Every finding on record at Green Meadow Haven

Based on observations, record reviews and interviews the facility failed to have a system in place to prevent accident hazards for 1 (#67) of 4 (#4, #46, #67, #84) sampled residents investigated for accidents. The facility failed to ensure coffee was served at a safe temperature to prevent burn injuries.The deficient practice resulted in an actual harm on 08/13/2024 at approximately 8:40 a.m. when Resident #67 spilled her breakfast coffee onto her lap. Resident #67 was not aware she had a burn to her left anterior thigh until S6 CNA (Certified Nursing Assistant) came to help her clean up and her left anterior thigh had a reddened area with blisters. S5 NP (Nurse Practitioner) was notified and identified the burn as a partial thickness burn of left upper thigh (2nd degree) and burn treatment began. The deficient practice had the likelihood to cause serious injury or harm to all of the 81 residents in the facility.Findings:Review of the American Burn Association Scald Injury Prevention Educator's Guide revealed in part: The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. Older adults, identified as a high risk group, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications .Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Third degree burns can occur within 1 second with hot water temperatures at 155 degrees Fahrenheit (F), within 2 seconds at 148 degrees F, within 5 seconds at 140 degrees F, within 15 seconds at 133 degrees F, and within 1 minute at 127 degrees F. All facility policies related to scald prevention were requested of S1 Administrator on 08/19/2025 at 1:34 p.m. and S1 Administrator reported there were no official policies in effect related to scald prevention.Review of Resident #67's record revealed an admit date of 11/04/2020 with a readmit date of 06/23/2025 with diagnoses that included type 1 diabetes mellitus with hyperglycemia and diabetic chronic kidney disease as well as unspecified polyneuropathy. Review of Resident #67's MDS (Minimum Data Set) assessment dated [DATE] revealed intact cognition with a BIMS (Brief Interview for Mental Status) score of 15, no functional impairment in range of motion, and set up only assistance required with eating. Further review of Resident #67's MDS revealed most recent assessment dated [DATE] indicated intact cognition with a BIMS of 14, no functional impairment in range of motion, and set up only assistance required with eating.Review of the facility's incident log revealed an injury incident regarding Resident #67 on 08/13/2024. Review of Resident #67's incident report dated 08/13/2024 at 12:42 p.m. prepared by S7 LPN (Licensed Practical Nurse) revealed in part: this nurse was notified by CNA of red marks on Resident #67's leg and a blister. Nurse entered the room, Resident #67 was in the bathroom, her left upper leg was visibly red with 2 blisters. Resident #67 said she spilled her coffee on her. Wound Care Nurse, NP (Nurse Practitioner), and resident's responsible party were notified. Wound care nurse measured the burn and applied Silvadene cream. Resident #67 reported she reached up to get her coffee off the bedside table and it hit the end of the table and spilled on her. Resident #67 reported she guessed she was still half asleep when it happened and didn't know it had burned her leg until she went to wash herself off in the bathroom and saw it. Review of Resident #67's Nurses Notes revealed the following notes in part: 08/13/2024 at 11:48 a.m. the nurse was notified by S6 CNA at 8:40 a.m. while bathing the resident she noted a red mark with some blisters. Resident #67 reported she spilt coffee on her leg but didn't think it burned her. S3 RN (Registered Nurse)/Wound Care Nurse applied cream. Will continue plan of care. No other complaints at this time. 08/14/2024 at 10:23 a.m. Resident #67 remains in acute care following incident on 08/13/2024 related to burn to upper left leg. No acute distress at this time. Resident has no complaints of pain or discomfort. Educated resident on importance of allowing coffee to cool down before trying to move it from table. Review of Resident #67's S5 NP Notes revealed the following notes in part:08/13/2024 at 12:00 a.m. seen today to evaluate a burn on her legs. She spilled coffee on her lap this AM and nursing aids noticed later she had some redness on her legs and blisters. She reports not hurting badly and is more concerned with knee pain.partial thickness burn of thigh. Apply Silvadene cream. Wound care nurse to monitor. 08/20/2024 at 12:00 a.m. seen today for follow up on burns on her upper left leg/groin. She spilled coffee on legs last week and had 2nd degree burns on her groin and upper leg. She reports it is feeling some better and doesn't really hurt that much. Bandages have a hard time staying on due to the area and when she does therapy exercises.continue to keep clean with wound cleanser. pat dry, apply Silvadene, cover with Xeroform and dry dressing every other day and as needed until healed. Type 1 diabetes mellitus with other skin complication: complicates burn. Healing rate may be delayed as a result. Monitor glucoses closely. Review of Resident #67 S4 Wound Care NP notes revealed the following notes in part:08/16/2024 at 9:32 a.m. burns (second or third degree) left anterior thigh.tissue painful.no signs or symptoms of infection. Continue with current treatment orders.08/22/2024 at 11:02 a.m. second degree thermal burn to left anterior thigh. Wound status improving. Decrease in size. No signs or symptoms of infection. Continue with treatment order. 08/29/2024 at 11:27 a.m. left anterior thigh partial thickness burn assessed.pt is at high risk of wound incidence due to impaired mobility, co-morbid conditions, impaired blood flow, inevitable effect of aging, scar tissue, and diabetes.09/05/2024 left anterior thigh partial thickness burn resolved. During an observation and interview on 8/19/2025 at 10:50 a.m. Resident #67 was sitting in a wheelchair in her room visiting with her daughter and son-in-law. A single serve pod coffee maker was noted in Resident #67's room. Resident #67 was asked about the burn she sustained. Resident #67 reported she fell asleep holding a cup of coffee and spilled it in her lap. Resident #67 was asked was the coffee from the single serve pod coffee maker in her room or was it the facility coffee. Resident #67 reported it was the facility coffee she spilled. Resident #67 reported she drank about half of it before she spilled it and never would have thought it would have caused a burn like it did. Resident #67 reported she did not realize she had burned herself until she went to clean herself up. Resident #67 reported they assessed and treated her burn and it healed with no concerns. Resident #67's daughter confirmed the facility notified her of the incident and denied any concerns. During an interview on 08/19/2025 at 12:35 p.m. S6 CNA reported it had been a while ago, but recalled when she was assisting Resident #67 in the bathroom she had noted a red area with a blister on Resident #67's hip and notified the nurse. S6 CNA reported Resident #67 told her she dozed off after she drank some of the coffee and spilled it on herself while she was in bed. When asked about any in-services after Resident #67 spilled coffee, S6 CNA reported the CNAs and LPNs in-serviced on ensuring the residents were awake and alert when serving coffee. During an interview on 08/19/2025 at 12:45 p.m. S7 LPN recalled being notified by the CNA that Resident #67 had a red area.S7 LPN reported when she went to assess Resident #67 she was on the toilet and she had a red area with blisters on her hip. S7 LPN reported Resident #67 told her she dozed off after drinking some coffee and spilled it on herself. S7 LPN reported she notified the wound care nurse, the NP and Resident #67's responsible party. S7 LPN reported after the incident the nurses and CNAs were in-serviced on making sure the coffee was not too hot when served. S7 LPN was asked how they ensured the coffee was not too hot and she reported she did not know if any temperatures were being taken but knew the coffee was not as hot as it used to be when it is poured into the cups. During an interview on 08/19/2025 at 12:50 p.m. S12 DM (Dietary Manager) was asked how they monitor temperatures on the brewed coffee. S12 DM reported the coffee was brewed in an industrial coffee maker that heats to 200 degrees F (Fahrenheit) then begins brewing the coffee into an insulated dispenser pot. S12 DM reported the kitchen staff brews coffee the first thing when they get in at 5:00 a.m. and the insulated dispenser pots were put on a stand on a cart in prep for service to the halls. S12 DM reported the CNAs got in at 6:00 a.m. and usually did not pick up the coffee pots to pass coffee on halls until about 6:30 a.m. so the pot has been sitting for about an hour and a half before being served. S12 DM reported other than the temperature reached for the coffee maker to brew there were no other temperatures measured. During an interview on 08/19/2025 at 1:10 p.m. S2 DON (Director of Nursing) reports she started as DON in June of 2025. S2 DON further reported S3 RN/Wound Care Nurse no longer worked at the facility. During an interview on 08/19/2025 at 1:15 p.m. S11 ADON (Assistant Director of Nursing) reported she recalled the previous DON talking with staff regarding burns and coffee after Resident #67's burn from spilled coffee but did not recall a formal in-service training with a sign in sheet. During an interview on 08/19/2025 at 1:34 p.m. S1 Administrator reported after the burn incident with Resident #67 the previous DON had worked on a scalding policy regarding hot liquids and resident assessments for serving coffee/hot liquids. S1 Administrator acknowledged there were no official assessments or policies in effect to ensure residents could safely drink coffee. S1 Administrator reported he did not know of any ongoing monitoring of coffee temperatures following Resident #67's burn incident. During an interview on 08/19/2025 at 1:44 p.m. S2 DON provided the working policy and resident assessment regarding scalding and hot liquids. S2 DON reported the policy and assessments had not been implemented and could not provide any documentation of formal in-service training of staff on scalding and hot liquids. During observation and interview on 08/19/2025 at 4:35 p.m. S12 DM started brewing a pot of coffee in the industrial coffee maker into an insulated dispenser pot. S12 DM reported it took about 7 minutes to brew the full pot of coffee. While the coffee was brewing surveyor went with S12 DM to measure the temperature of the coffee in two self-serve warming coffee pots noted on the counter outside the kitchen in the dining room. S12 DM reported the coffee in the pots was brewed and poured into the pots about an hour ago. S12 DM measured the temperature of the coffee from each warming pot after being poured into cups. One pot measured 147.8 degrees F and the other 161.7 degrees F. During observation on 08/19/2025 at 4:43 p.m. the coffee had completed brewing into the insulated dispenser pot. S12 DM transferred the insulated dispenser pot to a stand on a cart. S12 DM then measured the temperature of a poured cup from the insulated dispenser pot to read 164.8 degrees F. The coffee poured from the same insulated dispenser pot was measured by S12 DM an hour after brewing completed and then again an hour and a half after brewing. Temperatures were observed being measured by S12 DM and read 157.4 degrees F at 5:45 p.m. and read 163.2 degrees F at 6:16 p.m. During observation and interview with S13 LPN on 08/19/2025 at 5:04 p.m. Resident #67's left anterior thigh at the groin was observed to have a slightly darkened/shiny scarred skin area approximately one inch in length. Resident #67 indicated she could hardly see the area and indicated she noticed it most when she gets in the whirlpool and only because she knew it was there. During a phone interview on 08/20/2025 at 10:20 a.m. S5 NP recalled going to assess Resident #67 after a reported burn. S5 NP reported Resident #67 reported she spilled coffee on herself but Resident #67 played the burn off and had more pertinent concerns. S5 NP reported once noted and treatment began, Resident #67 became fixated on the burn. S5 NP indicated Resident #67 was anxious and had several issues so she saw Resident #67 frequently. S5 NP reported Resident #67 was a type 1 diabetic so there was some delay in wound healing but there were no complications with the wound or treatment. S5 NP reported S4 Wound Care NP was consulted and followed Resident #67 until the wound healed as well. S5 NP reported she had been coming to the facility for about a year and 8 months and had not known of any other residents being burned with coffee or any other hot liquid.

Based on record review, observations, and interviews the facility failed to ensure a resident received reasonable accommodation of needs by failing to have an assistive device accessible to 1 (#3) of 19 sampled residents.Findings:Review of Resident #3's medical record revealed an admission date of 05/16/2025 with diagnoses including, in part, spinal stenosis, lumbar region without neurogenic claudication; adult failure to thrive; contracture, right knee; and contracture, left knee.Review of Resident #3's Quarterly MDS (Minimum Data Sheet) assessment dated [DATE] revealed, in part, Resident #3 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe impaired cognition. Further review of Resident #3's MDS revealed Resident #3 was dependent on staff for all ADL (Activities of Daily Living) care. Review of Resident #3's care plan dated 07/17/2025 revealed Resident #3 had contractures of the right and left hands. During an observation on 08/19/2025 at 10:45 a.m., S11 ADON (Assistant Director of Nursing) placed the call bell button on the bed beside Resident 3#'s left elbow. Further observation revealed Resident #3 attempted to move both arms and hands and was unable to utilize the call bell button.During an interview on 08/19/2025 at 10:45 a.m. Resident #3 reported she had not been able to press the call bell button for assistance. During an interview on 08/19/2025 at 10:45 a.m. S2 DON (Director of Nursing) acknowledged Resident #3 was unable to press the button on the call light for assistance due to contractures of her arms and hands.

Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#4) of 6 (#1, #2, #4, #9, #12, and #51) residents reviewed for unnecessary medications. The facility failed to ensure Resident #4's PRN order for psychotropic medication was limited to 14 days. Findings:Review of Resident #4's medical record revealed an admit date of 01/04/2025 with diagnoses of but not limited to Alzheimer's disease, anxiety disorder, and schizophrenia.Review of Resident #4's physician orders revealed an order dated 07/07/2025 for Ativan Oral Tablet 1 MG (milligram) (Lorazepam); Give 1 tablet by mouth every 6 hours as needed for anxiety, end date indefinite. Review of Resident #4's August 2025 MAR (Medication Administration Record) revealed Ativan 1 MG was administered on the following dates/times:08/03/2025 7:20 p.m.08/04/2025 4:13 p.m. and 11:20 p.m.08/05/2025 9:29 p.m.08/06/2025 5:00 a.m.08/07/2025 9:34 p.m.08/08/2025 1:36 p.m. and 7:27 p.m.08/09/2025 8:34 p.m.08/10/2025 8:33 p.m.08/11/2025 5:10 a.m.08/12/2025 4:28 a.m. and 11:01 p.m.08/13/2025 7:47 p.m.08/18/2025 10:26 p.m.08/19/2025 11:40 a.m. and 10:04 p.m.08/20/2025 5:36 a.m. and 1:54 p.m.During an interview on 08/19/2025 at 12:11 p.m. S10 LPN (Licensed Practical Nurse) reported Resident #4 had been receiving PRN Ativan for anxiety.During an interview on 08/20/2025 at 3:11 p.m. S2 DON (Director of Nursing) reported Resident #4 had a PRN order for Ativan Oral Tablet 1 MG (Lorazepam) dated 07/07/2025 and had been receiving doses in August.

Based on record reviews and interviews, the facility failed to provide written notice to residents and/or their RP (Responsible Party) which specified the reason for transfer, effective date, location and statement of the resident's appeal rights and duration of the bed hold for 3 (#4, #81, #89) of 3 (#4, #81, #89) residents reviewed for transfers. Findings: Resident #4 Review of Resident #4's medical record revealed an admit date of 01/04/2017 with diagnoses of, but not limited to, fracture of unspecified part of neck of left femur, Alzheimer's disease with early onset, vascular dementia, unspecified severity, paranoid schizophrenia, and generalized anxiety disorder. Review of Resident #4's medical record revealed Resident #4 was sent to the ED (Emergency Department) on 06/08/2025 for evaluation. Further review of Resident #4's medical record failed to reveal a written notice of transfer/discharge had been provided to Resident #4 and/or RP at the time of transfer/discharge. Resident #81 Review of Resident #81's medical record revealed an initial admit date of 02/19/2025 with diagnoses of, but not limited to to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, cerebral infarction, vascular dementia, hypo-osmolality and hyponatremia, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #81's progress notes revealed Resident #81 was discharged to a local ER (Emergency Room) on 04/19/2025 with return to the facility on [DATE], discharged to a local ER on [DATE] with return to the facility on [DATE], and discharged to a local ER on [DATE] with return to the facility on [DATE]. Review of Resident #81's medical record failed to reveal Resident #81 and/or RP had been provided bed hold notice prior to transfer/discharge on [DATE], 05/13/2025, and 05/18/2025. Resident #89 Review of Resident #89's medical record revealed an initial admit date of 04/21/2025 and a discharge on [DATE] with diagnoses of, but not limited to, hypertensive chronic kidney disease, COPD (chronic obstructive pulmonary disease) unspecified, and hemiplegia unspecified affecting right dominant side. Review of Resident #89's 07/10/2025 Nurses Notes revealed Resident #89 was to be admitted to ________Rehab Center and was transported to the rehab. Review of Resident #89's medical record failed to reveal Resident #89 or RP had been provided bed hold notice prior to discharge on [DATE]. During an interview on 08/19/2025 at 9:30 a.m. S8 MDS (Minimum Data Set) Coordinator reported bed hold notifications are not sent with residents or resident's RP upon discharge/transfer. During an interview on 08/20/2025 at 10:00 a.m. S1 Administrator reported the Bed Hold notice was not being provided to residents' and/or their RP at transfer/discharge.

Based on record review and interview the facility failed to ensure a physician's order was implemented for 1 (#16) of 1 (#16) resident reviewed for urinary catheter. The facility failed to ensure Resident #16 received a referral appointment to Urology. Findings: Review of Resident #16's medical record revealed an admission date of 06/09/2025 with diagnoses, which included in part, displaced intertrochanteric fracture of left femur, Type 2 diabetes and generalized anxiety disorder.Review of Resident #16's admission MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 11, which indicated moderately impaired cognition. Further review of Resident #16's admission MDS revealed Resident #16 had an indwelling catheter in place. Review of Resident #16's written physician's orders revealed an order by S5NP (Nurse Practitioner) dated 06/30/2025 which read in part: Refer to Urology; Diagnosis: acute urinary retention. Review of Resident #16's medical record revealed a visit summary dated 06/30/2025 by S5NP which read in part: . seen today for evaluation of urinary retention.over the weekend, Resident #16 required another Foley catheter placement last night. Plan: Resident #16 experienced altered mental status and confusion, possibly related to urinary retention. Refer to Urology for further evaluation before attempting another voiding trial due to previous failure. Further review of Resident #16's medical record failed to reveal Urology referral appointment had been scheduled. During an interview on 08/20/2025 at 9:00 a.m., S9Ward Clerk reported she was responsible for scheduling referral appointments. S9Ward Clerk acknowledged Resident #16 had not been referred to Urology. During an interview on 08/20/2025 at 8:50 a.m., Resident #16 reported foley catheter was re-inserted a few months ago and S5NP was referring her to Urology. Resident #16 further reported the facility had not notified her of an Urology appointment. During an interview on 08/20/2025 at 9:50 a.m., S2DON (Director of Nursing) acknowledged Resident #16 had an order for a referral to Urology dated 06/30/2025 related to urinary retention. S2DON further acknowledged Resident #16 had not been scheduled an appointment to Urology and should have been.

Based on record review and interview, the facility failed to electronically submit Payroll Based Journal (PBJ) Staffing Data Report 1705D for Fiscal Year Quarter 2 2025 (January 1 - March 31). Findings: Review of the facility's Payroll Based Journal (PBJ) Staffing Data Report 1705D Fiscal Year (FY) Quarter 2 2025 (January 1 - March 31) revealed the facility failed to submit staffing data for the quarter.During an interview on 08/19/2025 at 3:15 p.m. S1 Administrator acknowledged the PBJ Staffing Data Report 1705D for FY Quarter 2 (January 1 - March 31) was not submitted and should have been.

Based on record review and interviews the facility failed to accurately submit mandatory direct care staffing information to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 2 2024 (January 1 - March 31). Findings: Review of the facility Payroll Based Journal (PBJ) Staffing Data Report for FY Quarter 2 2024 (January 1 - March 31) revealed triggers for the following: One Star Staffing Rating, Excessively Low Weekend Staffing, and No RN (Registered Nurse) Hours. Further review of the facility PBJ Staffing Data Report for FY Quarter 2 2024 revealed No RN Hours for the dates of 01/01/2024, 01/27/2024, 03/10/2024, 03/23/2024, 03/24/2024, 03/30/2024, and 03/31/2024. Review of the facility's weekend staffing patterns for FY Quarter 2 2024 revealed hours of direct care provided exceeded the hours of care required. Further review of the facility's weekend staffing patterns for FY Quarter 2 2024 and staffing pattern for 01/01/2024 revealed RN hours for the dates of 01/01/2024, 01/27/2024, 03/10/2024, 03/23/2024, 03/24/2024, 03/30/2024, and 03/31/2024. During an interview on 07/22/2024 at 3:25 p.m. S4 Bookkeeper reported this was her second week at the facility and she had not had to submit any information to CMS since she had been at the facility. During an interview on 07/24/2024 at 10:55 a.m. S4 Bookkeeper and S3 Human Resources indicated the previous bookkeeper submitted the information for the PBJ Staffing Data Report for FY Quarter 2 2024 to CMS and they were not sure where the information submitted came from. During an interview on 07/24/2024 at 1:40 p.m. S1 Administrator confirmed the previous bookkeeper submitted the information for the PBJ Staffing Data Report for FY Quarter 2 2024 to CMS and acknowledged the information was not accurate.

Based on record reviews and interview, the facility failed to ensure residents' drug regimens were free of unnecessary medications for 5 (#17, #34, #41, #44, #382) out of 26 total sampled residents. The facility failed to adequately monitor Residents #17, #34, #41, #44, and #382 for edema while receiving a diuretic. The facility failed to adequately monitor Resident #17 for bleeding while receiving an anticoagulant. Findings: Resident #17 Review of Resident #17's medical record revealed an admitted [DATE] with a re-admitted [DATE]. Further review of Resident #17's medical record revealed the following diagnoses, in part: congestive heart failure, coronary artery disease, and chronic atrial fibrillation. Review of Resident #17's physician's orders revealed an order dated 06/07/24 for Furosemide 20 mg (milligram) give 1 tablet by mouth one time a day. Further review of Resident #17's physician's orders revealed an order dated 06/24/2024 for Xarelto 20 mg give 1 tablet by mouth at bedtime. Review of Resident #17's July 2024 Medication Administration Record (MAR) failed to reveal documentation of monitoring for edema while receiving a diuretic. Further review of Resident #17's July 2024 MAR failed to reveal documentation of monitoring for bleeding while receiving an anticoagulant. Resident #34 Review of Resident #34's medical record revealed an admitted [DATE] with a re-admitted on 12/14/2022. Further review of Resident #34's medical record revealed the following diagnoses in part: heart failure-unspecified and chronic obstructive pulmonary disease. Review of Resident #34's physician's orders revealed an order dated 05/15/2023 for Acetazolamide 250 mg give 1 tablet by mouth three times a day. Review of Resident #34's MAR failed to reveal documentation of monitoring for edema while receiving a diuretic. Resident #41 Review of Resident #41's medical records revealed an admitted [DATE] with the following diagnoses, in part: cerebral infarction/unspecified, unspecified systolic (congestive) heart failure, and essential hypertension. Review of Resident #41's comprehensive care plan revealed - I have CHF (congestive heart failure)- evaluate me for excessive fluid retention. Review of Resident #41's physician's orders revealed an order dated 11/23/2020 - Furosemide tab 20 mg, give 20 mg via percutaneous endoscopic gastrostomy tube one time a day related to systolic congestive heart failure. Review of Resident #41's July MAR failed to reveal documentation of monitoring for edema while receiving a diuretic. Resident #44 Review of Resident #44's medical records revealed an admitted [DATE]. Diagnoses include but not limited to chronic pain syndrome, type 2 diabetes, major depressive disorder, and heart failure. Review of Resident #44's July 2024 physician orders revealed an order dated 07/01/2024 for Furosemide Tab 20 mg. Give 1 tablet orally one time a day related to heart failure, unspecified. Review of Resident #44's July 2024 MAR failed to reveal documentation of monitoring for edema while receiving a diuretic. Resident #382 Review of Resident #382's medical records revealed an admitted [DATE] with the following diagnoses, in part: heart failure/unspecified, type 2 diabetes mellitus with diabetic neuropathy/unspecified, and Chronic Obstructive Pulmonary Disease/unspecified. Review of Resident #382's comprehensive care plan revealed - potential for experiencing acute flare up of - evaluate me for excessive fluid retention. Review of Resident #382's physician's orders revealed an order dated 07/19/2024 for Bumetanide tablet 1mg give 1 tablet by mouth one time a day for fluid retention related to heart failure unspecified. Review of Resident #382's July MAR failed to reveal documentation of monitoring for edema while receiving a diuretic. During an interview on 07/23/2024 at 4:00 p.m. S2 DON (Director of Nursing) acknowledged she is unable to produce documentation that Residents #17, #34, #41, #44 and #382 were monitored for edema and Resident #17 was monitored for bleeding for the month of July 2024. S2 DON further acknowledged if there is no documentation in the MAR it probably wasn't monitored and should have been. 34708 40193

Based on record reviews and interviews the facility failed to provide adequate supervision for 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for impaired cognition and/or a diagnosis that may increase their risk of elopement. Findings: Review of Resident #1's medical record revealed a readmitted [DATE] and diagnoses including, but not limited to: Cerebral Infarction, Hemiplegia, Schizophrenia, Alcohol Abuse. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 05/09/2023 revealed in part, Resident #1 had a BIMS (Brief Interview Mental Status) score of 08 indicating moderately cognitive impairment; and Resident #1 independently walks in room, corridor and unit. During an interview on 8/14/2023 at 10:00 a.m. Resident #1 was standing outside of dementia unit, in smoking area smoking. Without prompting Resident #1 confirmed he remembers going to get a beer across the street and getting caught. Resident #1 acknowledged he was in the smoking area (the one everyone uses). Resident #1 indicated he waited for everyone to leave the smoking area and then went through the gate and walked across the road to the store. Resident #1 reported I wanted a beer and knew they (the facility) wouldn't like it, so I snuck out the gate. Resident #1 confirmed facility staff caught me and told me beer wasn't good with my medications. Resident #1 confirmed facility staff brought him back to the facility. Resident #1 indicated he did not fall down or get hurt on his trip to the store. During an interview 8/14/2023 at 11:30 a.m. S1 DON reported Resident #1 was talking to a staff member in the smoking area at 9:10 p.m. S1 DON acknowledged when the staff member left Resident #1 unattended in the smoking area, he left the facility through the side gate. At 9:20 pm. the clerk from the store across the street, called the facility and let them know Resident #1 was there. Facility staff immediately went to pick up Resident #1 from the store. Facility staff arrived just as Resident #1 was about to drink a 40 oz. beer. The beer was disposed of and Resident #1 was brought back to the facility at 9:30 p.m. The Administrator, MD and a friend where notified. Resident #1 was checked for physical injuries and no injuries were identified. Upon his return to the facility, Resident #1was place on every 15 minute checks in his room. The next morning the decision to move Resident #1 into the locked dementia unit was made.

Based on record reviews and interview the facility failed to ensure Adverse Action checks were completed at time of hire and then monthly for 6 [S2 CNA (Certified Nursing Assistant), S3 CNA, S4 CNA, S5 CNA, S6 CNA, S7 CNA] of 6 employees whose personnel files were reviewed. Findings: Review of S2 CNA's personnel file revealed a hire date of 07/01/2021. Further review of S2 CNA's personnel file revealed no Adverse Actions checks were completed. Review of S3 CNA's personnel file revealed a hire date of 10/19/2021. Further review of S3 CNA's personnel file revealed no Adverse Actions checks were completed. Review of S4 CNA's personnel file revealed a hire date of 01/30/2023. Further review of S4 CNA's personnel file revealed no Adverse Actions checks were completed. Review of S5 CNA's personnel file revealed a hire date of 02/09/2023. Further review of S5 CNA's personnel file revealed no Adverse Actions checks were completed. Review of S6 CNA's personnel file revealed a hire date of 03/17/2008. Further review of S6 CNA's personnel file revealed no Adverse Actions checks were completed. Review of S7 CNA's personnel file revealed a hire date of 06/03/2022. Further review of S7 CNA's personnel file revealed no Adverse Actions checks were completed. During an interview on 06/27/2023 at 11:30 a.m. S8 Human Resources reported the facility had not been performing Adverse Action checks on facility staff at time of hire or monthly.

Based on record review, observations, and interviews the facility failed to ensure residents who were unable to complete Activities of Daily Living (ADLs) received the necessary services to maintain proper grooming and hygiene for 1 (#40) of 1 (#40) resident reviewed for ADLs. The facility failed to ensure Resident #40 received nail care. Findings: Review of Resident #40's medical record revealed Resident #40 had an admitted [DATE] and had diagnoses that included, in part, Spastic diplegic cerebral palsy, Essential hypertension, Muscle wasting and atrophy unspecified site, and Critical illness myopathy. Review of Resident #40's 05/09/2023 Quarterly MDS (Minimum Data Set) revealed Resident #40 had a BIMS score of 14, which indicated Resident #40 was cognitively intact. Further review of the 05/09/2023 Quarterly MDS revealed Resident #40 required extensive assistance with personal hygiene. Review of Care Plan revealed: -I require assistance from staff with grooming and personal hygiene. Review of Policy with Subject: Fingernails/Toenails Care revealed: Responsibility: Nursing Assistant or Licensed Nurse Key Procedural Points: 1. Nails can be partially cleaned during bath care. 2. Nail care includes daily cleaning and regular trimming. 6. Finger-nail care will be documented weekly on the medication record for each diabetic resident. Review of May and June 2023 MARs (Medication Administration Record) failed to reveal any documentation that finger-nail care had been conducted. Review of nurses' notes revealed the last documentation of nail care was by S1 RN (Registered Nurse) on 05/15/2023 at 10:07 a.m. noting Clipped and filed resident's fingernails without complication. Tolerated well. Further review of nurses' notes prior to 05/15/2023 revealed documentation of nail care on 04/10/2023, 03/02/2023, and 02/22/2023. Observation on 06/26/2023 at 1:55 p.m. revealed Resident #40's fingernails were long and well past her fingertips and appeared dirty. During an interview on 06/26/2023 at 1:55 p.m. Resident #40 reported she wished her fingernails were shorter and no one had clipped them. Observation on 06/27/2023 at 4:00 p.m. revealed Resident #40's fingernails continued to be long and well past her fingertips and appeared dirty. During an interview on 06/27/2023 at 4:00 p.m. Resident #40 reported she had asked for her fingernails to be clipped and cleaned this morning but they had not been clipped yet. Further reported when her fingernails get long, they hurt. During an interview on 06/27/2023 at 4:08 p.m. S1 RN came to Resident #40 and acknowledged Resident #40's fingernails were long and needed to be cleaned and cut.

Based on observation, record review and interview the facility failed to ensure the accuracy of assessments for 1 (#23) of 2 (#4, #23) residents reviewed for smoking by classifying a resident with a history of smoking in the facility as a safe smoker. Findings: Resident #23 Review of the facility's Smoking policy revealed, in part, the following: Residents that are assessed as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials and may smoke in designated smoking areas without limitation . During observations on 06/06/2022 at 9:45 AM and 06/08/2022 at 8 AM, Resident #23's room smelled strongly of cigarette smoke. Resident #23 was lying in the bed with his eyes closed on both observations and did not respond when spoken to. During an interview on 06/07/2022 at 10:10 AM, Resident #23 confirmed he keeps his cigarettes and lighter and has them in his side table. Resident #23 stated he can go outside to smoke whenever he wants. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, dated dated dated [DATE] revealed Resident #23 had a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. Further review revealed the resident was independent with bed mobility, transferring, toilet use, and eating. Review of the medical record revealed Resident #23 was care planned for smoking. The approaches included: I may keep a lighter and cigarettes on me, and I will smoke in designated smoking areas at all times. Review of the nurses' notes revealed the following entries: 03/08/2022 at 9:58 PM-CNA (Certified Nursing Assistant) came and got this nurse at 5:15 PM and told me she believed that resident was smoking in his room again. Because the smoke smell was so strong. I informed DON, _____. She spoke with resident. Reminded resident of the no smoking policy. Resident verbalized understanding and stated he would not smoke in his room. By S6 LPN (Licensed Practical Nurse). 02/05/2022 at 6:10 PM-Resident at front desk waiting on cigarette, aide informed resident he could have 2 but not a whole pack. Resident started yelling that he is a grown man and we can't keep him from his cigarettes. Tried to talk to him to explain that he could not have them due to previously smoking in his room. Resident started pounding his fist on the counter and stepped in nurses' face saying we can't keep them from him. Resident was informed to back up and stop yelling. Resident stated we're not going to treat him like a child. He continued to yell. Resident was told to go to his room. He informed all staff to stay out of his room. He was not eating, drinking or taking any more medications. Nurse recommended CNA to stay out of his room at this time. Administrator notified of encounter. By S3 LPN. Review of the Safe Smoking assessment dated [DATE], completed by S5 LPN/MDS (Minimum Data Set) nurse revealed, in part, the following: Does the Resident have adequate vision? No Does the Resident demonstrate the ability to verbalize understanding that smoking materials are for use only in the designated smoking areas? Yes IDT (Interdisciplinary team) determination: Safe Smoker The IDT determines the degree of supervision the resident needs while smoking to be independent. During an interview on 06/08/2022 at 10:35 AM, S5 LPN/MDS nurse confirmed she was aware Resident #23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . S5 LPN/MDS further explained they had taken his cigarettes away and then gave them back because he is with it and knows they'd be taken away if he does it again. In an interview on 06/08/2022 at 11:15 AM, S7 Housekeeping, confirmed she had found evidence of Resident #23 smoking in his room around November or December when she found a cigarette butt in his toilet. In an interview on 06/08/2022 at 2:42 PM, S5 LPN/MDS Nurse acknowledged that according to the facility's smoking policy, a resident with a history of smoking incidents, such as smoking in their room, should have been assessed as modified independence with smoking.

Based on record review and interview the facility failed to ensure the plan of care was followed to meet the needs of 1 (#72) of 2 (#52, #72) residents reviewed for urinary catheters or urinary tract infections by failing to make ongoing assessments of the resident's urine. Findings: Resident #72 Review of the record for Resident #72 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS (Minimum Data Set) dated 05/27/2022 revealed Resident #72 had a BIMS (Brief Interview for Mental Status) score of 10 which indicated the resident had moderately impaired cognition. Further review of the MDS revealed Resident #72 required limited assistance by one person with bed mobility and transferring and was totally dependent with toilet use. Review of the medical record revealed Resident #72 was care planned for the use of an indwelling catheter with approaches that included catheter care every shift, evaluate fluid intake, assessing the resident for signs and symptoms of a urinary tract infection, and the ongoing assessment of color, clarity, and character of the resident's urine. Review of the April 2022, May 2022, and June 2022 Medication Administration Records failed to reveal evidence of any documentation of Resident #72's urine being assessed for color, clarity, and character of urine. During an interview on 06/08/2022 at 3:39 PM, S2 DON (Director of Nurses) reported Resident #72 had been hospitalized in May 2022 with a urinary tract infection. S2 DON acknowledged the nurses were not documenting the color, clarity, and character of urine for Resident #72 and should have been.

Based on record reviews and interviews, the facility failed to ensure that a resident who required [CONDITION(S)] received services consistent with professional standards of practice for 2 (#70, #86) out of 2 (#70, #86) residents reviewed for [CONDITION(S)] by failing to ensure communication and collaboration with the [CONDITION(S)] facility was done. Findings: Review of [CONDITION(S)] Information Update Transfer Policy revealed: POLICY: A [CONDITION(S)] information Update Transfer Form is completed each time a resident receives outpatient [CONDITION(S)]. This ensures enhanced communication between the two facilities. PROCEDURE: 1. The top section of the [CONDITION(S)] Information Update Transfer Form is completed by the nurse responsible for sending the resident to the [CONDITION(S)] unit/facility. 2. The bottom section of the form is completed by personnel responsible for the resident at the [CONDITION(S)] facility and returned to the Facility with the resident. 3. Once the form is completed in its entirety, the most recent form should be copied to the Director of Nursing (or designee) and the original placed under Consultant Reports in the medical record. . Resident #70 Review of Resident #70's face sheet revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 70's June Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 6/8/2022 at 11:00 AM S3 LPN (Licensed Practical Nurse) reported the top section of the [CONDITION(S)] communication form is completed by the facility and sent with the resident to the [CONDITION(S)] appointment with the resident. Upon return from [CONDITION(S)] the completed [CONDITION(S)] communication form is given to the ward clerk at the front desk. Review of Resident # 70's medical record failed to reveal [CONDITION(S)] communication sheet for the following days: 4/30/2022, 5/3/2022, 5/5/2022, 5/7/2022, 5/10/2022, 5/12/2022, 5/19/2022, 5/24/2022, 5/26/2022, 5/28/2022, 5/31/2022, 6/2/2022, 6/4/2022, and 6/7/2022. Review of Resident #70's [CONDITION(S)] communication form dated 5/21/2022 revealed the bottom section that should be completed by the [CONDITION(S)] facility was not completed. Resident #86 Review of Resident #86's medical record revealed Resident #86 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #86's June 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/6/2022 at 9:40 AM Resident #86 reported he attended [CONDITION(S)] on Tuesday, Thursday and Saturday. Review of Resident #86's medical record failed to reveal a [CONDITION(S)] communication form for 5/3/2022, 5/5/2022, 5/7/2022, 5/12/2022, 5/17/2022, 5/31/2022, and 6/4/2022. Further review of medical record revealed an incomplete [CONDITION(S)] communication form for 5/10/2022, 5/19/2022, and 6/2/2022, in which there was no information entered from the [CONDITION(S)] center. During an interview on 6/8/2022 at 12:30 PM S4 Transport reported the [CONDITION(S)] communication form is given to the nurse at the [CONDITION(S)] clinic but if the [CONDITION(S)] clinic is not ready to receive the resident she would leave the form with the resident to give to the [CONDITION(S)] nurse. S4 Transport reported when the resident returns from [CONDITION(S)] the [CONDITION(S)] communication form is given to the ward clerk but the communication forms are not always returned from [CONDITION(S)] with the resident. During an interview on 6/8/2022 at 2:00 PM S2 DON (Director of Nursing) reported when [CONDITION(S)] communication form is not returned from [CONDITION(S)] appointment the facility should call the [CONDITION(S)] clinic to request form be completed and returned or faxed. S2 DON reported the facility did not have a designated person responsible for ensuring this process was done.

Based on record review, observations and interviews the facility failed to ensure residents were free from accident hazards for 2 residents (#23, #65) out of a total sample of 35 residents. The facility failed to ensure: 1. the facility's smoking policy was followed for Resident #23 and 2. Resident #65 had a fall mat in place as per physician order. Findings: 1. Review of the facility's Smoking policy revealed, in part, the following: Policy: This is a smoke-free facility. No smoking or use of smoking materials will be allowed inside the building or in facility vehicles. Smoking is to occur only in designated areas and in accordance with each smoking resident's individualized plan of care based on the Smoking Safety Assessment/Evaluation. 1 . Residents that are assessed as independent with smoking: (and/or without history of smoking incidents; needing no interventions) will be permitted to keep and maintain their own smoking materials and may smoke in designated smoking areas without limitations. The resident may be permitted to keep fire materials on his/her person during waking hours if deemed appropriate per smoking assessment . Residents found to have modified independence with smoking: may be subject to smoking limitations. Limitations may include, but are not limited to: facility storage of tobacco products and/or fire materials, designated smoking times, assistance with lighting tobacco products supervised smoking by staff, and/or other protective/safety measures as determined appropriate by the individualized plan of care based on smoking assessment. During observations on 06/06/2022 at 9:45 AM and 06/08/2022 at 8:00 AM, Resident #23's room smelled strongly of cigarette smoke. Resident #23 was lying in the bed with his eyes closed on both observations and did not respond when spoken to. During an interview on 06/07/22 at 10:10 AM, Resident #23 confirmed he keeps his cigarettes and lighter and has them in his side table. Resident #23 stated he can go outside to smoke whenever he wants. Review of the medical record revealed Resident #23 was admitted on [DATE] with diagnoses that included, in part, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], other specified depressive disorder, and type 2 diabetes mellitus. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #23 had a BIMS (Brief Interview for Mental Status) score of 13, which indicated the resident was cognitively intact. Further review revealed the resident was independent with bed mobility, transferring, toilet use, and eating. Review of the medical record revealed Resident #23 was care planned for smoking. The approaches included: I may keep a lighter and cigarettes on me, and I will smoke in designated smoking areas at all times. Review of the nurses' notes revealed the following entries: 03/08/2022 at 9:58 PM-CNA (Certified Nursing Assistant) came and got this nurse at 5:15 PM and told me she believed that resident was smoking in his room again. Because the smoke smell was so strong. I informed DON, _____. She spoke with resident. Reminded resident of the no smoking policy. Resident verbalized understanding and stated he would not smoke in his room. By S6 LPN (Licensed Practical Nurse). 02/05/2022 at 6:10 PM-Resident at front desk waiting on cigarette, aide informed resident he could have 2 but not a whole pack. Resident started yelling that he is a grown man and we can't keep him from his cigarettes. Tried to talk to him to explain that he could not have them due to previously smoking in his room. Resident started pounding his fist on the counter and stepped in nurses' face saying we can't keep them from him. Resident was informed to back up and stop yelling. Resident stated we're not going to treat him like a child. He continued to yell. Resident was told to go to his room. He informed all staff to stay out of his room. He was not eating, drinking or taking any more medications. Nurse recommended CNA to stay out of his room at this time. Administrator notified of encounter. By S3 LPN. Review of the Safe Smoking assessment dated [DATE], completed by S5 LPN/MDS nurse revealed, in part, the following: Does the Resident have adequate vision? No Does the Resident demonstrate the ability to verbalize understanding that smoking materials are for use only in the designated smoking areas? Yes IDT determination: Safe Smoker The IDT determines the degree of supervision the resident needs while smoking to be independent. During an interview on 06/08/2022 at 10:35 AM, S5 LPN/MDS nurse confirmed she was aware Resident #23 had a history of smoking in the building and had been counseled about it. S5 LPN/MDS further explained they had taken his cigarettes away and then gave them back because he is with it and knows they'd be taken away if he does it again. In an interview on 06/08/2022 at 11:15 AM, S7 Housekeeping, confirmed she had found evidence of Resident #23 smoking in his room around November or December when she found a cigarette butt in his toilet. During an interview on 06/08/2022 at 11:29 AM, S8 LPN confirmed Resident #23 smokes without assistance. She explained she gave Resident #23 a pack of cigarettes last week. She explained he keeps a pack of cigarettes at a time and she just gives him a new pack when he runs out. In an interview on 06/08/2022 at 2:42 PM, S5 LPN/MDS Nurse acknowledged that according to the facility's smoking policy, a resident with a history of smoking incidents, such as smoking in their room, should have been assessed as modified independence with smoking, which would put limitations on the resident's smoking. 2. Review of Resident #65's medical record revealed Resident #65 was admitted to the facility on [DATE] and had diagnoses that included, in part, delusional disorders, ataxia, other lack of coordination, [CONDITION(S)] [CONDITION(S)], [CONDITION(S)], type 2 diabetes mellitus with diabetic [CONDITION(S)], and cognitive communication deficit. Review of Resident #65's physician orders revealed a 5/18/2022 order for fall mat at bedside-nurses to monitor. Review of Resident #65's 4/26/2022 Admission 5 day MDS (Minimum Data Set) revealed Resident #65 had a BIMS (Brief Interview Mental Status) score of 09 which indicated a moderate cognitive impairment. Review of 12/1/2021 thru 6/6/2022 Incident Log revealed Resident #65 had one fall without injury on 4/24/2022. Review of Care Plan revealed Resident #65 was at risk for falls and included approach of fall mat at bedside. Observation on 6/7/2022 at 10:17am revealed Resident #65 in bed with head of bed elevated and no fall mat was in place. Observation on 6/7/2022 at 3:35pm revealed Resident #65 resting quietly in bed and no fall mat was in place. During an interview on 6/8/2022 at 8:38am S2 DON (Director of Nursing) observed Resident #65's room and reported there was not a fall mat in place and should be.

Based on observations, record reviews, and interviews, the facility failed to ensure the residents remained free of accident hazards for 1 of 1 (#77) residents, who was transported in the facility's van via wheelchair, out of a total sample of 3 (#19, #77 and #78) residents reviewed for accidents. The deficient practice resulted in an Immediate Jeopardy situation for Resident #77 on 1/28/2021 at 8:00 am, when she was being transported to a doctor's appointment in the facility's van. During transport, Resident #77 slid out of her wheelchair and onto the van floor. S13 CNA (Certified Nursing Assistant) and S14 CNA picked Resident #77 up off the floor, placed her back in her wheelchair, and continued to transport the resident to her doctor's appointment. After the resident's fall was reported to the doctor, the doctor instructed the CNAs to take the resident to the emergency room where she was diagnosed with an acute right femur fracture. The resident was admitted to the hospital. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past non-compliance situation. S5 Administrator was notified of the past non-compliance Immediate Jeopardy situation on 5/18/2021 at 5:15 pm. Findings: Review of resident #77's clinical records revealed diagnoses that included: other [CONDITION(S)] with [CONDITION(S)] factor of right hand, left hand and multiple sites, ataxia, and age related [CONDITION(S)] without current pathological fracture. Review of resident #77's most recent MDS (Minimum Data Set) revealed a BIMS (Brief Interview for Mental Status) score of 15, cognitively intact. Review of the facility's investigation report dated 1/28/2021 for resident #77 revealed the following: Resident #77 had a fall/no head injury, no apparent injury. Location of the incident was the facility vehicle. Equipment involved w/c (wheelchair), non-motorized. Activity at the time of the incident resident #77 was a vehicle passenger. Two witnesses were S13 CNA and S14 CNA. Narrative of the incident and description of injuries: writer received a call from S13 CNA reporting resident #77 was sitting upright in w/c with cushion in chair. S13 CNA reported cushion started sliding and resident slid under seat belt out of chair onto left side. Resident #77 handgrip is very poor. S13 and S14 CNAs assisted resident #77 back into the wheelchair. Resident #77 was taken to Doctor______, and Doctor _______ sent her to the hospital emergency room . Resident #77 was later admitted for evaluation and treatment. No injury apparent reported from hospital. Later x-ray reports were faxed that included a fracture to right hip. Review of resident #77 clinical records revealed results of the local hospital's CT (computer tomography) of the Pelvis without contrast dated 1/28/2021 at 9:46 am final report revealed admitting diagnosis hip injury bilateral. Impression: Acute right sub-trochanteric femur fracture extending superiorly to involve part of the lesser trochanter, minimally displaced. Review of resident #77's Nurse's Notes dated 1/29/2021 at 10:24 am: Late entry 1/28/2021 by S8 ADON (Assistant Director of Nursing) writer documented she received a call from S13 CNA reporting resident #77 was sitting upright in a w/c (wheelchair) with a cushion in the chair. S13 CNA reported cushion started sliding and resident slid under seat belt out of chair onto her left side. Resident #77's handgrips are very poor. S13 CNA and S14 CNA lifted resident #77 back into her wheelchair. During an interview on 5/10/2021 at 11:30 am resident #77 reported she had fallen out of her wheelchair while riding in the facility's van. Resident #77 reported the 2 CNAs that were operating the van (S13 CNA and S14 CNA) did not know how to strap her in to prevent her from falling out of her wheelchair. Resident #77 confirmed she broke her hip when she fell from the wheelchair. During an interview on 5/13/2021 at 11:50 am resident #77 reported she was taken to the hospital right after she fell in the van. Resident #77 reported she was in pain, and her leg was broken. Resident #77 reported she was admitted for about 2 days. Resident #77 reported she used to get up in the wheelchair, but since the fall she has remained in bed. During an interview on 5/13/2021 at 12:10 pm S5 Administrator reported he did not know resident #77 had a fracture until a few hours later when she was admitted to the hospital. S5 Administrator reported resident #77 was being transported to a doctor's appointment when the incident occurred. S5 Administrator reported he did not know S13 CNA was the driver of the van. S5 Administrator reported S14 CNA is a part time employee and she doesn't drive; she just rides in the van to help. S5 Administrator was unable to provide documentation S13 CNA or S14 CNA had training to operate the facility van or how to transport residents in the facility van. During an interview on 5/18/2021 at 10:00 am S5 Administrator confirmed resident #77 was not medically assessed for injuries before the 2 CNAs removed her from the van floor. S5 Administrator reported if 2 people are on the van both are responsible for making sure the resident is secure. During an interview on 5/18/2021 at 10:30 am, S8 ADON reported when the incident occurred resident #77 was being transported to Doctor _____'s office for an appointment. S8 ADON confirmed resident #77 was medically assessed by S13 CNA and S14 CNA before she was removed from the van floor. S8 ADON reported if a resident falls in the facility they are assessed by a nurse before they are moved. S8 ADON confirmed the 2 CNAs could not medically assess resident #77 and she should not have been moved. S8 ADON reported the 2 CNAs did not phone her until after they had placed resident #77 back in her wheelchair. During an interview on 5/18/2021 at 10:45 am, S12 Transportation reported when she transported resident #77 she used the 2 cushions that stay on the side wall on the van to place in Resident #77's wheelchair to prevent her from sliding from her chair. S12 Transportation reported she had been instructed if a resident has an incident on the van while being transported she is to call 911 if they are injured, give the information of what happened, their location, then call the facility and let them know what happened. S12 Transportation reported she was instructed to never move a resident until emergency assistance arrives to assess them. During an interview on 5/18/2021 at 11:11 am S13 CNA reported S14 CNA was in the van with her on 1/28/2021 during the incident with resident #77. S13 CNA reported both she and S14 CNA secured resident #77 on the van. S13 CNA reported she had S14 CNA to ride with her because resident #77 was unable to grip, her hands being crippled. S13 CNA reported they did not know to use the seat cushions that were stored on the van. S13 CNA reported no one had ever instructed her to use those cushions to keep resident #77 from sliding out of her wheelchair. S13 CNA reported they just transported resident #77 with the wheelchair cushion she was sitting on. S13 CNA reported resident #77 slid forward out of her wheelchair to the van floor. S13 CNA confirmed resident #77 was complaining of hip pain. S13 CNA reported they were in the parking lot where she had an appointment to see the pain management doctor. S13 CNA reported they got resident #77 off the van floor then they called the facility and reported the incident to S8 ADON. S13 CNA reported she went into the doctor's office and reported the incident and the doctor's office told her to take Resident #77 across the street to the hospital emergency room . During an interview on 5/18/2021 at 1:07 pm S3 DON (Director of Nursing) reported if an incident happens on the van, staff are to call 911 just like here in the nursing home and let them know what happened, their location and the possible injury. S3 DON confirmed transport staff are not to move an injured resident. During an interview on 5/18/2021 at 1:10 pm S5 Administrator reviewed his records and was unable to provide documentation that training on van operation and resident transport had been provided for the transport staff prior to and immediately after the incident on 1/28/2021. Review of the facility's In-Service Training Report dated 3/23/2021 revealed training conducted by S5 Administrator and S12 Transportation for transport staff. Subject: How to properly transport residents, the correct way to apply seat belt and floor connectors to wheelchairs. Observation on 5/18/2021 at 10:45 am revealed S12 Transportation opened the rear entrance of the van and lowered the wheelchair ramp. S12 Transportation loaded her co-worker in a forward facing wheelchair up the ramp into the left side of the van. Once in the van, the wheelchair was locked in place and the four tie downs on the floor of the van were attached to the frame of the wheelchair front and back. The lap/shoulder belt attached to the left side of the van wall was brought across the co-workers left shoulder and around her right waist area and attached to a tie down to the floor. S12 Transportation presented to the surveyor the 2 wheelchair cushions stored on the side of the van wall that she used when she transported resident #77 to keep her from sliding. Review of the van user instructions compared to the demonstration by S12 Transportation revealed the wheelchair had been loaded and secured correctly. Review of the facility's policy and training documents verified that all components of the Plan of Correction were in place. S5 Administrator presented a written Plan of Correction that contained: The following will be the policy for transportation of residents. Drivers: Any employee who will be designated as a driver will be properly trained on all aspects and use of equipment and clear understanding transportation policies. Training will be conducted by our experienced main transportation employee and will take place before any driver is allowed to transport residents of _________. Training and in servicing will continue throughout the year and immediately after any accident concerning transport. Administrator, DON or ADON will review all training to assure training is conducted correctly. Drivers will be screened by our insurance company and must provide a clear and current unencumbered driver's license. Each driver will be in-serviced at least yearly on the following: 1. Types of passengers - Those that can sit in the van seats. Those in wheelchairs / reclining wheelchairs. 2. How many passengers can be in the van This determined by the number of safety restraints. Each passenger will have a safety restraint device (seat belt, chair belts, etc.) 3. How to safety load all types of passengers 4. How to safely restrain all passengers 5. How to safely unload all passengers 6. Protocols in case of accident Those residents who can sit in the standard seats will enter the vehicle via the door closet to their seat and be restrained with standard shoulder / seat belt. Exiting the vehicle will be accomplished in the same manner. Those residents in wheelchairs will be loaded via the back loading ramp and restrained with shoulder / seat belt and the chair will be locked and strapped to the floor of the van using the appropriate straps. Exiting the vehicle will be accomplished in the same manner. If the wheelchair has a slick surfaced cushion, it will be removed or covered to prevent the resident sliding out of the chair. In the event of an auto accident, the appropriate authorities will be called. The driver will then notify the facility. In the event a resident is injured in the van emergency services will be called. Once emergency help arrives the facility will be notified. The driver will follow all recommendations of emergency personnel. If the resident is taken by emergency services, the driver will follow if the vehicle condition allows. Staff at the facility will notify the resident's family. DON, ADON, and Administrator will monitor weekly for the next 5 weeks and then monthly for the next 3 months. Quarterly monitoring will be performed during the course for 2021. If the problems are found with new system, disciplinary action will be taken.

Based on observations, record reviews and interviews, the facility failed to be administered in a manner that used resources effectively and efficiently to ensure a resident's environment remained as free of accident hazards for 1 of 1 (#77) residents, who was transported in the facility's van via wheelchair, out of a total sample of 3 (#19, #77 and #78) residents reviewed for accidents. The deficient practice resulted in an Immediate Jeopardy situation for Resident #77 on 1/28/2021 at 8:00 am, when she was being transported to a doctor's appointment in the facility's van. During transport, Resident #77 slid out of her wheelchair and onto the van floor. S13 CNA (Certified Nursing Assistant) and S14 CNA picked Resident #77 up off the floor, placed her back in her wheelchair, and continued to transport the resident to her doctor's appointment. After the resident's fall was reported to the doctor, the doctor instructed the CNAs to take the resident to the emergency room where she was diagnosed with an acute right femur fracture. The resident was admitted to the hospital. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past non-compliance situation. S5 Administrator was notified of the past non-compliance Immediate Jeopardy situation on 5/18/2021 at 5:15 pm. Findings: Cross Reference F689 During an interview on 5/13/2021 at 12:10 pm S5 Administrator reported he did not know resident #77 had a fracture until a few hours later when she was admitted to the hospital. S5 Administrator reported resident #77 was being transported to a doctor's appointment when the incident occurred. S5 Administrator reported he did not know S13 CNA was the driver of the van. S5 Administrator reported S14 CNA is a part time employee and she doesn't drive; she just rides in the van to help. S5 Administrator was unable to provide documentation S13 CNA or S14 CNA had training to operate the facility van or how to transport residents in the facility van. During an interview on 5/18/2021 at 10:00 am S5 Administrator confirmed resident #77 was not medically assessed for injuries before the 2 CNAs removed her from the van floor. S5 Administrator reported if 2 people are on the van both are responsible for making sure the resident is secure. During an interview on 5/18/2021 at 10:30 am, S8 ADON (Assistant Director of Nursing) reported when the incident occurred resident #77 was being transported to Doctor _____'s office for an appointment. S8 ADON confirmed resident #77 was medically assessed by S13 CNA and S14 CNA before she was removed from the van floor. S8 ADON reported if a resident falls in the facility they are assessed by a nurse before they are moved. S8 ADON confirmed the 2 CNAs could not medically assess resident #77 and she should not have been moved. S8 ADON reported the 2 CNAs did not phone her until after they had placed resident #77 back in her wheelchair. During an interview on 5/18/2021 at 1:10 pm S5 Administrator reviewed his records and was unable to provide documentation that training on van operation and resident transport had been provided for the transport staff prior to and immediately after the incident on 1/28/2021. Review of the facility's policy and training documents verified that all components of the Plan of Correction were in place. S5 Administrator presented a written Plan of Correction that contained: The following will be the policy for transportation of residents. Drivers: Any employee who will be designated as a driver will be properly trained on all aspects and use of equipment and clear understanding transportation policies. Training will be conducted by our experienced main transportation employee and will take place before any driver is allowed to transport residents of _________. Training and in servicing will continue throughout the year and immediately after any accident concerning transport. Administrator, DON or ADON will review all training to assure training is conducted correctly. Drivers will be screened by our insurance company and must provide a clear and current unencumbered driver's license. Each driver will be in-serviced at least yearly on the following: 1. Types of passengers - Those that can sit in the van seats. Those in wheelchairs / reclining wheelchairs. 2. How many passengers can be in the van This determined by the number of safety restraints. Each passenger will have a safety restraint device (seat belt, chair belts, etc.) 3. How to safety load all types of passengers 4. How to safely restrain all passengers 5. How to safely unload all passengers 6. Protocols in case of accident Those residents who can sit in the standard seats will enter the vehicle via the door closet to their seat and be restrained with standard shoulder / seat belt. Exiting the vehicle will be accomplished in the same manner. Those residents in wheelchairs will be loaded via the back loading ramp and restrained with shoulder / seat belt and the chair will be locked and strapped to the floor of the van using the appropriate straps. Exiting the vehicle will be accomplished in the same manner. If the wheelchair has a slick surfaced cushion, it will be removed or covered to prevent the resident sliding out of the chair. In the event of an auto accident, the appropriate authorities will be called. The driver will then notify the facility. In the event a resident is injured in the van emergency services will be called. Once emergency help arrives the facility will be notified. The driver will follow all recommendations of emergency personnel. If the resident is taken by emergency services, the driver will follow if the vehicle condition allows. Staff at the facility will notify the resident's family. DON, ADON, and Administrator will monitor weekly for the next 5 weeks and then monthly for the next 3 months. Quarterly monitoring will be performed during the course for 2021. If the problems are found with new system disciplinary action will be taken.

Based on record reviews and interviews the facility failed to ensure gradual dose reductions (GDRs) recommended by the pharmacist were reviewed and addressed by the Physician/Nurse Practitioner (MD/NP) in a timely manner for 4 residents (#9, #62, #73, #77) out of 5 sampled residents reviewed for unnecessary medications and [CONDITION(S)] medications. Findings: Resident #9: Review of Resident #9's May 2021 physician's orders revealed the following: -an order dated 8/21/2020 for [MEDICATION(S)] ([MEDICATION(S)]) 300 milligram (mg) tablet give ½ tablet by mouth bid (twice a day) -an order dated 8/21/2020 for [MEDICATION(S)] 0.5 mg tablet by mouth bid -an order dated 8/21/2020 for [MEDICATION(S)] ([MEDICATION(S)]) 60 mg capsule by mouth daily Review of Resident #9's March 2021 pharmacy consultation report revealed a GDR recommendation dated 3/30/21 for [MEDICATION(S)] was signed by S3 DON (Director of Nursing) on 5/12/21. Resident #9's March 2021 [MEDICATION(S)] GDR recommendation was signed and addressed by S10 NP (Nurse Practitioner) on 5/12/21. Review of Resident #9's March 2021 pharmacy consultation report revealed a GDR recommendation dated 3/30/21 for [MEDICATION(S)] was signed by S3 DON on 5/10/21. Resident #9's March 2021 [MEDICATION(S)] GDR recommendation was signed and addressed by S10 NP on 5/11/21. Review of Resident #9's November 2020 pharmacy consultation report revealed a GDR recommendation dated 11/25/2020 for [MEDICATION(S)] was signed by S3 DON on 5/12/21. Resident #9's November 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10 NP on 5/12/21. Review of Resident #9's November 2020 pharmacy consultation report revealed a GDR recommendation dated 11/25/2020 for [MEDICATION(S)] was signed by S3 DON on 5/12/21. Resident #9's November 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10 NP on 5/12/21. Review of Resident #9's September 2020 pharmacy consultation report revealed a GDR recommendation dated 9/30/2020 for [MEDICATION(S)] was signed by S3 DON on 5/12/21. Resident #9's September 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10 NP on 5/11/21. Resident #62: Review of Resident #62's May 2021 physician's orders revealed the following: -an order dated 9/16/19 for [MEDICATION(S)] 10mg daily -an order dated 8/6/19 for [MEDICATION(S)] XR 150mg daily -an order dated 8/6/19 for [MEDICATION(S)] 15mg three times a day -an order dated 8/6/19 for Trazadone 100mg-2 tabs (200mg) at bedtime Review of Resident #62's January 2021 pharmacy consultation report revealed a GDR recommendation dated 1/31/21 for [MEDICATION(S)] XL ([MEDICATION(S)] XR) was signed by S3DON on 5/12/21. Resident #62's [MEDICATION(S)] XL GDR recommendation was signed and addressed by S10NP on 5/12/21. Review of Resident #62's March 2021 pharmacy consultation report revealed a GDR recommendation dated 3/31/21 for [MEDICATION(S)] was signed by S3DON on 5/12/21. Resident #62's March 2021 [MEDICATION(S)] GDR recommendation was signed and addressed by S10NP on 5/12/21. Review of Resident #62's November 2020 pharmacy consultation report revealed a GDR recommendation dated 11/25/2020 for [MEDICATION(S)] was signed by S3DON on 5/12/21. Resident #62's November 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10NP on 5/12/21. Review of Resident #62's August 2020 pharmacy consultation report revealed GDR recommendation dated 8/29/2020 for [MEDICATION(S)] ([MEDICATION(S)]) was signed by S3DON on 5/12/21. Resident #62's August 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10NP on 5/12/21. Review of Resident #62's July 2020 pharmacy consultation report revealed GDR recommendation dated 7/31/2020 for Trazadone was signed by S3DON on 5/12/21. Resident #62's July 2020 Trazadone GDR recommendation was signed and addressed by S10NP on 5/12/21. Resident #73: Review of Resident #73's medical record revealed an admitted [DATE] with a re-admission on 1/22/21. Review of Resident #73's May 2021 physician's orders revealed the following: -an order dated 1/22/21 for [MEDICATION(S)] HCL 125mg every AM -an order dated 1/22/21 for Trazadone 50mg at bedtime Review of Resident #73's November 2020 pharmacy consultation report revealed a GDR recommended for [MEDICATION(S)] was signed by S3DON on 5/12/21. Resident #73's November 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10NP on 5/12/21. Review of Resident #73's August 2020 pharmacy consultation report revealed a GDR recommended for Trazadone was signed by S3DON on 5/12/21. Resident #73's Trazadone GDR recommendation was signed and addressed by S10NP on 5/12/21. Resident #77: Review of resident #77's May 2021 physician's orders revealed the following: -an order dated 10/29/2019 [MEDICATION(S)] 100 mg one tab by mouth every night. Review of Resident #77's November 2020 pharmacy consultation report revealed a GDR recommendation dated 11/25/2020 for [MEDICATION(S)] ([MEDICATION(S)]) was signed by S3 DON on 5/12/21. Resident #77's November 2020 [MEDICATION(S)] GDR recommendation was signed and addressed by S10 NP on 5/12/21 During an interview on 5/12/2021 at 3:10 PM S15 RN (Registered Nurse) reported due to the pandemic she sent the Pharmacist all of the resident's MARs (medication administration record) and Physician Orders, for him to do the Monthly Pharmacy Reviews. S15 RN reported the Pharmacist would send any recommendations he made back to S3 DON by emails. During an interview on 5/12/2021 at 3:35 PM S10 NP reported she received the pharmacy reviews that had recommendations from S3 DON. S10 NP reported she reviewed the recommendations, responded to the recommendations and signed the recommendation, then she gave them back to S3 DON. During an interview on 5/13/2021 at 12:45 PM S10 NP reported GDRs are received from S3 DON. S10 NP reported she received, reviewed, and signed GDRs yesterday dating back to July of 2020. During an interview on 5/13/2021 at 1:26 PM S3 DON confirmed she received GDRs from pharmacist via email. S3 DON reported she printed copies of the GDRs and gives them to the Physician/NP for review. S3 DON acknowledged GDRs dating back to July of 2020 were provided to the S10 NP yesterday for review.

Based on interviews and record review, the facility failed to ensure alleged violations of abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency as required for 1 (#78) of 1 residents reviewed for accidents that required a SIMS (Statewide Incident Management System) report to be submitted. Findings: Review of Resident #78's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further record review revealed a BIMS (brief interview for mental status score) of 6 on a MDS (minimum data set) dated 4/20/21. A score of 6 indicated the resident had severely impaired cognition. Further review of the MDS revealed Resident #78 required limited assistance by one person with bed mobility, transferring, and toileting and required supervision with walking in room and corridor. Review of Resident #78's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's Elopement Risk Assessment completed 4/20/21 revealed Resident #78 ambulates independently, by walking unsteadily or with a wheelchair, was confused and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary stated: He is an elopement risk, will monitor whereabouts every one hour. Staff aware of elopement risk. Completed by S1 LPN/MDS Nurse (Licensed Practical Nurse/Minimum dat set). Review of the nurses' notes revealed the following: 4/24/21: By S2 LPN: At the beginning of shift Resident's BS (blood sugar) was checked and he was in his room. Resident was seen shortly after trying to go to the front of the building using wheelchair. Resident was reminded that he had to stay in his room for the time being. He then shook his head but went back to his room. At approximately 4:23 pm, a call was made that a resident was seen outside of the building. After the entire staff went looking for resident, he was found outside of the front of the building approximately 7 minutes later. CNAs (Certified Nursing Assistants) on duty reported resident getting aggressive with them when they brought him back. Resident repeated over and over again I am going home. Resident was finally brought back into the building and back to his room at approximately 4:40 pm. No injuries were acquired during the incident. Vital Signs 135/78 Pulse 60, Respirations 18 SPO2 (oxygen saturation) 96. Pain 2/10. Resident's wife notified of incident at approximately 5:10PM. CNAs stationed on hall __ to be aware of resident's location at all times. _____LPN notified S3 DON (director of nursing) of situation. Will continue to monitor. A review of the incident report dated 04/24/21 revealed in part: 4/24/21 at 4:45 pm Incident type: Wander from grounds Location: Off facility grounds Equipment: Wheelchair-motorized Reported to Supervisor: Yes Date/time: 4/24/21 at 4:45 pm Incident level-Non-witnessed Narrative of incident and description of injuries: PLEASE SEE NURSE'S NOTE FOR DETAILED REPORT OF INCIDENT Disposition: Observation Medical risk factors possibly related to incident: Confusion/disorientation Immediate actions taken: Resident brought back to his room. Family notified. Staff placed on hall. A review of the Missing Residents/Elopement policy provided by the facility revealed the following: Once the Resident is Located .6. The Administrator/DON will notify the Department of Health per State Regulations. In an interview on 5/12/21 at 3:05 pm, S2 LPN said we realized he was missing around medication pass time. She said she thought he was in the building because he wanders around and goes in other residents' rooms sometimes and lays down in their beds. She said S4 CNA found him in the parking lot. S2 LPN said she assessed him when she brought him back in the building. She said he was aggravated and saying he was going home. She said he was found on foot in the parking lot. She said she called S3 DON (Director of Nurses) and did an incident report. She said she put him back in his room and put extra staff in the living room area near his room to monitor. She said she doesn't know where he was found because she hadn't gone outside. In a phone interview on 5/12/21 at 3:10 pm, S4 CNA revealed she was not working but was passing by the facility in a car and saw a resident out in the parking lot and thought Is that one of our residents? She said she pulled in and saw Resident #78 in his wheelchair about half through the parking lot and heading away from the facility. She said she asked him where he was going and he said home to [NAME]. She said she brought him back to the building. In an interview on 5/12/21 at 3:15 pm, S3 DON (Director of Nurses) confirmed a SIMS report was not completed for this incident. In an interview on 5/12/21 at 3:28 pm, S5 Administrator confirmed a SIMS report was not done for this incident.

Based on interviews and record reviews, the facility failed to provide the appropriate treatment and services as outlined in the resident's plan of care to maintain, restore or improve the functional ability for resident 1 (#7) of 1 resident reviewed for restorative services. The facility failed to provide restorative services for resident #7. Findings: During an interview on 5/10/2021 at 12:30 pm, resident #7 voiced concerns that she does not receive any type of physical therapy or restorative services. Review of resident #7's Plan of Care revealed a problem onset 02/11/2021, at risk for falls. An approach outlined in the plan of care was to refer resident #7 to the restorative nursing program. Review of resident #7s current MDS (Minimum Data Set) revealed a BIMS (Brief Interview for Mental Status )score of 14, indicating resident was cognitively intact, and revealed resident #7 required extensive assistance with transfers, required total assistance with toilet use and bathing, and limited assistance with dressing. During an interview on 5/13/2021 at 9:50 am S1 LPN/MDS Nurse confirmed resident #7 is a Medicaid only resident. S1 LPN/ MDS Nurse confirmed she had written the plan to refer resident #7 to the restorative nursing program. S1 LPN/MDS Nurse reported the plan had not been picked up by nursing. S1 LPN/MDS Nurse reported the confirmation for restorative nursing is usually done verbally. S1 LPN/MDS Nurse confirmed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . S1 LPN/MDS Nurse confirmed no restorative services had been done due to the pandemic.

Based on record review and interview, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 35 COVID-19 negative residents currently residing in the facility out of a total census of 70 residents. An Immediate Jeopardy situation was identified by the survey team on 08/17/2020 when they observed that there were systemic failures in the facility's Infection Prevention and Control Program to identify and implement measures to help prevent the development and transmission of communicable diseases and infections. The facility allowed residents that tested positive for Covid-19 to remain cohorted in rooms with residents that tested negative for Covid-19, and did not immediately isolate residents that tested positive for Covid-19 from other residents and staff. The facility did not ensure that residents wore masks when out of their rooms, and allowed staff that tested positive for Covid-19 to return to work less than 10 days after receiving the results. The designated Covid-19 unit and rooms outside of the Covid-19 Unit were not identified with transmission based precaution signage. S1 Administrator was notified of the Immediate Jeopardy on 08/18/2020 at 6:55 PM. The Immediate Jeopardy was removed on 08/19/2020 at 3:30PM when the facility submitted the following I.J. Plan of Removal which included: -S1 Administrator and S2 Director of Nurses will conduct twice daily follow up on all COVID test results in the lab portal until the facility has 14 days without any positive cases. -On 08/17/2020 new results were obtained from testing agency. Upon those findings six residents were relocated to a different part of the facility. The Covid unit and Non Covid unit. By doing this we are able to keep positive residents and negative residents separate. -Certified Nursing Assistants (CNAs) responsible for Resident #16 and Resident #3 will monitor their use of front smoking area. A new smoking area for COVID positive residents was created. Monday 08/17/2020 they are both now using the back smoking section located in the COVID positive area. CNAs responsible for their supervision will be listed on schedule. -All Nursing staff on each shift will continue to monitor Resident #15, #16, #3, and #14 for non-compliance and reiterate the importance of social distancing, mask wearing, and hand washing. As listed above there designated CNAs will also continue to monitor while in smoking areas. -On 08/18/2020 staff was in serviced on proper signage on resident's doors that are COVID positive. Attachments were provided to staff for proper use of PPE (personal protective equipment), the importance of PPE that is provided, proper PPE donning and doffing. If COVID positive residents leave their room, make sure they have a mask and please direct them to the appropriate smoking areas. Employee return to work policy which states that employees will be off at least 10 days for quarantine and that all staff will be notified promptly of any positive test results. In servicing will be completed 08/20/2020. -Since the onset of COVID-19 April 10, 2020 Director of Nurses and nursing staff met with residents to explain the importance of wearing mask while in the hallways, social distancing, and hand washing. Nurses and CNAs are continuing to encourage all residents to wear masks anytime they are outside their room or outside around other residents and staff. -The DON, ADON, and Administrator will monitor room assignments daily with the goal of keeping negative rooming together and positives rooming together. -DON, ADON, or designee will monitor notifications daily to NP and MD of positive results as soon as they are received by the facility. -Logs will be created for Administrator, DON, ADON or designee to use daily to ensure proper signage is in place to notify staff and other residents of precaution requirements. The log will be used daily document employee's participation in proper use of PPE and disposal. It will also include a notification section where MD/NP were informed about new cases to residents. This log will continue for the next 4 weeks. -ADON, DON, or designee will conduct all surveillance tracking and trending daily as new cases occur for residents and staff. The purpose of the tracking will be to assist in determining exposure for proper quarantine application. DON and Administrator have revised the return to work policy that states any positive employee will self-quarantine for 10 days with mild cases, 20 days with severe cases. -DON, ADON, and Administrator will continue daily review for updated CDC guidelines to help with quality improvement and to update polices. Policies will be updated based on current information. -In-services will continue to be conducted weekly to inform staff of any changes. QA will be conducted twice weekly for the next four weeks and once weekly until the end of the COVID pandemic. DON, ADON, or designee will conduct daily rounds to ensure staff are hand washing and using gel in between patients and that masks and PPE are used properly. This deficient practice continued at a potential for more than minimal harm for 35 COVID-19 negative residents who resided in the facility. Findings Cross reference findings at F880. A review of the Emergency Plan for Contagion updated 08/01/2020 revealed in part: 5. Per CDC guidelines, mild to moderate symptoms will require a 10 day self-quarantine with return to work on the 11th day. Severe cases will require a 20 day self-quarantine with return to work on the 21st day. 6. Any resident testing positive for COVID-19 will be isolated in the COVID unit. During an interview on 08/17/2020 at 3:20 PM, S2 DON (Director of Nurses) verified that there are negative and positive COVID-19 residents residing on the 400 Hall and no transmission based precaution signage posted. She stated she assumes the nurses are communicating with the CNAs to let them know what the residents' COVID-19 statuses are. In an interview with S1 Administrator on 08/18/2020 at 6:55 PM, S1 Administrator acknowledged these negative residents were cohorted with COVID positive residents. S1 Administrator verbalized he had no place to put them and didn't want to move negative residents who would become positive. He further indicated they had been cleaning the 300 hall since Saturday, August 15, 2020, and it was not ready for use. Also, S1 Administrator acknowledged staff were returning to work before their 10 day self-quarantine was over because they received some bad information and thought the employees could come back to work in 24 hours after testing positive if they were asymptomatic. In a phone interview on 08/20/2020 at 1:30PM, S16 Medical Director confirmed he was unaware COVID-19 negative and positive residents were cohorted in the same room. He acknowledged he was unaware staff were returning to work without waiting the proper quarantine period. He confirmed he would keep COVID-19 positive residents in the COVID area and the negative residents should be separated from the positive residents.

Based on observations, record reviews and interviews, the facility failed to ensure an effective Infection Prevention and Control Program, including the establishment and implementation of measures to prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect any of the 35 COVID-19 negative residents currently residing in the facility out of a total census of 70 residents. An Immediate Jeopardy situation was identified by the survey team on [DATE] when they observed that there were systemic failures in the facility's Infection Prevention and Control Program to identify and implement measures to help prevent the development and transmission of communicable diseases and infections. The facility allowed residents that tested positive for Covid-19 to remain cohorted in rooms with residents that tested negative for Covid-19, and did not immediately isolate residents that tested positive for Covid-19 from other residents and staff. The facility did not ensure that residents wore masks when out of their rooms, and allowed staff that tested positive for Covid-19 to return to work less than 10 days after receiving the results. The designated Covid-19 unit and rooms outside of the Covid-19 Unit were not identified with transmission based precaution signage. S1 Administrator was notified of the Immediate Jeopardy on [DATE] at 6:55 PM. The Immediate Jeopardy was removed on [DATE] at 3:30PM when the facility submitted the following I.J. Plan of Removal which included: -S1 Administrator and S2 Director of Nurses (DON) will conduct twice daily follow up on all COVID test results in the lab portal until the facility has 14 days without any positive cases. -On [DATE] new results were obtained from testing agency. Upon those findings six residents were relocated to a different part of the facility. The COVID-19 unit and Non-COVID-19 unit. By doing this we are able to keep positive residents and negative residents separate. -Certified Nursing Assistants (CNAs) responsible for Resident #16 and Resident #3 will monitor their use of front smoking area. A new smoking area for COVID positive residents was created. Monday [DATE] they are both now using the back smoking section located in the COVID positive area. CNAs responsible for their supervision will be listed on schedule. -All Nursing staff on each shift will continue to monitor Residents #15, 16, 3, and 14 for non-compliance and reiterate the importance of social distancing, mask wearing, and hand washing. As listed above there designated CNAs will also continue to monitor while in smoking areas. -On [DATE] staff was in serviced on proper signage on resident's doors that are COVID positive. Attachments were provided to staff for proper use of PPE (personal protective equipment), the importance of PPE that is provided, proper PPE donning and doffing. If COVID positive residents leave their room, make sure they have a mask and please direct them to the appropriate smoking areas. Employee return to work policy which states that employees will be off at least 10 days for quarantine and that all staff will be notified promptly of any positive test results. In servicing will be completed [DATE]. -Since the onset of COVID-19 [DATE] Director of Nurses and nursing staff met with residents to explain the importance of wearing mask while in the hallways, social distancing, and hand washing. Nurses and CNAs are continuing to encourage all residents to wear masks anytime they are outside their room or outside around other residents and staff. -The DON, ADON, and Administrator will monitor room assignments daily with the goal of keeping negative rooming together and positives rooming together. -DON, ADON (Assistant Director of Nurses), or designee will monitor notifications daily to NP (Nurse Practitioner) and MD (Medical Director) of positive results as soon as they are received by the facility. -Logs will be created for Administrator, DON, ADON or designee to use daily to ensure proper signage is in place to notify staff and other residents of precaution requirements. The log will be used daily document employee's participation in proper use of PPE and disposal. It will also include a notification section where MD/NP were informed about new cases to residents. This log will continue for the next 4 weeks. -ADON, DON, or designee will conduct all surveillance tracking and trending daily as new cases occur for residents and staff. The purpose of the tracking will be to assist in determining exposure for proper quarantine application. DON and Administrator have revised the return to work policy that states any positive employee will self-quarantine for 10 days with mild cases, 20 days with severe cases. -DON, ADON, and Administrator will continue daily review for updated CDC (Centers for Disease Control) guidelines to help with quality improvement and to update polices. Policies will be updated based on current information. -In-services will continue to be conducted weekly to inform staff of any2 changes. QA (Quality Assurance) will be conducted twice weekly for the next four weeks and once weekly until the end of the COVID pandemic. DON, ADON, or designee will conduct daily rounds to ensure staff are hand washing and using gel in between patients and that masks and PPE are used properly. The deficient practice continued at a potential for more than minimal harm for 35 COVID-19 negative residents who resided in the facility. Findings: A review of the Emergency Plan for Contagion updated [DATE] revealed the following in part: 5. Per updated CDC guidelines, mild to moderate symptoms will require a 10 day self-quarantine with return to work on the 11th day. Severe cases will require a 20 day self-quarantine with return to work on the 21st day. 6. Any resident testing positive for COVID-19 will be isolated in the COVID unit. Cohorted Residents Review of Facility's Room Assignment Logs, Medical Records and Lab Results revealed Resident #1 remained in the same room with Resident #12 who was reported COVID-19 positive on [DATE] at 4PM. Review of Resident #1's room assignments revealed they remained in the same room from [DATE] through [DATE]. On [DATE] Resident #1 moved out of the room with Resident #12 and into the room of Resident #4. Resident #1's lab results revealed COVID-19 positive results were reported on [DATE] at 2PM. Resident #1 remained in the same room with Resident #4 until [DATE] at 4:23PM when Resident #1 was sent to the hospital. Resident #4 became ill and was sent to the hospital on [DATE] at 2:39AM. Resident #4 expired on [DATE] at 6:50AM with [DIAGNOSES REDACTED]. Review of Facility's Room Assignment Logs and Lab Results revealed Resident #3 remained in the same room with Resident #14 who was reported COVID-19 positive on [DATE]. Resident #3 was not moved to a room with a negative resident until [DATE] at approximately 2:25PM. Resident #3 subsequently reported positive on [DATE]. Review of Facility's Room Assignment Logs and Lab Results revealed Resident #6 remained in the same room as Resident #13 who was reported positive for COVID-19 on [DATE] at 1:07PM. These two residents were never separated and Resident #6 subsequently was reported positive on [DATE] at 3:36PM. In an interview on [DATE] at 12:10PM, Resident #6 stated she was never offered to be moved to a different room after Resident #13 tested positive. Review of Facility's Room Assignment Logs, Medical Records and Lab revealed Resident #10 remained in the same room with Resident #11 who was reported positive on [DATE] at 3:52PM. Resident #11 was not moved out of the room with Resident #10 until [DATE]. Resident #10 subsequently was reported positive on [DATE] at 2:02PM. Resident #10 expired on [DATE]. Review of Facility's Room Assignment Logs, Medical Records and Lab revealed Resident #15 remained in the same room with Resident #16 who was reported positive for COVID-19 on [DATE] at 1:07PM. Resident #15 was not moved out of the room until [DATE] at 2:25PM. During an interview on [DATE] at 2:00 PM, S6 LPN/Treatment Nurse confirmed Resident #1 was negative for COVID-19 when Resident #1 shared a room with Resident #12 who was COVID-19 positive. During an interview on [DATE] at 2:00 PM, S5 LPN confirmed residents who were COVID-19 positive were sharing rooms with COVID-19 negative residents on the COVID-19 unit. Resident #2 During an interview on [DATE] at 11:00 AM, S1 Administrator and S2 DON (Director of Nursing) reported all of the residents on the 200 Hall had been negative for COVID-19 until this morning when Resident #2's COVID-19 results came back positive. S1 Administrator confirmed he became aware of Resident #2's COVID-19 positive results the morning of [DATE] and confirmed he was not immediately relocated to the COVID-19 unit upon becoming aware of the resident's results. S1 Administrator verified Resident #2's COVID-19 positive results were reported on [DATE] at 7:12PM but no one checked the portal until [DATE]. During an interview on [DATE] at 11:30 AM, S9 CNA reported she was not aware that Resident #2 tested positive for COVID-19. During an interview on [DATE] at 11:35 AM, S10 LPN (Licensed Practical Nurse) reported she was working the 200 Hall and had not been notified that Resident #2 tested positive for COVID-19. During an interview on [DATE] at 11:35 AM, S2 DON confirmed that she became aware of Resident #2's positive test results on this morning and staff caring for Resident #2 had not been made aware of the positive results. Observation on [DATE] at 11:40 AM revealed Resident #2 in wheelchair sitting outside his room on the 200 hall not wearing a mask and no transmission based precaution signage on Resident #2's door. Observation on [DATE] at 3:00 PM revealed S1 Administrator moving Resident #2 without a mask from 200 Hall to the COVID-19 unit. Staff with COVID-19 Positive Results Review of Facility's Employee COVID positive list, Employee Timecard Reports, and Lab Results revealed the facility allowed S7 CNA (Certified Nursing Assistant) and S8 CNA who tested COVID-19 positive and returned to work before the 10 day quarantine requirement was met. S7 CNA tested positive on [DATE], was sent home on [DATE] and returned to work on [DATE]. S8 CNA tested positive on [DATE] and returned to work on ,[DATE] and [DATE]. S7 CNA and S8 CNA were observed working in the facility on [DATE]. During an interview on [DATE] at 2:05 PM, S8 CNA reported she received COVID-19 positive test results on [DATE] and was sent home. S8 CNA indicated later the same day S2 DON called her and told her to come back to work the next day, [DATE] from 2pm-10pm. S8 CNA reported she called before she came on [DATE] and spoke with S2 DON at 12:40 PM and told S2 DON she would do her 10 days off and come back the following Monday. S8 CNA confirmed S2 DON told her to come in on [DATE] as she is on the schedule and S8 CNA came to work at 1:30 PM. Resident #16 Observations on [DATE] at 2:20 PM revealed Resident #16, a COVID 19 positive resident, on the hallway in her wheelchair not wearing a mask Observation on [DATE] at 2:50 PM revealed Resident #16 sitting in her room. Resident #16 was alert and oriented, pleasant and talkative. In an interview with Resident #16, she reported her roommate Resident #15 tested negative and she tested positive. During an interview on [DATE] at 3:00 PM, S12 CNA reported Resident #16 leaves to go smoke all the time. S12 CNA further indicated she did not know negative residents were in rooms with positive residents and that the residents do not always wear a mask in their rooms. During an interview on [DATE] at 3:25 PM, S13 LPN and S14 LPN verified Resident #16 (COVID-19 positive) goes out to smoke passing through the ,[DATE] Hall to the smoking patio and does not always wear her mask. COVID-19 Positive Unit - 400 Hall During an interview on [DATE] at 2:05 PM, S11 CNA on COVID-19 unit reported she assumes everyone is COVID-19 positive on the 400 Hall because she does not know who is negative and who is positive. Observations on [DATE] at 2:15 PM revealed COVID-19 unit with Resident #3 COVID-19 negative) sharing a room with Resident #14 (COVID-19 positive), Resident #15 (COVID-19 negative) sharing a room with Resident #16 (COVID-19 positive), and Resident #6 (COVID-19 negative) sharing a room with Resident #13 (COVID-19 positive). Observation on [DATE] at 3:00 PM revealed the COVID-19 unit with no transmission based precaution signage on the entrance doors. An area directly outside the COVID-19 unit had one side of the hall with COVID-19 positive residents with no transmission based precaution signage on the doors. During an interview on [DATE] at 3:20 PM, S2 DON verified that there are negative and positive COVID-19 residents residing on the 400 Hall and she assumes the nurses are communicating with the CNAs to let them know what the residents' COVID-19 statuses are. During an interview on [DATE] at 12:10PM, Resident #6 stated she was never offered to be moved to a different room after Resident #13 tested positive. During an interview on [DATE] at 3:23 PM, Resident #15 reported that she was moved out of room on the 400 Hall on [DATE]. During an interview on [DATE] at 3:25 PM, S14 LPN reported she did not know which residents were positive or negative on the 400 Hall, but there is a list they give her each day. S14 LPN indicated she does not know if residents wear masks in their rooms. During an interview on [DATE] at 3:34 PM, S2 DON reported she was aware that Resident #3 was negative and shared a room with COVID-19 positive Resident #14. S2 DON further reported she does not know why there was a delay in moving Resident #3 out of the COVID-19 unit and that S1 Administrator is in charge of moving residents. During an interview on [DATE] at 4:00 PM, S1 Administrator indicated the delay in moving negative residents out of the COVID-19 unit was because he didn't have anywhere to move them and he didn't want to move negative residents who would become positive. During an interview with S1 Administrator on [DATE] at 6:55PM, S1 Administrator acknowledged these negative residents were cohorted with COVID positive residents. S1 Administrator verbalized he had no place or rooms to put them. He further indicated they had been cleaning the 300 hall since Saturday and it was not ready for use. Also, S1 Administrator acknowledged staff were returning to work before their 10-day self-quarantine was over because they received some bad information and thought the employees could come back to work in 24 hours after testing positive if they were asymptomatic. During an interview on [DATE] at 9:35AM, Resident #15 reported she did not know Resident #16 was COVID-19 positive when they were roommates. Resident #15 indicated they did not wear face masks in their room. Resident #15 reported she found out Resident #16 was positive on Monday when they moved her to the 300 Hall with Resident #3. During a telephone interview on [DATE] at 1:30 PM, S16 MD reported that he was not aware that negative residents were being cohorted with COVID-19 positive residents. S16 MD further indicated he would not agree with placing negative residents with COVID-19 positive residents.