resident 1 had an injury and needed surgery. The DON stated she and the Administrator (ADM) were notified by the DBD of Resident 1's injury and need for surgery. The DON stated a hip fracture was a serious injury. The DON stated a report should be made to CDPH As soon as we know they have an injury. The DON stated they did not report to CDPH because they were waiting on the hospital records. The DON stated they could have reported it without having hospital records. The DON stated the ADM was responsible for reporting falls with severe injuries to CDPH. The DON stated it was important for CDPH to be notified immediately so the investigation started on time and the facility could get guidance and on things that need to change.During an interview on 3/26/26 at 8:39 a.m. with the DBD, the DBD stated part of her job responsibility was to request hospital records when residents are transferred to the hospital. The DBD stated she called the hospital on 3/4/26 and confirmed Resident 1 was admitted for a hip fracture due to fall and needed surgery. The DBD stated the process at the facility was to report admission status to the DON and ADM. The DBD stated she notified the DON and the ADM on 3/4/26 of Resident 1's hip fracture. The DBD stated she documented the information in a progress note. The DBD stated the progress note was documented on 3/9/26 as a late entry (a note documented for a previous encounter) for 3/4/26.During a review of Resident 1's PN dated 3/4/26, the PN indicated, . LATE ENTRY . Spoke with nurse at [hospital name]. Confirmed pt [patient] admitted for fractured hip due to fall. Pt scheduled for surgery tomorrow (3/5) .During an interview on 3/26/26 at 8:54 a.m. with the ADM, the ADM stated, he was responsible for reporting falls with severe injuries to CDPH. The ADM stated Resident 1 fell on 3/4/26 and was diagnosed with a fracture of the hip. The ADM stated the fall with fracture was reported to CDPH on 3/18/26. The ADM stated they try and get the full story of what diagnosis, and the extent of the injuries are when they send residents out to the hospital. The ADM stated the facility's practice was to report to CDPH after they had documentation of the injury within 48 hours. The ADM stated if there was a suspicion of severe injury from a fall the facility could have been reported prior to receiving documentation from the hospital. The ADM would not answer when asked if documentation was required to make a report to CDPH. The ADM stated he was notified by the DBD on 3/4/26 that Resident 1 had a hip fracture. The ADM stated it was important to report to CDPH within 24 hours so that the fall could be investigated and abuse ruled out. The ADM stated the facility was making an adjustment in reporting to CDPH when any initial indication of serious injury would be reported rather than waiting on official documentation.During a review of Resident 1's INCIDENT REPORT dated 3/18/26, the INCIDENT REPORT indicated, . Incident type Fall w/fx [fall with fracture] Date/Time of Incident: 3/4/26 approx. 0530 [5:30 a.m.] Location of Incident: [facility name] . On 03/04/2026 at approximately 0530, the resident sustained an unwitnessed fall in their shared room while staff were assisting the roommate behind a privacy curtain and was subsequently transferred to the acute hospital, where follow-up confirmed a hip fracture . Nursing staff responded immediately . and noted complaints of left hip and lower back pain with Inability to move due to pain; the resident was kept in position to prevent further injury. The physician was notified and ordered transfer to the hospital . Multiple requests were made to the hospital to receive records of Injury. Documentation was received from [acute hospital name] on 3/18/26.During a review of Resident 1's ED [emergency department] to Hosp [hospital]-admission notes dated 3/4/26, the ED to Hosp-Admission indicated, . Procedure(s): 1) left hip hemiarthroplasty [surgical procedure replacing the femoral head in the hip] Imaging Results: XR [x-ray] Femur [long bone located in the thigh] Result Date: 3/4/2026 IMPRESSION: 1. Acute fracture [broken bone] of the femoral neck [part of the femur located near the top] with impaction [ends of a broken bone are jammed together] and angulation [broken bones are tilted at an angle].During a review of Resident 1's admission Record (AR) dated 3/24/26, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of Generalized Muscle Weakness and Altered Mental Status.During a review of the facility's policy and procedure (P&P) titled, Unusual Occurrence Reporting dated 2007, the P&P indicated, . Policy Interpretation and Implementation . Our facility will report the following events to appropriate agencies . Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents . Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty- four (24) hours of such incident .

Based on observation, interview, and record review, the facility failed to maintain a comfortable and homelike environment for one of three sampled residents (Resident 1) when the toilet in her room was not functional, and she had to use a bedside commode (BSC-a portable toilet designed for individuals with limited mobility to use as a toilet in close proximity to their bed) for toileting.This failure resulted in an environment that was not homelike and caused Resident 1 to feel unimportant.During a concurrent interview and record review on 3/5/26 at 8:46 a.m. with Resident 1, Resident 1's room, Resident 1 was lying in bed, dressed. Resident 1 stated, my toilet has not worked since I got into this room. Resident 1 stated, I can't even use the toilet. Resident 1 stated she had to use a bedside commode in the bathroom when using the restroom instead of the toilet. Resident 1's bathroom was observed, there are two doors, one leading into the room next door and one from Resident 1's room. There was a bedside commode without a lid across from the sink and on the wall next to the sink was a toilet with a plastic bag covering the entire toilet, tied closed. The bathroom had a strong urine odor similar to ammonia. Resident 1 stated she had reported the toilet issue to the previous Director of Maintenance (DOM) 1 and he looked at the toilet and told her it was fine. Resident 1 stated she had been forced to use the bedside commode at that time, so the toilet was already not working. Resident 1 stated the broken toilet makes her feel useless and not cared about. Resident 1 stated she had spoken to the administrator about the broken toilet, and he said he would do something about it but it had still not been fixed.During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included polymyalgia rheumatica (inflammatory disorder causing severe pain and stiffness in the shoulders, neck, and hips), asthma (chronic lung disease causing airway inflammation, swelling and mucus production making breathing difficult), chronic obstructive pulmonary disease (progressive, long-term lung disease that makes it hard to breathe by limiting airflow) and chronic respiratory failure (lungs cannot properly move oxygen into the blood or remove carbon dioxide). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident XX's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was not cognitively impaired. During a concurrent observation and interview on 3/5/26 at 9:50 a.m. with Certified Nursing Assistant (CNA) 1, Resident 1's bathroom was observed and there was a plastic bag covering the toilet. The bathroom had a strong ammonia smell when the door was opened and inside the bathroom. CNA 1 stated Resident 1 usually used the bathroom, or they would put the bedside commode next to her bed. CNA 1 stated she was unsure how long the toilet had been broken or who put the plastic bag over it. CNA 1 stated the smell in the bathroom was urine and it was very strong. CNA 1 stated the BSC did not have a lid on it but should have to prevent odors from leaking out. CNA 1 stated she would not want to use a BSC instead of a toilet if able to, because a toilet was more comfortable than a bedside commode. CNA 1 stated it was not homelike because there would be a functioning toilet and the strong odor would not be present at home.During an interview on 3/5/26 at 10:59 a.m. with CNA 2, CNA 2 stated the facility's toilets tend to become clogged frequently because some residents would flush too much toilet paper or paper towels causing the issue. CNA 2 stated Resident 1 was very alert and oriented and able to use the toilet. CNA 2 stated some BSC do not have lids which would cause the room to smell. CNA 2 stated she would not feel very good using a restroom with a strong urine smell.During a concurrent observation and interview on 3/5/26 at 11:14 a.m. with DOM 2, DOM 2 stated Resident 1's toilet was clogged due to excessive wipes being flushed. DOM 2 stated the facility called a plumber who had been to the facility on 2/26/26 to unclog the toilet. Resident 1's bathroom was observed; there was a plastic bag over the toilet and there was an Out of Order sign placed since previous observation. DOM 2 stated he was unsure who had placed a plastic bag over the toilet. DOM 2 stated the bathroom's smell was not a pleasant odor and smelled like urine. DOM 2 observed the discoloration on the floor between the BSC and toilet and stated it was probably urine. DOM 2 pulled the plastic bag back enough to see inside toilet and a piece of feces (waste material expelled during a bowel movement) was in the bottom of the toilet. DOM 2 stated whoever had placed the stool in the toilet probably tried to flush and the toilet would not flush. DOM 2 stated, I would not want that in my house.During a concurrent observation and interview on 3/5/26 at 11:35 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's bathroom was observed. LVN 2 stated she was aware the toilet had been broken previously and DOM 1 had come to check it and told us it was working again. LVN 2 stated a plumber had come to the facility a few days prior to fix the toilet. LVN 2 stated the broken toilet was originally discovered when Resident 1 first moved into the room, because she was the only resident in the two adjoining rooms to the bathroom who used the toilet. LVN 2 stated it was important for the bathroom to have a usable toilet for hygiene. LVN 2 stated the odor in the bathroom is not good.During a concurrent observation and interview on 3/5/26 at 3:01 p.m. with the Social Services Director (SSD), the SSD stated Resident 1's toilet was broken and a plumber came to the facility to fix it. The SSD stated when Resident 1 moved into the room on 1/31/26 it was discovered the toilet was not working and the issue was resolved. The SSD stated the toilet acted up again. The plastic bag was observed over the toilet, the SSD stated she had noticed the plastic bag during rounds on Monday (3/2/26). The SSD stated Resident 1's bathroom should not smell like that. The SSD stated it was important for the toilet to work to promote Resident 1's independence because she was able to go to the bathroom for toileting. The SSD stated a homelike environment was important because the facility was the resident's home and they should feel safe, cozy and have the comfort of home.During a concurrent observation and interview on 3/5/26 at 3:54 p.m. with the Administrator (ADM), in Resident 1's bathroom, the toilet was observed with the plastic bag covering the toilet. The ADM stated Resident 1's toilet would flush but there was a blockage in there. The ADM stated the flush was not strong enough to flush any debris in the toilet down. The ADM stated he was unsure if it was Resident 1's preference to use the toilet. The bathroom continued to have a strong odor in it, the ADM stated it was the pipes to the toilet causing the odor. The ADM stated housekeeping had thoroughly cleaned the bathroom several times, but the odor had continued because of the weak flush unable to clear piping. The ADM stated the plumber came out and snaked the piping but notified the ADM the entire piping for the toilet would have to be changed out. The ADM stated he was unsure whether the toilet had worked since the plumber was out to fix it.During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 2/2021, the P&P indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. a dignified existence.During a review of the facility's P&P titled Safe and Homelike Environment, dated 12/19/2022, the P&P indicated, . In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment. includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence. Environment refers to any environment in the facility that is frequented by residents. residents' rooms, bathrooms. homelike environment is one that de-emphasizes the institutional character of the setting. determination of homelike should include the resident's opinion of the living environment. Sanitary includes. preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for one of three sampled residents (Resident 1) when Resident 1 was assessed as having physically aggressive behaviors towards other residents and staff, was supposed to be on one on one supervision (1:1-staff provide constant, close oversight for resident needing extra safety due to cognitive issues [problems with mental functions like thinking, learning, memory and judgment], behavioral problems [disruptive patterns of action or conduct] or potential self/other harm) monitoring when out of his room and on 12/23/25 the staff assigned to Resident 1 left the resident unattended in his room and Resident 1 left his room unnoticed.This failure resulted in Resident 1 hitting Resident 2 in the face, causing swelling and a scratch to the upper lip requiring first aid to the left upper lip and had the potential for Resident 2 sustaining significant injuries.During a concurrent observation and interview on 1/7/26 at 10:35 a.m. with Resident 2, Resident 2 was lying in bed, no swelling noted to his upper lip. Resident 2 stated he was a couple weeks previously he was sitting in his wheelchair across from the therapy room and Resident 1 came up from behind him standing very close to him so he asked him to back off and come around front so he could see him. Resident 2 stated he turned his wheelchair around and Resident 1 punched him in the mouth. Resident 2 stated his lip split open and swelled up after Resident 1 hit him. Resident 2 motioned his hand to the left side of his lips and said the hit caused him to bleed. Resident 2 stated it surprised him more than causing pain. Resident 2 stated there was no staff with Resident 1 at the time of the incident. Resident 2 stated the Administrator (ADM) was walking by when the incident happened, came over and broke up the fight.During a review of Resident 2's admission Record, undated, the admission record indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection of the bone), type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control), acquired absence of right leg below knee (amputation due to surgery, accident or severe injury), and acquired absence of left leg below knee.During a review of Residents 2's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 2's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 2 was cognitively intact.During a review of Resident 2's Progress Note, dated 12/23/25, the progress note indicated, . Resident was victim of res to res altercation with another resident at approximately 1237 pm in front of the therapy by the front window. Resident [1] approach resident [2] while he was sitting in front window and started yelling at him. resident stated, He approached me from behind I turned my neck back and told him don't walk up from behind I don't know you like that. Res [1] started punching Res [2]. Both residents were punching.During a review of Resident 2's SBAR, dated 12/23/25, the SBAR, indicated, . Resident was victim of res to res altercation. Resident has a scratch to top left side of lip with swelling noted. NP [nurse practitioner-name of provider] in house gave new order. Cleanse scratch to top left side of lip with NS [normal saline], pat dry, apply pea size amount of triple antibiotic ointment, leave open to air.During a review of Resident 1's admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy (muscles shrink and become weaker), Type 2 diabetes mellitus, dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), alcohol abuse and anxiety disorders (feelings of fear, dread or apprehension).During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 03 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had severe cognitive impairment.During an interview on 1/7/26 at 11:10 a.m. with the ADM, the ADM stated Resident 1 had a history of post-traumatic stress disorder (PTSD) and had unprompted outbursts. The ADM stated he had watched a video of the altercation and it appeared resident 1 came in close proximity to Resident 2, when Resident 2 turned his wheelchair around, Resident 1 saw it as a threat and hit him. The ADM stated the altercation was unprompted and Resident 1 had a history of resident-to-resident altercations. The ADM stated he happened to be in the hallway at the time and separated the residents. The ADM stated Resident 1 was on a 1:1.During an interview on 1/7/26 at 12:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Residents 1 and 2. CNA 1 stated Resident 1 was known to have violent behavior towards others and was unpredictable. CNA 1 stated Resident 1's behavior would change quickly making it hard to predict. CNA 1 stated Resident 1 had been on a 1:1 prior to the incident.During an interview on 1/7/26 at 12:20 p.m. with CNA 2, CNA 2 stated she had taken care of Resident 1 several times. CNA 2 stated Resident 1 would get aggressive and strike out at times. CNA 2 stated Resident 1's demeanor would change quickly and the staff knew to step back away from him because he would hit. CNA 2 stated on the day of the altercation with Residents 1 and 2, Resident 1 had been napping right before the incident. He left the room and went to Resident 2 and hit him. CNA 2 stated Resident 1 was on 1:1 while he was having his episodes and when out of his room. CNA 2 stated Resident 1 had been left alone because he was asleep in his room prior to the incident. CNA 2 stated Resident 1 needed a staff member to stay with him for safety because nobody would know when he would wake up aggressive. CNA 2 stated on the day of the incident the night shift told the day shift in report Resident 1 had woken up mad. CNA 2 stated Resident 1 had a history of altercations with other residents.During a concurrent interview and record review on 1/7/26 at 12:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she usually took care of Resident 1 but was off the day of the altercation with Resident 2. LVN 1 stated Resident 1 was confused and had a history of altercations with other residents. Resident 1's altercation care plan dated 12/23/25 was reviewed. The Care plan indicated, . peer to peer altercation. Continue 1:1 when outside the room. Resident remains in private room. Staff continue to monitor from a respectful distance to minimize agitation as resident does not like staff walking next to him. LVN 1 stated Resident 1 had a verbal altercation with another resident earlier in the month and was supposed to have 1:1 supervision when he was out of his room. LVN 1 stated she was not sure why Resident 1 did not have a staff member with him during the altercation with Resident 2. During a telephone interview on 1/7/26 at 4:53 p.m. with LVN 2, LVN 2 stated she was familiar with Residents 1 and 2. LVN 2 stated Resident 1 would suddenly become very violent and hit staff. LVN 2 stated the staff would have to stay a safe distance from Resident 1 because his behavior was unpredictable. LVN 2 stated Resident 1 required a 1:1 for safety, but the staff had to follow safely behind him because he would get agitated if they walked with him. LVN 2 stated it was difficult to prevent Resident 1 from having altercations with other residents.During a telephone interview on 1/8/26 at 3:39 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was on a 1:1 while out of his room prior to the altercation on 12/23/25. The DON stated at the time a new CNA was assigned to Resident 1 for 1:1 supervision, but she did not stay with the resident. The DON stated the meal trays had come out and the CNA stepped away to help pass the trays leaving Resident 1 unattended. The DON stated if the CNA had stayed with Resident 1 she should have been able to prevent the altercation. The DON stated Resident 1 had frequent mood changes and a history of hitting other residents and staff. The DON stated she, the ADM, social services and rehabilitation staff heard the noise from the altercation in the hallway and went in to intervene.During a review of Resident 1's SBAR Communication Form, dated 12/23/25, the SBAR indicated, . Res/Res altercation punch another resident's face. started on: 12/23/2025. This condition, symptom, or sign has occurred before. yes. Treatment for last episode 1:1 supervision. Appearance. Resident was agitated this morning, pacing/yelling and cussing at staff and peers. Recommendations of Primary Clinicians. Monitor for aggressive behavior towards peers 1:1 supervision.During a review of Resident 1's Progress Note, dated 12/23/25, the note indicated, . At approximately 1237, the writer heard raised voices and yelling coming from the hallway near the large glass window. Observedthe resident striking peer resident. in the facial area. At the time of the incident, the resident was on one-to-one supervision. Supervision coverage and staff assignment were reviewed. Education and reinforcement were provided to assigned staff regarding continuous supervision requirements, including that residents on one-to-one supervision are not to be left unattended.During a review of Resident 1's note titled IDT (Interdisciplinary team- team from different healthcare disciplines who work together to provide comprehensive patient care), the note indicated, . Resident-to-Resident . Physical Altercation. Aggressor IDT Follow-Up. Incident. involved in resident-to-resident . physical altercation. Significant cognitive impairment BIMS 3 with poor safety awareness; partial recall of incident. History of repeated resident-to-resident aggression. IDT Determination. Based on repeated aggressive behaviors, prior history, and recent incident, the IDT determined that additional and escalated interventions are necessary to ensure the safety of the resident, peers, and staff. Current strategies require reinforcement and expansion to address. behavioral and supervision needs. Maintain continuous one-to-one supervision with uninterrupted visual monitoring. Protection of Others. Physical separation from vulnerable residents maintained. behaviors monitored and documented each shift. One-to-one supervision expectations reinforced with staff.During a review of Resident 1's behavior care plan dated 7/14/25, the care plan indicated, . altered behavior with potential to disrupt resident and/or others M/B [manifested by]: Verbal Aggression (screaming, cursing, threatening) Physical Aggression (punching, pushing, grabbing). Interventions. When resident ambulate[s] throughout the facility, a designated staff member will remain in close proximity, following at a safe distance, to provide immediate redirection if needed and to ensure that other residents are not placed at risk. Staff will maintain visual monitoring and safe positioning at all times, staying close enough to intervene promptly but not in a way that increases agitation. Date initiated: 08/23/2025. During a telephone interview on 1/13/26 at 10:07 a.m. with the Social Services Director (SSD), the SSD stated Resident 1 had a history of altercations with other residents and had behaviors or punching at people. The SSD stated the altercation between Residents 1 and 2 on 12/23/25 was the first time another resident was injured. The SSD stated at the time of the incident, Resident 1 was supposed to have 1:1 supervision when out of his room, but the assigned CNA left him alone to pass out meal trays. The SSD stated the CNA should not have left Resident 1 alone. The SSD stated Resident 1 had dementia but was physically able to walk and move quickly. The SSD stated on 12/23/25 she was in an office near where the altercation took place and heard a scream. The SSD stated she, the DON, the ADM and rehabilitation staff all ran to the scene, and she could see Resident 1 standing over Resident 2 who was in a wheelchair. The SSD stated after the incident she saw Resident 2 had a swollen lip.During a telephone interview on 1/13/26 at 2:24 p.m. with LVN 3, LVN 3 stated she was assigned to Resident 1 and was the charge nurse on 12/23/25 when the altercation took place. LVN 3 stated Resident 1 was extremely agitated when he woke up and she had administered his routine anti-anxiety medication which normally relieved his agitation and anxiety, but it was not effective that day. LVN 3 stated normally Resident 1 required 1:1 supervision when he left his room, but she was concerned about his behavior and assigned CNA 3 to stay with the resident throughout the shift. LVN 3 stated CNA 3 left to help pass meal trays at lunch and Resident 1 left his room undetected. LVN 3 stated CNA 3 should have stayed next to Resident 1's room to follow him when he left the room. LVN 3 stated she instructed CNA 3 that morning to quietly follow Resident 1 but to stay within proximity to prevent altercations.During a telephone interview on 1/13/26 at 3:57 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 had behaviors of being agitated and combative. The DSD stated CNA 3 was new and still on orientation at the time of the altercation on 12/23/25. The DSD stated she was unaware that LVN 3 assigned CNA 3 to do a 1:1 with Resident 1, so she had not provided CNA 3 education specific to Resident 1's needs beforehand. The DSD stated Resident 1 was agitated in the morning on 12/23/25, so the charge nurse had told her to follow the resident. The DSD stated CNA 3 should have stayed with Resident 1 and not left to pass the lunch trays. The DSD stated Resident 1 could move quickly and the distraction of the lunch trays allowed him to get out of the room undetected.During a telephone interview on 1/13/26 at 4:14 p.m. with CNA 3, CNA 3 stated the altercation between Residents 1 and 2 happened on her third day of orientation on the floor where she was assigned to shadow another CNA on Station 4. CNA 3 stated around 10:00 a.m. the Station 3 charge nurse told her, Hey can you follow him [Resident 1], don't talk to him, he is combative. Just watch him. CNA 3 stated she followed Resident 1 around the facility for a while and he returned to his room. CNA 3 stated the lunch trays came out and she started to help the other CNAs pass the lunch trays. CNA 3 stated she had passed out a few trays and then she saw the ADM walking Resident 1 back to his room. CNA 3 stated LVN 3 then instructed her to stay with Resident 1 until further notice. CNA 3 stated she was not aware she was supposed to provide Resident 1 with 1:1 supervision because it was not clearly communicated to her. CNA 3 stated if she had known she would have stayed with Resident 1. During a review of the facility's policy and procedure (P&P) titled Resident-to-Resident Altercations, dated 9/2022, the P&P indicated, . All altercations, including those that may represent resident-to-resident abuse, are investigated. If two residents are involved in an altercation, staff. separate the residents. identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals. Review the events. evaluate the effectiveness of interventions.During a review of the facility's P&P titled Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Safety risks. are identified on an ongoing basis. interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. Implementing interventions to reduce accident risks and hazards shall include. Communicating specific interventions to all relevant staff. Assigning responsibility for carrying out interventions. Ensuring that interventions are implemented correctly and consistently. Evaluating the effectiveness of interventions. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards. type and frequency of resident supervision may vary among the residents.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin (any injury without a reason the injury could have or did occur) in accordance with their abuse policy and procedure (P&P) for one of three sampled residents (Resident 1) when Resident 1 was found with discoloration (a different color than normal) around his right eye on 4/12/25 and the injury was not reported to the California Department of Public Health (CDPH) and adult protective services until 4/14/25. This failure led to the delay of the investigation into the cause of Resident 1 ' s injury to rule out the potential for abuse. Findings: During an interview on 4/30/25 at 1:29 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had Huntington ' s Disease (causes nerve cells in the brain to decay over time affecting a person ' s movements, thinking ability and mental health) with involuntary body movement (abnormal, random muscle movements) and confused at times. During an observation on 4/30/25 at 1:43 p.m., Resident 1 was groomed and dressed sitting in a wheelchair in his room. Resident 1 had involuntary movements in his body, head, arms and legs. Resident 1 was asked if he remembered what happened to his eye and appeared to shake his head no. Resident 1 attempted to speak but his words were not clear. During a review of Resident 1 ' s Admission Record, undated, the admission record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including Huntington ' s Disease and dementia (decline in thinking, memory and reasoning). During a review of Residents 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 04 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 had a severe cognitive impairment. During an interview on 4/30/25 at 1:57 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 had a black eye (bruise caused by a collection of blood under the skin) a couple of weeks ago. CNA 1 stated she had asked Resident 1 what happened to his eye, and he laughed. CNA 1 stated Resident 1 was on every 15-minute checks by staff before the black eye happened. CNA 1 stated a black eye could be a potential sign of abuse and needed to be reported to the charge nurse and Administrator (ADM) as soon as possible. During an interview on 4/30/25 at 2:28 p.m. with CNA 2, CNA 2 stated he frequently took care of Resident 1. CNA 2 stated when he started his shift on 4/12/25 at 6:30 a.m., he found Resident 1 with a black eye. CNA 2 stated he thought another CNA had reported the black eye to the charge nurse, so he did not tell the nurse himself. During a concurrent interview and record review on 4/30/25 at 2:34 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/12/25 around 8:00 a.m., LVN 2 notified her Resident 1 had discoloration around his right eye. LVN 1 stated LVN 2 had administered Resident 1 ' s morning medication and discovered the skin around his eye was discolored. Resident 1 ' s Progress Note, dated 4/12/25 at 10:05 a.m. was reviewed. The note indicated, During med pass, writer noted that resident has a black eye around right eye. The resident stated he doesn ' t know how he got the black eye .There were no reports of falls or accidents in the recent past that could explain the injury . LVN 1 stated the ADM was the facility ' s abuse coordinator and he should have been notified immediately because an unwitnessed injury of a bruised, discolored eye could indicate abuse. LVN 1 stated LVN 2 had notified the DON but was unable to locate documentation indicating when the DON was notified. LVN 1 was unable to locate documentation indicating the ADM had been notified. Resident 1 ' s IDT (Interdisciplinary team- team from different healthcare disciplines who work together to provide compressive patient care) note dated 4/14/25 at 12:39 p.m. was reviewed, the note indicated, . Resident was observed with red and blue discoloration around the right eye. No evidence of fall, physical altercation, or abuse was found . Per staff he was agitated on Friday [4/11/25] in dining room, he was redirected to his room until he was calm. Per staff interview there was no physical contact made with resident at that time . LVN 1 stated she had asked Resident 1 how he got the black eye, and he was unable to state how it happened. LVN 1 stated she had not suspected abuse, but the incident was unwitnessed, and Resident 1 was not able to report what happened, so it should have been treated as abuse. During an interview on 4/30/25 at 2:55 p.m. with LVN 2, LVN 2 stated she was Resident 1 ' s nurse on 4/12/25 and had gone into Resident 1 ' s room between 8:30 and 9:00 a.m. to administer his medications and noticed the discoloration around his eye. LVN 2 stated she had finished passing the other resident ' s medications before she notified the DON around 10:00 a.m. LVN 2 stated she did not notify the ADM. LVN 2 was unable to state who the facility ' s abuse coordinator was. LVN 2 was unable to locate documentation indicating she had notified the DON of Resident 1 ' s discolored eye. LVN 2 stated she did not call the police department, but she should have since a black eye could be a sign or abuse. During an interview on 4/30/25 at 3:05 p.m. with the DON, the DON stated LVN 2 had notified her immediately after Resident 1 ' s discolored eye was found, receiving the call around 10:00 a.m. The DON stated she thought the ADM had reported the incident to the police department but was unable to provide supporting documentation. The DON stated suspected abuse needed to be reported within two hours to the abuse coordinator and 24 hours to CDPH. The DON stated Resident 1 had been on 15-minute checks at the time of the discolored eye and she was unsure why the staff had not noticed his eye sooner. The DON stated there was no documentation in the electronic medical record indicating when the state licensing agency or ombudsman were notified. The DON stated she was unsure if the ADM had reported the incident to law enforcement. The DON stated Resident 1 ' s discolored eye could have been the result of abuse, but the IDT did not suspect abuse had caused it. During a concurrent telephone interview and P&P review on 5/5/25 at 9:55 a.m. with the ADM, the ADM stated he had a copy of the facility ' s abuse P&P. The facility ' s P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 4/2021, was reviewed and indicated, . If resident abuse . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . The ADM stated Resident 1 ' s discolored eye was an injury of unknown source because it was unwitnessed, and the resident could not state what happened. The ADM stated he notified the state licensing agency and ombudsman by fax on 4/14/25. The ADM stated the P&P indicated suspicion of abuse should have been reported within two hours according to the facility ' s P&P. The ADM stated the P&P was not followed. During a telephone interview with the Ombudsman (OMB-advocate who works to ensure the health, safety and well-being of nursing home residents), the OMB stated they received the report of Resident 1 ' s injury on 4/15/25. During a review of an e-mail provided by the ADM, indicated he sent the report regarding Resident 1 ' s injury to CDPH on 4/14/25 at 4:03 p.m. During a review of the State Operations Manual, dated 8/8/2024, the SOM indicated, . Injuries of unknown source-An injury should be classified as an injury of unknown source when all of the following criteria are met . source of injury was not observed by any person . source of injury could not be explained by the resident . injury is suspicious because of the extent of the injury or location of the injury . During a review of the facility ' s P&P titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 4/2021, . All reports of resident abuse (including injuries of unknow origin) . are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management . If resident abuse . or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . administrator or the individual making the allegation immediately . to the following persons or agencies . state licensing/certification agency responsible for surveying/licensing the facility . local/state ombudsman . Law enforcement officials . Immediately is defined as . within two hours of an allegation involving abuse .

Based on observation, interview, and record review, the facility failed to maintain essential equipment in a safe operating condition when one of two boiler systems (a device that heats the facility ' s water and/or ventilation system) was not monitored, maintained and failed to operate from 3/15/25 to 3/18/25. This failure resulted in a non-functioning boiler system, unable to heat water throughout the facility including the laundry, kitchen, showers and sink faucets and placed the residents at risk for poor hygiene, infectious disease and discomfort. The facility ' s residents were unable to shower for three days, had to eat with disposable flatware and Styrofoam trays, and clothing and linens were washed in subpar (below normal) temperatures according to the facility policy and procedure (P&P). (cross reference F880, F584) Findings: During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely) on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25. During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with Laundry Aide (LA) 1, LA 1 was in the clean linen area folding clothes. LA 1 stated when she came to work on 3/17/25, she was notified there was no hot water. LA 1 stated she washed the clothing and linens in cold water since no hot water was available. During a concurrent observation and interview on 3/18/25 at 10:20 a.m., with the Housekeeping Supervisor (HKS), the HKS stated she was also the supervisor for laundry. The HKS stated the facility washed clothing and linens in chemicals designed for low temperature washing. The HKS reviewed the laundry detergent label and stated it could be used at low temperatures, the recommended temperature was 130 degrees ( ) Fahrenheit ( F-unit of temperature measurement on which water freezes at 32 and boils at 212 ) to 150 F. The HKS stated the temperature was only recommended. There was a chemical dispenser on the wall next to the washers, the HKS stated it housed chlorine bleach, detergent and laundry sanitizer. The HKS stated the chemicals were automatically mixed to the wash by the dispenser. The HKS stated only white linens used bleach. During an interview on 3/18/25 at 10:29 a.m. with Resident 1, Resident 1 stated he was notified there was no hot water on Saturday (3/15/25). Resident 1 stated his scheduled shower days were Tuesdays and Fridays. Resident 1 stated he showered on Friday (3/14/25) and the facility had hot water at that time. Resident 1 stated he was given a bed bath earlier in the day and the CNA had not been notified there was an alternate source to get hot water for a bed bath. Resident 1 stated, she gave me a cold bed bath. It was like biting a bullet. Resident 1 stated he was expecting warm water, then was washed with cold water which gave him chills throughout the bed bath and was not a thorough cleaning. Resident 1 stated because there was no hot water to wash dishes, the meals were coming in Styrofoam containers with disposable utensils. During an interview on 3/18/25 at 10:35 a.m. Resident 2 stated his shower days were Saturdays and Wednesdays. Resident 2 stated he did not receive a shower or a bed bath on Saturday (3/15/25). Resident 2 stated he did not want a bed bath and had not bathed for 6 days. During an interview on 3/18/25 at 10:37 a.m. with Resident 3, Resident 3 stated he was scheduled for showers on Wednesdays and Saturdays. Resident 3 stated he did not receive a shower or bed bath on 3/15/25 and washed himself using cold water in the sink. During an interview on 3/18/25 at 10:40 a.m. with Resident 4, Resident 4 stated he was not told about the hot water outage until he had washed his face and brushed his teeth with cold water on 3/15/25. Resident 4 stated he asked a CNA and was told the hot water was not working. Resident 4 stated his shower days were Wednesdays and Saturdays. Resident 4 stated on Saturday he just cleaned himself up with cold water and did not get a bed bath. During a concurrent observation and interview on 3/18/25 at 11:00 a.m. with the DOM, the facility ' s hot water boiler was observed and there was no heat coming from the boiler. The boiler for the facility ' s heater ventilation system was working and heat could be felt standing next to it, its thermometer read 160 F. The DOM stated the water boiler system supplied the entire facility ' s hot water, and the module had stopped working on Saturday (3/15/25). The DOM stated the VDR came out and replaced the module but discovered gas valve was not working. The DOM stated the VDR did not provide routine maintenance to the boilers but would come out when there was a transition in season requiring a change between the air conditioner and heater. The DOM stated they call the VDR when there is issue, but no routine maintenance was scheduled. During a concurrent observation and interview on 3/18/25 at 11:05 a.m. with the DOM in the kitchen, there were three sinks observed, a dish washing sink, a hand washing sink and food preparation sink. The water temperatures were checked and indicated: Dish sink-61.7 deg F Food prep sink-64.6 deg F Hand wash sink-63.3 deg F During an interview on 3/18/25 at 11:10 a.m. with [NAME] (CK) 1, CK 1 stated she used the hand washing sink with cold water and soap to clean her hands while working in the kitchen and would then use hand sanitizer to ensure she had clean hands. CK 1 stated the dishwasher was still able to reach the correct temperature for sanitizing dishes, so they were able to wash the items they cooked with in hot water. CK 1 stated there was a dispenser for hot water which they used to make coffee, and they used the hot water from there for any needs for hot water such as dish washing by hand and the sanitation bucket. CK 1 stated their hands and dishes had to be sanitized correctly and if they were not then, that is bad for residents, they could get sick from the food. CK 1 stated the lack of hot water placed the resident ' s food at risk for cross contamination. During an interview on 3/18/25 at 11:15 a.m. with CK 2, CK 2 stated he washed his hands in cold water and soap then used gloves while cooking. CK 2 stated it was important to sanitize hands and dishes to prevent food borne illness (illness that comes from eating contaminated food). During an interview on 3/18/25 11:20 a.m. with Resident 5, Resident 5 stated he had been washing his hands in cold water. Resident 5 stated he was a new admit and was not notified the facility did not have hot water. During a concurrent observation and interview on 3/18/25 at 11:22 a.m. with the DOM, the sink temperature in Resident 5 ' s room was checked. The temperature read 64.8. The DOM stated the sink temperatures should be approximately 105 deg F. Several water temperatures were checked throughout the facility as follows: room [ROOM NUMBER]-bathroom sink- 65.8 F Station 2 shower- 64.9 F Station 1 shower- 66.0 F Station 4 shower 66.4 F Station 3 shower 60.4 F room [ROOM NUMBER]-bathroom sink-65.8 F room [ROOM NUMBER]-bathroom sink-65.8 F Laundry room sink- 66.9 F The DOM stated the water temperature, and the washing machine water temperature would be the same (66.9) because they were on the same water line. During an interview on 3/18/25 at 11:48 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated when she worked on Sunday, she was told the water heater was not working. CNA 1 stated they were instructed there was a hot water dispenser in the breakroom to get water for bed baths. CNA 1 stated they were using hand wipes to clean the residents ' hands as needed and before meals. During an interview on 3/18/25 at 11:54 a.m. with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated when she arrived at work, she was notified the boiler was not working, so there was no hot water. CNA 2 stated she gave Resident 1 a cold bed bath because she was not aware there was an alternate source for hot water available in the breakroom. CNA 2 stated, I felt so bad. CNA 2 stated Resident 1 was chilled and asked her during the bed bath when the facility would have hot water again. CNA 2 stated she should have used warm water for Resident 1 ' s bed bath. During a telephone interview on 3/18/25 at 2:06 p.m. with the VDR, the VDR stated they were called out on Saturday 3/15/25 because the water heater boiler was not working. The VDR stated he sent a technician out to fix the problem. The VDR stated the ignition control module was replaced, and it was then discovered the gas valve was not functioning. The VDR stated the module was the brains of the system and the gas valve was controlled by the module. The VDR stated both parts had to work together for the boiler to work correctly. The VDR stated the company was not scheduled for routine, preventative maintenance of the boiler and were only called out for emergencies and twice a year when contacted, to switch the heater to air conditioning and the air conditioning back to the heater as the weather changed. During a review of the Vendor ' s invoice to the facility dated 3/17/25, the invoice indicated, . pressure regulating gas V [valve-device for controlling passage] . Quantity 1 . IGN [ignition-firing something up] Module . Quantity 1 . During a review of the facility ' s policy and procedure (P&P) titled Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building, grounds, and equipment . Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order . Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . During a review of the facility ' s P&P titled Unusual Occurrence Reporting, dated 12/2007, the P&P indicated, . our facility reports unusual occurrences or other reportable events which affect the heath, safety, or welfare of our residents, employees or visitors . Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when one of two facility boiler systems (a device that heats the facility ' s water and/or ventilation system) stopped working and the laundry was washed in temperatures below the minimum water temperatures according to the facility ' s policy and procedure (P&P). This failure placed the 117 residents at risk for cross contamination from laundry not properly washed and sanitized according to the P&P. Findings: During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely) on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25. During a concurrent observation and interview on 3/18/25 at 10:15 a.m. with Laundry Aide (LA) 1, LA 1 was in the clean linen area folding clothes. LA 1 stated when she came to work on 3/17/25, she was notified there was no hot water. LA 1 stated she washed the clothing and linens in cold water since no hot water was available. During a concurrent observation and interview on 3/18/25 at 10:20 a.m., with the Housekeeping Supervisor (HKS), the HKS stated she was also the supervisor for laundry. The HKS stated the facility washed clothing and linens in chemicals designed for low temperature washing. The HKS reviewed the laundry detergent label and stated it could be used at low temperatures, the recommended temperature was 130 degrees ( ) Fahrenheit ( F-unit of temperature measurement on which water freezes at 32 and boils at 212 ) to 150 F. The HKS stated the temperature was only recommended. There was a chemical dispenser on the wall next to the washers, the HKS stated it housed chlorine bleach, detergent and laundry sanitizer. The HKS stated the chemicals were automatically mixed to the wash by the dispenser. The HKS stated only white linens used bleach. During a concurrent observation and interview on 3/18/25 at 11:22 a.m. with the DOM, the laundry room sink water temperature was tested at 66.9 F. The DOM stated sink ' s water temperatures should be approximately 105 deg F. The DOM stated the water temperature in the washing machine would be the same as the sink because they were on the same water line. During a concurrent interview and record review on 3/18/25 at 1:30 p.m. with the HKS, the facility ' s policy and procedure (P&P) titled, Departmental (Environmental Services)-Laundry and Linen, dated 1/2014 was reviewed. The P&P indicated, . Washing Linen and other Soiled Items . Laundry may be processed in either low-temperature or high-temperature cycles . For low-temperature processing, wash linen in water that is at least 71-77 F and use a . chlorine bleach rinse if the material can withstand bleach and remain intact . The HKS stated she was unsure if 66.9 F met the facility ' s P&P of 71-77 F. The HKS stated the DOM would be in charge of the water temperatures. The HKS stated there was no way to know if the washer water met the minimum temperature according to the facility P&P. The HKS stated the facility used chlorine bleach only for the whites and linens, but not on the colored laundry. During an interview on 3/18/25 at 1:33 p.m. with the DOM, the DOM stated he did not deal with laundry, and it would be up to the HKS to know if the laundry temperature P&P was followed. During a concurrent interview and record review on 3/18/25 at 2:28 p.m. with the Director of Nursing (DON), the DON stated the Infection Preventionist was on vacation. The DON stated the IP would usually oversee the infection prevention practices of the laundry department. The DON reviewed the facility ' s P&P titled Departmental (Environmental Services)-Laundry and Linen, and stated the P&P indicated for low temperature wash, the laundry should be washed at a minimum temperature of 71-77 F. The DON stated if the water temperature was below the 71 F, it did not follow the P&P. During an interview on 3/18/25 at 2:45 p.m. with the ADM, the ADM stated when the IP was off, the DSD would normally take her place. The ADM reviewed the P&P for laundry and stated he would have to check the water temperature in the laundry room to see if the 71-77 F was met. The ADM stated if the laundry room water temperature was in the 60 ' s then the policy was not followed. During a review of a professional reference found at https://www.cdc.gov/infection-control/hcp/environmental-control/laundry-bedding.html#:~:text=Several%20studies%20have%20demonstrated%20that,are%20carefully%20monitored%20and%20controlled. Titled G. Laundry and Bedding, dated 2003, the reference indicated, . Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient apparel . Several studies have demonstrated that lower water temperatures of 71 F-77 F . can reduce microbial contamination when the cycling of the washer, the wash detergent, and the amount of laundry additive are carefully monitored and controlled .

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of five sampled residents (Resident 1) when the facility ' s boiler system (a system of vessels and tubes, in which water is heated) was not functional, Certified Nursing Assistant (CNA) 2 gave Resident 1 a bed bath with cold water. This failure violated Resident 1 ' s right to a homelike environment and caused him to feel uncomfortable and chilled during the bed bath. Findings: During an interview on 3/18/25 at 10:00 a.m. with the Administrator (ADM), the ADM stated he received a phone call from the Director of Maintenance (DOM) on the morning of 3/18/25 because the boiler to the facility ' s water supply was not working. The ADM stated the Vendor (VDR) came out and replaced the ignition control module (electronic panel that manages the ignition process, ensuring the boiler is lit safely) on the boiler but discovered a gas valve (essential to control the flow of gas to the boiler) had also failed. The VDR did not have the gas valve in stock and could not order it until Monday 3/17/25. During an interview on 3/18/25 at 10:29 a.m. with Resident 1, Resident 1 stated he was notified there was no hot water on Saturday (3/15/25). Resident 1 stated his scheduled shower days were Tuesdays and Fridays. Resident 1 stated he was given a bed bath earlier in the day and the CNA had not been notified there was an alternate source to get hot water for a bed bath. Resident 1 stated, she gave me a cold bed bath. It was like biting a bullet. Resident 1 stated he was expecting warm water, then was washed with cold water which gave him chills throughout the bed bath and was not a thorough cleaning. During a concurrent observation and interview on 3/18/25 at 11:22 a.m., the sink temperature in Resident 1 ' s room was measured and registered 65.8 degrees ( ) Fahrenheit ( F- a unit of temperature measurement- 212 F is boiling, and 32 F is freezing). During an interview on 3/18/25 at 11:54 a.m. with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated when she arrived at work, she was notified the boiler was not working, so there was no hot water. CNA 2 stated she gave Resident 1 a cold bed bath because she was not aware there was an alternate source for hot water available in the breakroom. CNA 2 stated, I felt so bad. CNA 2 stated Resident 1 was chilled and asked her during the bed bath when the facility would have hot water again. CNA 2 stated she should have used warm water for Resident 1 ' s bed bath. During an interview on 3/18/25 at 1:41 p.m. with CNA 3, CNA 3 stated he used hot water from the dispenser in the breakroom for resident bed baths. CNA 3 stated it was important to use warm water when providing a bed bath to make sure the resident was comfortable. During an interview on 3/18/25 at 1:47 p.m. with the Director of Staff Development (DSD), the DSD stated the hot water heater stopped working on Saturday 3/15/25. The DSD stated she and the Director of Nursing (DON) provided in-services to the staff over the weekend regarding the alternate hot water source and hand hygiene. The DSD stated the CNAs were offering the residents bed baths since there was no hot water for showering. The DSD stated the CNAs were instructed to use the hot water available in the breakroom for bed baths. The DSD stated the expectation for bed baths was for the CNA to test the water temperature themselves and have the resident check the water temperature before giving the resident a bed bath because it was important to make sure the resident was comfortable. The DSD stated a resident should not have a bed bath with cold water because it could be a shock to the resident ' s system and the residents would become easily chilled because their body temperature was not always functioning correctly due to chronic illnesses. The DSD stated, they [the CNAs] would not take a cold bath themselves. During an interview on 3/18/25 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the staff received texts over the weekend notifying them the facility did not have hot water. LVN 1 stated the staff were instructed there was a hot water source from a dispenser in the breakroom to use for resident baths. During an interview on 3/18/25 at 2:28 p.m. with the DON, the DON stated she and the DSD had been giving the staff in-services and instructed the staff to use the hot water dispenser in the breakroom for resident bed baths. The DON stated her expectation was for the staff to use warm water at the resident ' s preferred temperature for bed baths. The DON stated the residents should not receive a cold bed bath because they were at higher risk for hypothermia (a significant and dangerous drop body temperature) due to their age or health conditions. During an interview on 3/18/25 at 2:45 p.m. with the ADM, the ADM stated the expectations for bed baths was for the staff to provide warm water to fill the basin. The ADM stated the water temperature should be checked on the arm prior to bathing the resident and he would hope a resident did not have a cold bed bath. During a review of the facility ' s policy and procedure (P&P) titled Bed Baths, dated 9/2/22, the P&P indicated, . It is the practice of this facility to assist residents with bed bathing to maintain proper hygiene and prevent skin issues . Fill the basin halfway with warm water to the touch (between 98.6 F to 103 F). Have the resident feel the water to ensure it is comfortable for them . During a review of the facility ' s P&P titled Resident Rights, dated 2/2021, the P&P indicated, . Employees shall treat all residents with kindness, respect, and dignity . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to . a dignified existence . be treated with respect, kindness, and dignity . self-determination . During a review of the facility ' s P&P titled Homelike Environment, dated 2/2021, the P&P indicated, . Residents are provided with a safe, clean, comfortable and homelike environment . Staff provides person-centered care that emphasizes the residents ' comfort, independence and personal needs and preferences .

Based on interview, record review, and facility policy review, the facility failed to ensure resident Minimum Data Set (MDS) assessments were accurate for 4 (Residents #19, #64, #68, and #217) of 28 residents reviewed for MDS accuracy. Findings included: A facility policy titled, MDS Error Correction, revised 09/2010, indicated, The assessment coordinator and/or the interdisciplinary assessment team will follow the established procedures for making corrections to the MDS. The policy revealed, 6. If an error is discovered in a record that has already been accepted by the QIES [Quality Improvement and Evaluation System] ASAP [Assessment Submission and Processing] system, implement procedures for either modification or inactivation of the information in the system within 14 days of the discovery of the error. 1. An Admission Record indicated the facility admitted Resident #217 on 01/21/2025. According to the Admission Record, the resident had a medical history that included a diagnosis of bacteremia. An admission MDS, with an Assessment Reference Date (ARD) of 01/27/2025, revealed Resident #217 had severe impairment in cognitive skills for daily decision-making and had short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS revealed the resident was receiving intravenous (IV) medications on admission and while a resident within the last 14 days prior to the assessment. The MDS revealed the resident received IV antibiotics on admission. The MDS did not indicate the type of IV access site. Resident #217's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 01/22/2025, for a central veinous catheter (CVC), with instructions to flush with 10 milliliters (ml) of normal saline, infuse medication, then flush with 10 ml of normal saline five times a day. On 02/05/2025 at 11:06 AM, the MDS Coordinator stated that when a resident was admitted to the facility, the staff completed an admission assessment. She stated an IV line and medication would be documented in the MDS assessment. She reviewed the admission MDS completed for Resident #217 and stated there was a section which should have indicated the type of IV line, and it was not coded. On 02/06/2025 at 8:43 AM, the Director of Nursing (DON) stated Resident #217 had a central line (central veinous catheter) on admission. She reviewed Resident #217's admission MDS and stated that the central line section on the MDS should have been coded. She stated the MDS was coded incorrectly. On 02/06/2025 at 9:07 AM, the Administrator stated the MDS coordinator's job was to ensure the MDS assessments were accurate. He stated he expected MDS assessments to be accurate, and communication needed to improve to ensure the accuracy of the MDS assessments. 45555 2. An Admission Record indicated the facility admitted Resident #19 on 05/18/2018. According to the Admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea. A quarterly MDS, with an Assessment Reference Date (ARD) of 12/20/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS did not indicate that the resident used a non-invasive mechanical ventilator. Resident #19's care plan included a focus area revised 05/06/2024 that indicated the resident was at risk for an alteration in respiratory status related to obstructive sleep apnea. Interventions directed staff to use a BiPAP (bilevel positive airway pressure) machine (a non-invasive mechanical ventilator). Resident #19's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 07/20/2024 for a BIPAP with an inhalation positive airway pressure of 24 centimeter of water (cmH20), exhalation positive airway pressure of 8 cmH20, with 24% fraction of inspired oxygen (FI02) with a goal of 88% blood oxygen saturation (Sp02) level. An observation on 02/03/2025 at 9:41 AM, revealed Resident #19 was in bed. A BiPAP machine was on the resident's nightstand with tubing in a black bag. During an interview on 02/06/2025 at 8:06 AM, the MDS Coordinator stated that information for the MDS came from interviews with the resident and family, observation, her own assessment to gather information, and she looked at other assessments and progress notes from all departments. She stated it was important for the MDS to be accurate for an appropriate care plan to be developed so that they could provide the proper care for the resident. The MDS Coordinator stated the BiPAP should have been coded on Resident #19's MDS. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate because it was the communication to the Centers for Medicare and Medicaid (CMS), and it determined the proper care for the resident. She stated it also determined their numbers on the quality measures report. She stated the information for the MDS should come from the resident's record. The DON stated Resident #19's BiPAP should have been coded on the MDS. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated it was important for the MDS to be accurate because it affected the care provided and accurately reflected the resident's needs. He stated the information for the MDS came from the assessments from all departments, and it was the MDS Coordinator's responsibility to ensure the accuracy of the assessments. He stated it was his expectation that the MDS was accurate. He stated Resident #19's BiPAP should have been coded. 3. An Admission Record revealed the facility readmitted Resident #64 on 01/10/2025. According to the Admission Record, the resident had a medical history that included type 2 diabetes mellitus with a foot ulcer, and an acquired absence of the right toe(s). A 5-day scheduled assessment MDS, with an Assessment Reference Date (ARD) of 01/14/2025, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated that the resident received injections three days during the assessment look-back period. The MDS did not indicate that the resident received insulin injections and antibiotics during the assessment look-back period. Resident #64's care plan included a focus area revised 08/30/2024, that indicated the resident was at risk for hypo/hyperglycemia (low/high blood sugar) related to type 2 diabetes mellitus. Interventions directed staff to administer diabetes medication as ordered by the doctor and monitor and document for side effects and effectiveness (initiated 08/21/2024). The care plan included a focus area revised 01/12/2025, that indicated the resident had an infection and was at risk for adverse reaction to antibiotic therapy. Interventions directed staff to administer antibiotics per the medical doctor's orders (initiated 01/10/2025). Resident #64's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 01/10/2025 for Augmentin (an antibiotic) 500 - 125 milligrams (mg) with instructions to give one tablet by mouth every eight hours for prophylactic foot surgery for 28 days. The Order Summary Report revealed an order dated 01/10/2025 for Humalog (insulin lispro) 100 units per milliliter (ml) with instructions to inject per sliding scale subcutaneously before meals. Resident #64's January 2025 Medication Administration Record [MAR], revealed staff documented that they administered Augmentin 500 - 125 mg once on 01/10/2025, three times a day on 01/11/2025, 01/12/2025, and 01/14/2025, and twice on 01/13/2025, during the MDS look-back period. The MAR revealed staff documented that they administered Humalog insulin during the MDS look-back period on 01/11/2025 at 4:30 PM, 01/13/2025 at 12:00 PM, and 01/14/2025 at 12:00 PM. During an interview on 02/06/2025 at 8:06 AM, the MDS Coordinator stated that information for the MDS came from interviews with the resident and family, observation, her own assessment to gather information, and she looked at other assessments and progress notes from all departments. She stated it was important for the MDS to be accurate for an appropriate care plan to be developed so that they could provide the proper care for the resident. The MDS Coordinator stated Resident #64 received insulin and after reviewing Resident #64's MDS she confirmed that it was not coded on the MDS but should have been. She stated she documented three injections but did not code the actual insulin. She also confirmed that the MDS should have been coded for the resident taking an antibiotic. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate because it was the communication to the Centers for Medicare and Medicaid (CMS), and it determined the proper care for the resident. She stated it also determined their numbers on the quality measures report. She stated the information for the MDS should come from the resident's record. She stated they should look under the active orders to determine what medications the resident was taking. She stated Resident #64 was receiving an antibiotic and insulin, and the medications should have been properly coded on the MDS. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated it was important for the MDS to be accurate because it affected the care provided and accurately reflected the resident's needs. He stated the information for the MDS came from the assessments from all departments, and it was the MDS Coordinator's responsibility to ensure the accuracy of the assessments. He stated it was his expectation that the MDS was accurate. He stated Resident #64's medications should have been coded on the MDS. 4. An Admission Record indicated the facility admitted Resident #68 on 12/14/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of bipolar disorder. An admission MDS, with an Assessment Reference Date (ARD) of 12/20/2024, revealed Resident #68 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was taking an antipsychotic medication with the indication noted. However, the section titled N0450. Antipsychotic Medication Review revealed it was incorrectly coded to indicate that antipsychotics were not received, and this caused the assessment to skip information related to gradual dose reduction (GDR). Resident #68's care plan included a focus area revised 12/17/2024, that indicated the resident received an antipsychotic medication for bipolar disorder. Interventions directed staff to administer medication as ordered and consult with the physician to consider dose reduction at least every three months. Resident #68's Order Summary Report with active orders as of 02/05/2025, revealed an order dated 12/14/2024, for quetiapine fumarate 50 milligrams (mg) with instructions to give one tablet by mouth two times a day for bipolar disorder. Resident #68's December 2025 Medication Administration Record [MAR], revealed staff documented that the resident received quetiapine fumarate 50 mg twice a day during the MDS look-back period from 12/15/2024 through 12/20/2024. During an interview on 02/06/2025 at 8:06 AM, the MDS Coordinator stated that information for the MDS came from interviews with the resident and family, observation, her own assessment to gather information, and she looked at other assessments and progress notes from all departments. She stated it was important for the MDS to be accurate for an appropriate care plan to be developed so that they could provide the proper care for the resident. The MDS Coordinator stated Resident #68 was taking an antipsychotic medication and after reviewing the MDS she confirmed that section N0450 was coded incorrectly. She stated it should have indicated that the resident was taking an antipsychotic. She stated it was overlooked. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate because it was the communication to the Centers for Medicare and Medicaid (CMS), and it determined the proper care for the resident. She stated it also determined their numbers on the quality measures report. She stated the information for the MDS should come from the resident's record. She stated they should look under the active orders to determine what medications the resident was taking. The DON stated Resident #68's MDS should have been coded to reflect the use of the antipsychotic on all parts of the MDS to ensure the accuracy of the assessment. She confirmed that section N0450 of the MDS was coded incorrectly. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated it was important for the MDS to be accurate because it affected the care provided and accurately reflected the resident's needs. He stated the information for the MDS came from the assessments from all departments, and it was the MDS Coordinator's responsibility to ensure the accuracy of the assessments. He stated it was his expectation that the MDS was accurate. He stated Resident #68's medication should have been coded.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure reusable resident care equipment was cleaned and disinfected after use and failed to ensure enhanced barrier precautions (EBP) were used for 1 (Resident #64) of 1 resident observed during wound care. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 09/27/2024, specified, Definitions: 'Enhanced barrier precautions' refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi-drug resistant organism] as well as those at increased risk of MDRO acquisition (e.g. [exempli gratia, for example], residents with wounds or indwelling medical devices). The policy revealed the section titled, Policy Explanation and Compliance Guidelines, included, c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. 2. Initiation of Enhanced Barrier Precautions - a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers). The policy also indicated, 3. Implementation of Enhanced Barrier Precautions - a. Make gowns and gloves available PRIOR TO PERFORMING TASKS. A facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, specified, d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). An Admission Record indicated the facility readmitted Resident #64 on 01/10/2025. According to the Admission Record, the resident had a medical history that included diagnoses of acquired absence of other right toe(s) and an encounter for orthopedic aftercare following surgical amputation. A 5-day scheduled assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2025, revealed Resident #64 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #64 had a surgical wound. Resident #64's care plan included a focus area initiated 01/12/2025, that indicated the resident had altered non-pressure skin integrity related to a surgical wound to the right foot. Interventions directed staff to provide treatments as ordered (initiated 01/12/2025). Resident #64's Order Summary Report, with active orders as of 02/05/2025, revealed an order dated 01/30/2025, to cleanse the resident's right foot transmetatarsal amputation (TMA) with normal saline, pat dry, and apply Medihoney when wrap with a gauze bandage every other day for surgical wound care. An observation on 02/03/2025 at 9:10 AM, revealed Resident #64 had a dried bloody dressing to the right foot. The observation revealed no EBP signage inside the room or outside the room in the hallway, and there was no PPE, including gowns, available in the room or in the hallway outside the room. An observation on 02/05/2025 at 1:16 PM, revealed Licensed Vocational Nurse (LVN) #2, who was also the treatment nurse, and LVN #3 entered Resident #64's room to provide wound care. LVN #2 and LVN #3 entered the resident's room after performing hand hygiene and donned gloves. LVN #2 and LVN #3 did not don a gown. LVN #2 was observed cutting off the resident's old dressing on their right foot with scissors. After providing wound care, LVN #2 was observed taking the scissors to the treatment cart and putting them in the drawer without cleaning or sanitizing them. During an interview conducted immediately after the provision of wound care, LVN #2 stated there was no signage up on the doorway and there were no PPE supplies available, so she did not think about EBP. LVN #2 stated that since the resident did have a wound that required a dressing, they should have put on gowns while providing the wound care. LVN #2 stated Resident #64 should have been put on EBP by the Infection Preventionist (IP) when the wound opened up and started requiring a dressing change. LVN #2 stated the scissors should have been cleaned and disinfected after using them. LVN #2 stated she should have placed them on a paper towel on the cart to prevent contamination and then cleaned them before they were put back in the drawer, but she was nervous and forgot. During an interview on 02/05/2025 at 2:29 PM, LVN #3 stated EBP should be used when a resident had an open wound that required a dressing to help prevent the spread of infection. LVN #3 stated she went into the room with LVN #2 as the interpreter and did not think about needing to put on a gown for EBP. During an interview on 02/05/2025 at 2:46 PM, the IP stated they started doing EBP in November (2024) for residents with chronic wounds, MDROs, dialysis access, gastrostomy tubes, catheters, colostomies, and intravenous (IV) access. The IP stated if the resident had an ulcer or open wound then they would need the EBP to prevent them from getting an infection. The IP stated she was the person responsible to put the precautions in place. The IP stated Resident #64 had a surgical incision that was an open wound that needed a dressing, and they should have been on EBP. The IP stated the nurses should have notified her, and they should have caught that EBP was needed. The IP stated training had been done on EBP at least every two weeks, and it was ongoing. The IP stated any reusable equipment used during wound care needed to be cleaned and disinfected after use, and the scissors should not have been put back into the cart without being cleaned first. During an interview on 02/06/2025 at 8:29 AM, the Director of Nursing (DON) stated reusable equipment should be disinfected immediately after the wound care was provided. The DON stated EBPs should be used on all residents with wounds, chronic pressure wounds, and when the staff had any contact with bodily fluids. The DON stated the IP was responsible to ensure that the EBPs were in place. The DON stated the staff had been educated, and the treatment nurse and the nurse assisting should have been using the gown and gloves. During an interview on 02/06/2025 at 9:03 AM, the Administrator stated staff should clean and disinfect reusable equipment after use for infection control reasons. The Administrator stated EBPs should be used with residents that had open wounds, dialysis access, and IV access sites. The Administrator stated staff should be aware of who was on the precautions, the proper signage should be up, and the cart with the PPE should be available. The Administrator stated Resident #64 had a change in condition with the wound, and the treatment nurse did not communicate it with the IP to update the information. During an interview on 02/06/2025 at 9:39 AM, the IP stated she was not aware that Resident #64's wound opened up and EBP was required. The IP stated it was a lack of communication between her and the treatment nurse.

Based on interview, record review, and facility policy review, the facility failed to ensure a discharge Minimum Data Set (MDS) assessment was completed and transmitted for 1 (Resident #30) of 2 residents reviewed for discharges. Findings included: A facility policy titled, MDS [Minimum Data Set] Completion and Submission Timeframes, revised 07/2017, indicated, Policy Interpretation and Implementation 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' [Centers for Medicare and Medicaid Services] QIES [Quality Improvement and Evaluation System] Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. The Centers for Medicare and Medicaid Services - Long term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 October 2024, revealed, Discharge Assessment-Return Not Anticipated - Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. - Must be completed (item Z0500B [MDS Assessment Completion Date]) within 14 days after the discharge date (A2000 [discharge date ] + 14 calendar days). - Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days). An Admission Record revealed the facility admitted Resident #30 on 03/17/2024. According to the Admission Record, the resident had a medical history included a diagnosis of type 2 diabetes. According to the Admission Record, Resident #30 discharged from the facility to an acute hospital on 12/07/2024. The MDS data records for Resident #30 revealed the last completed MDS was a quarterly assessment on 09/24/2024, and there was no discharge assessment. During an interview on 02/06/2025 at 8:07 AM, the MDS Coordinator stated Resident #30 did not have a discharge assessment completed. The MDS Coordinator stated a discharge assessment should have been completed, but she had overlooked it. During an interview on 02/06/2025 at 8:42 AM, the Director of Nursing (DON) revealed the discharge assessments were completed by the MDS Coordinator. The DON stated she expected the discharge assessments to be completed once the facility was aware of the discharge. During an interview on 02/06/2025 at 9:04 AM the Administrator stated discharge assessments should be completed by the MDS Coordinator.

Based on observation, interview and record review, the facility failed to ensure licensed nurses (LN) administered medications in accordance with professional standards of practice for one of seven sampled residents (Resident 5), when: 1. Resident 5's morning medications were left at the bedside unattended and not administered as prescribed by the physician on 9/16/24. This failure resulted in Resident 5 not receiving the medications as prescribed by the physician, which had the placed Resident 5 at risk for thrombosis (clotting of the blood), embolism (obstruction or blockage in a blood vessel) and had the potential for other facility residents to ingest the medications that were left unattended. 2. One of Two Licensed Nurses failed to lock the medication cart when the cart was out of the nurse ' s sight, according to the facility ' s policy and procedure (P&P). This failure had the potential for staff, visitors, or residents to access medications from the unlocked medication cart. Findings: During a concurrent observation and interview on 9/16/24 at 12:09 p.m. with Resident 5, in Resident 5 ' s room, a small, clear plastic cup was on Resident 5 ' s bedside table and contained four medications, a round white tablet, a round dark red tablet, a small yellow tablet, and a dark capsule. Resident 5 stated the nurse brought his medication in around 9:00 a.m. and left them on the table so he could take them later. Resident 5 stated he usually preferred to take his morning medication around lunchtime. During a review of Resident 5 ' s Admission Record, undated, the admission record indicated, Resident 5 was admitted to the facility on [DATE] with diagnosis of paraplegia (paralysis [loss of ability to move] of the legs and lower body), malignant neoplasm of the right testis (cancer in the testicle), malignant neoplasm of spinal cord (cancer spread to the spine [backbone]) and acute (sudden onset) embolism and thrombosis of the iliac vein (blood vessel in the pelvis). During a review of Residents 5 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 5 ' s Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 5 was cognitively intact. During a concurrent observation and interview on 9/16/24 at 12:12 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 5 ' s room, the cup of medication was observed on Resident 5 ' s bedside table. LVN 1 stated the medication was apixaban (medication to treat blood clots), magnesium (dietary supplement), multiple vitamin (dietary supplement), and vitamin D (dietary supplement). LVN 1 stated, I shouldn ' t have done that [left medication at bedside]. LVN 1 stated Resident 5 did not want to take his medication during the 8:00 a.m. medication pass, so she left the medication on his table. LVN 1 stated medication should never be left at bedside because there was no way to be sure the resident took the medication. LVN 1 stated medications left at bedside placed other residents at risk because they could wander in and take medication not prescribed to them. LVN 1 stated apixaban was a blood thinner and could place a resident at risk for bruising and bleeding if they it was not prescribed to them. During a concurrent interview and record review on 9/16/24 at 12:35 p.m. with LVN 2, Resident 5 ' s Order Summary Report, (OSR), dated September 2024 were reviewed. The OSR indicated, . [brand name for apixaban] Oral Tablet 2.5 mg [milligrams-unit of measurement] (Apixaban) Give 1 tablet by mouth two times a day . Magnesium Oxide Oral Tablet 400 mg (Magnesium Oxide) Give 1 tablet by mouth three times a day . Multiple Vitamin Tablet Give 1 tablet by mouth one time a day . Ergocalciferol [a form of vitamin D] Oral Capsule 1.25 MG . Give 1 capsule by mouth one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for vitamin D supplement . LVN 2 stated the medication should have been consumed within an hour of the scheduled 8:00 a.m. medication time. LVN 2 stated it was not safe to leave a medication unattended at bedside because another resident could consume the medication. LVN 2 stated if a resident took a blood thinner not prescribed to them it could cause bleeding. During an interview on 9/16/24 at 12:50 p.m. with LVN 3, LVN 3 stated another resident could have taken the medication left at bedside. LVN 3 stated it could cause adverse side effects and there would be no way to know if the resident took the medication which could affect the therapeutic level (maintain a certain level in the blood to work properly) if it is a medication needing a consistent blood level. During a review of the facility ' s P&P titled Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time . Residents may self-administer their own medication only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . During a telephone interview and P&P review on 9/24/24 at 3:32 p.m., with the Director of Nursing (DON), the DON stated medication should never be left at bedside. The DON stated if a resident wanted to self-administer medication there was a process to follow including an assessment, care plan and a doctor ' s order. The DON stated Resident 5 had not been assessed for self-administration and the medication should not have been left. The DON stated Resident 5 was on a blood thinner, so it was important for the nurse to verify he had taken the medication. The DON stated it was a safety issue if a resident with dementia had wandered in the room and taken the medication. The DON stated the P&P was to administer a medication within an hour of the scheduled time and the P&P was not followed. During a professional reference review of Lippincott Manual of Nursing Practice 10th Edition, dated 2014, indicated, .Standards of Practice .General Principles .Common Departures from the Standards of Nursing Care .Legal claims most commonly made against professional nurses include the following departures from appropriate care .failure to .follow physician orders .adhere to facility policy or procedure .administer medications as ordered . 2. During a concurrent observation and interview on 9/16/24 at 12:12 p.m. with LVN 1, the medication cart was observed with the lock pulled all the way out which indicated it was unlocked. LVN 1 took out the keys of her pocket and went to unlock the cart, did not put the key in the lock and placed the keys back into her pocket. LVN 1 stated, it [the medication cart] might have been left open. LVN 1 opened the drawer and took out the glucometer, then pushed the lock in locking the cart. LVN 1 stated the cart should be locked when she was not in front of the cart because anybody could access the medication. During an interview on 9/16/24 at 12:35 p.m. with LVN 2, LVN 2 stated she always locked the medication cart anytime she was not directly in front of it. LVN 2 stated the cart should never be unlocked if unattended. LVN 2 stated anyone including residents would be able to access the medication. During an interview on 9/16/24 at 12:50 p.m. with LVN 3, LVN 3 stated the medication cart needed to be locked anytime it was unattended. LVN 3 stated anybody could access the medication and narcotics were supposed to be kept under two locks, if one lock was undone the narcotics were not stored appropriately. During a telephone interview on 9/24/24 at 3:32 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the medication cart to be locked unless the nurse was actively working with it. The DON stated an unlocked medication cart was a safety issue because confused residents and visitors could access the medication. The DON stated it could also cause an issue with HIPPA (Health Insurance Portability and Accountability Act-a federal law that sets a national standard to protect medical records and other personal health information). During a review of the facility ' s P&P titled Administering Medications, dated 4/2019, the P&P indicated, . Medications are administered in a safe and timely manner, and as prescribed . During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . The cart must be clearly visible to the personnel administering medications . During a review of a professional reference retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and Reports/Reports/downloads/lewingroup.pdf, titled, CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services Long-Term Care Pharmacy Primer, dated December 30, 2004, the professional reference review indicated, .C. Administration of Medications by Nursing Facility Personnel . Nursing facility personnel administer medications pursuant to the prescription order. The personnel designated to administer medications must be trained by the nursing facility . Medication Carts . The carts contain locked, non-removable drawers for each resident's medications . Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with all drawers locked .

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect when Resident 1's call light was removed from the wall and taken away from her on 2/20/2024. This failure violated Resident 1's right to have her call light accessible and within reach and resulted in Resident 1 to feel isolated and alone and without the ability to call staff for assistance. Findings: During a review of Resident 1 ' s Admission Record (AR), dated 3/7/24, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had a history of Alzheimer (a brain disease that causes memory loss and other cognitive impairment), Right femur (upper leg bone) fracture (broken bone), Right Artificial Hip Joint (a surgical procedure in which an orthopaedic surgeon removes the diseased parts of the hip joint and replaces them with a new prosthesis), Muscle weakness, and Abnormal gait and mobility (unable to walk in a typical way). During a review of Resident 1's Minimum Data Set (MDS - an evaluation of a resident's cognitive and functional status), dated 2/16/24, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 9 (a score of 0 - 7 indicated severe impairment, 8 - 12 indicated moderate impairment, and 13 - 15 indicated minimal to no impairment). During a review of Resident 1's MDS for Functional Abilities And Goals (FAAG) dated 2/16/24, the FAAG indicated Resident 1 required assistance to complete activities of daily living (eating, toileting, bathing, transferring, etc.) During an interview on 3/7/24 at 9:15 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 stated Certified Nursing Assistant (CNA) 1 came to her room on 2/20/24 around 12 o ' clock a.m. to check her briefs (an adult diaper). Resident 1 stated, CNA 1 threw the blanket off me, pushed and shoved me. I had a right hip incision from a hip replacement. I tried to cover my hip because it was hurting, she grabbed my hand and pulled it away. Then she took my call light away for no reason. Resident 1 stated, I like my call light on my bed so I can reach it to call staff for assistance. Resident 1 stated she used the call light to call staff for pain medication and when she soils her briefs. Resident 1 stated without the call light there was no way of calling staff for help. During an interview on 3/7/24 at 10:21 a.m. with CNA 2, CNA 2 stated she worked during the night shift on 2/20/24. CNA 2 stated Resident 1 was pushing her call light all night long. CNA 2 stated CNA 1 was assigned to provide care to Resident 1 that night and CNA 1 stated Resident 1 was crazy and CNA 1 was not going answer Resident 1 ' s call light. CNA 2 stated CNA 1 was instructed by Registered Nurse (RN) 1 to take Resident 1 ' s call light away. CNA 2 stated it was not acceptable to take call lights away from residents under any circumstances. During an interview on 3/7/24 at 10:30 a.m. with LVN 1, LVN 1 stated she worked during the night shift on 2/20/24. LVN 1 stated RN 1 was assigned to provide care to Resident 1. LVN 1 stated Resident 1 was alert and cooperative most of the time, sometimes confused during the night, and particular about care. LVN 1 stated Resident 1 pushed the call light excessively (more than three times an hour). LVN 1 stated Resident 1 would push the call light when she was not happy with how staff folded her blanket. LVN 1 stated it was not acceptable to take away the call light from the resident even if the resident was confused. LVN 1 stated if the resident pushed the call light 100 times, staff must answer the call light 100 times. During an interview on 3/7/24 at 12:14 p.m. with the Director of Nursing (DON), DON stated staff was not allowed to take anything away from the resident. DON stated call lights should be placed on the bed with the resident when the resident is in bed. DON stated it was unacceptable to take away the call light even if the resident is confused or have behavioral issues. During an interview on 3/7/24 at 12:20 p.m. with the Administrator (ADM), ADM stated Resident ' 1 son reported that Resident 1 ' s call light was removed from the wall on 2/20/24. ADM stated an investigation was completed on 2/20/24 and concluded that Resident 1 ' s call light was not removed from the wall but RN 1 did instruct CNA 1 to place Resident 1 ' s call light on Resident 1 ' s bedside table to minimize Resident 1 from pushing the call light. ADM stated RN 1 and CNA 1 were placed on suspension during the investigation on 2/20/24 and terminated on 2/26/24. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident ' s symptoms; e. self-determination; f. communication with and access to people and services, both inside and outside the facility; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility . During a review of the facility ' s policy and procedure (P&P) titled, Answering the Call Light, dated 3/2021, the P&P indicated, Purpose: The purpose of this procedure is to ensure responses to the resident ' s requests and needs. General Guidelines: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident .

Based on interview and record review, the facility failed to follow its transfer and discharge policy and procedure for one of three sampled residents (Resident 1) when the facility failed to comply with the legal requirements to provide Resident 1 with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. This failure had the potential to result in Resident 1's unsafe discharge and increased likelihood of preventable re-admissions. Findings: During an interview on 9/29/23, at 2:05 p.m., with Resident 1, inside Resident 1's room, Resident 1 stated, On 8/18/23, the Social Services Director (SSD) 1 and Business Manager (BM) came to my room and gave me a copy of the Discharge Notice and they told me that the facility found a Residential Care Facility (RCFE, a homelike environment designed to promote resident independence and self-direction to the greatest extent possible in a residential, non-medical setting.) that is willing to care for me and I will be discharged on [DATE]. I told them that I have an on-going Workers Compensation claim against my former employer and they should be responsible in paying for my nursing home expenses. I got injured while at work. My next Workers Compensation hearing is on October 26, 2023. I am paraplegic (inability to voluntarily move the lower parts of the body), diabetic (elevated blood sugar), hypertensive (high blood pressure), chronic pain (persistent pain that lasts for months to years) and depressed (a persistent feeling of sadness and loss of interest). I need nursing care 24/7. I am bedbound During a concurrent interview and record review on 9/29/23, at 2:20 p.m., with the Social Services Director (SSD) 2, Resident 1's Interdisciplinary Team Note (IDT), dated 8/18/23 was reviewed. The IDT note indicated, . IDT REVIEW OF 30-DAY NOTICE OF DISCHARGE . [Resident 1] was given a notice of discharge secondary to non-payment . IDT recommendations: Social Services and Activities support visits x [for] 72 hours starting next business day, nursing to monitor x 72 hours for psychological distress . refer for psychological evaluation . IDT attendees: SSD 1, DON, Activity Director, and Business Office Manager . SSD 2 stated Resident 1 refused to participate in planning his discharge to a RCFE. SSD 2 stated there was no record of psychological evaluation being completed. SSD stated without the psychological evaluation completed by a qualified provider, Resident 1's psychological condition and readiness for discharge was not determined and discharge to another health care setting could be unsafe. During an interview with the Acting Director of Nursing (ADON) on 10/4/23, at 3:00 p.m., the ADON stated Resident 1 should have a psychological evaluation by a qualified provider to determine his psychological condition and readiness for discharge to another level of care. The ADON stated Resident 1 was bedbound with chronic medical conditions including Major Depression, Paraplegia, Diabetes, Chronic Pain, and High Blood Pressure. The ADON stated Resident 1's discharge to another health care setting without a psychological evaluation could result to an unsafe discharge and could lead to preventable re-admissions. During a review of Resident 1's Admission Record (AR, documents containing resident demographic information and medical diagnosis), dated 9/29/23, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Major Depression, Paraplegia, Type 2 Diabetes Mellitus, and Chronic Pain. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities), dated 7/7/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated Resident 1 had no cognitive impairment (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a review of Resident 1's MDS Mood and Behavior, dated 7/7/23, the MDS indicated, . Mood .Total Severity Score 0 [no symptoms] . Behavior . Potential Indicator of Psychosis . 0 [Behavior of hallucination or delusions are not exhibited] . During a review of Resident 1's Nursing Care Plan (CP), dated 10/9/23, the CP indicated, . At risk for mood and behavior changes related to diagnosis of major depressive disorder recurrent, unspecified without medication use. Date initiated: 12/07/23 . During a review of Resident 1's Nursing Care Plan (CP), dated 10/9/23, the CP indicated, . Needs pain management and monitoring related to: history of chronic back pain syndrome. Date initiated: 2/25/22 . During a review of the Department of Health Care Services Office of Administrative Hearings and Appeals (a government entity that handles discharge appeals for long-term care residents) document titled, Decision and Order, dated 9/26/23, the document indicated, . SUMMARY . The appeal is GRANTED. [Facility] has not complied with the legal requirements to involuntary discharge [Resident 1] in that it did not provide Resident with sufficient preparation and orientation to ensure a safe and orderly discharge from the facility. Therefore, the discharge is improper, and Resident shall be permitted to remain in Facility . During a review of the facility's P&P titled, Transfers and Discharges, undated, the P&P indicated, . Transfers and discharges should be handled appropriately to assure proper notification and assistance to residents and family in accordance with federal and state specific regulations .

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had her personal belongings accurately inventoried at the time of admission. This failure resulted in Resident 1 ' s loss of personal belongings and the right to have an accurate inventory of personal possessions. During an interview on 5/2/23, at 9:25 a.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 had a small television sitting on the table with pictures. CNA 1 stated, Resident 1 ' s closet was full of clothing, two pairs of shoes. CNA 1 stated, We are responsible to complete a inventory sheet and list all [residents] belongings on admission. CNA 1 stated the inventory sheet should be done for all residents to keep track of their belongings. During an observation and interview on 5/2/23, at 11:30 a.m., with Social Services Director (SSD) 1, inside Resident 1 ' s room, SSD 1stated, there was a television sitting on the table. SSD 1, stated, I am not sure who ' s television it is. SSD 1, stated, there was no name or markings on the television to indicate who it belonged to. SSD 1 stated, Resident 1 ' s inventory sheet of personal possessions was blank upon admission. SSD 1 stated, the inventory sheet should indicate Resident 1 did come into the facility with belongings. SSD 1 stated the blank inventory sheet showed Resident 1 did not have belongings when admitted . SSD 1 stated, when Resident 1 was discharge from the facility, the inventory sheet was not completed and there was no record of her belongings. SSD 1 stated, We have no way of knowing what Resident 1 had while here. SSD 1 stated, if Resident 1 reported items missing, the facility had no way of tracking or verifying her belongings. During an interview and record review, with on 5/2/23 at 11: 45 a.m., with SSD 2, SSD 2, stated, Resident 1 ' s family members contacted her to report Resident 1 ' s television was missing. SSD 2, stated she was not sure what belongings Resident 1 had or is missing at this time because the inventory sheet was incomplete. SSD 2 stated, This is not the correct process to care for residents ' belongings. SSD 2, stated the inventory of personal possessions should have been completed on admission for Resident 1. During a review of Resident 1 ' s Admission Record (AR) , (a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/2/23, the AR indicated, Resident 1 was admitted from the general acute care hospital (GACH) on 9/27/18 to the facility, with diagnosis which included Diabetes Mellitus (chronic condition that affects the way the body process blood sugar), Dementia(characterized by progressive or persistent loss of intellectual functioning), Hypertension (Elevated Blood Pressure), and Diverticulitis( inflammation of the colon). During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool which indicates physical, medical and cognitive abilities) , dated 3/29/23, the MDS indicated Resident 1 ' s Brief Interview for Mental Status (BIMS) score was 11 of points which indicated Resident 1 had moderate cognitive impairment. During a review of Resident 2 ' s, AR, AR indicated Resident 2 was admitted from an acute care hospital on 8/30/22to the facility, with diagnosis which included, Dysphagia (difficulty swallowing foods or liquids), Morbid Obesity, Congestive Heart Failure, and History of falling. During an interview on 5/2/23, at 12:30 p.m., with Administrator (ADM), the ADM stated, [Resident 1] was admitted to the facility in 2018 and the inventory of personal possessions is blank and was not completed on admission. The staff are responsible to complete the inventory document . The ADM stated Resident 1 did not had a complete inventory sheet on admission. The ADM stated the process was to complete the admission inventory sheet per facility Policy and Procedure. The ADM stated the Medical Records and Social Services Department were responsible to ensure the inventory sheet was accurately completed on admission and whenever family members would bring in new items for the resident. The ADM, stated the facility was responsible for residents ' belonging. The ADM stated, We are not following the process to address the rights of the residents to have all their belongings returned when discharged . During a concurrent telephone interview and record review, on 5/4 /23, at 2:05 p.m., with Medical Records Director, (MRD), Resident 1's Inventory of Personal Possessions, undated, was reviewed. The Inventory of Personal Possessions, indicated, . Instructions: Upon admission, identify the resident ' s personal belongings by indicating quantity of those items listed . MRD stated, there was no belongings listed, no date, or signatures of Resident 1,2, and 3 ' s personal belongings accurately inventoried on admission. MRD stated, facility staff should indicate in the inventory sheet any personal belongings brought in at the time of admission and update as necessary throughout the resident's stay in the facility. MRD stated, the staff failed to follow the facility's policy on Personal Property. During a review of the facility's policy and procedure (P&P) titled, Personal Property, dated 3/2021, the policy indicated, . Resident belongings are treated with respect by facility staff, regardless of perceived value . The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary .

Based on observation, interview, facility document and Policy and Procedure review, the facility failed to identify and address complications related to an enteral feeding (complete nutrition delivered via a feeding tube directly into the stomach) for one of one sampled residents (Resident 21) when dehydration risk was not care planned and monitored for Resident 21 who received enteral feedings as the sole means of nutrition and fluid. This failure caused dehydration in Resident 21 which could lead to further medical complications including but not limited to confusion, weakness, low blood pressure, kidney problems and in severe incidences, death. Findings: According to the Journal of Nutrients titled, Chronic Dehydration in Nursing Home Residents, dated [DATE], the journal indicated, The adult human body consists of about 60% water, with muscle functioning as the main reservoir of water, but in older adults, this amount is reduced to only around 50% due to reduced muscle mass. Among older adults, dehydration is common and is associated with several serious adverse events, including longer hospital stays and higher mortality (the state of being subject to death) rates . Chronic dehydration mainly occurs due to insufficient fluid intake over a lengthy period of time, and nursing home residents are thought to be at high risk for chronic dehydration.Chronic dehydration is mainly due to insufficient fluid intake over a lengthy period and is often insidious (proceeding in a gradual way but with harmful efffect) . Older adults are considered at risk for chronic dehydration due to their reduced sensitivity to thirst, lower urine concentrating ability, and lower fluid intake compared with young or middle-aged adults. Furthermore, older nursing home residents may be at high risk for chronic dehydration because lower fluid intake is commonly observed in nursing home residents .Chronic dehydration may be more problematic among nursing home residents, and establishing effective preventive strategies for chronic dehydration in this population would require identifying the risk factors for chronic dehydration. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709028/ According to the Nutrition in Clinical Practice Journal titled, Long-term enteral nutrition (a form of nutrition that is delivered into the digestive system as a liquid) support and the risk of dehydration, dated 12/20/2005, the Journal indicated, Dehydration is a serious risk for the long-term tube-fed patient who are not allowed oral intake, have an altered mental status, are unable to communicate, are elderly or fluid-restricted, or have thirst impairment. The intent of this review is to provide a case-based discussion regarding the evaluation, treatment, and prevention of dehydration in these types of patients. Identification of risk factors, along with evaluation of subjective, objective, and laboratory parameters, provides the basis for clinical evaluation . The method for treatment and prevention of dehydration depends on the presence or absence of hypovolemia (decreased volume of circulating blood in the body), type of body fluid losses, and whether the patient demonstrates hypernatremia (elevated sodium levels in the blood), normonatremia (normal sodium levels in the blood), or hyponatremia (low sodium levels in the blood). https://pubmed.ncbi.nlm.nih.gov/16306302. A review of Resident 21's Admission Record was initiated on 3/21/23. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included arthropathy (joint disease), unspecified protein-calorie malnutrition (nutritional disorder caused by inadequate quantities of protein and energy in the diet), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition and inactivity often accompanied by dehydration), cachexia (weakness and wasting of the body due to severe chronic illness), encounter for attention to gastrostomy (a surgical opening into the stomach from the abdominal wall for the introduction of food), dementia (condition characterized by progressive loss of intellectual functioning), gastro-esophageal reflux disease (a condition in which acidic gastric fluid [acidic fluid secreted by the stomach] flows backward into the esophagus [a muscular mucus lined tube that connects the throat to the stomach]), iron deficiency anemia (low iron in the blood), hyperlipidemia (high concentration of fat in the blood), alcohol abuse, and depression. The most recent Minimum Data Set (MDS, a resident assessment tool) dated 1/31/23), indicated a BIMS (brief interview for mental status) score of 3 out of a possible 15, indicating Resident 21 had severe cognitive impairment in decision making. A review of the facility document titled, Order Summary Report dated 2/28/23, showed on 11/11/22 an order for enteral feeding [Brand Name 1.5] 50 milliliters (mL-unit of measurement) per hour (mL/hr) for 20 hours for a total of 1000 mLs, 1500 calories (measurement of the energy content of food) was ordered for Resident 21 by the Physician. On 10/26/23 an order to flush with 90 mL of water four times per day was ordered for Resident 21 by the Physician. On 3/21/23 at 9:30 a.m., an observation was conducted of Resident 21. Resident 21 was alert, in bed watching television, gastrostomy tube (G-Tube a tube inserted directly into the wall of the belly that bring nutrition directly into the stomach) in place, lips appeared dry and cracked, tongue and mouth were covered with thick yellow saliva (watery fluid in the mouth which provides lubrication for chewing and swallowing). On 3/23/23 at 8:47 a.m., a review of Resident 21's MR and concurrent interview was conducted with the Registered Dietitian (RD). The RD confirmed Resident 21 was admitted to the facility from the hospital on 10/26/22. Review of the discharge summary from the hospital dated 10/26/22 was reviewed with the RD. The RD confirmed Resident 21's final diagnoses upon discharge from the hospital included: dementia, cachexia/malnourished/very poor appetite with PEG (percutaneous endoscopic gastrostomy- a feeding tube through the skin and the stomach wall) tube, hypertension (high blood pressure), arthritis (inflammation of joints), iron deficiency anemia, and status post C. difficile colitis (bacteria that causes inflammation of the colon). The RD confirmed Resident 21 was on enteral feeding [Brand Name 1.2] at 50 mL/hr in the hospital which provided 1200 mL, 1440 calories and 15 mL/hr of water which provided 360 mL water. The RD confirmed labs drawn when Resident 21 was in the hospital on 10/25/22 showed the following normal results: sodium result: 135. Sodium is an electrolyte mineral that helps with the function of nerves and muscles and helps keep the correct balance of fluids in the body. BUN (blood urea nitrogen [a waste product in the blood]) result: 25. BUN is a measurement of the chemical urea (a waste product that is excreted by the kidneys and measured in the blood). Creatinine result: 0.68. Creatinine is a waste product produced by muscles which is removed from the body by the kidneys. The RD confirmed these normal laboratory values indicated Resident 21's hydration status was normal. The facility document titled Nutrition Data V2.1-V2 completed by the RD on 10/28/22 was reviewed with the RD. Section 5. Dehydration Risk Factors showed Resident 21 had dementia. Section 8. Pertinent Labs Values (past 90 days) showed none (no lab values). The RD stated the Nutrition Data V2.1-V2 was a screening form. The RD agreed Resident 21 was at risk for dehydration related to dementia and the fact that Resident 21 was dependent on nursing to provide all nutrients and fluids via G-tube. The facility document titled Nutrition Assessment - V3 completed by the RD on 10/28/22 was reviewed with the RD. The RD confirmed the following: Section 1. Estimated Nutrient Needs showed 4. Fluid: 1125-1350 mL (1mL/kcal). Section 3. Nutrition Diagnosis showed enteral feeding [Brand Name 1.5] at 50 mL/hr for 20 hours providing 1000 mL/1500 kcal (calorie), 63 grams (g-unit of measurement) protein, and 760 mL water. Water flush 90 mL four times per day providing 360 mL. The enteral feeding (complete nutrition delivered via a feeding tube directly into the stomach) and water flushes provided 1120 mL in addition to water provided with medications 15 mL before and after administration. Section 5. Nutrition Goals 1. Enteral feeding tolerance. No signs/symptoms of aspiration (breathing in of food or fluid into the lungs), Gradual weight gain is desired Body Mass Index (BMI- person's weight divided by height) greater than 18.5. The RD confirmed the Nutrition Assessment -V3 she completed on 10/28/22 did not address the fact that Resident 21 was at risk for dehydration and no goal for maintaining hydration status was indicated. The RD stated, nursing was responsible to create the hydration care plan. The RD stated she assessed enteral feeding residents quarterly if they were stable. The discharge summary of care from the hospital emergency department dated 1/23/23 for Resident 21 was then reviewed with the RD. The RD confirmed Resident 21 was transferred from the facility to the hospital emergency department on 1/23/23. The RD confirmed the admitting diagnoses to the hospital emergency department included: complaint associated with gastric tube, tachycardia (abnormally rapid heart rate), hypernatremia (elevated sodium in the blood), dehydration (a harmful reduction in the amount of water in the blood) moderate. The RD confirmed the last labs drawn in the hospital emergency department on 1/23/23 at 1951 [7:51 PM] hours showed: sodium result: 154 (elevated). The normal reference range was documented as 135-145. BUN result 42 (elevated). The normal reference range was documented as 6-20. Calculated Osmolality result: 328 (elevated). Plasma osmolality measures the body's electrolyte-water balance (electrolytes are minerals in the blood that have an electric charge). The normal reference range was documented as 282-300. BUN/Creatinine ratio result: 60 (elevated). BUN/Creatinine ratio is used to diagnose kidney disease or damage. The normal reference range was documented as 15-20. RD confirmed the labs were consistent with a diagnosis of dehydration. The RD confirmed she usually looked at hospital transfer records but did not review the hospital emergency department discharge summary of care dated 1/23/23. The RD stated she thought the resident went to the hospital for a dislodged G-tube and was not aware Resident 21 was dehydrated. The RD stated she should have increased the water flush and recommended labs be repeated to assess Resident 21's hydration status when she was readmitted to the facility on [DATE]. Review of the facility document titled Nutrition Data V2.1-V2 Type: Quarterly completed by the Certified Dietary Manager (CDM) on 1/31/23 showed, Section 8. Pertinent Lab Values (past 90 days): none. Section 9. Summary showed 1. Additional Information .Receiving 100% of nutrition needs via PEG tube Water flushes as ordered.Will continue to monitor. Although the RD stated she assessed residents on enteral feedings quarterly, the quarterly assessment dated [DATE] was not completed by the RD. On 3/23/23 at 1:54 p.m., an observation of Resident 21 was conducted. Resident 21 appeared frail and thin. Resident 21's lips appeared dry and cracked. The interior of Resident 21's mouth appeared dry with thick saliva and a yellow-colored film on her teeth. When asked if she was thirsty, Resident 21 replied, Oh, yes! On 3/23/23 3:20 p.m., a review of Resident 21's MR and concurrent interview was conducted with the Assistant Director of Nursing (ADON). The ADON confirmed Resident 21 had a Change in Condition on 1/23/23 documented at 3:12 a.m. related to a G-tube blockage or displacement. Resident 21 was transferred to the hospital at 2:24 a.m. On 3/23/23 at 4:45 p.m., during an observation of Resident 21 and concurrent interview with the Director of Staff Development (DSD), the DSD confirmed Resident 21 was on an enteral feeding. The DSD stated Resident 21 was at risk for dehydration. The DSD confirmed Resident 21's lips were dry and cracked. The DSD was asked to test Resident 21's skin turgor (an assessment technique where a decrease in skin turgor [elasticity of the skin] is indicated when the skin on the back of the hand is pulled up for a few seconds and does not return to its original state and is a sign of dehydration). After the DSD tested the skin turgor on the back of Resident 21's hand, the skin did not return to its original state for three seconds. The DSD stated signs of dehydration included poor skin turgor, dry flakey skin, or cracked dry lips. The DSD stated Resident 21 looked dehydrated. On 3/24/23 at 10:59 a.m., a review of Resident 21's Medical Record (MR) and concurrent interview was conducted with Assistant Director of Nursing (ADON). The ADON was asked to explain the initial assessment process for newly admitted residents. The ADON stated nursing staff completed the facility form titled, Clinical Health Status with Baseline Care Plan V-4-V5 (CHSBCP). The CHSBCP for Resident 21 was reviewed with the ADON. The Section titled DEH. Nutritional/Dehydration Risk of the CHSBCP for Resident 21, showed Hydration Risk Score was medium risk. Question 4a., Does the resident have a current nutrition care plan? 2. No. Question 4c. Does the resident have a current hydration care plan? This question was not answered and left blank. The ADON confirmed the CHSBCP for Resident 21 was not complete for the hydration care plan question. The ADON stated, a care plan should have been created for dehydration risk based on the CHSBCP hydration medium risk score. The ADON stated, a dehydration risk care plan should have a focus such as resident was at risk for dehydration related to resident being dependent on others for nutrition and fluids, and impaired cognition. A dehydration care plan should have a goal to show no signs or symptoms of dehydration. Appropriate interventions for a dehydration care plan would be to monitor for signs and symptoms of dehydration such as skin turgor, dry mouth, dry mucus membranes, increased heart rate, and low blood pressure. The ADON confirmed a care plan for dehydration risk had not been implemented for Resident 21 upon admission. The ADON stated the facility did not have a plan to monitor Resident 21's dehydration risk. During the interview with the ADON, she confirmed Resident 21 was considered a readmission on 1/24/23 due to the fact that she was in the hospital over 24 hours. Resident 21 left the faciity on [DATE] at 0214 hours [2:14 a.m.] and returned to the facility on [DATE] at 0249 [2:49 a.m.] hours. The ADON confirmed a CHSBCP was not completed for Resident 21 when she returned to the facility on [DATE]. The ADON confirmed a nursing progress note dated 1/24/23 completed by Licensed Vocational Nurse (LVN) 12, stated MD (medical doctor) to review labs and adjust for dehydration . The ADON was unable to confirm the Physician was notified of Resident 21's return to the facility on [DATE]. The ADON stated typically the Physician is called or texted regarding the resident's return to the facility with an update on the Resident's condition and should be documented in the Resident's MR. During the interview with the ADON, she was asked to review the summary of care from the hospital emergency department dated 1/23/23 located in the physical MR chart for Resident 21. The ADON stated, nursing was responsible to review the summary of care received from the hospital emergency department and notify the Physician. The ADON confirmed that Resident 21 was admitted to the hospital emergency department on 1/23/23 with diagnoses which included hypernatremia (elevated sodium in the blood) and dehydration. The ADON confirmed the last documented water flush was given by nursing at the facility at 2100 [9:00 p.m.] hours on 1/23/23 prior to Resident 21 being transferred to the hospital, therefore Resident 21's gastrostomy tube (G-tube) was intact at 2100 [9:00 p.m.] hours. The next documentation from nursing was at 2:08 a.m. when the nurse found Resident 21's G-tube was dislodged. The ADON agreed Resident 21 could not become dehydrated from the G-tube becoming dislodged if the G-tube became dislodged between 2101 [9:01 p.m.] hours and 0208 [2:08 a.m.] hours, a total of five hours and seven minutes. The ADON stated if the facility noticed there was a problem with dehydration in a resident, they would notify the Physician and get an order for lab work. The ADON confirmed there were no Physician orders for lab work, nor any lab results in Resident 21's electronic MR or physical MR. The Physician progress notes for Resident 21 dated 2/1/23 and 3/1/23 were reviewed with the ADON. The ADON confirmed the Physician progress notes dated 2/1/23 and 3/1/23 showed he reviewed labs in the chart. The ADON confirmed the Physician did not mention dehydration in the Physician progress notes dated 2/1/23 or 3/1/23. The ADON was asked to review the last labs drawn for Resident 21 on 1/23/23 at 1951 [7:51 p.m.] hours prior to being discharged from the hospital emergency department. The ADON agreed the lab work for Resident 21 showed serum (part of the blood) sodium, BUN, calculated osmolality, and BUN/Creatine ratio were all elevated which indicated Resident 21 was dehydrated when she was discharged from the hospital. The ADON was asked to assess the photograph taken on 3/21/23 at 9:30 a.m. of Resident 21's mouth and lips. The ADON stated Resident 21 showed signs and symptoms of dehydration and that should raise concern. On 3/24/23 at 2:15 p.m. a review of Resident 21's MR and concurrent interview was conducted with the RD. The RD was asked to calculate the water content of the enteral feeding order on the discharge summary instructions from the hospital dated 10/26/22. The RD confirmed the enteral feeding and water flush orders on the discharge summary instructions from the hospital dated 10/26/22 provided a total of 1328 mL of water. The RD confirmed she changed the enteral feeding when Resident 21 was admitted to the facility on [DATE] to a more concentrated enteral formula that provided more calories but less water. The RD confirmed she recommended a total of 1120 mL water (enteral feeding plus water flush), 208 mL less water per day compared to the enteral feeding order from the hospital discharge summary instructions. When asked why the RD did not provide the same quantity of water for Resident 21 as the discharge summary instructions, the RD stated she calculated a range of water needs of 1125-1350 mL a day for Resident 21. The RD stated it would have been better to give the same quantity of water as the enteral feeding order on the discharge summary instructions. The RD agreed that over time, providing 208 mL less water per day could contribute to inadequate water intake for Resident 21. On 3/24/23 at 4:12 p.m. a review of Resident 21's MR and concurrent interview was conducted with Resident 21's Attending Physician (AP). The physician progress notes dated 2/1/23 and 3/21/23 stated labs were reviewed in chart. The AP was asked what labs he reviewed during his 2/1/23 and 3/1/23 visits to the facility. The AP stated his progress notes were a template he used on his computer. The AP confirmed he had not ordered any laboratory tests for Resident 21 since she was admitted to the facility on [DATE]. The AP stated he had not ordered lab work for Resident 21 because the facility had not notified him there was a problem with Resident 21. The AP was asked about the hospital emergency department admission on 1/23/23. The AP stated the facility did not inform him Resident 21 had returned to the facility. The AP further stated he was not aware Resident 21 was diagnosed with dehydration at the hospital emergency department. The AP stated the facility had not notified him Resident 21 was diagnosed with dehydration. The AP was shown the discharge summary of care dated 1/23/23 from the hospital emergency department for Resident 21 located in Resident 21's physical chart. The AP confirmed he did not review the discharge summary of care dated 1/23/23 from the hospital emergency department for Resident 21 when she was readmitted to the facility on [DATE]. The AP stated he currently only worked with electronic records and rarely saw paper records. The AP was asked to review the labs dated 1/23/23 at 1951 hours [7:51 p.m.] from the hospital emergency department. The AP stated, I fully agree that the resident was dehydrated. The AP was asked his opinion of the photograph taken on 1/21/23 at 9:30 a.m. of the Resident 21's lips and mouth. The AP stated, Resident 21 needed oral care. A review of the progress note written by LVN 12 for Resident 21 dated 1/24/23 at 1510 hours [3:10 p.m.] showed, Labs attempted x 5 without success for resident. Will return tomorrow. Writer will pass on need for increased fluids to assist with successful draw . A review of the facility document titled, Order Summary Report dated 3/24/23, showed on 3/23/23 an order to Flush [G-tube] with 160 [mL] of water q (every) six hours four times a day. A review of the lab work for Resident 21 dated 3/24/23 at 18:14 hours [6:14 PM] showed: Sodium result 147 (elevated). The normal reference range was documented as 135-145, BUN result 69 (elevated). The normal reference range was documented as 6 -[illegible] Calculated Osmolality 322 (elevated). The normal reference range was documented as [illegible]-300. BUN/Creatinine ration result 69 (elevated). The normal reference range was documented as 15-20. On 3/27/23 at 4:43 p.m. a review of Resident 21's lab results dated 3/24/23 and concurrent interview was conducted with the ADON. The ADON was asked what lab values were indicative of dehydration. The ADON stated elevated sodium, potassium (a mineral in the blood), BUN and calculated osmolality would be indicative of dehydration. The ADON confirmed the lab results for Resident 21 dated 3/24/23 indicated sodium, BUN and calculated osmolality were elevated. The ADON confirmed the lab results for Resident 21 indicated she was dehydrated. A review of the facility's Policy and Procedure (P&P) titled, Comprehensive Assessment, revised March 2022 showed, Comprehensive assessments are conducted to assist in developing person-centered care plans . Admission Assessment- The admission assessment is a comprehensive assessment for a new resident . Comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation of other health professionals on the interdisciplinary team. A review of the facility's P&P titled, Change in a Resident's Condition or Status, revised May 2017 showed, .The nurse will notify the resident's Attending Physician or physician on call when there has been a .need to transfer the resident to a hospital/treatment center . A review of the facility's P&P titled, Care Plans, Comprehensive Person Centered, revised December 2016 showed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will: .include measurable objectives and timeframes; .h. incorporate risk factors associated with identified problems; .aid in preventing or reducing decline in the resident's functional status and/or functional levels; .Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change .The interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident's condition .

Based on interview and record review, the facility failed to establish and implement a comprehensive antibiotic (ATB) stewardship (program designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) and surveillance program to identify, track, and monitor resident antibiotic use when the facility's ATB stewardship and surveillance program was not conducted for January 2023 and February 2023. These failures had the potential to place residents at risk for an adverse effect of antibiotics and/or develop an antibiotic-resistant (not effective to treat infection) organisms from unnecessary or inappropriate antibiotic use. Findings: During a concurrent interview and record review on 3/27/2023, at 1:32 p.m., with Infection Preventionist (IP) 2, IP 2 stated IP 1 assumed the position two weeks ago. IP 2 stated she is covering for IP 1. IP 2 reviewed the Order Listing Report for the month of January and February 2023. The IP 2 stated, .There are no surveillance line listings for antibiotic use for the month of January and February 2023 . IP 2 stated there should have been an infection surveillance log for antibiotic use to verify if antibiotic usage was appropriate for a resident. IP 2 stated the surveillance form line listing was important to determine if the infection was a healthcare associated infection (HAI-infection acquired when receiving care in a healthcare facility) or a community acquired infection (CAI- acquired in the general population). During an interview on 3/27/23, at 4 p.m., with Assistant Director of Nursing (ADON), ADON stated the expectation was for the IP to do the line listing to ensure residents on antibiotics meet the infection criteria. ADON stated IP should have been tracking the type of infections happening in the facility and one way to do it was completing a line listing of all the antibiotics used in the facility and the type of infections. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship Policy, undated, the P&P indicated, .1. Resident will be evaluated for infection using standardized tools and criteria . 2. Nursing staff will review laboratory or other diagnostic testing and report abnormal results to the practitioner . 6. Review of laboratory culture reports to determine if the antibiotic remains indicated or if adjustments to therapy should be made . During a review of the facility's clinical document titled, Infection Prevention and Control, undated, indicated, .Monitoring and documenting infections, including tracking and analyzing outbreaks of infection as well as implementing and documenting actions to resolve related problems . Surveillance, including process and outcome surveillance, monitoring, data analysis, documentation and communicable diseases reporting . Antibiotic review including reviewing data to monitor appropriate use of antibiotics in the resident population . Documenting observations related to the causes of infection and/or infection trends; and Implementing measures to prevent the transmission of infectious agents and to reduce risks for device and procedure- related infections . Essential elements of a surveillance system include use of standardize definitions and listings of the symptoms of infections, use of surveillance tools such as infection surveys and data collection templates . During a review of a professional reference from CDC (Centers for Disease Control) found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html dated CDC (Centers for Disease Control) Professional Reference titled, The Core Elements of Antibiotic Stewardship for Nursing Homes (found at www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html) indicated, . Leadership Commitment . Nursing home leaders commit to improving antibiotic use. Facility leadership, both owners and administrators, as well as regional and national leaders if the facility is part of a larger corporation, can demonstrate their support in the following ways . Communicate with nursing staff and prescribing clinicians the facility's expectations about use of antibiotics and the monitoring and enforcement of stewardship policies . Create a culture through messaging, education . which promotes antibiotic stewardship . Accountability . Nursing homes identify individuals accountable for the antibiotic stewardship activities who have the support of facility leadership . Empower the Director of Nursing to set the practice standards for assessing, monitoring and communicating changes in a resident's condition by front-line nursing staff. Nurses and nurse aides play a key role in the decision-making process for starting an antibiotic . Therefore, the importance of antibiotic stewardship is conveyed by expectations set by nursing leadership in the facility . Infection program coordinator . Infection program coordinators have key expertise and data to inform strategies to improve antibiotic use. This includes tracking of antibiotic starts, monitoring adherence to evidence-based published criteria during the evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility . Tracking and Reporting Antibiotic Use and Outcomes . Process Measures: Tracking how and why antibiotics are prescribed . Perform reviews on resident medical records for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with facility antibiotic use policies and practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians . Antibiotic use measures: tracking how often and how many antibiotics are prescribed . Track the amount of antibiotic used to review patterns of use and determine the impact of new stewardship interventions .

Based on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for seven of seven sampled residents (Residents 1, 22, 24, 36, 64, 81, and 367) when: 1. Resident 81 was receiving hospice services without a written physician order. 2. Resident 22 , Resident 367 and Resident 64 were receiving hospice services with unsigned hospice agreement. 3. Hospice personnel caring for residents under hospice services were not provided orientation to the facility's policies and procedures. These failures had the potential to place Residents 1, 22, 24, 36, 64, 81, and 367 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: 1. During a concurrent interview and record review, on 3/22/23, at 2:08 p.m., with the Acting Director of Nursing (DON), Resident 81's Physician's Order (PO), dated 3/22/23 was reviewed. The PO indicated, . Notify [Name of Hospice Agency] of any changes . Order Date 12/03/2022 . DON stated, he was unable to find a valid Hospice order for Resident 81. DON stated, the physician order verbiage starts with a sentence such as admit to hospice services with a terminal diagnosis of [blank] and the name of the hospice agency. I can't find the hospice order. DON stated, without a specific physician order for hospice services, Resident 81 could potentially receive care against her wishes. During a review of Resident 81's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on 10/12/22 to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). During a review of Resident 81's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Notify [Name of Hospice Agency] of any changes . Order Date 12/03/2022 . During a review of Resident 81's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Has a Terminal Prognosis/End Stage Condition with Less Than 6 Months to Live if Disease Follow It's Natural Course . Interventions . Work cooperatively with hospice team to ensure resident's spiritual, emotional, intellectual, physical and social needs are met . Date Initiated . 2/5/23 . During a review of the facility's P&P titled, Hospice Program, dated 7/2017, the P&P indicated, . 12. Our facility has designated the DON [Director of Nursing] to coordinate care provided to the resident by our facility staff and the hospice staff . Obtaining the following information from the hospice . Hospice physician and attending physician (if any) orders specific to each resident . 2. During a concurrent interview and record review, on 3/22/23, at 2:15 p.m., with the Acting Director of Nursing (DON), the facility's Hospice Agreement with [Name of Hospice Agency], dated 12/8/22 was reviewed. The hospice agreement indicated, . IN WITNESS WHEREOF, each of the undersigned has caused this Business Associate Agreement to be executed in its name and on its behalf by its duly authorized representative . DON stated, there was no signature from [Name of Hospice Agency] authorized representative. DON stated, the hospice agreement must be signed by both parties prior to initiating hospice services for Resident 22 and Resident 367's. DON stated, without the signature the hospice agreement was not valid. During a concurrent interview and record review on 3/22/23, at 2:20 p.m., with the Director of Nursing (DON), the facility's hospice agreement with [Name of Hospice Agency], dated 12/8/22 was reviewed. The document indicated, . IN WITNESS WHEREOF, each of the undersigned has duly executed this Agreement on behalf of the of the party and on the date set forth below . DON stated, there was no signature from the facility's authorized representative. DON stated, the hospice agreement must be signed by both parties prior to initiating Resident 64's hospice services. DON stated, without the signature the hospice agreement was not valid. During a concurrent interview and record review, on 3/23/23, at 9:30 a.m., with t Administrator (ADM), the facility's hospice agreement with [Name of Hospice Agency] and [Name of Hospice Agency] , dated 12/8/22 were reviewed. ADM stated, there were missing signatures on the two agreements and both should be signed prior to initiating hospice services to facility residents. ADM stated, without the signature of the authorized representative, the hospice agreement was not valid. During a review of Resident 22's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/22/23, the AR indicated, Resident 22 was admitted from an acute care hospital on 12/1/22 to the facility, with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Chronic Pain (experiencing pain greater than 6 months), and Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness). During a review of Resident 22's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] for End Stage Heart Disease . Order Date 11/17/2022 . During a review of Resident 22's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Patient is on Hospice care . Date Initiated . 12/1/22 . During a review of Resident 367's AR, dated 3/22/23, the AR indicated, Resident 367 was admitted from an acute care hospital on 2/20/23 to the facility, with diagnoses which included Alzheimer's Disease (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Heart Failure, and Palliative Care. During a review of Resident 367's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] . Order Date . 2/20/23 . During a review of Resident 367's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Has a Terminal Prognosis/End Stage Condition . Date Initiated . 2/12/23 . During a review of Resident 64's AR, dated 3/22/23, the AR indicated, Resident 64 was admitted from an acute care hospital on 9/20/22 to the facility, with diagnoses which included Protein Calorie Malnutrition, Dementia, Muscle Weakness, and Palliative Care. During a review of Resident 64's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit patient to [Name of Hospice Agency] . Order Date . 1/2/23 . During a review of Resident 64's Nursing Care Plan (CP), dated 3/22/23, the CP indicated, . Patient is on Hospice related to: End of Life Care . Date Initiated . 3/15/23 . During a review of the facility's P&P titled, Hospice Program dated 7/2017, the P&P indicated, . Hospice services are available to residents at the end of life . 6. The agreement with the hospice provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to any resident . 3. The facility failed to ensure that hospice personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures. During an interview on 3/22/23, at 9:06 a.m., with Hospice Aide (HHA), in Station 3 hallway, HHA stated, she was the assigned Hospice Aide for Resident 1 for over two months. HHA stated, she provided bed bath and personal care once a week to Resident 1. HHA stated, she does not recall having an orientation on the facility's policy and procedures or meeting the facility's Hospice Coordinator. During a concurrent interview and record review, on 3/22/23, at 2:30 p.m., with the Acting Director of Nursing (DON), the facility's Hospice Program Policy and Procedure (P&P), dated 7/2017 was reviewed. The P&P indicated, . 12. Our facility has designated [name] RN/DON to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . DON stated, he does not have any record or proof that an orientation on the P&P of the facility to hospice staff caring for facility residents was done. DON stated, the facility failed to follow its own hospice policy. DON stated, the lack of orientation to the facility's policy and procedure to hospice personnel could potentially result to not meeting the medical, physical, psychosocial, and spiritual needs of Residents 1, 22, 24, 36, 64, 81, and 367. During a review of Resident 1's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/24/23, the AR indicated, Resident 1 was admitted from an acute care hospital on 11/14//20 to the facility, with diagnoses which included Protein-Calorie Malnutrition (not consuming enough protein and calories), Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), and Chronic Obstructive Pulmonary Disease (COPD - is a chronic inflammatory lung disease that causes obstructed airflow of the lungs). During a review of Resident 1's Order Summary Report (OSR), dated 3/24/23, the OSR indicated, . Admit patient to [Name of Hospice Agency] with terminal diagnosis COPD . During a review of Resident 22's Admission Record (AR), dated 3/22/23, the AR indicated, Resident 22 was admitted from an acute care hospital on 12/1/22 to the facility, with diagnoses which included Heart Failure (weakness in the heart where fluid accumulates in the lungs), Chronic Pain (experiencing pain greater than 6 months), and Palliative Care (specialized medical care to ease symptoms without curing the underlying disease for people living with a serious illness). During a review of Resident 22's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] for End Stage Heart Disease . Order Date 11/17/2022 . During a review of Resident 24's Admission Record (AR), dated 3/22/23, the AR indicated, Resident 24 was admitted from an acute care hospital on 4/24/20 to the facility, with diagnoses which included Heart Failure, Unspecified Joint Pain, and Palliative Care. During a review of Resident 24's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] . Order Date 2/23/2023 . During a review of Resident 36's Admission Record (AR), dated 3/22/23, the AR indicated, Resident 36 was admitted from an acute care hospital on 6/13/22 to the facility, with diagnoses which included Cerebral Infarction (stroke), Epilepsy (a brain disorder that causes seizures), Hypertension (elevated blood pressure), and Palliative Care. During a review of Resident 36'sOrder Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] diagnosis of COPD . Order Date . 6/13/22 . During a review of Resident 64's Admission Record (AR), dated 3/22/23, the AR indicated, Resident 64 was admitted from an acute care hospital on 9/20/22 to the facility, with diagnoses which included Protein Calorie Malnutrition, Dementia, Muscle Weakness, and Palliative Care. During a review of Resident 64's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit patient to [Name of Hospice Agency] . Order Date . 1/2/23 . During a review of Resident 81's Admission Record (AR), dated 3/22/23, the AR indicated, Resident 81 was admitted from an acute care hospital on 10/12/22 to the facility, with diagnoses which included Protein-Calorie Malnutrition, Anxiety Disorder, Dementia, and Palliative Care. During a review of Resident 81's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Notify [Name of Hospice Agency] of any changes . Order Date 12/03/2022 . During a review of Resident 367's Admission Record (AR), dated 3/22/23, the AR indicated, Resident 367 was admitted from an acute care hospital on 2/20/23 to the facility, with diagnoses which included Alzheimer's Disease (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Heart Failure, and Palliative Care. During a review of Resident 367's Order Summary Report (OSR), dated 3/22/23, the OSR indicated, . Admit to [Name of Hospice Agency] . Order Date . 2/20/23 . During a review of the facility's P&P titled, Hospice Program, dated 7/2017, the P&P indicated, . 12. Our facility has designated [name] RN/DON to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being .

Based on observation, interview and record review, the facility failed to contain garbage and refuse (nonhazardous solid waste) properly when two out of three dumpsters were found to not have securely closing lids. This failure had the potential to attract rodents, insects and flies and could spread infection which placed residents at risk for foodborne illness. Findings: During a concurrent observation and interview, on 3/21/23, at 10:51 a.m., with Maintenance Supervisor (MS), in the back parking lot near the dumpsters, three dumpsters were observed with two lids atop of each the dumpsters. Two of the three dumpsters had lids that would not close. Two of the three trashcans were observed to have a gaps in the lids where they should be closed. MS stated, there were gaps between the lids on the two dumpsters observed and that a raccoon could potentially get inside the dumpster because of the gaps. During an interview on 3/22/23, at 9:15 a.m., with Housekeeping Supervisor (HS), HS stated the dumpster should have lids that close and the lids should be closed in the middle without a gap. During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, undated, the P&P indicated .All garbage and refuse containers are provided with lids or covers and must be kept covered when stored or not in continuous use .Outside dumpsters provided by garbage pickup services will be kept closed . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2022, the USFDA Food Code indicated, . Section 5-501.113 . Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered . With tight-fitting lids or doors if kept outside the food establishment .

Based on interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for two of four sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 experienced a continuous and progressive weight decline from ,d+[DATE] to ,d+[DATE], with a total weight loss of 55 pounds (lbs- a unit of measurement) (35 percent of body weight). 2. Resident 2 experienced a 13 lbs (9.8 percent) weight loss in 6 months, and 8 pounds (6.2 percent) loss in 1 month with no implemented interventions to address the weight loss. As a result, the facility's system was not effective at ensuring the Registered Dietitian (RD) and the Interdisciplinary team (IDT- a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) evaluated unplanned weight loss. The facility failed to consistently ensure that nutrition interventions to address identified nutritional concerns were implemented. These failures resulted in weight loss for Resident 1 and Resident 2. Findings: 1. During a review of Resident 1's face sheet (document containing personal and medical information) dated ,d+[DATE], the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's admission weight was documented as 157 lbs. Resident 1's admission diet order was a mechanical soft diet (is a texture modified diet that restricts foods that are difficult to chew or swallow). Resident 1's cognitive skills for daily decision making was severely impaired. During a review of Resident 1's Weight Record, on [DATE], Resident 1 experienced a continuous and progressive weight decline. On [DATE], Resident 1 weighed 153 lbs, a loss of 5 lbs since admission. Monthly weights taken on [DATE] (152 lbs), [DATE] (150 lbs), [DATE] (148 lbs) and [DATE] (147 lbs) demonstrated a gradual decline of Resident 1's weight. A weight taken on [DATE] was 141 lbs, an additional weight loss of 17 lbs (10 percent) over 6 months, which was considered severe. Resident 1's weight continued to decline. On [DATE], Resident 1's weight was documented at 118 lbs, an additional decrease of 23 lbs (16 percent) weight loss, since admission, of 35 lbs or 22 percent of her usual body weight. Resident 1 continued progressive monthly weight loss until [DATE] when Resident 1 expired. Resident 1's final weight was documented at 102 lbs on [DATE], an additional weight loss of 9 lbs (8 percent) in 3 months. Resident 1 experienced a total weight loss of 55 lbs, a loss of 35 percent of her body weight. During a review of Resident 1's Nutrition assessment dated [DATE], Resident 1's nutrition assessment indicated RD 1 documented Resident 1's estimated nutrient needs at 1600 calories (22 calories per kilogram (kg- a unit of measurement, body weight), 75 grams (g- a unit of measurement) Protein, 2150 milliliters (ml- a unit of measurement) fluid. RD 1 documented Resident 1's total nutrition intake met the estimated needs. RD 1 indicated in the summary notes that Resident 1 was at risk for weight loss, pressure injury and dehydration. RD 1 documented Resident 1's nutrition intake was greater than 50%. Based on the nutritional analysis of the facility menu and the estimated nutrient needs, Resident 1 would need approximately consume 73% of her meals. During a review of Resident 1's SBAR - change of condition notes dated [DATE], the SBAR indicated Registered Nurse (RN) 1 documented Resident 1 lost 5 lbs in one week and was reported to Resident 1's primary care physician (PCP) via phone. RN 1 indicated the recommendations was to encourage Resident 1 to eat healthy meals, assist resident during mealtime, and offer snacks. During a review of Resident 1's General Note dated [DATE], the Director of Nursing Services (DNS) 1 indicated Resident 1 lost 5 lbs in 30 days and consumed 60% of 10 meals. The recommendation was to add Med Pass (2 cal per milliliter [ml] oral nutrition supplement). Resident 1's Physician Orders, dated [DATE] indicated 2 calorie (cal) supplement 90 ml three times a day. No other weight loss interventions were documented. During a review of Resident 1's Medication Administration Record (MAR) dated ,d+[DATE] to [DATE], Resident 1's MAR did not indicate documentation if Resident 1 received or took the 2-cal oral nutrition supplement that was ordered three times a day for weight loss. During a record review of Resident 1's MAR dated [DATE] to [DATE], it indicated the facility administered the 2-cal oral supplement. The order was discontinued on [DATE]. While an intervention was recommended with and ordered by the physician, there was no documentation it was implemented until 7 days prior to being discontinued. During a review of Resident 1's Physician orders dated [DATE], the physician orders indicated Resident 1's diet was downgraded to pureed (type of diet where all the foods have a soft, pudding like consistency). On [DATE], an additional oral nutrition supplement was ordered (house supplement) with meals due to weight loss. There was no documentation in Resident 1's clinical record if this additional intervention was implemented. During a telephone interview with Licensed Nurse (LN) 2, on [DATE], at 2:39 p.m., LN 2 stated that prior to a system change, both the Med Pass and house supplement would need to be documented on the MAR to indicate how much the resident was taking the oral supplements. During a review of Resident 1's Nutrition Data dated [DATE], the Kitchen Supervisor (KS) indicated Resident 1 lost 5% of her weight or more in the last month [,d+[DATE]] or 10% in last 6 months and was not on a prescribed weight loss regimen. Resident 1's average meal intake was 25% per day and was on a pureed diet and received Med Pass between meals. The KS reviewed food choices and updated preferences which indicated Resident 1 ate in her room by herself. Resident 1's clinical record indicated there was no referral to the RD to address Resident 1's continued weight loss. During a review of Resident 1's Weight Note dated [DATE], the DNS 1 indicated Resident 1 lost 26 lbs in six months, 13 lbs over two months and consumed 52% of most meals. The DNS 1 indicated Resident 1 was on a pureed, fortified diet with Health shakes (house supplement -oral nutrition supplement) with meals and Med Pass between meals. Resident 1's clinical record indicated on ,d+[DATE], the facility implemented COVID-19 (an infectious disease caused by severe acute respiratory syndrome) isolation precaution for the building. Resident 1's weight note indicated Resident 1 needed to be cued for eating and that Resident 1 would do better with eating in the dining room. The DNS 1 indicated recommendations were to review food preferences with RP (Responsible party) due to the change of condition. The DNS 1 indicated RD 1, KS, Social Services (SS) and the Activity Director (AD) were present on the meeting. Resident 1's weight note indicated Resident 1 was on a fortified diet with no physician's order documented so it was unclear if or when it was implemented (Cross Reference F808). Resident 1's weight note did not include new interventions to address Resident 1's continued weight loss. During a review of Resident 1's Nutrition Assessment, dated [DATE], RD 1 lowered Resident 1's estimated nutrient needs to 1400 calories, and 60 grams protein. RD 1 indicated Resident 1's total nutrition intake met the estimated nutrient needs with a goal to consume greater than 55% of meals. Under summary notes, RD 1 indicated Resident 1's intake averaged greater than 50% this past week and there were no signs of malnutrition. RD 1 indicated Resident 1 lost 32 lbs per year and experienced a 15.6% severe weight loss over six months. During a review of Resident 1's clinical record, the facility did not conduct a root cause analysis or investigated the cause of her weight loss. The facility did not implement recommended changes to Resident 1's plan of care. During a review of the facility's menu and the resident's estimated nutrient needs, Resident 1 would need to consume approximately 62% of meals to meet her needs and to consume approximately 73% to re-gain weight. During a review of Resident 1's Weight Note dated [DATE], the DNS 1 indicated Resident 1 lost 6 lbs, or 4.8%, 23 lbs in six months. Resident 1's weight note indicated Resident 1 was on COVID-19 isolation and tested positive for COVID-19 on ,d+[DATE]. Resident 1 consumed 42% of 16 meals and was on a pureed fortified diet, with health shakes with meals and Med Pass. Resident 1 refused meals and was pocketing food. The facility recommendations were to assess with family about possible tube feeding due to Resident 1's full code status and to check if resident needed a dental assessment. Resident 1's weight note indicated RD 1, KS, DNS 1, SS, AD, Administrator (ADM) were present on the weight meeting. Resident 1's Physician's Orders dated [DATE], indicated Resident 1 was on hospice evaluation and treatment. During a review of Resident 1's Meal Intake records dated ,d+[DATE] to ,d+[DATE], the meal intake indicated on average, the facility was documenting Resident 1's meal intake 57% of the time each month, and on average Resident 1's nutrition intake met her estimated needs at 12% of the time. During a telephone interview with RD 2, on [DATE], at 2:25 pm, RD 2 stated she started working at the facility at the end of ,d+[DATE] and worked 8 hours, once a week on Tuesdays. RD 2 stated her typical routine at the facility include tasks which included attending the weight meetings. RD 2 stated part of her routine was to obtain residents weights and weights were usually obtained weekly or monthly. RD 2 stated residents with weight loss were monitored in the weight committee when there was a loss of 5% or 5 lbs in one month, 10% in 6 months or 7.5% in 3 months, or if there was a weekly weight loss of three or more lbs. During a telephone interview and concurrent record review with the DNS 2, on [DATE], at 1:27 p.m., DNS 2 stated she started working on the facility on [DATE]. DNS 2 reviewed Resident 1's clinical record and stated that Resident 1 continued to have weight loss from ,d+[DATE] to ,d+[DATE] and no new interventions were put in place to address the progressive weight decline. 2. During a review of Resident 2's clinical record, Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's admission weight was documented at 146 lbs and on the following day was documented at 141 pounds. Resident 2's admission diet order indicated Resident 2 was placed on regular diet with honey thick liquids. Resident 2's Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgement) on admission indicated Resident 2's BIMS score was 15 of 15 points which indicated Resident 2 had no cognitive impairment. During a review of Resident 2's clinical record dated [DATE], Resident 2 experienced a continuous and progressive weight decline. On [DATE], Resident 2 weighed 130 pounds, a loss of 11 pounds since the day after admission. Resident 2's monthly weights taken on [DATE] and [DATE] indicated a gradual decline and weight loss. Resident 2's weight taken on [DATE] indicated Resident 2 weighed 119 pounds, an additional loss of 11 pounds and 13 pounds weight loss (9.8 percent) in 6 months, which was considered a significant weight loss. Resident 2's clinical record dated [DATE] to [DATE] indicated Resident 2 lost 8 pounds (6.2 percent) in 1 month which was considered as severe weight loss. During a review of Resident 2's Physician's Orders dated [DATE], the physician's order indicated Resident 2 was on a regular diet with thin liquids. Resident 2's clinical record dated [DATE] at 3:42 p.m., indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's MAR dated [DATE] to [DATE] at 1 p.m., the MAR did not indicate documentation Resident 2 received or took the 2-cal oral nutrition supplement that was ordered for weight loss three times a day. Resident 2's MARs were blank for approximately 13 months. While an intervention was recommended with and ordered by the physician, there was no documentation it was implemented by the facility. During a review of Resident 2's Nutrition assessment dated [DATE], the nutrition assessment indicated RD 1 documented Resident 2's estimated needs were 1500 calories (25 cal/60 kg body weight), and 60 grams protein. RD 1 documented Resident 2's total nutrition intake met the estimated nutrition needs and no nutrition goals. Resident 2's nutrition notes indicated RD 1 documented Resident 2's weight was 132 lbs and was maintaining weight. RD 1 documented Resident 2 lost 14 lbs in 26 days related to [CONDITION(S)] present at admission without diuretic medication and his weight loss was prior to admission. RD 1 documented Resident 2's meal intake averaged greater than 75% this past week on a regular diet with the 2-calorie supplement. Based on the facility menu and the resident's estimated nutrient needs, Resident 2 would need to consume approximately 68% of meals to meet his needs. During a review of Resident 2's Physician's Orders dated on [DATE], the physician's order indicated Resident 2 was on a large portion diet with thin liquids. During a review of Resident 2's Nutrition Data dated [DATE], KS documented Resident 2 weight was 127 lbs on [DATE], and the usual body weight was 155 lbs. KS documented Resident 2's average meal intake was 75% per day and was on a regular large portion diet. KS documented Resident 2 received 2 Cal supplement between meals. KS documented she reviewed and updated food choices for Resident 2. During a review of Resident 2's Meal Intake Records dated ,d+[DATE] to ,d+[DATE], Resident 2's meal intake indicated on average the facility was documenting Resident 2's meal intake at 56% of the time each month. There was no documentation of the RD or IDT team meeting to discuss the weight changes after the [DATE] weight of 119 lbs on ,d+[DATE] and ,d+[DATE]. During a telephone interview and concurrent record review with RD 2, on [DATE], at 12:20 p.m., RD 2 reviewed Resident 2's clinical record and stated there was no documentation of the facility to address Resident 2's continued weight loss. RD 2 stated Resident 2 should have been added to the weight variance and monitored weekly. RD 2 stated the purpose of the weight meeting with all the team members was to discuss all the factors that contributed to the weight loss and to come up with new interventions to address the weight loss. RD 2 stated the goal of the weight meeting was to ensure if a resident was losing weight, to first maintain the weight they were at, and then if they were on a lower end of their ideal body weight, then to give extra calories to re-gain the weight. During a review of research from the American Academy of Family Physician Journal volume 65, number 4, dated [DATE], indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression, and death. Involuntary weight loss can lead to muscle wasting .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Nutrition Care of the Older Adult from the Academy of Nutrition and Dietetics, dated 2016, indicated, .The goal of Medical Nutrition Therapy is to maintain or restore the individual's usual body weight . During a review of the Academy of Nutrition and Dietetics Evidence Analysis Library regarding Unintended Weight Loss for Older Adults Evidence-Based Nutrition Practice Guidelines dated (,d+[DATE]), indicated the Registered Dietitian (RD) should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). During a review of the facility policy and procedure (P&P) titled, Weight Assessment and Interventions dated ,d+[DATE], the P&P indicated, .The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100]: 1 month - 5% weight loss/gain is significant . 3 months -7.5% weight loss/gain is significant . 6 months - 10% weight loss/gain is significant. It further indicated any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Registered Dietitian . During a review of the Facility Legend Report for recording undated, the meal intakes did not allow for a single value, rather was limited to the following ranges. It indicated 25 if the resident ate between ,d+[DATE]%, 50 if ate between ,d+[DATE]%, 75 if ate between ,d+[DATE]%, 99 if ate between ,d+[DATE]%, and RR for resident refused. While the facility would record these numbers there was no way to know the exact intake with this method of recording. The average of each range is the following: 12.5, 37, 62, 88 respectively. The facility document titled. Registered Dietitian dated ,d+[DATE], indicated, . The Dietitian is responsible for utilizing the nutrition care delivery process in providing nutritional care to the residents/patients in the facility. He/she advises Administration, Director of Nursing and Dietary Supervisor as needed on all clinical aspects of nutrition care and abides by all standards set forth by applicable regulatory agencies . 3. Assesses the nutritional status of residents/patients per standards of practice. 4. Collaborates with the interdisciplinary team to develop nutrition plans of care for the residents . 5. Monitors and evaluates effectiveness of nutritional interventions. 6. Ensures appropriate and timely documentation of nutrition assessment tools, recommended interventions, and follow-up . 9. Monitors all aspects of the nutrition care delivery process to ensure clinical excellence. 10. Ensures that the Food and Nutrition Services policies and procedures are adhered to .

Based on observation, interview and record review, the facility failed to follow established national standards of practice for the prevention of COVID-19 virus (a serious contagious respiratory (Lung) infection transmitted from person to person) outbreak (a sudden rise in the number of cases of a disease) for 45 of 59 sampled Residents (Resident 1, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 18, 20, 21, 22, 25, 27, 29, 30, 33, 37, 38, 39, 40, 43, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 63, 67, 68 and 69) and 22 staff members when: 1.Staff assigned to oversee and provide employees' return to work guidance after a sick-call absence did not follow the facility policy and Centers for Disease Control and Prevention (CDC- a United States federal agency under the Department of Health and Human Services agency to protect public health and safety through the control and prevention of disease, injury, and disability in the US and internationally) return to work standards for healthcare workers (HCW) for one of three staff Certified Nursing Assistant (CNA 1) and CNA 1 was permitted to return to work on [DATE] after a sick call on [DATE] experiencing COVID-19 symptoms (back pain, headache, muscle ache and difficulty breathing). On [DATE] CNA 1 providing direct resident care and services exposing Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60 to COVID-19 infection, which subsequently resulted in Resident 9, Resident 10, Resident 12, Resident 16, Resident 21, Resident 22, Resident 27, and Resident 60 testing positive for COVID-19 infection. CNA 1 test results dated [DATE] indicated CNA 1 tested positive for COVID-19 2. The Infection Preventionist (IP) did not provide education to employees on the most current signs and symptoms (s/s) of COVID-19 infection for two of three staff (CNA 2 and Laundry Aid (LD)). Resulting in CNA 2 provided resident care on [DATE] and [DATE] while experiencing symptoms of COVID-19 (fatigue, headache and body aches), subsequently exposing Residents 1, 3, 4, 5, 7, 8, 13, 14, 15, 18, 25, 29, 33, 43, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 63, 67, 68 and 69 to COVID-19 infection . CNA 2 test results indicated CNA 2 tested positive for COVID-19 on [DATE]. 3. Facility staff did not follow CDC standards and facility policy for actively screening healthcare workers (HCW) prior to the start of each shift resulting in HCWs (Laundry Aid (LD), Student (ST) and Registered Nurse (RN) 1) reporting to work without receiving active COVID -19 screening and CNA 1 and CNA 2 reported to work experiencing symptoms of COVID-19 and did not divulge symptoms during the screening process subsequently exposing Residents' 1, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 18, 20, 21, 22, 25, 27,29, 30, 33, 37, 38, 39, 40, 43, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 63, 67, 68 and 69. 4. Staff in the Persons Under Investigation (PUI -persons (residents) exposed to someone infected with COVID-19 or experiencing symptoms for COVID-19 without laboratory confirmed positive COVID-19 results) Yellow Zone did not follow CDC standards to keep resident room doors closed for five of 23 sampled residents (Resident 39, 41, 42, 44, and 45) to prevent the spread of COVID-19 virus. 5. IP did not follow facility policy and procedure and CDC standards on posting transmission based precaution (a sign used as an alert system to caution staff and visitor to adhere to practices to prevent spread of the disease) signage on doors or wall of designated COVID -19 PUI room for 23 of 23 sampled Residents 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 and 59. The cumulative effects of these failures resulted in the transmission of COVID-19 infection to 45 of 59 residents (Resident 1, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 18, 20, 21, 22, 25, 27, 29, 30, 33, 37, 38, 39, 40, 43, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 63, 67, 68 and 69) who were previously COVID-19 negative; 18 of the 59 residents (Residents 67, 69, 70, 71, 72, 73, 74,75, 76, 78, 79, 80, 81, 82, 83, 84, 85, and 86 ) were transferred to a higher level of care at local hospitals to care for their COVID-19 symptoms, four of the 17 residents (Residents 72, 77, 81, and 85) died related to their COVID-19 infection, and a total of 23 staff (Certified Nursing Assistants (CNA)1, 2, 3, 5, 6, 8, 9, 10, 12, 13, 14, 15, Therapy staff (T) 1, 2, 3, 4, License Vocational Nurses (LVNs) 1, 2, 3, Registered Nurse (RN) 1, Housekeeper (HSK) 1 and Housekeeper Supervisor (HSK SUP) 1 had COVID-19 positive lab results. Because of the serious actual harm to 17 of 59 residents and the serious potential harm to the additional 42 of 59 residents as a result of not following CDC infection control standards to prevent COVID-19 infection transmission, an Immediate Jeopardy (IJ) situation was called on [DATE] at 4:45 p.m. in the area of Code of Federal Regulations (CFR) 483.80 (F880-Infection Prevention and Control) with the facility Director of Nursing (DON), IP and Assistant Director of Nursing (ADON). On [DATE] at 4:45 p.m. the IJ Template was provided to the DON. The facility submitted a plan of removal on [DATE] at 6:30 p.m. to address the IJ situation, which included having a designated screener for each shift, to actively screen all Health Care Personnel (HCP) prior to the start of each shift; In-service training was provided to all staff on the signs and symptoms (s/s) of COVID-19; Infection Preventionist or designee will review staff screening logs daily to ensure that screening continues to be accurate and consistent; When staff call in sick to their supervisor or designee, they will be informed that they are not permitted to come back to work until contacted and cleared by the IP or qualified designee. IP or qualified designee will review call in logs daily and follow up with staff who did not come to work. The Plan of Removal was accepted on [DATE] at 1:51 p.m. While onsite, the surveyor verified by observations, interview and record reviews and confirmed the interventions to address the IJ situation on the Plan of Removal were fully implemented. The IJ was removed on [DATE] at 5:31 p.m., with the DON and IP. Findings: 1. During a concurrent interview and Record review on [DATE], at 9:00 a.m., with the Director of Nurses (DON) the DON review the facility document titled, (Resident) Census sheet dated [DATE] and stated the facility was experiencing a COVID-19 infection outbreak. The DON stated on [DATE] the facility had 36 residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 and 36) in the COVID-19 RED zone (area where resident with COVID-19 positive test results are housed) and 23 Residents (Residents 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 and 59) were quarantined (is the process of isolating a person suspected of being infected with [MEDICAL CONDITION] to a specific area in order to prevent the person from contaminating others) in the yellow zone (PUI). The DON stated the facility had a total of 23 staff that had COVID-19 positive test results. The DON stated these residents had been COVID-19 negative prior to the COVID-19 infection outbreak. During a concurrent interview and record review, on [DATE], at 11:56 a.m., with IP, the facility document titled Staff COVID Test Results (document used to tract employees' infections in the facility) undated was reviewed by the IP and stated she believed CNA 1 was positive for COVID-19 on [DATE] when he called off work experiencing COVID-19 symptoms. The IP stated CNA 1 had called off sick on [DATE] and [DATE] because he was experiencing COVID-19 like symptoms, headache and body aches. The IP stated CNA 1 had worked providing care to residents on [DATE] and [DATE]. The IP stated she had not conducted her investigation on which resident were in contact with CNA 1. During a phone interview on [DATE], at 12:39 p.m., with CNA 1, CNA 1 stated he had called off ill on [DATE] because he was experiencing back pain, headache, muscle ache and was out of breath. CNA 1 stated he knew the COVID-19 signs and symptoms but did not think he had [MEDICAL CONDITION]. CNA 1 stated he returned to work on [DATE] thinking he was experiencing flu like symptoms and not COVID-19 because he was thinking he could deal with the symptoms for one more day. CNA 1 stated on [DATE] he continued to have back pain, headache and shortness of breath while he was working providing care to Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60. CNA 1 stated by [DATE] his symptoms worsened and he called the facility and spoke with a Licensed Nurse and call off sick once again. CNA 1 state the reason he returned to work on [DATE] while experiencing COVID -19 like symptoms was because the IP did not call him at home to follow up with him reading his symptoms when he called off ill on [DATE]. CNA 1 stated since no one called him to tell him not to come into work the following day [DATE], he assumed it was okay to return to work. CNA 1 stated on [DATE] the IP phoned him at home asking him about his symptoms. CNA 1 stated he continued to have body aches, but his headache had subsided. CNA 1 stated IP told him that she will check with him again on [DATE] and that he may be able to return to work on [DATE] depending on his symptoms. CNA 1 stated on [DATE] he provided direct resident care and services exposing Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60 to the COVID-19 infection. CNA 1 stated he was tested for COVID-19 on [DATE] and his test results indicated he was positive for COVID -19 infection on [DATE]. During a concurrent interview and record review on [DATE], at 1:43 p.m., with IP, the facility document titled Employee Call-In (off) Log dated [DATE] was reviewed by the IP. The log indicated, (CNA 1) .Date call off XXX,[DATE] (20) .C/O: (complain of) Body Aches; Headache; tested Positive (+) for COVID on ,[DATE](20). The IP stated she had phoned CNA 1 on [DATE] to ask him how he was feeling because he had called off on [DATE] and told him that she would call him on [DATE] to check on how he was feeling. IP stated she informed him on [DATE] that if his symptoms improve, he may be able to return to work on [DATE]. The IP stated that on [DATE] CNA 1 informed her that he had tested positive for COVID-19 and would need to stay home and self-quarantine. The IP stated the documentation on the Employee Call-In (off) Log indicating CNA 1 tested COVID-19 positive on [DATE] was inaccurate. The IP stated she assumed CNA 1 was COVID-19 positive on [DATE] because of the symptoms he was experiencing. The IP stated that she should have not documented that CNA 1 tested COVID-19 positive on [DATE] because that was not accurate, CNA 1 did not get his COVID test until [DATE]. IP stated she was the designated staff to review all employee sick call off slips who were reporting signs and symptoms of COVID-19 infection. The IP stated her process was to call staff to follow up within 72 hours after they called off sick. The IP reviewed staffing sheet dated [DATE] which indicated CNA 1 returned to work on [DATE] after he had called off ill experiencing back pain, headache, muscle ache and was out of breath and stated she did not realize that CNA 1 had returned to work on [DATE]. The IP stated she did not check on [DATE] that CNA 1 had returned to work. The IP stated she had assumed that he did not return to work after he had called off sick on [DATE]. IP stated the staff would not know to self-quarantine if staff are experiencing COVID-19 like symptoms if she did not call them on the day of the call or the following day after staff called off ill. During a concurrent interview and record review, on [DATE], at 2:26 p.m., with DON, the facility document titled COVID 19 Mitigation Plan undated was reviewed, the plan indicated .If exposed HCP (Health care personnel) develop even mild symptoms consistent with COVID-19, they must notify their supervisor and cease resident care activities. These individuals will be prioritized for testing will be excluded from work until they meet the requirements for returning to work . DON stated according to the facility's mitigation plan CNA 1 should have been tested by the facility and excluded from work since he had called in with COVID-19 like symptoms on [DATE] and that did not occur because CNA 1 was allowed to work for eight hours on [DATE] while he was experiencing COVID-19 symptoms. During an interview on [DATE], at 4:33 p.m., with IP, the IP stated she had not reviewed the daily group assignment (document that assigns staff to designated residents) dated [DATE] when CNA 1 returned to work to investigate which residents came in contact with CNA 1 and exposed to COVID-19 infection. The IP stated CNA 1 worked Station 3 and 4 and assumed he had worked with all residents in station 3 and 4 (Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60). The IP stated she did not conduct contact tracing (method used to identify person to person contact) to identify all the residents CNA 1 had potentially exposed to COVID-19. During a concurrent interview and record review on [DATE], at 9:57 a.m., with IP, CNA 1's Daily Group Assignment (document that identifies residents that CNA 1 provided care on the assigned date) dated [DATE] was reviewed by the IP. IP stated, CNA 1 worked on [DATE] night shift (9:56 p.m. to 6:51 a.m.) and provided direct care to Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60 exposing the residents to COVID-19 infection. During a concurrent interview and record review on [DATE], at 12:40 p.m., with DON and IP, professional reference titled CDC COVID-19 guidance titled, Guidance for Businesses and Employers Responding to Coronavirus Disease 2019 (COVID-19) dated [DATE] was reviewed by the DON and the IP. The DON and IP stated the guidance indicated, . Prevent and Reduce Transmission Among Employees . Employees who have symptoms should notify their supervisor and stay home. CDC recommends testing for people with any signs or symptoms of COVID-19 and for all close contacts of persons with COVID-19 . IP stated she assumed that CNA 1 would not return to work after calling in on [DATE] and she did not call him to ensure CNA 1 did not return to work. DON Stated it was the IP's responsibility to ensure CNA 1 did not return to work until he had been cleared to return to work by IP. The DON stated when CNA 1 called off sick on [DATE] the IP should have called CNA 1 on that day or by the following day to instruct him to stay home and not work the following day and that did not occur. DON stated CNA 1 potentially exposed residents and staff to CVOID-19 on [DATE]. During a concurrent interview and record review on [DATE], at 2:47 p.m. with IP, the IP reviewed the facility document titled Resident COVID Test Results undated which indicated Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60 had been exposed to CNA 1 on [DATE] when CNA 1 was experiencing COVID-19 symptoms which resulted in these residents testing positive for COVID -19 infection. The IP stated the following COVID-19 test lab results indicated: Resident 9 tested positive for COVID-19 on ,[DATE] Resident 10 tested positive for COVID 19 on [DATE] (CNA 1 worked with Resident 10 on ,[DATE], ,[DATE] and [DATE]) Resident 12 tested positive for COVID 19 on [DATE] Resident 16 tested positive for COVID 19 on [DATE] Resident 21 tested positive for COVID 19 on [DATE] Resident 22 tested positive for COVID 19 on [DATE] Resident 27 tested positive for COVID 19 on [DATE] Resident 60 tested positive for COVID-19 on [DATE] IP stated CNA 1 provided care to these residents on ,[DATE], ,[DATE] and [DATE]. During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html dated [DATE] was reviewed. The guidance indicated, . Prevent and Reduce Transmission Among Employees . Employees who have symptoms should notify their supervisor and stay home. CDC recommends testing for people with any signs or symptoms of COVID-19 and for all close contacts of persons with COVID-19 . During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html dated [DATE] was reviewed. The guidance indicated, .Symptom-based strategy for determining when HCP can return to work. HCP with mild to moderate illness who are not severely immunocompromised: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved . 2. During a review of the facility document titled Employee Call-In (off) Log dated [DATE] indicated, CNA 2 .tested Pos (+) for COVID ,[DATE](20) During a phone interview on [DATE], at 3:51 p.m., with CNA 2, CNA 2 stated she had been employed at the facility for less than a month. CNA 2 stated she had COVID-19 symptoms on [DATE] which included fatigue, headache and body aches. CNA 2 stated she worked and provided resident care to (Residents 1, 3, 4, 5, 7, 8, 13, 14, 15, 18, 25, 29, 33, 43, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 63, 67, 68 and 69) while experiencing the COVID-19 like symptoms on [DATE] and [DATE]. CNA 2 stated she worked a 16 hour shift on [DATE] and 16 hours shift on [DATE] exposing staff and residents on both PM shift (2:00 p.m. - 10:00pm) and night shift (10:00 p.m. -7:00 a.m.) CNA 2 stated she did not think her symptoms were COVID-19 because s when she was hired, the facility had not educated her on the signs and symptoms of COVID-19 infection. CNA 2 stated she educated herself on the signs and symptoms of COVID-19 virus after the Director of Staff Development (DSD) called her and told her that she had tested positive for COVID-19 on [DATE]. CNA 2 stated if she had known the signs and symptoms of COVID-19, she would have called off sick and not worked exposing residents and staff. During a review of CNA 2's lab(oratory) report (COVID-19 test results), dated [DATE], the lab report indicated CNA 2 COVID-19 test specimen was collected on [DATE]. The lab results indicated CNA 2 tested positive for COVID-19 and results were reported to the facility on [DATE]. During an interview on [DATE], at 8:31 a.m., with DSD, the DSD stated she did not conduct staff in-service education regarding COVID-19 signs and symptoms. DSD stated the IP conducted the COVID-19 education to staff she did not. The DSD reviewed staff in-service education records and was unable to find CNA 2 in-service education records for COVID-19 education. During a concurrent interview and record review on [DATE], at 8:38 a.m., with Payroll Clerk (PL), CNA 2's Timecard dated ,[DATE] was reviewed. PL stated CNA 2 worked on [DATE] from, 2:24 p.m., through [DATE] 7:03 a.m., and [DATE] from 2:30 p.m. through [DATE] at 7:07 a.m. During a concurrent interview and record review on [DATE], at 9:32 a.m., with IP, the facility document titled Summary Report of Meeting, dated [DATE] was reviewed. The summary report indicated, .In Service .COVID-19 Review .Signs & Symptoms . IP reviewed the in-service attendance sign in sheet and stated CNA 2's name and signature were not on the list. IP reviewed additional In-services she had given and stated CNA 2's was not present in those in-service classes. IP stated CNA 2 was a new employee and had not received in-service education on COVID-19 signs and symptoms and she should have. During a concurrent interview and record review on [DATE], at 9:57 a.m., with IP, the facility document titled, Daily Group Assignment dated [DATE] and [DATE] was reviewed. The assignment sheet dated [DATE] indicated CNA 2 provided direct resident care to Residents 9, 10, 12, 16, 20, 21, 22, 27, 30, 37, 38, 39, 40, and 60. CNA 2 provided care on [DATE] to Residents 13, 14, 33, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 67, 68, and 69. IP stated CNA 2 should have been educated on the COVID-19 signs and symptoms at the time when she was hired. IP stated it was important for staff to know the COVID-19 signs and symptoms to protect staff and residents from potential exposure to COVID-19 virus. During a phone interview on [DATE], at 11:23 a.m., with LD, LD stated, she had been working at the facility since September of 2020. LD stated the facility did not have a designated staff member that would conduct staff COVID screening. LD stated she would report to work without staff screening her. LD stated at times when she self-screened, she would report fever, cough, bone pain, flu and headache. LD stated she did not know all the COVID -19 symptoms that she should report. LD stated she did not know the COVID -19 temperature reading that would be considered a fever, which would prevent her from reporting to work. LD stated her shift start time varied from 2:00 am to 4 a.m. and most of the time when she reported to work there was no screener at the front entrance. LD stated she had to start her shift when she entered the facility and if there was no screener, she would just sign the screening log and document NO on all the questions and would go to work. LD stated she had not received COVID-19 education, and no one would ask her about the times she was self-screening, so she assumed it was an approved practice. During an interview on [DATE], at 12:43 p.m., with DON, DON stated all employees should be educated on signs and symptoms of COVID-19, especially newly hired employees. The DON stated the facility had a previous COVID-19 outbreak in [DATE] which resulted from employees not knowing the signs and symptoms of COVID-19, self-screening and returning to work while experiencing COVID-19 symptoms which placed employees and residents at risk of COVID-19 exposure. The DON stated it was the DSD and the IP's responsibility to ensure all employees were educated on the s/s of COVID-19. During a concurrent interview and record review on [DATE], at 2:47 p.m. with IP, the Ip reviewed the facility document titled Resident COVID Test Results undated which indicated Residents 3, 13, 14, 15, 18, 29, and 67 tested positives for COVID -19. The IP stated CNA 2 had worked with these residents when she had worked experiencing COVID-19 symptoms which had resulted in the following COVID-19 test lab results indicating: Resident 3 tested positive for COVID 19 on [DATE] Resident 13 tested positive for COVID 19 on [DATE] Resident 14 tested positive for COVID 19 on [DATE] Resident 15 tested positive for COVID 19 on [DATE] Resident 18 tested positive for COVID 19 on [DATE] Resident 29 tested positive for COVID 19 on [DATE] Resident 67 tested positive for COVID 19 on [DATE] IP stated CNA 2 provided direct care to these residents on [DATE] and [DATE] while she was experiencing COVID-19 symptoms. During a concurrent interview and record review on [DATE], at 10:20 a.m., with IP, the facility document titled Summary Report of Meeting, dated [DATE] was reviewed. The summary report indicated, .In Service .COVID-19 Review .Signs & Symptoms . IP reviewed the attendance sheet and stated LD's name and signature was not on the list. IP reviewed additional In-services she had given, and stated LD was also not present in those in services. IP stated LD had not been received in-serviced education on the signs and symptoms of COVID-19 virus and she should have. During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.htm titled, Symptoms of Coronavirus dated [DATE] indicated, .Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea . During a review of the professional reference for the CDC published guidelines https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html titled Preparing for COVID-19 in Nursing Homes, dated [DATE] indicated, . Facilities should assign at least one individual with training in IPC (Infection Prevention and Control) to provide on-site management of their COVID-19 prevention and response activities because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of HCP, and auditing adherence to recommended IPC practices . 3. During a concurrent interview and record review on [DATE], at 10:10 a.m., with IP, the facility document titled Staff Surveillance Sign in Sheet was reviewed by the IP. The staff surveillance sign in sheet dated [DATE] indicated LD documented that she screened herself on the COVID-19 staff screening form and authorized herself to enter the facility. The IP reviewed the facility COVID -19 staff screening logs and stated there was second staff member that documented self-screened on the same date ([DATE]) but the IP was unable to identify the name of the staff who self-screened and would not be able to follow up with the staff to validate the staff was COVID-19 symptoms free. The IP stated LD continued to self-screen on [DATE] and [DATE] because the facility did not assign a staff member to conduct active screening for incoming staff. The IP stated the facility management team had planned to implement a system that would assign staff to conduct active COVID-19 staff screening prior to permitting staff to enter the facility but that did not occur. The IP stated employees should have been actively screened by a designated screener and should not have conducted their own screening. During a phone interview on [DATE], at 11:23 a.m., with LD, LD stated she had been working at the facility since September of 2020. LD stated when she self-screened, she did not know all the COVID-19 symptoms and would only report fever, cough, bone pain, flu and headache. LD stated she did not know additional COVID -19 symptoms to report. LD stated she did not know the COVID-19 temperature reading that would be considered a fever, which would prevent her from reporting to work. LD stated she would report to work and most of the time the facility did not have a screener at the front entrance. LD stated she had to start her shift when she entered the facility and if there was no screener, she would just sign the screening log and document NO on all the questions and would go to work. LD stated she had not received COVID-19 education, and no one asked her why she was self-screening, so she assumed it was an approved practice. During a concurrent interview and record review on [DATE], at 11:45 a.m., with DON, the facility document titles IJ Action Plan dated [DATE] was reviewed by the DON. The IJ plan indicated .IJ Removal plan XXX[DATE], 9:00 am . Need for immediate action, facility needs to ensure that staff, visitors and vendors area actively screened for symptoms of COVID-19 and take appropriate action as per CDC updated [MEDICAL CONDITION] symptoms dated [DATE] and facility policy for screening criteria. If an employee becomes symptomatic for COVID-19, the individual will not be allowed to enter the building. Immediate supervisor and Infection Preventionist (IP) will be contacted of findings to initiate contact tracing .The IP or qualified designee will educate the CNA entrance screeners on the revised screening tool .The staff member will show competency . and understanding of the screening tool. This will be done by the IP observing ten screenings done by the screener with 100 percent compliance .For shifts that are not covered by the entrance screeners, a specified floor staff member will be assigned to monitor the entrance . DON stated the facility did not follow the previous IJ removal plan addressing staff screening and they should have. DON stated there should have been a designated screener on all shifts and that did not occur. The DON stated the facility had agreed to implement a system during the facilities Immediate Jeopardy (IJ-a situation that has been identified as the facility placing resident in immediate risk of harm, dismemberment or death) on ,[DATE] that would ensure staff and visitors were actively screened prior to entry into the facility. The DON stated the facility did not implement the screening system which resulted in staff self-screening and coming in to work while experiencing COVID -19 symptoms. The DON stated it was not ok for employees to self-screen at the start of their shift. During an interview on [DATE], at 11:52 a.m., with IP, IP stated, the purpose of having a designated screener was to have a visual on the employee entering the facility to observe if they were showing COVID-19 Symptoms. IP stated she reviews the Staff Surveillance Sign in Sheet daily and signed and dated the staff screening sign in sheet for verifying accuracy on [DATE], [DATE] and [DATE]. IP stated she noticed staff were self-screening and she did not provide staff education to make sure LD did not to self-screen. IP reviewed the sign in screening logs and stated that LD's signature was on the screening sign in logs for ,[DATE], ,[DATE] and [DATE] which indicated LD self-screened on those days prior to entering the facility. During a concurrent interview and record review on [DATE], at 2:05 p.m., with IP, the IP reviewed the facility document titled Staff Surveillance Sign in Sheet and stated the sign in sheet indicated that on [DATE] RN 1 and ST continue to conduct self-screening. IP stated the facility was in an IJ situation and had not designated staff to be screeners at the screening station to ensure that staff like RN 1 and ST were not self-screening prior to entering the facility. IP stated she had not designated a screener and she did not know if anyone was assigned as the designated screener for the shift. The IP stated not designating staff to conduct active staff screening at the facility entrance prior to allowing staff to enter facility had the potential for staff to work while experiencing COVID-19 symptoms and exposing all resident and staff for the continuation of the COVID-19 outbreak to continue and not be controlled. During a review of the professional reference retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html titled, Preparing for COVID-19 in Nursing Homes dated [DATE] indicated, . nursing homes must remain vigilant for COVID-19 among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death .Reinforce sick leave policies, and remind HCP not to report to work when ill . performing infection surveillance, providing competency-based training of HCP .Actively screen all HCP at the beginning of their shift for fever and symptoms of COVID-19 .Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea . Fever is either measured temperature (greater than) 100.0 (degrees) F or subjective fever. Note that fever may be intermittent or may not be present in some individuals, such as those who are elderly, immunosuppressed (weak immune system), or taking certain medications . If HCP develop fever (T 100.0 F) or symptoms consistent with COVID-19 while at work, they should inform their supervisor and leave the workplace . 4. During an observation on [DATE], at 9:48 a.m., in the Yellow Zone, PUI unit, Resident 39, 41, 42, 44, and 45's-bedroom doors were left open. During a concurrent observation and interview on [DATE], at 10:15 a.m., with Licensed Vocational (TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide the level of assistance required for bed mobility for one of three sampled residents (Resident 1) when Resident 1's comprehensive assessment indicated Resident 1 required two person physical assistance for bed mobility and Resident 1 received bed mobility to provide care by one person on 2/7/20 and 2/28/20. These failures resulted in Resident 1 sustaining two falls on 2/7/20 and 2/28/20 from her bed during bed mobility to provide care. Resident 1's fall on 2/28/20 resulted in Resident 1 striking her head on the bedside nightstand table causing injury to her forehead, elbow and broken left arm. Resident 1's injuries required her to be transferred to the General Acute Care Hospital (GACH) emergency room (ER) for evaluation. Resident 1 was subsequently hospitalized for five days (2/28/20 -3/3/20). The GACH diagnosed Resident 1 with a contusion (bruise) to the right forehead, a compression fracture of L2 vertebra (2nd lumbar - broken spine bone), and a left humerus fracture (a break of the bone in the upper arm), causing Resident 1 to experience severe pain and suffering requiring pain management, immobilization and confining Resident 1 to her bed. Findings: During an observation on 3/5/20, at 2:20 p.m., in Resident 1's room, Resident 1 was lying on her right side in bed. Resident 1's bed had an inflated air mattress. Her bed was in a low position without side rails. Resident 1 was lying with the right side of her face flat on the pillow. Her left eye was visible and under her left eye was a dark blue discoloration. Resident 1 had a blue colored cloth sling (a device to limit movement of the shoulder, elbow and arm) supporting her left arm and shoulder. During a review of the clinical record for Resident 1, the document titled ADMISSION RECORD undated indicated, Resident 1 was admitted to the facility on [DATE], transferred to the GACH on 2/28/20 and returned to the facility on [DATE] with diagnoses of fracture to lumbar vertebra and fracture of the shaft of the left humerus. During a review of Resident 1's comprehensive assessment titled Minimum Data Set (MDS) assessment (a resident assessment tool used to plan care), dated 11/25/19, it indicated Resident 1 required extensive assistance (staff provided weight-bearing support) and two person physical assist with bed mobility (how resident moves to and from lying position, and side to side positions while in bed). Brief Interview for Mental Status (BIMS) assessment dated [DATE], indicated Resident 1 scored a 3 for cognitive skills for daily decision-making ability (total possible point 0-15- score, 0-7 = severe cognitive impairment, 8-12 = mild cognitive impairment, 13-15 = cognitive intact). During an interview on 3/5/20, at 3 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was Resident 1's nurse on 2/28/20, when Resident 1 rolled off the bed and hit her head on the bedside nightstand. LVN 1 stated CNA 3 told her that she (CNA 3) was changing Resident 1's bottom soiled sheet and as she pulled the sheet towards her, Resident 1 flipped over and off the side of the bed and hit her head on the bedside nightstand. LVN 1 stated CNA 3 was providing incontinence (Inability to control the flow of urine and/or feces) care to Resident 1 by herself without assistance. LVN 1 stated when she walked into Resident 1's room, Resident 1 was in her bed. LVN 1 stated CNA 3 had stated that she put Resident 1 back in bed after Resident 1 rolled off the bed. LVN 1 stated CNA 3 should have called for assistance and not have moved Resident 1 without first performing an assessment of the injuries to Resident 1. LVN 1 stated she conducted a physical assessment and identified that Resident 1 had a large lump on the right side of her forehead and complained of a headache but had no other complaints of pain. LVN 1 stated the Director of Nursing (DON) also conducted a physical assessment for Resident 1 on 2/28/20 and directed LVN 1 to notify Resident 1's doctor to send Resident 1 to the GACH ER for evaluation. LVN 1 stated when the paramedics transferred Resident 1 onto the ambulance gurney she complained of left shoulder and arm pain. LVN 1 stated after the fall of 2/28/20, Resident 1 no longer gets out of bed and stays in bed because of her injuries. LVN 1 stated prior to the fall of 2/28/20, Resident 1 would be out of bed at least once a day in a wheelchair. During a review of Resident 1's Physical Therapy (PT), therapist Progress and Discharge Summary note, dated 12/20/19 indicated, start of care PT was 11/21/19, and end of therapy services 12/20/19 indicated Resident 1 had Functional Deficits with Bed Mobility, *ROLL LEFT AND RIGHT .Current level .Substantial/Max[imum] assist .continues to require extensive assistance for bed mobility and positioning . During a clinical record review of Resident 1's fall risk care plan, dated 11/20/19, indicated, Focus . At risk for falls related to [requiring] extensive to total assistance with most ADL's [Activities of Daily Living], [due to] impaired cognition, [and] balance deficits .interventions .dated 11/21/19 [keep] bed in low position .dated 11/25/19 .ensure proper positioning in bed . During a clinical record review of Resident 1's physical functioning deficit care plan, dated 11/20/19 indicated, Focus .physical functioning deficit related to generalized weakness . I require extensive 1-2 person assist . During a clinical record review of Resident 1's Progress Notes dated 11/25/19 at 2:18 a.m., indicated, .Resident fell in Resident room .unwitnessed fall .details: Roll/slid out of bed . Resident [1's] roommate called for help stating roommate fell out of bed. Resident [1] was found on blankets on floor next to bed . Resident [1] unable to explain what happened . no injuries .Resident returned to bed .[intervention] .ensure proper positioning in bed .[dated] 11/25/19 . During a clinical record review of Resident 1's Progress Notes, dated 2/7/20 at 6:12 p.m., indicated, .CNA [Certified Nursing Assistant 3] was changing resident for incontinence, CNA turned resident and resident rolled from bed and fell on floor .head to toe assessment done. No pain and discomfort noted. No visible injuries noted . During a clinical record review of Resident 1's Progress Notes, dated 2/28/20 at 3:39 p.m., indicated, .Summoned to resident's room .Certified Nursing Assistant alarming that while administering incontinence care, resident rolled over to the left side, resident lost balance and hit head on bedside nightstand .Resident Assessed .skin tear noted to right elbow .Hematoma (bruise) noted to right side of forehead .Physician notified .Resident transferred to [GACH] . During a review of Resident 1's GACH clinical record titled, Summary of Care dated 2/28/20 indicated, Problem list .compression fracture of L2 (2nd lumbar vertebra] .contusion of face (right forehead) due to fall from bed, without open wound .Closed left proximal (near to the point of attachment to the shoulder) humerus fracture with impaction .[due to resident medical condition] no ortho (orthopedic- a branch of medicine dealing with injuries to the bone) intervention .Pain Control in place .Sling LUE [Left upper extremity] .Ombudsman [resident advocate agency] was called and APS (Adult Protection Agency] is investigating .patient case will be followed by . conduct investigation . During a clinical record review for Resident 1, the Order Summary Report dated 3/2020, indicated, oxycodone (strong pain medication) .5 mg (milligrams-unit of measurement) .give 2.5 mg .every 8 hours as needed for moderate to severe pain . During an interview on 3/5/20, at 4:40 p.m., with the director of staff development (DSD), the DSD stated the level of assistance needed by Resident 1 for ADL care was on the Kardex form (document identifying resident level of care needed) at the nurses' stations in a binder and was accessible for CNA 3 to review prior to providing care to Resident 1. The DSD stated the information on the Kardex was generated from Resident 1's MDS and the level of assistance needed for ADLs was documented on Resident 1's Kardex form. During a concurrent interview and record review on 3/6/20, at 10:33 a.m., with the DON, the DON reviewed Resident 1's Kardex form. The DON stated Resident 1's Kardex indicated Resident 1 required extensive 2-person physical assistance with bed mobility. The DON stated CNA 3 should have had a second person with her while providing Resident 1 incontinent care and she did not do that. During a review of Resident 1's MDS Kardex Report ., undated, indicated, . admitted : 11/20/19 .ARD [Assessment Reference Date -refers to the last day of observation for gathering assessment information on a resident's strengths and needs] 11/25/19 .Bed Mobility: Extensive assistance . two + person physical assist for bed mobility . During a clinical record review of Resident 1's ADL- Documentation Survey Report . dated 11/2019, indicated, .Two-person physical assist for bed mobility occurred three times out of 30 opportunities of providing care, and one-person physical assist occurred 27 times . During a clinical record review of Resident 1's ADL- Documentation Survey Report ., dated 12/2019, indicated, .Two-person physical assist for bed mobility occurred eight times out of 90 opportunities of providing care, and one-person physical assist occurred 82 times . During a clinical record review of Resident 1's ADL- Documentation Survey Report ., dated 1/2020, indicated, Two-person physical assist for bed mobility occurred two times out of 88 times, and one-person physical assist occurred 86 times . During a clinical record review of Resident 1's ADL- Documentation Survey Report ., dated 2/2020, indicated, Two-person physical assist for bed mobility occurred three times out of 79 opportunities, and one-person physical assist was documented 76 times . During a clinical record review of Resident 1's ADL- Documentation Survey Report ., dated 3/2020, indicated, One-person physical assist for bed mobility each shift for 3/3/20, 3/4/20, and 3/5/20 . During a concurrent interview and record review on 3/6/2020, at 10:45 a.m., with the DON, the DON reviewed Resident 1's fall care plans. The care plan for physical functioning deficit dated 11/20/19 indicated Resident 1 required extensive assistance for most ADLs. The DON stated the care plan interventions were not specific to Resident 1's two person ADL assistance needs. The DON stated the care plan should reflect the resident's status, the plan of care and it should be resident specific. The DON stated there was no care plan or intervention which indicated the level of support or assistance needed by Resident 1 for bed mobility. During a review of Resident 1's care plan dated 2/7/20 indicated, .fall [on] 2/7/20 from bed .interventions .bed should be in lowest position .Ensure proper placement in bed . The care plan did not address Resident 1's need for two-person physical assist with bed mobility. During a concurrent interview and record review on 3/6/20, at 10:51 a.m., with the DON, the DON reviewed Resident 1's .fall [2/7/20] from bed . care plan, dated 2/7/20. The care plan indicated the following interventions: the bed should be in the lowest position, call lights answered in timely manner, ensure proper placement in bed. The DON stated the interventions did not address the root cause of Resident 1's fall on 2/7/20. The DON stated the intervention should have been for a two-person physical assistance for Resident 1 during bed mobility. The DON stated there were no new interventions developed or implemented for Resident 1 following her fall from her bed on 2/7/2020 to attempt to prevent another fall out of bed. During a concurrent interview and record review on 3/6/20, at 11:24 a.m., with RN 1, RN 1 reviewed Resident 1's care plans and stated there was no care plan with specific interventions which addressed Resident 1's assessed bed mobility need. RN 1 stated she was aware Resident 1 rolled out of bed on 2/7/20 during incontinence care. RN 1 stated a care plan should have been developed for Resident 1's specific ADL/ bed mobility needs. RN 1 stated after Resident 1 rolled out of bed on 2/7/20, nurses should have developed and implemented a care plan that Resident 1 required two-person physical assistance with bed mobility. During an interview on 3/6/20, at 2:30 p.m., with the DON, the DON stated the Interdisciplinary Team (IDT- a group of healthcare professionals who work together toward the resident's goals) were responsible for determining the root cause of a fall by collecting fall information and then recommend and developed interventions for Resident 1's plan of care to attempt to prevent additional falls and that did not occur. During an interview on 3/6/20, at 2:46 p.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated after Resident 1's falls 11/25/19, 2/7/20 and 2/28/20, the IDT reviewed the nurses' progress notes about the fall, documented in the IDT note with the fall analysis, then updated the resident's care plan adding new fall prevention interventions. The MDSC stated she usually updated resident care plans. The MDSC reviewed Resident 1's fall risk care plan dated 2/7/20 and stated she did not assess the need for Resident 1 to have a two-person assistance for bed mobility/incontinence care after Resident 1 fell on [DATE] during incontinence care provided by only one CNA. The MDSC stated the intervention put in place on the fall care plan to ensure proper placement in bed was a short-term intervention and would not prevent another fall. The MDSC stated a new care plan intervention was not developed or implemented for Resident after Resident 1's fall from her bed on 2/7/20 and an intervention should have been implemented. During an interview on 3/6/20, at 3:35 p.m., with CNA 2, CNA 2 stated she cared for Resident 1 and usually provided bed mobility and incontinence care for Resident 1 without assistance. CNA 2 stated resident was on an air mattress and that made turning her easier. CNA 2 stated Resident 1 would easily roll from side to side. CNA 2 stated Resident was confused, quiet and easy to provide care too. CNA 2 stated she did not review Resident 1's Kardex prior to providing care because she knew that she was able to provide the care without assistance. During an interview on 3/10/20, at 2:45 p.m., with CNA 3, CNA 3 stated on 2/28/20, at approximately 2:15 p.m., she was changing Resident 1's brief and soiled bed linen. CNA 3 stated she was turning Resident 1 on to her left side as she [CNA 3] attempted to pull the fitted bed sheet over the bottom part of the mattress on the left side when she saw Resident 1 roll off the bed. CNA 3 stated it happened so quick and she heard a thunk (a sound made when a body part strikes a solid surface). CNA 3 stated Resident 1 had her head wedged between the side of the bed and a bedside nightstand with her left shoulder wedged under the mattress. CNA 3 stated Resident 1's legs and feet were on the floor next to the bed. CNA 3 stated she could only see the back of Resident 1's head. CNA 3 stated she was afraid Resident 1 would continue to fall on her face, so she grabbed Resident 1 under the left shoulder and rolled her back into bed and called the nurse for help. During an interview on 3/10/20, at 12:15 p.m., with CNA 4, CNA 4 stated on 2/7/20, she had rolled Resident 1 to the side to change her brief and Resident 1 rolled out of the bed onto the floor. CNA 4 stated, She [Resident 1] went over. CNA 4 stated it happened, .so fast. CNA 4 stated she provided incontinence care for Resident 1 without assistance of another person. CNA 4 stated she did not need to have another person when she was providing Resident 1 care, she did it by herself all the time. During an interview on 3/18/20, at 1:45 p.m., with CNA 7, CNA 7 stated she had been assigned to Resident 1 and had provided incontinence care to Resident 1 alone and did not need another CNA to help her. CNA 7 stated Resident 1 was easy to turn in bed but Resident 7 tended to put her feet over the side of the bed when she was turned to the side. During a review of the facility's policy and procedure titled Fall Prevention and Fall Related Injury Management, dated 4/11/17 indicated, .At a minimum, the IDT will re-assess the patient/resident risk for falls according to the RAI [Resident Assessment Instrument- a guide to conduct assessment on a resident's strengths and needs which must be addressed in a resident's individualized care plan] .The IDT will review, revise, and alter the plan of care based on the patient/resident conditions and risk factors as needed . During a review of the policy and procedure titled Care Planning Process dated 12/11/17, indicated, .The interdisciplinary team shall prepare a comprehensive person centered care plan .to assist the patient/resident to reach his/her highest practicable level .On-going reviews and update will occur in conjunction with the [comprehensive assessment] process .

Based on observation, interview and record review, the facility failed to implement and maintain a safe environment with an effective infection prevention and control program (ICP) necessary to prevent a [MEDICAL CONDITION] (COVID-19- a serious contagious respiratory (lung) infection transmitted from person to person) outbreak (a sudden rise in the number of cases of a disease) for one of 85 sampled Residents (Resident 1) and for four of four employees, Infection Preventionist (IP), Licensed Vocational Nurse-(LVN) 2, Central Supply Clerk (CS), and the Assistant Director of Nursing (ADON) when: 1.The facility did not follow Centers for Disease Control (CDC) and Prevention return to work guidance, for four of four staff, the IP (responsible for monitoring infection control process (ICP) and ensuring ICP were being followed and implemented to prevent the spread of infections in the facility), ADON, LVN 2, and CS. These employees were permitted to return to work providing resident care and services while experiencing COVID-19 symptoms (a physical or mental feature indicating a condition of disease) and CS was permitted to return to the facility to perform student related duties (providing resident care and services) on 11/12/2020 while experiencing symptoms of COVID-19 infection. 2. The facility did not follow CDC COVID-19 screening recommendations, to have dedicated, and readily available, trained staff to conduct active screening of Health Care Personnel (HCP) prior to permitting entry into the facility. 3. The facility did not implement a facility wide infection control (IC) program that followed CDC standards for the prevention of spread of infections and did not ensure IP 1 possessed competencies to oversee the infection prevention program to aide in the prevention and containment of COVID-19 infection outbreak. These failures resulted in HCP screening themselves for symptoms of COVID-19 infection without actively verifying symptoms and body temperatures which subsequently exposed Resident 1 who tested positive for COVID-19 infections and placed 84 of 85 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16,17,18,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45,46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76,77, 78, 79, 80, 81, 82, 83, 84, and 85 at risk of being infected with COVID-19 virus. Because of these failures to maintain an essential and effective IC program necessary to reduce the spread of COVID-19, prevent an outbreak, the potential serious harm to Resident 1 from COVID-19 infection and the potential serious harm to Residents 2, 3, 4, 5, 6 , 7, 8, 9 ,10 ,11, 12 , 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, and 85, related to employees (CS, IP 1, ADON, and LVN 2) working with symptoms associated with COVID-19 infection, an Immediate Jeopardy situation (IJ) was called on 11/19/2020, at 5:25 p.m., under Code of Federal Regulations (CFR) 483.80 (F880-Infection Prevention and Control) with the facility Administrator (ADM), Director of Clinical Operations (DCO) and the Business Office Administrator (BOA). The facility submitted a plan of removal to address the IJ situation, which included having a designated screener, actively screening all staff prior to start of shift for each scheduled shift of workers. In-service training was provided to all staff on signs and symptoms of COVID-19. In-services were conducted to all employees regarding signs and symptoms of COVID-19 and a schedule of in-services to be completed on an on-going basis. Ensure the facility had a full time Infection Preventionist (IP- in accordance with the facility's mitigation plan) to implement monitoring and surveillance to track COVID-19 infections in the facility and staff compliance with transmission-based precautions (are measures designed for patients with documented or suspected infection use of personal protective equipment, glove and gown, use of dedicated medical equipment) to contain and prevent the spread of COVID-19. The plan of removal was accepted on 11/22/2020 at 11:03 a.m. The interventions to address the IJ situation on the Plan of Removal were fully implemented and the surveyor verified and confirm that IJ was removed while onsite. The IJ was removed on 11/24/2020 at 5:03 p.m., with the ADM, DON and DCO. The severity of the violation remained at a scope and severity of an L. Findings: 1.During a concurrent interview, and record review with the ADM, on 11/17/2020, at 9:55 a.m., the ADM stated prior to 11/12/2020, the facility had been COVID-19 infection free. The ADM stated the resident daily census was 85 on 11/12/2020. The ADM stated the facility outbreak began on 11/12/2020 when four staff (CS, IP, and ADON) tested positive for COVID-19 infection. The ADM stated one residents (Resident) 1 was tested for COVID-19 infection during the weekly COVID-19 facility testing on 11/13/2020 and result received on 11/16/2020 indicated that he was COVD-19 positive. The ADM stated Resident 1 was moved to a private room [ROOM NUMBER]/17/2020 in the Red Zone (COVID-19 unit) after the test results confirmed that he was positive for COVID-19 infection. The ADM stated Resident 1 had not left the facility and no visitors could visit. The ADM stated Resident 1 would have acquired COVID-19 infection while in the facility. The ADM stated the facility had followed all the CDC recommendations and did not know how the outbreak began. The ADM reviewed the facility record titled Line list dated 11/2020 and stated the CS had been ill on 11/5/2020 and was tested for COVID 19 on 11/6/2020 through an outside clinic. The ADM stated the CS received COVID -19 positive teste results on 11/12/2020 while she was in the facility as a nursing student. The ADM stated CS was also in a nursing program that performed nursing clinical practices in the facility. The ADM stated the CS notified her supervisor (Business office Manager (BOM)) of the positive COVID-19 test result on 11/12/2020 when the CS was in the facility performing student related resident care and administering medications to Residents 6 and Resident 7. The ADM stated CS went home after she informed her supervisor and her nursing instructor of the COVID positive results. The ADM stated he did not know what time the CS left the faciity on [DATE]. The ADM stated four facility staff had tested positive for COVID-19 on 11/12/2020, CS, the ADON, IP 1 and LVN 2. The ADM stated the facility did not have a full time IP in accordance with the facility's Mitigation Plan because IP 1 was out ill, tested positive for COVID -19 infection on 11/12/2020. The ADM stated the DON was the IP backup since IP 1 had been out ill since 11/8/2020. The ADM stated DON was not working for the remaining on the week (11/17, 11/18, 11/19 and 11/20/2020) because he had a family emergency. The ADM stated the facility brought in a part time IP (IP 2- IP for one of the sister facilities) to cover for two days since IP 1 was out ill and the DON was gone. During a review of the IP 1's timecard titled, Time and attendance- Employee Timecard dated 11/2020, indicated IP 1 had worked on 11/6/2020 from, .9:02 a.m., through 6:07 p.m., (sick 11/8 & 11/9) .11/10/2020 (clocked in) from 9:48 a.m., to 10:48 a.m. During a review of the facility document titled, SURVEILLANCE/SCREENING SIGN-IN SHEET dated 11/6/2020 which indicated, (IP 1) .(did not identify her) COVID-19 symptoms . NO . temperature 89.9 degree Fahrenheit (° F) . screened by (self- IP 1) .sticker given (permitting entrance) . surveillance/screening sign-in sheet dated 11/10/2020 did not contain documentation indicating IP 1 had been screened prior to entry to the facility. During a phone interview with the CS on 11/17/2020, at 3:20 p.m., the CS stated her job consisted of her delivering over the counter medical supplies throughout the facility including delivery of resident care products into resident rooms. The CS stated she developed a fever that continued for the remainder of 11/4/2020, and 11/5/2020. The CS stated she let her supervisor (Business Office Manager -BOM) know by text on 11/5/2020 that she was not feeling well, had a fever and did not go into work on 11/5/2020 and 11/6/2020. The CS stated on 11/6/2020 she felt better and sent her supervisor a text message informing her supervisor that she would report for work on 11/7/2020. The CS stated her supervisor did not disagreed with her returning to work. The CS stated she assumed it was safe to return to work having potential COVID-19 symptoms since her supervisor did not advise her to stay home. The CS stated, I did not think it was COVID . During a review of the CS's timecard titled, Time and attendance- Employee Timecard dated 11/2020, indicated CS worked on 11/4/2020 from, 11:42 a.m., through 4:52 p.m., 11/7/2020 from 9:30 a.m., to 3:30 p.m., 11/10/2020 from 1:11 p.m., to 5:00 p.m., and 11/11/2020 from 12:38 p.m., to 5:00 p.m. During a review of the facility document titled, SURVEILLANCE/SCREENING SIGN-IN SHEET dated 11/4/2020 which indicated, (CS) .COVID-19 symptoms . NO . temperature 94.8 (° F) . sticker given (YES- permitting entrance) .11/7/2020 . COVID-19 symptoms . NO . temperature 93.7 (° F) . sticker given (YES- permitting entrance) .11/10/2020 . COVID-19 symptoms . NO . temperature 94.8 (° F) . sticker given (YES- permitting entrance) . 11/11/2020 . COVID-19 symptoms . NO . temperature 96.9 (° F) . sticker given (YES- permitting entrance) . During a review of the surveillance/screening sign-in sheet dated 11/12/2020, the surveillance sign in sheet did not contain documentation indicating CS had been screened prior to entry to the facility on [DATE] when she was in the facility as a nursing student. During a phone interview with ADON, on 11/17/2020, at 3:35 p.m., the ADON stated the last day she was in the facility was on 11/10/2020. The ADON stated on 11/9/2020, she started having symptoms of a head cold and sinus congestion. The ADON stated, I did not let anyone know because I had a sinus infection before. The ADON stated she did not think she had COVID-19 because the facility had been COVID free. The ADON stated on 11/10/2020, she had a headache, runny nose, congestion and body ache and reported to work to arrange for a nurse to provide the wound doctor with resident assistance while the doctor was treating resident wounds. The ADON stated she informed the DON that she was not feeling well when she started the shift on 11/10/2020 and that after she finished, she was going home. The ADON stated by 11/11/2020, she had a lost the sense of taste and smell and continued to have body aches. The ADON stated she communicated her symptoms to the DON on 11/11/2020. The ADON stated she was notified of her positive COVID-19 test result on 11/12/2020. The ADON stated she shared an office with CS, IP and Business Office Manager (BOM). During a review of the ADON's timecard titled, Time and attendance- Employee Timecard dated 11/2020, indicated ADON worked on 11/4/2020 from, 7:27 a.m., through 5:11 p.m., . 11/9/2020 from 7:17 a.m., to 6:06 p.m., and 11/10/2020 from 7:30 a.m., to 10:30 a.m. During a phone interview with IP 1, on 11/17/2020 at 3:55 p.m., IP 1 stated on 11/8/2020, she started having symptoms of fever, headache, weakness, and cough. IP 1 stated she began feeling better the following day on 11/9/2020. IP 1 stated on 11/10/2020, she continued to have fever and congestion and let her supervisor know on 11/10/2020. IP 1 stated the ADM and DON asked her to go into work (the facility) to get tested for COVID-19 on 11/10/2020. IP 1 stated prior to entering the facility she self-screened and took her own temperature but did not remember what her temperature was. IP 1 stated she went into the facility to get tested for COVID-19 infection and was in the facility for approximately an hour and left. IP 1 stated the last day she worked in the facility was 11/7/2020 she was performing staff COVID -19 testing for about an hour. IP 1 stated on 11/12/2020, she received a call from the Director of Nursing (DON), notifying her of the positive COVID-19 infection test result. During a concurrent interview with IP 1 and review of the facility document titled, SURVEILLANCE/SCREENING SIGN-IN SHEET dated 11/9/2020 which indicated, (ADON) .COVID-19 symptoms . (left blank) . temperature 97.5 (° F) .(self-screened) . sticker given (YES- permitting entrance) .11/10/2020 . COVID-19 symptoms . NO (COVID-19 symptoms were reported) . temperature 89.0 (° F) . sticker given (YES- permitting entrance) . IP stated that she did not verify her temperature reading when she self-screened for COVD-19 symptoms and she did not indicate that she was experiencing COVID 19 symptoms because she did not think she had the COVID-19 virus. During a concurrent interview and record review with the BOM, on 11/18/2020, at 10:37 a.m., the BOM stated the CS called in 11/5/2020 and 11/6/2020. The BOM (CS supervisor) reviewed call-in slip dated 11/5/2020 and 11/6/2020, and documentation on the remark area indicated, ILL. The BOM stated the CS had gastric issues in the past and did not ask her questions regarding her symptoms. The BOM stated she shared an office with CS and would know when she was not feeling well. The BOM stated she received a text message from the CS on 11/6/2020, informing her that she was feeling better, no longer having a fever, but she did not ask her if she was still taking any fever reducing medication. The BOM stated she did not ask the CS to stay home and permitted the CS to return to work on 11/7/2020 while experiencing potential COVID-19 symptoms. The BOM stated she did not think CS's symptoms were COVID-19 infection. The BOM stated she did not inform the IP 1 or the DON of the CS calling off sick for 11/5/2020 and 11/6/2020 and she should have. The BOM stated she decided it was safe for the CS to return to work without a medical clearance or discussing it with the DON and IP 1. During a concurrent observation and interview with Resident 1 on 11/18/2020 at 12:30 p.m., Resident 1 was in a room in the COVID -19 positive unit (area where residents that tested positive for COVID-19 were housed), sitting in a wheelchair watching TV. Resident 1 stated he did not understand how he became infected with COVID-19 because he had not left the facility and he had no visitors. Resident stated that he did not have a fever and or cough, yet. During a concurrent interview and record with the ADM, on 11/18/2020 at 1:15 p.m., he reviewed the facility document titled, List of COVID-19 resident and staff dated 11/2020, the ADM stated LVN 2 was tested for COVID-19 on 11/12/2020. The ADM stated LVN 2 had been working performing resident care duties on 11/13/2020, 11/14/2020, and 11/15/2020 experiencing eye pain, runny nose, sneezing, Allergy symptoms. The ADM stated LVN 2 COVID-19 test results were received on 11/16/2020. The ADM stated LVN 2's last day of work was on 11/15/2020. During a concurrent interview and record review with the ADM, on 11/18/2020 at 1:17 p.m., he reviewed the document titled, Line list dated 11/2020 which indicated the IP 1 was tested for COVID-19 on 11/10/2020 and received positive test results on 11/12/2020. The ADM stated the last day the IP worked was on 11/6/2020 but returned to the facility on [DATE] to get tested for COVID-19 in the facility. During a concurrent interview and record review with the ADM on 11/18/2020 at 1:19 p.m., of COVID-19 infection of the ADON, the ADM stated the ADON was tested for COVID-19 on 11/9/2020. The positive test result was received on 11/12/2020. The ADM stated the last day the ADON was in the facility was on 11/10/2020. During an interview with LVN 6 on 11/18/2020 at 2:30 p.m., LVN 6 stated she was aware that facility staff were working while experiencing COVID-19 symptoms. LVN 6 stated, But as soon as the results was available, they were sent home. LVN 6 stated she did not want to indicate which staff were working while experiencing COVID-19 symptoms. During a review of the professional reference titled CDC - Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection . dated 8/10/2020 retrieved from https://www.cdc.gov/ , indicated, . For HCP who were suspected of having COVID-19 and had it ruled out, either with at least one negative test or a clinical decision that COVID-19 is not suspected and testing is not indicated, then return to work decisions should be based on their other suspected or confirmed [DIAGNOSES REDACTED]. Symptom-based strategy for determining when HCP can return to work .HCP with mild to moderate illness . (should not return to work until) At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved . consider .consultation with local infectious diseases experts if concerns exist for the HCP being infectious . During a phone interview with LVN 2, on 11/18/2020, at 3:15 p.m., LVN 2 stated on 11/12/2020 she had worked a 16-hour shift and had symptoms of runny nose and sneezing. LVN 2 stated she had direct contact with IP 1, ADON and CS daily when they were working. LVN 2 stated she had also experienced eye pain on 11/10/2020 and had gone to see an eye doctor on 11/11/2020. LVN 2 stated she discussed her symptoms with the DON and her history of seasonal allergy on 11/12/2020 and both decided her symptoms were allergies and not COVID-19 infection. LVN 2 stated on 11/12/2020, 11/13, 11/14 and 11/15/2020 she was working and had direct contact with all the residents on station four, 23 resident (Resident 1, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57) and all 29 residents (Resident 8, 9, 10, 5, 11, 12, , 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29., 30, 31, 32, 33, 34, and 35) on station 3. LVN 2 stated she had used a procedural mask while she interacted with residents. LVN 2 stated the DON called her on 11/16/2020, to let her know of the positive COVID-19 infection test result. During a review of LVN 2's timecard titled, Time and attendance- Employee Timecard dated 11/2020, indicated LVN 2 worked on: 11/4/2020 from, 6:21 a.m., to 2:20 p.m., (IP 1, ADOM and CS also clocked in) 11/6/2020 from 6:19 a.m., to 11 p.m., (IP 1, and ADOM also clocked in) 11/7/2020 from 2:16 p.m., to 11:15 p.m., (IP and CS also clocked in) 11/8/2020 from 2:08 p.m., to 10:43 p.m., 11/9/2020 from 2:05 p.m., to 10:55 p.m., 11/10/2020 from 2:01 p.m., to 7 :001 p.m., (IP 1, ADOM and CS also clocked in) 11/12/2020 from 6:15 a.m., to 10:54 p.m., 11/13/2020 from 2:23 p.m., to 11:20 p.m., 11/14/2020 from 2:15 p.m., 10:54 p.m., 11/15/2020 from 2:14 p.m., to 11:23 p.m. During a review of the SURVEILLANCE/SCREENING SIGN-IN SHEET dated 11/12/2020, and 11/15/2020, the surveillance/screening sig-in sheet did not contain documentation that LVN 2 was screened prior to entry to the facility on [DATE] and 11/15/2020. During a review of the facility document titled, SURVEILLANCE/SCREENING SIGN-IN SHEET dated 11/2020 did not contain documentation that LVN 2 was screened prior to entry to the facility. The surveillance/ screening sig-in sheet dated 11/13/2020, indicated, (LVN 2) .COVID-19 symptoms . (NO) (COVID-19 symptoms were reported during screening process) . temperature 97.2 (° F) . sticker given (YES- permitting entrance) .11/14/2020 . COVID-19 symptoms . NO (COVID-19 symptoms were reported during screening process) . temperature 90.0 (° F) . sticker given (YES- permitting entrance) . During a concurrent interview and record review on 11/18/2020, at 4:45 p.m. with IP 2, he stated no one with suspected COVID-19 infection symptoms should have been allowed entry into the facility to prevent exposure of residents and other staff. IP 2 stated he was the IP at a sister facility and all the facilities follows the same corporate guidelines, not permitting staff experiencing potential COVID-19 virus symptoms to work. IP 2 stated all facility staff must comply with the staff surveillance screening requirement. IP 2 reviewed the facility document titled, Staff Surveillance, dated 5/9/2020 which indicated, .Must be fever free for 72 hours without taking fever reducing medications . IP 2 stated all staff must follow the same corporate surveillance questionnaire requirements. IP 2 stated according to the sick call in slips, the CS reported she had elevated temperature for 72 hours and should not have been allowed to return to work without a medical clearance. IP 2 stated CS was permitted to return to work while exhibiting symptoms and that should not have happened. CS placed other staff and residents at risk of COVID-19 infection. During a phone interview with IP 1 on 11/20/2020, at 12:57 p.m., and review of the facility record timecard for IP 1 titled, Time and attendance- Employee Timecard dated 11/2020, indicated IP had worked on 11/6/2020 from, .9:02 a.m., through 6:07 p.m., (and) 11/10/2020 from 9:48 a.m., to 10:48 a.m. IP 1 stated she had worked a full day on 11/6/2020 but had also worked on 11/7/2020 performing COVID-19 test on staff and residents. IP 1 stated she returned to the facility on [DATE] because the ADM and the DON had asked her to return to the facility to get COVID-19 tested . IP stated she had a temperature and was not feeling well while in the facility but was only in the facility for one hour. During a concurrent interview with IP 1 on 11/20/2020, at 12:59 p.m., and review of the facility document titled, SURVEILLANCE/SCREENING SIGN-IN SHEET dated 11/6/2020 which indicated, (IP 1) .COVID-19 symptoms . NO . temperature 89.9 degree Fahrenheit (° F) . screened by (self- IP 1) .sticker (permitting entrance) . surveillance/screening sign-in sheet dated 11/7/2020 and 11/10/2020 did not contain documentation indicating IP 1 had been screened prior to entry to the facility. IP 1 stated she conducted her own COVID -19 screening on 11/6/2020 but did not notice that her body temperature reading was so low. IP 1 stated the equipment needed to be calibrated because there was no way her temperature was 89.9° F. IP 1 stated staff self-screening was an acceptable practice for the facility. IP 1 stated if the screening document dated 11/7/2020 and 11/10/2020 did not have her name on it, it was because she was not screened prior to going into the facility, and she should have been screened because she was not feeling well on 11/8/2020. During a phone interview with the IP 1, on 11/20/2020, at 12:50 p.m., IP 1 stated she was feeling ill and called off work on 11/8/2020 and 11/9/2020. IP 1 stated she took her temperatures at home on 11/8/2020 and had a temperature of 100.8 ° F. IP 1 stated her home temperature reading on 11/9/2020, was 100.2 ° F and on 11/10/2020, her temperature reading at home was 99.8 ° F. IP 1 stated her whole family got sick after she got sick but decided not to get her family tested , because she knew they had COVID-19 infection because she had tested positive for COVID-19 on 11/12/2020. During a phone interview with the CS on 11/20/2020, at 2:16 p.m., the CS stated on 11/4/2020, during her shift she felt her body was hot but did not verify her temperature. The CS stated she let her supervisor (BOM) know that she was feeling warm. CS stated her supervisor did not instruct her to take her temperature and did not ask her to go home and she worked until 5 p.m., then went home. The CS stated when she arrived home from work on 11/4/2020 she took her body temperature and had a fever registering at 101.2-degree Fahrenheit (° F -scale of temperature measuring- review of professional reference www.health.harvard.edu 2020, an adult average normal body temperature is 97.5 ° F). The CS stated on the morning of 11/5/2020 she sent a text message to her supervisor (BOM) informing her she was not feeling well and that she had a temperature of 102.8 ° F. The CS stated she sent a text message to her supervisor again in the afternoon informing her she felt a heavy head and could not lower her temperature from 99.8 ° F despite using fever reducing medications. The CS stated on 11/6/2020, she took fever reducing medication in the morning to avoid feeling sick all day and sent a text message to her supervisor at around 2 p.m., to let her know she was going to get tested for COVID-19. CS stated she was feeling better because her temperature was 98.7 ° F and decided she was going to return to work on 11/7/2020. The CS stated she did not receive a response from her supervisor, so she reported to work the following day (11/7/2020). The CS stated she still did not feel well and asked the screener to deliver resident supplies for her and she would complete her other duties for that day. The CS stated she was off for a few days and was back in the facility as a nursing student on 11/12/2020, at 8:45 a.m., where she performed resident care and administered medications to Residents 7 and Resident 8. The CS stated she received the positive COVID-19 test result by electronic mail and text message on 11/12/2020 while she was in the facility. The CS stated she notified her nursing instructor and her work supervisor (BOM) right away and was asked to finish what she was doing and leave the facility. During a telephone interview on 11/20/2020, at 3:30 p.m., with ADON, the ADON stated she went to work on 11/10/2020 knowing she was exhibiting symptoms, but she did not think the symptoms were possible COVID-19 symptoms. The ADON stated she meet with the wound doctor and nurses while she was in the facility. The ADON stated she told the DON she was not feeling well when she came into work and that she was planning on leaving after she completed her work. The ADON stated she informed the DON that she had a head cold, body aches, stuffy nose and headache. The ADON stated she and the DON did not think she had COVID because the facility had been COVID-19 free. The ADON stated the DON and the ADM were aware of her symptoms and permitted her to work. The ADON stated she self-screened and took her own temperature when entered the facility. The ADON stated she did not remember her temperature reading and no one verified the information she self-documented on the screening form. The ADON stated she was in the facility for approximately an hour and left. The ADON stated that she was aware that if staff had symptoms like fever, headaches and body aches, staff should not be allowed entry in the facility to prevent exposure of residents and other staff. The ADON stated she should not have been in the facility while exhibiting COVID -19 symptoms. During a professional reference review retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 12/3/2020, titled, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 (COVID-19) Infection dated 8/10/2020 indicated, (Health care personnel) HCP with symptoms of COVID-19 should be exclude from work at least 10 days and up to 20 days have passed since symptoms first appeared .At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms (e.g., cough, shortness of breath) have improved . (prior to returning to work) Consider consultation with infection control experts . If HCP develop fever (T (temperature) 100.0 F) or symptoms consistent with COVID-19 while at work, they should inform their supervisor and leave the workplace . 2. During a concurrent interview and record review with Screener 1 (SC 1), on 11/17/2020, at 2:43 p.m., SC 1 stated he would sometimes be assigned to screen staff on weekends and sometimes on weekdays. The SC 1 stated when the facility did not designate a staff member to screen staff, staff would screen themselves. SC 1 stated the facility did not have a screener for the night shift (10 p.m.) and the staff would self-screen. SC 1 stated his normal working hours would start from 6:30 a.m. and end at 3:00 p.m. SC 1 stated he would screen staff from the morning shift, staff starting at 6 :30 a.m. and occasionally screen the evening shift (staff starting at 2:00 p.m. SC 1 stated he would ask staff questions regarding COVID symptoms, check temperature, instruct staff to use the alcohol gel, wear N95 (a mask that filters at least 99% of airborne particles) respirator and gives a dated stickers indicating staff did not have COVID-19 symptoms like fever, headaches, body aches or cough and had been cleared to enter the facility. SC 1 stated if staff temperatures were above 99.6 ° F, staff were not allowed entry and needed to go home. SC 1 stated he did not know who would send staff home, because he had never sent any staff home. SC 1 stated he had not received training on what to do when a staff indicated they had one of the symptoms or had a temperature above 99.6 ° F. SC 1 stated once the screening documents were completed he placed them in a box for the IP 1 and he did not know who reviewed the screening documents that he put in the box. SC 1 stated the staff screened themselves after he left, just like he screened himself when he arrived to work in the morning prior to starting his shift. SC 1 stated the staff checked their own temperatures using the thermal scanner available in the lobby, document their temperature reading and answer symptom questions on the surveillance sheet. SC 1 reviewed facility document titled, STAFF SURVEILLANCE SIGN IN SHEET, dated 11/9/2020 indicated, (Staff 1) .(symptoms) YES (symptoms were not indicated on the screening form) . temperature 93.9 (° F) .if (staff indicates a response of ) YES, LN must complete health screening addendum before staff start shift . SC 1 stated he did not screen staff 1. SC 1 stated staff 1 was screened by Social Worker (SW) 1 and he did not know if Staff 1 was sent home because staff 1 indicated they had COVID-19 symptoms. SC 1 stated according to the screening form, symptomatic staff 1 was permitted entry into the facility. SC 1 stated the facility did not provide training for staff screening and staff were just completing the form. SC 1 stated he had never had a staff answered yes to any of the questions and did not know he had to call for an LN to complete a health screening addendum for staff that answered questions with a yes. SC 1 reviewed the STAFF SURVEILLANCE SIGN IN SHEETS dated 11/1/2020 through 11/15/2020, which indicated the flowing documented temperature readings ranging from 89.0 ° F through 89.9 ° F (88 staff- temperature readings recorded with those temperature readings), 90.0 ° F through 94.0 ° F, (80 staff) had temperature readings recorded within those ranges (review of professional reference www.health.harvard.edu 2020, an adult average normal body temperature is 97.5 ° F). SC 1 reviewed the body temperature readings and stated he had recorded some of the temperature readings indicating 89.0 ° F. SC 1 stated the other body temperature reading of 89. Degree F were documented by the staff that were self-screening. SC 1 stated that he had never noticed the out of range body temperatures. SC 1 stated he had not received education to know at what body temperatures ranges to check the device being used to take body temperatures. SC 1 stated he did not know if anyone reviewed the screening documents for accuracy of the screening process. SC 1 state no one had ever asked or informed him if he was documenting staff screening accurately. During a concurrent interview and record review with SC 2, on 11/20/2020, at 12:11 p.m., SC 2 stated she worked weekdays from 6:00 a.m. to 3:00 p.m., SC 2 stated she screened herself in the mo (TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents were free from misappropriation of resident funds for one of four sampled residents (Resident 1) when the Assistant Social Worker (ASW) demanded and coerced Resident 1 to pay for ASW's personal items on 10/24/19 while accompanying Resident 1 on a shopping outing. This failure resulted in the misappropriation of one-thousand four dollars of Resident 1's personal funds. Resident 1 was exploited while out on a shopping outing and suffered feelings of distress of not having sufficient funds to pay for her share of cost and the potential of getting discharged from the facility. Findings: During a review of the facility document titled, Facility Reported Event dated 11/8/19, at 5 p.m., indicated, . (Resident 1) showed us her bank statement for the month of October (2019). On that report there were charges on 10/24/2019, on the day they (ASW and Resident 1) went out shopping, from (name international shopping vendor) for 662.54, (name of clothing store 1) for 184.95 and 156.56 and (name of clothing store 2) for 27.56. (Resident 1) stated that she was going to purchase items from (international shopping center) at check out and while waiting in line, (ASW) came up and put her personal items on the checkout and told the resident that the resident was going to pay for (ASW's) items. They then went to (name of clothing store 1 at a local mall) where the resident purchased dresses for herself. Next they went to (name clothing store 2) where (ASW) had the resident purchase (ASW) a pair of shoes for over $100.00 dollars. While at (name of clothing store 2) (ASW's) son joined them and (ASW) had the resident purchase (ASW's) son clothes as well .The belongings list created by (ASW) when they returned was; 10 pairs of socks, 3 dresses, 2 pajama dress, 2 turtle neck sweaters and 1 cardigan, which would not account for the total amount spent. (ASW) did admit to receiving a pair of shoes from the resident but said that the resident told her it was a gift. On November 8, 2019 the resident had her shoes of cost/rent due and did not have sufficient funds to pay her share of cost due to the shopping costs. The resident approached (ASW) about the money that was spent and wanted to know when she could expect to be paid back. (ASW) told her she couldn't pay her back all of the money she wanted but would try to pay her back some each pay period . During an interview on 11/21/19, at 8 a.m., with the Administrator (ADM), the ADM stated ASW was suspended from the facility on 11/8/19 for the alleged financial abuse to Resident 1 and was terminated on 11/13/19. The ADM stated the local police department was notified on 11/9/19 and the ASW was taken into custody. During a concurrent observation and interview on 11/21/19, at 8:30 a.m., with Resident 1 in her room, Resident 1 was lying in bed and watching TV. Resident 1 stated ASW accompanied her shopping on 10/24/19 at three different stores, (name of clothing store 1), (name of clothing store 2) and (name of international shopping vendor). Resident 1 stated the ASW placed her personal shopped items when they shopped at the international shopping center while they were at the cashier counter. Resident 1 stated the ASW demanded Resident 1 pay for the items placed on the cashier's counter. Resident 1 stated the ASW took her son to the shopping outing on 10/24/19 and shopped for her son's personal items in clothing store 2. Resident 1 stated the ASW told her since she accompanied her shopping then she needed to pay for the ASW's personal shopped items. Resident 1 was tearful and stated, I did not know (the ASW) that well. That day I got to know what kind of person she (the ASW) was, she (the ASW) was a bad person. Resident 1 stated the incident made her very upset because she needed the money to pay for the share of cost (a set amount based on how much money a person makes) owed to the facility. Resident 1 stated she did not have sufficient funds to pay her share of cost and was afraid she might get discharged from the facility. After the incident Resident 1 stated the facility ADM told her she would receive a refund of the money she paid for ASW's personal shopped items. Resident 1 stated she managed her own money and credit card. Resident 1 stated she ordered a new credit card and gave the previous credit card to the Business Office. During a review of Resident 1's BIMS (brief interview for mental status- a tool used to assess cognition), dated 10/9/19, the BIMS indicated, Resident 1 had a BIMS of 15 (cognitively intact). During a review of Resident 1's face sheet (document with personal and background information) dated 11/8/19, indicated Resident 1 was self responsible and was her own representative. During a review of Resident 1's Progress Notes, dated 11/11/19, the Progress Notes indicated, . Administrator spoke with resident in regards to financial abuse. Resident was upset by what happened and concerned about being able to pay her share of cost for the month. Resident also voiced concern about (ASW) returning to the facility . During a review of the facility document title Preventing Resident Abuse, dated 1/2/19, indicated ASW attended the Abuse training for abuse prevention and being an abuse mandated reporter. During an interview on 11/21/19, at 8:40 a.m., with Social Services Director (SSD), the SSD she accompanied Resident 1 shopping twice on 10/24/19. SSD stated facility staff were not allowed to accept gifts or money from residents. SSD stated she was not able to accompany Resident 1 shopping on 10/24/19 and had asked the ASW to accompany Resident 1 shopping. SSD stated the ASW accompanied Resident 1 shopping on 10/24/19. During an interview on, 11/21/19, at 9:49 a.m., with the Business Office Manager (BOM), BOM stated Resident 1 was offered the option on admission to open a trust fund with the facility. BOM stated Resident 1 declined the trust fund option and preferred to manage her own money. BOM stated Resident 1 did not have any issues of managing her own money and was able to pay her facility share of cost on time. BOM stated she had accompanied Resident 1 shopping and Resident 1 had offered to buy her items and she would decline. BOM stated Resident 1 was a very frugal shopper and shopped at thrift stores. BOM was unable to produce documents that Resident 1 declined the option to open a trust fund in the facility. During a concurrent telephone interview and record review on 1/9/2020, at 2:45 p.m., with the Director of Nursing (DON), the DON reviewed the facility employee Handbook, dated 12/16/16 indicated, . Each resident and patient has the right to be free from . abuse . Each resident and patient must be treated with . respect in full recognition of his or her dignity . Your behavior must reflect your belief in these resident/patient rights . Employees are prohibited from accepting . gifts or loans from residents . The DON stated the ASW was trained on abuse prevention and received the Employee Handbook upon hire. The DON stated the ASW was not allowed to receive gifts from residents and especially taking money from residents. The DON stated it was not acceptable for staff to receive gifts and take money from residents. The DON stated ASW should have followed the Employee Handbook and Policy and Procedure on abuse. During a concurrent telephone interview and record review on 1/22/2020, at 8:30 a.m., with the ADM, the ADM reviewed the facility Employee Handbook, dated 12/16/16 and stated the ASW should have followed the Employee Handbook and Policy and Procedure and did not. The ADM stated During a review of Resident 1's bank statement, dated 10/24/19, the bank statement indicated, . Withdrawal Adjustment Dispute Adj (name of bank) provisional credit debit dispute (international shopping center) . credits 662.54 . (name of clothing store 1) . credits 184.96 . (name of clothing store 1) . credits 156.56 . (total) 1,109.00 . During a review of the police report dated 2/25/2020, indicated, Incident Overview Report Purpose .Property Crime .Special Factors Confidential, Dependent Adult, Elder Abuse (65+) .Offenses .THEFT BY CARETAKER .From Date 10/24/2019 from time (9 a.m.,) To Date 10/24/2019 To Time (7 p.m.) .Narrative .SOURCE: ON 11-09-19 AT ABOUT (9;15 A.M.), I WAS DISPATCHED TO THE (SKILLED NURSING FACILITY-(SNF)) .REGARDING A REPORT OF FINANCIAL ABUSE .INVESTIGATION; .SUSPECT IN THIS CASE IS (ASW) .THIS CASE INVOLVES A VICTIM (Resident 1) WHO IS IN THE CARE OF THE (SNF) AND WHILE ON A SHOPPING TRIP, HER SOCIAL WORKER FOR THE TRIP WAS (ASW) AND AT TWO DIFFERENT STORES .TRANSACTION: 1. (name of international shopping vendor) TRANSACTION AT 11:51(A.M.,) SPENT TOTAL AMOUNT $662.54 . 2.(name of clothing store 1) AT (1:59 P.M.,) SPENT TOTAL AMOUNT $184.96 .3. (name of clothing store 1) AT (2:37 P.M.,) SPENT TOTAL AMOUNT $156.56. THE AMOUNT NOTED ABOVE WERE THE TOTAL AMOUNT (ASW) HAD THE VICTIM SPEND ON HER WHILE ON THE SHOPPING TRIP PER THE VICTIM .(ASW) SAID SHE BOUGHT TWO PAIRS OF SHOES AND PAID (RESIDENT 1) BACK IN CASH FOR IT WHEN THEY GOT TO HER CAR .(ASW) SAID SHE BOUGHT HER SON SHIRTS AND SHOES THERE (name of clothing store 1) .CONCLUSION/DEDUCTION: (ASW) WORKS AT THE (SNF) WHERE THE VICTIM (Resident 1) RESIDES. ON 10-24-19 AT ABOUT 9 A.M., (ASW) ESCORTED THE VICTIM (Resident 1) ON A SHOPPING TRIP. (ASW) USED THE VICTIMS (Resident 1) CREDIT CARD BY JOINING HER PURCHASE TO HERS AT (name of international shopping vendor). (ASW) LATER JUST MADE THE VICTIM (Resident 1) PAY FOR HER PURCHASES AT (name of clothing store 1), A STORE THE VICTIM (Resident 1) DID NOT INTEND TO GO. THE TOTAL AMOUNT TAKEN VIA DEBIT ACCOUNT IS $1004.46 DOLLARS. VICTIM (Resident 1) WAS NERVOUS TO CONFRONT HER BUT WHEN SHE DID (ASW) TRIED TO MAKE PAYMENT TO HER INSTEAD OF RETURNING THE ITEMS FOR THE MONEY TO BE RETURNED. THIS NEGOTIATION TACTIC IS COMMON PLOY IN THESE CASES WHEN EMBEZZLEMENT IS DONE FROM AN ELDER VICTIM .CONCLUSIONS .(ASW) used coercion to get victim (Resident 1) to pay for her purchases knowing she had disabilities and anxiety . During a review of the facility's policy and procedure titled, Protection from Abuse Social Services, dated 4/1/16, . All residents in the Living Center will be free from . abuse . The social services staff is bound by accepted standards of practice to intervene when abuse is suspected .

Based on observation, interview and record review, the facility failed to ensure the environment was free of accident hazards when 29 of 106 resident beds ( Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30) had exposed rough, jagged metal on the lower end of the side rails. This failure resulted in a 14 centimeter (measurement of length) laceration (cut) to Resident 1's right leg that required transfer to the General Acute Care Hospital (GACH) and placement of 17 staples to close the wound and placed other residents at risk for injury. Findings: Review of Resident 1's admission record (document containing resident personal information) indicated Resident 1 was [AGE] years old and was admitted to the skilled nursing facility (SNF) on 6/5/18 with [DIAGNOSES REDACTED]. Review of Resident 1's minimum data set (MDS, a resident assessment tool used to plan care) assessment dated [DATE] indicated a Brief Inventory of Mental Status (BIMS) score of 15 points out of a possible 15 points which indicated Resident 1 was cognitively (pertaining to memory, judgement and reasoning) intact. Review of Resident 1's progress notes dated 7/2/18, untimed, indicated, During transfer resident (Resident 1) leg was caught on the bottom of the side rail where the right front calf had a laceration. 9/10 for pain (on a scale from 0 to 10 where 0 is no pain and 10 is the worst imaginable pain). Minimal bleeding present .Reported to primary care clinician .Family/healthcare agent notified .7/2/18 12:45 p.m. Review of Resident 1's physician orders [REDACTED].She (Resident 1) needs stitches .Services available at the receiving facility to meet the resident need(s): (GACH) one time only for acute injury for 1 day. Review of Resident 1's transfer/discharge report (document that accompanies a resident upon transfer to another facility) dated 7/2/18 at 12:45 p.m., indicated Resident 1 was transferred to the GACH for an acute (sudden onset) injury. On 7/18/18 at 9:30 a.m., during a concurrent observation and interview in Resident 1's room, the maintenance supervisor (MS) stated he was informed by the administrator (Adm) on 7/2/18 at 12:30 p.m. about Resident 1's injury during the transfer from her bed to her wheelchair. The MS stated on 7/2/18 Resident 1's upper side rail was missing a black plastic cap that covered the exposed metal on the bottom of the side rail. The MS stated Resident 1's leg was cut by the exposed metal on 7/2/18 during the transfer. The MS stated he replaced the missing black plastic cap on Resident 1's side rail after the Adm informed him of the injury. The MS demonstrated the presence of a black cap on the bottom of the side rail of Resident 1's bed. The MS toured seven resident rooms and observed 16 resident beds ( Residents 7, 8, 11, 12, 13, 15, 16, 20, 21, 22, 23, 24, 25, 28, 29, 30) missing one or more black plastic caps at the bottom of the side rails. The MS stated his job duties included maintaining and repairing resident beds. The MS stated he was aware for the past month and a half of black plastic side rail caps missing in numerous resident rooms leaving the rough metal edges exposed. The MS stated, I should have paid more attention to the missing caps after the incident with Resident 1 and replaced all the missing caps immediately to prevent injury to other residents. The MS stated all side rails should have protective plastic caps in place. On 7/18/18 at 10 a.m., during an interview, the MS stated he had a list of other resident beds missing plastic protective caps on the bottom of the side rails. The MS produced a list which indicated 12 additional resident beds ( Residents 2, 3, 4, 5, 6, 9, 14, 17, 18, 19, 26, 27) missing one or more plastic protective caps on the bed side rails. On 7/18/18 at 10:15 a.m., during an interview, certified nursing assistant (CNA) 1 stated on 7/2/18 Resident 1 wanted to go to her room for lunch. CNA 1 stated she wheeled Resident 1 into her room and lifted the bed side rail up toward the headboard. CNA 1 stated she transferred Resident 1 from her wheelchair to her bed and then noticed Resident 1's right leg was bleeding. CNA 1 stated she looked at the side rail and noticed a piece of skin or tissue hung off the rail on the exposed metal at the bottom of the side rail. CNA 1 stated she reached down and felt the metal end of the side rail. CNA 1 stated the metal end of the side rail was jagged and the protective plastic cap was missing. CNA 1 stated Resident 1's right leg had a large, bleeding laceration. CNA 1 stated she immediately alerted the licensed nurse of Resident 1's laceration. CNA 1 stated the exposed metal ends of the side rails were rough and jagged and should be covered by plastic caps to protect the residents from injury. On 7/18/18 at 10:30 a.m., during an interview, CNA 2 stated she noticed missing caps on two resident beds two weeks before. CNA 2 stated she did not report the missing caps to anyone. CNA 2 stated I should have reported the missing caps because of the hazard. CNA 2 stated some of the side rails with missing black plastic caps were sharp and jagged and could cause injuries to residents. On 7/18/18 at 10:45 a.m., during a concurrent observation and interview, Resident 1 was alert, lying in her bed with her legs covered by bed clothes. Resident 1 stated on 7/2/18 CNA 1 was assisting her from her wheelchair to her bed. Resident 1 stated during the transfer she felt something sharp brush her right leg and felt immediate pain. Resident 1 stated her right leg was cut during the transfer on 7/2/18 by sharp metal on the bed. Resident 1 stated she currently had pain of 4/10 on her injured right leg. On 7/18/18 at 11:15 a.m., during an interview, Resident 20 stated there were two missing plastic caps on the left side rail of her bed. Resident 20 stated she reported the missing caps and exposed metal edges to facility staff about a month ago. Resident 20 stated she was unable to recall which facility staff she informed about the missing caps. Resident 20 stated, Nothing was done (about the missing plastic caps). On 7/18/18 at 11:25 a.m., during an interview, the director of nursing (DON) stated there were still rooms with missing side rail caps. The DON stated the missing caps created an accident hazard for residents, family members and staff. The DON stated all missing caps should have been replaced immediately after Resident 1's accident with injury on 7/2/18. On 7/23/18 at 11:20 a.m. during a telephone interview, the Adm, stated she was walking down the hallway on 7/2/18 when CNA 1 came out of Resident 1's room looking for the licensed nurse. The Adm stated she observed Resident 1 had a cut to her right leg. The Adm stated she called the MS who brought a black plastic cap for the side rail and placed it on Resident 1's bed. The Adm stated there was a risk of injury to residents because the black plastic caps were missing on some beds, exposing residents to sharp, jagged metal edges. Review of Resident 1's GACH emergency department physician notes titled, Final Report dated 7/2/18 at 1:32 p.m. indicated, Brief History: [AGE] year old female .BIBA (brought in by ambulance) presents to the ED (emergency department) s/p (status [REDACTED]. Pt (Patient) reports she lives in a SNF and her nurse was transporting her from wheelchair to bed when she somehow scraped her right leg against the railing of the bed .Description/repair: Laceration 14 cm (centimeters) in length right lateral (side) lower leg. Shape: curvilinear (long curve shaped). Depth: superficial (near the surface of the body) . Anesthesia (medication to interrupt pain signals during a procedure) 10 ml (milliliters, a liquid measurement) 0.5% (percent) [MEDICATION NAME] (local anesthetic given by injection into the skin) .Skin Closure: 17 staples. Notes: Patient tolerated procedure well and is advised to have staples removed in 10 days . Review of facility document titled Job Description dated 10/2/13 indicated, Job Title: Director Facilities Maintenance. General Purpose: . Responsible for establishing, directing, analyzing and monitoring systems for all aspects of services that focus on safety, physical plant, and preventative maintenance programs that meet or exceed all state and federal codes, regulations and permits .Directs and monitors safety compliance .