Every finding on record at Hawthorne Center for Rehabilitation and Healing of

Based on record review and interviews, the facility failed to ensure three residents (Resident #2, #4, and #5) /resident representatives were refunded within 30 days from the residents' date of discharge from the facility. Findings included: A review of the Admission Record for Resident #2 revealed he was initially admitted to the facility on [DATE] with a primary diagnosis of respiratory failure. The resident expired and was discharged from the facility on [DATE]. A Cashier's Check dated [DATE] at 10:42 a.m. in the amount of $18,608.00 was purchased by Resident #2's family member and paid to the facility. A Notice of Case Action form from an outside agency dated [DATE] showed Resident #2 was approved for Medicaid benefits dated [DATE]. The form also showed he was eligible for benefits for Dec. 2023 and Jan. 2024. A review of the Transaction Report by Effective Date dated [DATE] to [DATE] showed Resident #2 was discharged on [DATE] and was owed a refund of $15,962.60. On [DATE] at 9:33 a.m., Resident #2's family member stated she finally heard from the Business Office Manager (BOM) yesterday and was told she would be getting a refund. On [DATE] at 9:37 a.m., the Business Office Manager (BOM) reported she spoke to Resident #2's family member yesterday and confirmed she was owed a refund of $15,000. On [DATE] at 9:48 a.m., the BOM stated prior to applying for Medicaid, Resident #2 had health insurance with another company and in December he switched to Medicare. He was skilled and they thought he would run out of money, so they wanted to apply for Medicaid. When Resident #2 and his family came in to apply for Medicaid, she found out they had a joint account, and she could not prove who money was in the account. She gave them options to obtain an attorney, spend the money down, or put the money in an irrevocable trust because there was over $2,000 in the account. The family member opted to pay the facility $18,000, the $18,000 was going towards his stay because they didn't think the Medicaid application would be approved. The family member wrote a check for $18,000 on [DATE]. They had to wait several months for Medicaid approval. The application was approved on February 28th, and he was eligible for December and January. They had problems with getting the insurance company paid. He had a balance with Medicare for $2,007.53, Medicaid for $1,020, and Hospice for $27.00. The BOM stated their policy was residents must wait until all insurance companies are paid before they are issued a refund. They have processed the refund and are now waiting for corporate to sign off. A review of the Admission Record for Resident #4 showed she was initially admitted to the facility on [DATE] with a primary diagnosis of fracture foe routine healing. The resident was discharged from the facility on [DATE]. The Transaction Report by Effective Date [DATE] to [DATE] showed Resident #4 was owed a balance of $3,227.30. A review of the Admission Record for Resident #5 showed she was initially admitted to the facility on [DATE] with a primary diagnosis of spondylolisthesis. The resident was discharged from the facility on [DATE]. The Transaction Report by Effective Date [DATE] to [DATE] showed Resident #5 was owed a balance of $1,511.78. On [DATE] at 12:45 p.m., the BOM stated anytime there was a balance or credit on the account, they do not refund until all claims have been cleared. She explained the policy to the families. On [DATE] at 12:50 p.m., the Regional Business Office Consultant reported Resident #4 was discharged on [DATE]. The Regional Business Office Consultant stated Resident #4 and Resident #5 were owed a refund but their policy states that all outstanding third-party payments must be paid before issuing a refund per their policy. The policy provided by the facility Refunds revised on ,d+[DATE] revealed the following: Refunds will be made within thirty (30) days of the Resident's discharge, transfer, or death, or upon payment in full of any outstanding third-party payments.

Based on observation, record review, and interview, the facility failed to ensure medications with shortened shelf life once opened were dated in three (100, 200/500, and 600) out of six medication carts, failed to ensure two medications in pre-filled syringes were not stored mixed together in one (600) out of six medication carts and one (300/400) out of three medication rooms, and expired medications had been removed from two (300 and 600) out of six medication carts. The facility failed to ensure medications were not left unattended and inaccessible to unauthorized staff, residents, and visitors for three (Residents #98, #74, and #314) of 45 sampled residents. Findings included: An observation was made during medication administration on 3/11/24 at 11:53 a.m. with Staff B, RN. The staff member reported a resident required 4 units of insulin. Staff B removed an opened bottle of Humalog from the cart which was labeled with an open date of 1/15/24. The staff member turned the vial around and reported the expiration date was 10/6/2026 (manufacturer's printed date). Staff B reported not knowing when the insulin expired, going to the medication room and removing a vial of Admelog for the resident. According to humalog.com/u100, reviewed on 3/14/24 at 8:07 p.m.,Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. The review of the website on humalog.com revealed 28 days after the open date of 1/15/24 was 2/12/24, 28 days prior to the observation. An observation was conducted on 3/11/24 at 11:53 a.m. with Staff B, RN of the 300/400 medication unit. The observation revealed a drawer with multiple prefilled syringes of Normal Saline and Heparin. The syringes were not separated and were stored lying intermixed within the drawer. The staff member stated they were going back to the pharmacy. On 3/13/24 at 11:45 a.m., an observation was made with Staff C, Registered Nurse (RN) of the 100-hall medication cart. The observation revealed the following: - an opened Latanoprost Ophthalmic solution bottle, not dated with open date. The bottle had a pharmacy label attached to it and the box holding the bottle had a label attached to it with a space for Date Opened which was blank. The bag holding the box and bottle had a sticker instructing Throw Away Any Drug Left After 6 Weeks. - an opened Bottle of Timolol Maleate Ophthalmic solution, undated. The attached pharmacy tag had a space for Date Opened: which was blank. The box containing the bottle also had a label attached with no date. - an opened Humalog insulin vial, undated with open date. the pharmacy tag Date Opened: was blank. The sticker on bag containing the vial and box read Throw Away Any Medication That Remains 28 Days After First Use. - an opened Humalog insulin vial, undated with open date. The pharmacy tag attached to vial was not dated and the box with a tag Date Opened: was not dated. - an open vial of Semglee insulin, undated, pharmacy tag with a space for Date Opened was blank. - an open vial of Insulin Aspart, with an undated attached pharmacy tag. A sticker attached to the bag holding the vial read Throw Away Any Medicine That Remains 28 Days After First Use. - an open vial of Lantus insulin with an undated attached pharmacy tag and also a pharmacy tag on the box Date Opened was blank. The bag containing the box and vial was dated 2/13 and a sticker instructed staff to Throw Away Any Medicine That Remains 28 Days After First Use. A review of the monthly calendars revealed 28 days from 2/13 was 3/12, the day before the observation. - an opened Insulin Glargine prefilled insulin pen was undated. The sticker attached to the bag containing the pen read Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 2/24. -an opened Insulin Glargine prefilled insulin pen was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 3/4. - an opened Insulin Glargine prefilled insulin pen was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated either 2/14 or 2/24. - an opened Insulin Glargine prefilled insulin pen was dated either 2/21/24 or 2/4/24. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 2/23. - an opened Admelog insulin pen with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened prefilled Insulin Glargine pen with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Admelog insulin pen with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. The bag was dated 3/11. - An opened Advair diskus was observed lying on the bottom of the drawer. The nearby Advair box was opened and lying on its side. An observation and review was conducted on 3/13/24 at 12:06 p.m. with Staff B, RN of the 200/500 medication cart. The observation revealed the following: - An opened prefilled Insulin Glargine with an attached pharmacy tag was undated. The sticker attached to the bag containing the pen instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Admelog prefilled insulin pen was undated, the pharmacy sticker instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened prefilled Insulin Glargine pen was undated, the attached pharmacy tag, Date Opened: was blank. The pharmacy sticker instructed to Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Insulin Aspart vial was dated 3/11/24. The pharmacy label attached to the plastic bag containing the vial was dated 3/11/24 and a pink sticker attached to the bag was dated 3/9. An observation and review was conducted on 3/13/24 at 12:56 p.m., with Staff A, RN of the 600 medication cart. The observation revealed the following: - Two opened bottles, one of Latanoprost and one of Brinzolamide, were rolled up in plastic bags together in the top drawer of the cart. The bottles were undated. The pharmacy label was dated 12/16. The Latanoprost label instructed to throw away left over drug after 6 weeks. - An opened bottle of Dorzolamide and Timolol Ophthalmic solution was observed with a pharmacy tag labeled Date Opened which was blank with no date. - An opened bottle of Brimonidine Ophthalmic solution was observed with an attached pharmacy tag reading Date Opened which was blank without a date. - An opened bottle of Latanoprost Ophthalmic solution was observed with an attached pharmacy tag labeled with a blank Date Opened. The sticker attached to bag instructed user to discard after 6 weeks. - An opened bottle of Latanoprost Ophthalmic solution was observed with an undated pharmacy tag, the box containing the bottle had an undated pharmacy tag. The bag containing the box and bottle was labeled with a sticker instructing users to Throw Away Any Drug Left After 6 weeks. - An opened bottle of Dorzolamide/Timolol was undated. - An opened bottle of Brimonidine was undated and the box containing the bottle had an attached pharmacy tag with a space to label date opened which was blank. - An opened prefilled Insulin Glargine pen with an attached pharmacy label allowing to document Date Opened which was blank. The bag containing the pen was labeled Throw Away Any Medicine That Remains 28 Days After First Use. - An opened prefilled Admelog insulin pen without a pharmacy label was undated. The pharmacy label attached to the bag containing the pen instructed Throw Away Any Medicine That Remains 28 Days After First Use. - An opened Insulin Glargine vial was observed with a pharmacy tag allowing to document Date Opened. The pharmacy sticker attached to the bag containing the vial instructed Throw Away Any Medicine That Remains 28 Days After First Use. The bag was labeled 2/27. - An opened Insulin Glargine pre-filled pen with an attached pharmacy tag, Date Opened was undated. The bag containing the pen was labeled with Throw Away Any Medicine That Remains 28 Days After First Use. The sticker attached to the bag was dated 2/27. - An opened Insulin Glargine pre-filled pen with an attached pharmacy tag, Date Opened was undated. The bag containing the pen was labeled with Throw Away Any Medicine That Remains 28 Days After First Use. The sticker attached to the bag was dated 3/12. - An opened Insulin Glargine pre-filled pen was observed with a partially removed pharmacy tag and was undated. The pharmacy label attached to the bag containing the pen was dated 3/8/24. The pink sticker, Date Opened was undated and another sticker instructed Throw Away Any Medicine That Remains 28 Days After First Use. A date of 3/8/24 was handwritten on the pharmacy label. - An opened vial of Novolog was observed with an undated pharmacy tag. The sticker attached to the pharmacy bag instructed Throw Away Any Medicine That Remains 28 Days After First Use. - An opened vial of Insulin Lispro was observed with an undated pharmacy tag. The bag containing the vial and box instructed Throw Away Any Medicine That Remains 28 Days After First Use. - An opened vial of Insulin Glargine was observed with an undated attached pharmacy tag. The bag was labeled to Throw Away Any Medicine That Remains 28 Days After First Use. The bag containing the vial was dated 2/13/24, which showed the insulin was to be discarded on 3/12/24, the day before the observation. - A box was observed in a drawer containing both prefilled syringes of 10 milliliter (mL) normal saline and 50 units in 5 mL Heparin. - In the bottom drawer of the cart was a container of MicroKill disinfecting wipes and a bottle of a chemical drug disposal system, stored along with liquid oral medications. According to medlineplus.gov, reviewed on 3/14/24, revealed Latanoprost, Once opened, the bottle can be kept at room temperature for either 6 weeks (Xalatan) or 30 days (iyuzeh). On 3/10/24 at 2:03 p.m., Resident #98 was observed lying in bed with a nebulizer machine on the bedside dresser. The observation revealed a vial of Ipratropim Bromide and Albuterol was lying next to the machine. Immediately following the observation, Staff B observed the vial and stated no the medication should not be at bedside. Staff F, Licensed Practical Nurse (LPN) stated no it should not be at the bedside and admitted to administering the resident a treatment this morning, 3/10/24. On 3/11/24 at 3:25 p.m., the Director of Nursing reviewed the photo of the vial and stated no resident in the facility was allowed to self-administer medications. She confirmed the vial should not be left at bedside. The DON reviewed Resident #98's medication and confirmed the resident was not ordered the duo of Ipratropium and Albuterol. She stated she was not going to answer it should be the correct medication. Review of Resident #98's March Medication Administration Record revealed the resident had a order for Budesonide Inhalation Suspension 0.5 milligram (mg)/2 milliliter (mL) (Budesonide Inhalation) - 1 vial inhale orally two times a day for shortness of breath (sob) and Albuterol Sulfate (2.5 mg/3 mL) 0.083% nebulization solution - 1 vial inhale orally via nebulizer three times a day for chronic obstructive pulmonary disease (COPD)/SOB. (Photographic Evidence Obtained) On 03/10/24 at 12:02 p.m. an inhaler labeled Trelegy Ellipta was observed at Resident #314's bedside table. Resident #314 stated she inhaled it once daily as needed for shortness of breath (SOB). She stated she kept it on her person. She stated she had taken it that morning and the day before. During this time, an observation was also made of a small white round tablet on the floor to the right side of the resident's bed. On 03/10/24 at 9:56 a.m., an interview was conducted with Staff E, Registered Nurse (RN). She stated there was no one self-administrating medications on this hall. She stated the resident should not keep the inhaler on her, it should be locked in the med cart. She stated the tablet was Furosemide/Lasix. Staff E said, it should not be on floor, I watched her take her meds this morning. It might be from yesterday. Resident #314's family member said, No, it was not here yesterday afternoon. On 03/10/24 at 10:19 a.m. a follow -up interview was conducted with Staff E, RN. She stated she reviewed the resident's record and confirmed the tablet was Lasix. She stated she would let the doctor know and ask if she would have to administer another dose. She stated the resident shook quite a bit. She said, She may have dropped it. The expectation is to watch the residents take their meds. Staff E, RN stated the resident did not have orders for the inhaler. She stated the resident should have turned it in. She stated she did not see it on the bedside table. She stated she would contact the doctor to get administration orders. Review of Resident #314's record showed progress note indicating on 3/10/24 Pt (patient) educated about keeping medication in room. MD (Medical Doctor) notified. New orders for Trelegy Ellipta once daily. Review of Resident #314's physician orders confirmed the resident was prescribed Furosemide Oral Tablet 20 MG, Give 1 tablet by mouth one time a day for Edema. The review did not show this resident was prescribed Trelegy Ellipta inhaler. The review showed an order for Fluticasone-salmeterol 100-50 MCG/ACT, give 1 inhalation by mouth two times a day for SOB. On 3/11/24 Note Text: Lasix pill found on resident's floor on 3/10 and inhaler located at bedside. Pill discarded and inhaler removed. Message sent to MD to notify that resident may have inadvertently missed a dose of Lasix. Awaiting return call. On 3/12/24: Note Text: Message sent to MD, again, to attempt to notify of Lasix pill found on floor on 3/10 and inhaler at bedside. Awaiting return call for any orders that may be indicated. Also, sent message to Medical Director to notify. Awaiting return call. On 03/11/24 at 3:13 p.m. an interview was conducted with the Director of Nursing (DON). She stated they did not have any one on self-administration of medications at the facility. She stated the expectation was for nurses to stay with the resident and verify meds had been received. She said, If a medication is found on the floor, the nurse is to confirm or verify what the medication was and then call the doctor for further follow -up. She stated upon admission, the nurse should confirm if the resident had any medications on them and obtain orders to administer. The DON stated the nurse should have notified the doctor and followed any new orders. During a tour of Resident #74's room on 03/10/24 at 12:58 p.m., an observation was made of a tube of zinc oxide at the bedside and a white tablet on the floor to the left side of the resident's bed. The resident stated she did not know why a tablet was on the floor. On 03/10/24 at 1:03 p.m., an interview was conducted with Staff E, RN. She stated the resident shook when she took her medication, she probably dropped it herself. She stated the resident liked her medications spoon fed to her without applesauce or yogurt. She stated she would check to see what the tablet was. On 03/10/24 at 1:50 p.m., Staff E, RN stated the treatment nurse must have left the cream at bedside. She stated it should be kept in the treatment cart. She stated the tablet on the floor was Trazodone, probably from the night before. She restated all mediations should be locked in the medication cart per facility protocol. Review of Resident #74's physician orders revealed the resident was not prescribed Trazodone medication. On 03/11/24 at 03:19 p.m., a follow-up interview was conducted with the DON. She stated all prescribed medications should be secured and administered by the nurse as ordered. She stated residents should be supervised during medication administration. Review of an undated facility policy titled, Medication Storage showed medication will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health Guidelines. Under procedure: With the exception of emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by policy. Surveyor: [NAME], [NAME] 43453

Based on observation, record review, and interview, the facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for three (Residents #14, #26, and #83) out of thirty-two residents initially sampled to include review of their PASRR's. Findings included: Review of Resident #14's Admission Record revealed an admitted [DATE]. The record included diagnoses not limited to chronic Post-Traumatic Stress Disorder (PTSD), memory deficit following other cerebrovascular disease, unspecified anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood. The record showed the diagnosis of PTSD had an onset date of 3/17/22, approximately 3 months after the resident was admitted to the facility. The Minimum Data Set (MDS) Significant Change in Status, 3/27/23, revealed the resident had an active diagnosis of PTSD. Review of Resident #14's PASRR completed at the facility on 12/22/21, two days after admission, showed the resident had Mental Illness (MI) or Suspected Mental Illness (SMI) diagnoses of anxiety and depressive disorder with the findings based on medications. The pre-screening evaluation did not show the resident was receiving or had previously received services for MI. The PASRR did not include the resident's diagnosis of adjustment disorder. The PASRR showed the resident's admission was not provisional and a Level II evaluation was not required due to no diagnosis or suspicion of a SMI or Intellectual Disability (ID). Review of the facility provided PASRR, dated 12/22/21, showed the facility failed to complete a PASRR after the diagnosis of PTSD was added to the resident's profile. During an interview on 3/12/24 at 11:35 a.m., the Director of Nursing (DON) reviewed Resident #14's PASRR and Admission record stating the PASRR should have been redone to include the diagnosis of PTSD. Review of Resident #26's Admission Record revealed an admitted [DATE]. The record included diagnoses not limited to Pseudobulbar Affect, unspecified anxiety disorder, and other specified depressive episodes. The record showed the above mentioned diagnoses had an onset date of 4/19/17. The Annual Minimum Data Set (MDS) assessment dated [DATE], included the diagnosis code of F48.2 - Pseudobulbar Affect (accessed at ICD10Data.com on 3/14/24). Review of Resident #26's PASRR, completed at the facility on 12/6/23, showed the resident had Mental Illness (MI) or Suspected Mental Illness (SMI) diagnoses of anxiety and depressive disorder with the findings based on documented history and medications. The pre-screening evaluation did not show the resident was receiving or had previously received services for MI. The PASRR did not include the resident's diagnosis of Pseudobulbar Affect. The PASRR showed the resident's admission was not provisional and a Level II evaluation was not required due to no diagnosis or suspicion of a SMI or Intellectual Disability (ID). Review of the facility provided PASRR, dated 12/6/23, showed the facility failed to complete an accurate PASRR to include the diagnosis of Pseudobulbar Affect. During an interview on 3/12/24 at 11:30 a.m., the Director of Nursing (DON) reported being new at doing PASRR's. She said the ones she had changed were the ones we had done a Gradual Dose Reduction (GDR) on and a diagnosis had been added. She stated a SMI would be a primary diagnosis of dementia or schizophrenia. The DON reviewed Resident #26's and stated the Pseudobulbar Affect should have been added. Review of Resident #83's Admission Record revealed an admitted [DATE] and a readmitted [DATE]. The record included diagnoses not limited to unspecified persistent mood (affective) disorder, unspecified depression, unspecified anxiety disorder, unspecified schizoaffective disorder, unspecified mood disorder due to known physiological condition, unspecified not intractable epilepsy without status epilepticus, and unspecified severity unspecified dementia with psychotic disturbance. The record included a primary diagnosis (onset date 2/29/24) of brief psychotic disorder. Review of Resident #83's PASRR, completed at the facility on 3/6/24, showed the resident had Mental Illness (MI) or Suspected Mental Illness (SMI) diagnoses of anxiety, bipolar, psychotic, schizoaffective and mood disorders as well as brief psychosis. The evaluation did not show the resident had the related condition of Epilepsy or was receiving or had previously received services for MI. The PASRR showed the resident's admission was not provisional and a Level II evaluation was not required due to no diagnosis or suspicion of a SMI or Intellectual Disability (ID). The evaluation revealed the resident had not exhibited actions or behaviors that may make them a danger to themselves or other, the resident did not have psychiatric treatment more intensive than outpatient care (e.g. partial hospitalization or inpatient hospitalization ), and did not have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis was a SMI or ID. An interview was conducted with the Nursing Home Administrator (NHA) on 3/13/24 at 8:43 a.m. The NHA reviewed an incident on 2/1/24 involving Resident #83. The NHA reported the resident was found on the floor facing the door, after being just seen by the nurse. She stated Resident #83 had a history of throwing self out of chair, was working with therapy to become more mobile, would scoot self in bed, and had behaviors from being calm to inconsolable yelling out. The resident had complained of (c/o) pain to right knee which an x-ray found to be negative of acute findings. The NHA reported it had been hard to find a regimen: a plan of care and medications for the resident, had pending genetic testing for administration of medications. The next day the resident c/o pain in leg and an x-ray showed a comminuted fracture of the distal tibia. The NHA reported the hospital reported it was noncomminuted spiral fracture of the distal tibia. The interview continued as the NHA reported on incidents leading to the resident being [NAME] Act on 2/25/24. She reported the resident had increased behaviors that day, was threatening to throw self out of chair and window, several attempts had been made to calm the resident which would last about 10 minutes, then the resident did throw self from chair, complaining of pain to left hip and legs. The resident attempted to take off right leg soft cast and to crawl out of bed. The Attending physician and Psychology Nurse Practitioner (NP) was notified, the NP completed and signed a Certificate of Professional Involuntary Examination, on 2/25/24 at 11:00 a.m. due to there was a substantial likelihood that without care or treatment the person will cause serious bodily harm to self and others, cannot be redirected. The NHA stated following the hospitalization psychology and psychiatry follow weekly. She stated the resident was sent to a certain local hospital due to the fact they have a geriatric psych wing. During an interview on 3/12/24 at 11:40 a.m., the Director of Nursing (DON) reviewed Resident #83's PASRR, stating the epilepsy and dementia should have been added and a Level II should have been done. Review of the policy - Pre-Admission Screening and Resident Review (PASRR), undated, revealed The purpose of the PASRR is to ensure individuals who are being considered for placement in a nursing facility are evaluated for serious mental illness and/or intellectual disability and are offered the most integrated setting appropriate for their long term care needs (including determining whether a Nursing Facility is appropriate). All persons, regardless of payer or age, needing admission to a Nursing Facility must first be screened for possible mental illness or the presence of an intellectual disability (ID) or both (level 1). If a mental illness (MI) or intellectual disability (ID) appears to exist, the person must be referred for further evaluation (Level II) before Nursing Facility admission. There are two elements of PASRR: - Level I determines whether an individual referred for admission into a nursing facility has or is suspected of having an SMI and/or ID diagnosis. - Level II is an individualized, in-depth evaluation of an individual, including confirming or ruling out the suspected diagnosis and determining the need for Nursing Facility services. If a Nursing Facility is the most integrated setting appropriate to meet that individual's long -term care needs, the Level II PASRR must also evaluate what specialized services if any are needed for the individual. The Level I PASRR screen must be done prior to admission for all persons seeking admission to the facility. Note: a Level I PASRR screen does not have to be completed when a resident has been discharged to the hospital and is returning to the nursing facility after being in a hospital for 90 days or less and there is no significant change triggering a new PASRR or when the resident is accepted or transferred to another nursing facility. A copy of the most recent PASRR should be sent with the resident (if our facility is transferring a resident to another facility) or requested from the transferring facility (if our facility is receiving a resident from another facility). The Level II PASRR must be done prior to admission for all persons seeking admission except when the following exemption applies for a provisional admission: - individuals who are discharged from a hospital into a Nursing Facility after receiving acute inpatient care, and require Nursing Facility services, for which they received the inpatient hospital care, may be admitted to the Nursing Facility if a physician certifies on the AHCA-5000-3008 form before admission that the individual is likely to require less than 30 days of Nursing Facility services. Should the individual require a stay in the Nursing Facility longer than 30 days, in advance of the expiration of 40 days, the facility must notify KEPRO on or before the 25th day of the stay to request a Level II PASRR. A Resident Review (RR) - Evaluation Request, is the reevaluation of an individual, and the reassessment of appropriateness of continued placement and recommended specialized services, as applicable, following a significant change in the resident's physical or mental condition or if there is a new onset of mental illness or intellectual disability/developmental disability diagnosed . Resident Reviews (RR) are triggered when: a) An individual undergoes a significant change in condition and that change has a material impact on their functioning as it relates to their MI/ID status. The notion of significant change is defined by responses to the Minimum Data Set (MDS). b) Referral for Level II Resident Review Evaluations is Required for Individuals Previously Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: Note: this is not an exhaustive list: - A resident who demonstrates increased behavioral, psychiatric, or mood related symptoms. - A resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment. - A resident who experiences an improved medical condition - such that the resident's plan of care or placement recommendations may require modifications. - A resident whose significant change is physical, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living. - A resident who indicates a preference (may be communicated verbally or through other forms of communication, including behavior) to leave the facility. - A resident whose condition or treatment is or will significantly different than described in the resident's most recent PASRR Level II evaluation and determination. (Note that a referral for a possible new Level II PASRR evaluation is required whenever such a disparity is discovered, whether or not associated with a SCSA.) c) Referral for Level II Resident Review Evaluations is Also Required for Individuals Who May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual disability/Developmental Disability, or a Related Condition in the Following Circumstances: Note: this is not an exhaustive list: - A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where dementia is not the primary diagnosis). - A resident whose intellectual disability as defined under 42 CFR 483.100, or related condition as defined under 42 CFR 435.1010 was not previously identified and evaluated through PASRR. - A resident transferred, admitted , or readmitted to a Nursing Facility following an inpatient psychiatric stay.

Based on observation, record review, and interview, the facility failed to allow one (Resident #94) of three residents sampled for care planning, to participate in developing and revising their care plan related the side rails. Findings included: On 3/10/24 at 11:53 a.m., Resident #94 was observed lying in bed, bilateral legs were offloaded on pillows, and she was alert and oriented. The resident reported to having asked for side rails however the state made a ruling (against them) because of being to restricted. The resident stated her legs did not work and with side rails she could use upper her arms to roll side to side and sit up. She said she have begged and begged and they won't do it. The resident stated she did not not know about quarterly care plan meetings. The observation showed Resident #94 did not have any side or adaptive rails on either side of bed. Review of Resident #94's Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status score of 15 out of 15, which indicated intact cognition. Review of Resident #94's Admission Record showed the resident was admitted on [DATE] and included diagnoses not limited to acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral([NAME]), unspecified malignant neoplasm of cervix uteri, secondary malignant neoplasm of bone, and unspecified spinal stenosis site. Review of Resident #94's clinical record showed one Care Plan progress note, dated 2/9/24, showing Quarterly Care Plan conference held by Interdisciplinary Team (IDT) for [resident name]. Plan of care and medication reviewed. No changes made. Will proceed with current Plan of Care (POC). The note did not show the resident or representative had been involved with the meeting. The record did not include a care plan signature log of who attended the care plan meeting(s) of the resident. Review of Resident #94's care plan revealed the following focuses and interventions were included: - Resident has the capacity to make health care decisions and has the following Advance Directives on file: Do Not Resuscitate (and) Health Care Surrogate. - Resident is independent for meeting emotional, intellectual, physical, and social needs. - Resident has an Activities of Daily Living (ADL)self-care performance deficit related to (r/t) Activity Intolerance, Disease Process, Impaired balance, Limited Mobility. The interventions included: Side Rails/Enablers for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use, initiated 7/30/23 and revised on 8/10/23. An intervention showed the resident required one person limited assistance for bed mobility. - Resident has potential for pressure ulcer development r/t impaired mobility. The interventions included to educate resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. An interview was conducted with the MDS Coordinator on 3/12/24 at 11:50 a.m. The coordinator stated the care plan meetings were held in the resident rooms and were held upon admission and quarterly. The staff member reported the clinical record should have a downloaded signature page (of meeting attendees) and a Care Plan progress note. The process was to schedule the meeting, an invitation was sent to the family, and one was placed in the resident's room. The coordinator reviewed the care plan and stated Resident #94's side rail intervention should have been revised. She said the process was to go through each intervention and during the quarterly assessment the facility looked for changes and revised as needed. The MDS Coordinator reviewed the record downloads and progress notes and confirmed there were no signature logs and no other care plan progress notes. A continued interview was conducted with the MDS Coordinator on 3/12/24 at 12:32 p.m. The coordinator stated there were no admission care plan meetings for Resident #94 and no further information. She confirmed the note on 2/9/24 did not specify whether the resident attended the meeting or not and there was no documentation of quarterly meetings. The policy - Person Centered Care Planning, revised 12/2016, revealed When admitted , each resident will have physician orders, dietary needs, medications, treatments, and preliminary discharge plans reviewed by the IDT and we'll have an interim care plan developed within 24 hours of admission, along with input from the resident and or representative. This assures that the resident's immediate needs are met and his/her preferences are considered. This plan will be implemented and updated as needed until the staff can conduct a comprehensive assessment and develop a complete interdisciplinary plan of care. - The facility's IDT, in coordination with the resident, the resident's family or representative, develops and maintains this care plan in an effort to attain and/or maintain the highest level of function the resident may be expected to reach. - The facility's IDT will be made of up of a registered nurse and certified nursing assistant responsible for the care of the resident, along with a food and nutrition staff member, Social Service Director, Activity staff member, MDS nurse, the attending physician, and other appropriate staff or professionals in disciplines as determined by the residents needs or as requested by the resident. - The Social Service Director or designee will notify the resident of his/her right to participate in his/her treatment and care planning process. The facility will support the resident in this right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person centered plan of care. - The Social Service Director or designee will schedule any upcoming care plan meeting with the resident and his/her family or representative. Social Service Director will be responsible for notifying all parties of the upcoming care plan meeting and maintaining records of the method of notification (mail, telephone, e-mail, etc.), and whether the resident or family or representative declined to participate. Every effort will be made to schedule the care plan meeting at a date and time convenient for the resident and/or representative. - An explanation will be included in the resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the of the resident's care plan. At the care plan meeting, the resident, and the resident's family or representative are encouraged to participate in the development of goals and approaches most suited to that resident. The care plan should be built on the resident's strengths, preferences, choices, incorporating identified problems, and risk factors. - Care plans are to be revised as changes in the resident's condition warrant or when there is a change in resident's preference or choice of treatment.

Based on observation, record review, and interview, the facility failed to obtain a physician order prior to administering oxygen for one (Resident #273) of two residents reviewed for oxygen. Findings included: During an observation on 03/10/24 at 12:10 p.m., Resident # 273's oxygen concentrator was set at 5 liter per minute (lpm). Photographic evidence obtained. During an interview on 03/10/24 at 12:10 p.m., Resident #273 stated that he usually did not wear oxygen however he had been wearing it since admission from the hospital. Review of the Admission Record showed Resident #273 was readmitted to the facility on [DATE] with diagnoses included but not limited to Rhabdomyolysis, Chronic Obstructive Pulmonary Disease (COPD) and other Asthma. Review of the Order Summary Report on 03/10/24 at 12:12 p.m., showed no current order for oxygen. A review of Resident #273's care plan showed, a focus of The resident has COPD, Asthma. The goal showed, The resident will display optimal breathing patterns daily through review date. The interventions included but not limited to Oxygen Settings: O2 [oxygen] via nasal cannula per MD orders. During an interview on 03/11/24 at 3:05 p.m., the Director of Nursing (DON) stated typically a resident came into the facility with an order for oxygen. The DON stated in this case Resident #273 came back to the facility via ambulance with oxygen being administered at 5 lpm. The DON stated Resident #273 was readmitted to the facility on [DATE] and the nurse should have immediately addressed Resident #273's oxygen administration and lack of physician order for oxygen administration during re-admission. The DON stated, it was the facility's policy that oxygen should not be administered without a physician order. The DON stated she was told by staff they watched a state surveyor looking at Resident #273's oxygen concentrator on 03/10/24 and then also reviewed his oxygen administration and realized there was no current order. A review of the facility's policy Oxygen Administration not dated showed, .7. Turn on oxygen. Start the flow rate of oxygen at the prescribed rate.

Based on observation, interview, and record review, the facility did not ensure staffing posting information was up-to-date and current. Findings included: Upon entering the facility on 03/10/24 at 9:15 a.m., an observation was made of a posting titled, Daily work Hours by Provider Position, date range 03/08/24 to 03/08/24. The review showed the staff posting was not updated on 03/09/24 and 03/10/24. On 03/10/24 at 11:12 a.m., the staffing posting was still not updated. On 03/13/24 at 12:28 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the Staffing Coordinator. The NHA stated the staff posting was supposed to be updated daily. The Staffing Coordinator stated it was her responsibility to update the posting. She stated she worked Monday through Friday. She said, On the weekends I print the sheet out for the days I will be out until Monday. I adjust the numbers as needed when I return. The receptionist changes the posting to the updated one. The NHA stated they should have had it up to date. A review of an undated facility policy titled, Nurse Staffing Information showed: 1. Data requirements the facility must post the following information on a daily basis: i. Facility name. ii. Current date. iii. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. A. Registered Nurses. B. Licensed practical nurse or licensed nurses. C. Certified Nursing Assistants, Personal Care Assistants or other Direct care staff.

Based on observation, record review, and interview, the facility failed to ensure medications for two (Residents #78 and #83) of eleven residents observed during the administration of medications and reviewed for the appropriateness of medications had received medications within the parameters set by the physician. Findings included: 1. On 3/12/24 at 8:37 a.m., an observation was conducted of the administration of medications for Resident #78 with Staff D, Licensed Practical Nurse (LPN)/Unit Manager (UM). The staff member was observed dispensing the following medications placing them into a single medication cups: - Iron 325 milligram (mg) over-the-counter (otc) tablet - Vitamin C 500 mg otc tablet - Multi Vitamin otc tablet - Gabapentin 300 mg capsule - Baclofen 10 mg tablet - Escitalopram 10 mg tablet - Amlodipine 5 mg tablet - Oxycodone 10 mg tablet Staff D poured 30 milliliters of liquid protein into another medication cup and dispensed a 25 mg tablet of Metoprolol Tartrate into separate cup saying the blood pressure previously taken was 127/74, and said the blood pressure would be retaken. The staff member entered the resident room and obtained a manually-taken blood pressure of 118/78. Staff B administered the oral tablets in the one cup and liquid protein. The staff member informed this writer and resident of holding Metoprolol due to blood pressure. Staff B returned to the medication cart and reported the resident's Amlodipine should have been held also, confirming the administration of Amlodipine, the staff member said I'm so sorry. Review of the March Medication Administration Record (MAR) for Resident #78 included the following orders: - Amlodipine Oral Tablet 5 mg - Give 1 tablet by mouth one time a day for hypertension (HTN). Hold is systolic blood pressure (BP) less than (<) 120. - Metoprolol Tartrate Oral Tablet 25 mg - Give 1 tablet by mouth two times a day for HTN. Hold for SBP less than 120. Review of the MAR documentation for Amlodipine showed the resident received the medication outside of the physician ordered parameters on 3/2: 110/60, 3/3: 119/69, 3/4: 117/65, 3/7: 111/68, 3/8: 118/70, 3/11: 108/60, 3/12: 118/78, and 3/13/24: 113/66. The review showed the resident had been administered Amlodipine outside the parameters 8 out of 13 opportunities. Review of the MAR documentation for Metoprolol Tartrate showed the resident received the medication outside of physician ordered parameters on 3/2: 110/60, 3/3: 119/69, 3/4: 117/65, 3/7: 111/68, 3/8: 118/70, 3/11: 108/60, and 3/13/24: 113/66. The review showed the resident had been administered Metoprolol outside the parameters 7 out of twenty-five opportunities. 2. Review of Resident #83's Admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to Brief Psychotic Disorder, unspecified Persistent Mood (Affective) Disorder, unspecified anxiety disorder, unspecified depression, unspecified schizoaffective disorder, and unspecified severity dementia with psychotic disturbance. Review of Resident #83's February MAR showed a physician order, Clonidine oral tablet 0.1 mg - Give 1 tablet by mouth two times a day for lowering blood pressure (BP) to reduce anxiety. Hold for systolic blood pressure (SBP) less than < 90 and diastolic blood pressure (DBP) < 40. Review of Resident #83's February MAR showed NA instead of documented blood pressure during the administration of Clonidine on 3/17, 3/18 and 3/23/24. The resident received Clonidine without verifying blood pressures were within parameters three out of 18 opportunities. Review of the March Medication Administration Record (MAR) for Resident #83 revealed the physician had ordered Clonidine 0.1 milligram (mg) daily for anxiety, Hold for systolic blood pressure (SBP) less than < 110 and diastolic blood pressure (DBP) < 60. Review of the March MAR revealed the documentation for Clonidine from 3/2 - 3/13/24, the blood pressure (bp) spaces were X'd out and not allowing for documentation of the blood pressure at the time of administration. The MAR did instruct staff to obtain vital signs every shift (6 a.m. - 6 p.m. and 6 p.m. and 6 a.m.) the observation did not identify when the blood pressures were taken during the 12 hour shift. The documentation of vital signs showed the resident would have received Clonidine outside the physician order parameters 3 out of 13 opportunities. An interview was conducted with the Director of Nursing (DON) on 3/13/24 at 10:24 a.m. The DON stated staff should be obtaining blood pressures prior to administration of Clonidine, should always get a blood pressure when giving Clonidine. The staff member reviewed Resident #83's March MAR and BP summary then confirmed the Clonidine should have been held. The DON confirmed no other blood pressures had been obtained at the time of documentation. She reviewed the February MAR and not applicable (documented in space for blood pressure) and stated what does that mean, confirming blood pressures had not been taken and should have been. The policy - Oral Medications, undated, revealed The purpose of this procedure is to provide guidelines for the administration of oral medication. The procedure instructed staff to Verify the physician's medication order for resident's name, drug name, dose, time, and route of administration. Perform preadministration assessment (e.g. pulse rate or blood pressure) , if necessary.

Based on observations, interviews, and record review, the facility failed to ensure pain was managed effectively for three residents (#4, #5, and #3) out of three residents sampled for pain management. Findings included: An observation was conducted on 1/3/24 at 9:36 a.m. of Staff D, Registered Nurse (RN) preparing and administering medication for Resident #4. Resident #4 was observed sitting in a chair at her bedside. The nurse did not ask the resident about pain level or characteristics of the pain. Staff D, RN administered Percocet 5-325 mg (milligram) x 1 tablet at 9:36 a.m., 1 hour and 36 minutes passed the 8:00 a.m. ordered time. Review of Admission Record showed Resident #4 was admitted on [DATE] with diagnoses including hypertensive heart disease, arthritis, chronic pain, acquired absence of other left toes, peripheral vascular disease, and chronic kidney disease. Review of Resident #4's Order Summary Report for January 2024 showed the following: - Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) *Controlled Drug* Give 1 tablet by mouth three times a day for moderate to severe pain hold for sedation. Start date of 02/12/2023 and scheduled at 8:00-1600-2200 for administration. An interview was conducted on 1/3/24 at 12:02 p.m. with Resident #4. The resident said she had pain every day, especially in the right shoulder from a previous fracture. Resident #4 said occasionally her pain medication is late. The resident said it was late that morning and her pain level had reached an 8 out of 10 on the pain scale. Resident #4 stated, I got through it, what else am I going to do? Review of Resident #4's Weights and Vitals Summary showed 0 was documented for pain everyday twice a day from 10/01/23 through the morning of 1/03/24. Review of Resident #4's Medication Administration Audit Report, over a 14-day period from 12/20/23 to 1/3/24, revealed Resident #4 was administered her pain medication, Percocet, over an hour passed the scheduled dose 7 times. Review of Resident #4's significant change Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive Patterns, the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating she was cognitively intact. Review of Resident #4's medical records showed a care plan in place for Chronic Pain related to arthritis, dated 1/26/22. Interventions included administering analgesia as per orders, and monitor for effectiveness. An observation was conducted on 1/3/24 at 9:56 a.m. of Staff A, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #5. Staff A, LPN administered Baclofen 10 mg x 1 tablet, Gabapentin 300 mg x 1 tablet, and Oxycodone 10-325 mg x 1 tablet at 9:56 a.m., 1 hour and 56 minutes passed the 8:00 a.m. ordered time. The resident was observed lying in his bed with the head of the bed elevated. The nurse did not ask the resident about pain level or characteristics of the pain. Review of Admission Record showed Resident #5 was readmitted on [DATE] with diagnoses including encephalopathy, paraplegia, cervical disc disorder, muscle weakness, and chronic pain syndrome. Review of Resident #5's Order Summary Report for January 2024 showed the following: -Oxycodone HCl ER Oral Tablet ER 12 Hour Abuse-Deterrent 10 mg (Oxycodone HCl) Give 1 tablet by mouth two times a day for chronic pain. Start date 11/20/2023. Scheduled to Administer at 0800 and 2000. -Oxycodone-Acetaminophen Oral Tablet 10-325 mg (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 4 hours for pain. Start date 11/20/2023. Scheduled to administer at 0000, 0400, 0800, 1200, 1600 and 2000. -Baclofen Oral Tablet 10 mg (Baclofen) Give 1 tablet by mouth three times a day for Muscle Spasms 11/18/23. Start date 11/18/2023. Scheduled to administer at 0800, 1600, and 2200. -Gabapentin Oral Capsule 300 mg (Gabapentin). Give 1 capsule by mouth two times a day for Neuropathy. Start date 11/18/23. Scheduled to administer at 0800 and 2000. An interview was conducted on 1/3/24 at 1:08 p.m. with Resident #5. Resident #5 said his pain level had reached a 6 or 7 out of 10 this morning by the time he got his medication. The resident said when he gets his pain medication regularly it keeps his pain under control. Resident #5 stated he was having more muscle spasms in his legs than normal. The resident confirmed he took Oxycodone and Gabapentin for his pain and Baclofen to help with muscle spasms. Review of Resident #5's Medication Administration Audit Report over a 14-day period, from 12/20/23 to 1/3/24, showed Resident #5 was administered his prescribed medications of Oxycodone, Gabapentin, and Baclofen over an hour passed the scheduled administration time a total of 61 times. (all three medications combined). Resident #5's Medication Administration Audit Report showed on 1/3/24 he was administered the 8:00 a.m. dose of Oxycodone 10-325 mg at 10:05 a.m., the 10:00 a.m. dose of Oxycodone Extended Release 10 mg at 11:10 a.m. and the 12:00 p.m. dose of Oxycodone 10-325 mg at 11:14 a.m. All three doses given within 1 hour and 9 minutes of each other instead of the Oxycodone 10-325 mg being spaced four hours apart as ordered with the Extended Release given in the middle. Review of Resident #5's Quarterly MDS, dated [DATE], Section C-Cognitive Patterns, showed the resident had a BIMS score of 15, indicating he was cognitively intact. Review of Resident #4's medical records showed a care plan in place for Chronic Pain related to arthritis, dated 6/14/23. Interventions included: administering analgesia as per orders, monitor for effectiveness and monitor/record pain characteristics PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. The resident also had a care plan in place for paraplegia related to spinal issues, dated 6/14/23. Interventions included: give medications as ordered and pain management as needed. An interview was conducted on 1/3/24 at 2:03 p.m. with Staff A, LPN. Staff A, LPN confirmed Resident #5's medications were due at 8:00 a.m. When discussing the observation of medication administration was at 9:56 a.m. he nodded and said, They were late. Staff A, LPN confirmed the medications should have been given between 7:00 a.m. and 9:00 a.m. Staff A, LPN did not give a reason as to why they were late. An interview was conducted on 1/3/24 at 2:21 p.m. with Resident #3. Resident #3 stated he was at the facility for two weeks after having his toe amputated and would not receive his pain medication on time. He stated the pain medication would control his pain, If I got it in a reasonable amount of time. Resident #3 said a couple of times he was in a significant amount of pain for a while and at that point it didn't do any good to take another pill. He said it could take 4-6 hours to get the pain level back down. Resident #3 said one time he didn't get his pain medication for three hours and he was at The tip of the edge on that one. He said his pain was 9 out of 10 on the pain scale for a long time. Review of Admission Record showed Resident #3 was admitted on [DATE] and was discharged on [DATE] with diagnoses including osteomyelitis, acquired absence of left toe, gout, and rheumatoid arthritis. Review of Resident #3's Medicare 5 Day MDS, dated [DATE], Section C-Cognitive Patterns, showed the resident had a BIMS score of 15, indicating he was cognitively intact. Review of Resident #3's Order Summary Report for January 2024 showed the following: - Oxycodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain. Start Date 11/20/23. Discontinued 12/1/23. - Oxycodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. Start Date 12/1/23. - Oxycodone ER Oral Capsule ER 12 Hour Abuse-Deterrent 9 mg. Give 1 capsule by mouth two times a day for Pain for 30 Days. Start Date 12/1/23. Scheduled administration at 0800 and 2000. - Ibuprofen Oral Tablet 600 mg. Give 1 tablet by mouth every 8 hours as needed for pain. Start Date 11/30/23. Review of Resident #3's medical record showed a care plan in place for risk for pain. Interventions included administering analgesia as per orders, and monitor for effectiveness. Review of Resident #3's Medication Administration Audit Report over a 11-day period, from 11/30/23 to 12/11/23 showed Resident #3 was administered his pain medication, Oxycodone, over an hour passed the scheduled dose 5 times. An interview was conducted on 1/3/24 at 12:15 p.m. with the Director of Nursing (DON). The DON stated medications should be administered in a two-hour window, one hour before the scheduled time until one hour after the scheduled time. She said the facility recently educated all the nursing staff on the Five Rights of Medication-right patient, right drug, right time, right dose, and right route. A follow-up interview was conducted on 1/3/24 at 2:25 p.m. with the DON. The DON reiterated the nurses have one hour before and one hour after the scheduled time to give medication. She said the morning medications should have been given between 7:00 a.m. and 9:00 a.m. The DON said they did not have a staffing issue, the nurses' resident load was not too heavy, and they should have plenty of time to pass the medication on time. The DON was unaware there was an issue with residents not receiving medications on time. Review of a facility policy titled, Pain Management-Overview, undated, showed the following: The facility will strive to improve resident comfort and quality of life and to minimize pain as much as possible. The overall goal of the Pain Management Program will be to: -Identify residents with the potential for pain. -Recognize the onset or presence of pain. -Address and/or treat the underlying cause of the pain, to the extent possible. -Develop and implement approaches to manage pain. -Monitor for effectiveness or adverse consequences related to approaches. -Modify the approaches as indicated. Review of a facility policy titled, NURSING- Medications, Oral, undated, showed the following: Purpose The purpose of this procedure is to provide guidelines for the administration of oral medication. Procedure 2. Verify the physician's medication order for resident's name, drug name, dose, time, and route of administration. .

Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for three residents (#4, #5, #6) out of four sampled residents who were administered medications. This resulted in 19 errors from 20 medication administration opportunities for a medication error rate of 95%. Findings Included: An observation was conducted on 1/3/24 at 9:36 a.m. of Staff D, Registered Nurse (RN) preparing and administering medication for Resident #4. Staff D, RN prepared the following medications: -Amlodipine 5 mg x 1 tablet -Docusate sodium 100 mg x 1 tablet -Iron 325 mg x 1 tablet -Furosemide 720mg x 1 tablet -Percocet 5-325 mg x 1 tablet -Vitamin B-12 1000 mg x 1 tablet -Folic acid 1 mg x 1 tablet -Vitamin C 500 mg x 1 tablet Review of physician orders showed the Vitamin C order did not have a dose listed and all the prepared medications were due at 8:00 a.m. The medications were observed to be administered at 9:36 a.m., 1 hour and 36 minutes passed the ordered time. Review of admission records showed Resident #4 was admitted on [DATE] with diagnoses including hypertensive heart disease, arthritis, chronic pain, acquired absence of other left toes, peripheral vascular disease, and chronic kidney disease. An observation was conducted on 1/3/24 at 9:56 a.m. of Staff A, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #5. Staff A, LPN prepared the following medications: -Amlodipine 5 mg x 1 tablet -Ascorbic Acid 500 mg x 1 tablet -Baclofen 10 mg x 1 tablet -Escitalopram Oxalate 10 mg x 1 tablet -Gabapentin 300 mg x 1 tablet -Iron 325 mg x 1 tablet -Metoprolol 25 mg x 1 tablet -Multivitamin x 1 tablet -Liquid Protein 30 ml -Oxycodone 10-325 mg x 1 tablet Review of Resident #5's physician orders showed all the prepared medications were due at 8:00 a.m. The medications were observed to be administered at 9:56 a.m., 1 hour and 56 minutes passed the ordered time. Review of admission records showed Resident #5 was readmitted on [DATE] with diagnoses including encephalopathy, paraplegia, cervical disc disorder, anxiety, depression, muscle weakness, and chronic pain syndrome. An interview was conducted on 1/3/24 at 2:03 p.m. with Staff A, LPN. Staff A, LPN confirmed Resident #5's medications were due at 8:00 a.m. When discussing the observation of medication administration was at 9:56 a.m. he nodded and said, They were late. Staff A, LPN confirmed the medications should have been given between 7:00 a.m. and 9:00 a.m. Staff A, LPN did not give a reason they were late. An observation was conducted on 1/3/24 at 11:44 a.m. of Staff C, LPN completing a blood sugar check for Resident #6. The resident had a blood sugar level of 433. Staff C, LPN said she needed to administer 10 units of insulin and call the doctor. Staff C, LPN was observed taking out Resident #6's insulin pen, turning the dial to 10 units, and administering the insulin. Staff C, LPN did not prime the insulin pen prior to turning the dial to 10 units and administering the insulin. The insulin pen Staff C, LPN used to administer insulin to Resident #6 was an Admelog SoloStar (insulin Lispro injection). (Photographic evidence obtained.) Review of admission records showed Resident #6 was admitted on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia and type II diabetes mellitus. Review of Resident #6's orders showed the following insulin order dated 12/26/23: -Admelog SoloStar 100 UNIT/ML Solution pen-injector. Inject subcutaneously before meals and at bedtime for DM Inject as per sliding scale: if 0 - 149 = 0 units; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 400 = 10 units; 401+ = 10 units. For blood sugar greater than 400 give 10 units and call physician. An interview was conducted on 1/3/24 at 11:58 a.m. with Staff C, LPN. When asked about priming an insulin pen, Staff C, LPN looked very confused and said she has never done that and didn't know what it meant. Staff C, LPN said she did not know about priming insulin pens and had not been educated on it. Staff C, LPN said she had worked in the facility for one year. An interview was conducted on 1/3/24 at 12:15 p.m. with the Director of Nursing (DON). The DON stated medications should be administered in a two-hour window, one hour before the scheduled time until one hour after the scheduled time. She said the facility recently educated all the nursing staff on the Five Rights of Medication--right patient, right drug, right time, right dose, and right route. The DON stated insulin pens should be primed prior to dialing the pen to the ordered dose and administering the insulin. She stated, I'd have to look for a policy outlining the proper method for priming insulin pens. During a follow-up interview with the DON on 1/3/24 at 2:25 p.m. the DON stated they had no policy on the use of insulin pens and there had been no previous education to the nurses on the use of insulin pens. Review of the Admelog SoloStar instructions provided by the facility showed the following: Step 1: Check your pen . Step 2: Attache a new needle . Step 3: Do a safety test. Always do a safety test before each injection to: -Check your pen and the needle to make sure they are working properly. -Make sure that you get the correct insulin dose. 3A. Select 2 units by turning the dose selector until the dose pointer is at the 2 mark. 3B. press the inject button all the way in. -When insulin comes out of the needle tip, your pin is working correctly. Step 4: Select the dose . Step 5: Inject your dose . Review of a facility policy titled NURSING- Medications, Oral, undated, showed the following: Purpose The purpose of this procedure is to provide guidelines for the administration of oral medication. Procedure 1. Sanitize hands thoroughly before beginning the procedure. 2. Verify the physician's medication order for resident's name, drug name, dose, time, and route of administration. .

Based on review of the medical record, incident logs, policy and procedure review, interviews with administrative, nursing and therapy staff, the resident's physician, and the resident's representatives it was determined the facility failed to provide a systematic process to carry out their abuse policy for one (Resident #2) of two residents reviewed for abuse. The facility failed to take actions to report, investigate and prevent abuse to its residents. The facility failed to suspend staff alleged to perpetrate abuse and failed to thoroughly investigate to determine the root cause of the reported abuse to ensure the safety of the resident involved and ensure that all facility residents would remain safe from a similar incident. On 1/11/2022 a nursing staff member reported to the Assistant Director of Nursing (ADON) that they overheard a nurse verbally abusing Resident #2 telling him in foul language to stop getting out of bed. Shortly afterwards, on 01/11/2022, two therapy staff members reported to the abuse coordinator they observed Resident #2 with his legs tied together above the knees with a gown that was tightly knotted twice and wrapped in a blanket tucked around and under him. Reports to the required abuse hotline showed the facility reported the verbal incident on 2/1/2022 and the gown incident on 1/13/2022. The facility suspended one staff member on 2/1/2022. The investigation was not carried out in a consistent and thorough manner. This resulted in the findings of Immediate Jeopardy occurring on 1/11/2022. The immediacy was removed on 02/17/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings include. Review of Resident #2's Admission Record revealed he was geriatric in age and was transferred from a local hospital on 12/31/2021 having pneumonia. His Admission Record showed he was admitted for short term rehabilitation with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status coded as a 0. The code of 0 indicated No (resident is rarely/never understood). Further review of the MDS Section G Functional Status showed for bed mobility self-performance coded as the number 3. The number 3 reflected extensive assistance. Support needed for bed mobility was coded as a 3 and indicated two plus persons physical assist. Dressing was coded at self-performance as the number 3 indicating extensive assistance. Personal hygiene was coded as the number 3 indicating extensive assistance, and support needed was coded as a 3 indicating two plus persons physical assist. Review of Resident #2's medical record reflected a progress note dated 01/11/2022 at 3:43 p.m. (1543) notified by therapy of resident having a skin tear on his right forearm 1.5 cm (centimeters) x .5 cm. Cleansed and band aid applied. Pink abrasion noted to right scapula. Resident had a fall this morning. Notified doctor of skin tear and abrasion. Review of the facility report titled, Incidents by Incident Type, from 11/1/21 to 1/31/22 revealed Resident #2 had a witnessed fall on 01/11/2022 at 8:30 a.m. Further record review revealed Resident #2 was listed on the Abuse and Neglect log dated on 01/13/2022. On 02/01/2022 at 12:21 p.m. an interview was conducted with Staff D, Certified Nursing Assistant (CNA) and she said she worked at the facility for over five years. Staff D said on 01/11/2022 she was the CNA who called Staff E, CNA to Resident #2's room. She said in the morning I heard a loud bang in the room and called for [Staff E] to come down to the room. I told her it sounded like a resident fell . Staff D said on that day she was working on the unit directly next to the COVID-19 unit (600 - isolation unit). She stated from the angle I was at, I could see that (Resident #2's) door was wide open, but I could not see inside of the room. She said she heard Staff E calling out for the nurse at that time. She said Staff C, Licensed Practical Nurse (LPN) arrived at the room, and she could see her standing outside of the resident's door stating yep, he is on the floor. I then overheard the nurse (Staff C, LPN) tell him, Keep your [explicative] in this bed because am not coming in here all day to do this. Staff D, CNA stated, I immediately told [Staff C] don't speak to residents that way. Staff C told me he doesn't speak English anyway. Staff D said that she told Staff F (former Assistant Director of Nursing/Registered Nurse, ADON/RN) immediately what happened, and she was told to write a statement. Staff D, CNA said she recalled Resident #2 and cared for him and his wife for over a week during his stay at the facility. She said he was very confused, he did speak some English, mostly Spanish. Staff D said he would need help with set up for his meals, and he would eat by himself. She said he was not capable of tying his own shoes and denied ever seeing him wrapping or fidgeting with his hands. She indicated he required extensive assistance to get dressed. She stated, He would stand up and walk right out of the bedroom. Staff D went on to say that about a week later she got a phone call at home from the Risk Manager (RM). Staff D said She wanted to know what I wrote in my statement. I repeated to her what I wrote. On 02/01/2022 at 9:40 a.m. an interview was conducted with Staff A, Physical Therapy Assistant (PTA) and Staff B, Certified Occupational Therapy Assistant (COTA). They both said on the morning of 01/11/2022 at approximately 8:00 a.m., just prior to entering Resident #2's bedroom, Staff E, CNA told them he (Resident #2) had just fallen. Staff A, PTA said, I asked her what happened. Staff A said she would not tell us anything she just looked at us and walked away. Staff A said they both entered the room and Resident #2 was lying in bed on his back. She said that you could see he was wearing white T-shirt with a blanket that was swaddled around his torso. She further explained the blanket was wrapped around his back across his legs and tucked under his bottom. She said after we unwrapped him, we found a green hospital gown. She then stated, The gown was wrapped twice, in a figure eight and tightly knotted just above his knees. It was not only knotted once but twice. Staff A continued, That is the way you would hobble a horse, so you can't move your legs. Staff A, PTA and Staff, B, COTA said they immediately alerted Staff F, former ADON/RN and the former Social Service Director (SSD). She said they both entered the room and were present to observe the situation. Staff A and B said the former SSD took pictures of the gown wrapped around his legs. Staff A stated the former SSD then told us not to write statements. He said he had it taken care of. Staff B, COTA said we all wrote statements including Staff F, former ADON/RN. Staff A, PTA confirmed she knew Resident #2 very well. She said she had provided therapy services to him five days a week for three weeks. Staff A and B both stated, There was no way he could have wrapped the gown around his legs and tied it twice. He doesn't have the coordination, dexterity, strength nor cognition to have done it. Staff A confirmed Resident #2's primary language was Spanish, but his son had told them he understands English. On 02/15/2022 at 2:52 p.m. a phone interview was conducted with Staff E, CNA she confirmed she worked full time at the facility. She said she recalled Resident #2 had fallen. She immediately stated the nurse (Staff C) has a high-toned voice and stated, The nurse was talking to the CNA (Staff E), not yelling. She denied the nurse had told her to keep him in the bed. She said we needed to keep an eye on him because he tries to walk. We got to watch him. Every chance I would get I would walk to the room and make sure he is in the chair not trying to get up. He was trying to get up all day. Staff E said we [Staff C] had picked him up and put him in the bed. I gave him his breakfast. I took the tray when he was done. She said therapy had taken him out of the bed and in the bathroom. She denied knowing about a blanket that was wrapped around him. She said I just put it over him. Then stated, He had wrapped himself. She said he was wearing a T-shirt underneath the gown, and he takes his clothes off. Staff E stated, I don't understand the part about the gown around his legs. We picked him up from under his arms. How did we not see the gown around the legs? We did not see a gown. We walked him back to bed. Staff E said she had been a certified nursing assistant for [AGE] years. She confirmed she had used restraints in the past, but they are not used anymore. Staff E repeated, I could not understand how his gown was wrapped around his leg. Then stated, Did not see him anymore after giving him his tray. She confirmed no one asked her to write a statement until the next day. The former SSD told me about the gown the next day. He asked me if the nurse was yelling at the resident or me. I told him she was talking to me then added she did not cuss. Staff E said the RM (Risk Manager) talked to her the day after that about the gown, not about the verbal allegation. She confirmed she had been educated on speaking to residents and falls. She could not recall how long ago it had been. She confirmed recent training on abuse and neglect. On 01/31/2022 at 3:06 p.m. an interview was conducted with Staff C (LPN). She said she remembered Resident #2. She said he was friendly, pleasant but very confused. She went on to say he only spoke Spanish and was not even able to understand what Spanish speaking staff members were saying. His wife was the only one that was able to communicate to him. Staff C, LPN confirmed on 1/11/2022 he fell but added to me it wasn't a fall. Each time a patient touches the ground is not a fall, he just slid off the bed. She said the resident was trying to get out of bed. We saw him halfway on the mattress and his feet were on the ground. His bed was in the lowest position. His bottom was still in the bed with his feet on the floor. She said she didn't remember if he was wearing anything on his feet, but recalled he was wearing a white T-shirt and a brief. She repeated he was Spanish speaking only and the CNA told me that he does this all the time. Staff C, LPN said we had put him back to bed. Together we assisted him. You know he can walk and stated, We systematically put him in bed. On 02/02/2022 at 12:15 p.m. a phone interview was conducted with the facility's former Social Service Director (SSD). He stated he had been the Interim SSD. He said on 01/11/2022 he received a text message from one of the nurses that he was needed on the COVID unit. There had been an issue with a nurse. He said he arrived on the unit 20 minutes after he received the text. He was unable to recall the exact time. He said he was told by Staff D, CNA the nurse was yelling at Resident #2. The former SSD said only Staff E, CNA and Staff C, LPN were in Resident #2's room. He said Staff D, CNA was not in the room, and she had overheard the yelling from the hallway. He said he had informed the RM about it. He said he was asked to go to Resident #2's room two times the morning of 01/11/2022. He was unable to recall the time of the day. The former SSD said he was asked to look at a gown that was tied, but to him it did not look like it was tied, but rather it was tangled. He confirmed he did not look closely at the gown to determine if it was tied. The former SSD stated, It didn't feel like it looked tied. That's my judgement. I couldn't see the nurse or the CNA tying the gown. He went on to say it would not have prevented the resident from getting out of the bed. The former SSD said the next day the therapists were asked for statements. He added that he heard the therapists were very adamant the gown had been tied. On 02/16/22 at 3:07 p.m. an interview was conducted with Staff J, the current Social Service Director (SSD), she stated the former SSD was here for a few days when she first started. He told me he wanted to stay but they would not let him. Staff J confirmed she was aware of the verbal abuse and informed him that everyone should have been notified about it. She added I told him he should have had psychiatry consult evaluate the resident. I told him the Abuse Coordinator [the former SSD] was held to a higher level and the Risk Manager should have been informed right away. I informed him that education should have been done and educational in-services should have been started within 24 hours if the incident did happen. She stated, Staff can never use foul language in a facility whether it is toward the resident or a certified nursing assistant [CNA]. Staff J stated, The nurse should have been suspended right then until the investigation was done. No one should have to put up with that. Staff J went on to say he should have gone to the NHA if he did not know what to do. He should have looked at the policy and procedures, looked at his job description, call the Director of Nursing (DON), call the RM, call corporate, something. She repeated he should have gone to the NHA and the DON as soon as possible. She confirmed the investigation should have happened in less than 24 hours. Staff J repeated the nurse should have been suspended at the time, for cussing at a resident or an employee, but nothing was done. She said she would have called the department heads in, suspended the nurse, and started the investigation. Staff J said she did not speak at length with the former SSD regarding the restraint allegation because he kept changing his story as to what he observed. Staff J stated, He told me he saw [Resident #2] tied up, but then he changed the story. I told him if he was not going to be honest with me, I was not going to comment. On 02/14/2022 at 1:43 p.m. Staff F, former ADON/RN was interviewed by phone. She confirmed she worked on 01/11/2022. She said that morning CNA (Staff D) came to her and informed her a resident had just fallen. Staff F stated she overheard Staff D, CNA telling Staff C, LPN she could not swear at the residents. Then Staff C, LPN informed me she was swearing at Staff E, CNA in the room not the resident. Staff F said she had worked with Staff D for over two years and Staff D goes above and beyond for the residents. She added that Resident #2 understood English. Staff F went on to say that same morning (Staff A, PTA) called her into Resident #2's room. Staff F said she entered the room and (Staff A, Staff B and the former SSD) were present. (Staff A and B) showed us that a gown was wrapped around his thighs. Staff F stated, I could tell it was so very intentional. She described it as two knots beside each other and no hanging loose ends. She stated, To me it looked like whoever did it had done it in the past. Staff F was informed of the former SSD's statement indicating the gown was tangled. She stated, The SSD stood right next to me and saw it was tied. Staff F stated, The SSD was the abuse and neglect coordinator at the time. He (SSD) would have been the one to start an investigation. Staff F said on the following Monday, 01/17/2022, the RM came to the unit/floor that I was working on. I explained to her what happened. I gave the RM my written statement for that day. She directed me to separate the allegations into two, one for verbal and one for the restraint. She gave the RM both statements. She said the former SSD told her that he was suspended on Friday 01/14/2022 and Staff E, CNA had been suspended on Friday 01/14/2022. Then she found out nothing was done, and she was very upset about it and resigned on 01/20/2022. She stated, I kept a copy of my statement and will send it via e-mail. On 01/31/2022 at 1:14 p.m. an interview was conducted with the RM she said the resident had a fall earlier in the morning on 01/11/2022 while attempting to get out of bed. She said the certified nursing assistant came in that morning (01/11/2022) and performed vital signs on the resident at 7:00 a.m. Then at approximately 8:30 a.m. the patient was found on the floor. She said the nurse and his certified aide placed him back in bed and he was given his breakfast tray. She confirmed the medical record did not contain any documentation of the fall. The RM went on to say the fall log indicated it was a witnessed fall, but it wasn't. She said the nurses think if they see a resident on the floor it was witnessed. The RM went on to say the resident had recently been transferred off the 100 unit where he shared a room with his wife. He was anxious. He was taken to the 600-isolation unit due to testing positive for COVID-19. She said the resident wanted to see his wife; that might have attributed to the fall. On 01/31/2022 at 1:30 p.m. a continued interview was conducted with the RM who confirmed an abuse and neglect investigation was conducted on 01/13/2022. She confirmed it was two days after the incident occurred. The RM said she spoke with the Nursing Home Administrator (NHA) and it was determined the allegation should have been reported. She said on 01/11/2022 two therapists entered Resident #2's room and observed a gown wrapped around his legs just above his knees. They informed the SSD at the time, as he was the acting abuse and neglect coordinator. The SSD came into the room. The RM said the SSD said it appeared it was tangled. She added that only the SSD and the therapists saw the gown around his legs. They untangled the gown. The RM said on 01/13/2022 she spoke with the certified aide (Staff E) and the nurse (Staff C) who worked on 01/11/2022, but neither one were aware of the gown around his knees. The RM said she talked with the resident and then stated, I had seen him holding on to the call light and was wrapping the call light cord around his hand. The RM said after the investigation was completed it was determined to be substantiated that the gown was tangled, but that it was not intentional. The RM confirmed during the investigation process there were no staff members suspended. On 02/16/2022 at 10:47 a.m. a copy of Staff F's, former ADON/RN written statement dated 1/11/2022 was received. It showed, Date and time of event was on 01/11/2022 at 8:00 a.m. overheard (Staff C, LPN) talking loudly to (Staff D, CNA). She was stating, I was speaking to the tech in the room, not the resident and the resident does not understand English anyway. Called into the room by therapy. I observed a facility gown wrapped around the bilateral legs above the knees with tight knots in it. Therapy reported a skin tear to his right arm which I cleaned and applied a dressing. On 02/16/2022 at 11:09 a.m. an interview was conducted with Staff K, Rehabilitation Director, she said she worked at the building for over [AGE] years. She confirmed she was given written statements from Staff A PTA and B COTA on 01/12/2022 about Resident #2. She said that (1/11/2022) was the day the COVID unit opened, and they brought them to me the next day. Staff K verified the statements as she reviewed them, she pointed out a signature on the bottom that indicated it was given to Staff F (former ADON/RN). Staff K said we have morning meetings on Wednesday, that was the next day, and we discussed falls. Resident #2 had a fall, so he was discussed. Staff K said she brought the incident up about the hospital gown at the morning meeting, and later at the second weekly meeting. Staff K said the NHA was possibly at the meeting adding that he will frequently walk in and out. She said the former SSD was normally at the morning meeting and was at the second meeting that day. She said the weekly meeting was on the 12th of January. The meeting consists of staff at the administrative level. On 02/14/2022 at 12:45 p.m. an interview was conducted with the Medical Director (MD) he said he remembered Resident #2 and his spouse. He said he saw them on 01/13/2022 on the COVID unit. He stated, Both had moderate confusion. He indicated it was related to COVID, as it causes confusion with the elderly. The MD said he was informed of the abuse allegation that occurred on 01/11/2022. He said he was informed about it on 01/13/2022 in the late afternoon by the Therapy Director. He stated, It was explained to me that the resident (#2) had been tied with a gown and it was like restraining him; the former Social Service Director came in and that was when it was reported. The MD stated, Honestly I know 100% that the resident would not be able to tie the gown. He is not physically capable of doing it. When he was informed of the interviews and statements that the resident was restrained, horse hobbled, he became silent on the phone. He went on to state the therapists at the facility are very professional. He asked if the staff members had been suspended. He was told no and he reacted in surprise that they were not sent home. He stated this has never happened in the [AGE] years as being a medical director. The MD confirmed he was unaware the facility failed to report the allegations timely. He did state on 02/01/2022 he was notified about the verbal abuse. He said he was not happy when he heard about it. The MD repeated, I have been a medical director for [AGE] years. Something like this has never happened in [AGE] years. He confirmed his expectation was the facility would conduct an immediate and thorough investigation and he would be notified of the allegations in a timely manner. On 02/14/2022 at 10:58 a.m. a phone interview was conducted with Resident #9 who confirmed he shared a room with Resident #2 for a short period of time on the COVID unit. He said he was not aware that his roommate had any falls. He stated, I could have been asleep or out for physical therapy (PT). The resident said he was unable to understand his roommate except for a couple of words. He added that he was probably confused. He said he had recalled feeling sorry for the staff when they cared for his roommate. He stated, When they tried to help him and when they wanted him to get up, he would fight them. Resident #9 stated, He would have lost his temper if he had to work with him. He said he did not hear anyone yell at him, but they had to be firm with him to get him to follow instruction. They would have to repeat the directions and say it stronger like, Come up and eat. During a second interview with Resident #9 on 02/16/22 at 10:44 a.m., he stated his bed was next to the window. He stated they always closed his curtain when providing care for him or his roommate (Resident #2). On 02/14/22 at 3:56 p.m. a phone interview was conducted with Resident #2's family member. He said (Resident #2) currently lived with him. He said the facility called him about the incident, about getting COVID-19. He said (Resident #2) lived with him prior to going to the nursing home, he required hospitalization due to getting pneumonia. He said (Resident #2) will sometimes take off his shirt and if it had long sleeves, tie the sleeves into knots. He then stated, He's been on a slow downward slope of dementia. He was asked if the facility had notified him of an allegation of being restrained, he stated No. Then he said that at night (Resident #2) up walking all over. On 02/14/22 at 4:06 p.m. a phone interview was conducted with another family member. She stated the facility's ADON called her. I was told that one morning PT (Physical Therapy) came into the room and found my dad's feet were wrapped in his sheets. The ADON told her it was part of their procedure to let the family know. The daughter stated, I called back, confused about it all and I called back the next day. I was concerned as to why this was brought up. No one has returned my call. She said the RM (Risk Manager) told me an altercation happened in his room, and they were still investigating. It had to do with my father, another resident, a nurse, and a CNA. She told me that it was loud in the room, and she was still researching it. They don't know who was involved. She said she was informed of this over a week ago. No one had called her back. On 02/01/2022 at 3:00 p.m. an interview was conducted with the NHA. He said he just became aware of the statement from Staff D, CNA about the allegation of verbal abuse towards Resident #2 on 1/11/2022. The NHA indicated he would be going forward with it. On 02/01/2022 at 1:15 p.m. an interview was conducted with the RM. She said she was not at the facility on 01/11/2022 or 01/12/2022, and 01/13/2022 was the first time she heard about the verbal altercation. She stated it was after she called the former Social Service Director (SSD). She said the former SSD told her everything was unsubstantiated; they are not fighting anymore. So, I did not write an allegation of verbal abuse. She went on to say Staff C, LPN sometimes speaks that way, and Staff C was directing her statement at the certified nursing assistant and not the resident. The RM said she talked to Staff C and told her it was not appropriate to speak that way in a resident area. On 02/01/2022 at 2:30 p.m. an interview was conducted with the RM and she indicated only the therapists and the former SSD were present during the observation of the gown wrapped around Resident #2's legs. She was asked about the statement from Staff F, former ADON/RN and she said, How do you know that? She then stated, I can't find (Staff F's) statement. On 02/15/2022 at 11:48 a.m. an interview was conducted with the RM, DON and the NHA. The RM said the allegation of abuse occurred on the COVID unit. She said she didn't have many statements about it. She stated her process was to get statements and talk to the direct care staff. That was the LPN (Staff C) and CNA (Staff E), they said they were not aware of the incident, and they had not seen anything around the legs. The RM went on to say, that day I was focused on his fall, adding that she was out sick and when she came back, she was informed about his fall. Then the gown and then the verbal abuse allegation. The RM said she found out the therapists had spoken with the former SSD. The former SSD was the abuse coordinator and would be the one to write the report. The RM stated, I have not seen the exact incident and was relying on the statements. The RM was informed during the interview process three licensed staff members were eyewitness to the gown being tied. The RM verified the nurse and aide were the last people to see the resident with breakfast. The RM stated that based on the statements of the former SSD, he made the decision it was not abuse and no one was suspended. The DON and the RM said on 02/01/2022 Staff C (LPN) was given a teaching moment, verbal education, and said it was related to the verbal allegation from 1/11/2022. They said Staff C LPN was suspended on 02/01/2022 and was still out on 2/15/2022. The NHA stated, We did not substantiate it (abuse allegation about the gown) because the two therapists said it was tied. The former SSD said it was tangled. The NHA stated, He (Resident #2) was known for tying things. The RM said if they (Staff A, B and F) were so upset about the restraints why didn't they tell the NHA, RM, or the DON about it? The NHA stated, After the verbal allegation, the stories grew, and no one said anything to us. The NHA said, we have responded with education for abuse and neglect, restraints, dignity, skin sweep audits, abuse interviews, abuse audits, restraint audits and called the roommate. The NHA confirmed the former SSD was responsible. He stated, It's like a he said she said issue. His roommate heard nothing; the statements were exactly alike. On 02/17/2022 at 10:15 a.m. an interview was conducted with the NHA, RM and DON. They stated they had educated 100% of their staff members on the facility policy on restraints, abuse and neglect, as of yesterday. They indicated the education was started on 02/01/2022 and completed on 02/16/2022. The RM stated we included restraints to explain what a restraint is and correlate it with physical abuse, based on the incident that happened. The NHA confirmed that Staff C was not suspended until 02/01/2022. The former SSD was aware and should have notified the NHA, but he never did. The RM stated the former SSD made the decision it was not substantiated, he did not refer the allegation to the NHA. The NHA said he and the RM were told about the allegations on 1/13/2022. The RM stated in the morning meeting they started talking about falls and the Therapy Director brought the gown incident up on 01/13/2022. The NHA agreed at that time the Abuse Neglect and Misappropriation (ANM) policy should have been followed. The NHA said he spoke with the former SSD on the 1/13/2022 and asked him why he did not report the verbal incident or tangled gown incident. He said the SSD told him he should have reported it to him. The NHA provided a copy of the Resident Council meeting agenda that had taken place on 02/16/2022 that outlined abuse and neglect education. The RM stated she had re-started the investigation. The RM stated, The former SSD made the decision that it was not substantiated, and that was his decision. Review of the facility policy and procedure titled, Administrator/Employment Administration/Nursing Policies/Risk Management/Social Services/ Staff Development- Abuse, Neglect, Exploitation & Misappropriation, with a revision date of December 2016, revealed: Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensured that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. The Abuse Coordinator/designee shall immediately report any alleged violation of abuse, neglect, exploitation, misappropriation, or injury of unknown source that meet the reporting criteria to the Agency for Health Care Administration. The Adult Protective Service, and the local law enforcement if they feel a crime has occurred. Procedure: This facility shall take the following steps to prevent, detect, and report suspected maltreatment. 3. PREVENTION The facility identifies, corrects, and intervenes on situations of alleged abuse, neglect, and exploitation and focuses on the following areas for prevention: d. Maintenance of an open system of communication and encouraging the submission of complaints e. A commitment to follow through on all complaints and provide feedback to those involved, when possible. 4. IDENTIFICATION Reporting of suspected maltreatment is required of all staff. 5. PROTECTION a. If the circumstance warrant, any staff member shall remove a resident suspected of being the subject of maltreatment to an environment where the resident's safety can be assured. 2) If the suspected perpetrator is an employee, the Administrator or their designee shall place the employee on immediate suspension, pending the outcome of the investigation. B. where the circumstances of the alleged violation warrants, the Director of Nursing/designee shall initiate an assessment of the resident and document the findings. REPORTING All staff members are required to report suspected maltreatment. They may report to the Abuse Hotline: however, they are also to report to a supervisor or department manager in the facility so that the resident may immediately be protected from further maltreatment. The Administrator, Risk Manager, Social Service Director, and the Director of Nursing are to be informed of the situation immediately. The DON/designee shall notify the physician and the resident's representative concerning the suspected maltreatment and the finding of the assessment. The DON/designee shall reassure that resident representative that an investigation had been initiated, that the resident is being protected and that appropriate action had been taken. Upon initial investigation, where there is a suspicion that Abuse N [TRUNCATED]

Based on review of the medical record, incident logs, policy and procedure review, interviews with administrative, nursing and therapy staff, the resident's physician, and the resident's representatives it was determined the facility failed to [MEDICATION(S)] to promptly report alleged abuse of one (Resident #2) of two residents reviewed for abuse. On 1/11/2022 a nursing staff member reported to the Assistant Director of Nursing (ADON) that they overheard a nurse verbally abusing Resident #2, telling him in foul language to stop getting out of bed. Shortly afterwards, on 01/11/2022, two therapy staff members reported to the abuse coordinator they observed Resident #2 with his legs tied together above the knees with a gown that was tightly knotted twice and wrapped in a blanket tucked around and under him. Reports to the required abuse hotline showed the facility reported the verbal incident on 2/1/2022 and the gown incident on 1/13/2022. This resulted in the findings of Immediate Jeopardy starting on 1/11/2022. The immediacy was removed on 02/17/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings include: Review of the facility policy and procedure titled, Administrator/Employment Administration/Nursing Policies/Risk Management/Social Services/ Staff Development- Abuse, Neglect, Exploitation & Misappropriation, with a revision date of December 2016, revealed: Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensured that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. The Abuse Coordinator/designee shall immediately report any alleged violation of abuse, neglect, exploitation, misappropriation, or injury of unknown source that meet the reporting criteria to the Agency for Health Care Administration. The Adult Protective Service, and the local law enforcement if they feel a crime has occurred. Procedure: This facility shall take the following steps to prevent, detect, and report suspected maltreatment. 3. PREVENTION The facility identifies, corrects, and intervenes on situations of alleged abuse, neglect, and exploitation and focuses on the following areas for prevention: d. Maintenance of an open system of communication and encouraging the submission of complaints e. A commitment to follow through on all complaints and provide feedback to those involved, when possible. 4. IDENTIFICATION Reporting of suspected maltreatment is required of all staff. 5. PROTECTION a. If the circumstance warrant, any staff member shall remove a resident suspected of being the subject of maltreatment to an environment where the resident's safety can be assured. 2) If the suspected perpetrator is an employee, the Administrator or their designee shall place the employee on immediate suspension, pending the outcome of the investigation. B. where the circumstances of the alleged violation warrants, the Director of Nursing/designee shall initiate an assessment of the resident and document the findings. REPORTING All staff members are required to report suspected maltreatment. They may report to the Abuse Hotline: however, they are also to report to a supervisor or department manager in the facility so that the resident may immediately be protected from further maltreatment. The Administrator, Risk Manager, Social Service Director, and the Director of Nursing are to be informed of the situation immediately. Upon initial investigation, where there is a suspicion that Abuse Neglect and Exploitation (ANE) may have occurred, the Abuse Coordinator/designee shall report the alleged violation, accordingly, to reporting guidelines, to the Agency for Health Care Administration (for the Federal report), Adult Protective Services, and the local law enforcement when appropriate. The Risk Manager/designee will file the Immediate Federal report with Agency For Health Care Administration (AHCA), and then submit the summary and findings of the investigation with the 5-Day Federal Report. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status coded as a 0. The code of 0 indicated No (resident is rarely/never understood). Further review of the MDS Section G Functional Status showed for bed mobility self-performance coded as the number 3. The number 3 reflected extensive assistance. Support needed for bed mobility was coded as a 3 and indicated two plus persons physical assist. Dressing was coded at self-performance as the number 3 indicating extensive assistance. Personal hygiene was coded as the number 3 indicating extensive assistance, and support needed was coded as a 3 indicating two plus persons physical assist. Review of Resident #2's medical record reflected a progress note dated 01/11/2022 at 3:43 p.m. (1543) notified by therapy of resident having a skin tear on his right forearm 1.5 cm (centimeters) x .5 cm. Cleansed and band aid applied. Pink abrasion noted to right scapula. Resident had a fall this morning. Notified doctor of skin tear and abrasion. Review of the facility report titled, Incidents by Incident Type, from 11/1/21 to 1/31/22 revealed Resident #2 had a witnessed fall on 01/11/2022 at 8:30 a.m. Further record review revealed Resident #2 was listed on the Abuse and Neglect log dated on 01/13/2022. On 02/01/2022 at 12:21 p.m. an interview was conducted with Staff D, Certified Nursing Assistant (CNA) and she said she worked at the facility for over five years. Staff D said on 01/11/2022 she was the CNA who called Staff E, CNA to Resident #2's room. She said in the morning I heard a loud bang in the room and called for [Staff E] to come down to the room. I told her it sounded like a resident fell . Staff D said on that day she was working on the unit directly next to the COVID-19 unit (600 - isolation unit). She stated from the angle I was at, I could see that (Resident #2's) door was wide open, but I could not see inside of the room. She said she heard Staff E calling out for the nurse at that time. She said Staff C, Licensed Practical Nurse (LPN) arrived at the room, and she could see her standing outside of the resident's door stating yep, he is on the floor. I then overheard the nurse (Staff C, LPN) tell him, Keep your [explicative] in this bed because am not coming in here all day to do this. Staff D, CNA stated, I immediately told [Staff C] don't speak to residents that way. Staff C told me he doesn't speak English anyway. Staff D said that she told Staff F (former Assistant Director of Nursing/Registered Nurse, ADON/RN) immediately what happened, and she was told to write a statement. Staff D, CNA said she recalled Resident #2 and cared for him and his wife for over a week during his stay at the facility. She said he was very confused, he did speak some English, mostly Spanish. Staff D said he would need help with set up for his meals, and he would eat by himself. She said he was not capable of tying his own shoes and denied ever seeing him wrapping or fidgeting with his hands. She indicated he required extensive assistance to get dressed. She stated, He would stand up and walk right out of the bedroom. Staff D went on to say that about a week later she got a phone call at home from the Risk Manager (RM). Staff D said She wanted to know what I wrote in my statement. I repeated to her what I wrote. On 02/01/2022 at 9:40 a.m. an interview was conducted with Staff A, Physical Therapy Assistant (PTA) and Staff B, Certified Occupational Therapy Assistant (COTA). They both said on the morning of 01/11/2022 at approximately 8:00 a.m., just prior to entering Resident #2's bedroom, Staff E, CNA told them he (Resident #2) had just fallen. Staff A, PTA said, I asked her what happened. Staff A said she would not tell us anything she just looked at us and walked away. Staff A said they both entered the room and Resident #2 was lying in bed on his back. She said that you could see he was wearing white T-shirt with a blanket that was swaddled around his torso. She further explained the blanket was wrapped around his back across his legs and tucked under his bottom. She said after we unwrapped him, we found a green hospital gown. She then stated, The gown was wrapped twice, in a figure eight and tightly knotted just above his knees. It was not only knotted once but twice. Staff A continued, That is the way you would hobble a horse, so you can't move your legs. Staff A, PTA and Staff, B, COTA said they immediately alerted Staff F, former ADON/RN and the former Social Service Director (SSD). She said they both entered the room and were present to observe the situation. Staff A and B said the former SSD took pictures of the gown wrapped around his legs. Staff A stated the former SSD then told us not to write statements. He said he had it taken care of. Staff B, COTA said we all wrote statements including Staff F, former ADON/RN. Staff A, PTA confirmed she knew Resident #2 very well. She said she had provided therapy services to him five days a week for three weeks. Staff A and B both stated, There was no way he could have wrapped the gown around his legs and tied it twice. He doesn't have the coordination, dexterity, strength nor cognition to have done it. Staff A confirmed Resident #2's primary language was Spanish, but his son had told them he understands English. On 02/15/2022 at 2:52 p.m. a phone interview was conducted with Staff E, CNA she confirmed she worked full time at the facility. She said she recalled Resident #2 had fallen. She immediately stated the nurse (Staff C) has a high-toned voice and stated, The nurse was talking to the CNA (Staff E), not yelling. She denied the nurse had told her to keep him in the bed. She said we needed to keep an eye on him because he tries to walk. We got to watch him. Every chance I would get I would walk to the room and make sure he is in the chair not trying to get up. He was trying to get up all day. Staff E said we [Staff C] had picked him up and put him in the bed. I gave him his breakfast. I took the tray when he was done. She said therapy had taken him out of the bed and in the bathroom. She denied knowing about a blanket that was wrapped around him. She said I just put it over him. Then stated, He had wrapped himself. She said he was wearing a T-shirt underneath the gown, and he takes his clothes off. Staff E stated, I don't understand the part about the gown around his legs. We picked him up from under his arms. How did we not see the gown around the legs? We did not see a gown. We walked him back to bed. Staff E said she had been a certified nursing assistant for [AGE] years. She confirmed she had used restraints in the past, but they are not used anymore. Staff E repeated, I could not understand how his gown was wrapped around his leg. Then stated, Did not see him anymore after giving him his tray. She confirmed no one asked her to write a statement until the next day. The former SSD told me about the gown the next day. He asked me if the nurse was yelling at the resident or me. I told him she was talking to me then added she did not cuss. Staff E said the RM (Risk Manager) talked to her the day after that about the gown, not about the verbal allegation. She confirmed she had been educated on speaking to residents and falls. She could not recall how long ago it had been. She confirmed recent training on abuse and neglect. On 01/31/2022 at 3:06 p.m. an interview was conducted with Staff C (LPN). She said she remembered Resident #2. She said he was friendly, pleasant but very confused. She went on to say he only spoke Spanish and was not even able to understand what Spanish speaking staff members were saying. His wife was the only one that was able to communicate to him. Staff C, LPN confirmed on 1/11/2022 he fell but added to me it wasn't a fall. Each time a patient touches the ground is not a fall, he just slid off the bed. She said the resident was trying to get out of bed. We saw him halfway on the mattress and his feet were on the ground. His bed was in the lowest position. His bottom was still in the bed with his feet on the floor. She said she didn't remember if he was wearing anything on his feet, but recalled he was wearing a white T-shirt and a brief. She repeated he was Spanish speaking only and the CNA told me that he does this all the time. Staff C, LPN said we had put him back to bed. Together we assisted him. You know he can walk and stated, We systematically put him in bed. On 02/02/2022 at 12:15 p.m. a phone interview was conducted with the facility's former SSD. He stated he had been the Interim Social Service Director. He said on 01/11/2022 he received a text message from one of the nurses that he was needed on the COVID unit. There had been an issue with a nurse. He said he arrived on the unit 20 minutes after he received the text. He was unable to recall the exact time. He said he was told by Staff D, CNA the nurse was yelling at Resident #2. The former SSD said only Staff E, CNA and Staff C, LPN were in Resident #2's room. He said Staff D, CNA was not in the room, and she had overheard the yelling from the hallway. He said he had informed the RM about it. He said he was asked to go to Resident #2's room two times the morning of 01/11/2022. He was unable to recall the time of the day. The former SSD said he was asked to look at a gown that was tied, but to him it did not look like it was tied, but rather it was tangled. He confirmed he did not look closely at the gown to determine if it was tied. The former SSD stated, It didn't feel like it looked tied. That's my judgement. I couldn't see the nurse or the CNA tying the gown. He went on to say it would not have prevented the resident from getting out of the bed. The former SSD said the next day the therapists were asked for statements. He added that he heard the therapists were very adamant the gown had been tied. On 02/16/22 at 3:07 p.m. an interview was conducted with Staff J, the current Social Service Director (SSD), she stated the former SSD was here for a few days when she first started. He told me he wanted to stay but they would not let him. Staff J confirmed she was aware of the verbal abuse and informed him that everyone should have been notified about it. She added I told him he should have had psychiatry consult evaluate the resident. I told him the Abuse Coordinator [the former SSD] was held to a higher level and the Risk Manager should have been informed right away. I informed him that education should have been done and educational in-services should have been started within 24 hours if the incident did happen. She stated, Staff can never use foul language in a facility whether it is toward the resident or a certified nursing assistant [CNA]. Staff J stated, The nurse should have been suspended right then until the investigation was done. No one should have to put up with that. Staff J went on to say he should have gone to the NHA if he did not know what to do. He should have looked at the policy and procedures, looked at his job description, call the Director of Nursing (DON), call the RM, call corporate, something. She repeated he should have gone to the NHA and the DON as soon as possible. She confirmed the investigation should have happened in less than 24 hours. Staff J repeated the nurse should have been suspended at the time, for cussing at a resident or an employee, but nothing was done. She said she would have called the department heads in, suspended the nurse, and started the investigation. Staff J said she did not speak at length with the former SSD regarding the restraint allegation because he kept changing his story as to what he observed. Staff J stated, He told me he saw [Resident #2] tied up, but then he changed the story. I told him if he was not going to be honest with me, I was not going to comment. On 02/14/2022 at 1:43 p.m. Staff F, former ADON/RN was interviewed by phone. She confirmed she worked on 01/11/2022. She said that morning CNA (Staff D) came to her and informed her a resident had just fallen. Staff F stated she overheard Staff D, CNA telling Staff C, LPN she could not swear at the residents. Then Staff C, LPN informed me she was swearing at Staff E, CNA in the room not the resident. Staff F said she had worked with Staff D for over two years and Staff D goes above and beyond for the residents. She added that Resident #2 understood English. Staff F went on to say that same morning (Staff A, PTA) called her into Resident #2's room. Staff F said she entered the room and (Staff A, Staff B and the former SSD) were present. (Staff A and B) showed us that a gown was wrapped around his thighs. Staff F stated, I could tell it was so very intentional. She described it as two knots beside each other and no hanging loose ends. She stated, To me it looked like whoever did it had done it in the past. Staff F was informed of the former SSD's statement indicating the gown was tangled. She stated, The SSD stood right next to me and saw it was tied. Staff F stated, The SSD was the abuse and neglect coordinator at the time. He (SSD) would have been the one to start an investigation. Staff F said on the following Monday, 01/17/2022, the RM came to the unit/floor that I was working on. I explained to her what happened. I gave the RM my written statement for that day. She directed me to separate the allegations into two, one for verbal and one for the restraint. She gave the RM both statements. She said the former SSD told her that he was suspended on Friday 01/14/2022 and Staff E, CNA had been suspended on Friday 01/14/2022. Then she found out nothing was done, and she was very upset about it and resigned on 01/20/2022. She stated, I kept a copy of my statement and will send it via e-mail. On 01/31/2022 at 1:14 p.m. an interview was conducted with the RM she said the resident had a fall earlier in the morning on 01/11/2022 while attempting to get out of bed. She said the certified nursing assistant came in that morning (01/11/2022) and performed vital signs on the resident at 7:00 a.m. Then at approximately 8:30 a.m. the patient was found on the floor. She said the nurse and his certified aide placed him back in bed and he was given his breakfast tray. She confirmed the medical record did not contain any documentation of the fall. The RM went on to say the fall log indicated it was a witnessed fall, but it wasn't. She said the nurses think if they see a resident on the floor it was witnessed. The RM went on to say the resident had recently been transferred off the 100 unit where he shared a room with his wife. He was anxious. He was taken to the 600-isolation unit due to testing positive for COVID-19. She said the resident wanted to see his wife; that might have attributed to the fall. On 01/31/2022 at 1:30 p.m. a continued interview was conducted with the RM who confirmed an abuse and neglect investigation was conducted on 01/13/2022. She confirmed it was two days after the incident occurred. The RM said she spoke with the Nursing Home Administrator (NHA) and it was determined the allegation should have been reported. She said on 01/11/2022 two therapists entered Resident #2's room and observed a gown wrapped around his legs just above his knees. They informed the SSD at the time, as he was the acting abuse and neglect coordinator. The SSD came into the room. The RM said the SSD said it appeared it was tangled. She added that only the SSD and the therapists saw the gown around his legs. They untangled the gown. The RM said on 01/13/2022 she spoke with the certified aide (Staff E) and the nurse (Staff C) who worked on 01/11/2022, but neither one were aware of the gown around his knees. The RM said she talked with the resident and then stated, I had seen him holding on to the call light and was wrapping the call light cord around his hand. The RM said after the investigation was completed it was determined to be substantiated that the gown was tangled, but that it was not intentional. The RM confirmed during the investigation process there were no staff members suspended. On 02/16/2022 at 10:47 a.m. a copy of Staff F's, former ADON/RN written statement dated 1/11/2022 was received. It showed, Date and time of event was on 01/11/2022 at 8:00 a.m. overheard (Staff C, LPN) talking loudly to (Staff D, CNA). She was stating, I was speaking to the tech in the room, not the resident and the resident does not understand English anyway. Called into the room by therapy. I observed a facility gown wrapped around the bilateral legs above the knees with tight knots in it. Therapy reported a skin tear to his right arm which I cleaned and applied a dressing. On 02/16/2022 at 11:09 a.m. an interview was conducted with Staff K, Rehabilitation Director, she said she worked at the building for over [AGE] years. She confirmed she was given written statements from Staff A PTA and B COTA on 01/12/2022 about Resident #2. She said that (1/11/2022) was the day the COVID unit opened, and they brought them to me the next day. Staff K verified the statements as she reviewed them, she pointed out a signature on the bottom that indicated it was given to Staff F (former ADON/RN). Staff K said we have morning meetings on Wednesday, that was the next day, and we discussed falls. Resident #2 had a fall, so he was discussed. Staff K said she brought the incident up about the hospital gown at the morning meeting, and later at the second weekly meeting. Staff K said the NHA was possibly at the meeting adding that he will frequently walk in and out. She said the former SSD was normally at the morning meeting and was at the second meeting that day. She said the weekly meeting was on the 12th of January. The meeting consists of staff at the administrative level. On 02/14/2022 at 12:45 p.m. an interview was conducted with the Medical Director (MD) he said he remembered Resident #2 and his spouse. He said he saw them on 01/13/2022 on the COVID unit. He stated, Both had moderate confusion. He indicated it was related to COVID, as it causes confusion with the elderly. The MD said he was informed of the abuse allegation that occurred on 01/11/2022. He said he was informed about it on 01/13/2022 in the late afternoon by the Therapy Director. He stated, It was explained to me that the resident (#2) had been tied with a gown and it was like restraining him; the former Social Service Director came in and that was when it was reported. The MD stated, Honestly I know 100% that the resident would not be able to tie the gown. He is not physically capable of doing it. When he was informed of the interviews and statements that the resident was restrained, horse hobbled, he became silent on the phone. He went on to state the therapists at the facility are very professional. He asked if the staff members had been suspended. He was told no and he reacted in surprise that they were not sent home. He stated this has never happened in the [AGE] years as being a medical director. The MD confirmed he was unaware the facility failed to report the allegations timely. He did state on 02/01/2022 he was notified about the verbal abuse. He said he was not happy when he heard about it. The MD repeated, I have been a medical director for [AGE] years. Something like this has never happened in [AGE] years. He confirmed his expectation was the facility would conduct an immediate and thorough investigation and he would be notified of the allegations in a timely manner. On 02/14/2022 at 10:58 a.m. a phone interview was conducted with Resident #9 who confirmed he shared a room with Resident #2 for a short period of time on the COVID unit. He said he was not aware that his roommate had any falls. He stated, I could have been asleep or out for physical therapy (PT). The resident said he was unable to understand his roommate except for a couple of words. He added that he was probably confused. He said he had recalled feeling sorry for the staff when they cared for his roommate. He stated, When they tried to help him and when they wanted him to get up, he would fight them. Resident #9 stated, He would have lost his temper if he had to work with him. He said he did not hear anyone yell at him, but they had to be firm with him to get him to follow instruction. They would have to repeat the directions and say it stronger like, Come up and eat. During a second interview with Resident #9 on 02/16/22 at 10:44 a.m., he stated his bed was next to the window. He stated they always closed his curtain when providing care for him or his roommate (Resident #2). On 02/01/2022 at 3:00 p.m. an interview was conducted with the NHA. He said he just became aware of the statement from Staff D, CNA about the allegation of verbal abuse towards Resident #2 on 1/11/2022. The NHA indicated he would be going forward with it. On 02/01/2022 at 1:15 p.m. an interview was conducted with the RM. She said she was not at the facility on 01/11/2022 or 01/12/2022, and 01/13/2022 was the first time she heard about the verbal altercation. She stated it was after she called the former Social Service Director (SSD). She said the former SSD told her everything was unsubstantiated; they are not fighting anymore. So, I did not write an allegation of verbal abuse. She went on to say Staff C, LPN sometimes speaks that way, and Staff C was directing her statement at the certified nursing assistant and not the resident. The RM said she talked to Staff C and told her it was not appropriate to speak that way in a resident area. On 02/01/2022 at 2:30 p.m. an interview was conducted with the RM and she indicated only the therapists and the former SSD were present during the observation of the gown wrapped around Resident #2's legs. She was asked about the statement from Staff F, former ADON/RN and she said, How do you know that? She then stated, I can't find (Staff F's) statement. On 02/15/2022 at 11:48 a.m. an interview was conducted with the RM, DON and the NHA. The RM said the allegation of abuse occurred on the COVID unit. She said she didn't have many statements about it. She stated her process was to get statements and talk to the direct care staff. That was the LPN (Staff C) and CNA (Staff E), they said they were not aware of the incident, and they had not seen anything around the legs. The RM went on to say, that day I was focused on his fall, adding that she was out sick and when she came back, she was informed about his fall. Then the gown and then the verbal abuse allegation. The RM said she found out the therapists had spoken with the former SSD. The former SSD was the abuse coordinator and would be the one to write the report. The RM stated, I have not seen the exact incident and was relying on the statements. The RM was informed during the interview process three licensed staff members were eyewitness to the gown being tied. The RM verified the nurse and aide were the last people to see the resident with breakfast. The RM stated that based on the statements of the former SSD, he made the decision it was not abuse and no one was suspended. The DON and the RM said on 02/01/2022 Staff C (LPN) was given a teaching moment, verbal education, and said it was related to the verbal allegation from 1/11/2022. They said Staff C LPN was suspended on 02/01/2022 and was still out on 2/15/2022. The NHA stated, We did not substantiate it (abuse allegation about the gown) because the two therapists said it was tied. The former SSD said it was tangled. The NHA stated, He (Resident #2) was known for tying things. The RM said if they (Staff A, B and F) were so upset about the restraints why didn't they tell the NHA, RM, or the DON about it? The NHA stated, After the verbal allegation, the stories grew, and no one said anything to us. The NHA said, we have responded with education for abuse and neglect, restraints, dignity, skin sweep audits, abuse interviews, abuse audits, restraint audits and called the roommate. The NHA confirmed the former SSD was responsible. He stated, It's like a he said she said issue. His roommate heard nothing; the statements were exactly alike. On 02/17/2022 at 10:15 a.m. an interview was conducted with the NHA, RM and DON. They stated they had educated 100% of their staff members on the facility policy on restraints, abuse and neglect, as of yesterday. They indicated the education was started on 02/01/2022 and completed on 02/16/2022. The RM stated we included restraints to explain what a restraint is and correlate it with physical abuse, based on the incident that happened. The NHA confirmed that Staff C was not suspended until 02/01/2022. The former SSD was aware and should have notified the NHA, but he never did. The RM stated the former SSD made the decision it was not substantiated, he did not refer the allegation to the NHA. The NHA said he and the RM were told about the allegations on 1/13/2022. The RM stated in the morning meeting they started talking about falls and the Therapy Director brought the gown incident up on 01/13/2022. The NHA agreed at that time the Abuse Neglect and Misappropriation (ANM) policy should have been followed. The NHA said he spoke with the former SSD on the 1/13/2022 and asked him why he did not report the verbal incident or tangled gown incident. He said the SSD told him he should have reported it to him. The NHA provided a copy of the Resident Council meeting agenda that had taken place on 02/16/2022 that outlined abuse and neglect education. The RM stated she had re-started the investigation. The RM stated, The former SSD made the decision that it was not substantiated, and that was his decision. Facility Actions to Remove Immediate Jeopardy: On 02/17/2022 at 2:51 p.m. a Removal Plan was received. (Photographic Evidence Obtained) 1. Investigation of the incident had been reinstated which includes re-interviewing the following staff: Staff A, B, M, F, I, C, E, D, and the Medical Director. Investigation reopened and interviews started 2/17/2022 at 12:05 p.m. 2. Suspension pending investigation of the following staff effective 2/17/2022: Staff members A, B, C, E, and D. 3. Completing root cause analysis as the investigation continues. 4. 100% education has been completed-began on 2/1/2022, and completed on 2/17/2022 related to Abuse, Neglect, Exploitation as well as reporting requirements for all staff. The facility will continue to reinforce this initial education and request return demonstration on the following: What to report, When to report, and Who to report to. 5. Individual education provided by Regional Director of Operation related to abuse neglect and exploitation reporting and investigations to the following: Administrator 2/17/2022, Director of Nursing 2/17/2022, Risk Manager 2/17/2022, and Social Services Director 2/17/2022. 6. Ad Hoc QAPI (Quality Assessment Performance Improvement) meeting is scheduled for 2/17/2022 at 3:00 p.m. to inform committee of plan to address as well as provide for additional suggestions of interventions to prevent recurrence. 7. Resident Council held 2/16/2022 to inform residents of the facility's abuse policy and who to notify of any allegations. On 02/16/2022 interviews were conducted with Staff E CNA, Staff P CNA, Staff Q CNA, Staff R CNA, Staff S LPN, and Staff T CNA at the facility regarding the policies and procedures on Abuse, Neglect and Misappropriation and Restraints. All staff were able to define verbal abuse, physical confinement, and restraints. They verbalized knowing the need for timely reporting of an allegation. They knew who to report verbal and physical allegations to and were familiar with the facility policies in place to protect residents and prevent abuse.

Based on review of the medical record, incident logs, policy and procedure review, interviews with administrative, nursing and therapy staff, the resident's physician, and the resident's representatives it was determined the facility failed to provide a systematic process to carry out their abuse policy for one (Resident #2) of two residents reviewed for abuse. The facility failed to failed to thoroughly investigate to determine the root cause of the reported abuse and failed to suspend staff alleged to perpetrate abuse to ensure the safety of the resident involved and ensure that all facility residents would remain safe from a similar incident. On 1/11/2022 a nursing staff member reported to the Assistant Director of Nursing (ADON) that they overheard a nurse verbally abusing Resident #2 telling him in foul language to stop getting out of bed. Shortly afterwards, on 01/11/2022, two therapy staff members reported to the abuse coordinator they observed Resident #2 with his legs tied together above the knees with a gown that was tightly knotted twice and wrapped in a blanket tucked around and under him. Reports to the required abuse hotline showed the facility reported the verbal incident on 2/1/2022 and the gown incident on 1/13/2022. The facility suspended one staff member on 2/1/2022. The investigation was not carried out in a consistent and thorough manner. This resulted in the findings of Immediate Jeopardy starting on 1/11/2022. The immediacy was removed on 02/17/2022 after verification of the implementation of removal action(s). The scope and severity was reduced to a D (no actual harm with potential for more than minimal harm). Findings include: Review of the facility policy and procedure titled, Administrator/Employment Administration/Nursing Policies/Risk Management/Social Services/ Staff Development- Abuse, Neglect, Exploitation & Misappropriation, with a revision date of December 2016, revealed: Policy: It is the policy of this facility to take appropriate steps to prevent abuse (be it verbal, sexual, physical, or mental), neglect, exploitation and misappropriation and the occurrence of an injury of an unknown source, and to ensured that all alleged violations of Federal and/or State laws are reported immediately to the Administrator, the Risk Manager, the Social Service Director, and the Director of Nursing. The Abuse Coordinator/designee shall immediately report any alleged violation of abuse, neglect, exploitation, misappropriation, or injury of unknown source that meet the reporting criteria to the Agency for Health Care Administration. The Adult Protective Service, and the local law enforcement if they feel a crime has occurred. Procedure: This facility shall take the following steps to prevent, detect, and report suspected maltreatment. 3. PREVENTION The facility identifies, corrects, and intervenes on situations of alleged abuse, neglect, and exploitation and focuses on the following areas for prevention: d. Maintenance of an open system of communication and encouraging the submission of complaints e. A commitment to follow through on all complaints and provide feedback to those involved, when possible. 4. IDENTIFICATION Reporting of suspected maltreatment is required of all staff. 5. PROTECTION a. If the circumstance warrant, any staff member shall remove a resident suspected of being the subject of maltreatment to an environment where the resident's safety can be assured. 2) If the suspected perpetrator is an employee, the Administrator or their designee shall place the employee on immediate suspension, pending the outcome of the investigation. B. where the circumstances of the alleged violation warrants, the Director of Nursing/designee shall initiate an assessment of the resident and document the findings. The DON/designee shall notify the physician and the resident's representative concerning the suspected maltreatment and the finding of the assessment. The DON/designee shall reassure that resident representative that an investigation had been initiated, that the resident is being protected and that appropriate action had been taken. Upon initial investigation, where there is a suspicion that Abuse Neglect and Exploitation (ANE) may have occurred, the Abuse Coordinator/designee shall report the alleged violation, accordingly, to reporting guidelines, to the Agency for Health Care Administration (for the Federal report), Adult Protective Services, and the local law enforcement when appropriate. The Risk Manager/designee will file the Immediate Federal report with Agency For Health Care Administration (AHCA), and then submit the summary and findings of the investigation with the 5-Day Federal Report. 7. INVESTIGATION A thorough investigation will be conducted. The Abuse Coordinator/designee will initiate procedures for conducting the investigation. The investigation will include a. The type of allegation b. What occurred, when, where and to whom? By whom? Get a physical description or identify the alleged perpetrator, if possible, c. Describe the injury and any treatment, d. Interview witnesses separately; interview caregivers, roommates; get statements; observe/documents demeanor; include names, addresses, and phone numbers of actual witnesses e. Document cognitive status of victim, resident witnesses; document of creditable/believable . g. Review alleged perpetrators past performance and reputation, h. Describe action taken to protect resident, i. Note any bias between alleged perpetrator and witness . n. Review schedules and assignments . p. Review facility's P&P [policy and procedures] for unsafe technique used by staff . q. Review nursing notes and other records for information about the incident. Upon completion of the investigation, the facility should prepare a summary report of the findings and conclusions, including any actions taken by the facility. 8. CORRECTIVE ACTION The facility shall make all reasonable efforts to determine the cause of the suspected maltreatment and take corrective action consistent with the investigation findings to eliminate any ongoing danger to the resident or other residents. The DON/designee may initiate a care plan to reflect the resident's condition and measures to be taken to prevent reoccurrence of the incident. This may include in-services and other measures, as appropriate. All corrective actions will be documented. Any ANE incident will be reviewed at the Quality Assurance Committee meeting. Review of Resident #2's admission Minimum Data Set (MDS), dated [DATE], Section C Cognitive Patterns showed the Brief Interview for Mental Status coded as a 0. The code of 0 indicated No (resident is rarely/never understood). Further review of the MDS Section G Functional Status showed for bed mobility self-performance coded as the number 3. The number 3 reflected extensive assistance. Support needed for bed mobility was coded as a 3 and indicated two plus persons physical assist. Review of Resident #2's medical record reflected a progress note dated 01/11/2022 at 3:43 p.m. (1543) notified by therapy of resident having a skin tear on his right forearm 1.5 cm (centimeters) x .5 cm. Cleansed and band aid applied. Pink abrasion noted to right scapula. Resident had a fall this morning. Notified doctor of skin tear and abrasion. Review of the facility report titled, Incidents by Incident Type, from 11/1/21 to 1/31/22 revealed Resident #2 had a witnessed fall on 01/11/2022 at 8:30 a.m. Further record review revealed Resident #2 was listed on the Abuse and Neglect log dated on 01/13/2022. On 02/01/2022 at 12:21 p.m. an interview was conducted with Staff D, Certified Nursing Assistant (CNA) and she said she worked at the facility for over five years. Staff D said on 01/11/2022 she was the CNA who called Staff E, CNA to Resident #2's room. She said in the morning I heard a loud bang in the room and called for (Staff E) to come down to the room. I told her it sounded like a resident fell . Staff D said on that day she was working on the unit directly next to the COVID-19 unit (600 - isolation unit). She stated from the angle I was at, I could see that (Resident #2's) door was wide open, but I could not see inside of the room. She said she heard Staff E calling out for the nurse at that time. She said Staff C, Licensed Practical Nurse (LPN) arrived at the room, and she could see her standing outside of the resident's door stating yep, he is on the floor. I then overheard the nurse (Staff C, LPN) tell him, Keep your [explicative] in this bed because am not coming in here all day to do this. Staff D, CNA stated, I immediately told [Staff C] don't speak to residents that way. Staff C told me he doesn't speak English anyway. Staff D said that she told Staff F (former Assistant Director of Nursing/Registered Nurse, ADON/RN) immediately what happened, and she was told to write a statement. Staff D, CNA said she recalled Resident #2 and cared for him and his wife for over a week during his stay at the facility. She said he was very confused, he did speak some English, mostly Spanish. Staff D said he would need help with set up for his meals, and he would eat by himself. She said he was not capable of tying his own shoes and denied ever seeing him wrapping or fidgeting with his hands. She indicated he required extensive assistance to get dressed. She stated, He would stand up and walk right out of the bedroom. Staff D went on to say that about a week later she got a phone call at home from the Risk Manager (RM). Staff D said She wanted to know what I wrote in my statement. I repeated to her what I wrote. On 02/01/2022 at 9:40 a.m. an interview was conducted with Staff A, Physical Therapy Assistant (PTA) and Staff B, Certified Occupational Therapy Assistant (COTA). They both said on the morning of 01/11/2022 at approximately 8:00 a.m., just prior to entering Resident #2's bedroom, Staff E, CNA told them he (Resident #2) had just fallen. Staff A, PTA said, I asked her what happened. Staff A said she would not tell us anything she just looked at us and walked away. Staff A said they both entered the room and Resident #2 was lying in bed on his back. She said that you could see he was wearing white T-shirt with a blanket that was swaddled around his torso. She further explained the blanket was wrapped around his back across his legs and tucked under his bottom. She said after we unwrapped him, we found a green hospital gown. She then stated, The gown was wrapped twice, in a figure eight and tightly knotted just above his knees. It was not only knotted once but twice. Staff A continued, That is the way you would hobble a horse, so you can't move your legs. Staff A, PTA and Staff, B, COTA said they immediately alerted Staff F, former ADON/RN and the former Social Service Director (SSD). She said they both entered the room and were present to observe the situation. Staff A and B said the former SSD took pictures of the gown wrapped around his legs. Staff A stated the former SSD then told us not to write statements. He said he had it taken care of. Staff B, COTA said we all wrote statements including Staff F, former ADON/RN. Staff A, PTA confirmed she knew Resident #2 very well. She said she had provided therapy services to him five days a week for three weeks. Staff A and B both stated, There was no way he could have wrapped the gown around his legs and tied it twice. He doesn't have the coordination, dexterity, strength nor cognition to have done it. Staff A confirmed Resident #2's primary language was Spanish, but his son had told them he understands English. On 02/15/2022 at 2:52 p.m. a phone interview was conducted with Staff E, CNA she confirmed she worked full time at the facility. She said she recalled Resident #2 had fallen. She immediately stated the nurse (Staff C) has a high-toned voice and stated, The nurse was talking to the CNA (Staff E), not yelling. She denied the nurse had told her to keep him in the bed. She said we needed to keep an eye on him because he tries to walk. We got to watch him. Every chance I would get I would walk to the room and make sure he is in the chair not trying to get up. He was trying to get up all day. Staff E said we [Staff C] had picked him up and put him in the bed. I gave him his breakfast. I took the tray when he was done. She said therapy had taken him out of the bed and in the bathroom. She denied knowing about a blanket that was wrapped around him. She said I just put it over him. Then stated, He had wrapped himself. She said he was wearing a T-shirt underneath the gown, and he takes his clothes off. Staff E stated, I don't understand the part about the gown around his legs. We picked him up from under his arms. How did we not see the gown around the legs? We did not see a gown. We walked him back to bed. Staff E said she had been a certified nursing assistant for [AGE] years. She confirmed she had used restraints in the past, but they are not used anymore. Staff E repeated, I could not understand how his gown was wrapped around his leg. Then stated, Did not see him anymore after giving him his tray. She confirmed no one asked her to write a statement until the next day. The former SSD told me about the gown the next day. He asked me if the nurse was yelling at the resident or me. I told him she was talking to me then added she did not cuss. Staff E said the RM (Risk Manager) talked to her the day after that about the gown, not about the verbal allegation. She confirmed she had been educated on speaking to residents and falls. She could not recall how long ago it had been. She confirmed recent training on abuse and neglect. On 01/31/2022 at 3:06 p.m. an interview was conducted with Staff C (LPN). She said she remembered Resident #2. She said he was friendly, pleasant but very confused. She went on to say he only spoke Spanish and was not even able to understand what Spanish speaking staff members were saying. His wife was the only one that was able to communicate to him. Staff C, LPN confirmed on 1/11/2022 he fell but added to me it wasn't a fall. Each time a patient touches the ground is not a fall, he just slid off the bed. She said the resident was trying to get out of bed. We saw him halfway on the mattress and his feet were on the ground. His bed was in the lowest position. His bottom was still in the bed with his feet on the floor. She said she didn't remember if he was wearing anything on his feet, but recalled he was wearing a white T-shirt and a brief. She repeated he was Spanish speaking only and the CNA told me that he does this all the time. Staff C, LPN said we had put him back to bed. Together we assisted him. You know he can walk and stated, We systematically put him in bed. On 02/02/2022 at 12:15 p.m. a phone interview was conducted with the facility's former SSD. He stated he had been the Interim Social Service Director. He said on 01/11/2022 he received a text message from one of the nurses that he was needed on the COVID unit. There had been an issue with a nurse. He said he arrived on the unit 20 minutes after he received the text. He was unable to recall the exact time. He said he was told by Staff D, CNA the nurse was yelling at Resident #2. The former SSD said only Staff E, CNA and Staff C, LPN were in Resident #2's room. He said Staff D, CNA was not in the room, and she had overheard the yelling from the hallway. He said he had informed the RM about it. He said he was asked to go to Resident #2's room two times the morning of 01/11/2022. He was unable to recall the time of the day. The former SSD said he was asked to look at a gown that was tied, but to him it did not look like it was tied, but rather it was tangled. He confirmed he did not look closely at the gown to determine if it was tied. The former SSD stated, It didn't feel like it looked tied. That's my judgement. I couldn't see the nurse or the CNA tying the gown. He went on to say it would not have prevented the resident from getting out of the bed. The former SSD said the next day the therapists were asked for statements. He added that he heard the therapists were very adamant the gown had been tied. On 02/16/22 at 3:07 p.m. an interview was conducted with Staff J, the current Social Service Director (SSD), she stated the former SSD was here for a few days when she first started. He told me he wanted to stay but they would not let him. Staff J confirmed she was aware of the verbal abuse and informed him that everyone should have been notified about it. She added I told him he should have had psychiatry consult evaluate the resident. I told him the Abuse Coordinator [the former SSD] was held to a higher level and the Risk Manager should have been informed right away. I informed him that education should have been done and educational in-services should have been started within 24 hours if the incident did happen. She stated, Staff can never use foul language in a facility whether it is toward the resident or a certified nursing assistant [CNA]. Staff J stated, The nurse should have been suspended right then until the investigation was done. No one should have to put up with that. Staff J went on to say he should have gone to the NHA if he did not know what to do. He should have looked at the policy and procedures, looked at his job description, call the Director of Nursing (DON), call the RM, call corporate, something. She repeated he should have gone to the NHA and the DON as soon as possible. She confirmed the investigation should have happened in less than 24 hours. Staff J repeated the nurse should have been suspended at the time, for cussing at a resident or an employee, but nothing was done. She said she would have called the department heads in, suspended the nurse, and started the investigation. Staff J said she did not speak at length with the former SSD regarding the restraint allegation because he kept changing his story as to what he observed. Staff J stated, He told me he saw [Resident #2] tied up, but then he changed the story. I told him if he was not going to be honest with me, I was not going to comment. On 02/14/2022 at 1:43 p.m. Staff F, former ADON/RN was interviewed by phone. She confirmed she worked on 01/11/2022. She said that morning CNA (Staff D) came to her and informed her a resident had just fallen. Staff F stated she overheard Staff D, CNA telling Staff C, LPN she could not swear at the residents. Then Staff C, LPN informed me she was swearing at Staff E, CNA in the room not the resident. Staff F said she had worked with Staff D for over two years and Staff D goes above and beyond for the residents. She added that Resident #2 understood English. Staff F went on to say that same morning (Staff A, PTA) called her into Resident #2's room. Staff F said she entered the room and (Staff A, Staff B and the former SSD) were present. (Staff A and B) showed us that a gown was wrapped around his thighs. Staff F stated, I could tell it was so very intentional. She described it as two knots beside each other and no hanging loose ends. She stated, To me it looked like whoever did it had done it in the past. Staff F was informed of the former SSD's statement indicating the gown was tangled. She stated, The SSD stood right next to me and saw it was tied. Staff F stated, The SSD was the abuse and neglect coordinator at the time. He (SSD) would have been the one to start an investigation. Staff F said on the following Monday, 01/17/2022, the RM came to the unit/floor that I was working on. I explained to her what happened. I gave the RM my written statement for that day. She directed me to separate the allegations into two, one for verbal and one for the restraint. She gave the RM both statements. She said the former SSD told her that he was suspended on Friday 01/14/2022 and Staff E, CNA had been suspended on Friday 01/14/2022. Then she found out nothing was done, and she was very upset about it and resigned on 01/20/2022. She stated, I kept a copy of my statement and will send it via e-mail. On 01/31/2022 at 1:14 p.m. an interview was conducted with the RM she said the resident had a fall earlier in the morning on 01/11/2022 while attempting to get out of bed. She said the certified nursing assistant came in that morning (01/11/2022) and performed vital signs on the resident at 7:00 a.m. Then at approximately 8:30 a.m. the patient was found on the floor. She said the nurse and his certified aide placed him back in bed and he was given his breakfast tray. She confirmed the medical record did not contain any documentation of the fall. The RM went on to say the fall log indicated it was a witnessed fall, but it wasn't. She said the nurses think if they see a resident on the floor it was witnessed. The RM went on to say the resident had recently been transferred off the 100 unit where he shared a room with his wife. He was anxious. He was taken to the 600-isolation unit due to testing positive for COVID-19. She said the resident wanted to see his wife; that might have attributed to the fall. On 01/31/2022 at 1:30 p.m. a continued interview was conducted with the RM who confirmed an abuse and neglect investigation was conducted on 01/13/2022. She confirmed it was two days after the incident occurred. The RM said she spoke with the Nursing Home Administrator (NHA) and it was determined the allegation should have been reported. She said on 01/11/2022 two therapists entered Resident #2's room and observed a gown wrapped around his legs just above his knees. They informed the SSD at the time, as he was the acting abuse and neglect coordinator. The SSD came into the room. The RM said the SSD said it appeared it was tangled. She added that only the SSD and the therapists saw the gown around his legs. They untangled the gown. The RM said on 01/13/2022 she spoke with the certified aide (Staff E) and the nurse (Staff C) who worked on 01/11/2022, but neither one were aware of the gown around his knees. The RM said she talked with the resident and then stated, I had seen him holding on to the call light and was wrapping the call light cord around his hand. The RM said after the investigation was completed it was determined to be substantiated that the gown was tangled, but that it was not intentional. The RM confirmed during the investigation process there were no staff members suspended. On 02/16/2022 at 10:47 a.m. a copy of Staff F's, former ADON/RN written statement dated 1/11/2022 was received. It showed, Date and time of event was on 01/11/2022 at 8:00 a.m. overheard (Staff C, LPN) talking loudly to (Staff D, CNA). She was stating, I was speaking to the tech in the room, not the resident and the resident does not understand English anyway. Called into the room by therapy. I observed a facility gown wrapped around the bilateral legs above the knees with tight knots in it. Therapy reported a skin tear to his right arm which I cleaned and applied a dressing. On 02/16/2022 at 11:09 a.m. an interview was conducted with Staff K, Rehabilitation Director, she said she worked at the building for over [AGE] years. She confirmed she was given written statements from Staff A PTA and B COTA on 01/12/2022 about Resident #2. She said that (1/11/2022) was the day the COVID unit opened, and they brought them to me the next day. Staff K verified the statements as she reviewed them, she pointed out a signature on the bottom that indicated it was given to Staff F (former ADON/RN). Staff K said we have morning meetings on Wednesday, that was the next day, and we discussed falls. Resident #2 had a fall, so he was discussed. Staff K said she brought the incident up about the hospital gown at the morning meeting, and later at the second weekly meeting. Staff K said the NHA was possibly at the meeting adding that he will frequently walk in and out. She said the former SSD was normally at the morning meeting and was at the second meeting that day. She said the weekly meeting was on the 12th of January. The meeting consists of staff at the administrative level. On 02/14/2022 at 12:45 p.m. an interview was conducted with the Medical Director (MD) he said he remembered Resident #2 and his spouse. He said he saw them on 01/13/2022 on the COVID unit. He stated, Both had moderate confusion. He indicated it was related to COVID, as it causes confusion with the elderly. The MD said he was informed of the abuse allegation that occurred on 01/11/2022. He said he was informed about it on 01/13/2022 in the late afternoon by the Therapy Director. He stated, It was explained to me that the resident (#2) had been tied with a gown and it was like restraining him; the former Social Service Director came in and that was when it was reported. The MD stated, Honestly I know 100% that the resident would not be able to tie the gown. He is not physically capable of doing it. When he was informed of the interviews and statements that the resident was restrained, horse hobbled, he became silent on the phone. He went on to state the therapists at the facility are very professional. He asked if the staff members had been suspended. He was told no and he reacted in surprise that they were not sent home. He stated this has never happened in the [AGE] years as being a medical director. The MD confirmed he was unaware the facility failed to report the allegations timely. He did state on 02/01/2022 he was notified about the verbal abuse. He said he was not happy when he heard about it. The MD repeated, I have been a medical director for [AGE] years. Something like this has never happened in [AGE] years. He confirmed his expectation was the facility would conduct an immediate and thorough investigation and he would be notified of the allegations in a timely manner. On 02/01/2022 at 3:00 p.m. an interview was conducted with the NHA. He said he just became aware of the statement from Staff D, CNA about the allegation of verbal abuse towards Resident #2 on 1/11/2022. The NHA indicated he would be going forward with it. On 02/01/2022 at 1:15 p.m. an interview was conducted with the RM. She said she was not at the facility on 01/11/2022 or 01/12/2022, and 01/13/2022 was the first time she heard about the verbal altercation. She stated it was after she called the former Social Service Director (SSD). She said the former SSD told her everything was unsubstantiated; they are not fighting anymore. So, I did not write an allegation of verbal abuse. She went on to say Staff C, LPN sometimes speaks that way, and Staff C was directing her statement at the certified nursing assistant and not the resident. The RM said she talked to Staff C and told her it was not appropriate to speak that way in a resident area. On 02/01/2022 at 2:30 p.m. an interview was conducted with the RM and she indicated only the therapists and the former SSD were present during the observation of the gown wrapped around Resident #2's legs. She was asked about the statement from Staff F, former ADON/RN and she said, How do you know that? She then stated, I can't find (Staff F's) statement. On 02/15/2022 at 11:48 a.m. an interview was conducted with the RM, DON and the NHA. The RM said the allegation of abuse occurred on the COVID unit. She said she didn't have many statements about it. She stated her process was to get statements and talk to the direct care staff. That was the LPN (Staff C) and CNA (Staff E), they said they were not aware of the incident, and they had not seen anything around the legs. The RM went on to say, that day I was focused on his fall, adding that she was out sick and when she came back, she was informed about his fall. Then the gown and then the verbal abuse allegation. The RM said she found out the therapists had spoken with the former SSD. The former SSD was the abuse coordinator and would be the one to write the report. The RM stated, I have not seen the exact incident and was relying on the statements. The RM was informed during the interview process three licensed staff members were eyewitness to the gown being tied. The RM verified the nurse and aide were the last people to see the resident with breakfast. The RM stated that based on the statements of the former SSD, he made the decision it was not abuse and no one was suspended. The DON and the RM said on 02/01/2022 Staff C (LPN) was given a teaching moment, verbal education, and said it was related to the verbal allegation from 1/11/2022. They said Staff C LPN was suspended on 02/01/2022 and was still out on 2/15/2022. The NHA stated, We did not substantiate it (abuse allegation about the gown) because the two therapists said it was tied. The former SSD said it was tangled. The NHA stated, He (Resident #2) was known for tying things. The RM said if they (Staff A, B and F) were so upset about the restraints why didn't they tell the NHA, RM, or the DON about it? The NHA stated, After the verbal allegation, the stories grew, and no one said anything to us. The NHA said, we have responded with education for abuse and neglect, restraints, dignity, skin sweep audits, abuse interviews, abuse audits, restraint audits and called the roommate. The NHA confirmed the former SSD was responsible. He stated, It's like a he said she said issue. His roommate heard nothing; the statements were exactly alike. On 02/17/2022 at 10:15 a.m. an interview was conducted with the NHA, RM and DON. They stated they had educated 100% of their staff members on the facility policy on restraints, abuse and neglect, as of yesterday. They indicated the education was started on 02/01/2022 and completed on 02/16/2022. The RM stated we included restraints to explain what a restraint is and correlate it with physical abuse, based on the incident that happened. The NHA confirmed that Staff C was not suspended until 02/01/2022. The former SSD was aware and should have notified the NHA, but he never did. The RM stated the former SSD made the decision it was not substantiated, he did not refer the allegation to the NHA. The NHA said he and the RM were told about the allegations on 1/13/2022. The RM stated in the morning meeting they started talking about falls and the Therapy Director brought the gown incident up on 01/13/2022. The NHA agreed at that time the Abuse Neglect and Misappropriation (ANM) policy should have been followed. The NHA said he spoke with the former SSD on the 1/13/2022 and asked him why he did not report the verbal incident or tangled gown incident. He said the SSD told him he should have reported it to him. The NHA provided a copy of the Resident Council meeting agenda that had taken place on 02/16/2022 that outlined abuse and neglect education. The RM stated she had re-started the investigation. The RM stated, The former SSD made the decision that it was not substantiated, and that was his decision. Facility Actions to Remove Immediate Jeopardy: On 02/17/2022 at 2:51 p.m. a Removal Plan was received. (Photographic Evidence Obtained) 1. Investigation of the incident had been reinstated which includes re-interviewing the following staff: Staff A, B, M, F, I, C, E, D, and the Medical Director. Investigation reopened and interviews started 2/17/2022 at 12:05 p.m. 2. Suspension pending investigation of the following staff effective 2/17/2022: Staff members A, B, C, E, and D. 3. Completing root cause analysis as the investigation continues. 4. 100% education has been completed-began on 2/1/2022, and completed on 2/17/2022 related to Abuse, Neglect, Exploitation as well as reporting requirements for all staff. The facility will continue to reinforce this initial education and request return demonstration on the following: What to report, When to report, and Who to report to. 5. Individual education provided by Regional Director of Operation related to abuse neglect and exploitation reporting and investigations to the following: Administrator 2/17/2022, Director of Nursing 2/17/2022, Risk Manager 2/17/2022, and Social Services Director 2/17/2022. 6. Ad Hoc QAPI (Quality Assessment Performance Improvement) meeting is scheduled for 2/17/2022 at 3:00 p.m. to inform committee of plan to address as well as provide for additional suggestions of interventions to prevent rec [TRUNCATED]

Based on interview and record review the facility failed to prevent a significant medication error for one (Resident #10) of three sampled residents. The facility administered Normal Saline ordered for Resident #2 Intravenously without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #10 was admitted on [DATE] and discharged on [DATE]. Record review showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 5-day Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 or severe impairment. She required extensive assistance for bed mobility, transfers and toileting. Record review of the Order Listing Report (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Complete Blood Count (CBC) and Basic Metabolic Panel (BMP) on 01/03/22 CBC and BMP on 01/06/22 May insert peripheral IV on 01/06/22 written by Staff L, Registered Nurse (RN) May insert peripheral IV for antibiotic on 01/06/22; Sodium Chloride Solution 0.9% use 1 liter intravenously for electrolyte imbalance run at 60 ml / hour as of 01/06/22 written by Staff H, Licensed Practical Nurse (LPN) Stat CBC and BMP for lab values on 01/07/22 inputted by Risk Manager (RM). Review of the care plans showed a lack of a focus, goal or interventions related to IV therapy or need for IV fluids for Resident #10. Record review of the progress notes showed the following: On 01/04/22, BMP showed Sodium of 135. The physician was notified and awaiting any new orders. On 01/04/22, showed no new orders On 01/06/22 at 15:03 (3:03 p.m.) showed BMP showed Sodium 137. The physician was notified and no new orders. On 01/06/22 at 17:26 (5:26 p.m.) Staff G, Licensed Practical Nurse (LPN) documented peripheral line placed at right lower arm to receive Normal Saline, one liter. The daughter was at bedside and aware. On 01/07/22 at 14:33 (2:33 p.m.) Staff G, LPN documented Resident's daughter complained to nurse that the resident was not feeling well. She stated that her chest hurts and that she had a headache. Resident received Tylenol 500 mg. Vital signs: respirations 20 and blood pressure 120/74 (no pulse documented in note). At 11:30 p.m. resident has no complaints at this time, she was feeling better. Physician was called with no return call. On 01/07/22 at 15:32 (3:32 p.m.) Staff G, LPN documented noted IV was infiltrated, site was red and warm to touch. Peripheral line was removed. Physician was made aware of situation. Orders were given to discontinue peripheral line. Resident calm and in no distress. On 01/07/22 at 19:14 (7:14 p.m.) Late Entry by Resident #10's physician showed, this MD was paged earlier today times 2 on the above resident. Multiple attempts to reach nurse even at designated extension of 503, 504, 215 were unsuccessful. Treating nurse contacted this MD directly on his cell phone at approximately 5 p.m. stating above resident IV had infiltrated. The MD was confused as he had not ordered IVF (intravenous fluids) on this resident, but on review had ordered IVF on roommate / husband / Resident #2. Order was to discontinue IVF and line. Director of Nursing (DON) stated he assessed Resident #10 and there were no adverse reactions and only approximately 500 cc of IVF actually was received. Stat labs were ordered on both Resident #2 and #10 to ensure no electrolyte abnormalities occurred. Both residents were to be monitored closely by nursing for any changes. Review of Resident #2's Admission Record document revealed he was geriatric in age and was transferred from a local hospital on 12/31/2021 having pneumonia. His admission record showed he was admitted for short term rehabilitation with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the handwritten physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/15/22 at 11:48 a.m. an interview was conducted with the Nursing Home Administrator (NHA), the Risk Manager (RM), and the Director of Nursing (DON) regarding a significant IV medication error regarding both Resident #2 and Resident #10. The RM and the DON were giving the account of the incident. The physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents were residing in the same room. The physician had ordered the IV based on the results of the labs from 01/03. Staff H, LPN, the nursing supervisor that night, entered the order on 01/05/22 at approximately 11 p.m. (Wednesday) under Resident #10 instead of Resident #2 as per the order. The order was written for Resident #2, but someone had added Resident #10's room number on the handwritten order (right resident / wrong bed). Resident #10 had an IV started on 01/06 by an outside IV team. The facility was unaware of how many attempts were made to start the IV. The DON stated that the IV company came in and started the IV and then asked the nurse for the order. The nurse at the time was having computer problems, so Staff L, RN, Assistant Director of Nursing (ADON) inputted the order also under Resident #10's name. The Normal Saline was being administered to Resident #10. On Friday, 01/07, the daughter approached Staff G, LPN regarding her parent's care including the IV. The IV became infiltrated during the daughter's visit. Staff G called the physician to report the infiltration of the IV and asked if he wanted the IV restarted or discontinued. The DON stated that the physician called him back when he realized the IV was given to the wrong resident. The physician stated that it was for Resident #2 not Resident #10. Staff L, ADON informed the family it was Resident #10 that received the IV instead of Resident #2 as was ordered. The physician ordered repeat stat labs for both the residents for the next morning. When asked about having to put Resident #10 through an intravenous stick as well as another set of labs as well as Resident #10 through another set of labs, the DON had no comment. The DON stated that they were auditing the IV orders now. He was not sure of the date the audits started. The DON stated that they did not do an immediate reporting about the incident as they felt it was only a Medication Error and filled out a Medication Error Reporting Form. Review of the In-Service Education / Meeting report dated 01/07/22 showed MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that the Medical Director and / or physician of the residents was upset about the medication error. Received In-Service Education / Meeting Report dated 01/07/22 showing Staff H, Staff L, Staff G, and the DON were educated on MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Received an In-Service Education / Meeting Report dated 01/28/22 showing Monthly Meeting-Nursing Department. Eight additional staff members had signed it. The Medication Error Reporting Form and Root Cause Analysis as well as the labs of both residents and orders for Resident #10 were attached. Review of the facility's, Medication Error Reporting Form, showed date of error was on 01/07/22 at approximately 6:00 p.m. Sodium Chloride 0.9% run at 0 ml/hour x 1 liter. The physician was notified on 01/07/22 at 6:00 p.m. Type of error was wrong resident. Attached were the Root Cause Analysis and the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Root Cause Analysis: was presented on a word document, not dated nor the name of author was documented. It showed 1. wrong order entered for wrong resident, order written for Resident #2 and entered for Resident #10 2. Evening supervisor had reviewed labs related to residents and inadvertently transcribed the order for Resident #10 and not Resident #2. 3. Order entered later in the shift and not verified with the physician 4. Name alerts not on chart to alert staff to double check orders prior to transcription 5. Lab results received on both residents the same day at the same time 6. Supervisor made error due to lab results combined with similar name in same room and reading written order incorrectly. Record review of the facility's policy, Medication Error Reporting, Section 7/2 not dated showed Purpose: the facility will administer medications as ordered by the attending physician and in accordance with acceptable practice. If any deviation from this practice occurs, a reporting form will be completed and given to the Director of Nursing. Procedure: 1. The nurse will complete the reporting form giving all information requested. 2. The form will be given to the Director of Nursing. 2. The DON will log on a facility QA Tracking log and discuss report with Administrator and facility Risk Manager. 4. Corrective action will be taken as indicated by nurse and DON. 5. The form will be retained for employee counseling needs, provide information to the Pharmacy, or as back up for QA Log. 6. When all corrective actions and follow up action is completed, the report will be filed according to facility policy. QA Tool: q. the Medication Error Log is to be utilized to track and trend errors. 2. The Director of Nursing and the Risk Manager will review log prior to the monthly QA meeting. 3. This tracking tool may be incorporated into QA minutes, as it is a confidential form. Record review of the facility's policy, Medication Dispensing System, without an effective date showed D. Medication Inspection: 1. Confirm that medication name and dose are correct. G. Prior to Medication Administration: 1. Verify each medication preparation that the medication is the RIGHT DRUG, at the RIGHT DOSE, the RIGHT ROUTE, at the RIGHT RATE, at the RIGHT TIME for the RIGHT CUSTOMER. 2. Verify that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, record reviews, and interviews the facility failed to identify skin conditions by not ensuring weekly skin assessments were completed for one resident (#41) out of thirty-eight sampled residents. Findings included: Resident #41 was observed and interviewed at 11:46 a.m. on 12/7/21. The resident was observed sitting in a wheelchair next to the bed with an over-the-bed table in front of the chair. The resident reported an ongoing rash and staff were applying [MEDICATION(S)] powder. In an interview at 2:11 p.m. on 12/8/21 Resident #41 stated the rash had concrete scabs and was getting [MEDICATION(S)] powder. The Admission Record revealed Resident #41 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status score of 15 out of 15 for the resident revealing an intact cognition. The MDS in Section M Skin Conditions indicated that Resident #41 did not have any pressure ulcers or other ulcers, wounds, and skin problems. A review of Resident #41's clinical record on 12/8/21 did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed the last weekly skin assessment for the resident was completed on 8/19/21. The weekly skin assessment, dated 8/12/21, identified non-bleachable [CONDITION(S)] pressure ulcer to the right toe and redness to left and right gluteal folds. The assessment, on 8/12/21 (Thursday), indicated the resident's skin was not impaired. The weekly skin assessment, dated 8/19/21, indicated non-bleachable [CONDITION(S)] pressure ulcer to the right toe and redness to left and right gluteal folds. The weekly skin assessment, on 8/19/21 (Thursday), identified that the resident's skin was not impaired. The clinical record did not include 15 weekly skin assessments from 8/27/21 to 12/3/21. The active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the order for the resident's weekly skin sweep indicated the order type was other orders (no documentation required). On 12/8/21 at 2:59 p.m., Staff D, Licensed Practical Nurse (LPN), identified herself as the floor nurse for Resident #41. The staff member stated that skin assessments are daily or weekly depending on the physician order. She stated she looked at all of her residents' skin daily and the assessments could be found in the computer under the Evaluation tab. The LPN identified Resident #41 used a powder or cream and after reviewing the resident's orders she stated the resident used skin prep and [MEDICATION(S)] to the buttocks. Staff D stated the resident did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff member confirmed Resident 41's last weekly skin sweep was conducted on 8/19/21. Staff G, Risk Manager, stated at this time she knew Resident #41 had a skin assessment a couple weeks ago because the resident had complained about being red all over. Staff E, Unit Manager (UM), reviewed at this time the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM reviewed the Certified Nursing Assistant (CNA) shower sheets and was unable to locate one for the resident's shower on 12/8/21. The UM informed Staff D, LPN that since she had been in the shower with the resident, she could have filled out one of the shower sheets. Staff D informed the UM the resident had complained of a rash, but the staff member had observed it as dry skin. An observation was conducted of Resident #41's skin, on 12/8/21 at 4:50 p.m. with Staff E, UM. The resident was lying in bed, wearing bilateral offloading boots, and very specific in the way she was positioned. The UM was assisted in positioning the resident by Staff H, MDS Coordinator. The following areas were identified by the UM: - non-reddened raised areas to Left shoulder and arm. - reddened area under right breast. - macerated left groin, approximately 4 x 2 centimeter (cm). - 4 areas on left buttock - 3 reddened areas with peeling skin around edges and one open area approximately 1 x 1 cm. - reddened, dry and peeling skin on right gluteal fold. The resident exclaimed the area to the right gluteal fold was tender to touch. The progress notes for Resident #41 indicated that Staff E, UM had documented, effective on 12/8/21 at 4:14 p.m., a skin sweep was done and some skin issues were noted: right breast reddened, left groin macerated, left buttock with several areas that dry and skin peeling, inner left buttock with small open area, left shoulder with rash, and right gluteal fold with area that dry, tender to touch, and skin peeling. The note indicated the physician was notified with new orders for [MEDICATION(S)] powder to right breast, left groin, left buttock, left shoulder, right gluteal fold, and the antifungal medication [MEDICATION(S)] daily for 10 days. During an interview, on 12/10/21 at 1:15 p.m., the Director of Nursing (DON) stated all residents were to have weekly skin assessments. The DON stated that under evaluation the root cause reason for Resident #41 not having a weekly skin assessment was that it had not been scheduled. The facility provided, per request, the last three Comprehensive CNA Shower Reviews. The CNA Shower Review dated 11/27/21 indicated the left shoulder was circled. The CNA did not identify what type of issue was observed on the left shoulder, and the review was not signed by the charge nurse. The CNA Shower Review dated 12/4/21 indicated left rashes, was signed by the CNA but not signed by the charge nurse. The CNA Shower Review dated 12/8/21 was signed by Staff D, LPN and indicated skin conditions were observed to the right and left chest area, groin, and buttocks. The skin condition identified was dry skin to Left shoulder upper chest, no other skin issue was described. The review was signed by Staff D on 12/8/21 with a new order (n.o.) obtained and was signed by the CNA on 12/10/21. The policy titled Skin Care and Wound Management - Regular skin inspections and prompt interventions to address changes, effective February 2007 and revised January 4, 2021, identified: The facility will inspect the resident's skin on a regular and ongoing basis to provide documentation and prompt interventions of any changes noted. The procedure indicated: - 1. Skin inspections will be conducted by the licensed nurse using the Skin Sweep evaluation for documentation at the time of admission and weekly. - 2. In addition, the Certified Nursing Assistant assigned to the resident will observe the condition of the resident's skin during daily routine care and will report changes or areas of concern to the nurse assigned to the resident. - 3. Any identified skin impairment will be documented by the nurse at the time of discovery and weekly thereafter until healed using the appropriate Skin Sweep evaluation. All non-pressure related skin impairments as surgical wounds, skin tears, bruises, etc. should be documented on the Weekly Skin Evaluation.

Based on observations, interviews and record review the facility did not ensure a resident's dignity was respected related to not providing a privacy bag for a catheter drainage bag for one resident (#346) of two sampled residents for catheter care. Findings included: On 12/07/21 at 11:01 a.m., Resident #346 was observed with a catheter bag resting on his right leg while sitting in his room in a wheelchair. The catheter drainage bag appeared 3/4 full and was visible from the hallway. There was no privacy bag covering the catheter drainage bag. On 12/08/21 at 1:55 p.m., a second observation of Resident #346 in his room in a wheelchair and the catheter drainage bag was observed to on his left leg 1/4 full and with no privacy bag. The catheter drainage bag was visible from the hallway. On 12/09/21 at 10:58 a.m., a third observation of Resident #346 in his room revealed the catheter drainage bag was observed from the hallway. The catheter drainage bag was at the resident's left side as the resident was in his wheelchair. No privacy bag was noted. The Assistant Director of Nursing [ADON] was in the room at this time interviewing the resident's roommate. A review of Resident #346's Admission Record revealed the resident was admitted on [DATE]. The Admission Record showed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an active physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #346 had the following care plan focus completed on 12/06/21: The resident has a nephrostomy tube r/t [related to] obstructive [CONDITION(S)]. The interventions included: -Monitor and document output as per facility -monitor/document for pain/discomfort due to catheter -monitor/record/report to MD for s/sx [signs/symptoms] [CONDITION(S)] [urinary tract infection]. On 12/09/21 at 12:32 p.m., the Director of Nursing [DON] and Staff A, License Practical Nurse [LPN] confirmed Resident #346 had a catheter with no privacy bag. Staff A denied it being the resident's preference to not have one. Staff A immediately went to supply room to get privacy bag. The DON stated this is something that should have been easily preventable. A review of the facility's Catheter Care, including Drainage Bag Care/Maintenance policy stated, 11. For purpose of privacy and dignity, when the resident is out of bed, drainage bags should be in privacy bag.

Based on record review, observation, and interviews the facility did not ensure a care plan intervention was implemented related to a pressure relieving low air loss mattress for one resident (#49) of two residents reviewed for pressure ulcers. Findings included; Review of the Admission Record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], significant change, Section C - Cognitive Patterns, revealed Resident #49 was rarely/never understood. Review of Section G - Functional Status showed Resident #49 required extensive assistance for her ADLs (activities of daily living) of two persons for bed mobility and transfers. Further review of Section G reflected upper extremity impairment on both sides, and lower extremity impairment on one side. A review of Section M - Skin Conditions, revealed Resident #49 had an unstageable deep tissue injury and seven venous and arterial ulcers. The section under skin and ulcer/injury treatments was marked to indicate a pressure reducing device for bed was in use. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/08/21 at 9:38 a.m. an observation was conducted in Resident #49's room. Resident #49 was in her bed lying on her back on pillows and covered with a blanket. There wasn't a pressure relieving mattress present. On 12/08/21 at 5:01 p.m. an interview was conducted with Staff B, Licensed Practical Nurse (LPN), who was the treatment nurse at the facility. Staff B, LPN said Resident #49 had a low air loss mattress on the bed. Resident #49 was moved from the other side (of the facility). Staff B, LPN said she orders the low air loss mattresses. The facility has them here. Staff B, LPN said she puts an order in [electronic work order system] and maintenance brings the mattress. Staff B, LPN said Resident #49 does have a deep tissue injury. Staff B also confirmed there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she did not recall seeing the LAL mattress yesterday (12/7/21) when she did rounds with the doctor. On 12/09/21 at 3:11 p.m. an interview was conducted with the Director of Nursing (DON). The DON said the air mattress deflated the night before and it was in the supervisor's note. They had to wait for a new one, which came yesterday. He was unable to provide any documentation. He said it was discussed in the morning meeting. We didn't have any extra LAL mattresses and had to call the company to deliver some.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-four medication administration opportunities were observed, and six errors were identified for three residents (#9, #37, and #89) of five residents observed. These errors constituted a 17.65% medication error rate. Findings included: 1. On [DATE] at 11:22 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse (LPN) was conducted with Resident #9. The staff member was observed administering the following medication: - Novolog 100 unit/milliliter (u/mL) [MEDICATION(S)] - 2 units. Staff D removed a second Novolog [MEDICATION(S)] for Resident #9 from the top drawer of the medication cart, as the first one removed was expired. The staff member applied a needle, dialed the dosage selector to 2 units. She entered the room, went to the bathroom, rinsed hands one at a time under running water, donned gloves , extracted the needle cap, pulled gown of resident up, and was asked to step away from the resident for a moment. The staff member looked quizzical and asked what do you mean regarding the priming of the Novolog [MEDICATION(S)]. She stated she never does (priming) and that she looks to see if there was a bubble. As she had dropped the available alcohol pad, she returned to the medication cart, removed the needle, obtained another pad and needle, she put a new needle on the [MEDICATION(S)], dialed the dosage selector to 2 units, returned to the resident and injected 2 units into the left upper quadrant of Resident #9. The Director of Nursing (DON) stated, on [DATE] at 12:43 p.m., yes, the Novolog [MEDICATION(S)] needed to be primed prior to use. According to the manufacturer Novolog information for Novolog [MEDICATION(S)], located at https://www.novo-pi.com/novolog.pdf, instructed users: - Giving the airshot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: -- Turn the dose selector to select 2 units -- Hold your NovoLog [MEDICATION(S)] with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. -- Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the NovoLog [MEDICATION(S)]. 2. On [DATE] at 8:17 a.m., an observation of medication administration with Staff I, Assistant Director of Nursing (ADON), was conducted with Resident #37. The resident's profile was colored red and the ADON stated the above medications were due at 6:00 a.m. and the reason they were late was that she was not on the cart at that time. The resident was observed completing the container of yogurt from her breakfast tray and there was evidence that other breakfast items had been eaten. The staff member administered the following medication: - [MEDICATION(S)] 112 microgram (mcg) oral tablet - [MEDICATION(S)] 20 milligram (mg) oral capsule. A review of the active physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on [DATE] at 12:47 p.m., the Director of Nursing stated [MEDICATION(S)] should be at 6 a.m. on an empty stomach. He reported the policy of the facility was that [MEDICATION(S)] be administered by the night shift. According to [MEDICATION(S)].com (https://www.[MEDICATION(S)].com/starting/taking-[MEDICATION(S)]-the-right-way) Taking [MEDICATION(S)] the right way. In order for [MEDICATION(S)] to be effective, it should always be taken the same way every day. This is important because the amount of medicine you need is very precise. And even the way you take [MEDICATION(S)] can affect how much medicine your body is getting. It's important to always take your medication exactly as your doctor prescribed. The information indicated The right way, every day. Take [MEDICATION(S)] once a day, every day at the same time before breakfast. Take [MEDICATION(S)] with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water. According to Medlineplus.gov (https://medlineplus.gov/druginfo/meds/a 0.html), the Prescription [MEDICATION(S)] should be taken at least 1 hour before a meal. Prescription [MEDICATION(S)] is usually taken once a day before a meal but may be taken twice a day when used with other medications to eliminate H. pylori, or up to three times a day, before meals when used to treat conditions in which the stomach produces too much acid. The Admission Record for Resident #37 identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On [DATE] at 8:40 a.m., an observation of medication administration with Staff F, Registered Nurse (RN) was conducted with Resident #89. Staff F obtained a blood glucose level of 129 from the resident which indicated the resident did not need Novolog coverage. The staff member was observed administering the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - Active liquid protein 30 milliliter (mL) orally - [MEDICATION(S)] Sodium 100 milligram (mg) softgel orally - [MEDICATION(S)] Coated aspirin 81 mg tablet orally - [MEDICATION(S)] 500 mg chewable tablet orally - [MEDICATION(S)] 200 mg tablet orally - [MEDICATION(S)] 10 mg tablet orally - [MEDICATION(S)] 40 mg tablet orally - [MEDICATION(S)] 20 mg capsule orally - Ferrix X-150 150 mg tablet orally - [MEDICATION(S)] insulin [MEDICATION(S)] solution pen - 5 units - Vitamin D3 25 microgram (mcg)/1000 international unit (iu) 2 tablets orally. A review of the [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - Protein Liquid 30 mL one time a day - [MEDICATION(S)] ([MEDICATION(S)] Sodium) 100mg two times a day - Aspirin Delayed Release 81 mg tablet one time a day - [MEDICATION(S)] 1250 mg (500 Ca) tablet two times a day - [MEDICATION(S)] [MEDICATION(S)] (HCl) 200 mg - 2 tablets one time a day - [MEDICATION(S)] 10 mg tablet one time a day - [MEDICATION(S)] ([MEDICATION(S)]) 40 mg one time a day - [MEDICATION(S)] Capsule Delayed Release 40 mg one time a day - Nu-Iron 150 mg capsule one time a day - [MEDICATION(S)] Solution Pen-injector 100 u/mL - 5 units subcutaneously one time a day for Diabetes Mellitus 2 (DM2) - [MEDICATION(S)] 50 mcg capsule one time a day - [MEDICATION(S)] 100 mg tablet one time a day - [MEDICATION(S)] Extended Release (ER) 60 mg two times a day The observation indicated one tablet of 200 mg [MEDICATION(S)] and 20 mg of [MEDICATION(S)] were administered. The observation identified the [MEDICATION(S)] insulin pen had not been primed prior to administration, the staff member stated he does not have to prime the insulin pen, just dial it to the amount to be given, because it was already primed, he stated the pen was not like vials of insulin. The staff member stated the profile for the insulin [MEDICATION(S)] was colored red as it was due at 8:00 a.m., and he had a lot of accuchecks (7) on the unit. During an interview on [DATE] at 12:43 p.m., the Director of Nursing stated he did not know if the [MEDICATION(S)] insulin pen needed to be primed prior to use. According to manufacturer information, located at https://www.semgleehcp.com/en/pen, Step 3. Prime your pen needle: - Always perform the safety test before each injection. - Performing the safety test ensures that you get an accurate dose by: -- ensuring that pen and needle work properly -- removing air bubbles. The information instructed users to: - Select a dose of 2 units by turning the white dose knob. - Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. - Hold the pen with the needle pointing upwards. - Tap the cartridge so that any air bubbles rise up towards the needle. - Press the purple injection button all the way in. Check if insulin comes out of the needle tip. - You may have to perform the safety test several times before insulin is seen. If no insulin comes out, check for air bubbles and repeat the safety test two more times to remove them. If still no insulin comes out, the needle may be blocked. Change the needle and try again. If no insulin comes out after changing the needle, your [MEDICATION(S)] may be damaged. Do not use this [MEDICATION(S)]. The policy titled, Administering Medications, dated 2001 and revised [DATE], identified: Medications shall be administered in a safe and timely manner, and ad prescribed. The Interpretation and Implementation of the policy indicated: - The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. - Medications must be administered in accordance with the orders, including any required time frame. - Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). - The expiration/beyond use date on the medication label must be checked prior to administering.

Based on observations, policy review, and interview the facility failed to ensure medications were disposed of when expired, failed to ensure medicated eye drops were dated when opened and failed for two medication carts (300 Hall and ,d+[DATE] Hall) and failed to ensure one medication cart (300 Hall) was organized and uncluttered of five medication carts. Findings included: During the medication administration observation on [DATE] at 11:22 a.m., conducted with Staff D, Licensed Practical Nurse (LPN), a Novolog insulin [MEDICATION(S)] was removed from the 300-hall medication cart. The Novolog pen indicated it was opened on [DATE] and the label instructed users to discard after 28 days. The staff member counted the days and stated the expiration date of the Novolog pen was [DATE]. The Unit Manager, Staff E, arrived to the cart and Staff D, LPN informed her the insulin expired in 28 days not the 30 days they had thought. Staff E reported they had just gone through the (medication) carts yesterday and this one must have been missed. (Photographic Evidence Obtained) On [DATE] at 12:09 p.m., a review of the contents of the 300-hall medication cart was conducted with Staff D and E. The observation revealed the bottom drawer of the cart was disorganized, contained non-medication items (i.e. stethoscopes and manual blood pressure cuffs) stored in the same section of the drawer as medication blister cards currently in use for residents. (Photographic Evidence Obtained) In a section of the top drawer were multiple bags with an assortment of medicated eye drops: - an unopened bottle of [MEDICATION(S)] 0.005% solution which was labeled Refrigerate until Opened. The pharmacy label indicated the bottle of [MEDICATION(S)] was dispensed on [DATE]. - an opened, undated bottle of [MEDICATION(S)] 0.005% solution labeled, Throw Away Any Drug Left After 6 Weeks. - an opened, undated bottle of [MEDICATION(S)] 0.005% solution labeled to discard after 42 days. The pharmacy label indicated this bottle was dispensed on [DATE]. - an opened, undated bottle of [MEDICATION(S)] 0.005% solution. The pharmacy label indicated the bottle was dispensed on [DATE]. - an opened, undated bottle of [MEDICATION(S)] 0.005% solution. The bag indicated, Throw Away Any Drug Left After 6 weeks. The pharmacy label identified the medication was dispensed on [DATE]. - an opened, undated bottle of [MEDICATION(S)] Mal ([MEDICATION(S)]) 0.5% solution. The pharmacy label indicated it was dispensed on [DATE]. - an opened bottle of [MEDICATION(S)] 0.005% solution. The label indicated it was dispensed on [DATE] and opened on [DATE]. - an opened, undated bottle of [MEDICATION(S)] 0.005% solution. The label indicated the medication was dispensed by the pharmacy on [DATE] and to Discard After 42 Days. - an opened, undated bottle of [MEDICATION(S)] 0.005% solution. The label indicated the medication was dispensed by the pharmacy on [DATE]. - a bottle of Dorzolamide 2% solution, opened on ,d+[DATE] (2021). - a bottle of Dorzolamide 2% solution, undated as to when it was opened. The label had spaces available for staff to document the date opened, expiration (exp) date, and initial, this label was blank of any staff documentation. Staff D, LPN and Staff E, UM confirmed the above findings. Staff E, UM stated that eye drops should be dated when opened. The package insert for the [MEDICATION(S)] ([MEDICATION(S)]) Ophthalmic solution, located at https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]s044lbl.pdf, indicated, Once a bottle is opened for use, it may be stored at room temperature up to 25C (celsius) (77 F) for 6 weeks. According to the manufacturer information, located at https://patient.info/medicine/dorzolamide-eye-drops-for-[CONDITION(S)]-eydelto-[MEDICATION(S)]-vizidor, Bottles of eye drops only keep for four weeks once the bottle has been opened, so do not use the drops if the bottle has been open for longer than this. This will help to prevent the risk of eye infections. On [DATE] at 12:11 p.m., an observation was conducted with Staff A, LPN of the medication cart for the 100 and 500 hall. A vial of insulin was opened on [DATE]. The bottle containing the vial instructed users to discard after 28 days. A review of the calendar indicated 28 days from [DATE] was [DATE]. A policy titled, 5.0 Medication Storage, without an effective date, indicated, Medications will be stored in a manner that maintains the integrity of the product an ensures the safety of the residents and is in accordance with Florida (FL) Department of Health guidelines. The procedure identified: - Medications will be stored in an orderly, organized manner in a clean area. - Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.

Based on observations, record review, and interviews the facility failed to ensure one resident (#37) received physician ordered laboratory services related to obtaining a urinalysis out of thirty-eight sampled residents. Findings included: The Admission Record revealed Resident #37 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation at 11:23 a.m. on 12/7/21 of Resident #37 indicated the resident sitting in a wheelchair in the resident's room. On 12/8/21 at 8:53 a.m. Resident #37 was observed sitting in a wheelchair with a meal tray on the over-bed-table. The review of the clinical record identified a progress note, dated 12/6/21, that indicated nursing staff had received an order from the physician for a urinalysis (UA) with a culture/sensitivity (CS) related to cloudy, foul-smelling urine. A progress note, dated 12/7/21 indicated two attempts were made to collect a urinalysis as ordered, [Resident #37] did not cooperate, and the information would be passed to the next shift for follow-up. A review of the December 2021 Medication Administration Record (MAR) identified that a UA and CS was ordered to be obtained on 12/6/21 for one time only for 1 day. The MAR indicated a nurse had signed that on 12/6/21 the order had been administered. An interview was conducted at 3:51 p.m. on 12/9/21 with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). The LPN/UM stated the UA for the resident was originally ordered two days ago and that she was going to call the physician and ask for an order to straight cath Resident #37 to obtain a urine sample. On 12/9/21 at 3:58 p.m., Staff D, LPN, stated she had not gotten in report that Resident #37 needed a urine sample for testing. The UM reviewed the resident's MAR and confirmed the UA C/S was signed off on 12/6/21 at 4:55 p.m. by a staff member. Staff D confirmed it was her initials that had signed off on the UA on 12/6/21. The UM stated her expectation was that if a lab was not obtained it be reported to her, and the next shift nurse, and the physician should be notified. Staff D stated she had given the order to the 600-hall night shift to obtain the urine from the resident. A review of the laboratory requisitions for 12/6/21 and 12/7/21 was conducted with the UM and confirmed there was no requisition on those dates for Resident #37. The UM spoke with the laboratory vendor, on 12/9/21 at 4:13 p.m., and confirmed that a urine sample for the resident was not sent to the lab. She stated all lab requisitions were printed on the other side, pointing toward the unit on the other side of the building. The UM stated she had printed an order listing report, and confirmed the lab was not on the requisition forms. The UM stated she did not know why the order was missed, she had noticed it today, and was going to call the physician. At the time of the interview, the UM called the physician and informed him the urinalysis for Resident #37 had not been done. During an interview, on 12/10/21 at 1:04 p.m. the Director of Nursing (DON) stated all labs go to the 600-hall. He stated the physician probably was the one who told staff the UA was not done as he was very particular. The DON stated that it was his interpretation when the order was signed off (on the MAR) it indicated the UA was attempted. The DON stated that it was dropped and followed up on. A policy titled, Laboratory Tests/Diagnostic, effective December 2016, indicated, The facilty will track ordered labs and diagnostic procedures and promptly notify the resident's physician or nurse practitioner or physician's assistant of results of resident labs results and diagnostic procedure findings. The resident and/or resident representative will also be made aware of lab and diagnostic procedure results. The procedure indicated the nurse receiving the order is responsible for completing the lab requisition or verifying the diagnostic procedure appointment has been made as part of noting the order. The ordered lab is logged in on the lab log sheet found in front of each date in the binder. Designated nurse will review lab log sheets daily to verify protocol is followed. The designated nurse will follow up on any discrepancies noted.

Based on observation, interview, and record review the facility failed to ensure sufficient staffing to provide care according to the careplan and resident assessment for two (300 and 400 hallway) of six hallways as evidenced by two Certified Nursing Assistants (Staff C and Staff D) assigned to 45 residents of which 17 required two-staff members for transfers. The facility's failure resulted in three (Resident #4, #5, and #6) of three dependent sampled residents not being provided with bi-weekly showers, and two (Resident #4 and #6) of three assistive-device dependent transfer residents not being assisted out of bed within a timely manner after a request. Findings included: 1. An initial tour was conducted on 06/28/21 at 9:23 a.m. of the 300 and 400 hallways. A white board was observed with the daily direct care staff scheduling listed. The white board revealed two certified nursing assistants (CNAs), Staff C and Staff D, and two nurses were assigned to the 45 residents residing on the 300 and 400 halls. Staff D, CNA was assigned rooms 301-315A and Staff C, CNA was assigned rooms 315B-317, and 401-414. Photographic evidence was obtained. An interview on 06/28/21 at 9:24 a.m. with Staff A, CNA revealed the 300 and 400 hallways were considered the long-term care residents. Staff A stated there were many residents in these rooms that required a mechanical lift, or required two-staff members to assist with transferring and mobility. Staff A stated while the nurses on the unit did assist with resident care it was a heavy workload for the two CNAs assigned to the unit as the nurses still had their own duties such as medication administration. Staff A stated due to the number of residents residing in the long-term care rooms that required two staff members to assist with care, it was difficult to . provide the residents with the care that they need. An interview on 06/28/21 at 9:45 a.m. with Staff B, Licensed Practical Nurse (LPN) revealed due to the resident need requirements on the long-term care unit, and only having two CNAs to assist with their care, it was difficult to provide care within a timely manner. Staff B stated there have been many times where residents would have to soil themselves in their briefs due to staff not being able to answer their call lights and help. A record review of the Midnight Census Report, dated 06/28/21, revealed Staff C, CNA was assigned to provide direct care to 23 residents, and Staff D, CNA was assigned to provide direct care to 22 residents. A record review provided by the facility on 06/29/21 revealed that 37.8% of the 300 and 400 hallway resident population required two direct care staff for transfers. There were 8 residents residing on the 300 hallway who required a Hoyer lift for transfers, 6 residents residing on the 400 hallway who required a Hoyer lift for transfers, and 3 residents residing on the 300 hallway who required a [NAME] lift (sit-to-stand) for transfers of 45 residents total. A record review of the Facility Assessment 2021, dated 02/17/20 to 02/16/21, revealed under section B.1. Acuity-Sufficiency Analysis Summary that The facility patients currently demonstrates a need for medium to high acuity care and services . 2. An observation and interview on 06/28/21 at 10:35 a.m. with Resident #5, who resided on the 300 hallway, revealed her lying in bed under the bedsheets wearing a night gown with a toothbrush and wet rag on the bedside table in front of her. Resident #5 stated she required a Hoyer lift for transfers and used a bed pan for toileting. Resident #5 stated she may have to wait between 20-40 minutes at times for staff assistance due to the facility being understaffed on her hallway. Resident #5 stated she was provided with one shower a week and was told . they [staff] can't always give me two showers a week because they don't have enough people. While she would like to shower everyday like she would at home, she would like at least two showers a week which is what . the policy is. Resident #5 stated only now (today) was she provided with a toothbrush and a washcloth to clean her face. A review of Resident #5's Face Sheet revealed the latest admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #5's Progress Notes, dated 5/27/21 revealed she was alert and oriented to person and place with the ability to make needs known. A review of Resident #5's MDS [Minimum Data Set] 3.0 Nursing Home Comprehensive, dated 11/27/14, revealed under Section F: Preferences for Customary Routine and Activities that it is Very important for Resident #5 to choose between a tub bath, shower, bed bath, or sponge bath. Resident #5's MDS assessment dated [DATE], revealed under Section G: Functional Status that extensive assistance of two persons are required for transfers. Resident #5 was totally dependent on staff for bathing. A review of Resident #5's Care Plan revealed a problem area, a start date of 08/09/18, of . at risk for falling related to weakness, decreased mobility, and need for staff/mechanical lift for transfers and use of hypnotic med [medication]. An approach to the above listed problem included 2 staff members at all times, transfers remain 3 assist with mechanical lift. 5/7/21 resident no longer 3 assists for transfers. Continue with 2 staff members and Hoyer lift for transfers. Further review of the Care Plan revealed a problem area, start date of 10/09/15, of . at risk for skin breakdown R/T [related to] decreased mobility and incontinence . A review of Resident #5's Point of Care History, under section Type of Bath? dated 06/02/21 to 06/26/21, revealed 3 showers were provided in 25 days, 06/02/21, 06/09/21, and 06/16/21. 3. An observation and interview on 06/28/21 at 10:40 a.m. with Resident #4, who resided on the 400 hallway, revealed her lying in bed under the bedsheets wearing a nightgown. Resident #4 stated she required two staff members to be present and assist with transferring her. Resident #4 stated she was normally provided with one shower a week and staff mostly provide her with bed baths. Resident #4 stated she would like two showers a week because .a shower just makes you feel better. Resident #4 stated there have been times recently were she soiled herself in her brief and staff told her she needed to wait to be changed. This was because two CNAs are needed to change her due to her weight and assistance requirements. She reported that there were not enough aides on the floor due to them also providing care to other residents. Resident #4 stated she was currently waiting for a shower. A review of Resident #4's Face Sheet revealed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's Comprehensive MDS assessment, dated 05/23/21, revealed under Section C: Cognitive Patterns a Brief Interview for Mental Status [BIMS] score of 15, indicating she was cognitively intact. Section F: Preferences for Customary Routine and Activities that is it Very important for Resident #4 to choose between a tub bath, shower, bed bath, or sponge bath. Section G: Functional Status revealed Resident #4 was totally dependent on staff for transfers and bathing. A review of Resident #4's Progress Notes, dated 6/16/21 revealed she was alert and oriented to person and place and, . Assist of one [staff] for ADLs [activities of daily living] and 2 [staff] for transfers, resident unable to use stand up lift, Hoyer now being used. A review of Resident #4's Care Plan revealed: A problem area initiated 05/19/21 for Resident has self-care deficits and requires assistance with ADL tasks and mobility r/t weakness, impaired mobility . She has contractures to bilateral hands, foot drop to bilateral feet which impedes her ability to perform her daily adl's. An approach to the above listed problem included She requires max to total assist with bed mobility, transfers . dressing, toileting and personal hygiene A problem area initiated 05/19/21 for Resident is at risk for pressure ulcer due to Decreased mobility . She requires max assist with bed mobility. An approach to the above listed problem area included, Turn and reposition frequently. A problem area initiated 05/19/21 for [Resident #4] requires extensive-total assistance of 1-2 [staff] for ADL's: transfer, bed mobility. An approach for the above listed problem area included, [Resident #4] prefers to be up in her w/c [wheelchair] by 11am daily. A review of Resident #4's Point of Care History, under section Type of Bath? dated 05/27/21 to 06/26/21, revealed only 1 shower was provided in the month of June (06/17/21). A follow-up interview on 06/28/21 at 12:32 p.m. with Resident # 4 revealed her lying in bed under the bedsheets with different clothing. Resident #4 stated she was not provided with a shower, but her clothing was changed. Resident #4 said, . I just want to get out of bed at this point. Resident #4 stated she had not been assisted out of bed today because there were not enough staff on the unit to assist all the residents requiring two-staff transfers. Resident #4 stated this was not the first time her shower or getting out of bed has been skipped due to not enough staff on the floor to assist. 4. An observation on 06/28/21 at 12:00 p.m. revealed Resident #6's Daughter/Power of Attorney (POA) speaking with Staff A, CNA. The POA stated she requested Resident #6 to be assisted out of bed at 10:30 a.m. and was still waiting for assistance by the direct care staff. An observation of Resident #6 revealed her lying in bed under the bedsheets and was non-responsive to communication. The POA stated Resident #6 was on hospice and the main goal was to provide her with the . best quality of life. The POA requested Resident #6 to be transferred out of bed so by lunch she could assist her with eating. The POA stated at 2:00 p.m. Resident #6 would be placed back into bed for the rest of the evening thus she is out of bed for a limited amount of time. The POA stated her mother had not been assisted out of bed because there were not enough aides on the unit to assist all the mechanical lift and sit-to-stand residents. She said, No Hoyer lift residents have been out of bed today. Resident #6 resided on the 300 hallway. A review of Resident #6's Face Sheet revealed the most recent admitted was 08/29/19 with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #6's Progress Notes, dated 06/28/21 revealed Resident #6 was under the care of Hospice and had an expected decline in health. A review of Resident #6's MDS [Minimum Data Set] 3.0 Nursing Home Comprehensive, dated 03/30/21, revealed under Section C, Cognitive Patterns, the resident was severely impaired for daily decision-making skills and had short-and long-term memory problems. Section G: Functional Status revealed Resident #6 was totally dependent on staff for transfers and bathing. Section F: Preferences for Customary Routine and Activities revealed that it was Very important for Resident #6 to choose between a tub bath, shower, bed bath, or sponge bath. A review of Resident #6's Care Plan initiated 08/06/19 revealed a problem area of [Resident #6] is receiving hospice services Goal . Quality of life will be maintained during this quarter . An approach to the above listed problem included Address resident's choices as outlined . Address Resident's specific choices related to end of life. Further review of the Care Plan revealed a problem area initiated 06/23/15, of [Resident #6] is at risk for skin breakdown R/T due to urinary incontinence, decreased mobility, poor nutrition and [CONDITION(S)] . She requires max assist with bed mobility. A review of Resident #6's Point of Care History, under section Type of Bath? dated 06/01/21 to 06/27/21, revealed 5 showers were provided in the month of June (06/02/21, 06/05/21, 06/16/21, and two on 06/19/21). A follow-up interview and observation on 06/28/21 at 12:20 p.m. revealed Resident #6 lying in bed under the bedsheets. An interview with Staff A, CNA confirmed Resident #6's POA requested her mother to be transferred out of bed at 10:30 a.m. The POA asked Staff A, CNA why her mother and other Hoyer lift residents have not been assisted out of bed and Staff A responded . because we just don't have enough staff right now. Staff A stated only one Hoyer lift resident, Resident #5, was assisted out of bed today. A follow-up observation and interview on 06/28/21 at 1:48 p.m. revealed Resident #6 lying in bed under the bedsheets. Resident #6's POA stated Resident #6 should receive 2 showers a week. The POA stated part of her worry regarding the limited staffing on the unit such as today, is, . what would that mean on a shower day? Would that mean her [Resident #6] shower would just be skipped? If you walk down the hallway you can see that no other resident has been assisted out of bed today either 5. An interview on 06/28/21 at 12:36 p.m. with Staff C, CNA confirmed her current work assigned consisted of over 20 residents. Staff C stated the procedures for resident showers include asking the resident if they would like a shower and documenting the shower or bath in the online medical record. If the resident refuses a shower, then the nurse on duty was notified. Staff C confirmed that no 2-staff transfer required residents were assisted out of bed and no resident had been provided with a shower today, only bed baths today. She said this was because there was only one other CNA on the floor who can assist with resident transfers and while they do the best they can, staff cannot provide adequate care to the residents with such a heavy load. When a resident was being provided with a shower, that would leave only 1 CNA on the floor to assist with the remaining residents, so sometimes a resident's shower will have to be skipped to make sure other residents needs can be met. An interview on 06/28/21 at 12:40 p.m. with Staff B, LPN confirmed that no 2-staff transfer required residents were assisted out of bed today. Staff B, LPN confirmed there was no other reason for these residents not to be assisted out of bed except that there were not enough staff on the unit today to assist the residents out of bed and still provide care and complete other duty requirements. Staff B, LPN confirmed that a resident should be provided with 2 showers a week. If the resident refuses, then the CNA will notify the nurse and the nurse should reapproach the resident to see if they would like one at another time. If the resident continues to refuse, then the refusal should be documented. An interview on 06/28/21 at 1:55 p.m. with the Director of Nursing (DON) revealed the facility does not have a set schedule for when residents are assisted out of bed, however, anytime a resident wants to get out of bed they can. Two staff members are required to use the Hoyer lift. It is a team collaboration to determine a resident's preferences, but . if a resident is requesting to get up then they [staff] should follow-up . The DON stated the timeframe for assisting a resident out of bed if they have requested to be assisted would be about an hour. The consequences related to a resident not being assisted out of bed are the possible development of pressure ulcers and psychological problems related to them wanting to get up but are not assisted. Additionally, while the residents have a shower schedule, if a resident request a shower, they can have one. A follow-up interview on 06/28/21 at 2:39 p.m. with the DON revealed residents should be offered and provided showers twice a week and the bathing should be documented in the online medical chart. Additionally, two staff members are required to be present for use of the sit-to-stand transfer equipment. An interview on 06/29/21 at 9:19 a.m. with the Nursing Home Administrator (NHA), the Human Resources (HR) Manager, and the DON revealed the staffing schedules were discussed prior to 11 a.m. to review who was on the schedule and the daily staffing ratios. If there were needs identified, a text would be sent out to see if someone could come in. On Tuesdays, the facility has labor meetings with departments to determine needs. Staffing acuity was reviewed using the facility matrix along with discussions with the nursing staff to determine how many aides were necessary depending on the resident needs. The DON stated administration has an open-door policy if staff need additional assistance and staff may need education as there was . never a reason that a staff member should say they cannot get someone out of bed because they don't have enough time. The DON said, . yesterday, yes, they did only have two CNAs on the unit but that is not the standard . A review of the CNA Duties List forms for the Month of June revealed Resident #4 refused a shower on 6/7/21 and 6/24/21. There were no other completed CNA Duties List forms provided from the facility which revealed shower refusals from Resident #4, #5, or #6. An interview on 06/29/21 with the Education Consultant, NHA, DON, and the HR Manager revealed the purpose of the CNA Duties List was for the CNAs to log the resident vitals, and if they have received a shower or not. The nurses will review this form throughout the shift to see if there were any resident complaints. On 06/29/21 at 12:21 p.m., the DON and NHA stated a bed bath was interchangeable with a shower, but confirmed that if a resident requested a shower they should be given a shower. If a resident does not like or want a shower, they may be provided with a bed bath. A policy review of Lifting Devices, revised January 2008, revealed . It is the policy of this facility that the nursing department use lifting devices for all residents that require assistance with transfers as identified on their plan of care . Procedure: 1. All residents will be assessed, and if mechanical lift is required it will be identified on their plan of care. 2. All staff will be instructed on the proper use of the lifts, and each staff person will do a return demonstration . A policy review of Staffing, revised September 2018, revealed . Staffing shall be based on the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This determination shall be made separately for both licensed and non-licensed personnel Purpose: To provide adequate staffing for proper resident care . Procedures: 1. Staffing needs will be determined by the Administrator, Director of Nursing or designee based on the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A policy review of Bath (Shower), revised January 2004, revealed . Objectives: 1. To cleanse and refresh the resident . Documentation: 1. Date and shower, given . Resident Care Plan: Amount of Assistance required should be listed on the resident's plan of care .

Based on observations, interviews with the Nursing Home Administrator(NHA), the Director of Nursing (DON), Assistant Director of Nursing (ADON), nursing staff, the resident's attending physician/Medical Director, and review of clinical records, policies and procedures it was determined that the facility failed to provide an environment that remained as free of accident hazards as possible and ensured residents were safe [MEDICAL CONDITION] scalding hot liquids served during meals. Failure to maintain safe hot liquid temperatures caused hot [MEDICAL CONDITION] two Residents #3 & #57 on 9/2/20, who requested hot liquids. Both residents required supervision of one person for eating and drinking. After learning of the two hot [MEDICAL CONDITION] 9/2/20, the facility failed to investigate the temperatures of scalding hot liquids for 21 days from 9/2/20 until 9/23/20. The facility failed to identify and investigate [MEDICAL CONDITION] on the event log. The facility further failed to document the [MEDICAL CONDITION] detail and have the wound care nurse or physician assess and monitor the scald burns. The facility failed to investigate and identify scalding hot liquid hazards although the event log was updated to reflect the scald burns. The management team to include the Administrator/ Risk Manager, Certified Dietary Manager, Director of Nursing and Assistant Director of Nursing failed to ensure 52 residents, who could request hot liquids, of a total census of 55 residents, were free from potential scalding of hot [MEDICAL CONDITION] 21 days and failed to identify and prevent two vulnerable Residents, #3 and #57, from receiving scalding hot liquid burns. This resulted in the findings of Immediate Jeopardy, occurring on 9/2/20 and removed at 5:00 p.m. on 9/25/20 with the scope and severity reduced to a D. Findings included: 1. On 9/23/20 at 10:00 a.m. Resident #3's electronic progress notes documented by staff member E, Registered Nurse (RN) on 9/2/20 at 11:40 a.m., found that staff member E, RN was called to Resident #3's room for Evaluation of redness to the left thigh. Reddened area noted to left outer thigh, two dry ruptured blisters also noted. Resident states that she had spilled her coffee on it - was unsure of when it had happened. Physician and daughter notified. During an interview on 9/23/20 at 11:50 a.m. with staff member E., RN, she stated Resident #3 spilled her coffee on her left outer thigh. The thigh was red and had a burn. Staff member E, RN stated we document on the progress notes, event logs in the computer and the night shift nurse normally completed progress notes related to skin sweeps. Staff member E, RN stated Resident #3 currently had a red area that was not open. 2. On 9/23/20 at 10:40 a.m., an interview was conducted with the facility's Certified Dietary Manager (CDM) related to who was responsible for the brewing and maintaining of hot liquids to include coffee. The CDM revealed that it was the kitchen's responsibility to make and send out coffee to the floors/units. She further revealed that, since the COVID pandemic, there were only two places to make coffee and hot water, which were 1) In the kitchen, and 2) In the main dining room area. The CDM confirmed that currently, they brew the coffee for residents utilizing a leased coffee machine, which was in the main kitchen. The CDM further confirmed that the leased coffee machine in the main dining room was on and that they used it, but the main machine from the kitchen was only for residents. The CDM was then asked if she could remember any residents in the building being burned by either hot coffee or hot water. She said, I was told by staff maybe a few weeks ago that a resident received too hot of coffee but was never told if that resident received any burn injuries. She further confirmed it had not been brought to her attention from management about coffee serving temperatures, nor did management ever bring to her attention that a resident or residents were burned by hot liquids. The CDM was then asked how she brewed coffee/hot water. She again explained that there was a leased coffee machine that brewed the coffee and the temperature was set within. She was asked how she maintained the coffee machine liquid temperatures and explained that the machine was always on preset temperatures so the coffee would either have to cool by placing it in the walk in refrigerator if too hot, or let sit out in kitchen area near the coffee machine for a period of forty-five minutes to an hour. The CDM was asked how she monitored the coffee and hot water temperatures and was also asked what her and the facility's expectations were when it came to safe coffee/ and or hot water service to residents. The CDM stated that previously, she did not monitor the temperatures of coffee or hot water coming out from the machine, she did not monitor coffee or hot liquids prior to going out to the floor/units, and did not monitor coffee or hot liquids after it reached the floor/units. The CDM was asked if she had any type of log or documentation to show that she had taken temperatures of coffee or hot liquid in the past. She confirmed that was something she had never done and did not have a temperature log of the coffee or hot water temperatures. During this time, the CDM was asked to show what the coffee/hot water temperatures were immediately after brewing and when they reach the floor to be served. On 9/23/20 at 11:00 a.m., the CDM stated that the coffee was ready to go out to the units/floor and was sitting in the metal coffee carafes for about one hour. She did not know what the coffee/hot water temperatures were prior to going out to the floor. Prior to leaving the kitchen area, the CDM was asked how she took temperatures of the hot coffee and hot water. She explained she utilized a regular stick, non-digital thermometer and calibrated it daily. She was asked what the process was in order to calibrate the thermometer. The CDM revealed she stuck the thermometer in a cup of ice and water and waited about 30 seconds to see what the dial read. She indicated the dial should reach 32 degrees Fahrenheit (F). She further explained that if it was not at 32 degrees F., she would then twist the gauge nut until the dial reached 32 degrees F. The CDM revealed that she last calibrated this thermometer earlier today, 9/23/20, prior to the breakfast meal service. The CDM indicated that they only made and served coffee to the residents three times a day, which included, 1. Breakfast meal service, 2. Lunch meal service, and 3. Dinner service. The following was observed: On 9/23/2020 at 11:55 a.m., the CDM pushed a meal cart to the 400 hall. The cart had the coffee and hot water placed on top. The cart reached the 400 hall at 11:57 a.m. The CDM then poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 146 degrees F. The CDM confirmed the temperature at 146 degrees F. At 12:00 p.m., the CDM pushed another tray cart to the 200 hall. At 12:02 p.m., she poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 130 degrees F. The CDM confirmed the temperature at 130 degrees F. At 12:05 p.m., the CDM pushed another tray cart to the 600 transitional unit. At 12:07 p.m., she poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 145 degrees F. The CDM confirmed the temperature at 145 degrees F. At 12:11 p.m., the CDM pushed the final tray cart to the 300 hall. At 12:13 p.m., she poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 165 degrees F. The CDM confirmed the temperature at 165 degrees F. The CDM was asked what the expectations were for serving hot coffee and hot liquids to elderly and compromised residents. She could not give a specific number in degrees but rather stated, Coffee and hot liquids should be at palatable temperatures. The CDM and Surveyor then walked back to the kitchen to observe the coffee machine's liquid service temperatures. The following was observed: 1. The coffee machine in the main dining room had a door on it and had to be unlocked with a key. The key had already been in the lock. The door was opened and there was a digital read out that had a Tank temperature and a Dispense temperature. The dispensing temperature read 193 degrees F. The tank hold temperature read 198 degrees F. The kitchen coffee machine was also observed with a door with a key in the lock. The door was opened and revealed a dispensing temperature of 193 degrees F. The hold temperature read 198 degrees F. (Photographic evidence was taken). The CDM confirmed both machine temperatures and did not know what the temperatures should be and did not know what a safe hot liquid temperature should be for elderly and compromised residents. She also indicated that she could not change or adjust the temperatures but would call the coffee machine company serviceman to come out and look at it. 3. During an interview with Staff member F, Licensed Practical Nurse (LPN) on 9/23/20 at 1:00 p.m., she stated a resident was burned after spilling coffee a few weeks ago. Staff member F, LPN stated it was Resident #57, a recently admitted resident at the time. Staff member F, LPN stated her responsibility and protocol was to create the event report, document progress notes, notify the family and physician, and get orders. Staff member F, LPN stated that all nursing staff and administration could see the event log and that management would review. Staff member F, LPN stated she could print the reports for her residents in case she forgot to get report on someone or give report about an event. She said she would print out an event report for the oncoming nurse to review so they were aware. On 9/23/20 at 1:00 p.m., an interview was conducted with the Nursing Home Administrator and Director of Nursing. They were asked if they could provide information related to hot liquid [MEDICAL CONDITION] occurred on 9/2/20 with regards to Residents #3 and #57. Neither the Nursing Home Administrator nor the Director of Nursing could recall any residents being burned by hot liquids recently. They both indicated that they would look at the incident/accident injury event log. Once they looked at the incident/accident injury event log, they were able to see that both Residents #3 and #57 received hot [MEDICAL CONDITION] 9/2/20. 4. During review of the event log and interview on 9/23/20 at 3:48 p.m., with the ADON, she stated that she created the event log daily. She said, she input the information from the 9/2/20 events into the event log but did not investigate them. Review of the event log found Resident #3's event occurred on 9/2/20 at 2:28 p.m., in her room. She was alert and oriented. Type of event was documented as skin tear/laceration. Possible cause was documented as Spilt hot beverage on lap and investigated cause was documented as Spilt hot beverage on lap. Injury described as left outer thigh- red and small open blister noted. Doctor and family notified. Review of the event log for Resident #57's event found it occurred on 9/2/20 at 2:26 p.m., in her room. She was alert and oriented. Type of event was documented as skin tear/laceration. Possible cause was documented as Spilt hot beverage on lap and investigated cause documented as Spilt hot beverage on lap. Injury described as left upper thigh noted with red area. The ADON stated she did not investigate them since the CDM was made aware by the nurse. 5. During an interview with the NHA, DON, and the CDM on 9/23/20 at 3:55 p.m., the NHA stated the coffee company was contacted and the CDM was notified of the incidents. The Administrator stated the CDM had the coffee carafes sit for 45 minutes prior to serving. The CDM stated she could not recall having a conversation about coffee burns. The Administrator stated that coffee temperatures are quantitative, and the temperatures could not be monitored without taking temperatures of the coffee in the carafe. The Administrator and DON were asked during the conversation, what the facility did from 9/2/20 to 9/23/20 related to [MEDICAL CONDITION] hot liquid. The Administrator stated the facility called the coffee machine company on 9/23/20 and, going forward, temperatures would be taken prior to serving. The Administrator stated the vendor would be coming to adjust the temperature of the coffee machine. During an interview with the DON on 9/23/20 at 4:02 p.m., the DON stated they did not have a policy related to event investigations and would look for one related to hot liquids. 6. During an interview on 9/23/20 at 4:15 p.m., with the CDM she stated that she was unsure how many residents drank hot liquids and would print out a list. The CDM stated she was not sure how many residents preferred coffee. During an interview with the CDM while in the kitchen, she stated the water temperature was 120 degrees after sitting for 20 minutes from the coffee machine. During an interview with Staff member U, dietary aide on 9/23/20 at 4:30 p.m., she stated she had taken the temperature of coffee after dispensing from the coffee machine. The temperature was 165 degrees F. So she put the coffee in the cooler for ten minutes. On 9/23/2020 at 4:25 p.m., the CDM was asked to provide demonstration how the kitchen maintained and served coffee and hot water to residents. She indicated that coffee had already been poured from the machine and that they were sitting on the carts in insulated metal carafes, ready to be taken out to the floor. At 4:30 p.m., a kitchen aide (Employee T) was observed in the kitchen carrying two metal insulated coffee carafes from the walk-in refrigerator to the dining room to place the coffee on the meal carts. Employee T said she had just removed the carafes from the walk-in refrigerator and tested the temperatures. She said, the temperature was 120 degrees F. She further indicated that they now go on the meal carts to be transported to the floor/units. Employee T said that when coffee was poured from the coffee/hot water machine, the temperatures were at 165 degrees F. The CDM was asked to take the temperature of the coffee once it reached the floor/units. Prior to that, the coffee/hot water machine in the kitchen and the coffee/hot water machine in the main dining room were observed for internal liquid temperatures. The machines had a digital read out that included the dispensing temperature and tank holding temperature. At 4:40 p.m. both coffee machines in the kitchen and dining room had the following: 1. Dispensing temperature - 193 degrees F. and 2. Tank holding temperature - 198 degrees F. (Photographic evidence was taken). The following was observed on 9/23/20 during the dinner service: The CDM pushed the meal tray cart from the kitchen at 4:42 p.m., and reached the 600-transition unit at 4:43 p.m. She poured a half cup of coffee into a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 132 degrees F. The CDM confirmed the temperature reached 132 degrees F. The staff was observed serving the coffee to the residents, they provided assistance such as adding cream, sugar, and sugar substitute if requested, and ensured the residents were able to reach the coffee cup. The CDM pushed a meal tray cart from the kitchen and reached the 200 hall at 4:46 p.m. She poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 127 degrees F. She confirmed that the temperature reached 127 degrees F. The CDM pushed a meal tray cart from the kitchen and reached the 400 hall at 4:56 p.m. She poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 139 degrees F. She confirmed that the temperature reached 139 degrees F. The CDM pushed a meal tray cart from the kitchen and reached the 300 hall at 5:15 p.m. She poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 122 degrees F. She confirmed the temperature reached 122 degrees F. The CDM stated, I don't know how the coffee temperature rose as I believed my staff temped the coffee prior to leaving the kitchen at 120 degrees F. During an interview on 9/23/20 at 4:56 p.m., with the Administrator, he confirmed the facility did not have a hot liquid policy, just hot food policy. At approximately 5:30 p.m., the Nursing Home Administrator was interviewed and informed about the lunch meal service coffee temperatures. He stated he understood about the high liquid temperatures and would have an action plan to put in place. 7. On 9/24/20 at 6:10 a.m. the building was entered in order to observe coffee/hot water service prior to breakfast meal service. At 7:08 a.m., the CDM and two cooks revealed that this a.m. at 5:00 a.m. they prepared coffee. The CDM related that the coffee machines were always on in the kitchen and the main dining room. She revealed that she and her staff poured coffee from the coffee machine in the kitchen and took it directly to the freezer to cool. The CDM indicated that the pour temperature was 167 degrees F. and coffee/hot water after pour was taken to the walk-in freezer to sit for an unspecified time. She added that the coffee was then removed from the freezer and tested with a calibrated thermometer. She reported that the temperatures reached 120 degrees F. The CDM was asked to take coffee/hot liquid temperatures once they reached the floor/units. The process was as follows. A meal tray cart left the main dining room/kitchen area at 7:08 a.m. and reached the 200 hall at 7:10 a.m. The CDM poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 110 degrees F. She confirmed the temperature reached 110 degrees F. A meal tray cart left the main dining room/kitchen area at 7:13 am. and reached the 600-transition hall at 7:15 a.m. The CDM poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 110 degrees F. She confirmed the temperature reached 110 degrees F. A meal tray cart left the main dining room/kitchen area at 7:18 a.m. and reached the 400 hall at 7:20 a.m., The CDM poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 125 degrees F. She confirmed the temperature reached 125 degrees F. A meal tray cart left the main dining room/kitchen area at 7:35 a.m. and reached the 300 hall at 7:35 a.m. The CDM poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 120 degrees F. She confirmed the temperature reached 120 degrees F. 8. A review of the American Burn Association Scald Injury Prevention, Educator's guide, ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf, revealed: General background information on [MEDICAL CONDITION]- Although [MEDICAL CONDITION] happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Most scald burn injuries happen in the home, in connection with the preparation of hot food or beverages, or from exposure to hot tap water in bathtubs or showers. Both behavioral and environmental measures may be needed to protect those vulnerable to scalds because of age or disability, or because they do not have control of the hot water temperature in multi-unit residential buildings. The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees F. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140 degrees F. it takes only five seconds or less for a serious burn to occur. Coffee, tea, or other hot beverages are usually served at 160 degrees F. to 180 degrees F., resulting in almost [MEDICAL CONDITION] will require surgery. Since immediate removal of the hot liquid from the skin may lessen the severity, splash and [MEDICAL CONDITION] not be as deep [MEDICAL CONDITION] in a bathtub. High Risk Groups Older Adults - Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. People with Disabilities or Special Needs - Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids.[MEDICAL CONDITION] the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Moving hot liquids can be extremely difficult or someone who uses a can or walker. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the persona may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgement or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. While the basic principles of scald prevention apply to the general population the additional concerns affecting these high risk groups must be addressed. Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Prevention of scald injuries is always preferable to treatment and can be largely accomplished through simple changes in behavior and in the home environment. Time and Temperature Relationship to Severe Burns Water temperature Time for a third degree burn to occur 155 degrees F. 68 degrees C. 1 second 148 degrees F. 64 degrees C. 2 seconds 140 degrees F. 60 degrees C. 5 seconds 133 degrees F. 56 degrees C. 15 seconds 127 degrees F. 52 degrees C. 1 minute 124 degrees F. 51 degrees C. 3 minutes 120 degrees F. 48 degrees C. 5 minutes 100 degrees F. 37 degrees C. safe temperature for bathing 9. During interview and observation of Resident #3 after readmission on 9/25/20 at 6:30 p.m., the resident stated she spilled her coffee on herself, but it no longer hurts and It's healed now. Resident #3 consented to observation and revealed a pink left outer thigh area measuring approximately 5 centimeters long by 1 centimeter wide. Resident #3 rubbed her hand over the area and again stated, It's healed now. Review of the electronic record for Resident #3 revealed a Brief Interview for Mental Status (BIMS), dated 8/17/20, of 12 indicating moderate impairment. Section G, from Minimum Data Set (MDS) functional status, H. eating - how resident eats and drinks regardless of skill revealed a self- performance of 1. Supervision - oversight, encouragement or cueing and support of 1 indicated set up help only. Review of Resident #3's physician order: Regular diet dated 8/12/20. Resident on hospice dated 8/12/20. Skin sweep once a day on Thursday from 6:00 p.m. to 6:00 a.m., dated 8/17/20. Monitor burn to left upper thigh until resolved twice a day dated 9/2/20. Review of physician telehealth visit on 9/2/20 revealed limited exam due to COVID 19. Skin checked as intact no [MEDICAL CONDITION], rash, ulcer. Review of Resident #3's nursing progress notes revealed on: 9/2/20 at 9:02 p.m., the RN documented Resident #3's left outer hip remains pink, painless per resident. No signs or symptoms of infection. 9/4/20 at 12:26 a.m., the RN documented weekly skin sweep. No new areas noted on resident. 9/5/20 at 10:11 p.m., the RN documented burn on left outer hip remains pink painless per resident. No signs or symptoms of infection. 9/6/20 at 10:20 p.m., the RN documented burn on left outer hip remains pink painless per resident. No signs or symptoms of infection. 9/7/20 at 10:54 p.m., the RN documented burn on left outer hip remains pink painless per resident. No signs or symptoms of infection. 9/8/20 at 9:20 p.m., the RN documented burn on left outer hip remains pink painless per resident. No signs or symptoms of infection. 9/9/20 at 11:14 a.m., the RN documented resident is alert and oriented times two with confusion, able to make needs known. Assist of 2 for transfers and one for activities of daily living. Reddened area to outer left thigh pink and painless per resident. 9/9/20 at 9:30 p.m., the RN documented burn on left outer hip remains pink painless per resident. No signs or symptoms of infection. 9/10/20 at 8:28 p.m., the RN documented skin sweep performed on resident. No new areas of concern. 9/13/20 at 11:09 a.m., the LPN documented patient alert and oriented times 3, hard of hearing. Assist of one with activities of daily living. 9/16/20 at 9:03 p.m., the RN documented Burn on left outer hip healed; painless per resident. No signs or symptoms of infection. 9/18/20 at 5:11 a.m., the RN documented a weekly skin sweep- no new areas noted on resident. Burn on left outer thigh area is light pink. 9/23/20 at 7:56 a.m., the RN documented a note and edited the note on 9/23/20 at 11:57 a.m. to add: reddened area to left outer thigh remains, skin intact. Review of the telemedicine wound care visit dated 9/8/20 at 11:37 a.m., 9/15/20 at 11:40 a.m. and 9/22/20 at 10:05 a.m. did not discuss left outer thigh. Review of Resident #3's treatment administration record revealed, on 9/2/20, an order to monitor burn to left upper thigh until resolved twice a day. Completed. Review of Resident #3's treatment administration record found, on 8/17/20, skin sweeps documented on Thursdays. Completed. Review of Resident #3's care plan with last revision date 8/19/20, identified problem start date on 10/11/18 of impaired vision related to [DIAGNOSES REDACTED]. Goal date of 11/19/20, resident will not experience negative consequences of vision loss as evidenced by; remaining physically safe, and participating in social, and self-care activities. Review problem dated 9/23/20, revealed resident at risk for spilling her coffee related to shaking. Approach dated 9/23/20, resident to have a ½ cup of coffee to be provided and nursing to evaluate. During an interview on 9/25/20 at 1:41 p.m. with Director of Rehab (DOR), she stated Resident #3's biggest issue was her vision loss. Review of the occupation therapy evaluation, dated 6/19/20 to 7/18/20, found self-feeding underlying impairments as low vision. 10. Review of Resident #57's electronic nursing progress notes on 9/2/20 at 12:04 p.m. found the LPN documented, She was summoned to resident's room by therapist. The nurse made aware of quarter size red area to upper left thigh. Therapist informed the nurse that she observed coffee stain on resident's gown. Resident unaware of what happened. Resident does complain of area burning. The nurse spoke with the resident's son and notified him of the area on the left upper thigh red area. During a phone interview with Staff member Z, RN on 9/25/20 at 1:00 p.m., She confirmed she completed the wound care for the facility. Staff member Z, RN stated Resident #57's nurse contacted her on 9/22/20 and asked her to assess the burn as the nurse thought the wound may be infected. Staff member Z, RN stated the wound was not infected. Staff member Z, RN stated Resident #57 was not on the wound list to be seen and had not been assessed by the wound nurse prior to 9/22/20. During an interview with the DOR (Director of Rehabilitation) on 9/25/20 at 1:08 p.m., she confirmed she observed Resident #57 sitting in a big puddle of coffee on the floor under her wheelchair and cleaned up the floor. The Director of Rehab stated she could not see anything on Resident #57's clothes but halfway through therapy the resident started complaining the inside of her leg felt weird. The DOR stated she looked at Resident #57's left inner leg. It was a red long oval shaped area. The DOR stated she went to get the nurse and she could see the top layer of skin was peeling (like a sunburn). The nurse went to get a dressing. The DOR stated the residents in the building had not been assessed for safety and handling hot liquids, It's not something we usually do. Review of the nursing progress notes, dated 9/9/20 at 1:33 p.m., and documented by the LPN revealed an area to left upper thigh is no longer red in color. Color is brownish. No complaints offered. Review of the nursing progress notes dated 9/12/20 at 5:52 a.m., documented by the LPN revealed Resident #57 complaining of itching on the red area on her left upper thigh. When checked, the area appears to be scabbing. Site is cleansed and covered with dressing to avoid unconscious scratching and reopening of the scabs. Resident tolerated it well throughout the night. Review of the nursing progress notes, dated 9/13/20 at 2:26 a.m., and documented by the LPN revealed no new skin issues noted during skin check. Existing skin concerns have treatments in place. Review of the nursing progress notes dated 9/13/20 at 1:07 p.m. and documented by the LPN revealed Resident #57's observed dressing on left upper thigh. Dressing removed observed drainage on dressing. Observed area with slough. Area cleaned with normal saline, triple antibiotic ointment and dressing applied. Resident denies pain to area. Review of the nursing progress notes dated 9/18/20 at 4:48 p.m., documented by the RN revealed the resident with open area located to left upper thigh. Observed redness around the area, hot to touch. Resident referred itching and discomfort. Treatment completed as ordered with triple antibiotic ointment during the shift. Physician notified. Waiting for wound care evaluation. Oncoming nurse notified. Continues monitoring. Review of the social services note dated 9/22/20 at 1:11 p.m., revealed poor safety awareness. Review of the nursing progress notes dated 9/24/20 at 11:29 a.m., documented as late entry-9/22/20, read as follows. Nurse requested that wound nurse assess wound on left medial thigh as she voiced concern it was infected. Scant serous drainage. Dime size open area, the rest of the area is scabbed and open to air. No signs and symptoms of infection. A (TRUNCATED)

Based on interviews with the Nursing Home Administrator (NHA)/Risk Manager, Director of Nursing (DON), and Assistant Director of Nursing (ADON), Nursing staff, the attending Physician/Medical Director, record review of resident #3 and #57's medical record, review of the facility's policies, the facility's Administration failed to utilize its resources effectively by failing to investigate and act on two documented burn injuries for residents #3 and #57. A total of 52 out of 55 residents had the potential to request hot liquids. The facility documented the hot [MEDICAL CONDITION] 9/2/20 on the event log for September then failed to investigate and remove the burn risk potential for 52 of 55 residents. Further, the facility's Administration failed to identify, and decrease the risk for hot [MEDICAL CONDITION] failed to monitor the temperatures for the hot liquids for 21 days from 9/2/20 to 9/23/20. The Administration further failed to provide education/in servicing to kitchen staff and care staff related to identification of residents presenting with scald burn injuries and related to the identification of liquids being too hot for compromised and elderly residents. This resulted in the findings of Immediate Jeopardy, occurring on 9/2/20 and removed at 5:00 p.m. on 9/25/20 with the scope and severity reduced to a D. Findings included: 1. Review of the job description titled Nursing Home Administrator, last revised 11/28/2017 revealed Job Function: Responsible for directing the overall operation of the facility's activities with current applicable federal, state, local and corporate standards, guidelines and regulations ensuring the highest degree of quality resident care is always provided. Primary Responsibilities: Assure that the goals of the Nursing Home are being met - the provision of quality resident care in a highly respectful, highly regulated, well managed, and caring environment and billing and collection for these services. Complete other duties as assigned by supervisor Specific Duties: Responsible for training all Department Heads, by following Personal Policies, management training and budgeted hours. Participation in orientation-training program for new employees and monitor all training including, but not limited to, OJT, and in-services, monitor staff training period for all employees. Quality Assurance Committee including Pharmaceutical and Infection: Control Committees, Safety Committee, Department Head Meeting, Census and Medicare Meeting, Abuse Investigations and any required notifications, HIPPA Compliance Officer, Developing Implementing Plans of Correction, Risk Management Concerns I.e. Sentinel Events, Grievance Officer, Responsible for the Food Service Program, Monitor and control all contractual services and outside agencies. Review of job description titled Director of Nursing, last revised 4/3/2018, revealed: Job Function: Coordinate and direct all health care services provided to Resident. Supervises: Shift Coordinators, CNAs, MDS coordinators, Shift Nurses, Medical Services, Medical Records, Pharmacist. Reports to: Administrator Primary Responsibilities: Implement and monitor Facility Policies and Procedures to ensure that the facility is in compliance with all Federal and State Minimum Standards as they apply to nursing and medical services, Supervise all documentation of services provided to residents, interview, hire, train and supervise all employees under your supervision and review staff competency in dealing with medical issues and provide training on a regular and as needed basis, perform other duties as assigned by administrator. Specific Duties: Make rounds to check all aspects of resident care. Plan the day's medical activities, provide on-the-job training for new staff that works under your supervision, Supervise and conduct monthly meetings and other meetings as needed. Provide in-service training as scheduled. Develop an annual training calendar in advance to meet regulatory requirements, Complete weekly Accident and Incident Reports and compile a monthly report to be submitted to the Safety and QAPI Committees. Review numbers of Accidents and Incidents in facility to determine areas of concern. Develop a plan to correct and avoid reoccurrence of areas identified, Schedule and complete QAPI audits based on assessed resident' needs. Provide reports of findings, plans of actions and results at quarterly QAPI meetings, monitor completion of weekly measurements and documentation of wounds, Assist the Administrator with completion of Sentinel Events as needed, Spot check all nurses documentation by randomly auditing charts daily. 2. On 9/23/20 at 1:00 p.m., an interview was conducted with the Nursing Home Administrator and Director of Nursing. They were asked if they could provide information related to hot liquid [MEDICAL CONDITION] occurred on 9/2/20 with regards to Residents #3 and #57. Neither the Nursing Home Administrator nor the Director of Nursing could recall any residents being burned by hot liquids recently. They both indicated that they would look at the incident/accident injury event log. Once they looked at the incident/accident injury event log, they were able to see that both Residents #3 and #57 received hot [MEDICAL CONDITION] 9/2/20. Neither the Nursing Home Administrator nor the Director of Nursing could provide any further information. The Nursing Home Administrator and Director of Nursing (DON) both confirmed they never investigated either of the hot liquid burn incidents. At this time the Nursing Home Administrator (NHA) and DON were asked how they monitor hot liquid temperatures to ensure residents do not get burned or injured. They both indicated that it was the Certified Dietary Manager's (CDM) responsibility and they could not speak to exactly how that was done. The NHA and DON were both made aware that since they did not know how hot liquids were monitored for resident safety, that a coffee and hot water temperature demonstration would need to be conducted immediately and prior to the next meal service. During an interview on 9/25/20 at 1:47 p.m., with the Administrator and the DON, the DON stated the event log and the corresponding progress note in the computer were to be discussed in the morning meeting every day. However, on 9/2/20 the DON stated no events were discussed in the morning meeting and could not elaborate on the reason they were missed. The DON again confirmed the events were not discussed on 9/2/20 and did not have an answer why [MEDICAL CONDITION] not reviewed or investigated for 21 days from 9/2/20 to 9/23/20. The NHA confirmed the best practice would be to discuss events at the morning meeting but [MEDICAL CONDITION] 9/2/20 were missed. The NHA said the DON was responsible to review the events with the morning meeting management team. The DON was asked where the facility failed and she stated, It was with the date 9/2/20 because [MEDICAL CONDITION] it to the log but were never reviewed at the morning meeting. The DON stated she thought they failed to discuss [MEDICAL CONDITION] stated they need to evaluate why at the morning meeting they did not discuss the burns. The DON stated she was not sure why she was not notified about [MEDICAL CONDITION] would have expected the RN or LPN to notify her immediately. The DON stated once the facility was notified of [MEDICAL CONDITION] 9/23/20 the staff were trained on palatable coffee and if the resident requested hotter coffee, staff would need to go to the kitchen and only get the coffee from the dietary staff and not heat up the coffee. Dietary would do all temps on coffee before all meals. During review of the event log for September and interview on 9/23/20 at 3:48 p.m., with the ADON, she stated she created the event log from the event reports that are initiated by the nurses in the computer. The ADON confirmed she added Resident #3 and #57 to the event log related to [MEDICAL CONDITION] did not investigate the events as she thought the CDM was made aware by the nurse. Review of the event log for September found Resident #3's event occurred on 9/2/20 at 2:28 p.m., in her room. She was alert and oriented. Type of event was documented as skin tear/laceration. Possible cause was documented as Spilt hot beverage on lap and investigated cause was documented as Spilt hot beverage on lap. Injury was described as left outer thigh- red and small open blister noted. Doctor and family notified. Review of the event log for September for Resident #57's event found it occurred on 9/2/20 at 2:26 p.m., in her room. She was alert and oriented. Type of event was documented as skin tear/laceration. Possible cause was documented as Spilt hot beverage on lap and investigated cause was documented as Spilt hot beverage on lap. Injury was described as left upper thigh noted with red area. During an interview with the NHA, DON, and CDM on 9/23/20 at 3:55 p.m., the NHA stated the coffee machine company was contacted and the CDM was notified of the incidents. The Administrator stated the CDM had the coffee carafes sit for 45 minutes prior to serving. The CDM stated she could not recall having a conversation about coffee burns. The Administrator stated, That coffee temperatures are quantitative, and the temperatures could not be monitored without taking temperatures of the coffee in the carafe. The Administrator and DON were asked during the conversation, what the facility did from 9/2/20 to 9/23/20 related to [MEDICAL CONDITION] hot liquid. The Administrator stated the facility called the coffee machine company on 9/23/20 and, going forward, coffee and hot liquid temperatures would be taken prior to serving. The Administrator stated the vendor would be coming to adjust the temperature of the coffee machine. During an interview with the DON on 9/23/20 at 4:02 p.m., the DON stated they did not have a policy related to event investigations and would look for one related to hot liquids. During an interview with the DON on 9/24/20 at 12:19 p.m., she stated that she and the ADON were responsible for investigating events and she would have to look and see if she had any other documentation related to [MEDICAL CONDITION] than the event log. During an interview on 9/25/20 at 1:08 p.m. with the Director of Rehab (DOR), she stated, the residents in the building had not been assessed for safety and handling hot liquids, It's not something we usually do. 3. On 9/23/20 at 10:00 a.m. Resident #3' s electronic nursing progress notes documented by staff member E, Registered Nurse (RN) on 9/2/20 at 11:40 a.m., revealed that staff member E, RN was called to Resident #3's room for Evaluation of redness to the left thigh. Reddened area noted to left outer thigh, two dry ruptured blisters also noted. Resident states that she had spilled her coffee on it - was unsure of when it had happened. Physician and daughter notified. During an interview on 9/23/20 at 11:50 a.m. with staff member E., RN, she stated Resident #3 spilled her coffee on her left outer thigh. The thigh was red and had a burn. Staff member E, RN stated we document on the progress notes, event reports in the computer and the night shift nurse normally completed progress notes related to skin sweeps. Staff member E, RN stated Resident #3 currently had a red area that was not open. 4. Review of Resident #57's electronic nursing progress notes on 9/2/20 at 12:04 p.m. found the LPN documented, She was summoned to resident's room by therapist. The nurse made aware of quarter size red area to upper left thigh. Therapist informed the nurse that she observed coffee stain on resident's gown. Resident unaware of what happened. Resident does complain of area burning. The nurse spoke with the resident's son and notified him of the area on the left upper thigh red area. During an interview with Staff member F, Licensed Practical Nurse (LPN) on 9/23/20 at 1:00 p.m., she stated a resident was burned after spilling coffee a few weeks ago. Staff member F, LPN stated it was Resident #57, a recently admitted resident at the time. Staff member F, LPN stated her responsibility and protocol was to create the computer event report, document progress notes, notify the family and physician, and get orders. Staff member F, LPN stated that all nursing staff and administration could see the event log and that management would review. Staff member F, LPN stated she could print the reports for her residents in case she forgot to get report on someone or give report about an event. She said she would print out an event report for the oncoming nurse to review so they were aware. 5. On 9/23/20 at 10:40 a.m., an interview was conducted with the facility's Certified Dietary Manager (CDM) related to who was responsible for the brewing and maintaining of hot liquids to include coffee. The CDM revealed that it was the kitchen's responsibility to make and send out coffee to the floors/units. She further revealed that, since the COVID pandemic, there were only two places to make coffee and hot water, which were 1) In the kitchen, and 2) In the main dining room area. The CDM confirmed that at this point and currently, they brew the coffee for residents utilizing a leased coffee machine, which was in the main kitchen. The CDM further confirmed that the leased coffee machine in the main dining room was on and that they used it, but the coffee machine from the kitchen was only for residents. The CDM was then asked if she could remember any residents in the building being burned by either hot coffee or hot water. She said, I was told by staff maybe a few weeks ago that a resident received too hot of coffee but was never told if that resident received any burn injuries. She further confirmed it had not been brought to her attention from management about coffee serving temperatures, nor did management ever bring to her attention a resident or residents were burned by hot liquids. The CDM was then asked how she brewed coffee/hot water. She again explained that there was a leased coffee machine that brewed the coffee and the temperature was set within. She was asked how she maintained the coffee machine liquid temperatures and explained that the machine was always on preset temperatures so the coffee would either have to cool by placing it in the walk in refrigerator if too hot, or sit out in kitchen area near the coffee machine for a period of forty-five minutes to an hour. The CDM was asked how she monitored the coffee and hot water temperatures and was also asked what her and the facility's expectations were when it came to safe coffee/ and or hot water service to residents. The CDM stated that previously, she did not monitor the temperatures of coffee or hot water coming out from the machine, she did not monitor coffee or hot liquids prior to sending them out to the floor/units, and did not monitor coffee or hot liquid temperatures after they reached the floor/units. The CDM was asked if she had any type of log or documentation to show that she had taken temperatures of coffee or hot liquid in the past. She confirmed that was something she had never done before. During this time, the CDM was asked to show what the coffee/hot water temperatures were immediately after brewing and when they reach the floor to be served. On 9/23/20 at 11:00 a.m., the CDM stated that the coffee was ready to go out to the units/floor and was sitting in the metal coffee carafes for about one hour. She did not know what the coffee/hot water temperatures were prior to going out to the floor. Prior to leaving the kitchen area, the CDM was asked how she took temperatures of the hot coffee and hot water. She explained she utilized a regular stick, non-digital thermometer and calibrated it daily. The CDM said that she last calibrated this thermometer earlier today, 9/23/20, prior to the breakfast meal service. The CDM indicated that they only made and served coffee to the residents three times a day, which included, 1. Breakfast meal service, 2. Lunch meal service, and 3. Dinner service. The following was observed: On 9/23/2020 at 11:55 a.m., the CDM pushed a meal cart to the 400 hall. The cart had the coffee and hot water placed on top. The cart reached the 400 hall at 11:57 a.m., The CDM then poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 146 degrees F. The CDM confirmed the temperature at 146 degrees F. At 12:00 p.m., the CDM pushed another tray cart to the 200 hall. At 12:02 p.m., she poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 130 degrees F. The CDM confirmed the temperature at 130 degrees F. At 12:05 p.m., the CDM pushed another tray cart to the 600 transitional unit. At 12:07 p.m., she poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 145 degrees F. The CDM confirmed the temperature at 145 degrees F. At 12:11 p.m., the CDM pushed the final tray cart to the 300 hall. At 12:13 p.m., she poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 165 degrees F. The CDM confirmed the temperature at 165 degrees F. The CDM was asked what the expectations were for serving hot coffee and hot liquids to elderly and compromised residents. She could not give a specific number in degrees but rather stated, Coffee and hot liquids should be at palatable temperatures. The CDM and Surveyor then walked back to the kitchen to observe the coffee machine's liquid service temperatures. The following was observed: 1. The coffee machine in the main dining room had a door with a key. The key had already been in the lock. The door was opened and showing a digital read out that had a Tank temperature and a Dispense temperature. The dispensing temperature read 193 degrees F. The tank hold temperature read 198 degrees F. The kitchen coffee machine was also observed with a door with a key in the lock. The door was opened and revealed a dispensing temperature of 193 degrees F. The hold temperature read 198 degrees F. (Photographic evidence was taken). The CDM confirmed both machine temperatures and did not know what the temperatures should be and did not know what a safe hot liquid temperature should be for elderly and compromised residents. She also indicated that she could not change or adjust the temperatures but would call the coffee machine company serviceman to come out and look at it. On 9/23/2020 at 4:25 p.m., the CDM was asked to provide demonstration how the kitchen maintained and served coffee and hot water to residents. She indicated that coffee had already been poured from the machine into insulated metal carafes, ready to be taken out to the floor. At 4:30 p.m., a kitchen aide (Employee T) was observed in the kitchen carrying two metal insulated coffee carafes from the walk-in refrigerator to the dining room to place on the meal carts. Employee T said she had just removed the carafes from the walk-in refrigerator and tested the temperatures and said the temperature was 120 degrees F. She said that they now go on the meal carts to be transported to the floor/units. Employee T said that when the coffee was poured from the coffee/hot water machine, the temperatures were at 165 degrees F. The CDM was asked to take the temperature of the coffee once it reached the floor/units. Prior to that, the coffee/hot water machine in the kitchen and the coffee/hot water machine in the main dining room were observed for internal liquid temperatures. The machines had a digital read out that included the dispensing temperature and tank holding temperature. At 4:40 p.m. both coffee machines in the kitchen and dining room had the following: 1. Dispensing temperature - 193 degrees F. and 2. Tank holding temperature - 198 degrees F. (Photographic evidence was taken). The following was observed on 9/23/20 during the dinner service: The CDM pushed the meal tray cart from the kitchen at 4:42 p.m., and reached the 600-transition unit at 4:43 p.m. She poured a half cup of coffee into a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 132 degrees F. The CDM confirmed the temperature reached 132 degrees F. The staff was observed serving the coffee to the residents, they provided assistance such as adding cream, sugar, and sugar substitute if requested, and ensured the residents were able to reach the coffee cup. The CDM pushed a meal tray cart from the kitchen and reached the 200 hall at 4:46 p.m. She poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 127 degrees F. She confirmed that the temperature reached 127 degrees F . The CDM pushed a meal tray cart from the kitchen and reached the 400 hall at 4:56 p.m. She poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 139 degrees F. She confirmed that the temperature reached 139 degrees F . The CDM pushed a meal tray cart from the kitchen and reached the 300 hall at 5:15 p.m. She poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 122 degrees F. She confirmed the temperature reached 122 degrees F. The CDM stated, I don't know how the coffee temperature rose as I believed my staff temped the coffee prior to leaving the kitchen at 120 degrees F. During an interview on 9/23/20 at 4:56 p.m., with the Administrator, he confirmed the facility did not have a hot liquid policy, just a hot food policy. On 9/23/20 at approximately 5:30 p.m., the Nursing Home Administrator was interviewed and informed about the lunch meal service coffee temperatures. He stated he understood about the high liquid temperatures and would have an action plan put in place. On 9/24/20 at 6:10 a.m. the building was entered in order to observe coffee/hot water service prior to breakfast meal service. At 7:08 a.m., the CDM and two cooks revealed that this a.m. at 5:00 a.m. they prepared coffee. The CDM related that the coffee machines were always on in the kitchen and the main dining room. She revealed that she and her staff poured coffee from the coffee machine in the kitchen and took it directly to the freezer to cool. The CDM indicated that the pour temperature was 167 degrees F. and coffee/hot water after pour was taken to the walk-in freezer to sit for an unspecified time. She added that the coffee was then removed from the freezer and tested with a calibrated thermometer. She reported that the temperatures reached 120 degrees F. The CDM was asked to take coffee/hot liquid temperatures once they reached the floor/units. The process was as follows. A meal tray cart left the main dining room/kitchen area at 7:08 a.m. and reached the 200 hall at 7:10 a.m. The CDM poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 110 degrees F. She confirmed the temperature reached 110 degrees F. A meal tray cart left the main dining room/kitchen area at 7:13 am. and reached the 600-transition hall at 7:15 a.m. The CDM poured a half cup of coffee in a white disposable cup, from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 110 degrees F. She confirmed the temperature reached 110 degrees F. A meal tray cart left the main dining room/kitchen area at 7:18 a.m. and reached the 400 hall at 7:20 a.m., The CDM poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 125 degrees F. She confirmed the temperature reached 125 degrees F. A meal tray cart left the main dining room/kitchen area at 7:35 a.m. and reached the 300 hall at 7:35 a.m. The CDM poured a half cup of coffee in a white disposable cup from one of the metal coffee insulated carafes. After the thermometer was in the cup for about thirty seconds, the temperature reached 120 degrees F. She confirmed the temperature reached 120 degrees F. During an interview on 9/23/20 at 4:15 p.m., with the CDM she stated that she was unsure how many residents drank hot liquids and would print out a list. The CDM stated she was not sure how many residents preferred coffee. She provided a beverage roster that revealed eight residents preferred hot tea, coffee or cocoa. However, she said any resident can request coffee, but those eight were the only residents she had documented. At 5:30 p.m. the NHA and DON were asked how many residents had the likelihood to drink hot liquids. The NHA and DON provided the list on 9/24/2020 at approximately 11:00 a.m. During an interview with the CDM while in the kitchen, she stated the water temperature was 120 degrees after sitting for 20 minutes from the coffee machine. During an interview with Staff member U, dietary aide on 9/23/20 at 4:30 p.m., she stated she had taken the temperature of coffee after dispensing from the coffee machine. The temperature was 165 degrees F. So, she put the coffee in the cooler for ten minutes. 6. During an interview with the coffee machine representative on 9/24/20 at 3:54 p.m., he stated that all the coffee machines come from the company with a stock temperature of 190 degrees which could be adjusted to as low as possibly 110 degrees. The representative stated I can't tell anyone what to set the temperature to. However, I could tell someone how to reduce the temperature. The representative stated he was told the scald point is about 150 degrees and stated the Administrator told him to set the machine at 135 degrees. The representative stated he was not contacted to adjust the coffee temperatures until today but could have walked the CDM through it over the phone. He stated the machine would take a while to drop the temperature of the coffee and recommended the facility place the coffee in the chiller for about 10 minutes to drop the temperature down 20 to 30 degrees. 7. During an interview and observation of Resident #3 after readmission on 9/25/20 at 6:30 p.m., the resident stated she spilled her coffee on herself, but it no longer hurts, it's healed now. Resident #3 consented to observation which revealed a pink left outer thigh area measuring approximately 5 centimeters long by 1 centimeter wide. Resident #3 rubbed her hand over the area and stated again stated, It's healed now. Review of the electronic record for Resident #3 revealed a Brief Interview for Mental Status (BIMS), dated 8/17/20, of 12 indicating moderate impairment. Section G, from Minimum Data Set (MDS) functional status, H. eating - how resident eats and drinks regardless of skill revealed a self- performance of 1. Supervision - oversight, encouragement or cueing and support of 1 indicated set up help only. Review of Resident #3's physician order: Regular diet dated 8/12/20. Resident on hospice dated 8/12/20. Skin sweep once a day on Thursday from 6:00 p.m. to 6:00 a.m., dated 8/17/20. Monitor burn to left upper thigh until resolved twice a day dated 9/2/20. Review of Resident #3's care plan with last revision date 8/19/20 identified problem start date on 10/11/18 of impaired vision related to [DIAGNOSES REDACTED]. Goal date of 11/19/20, resident will not experience negative consequences of vision loss as evidenced by; remaining physically safe, and participating in social, and self-care activities. Review problem dated 9/23/20 revealed resident at risk for spilling her coffee related to shaking. Approach dated 9/23/20 resident to have a ½ cup of coffee to be provided and nursing to evaluate. During an interview on 9/25/20 at 1:41 p.m., with Rehab Director, she stated Resident #3's biggest issue was her vision loss. Review of the occupation therapy evaluation, dated 6/19/20 to 7/18/20, found self-feeding underlying impairments as low vision. 8. During an interview with the Director of Rehab (DOR) on 9/25/20 at 1:08 p.m., she confirmed she observed Resident #57 sitting in a big puddle of coffee on the floor under her wheelchair and cleaned up the floor. The Director of Rehab stated she could not see anything on Resident #57's clothes but halfway through therapy the resident started complaining the inside of her leg felt weird. The DOR stated she looked at Resident #57's left inner leg. It was a red long oval shaped area. The DOR stated she went to get the nurse and she could see the top layer of skin was peeling (like a sunburn). The nurse went to get a dressing. Review of the physical therapy daily treatment notes, dated 9/2/20 at 6:23 p.m., revealed the Director of Rehab documented Resident #57 received for therapy this date sitting up in wheelchair with large puddle of (what appeared to be) coffee on floor underneath/behind her chair. Empty cup was sitting on tray table; however; patient had no recollection of spilling it. This therapist cleaned up spill and commenced treatment without incident. About halfway through session, patient with complaints of a burning sensation at inner thigh. Skin was inspected with a small red streak and slight peeling of top layer of skin evident at left inner thigh. Nurse F, LPN was made aware. Performing skin inspection and topical treatment at the end of the physical therapy session. Plan for next session. Review of the nursing progress notes for Resident #57, dated 9/9/20 at 1:33 p.m., and documented by the LPN revealed an area to left upper thigh is no longer red in color. Color is brownish. No complaints offered. Review of the nursing progress notes, dated 9/12/20 at 5:52 a.m., documented by the LPN revealed Resident #57 complaining of itching on the red area on her left upper thigh. When checked, the area appears to be scabbing. Site is cleansed and covered with dressing to avoid unconscious scratching and reopening of the scabs. Resident tolerated it well throughout the night. Review of the nursing progress notes, dated 9/13/20 at 2:26 a.m., and documented by the LPN revealed no new skin issues noted during skin check. Existing skin concerns have treatments in place. Review of the nursing progress notes dated 9/13/20 at 1:07 p.m. and documented by the LPN revealed Resident #57's observed dressing on left upper thigh. Dressing removed observed drainage on dressing. Observed area with slough. Area cleaned with normal saline, triple antibiotic ointment and dressing applied. Resident denies pain to area. Review of the nursing progress notes dated 9/18/20 at 4:48 p.m., documented by the RN revealed the resident with open area located to left upper thigh. Observed redness around the area, hot to touch. Resident referred itching and discomfort. Treatment completed as ordered with triple antibiotic ointment during the shift. Physician notified. Waiting for wound care evaluation. Oncoming nurse notified. Continues monitoring. Review of the physician orders [REDACTED]. Start dated of 9/13/20 revealed to cleanse left upper thigh with normal saline, apply triple antibiotic ointment and cover with dressing daily. Start date 9/7/20 skin sweep once a day on Saturday. Review of car (TRUNCATED)