Every finding on record at Heritage Hall-Leesburg

Based on staff interview, clinical record review, and facility document review, staff interview, the facility staff failed to maintain a resident free of unnecessary medications for one of 44 residents in the survey sample, Resident #97 (R97). The findings include: For (R97), facility staff failed to administer a prn (as needed) the pain medication Oxycodone (1) within the physician ordered pain level parameters. (R97) was admitted to the facility with a diagnosis that included but was not limited to back pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/22/2025, R97 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating (R15) was cognitively intact for making daily decisions. The physician's order for R97 documented in part, oxycodone (pain medication) HCl (hydrochloride) Oral Tablet 5 (five) MG Milligrams). Give 1 (one) tablet by mouth every 6 (six) hours as needed for pain as needed for pain rate >6/10 (greater than six out of ten). Order Date: 11/26/2024. The eMAR (electronic medication administration record) for R97 dated December 2024 documented the physician order as stated above. Further review of the eMAR revealed that R97 received five milligrams of Oxycodone on 12/05/2024 with pain level of five, 12/09/2024 with pain level of five, 12/20/2024 with pain level of five, 12/21/2024 with pain level of five, and on 12/31/2024 with pain level of three. The eMAR (electronic medication administration record) for R97 dated January 2025 documented the physician order as stated above. Further review of the eMAR revealed that R97 received five milligrams of Oxycodone on 01/03/2025 with pain level of three and on 01/23/2025 with pain level of five. On 01/29/2025 at approximately 9:25 a.m., an interview was conducted with LPN (licensed practical nurse) #2. After reviewing the physician's order for oxycodone and the eMARS dated above for R97, LPN #2 was asked about the administration of pain medication on the dates listed above. LPN #2 stated, The physician's order was not followed for the administration of oxycodone. The facility's policy Medication Administration. General Guidelines documented in part, Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls the provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. On 01/29/2025 at approximately 12:20 p.m., ASM (administrative staff member) # 1, administrator and ASM # 2, assistant administrator and ASM #3, director of nursing, were made aware of the above findings. No further information was presented prior to exit. References: (1) Oxycodone is used to relieve moderate to severe pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682132.html.

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a medication error rate less than five percent for one of three residents observed during the medication administration observation, Resident #23. During the medication administration observation, two errors out of 29 opportunities occurred, resulting in a 6.9 percent medication error rate. The findings include: For Resident #23 (R23), LPN (licensed practical nurse) #1 failed to administer gabapentin and Breo Ellipta per physician's orders. A review of R23's clinical record revealed a physician's order dated 1/29/24 for gabapentin 100 mg (milligrams)- one capsule by mouth in the morning for pain and a physician's order dated 5/2/24 for Breo Ellipta 100/25 mcg (micrograms)- one inhalation in the morning for chronic obstructive pulmonary disease (lung disease), rinse mouth with water post use. On 1/28/25 at 7:38 a.m., an observation of LPN #1 preparing and administering medications to R23 was conducted. LPN #1 administered two capsules (instead of the physician prescribed one capsule) of gabapentin 100 mg to the resident. Also, LPN #1 failed to offer/assist R23 with rinsing her mouth with water after the Breo Ellipta was administered. On 1/28/25 at 1:28 p.m., an interview was conducted with LPN #1. LPN #1 reviewed R23's physician's orders. LPN #1 stated, I administered two capsules of gabapentin to R23, and I should have only administered one capsule. LPN #1 further stated, I should have assisted R23 with rinsing her mouth after the Breo Ellipta administration. On 1/28/25 at 4:15 p.m., ASM (administrative staff member) #1 (the administrator), ASM #2 (the assistant administrator), and ASM #3 (the director of nursing) were made aware of the above concerns. The facility policy titled, Medication Administration documented, 3. Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record. No further information was presented prior to exit.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to provide accommodations of resident needs by ensuring the call bell (a device with a button that can be pushed to alert staff when assistance is needed) was within reach for two of 44 residents in the survey sample, Residents #19, (R19) and R67. The findings include: 1. For R19, the facility staff failed to keep the call bell within reach. R19 was admitted to the facility with a diagnosis that included by not limited to difficulty breathing. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/07/2024, R19 scored 12 out of 15 on the BIMS (brief interview for mental status), indicating R19 was moderately impaired of cognition for making daily decisions. On 01/27/25 at approximately 7:44 p.m. an observation revealed R19 lying in bed. When asked to locate the call bell R19 was unable to find it and stated she did not know where the call bell was located. Observation of the bed revealed the call bell hanging from the underside of the bed. After being informed of the location of the call bell, R19 was asked if she could reach the call bell. R19 stated no. On 01/29/2025 at approximately 9:03 a.m. an interview was conducted with [NAME] CNA (certified nursing assistant) #1 regarding the placement of a resident's call bell. She stated that the call bell is placed within the resident's reach, clipped to the resident's blanket in front of the resident. CNA #1 further stated the resident's call bell placement should be checked each time staff go into the resident's room. The facility's policy Answering the Call Light it documented in part, General Guidelines. 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. On 01/29/2025 at approximately 12:20 p.m., ASM (administrative staff member) # 1, administrator and ASM # 2, assistant administrator and ASM #3, director of nursing, were made aware of the above findings. No further information was presented prior to exit. 2. For R67, the facility staff failed to keep the call bell within reach. R67 was admitted to the facility with a diagnosis that included by not limited to muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/06/2025, R67 scored 2 (two) out of 15 on the BIMS (brief interview for mental status), indicating R67 was severely impaired of cognition for making daily decisions. On 01/28/25 at approximately 8:46 a.m., an observation revealed R67 slouched in bed, leaning to the right side, the head of the bed raised. Observation of call bell revealed it was clipped to top left corner of the mattress at the head of the bed. On 01/28/25 at approximately 8:52 a.m., an observation of R67, the call bell and interview were conducted with CNA (certified nursing assistant) #1. When asked if R67 could reach the call bell, CNA #1 stated the call bell was not withing R67's reach. On 01/29/2025 at approximately 9:03 a.m. an interview was conducted with CNA (certified nursing assistant) #1 regarding the placement of a resident's call bell. She stated , The call bell is placed within the resident's reach, clipped to the resident's blanket in front of the resident. CNA #1 further stated, The resident's call bell placement should be checked each time staff go into the resident's room. On 01/29/2025 at approximately 12:20 p.m., ASM (administrative staff member) # 1, administrator and ASM # 2, assistant administrator and ASM #3, director of nursing, were made aware of the above findings. No further information was presented prior to exit.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide respiratory care and services for one of 44 residents in the survey sample, Resident #32 (R32). The findings include: For R32, facility staff failed to store the incentive spirometer (1) in a sanitary manner. R32 was admitted to the facility with a diagnosis that included by not limited to generalized muscle weakness. On the most recent comprehensive MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/23/2024, R32 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating R32 was cognitively intact for making daily decisions. On 01/28/25 at approximately 8:18 a.m., an observed revealed R32 lying in bed. Observation of an incentive spirometer laying on top of the bedside table inside a plastic bag. Further observation revealed the mouthpiece of the incentive spirometer hanging outside of the bag resting on the bedside table. On 01/28/25 at approximately 11:20 a.m., an observed revealed R32 lying in bed. Observation of an incentive spirometer laying on top of the bedside table inside a plastic bag. Further observation revealed the mouthpiece of the incentive spirometer hanging outside of the bag resting on the bedside table. The physician's order for R32 documented in part, Encourage resident to use incentive spirometer q (every) shift as tolerated. For respiratory therapy. Order date: 10/15/2024. On 01/28/2025 at approximately 11:25 a.m., an interview was conducted with R32 regarding the use of the incentive spirometer. R32 stated that He used the spirometer. On 01/29/2025 at approximately 12:25 p.m., an interview was conducted with LPN (licensed practical nurse) #3 regarding the storage of a resident's incentive spirometer when not in use. She stated, The spirometer including the mouthpiece should be kept in a plastic bag to keep it from being contaminated. On 01/29/2025 at approximately 12:20 p.m., ASM (administrative staff member) # 1, administrator and ASM # 2, assistant administrator and ASM #3, director of nursing, were made aware of the above findings. No further information was presented prior to exit. References: (1) A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm.

Based on observation, staff interview, and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens. The findings include: On 9/20/22 at 12:15 PM, a tour of the facility kitchen was conducted with OSM #1 (Other Staff Member) the Dietary Manager. In the walk-in freezer, a box of dinner rolls was noted to have been opened, and the bag inside with the dinner rolls was left open to air, exposing the rolls to the freezer environment. When asked if the box should be left open, OSM #1 stated that it should be closed and sealed. He removed the box and discarded it. The facility policy, Cost Containment - Food Storage: General was reviewed. This policy documented, 6. All foods that have been opened and partially used shall be dated and sealed before returning to a storage area. On 9/21/22 at 1:05 PM, ASM #1 (Administrative Staff Member) was made aware of the findings. No further information was provided by the end of the survey.

Based on staff interview, clinical record review, and facility document review, it was determined the facility staff failed to accurately code an MDS (Minimum Data Set) assessment for two of 40 residents, Resident #2 and Resident #433. The facility staff failed to code an MDS (minimum data set) discharge assessment for Resident #2 and Resident #433. The findings include: 1. Resident #2 was admitted to the facility on [DATE] and discharged home on 4/27/22. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 4/27/22, coded the resident as scoring a 10 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. Further review of Resident #2's MDS dated [DATE], the last MDS done for this resident revealed Section A0310 Type of Assessment: F: Entry/Discharge Reporting: revealed coding of 99 (none of the above). MDS Section A2000 discharge date : revealed no discharge date entered. A review of the nursing progress note dated 4/27/22, revealed, Resident discharge home with family. An interview was conducted on 9/21/22 at 1:25 PM with RN (registered nurse) #2, the MDS coordinator. When asked to review Resident #2's MDS dated [DATE] Section A2000, RN #2 stated, yes, there should have been a discharge date entered there. When asked what standard is followed for MDS completion, RN #2 stated, we follow the RAI (resident assessment instrument). On 9/21/22 at 2:15 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations and ASM #4, the administrator in training. A review of the RAI included: Assessment Types and Definitions: In order to understand the requirements for conducting assessments of nursing home residents, it is first important to understand some of the concepts and definitions associated with MDS assessments. Concepts and definitions for assessments are only introduced in this section. Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility . No further information was provided prior to exit. 2. Resident #433 was admitted to the facility on [DATE] and discharged on [DATE]. The most recent MDS (minimum data set) assessment, a 5 day Medicare assessment, with an ARD (assessment reference date) of 5/16/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. Further review of Resident #433's MDS dated [DATE], the last MDS done for this resident revealed Section A0310 Type of Assessment: F: Entry/Discharge Reporting: revealed coding of 99 (none of the above). MDS Section A2000 discharge date : revealed no discharge date entered. A review of the nursing progress note dated 5/16/22, revealed, Resident discharge to assisted living facility. An interview was conducted on 9/21/22 at 1:25 PM with RN (registered nurse) #2, the MDS coordinator. When asked to review Resident #433's MDS dated [DATE] Section A2000, RN #2 stated, yes, the resident came off of skilled services on 5/16/22 and transferred to an ALF (assisted living facility) and there should there have been a discharge assessment completed return not anticipated, there should have been a discharge date entered there. When asked what standard is followed for MDS completion, RN #2 stated, we follow the RAI (resident assessment instrument). On 9/21/22 at 2:15 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the regional vice president of operations and ASM #4, the administrator in training. A review of the RAI included: Assessment Types and Definitions: In order to understand the requirements for conducting assessments of nursing home residents, it is first important to understand some of the concepts and definitions associated with MDS assessments. Concepts and definitions for assessments are only introduced in this section. Discharge Assessment refers to an assessment required on resident discharge from the facility, or when a resident's Medicare Part A stay ends, but the resident remains in the facility . No further information was provided prior to exit.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to conduct a review of the advance directive for one of 40 residents in the survey sample, Resident # 44 (R44). The findings include: For (R44) the facility staff failed to evidence documentation of a discussion regarding advance directives for Resident # 44. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/12/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Review of the facility's Advance Directive Acknowledgement for (R44) dated 08/24/2020 revealed that (R44) executed an advance directive and provided the facility with a copy of the advance directive. The facility's social service note for (R44) dated 02/05/2022 documented in part, Resident will remain a DNR code status. Further review of the social service note failed to evidence discussion of an advance directive. The POS (physician's order sheet) for (R44) dated September 2022 documented in part, Do Not Resuscitate (DNR). Order Date: 12/06/20. The social service note for (R44) dated 07/18/2022 documented in part, Resident remains a DNR per her choice. Further review of the note failed to evidence that (R44's) advance directive was discussed or reviewed. On 09/21/22 at approximately 12:29 p.m., an interview was conducted with OSM (other staff member) #2, director of Social Services. After reviewing their notes for (R44) dated 07/18/2022 and the facility's policy for advance directives, OSM #2 was asked about the review of (R44's) advance directive. OSM #2 stated that it was discussed, however did not have documentation of it. OSM # 2 further stated that if it was not documented then they could not say it was done. The facility's policy Advance Directives documented in part, 18. The Interdisciplinary Team will review annually with the resident his or her advance directive to ensure that such directives are still the wishes of the resident . On 09/21/2022 at approximately 2:17 p.m., ASM (administrative staff member) # 1, administrator, and ASM # 2, director of nursing, ASM # 3, regional VP of operations, ASM # 4, administer in training and ASM # 5, regional nurse consultant, were made aware of the above findings. No further information was provided prior to exit

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to follow the comprehensive care plan for one of 40 residents in the survey sample; Resident #6. The findings include: For Resident #6, the facility staff failed to implement the comprehensive care plan for administering oxygen at the ordered rate. Resident #6 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], the resident was coded as being cognitively intact in ability to make daily decisions. The resident was coded as being on oxygen therapy. On 9/20/22 at 12:30 PM and 9/21/22 at 8:05 AM, Resident #6 was observed in bed, wearing the nasal cannula for the oxygen. The oxygen concentrator was set for 2.5 liters per minute. A review of the comprehensive care plan revealed one dated 3/5/20 for At risk for respiratory/cardiac complications This care plan included an intervention dated 12/12/21 for O2 per order. A review of the clinical record revealed a physician's order dated 12/21/21 for O2 (oxygen) on 2L (two liters) via NC (nasal cannula) cont (continuous). On 9/21/22 at 8:10 AM an interview was conducted with LPN #3 (Licensed Practical Nurse). She stated that the resident's oxygen rate should be at 2 liters. She observed the oxygen concentrator and verified it was set at 2.5 liters. She adjusted the rate. When asked if the care plan for administering oxygen at the physician ordered rate was being followed, she stated that it was not. The facility policy Care Plans, Comprehensive Person-Centered was reviewed. This policy documented, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. On 9/21/22 at 1:05 PM, ASM #1 (Administrative Staff Member) was made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to administer oxygen at the physician ordered rate for 1 of 40 residents in the survey sample; Resident #6. The findings include: For Resident #6, the facility staff failed to administer oxygen at the physician ordered rate. Resident #6 was admitted to the facility on [DATE]. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], the resident was coded as being cognitively intact in ability to make daily decisions. The resident was coded as being on oxygen therapy. A review of the clinical record revealed a physician's order dated 12/21/21 for O2 (oxygen) on 2L (two liters) via NC (nasal cannula) cont (continuous). On 9/20/22 at 12:30 PM and 9/21/22 at 8:05 AM, Resident #6 was observed in bed, wearing the nasal cannula for the oxygen. The oxygen concentrator was set for 2.5 liters per minute. On 9/21/22 at 8:10 AM an interview was conducted with LPN #3 (Licensed Practical Nurse). She stated that the resident's oxygen rate should be at 2 liters. She observed the oxygen concentrator and verified it was set at 2.5 liters. She adjusted the rate. When asked how is the rate read, she stated that the ball is set at the line for the ordered rate, with the line crossing through the center of the ball. When asked if physician's orders for oxygen being followed, she stated it was not. A review of the comprehensive care plan revealed one dated 3/5/20 for At risk for respiratory/cardiac complications This care plan included an intervention dated 12/12/21 for O2 per order. The facility policy Oxygen Administration was reviewed. This policy documented, 1. Verify that there is a physician's order for this procedure. Review the physician's orders of facility protocol for oxygen administration. On 9/21/22 at 1:05 PM, ASM #1 (Administrative Staff Member) was made aware of the findings. No further information was provided by the end of the survey.

Based on resident interview, observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a clean and homelike environment for one of four shower rooms observed in the facility, (Unit two shower room). The facility staff failed to maintain the shower room on Unit two in a sanitary manner. The findings include: On 5/4/2021 at approximately 4:40 p.m., an interview was conducted with Resident #108. Resident #108 stated that the care they received at the facility was excellent and the staff were wonderful however there was always visible mold in the shower room when they took a shower. Resident #108 stated that they were a former housekeeper and noticed things like that. Resident #108 was admitted to the facility with diagnoses that included but were not limited to heart failure (1) and diabetes (2). Resident #108's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/19/21, coded the resident as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. On 5/5/2021 at approximately 9:30 a.m., an observation was made of the shower unit on Unit two. Observation revealed a black substance along the border near the floor between the tile flooring and the shower wall. Observation revealed the black substance came off when scraped with a finger. The black substance on the border was observed isolated to the interior of the shower stall walls only. On 5/5/2021 at approximately 9:35 a.m., an interview was conducted with OSM (other staff member) #2, the director of environmental services. OSM #2 observed the black substance along the border of the shower stall on Unit two and touched the film with their finger to determine that it scraped off. OSM #2 stated that stated that housekeeping staff cleaned the shower room walls each day with a peroxide cleaner. OSM #2 stated that housekeeping staff performed a deep cleaning of the shower rooms weekly where they clean the tiles with bleach and scrub them with a brush. OSM #2 stated that they had looked at the shower room the past week and it did not look like it currently did. OSM #2 stated that staff did not have a set schedule of when to do the deep clean so they were not sure when this was last done. OSM #2 stated that the black film along the shower floor border may have been a little more than a week's worth of buildup. OSM #2 stated that they had discussed that the possible cause of the black film in the area may have been caused by the caulking coming up. OSM #2 stated that they had not discussed a plan to fix the problem and they planned to put in a maintenance request to have them look at the area. OSM #2 stated that the area Needed a good scrubbing, and that they would have a staff member take care of it. OSM #2 stated that the presence of the black film around the shower border did not promote a homelike environment for residents. The facility policy, Support Area documented in part, .Support Areas: Pantries, Shower rooms, soiled and clean linen, storage, central bathing, public bathrooms, offices, employee breakroom, locker rooms, and any other rooms that residents do not have access to without supervision. These are rooms that are used to support the staff and building . The policy further documented, .Restroom/bathing areas: Clean and disinfect using disinfectant and ORANGE cleaning rags. Change rag as needed to ensure saturation. No double dipping .Wipe shower or tub/shower .Clean tile for mold and dirt . On 5/5/2021 at approximately 2:15 p.m., ASM (administrative staff member) #1, the administrator was made aware of the above concern. No further information was presented prior to exit. References: 1. Heart failure: A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/ 8.htm. 2. Diabetes mellitus: A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm.

Based on observation, staff interview, and facility document review it was determined facility staff failed to discard food items past their use-by date in one of three pantry/nourishment rooms observed, (Unit one pantry room). The facility staff failed to discard four bottles of Ensure (nutritional supplement drink) that were past their use-by date and available for resident use in the Unit one pantry/nourishment room in the facility. The findings include: On [DATE] at approximately 9:45 a.m., an observation was made of the refrigerator located in the pantry/nourishment room on Unit one at the facility. Observations revealed two Ensure French Vanilla flavored 11 fl. oz. (fluid ounce) bottles labeled with a resident name and room number. The two bottles were observed with a manufacturer's use-by date of 1JAN2021 ([DATE]). Additional observations revealed another Ensure French Vanilla flavored 11 fl. oz. bottle labeled with a resident name and room number with a manufacturer use-by date of 1OCT2020 ([DATE]). Further observation of the Unit one refrigerator revealed one Ensure Mixed Berry 11 fl. oz. bottle labeled with a resident name and room number with a manufacturer use-by date of 1FEB2021 ([DATE]). The bottles were observed located in the refrigerator drawer available for use. On [DATE] at approximately 9:55 a.m., an interview was conducted with OSM (other staff member) #1, the dietary manager. OSM #1 stated that the dietary staff maintained the stock of the snacks and drinks that were available for use in the pantry/nourishment rooms in the facility. OSM #1 stated that dietary staff monitor the use-by dates on everything in the rooms daily. OSM #1 stated that the four bottles of Ensure labeled with the resident's name and room number were expired and should not have been available for use. OSM #1 stated that the bottles should have been thrown away. OSM #1 stated that their staff may have thought that they did not need to check those items because they had a resident name on them. OSM #1 stated that they would remove the items and re-educate the staff that they were responsible for all items in the pantry/nourishment rooms. The facility policy Covering, Labeling, Dating Food, dated [DATE].2015, Updated 12.1.2018 documented in part, .Pantry Refrigerators Storage: 1. Follow manufacturer expiration dates or use by dates when provided to determine when a food should be discarded .4. All nutritional supplements are to be checked daily for expiration dates. All products with expired dates are to be discarded . On [DATE] at approximately 2:15 p.m., ASM (administrative staff member) #1, the administrator was made aware of the findings. No further information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to implement its policy to report an allegation of abuse for one of eight residents in the survey sample, Resident #7. The facility staff failed to report an allegation of sexual abuse for Resident #7 within two hours. The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/4/202, Resident #7 was coded as being moderately impaired for making daily decisions, having scored 10 out of 15 on the BIMS (brief interview for mental status). He was coded as expressing feeling down and feeling tired more than once during the lookback period. He was coded as having no hallucinations or delusions during the lookback period. He was coded as requiring the extensive assistance of staff for all activities of daily living, as being unsteady for balance, and as using a wheelchair and walker for locomotion. On 1/21/21 at 12:29 p.m., Resident #7 was observed sitting on the side of his bed in his room. Resident #7 did not respond to attempted interview questions from the surveyor. A review of the FRI (facility reported incident) submitted by the facility to the state agency on 1/13/21 revealed, in part: Incident: Allegation of sexual abuse .Report date: 1/13/21 .Incident date: 1/12/21 .On 1/9/21 (Resident #7) stated there was a creepy man standing at the end of his bed. The DON looked around and there were no men around and she continued to try to reassure (Resident #7) that he was safe. (ASM (administrative staff member) #2, the director of nursing) called the spouse and she stated that 'He has those delusions; they have been going on for years.' On 1/12/21 (Resident #7) called the police and told them he had been sexually abused. The social worker went to his room and spoke to (Resident #7) and there was no one there bothering him and he was stating it occurred at work last week. She kept reassuring him that he was safe. He states there is a tall, white man, and there were only female employees working on that unit. Resident assessed and there were no injuries. Staff is providing frequent psychosocial checks for his health and wellness. Full investigation to follow. FINAL: DON (Director of Nursing) spoke with (name of Detective). Detective did not open a case based on resident accusations and validity. There had not been any males taking care of resident on the unit meeting resident's observation. Resident had reported a large white male named Earl, creepy (sic) staring at him. (Resident #7) was assessed by NP (nurse practitioner) and there was no injury. Ongoing confusion noted. (Resident #7) was also assessed to assure all psychosocial needs are being met. Resident is able to voice his needs and voices no complaints or concerns. Social Services will continue to follow up and assess as needed to ensure (Resident #7)'s needs are being met. Social Services will continue to follow up and assess as needed to assure needs are being met. (Name of APS 9adult protective services) staff member) also reviewed resident's [DIAGNOSES REDACTED].APS also concluded that resident was not in any danger of immediate harm. A review of Resident #7's clinical record revealed a note from ASM #3, the NP (nurse practitioner), which was dated 1/13/21. The note documented a full physical assessment of the resident, with no bruising or other evidence of injury or abuse. The note documented: Confusion continues. On 1/22/21 at 11:03 a.m., OSM (other staff member) #4, the social worker, was interviewed. She stated that at the time of the incident described in the above referenced FRI, ASM #1, the administrator, was out sick. She stated she and ASM #2, the DON, and a regional administrator worked together to investigate the allegation. She stated staff members were interviewed, and other residents were also interviewed. She stated that based on the evidence, including Resident #7's history of dementia and delusions, the facility staff determined the allegation of sexual abuse made by the resident was unsubstantiated. On 1/22/21 at 11:11 a.m., ASM #4, the assistant administrator, was interviewed. She stated that at the time of the incident, It was just (ASM #2) and me. She added a regional corporate manager was also in the building and provided guidance regarding the investigation and reporting of this incident. She stated ASM #2, (the director of nursing) reported that Resident #7 had called the police, and had told ASM #4 that he had been assaulted last week at work. ASM #4 stated ASM #2 reported this information to her on 1/12/21, and that she completed the FRI and sent it to the state agency on 1/13/21. On 1/22/21 at 11:31 a.m., ASM #2, the DON, was interviewed. She stated that at approximately 6:00 p.m. on 1/12/21, she was informed by ASM #4 that Resident #7 had contacted the police and told them that there was currently a male standing in his room. She stated she and ASM #4 had gone to Resident #7's room and had found no one there. ASM #2 stated she and ASM #4 provided reassurance to Resident #7, assuring him that he was safe. She stated that a regional administrator had provided guidance to her and to ASM #4 regarding the investigation, and the reporting of the incident. ASM #2 stated, We knew we had 24 hours to report it. On 1/22/21 at 3:00 p.m., ASM #1 was notified of these concerns. She stated she was not in the facility at the time the FRI was submitted, and she did not have first-hand knowledge about the timing of the report to the SA. A review of the facility policy, Abuse, Neglect and Exploitation Prevention and Reporting, revealed, in part: 'Sexual Abuse' is non-consensual contact of any type with a resident .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. No further information was provided prior to exit. References: (1) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm. (2) A delusion is a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary. The belief is not congruent with one's culture or subculture, and almost everyone else knows it to be false .The [DIAGNOSES REDACTED]. An individual's cultural beliefs merit consideration before coming to the diagnosis. Cultural beliefs also impact the content of delusions. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK 5/

Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to report an allegation of abuse immediately, but not later than 2 hours after the allegation was made for one of eight residents in the survey sample, Resident #7. The facility staff failed to report an allegation of sexual abuse within two hours for Resident #7 to the State Survey Agency other officials. The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 12/4/202, Resident #7 was coded as being moderately impaired for making daily decisions, having scored 10 out of 15 on the BIMS (brief interview for mental status). He was coded as expressing feeling down and feeling tired more than once during the lookback period. He was coded as having no hallucinations or delusions during the lookback period. He was coded as requiring the extensive assistance of staff for all activities of daily living, as being unsteady for balance, and as using a wheelchair and walker for locomotion. On 1/21/21 at 12:29 p.m., Resident #7 was observed sitting on the side of his bed in his room. Resident #7 did not respond to attempted interview questions from the surveyor. A review of the FRI (facility reported incident) submitted by the facility to the state agency on 1/13/21 revealed, in part: Incident: Allegation of sexual abuse .Report date: 1/13/21 .Incident date: 1/12/21 .On 1/9/21 (Resident #7) stated there was a creepy man standing at the end of his bed. The DON looked around and there were no men around and she continued to try to reassure (Resident #7) that he was safe. (ASM (administrative staff member) #2, the director of nursing) called the spouse and she stated that 'He has those delusions; they have been going on for years.' On 1/12/21 (Resident #7) called the police and told them he had been sexually abused. The social worker went to his room and spoke to (Resident #7) and there was no one there bothering him and he was stating it occurred at work last week. She kept reassuring him that he was safe. He states there is a tall, white man, and there were only female employees working on that unit. Resident assessed and there were no injuries. Staff is providing frequent psychosocial checks for his health and wellness. Full investigation to follow. FINAL: DON (Director of Nursing) spoke with (name of Detective). Detective did not open a case based on resident accusations and validity. There had not been any males taking care of resident on the unit meeting resident's observation. Resident had reported a large white male named Earl, creepy (sic) staring at him. (Resident #7) was assessed by NP (nurse practitioner) and there was no injury. Ongoing confusion noted. (Resident #7) was also assessed to assure all psychosocial needs are being met. Resident is able to voice his needs and voices no complaints or concerns. Social Services will continue to follow up and assess as needed to ensure (Resident #7)'s needs are being met. Social Services will continue to follow up and assess as needed to assure needs are being met. (Name of APS 9adult protective services) staff member) also reviewed resident's [DIAGNOSES REDACTED].APS also concluded that resident was not in any danger of immediate harm. A review of Resident #7's clinical record revealed a note from ASM #3, the NP (nurse practitioner), which was dated 1/13/21. The note documented a full physical assessment of the resident, with no bruising or other evidence of injury or abuse. The note documented: Confusion continues. On 1/22/21 at 11:03 a.m., OSM (other staff member) #4, the social worker, was interviewed. She stated that at the time of the incident described in the above referenced FRI, ASM #1, the administrator, was out sick. She stated she and ASM #2, the DON, and a regional administrator worked together to investigate the allegation. She stated staff members were interviewed, and other residents were also interviewed. She stated that based on the evidence, including Resident #7's history of dementia and delusions, the facility staff determined the allegation of sexual abuse made by the resident was unsubstantiated. On 1/22/21 at 11:11 a.m., ASM #4, the assistant administrator, was interviewed. She stated that at the time of the incident, It was just (ASM #2) and me. She added a regional corporate manager was also in the building and provided guidance regarding the investigation and reporting of this incident. She stated ASM #2, (the director of nursing) reported that Resident #7 had called the police, and had told ASM #4 that he had been assaulted last week at work. ASM #4 stated ASM #2 reported this information to her on 1/12/21, and that she completed the FRI and sent it to the state agency on 1/13/21. On 1/22/21 at 11:31 a.m., ASM #2, the DON, was interviewed. She stated that at approximately 6:00 p.m. on 1/12/21, she was informed by ASM #4 that Resident #7 had contacted the police and told them that there was currently a male standing in his room. She stated she and ASM #4 had gone to Resident #7's room and had found no one there. ASM #2 stated she and ASM #4 provided reassurance to Resident #7, assuring him that he was safe. She stated that a regional administrator had provided guidance to her and to ASM #4 regarding the investigation, and the reporting of the incident. ASM #2 stated, We knew we had 24 hours to report it. On 1/22/21 at 3:00 p.m., ASM #1 was notified of these concerns. She stated she was not in the facility at the time the FRI was submitted, and she did not have first-hand knowledge about the timing of the report to the SA. A review of the facility policy, Abuse, Neglect and Exploitation Prevention and Reporting, revealed, in part: 'Sexual Abuse' is non-consensual contact of any type with a resident .Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. No further information was provided prior to exit. References: (1) Dementia is a gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information is taken from the website https://medlineplus.gov/ency/article/ 6.htm. (2) A delusion is a fixed false belief based on an inaccurate interpretation of an external reality despite evidence to the contrary. The belief is not congruent with one's culture or subculture, and almost everyone else knows it to be false .The [DIAGNOSES REDACTED]. An individual's cultural beliefs merit consideration before coming to the diagnosis. Cultural beliefs also impact the content of delusions. This information is taken from the website https://www.ncbi.nlm.nih.gov/books/NBK 5/

Based on observation, staff interview and facility document review it was determined that facility staff failed to implement infection control procedures to prevent the transmission of communicable disease during a COVID 19 outbreak for eight of eleven residents in the survey sample, (Residents #1, #2, #3, #4, #5, #6, #7 and #8). Observation revealed Residents #1, #2 and #3 seated together in the facility common area prior to and during the lunch service not [MEDICATION NAME] social distancing or wearing masks per COVID 19 CDC (Center for Disease Control) guidance. Observation revealed Residents #4, #5, #6, #7 and #8 seated together in the facility common area prior to and during lunch service not [MEDICATION NAME] social distancing or wearing masks. Observation failed to reveal staff attempting to redirect residents to alternate seating to allow for six feet of distance and separation between residents. The findings include: Remote review of the Line List for COVID-19 (1) Outbreaks in Long Term Care Facilities, submitted by the facility for review by fax on [DATE] revealed 58 residents had tested positive for the COVID-19 virus and 10 had expired. The following documented entry for Residents #1, #2, #3, #4, #5, #6, #7 and #8. Remote review of the facility's Dementia (2) Unit test results, revealed a documented listing of residents on the Dementia unit. The listing documented 22 residents with test dates of [DATE], result dates of [DATE], with all results listed, Result- Neg (negative). The list included Residents #1, #2, #3, #4, #5, #6, #7 and #8, as tested for COVID 19 on [DATE] with negative results on [DATE]. On [DATE] at 11:15 a.m., an observation was conducted of the facility's Dementia unit. Two common areas connected by a foyer with an exit door were observed to the right of the entrance to the unit. An approximately 640 square foot room was located to the right of the entrance to the unit, which contained three round tables approximately four feet in diameter to the left wall of the room against the outside window. The room also contained 2 (two) square tables placed side by side measuring approximately four feet by four feet each located near the inside window on the right side of the wall and 1 (one) round table approximately four feet in diameter near the right side of the wall as well. Observation revealed eleven residents sitting in the room, none of the residents were wearing masks. Three residents were observed seated individually at the three round tables beside the outside window on the left side of the room. Three residents were observed seated together at the round table near the inside window on the right side of the room. LPN (licensed practical nurse) #1 identified the three residents observed as Resident #1, #2 and #3. Observation revealed Resident #2 seated with their back to the wall facing the room in between Resident #1 and Resident #3 at the table. Residents #1, #2 and #3 were distanced less than four feet from each other while seated at the table by using the approximately two by four ceiling tiles above the residents as a guide. Residents #1, #2 and #3 were not wearing masks. Five residents were observed to be seated at the two square tables placed together near the inside window. LPN #1 identified the five residents observed as Resident #4, #5, #6, #7 and #8. Resident #4 was observed to be seated at the end of the table closest to the inside window facing the room with Resident #5 to the right and Resident #6 to the left. Resident #7 was seated beside Resident #6 and Resident #8 was seated beside Resident #5 as identified by LPN #1. Observation revealed Residents #4, #5, #6, #7 and #8 were distanced less than 4 feet from each other while seated at the table by using the approximately two by four ceiling tiles above the residents as a guide. Residents #4, #5, #6, #7 and #8 were not wearing masks. Observation failed to reveal staff attempting to redirecting residents to alternate seating to allow for six feet of distance and separation between residents. On [DATE] at 11:35 a.m., an observation of the lunch tray delivery was conducted on the Dementia unit. All the residents remained seated in the common area as described above. The facility staff served the lunch trays to the residents and assisted the residents requiring assistance with eating. At 12:11 p.m., Residents #1, #2 and #3 had left the common area; Residents #4, #5, #6, #7 and #8 remained seated at the tables together in the common area as described above. Remote review of Resident 1's clinical record revealed, Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #1 as being severely impaired of cognition for making daily decisions. Resident #1 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #1 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #1) is at risk for alteration in Psychosocial well-being related to restriction on visitation do (sic) to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 2's clinical record revealed, Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of [DATE], coded Resident #2 as moderately impaired of cognition for making daily decisions. Resident #2 was coded as requiring limited assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #2 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #2) is at risk for alteration in Psychosocial well-being related to restriction on visitation due to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 3's clinical record revealed, Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #3's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #3 as scoring a 6 (six) on the brief interview for mental status (BIMS) of a score of 0 - 15, 6 - being severely impaired of cognition for making daily decisions. Resident #3 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #3 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #3) is at risk for alteration in Psychosocial well-being related to restriction on visitation do (sic) to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 4's clinical record revealed, Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #4 as severely impaired of cognition for making daily decisions. Resident #4 was coded as requiring limited assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #4 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #4) is at risk for alteration in Psychosocial well-being related to restriction on visitation due to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 5's clinical record revealed, Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #5's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #5 as severely impaired of cognition for making daily decisions. Resident #5 was coded as requiring extensive assistance of two or more staff members for activities of daily living. The comprehensive care plan for Resident #5 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #5) is at risk for alteration in Psychosocial well-being related to restriction on visitation due to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 6's clinical record revealed, Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #6's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #6 as scoring an 11 on the brief interview for mental status (BIMS) of a score of 0 - 15, 11 - being moderately impaired of cognition for making daily decisions. Resident #6 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #6 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #6) is at risk for alteration in Psychosocial well-being related to restriction on visitation do (sic) to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 7's clinical record revealed, Resident #7 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #7's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #7 as severely impaired of cognition for making daily decisions. Resident #7 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #7 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #7) is at risk for alteration in Psychosocial well-being related to restriction on visitation do (sic) to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. Remote review of Resident 8's clinical record revealed, Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #8's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of [DATE], coded Resident #8 as severely impaired of cognition for making daily decisions. Resident #8 was coded as requiring extensive assistance of one staff member for activities of daily living. The comprehensive care plan for Resident #8 dated [DATE] documented in part, Date Initiated [DATE]. Focus- (Name of Resident #8) is at risk for alteration in Psychosocial well-being related to restriction on visitation do (sic) to COVID-19. Under Interventions, it documented Encourage alternative communication with visitors. Monitor for psychosocial changes. Observe and report any changes in mental status caused by situational stressor. Provide opportunities for expression of feelings related to situational stressor. On [DATE] at 12:19 p.m., an interview was conducted with LPN #1 regarding dining on the Dementia unit. LPN #1 stated that it was a challenge with the dementia residents to keep them distanced on the unit. LPN #1 stated that the residents did not have assigned seating and sat wherever they liked during meals. LPN #1 stated that they tried to distance the residents six feet apart but it was hard to do because the residents moved themselves and they chose to come to the common areas. LPN #1 stated that if a resident moved close to another resident, and was not distancing adequately from the other residents, they (staff) explain to them (resident) to keep their space, but it was hard because they did not understand. LPN #1 stated that on the unit they tried to keep the same routine for the residents and that they had implemented additional monitoring of residents and enhanced cleaning of the unit during the COVID 19 pandemic. LPN #1 stated that the staff made sure that they had their masks on at all times and that they monitored the residents each morning. LPN #1 stated that all residents had tested negative (for COVID 19), a while ago and that gave them (staff), more peace of mind. On [DATE] at 1:40 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. When asked about the communal dining on the Dementia unit, ASM #2 stated that all communal dining was ceased a while ago except for on the Dementia unit. ASM #2 stated that the common area on the unit did not really allow for social distancing and that they had been unable to prevent the residents from being in one another's space. ASM #2 stated that it would be gravely difficult to separate residents 6 (six) feet during meals. ASM #2 stated that the staff had been trying to maintain the same routine for the residents on the Dementia unit and kept things as steady they could. ASM #2 stated that they had increased cleaning the area several times a day with a hydrogen peroxide based product and that all staff were wearing N95 masks on the unit as well as enhanced hand-washing procedures. ASM #2 stated that all of the residents on the Dementia unit had tested negative for COVID and all of the staff that worked on the unit had tested negative as well. ASM #2 stated that she was aware that anyone's test results could change in a day. Review of the facility policy, COVID-19-Pathogens-Cleaning and Disinfecting Policy and Procedures, Date Effective [DATE] documented in part, There is much to learn about the novel coronavirus that causes coronavirus disease 2019 (COVID-19). Based on what is currently known about [MEDICAL CONDITION], spread from person-to-person happens most frequently among close contacts (within about 6 (six) feet) . Review of a document provided by the facility titled, Considerations for Memory Care Units in Long-term Care Facilities/CDC (Centers for Disease Control), [DATE] revealed in part the following, Infection Prevention and Control (IPC) Guidance for Memory Care Units .In addition to the current IPC guidance for long-term care facilities, nursing homes and assisted living facilities providing memory care should consider the following: Routines are very important for residents with dementia. Try to keep their environment and routines as consistent as possible while still reminding and assisting with frequent hand hygiene, social distancing, and use of cloth face coverings (if tolerated). Cloth face coverings should not be used for anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask without assistance . Limit the number of residents or space residents at least 6 (six) feet apart as much as feasible when in a common area, and gently redirect residents who are ambulatory and are in close proximity to other residents or personnel . Review of CMS (Centers for Medicare and Medicaid Services) memo QSO-,[DATE]-NH dated [DATE] documented in part, . Residents are not forced to eat in their rooms. Residents may still eat in dining rooms; however, nursing homes should adhere to social distancing, such as being seated at separate tables at least six feet apart. We note that social distancing should be practiced at all times (not just while dining). We further note that eating in dining areas with appropriate social distancing only applies to residents without signs or symptoms of a respiratory infection, and without a confirmed [DIAGNOSES REDACTED]. On [DATE] at approximately 1:40 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional director of clinical services were made aware of the findings. No further information was provided prior to exit. References: 1. COVID-19- is caused by a coronavirus called [DIAGNOSES REDACTED]-CoV-2. Coronaviruses are a large family of viruses that are common in people and may different species of animals, including camels, cattle, cats, and bats. Rarely, animal coronaviruses can infect people and then spread between people. This occurred with MERS-CoV and [DIAGNOSES REDACTED]-CoV, and now with [MEDICAL CONDITION] that causes COVID-19. [DIAGNOSES REDACTED]-CoV-2 virus is a betacoronavirus, like MERS-CoV and [DIAGNOSES REDACTED]-CoV. All three of [MEDICAL CONDITION] have their origins in bats. The sequences from U.S. patients are similar to the one that China initially posted, suggesting a likely single, recent emergence of this virus from an animal reservoir. However, the exact source of this virus is unknown. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#How-COVID-19-Spreads 2. Dementia- A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/ 9.htm. 3. Diabetes mellitus -A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm. 4. [MEDICAL CONDITION] - condition that makes your bones weak and more likely to break. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html. 5. [MEDICAL CONDITION] occurs when a person loses contact with reality. The person may have false beliefs about what is taking place, or who one is (delusions), see or hear things that are not there (hallucinations). This information was obtained from the website: https://medlineplus.gov/ency/article/ 3.htm. 6. Cognitive communication deficit- Cognitive deficits are changes in thinking, like difficulty solving problems. This category also includes dementia and memory problems, as well as many kinds of communication challenges. This information was obtained from the website: https://www.stroke.org/en/about-stroke/effects-of-stroke/cognitive-and-communication-effects-of-stroke 7. Dysphagia A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html.

Based on observation and staff interview, the facility staff failed to properly maintain an ice machine in a manner to prevent the spread of disease for one of four facility ice machines, (the kitchen ice machine). The facility staff failed to ensure the drainage pipe for the ice machine in the kitchen was above the level of the floor drain in the kitchen. The findings include: Observation was made of the ice machine in the kitchen on 5/7/19 at 12:18 p.m. The plastic drainage pipe was resting on the metal floor drain. This observation was verified with OSM #7, the director of maintenance. When asked if the drain was at the proper height, OSM #7 stated, No, I check it weekly. They must be hitting it when the mop. On 5/7/19 at approximately 4:00 p.m., OSM #7 presented a document of Work History Report that documented on 4/13/19 the ice machines in the building were inspected and the air gaps were functioning properly. On 5/9/19 at approximately 9:00 a.m., OSM #7 presented a document titled, What is An Air Gap? that documented in part, Health codes require two air gap installations for each ice machine .The other air gap, or backflow prevention, must be between an ice machine drain and the sewer drain. This makes sure sewer lines can't create a vacuum which allows water to flow back up into the machine contaminating ice that could end up in someone's drink. ASM (administrative staff member) #1, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant were made aware of the above concern on 5/8/19 at 4:45 p.m. No further information was provided prior to exit.

Based on observation, staff interview, and facility document review, it was determined the facility staff failed to store and serve food in a sanitary manner in the kitchen and in the main dining room. 1. The facility staff failed to cover a salad in the refrigerator and had an expired milk available for use. 2. The facility staff failed to serve food in a sanitary manner in the Main Dining Room. Facility staff who were at the steam table plating the food handled the plates with their thumbs on the top side of the outer perimeter of the food surface area of the plates while plating food. The findings include: 1. The facility staff failed to cover a salad in the refrigerator and had an expired milk available for use. Observation was made of the kitchen on [DATE] at 11:55 a.m. accompanied by other staff member (OSM) #6, the dietary service director. Observation was made of the milk cooler. One fat free half pint milk carton was dated as expired on [DATE]. When asked if the milk was available for use, OSM #6 stated, Yes, Ma'am. Observation was made of the cook's reach in refrigerator. A half pan of a salad made of what appeared to be lettuce and tomatoes was not completely covered with approximately one third of the plastic wrap off the pan and a large slotted spoon in the salad. When asked if the salad should be uncovered, OSM #6 stated, No, but we just finished lunch. When asked if anything in the refrigerator should be uncovered, OSM #6 stated, No, Ma'am. The facility policy, Food Storage - covering, labeling, dating food, documented in part, Refrigeration Storage: 1. All foods must be covered, labeled and dated with a date label. All food should be monitored each day to be assured that the foods will be used, consumed or discarded by the use by date or expired date. The policy further documented, Pantry Refrigerators Storage: 1. Follow the manufacturer' expiration dates or use by dates when provided to determine when a food should be discarded. SAM (administrative staff member) #1, SAM #2, the director of nursing, and SAM #3, the regional nurse consultant were made aware of the above concern on [DATE] at 4:45 p.m. No further information was provided prior to exit. 2. The facility staff failed to serve food in a sanitary manner in the Main Dining Room. Facility staff who were at the steam table plating the food handled the plates with their thumbs on the top side of the outer perimeter of the food surface area of the plates while plating food. On [DATE] at 5:07 PM, an observation was made of the Main Dining Room dinner service. Two staff members, OSM #1 (dietary aid) and OSM #2 (dietary cook) were at the steam table plating food for dinner service to the residents. OSM #1 and OSM #2 had gloves on, but were handling multiple items, including tongs, serving spoons, plates, bowls, meal tickets, etc., thus contaminating their gloves, and were then observed placing their thumbs on the top side of the outer perimeter of the food surface area of the plates while plating food. On [DATE] 8:30 AM, in an interview with OSM #2 through her daughter OSM #3 (Ancillary Aid), as an interpreter, OSM #2 stated that she did not recall having her thumbs on top of the plate but that the plate is supposed to be handled with the hand underneath and no fingers on top. A review of the facility policy Preventing Foodborne Illness - Food Handling documented, 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. On [DATE] at 5:20 PM, ASM #1 (Administrative Staff Member, the Administrator) and ASM #2 (the Director of Nursing) and ASM #3 (Regional Nurse Consultant) were made aware of the findings. No further information was provided by the end of the survey.

Based on facility document review and clinical record review, it was determined the facility staff failed to ensure one of 50 residents in the survey sample, received care and services in accordance with professional standards for Resident #29. The facility staff failed to have a hospice care order for Resident #29. The findings include: Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 3/6/19, coded the resident as scoring a 9 out of 15 on the BIMS (brief interview for mental status) score, indicating she was moderately cognitively impaired for daily decision making. The physician orders [REDACTED]. The POS failed to evidence an order for [REDACTED].>Review of facility document titled Omnicare Request for Admission Medication Review dated 2/27/19, documented, Coming from home under respite care x5 (for five) days then hospice. The request was documented by, LPN (licensed practical nurse) #1, the Lead Unit Manager. On 05/09/19 at approximately 8:48 a.m., an interview was conducted with LPN #1. LPN #1 was asked if Resident #29 was receiving hospice care at the facility. LPN #1 replied, Yes. She came in under respite care but she is hospice now. LPN #1 was asked if Resident #29 had an order for [REDACTED]. On 05/09/19 at approximately 9:27 a.m., a follow up interview was conducted with LPN #1. LPN #1 presented a document titled Hummingbird Clinical: Orders dated 5/9/19, which documented in part, Admit to routine Hospice care at Heritage Hall, Date order received: 3/4/2019, Order Type: Verbal. LPN #1 was asked if this order was part of Resident #29's clinical record. LPN #1 replied, The hospice company sent it over today. It was not, it's my fault I transcribed her orders but I did not transcribe this order into the system, it should have been done. I called our doctor and got a clarification order today. On 05/09/19 at approximately 11:32 a.m., an interview was conducted with ASM (administrative staff member) #2, the Director of Nursing (DON) and LPN #1. ASM #2 presented this surveyor a document titled (Name of Hospice Company) Long Term Care Billing Information Sheet, Administration and Billing dated 3/5/19, which documented in part, Nursing facility custodial care bed (hospice routine home care). ASM #2 was asked if the facility had an order for [REDACTED]. On 5/9/19 at approximately 11:37 a.m., LPN #1 presented this surveyor with a Physician Telephone Order dated 5/9/19, which documented in part, Resident is under (name of Hospice Company) routine. The facility policy titled Medication and Treatment Orders, Dental Services dated (MONTH) 2014, document in part, All orders must be charted and made a part of the resident's medical record and care plan. On 5/9/19 at approximately 12:45 p.m., ASM (administrative staff member) #1, the Administrator, ASM #2, the Director of Nursing, and ASM #4, Regional Vice President of Operations, were made aware of the findings. No further information was provided prior to exit. (1) Kidneys are damaged and can't filter blood as they should. This information was obtained from the website: https://medlineplus.gov/chronickidneydisease.html. (2) Not enough [MEDICAL CONDITION] hormone to meet your body's needs. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html.

Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to review and revise the comprehensive care plan for two of 50 residents in the survey sample, Residents # 46 and #36. 1. The facility staff failed to review and revise the comprehensive care plan when Resident #46 was placed under hospice care. 2. The facility staff failed to review and revise the comprehensive care plan for Resident #36 for a discontinued incentive spirometer (1). The findings include: 1. The facility staff failed to review and revise the comprehensive care plan when Resident #46 was placed under hospice care. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an unscheduled assessment for Medicare Part A, with an assessment reference date of 4/9/19, coded the resident as having both short and long-term memory issues and being severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance to total dependence upon one or more staff members for all of her activities of daily living. The physician order [REDACTED]. The physician order [REDACTED]. (Note: The GIP hospice care has to do with payment sources; it does not affect the care of the resident). The comprehensive care plan dated, 3/7/19, documented in part, Problem/Need - (Resident #46) is in need of rehabilitative services prior to return to home environment. The Goal & Target Date documented, (Resident #46) will discharge to home environment with appropriate services and/or equipment established within the next 90 days. The Approaches documented, Observe (Resident #46)'s progress with rehabilitative program. Communicate with (Resident #46) and family regarding progress and discharge planning needs and requests. Establish any needed services and/or equipment prior to discharge. Problem/Need - (Resident #46) anticipates a short term rehab (rehabilitation) stay, needs assistance to facility group activities of assessed interest. The Goal & Target Date documented Will engage in independent leisure activities of choice and participate in group activities of assessed interest and show signs of enjoyment around her rehab and nursing schedule's. An interview was conducted with LPN (licensed practical nurse) #5 on 5/8/19 at 1:43 p.m. The above care plan was shown to LPN #5. When asked if the care plan was correct, LPN #5 stated, No, she's on hospice care now. When asked who updates the care plan, LPN #5 stated the MDS staff do the updates. On 5/8/19 at 1:48 p.m., an interview was conducted with LPN #6, the MDS nurse. LPN #6 reviewed the care plan above. After reviewing the car plan LPN #6 was asked if there was a concern with the care plan. LPN #6 stated, I see, I see. Social services and activities have not changed their care plan to meet the resident's needs. They were both aware of the resident being placed on hospice care. They have to update their care plans when there is a change in the resident's condition. LPN #6 went to the computer and found that social services had updated the care plan on 4/15/19 but failed to print it out and put it on the active care plan on the unit. When asked where the most up to date care plan is kept, LPN #6 stated, The printed copy on the unit is the most accurate, up to date care plan. An interview was conducted with other staff member (OSM) # 5, the social services director, on 5/8/19 at 1:59 p.m. When asked if Resident #46 was on hospice care, OSM #5 responded that she was on hospice care. When asked if the care plan should be updated if a resident goes onto hospice care, OSM #5 stated, Yes. The active care plan was shown to OSM #5. OSM #5 stated, It needs to be updated. An interview was conducted with OSM #4, the activities director, on 5/8/19 at 2:03 p.m. The above care plan was reviewed with OSM #4. When asked if this care plan is correct for the present condition of the resident, OSM #4 stated, When she came in she as here for short term but things have changed and she is now on hospice care. When asked if the care plan should be reviewed and revised to address and reflect this change in the residents care and status, OSM #4 stated, Yes, it should be. The facility policy, Care Plans, Comprehensive Person-Centered documented in part, 12. Assessments of resident are ongoing and care plans are revised as information about the residents and the resident's conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay. d. At least quarterly, in conjunction with the required quarterly MDS assessment. According to Fundamentals of Nursing Lippincott[NAME] and Wilkins 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care .expect to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders . ASM (administrative staff member) #1, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant were made aware of the above concern on 5/8/19 at 4:45 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 447. 2. The facility staff failed to review and revise the comprehensive care plan for Resident #36 to address a discontinued incentive spirometer (1). Resident #36 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set), a significant change of status Medicare assessment, with an ARD (Assessment reference date) of 3/12/19, coded the resident as scoring a 14 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident had no cognitive impairment for daily decision making. The resident required supervision and set up for eating; limited assistance for dressing, toileting, hygiene, and transfers; and was occasionally incontinent of bladder and frequently incontinent of bowel. On 5/7/19 at 3:47 PM, an observation was made of Resident #36's incentive spirometer sitting on the bedside table. On 5/8/19 at 9:48 AM, an observation was made of Resident #36's incentive spirometer laying on the bed. On 5/8/19 at 3:06 PM, an observation was made of Resident #36's incentive spirometer laying on the bed. When Resident #36 was asked where she received the incentive spirometer, she stated, Oh, I have gotten some from here and from the hospital. In fact, I got two from here. A review of the clinical record revealed a physician's orders [REDACTED].Encourage resident use of incentive spirometer 10 times every hour while awake as tolerated . with a discontinued date of 3/4/19. A review of the clinical record revealed a comprehensive care plan that was dated 9/24/18, which documented in part, Problem .at risk for respiratory .complications related to .[MEDICAL CONDITION] .Approaches .encourage to use incentive spirometer per order . The care plan was not revised to remove the use of the incentive spirometer when it was discontinued on 3/4/19. On 5/9/19 at 12:19 PM, an interview was conducted with LPN (Licensed Practical Nurse) #7. When asked about the process staff follows for reviewing and revising a resident's comprehensive care plan for an incentive spirometer, LPN #7 stated, If a resident came from the hospital or if the doctor wrote an order for [REDACTED].#7 stated, Most of the time it would the MDS nurse. On 5/9/19 at 1:23 PM, ASM (Administrative Staff Member) #1 (Administrator) and ASM #4 (Regional Vice President of Operations) were made aware of the findings. No further information was provided by the end of the survey. References: (1) A device used to help you keep your lungs healthy after surgery or when you have a lung illness, such as pneumonia. Using the incentive spirometer teaches you how to take slow deep breaths. Deep breathing keeps your lungs well-inflated and healthy while you heal and helps prevent lung problems, like pneumonia. By using the incentive spirometer every 1 to 2 hours, or as instructed by your nurse or doctor, you can take an active role in your recovery and keep your lungs healthy. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/ 1.htm. (2) [MEDICAL CONDITION]: [MEDICAL CONDITION] is a type of lung condition involving damage to the air sacs (alveoli) in the lungs. As a result, your body does not get the oxygen it needs. [MEDICAL CONDITION] makes it hard to catch your breath. You may also have a chronic cough and have trouble breathing during exercise. This information was obtained from the following website: https://medlineplus.gov/[MEDICAL CONDITION].html (3) dysphonia: [DIAGNOSES REDACTED] is difficulty speaking due to spasms ([DIAGNOSES REDACTED]) of the muscles that control the vocal cords. This information was obtained from the following website: https://medlineplus.gov/ency/article/ 3.htm

Based on staff interview and clinical record review, it was determined the facility staff failed to complete a significant change assessment when one of 50 residents in the survey, was placed on hospice care, Resident #46. The facility staff failed to complete a significant change assessment when Resident #46 was placed on hospice care on 4/18/19. The findings include: Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an unscheduled assessment for Medicare Part A, with an assessment reference date of 4/9/19, coded the resident as having both short and long-term memory issues and as severely impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance to totally dependent upon one or more staff members for all of her activities of daily living. The physician order [REDACTED]. The physician order [REDACTED]. (Note: The GIP hospice care has to do with payment sources; it does not affect the care of the resident.) Review of the clinical record failed reveal completion of a significant change MDS assessment for Resident #46 after the resident was placed on hospice care on 4/19/19. An interview was conducted with LPN (licensed practical nurse) # 6, the MDS nurse, on 5/8/19 at 1:48 p.m. When asked if a significant change assessment should be completed when a resident is placed under hospice care, LPN #6 stated, Yes. When asked why the significant change MDS was not completed for Resident #46, LPN #6 stated, I'd have to look. LPN #6 stated that when a resident is put on hospice care, a significant change assessment should be started. Per the RAI 3.0 Manual, pg. 2-23: A SCSA (significant change in status assessment) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. ASM (administrative staff member) #1, ASM #2, the director of nursing, and ASM #3, the regional nurse consultant were made aware of the above concern on 5/8/19 at 4:45 p.m. No further information was provided prior to exit. (1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and Chapman, page 447.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, it was determined the facility staff failed to ensure the right to self determination and access to services outside the facility for one of 50 residents in the survey sample, Resident #117. The facility staff failed to assist Resident #117 in attaining a legal Identification Card (ID) from the Department of Motor Vehicles. The findings include: Resident #117 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The most recent MDS (Minimum Data Set), a quarterly Medicare assessment, with an ARD (Assessment reference date) of [DATE], coded the resident as scoring a 15 out of 15 on the BIMS (Brief Interview for Mental Status) score, indicating the Resident had no cognitive impairment for daily decision making. The resident required supervision and set up for eating; extensive assistance for hygiene, dressing, and toileting; total assistance for transfers and bathing; and was always incontinent of bowel. In Section H - Bladder and Bowel, the resident was coded as having an indwelling urinary catheter during the look back period. On [DATE] at 9:59 AM, an interview was conducted with Resident #117. Resident #117 stated, I want and need a new walking ID (identification card). I am unable to get a driving service to the DMV I need as it is outside of (name of city). I asked the facility to take me. I asked the social worker (OSM #5 - Other Staff Member) #5 one month ago about five to six times and she is working on it. I went to get my ID last Friday ([DATE]) but when I got on the bus, the driver told me he could not take me because it was not in (name of city). I went to (name of store and restaurant) instead. I was not able to use my gift card because I did not have an ID. On [DATE] at 10:39 AM, an interview was conducted with OSM #5. When OSM #5 was asked about assisting Resident #117 to obtain an ID or a walking ID, OSM #5 stated, Trying to just help coordinating and following up with the DMV paperwork. Getting him there and sitting with him. It is just one of those things I helped him with, first it was in (name of city). Then getting his birth certificate. That was a few years back. OSM #5 was asked when Resident #117 asked her for assistance with obtaining his ID from the DMV, OSM #5 stated, It has been about a month. He just started going back out in the community. When OSM #5 was asked if the resident requests help should he receive the assistance, OSM #5 stated, Well regardless of all of that, he wants this done. It is his rights and I get it. Of all of the things to be done in a 24-hour day. I have a million things to do. I know that's not your problem or his problem. I understand. I get it. It should have been done. When OSM #5 was asked if her department makes arrangements for Resident #117 to go out into the community, OSM #5 stated, We have taken him in the facility van. On [DATE] at 10:50 AM, a follow up interview with OSM #5 was conducted. OSM #5 stated, It (Resident #117's license) expired on [DATE]. He was going out beforehand. It was this past year due to medical reasons he stopped going out. When OSM #5 was asked what is needed to assist Resident #117 obtain an ID, OSM #5 stated, I can go and make calls to find out what I need to do. When OSM #5 was asked the reason this was not done when the resident previously asked for assistance, OSM #5 stated, I getcha (sic) (OSM #5 was observed to shrug her hands). Well he has gone out in the community. I get that. I was not aware of everything and this was expired since 2014. I do the best that I can. When OSM #5 was asked if she has an assistant, she stated, Yes. When OSM #5 was asked if the facility administration was aware of Resident #117's request, OSM #5 stated, I am not sure if I have discussed this with them. When OSM #5 was asked how long she has worked at this facility, she stated, I have been here almost six years. On [DATE] at 10:58 AM, an interview with ASM (Administrative Staff Member) #2 (Director of Nursing) was conducted. ASM #2 was asked about her knowledge of Resident #117's request to the social worker (OSM #5), to obtain an ID approximately a month ago and of the residents own attempts to obtain the ID when assistance was not provided as requested. ASM #2 stated, I saw him in the hall and he told me on Friday he 'was going to get his ID.' I said to him, Oh you're going on an outing. He calls the transport. I asked him if he was going by himself and he said, 'I got it all arranged.' Then I asked him what kind of ID he needed. I was just curious and if he is safe. Then I said Good for you (Resident #117's name). I thought he had it all under control and making his own arrangement. And I thought good for him. When ASM #2 was asked why Resident #117 needed an ID, ASM #2 stated, He told me he was going to get it done and had arrangements. When ASM #2 was asked if she has spoken with social worker (OSM #5) about Resident #117's request, ASM #2 stated, I have not talked to OSM #5 about this. I even told him we could put him on the van and take you. He always talks with me. He knows how to get a hold of me. He knows how to get me. I wish if he did not get his needs met he would have talked with me. (Resident #117's name) has a long history of psych (psychiatric) and manipulation. I'm sorry; I thought he already got it done. Maybe it is tomorrow on Friday. On [DATE] at 11:10 AM, ASM #2 and two surveyors spoke with Resident #117 regarding going out in the community last week and his conversation with ASM #2. Resident #117 stated, I made arrangements to get the ID, but when I got on the bus the driver would not take me out of (name of city). ASM #2 then stated, He told me he was going to do it but did not tell me he was not able to get it done. ASM #2 then told Resident #117 she would make the arrangements to get his ID tomorrow. On [DATE] at 11:52 AM, a follow up interview with OSM #5 was conducted. When OSM #5 was asked where she would document notes regarding assisting residents, she stated, I would put them in the electronic clinical record. When OSM #5 was asked if she documented her conversation with Resident #117 when he asked her for assistance a month ago, she looked in the electronic clinical record and stated, No. I do not have any documentation about that. A review of the clinical record did not reveal nurses notes related to Resident #117's ID request. A review of the facility's policy Resident Rights with a revised date of (MONTH) (YEAR) that documented in part, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .Policy interpretation and Implementation .1. Federal and state laws guarantee certain basic rights to all residents in this facility .a. a dignified existence; .e. self-determination .f. communication with and access to people and services, both inside and outside the facility .g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .h. be supported by the facility in exercising his or her rights .x. communicate with outside agencies .regarding any matter . On [DATE] at 1:23 PM, ASM #1 (Administrator) and ASM #4 (Regional Vice President of Operations) were made aware of the findings. No further information was provided by the end of the survey. Reference (1) [MEDICAL CONDITION]: Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. Paralysis of the lower half of your body, including both legs, is called [MEDICAL CONDITION]. Paralysis of the arms and legs is [MEDICAL CONDITION]. Most paralysis is due to [MEDICAL CONDITION] or injuries such as spinal cord injury or a broken neck. This information was obtained from the following website: https://medlineplus.gov/paralysis.html