Every finding on record at Heritage Inn Health and Rehabilitation

Based on interviews, record reviews, and review of the facility's policy titled Abuse Prohibition, the facility failed to ensure one out of six sampled residents (R) (R66) was free from abuse. Specifically, R66 was hit by another resident (R11), resulting in the facility's failure to protect R66 from resident to resident physical abuse.Findings include:Review of the facility's policy titled, Abuse Prohibition dated December 27, 2025 documented under Intent revealed, It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and/or their property. The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse. This policy applies to anyone subjecting a patient to abuse including, but not limited to, center staff, other patients, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Whenever a patient, family member, or anyone else makes a complaint on behalf of the patient that alleges abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation has occurred, the procedures listed in this policy will be adhered to. Neither the center nor any person employed by the center will discriminate or retaliate in any manner against any person for making a report or providing information related to an incident.Review of the electronic medical records (EMR) for R11 revealed the resident was a 74 year old female admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Friedreich's ataxia, Alzheimer's disease, and mild dementia with agitation.Review of the EMR for R66 revealed the resident was an 82 year old female admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease.Review of R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, and R66's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, indicating both residents had moderate cognitive impairment.Review of the Facility Reported Incident (FRI) dated 04/09/2026 revealed that, during the investigation, R63 reported witnessing an incident between R11 and R66. The facility immediately ensured the safety of all residents involved by separating the residents and confirming that R11, R66, and R63 all felt safe. A head to toe skin assessment was completed on R11 and R66, with no redness, bruising, or other injuries identified. Pain assessments were also completed for both residents, with no complaints or signs of pain noted. Behavior assessments were completed on all three residents, with no acute behavioral changes observed and no evidence of psychosocial trauma identified.Residents with a Brief Interview for Mental Status (BIMS) score of 10 or greater were interviewed to determine whether they ever felt unsafe, had been mistreated by another resident, or had witnessed another resident being mistreated. Residents with a BIMS score lower than 10 received head to toe skin assessments, and no concerns were identified.Record review revealed on 04/07/2026, all three residents were evaluated by Care Now Services. As a result of that evaluation, R11 received a new medication order, and R66 and R63 were recommended for behavior monitoring. The facility completed all required notifications, and a report was filed. The attending physician and family representatives were notified. Multidisciplinary staff were interviewed as part of the investigation. Staff reported that R11's diagnosis of Friedreich's ataxia caused extreme shaking and involuntary movement. Record Review of Certified Nursing Assistant (CNA) AA's interview statement dated 04/04/2026 revealed: Myself (CNA AA) and my co worker (CNA BB) were walking in the conference room to put our belongings down when we heard one of the residents (R11) yelling at another resident (R66) to get out of R63's room. R11 was saying that's not your room-at this time R11 was in her room, which is across from R63. As myself and CNA BB walked into the hallway, the kitchen manager was walking down the hallway saying someone needs to get her (R11). As we started to approach, R11 was yelling (now out of her room) getting louder for R66 to move. R11 started pulling on R66's wheelchair and the back of her hair. R11 then proceeded to draw her right arm back and hit R66 at least three times in her right shoulder area. R63 was screaming for R11 to get off of R66. I pulled R11 away and yelled for a nurse to come. As I gave report to the nurse of what we just witnessed, R63 was very upset yelling she (R11) hit her (R66) for no reason. CNA BB went to calm both residents (R66 and R63) down as I talked with R63 and nurse. Record Review of CNA BB's interview statement dated 04/04/2026 documented I, CNA BB, clocked in for my shift and went into the conference room with my coworker to sit our bags down. When we heard R11 (patient) yelling at R66 (patient) to get out of R63's room. As we stepped outside of the conference room to approach the situation, R11 was trying to pull R66 out of the room and was pulling her by her wheelchair and hair. The dietary manager yelled someone get them and R11 began to strike R66 three to four times. CNA AA then screamed for the nurse and separated the two away from each other while I went to calm down R63, as she was visibly hysterical about the incident. She just kept repeating 'she (R66) was only asking about my flowers and she (R11) started hitting her (R66)'. The incident was reported to the nurse on duty.Interview on 07/22/2026 at 08:19 PM with Licensed Practical Nurse (LPN) CC revealed she was familiar with the resident to resident incident involving R11 and R66 and confirmed she wrote a statement. She explained that after returning from the dining room, R66 stopped outside another resident's room to talk about flowers while R11 was in the doorway of her own room. R11, who had Friedreich's ataxia and limited control of her arm movements, approached R66 and attempted to grab the arm of her wheelchair to get her attention and let her know she was at the wrong room. During the attempt, R11 made contact with R66's arm. She stated she did not believe the contact was intentional, and the residents were immediately separated. She reported there were no visible injuries or marks, noted that the two residents were friends, and stated that regardless of the circumstances, the incident should have been documented in a nursing note.Interview on 07/23/2026 at 02:39 PM with the Director of Nursing (DON) confirmed that R11 did exhibit emotional behaviors. She stated that all resident to resident altercations, regardless of whether they were believed to be intentional or unintentional, must be reported to the State within two hours.Interview on 07/23/2026 at 01:52 PM with the Administrator revealed that when a resident to resident abuse allegation occurred, the facility immediately separated the residents, notified the medical director and families, interviewed witnesses and the residents involved, completed staff and resident audits, performed skin assessments based on residents' BIMS scores, notified law enforcement and the State, arranged behavioral health services through Care Now, completed behavioral and psychosocial assessments through Social Services, and closely monitored the residents. If the residents shared a room, the facility attempted to relocate one of them if appropriate and agreed upon. She stated the investigation was unable to determine whether the altercation was intentional and could not exclude the possibility that physical contact occurred. She further stated the facility monitored for potential or actual abuse allegations by providing monthly staff education on abuse reporting, closely monitoring residents with behavioral concerns, and reviewing 24 hour reports during morning meetings to identify any resident behaviors or incidents.

Based on interviews, record reviews, and review of the facility's policy titled Abuse Prohibition - Reporting and Investigating, the facility failed to report abuse in a timely manner after a resident to resident altercation for one of six sampled residents (R11). This deficient practice resulted in a delay in notifying the State Survey Agency, which placed residents at risk for unrecognized abuse, delayed protective interventions, and inadequate oversight of resident safety.Findings include:Review of the facility's policy titled Abuse Prohibition - Reporting and Investigating, dated December 27, 2025, documented under INTENT It is the intent of this center to establish standards of practice for investigation and reporting of abuse, neglect, mistreatment, exploitation, and misappropriation of property. GUIDELINE-Reporting. All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours.Review of the electronic health records (EHR) for R11 and R66 revealed they both had a diagnosis of dementia. In addition, R11 had a diagnosis of psychological and behavioral factors associated with disorders or diseases classified elsewhere.Review of R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, and review of R66's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, indicating both residents had moderate cognitive impairment.Review of progress notes for R11 dated 04/04/2026 revealed documentation of the incident that occurred and that the Director of Nursing (DON), physician, and family members were notified; however, there was no documentation showing the incident was reported.Review of progress notes for R66 dated 04/04/2026 revealed documentation of the incident that occurred and that the Director of Nursing (DON), physician, and family members were notified; however, there was no documentation showing the incident was reported.Interview on 07/23/2026 at 11:09 AM with the Corporate Clinical Standards and Quality Nurse confirmed the Administrator was notified of the incident between R11 and R66 on the day it occurred by the DON, who had been informed by a nurse. The nurse believed the contact was unintentional due to R11's Friedreich's ataxia. The incident was discussed the following morning. The incident was not reported until corporate became involved after an anonymous complaint was submitted to the compliance hotline. During the investigation, the Administrator and DON were suspended, interviews were conducted, and staff and the Administrator received education that all allegations of abuse must be reported regardless of intent. The facility immediately ensured resident safety through assessments and interviews, found no injuries or psychosocial trauma, implemented increased supervision, and will continue monitoring behaviors and intervening when concerning behaviors are observed.Interview on 07/22/2026 at 08:19 PM with Licensed Practical Nurse (LPN) CC revealed she was familiar with the resident to resident incident involving R11 and R66 and confirmed she wrote a statement. She explained that after returning from the dining room, R66 stopped outside another resident's room to talk about flowers while R11 was in the doorway of her own room. R11, who had Friedreich's ataxia and limited control of her arm movements, approached R66 and attempted to grab the arm of her wheelchair to get her attention and let her know she was at the wrong room. During the attempt, R11 made contact with R66's arm. She stated she did not believe the contact was intentional, and the residents were immediately separated. She reported there were no visible injuries or marks, noted that the two residents were friends, and stated that regardless of circumstances, the incident should have been documented in a nursing note.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner, failed to ensure food items were dated, and failed to discard food items on or before their expiration or discard dates. These failures had the potential to create an environment for food-borne illnesses, which could affect 52 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled Cleaning and Sanitizing, dated 12/27/2024, indicated, It is the intent of this center to clean and sanitize utensils, dishware, pots and pans, workspace, and equipment to minimize the risk of food-borne illnesses . Cleaning schedules should be implemented and maintained for all areas of the kitchen. Review of the facility's policy titled, Storage Areas, dated 12/27/2024, indicated, It is the intent of this center to store food in a manner that maintains quality and safety . Items should be inspected for quality and temperature control upon receipt. Items should be covered, sealed, labeled, and dated appropriately. Storage areas should maintain an overall clean environment. 1. Observation during the initial kitchen inspection on 6/16/2025 from 8:35 am to 9:05 am, with the Dietary Manager (DM) present, revealed the following unclean food preparation and storage equipment: a. The kitchen's two ovens had a heavy accumulation of dried and burned food substances on their inner cooking compartments. b. The kitchen's large manual can opener had dried and sticky substances on its blade and table base attachment. c. Eight metal shelves in the kitchen's walk-in refrigerator and the bottom shelf of one of the kitchen's reach-in refrigerators were unclean with a black substance that could be wiped away with a paper towel. During an interview with the DM, during the initial kitchen inspection on 6/16/2025 from 8:35 am to 9:05 am, the DM confirmed that the kitchen's two ovens, large manual can opener, and refrigerator shelves were unclean. The DM stated that dietary staff were expected to follow the kitchen's cleaning schedule and keep all kitchen equipment clean. 2. Observation during the initial kitchen inspection on 6/16/2025 from 8:35 am to 9:05 am, with the DM present, revealed the following concerns with food storage: a. Observation of the kitchen's walk-in refrigerator revealed one package of hot dog buns with an expired use-by date of 6/3/2025 and two loaves of white bread with expired use-by dates of 6/10/2025. b. Observation of one of the kitchen's reach-in refrigerators revealed 11 four-ounce thawed nutritional shakes that were not dated. c. Observation of the kitchen's dry food storage room revealed two undated packages of hot dog buns, six undated loaves of bread, one 46 fluid ounce container of thickened orange juice with an expiration date of 6/5/2025, and 12 packages of tortilla shells with expired use by dates of 6/11/2025. During an interview with the DM, during the initial kitchen inspection on 6/16/2025 from 8:35 am to 9:05 am, the DM confirmed the bread products observed stored in the kitchen that were undated or had expired use by dates, the undated 11 thawed nutritional shakes stored in a reach-in refrigerator, and the container of thickened orange juice stored in the kitchen's dry food storage room with an expired expiration date. The DM stated staff were expected to date items when placed in storage and to discard any food or beverage with an expired expiration or use-by date. 3. Observation on 6/17/2025 at 10:55 am of food stored in the refrigerator in the facility's Diet Kitchen, with the DM present, revealed one opened 46-ounce container of thickened apple juice with a handwritten open date of 6/2/2025 on the container. Review of the directions on the side of the carton indicated the juice may be kept up to seven days under refrigeration after opening. During an interview on 6/17/2025 at 10:55 am, the DM confirmed the container of thickened apple juice had an opened date of 6/2/2025 handwritten on its container and should have been discarded seven days after being opened. DM stated that the dietary staff were responsible for checking the expiration dates on products stored in the diet kitchen's refrigerator and were to discard any expired or outdated items.

Based on observation, record review, and staff interviews, the facility failed to ensure safe resident transfers by using two staff to assist with a transfer by a mechanical lift for one of one resident (R) (R4) reviewed for transfers out of 20 sampled residents. This had the potential to place the resident at risk for injury. Findings include: 1. Review of R4's Face Sheet, located in the admission Record tab of the electronic medical record (EMR), revealed R4 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia and osteoarthritis. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/2025, located under the MDS tab of the electronic medical record (EMR), revealed a staff assessment for mental status was completed, which indicated short- and long-term memory problems. R4 was dependent on staff to roll left to right, and transfers were not completed due to medical conditions or safety concerns. Review of R4's Care Plan located under the Care Plan tab of the EMR revealed the resident was a two-person assist with transfers and used a lift sling (mechanical lift), reviewed 8/17/2024. During an observation on 6/16/2025 at 10:04 am, Certified Nursing Assistant (CNA) 3 went into R4's room with a mechanical lift and a shower bed and shut the door after. R4 was lying in bed. Continued observation revealed that at 10:18 am, CNA3 came out of R4's room with R4 on the shower bed and transported her to the shower room. No other staff members entered R4's room. During an observation on 6/16/2025 at 10:37 am, CNA3 brought R4 back to her room on the shower bed and closed the door. Continued observation revealed that at 10:50 am, CNA3 came out of R4's room, where the resident was observed in bed. The CNA brought the mechanical lift and the shower bed out with her when she exited the resident's room. No additional staff members entered the resident's room to assist CNA3 with the transfer. During an interview on 6/16/2025 at 10:50 am, CNA3 stated R4 required a mechanical lift for transfers. The CNA stated that the assistance level with a mechanical lift required two staff members. When asked if two staff members were utilized when the resident was transferred from her bed to the shower bed and then back to her bed from the shower bed, CNA3 stated, To be honest, I didn't. She's so easy to get right up to the shower bed. I should have. During an interview on 6/17/2025 at 11:05 am, the Director of Nursing (DON) stated it was her expectation that two staff members would be utilized to transfer a resident who was care planned to use a mechanical lift. During an interview on 6/17/2025 at 12:00 pm, the Administrator stated the facility did not have a policy on transferring residents with mechanical lifts. The Administrator provided an undated paper titled Electrical/Mechanical Lift Skills Check-Off, with an education/training paper attached, which documented, [Mechanical lift name] lifts are to be done by two qualified staff members when transferring.

Based on observation, record review, staff interviews, and review of the facility policies titled Skilled Nursing Services Use of Oxygen Therapy, and Medication Administration - General, the facility failed to ensure an effective infection control and prevention program was maintained for two of 20 sampled residents (R) (R17 and R1). These failures placed the residents at risk for the transmission and spread of infections. Findings include: Review of the facility's policy titled Skilled Nursing Services Use of Oxygen Therapy, reviewed 12/27/2024, indicated, Intent-to ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. It further indicated, Guideline-Physician's order for oxygen should be obtained and include: oxygen with liter flow as ordered, indicated if use should be continuous or PRN (as needed), method of oxygen delivery via nasal cannula, mask, etc.Oxygen tubing, simple mask .oxygen devices should be changed when soiled or dirty . Review of the facility's Medication Administration - General guidelines, dated 202024, revealed: If breaking tablets is necessary to administer the proper dose . hands are washed with soap and water or alcohol gel prior to handling tablets, and the following guidelines are adhered to: a tablet-splitter or alternate device is used to avoid contact with the tablet. 1. Review of R17's undated medical diagnoses under the Face Sheet tab and located in the Electronic Medical Record (EMR) revealed R17 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD). Review of R17's Resident's Consolidated Physician Orders, located under the Orders tab of the EMR, revealed an order dated 8/1/2024 of Oxygen: Nasal Cannula . 2 Liters per minute nasally every 8 hours as needed for SOB/Wheezing [Shortness of Breath/Wheezing]. During an observation and interview on 6/16/2025 at 10:29 am, R17 was lying in bed. Continued observation revealed the resident's oxygen concentrator was on and the oxygen flow rate was set at two liters per minute. The nasal cannula nose piece of the oxygen tubing was lying directly on the floor, under the head of the resident's bed, and underneath the front wheel of the resident's bed. During an observation on 6/16/2025 at 3:25 pm, R17 was sitting up in bed. The resident's oxygen nasal canula was still lying directly on the floor. During an observation on 6/17/2025 at 8:23 am, R17 was lying in bed with her eyes closed. R17 was not utilizing her oxygen, and the nasal canula was lying directly on the floor. During observations on 6/17/2025 at 12:19 pm and at 12:53 pm, R17 was observed lying in bed with her eyes closed. The resident was not utilizing her oxygen, and the nasal cannula was again lying directly on the floor, underneath the bed, and under the front wheel of the resident's bed. During a record review and interview on 6/17/2025 at 12:59 pm, the Assistant Director of Nursing (ADON) reviewed R17's physician orders and confirmed the resident was ordered to use oxygen for shortness of breath. During an observation and interview on 6/17/2025 at 1:07 pm, R17 was lying in her bed with her eyes closed. Continued observation revealed that when the ADON moved R17's oxygen concentrator away from R17's bed, the resident's nasal cannula oxygen tubing and nose piece of the tubing were lying directly on the floor. The ADON stated, That should not be there [the nasal canula lying directly on the floor]. It would absolutely be an infection control issue. The ADON then stated, I will have to bring in a new nasal cannula and replace all the tubing. At no time should the oxygen tubing be on the floor. During an interview on 6/17/2025 at 1:13 pm, the Director of Nursing (DON) stated, If there is ever oxygen tubing on the floor, especially the nasal cannula piece that goes into the resident's nose, that would be considered an infection control issue for sure. If not in use, the oxygen tubing is supposed to be in a bag. During an interview on 6/18/2025 at 8:00 am, the Corporate Divisional Nurse (CDN) stated, It would be a standard of practice to change out the oxygen tubing if staff see it on the floor. I would expect staff to get a new one if they see it on the floor. During an interview on 6/19/2025 at 9:29 am, the Administrator stated, I would expect staff to throw the oxygen tubing away if it's on the floor .That would be an infection control issue. 2. Review of R1's Face Sheet, located in the admission Record tab of the EMR, revealed R1 was admitted to the facility on [DATE] and had diagnoses which included epilepticus (seizures) and migraine. Review of R1's Electronic Medication Administration Record (eMAR) located in the Med & Treat tab of the EMR revealed medications scheduled at 9:00 am: clonazepam (anti-anxiety) two milligrams (mg), diazepam (anti-anxiety) two mg, aspirin 325mg, docusate sodium (stool softener) 100mg, phenobarbital 97.2mg (anti-seizure), and two tablets of senna (laxative) 8.6mg. In addition, there was an as-needed (PRN) order for oxycodone-acetaminophen 10-325mg. During an observation on 6/18/2025 at 8:19 am, Registered Nurse (RN) 2 performed hand hygiene using hand sanitizer. RN2 then opened a drawer of the medication cart and unlocked the controlled medication compartment. RN2 pulled up the clonazepam card, punched a pill out into his left hand, and placed it in a paper medication cup. He then pulled up the diazepam card, punched a pill out into his left hand, and placed it in the paper medication cup. RN2 then opened a different drawer of the medication cart, removed two bottles of liquid medication, and poured them into plastic medication cups before returning them to the cart. RN2 opened the controlled compartment back up and, one at a time, punched a pill of phenobarbital and a pill of oxycodone-acetaminophen out of their respective cards into his left hand and placed them into the paper medication cup. RN2 opened a drawer of the medication cart, removed a bottle of senna, and dispensed the pills into his left hand before placing them in the medication cup. RN3 then removed another bottle and properly dispensed a pill from the bottle into the lid of the bottle and into the medication cup, without touching the pill with his hands. RN4 took all medications into R1's room and administered them to her. During an interview on 6/18/2025 at 12:00 pm, RN2 stated pills in bottles should be placed in the lid of the bottle and then into the medication cup. Pills in cards should be punched out directly into the medication cup. When asked about the observations of him touching pills with his hand, R2 responded, Unfortunately, sometimes I'm clumsy. I need to get in the habit of punching out meds [medications] over the med cup. During an interview on 6/18/2025 at 1:57 pm, the Infection Preventionist (IP) stated pills should be punched directly into a cup. Staff should not touch pills with their hands. During an interview on 06/18/2025 at 2:14 PM, the Director of Nursing (DON) stated narcotic pills in cards were expected to be punched out into a cup and not a hand. Pills in bottles were expected to be put into the lid of the bottle and then into a cup.

Based on staff interviews, record review, and review of the facility policy titled Immunization of Patients, the facility failed to administer pneumonia vaccines to residents who were due for them and had signed a consent to receive the vaccine for two of five residents (R) (R2 and R6) reviewed for immunizations out of a sample of 20 residents. This failure had the potential to place R2 and R6 at an increased risk of contracting pneumonia. Findings include: Review of the facility's Immunization of Patients guidelines, reviewed 12/27/2024, revealed that for pneumococcal vaccines, Patients that are not up to date on pneumococcal vaccines per CDC [Centers for Disease Control and Prevention] recommendations must be offered pneumococcal vaccines. The facility will document the administration of the vaccine or did not receive the vaccine based on declination or medical contraindication. 1. Review of R2's Face Sheet, located in the admission Record tab of the electronic medical record (EMR), revealed she was [AGE] years old. She was admitted to the facility on [DATE] and had diagnoses that included vascular dementia and diabetes. Review of R2's Immunization tab of the EMR revealed she had a Pneumovax 23 vaccine on 12/05/2018 and a Prevnar 13 vaccine on 1/16/2020. Review of R2's Scan Docs tab of the EMR revealed a signed consent for the pneumonia vaccine dated 1/07/2025. 2. Review of R6's Face Sheet, located in the admission Record tab of the EMR, revealed she was [AGE] years old. She was admitted to the facility on [DATE] and had diagnoses that included diabetes and chronic obstructive pulmonary disease. Review of R6's Immunization tab of the EMR revealed she had an unknown type of pneumonia vaccine on 10/05/2015. Review of R6's Scan Docs tab of the EMR revealed signed consents for the pneumonia vaccine dated 11/12/2024 and 1/04/2025. During an interview on 6/18/2025 at 1:51 pm, the Infection Preventionist (IP) reported that when she started in the role of IP in October, she started to ask new residents if they wanted vaccines, including pneumonia. She stated that she reviewed new and current residents' vaccine status on the Georgia Registry of Immunization Transactions and Services, and if residents were due for a pneumonia vaccine per CDC guidelines, they were administered the vaccine if they wanted it. The IP verified that R2 and R6 had not received pneumonia vaccines as requested. She further stated that when R2's consent was signed, she was not quite due for the vaccine, and she forgot to circle back to her. The IP stated that R6 never had an order put in for the vaccine, and so it had not come from the pharmacy or been administered as it should have been. During an interview on 6/18/2025 at 2:29 pm, the Director of Nursing (DON) stated she expected vaccinations to be administered per CDC guidelines and resident request.

Based on observation, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medications by Patients, the facility failed to ensure one resident (R) (R18) reviewed for self-administration of medications did not have medications stored at the bedside. This deficient practice had the potential to allow R18 to administer the medications in an unsafe manner. The sample size was 29 residents. Findings include: A review of the facility's undated policy titled Self-Administration of Medications by Patients, revealed the Policy Statement: Each patient who desires to self-administer medication is permitted to do so if the nursing center's interdisciplinary team has determined that the practice would be safe for the patient and other patients of the healthcare center and that the patient is able to accurately self-administer. The Guideline section revealed: Each patient is offered the opportunity to self-administer his or her medications during the routine assessment by the nursing center's interdisciplinary team. The interdisciplinary team determines the patient's ability to self-administer medications by means of a skill assessment (Assessment for Self-Administration of Medication Form). The results of the interdisciplinary team assessment are recorded in the Patient Care Plan, which is placed in the patient's medical record. If the patient demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted. Nurses and Aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Observations on 1/23/2024 at 10:37 am, and on 1/24/2024 at 8:41 am and 12:19 pm revealed a container of nystatin 100,000 units per gram topical powder (a medication used to treat fungal skin infections) with a label containing R18's name on the resident's bedside table and within the resident's reach. Further observation revealed a box containing a tube of ketoconazole 2% cream (a medication used to treat fungal skin infections) located on the resident's walker. R18 informed the surveyor she had a skin rash, and she used the powder and the cream every day. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed section C - Cognitive Patterns: Brief interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. A review of R18's electronic medical record (EMR) under the Order tab revealed that R18 did not have a current order for the triamcinolone and ketoconazole topical cream, the nystatin topical powder, or an order for self-administration of medications. Further review of the EMR revealed that R18 did not have an assessment to self-administer medications or keep medications at the bedside. A review of a progress note dated 1/4/2024 located under the Nurses Note tab of the electronic record revealed triamcinolone (a medication used to treat skin conditions) was discontinued by the Physician Assistant (PA) due to no redness or rash and the resident reporting a decrease in itching. During an interview on 1/24/2024 at 12:19 pm, R18 revealed she was being treated for a skin rash by a dermatologist. The resident further stated she uses the topical cream and powder daily. R18 also informed the surveyor that she removed the cream from the tube and placed it into a black container because it was easier for her to apply. R18 opened the black container and there was a white cream inside. During an interview on 1/24/2024 at 12:22 pm, Certified Nursing Assistant (CNA) AA revealed that she provides care for R18. CNA AA further stated that she had not noticed any medications at the resident's bedside. During an interview on 1/24/2024 at 12:31 pm, Licensed Practical Nurse (LPN) BB revealed she was not aware R18 had an antifungal powder at her bedside. LPN BB stated that she was not aware that the resident did not have a current order for the ketoconazole cream. During an interview on 1/24/2024 at 12:37 pm, the Director of Nursing (DON) revealed that R18 was deemed appropriate to self-administer medication by the physician. The DON stated the physician made the determination based on the resident's cognitive status. The DON further stated the facility does not utilize an assessment to aid in the determination of allowing residents to self-medicate. The DON stated the order should indicate the resident may self-administer or keep at the bedside. The DON also stated all medications R18 used to self-administer must be maintained in the original container and kept in a closed drawer. The DON further stated that all medications used by R18 must have a physician's order. The DON verified that R18 did not have current physician orders for triamcinolone topical cream, ketoconazole topical cream, or nystatin antifungal powder. During walking rounds on 1/14/2024 at 12:48 pm with the Director of Nursing (DON), she verified R18 had a black container containing a white cream, a container of nystatin antifungal powder on the bedside table, and a tube of ketoconazole 2% cream on residents' walker. R18 informed the DON she had more containers of cream in her dresser drawer. The DON retrieved a tube of triamcinolone acetonide ointment. The DON asked permission to remove the medications to check the orders. The DON stated it was her expectation that nurses check residents' clinical records to see if residents are allowed to have medication at the bedside.

Based on observations and staff interviews, the facility failed to ensure a privacy curtain was provided to ensure full visual privacy for one resident (R) (R17). The sample size was 29 residents. Findings include: Observation on 1/23/2024 at 10:38 am revealed there was not a privacy curtain for R17's bed. The door to the room was fully open and R17 was visible from the hallway. Further observation revealed there were no curtain hooks in the curtain track above R17's bed. Observation on 1/25/2024 at 11:12 am revealed there was still no privacy curtain for R17's bed and no curtain hooks in the curtain track above R17's bed. R17 was visible from the hallway when the door was open. During an interview on 1/25/2024 at 11:45 am with Certified Nursing Assistant (CNA) EE, she confirmed that R17's bed should have a privacy curtain to provide privacy for the resident. During an interview on 1/25/2024 at 11:50 am with the Maintenance Assistant, he stated that the curtain was missing when he started working in this facility. During an interview on 1/25/2024 at 11:55 am with the Housekeeping Supervisor, she revealed that she was not sure why this room was missing a privacy curtain. She further stated that this could have happened when the facility replaced all curtains. She was not able to recall when the facility replaced the privacy curtains. During an interview on 1/25/2024 at 11:58 am with the Maintenance Supervisor, he stated that privacy curtain installation was the responsibility of the Maintenance Department, and he was not aware that a privacy curtain was missing in R17's room. During an interview on 1/25/2024 at 12:30 pm, the Administrator and Corporate Nurse Consultant confirmed that the facility did not have a policy related to resident privacy.

Based on observation, staff interviews, record review, and review of the facility policy titled Patient's Plan of Care, the facility failed to implement a person-centered care plan for two residents (R) (R18 and R2) related to following physician's orders for self-administration of medications for R18 and assisting with meals and utilizing adaptive equipment, specifically a spill-proof cup, during meals for R2. The sample size was 29 residents. Findings include: A review of the facility policy titled Patient's Plan of Care, reviewed 12/30/2022, revealed the Guideline section stated: Each resident would have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals and address the patient's medical, physical, mental, and psychological needs. 1. A review of R18's care plan revealed a care area/problem of self-administration which was updated on 12/11/2023. This care plan was developed related to triamcinolone and ketoconazole topical cream for erythema intertrigo and dermatitis diagnoses. The goal indicated the resident will take medications safely and as prescribed. Interventions included monitoring the resident's self-administration frequently. A review of R18's electronic medical record (EMR) under the Order tab revealed that R18 did not have a current order for the triamcinolone and ketoconazole topical cream, the nystatin topical powder, or an order for self-administration of medications. During an interview on 1/25/2024 at 2:15 pm, the Minimum Data Set (MDS) Coordinator verified that R18 did not have current physician orders for the medications at her bedside, therefore the care plan was not being followed. 36377 2. A review of R2's care plan revealed a care area/problem dated 12/8/2023: Needs assistive feeding devices and a history of significant weight loss. The goal was for the patient to utilize an assistive feeding device during meals through the review period onset and the patient will be satisfied with intake through the review period onset. Interventions included administering supplements and snacks as ordered, Dietitian referral as indicated, divider plate, spill-proof cup, observing intake, offering snacks frequently, and resident should eat meals in the dining room. Additionally, R2's care plan revealed a care area/problem dated 12/8/2023: Vision Impairment. Interventions included assisting the resident with meals as needed. Observations on 1/23/2024 at 1:06 pm, 1/24/2024 at 12:25 pm, and 1/25/2024 at 11:33 am revealed that R2 was not provided with an adaptive cup and did not receive assistance from staff with meals. In an interview on 1/25/2024 at 1:59 pm, the MDS Coordinator Director reported that her expectation was for staff to utilize and follow the care plan and to assist the resident according to the care plan.

Based on observations, staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) assistance for one dependent resident (R) (R2). Specifically, the facility failed to assist with eating, failed to ensure the meal setup included a prescribed therapeutic adaptive cup, and failed to ensure the proper dining table height for positioning of body alignment to ensure the resident consumed meals of nutritional value. This deficient practice had the potential to create avoidable weight loss for R2. The sample size was 29 residents. Finding include: A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C - Cognition: Brief Interview Mental Status Score (BIMS) of unable to detect/severe cognitive impairment. Section E - Behaviors: rejection of care not exhibited. Section GG - Functional Abilities: dependent for eating assistance. Section K - Swallowing/Nutritional Status: documented loss of liquids/solids from mouth when eating or drinking, coughing, or choking during meals when swallowing medications, mechanically altered diet. A review of R2's electronic medical record (EMR) revealed diagnoses of, but not limited to, unspecified intellectual disabilities, unspecified dementia, feeding difficulties, dysphagia, oral phase, left-hand contracture, and abnormal posture. A review of the RD (Register Dietician) Nutrition assessment dated [DATE] documented interventions of allowing eating at own pace and providing necessary assistance with food and fluids. The goals were to maintain acceptable nutritional parameters and, the patient receive necessary assistance with food and fluids. A review of the facility electronic form titled Section GG Assessment V2.0 dated 11/9/2023 documented: Eating - How much assistance does the resident need to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident? 01-Dependent/two-person assistance. A review of the facility electronic form titled Comprehensive Nursing Assessment V5.0 dated 11/9/2023 documented: If the patient needs assistance with using utensils and bringing food/liquids to mouth after setup of meal, answer the following. (m) - Staff completes all of the tasks (01). A review of the facility electronic form titled Occupational Therapy (OT) Form dated 11/16/2023 documented: Pt. (patient) would benefit from using another cup for better performance and with no spillage. OT Eval (evaluation) recommended further assessment for an appropriate and safe drinking cup for pt. to use needed to decrease spillage. A record review revealed a diet order dated 7/13/2022 for large portions, nutritional shakes one carton by mouth after meals, and frozen nutritional treats three times a day with meals related to weight loss. A review of a copy of the meal ticket slip revealed: cup w/lid (with lid) (1 each) divided plated (1 each). A review of the Physician Progress Notes revealed a note dated 12/31/2023 Patient is being seen for LTC (Long Term Care) follow up for medical management with inability to care for self at home, requiring nursing assistance and assistance with ADLs, visual changes and no behavioral disturbances. Observation on 1/23/2024 at 1:06 pm revealed R2 eating lunch in the dining room. The meal setup included two regular cups instead of spill-proof cups. R2 was observed trying to lift the regular cup with her left hand, which had a contracture. R2 raised the cup and the nutritional drink spilled from the cup to the floor. Continued observation revealed large clumps of food on the food protector on R2's chest and food spillage on the table. Each time R2 raised her spoon to feed herself, the food fell from her spoon. Further observation revealed the dining table height was elevated, and R2 was observed to have difficulty with eating her meal. During the observation, the Infection Control Preventionist (ICP) and Registered Nurse (RN) RCC were observed in the dining area. RN RCC was seated in a chair adjacent to the table R2 was seated at. Observations revealed there were no interactions from staff to assist R2. Observation on 1/24/2024 at 12:25 pm revealed R2 eating lunch in the dining room. Observation revealed large clumps of food items on R2's clothing protector and the floor. Observation revealed that R2 spilled her nutritional shake as she attempted to pick up the regular cup provided to her. She attempted to pick up another regular cup containing tea and was unable to lift the cup. R2's beverages were in two regular cups instead of spill-proof cups. Further observation revealed that R2 had difficulty directing the food items to her mouth when raising her hands to reach the food due to the height of the dining table. The Director of Nursing (DON) and the ICP were observed in the dining room and did not offer feeding assistance to R2. In an interview, the DON stated that R2 refused assistance and was coded for refusing care. During an observation of R2 eating lunch on 1/25/2024 at 11:33 am, the Physical Therapist (PT) confirmed a spill-proof cup should have a grip on the side and confirmed the cup R2 was provided with was not a spill-proof cup. In a telephone interview on 1/25/2024 at 11:56 am the Occupational Therapy (OT) Director reported being unaware that R2 was not utilizing a spill-proof cup. The OT Director stated that R2 was assessed to use a spill-proof cup because it has two handles, and a regular cup is too heavy and will result in spillage. The OT Director further stated that R2 was assessed on 12/7/2023 and was able to demonstrate using the spill-proof cup with success. The OT Director stated that the cup was given to the Dietary Staff for R2 to use. She further stated that her recommendation was for staff to change the height of the dining table and ensure the R2 uses a spill-proof cup for all meals. In an interview on 1/25/2024 at 1:11 pm, Certified Nursing Assistant (CNA) AA reported being aware that R2 had trouble with eating and having large food spillage during meals. She stated that R2 was known to refuse help. She further stated that CNAs are informed to attempt at least three times to help the resident. She stated she had voiced concerns in the past and was told to clean up the food spillage. In an interview on 1/25/2024 at 1:24 pm, CNA EE confirmed being aware of R2's food spillage on the floor and her clothing protector. She stated that she did not feel that the resident was consuming a lot of food during mealtime. She stated she felt the resident could use the spoon but had difficulty holding a regular cup. In an interview on 1/25/2024 at 1:26 pm, RN RCC reported that R2 will allow staff to feed her on some days and some days she will not. She confirmed sitting in the dining room on 1/23/2024 and observing R2 spilling her drink in her attempts to lift the cup and the large spillage of food on R2. She confirmed she did not assist the resident with the meal. In an interview on 1/25/2024 at 12:47 pm, Dietary Manager CC reported that R2 had two spill-proof cups and both tops (lids) were lost. She reported that her expectation was for the dietary staff to ensure a spill-proof cup was provided during meals. In an interview on 1/25/2024 at 1:37 pm, the DON reported that her expectation was for staff to attempt to assist R2 during mealtimes. In an interview on 1/25/2024 at 1:45 pm, the ICP reported that R2 resisted assistance from staff with meals. The ICP reported that she thought the height of the table and the resident not sitting in an erect position affected her ability to eat. She confirmed observing the resident eat lunch on 1/23/2024 and 1/24/2024 and stated did not pay attention to the type of beverage cup that R2 was provided. She confirmed observation of the food spillage on both days and confirmed she did not assist R2 with the meals. In an interview on 1/25/24 at 2:19 pm, the Administrator reported her staff provides help to their residents and that R2 has received help. She stated she did not feel that there was a problem if a resident had food spillage at meals. She further stated there was a Patient at Risk (PAR) plan and the Regional Director planned to order another cup. She stated she was unaware of the expectations for resident dining table heights. During an observation and interview on 1/25/2024 at 2:30 pm, the Administrator observed the dining table with measurements of 31.5 inches and confirmed the table height.

Based on observation, record review, facility staff and Hospice staff interviews, the facility failed to provide adequate supervision when serving hot broth to one resident (R) (R#1) of six sampled residents. This failure resulted in actual harm for R#1 who sustained [CONDITION(S)] on her body. Findings include: Review of the [NAME] Health Care website (standfordhealthcare.org) Burn Stages revealed that First degree [CONDITION(S)] were superficial and affected only the epidermis, or outer layer of skin. The burn site was red, painful, dry and had no blisters. A mild sunburn was an example. Second-degree [CONDITION(S)] involved the epidermis and part of the dermis layer of skin. The burn site appeared red, blistered and may be swollen and painful. Third-degree [CONDITION(S)] destroyed the epidermis and dermis and may damage the underlying bones, muscles and tendons. The burn site appeared white or charred and there was no sensation in the area because the nerves endings were destroyed. R#1 was admitted [DATE] with diagnoses of [CONDITION(S)] (COPD), [CONDITION(S)] disease, Adult Failure to Thrive, [CONDITION(S)], and hypertension. She was admitted to Hospice Services on 2/3/21. Review of the resident's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 indicating that she had moderate cognitive impairment and required supervision (oversight, encouragement, queuing) of one-person physical assist for eating. Review of the Hospice Skilled Nursing Visit Note dated 2/4/21 at 11:30 a.m. revealed that the resident's lunch tray was brought to her room by a Certified Nursing Assistant (CNA) during the visit by the Hospice Registered Nurse (RN) BB. Hospice RN BB inquired of the CNA if R#1 was fed and the CNA informed the Hospice RN that the resident fed herself when she felt like eating. Hospice RN BB noted the resident's contracted hands and believed she would have difficulty using utensils to feed herself. Continued review revealed that the Hospice RN asked R#1 if she wanted to be fed and the resident said yes. The resident consumed one half cup of the jello before she stopped due to fatigue and increased shortness of breath. Hospice RN BB then requested the CNA feed R#1 when the resident was ready to eat again. Further review revealed that the Hospice RN spoke with the MDS coordinator and requested that physician orders be changed to feed R#1 every meal which may increase her intake. Review of the resident's medical record revealed that there was no Physician Order for staff to feed R#1 every meal. Review of the Nurses' Note dated 2/8/21 at 11:51 a.m. revealed that R#1 was provided her lunch tray. The resident turned over the bowl of broth and it poured down her right side. Licensed Practical Nurse (LPN)/Resident Care Coordinator (RCC) AA documented that she assessed R#1 with a small amount of redness but there were no blisters noted. The Nurse Practitioner was notified and ordered staff to monitor the resident. The resident's family member was notified. On 2/8/21 at 1:48 p.m. a Physician's Order was obtained for [MEDICATION(S)] ointment (used to treat minor skin irritations by forming a barrier from irritants/moisture), apply three times per day to blisters on abdomen. This order was changed on 2/8/21 at 4:12 p.m. for staff to apply [MEDICATION(S)] 1% topical cream (an antibiotic used to treat or prevent serious infection on areas of skin with second- or third-degree [CONDITION(S)]) three times per day to right abdominal blisters. Review of the Nurses' Note dated 2/9/21 at 11:40 a.m., revealed that the Nurse Practitioner was notified that the blisters were opening and ordered oral antibiotic therapy for seven days. Review of the Hospice Skilled Nursing Visit Note dated 2/11/21 at 1:30 p.m., revealed that Hospice RN BB assessed R#1 with first degree burn on her right lower medial outer abdominal quadrant with 50% slough and 50% granulating tissue. Review of the Hospice Skilled Nursing Visit Note dated 2/15/21 at 11:00 a.m. revealed that the [CONDITION(S)] to the resident's right abdominal quadrant had 100% pink/red tissue and had improved. Review of the Nurse Practitioner's Progress Note dated 3/3/21 revealed that R#1 had received superficial [CONDITION(S)] last month. Large blisters, some open, some intact, were noted across the right side of the resident's abdomen and flank. The resident complained of pain to the area and received as needed pain medication. On 3/5/21, a Physician's Order was obtained for staff to clean blisters on the resident's abdomen, right thigh and buttocks with normal saline, pat dry, apply hydrogel gauze (a dressing used to cool and soothe [CONDITION(S)] and painful wounds), and cover with a composite dressing every three days. Review of the resident's medical record revealed that staff provided treatments to the resident's [CONDITION(S)], monitored her for infection, and administered pain medication as needed. Observation on 5/18/21 at 10:30 a.m. revealed R#1 was lying in the bed with oxygen infusing via nasal cannula at 3 liters. The resident was alert but frail and spoke in a low tone. She appeared well hydrated. Interview with Hospice RN BB, who was in the resident's room at this time, revealed that staff had told her that a staff member was in the room during a meal, turned her head for a minute and the resident spilled broth on herself. Continued interview with Hospice RN BB revealed that she assessed the resident several days later (on 2/11/21) and noted blistering [CONDITION(S)] on her right abdomen and right thigh. Further interview revealed that the blisters opened over time and had slough. The corporate Wound Care Consultant assessed the [CONDITION(S)] and changed the treatment to hydrogel gauze every three days which helped the healing of the [CONDITION(S)] significantly. Observation of lunch on 5/19/21 at 12:00 noon revealed a CNA sitting next to R#1's bed attempting to feed the resident. R#1 turned her head away and refused to eat even after much encouragement from the CNA. Interview with LPN/RCC AA on 5/19/21 at 11:03 a.m. revealed that she sometimes fed residents who required assistance with meals. She stated that R#1 would sometimes feed herself but, staff would stay in her room during the meal to assist her as needed. Continued interview revealed that on 2/8/21 at lunch, the resident's meal tray which included hot broth, did not come out on the meal cart but was served directly from the kitchen. LPN/RCC stated that she set up the resident's meal tray on the overbed table and placed the bowl of hot broth on the back of the tray away from the resident. She stated that she felt the bottom of the bowl and it was hot but she did not realize it was that hot. Further interview revealed that she told the resident that the bowl of broth was hot. She gave the container of jello to R#1 who was holding the container and feeding herself the jello. Continued interview revealed that LPN/RCC AA saw a resident in the hall who was about to fall and ran into the hall to assist him. LPN/RCC AA then was told that she had a phone call from the physician and took the call in her office which was several doors down from R#1's room. LPN/RCC AA stated that she was gone from the resident's room no more than 4-5 minutes and was on her way back to the resident's room when she heard R#1 yell out. When she arrived to the resident's room, R#1 had flipped the bowl of hot broth onto her abdomen. LPN/RCC AA stated that she called for help, got a towel to wipe off the hot broth and she and another staff member changed the resident's clothes and linens. She assessed the resident's skin at that time and it appeared red like a sunburn but, there were no blisters. Further interview revealed that the previous Treatment Nurse assessed the resident later that afternoon and blisters were beginning to develop. Interview with the RN/MDS Coordinator on 5/19/21 at 2:21 p.m. revealed that Hospice RN BB had recommended that staff feed R#1 but, the resident was feeding herself at that time with prompting from staff. The RN/MDS Coordinator stated that she did not write a Physician's Order for staff to feed the resident because Hospice usually wrote their own Physician Orders. During observation of wound treatment by the Director of Nursing (DON) on 5/20/21 at 10:00 a.m., R#1 had a healing burn approximately 10 to 11 centimeters (cm) wide beginning on her right abdomen extending down her right hip and right upper thigh. Several [CONDITION(S)] approximately 1 ½ cm wide extended down her right buttock. The [CONDITION(S)] had pink tissue and were without exudate. The DON used appropriate infection control during the wound treatment and R#1 tolerated the treatment well without signs of pain. The facility failed to provide adequate supervision when serving hot broth to R#1 resulting in the resident sustaining [CONDITION(S)] on her body.

Based on observation, interviews, record review, and policy review, the facility failed to ensure staff followed infection control policies related to transmission-based precautions to prevent the spread of infections for two of five residents (R) (#1 and #2) observed for infection control practices. Specifically, Certified Nursing Assistant (CNA) AA provided care for the [MEDICAL TREATMENT] residents on transmission-based precautions due to the COVID 19 pandemic without wearing full Personal Protective Equipment (PPE) and without proper handwashing between resident care. Findings include: Review of the facility's policy, revised on 4/23/20, Pandemic Response Plan, directed when High-COVlD 19 is suspected or confirmed in your center . New Admissions, non COVID19 .may be admitted using the following guidance: **Patient should be placed into private room under droplet precautions for 14 days. Review of the facility's undated policy, TRANSMISSION-BASED PRECAUTIONS, directs the use of barriers in addition to those used for Standard Precautions .Use of Personal Protective Equipment (PPE) . Wear gloves whenever touching the resident's intact skin or surfaces and articles in close proximity to the resident (e g., medical equipment, bedrails). Don gloves upon entry into the room. During an interview on 8/5/20 at 10:00 a.m., the Director of Nursing (DON) stated that the facility had a COVID 19 outbreak on 6/26/20 and experienced four COVID related deaths; however, no one in the facility on 8/5/20 was positive for COVID. The DON stated the facility has three residents on [MEDICAL TREATMENT] who go out of the facility for [MEDICAL TREATMENT] three times a week. The DON stated the residents on [MEDICAL TREATMENT] are treated like new admission/readmissions and have been on quarantine precautions since the beginning of the COVID 19 pandemic in March 2020. The DON stated the facility has a COVID Policy and follows Centers for Disease Control and Prevention (CDC) guidance for the COVID 19 pandemic. Review of R#1's Face Sheet revealed the resident has End Stage [MEDICAL CONDITIONS] (failure of the kidneys to produce urine) and is dependent on [MEDICAL TREATMENT]. Review of R#2's Face Sheet revealed the resident has [MEDICAL CONDITION] and is dependent on [MEDICAL TREATMENT]. Observation on 8/5/20 at 8:50 a.m. revealed R#1 and R#2 were in a semiprivate room and the door had signage posted for DROPLET PRECAUTIONS and ENHANCED BARRIER PRECAUTIONS wear gloves and gown for high contact resident activities . changing linens. On 8/5/20 at 8:50 a.m., CNA AA was observed outside R#1 and R#2s' room at the isolation cart donning (putting on) an isolation gown; he already had on an N95 mask and goggles. The CNA entered the room without donning gloves and straightened up R#2's empty bed with his bare hands. Without washing his hands, he went to assist R#1 in his bed with items on his bedside table and straightened the linens on his bed. CNA AA went into the bathroom in the room, washed his hands and came out wearing gloves. During an interview on 8/5/20 at 8:55 a.m., CNA AA stated he was not wearing gloves when he entered the room because he forgot and placed them on when he remembered. During an interview on 8/5/20 at 2:22 p.m., the Assistant Director of Nursing/Infection Preventionist (ADON) stated that all the [MEDICAL TREATMENT] residents are on transmission-based precautions and staff should be wearing full Personal Protective Equipment (PPE), gown, gloves, N95 mask and eye protection, when entering the residents' rooms. The ADON further stated that the signage the facility uses to denote the transmission-based precautions are for droplet and barrier precautions and that handwashing between resident contact is required to adhere to Standard precautions.

Based on observation, record review, review of the facility Grievances: Abuse Prevention Procedural Guidelines (updated 8/2017) and resident and staff interview, the facility failed to ensure that one (1) resident (R#7) was adequately protected from further abuse by another resident (R#6) after R#7 verbalized to staff that she was afraid. The sample was eight (8) residents. Findings include: Review of the facility Grievances: Abuse Prevention Procedural Guidelines (updated 8/2017) revealed that the facility would identify residents whose behavior was abusive to other residents A thorough assessment would be completed to include any identified situations or factors that trigger abusive behavior From the assessment, intervention strategies would be developed on the care plan or behavioral management plan to prevent occurrences including monitoring for factors that trigger abusive behavior for that resident .The care plan including interventions would be evaluated on a regular basis and revised as necessary .The facility will identify, correct and intervene in situations in which abuse was more likely to occur to include the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms and those residents who are totally dependent on staff. 1. R#7 (wife and roommate of R#6) was admitted [DATE] with [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 8, indicating that she was cognitively impaired and that she had verbal behaviors 1 to 3 days in the last 7 day look back period. Continued review revealed that she was non-ambulatory; was totally dependent on staff for bed mobility and other activities of daily living (ADLs); and received antianxiety and antipsychotic medications daily. Review of her care plan dated 3/24/19 revealed that staff had developed appropriate interventions to address her cognitive deficit, risk for mood swings, anxiety, impaired physical mobility, self- care deficit and diagnoses. Further review revealed that staff revised the care plan on 12/19/18 to address her adjustment to new married life (to R#6). On 9/19/19 at 9:00 a.m. R#7 was observed lying in bed in her room close to the nurses' station. R#7 did not have any bruising noted on her throat, face or arms. Although R#7 was alert but, an attempt to interview her at that time was unsuccessful. 2. R#6 (husband and roommate of R#7) was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Date Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 12, indicating that he had some cognitive impairment and had other behaviors 1 to 3 days in the last 7 day look back period. Continued review revealed that he required extensive assistance from staff for ambulation and other activities of daily living (ADLs). Further review revealed that he received oxygen therapy, an antipsychotic, an antianxiety and antidepressant medication daily. Review of the care plan for R#6 revealed that staff developed interventions to address his anxiety, depression, rejection of care, cognitive deficit and diagnoses. On 9/19/19 at 8:40 a.m., R#6 was lying in bed in his room on another hall from R#7. He was receiving a breathing treatment. He stated at that time that he was being transferred shortly to the hospital for shortness of breath. Review of the electronic medical record (e-record) for R#6 revealed a Nurses Note dated 8/28/19 at 1:38 p.m. that R#6 was observed by a Certified Nursing Assistant (CNA) holding his hand over his wife's/roommate's (R#7's) mouth and nose. The nurse was notified and she notified the Interim Director of Nursing (DON) and Administrator. The Advanced Practice Registered Nurse (APRN) was notified and ordered R#6 transferred to the behavioral unit. The daughter for R#6 and family for R#7 were notified about the incident. Review of the Behavioral Assessment form dated 8/28/19 at 2:29 p.m. revealed that the Social Service Director (SSD) and a nurse spoke with R#6 about covering his wife's mouth and nose but, R#6 did not admit to covering her mouth. Continued review revealed that he was upset because R#7 had another boyfriend and she told R#6 that she was going to divorce him. Review of the Nurses Note dated 8/28/19 at 4:02 p.m. revealed that R#7 was moved to another room related to issues with current roommate (R#6) and that family was notified. Review the Nurses Note dated 8/28/19 revealed that R#6 was transferred to the behavioral unit at 6:45 p.m. Review of the care plan for R#7 revealed that staff revised her care plan on 8/30/19 to address her conflict with family with the goal that R#7 would demonstrate effective coping behavior during the review period. Interventions developed included staff to allow the resident to talk about her feelings and let her know staff is empathetic; assist resident to process feelings/find positive outcomes; and discuss situation with family member if appropriate. However, the care plan did not include an appropriate intervention to monitor/supervise R#7 to ensure she was kept safe from further abuse from R#6. Review of the care plan for R#6 revealed that staff revised his care plan on 8/28/19 to address his behavioral changes and conflict with family with the goal that he would demonstrate improvements during the review period with an intervention for staff to refer to psych (psychiatric) as needed. However, the care plan did not include an appropriate intervention to monitor/supervise R#6 to ensure he did not abuse R#6 again. Interview on 9/19/19 at 8:45 a.m. with Certified Nursing Assistant (CNA) BB revealed that she had worked at facility about two months and had not witnessed or heard about any resident to resident altercations. Continued interview revealed that if she did witness an altercation she would separate the residents and monitor that they were kept apart to prevent further altercations. Interview with Licensed Practical Nurse (LPN) AA on 9/19/19 at 8:50 a.m. revealed that she had heard that R#6, who was the roommate and husband of R#7, had attempted to suffocate R#7 about one month ago. LPN AA stated at that time that R#6 was sent to the behavioral unit for psychological evaluation and treatment. Interview with CNA CC on 9/19/19 at 10:36 a.m. revealed that she heard that CNA DD saw R#6 with his hands around the throat of R#7 and that R#7 was crying and asking for help. Continued interview revealed that she had not been informed by supervisory staff to monitor R#6 to ensure that he did not enter the room of R#7. A follow up interview with LPN AA on 9/19/19 at 10:40 a.m. revealed that she was informed by supervisory nursing staff to monitor the whereabouts of R#6 to ensure that he did not enter the room for R#7. Continued interview revealed that one day last week, R#6 attempted to go to R#6's room but, was redirected back to his room before he could enter. Further interview revealed that she told R#6 that he was not allowed to see R#7. Interview with CNA DD on 9/19/19 at 11:30 a.m. revealed that on 8/28/19 she was in the hall when she saw R#6 leaning over his wife's (R#7) bed with his left hand over her mouth and nose. Continued interview revealed that she entered the room and asked R#6 what he was doing. He started rubbing his wife's face and stated I'm just messing with her. CNA DD stated at that time that R#7's face was red and her eyes were big. R#7 was not crying and did not say anything to her about her husband trying to hurt her. Further interview revealed that R#7 could tell staff if she felt someone was trying to hurt her. CNA DD stated that she was not instructed by supervisory nursing staff to monitor R#6's whereabouts or to monitor R#7 to ensure she was safe from R#6. Review of the Five Day Summary Investigation dated 9/3/19 and sent to the State Agency (SA) revealed that the incident on 8/28/19 was first reported to the SA on 8/29/19 (Facility Reported Incident # 895). Continued review revealed that a CNA observed R#6 (husband) with his hand over the nose and mouth of R#6 (wife). R#7 was moved to another room and R#6 transferred to the behavioral unit. A statement from CNA DD was obtained regarding her observation of the incident. Review of the psychiatric evaluation dated 8/29/19 and included in the Summary revealed that R#6 told the psychiatric staff that R#7 asked him how it felt not to be able to breathe and he tried to show her. He stated that he would not do anything to hurt her. Further review of the Summary revealed that the facility took actions to prevent recurrence including staff education to be provided on how to deal with conflicts with residents and interventions for de-escalating conflicts. Review of the in-services dated 8/28/19 revealed that the Administrator provided education on Abuse and Neglect and that seven (7) CNAs attended. An In-service on Abuse was also provided on 9/9/19 but, only included registered nursing staff, licensed nursing staff and the Interim DON. There was no indication that certified nursing staff were instructed specifically to monitor R#7 to ensure that she was kept safe from any further abuse from R#6 or to monitor R#6 to ensure that he had no additional contact with R#7. Interview with the Administrator on 9/19/19 at 1:10 p.m. revealed that on 8/28/19, she asked R#7 if she felt safe staying in her room with her husband (R#6) and R#7 said No. Continued interview revealed that she asked R#7 if her husband was trying to hurt her and R#7 shook her head No but, did not speak. The Administrator stated at that time that R#7 could verbalize if someone had hurt her. Further interview with the Administrator revealed that she did not believe a crime had been committed because R#7 did not tell staff that R#6 was trying to hurt her and there had been no prior altercations between them. Continued interview revealed that staff had protected R#7 from R#6 by moving her to another room that was closer to the nurses' station for closer supervision. The Administrator stated that the CNAs were instructed to closely watch R#7 and R#6 to ensure R#7's safety. When informed that interviews with Certified Nursing Staff did not confirm their knowledge to monitor R#7 for safety and prevent any future interactions with R#6, she stated that they had been in-serviced. Interview with R#7 on 9/19/19 at 1:40 p.m. revealed that she was more alert than during an earlier attempt to interview her. When asked what her husband did to her, R#7 stated he choked me and he slapped me he tried to kill me. The Administrator was notified immediately about the resident's allegation. Review of the statement provided by R#7 to the Social Service Director (SSD) and Interim DON on 9/19/19 at 2:45 p.m. revealed that R#6 tried to kill her. He also hit her on the left side of the face with his fist and choked her. Interview with the Social Service Director on 9/20/19 at 9:25 a.m. revealed that she spoke with R#7 several days after the incident with R#6 and that R#7 told her she was afraid because R#6 had placed his hand over her mouth. Continued interview revealed that R#7 did not say that she believed R#6 was trying to kill her. Interview with the Interim DON on 9/20/19 at 11:03 a.m. revealed that R#7 had an appointment scheduled with Tele-psychiatry on 9/24/19 prior to the 8/28/19 incident. Continued interview revealed that the interdisciplinary team discussed having R#7 assessed by Tele-psychiatry after the incident on 8/28/19 but, R#7 did not exhibit any emotional distress after the incident. Although the facility moved R#7 to another room on a different hall after her roommate and husband (R#6) was observed holding his hand over her mouth and nose, the facility failed to ensure that R#7 was adequately protected from further abuse by R#6 after she informed staff on 8/28/19 that she was afraid. Furthermore, the facility failed to revise the care plan for R#6 to address his abuse of R#7 with an appropriate intervention for staff to monitor his whereabouts. The facility failed to revise the care plan for R#7 to address her need for safety from further abuse by R#6 with an appropriate intervention for staff to monitor that R#6 be prevented from further contact with her.

Based on record review and staff interview, the facility failed to revise the care plans for two (2) residents (R#7 and R#6) with appropriate interventions to ensure the safety of R#7 from further abuse by R#6. The sample size was eight (8) residents. Findings include: R#6 (husband and roommate of R#7) was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the care plan for R#6 revealed that staff developed appropriate interventions to address his anxiety, depression, rejection of care, cognitive deficit and diagnoses. R#7 (wife and roommate of R#6) was admitted [DATE] with [DIAGNOSES REDACTED]. Review of her care plan dated 3/24/19 revealed that staff had developed appropriate interventions to address her cognitive deficit, risk for mood swings, anxiety, impaired physical mobility, self- care deficit and diagnoses. Further review revealed that staff revised the care plan on 12/19/18 to address her adjustment to new married life (to R#6). Review of the electronic medical record (e-record) for R#6 revealed a Nurses Note dated 8/28/19 at 1:38 p.m. that R#6 was observed by a Certified Nursing Assistant (CNA) holding his hand over his wife's/roommate's (#7's) mouth and nose. The nurse was notified and she notified the Interim Director of Nursing (DON) and Administrator. The Advanced Practice Registered Nurse (APRN) was notified and ordered R#6 transferred to the behavioral unit. The daughter for R#6 and family for R#7 were notified about the incident. R#7 was moved to a room closer to the nurses station. Review of the care plan for R#7 revealed that staff revised her care plan on 8/30/19 to address her conflict with family with the goal that R#7 would demonstrate effective coping behavior during the review period. Interventions developed included staff to allow the resident to talk about her feelings and let her know staff is empathetic; assist resident to process feelings/find positive outcomes; and discuss situation with family member if appropriate. However, the care plan did not include an appropriate intervention to monitor/supervise R#7 to ensure she was kept safe from further abuse from R#6. Review of the care plan for R#6 revealed that staff revised his care plan on 8/28/19 to address his behavioral changes and conflict with family with the goal that he would demonstrate improvements during the review period with an intervention for staff to refer to psych (psychiatric) as needed. However, the care plan did not include an appropriate intervention for staff to monitor/supervise R#6 to ensure he did not abuse R#6 again. Interview with CNA CC on 9/19/19 at 10:36 a.m. revealed that she heard that CNA DD saw R#6 with his hands around the throat of R#7 and that R#7 was crying and asking for help. Continued interview revealed that she had not been informed by supervisory staff to monitor R#6 to ensure that he did not enter the room of R#7. Interview with CNA DD on 9/19/19 at 11:30 a.m. revealed that on 8/28/19 she was in the hall when she saw R#6 leaning over his wife's (R#7) bed with his left hand over her mouth and nose. Continued interview revealed that she entered the room and asked R#6 what he was doing. He started rubbing his wife's face and stated I'm just messing with her. CNA DD stated at that time that R#7's face was red and her eyes were big. R#7 was not crying and did not say anything to her about her husband trying to hurt her. Further interview revealed that R#7 could tell staff if she felt someone was trying to hurt her. CNA DD stated that she was not instructed by supervisory nursing staff to monitor R#6's whereabouts or to monitor R#7 to ensure she was safe from R#6. The facility failed to revise the care plan for R#6 to address his abuse of R#7 with an appropriate intervention for staff to monitor his whereabouts to prevent further abuse of R#7. The facility failed to revise the care plan for R#7 to address her need for safety from further abuse by R#6 with an appropriate intervention for staff to monitor that R#6 be prevented from further contact with her.

Based on observation, staff interview, document review, and review of policy titled Cleaning and Sanitizing revealed the facility failed to ensure the three-compartment sink in the kitchen was adequately maintained and the proper chemical concentration was being utilized to prevent the spread of foodborne illness for 75 residents out of 78 residents in the facility who received meals from the kitchen. Findings include: The initial kitchen observation/inspection was conducted with the Dietary Manager (DM) on 2/11/2019 from 11:00 a.m. to 11:30 a.m. with the following sanitation issue noted: The three-compartment sink had water in all three compartments, of the sink, although the compartments were not labeled. The DM stated the compartment on the right was the sanitizer rinse sink. The Quat litmus test done by the DM revealed the level below 150 parts per million (ppm) utilizing test strips with an expiration date of 12/19/2019. She stated the test strip result should be between 150-400 ppm. She retested , and it still read below 150 ppm. The sanitizer rinse sink contained three metal serving pans/trays. She took the pans out of the sink and rewashed them. She drained the sanitizer rinse sink and refilled it with the water and chemical. The water in the sanitizer rinse sink still read below 150 ppm. She noted the Quat sanitizer chemical container was almost empty and stated she was going to replace it with a new/full container. A second observation made of the kitchen on 2/13/2019 at 9:16 a.m. revealed they were not using the sanitizer rinse sink. The DM stated her staff are pre-washing in the wash sink, rinsing in the rinse sink and then putting everything through the hot water dishwasher. She stated she put in a work order on 2/12/2019 with (name) maintenance company to come inspect the sanitizer rinse sink. The maintenance log revealed an entry for 2/12/2019 kitchen sink/three compartment sink and maintenance company was notified. Review of the maintenance company visit form dated 2/13/2019 at 2:49 p.m. revealed a fix to the dispensing system. A third observation of the three-compartment sink on 2/14/2019 at 7:57 a.m. revealed the Quat test strip read 150 ppm. No pots/pans were observed in the sink. An interview with the DM on 2/14/2019 at 7:57 a.m. revealed the maintenance company came to the facility on [DATE] and fixed the dispensing system for the sanitizer rinse sink. She stated the sink has been working well since yesterday afternoon. She stated she expects her staff to always check the sanitizer water after filling the sink and to log the results. She also expects them to notify her if the level below 150 ppm. An interview with Dietary Assistant(DA) AA on 2/14/2019 at 8:07 a.m. revealed she washes pot and pans in the three-compartment sink and is now aware of the process for filling the sink with santitation solution and what to do if it does not reach 150 ppm. If the level is to low then she would drain the sink and refill it and retests for proper solution level. She stated they check the sanitation sink three times a day after the meal and the results are logged on the daily form. Review of the Three Compartment Sink Sanitizer Log revised 11/1/2017 for (MONTH) 2019 and (MONTH) 2019 revealed the sink was checked that morning and all answers were checked yes. The log does not reveal a time just breakfast, lunch, and dinner and has three categories: Temp wash/rinse, Temp sanitizer sink, and Testing strip. Each sub category has a Y or N to answer. They do not document temperatures or the Quat levels. The form has a procedure on the bottom and a general recommendations guide for the sanitizer rinse sink. It stated to follow manufactures recommendations. Review of the document titled (name) Multi-Quat Sanitizer revealed that an EPA-registered sanitizer for pre-cleaned use on non-porous food prep surfaces and ware is effective against foodborne organisms. The Quat Range is 150-400 ppm. Directions for use indicated to apply the sanitizer at proper use solution. Expose all surfaces of equipment, ware, or utensils to the sanitizing solution for a period of not less than one minute. Review of the education/in-services on the Use of the Three Compartment Sink revealed the signature sheet was signed by the kitchen staff on 1/22/2019, 1/23/2019 and 1/24/2019. The in-service topics included the sink must be set up correctly before use and how to get ready to wash, rinse and sanitize. Review of the policy titled Cleaning and Sanitizing updated (MONTH) 2019 revealed the three- compartment sink: a. Manufacturer guidelines will be followed b. Sanitizer/temperature monitoring log will be maintained c. General guidelines: i. Items will be washed, rinsed and sanitized ii. Water temperatures will be maintained at appropriate ranges iii. Items will be fully submerged in the sanitizer solution for at least one minute iiii. Appropriate sanitizer concentration: 150-400 ppm

Based on interviews, record review, review of a facility policy entitled Advance Directives updated (MONTH) 2019 and review of the state of Georgia Physician order [REDACTED].#50. The sample size was 32. Findings include: Record review revealed that R#50 was admitted with [DIAGNOSES REDACTED]. A review of a form entitled Physician order [REDACTED]. Code Status instructing health care providers to Allow Natural Death (AND) - Do Not Attempt Resuscitation. The POLST form is signed by two physicians and dated 12/7/18. There was no signature in the section entitled Patient or Authorized Person Name. R#50 does not have an Advanced Directive or designated health care proxy/decision maker. Page two (2) of the POLST form states: 5. If the patient lacks decision making capacity, the POLST form may be signed by an authorized person , which includes, in the following order of priority: a. the agent named on the patient's durable power of attorney for health care or a health care agent named on the patient's advance directive for health care; b. a spouse: c. a court-appointed guardian; d. son or daughter (age 18 or older); e. parent; f. brother or sister (age 18 or older); 6. If an authorized person completes and signs the POLST form, treatment choices should be based in good faith on what the patient would have wanted if the patient understood his or her current circumstances. R#50 has a sister who acted as his decision maker. The sister's signature was not on the POLST form and there was no documentation in the medical record detailing any discussions related to code status. A review of Physician order [REDACTED]. entered on 9/14/18 and discontinued 12/4/18; and Code Status Full Code . entered 12/05/18 and discontinued 2/6/19. A review of the current monthly Physician order [REDACTED].; entered 2/6/19 . A review of the care plan for R#50 revealed a problem/focus area entitled Advanced Directive listing a review of the goal(s) by the social worker on 12/21/18. The interventions listed include Follow Advance Directives as written (8/14/18 onset) and Provide education on Advance Directives and Advance Care Planning (8/9/18 onset). The care plan did not list or indicate the change in code status from the physician's orders [REDACTED]. An interview was conducted on 2/14/19 at 12:15 p.m. with the Administrator requesting a copy of any facility policy related to POLST forms, do not resuscitate or allow natural death orders. She provided a copy of a policy entitled Advanced Directives, updated (MONTH) 2019. The policy states that the procedure for periodically reviewing patient choices and preferences related to health care decision after admission is ongoing and that Results of advance care planning discussions will be documented in the patient's medical record. This documenation will include identification of new care instructions, clarification of care instructions, changes in care instructions or whether care instructions are to remain the same. An interview was conducted on 2/14/19 at 12:30 p.m. with Registered Nurse (RN) DD and Minimum Data Set (MDS) Director who provided a copy of a document entitled Patient Education V2 dated 12/21/18. The form indicates the topic of Advanced Directives was discussed with R#50's sister on 12/21/18. RN DD confirmed that the form does not indicate the code status/order change from a full code to a Do Not Resuscitate (DNR) status was discussed specifically. She also confirmed that the POLST form dated 12/7/18 was signed by two physicians but not signed by the resident or any authorized person. She confirmed there is nothing in the chart declaring the resident is not competent to make his own decisions. RN DD also confirmed that the care plan problem/focus Advanced Directive was reviewed by the Social Worker on 12/21/18 and that there were no new interventions added at that time, including the fact that R#50's code status had changed from full code to DNR/AND. RN DD confirmed that the Patient Education V2 form was not accessable in the electronic medical record. An attempt was made to reach R#50's responsible party on 2/14/19 at 12:39 p.m. via telephone with no answer. During an interview with the Administrator conducted on 2/14/19 at 3:00 p.m. she provided a copy of the POLST for R#50 with a new signature of the responsible party under Patient or Authorized Person Signature and dated 2/14/19. The Administrator also provided a copy of a page of a hospital discharge summary dated 12/19/18 with a fax transmission date of 2/14/19 at 2:07 p.m. The discharge summary notes revealed a discussion with the patient's sister indicating he would not want compressions or intubation. The Administrator confirmed that this information was not in their medical record.

Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in four resident rooms on one of three halls (T-1 B, T-5 B, T-6 A, T-7 B); also stained ceiling tiles in hall at Nurses station. Findings include: Observation on 2/11/19 at 10:25 a.m., revealed in room T-1 B, air conditioner unit dusty underneath face grill. Observation on 2/11/19 at 10:52 a.m. revealed in room T-6 A, ceiling spackling in bathroom chipped and peeling off and ventilation fan in bathroom dusty. Observation on 2/11/19 at 10:47 a.m. revealed in room T-5 B soap dispenser in bathroom too high for resident's reach. Observation on 2/11/19 at 1:00 p.m. revealed two light brown stained ceiling tiles at nurses station with approximately three inches by three inches diameter. Observation on 2/11/19 at 1:13 p.m. revealed in room T-7 B, two quarter sized holes above the paper towel dispenser in bathroom. An interview on 2/14/19 at 9:53 a.m. with Housekeeping Aide HH, stated her daily duties include sweeping and mopping resident rooms, cleaning bed rails, windows, air conditioner (AC) units, over bed tables, night stand, cleans bathroom including toilets, sinks and mirrors. She stated that she cleans the AC units two times per month. She further stated that the maintenance department cleans behind the face grills of the AC units. An interview and observation on 2/14/19 at 12:02 p.m. with Maintenance Supervisor, stated that he gets work orders through the TELS computer system. He verified the concerns identified during the survey this week during a tour of the areas listed above. He further stated that he did not have any work orders pertaining to the above identified concerns.

Based on interviews and record review, the facility failed to accurately assess and document information on the Minimum Data Set (MDS), a Resident Assessment Instrument (RAI) for two residents (R), R#43 and R#4, of 32 sampled residents. R#43 was not assessed accurately related to refusal of medical care and treatment and R#4 was not accurately assessed related to her smoking status. Findings include: 1. Record review revealed that R#43 was admitted with [DIAGNOSES REDACTED]. A review of the Quarterly MDS with an assessment reference date (ARD) of 10/9/18 under section E0800 asks if the resident exhibited the behavior of rejection or refusal of care during the look-back period. The look back period includes seven days with the last day being the ARD of 10/9/18. R#43 is coded as 0 or Behavior not exhibited. The resident was assessed with [REDACTED]. A review of nurse's notes dated 10/9/18 document R#43's refusal to go to [MEDICAL TREATMENT] ([MEDICAL TREATMENT]). Additional nurse's notes revealed other incidents of refusal of care as follows: 12/20/18: refused to go to [MEDICAL TREATMENT] when transport arrived; 12/6/18: refused shower; 11/12/18, 10/25/18 and 10/22/18: refused nurse applying a dressing and treatment to a surgical site on side of face; 10/16/18: refused to go to [MEDICAL TREATMENT]; 10/9/18: refused to go to [MEDICAL TREATMENT]; 9/29/18: refused shower; 8/17/18: refused prostat (medication supplement); and 7/25/18: refused shower. During an interview conducted with R#43 on 2/13/19 at 11:21 a.m. he confirmed he has refused [MEDICAL TREATMENT] several times, as well as, refusing treatments and showers. An interview was conducted on 2/13/19 at 12:55 p.m. with Registered Nurse DD, the MDS Director, who confirmed that the ARD is included in the look-back period. She further revealed that the Quarterly MDS assessment for R#43 with an ARD of 10/9/18 would have included any behaviors that occurred on 10/9/18 up until midnight. She further stated she obtains information from staff interviews, Nurse's Notes, and other assessments. RN DD verified that R#43's refusal to go to [MEDICAL TREATMENT] on 10/9/18 should have been included in Section E0800. 2. Record review revealed R#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicates no cognitive impairment. Section J revealed resident is not a smoker. Review of Patient Smoking Assessment List revealed that R#4 was assessed on 6/12/17, 9/13/17, 12/13/17, 3/31/18, 8/9/18, 11/7/18 and 11/20/18 for smoking in outside designated area, needs assistance at times with lighting cigarette and needs to wear smoking apron. Review of Smoking Risk dated 11/28/18 revealed resident requires supervision with smoking: Cigarettes and lighter will be kept at the nurse's station/designated area. Staff/family will light cigarette and remain in attendance while the cigarette is burning. Considered Unsafe Smoker. Review of the care plan initiated on 3/26/18 revealed resident is at risk for injury related to smoking. Interventions include cigarettes and lighter will be kept at nurses station/designated area, per guidelines, counsel resident on designated smoking areas, counsel on smoking in designated areas, instruct resident on smoking guidelines. Interview on 2/13/19 at 10:40 a.m. with Minimum Data Set (MDS) Nurse CC, revealed that the two MDS Nurses work together to get the assessments and care plans done. She stated that she does face to face visits with residents, interviews with resident, staff members, family members, as well as record review, hospital records, medication administration records to gather information for the completion of the assessments. Interview on 2/13/19 at 11:22 a.m. with MDS RN DD, stated that she looks at medical records and also interviews staff members about the care residents receive. She further stated that the Assessments that are completed by the admission nurse generate the care plans and that is probably why she has a care plan for smoking. She stated that she is not sure how she missed the assessment for Smoking on R#4. She stated that she had made the correction today. Review of the Section X of the MDS dated [DATE], revealed a correction was made to Section J1300 due to data entry error and Section Z revealed the correction was completed on 2/13/19.

Based on interviews, record review and review of a facility policy entitled Patient's Plan of Care, the facility failed to revise the care plan for one resident (R), R#50, of 32 sampled residents, related to advance directives. Findings include: Record review revealed that R#50 was admitted with [DIAGNOSES REDACTED]. A review of a form entitled Physician order [REDACTED]. Code Status instructing health care providers to Allow Natural Death (AND) - Do Not Attempt Resuscitation. The POLST form is signed by two physicians and dated 12/7/18. There was no signature in the section entitled Patient or Authorized Person Name. R#50 does not have an Advanced Directive or designated health care proxy/decision maker. Page two (2) of the POLST form states: 5. If the patient lacks decision making capacity, the POLST form may be signed by an authorized person , which includes, in the following order of priority: a. the agent named on the patient's durable power of attorney for health care or a health care agent named on the patient's advance directive for health care; b. a spouse: c. a court-appointed guardian; d. son or daughter (age 18 or older); e. parent; f. brother or sister (age 18 or older); 6. If an authorized person completes and signs the POLST form, treatment choices should be based in good faith on what the patient would have wanted if the patient understood his or her current circumstances. R#50 has a sister who acted as his decision maker. The sister's signature was not on the POLST form and there was no documentation in the medical record detailing any discussions related to code status. A review of Physician order [REDACTED]. entered on 9/14/18 and discontinued 12/4/18; and Code Status Full Code . entered 12/05/18 and discontinued 2/6/19. A review of the current monthly Physician order [REDACTED].; entered 2/6/19 . A review of the care plan for R#50 reveals a problem/focus area entitled Advanced Directive listing a review of the goal(s) by the social worker on 12/21/18. The interventions listed include Follow Advance Directives as written (8/14/18 onset) and Provide education on Advance Directives and Advance Care Planning (8/9/18 onset). The care plan did not list or indicate the change in code status from the physician's orders [REDACTED]. An interview was conducted on 2/14/19 at12:30 p.m. with Registered Nurse (RN) DD and Minimum Data Set (MDS) Director, confirmed that the care plan problem/focus Advanced Directive was reviewed by the social worker on 12/21/18 and that there were no new interventions added at that time, including the fact that R#50's code status had changed from full code to DNR/AND. A review of a facility policy entitled Patient's Plan of Care, reviewed and updated (MONTH) (YEAR) revealed: It is the intent of this center to develop and maintain an individualized plan of care for each patient. 1. C. Interventions - should be specific individualized approaches that staff will take to assist the resident to achieve the identified goal. They should be instructions for care and should be easily understood by staff. Interventions are to be carried out by staff. 1. E. Evaluation - the effectiveness of the care plan must be evaluated and modified as necessary. If the goal is not met, the plan should be adjusted. The goal date must be updated with each review. All changes to the care plan should be signed and dated. 10. Other areas to consider: F. Advanced Care planning, G. Informed Decisions/Refusal of Care. Cross reference to F578.

Based on record review, staff interview, and the facility policy titled Patient Plan of Care, the facility failed to develop a discharge plan of care for one resident (R), R#79 who was discharged from the facility. Findings include: Review of the close medical record for R#79 revealed an admission date of [DATE] and the following [DIAGNOSES REDACTED]. R#79 's Discharge document revealed a discharge date on 12/16/18. Record review of the Social Worker notes dated 12/14/18 read pt. (patient) will discharge to the (name) ALF on 12/16/18 with (name) Hospice .etc. Record review of a document titled Interdisciplinary Discharge Summary revealed that R#79 received Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) during her stay. R#79 progress for discharge was coded as Good and he met his discharge goals although the Discharge Summary was not completed for all sections. Record review of R#79s Baseline Care Plan revealed that the plan of care was completed on 11/20/18 and placed in the electronic record on 12/7/18. The goal setting listed on the baseline care plan stated that R#79 overall expectation was to discharge to another setting at the time of his admission to the facility. Further review of R#79 's Comprehensive Care Plan dated 12/1/18 revealed that a discharge care plan with goals and interventions towards discharge was not included and addressed in his ongoing plan of care. During an interview on 2/14/19 at 1:19 p.m., the Resident Assessment Instrument (RAI) Minimum Data Set (MDS) Coordinator revealed that she was not aware that a discharge plan was not included in the comprehensive care plan and that the summary process was not fully completed. During an interview on 2/14/19 at 2:30 p.m., the Director of Nursing (DON) revealed that her expectations are for staff to create a discharge plan of care for any residents who desire to return to the community. The DON stated that she was unaware that R#79 did not have a discharge care plan. She further stated that the RAI/MDS Coordinator is responsible for implementing the care plan with input from interdisciplinary staff, which includes the licensed nursing staff who are involved in the resident care program. She stated that the interdisciplinary staff team should address each resident 's need and treatment program during their morning meetings and their discussions addresses discharge planning for residents. Review of policy titled: Patient 's Plan of Care read It is the intent of this center to develop and maintain an individualized plan of care for each patient. Developing an Interdisciplinary Care Plan: Components: A. Problem Statement-Problems, limitations, needs, behaviors, possibilities for improvement, and risk should be identified. Goal -should lead to an outcome. The goal should be measurable and have a time frame for completion or evaluation. The goal statement should contain: a subject, verb, modifier, and a time frame. Goals can be: Improvement, prevention, palliative. C. Interventions-should be specific individualized approached that staff will take to assist the resident to achieve the identified goal. They should be instructions for care and should be easily understood by staff. Interventions are to be carried out by staff. D. Discipline assigned to complete the intervention-Each intervention must have a discipline assigned to complete that task. The interventions must have a discipline assigned to complete that task. The interventions must be communicated to the direct care staff that is to complete the task. E. Evaluation -the effectiveness of the care plan must be evaluated and modified as necessary. If the goal is not met, the plan should be adjusted. The goal date must be updated with each review. All changes to the care plan should be signed and dated. 7. Other areas to consider: A. Discharge Planning