Every finding on record at Liliha Healthcare Center

Based on interview and document review, the facility did not have a process in place to maintain documentation of grievances. Six out of the six grievances sampled, did not meet the documentation requirements for the grievance decision. In addition the facility did not follow their own policy. As a result of this deficient practice, it is unknown what action had been taken, and if Residents/Representatives were satisfied with the outcome. Findings include: 1) Reviewed the facility policy titled Resident and Family Grievance, revised date 01/2025. The policy included: 1. The Administrator has been designated as the Grievance Official . 2. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances though the conclusion .; Issuing written grievance decisions to the resident; . 3. The Social Services Director, in coordination with the Grievance Official, is responsible for conducting any necessary investigations by the facility, ensuring the facility's grievance form is completed for any grievance filed; conducting correspondence with the individual who filed the grievance .; and informing the resident(s) and/or resident representative of their right to a written summary of the grievance, including the outcome of the grievance, and resolution; providing a written summary to the individuals, if requested; completing the Grievance Log, and maintaining grievances for 3 years. 11b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated form, or assist the resident . 11c. The Social Services Director, in coordination with the Grievance Official, will take steps to resolve the grievance, and record information about the grievance, and those actions taken, on the grievance form. 11g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Social Services Director will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. 2) Reviewed the designated form referenced in the policy which is titled Concern Form. The form includes the following: First part of the form: Date of Report, Time of Report, Date of incident, Name of Affected Residents(s), Person reporting the incident with Phone number, Location of incident /Circumstances surrounding incident, Resident account of Incident, Immediate Action Taken and who initiated them. The last question was if the Resident/Family were Satisfied. Second part of the form included: Follow-up needed? (Check box for Yes or No) Reported to: Check box for Administrator, DON (Director of Nursing)/Unit Mgr (manager) Social Services, Maintenance, Housekeeping, Dietary, Laundry, Transportation, other, or NA (not applicable). Departments(s) action taken to prevent recurrence. Complainant Notified? Check box, Yes or No. Department head signature and date, Social Services signature and date, and Administrator signature and date reviewed. 3) On survey entry, a request was made for the grievance log from February 2025 to current. The Administrator provided six individual Concern Forms, which included the following: Resident (R)4 had three concern forms initiated on 04/24/2025, which included the following: - Saw mold and water damage on ceiling in the first floor day room. The form was incomplete and had no immediate action taken, or documentation on the second part of the form regarding investigation and follow up. - Need for more CNA's (Certified Nurse Assistants) during night shift. There were only 2 CNA's [sic] working and had to wait long periods for call light to be answered. The form was incomplete and had no immediate action taken, or documentation on the second part of the form regarding - investigation and follow up. - Notified 3 weeks ago he was missing 1 blue blanket, 1 plaid blanket and one sweater. The form was incomplete and had no immediate action taken, or documentation on the second part of the form regarding investigation and follow up. It is unknown how this was resolved and if R4 was satisfied with the outcome. R5's family member (FM) had one concern initiated on 04/14/2025 and two on 04/16/2025, which included the following: - 04/14/2025: .called her (FM) to ask if okay for resident to come out to day room for day time stimulation p (after) Covid; Another nurse .talked to her and stated, resident (R5) is out @ the day room, looks tired & sleepy. I (FM) still want my mom to be out @ the same time (11:00-11:30 AM) allow her to sleep after medpass because her meds make her sleepy & if she's still tired, keep her inside the room until she's fully recovered because I don't want her to make other people/resident sick even if she's already covid negative. Actions documented by the Unit Manager (UM)1 were Informed Administrator-Both nurses were verbally educated, reminders added to shift report reminders. The form did not indicate if FM was satisfied, and there was no documentation on the second part of the form. -04/16/2025 at 03:50 PM, FM reported a concern. The form documented the following: Concern was: Nurse called her to get consent for OT (occupational therapy) - OT seen [sic] resident without family's idea. Still waiting for Rehab to provide updates on resident's status with physical therapy and OT evaluation. RNA's (restorative nurse aid) not supposed to walk her yet until PT (physical therapy) provides update with education. Actions taken by UM1: Immediate action taken: Emailed Rehab Director. Provided reminder to RNA as well-verbal reminder to floor nurses- Added to shift report reminders. The form did not indicate if FM was satisfied, and there was no documentation on the second part of the form to indicate the status of R5's PT and OT evaluations. - 04/16/2025 at 05:30 PM, the FM reported a concern: Rotten banana (served during dinner) CN1 documented: Immediate Action Taken: Notified Administrator - went down to kitchen and checked all supplies of bananas, met with kitchen staff. The form did not indicate if Family was satisfied, and there was no documentation on the second part of the form. 4) On 06/09/2025 at 11:50 AM, observed dark spots on the ceiling tile in the first floor day room located by the AC unit, which was reported as a concern by R4 on 04/24/2025. 5) On 06/06/2025, interviewed the Administrator (ADM), who confirmed he was the designated Grievance Official. He stated the facility currently does not have a Social Service Director, and said they followed up on the grievances, but acknowledged they had not been able to keep up with the required documentation. At that time, asked the status of R4's concern about ceiling tile mold, and he replied the issue was referred to maintenance. He went on to say it was not fixed yet, and there was no work order available to document the work request. Inquired if there had been follow up with R4 about the staffing concern, and the ADM said he had reviewed staffing schedules and did not find shortages of concern. He said he had discussed the situation with R4, but had not documented it. The ADM said they had not been able to keep the grievance log up to date with the open Social Services position.

Based on observation, interviews and record review, the facility failed to have a process in place to ensure resident repositioning to prevent pressure ulcers (damage to the skin with open wound as a result of prolonged pressure). The facility did not have evidence that three of three Residents(R)1, R2 and R6 that were at risk for pressure ulcers, and who required assistance for bed mobility, were repositioned to prevent pressure ulcers. There was not a schedule/regimen for staff to follow and process to document the task. As a result of this deficient practice there is a higher risk residents will develop a pressure ulcer (PU). Findings include: 1) R1 was a [AGE] year old female admitted to the facility on [DATE]. Her diagnosis list included functional quadriplegia, hemiplegia (weakness or paralysis) and hemiparesis (severe or complete loss) affecting left dominant side, following a stroke. She was incontinent of bowel and bladder and required assist of one staff for bed mobility. Reviewed R1's care plan (CP), which included the problem .at risk for alteration in skin integrity . An identified intervention to ensure skin integrity was turn and reposition per rounding schedule. Reviewed R1's nursing progress notes, dated 06/01/2025 at 09:57 PM to 06/08/2025 06:42 PM, which revealed the following entries related to positioning and turning: 06/02/2025, 04:19 PM: .Turned and repositioned for pressure relief and comfort. 06/02/2025, 11:06 PM: .Turned and repositioned for pressure relief and comfort. 06/03/2025, 11:05 PM: .Turned and repositioned for pressure relief and comfort. 06/05/2025, 05:36 PM: .Turned and repositioned for pressure relief and comfort. 06/06/2025, 12:40 PM: .Turned and repositioned q2h (every two hours) and prn (as needed) for pressure relief and comfort. 06/07/2025, 03:47 PM: .Turned and repositioned for pressure relief and comfort. On 06/09/2025 at 12:00 PM, observed R1 lying in bed, positioned on her back. On 06/09/2025 at 03:30 PM, observed R1 lying in bed, in the same position on her back. 2) R2 was a [AGE] year old female admitted to the facility on [DATE]. R2 had limited mobility related to Parkinson's and functional quadriplegia (complete inability to move). She is bedbound and requires assistance of one staff with bed mobility. Reviewed R2's CP, which included the problem .at risk for alteration in skin integrity due to secondary weakness and deconditioning, impaired bed mobility, bladder and bowel incontinence. An identified approach to ensure skin integrity included turn and reposition per rounding schedule. Reviewed R2's medical records that included the CNA task documentation and nursing progress notes. There was no documentation by the CNA's that R2 was turned and repositioned. Review of the Nursing Progress notes from 05/08/2025 (readmitted 04:47 PM) to 06/08/2025 day shift, revealed the following entries related to positioning, with no details: 05/09/2025, 04:24 PM: .Turned and repositioned for pressure relief . 05/12/2025, 04:36 PM: .Turned and repositioned for pressure relief . 05/13/2025, 04:20 PM: .Turned and repositioned for pressure relief . 05/14/2025, 04:41 PM: .Turned and repositioned for pressure relief . 05/19/2025, 05:03 PM: .Encouraged with turning and repositioning . 05/21/2025, 05:14 PM: .Turned and repositioned q 2 h (every two hours) and prn (as needed) for pressure relief 05/22/2025, 04:38 PM: .Turned and repositioned q2H and prn . 05/22/2025, 11:33 PM: .Turned and repositioned for comfort and pressure relief. 05/29/2025, 04:13 PM: .Turned and repositioned for pressure relief . There were no additional notes found 05/29/2025 to 06/08/2025 about positioning. On 06/09/2025 at 12:00 PM, observed R2 lying in bed, positioned on her back. On 06/09/2025 at 03:30 PM, observed R2 lying in bed in the same position. 3) R6 was an [AGE] year old female long term resident at the facility. Her medical history included advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder and hypertension. R6 was incontinent of bowel and bladder and required 1-2 person assist for bed mobility. Reviewed R6's Wound Care progress notes, which revealed on 02/19/2025 she had a wound on her buttocks that measured 1.5 cm (centimeters) length x .2 cm width. The note dated 03/15/2025 documented Wound on Lt (left) buttock is healed this week. Reviewed R6's CP, which included the problem .at risk for alteration in skin integrity R/T (related to) aging process, history of skin bruising. An identified approach to ensure skin integrity included Assist with turning, frequent repositioning, PRN. Reviewed R6's Nursing progress notes 04/01/2025 at 12:59 PM through 04/10/2025, which revealed the following entries r/t positioning: 04/02/2025, 11:50 PM: .Turning and repositioning for pressure relief and comfort. 04/04/2025, 11:34 PM: .Turning and repositioning done for pressure relief and comfort. 04/05/2025, 11:38 PM: .Turned and repositioned for pressure relief and comfort. 04/06/2025, 04:04 AM: .Turned and repositioned for pressure relief and comfort. 04/06/2025, 11:21 PM: .Turned and repositioned for pressure relief and comfort. 04/07/2025, 09:09 AM: .Turned and repositioned for pressure relief and comfort. 04/07/2025, 03:40 PM: .Turned and repositioned every 2 hours for pressure relief and comfort. 04/09/2025, 11:34 PM: .Turned and repositioned for pressure relief and comfort. 4) On 06/09/2025 at 12:00 PM. interviewed Certified Nurse Assistant (CNA)2 .She stated she was hired at the facility about two months ago. Inquired what the CNA role was to help prevent pressure ulcers, and she said they are to rotate Residents who are at risk every two hours and make sure they are comfortable. Informed CNA had seen per rounding schedule in Residents' CPs, and asked what that meant. She said she was not sure, but that she thought the second floor still had clocks in the rooms, which indicated when and how to reposition a Resident, and it might have something to do with that. She went on to say the first floor did not have the clocks anymore. On 06/10/2025 at approximately 02:00 PM, during an interview with Unit Manager (UM)1, she confirmed the CNAs currently do not have a process in place to document when a resident is turned or what position they are placed. UM1 said the nurses have been documenting turning and positioning in the progress notes.

Based on interview and record review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for one Resident (R)3 of a sample size of three reviewed for abuse. This deficient practice potentially compromised the protection and safety of all residents on the unit where R3 resided. Findings include: On 02/24/2025 at 07:05 PM, the State Agency (SA) received a facility-reported incident (FRI) for ASPEN Complaints/Incidents Tracking System (ACTS) #11520, documenting an allegation of staff-to-resident abuse by Certified Nurse Aide (CNA)12 to R3. On 06/05/2025, the SA entered the facility to investigate the allegation. On 06/05/2025, the facility provided a copy of the 02/24/2025 Nurse staff schedule for the second-floor unit which revealed four CNAs (including CNA12) and two Registered Nurses (RN) working at the time the incident allegedly occurred (day shift). On 06/05/2025 at 11:30 AM, a review of the facility's investigation packet revealed that the facility obtained information from CNA12. There was no evidence provided to indicate the facility interviewed or obtained statements from the other staff members working at the time of the incident. There was also no evidence of interviews with R3's roommates and other residents residing on the second-floor unit, and no evidence that residents who were not interviewable were assessed for signs and symptoms of abuse. On 06/05/25 at 02:00 PM, an interview was done with the Administrator (ADM) in his office and confirmed that the facility did not conduct interviews with other staff members working at the time of the incident, R3's roommates, and other residents residing on the unit. The ADM stated, The focus was just on that resident. A review of the facility's policy titled, Abuse, Neglect, and Exploitation, last revised 06/2023, under V. Investigation of Alleged Abuse, Neglect, and Exploitation, the following was noted: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect .has occurred, the extent . 6. Providing complete and thorough documentation of the investigation.

Based on observation, interview and medical record review, the facility failed to make timely revisions to two resident's (R)1 and R2's Comprehensive Care Plans (CP) of a sample size of six. As a result of this deficient practice, staff did not have all the information necessary to effectively address the resident's status, condition, and/or needs adequately so that they could meet their highest potential of physical and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) R1 was a [AGE] year old female admitted to the facility on [DATE]. Her medical history included but not limited to chronic obstructive pulmonary disease, stroke affecting the left side, dysphasia (difficulty swallowing), dementia, Type 2 diabetes, and anemia. R1 was incontinent of bowel and bladder and had a feeding tube (tube placed in stomach) for long term nutritional support. She required one person assist with bed mobility. On 06/09/2025 at 12:00 PM, observed R1 lying in bed and noted she had protective arm sleeves on both arms. Reviewed R1's provider orders, which included an order dated 04/29/2025, for GERI (skin protector) sleeves to bilateral arms for protection. Reviewed R1's nursing progress note, dated 06/03/2025 at 04:37 PM. The note read Resident noted with several small open wounds on BUE (bilateral upper extremities) due to resident's scratching. Reviewed R1's CP, which indicated that she was at risk for skin issues due to fragile skin, but the CP was not updated to include the GERI sleeves to protect her skin. 2 ) R2 was a [AGE] year old female admitted to the facility on [DATE]. Her medical history included Parkinson's. Reviewed R2's provider orders, which included an order dated 05/08/2025 for Prevalon Boot to R (right) ankle/foot for protection. Monitor for skin breakdown. On 06/09/2025 at 11:55 PM, interviewed RN1 in the first floor nursing station. Inquired why R2 had a boot ordered for her ankle. RN1 demonstrated how R2's Right (Rt ) foot rotated out, causing pressure on the ankle bone. At that time, reviewed R2's CP with RN1, who confirmed the boot was not included as an intervention for skin integrity. She said the boot should be in the care plan. On 06/09/2025 at 12:10 PM, accompanied RN1 to R2's room and observed her lying in bed. It was noted that she was not wearing the Prevalon Boot on her Rt foot. At that time, RN1 obtained the boot from the cabinet, and placed it on her foot. Observed a small area of redness to the outside of R2's ankle area, which is the reason the boot was ordered.

Based on interviews, medical record and document review, the facility failed to provide the standard of nursing care to one Resident (R)6 of a sample size of three. Specifically, when R6 was diagnosed with COVID infection, the nursing staff failed to consistently monitor all vitals signs, which would include temperature (T), blood pressure (BP), pulse rate (P), respiration rate (R), and pulse oximetry (O2% - measures oxygen in blood). As a result of this deficient practice, there was a higher risk that changes in condition may be missed. Findings include: 1) R6 was an [AGE] year old female long term resident at the facility. Her medical history included advanced dementia, breast cancer, Type 2 diabetes, major depressive disorder and hypertension. R6 had dysphasia, which affected her ability to communicate and at baseline, she was not alert or oriented. On 03/30/2025 she was diagnosed with COVID infection, and placed in isolation until 04/08/2025. On 04/10/2025, R6 was transferred to the hospital for a higher level of care due to altered mental status and high blood sugar, where she was admitted with diagnosis that included sepsis (life threatening reaction to infection), metabolic encephalopathy (brain dysfunction), respiratory failure, hypernatremia (high sodium levels) and hyperglycemia (high blood sugar levels). 2) After R6 was diagnosed with COVID, the nursing staff were to monitor and record her vital signs each shift (twice a day). Monitoring vitals signs to include T, R, Pulse Oximetry on room air and/or oxygen, P and BP are important to identify early decline of Residents with COVID. Review of the vital signs record from 03/30/2025 to 04/10/2025, revealed the following vital signs were not taken. 03/30/2025: Day shift, No P, No R, No PO2 04/01/2025: No P, No R all day 04/02/2025: No P, No R all day 04/03/2025: No P, No R all day 04/04/2025: No P, No R all day 04/05/2025: No P, No R all day 04/06/2025: No P, No R all day 04/07/2025: No P, No R all day 04/07/2025: Noc shift, No P, No R 04/08/2025: Day shift, No T, No P, No R, No PO2 04/08/2025-04/09/2025: Noc shift, No P, No R, No PO2 04/09/2025: Day shift, No T, No P, No R, No PO2 04/10/2025 Only BP was taken during the day. Just prior to end of shift, at 06:34 PM, a full set of vitals were taken, which were recorded as BP 135/88, P 121, Temp 98.4 (Temporal), R21, PO2 92% on room air. Oxygen was then provided at 2 liters per minute, and her PO2 was recorded to improve at 06:34 PM to be 95%. Review of Nursing Progress notes revealed the following: - 04/10/2025 at 02:05 PM: Daughter visited today shortly before lunch. c/o (complain of) resident appears so sleepy, unable to wake her up, worried and concerned about resident's status especially since she just came out of COVID, she is coughing, looking tired and sleepy. Family met with administrator to discuss concern.chest xray, . CBC (lab test, complete blood count) with diff (differential), bmp (basis metabolic profile), IPRAT q shift (Ipratropium and albuterol/bronchodilater every shift) and PRN (as needed) x 3 days for cough. Endorsed to floor nurse. - 04/10/2025 entered at 04:00 PM: In bed, resident appears sleepy, able to consume 50% breakfast, and CNA (Certified Nurse Assistant) staff was able to feed her lunch with 75% consumed at 02:00 PM. Order of CXR (chest xray) was facilitated, STAT (immediate) cbc with diff and BMP done, awaiting result. Started ipratropium-albuteral at 14:30 (02:30) pm. PRN Tussin administered for coughing, low pitch wheezing assessed before nebulization improved. - 04/10/2025 entered at 10:40 PM: Received resident lying in bed, appears comfortable, however sleepy though responding to tactile stimulation and open her eyes. Around 4:10 (PM), 2 staff assist in bedside care/changed her adult brief . Vital signs .BS (blood sugar) 313 mg/dl (high) at 4:46 (PM). After the daughter expressed concern about R6's condition to the Unit Manager (UM)1 at 02:05 PM, nursing provided a nebulizer treatment. Although lung sounds were documented in the progress notes as above, there was no pre-nebulizer baseline assessment that included pulse, respiratory rate, and oxygen saturation, which is the standard of care (Nursing Fundamentals and Skills, Nebulizer Therapy, November 24,2024). At 03:50 PM, a T and PO2 was taken, but no P, R or BP. In addition, a thorough nursing assessment including level of consciousness should be done in a timely manner after someone expresses concern of resident's level of consciousness. 3) On 06/09/2025 at approximately 02:30 PM, during an interview with UM1, reviewed the documentation of R6's vital signs. At that time UM1 confirmed it was the expectation that vitals were taken twice a day and that they should include T, P, R, PO2, and BP. She agreed the vitals signs were incomplete and did not meet the standard of care.

Based on staff interview and review of facility assessment, the facility did not fulfill the requirement to designate a registered nurse as the Director of Nursing (DON). As a result of this deficiency, there was risk of negative impact on quality of care and outcomes. Findings include: Cross-reference to F868 Quality Assessment and Assurance. During staff interview on 01/27/25 at 08:20 AM, Administrator (Admin) said that there was no DON and that the facility was currently looking for one. During Quality Assurance Performance Improvement review on 01/31/25 at 01:35 PM, Admin further said that the previous DON left a few months ago and that currently other staff were covering some of the duties and responsibilities of that position. Review of Facility Assessment read the following: Purpose, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is to be used to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 3, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . The following type of staff and other professionals provide the needed care to our resident population . Nursing Services, we provide 24-hour nursing care. Our nursing staff consists of a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide .

Based on staff interview and review Quality Assurance Performance Improvement (QAPI) program, the facility did not fulfill the requirement to have Director of Nursing (DON) participation on the Quality Assessment and Assurance Committee. As a result of this deficiency, there was risk of negative impact on coordination and evaluation activities under the QAPI program. Findings include: Cross-reference to F727 Registered Nurse, DON. During staff interview on 01/27/25 at 08:20 AM, Administrator (Admin) said that there was no DON and that the facility was currently looking for one. During Quality Assurance Performance Improvement review on 01/31/25 at 01:35 PM, Admin further said that the previous DON left a few months ago and that currently other staff were covering some of the duties and responsibilities of that position. Review of the QAPI meeting minutes for the past two months did not show a DON present. Review of Facility Assessment read the following: Purpose, the purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. This assessment is to be used to make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being . Part 3, Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies . The following type of staff and other professionals provide the needed care to our resident population . Nursing Services, we provide 24-hour nursing care. Our nursing staff consists of a DON, ADON, MDS nurses, RN, LPN, CNA, Licensed Treatment Nurse, Treatment Nurse Assistant and Rehab Nurse Aide .

Based on observation, interview, and record review, the facility failed to ensure cooked and stored food were properly labeled in accordance with professional standards for food service safety and failed to ensure bottles of sauce were labeled with the manufacturer's expiration date for one of one kitchen observed. Failure to appropriately label cooked and stored food has the potential to affect residents that receive food from the kitchen, and visitors and staff who have meals served by the facility, placing them at risk for serious complications from foodborne illness. Findings include: On 01/28/25 at 08:05 AM, during interview and observation of the kitchen with Dietary [NAME] (DC) 1, observed a container of cooked white rice, confirmed by DC1, in a small refrigerator without a label identifying the food item or preparation and discard date. DC1 reported the rice was prepared this morning and a label should have been created with today's date and a discard date. Further observed in the dry food storage room, multiple unopened bottles of Browning and Seasoning Sauce with a yellow cap that included the best-by-date. Two of the bottles did not have a yellow cap to determine the best-by-date, but were unopened and sealed. DC1 was not sure why the bottles did not have a cap and removed the two bottles from the storage room. Review of the facility's policy and procedure Food Safety Requirements reviewed/revised 06/2023 documented Follow contract/vendor procedures when food arrives damaged or concerns are noted. Remove these foods from use .Labeling dating, and monitoring refrigerated food, including, but not limited to leftovers, so it used by its use-by-date, or frozen (where applicable)/discarded .

Based on resident interview and policy review, the facility failed to treat one Residents (R) 10 of eight residents sampled, with respect and dignity. As a result of this deficiency, R10 felt the right to a dignified existence was violated. Findings include: Resident interview on 01/29/25 at 12:30 PM, R10 said there were many times where staff were speaking in their native language (not English) and R10 felt staff were talking about him/her. Review of policy on Resident Rights read Policy; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights; The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

Based on observation, family interview, staff interview and review of policy, the facility failed to maintain a clean environment as evidenced by noted stains, spots on the cloth napkins. As a result of this deficiency, the facility increased the risk for spread of disease-causing organisms. Findings include: During family interview on 01/27/25 at 10:05 AM, said they saw numerous stains, spots on the cloth napkins that came with the meal trays. Observation of the breakfast trays on 01/28/25 at 07:30 AM, revealed several cloth napkins with spot stains and smudge stains. Staff interview on 01/28/25 at 01:50 PM, Dietary Manager looked at all the stored cloth napkins and acknowledged several with spots, stains as previously described. Review of facility policy on Safe and Homelike Environment read; Policy, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible . Sanitary, includes but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .

Based on interviews and record review, the facility failed to provide an environment free from any physical restraint imposed for purposes of convenience, for one of one sampled residents (Resident (R) 5) for restraints. This deficient practice placed R5 at risk for physical harm and has the potential to affect all the residents in the facility. Findings Include: During a Facilty Reported Incident (FRI) investigation, interview was conducted on 01/30/25 with Unit Manager (UM) 2. UM2 stated that Certified Nurse Aide (CNA) 10 approached her on 12/31/24. CNA10 had informed her that while providing personal care, R5 was resisting care by pushing down with her hands. CNA10 decided to wrap R5's hands with the lower portion of her gown so that CNA10 can finish changing her incontinence brief. Interview was conducted on 01/31/25 at 09:35 AM with the Administrator. The Administrator stated that during an investigation interview, CNA10 had mentioned wrapping up R5's hands with the lower portion of her gown. CNA10 confirmed that R5 continued to push her hands down while it was wrapped and that CNA10 did it so that she can perform personal care on her. The Administrator stated that CNA10 had demonstrated what she had done with hand gestures and described the hand wrapping as being tight. A review of the facility policy titled, Restraint Free Environment, with a revised date of 06/01/23 was conducted. The policy documented, The resident has the right to be treated with respect and dignity, including the right to be free from any physical or chemical restraint imposed for the purpose of discipline or staff convenience, and not required to treat the resident's medical symptoms.

Based on record review, staff interview, and review of policy, the facility failed to provide written notice of discharge for one Resident (R)76 out of two residents sampled. As a result of this deficiency, there was a potential for miscommunication. Findings include: Review of the Electronic Health Record (EHR) indicated that R76 was discharged to the hospital on [DATE]. Further review did not show any written notice of discharge to the resident and/or representative. During staff interview on 10/31/25 at 11:00 AM, Social Services Director acknowledged that the facility did not provide written notification of discharge on [DATE]. Review of facility policy on Transfer and Discharge (including AMA) read; Policy, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances . Emergency Transfers/Discharges, initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated .

Based on review of records and staff interviews, three of ten staff sampled for cardiopulmonary resuscitation (CPR) competency were not properly trained to provide basic life support subject to accepted professional guidelines. This deficient practice could result in the facility not providing the necessary care, placing residents at risk for decline in health status and/or death. Findings Include: A review of Cardiopulmonary Resuscitation (CPR) documentation for three staff was done on [DATE] at 11:15 AM. Documentation for Registered Nurse (RN) 11, Certified Nurse Aide (CNA) 12 and CNA13 reflects training from an online training course that does not provide hands-on practice and in-person skills assessment. Interviewed the Administrator on [DATE] at 11:49 AM, in his office, regarding CPR requirements for the facility. Administrator stated there is nothing in writing for CPR training requirements. Administrator stated on [DATE] at 11:59 AM that he spoke to the Infection Preventionist (IP), who provided clarification that Basic Life Support (BLS) is required for the Licensed Nurse. A Review of the American Heart Association (AHA) website stated that the AHA BLS course Trains participants to promptly recognize several life-threatening emergencies, give high-quality chest compressions, deliver appropriate ventilations and provide early use of an AED. Reflects science and education from the American Heart Association Guidelines Update for CPR and Emergency Cardiovascular Care (ECC). This is accomplished thorough a full classroom course or blended learning course (HeartCode BLS + a hands-on skills session training). Website link: https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/basic-life-support-bls-training, Interviewed RN11 on [DATE] at 12:03 PM. RN11 confirmed that the current CPR training course she completed did not have any hands-on practice and in-person skills assessment.

Based on interview and record review, the facility failed to ensure one of one resident sampled (Resident (R) 22) for elopement, received adequate supervision to prevent accidents when he was an elopement risk. As a result of this deficient practice, R22 left the facility without authorization. This put R22 at risk of injury or getting hit by a car at a busy street. Findings include: R22 was admitted to the facility on [DATE] with diagnoses, but not limited to, pyogenic arthritis, muscle weakness, difficulty in walking, other abnormalities of gait and mobility, anxiety, depression, cognitive communication deficit, and attention-deficit hyperactivity disorder. Review of R22's admission Minimum Data Set (MDS) with assessment reference date of 12/16/24 found R22's Brief Interview for Mental Status (BIMS) score a 15 (cognitively intact). In Section GG. Functional Abilities and Goals, mobility devices used were cane/crutch and wheelchair. Further documented R22 needed supervision or touching assistance when walking 10 feet and 50 feet. Walking 150 feet, 10 feet on uneven surf and one step (curb) was not attempted due to medical condition or safety concerns. Review of an Event Report completed by the facility on 12/26/24, the facility reported R22 attempted .to exit the facility, through the main entrance, following a visitor out the door on 12/17/24 at approximately 11:30 AM. Social Services Director (SSD), was supervising and observing the resident from his office, which has a window and clear view of the lobby, Resident was seated in a chair, in the lobby. Social Services Director, observed resident stand from chair and head towards the front door. SSD immediately stood from his desk and headed to the found door. At the time the SSD reached the resident, resident made his way through the front door to the outside of the facility The visitor, who the resident followed out of the facility, put his arm out in attempts to redirect resident back in the facility. SSD attempted redirection, not able to redirect resident back into the building. Per SSD, resident stated he wanted to go home Resident is ambulatory and began walking down the facility's entrance ramp and up the street. SSD escorted and supervised resident, walking with resident Facility's transporter witnessed resident and SSD walking on the sidewalk. Assisted SSD by walking behind resident with a wheelchair. Prior to the incident the event report documented R22 attempted to elope and expressed he wanted to return home that morning. On 01/29/25 at 09:01 AM, an interview with Licensed Practical Nurse (LPN) 2 was done. LPN2 confirmed she worked the night before R22 eloped from the facility. LPN2 reported R22 was restless that night and walking in the hallway. Since admission, R22 wanders in the hallway but is redirectable. On 01/30/25 at 08:06 AM, an interview with Certified Nurse Aide (CNA) 6 was done. CNA6 reported on admission and when R22 first arrived at the facility, R22 expressed he wanted to go home and was easily redirectable during the night shift. Review of R22's nursing note on 12/11/24 at 11:39 PM documented Received resident up in wheelchair at dining area. Noted to be agitated during beginning part of shift, unable to redirect, want to go home to get some clothes and come back to facility. Called wife, will drop off clothes tomorrow morning. PRN [as needed] Lorazepam 0.5mg [milligrams] give at 6:10pm for behavior issues with relief . On 01/29/25 at 09:22 AM, an interview with Receptionist was done. Receptionist reported a nursing staff asked her to monitor R22 in the lobby on 12/17/24. Receptionist reportedly observed R22 to be sitting in the lobby but had also been observed to get up and walk back and forth. Receptionist was located behind her desk and was not able to continuously monitor him when busy answering the phone or when a visitor enters the facility. Receptionist stated she did not see the resident leave the facility on 12/17/24. On 01/29/25 at 09:38 AM, an interview with Licensed Practical Nurse (LPN) 3 was done. LPN3 was not assigned to R22 but confirmed she worked the day R22 eloped from the facility on 12/17/24. At approximately 09:00 AM the day of the incident, LPN3 reported she was on the phone at the nurse's station when a staff member yelled R22 is outside. LPN3 hung up the phone and located R22 outside of the facility's main entrance door at the end of the walkway ramp to the public sidewalk. LPN3 showed this surveyor exactly where she found R22 outside, a busy main street is located right outside the facility. LPN3 asked R22 where he was going and R22 responded he wanted to go home. LPN3 was able to convince R22 to return the facility. LPN3 confirmed that was the first elopement that day and a second elopement occurred when SSD had followed R22 out of the door. A second interview was done with LPN3 on 01/30/25 at 10:11 AM, LPN2 stated one to one supervision was not provided after the first elopement but close supervision was provided. Inquired who was providing the close supervision, LPN3 was not sure but saw Central Supply Coordinator (CSC) with R22. On 01/30/25 at 10:13 AM, an interview with CSC was done. CSC stated no one asked her to provide supervision or monitor R22. CSC heard he attempted to elope and expressed he wanted to go home so decided to try and talk to him to provide comfort but was unsuccessful at approximately 10:00 AM on 12/17/24. CSC spoke to him for about five to 10 minutes but noticed resident was getting more agitated. On 01/30/25 at 08:45 AM, an interview with Unit Manager (UM) 1 was done. UM1 was on vacation when the incident occurred. UM1 stated if a resident was actively attempting to elope, one on one supervision should be provided. UM1 was not able to confirm if R22 received one on one on 12/17/24 after the first elopement which may have prevented or decreased the risk of R22 eloping the second time that day. On 01/30/25 at 09:28 AM, an interview with SSD was done. SSD reported he sat with R22 in the morning at the lobby on 12/17/24, prior to the second elopement, and the resident had expressed he wanted to go home and reportedly observed him trying to push the front doors open that morning. No one asked him to monitor or provide close supervision to the resident but does keep an eye on residents when they are in the lobby from his window. SSD reportedly observed R22 go outside the facility main doors after a vendor entered the facility and followed him out the door. SSD continued to encourage R22 back into the facility but was unsuccessful. R22 began walking up the street and SSD continued to follow and attempt to encourage resident back to the facility with casual conversation. R22 reportedly expressed he was going to walk home. The facility's transport driver was on his way back to the facility when he saw R22 and SSD walking up the street and brought a wheelchair and walked behind the resident. While walking up the street, R22 would cross the street with no cross walk or safety awareness. R22 stopped in the middle of the road. SSD reported he positioned himself toward oncoming traffic because of the dangerous situation. SSD was able to convince R22 to sit in the wheelchair and attempted to take R22 back to the facility but R22 stopped the wheelchair and began walking up the street again. R22 crossed the street without looking both way or demonstrate safety awareness. R22 walked toward a residence and sat in front of an unknown residence's home. During this time, the transport driver went back to the facility to inform the administrator. SSD stated that it was not until further into walking that he realized R22 was not coherent to place and referred to the area as Boston. SSD stated he was with the resident for about an hour until the administrator arrived and the administrator was able to redirect R22 back to the facility. On 01/30/25 at 11:02 AM, an interview with Administrator was done. Administrator believed nursing staff knew R22 was missing but was not notified. Only after the transport driver notified him, he became aware that R22 was missing. Administrator did not know R22 left the doors of the facility and made it to the end of the ramp earlier in the morning prior to the incident. Inquired if R22 would have benefited from one on one after demonstrating exit seeking behavior throughout the morning on 12/11/24, Administrator stated it may have prevented or decreased the risk of him actually leaving the facility. Review of the facility's policy and procedure (P&P) Elopements and Wandering Residents reviewed/reviewed 06/2023 documented elopement .occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Under monitoring and managing residents at risk for elopement in the P&P, Adequate supervision will be provided to help prevent accidents or elopements. The procedure for locating missing resident documented Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol.

Based on observation, interview, and facility policy review, the facility failed to ensure drugs and biologicals are stored in a locked compartment for one out of four medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. Findings Include: Concurrent observation and interview with Registered Nurse (RN) 10 were conducted on 01/28/25 at 01:46 PM on the second-floor hallway. One of the medication carts was left unlocked and two staff members were observed passing the unlocked cart. A few minutes later RN10 returned to the medication cart and locked it. RN10 then confirmed that the medication cart should have been locked and secured when left unattended. Interview was conducted with Unit Manager (UM) 2 on the second floor. UM2 confirmed that unattended carts should be locked and secured. A review of the facility policy titled, Medication Storage, with a revised date of 06/01/23 was conducted. The policy documented, All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .

Based on observation and staff interviews, the facility failed to ensure a clean working area before initiating wound care for one of one sampled resident (Resident (R) 35) for wounds. This failed practice has the potential to place a resident at risk for the development of infection and has the potential to affect all the residents that require dressing changes. Findings Include: Observation was conducted on 01/29/25 at 10:13 AM in R35's room during wound care rounds. R35 was turned to her side in bed and noted to have bowel movement on her buttocks, extending to the bottom edge of the resident's dressing located over her sacral area. Physician Assistant (PA) 1 proceeded to remove the dressing to the sacral area, and assessed the wound area before the bowel movement of R35 was cleaned, and before a clean brief was placed under the resident. Certified Nurse Aide (CNA) 11 proceeded to clean the bowel movement after PA1 was done with the wound assessment. Interviewed the Infection Preventionist (IP) on 01/29/25 at 12:50 PM at the second-floor nurse's station. IP confirmed that the CNA should clean a resident's incontinence before a wound is looked at. Interviewed Unit Manager (UM) 2 on 01/30/25 at 08:26 AM near the second-floor nurse's station. UM2 stated that for infection control, incontinence should be cleaned first before starting wound care. Interviewed CNA11 on 01/31/25 at 07:31 AM at the second-floor resident unit hallway. CNA11 verbalized that the resident needs to be cleaned first before nursing does the wound dressing to prevent infection.

Based on observations, record review, and interview with staff members, the facility did not ensure that the development and implementation of comprehensive person-centered care plans were done for 3 of 25 residents (Residents 33, 60 and 139) in the sample. As a result of this deficient practice, these residents were placed at risk for a decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Cross-reference to F688 Increase/Prevent Decrease in ROM/Mobility. Despite identifying positioning/mobility needs for Resident (R)33, the facility failed to develop a care plan to effectively address those needs. 36930 2) During interview with R60 on 01/23/2024, R60 expressed a desire to mobilize more with the Hemi-Walker available to R60. R60 feels confident this could be achieved if staff walked him daily. R60 had a care plan in place for altered ADL function, with an approach/intervention stating uses Hemi-walker and Wheelchair for mobility stating CNAs and nursing are the responisble disciplines to carry out this approach/intervention. Record review conducted on 01/24/2024, showed that R60 particpated in a restorative nursing program, which provided R60 assistance and guidance in using the Hemi-Walker. The care plan was missing the frequency of occurance for this intervention for R60. Interview with MDS staff, confirmed there was no frequency included in the care plan, as the care plans are generalized and not indivalized. 3) Minimum Data Set (MDS) for R139, displayed under Section GG, that R139 required substantial assistance for movement, including moving from lying to sitting, sitting to lying and moving from left to right sides and vice versa. Progress notes have documented on several occasions that R139 requires 3-4 person assist. Due to extensive edema to both lower and upper extremities, R139 is dependent on staff for all movement. Care plans are in place for R139 for altered self care and decrease in Activities of Daily Living (ADL) performance. These careplans have interventions in place to encourage resident to use enablers and to be independent. There are no interventions that state the required amount of assistance that R139 requires to move in bed, sit from lying and lie down from sitting. Interview with MDS staff member verified there are no specific interventions on the amount of assistance that is required by R139, stating their careplans are generalized an individualized.

Based on observations the facility failed to provide a comfortable environment for residents, staff and the public by not maintaining the environment in good repair. Findings include: Observations on 01/23/2024 - 01/26/2024, showed wallpaper on upper half of walls in the hallway of 1st floor, is lifting off in several areas and curling over. Outside of room [ROOM NUMBER] there is patch of wallpaper missing, approximately 12 x 18. It appears this patch has been torn off. On the opposite wall a picture has been removed with the area underneath significantly lighter in color than the rest of the wallpaper, providing an appearance of unkept cleaning of walls. The disrepair of the state of the wallpaper, is unkept and not conducive to a homelike environment. Watermarks are apparent on several areas of the wallpapered area of the hallway on the 1st floor unit.

Based on resident interviews and policy review, the facility failed to treat two Residents (R) 9 and R139, 68 of eight residents sampled, with respect and dignity. Findings include: Resident interview on 01/23/24 at 01:30 PM, R68 said that Staff would respond to the call bell and say they would be back but not return until several hours later. R68 said that this made him/her feel ignored. Resident interview on 01/24/24 at 08:45 AM, R9 revealed the following: Staff would respond to the call bell and say they would be back but it would take several hours for them to return, Staff would ignore and not pass on a request to speak to the doctor or other person, Staff would speak to each other in a language other than English and it felt as if they were talking about him/her. Review of policy on Resident Rights read Policy; The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Resident rights; The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . 36930 R139 stated during an interview on 01/23/2024 that often he would press call bell, staff would acknowledge the call bell and state to R139 they would be back soon. R139 went onto to say staff would return after a long time, one time 40 minutes. Minimum Data Set (MDS) for R139 displayed under Section GG, that R139 required substantial assistance for movement. R139 due to extensive edema of both lower and upper extremities was unable to move by themselves without staff assistance. R139 stated during interview on 01/29/2023, that they would call for assistance to move when in pain, and waiting lengthy time periods increased the pain. R139 was tearful during the interview while relying this information. R139's reliance on staff assistance, and their lack of timely assistance did not provide care for these residents in a dignified manner.

Based on record review and interview, the facility failed to ensure 2 of 6 residents sampled (Residents 33 and 55) were informed of their right to develop an advance health care directive, aided in doing so, and/or was periodically reassessed in his/her decision-making capacity to do such. As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 01/24/24 at 11:23 AM, during a review of Resident (R)33's electronic health record (EHR), an advance health care directive (AHCD) was not found. A review of the social services progress notes revealed no mention of an AHCD. The documentation was requested from the facility. On 01/25/24 at 02:22 PM, an interview with the Social Services Director (SSD) was done in his office. The SSD confirmed that R33 was admitted to the facility in August of 2023, and that there was no documentation available indicating that R33 had an AHCD, or was offered assistance in creating one. 36930 2) An AHCD was not found during a review of R55's EHR on 01/24/2024. A request to the SSD was made on 01/24/2024 for the AHCD for a list of residents including R55. No AHCD was found by the SSD for R55. A request to the SSD was made on the afternoon of 01/25/2024 for any documentation to show that R55 had been offered information on the option of formulating an AHCD on admission and was further offered on other occasions during the resident's admission. No documentation was provided. The same request was made to the administrator on the morning of 01/26/2024. No documentation was received.

Based on record review and interview with staff members, the facility failed to ensure one of four residents (Resident (R) 48) sampled for accidents received adequate supervision to prevent a fall that resulted in a laceration of the head, fracture to neck of right femur, hospitalization , and surgery after R48 displayed atypical behavior and has history of falls. The facility failed to ensure a second resident R15 was identified as a high risk of leaving the facility to obtain cigarettes and alcohol. R15 did not receive the admission agreement, (cross reference (CR) to F572 notice of rights and rules) which included the rules about consumming alcohol in the facility and that it was prohibited without a physicians order. In addition, The facility did not include interventions on the baseline care plan to address the risk for elopement based on R15 alcoholic cirrhosis of the liver and history of substance abuse (cross reference to F655 baseline care plan). The resident left the facility unsupervised on two occasions to purchase cigarettes (06/19/23) and alcohol (06/25/23). The deficient practice left R15 and other residents in the facility at an increased risk for harm. Findings include: 1) R48 is a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses of but not limited to vascular dementia, repeated falls, post-traumatic stress disorder, muscle weakness, and difficulty in walking. R48's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 06/05/23 in Section G Functional Status, under G.0110.Activities of Daily Living (ADL) Assistance, R48 required supervision and one person physical assistance in transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and locomotion on unit (how resident moves between locations in his room and adjacent corridor on same floor). Under G0300.Balance During Transitions and Walking, R48 was documented to be not steady, only able to stabilize with staff assistance in moving from seated to standing position and was documented the activity did not occur for turning around and for walking. R48 used a wheelchair. Review of R48's care plan documented R48 at risk for fall and injury due to .impaired mobility/balance, impaired cognition with poor safety awareness secondary to Vascular Dementia, possible effect of antidepressant, HTN [hypertension], and DM [diabetic] meds; h/o [history of] falling . and further documented to notify staff that R48 is a high fall risk resident. Review of R48's Event Report regarding an incident 06/16/23, R48 had a witnessed fall and sustained fracture to neck of right femur. The report documents R48 in the dining area, self-propelling himself with wheelchair and attempting to get a closer look out the window. R48 attempted to stand, went forward, fell on his right side and hit his head, right temple with laceration. R48 complained of pain to right temple and right leg and hip. After assessment by nurse, R48 consumed an Ensure supplement and vomited shortly after. R48 was transferred to acute care with pending results for electrocardiogram (EKG), X-ray and lab results. On 06/30/23 at 09:29 AM interview with Certified Nurse Aide (CNA) 20 was done. CNA20 confirmed she worked on 06/16/23, the day of the incident. CNA20 reported prior to the incident R48 displayed signs of confusion and was attempting to get to the window side of his room. CNA20 reported she brought R48 out to the dining area for breakfast and left to help other residents. After breakfast, CNA20 was alerted by another resident that R48 was in another resident's room at the window side. CNA20 brought R48 back to the dining room area to participate in activities, the activity volunteer was in the dining room and the charge nurse was at the medication cart when she left R48 in the dining room area. CNA20 further reported she informed the nurse that she thought R48 was confused and had been trying to go to the window. CNA20 stated that this was not R48's .normal behavior that is why I reported it to the charge nurse. Inquired if further instructions were given after reporting the behavior to the charge nurse, CNA20 stated there was none and she went back to assist other residents. Inquired if R48 needed close supervision, CNA20 did not answer the inquiry, stated she needed to help other residents and reiterated the activity volunteer was in the dining room and further stated the facility does not provide one on one (1:1) supervision but after the incident 1:1 supervision was provided to R48. CNA20 confirmed R48 was a fall risk. On 06/29/23 at 02:48 PM interview with Registered Nurse (RN) 3 was done. RN3 confirmed she worked on 06/16/23, the day of the incident. RN3 reported that R48 was restless in the morning and was wandering in resident rooms to peak out the window. RN3 confirmed R48 attempting to look out the window was not atypical behavior and was the first time she heard of this behavior from him, usually he would want to go to the bathroom frequently. RN3 reported she later found out from R48's family member that R48 thought someone was watching over him due to Post-Traumatic Stress Disorder and social history. RN3 reported prior to the incident she was at the medication cart at the nurse station when the incident happened but did not witness the incident. RN3 stated she heard the activity volunteer yell for help and found R48 on the ground near the window in the dining room, on the other side of the room from the nurse's station. RN3 reported after her assessment, providing 1:1 supervision for R48, informing the physician and following the physician's order, R48 vomited after drinking Ensure and was transferred to acute care. RN3 stated R48 needs close supervision and needs to have staff a proximity to him and stated at times R48 would benefit from 1:1 supervision, particularly on the day of the incident, because although he is unsteady, he is quick and was displaying a new behavior. RN3 confirmed R48 is a risk for falls and has had multiple falls in the facility. On 06/30/23 at 09:02 AM interview with Activity Volunteer (AV) 1 and Activity Director (AD) was done. AV1 started volunteering at the facility from November 2022 through a partnership with a senior vocational program. During the interview AV1's hearing aid was not working properly and was hard of hearing. AV1 confirmed she was at the facility and witnessed the incident on 06/16/23. AV1 demonstrated and explained she was at the activities table with other residents when R48 began propelling himself toward the window. AV1 reported when R48 got closer to the window he stood up and began dragging his wheelchair from behind him and attempted to reach the curtain but could not open it. AV1 further reported while standing R48 began pivoting toward another window when he fell . AV1 stated I was not near him. I was just watching him. What I know he can walk. I am alone . in the dining room. AV1 reported two nurses came and helped after she yelled for help. AD inputted that the activity aide who usually works with the AV1 was on leave and that although activity aides may help with transfers, sitting, or standing, the volunteers are to just assist the activity aide by passing out items, or check bingo cards, not care type duties. AD stated she was at a meeting when the incident happened, and it was not communicated with her that the activity staff should provide close supervision to R48 due to a new behavior that morning. AD stated AV1 would not have known R48 was a fall risk or what his level of function was and R48 does not usually participate in activities but may come to the common area to watch television. On 06/30/23 at 10:47 AM interview with Nurse Manager (NM) 2 was done. NM2 confirmed she worked on 06/16/23 and was at a meeting when the incident happened. NM2 confirmed R48 had frequent falls at the facility and can be impulsive when he gets up. NM2 confirmed R48 does not normally wander to resident rooms but may go to the closest bathroom. NM2 further confirmed that R48 going toward the window in his room and other resident's rooms was not normal behavior for R48. Inquired with NM2 what type of supervision would have been appropriate for R48 prior to the incident, NM2 reported the facility does not really provide 1:1 supervision but at least close supervision should have been provided due to displaying confusion and at risk for falls. NM2 stated a staff member should have been at proximity and at line of sight to assist if he stands or gets up. NM2 further explained the activity volunteers are not to provide close supervision because they are not going to support or assist the patient to get up and is not sure what training the activity volunteers receive. NM2 reported after the incident R48 was sent to the emergency room and was hospitalized due to a fracture to right femur and needing surgery. NM2 reported R48 needed surgery based on the hospital's report because he would suffer more if he did not. Review of the hospital's admission report dated 06/16/23 documents right femoral neck fracture due to fall. Overall, patient has acceptable risk for surgery, since without surgery the patient's risk for significant morbidity and mortality is much higher. Review of the facility's policy and procedure for volunteers last reviewed on 02/2023, documents Volunteers are not allowed to provide care for residents in place of care that normally provided by staff members. 38870 2) Reviewed the facility reported incident intake on 06/28/23, that OHCA received from the facility via email on 06/19/23. Per the report on 06/19/23 at 09:30 AM, the unit manager (UM) was notified that R15 could not be found on the campus. At 09:45 AM R15 returned to the campus with a pack of cigarettes. Resident who is mentally and physically capable of living independently left facility without realizing it was against facility policy. He returned safely and apologized for actions. Signed by the Administrator. Reviewed the following notes from the electronic medical record (EMR).: R15's history and physical from the acute care facility dated 06/14/23. [AGE] year-old male with history of alcohol use disorder, alcoholic cirrhosis .social history includes smoking 1 pack for two weeks. Alcohol, drinks beer 12 cans every 3 days, patient drank 200 ml vodka on 06/09/23 for his pain . R15's care plan on 06/29/23 at 10:13 AM. Start Date: 06/20/2023 .risk for elopement due to history of substance abuse. Resident is alert and oriented. Noted the start date was not implemented for R15's alcohol use disorder and risk for elopement prior to the first elopement on 06/19/23. Nursing note dated 06/25/23 at 19:05. At around 18:30 resident was nowhere to be found. Resident was last seen by the front door getting fresh air with another male resident. This writer and other staff looked inside all facility rooms, bathrooms, activity area, rehab gym, basement/facility parking area, bus stop, Korean church parking area and immediate vicinity areas but still resident nowhere to be found. Roommate that was with him at the front door informed staff that R15 went to the convenient store. This writer went to nearby stores and saw resident walking back from a grocery store. After resident returned, he went to his room to rest. Went to observe and check on the residents to make sure everything was alright. When I spoke to the residents in the room, they both smelled like alcohol, especially when they spoke you could smell alcohol on both residents breath. Resident had a bottle of alcohol in the room hidden and a drink made at bed side that contains alcohol in his gray water pitcher container. Spoke to both residents and diffused the arguing and both residents got into their bed and went to sleep. Notified MD, UM and Administrator. SS note dated 06/26/2023 at 11:09 AM The resident left the facility around 10:30 AM. a bottle of vodka and cigarettes were found inside the bedside cabinet. Interview with S27 on 06/30/2023 at 11:10 AM regarding the incident with R15. S27 stated the first time, on 6/19 at 9:30 AM he left the facility and returned at 9:45 AM, resident said he went to the store for cigarettes. The second time he left the facility was on 6/25/23 at 6:30 PM, R15 went to the store for cigarettes and alcohol. 06/30/23 Interview with S23, who stated that she told the CNA's to make sure they watched him because he was outside on the front porch. At around 6:30 PM I went to check on him and he was not there. I went outside and didn't see anybody. I walked down the street to look for him and saw him coming out of the store. I asked him where he went, and he said he ran out of cigarettes and bought some more, we walked back to the facility (cr F572 notice or rights and rules). Telephone interview with S25 on 06/30/23 at 12:10 PM to ask her to recall the incident when R15 left on 06/25/23. Around 8:30 or 9 PM I found the bottle of alcohol that was hidden in the drawer. Facility Elopement and Wandering Residents policy dated 02/23 reviewed on 06/30/2023 at 12:45 PM . Page one, paragraph two: The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement .including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks . 06/30/23 at approximately 2:00 PM, interviewed the SSD and asked for a copy of R15's signed admission agreement. There was none found, indicating that the resident didn't ever receive the admission agreement at the time of admission. SSD stated R15 was admitted late on a Friday afternoon. Reviewed the facility admission agreement on 06/30/23 at 3:00 PM. Page five, paragraph four states: Smoking Regulations: Facility is a smoke-free environment .failure to comply with the facility regulations will result in the voluntary or involuntary discharge of the resident. Paragraph Five states: The resident understands .that consumption of alcohol could result in the voluntary or involuntary discharge of the resident.

Based on observations, interviews and record review, the facility failed to protect one resident (R)33 from physical harm. R33 was totally dependent on staff for all activities of daily living (ADL's), including repositioning every two hours. R33 suffered an unwitnessed and unexplainable injury due to the manner in which her care was provided. As a result, R33 suffered a dislocated left (L) shoulder and pain, which affected her ability to achieve and maintain her highest level of physical well being. All residents dependent on staff are at risk of this type of unintentional abuse if they are not handled in a safe, secure manner to prevent injury. Findings include: 1) The Office of Healthcare Assurance received an initial facility incident report (FRI) regarding the injury on 12/13/2022 and the completed report on 12/20/2022 (date recorded as 2020 in error). The type of incident was marked injuries of unknown source. The FRI included It was noted during breakfast that her L shoulder was swollen and warm to touch. X-ray results in PM revealed subluxation (partial dislocation) of her humerous [sic]. Resident sent to ER for further treatment.Resident return from hospital but could not relocate injury due to swelling.Could not identify incident that would have been the source of the injury. As the resident is completely dependent upon staff we can only assess that it may have occurred during transfer or repositioning of the resident, or if while laying on her left side.'' 2) Review of the Hospital medical records revealed the following: 12/14/2022 Hospitalist Discharge Summary: Principal Diagnosis: Anterior dislocation of left shoulder, initial encounter. Brief history of presentation included: . Hx of CVA dysarthria/hemiplegia/bedbound and other medical problems presenting to the ER post fall resulting in a shoulder displacement. Apparently, the patient was found with a contracted left upper extremity during rounds . X-ray -Humerus: .Reason for Exam: Trauma . Findings: Anterior shoulder dislocation. CT-Shoulder: Reason for Exam: Shoulder Trauma, instability or dislocation suspected, xray done; Shoulder dislocation comparison Impression: 1. Anterior Glenohumeral Subluxation (Partial dislocation) 2. Small Cortical irregularity of the posterior humeral head, likely related to impaction. 3) R33 is a [AGE] year old female admitted to the facility on [DATE]. She has hemiplegia (paralysis one side of the body), hemiparesis (weakness or the inability to move on one side of the body), dysphasia (swallowing disorder) and dsyarthria (speech disorder caused by muscle weakness) following a cerebral infarction (stroke) affecting her left non-dominant side. In addition her diagnosis included, but not limited to dementia, stage 3 pressure ulcer sacral area, hypertension, diabetes type 2 and age related osteoporosis without pathological fractures. R33 was incontinent of bowel and bladder and wore diapers. She had difficulty making herself understood due to her dysarthria, had impaired vision and cognitive loss. 4) Review of R33' records included: Minimum Data Set (MDS) dated [DATE] Section G, Functional Status coded R33 to be totally dependent (Full staff performance every time during entire 7-day period) for bed mobility, transfers (occurred once or twice) and required the support of one staff for assist for all ADL's including dressing, bathing and eating. Nursing Progress notes: 12/13/2022 09:05 AM: Resident (R33) noted by CNA (certified nurse assistant) when feeding her this AM at about 07:50 AM that her contracted hand (L)=elbow was swollen and warm to touch and with facial grimacing when touched. RN aware and will call MD as appropriate. 12/13/2022 05:00 PM: R33 sent to Emergency Department (ER) by private ambulance. Resident crying during transfer . 12/13/2022 0836 PM: ER called and spoke with emergency room Physician (MD)1.questions with resident's ADLs and assessment when it (injury) was noted. 12/14/2022 08:35 PM: readmitted resident at 15:32 with principal diagnosis of Anterior dislocation of the left shoulder.Resident looking calm and comfortable however with pressure or movement to L arm, observed with moaning and crying and attempts to guard L arm using R arm. L arm with swelling lower arm. 12/15/2022 11:16 PM: .Left elbow/arm remains swollen and left arm still with bruise and discoloration. Continue nursing care with comfort. Noted with facial grimace during nursing care only. 12/18/2022 10:24 PM: Left elbow/arm remains swollen and left arm still bruise/dislocation. Treatment to coccyx wound done this evening as ordered with 2 person assist. Continue nursing care with comfort and gently handling.Noted with facial grimace during nursing care only. 12/21/2022 03:39 PM: . Advised caregiver assigned to maintain 2 staff assistance during nursing care, especially during turning and repositioning to ensure proper positioning while keeping L arm free of any pressure . Care Plan: 03/24/2022, the problem self care/ADL deficit included the interventions of bilateral mobility bars and 1 staff assistance for bed mobility, and use of Hoyer lift for transfers. 5) Reviewed the policy titled Safe Resident Handling/Transfers last reviewed/revised 05/20/2022, which included: Policy statement read It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines: 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. 2. The resident's mobility needs will be addressed and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. The facility provided a policy titled Resident Rights-Freedom from abuse, neglect and exploitation last revised 04/11/2018. Review of the policy included: - Policy header had a different (sister) facility (F2) name on it. - Section Procedure for preventing resident abuse . 2. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. - Section Procedure for preventing resident abuse .Does not tolerate any of the following actions, regardless of a resident's age, ability to comprehend, or degree of disability: .10. Any hitting, slapping punching, pushing, pulling . or other means of physical control of a resident. (Physical Abuse) - An attachment of a flow chart (no date or resource reference) titled Incident Reporting for Alleged Abuse. The first step of the process was to answer Was there willful infliction of injury to a resident? Note: Instances of unintended or ignorant harm does not meet facility policy or definition. 6) On 02/10/2023 at 11:30 AM, observed R33 lying in bed on her back sleeping with both arms across her chest under the sheet. On 02/10/2023 at 01:30 PM, observed R33 lying in bed positioned on her right side sleeping with both arms across her chest under the sheet. 7) On 02/10/2023 at 01:35 PM, during an interview with Charge Nurse (CN)1, inquired the last time R33 was out of bed. She said R33 doesn't really get out of bed anymore because of the pressure ulcer on her buttock. CN1 said the last time she recalled the Hoyer lift (mechanical equipment used for transfers) being used or R33 getting out of bed was when she went to the hospital for x-rays (12/13/2022). On 02/10/2023 at 04:00 PM, interviewed the two CNA's working day shift, who both said since R33's injury, when they provide care for her, they now use two staff. 8) Cross Reference F641-Accuracy of Assessments. Although R33 was to have two person assist starting 12/18/2022, the required staff support documented on the MDS (Minimal Data Sheet) dated 12/20/2022 was one person assist. In addition two of four weekly (from 01/14/2023 to 02/02/2023) assessments after the injury did not accurately reflect R33's need for two staff support for activities of daily living (ADL's). It is unknown if one person assist was the actual support being provided, or if it inappropriately documented by the RN. 9) Cross Reference 657- Care Plan (CP) Revision R33's CP was not revised timely to reflect she needed two person staff support for all ADL's. 10) Due to R33's immobility, she would not have been able to injury herself by striking anything and could not turn herself to roll off the bed. Staff validated she had not been out of bed or transferred using the Hoyer lift and that she had been bedbound. The shoulder can dislocate forward, backward, or downward, and completely or partially. Contact sports injuries, trauma from motor vehicle accidents and falls are the most common source of dislocation. Mechanism of injury is usually a blow to an abducted (movement of a limb away from the midline of the body), externally rotated and extended (fully stretched out) extremity. (Shoulder Dislocations Overview; StatPearls Publishing LLC. 2022)

Based on observations, interviews, and record review, the facility failed to ensure a resident who is unable to carry out acitvities of daily living receives the necessary services to maintain grooming, and personal and oral hygiene for two of four residents (Resident (R)37 and R3) sampled. R37 unable to perform ADLs due to diagnosis of hemoplegia, hemiparesis, progressing Dementia and is dependent on staff for all ADLs needs. Observations on 02/07/23 through 02/10/23 documented R37's ADLs were not completed, appeared increasingly unkept, lips progressed to crack, and body odor was pungent. R3 is dependent on staff for oral hygiene did not receive lip care for dry lips. As a result of severity in the neglect of R37's ADLs, any reasonable person would experience psychosocial harm. Findings include: Cross reference to F656 Develop/Implement Comprehensive Care Plan 1) Centers for Medicare & Medicaid Services (CMS), Appendix P, Seiction IV, E, Psychosocial Outcome Severity Guide, October 2022, defines the resonable person concept as a tool to assist the survey team's assessment of the severity level of negative, or potentially negative, psychosocial outcome the deficiency may have had on a reasonable person in the resident's position. It also defines psychosocial as the combined influence of psychological facotrs and the surrounding social envirno,ent on physical, emotional, and/or mental wellness. R37 is a [AGE] year-old female that was admitted to the facility on [DATE] with diagnosis that include hemiplegia, hemiparesis following a cerebral infarction (stroke) affecting the left non-dominant side and dementia. Multiple observations (02/07/23 at 10:31 AM, 12:30PM, 03:35 PM; 02/08/23 at 08:51 AM, 09:34 AM, 11:21 AM; 02/09/23 at 09:15 AM, 11:15 AM, 02:45 PM; 02/10/23 at 08:30 AM, 10:15 AM, 1:13 PM) were made of R37. During the first observsation, this surveyor asked R37 questions and asked the her to grab her call light. R37 was unable to speak and could not move her arms to grab the call light. Observed on 02/07/23 at 10:31 AM, R37 appeared unkept, her lips were cracked and peeling, and was malodorous. R37's had yellow-nonslip socks (toe of the sock was cut to allow the resident's hand through) applied to both arms that was visibly dirty with brown markings and appeared worn. The fabric strip from the socks dug into the skin between the pointer finger and thumb. On 02/09/23 at 01:54 PM, conducted a review of R37's EHR. Review of R64's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/22 Section C., Cognitive Pattern documented the Brief Interview for Mental Status (BIMS) attempt to conduct interview with resident was not conducted (0. No (resident is rarely/never understood). Section G., Functional Status, R37 is totally dependent (full staff performance every time during entire 7-day period) and requires the support of two or more staff for bed mobility and one or more staff for dressing, eating, toilet use, and personal hygiene. Review of the quarterly MDS with an ARD of 11/21/22 R64's BIMS was not completed and Section G., Functional Status, remained the same and during the 7-day look back period, R37 was not transferred out of bed. Review of R37's CP documented the resident has self-care deficits due to dementia, hemiplegia gastritis, anarthria, and decreased mobility, the goal for R37 to remain clean and comfortable, odor free, and will be treated with dignity in daily basis with an approach to assist in completing ADL task each day (started 03/24/22), encourage the use of call lights when ADL assistance is needed (started 03/24/22). On 02/10/23 at 04:15 PM, conducted an interview with Certified Nurse Aide (CNA)87 regarding R37's ADLs. CNA87 showed this surveyor R37's shower schedule and stated R37's receives baths on Monday, Thursdays, and as needed. CNA87 reported that R37 does not receive bed baths and is transferred from the bed to the shower room. Inquired with CNA87 for documentation supporting R37's received showers as scheduled. CNA87 logged on the EHR and could not provide documentation that R37 was showered. CNA87 confirmed R37 had not received a shower that week and knew this because he/she had been working with the resident that week. On 02/10/23 at 04:20 PM, conducted a concurrent observation of R37 and interview with RN33. RN33 confirmed R37's lips were cracked and appeared unkept. This surveyor pulled R37's blanket down to inspect R37's arms and RN33 confirmed that R37's malodor was noticeable through the surgical mask he/she wore and stated he/she thought this surveyor was going to reveal an untreated/unknown wound due to how bad the odor was. RN33 confirmed R37's ADL needs were not being met. RN33 also confirmed that due to R37's cognitive impairment, any resonable person with the same state of ADLs as R37 would experience negative psychosocial outcomes such as depressed mood and personal embarssment to the level that would change a person's social interactions resulting in isolation. 43414 2) CMS defines oral care in the State Operating Manual (SOM) Appendix PP revised on 10/21/22 as .the maintenance of a healthy mouth, which includes not only teeth, but the lips . R3 was admitted to the facility on [DATE] with diagnoses not limited to hemiplegia and hemiparesis, dysphagia following cerebral infarction, hyperlipidemia, contractures to left hand, left elbow, and ankles, gastro-esophageal reflux disease without esophagitis, and chronic gingivitis non-plaque induced. R3 has tube feeding and has a dietary order of nothing by mouth (NPO). R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/22 under Section G. Function Status for F0110. ADL Assistance R3 needs extensive assistance with one person physical assistance for personal hygiene. Under Section GG. Functional Abilities and Goals for GG0130. Self-Care R3 is dependent in oral hygiene. During an initial observation of R3 on 02/07/23 at 08:52 AM, observed R3 lips to be dry with thick patches of peeling skin on R3's bottom lip, as well as, cracks on her top and bottom lips. Subsequent observations of R3's lips to be dry with thick patches of peeling skin and cracks on her lips were done on 02/07/23 at 12:32 PM and 03:25 PM, on 02/08/23 at 07:59 AM and 12:07 PM. On 12/09/23 at 08:26 AM observed R3's lips without thick patches of peeling skin but observed to be dry and cracked. Review of R3's Electronic Health Record (EHR) noted R3's family member visited her in the evening on 12/08/23. Review of R3's physician order documents a reminder for nursing staff to apply Vaseline to lip every shift to moisturize and sooth dry, cracked lips. Special instructions indicated Reprocessed due to concerns received from Daughter. Review of R3's comprehensive care plan under skin integrity R3 is to use lip balm or emollient on lips. On 02/10/23 at 08:15 AM and at 11:23 AM observed R3's lips to be dry but smooth, no peeling skin or cracks. On 02/10/23 at 11:26 AM interview with Unit Manager (UM) 1 was done. UM1 stated the Nurse puts Vaseline on R3's lips after oral care, for the day shift they put Vaseline before 10:00 AM because she has tube feeding. Concurrent review of the Administration History documents nursing staff had put Vaseline on R3's lips everyday for day, evening, and night shift. Inquired if it would be obvious if R3 did not receive Vaseline on her lips and if it makes a difference, UM1 stated the Vaseline does make a difference because her lips would become so dry that her lips would be bleeding. UM1 reported if R3 did not receive Vaseline, her lips would have white dry skin on top of her lips.

Based on interviews, record reviews, and review of facility policies and procedures, the facility failed to have adequate knowledge of the facility's COVID-19 policies and procedures in order to effectively implement the facility's COVID-19 plan during an outbreak as evidenced by failing to established a facility-wide infection control plan including written infection control standards, policies, and procedures that are current and based on the facility assessment and national standards, failing to notify state authorities of COVID-19 cases in the facility, failing to provide education to staff on COVID-19, proper use of PPE, and hand hygiene and failing to have an infection surveillance plan in place to monitor and evaluate clusters or outbreaks of illness among staff and residents. The deficient practices placed the COVID-19 negative residents at risk for contracting the COVID-19 infection. There were four staff members and 25 residents that tested positive for COVID-19. One Resident (R)10 with a positive COVID-19 test result expired. Findings Include: Cross Reference to F882, Infection Preventionist. The facility failed to clearly identify an individual responsible for the Infection Preventionist position, failed to ensure that the IP was performing the duties of the position, including an understanding of the facility's COVID-19 policies and procedures. Cross Reference to F886, COVID-19 resident and staff testing. The facility failed to conduct testing in a manner that is consistent with current standards of practice for COVID-19 tests. On [DATE] at 08:30 AM, the Administrator was interviewed and stated that the facility had a COVID-19 outbreak two weeks ago and that there were still some residents coming out of isolation. On [DATE], a review of the facility's COVID-19 staff line list (flowsheet that shows who tested positive and date of when they were tested , COVID-19 symptoms if any and onset date, location of place last worked, and whether vaccinated or not) indicated that the following staff had been tested for COVID-19 on the following dates: Certified Nursing Assistant (CNA) 1 on [DATE], CNA2 on [DATE], Licensed Professional Nurse (LPN) 1 on [DATE], and CNA3 on [DATE]. All four staff had COVID-19 symptoms prior to being tested and subsequently tested positive A review of resident line listing (flowsheet that shows who tested positive, location of room, COVID-19 symptoms if any with onset date, PCR test results and date collected, and vaccination status) indicated 25 residents were listed as tested positive for COVID-19 from [DATE] to [DATE]. Resident (R) 24 was the first resident that tested positive for COVID-19 on [DATE] for symptoms of sore throat, cough, and increased phlegm. On [DATE] at 12:19 PM, Director of Nursing (DON) and DON2 (DON of the facility's sister facility) were interviewed. DON stated that she is covering for the Infection Preventionist (IP) position and had completed the Centers For Disease Control and Prevention (CDC) modules on infection prevention. DON reported she was not at the facility during the first week of the outbreak due to attending a conference and was on medical leave afterwards. DON stated the outbreak started after the first resident tested positive for COVID-19 on [DATE], R24, who receives [CONDITION(S)] services offsite. DON did not mention any information about staff testing positive prior to R24 testing positive. DON further stated that the facility isolated R24 and tested his roommate who also tested positive. Due to DON not available during the outbreak, DON2 stated that she was asked to come to the facility to assist with the outbreak. DON2 recommended the facility to test all the residents and staff. DON2 stated that the outbreak had started with three staff testing positive for COVID-19. DON2 confirmed four staff members and 25 residents tested positive for COVID-19. DON2 further stated that Resident (R) 10, who was still positive for COVID-19, was found unresponsive and passed away last night ([DATE]). When inquired to see the facility's infection prevention manual, DON stated that Assistant Director of Nursing (ADON) was in the next room printing it and putting it together. On [DATE] at 1:00 PM a subsequent interview was done with DON2. DON2 stated that she had previously worked as the facility's IP, but then transferred to work as the DON at a sister facility in [DATE]. DON2 reported the facility has not had an IP since then. DON2 stated that the Administrator called her on [DATE] to assist with the outbreak at this facility. DON2 reported that when she came to the facility on [DATE], there was no COVID-19 line list for staff and residents, no contact tracing done, and not enough (Personal Protective Equipment) PPE carts on the floor. DON2 further reported it took her a week to gather information on the outbreak. She stated that only the roommates of positive residents had been tested for COVID-19 and staff that had been in contact with R24 had not been tested . A total of nine residents were positive for COVID-19 when she arrived. She stated she then had all staff and residents tested , with 11 other residents testing positive. DON2 stated that she had to create the resident line list for the facility and that the facility does not have their own policies and procedures for COVID-19. DON2 explained that the facility had a general COVID-19 plan from their corporate company, but that the facility should have taken that plan and catered it the needs of their own facility. On [DATE] at 1:50 PM, a concurrent record review and interview was done with ADON. ADON stated that she initially was hired as a shift supervisor on [DATE] and was promoted to ADON on [DATE]. On [DATE], the facility asked her to assume the role of infection preventionist and that she could work under the DON who was IP certified, until ADON was certified herself. During the COVID-19 outbreak, ADON stated that the facility told her that the DON would not be onsite, and that DON2 would be at the facility for two days to assist with the outbreak. Prior to DON2 assisting with the outbreak, ADON stated the facility tested on e resident on [DATE], one resident on [DATE], three residents on [DATE], two residents on [DATE], and two residents on [DATE] for COVID-19, a total of nine residents tested positive for COVID-19. ADON confirmed there was no COVID-19 line listing for staff and residents and that she was not sure if there was mass testing prior to being asked to take on the IP role. ADON stated that on [DATE], she assisted with mass testing. During concurrent review of the facility's policy and procedures, ADON confirmed that the facility's infection prevention policies dated ,d+[DATE], were directly from their corporate company. ADON stated that the facility does not have their own infection control policies and that she had received and printed out the policies from their regional director today. ADON confirmed that she was not familiar with these policies and today was the first time she seen them. When inquired about R10, the resident who tested positive for COVID-19 and deceased on [DATE], ADON reviewed R10's medical record and stated that R10 had tested positive for COVID-19 on [DATE]. ADON stated that R10 was supposed to be transferred to another facility for care, but the transfer was delayed due to her contracting COVID-19. ADON stated the other facility would not accept R10 until she was cleared from COVID-19, with a negative test result. ADON stated that on [DATE], R10 was found unresponsive in her room, 911 was called, and R10 was taken to the hospital. ADON stated that R10 could not be revived. Review of R10's Electronic Health Record (EHR) indicated that R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . COVID-19 resident line listing stated that R10 tested positive for COVID-19 on [DATE] and that she had symptoms of cough, fatigue, sleeping more, and eating less. Progress note dated [DATE] at 09:30 AM stated Covid antigen swab done [DATE] still positive. Re[s]ults relayed to son at bedside. Resident currently still has slight cough per son but no other symptoms. Progress note dated [DATE] at 04:30 PM stated that at 01:40 PM, R10 resident was on ongoing oxygen support at 2 liters per minute via nasal cannula and had unlabored breathing, sitting at the edge of the bed. When nurse went to room again about 10 minutes later, R10 was found still sitting at the edge of the bed but with her head down. R10 was unresponsive. 911 was called and R10 was taken to the hospital. Progress note dated [DATE] at 8:51 PM stated Follow up condition of resident at KMC-ER. Per ER nurse, resident had [CONDITION(S)], expired at 15:09. ADON informed. On [DATE] at 08:26 AM a second interview with DON was done. Inquired with DON the timeline of the recent COVID-19 outbreak at the facility, DON stated that she was at a conference offsite from [DATE] to [DATE] and while at the conference, she had received a phone text from staff reporting R24 was a presumptive positive and that there were more cases of COVID-19 in the facility. DON stated that she did not actively manage the outbreak while she was at the conference and that she was only in communication with the facility about what was happening. When inquired for documentation of the phone texts DON received from staff, none was provided. DON stated that she did not know the timeline of interventions taken for COVID-19 at the facility. When DON returned to the facility on [DATE], DON stated that she had received a call on [DATE] from the Department of Health (DOH) to follow-up on R24 whom had tested positive for COVID-19. When inquired if the facility informed the DOH of R24 being positive for COVID-19 beforehand, DON stated that she was not sure, and she did not report the positive cases to DOH. DON stated that she was on medical leave thereafter and returned to work on [DATE]. Inquired with DON what responsibilities or role she had as DON for infection control, DON stated that she was in the process of working with the ADON on the facility's infections tracker. DON stated that the DON would be responsible for reporting diseases to the DOH. When inquired what diseases she would report, DON pointed to facility's infection control binder and stated that the information was somewhere in the binder and did not specify what disease she would report. When inquired what she would do if a staff member showed signs and symptoms of COVID-19 today, DON stated that she would have the staff member sent home and tested for COVID-19. When further inquired if there would be any other steps that would be done after staff member was sent home, DON remained silent and stared at surveyor. Surveyor then asked if any contact tracing would be done. DON then stated that they would find who the positive employee worked in close contact with or had any significant exposure to. Inquired what would constitute a close contact or significant exposure, DON looked in the facility's infection control binder for a few minutes for the definition of a significant exposure. Inquired if the facility had done contact tracing for the staff who tested positive on the facility's staff line listing for COVID-19, DON reviewed the staff line listing for COVID-19 and stated that she did not know who created it. DON further stated that she was not sure if there was any documentation showing if there was any follow-up or contact tracing done regarding staff who had tested positive for COVID-19. DON confirmed that the policies and procedures for Infection Control dated ,d+[DATE] were received and printed from their corporate company yesterday, [DATE]. DON stated that they store their infection control policies and procedures on the computer and that she hasn't had time to review it. DON reported that these policies and procedures have not been reviewed by the facility's QAPI committee. When further inquired if any staff education or audits had been done regarding PPE use, hand hygiene, and COVID-19, DON was not able to confirm and said that she would look for any documentation. On [DATE] at 10:36 AM, a third interview and concurrent record review was done with DON. DON provided a schedule for [DATE], confirming that there was a conference from [DATE] to [DATE]. DON stated that the DOH called the facility to follow-up on R24 on [DATE] and another call from DOH to the facility was done on [DATE]. The calendar did not indicate that there were phone calls from DOH made on those dates. DON confirmed she did not report to DOH when staff and/or residents were positive for COVID-19 and the DOH was not initially notified by the facility of R24 when tested positive for COVID-19. On [DATE] at 10:48 AM and interview with the Administrator was done. Administrator stated on [DATE] he was notified that there was an outbreak of COVID-19 and that he was out of the facility two weeks prior. Administrator stated that he inquired if DON called the DOH and that the DON reported she had had already spoken to someone. Administrator understood DON was taking the lead on the recent COVID-19 outbreak. Administrator further stated that on [DATE], he received a call from the DOH reporting they received information that the facility had positive COVID-19 residents and they were trying to contact DON. Administrator stated from then he realized DON did not initially call DOH to report COVID-19 positives at the facility and DON was not following-up on the outbreak, but by then DON was out on medical leave. On [DATE] at 11:30 AM DON further confirmed that there was no documentation for audits for compliance with PPE use and hand hygiene, no staff education on PPE use and hand hygiene, and no documentation for staff training on COVID-19. DON also stated that there was no documentation on follow-up contact tracing for staff who had tested positive for COVID-19. On [DATE] at 01:12 PM, a fourth interview and concurrent record review was done with DON regarding R24's EHR, the first resident that test positive for COVID-19 at the facility. DON confirmed that R24 required [CONDITION(S)] services offsite every Monday, Wednesday, and Friday. DON confirmed that progress note dated [DATE] at 2:57 PM stated that resident was tested for COVID-19 due to sore throat and that resident was sent afterwards to his hemodialysis appointment. DON reviewed R24's lab results dated [DATE] at 05:48 AM which stated that R24 was tested for COVID-19 on [DATE] at 2:00 PM, with positive COVID-19 results on [DATE] at 05:48 AM. DON reviewed [CONDITION(S)] Communication Record dated [DATE] and confirmed that there was no documentation on the record regarding R24 being tested for COVID-19 and that R24 left the facility for [CONDITION(S)] at 3:00 PM. DON stated that the [CONDITION(S)] facility should have been informed of R24 being tested for COVID-19 prior to R24 leaving the facility for [CONDITION(S)] since the [CONDITION(S)] facility does not accept residents who are currently COVID-19 positive. When inquired if there were any policies and procedures regarding residents who required offsite [CONDITION(S)] services but were being tested for COVID-19 or were positive for COVID-19, DON stated that she was not sure. Review of the facility's Infection Prevention and Control Assessment Tool for Long-Term Care Facilities (ICAR), which was conducted by Infection Control Consultant (ICC) from the Disease Outbreak Control Division at the Hawaii State Department of Health on [DATE] in response to an earlier COVID-19 outbreak at the facility. The ICAR included the following discrepancy in the facility's IP program, III. Surveillance and Disease Reporting and IV. Hand Hygiene. The ICAR documents the facility does not have .a written surveillance plan or policy outlining the activities for monitoring/tracking infections occurring in residents of the facility . and .all personnel receive training and competency validation on HH [Hand Hygiene] at the time of employment and within the past 12 months. It was recommended for the facility to Include Hand Hygiene in orientation.

Based on interviews and record reviews, the facility failed to properly prevent and contain COVID-19 as evidenced by failing to clearly identify an individual responsible for the Infection Preventionist (IP) position, failing to ensure that the IP was performing the duties of the position and demonstrated understanding of the facility's COVID-19 policies and procedures. The deficient practice puts all residents at risk of infection diseases, including COVID-19. Four staff and 25 residents tested positive for COVID-19. One Resident (R)10 with a positive COVID-19 test result expired. Findings Include: Cross Reference to F880, Infection Prevention and Control. The facility failed to have adequate knowledge of the facility's COVID-19 policies and procedures in order to effectively implement the facility's COVID-19 plan during an outbreak as evidenced by failing to establish a facility-wide infection control plan including written infection control standards, policies, and procedures that are current and based on the facility assessment and national standards, failing to notify state authorities of COVID-19 cases in the facility, failing to provide education to staff on COVID-19, proper use of PPE, and hand hygiene and failing to have an infection surveillance plan in place to monitor and evaluate clusters or outbreaks of illness among staff and residents. Cross Reference to F883, Influenza and Pneumococcal Immunization. The facility failed to offer updated influenza and pneumococcal immunizations to four residents. The facility's policy and procedures document the IP responsible for ensuring the pneumococcal vaccination was given or offered to residents and documented. On [DATE] at 08:30 AM, the Administrator was interviewed and stated that the facility had a COVID-19 outbreak two weeks ago and that there were still some residents coming out of isolation. On [DATE], a review of the facility's COVID-19 staff line list (flowsheet that shows who tested positive and date of when they were tested , COVID-19 symptoms if any and onset date, location of place last worked, and whether vaccinated or not) indicated that the following staff had been tested for COVID-19 on the following dates: Certified Nursing Assistant (CNA) 1 on [DATE], CNA2 on [DATE], Licensed Professional Nurse (LPN) 1 on [DATE], and CNA3 on [DATE]. All four staff had COVID-19 symptoms prior to being tested and subsequently tested positive A review of resident line listing (flowsheet that shows who tested positive, location of room, COVID-19 symptoms if any with onset date, PCR test results and date collected, and vaccination status) indicated 25 residents were listed as tested positive for COVID-19 from [DATE] to [DATE]. Resident (R) 24 was the first resident that tested positive for COVID-19 on [DATE] for symptoms of sore throat, cough, and increased phlegm. On [DATE] at 12:19 PM, Director of Nursing (DON) and DON2 (DON of the facility's sister facility) were interviewed. During this interview, DON stated the facility does not have a dedicated Infection Preventionist (IP) position but has completed the Center for Disease Control and Prevention (CDC) modules on infection prevention and is covering for now. DON further stated the Assistant Director of Nursing (ADON) will eventually be taking on the role of IP and is in training to be a certified IP. DON reported she was not at the facility during the first week of the outbreak due to attending a conference and was on medical leave afterwards, returned to work on [DATE]. Due to DON not available during the outbreak, DON2 stated that she was asked to come to the facility to assist with the outbreak. DON2 confirmed 4 staff and 25 residents total tested positive for COVID-19 and a resident, R10, who was still positive for COVID-19, was found unresponsive and passed away last night ([DATE]). When inquired to see the facility's infection prevention manual, DON stated that ADON was in the next room printing it and putting it together. On [DATE] at 1:00 PM a subsequent interview with DON2 was done. DON2 stated that she had previously worked as the facility's IP, but then transferred to work as the DON at a sister facility in [DATE]. DON2 stated that the facility has not had an IP since then. DON2 reported that the current ADON was hired recently and was not IP certified and the DON was never supposed to be the IP. DON2 further reported during an assessment done by an Infection Control Consultant (ICC) from the Disease Outbreak and Control Division at the Hawaii State Department of Health in the summer, the DON informed the ICC she was not going to be the IP. DON2 stated that the Administrator called her on [DATE] to assist with the outbreak at this facility. DON2 reported that when she came to the facility on [DATE], the facility did not implement the facility's COVID-19 plan due to not developing a facility COVID-19 plan and/or policy and procedures to prevent and control the COVID-19 outbreak. On [DATE] at 1:50 PM, a concurrent record review and interview was done with ADON. ADON stated that on [DATE], the facility asked her to assume the role of infection preventionist and that she could work under the DON who was IP certified, until ADON was certified herself. ADON reviewed and confirmed that the facility's infection prevention policies dated ,d+[DATE], were directly from their corporate company. ADON stated that she was not familiar with the facility's infection prevention policies, and they were printed today. On [DATE] at 08:00 AM, a record review was done of the facility's Infection Prevention and Control Assessment Tool for Long-Term Care Facilities (ICAR), which was conducted by an ICC from the Disease Outbreak and Control Division at the Hawaii State Department of Health on [DATE] in response to an earlier COVID-19 outbreak at the facility. The ICAR stated the following discrepancy in the facility's IP program for I. Infection Control Program and Infrastructure .Elements to be assessed: A. The facility has specified person (e.g. staff, consultant) who is responsible for coordinating the IC program .Assessment: Yes .Notes/areas for improvement: Need an IP On [DATE] at 08:26 AM, a second interview and concurrent interview was done with the DON. Inquired about the facility's ICAR and DON stated that she had informed ICC and Administrator that it was not realistic for herself to be both the IP and DON at the facility. DON stated that she has worked at the facility as the DON since [DATE]. DON stated that the facility previously had an IP consultant, but the contract had ended. DON stated that she was qualified to be an IP and that the facility was currently in the process of having the ADON become IP certified and assume the role of IP. DON confirmed the facility does not currently have a staff member in the IP position and reiterated she was clear with Administrator she cannot take on the role. When inquired what responsibilities DON had for infection control, DON stated that she was in the process of working with the ADON on the facility's infections tracker and would be responsible for reporting diseases to the state department of health. When inquired what diseases she would report, DON pointed to facility's infection control binder and stated that the information was somewhere in the binder and did not provide surveyor diseases she would report. DON stated the facility did not have COVID-19 policies in place when she started working at the facility. DON confirmed that the facility's infection prevention policies dated ,d+[DATE], were directly from their corporate company and were printed yesterday, [DATE]. DON stated that she has not read and is not familiar with the facility's infection prevention policies because they are stored in the computer and has not had time to review it. Due to the facility not having a dedicated IP, DON reported no one can speak into the policies and the policies have not been reviewed by the facility's Quality Assurance and Performance Improvement (QAPI) committee. On [DATE] at 10:48 AM, Administrator was interviewed. Administrator stated that the DON was hired in [DATE] and that the facility did not have an IP at that time. When inquired who the facility's IP was, Administrator stated the DON was certified to be an IP and the ADON is in training to be the facility's IP under DON. Clarified with Administrator if DON agreed to take on the role as IP, Administrator stated that DON was responsible for making sure that all the infection control policies were followed, and that DON was responsible for delegating the IP role as necessary. During the most recent COVID-19 outbreak, Administrator stated he initiated the placement of a new IP who was the ADON, although the ADON was not certified. Administrator stated that DON2 from their sister facility assisted ADON during the outbreak. On [DATE] at 12:00 PM, a review of an e-mail dated [DATE], Re: Liliha IP support and leadership during outbreak, Administrator responded to the ICC , Thank you for working with [name of DON2] while [name of DON] was out unexpectedly due to an acute health concern (return undetermined). As [name of DON2] is the DON at [sister facility's name], our sister facility, she cannot provide the required 20 hours of support for IP activities. She will be providing direct and remote support to our new ADON/IP [name of ADON], RN, going forward. [Name of ADON] is not IP certified. However, [name of DON2 and name of regional consultant], RN, our Regional Nurse Consultant, will also be supporting [name of ADON] in her transition and to bring this outbreak to a speedy conclusion. Review of the facility's job description for Infection Preventionist documented the position purpose, Develops, implements, and maintains a facility-wide infection prevention and control program. Duties and responsibilities in the job description include but is not limited to: Develops and implements an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable enviroment. Establish facility-wide systems for prevention, identification, reporting, investigation, and control of infections and communicable disease of residents, staff, and visitors. Develops and implements written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevent and control .Leads the facility's Infection and Prevention Control Committee. Develops actions plans to address opportunities for improvement .Reviews and/or revises the facility's infections prevention and control program, its standards, policies, and procedures annually and as needed for changes to the facility assessment to ensure they are effective and in accordance with current standards of practice for preventing and controlling infections. Provides educations related to infection preventions and control principles, policies, and procedures to staff, residents, and families .Ensure public health is notified of reportable diseases .maintains documentation of infection prevention and control program activities.

Based on interview with staff members and record review the facility failed to demonstrate that all nursing staff possessed the competencies and skill set necessary to identify a change in condition and provide nursing and related services to meet the needs of one of three residents (Resident (R)5) sampled to maintain her highest practicable physical well-being. Nursing staff failed to document they report to the physician that R5 had a trend of hypotensive (low blood pressure) episodes. On [DATE], R5 fell and was diagnosed with a fractured right (R) hip, nursing staffs' initial and ongoing assessments while R5 remained in the facility (over eight hours) until non emergent transfer to the Emergency Department, failed to include assessment of the skin or pulse of the affected extremity. At the time of transfer, R5 was assessed to have diminished pulse of the extremity and it was cold to touch. R5 expired at the hospital prior to going to surgery. The lack of nursing skill set to properly assess and respond to R5's needs and delay in transfer resulted in harm and may have contributed to her death. Findings include: The Office of Healthcare Assurance received the initial Facility Incident Report (ACTS # 9868) that R5 fell on [DATE]. An updated report included the following: Resident assessed at the time of fall with resident complaint of Right side hip/low back pain. resident assisted [sic] back to bed with 1:1 supervision while awaiting Mobile imaging services. Images revealed R Hip fracture(fx). Orders given to send resident to ER for further evaluation and treatment. Update: Resident expired at acute hospital before going into operating room for hip surgery. R5 was a [AGE] year old female who had lived at the facility since [DATE]. Her pertinent medical history included Alzheimer's, hypertension, age related physical debility, Type 2 diabetes, [CONDITION(S)], gastro-espohageal reflux, muscle weakness, dysphasia, and unsteadiness on feet. R5 used a front wheel walker (FWW) and frequently ambulated the halls. She was on losartan 25 milligrams (mg) and [MEDICATION(S)] 100 mg once a day for high blood pressure. The medication order for these two medications included criteria to hold the medication if R5s blood pressure was less than 100 systolic (top number) blood pressure. Review of R5's Records revealed the following: [DATE] Physician (MD)1's Progress note documented: ongoing significant weakness. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of repeat blood pressure, assessment if R5 was symptomatic, or notification of the trend to the physician. [DATE]: BP [blood pressure] ,d+[DATE], Not administered: On hold [DATE]: BP ,d+[DATE], Not administered: On hold [DATE]: BP ,d+[DATE], Not administered: On hold [DATE]: BP ,d+[DATE], Not administered: On hold Time frame of pertinent events related to R5's fall on [DATE]: [DATE], 02:55 PM Nursing notes: Witnessed fall from standing position while using FWW. Did not hit head.restless after fall .1:1 supervision. [DATE], 03:45 PM Nursing note: vomited 1x; lab and x-rays ordered. Medication given for nausea/vomiting. [DATE], 03: ,d+[DATE]:45 PM Nursing note: ETA (estimated time of arrival) imaging 05:00 PM. [DATE], 07:30 PM Nursing note: x-rays done [DATE], 08:30 PM Radiology report signed with impression: acute right hip fracture. It is unknown what time the facility received the report. [DATE], 09:25 PM Nursing note: Notified MD1 of x-ray result. Ordered transfer to the Emergency Department. [DATE], 11:30 PM Nursing note: Scheduled transport with . ETA 11:30 PM [DATE], 11:50 PM Nursing note: Right LE (lower extremity) appears pale, cold, clammy to touch, diminished pedal pulses ., ambulance came in at 11:35 PM, Left facility at around 11:50 PM. [DATE] ([DATE] PM 07:29 PM Recorded as late entry) by MD1: D/C (discharge) --fell R HIP PAINS= = R HIP FRACTURE/N/V LATER = = TO ER ASAP X-rays were not done in a timely manner, the results of the x-rays were not provided to the MD1 in a timely manner and the transfer to the hospital was not done in a timely manner. On [DATE] at 01:00 PM, during an interview with Registered Nurse (RN)1, inquired what the practice was if a blood pressure medication was held due to low blood pressure outside the physicians defined parameter. She said they are supposed to recheck the BP, document the second reading, and if way high or low, would notify the physician. RN1 went on to say that some residents are asymptomatic even if their blood pressure is low, but if it continues .to be low daily, at least two to three days, would usually call the physician, and document it in the progress notes. RN1 further stated they (RNs) just follow the parameters identified by the physician. RN1 was assigned R5 the day of the fall. She said R5 spoke Korean, and uses mostly gestures to communicate. Her baseline is oriented to self only. RN1 said she assessed R5 after the fall and did not see any signs of fx. She checked her vitals, called the physician, gave Tylenol for pain and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She then got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN1 said when she called for the X-rays and was told they would come at 05:00 PM. RN1 stated R5 kept wanting to stand, so had a CNA (certified nurse assistant) watching her the whole time. RN1 said when she left R5 was still sitting on the edge of the bed. When RN1 was informed R5 did not leave the facility until 11:50 PM, she said that's too long. She said she had heard her coworker was only able to notice everything when R5 was on the gurney lying down. On [DATE] at 03:10 PM, during an interview with RN2, she said she notified MD1 of P5's x-ray results. Inquired with RN2 what kind of monitoring and assessments should be done after a similar fall, RN2 stated they would monitor level of consciousness, vitals signs, assess for pain, bruising and limitation of movement. RN2 said they usually have a vendor come to the facility to do x-rays for this type of injury, who provides ETA (Estimated Time of Arrival). RN2 stated it often takes four to five hours, sometimes even seven, and then it takes one to two hours to get the results. When inquired how it was determined to transfer a resident by 911, or nonemergent ambulance, RN2 said it depends on our assessment and vital signs. RN2 said the physician will sometimes say it is OK to transfer via non emergent ambulance, depending on residents condition. She said R5 was hard to assess because she wouldn't lay down. RN2 said after X-rays are taken, they have to keep checking to see if the report has been sent. She said when she got the results, she called MD1 with the report and asked to transfer R5 to the hospital. RN2 reported the doctor said she could call the nonemergency ambulance. RN2 stated R5 had been sitting at the time, vitals were OK, and she was moving a lot in bed. RN2 said they had the LPN (licensed practical nurse) stay with R5 the entire time. She went on to say when getting ready to transfer her, R5 was able to lay down. At that time, she said she was able to check her, and the leg looked pale, was cold and moist with a weak pulse. RN2 said she checked the color of her leg and touched it earlier, but didn't document it. Inquired if RN2 notified MD1 of R5's condition at the time she left the facility, and she replied I'm not sure. There was no documentation RN2 notified MD1 of this change in condition in the medical record. Inquired if RN2 would notify the physician if a medication was held when the BP was outside the parameters identified in the MD order, RN2 stated she would not. RN2 stated the MD can see the vitals in the MAR. RN2 further stated if it happened several days in a row, we would usually update the doctor, and ask if they wanted to reduce the medication. On [DATE] at 02:30 PM concurrent record review and interview with Assistant Director of Nursing (ADON) was done. Inquired what should be included in the initial and ongoing assessments when a resident falls and diagnosed with a hip fx. ADON stated she would expect to see documentation of a head to toe assessment, neurological status, skin issues, notable different leg lengths, and vitals. Asked if they should document pulses and temperature of skin of the extremity, and the ADON said, Of course. ADON stated the staff should use 911 for transport of hip fractures as it would be considered a medical emergency. Concurrent review of R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled Notification of Changes last reviewed on ,d+[DATE] included the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician . when there is a change requiring notification. Circumstances requiring notification include: 2. significant change in the resident's physical, metal or psychosocial condition such as deterioration in health, .That may include: a. life-threatening conditions, or b. Clinical complications. 3. Circumstances that require or may need to alter treatment. This may include .b. Discontinuation of current treatment due to: i. Adverse consequences. ii Acute condition. iii. Exacerbation of a chronic condition.

Based on interviews, record review (RR) and observation, the facility lacked evidence that the allegation of abuse brought to their attention on 06/02/21 was thoroughly investigated. The Resident (R)1 was not interviewed in her primary language and there was no documentation R1 was monitored for behavioral changes post alleged incident. In addition, there was conflicting information obtained from interviews from R1's family members (FM's) and the Director of Nursing (DON) regarding notification of the alleged incident and a conversation FM2 had with the DON on 06/22/21. The investigation response document provided by the DON included inaccurate information. As a result of this deficiency, there was potential the facility did not have critical information during the investigation to determine if the allegation was substantiated or not. If a thorough investigation is not conducted, there is potential all residents could be in an unsafe environment. Findings include: 1) On 06/02/21, Certified Nursing Assistant (CNA) 1 reported to the Administrator (ADM), Director of Nursing (DON), and Human Resources Director (HRD) that he witnessed his preceptor, CNA2 slap R1's hand and then R1's face as R1 was pinching CNA2 during morning care on or about 05/27/21. CNA2 was the preceptor for CNA1 who was a new hire and started his orientation on 05/26/21. 2) Time frame from interviews and documents (Adult Protective Services [APS], Facility investigation notes and staff questionnaires): 05/27/21 Facility determined date alleged abuse may have occurred 06/02/21 Approximately 10:30 AM, CNA1 reported the allegation of abuse reported to the DON. Investigation conducted by leadership team. 06/02/21 03:00 PM facility reported to APS. Report did not include information on alleged perpetrator (AP) or witness. 06/02/21 05:11 PM: facility left message left on APS after hours voice mail box the DON had determined that the allegations were unsubstantiated and to contact DON for additional information. 06/03/21 Both CNA1 and CNA2 returned to work. CNA2 assigned to second floor where R1 resides and CNA1 reassigned to first floor. CNA1 requested to go home after meeting with DON and receiving disciplinary action for failure to report the incident immediately. 06/20/21 R1's FM 1 contacted by attorney generals office inquiring about the allegation. 06/22/21 R1's FM1 and FM2 presented to the facility unannounced for meeting regarding allegation. Later that day FM2 contacted the DON to discuss additional concerns related to the allegation. 3) On 07/14/21 at 10:05 AM during an interview with the DON, he said he interviewed staff that worked that day of the alleged abuse, but also wanted to get information from other staff who CNA2 oriented and worked with her. On 06/02/21, the DON documented in the investigation notes; 5 staff members were individually interviewed in accordance with Critical Element Pathway Guidelines, CMS form (5/2017). They also answered a standardized questionnaire about the alleged incident. On 07/14/21 reviewed the staff questionnaires. There were six questionnaires provided by the DON which were all dated 06/03/21. Five were completed by CNA's (CNA3, CNA4, CNA5, CNA6 and CNA7) and one by a Registered Nurse (RN)1. All staff that completed the questionnaire were working the day the incident was reported (06/02/21). Review of the staffing schedules revealed only two of the five CNA's (CNA3, CNA4) worked the day (05/27/21) the facility determined to be the date of the alleged incident. The other staff working 05/27/21 were not interviewed. When the DON was asked to clarify the date on the questionnaire, he said, I gave the staff the form late in the afternoon on the 2nd (06/02/21), but I dated them wrong (06/03/21) when I wrote everything up. 4) On 07/14/21 reviewed the document provided by the DON of the facility response and investigation of the allegation. On 06/03/21, the DON wrote; Of note, resident's daughter took resident to the hairdresser the next day May 28, 2021 by vehicle. The daughter and son are very active in their mother's well-being. Resident has always conversed with daughter and son about any concerns, changes, wants or needs in the past. There were no concerns verbalized by daughter upon returning her mother back to the facility. Resident appeared in her usual state of health, personality, and mentation. During an interview with the DON on 07/14/21, he said he felt if something had happened, R1 would have mentioned it to her daughter when she took her to the hairdresser. The DON later said he became aware that R1 did not go out to the hairdresser with her daughter. 5) During an interview with R1's daughter on 07/14/21 at 04:05 PM, stated the first time she saw R1 after the alleged abuse allegation was 06/01/21 and again on 06/15/21, when she took R1 to see the acupuncturist. R1 mentioned that someone was hitting her but I just let it go . She (R1) said it so matter of fact and wasn't angry. She (R1) repeated it a couple of times. At that time, the daughter was not aware of the allegation and did not find out until her brother called her on 06/20/21. On 06/22/21, me and my brother went down there [the facility] . unannounced and met with DON for the first time for a meeting. R1's daughter explained after the meeting she called the DON the same day and expressed her disappointment with facility not informing her brother or her of the allegation. R1's daughter then informed DON of what R1 said to her on 06/01/21 and 06/15/21. She said the DON responded with .why didn't you tell me earlier when in the office, you should have told me about it . 6) Interview with DON on 07/14/21 at 10:05 AM, he said he did not think he took notes during the family meeting on 06/22/21. The DON said , I should have called them (family) right away. That was my error. On 07/15/21 at 01:08 PM during a second interview with the DON, he confirmed R1's daughter called him after the meeting and wanted to talk about the blood on the mask. He said the daughter told him one time the acupuncturist changed R1's mask when she was at the appointment because there was blood on it. The DON said he followed up with the Charge Nurse (CN) and it was determined that the blood was probably due to R1's dry cracked lips. The DON said he had a hard time understanding her (daughter) and tried to ask her so I could understand. The DON said he did not hear the daughter say R1 told her on two separate occasions that someone was hitting her. 7) Cross reference Ftag 607 Develop/implement Abuse/neglect Policies. The facility failed to develop and implement adequate policies and procedures for investigation and response to an allegation of abuse. Although the facility had a policy in place, it lacked guidance/procedures to assist the leadership team in the response to an allegation of abuse. The facility did not have adequate documentation in the medical record regarding notifications to physician and family, or follow up with the R1. In addition, the facility took actions toward the reporter in a manner that did not promote reporting for fear of reprisal. 8) Cross reference Ftag 552 Right to be informed in a language that is understood. The facility failed to offer or provide translation services to R1 in her primary language when investigating the allegation of abuse. R1 had limited English Proficiency and primary language was Korean. The facility did not immediately contact the family who could have assisted with interpretation in an emergency. In addition, there was a CNA on duty at the time that spoke fluent Korean who knew R1. 9) On 07/14/21 at 08:45 AM, spoke with R1 in her room in English, R1 initially nodded her head up and down in response with surveyor's introduction and questions and then began to respond with one word per question. Surveyor who also knows Korean asked R1 questions in Korean and R1 responded with one word per question. At 01:11 PM, surveyor went back to speak with R1 in Korean and R1 conversed in 3 to 4 word sentences. Surveyor inquired if R1 had been hit by someone who works at the facility and R1 stated no in Korean, then began changing the subject. Surveyor then inquired if she is enjoying her time at the facility, R1 stated she is having a hard time at the facility but did not further elaborate and changed the subject. On 07/15/21 at 01:40 PM, interviewed R1 utilizing the facility's recent contracted interpreter services over the phone, utilizing a Korean interpreter. Initially R1 responded to questions by nodding her head up and down, with occasional no responses. Surveyor inquired if a staff member had hit her and if a staff member hit her in the face, R1 did not respond to both questions. Surveyor then asked if a staff member hurt her, R1 responded and stated a staff member pulled her hair about 2 months ago. Further inquired about the incident and R1 stated the staff member was angry at her so she pulled her hair while taking a shower. R1 informed the staff member the water was too cold when the staff member pulled her hair. Surveyor inquired if R1 had let anyone know about the incident and R1 stated she informed a Korean supervisor who responded by asking R1 why she did not inform someone sooner. At the end of the interview R1 repeatedly stated she was scared.

Based on observations, interviews, and record review (RR), the facility failed to provide adequate supervision and have a system in place to minimize the potential of elopement. One of three residents (Resident (R)1 sampled eloped on 02/27/21 and was found in an unsafe environment. After the event, the facility failed to ensure the action plan interventions were implemented correctly and consistently and evaluate the effectiveness of the interventions. At the time of survey, the wander guard alarm system was found not to be working properly and the facility did not check the system or utilize the bands according to manufacturer's instructions. In addition, one of the interventions to prevent elopements was to lock the laundry room door that led to the elevator on each unit. The first-floor laundry door was found unsecured on 03/11/21 at 12:30 PM. The facility did not minimize the potential of a resident leaving a safe area, and put them at risk of potential harm, or death. The facility Administrator was informed of an immediate jeopardy on 03/12/21 at 02:15 PM. An abatement plan was accepted at 03/12/21 at 03:50 PM. Findings include: 1) On 03/05/21, the Office of Healthcare Assurance (OHCA) received an event report from the facility regarding the elopement of R1. The report documented; R1 is an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis (dx) [CONDITION(S)], Alzheimer's Disease. BIMS (Brief Interview for Mental Status) of 9 (severe cognitive impairment). Currently being followed by Psychiatrist (MD)1 for dx (diagnosis) [CONDITION(S)] in Dementia and treated with [MEDICATION(S)] (antipsychotic) 0.25 mg (milligrams) BID (twice a day), and [MEDICATION(S)] (for anxiety) 0.5 mg BID prn (as needed) for nondirectable agitation and anxiety disorder. Resident has had 2 (two) episodes of trying to exit the facility on 02/27/21, with Wander guard activation both times. At 14:59 on 02/27/21, charge nurse noted that resident (R1) was not in the great room on the second floor. Staff was then deployed to search the perimeter of the facility including adjacent areas outside the building. Staff was noted to be doing end of shift rounds while also attending to other residents. After being alerted by the CN (Charge Nurse) that resident was not in her room or the great room, staff searched all rooms and adjacent areas in the facility and the outside of the building.Resident was located by the CNA (Certified Nurse Assistant) passed [sic] the bus stop in front of the building, next door to the facility. 2) The facility utilizes a wander guard system that helps monitor residents who are identified to be at risk of elopement. The alarm includes sensors installed at each unit (first and second floor) glass double door entrance and the fire exit door. The resident at risk wears a band with a transmitter that is designed to activate an alarm and lock the door when the resident approaches the door. The alarms help monitor a resident's activities, they do not replace necessary supervision, and require scheduled maintenance and testing to ensure proper functioning. 3) At the time of survey, the facility had three R's who were assessed at risk for elopement and wore a wander guard band to help monitor activity. Two R's (R1 and R2) resided on the second floor and R3 on the first floor. 4) RR of R1's care plan (CP) revealed she was at risk for injury including elopement; related to her impaired cognition. R1 had poor safety awareness because of dementia with behavioral disturbances/[CONDITION(S)] and Alzheimer's disease evidenced by trying to leave the facility using the exit door, asking where the bus stop is, pacing, and wandering back and forth to the nurse's station. She is ambulatory without assistive device, confused, packs her belongings, and verbalizes catching the bus to go to work or wait for her husband to pick her up. R1's CP revealed she was also at risk for injury due to the potential for falls related to limited mobility, weakness and episodes of dizziness. 5) On 03/11/21 at 09:30 AM during an interview with the Director of Nursing (DON), he said staff tested the system when R1 returned to the facility after the elopement. He said the staff tested the alarm by walking her through the glass door and the alarm activated. The DON said he noted a trend that R1's exit seeking behavior increases in the afternoon. The DON said their investigation revealed R1 had been in the middle of the day (great/dining) room when the CNA responded to a call light. He went on to say the paramedics were transporting another resident about that time and would have come in and out through the glass door. The DON felt the alarm would have gone off if R1 exited through the glass door and felt she would have been seen if she left the building through the main entrance once on the first floor. We think she went in the unlocked laundry room door, saw the elevator, went to the basement to the parking lot and then out to the sidewalk. The DON went on to say, one of the CNA's driving by saw R1 at the corner by the stoplight, stopped the car and yelled for her to wait. She called the facility to inform them of R1's location. The DON said each unit checks the alarm system every shift, and the alarm activates three to five feet when the door is approached. The action plan after the incident included more diversional activities with R1 and locks on the laundry doors. The key to the door for staff access was hung on a hook placed on the wall next to the door. 6) On 03/11/21 at 12:30 PM, the first-floor unit laundry room door was found unlocked and the key was not on the hook. At that time, CN1 was interviewed. When asked why the door was not locked, she said Because of the incident last week. CN1 went on to say one of the residents (R3) is an elopement risk and was trying to get out the laundry room door, so staff took the key because they thought she might be able to get out. CN1 said the incident happened about a week ago and the key had been kept in a drawer in the nursing station since. She stated, We keep the door closed, but unlocked. On 03/11/21 at 12:45 PM, observed R3 sitting on the bench between the laundry room and front entrance with a wander guard band on her ankle. R3 was working on an activity that involved hand dexterity, and was noted to do the activity with ease. R3 would be able to reach the key and potentially have opened the locked door. RR revealed R3's elopement risk assessment dated [DATE] indicated she was able to ambulate independently, had verbally expressed the desire to leave, and her behavior was goal oriented. R3's progress notes indicated her behavior has become more aggressive the past several weeks, continues to wander, is often confused and forgetful, and often requires close supervision. The progress note dated 02/20/21 entered at 11:20 AM documented R4 had [CONDITION(S)] (swelling) both feet, and CN (CN1) tried to move wander guard to resident's hand/wrist, but she refused. Observed the hooks for the keys on the wall by laundry room doors were visible to staff and R's. The first floor hook was measured to be placed at seven feet. When the key is hung on the hook, it is attached to a string and is at a length that can be reached by staff. 7) On 03/11/21 at approximately 01:00 PM, the DON and surveyor toured the facility and did a reenactment of the route he felt R1 took when she eloped. It was observed that the back door of the elevator is easily seen on entry to the laundry room, and both elevator doors on the basement floor open to hallways that lead to the parking lot. The parking lot entrance and drive both have inclines, and lead to the sidewalk/street in front of the building. The intersection where R1 was found was observed to be a busy intersection with stoplights. The DON said the area around the building next door was an area they had concerns about potential drug use activity. The inclines of the parking lot and drive would be considered a hazard for any R who was at risk for falls. The DON used the alarm test box to demonstrate how the second-floor fire door exit functions with the wander guard. The door lock was not activated the first two times, but on the third attempt, the lock was activated and secured the door. This door had not been routinely tested and documented it was functioning correctly. \ Observed R1's room was the first room next to the fire exit door, and her bed was the first of three beds in the room. Observed the DON then test the second-floor glass door alarm which activated and alarmed inconsistently. Surveyor informed the DON the CN2 on the second floor had been informed by the Maintenance Supervisor (MS) the bands worked better when worn on the ankle versus the wrist. The DON said he had not been made aware of this, but additional tests confirmed it to be accurate. 8) On 03/12/21 at 10:00 AM during an interview with the Assistant Director of Nursing (ADON), requested documentation the nursing staff had been trained on the wander guard system/bands and the content of that training. The ADON later reported the MS does the training, but there was no documentation. The ADON said it is the Registered Nurse's (RN's) role to put the wander guard band on the R and it is the R's preference where to put the band, but it is usually on the wrist. The ADON said the RN's check the system is intact and working every shift, and it's done using a machine described as a small box to test the door. The box is also used to test the band. The staff document on a log the band is intact by the R's name with a wander guard. The ADON said it is the facility policy to complete a risk elopement assessment on all new admissions. If the R is determined to be at risk, the MD is contacted for a wander guard order and it is added to the CP. The ADON said they have a daily standup meeting and discuss the at-risk residents. 9) On 03/12/21 at 01:30 PM conducted a RR with the MDS Coordinator that revealed two (R5 and R6) of the eight new admissions sampled did not have a risk elopement conducted. R5 was admitted on [DATE] at 10:15 AM, and R6 was admitted on [DATE] at 03:02 PM. 10) The ADON provided the wander guard (Secure Care) strap (band) instructions dated 03/20/15. The strap instructions included 1. Place the strap around the resident's ankle comfortably. The instructions also include ensuring the ankle transmitter is in place. This must be done at each shift change. Each transmitter should be tested daily to ensure the transmitter is working properly. Date imprinted transmitters should be checked for expiration date at this time. Actual expiration date is the last day of the month engraved on the transmitter. The #707 Tester is available for purchase for fast, easy testing of all transmitters. A documented test of each ankle transmitter is working properly must be made each day. This includes those transmitters not currently in use. The second floor had the tester, but the first floor did not. The first floor physically walked the R with the band through the door to see if it alarms. The second floor knew the band displayed a green indicator light if it was functioning properly when tested , but the first floor did not. 11) On 03/12/21 at 09:10 AM, during an interview with CNA1, she said the CNA role is to make sure the wander guard is on every shift. When asked where the band is worn by the R, she said either the hand or foot. On 03/12/21 at 09:14 AM, during an interview with RN1, she said the first-floor unit had two R's with wander guards. The previous day surveyor had been informed there was one R with a wander guard. RN1 identified the other resident as R4, who was in the great room. It was observed R4 did not have a wander guard band on. RN1 was surprised and unable to answer why R4 did not have it on. Further investigation revealed R4 was previous an elopement risk, reassessed and had an order to discontinue the wander guard. On 03/11/21 at 04:40 PM during an interview with CNA2, she said the wander guard could be placed on either the arm or the leg. On 03/12/21 at 9:30 AM, during an interview with CN2 (second floor), she said the wander guard bands are now placed on the leg on the suggestion of the Maintenance Supervisor (MS). When asked if there had been a memo or communication of some type to inform all nursing staff, she said there was not. It is imperative that all staff are aware that the wander guard is to be placed on the ankle according to manufacturer's instructions and at all times know who is a risk for elopement with a wander guard band. 12) R1's care plan (CP) was revised on 03/01/21 after her elopement by the MDS coordinator with the following entry: Check/ensure that wander guard is properly functioning at the beginning of the shift. Also check for expiration date. On 03/12/21 at approximately 02:00 PM, CN2 said she was not aware of an expiration date on the wander guards bands. 13) On 03/12/21 at 09:00 AM during an interview with the MS, he said the facility maintenance department does not do any preventive maintenance (PM) on the wander guard alarm system, and nursing does the testing. The MS said the facility did not have the manual for the alarm system. He said his role was limited to contacting the vendor (V)1, who installed the equipment when there is a reported issue and they would come and fix it. The MS did not recall the last time the company was called and did not have any invoices. The MS said the sensors (approximately 18 inches long) are located toward the bottom of each side of the doors and he found putting the band on the ankle had better results activating the alarm. When asked, MS said R1 had the wander guard band on her wrist when she eloped. On 03/12/21 at 09:10 AM, at the request of surveyor, the MS put the wander guard band on his ankle and walked through the glass door on the first floor. The alarm did not activate when he approached and went out the middle of the door. It did activate if he approached either side of the door. The MS then put the band on his wrist and went through the door several times and the alarm was not activated The MS notified V1 and requested a manufacturers manual and asked them to come to check the alarm system. On 03/12/21 at 01:39 PM, V1 delivered a manual to the facility and met with the MS to review the recommended weekly checks for the alarm system. The MS said he would be adding the checks to his weekly PM. On 03/12/21 at 1:50 PM, V1 confirmed the wander guard alarm on the first floor was not functioning properly, and validated the alarm was not activating through the center of the door. V1 adjusted the sensors and said he would provide the facility with his findings. V1 was then going to check the system on the second floor. 14) The facility policy titled Elopement Exposure and Control Policy dated August 2014 policy statement read; Elopement from a structured, supervised and/or unsupervised environment can be a life-threatening situation that may result in serious injury or an accident. The facility will attempt to prevent elopement and protect from injury, a chronic wanderer and who has the potential to elope or who has an elopement history. The policy states, All residents with the ability to walk on their own will be assessed upon admission using the Elopement Risk Assessment Tool to determine the risk level of elopement. The policy did not include assessment of a resident who can self-propel a wheelchair, who may potentially also be at risk for elopement. The policy read, Residents identified as a flight risk must be given a transmitter bracelet, and Transmitter bracelet on residents should be checked every week to make sure that it is working. In addition, the policy said, Door and exit alarms much be in good working order. The policy did not specify where the band should be placed or specifics who, what, when and how the system alarm, bands and fire exit doors were to be checked. The Elopement Risk Assessment Tool attached to the policy was no longer used and had been replaced with a different tool. 15) Review of the Facility assessment dated [DATE], listed [CONDITION(S)] (hallucination, delusions, etc.), Impaired Cognition, . Anxiety Disorder, Behavior that Needs Interventions as conditions Our facility accepts and able to care for. The document also stated; Behavior problem is [sic] very common concern for some residents with dementia . In some situations, although not often, close monitoring or even one-on-one attention is required for resident's safety.

Based on observations, interviews and record review, the facility failed to properly prevent and contain a COVID-19 outbreak. The facility failed to control and manage a spread of COVID-19 among residents and staff in the facility as evidenced by a lack of appropriate cohorting of residents with positive COVID-19 test results. The facility failed to designate nursing staff to care for the residents with positive COVID-19 test results on a designated unit for only COVID-19 positive residents. The COVID-19 positive residents were housed on a unit with COVID-19 negative residents. The staff working on the unit were utilizing personal protective equipment (PPE) gowns and N95 masks incorrectly. The facility failed to update its COVID-19 infection control policy's to manage staff and potential shortages during a COVID-19 outbreak. The deficient practice resulted in 21 residents and five nursing staff infected with the COVID-19. One Resident (R)1 with a positive COVID-19 test result expired. Findings include: Surveyor interviewed the director of nursing (DON) on 10/05/20 at 09:00 AM. Census 38 on 2nd floor and 18 on 1st floor COVID-19 unit. First staff identified COVID-19 positive on 09/16/20 during monthly required testing. Mass testing of all residents and staff began on 09/18/20 and a 2nd staff (activity aide) was identified. 15 residents who were COVID-19 asymptomatic were transferred out to an acute care facility on 09/25/20 due to shortage of nursing staff who tested positive for COVID-19. Nine residents to come back facility from the acute care facility who are asymptomatic on Thursday October 8, 2020. Currently the facility has eight COVID-19 positive residents. All positive staff are at home in quarantine. Testing for all staff and residents is every Thursday. Surveyor reviewed the facility proposed COVID Bed Chart for 1st and 2nd floors Red zone represents COVID positive residents, yellow zone represents COVID-19 positive recovered, orange zone is a barrier, and green zone represents the COVID-19 negative residents. Surveyor interviewed the infection preventionist (IP) on 10/05/20 at 10:00 AM reviewed the line listing for testing. Explained that negative staff on the COVID-19 unit are cared for by one registered nurse (RN) and two to three CNA's. Those residents are kept in their room Surveyor reviewed the Line listing that represents the testing of staff and residents at the facility: verified that 21 total residents positive. 15 moved out of the facility. Of the 15, nine are scheduled to return on Thursday and placed in COVID unit. Five nursing staff tested positive for COVID-19. Surveyor observed nursing staff on 10/05/20 at 11:29 AM on the 1st floor COVID-19 unit. Five Certified Nurse Aides, (CNA)'s were providing patient care on the Unit that house both COVID positive and negative residents. Noted the COVID-19 negative resident rooms were in rooms 102, 103, 104, 105, and 106. The COVID-19 positive residents were in rooms 107, 108, 111, and 112 in close proximity to the COVID-19 negative residents. Three CNA's were assigned to provide care to the COVID-19 negative residents, and one CNA was assigned to provide care to the COVID-19 positive residents. The CNA's were working in and around each other in the corridor. There was no isolation barrier in place in the unit to separate the COVID-19 positive and negative residents. There was no COVID-19 designated licensed staff. Surveyor interviewed CNA3 on 10/05/20 at 12:05 PM. CNA3 stated that each resident is required to stay in their room and to place a mask on when the staff enter the room, we're working 12 hour shifts, its tiring. A rolling cart with lunch trays was brought to the unit at 12:00 PM. Licensed practical nurse LPN1 went to the door to pull the cart with lunch trays inside the unit. Contents included trays with paper plates, bowls, cups and utensils. One side of the trays were not in a plastic bag, (for the COVID negative residents and the other meals were all placed in a plastic bag onto the tray (for the COVID positive residents). Two CNA's passed the uncovered trays to the non COVID residents while only one CNA3 passed the covered meals to the seven COVID positive residents. All staff were noted to be working around each other and passing each other in the hallway. CNA3 started passing the lunch trays to the COVID-19 positive residents at 12:15 PM. Surveyor observed CNA3 wearing an N95 mask then don booties (over booties he is wearing), gown, head cover (over a head cover he was wearing), disposable mask that he placed over his N95 respirator, and a face shield, After a few minutes noted CNA3 came out of the room wearing the N95 mask and without a PPE gown, disposable surgical mask, gloves, head cover and feet booties. Surveyor observed CNA3 repeat the process for six more COVID-19 positive residents until he finished passing trays at 12:50 PM. When asked if he is the only staff to pass lunch trays to the COVID-19 residents replied, yes its just me and it takes a long time because I don and doff my PPE for each COVID-19 positive resident. Surveyor interviewed the RN2 on the 1st floor COVID-19 unit on 10/05/20 at 12:20 PM, stating we only have one CNA to take care of the COVID-19 positive residents. It is hard with only one, it takes a long time to pass their meal trays or answer call lights since he has to don and doff his PPE gear each time he goes in their room. When asked if any of the COVID-19 positive residents have symptoms, replied, no fevers although some of them are coughing. Surveyor interviewed the Director of Nursing (DON) on 10/05/20 at 1:20 PM. When asked how the nursing staff became infected, replied that all nursing staff were exposed here while taking care of the COVID-19 positive residents. They were wearing full PPE including hair cover, shoe cover, gown, face shield and N95 mask. When asked if the CNA's rotate assignments to take turns caring for the COVID-19 positive residents. Surveyor interviewed Occupational Therapist (OT)1 who came into the facility to provide therapy to residents in the facility. When asked if she had concerns about the facilities response to the COVID-19 outbreak replied that she was concerned that the numbers of COVID-19 positive residents are still going up since the initial positives were identified on 09/18/20. Why is that? They are wearing full PPE, what are they going to do with the asymptomatic COVID-19 positive residents who come back here from the acute care facility? In a previous facility I worked in, there was a barrier to go into one section disinfect yourself, then go into the next section to DON PPE before going on the unit, they don't have that here. There are COVID-19 positive residents on the same unit as negative COVID-19 residents, they are right next door to each other. It is very close. I saw a staff wearing three N95 masks. They are also spraying the N95 masks with alcohol to disinfect it after their shift, is that safe? Surveyor entered first floor unit on day two of the Focused Infection Control (FIC) survey on 10/06/20 at 09:50 AM . A new large plastic barrier was in place and hanging from the ceiling to the floor and placed in the hallway between rooms [ROOM NUMBERS]. Upon closer inspection noted the barrier contained heavy plastic with a zipper down the middle, it was secured to the ceiling and walls, inside were plastic carts. Surveyor interviewed Licensed Practical Nurse (LPN)1 at 09:50 AM in front of the 1st floor nurse's station. Stated we have a barrier and when we go inside it is a clean area. When I need to go into the room to pass meds or provide care, I put on my personal protective equipment (PPE) gown, disposable mask over my N95, then clean face shield and gloves. The COVID area is on the other side of the barrier where I put on a second gown to go into the COVID patient room. When I come out of the COVID room, I doff one of the gowns, keeping the first one on, then sanitize hands in the clean area then go out. There is a door in the back of the hall that goes downstairs where there is a break room for the staff who are working back there. Today 2 CNA's are working back there. They stay back there and only come out at the end of their shift. LPN1 verified that she does not stay in the COVID-19 area and cares for all of the residents on the unit. Surveyor interviewed RN2 on 10/06/20 at 10:20 AM. When asked what is the process for reusing the N95 mask? RN2 responded we wear it until it is soiled then we throw it away. Surveyor asked how many times or shifts do you wear the mask? We are supposed to wear it for 5 shifts then throw it away. We sanitize with alcohol at the end of each shift, then place it in an envelope and place the face shield in an envelope which is kept in the area by the front door. The staff working on the unit have a cart where they keep their face mask in a large envelope. Surveyor interviewed Administrator at on 10/06/20 at 10:10 AM in his office. When asked to describe the decision to put up the barrier that was in place this morning, responded we had a conversation with the DOH, the intent was to have all of the COVID positive behind the barrier. The COVID post positive residents that are coming back from Wahiawa will also be going behind the barrier. When anyone goes back in the red zone, they are still contagious, we don't want them going into the green area because we don't want the negative residents to get infected. Administrator explained when the outbreak first started, the DOH didn't come into the facility. We let them know about the COVID-19 positive staff and residents and they assisted us. It was really not until last week that the State epidemiologist got together with her team, and we had a post evaluation via phone conference about the mass discharge of 15 of our asymptomatic COVID-19 positive residents to an acute care hospital. The DOH didn't give us any interventions or recommendations at that time. We put up the barrier on the COVID-19 unit in the beginning at the end of the hall. There was no one symptomatic outside the barrier. The barrier didn't seem to help prevent the spread, since more were coming up positive so we took down the barrier and treated each room as an isolated case. When asked who made the decision to take the barrier down and what guidelines were used to make that decision, the administrator replied that once we identified a resident outside of it, we decided to isolate the whole unit. During that week I didn't have enough staff to protect those zones. I didn't have enough bodies to keep a staff member in the zone. We didn't want a bunch of movement. The administrator did not follow the Center for Disease and Control and Prevention (CDC) guidelines or Centers for Medicare and Medicaid services (CMS) recommendations on cohorting COVID-19 positive residents. Review of the American Health Care Association and National Center for Assisted Living. Cohorting Residents to Prevent the Spread of COVID-19 dated April 4, 2020 states cohorting refers to the grouping of individuals with the same condition in the same location .keeping residents who are COVID-19 positive or are suspected to have COVID-19 in the same space that is separate from those who are COVID-19 negative or do not have exposure to COVID-19. All nursing homes .should make plans for cohorting residents . per CMS guidance .isolation unit should be a separate, well-ventilated area, ideally with a separate entrance. Review of the CMS COVID-19 Long-Term Care Facility Guidance dated April 2, 2020. Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control. Long term care facilities should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status. In addition, the administrator didn't follow CDC guidelines or CMS recommendations regarding staffing. The CMS COVID-19 Long-Term Care Facility Guidance dated April 2, 2020 states: To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19 positive residents .to have the capacity, staffing, and infrastructure to manage higher intensity patients. When asked how was it decided to send the residents to the acute care facility replied, when I got the call I was working remotely on the big island and was told by the DON about the staffing situation, our staff were calling out sick due to being exposed to the staff who tested positive. I tried calling agencies last week, but no nursing staff wanted to come into a COVID-19 positive unit. Staffing was our issue. The DON reached out for community support from local leadership who was able to help locate a placement for the residents to the acute care facility. We started having our staff who were still here work 12 hour shifts to cover the staff shortage. That's when we moved the 15 COVID-19 positive residents on the 25th. Surveyor interviewed the IP on 10/06/20 at 11:30 AM. When asked to talk about the barrier that went up on the first floor unit stated in the first days of our COVID-19 outbreak, replied we put up a barrier and placed the positive residents in the back two rooms. We took it down on 09/24/20 because the other negative residents started to get infected, we didn't see that it was being effective. The new barrier that we just put up yesterday will create space to separate the clean residents from the positive residents. It will prevent staff from moving in and out of the clean area. The IP did not present updated COVID-19 infection control policy. When asked if fit testing was provided to the staff, replied that we don't have the fit testing done, we only had one size N95 mask available. Surveyor asked what the Quality Assurance Prevention Improvement (QAPI) plan looks like and were any projects being done since the COVID-19 outbreak started. The IP replied, We have our different team members, we discuss the issue's quarterly. What is the findings. What are the corrective actions. Surveillance involves twice per week I do my rounds in the whole department, nursing, kitchen and laundry, l check to see if they have disinfectant, expired medications. I'll check room by room for clutter, disinfectants available. Once during my rounds I saw someone who didn't wash their hands and offered them feedback. With the COVID I make sure they're using the face mask and face shield. Checking the PPE available for the carts. Administrator and maintenance are tracking the PPE supplies. Surveyor was not provided a copy of the QAPI. Survey team met with the administrator, IP, and DON on 10/06/20 at 3:07 PM to discuss the immediate jeopardy. Surveyor requested an updated COVID-19 policy that is specific to their facility and addresses mitigation with adequate staffing during a COVID-19 outbreak. the Administrator queried what is wrong with the current plan? Surveyor reviewed the facility's policy Rocky Mountain Care Emergency Staffing dated July 2019. The policy states; It is the policy of this facility to establish procedures for handling staffing challenges in the case of an emergency or disaster . The policy did not address COVID-19 pandemic. Nor was the policy updated with current CDC guidelines. 2a) During the survey, it was revealed the facility failed to maintain a strict barrier to effectively quarantine or cohort the residents who were COVID-19 positive from those residents who tested negative. Although an initial barrier and room changes had been made on 09/20/20, the distinct, physical separation barriers, (e.g., a red zone for the positive cases, a yellow zone for those in post-recovery or PUIs (persons under investigation) and a green zone for the negative cases), had been eliminated and taken down on 09/24/20 per the Infection Preventionist (IP) during his interview with the State Agency (SA) on 10/06/20. From interviews conducted with the staff, it was found that they were required to care for COVID-19 positive residents without these distinct zone or separation barriers in place. As such, there was a high likelihood that some of the facility's staff became infected, and may have contributed to the spread of the coronavirus to their residents. The facility's COVID-19 outbreak included a total of 21 residents along with numerous staff who became ill. Further, based on observations and interviews with the staff, it was revealed the staff covered their N95 respirators (N95) with another procedure mask. They also had not been fit tested to wear their N95s. The staff, while caring for the COVID-19 positive residents (positive residents), donned (put on) an additional procedure mask over their N95, and wore a second gown over their first gown. This was a potential means of increased transmission risk and spread of the coronavirus, since staff would only take off the extra procedure mask and extra gown after caring for a positive resident, but failed to fully doff or remove their Personal Protective Equipment (PPEs) before going in to care for a resident who was negative for the coronavirus (negative residents). Review of their policy found it did not contain such a practice to double mask nor double gown, and, there was no procedure for staff to follow for the appropriate wear of PPEs while caring for both COVID-19 positive and negative residents. During an interview with the Director of Nursing (DON) on 10/06/20 at 12:15 PM, she confirmed their licensed staff did not discard their N95 when they cared for both COVID-19 positive and negative residents. Further, the DON said the licensed staff were told to discard the procedure (face) mask covering their N95 and the outer gown, and put on a new mask and gown when they crossed over to care for a COVID-19 positive resident with a resident who remained negative. The DON also acknowledged she failed to assign dedicated line staff to only care for the COVID-19 positive residents. Thus, as the staff crossed over to care for both the positive and negative residents, and by failing to don and doff their PPEs accordingly, this posed an increased infection control risk with a high potential for cross-contamination and transmission of the coronavirus to other residents. 2b) During an interview with the Assistant Director of Nursing (ADON) on 10/06/20 at 09:58 AM, she was observed wearing a procedure mask with a white N95 over it. The ADON explained the double masking was for protection. She said when licensed staff, go inside the room of positive resident, they have to put on a regular face mask to cover their N95 and a new face shield. She further said, Once they come out of the positive one, then have to remove the regular surgical face mask and throw it away. The ADON said the licensed staff did not have to remove their N95s and were able to continue into the areas where the negative residents were. The ADON stated this was the same for their double gown use. The ADON stated for a licensed staff, once they entered the positive part, staff would don (put on) another gown over the gown they wore into the unit, and be double gowned. Then staff would also cover their N95 with a surgical mask, change their face shield and put on shoe and head covers. The ADON reiterated their staff, can keep the gown they were wearing for the negative room on. The N95 mask was also kept as the wearer only discarded the procedure mask. This was the potential for cross-contamination as the licensed staff entered a COVID positive room and then exited, without doffing (removing) all potentially contaminated face masks and gowns, before entering the COVID negative resident unit. The ADON reaffirmed staff were allowed wear their PPEs in this manner as they went between the COVID-19 positive and negative areas. In addition, the ADON verified they had not been fit tested to wear their N95s during the time the first resident (R1) was identified to be COVID-19 positive on 09/20/20. The ADON also affirmed three of the staff who cared for this resident tested positive for the coronavirus during their second PCR testing that was done. She also verified the plastic barrier walls to separate the negative from the COVID positive rooms was put up around 6:00 PM, last night, which was 10/05/20. The first COVID-19 positive resident was identified on 09/20/20. 2c) The facility failed to implement and monitor the use of personal protective equipment (PPE) worn by their staff. A review of the facility's corporate policies found their policies were comprised of revised minutes related to operational changes, but without clear and distinct guidelines related to the appropriate use of PPEs during a COVID-19 outbreak. The SA's review of the corporate policies included a 03/12/20 Revision Updates of their COVID 19 Guidance, and a section entitled, Meeting Minutes: 09/23/20. The 09/23/20 minutes were revision updates that included the following: - 5/5/20 and 5/7/20: Revision Update and Meeting Minutes -N95 Mask Fitting- N95s manufacture's guidelines will be followed for the fitting of N95 masks, where applicable. Current (corporate) stock of N95 masks are self-fitting using the packaging instructions and the (corporate) PPE conservation guidance as outlined on 'COVID (corporate) Guidance.' - 4/6/20: Revision Update - Mask usage. Each employee will wear a face mask and face shield (see update) combination at all times . (Note: face shield (see update) had been lined out). Yet, it continued to say, The mask/shield will only be removed to eat/drink and if the employee is entering an isolation room. Direct care staff will wear surgical mask and face shield combination, non-direct care staff will wear cloth face mask and face shield combination, if available, cloth masks will be used if surgical masks are exhausted or unavailable. The facility's mask usage policy was found confusing and likely contributed to the way their nursing staff differed in how to wear their PPEs. Observations done on 10/06/20 at 08:59 AM, found one Certified Nurse Aide (CNA1) wearing a procedure mask and a face shield. CNA1 said this was standard PPE wear because the second floor did not have any COVID-19 positive residents. At 09:03 AM, a Nurse Aide (NA1) was observed wearing a procedure mask covered by a KN95 face mask and a face shield. NA1 said, Yes, that she was taught to wear the procedure mask first and a KN95 (not an N95) on top of it. On 10/06/20 at 09:05 AM, a Registered Nurse (RN1) was interviewed about their PPE usage. RN1 wore a green N95 respirator with a procedure mask over it. She stated she wore it this way because she would discard only the procedure mask after her shift, but kept the N95 for five days to reuse. RN1 said she would place her N95 into a bag after her shift, but did not date it since she worked five days straight (Monday through Friday), and discarded her N95 by end of shift on Friday. There was no written respiratory program instructing staff to reuse their N95 in the manner RN1 stated. Upon further query, RN1 confirmed they had not been fit tested nor medically cleared to wear the N95s. RN1 stated the N95s were provided to them when the first resident tested positive on the first floor. She said staff were told, for everyone to wear for precaution. Out of extra caution to avoid contracting the coronavirus, their nursing staff decided to double mask, which the DON verified was their current practice. The mask usage policy did not include any reference to CDC guidance related to PPE use, and failed to clearly outline how PPE use such as the N95, was to be safely utilized by their staff following national CDC/NIOSH/OSHA guidelines. The facility's policy stated, Surgical masks will be used up to five times. Masks should be dated and assessed each shift for breakdown to straps or body of mask. If mask remains in intact repair, mask will be utilized for five shifts. If you begin to run low on supplies please call (corporate person and number). During an interview with the DON on 10/06/20 at 12:15 PM, she said, Actually, this N95, we're asked to use it 15 times, and to sanitize it, but it doesn't really last 15 times because it becomes soft. The DON verified the staff had not been fit tested although they were issued and instructed to wear N95s to care for their COVID-19 positive residents. She said one of their first nursing staff infected with the coronavirus, CNA2, tested positive with the first positive resident cases on 09/20/20. The DON said CNA2 had been provided an N95, and said, Yeah, they were provided the N95 and instructed to wear it all the time during nursing care. I know that we need to do fit testing, but while waiting we cannot just let them do without . The DON said they did not do fit testing because such a schedule was difficult to obtain. The DON reverified the use of the procedure mask was to cover and protect the N95, but again, could not provide a policy nor CDC/NIOSH/OSHA guidance for an N95 to be reused up to 15 times and be covered by another mask. Further, in response to the facility's policy which states their current (corporate) stock of N95 masks are self-fitting, it should be noted an N95 respirator cannot be self-fitted. Toward this, the SA references the CDC NIOSH Science Blog, Respiratory Protection vs. Source Control - What's the difference, (Cichowicz, Casey and D'Alessandro, publication date 09/08/2020). This article states in part, Additionally, if the respirator does not form a tight seal with the face, it cannot provide the expected level of protection. The Occupational Safety and Health Administration (OSHA) requires that workers are fit tested on the make and model of respirator that will be used, the first time it is used and every year after . Due to the way [DIAGNOSES REDACTED]-CoV-2 spreads, the work duties of healthcare workers (e.g., directly caring for persons with suspected or known COVID-19), and possible supply shortages of respiratory protection, it is critical that those workers who need respiratory protection have it readily available to perform their work safely. Those required to wear respirators in the workplace must pass a medical evaluation to determine their fitness for wearing a respirator. Another CDC/NIOSH publication, at https://doi.org/10XXX /NIOSHPUB 30 (DHHS NIOSH Publication No. 2018-130) Filtering out Confusion: Frequently Asked Questions about Respiratory Protection User Seal Check, states, Can a user seal check be considered a substitute for a fit testing? No. The user seal check does not have the sensitivity and specificity to replace either fit test methods, qualitative or quantitative, that are accepted by OSHA (29 CFR 1910.134). A user should only wear respirator models with which they have achieved a successful fit test within the last year . Thus, an N95 respirator is not a self-fitting mask. During her interview, the DON acknowledged that fit testing should have been part of their pandemic preparedness plan and not during an actual COVID-19 outbreak in their facility. The DON verified the Administrator was presently trying to schedule an N95 fit testing for their staff with the local national guard. In addition, the DON showed their current N95 stock supply was a count of 40 as of 09/28/20, with another 20 on order by 10/12/20. The SA queried whether the facility had enough in stock since the DON said they were to receive about four returning COVID-19 residents from an acute hospital on [DATE]. (Of note, a total of 15 asymptomatic positive residents had been transferred out to an acute hospital when the facility's COVID-19 outbreak coupled to a lack of staff became unmanageable. The DON acknowledged it had spread, with 19 additional residents testing positive from 09/25/20 up to 10/02/20.) Yet, the DON was uncertain if they would have enough N95s for nursing staff to use prior to receiving these residents back and reiterated they would receive the other 20 N95s by Monday. When the DON was further queried if she calculated their PPE burn rate and surge capacity as part of their pandemic preparedness plan, she said, But we already provided them with N95, either end of July or August, between that month, but I cannot really say. It was revealed the DON could not discuss or provide a surge plan to ensure there would be enough N95s in stock, nor had she looked at other available sources. The facility's corporate policy states to call a specific individual if, low on supplies, but the DON reiterated it was their medical supplier that could not assure availability of stock. 2d) The cumulative review found adequate Transmission Based Precautions (TPB) and PPE use were not in place during and after the facility's COVID-19 outbreak. There also was an on-going failure by the DON and IP to monitor their staff for appropriate PPE usage, including having their staff cross between their positive and negative resident rooms without barriers. The initial barriers came down on 09/24/20, and were only put back up (plastic divider walls) after the first day of the FIC survey. As a result, the overall failure to contain and strictly isolate the COVID-19 positive residents may have contributed to its spread to an additional 19 more residents and to their staff. As such, an immediate jeopardy was identified for those residents who had been exposed and for those residents who were vulnerable and still had the potential to become exposed to COVID-19.

Based on observations, interviews and record review (RR), the facility failed to recognize and thoroughly address the physical needs of one of one Resident (R)27sampled. R27 had a [DIAGNOSES REDACTED]. Findings include: 1. R27 was a [AGE] year-old who had a complex medical history with multiple [DIAGNOSES REDACTED]. Due to the dysphasia, R27 was fed through a gastrointestinal tube ([DEVICE]) placed in her abdomen. She was first admitted to the facility on [DATE] after the stroke. 2. On 08/20/19 at 01:20 PM, observed R27 lying in bed sleeping. Brief interview conducted with a family member. On 08/21/19 noted R27's bed was empty and was informed R27 had been transferred to the hospital. 3. RR revealed R27 had several hospital admissions. The hospital discharge summaries contained the following: Discharge summary prior to facility admission, dated 03/16/19: [MEDICAL CONDITION] 03/12/19 Na (Sodium)152 (normal 133-145), 03/13/19 Na 156. Started on free water flushes (additional water via [DEVICE] to meet needs.) 03/14/19 Na 154. Recommendations: Ensure good hydration - can schedule free water flushes via [DEVICE] if needed. The treatment for [REDACTED]. 04/30/19 to 05/16/19 (First hospital admission): Facility found R27 to be lethargic (sleepy) and became unresponsive. Principal Diagnoses: [REDACTED]. Hospital Course: .CKD stage 4/ [MEDICAL CONDITION] .Now has [MEDICAL CONDITION] and undergoing free water flush. 05/17/19 to 06/07/19 (Second hospital admission): R27 admitted for respiratory distress . Principal Diagnoses: [REDACTED]. Secondary Diagnoses: [REDACTED]. After diuresis (loss of a great amount of water) developed [MEDICAL CONDITION] with Sodium peaking at 154. It was corrected with intravenous fluids and increased free water flushes. 07/03/19 to 07/08/19 (Third hospital admission): transferred to rule out gastrointestinal (GI) bleeding. Principal Diagnosis: [REDACTED]. Hospital course treatment for [REDACTED]. balance, levels of electrolytes like sodium and potassium, and how well the kidneys are working) IN 2-3 DAYS TO ENSURE NO(SIC) STABILIZATION OF SODIUM AND WOULD RECOMMEND TO CHECK SODIUM AT LEAST Q (every) WEEKLY (sic) Discharge notes: The pending discharge issues .PLEASE CHECK BMP (SODIUM) in two days AFTER DISCHARGE to ensure no worsening of [MEDICAL CONDITION] and adjust free water flushes as needed. 08/21/19 Transferred to hospital for fourth admission for [MEDICAL CONDITION]. 4. RR revealed R27's orders at the time of admission on 07/08/19 included: free water flushes (250 cc q 4 h) and lab tests (CBC,CMP (comprehensive metabolic panel) .). Laboratory (lab) results on 07/10/19 revealed abnormal GFR (Glomerular filtration rate-a measure of kidney function). Sodium 143 (normal 133-145) GFR 26 (normal >89) 5. RR of 07/13/19 Nursing Progress Note: Seen by MD1 this morning. Relayed . lab test result. Sodium Test within normal.order to discontinue weekly Na test . 07/13/19 Written order by MD1, Discontinue weekly Sodium (Na) test. 6. RR of Nursing Progress Notes: 08/19/19 05:37 PM .client appears more sleepy lately . 08/19/19 11:17 PM MD1 made aware regarding sleepiness. Order received to decrease [MEDICATION NAME] .for neuropathic pain 08/20/19 No nursing progress notes documented any of the three shifts. 08/21/19 09:48 AM still with sleepiness but easily arousable .MD1 made aware with order to Dc (discontinue) [MEDICATION NAME] ([MEDICATION NAME]), and lab work ordered. 08/21/19 03:00 PM entry: Resident frequently checked at bedside at 10:00 AM eyes closed, unable to respond to verbal and tactile stimuli. Not responding to even pain .As per daughter, wants to transfer resident to hospital for further treatment and evaluation. Called and notify MD1 at 10:30 AM with order to transfer .Called 911 .Transfer at 10:40 AM. 7. RR lab results drawn 08/21/19: Sodium 170 (normal 133-145), and GFR 8 (normal > 89). 8. On 08/23/19 at 02:32 PM during an interview with Director of Nursing (DON) discussed the 07/16/19 hospital discharge summary and recommendations made for monitoring and treating R27's [MEDICAL CONDITION] which included weekly sodium lab tests and then adjusting water flushes as needed based on the lab results. DON reviewed the chart and stated, On admission, the nurses take the recommendations off the discharge summary from the hospital and call the physician to get the orders. MD1 was her physician, and he bases his labs on symptoms. That's the only time he's going to order labs. Queried if the Medical Director gets involved if there are several readmissions. DON stated he does get involved if we bring it to his attention. Asked if R27's hospitalization s had been brought to the Medical Directors attention, and DON replied, No. Reviewed Nursing Progress notes, and discussed expectation for documentation of nursing assessments. DON said, They (Registered Nurses) should be documenting every shift for someone in her (R27's) condition. I don't know why they didn't document

Based on observations, record review and staff interviews, the facility failed to maintain the necessary nutritional requirements for two residents (R38 and R19) who experienced significant weight loss resulting in actual harm for R38. Findings include: 1. Resident (R38) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation of R38 on the morning of 09/25/18 at 9:10 AM found his tube feeding formula hanging from an IV pole with approximately 250 cc left in the bag. R38 was not connected to the formula bag. The label on the bag noted the resident's name and physician's orders [REDACTED]. R38 was alert but unable to verbalize. An observation of R38 on the morning of 09/26/18 at 10:30 AM found him sitting up in bed watching a Filipino TV show. An observation of R38 on the afternoon of 09/26/18 at 02:30 PM found him sitting up in bed watching a Filipino TV show. An observation of R38 on the morning of 09/27/18 at 10:00 AM found him in a sitting position where he had just been connected to his tube feeding by a Treatment Nurse's Aide (TNA1). Licensed Nurse (LN13) was present observing TNA1. Interview of LN13 revealed he is not always present during TNA1's connection/disconnection of [DEVICE]. LN13 stated he will observe the TNA performing tube feeding connections if he's not busy. Otherwise the TNA is left to connect residents to their [DEVICE] feedings independently. An interview of the Director of Nursing (DON) on the morning of 09/26/18 at 08:41 AM when she noted R38 left the faciity on [DATE] to the hospital. R38 had been evaluated by a Speech Language Pathologist (SLP) who recommended oral feedings. The [DEVICE] he was admitted with in (MONTH) (YEAR) had been discontinued when he was upgraded to oral feedings. During his 03/24/18 hospitalization , another [DEVICE] was inserted. R38 returned from the hospital on [DATE] with the [DEVICE]. The DON reported TNAs did the tube feedings during day shifts. The DON utilizes four TNAs who received special training for tube feedings, simple dressings and treatments such as topical creams. The DON further noted the TNAs are responsible for documentation of tube feedings. When asked about assessing residents for tube feeding tolerance, the DON reported one nurse (LN1) assessed the residents who were stable for tube feeding tolerance on weekends (Saturday and Sunday). The unstable residents were assessed daily by the Charge Nurse on duty to look for signs and symptoms of aspiration. A review of the nurses notes dated (MONTH) (YEAR) through (MONTH) (YEAR) found day shift LNs rarely documented notes for R38. A few of the notes stated, [DEVICE] feeding tolerated per report. In reference to the tube feeding label without a date and time, the DON revealed the evening shift prepares the bags for next day use. She reported the staff usually label the bags to include the date/time. A concurrent medical record review and Registered Dietician (RD) interview on the morning of 09/26/18 at 11:48 AM found R38 was admitted to the facility in (MONTH) (YEAR) with a [DEVICE] and was later upgraded to oral feedings. The RD was unsure if the [DEVICE] was removed when R38 was on oral feedings. In (MONTH) (YEAR) R38 went to the hospital when he was on fine chopped solids and honey thick liquids. The RD noted she saw R38 in (MONTH) (YEAR) when he weighed 131 pounds. He was due for an update in (MONTH) (YEAR) but he went out to the hospital. The RD then saw R38 in (MONTH) (YEAR) when he weighed 120 pounds. The RD reassessed R38 on 07/25/18 when he had not been weighed since 05/23/18 at 121 pounds. The RD requested a weight since she didn't have a weight for (MONTH) (YEAR). On 07/26/18 R38 weighed 115 pounds (5% loss since last weight 05/23/18). The facility re-weighed R38 on 07/29/18 when he was 115 pounds. The RD noted the facility should weigh R38 at least monthly. The RD stated R38 had pneumonia in (MONTH) (YEAR) which may have contributed to his overall well being. On the morning of 09/26/18 at 12:00 PM a review of the RD's notes found one dated 07/25/18 stating R38 is dependent on [DEVICE] nutrition and hydration which he was tolerating without issues. She noted R38 experienced occasional constipation - 3 days without bowel movement despite generous fluids provided via [DEVICE]. She noted no recent weight recorded, new weight requested. And finally, Will continue with care plan. Another RD note dated 08/08/18 indicated R38 was 115 pounds, below his ideal body weight. The note stated R38's tube feeding was increased on 08/03/18. She again noted R38 was tolerating tube feedings without issues. He was noted with recent constipation but receiving generous fluids via [DEVICE]. A review of the nurses notes found an entry dated 07/26/18 when the Assistant Director of Nursing (ADON) noted R38 experienced significant weight loss and she would make a referral to the RD. The RD reported she was notified of R38's significant weight loss on 08/03/18. After being apprised of R38's weight loss, the RD increased the resident's feeding to [MEDICATION NAME] 1.2 300 ml 5 times per day (increased from 300 ml 4 times per day). On 08/08/18 the RD returned to assess R38 - weight was 115 pounds. A review of R38's resident assessment, Minimum Data Set (MDS), dated [DATE] noted the resident did not have a feeding tube at the time. It further noted a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severely impaired cognitive function. Upon return to the facility, R38's MDS dated [DATE] indicated he had a feeding tube. R38's readmission assessment dated [DATE] noted a BIMS score of 05/15 or severely impaired cognitive function. The 07/24/18 assessment noted R38 required extensive assistance with one person assistance for bed mobility; limited assistance with one person assistance for transfer; Total dependence with one person assistance for eating; and total dependence with one person assistance for toileting. The 07/24/18 assessment noted R38 experienced a significant weight loss but not on a physician prescribed weight loss program. An interview of the ADON on 09/26/18 at 12:18 PM revealed she was the person who reviews all residents weights. She stated that if she finds a weight discrepancy the resident is re-weighed the next day. R38's weight loss was identified on 07/26/18 but he wasn't re-weighed until 07/29/18. The ADON reported she thought the scale may have been broken because R38 and some other other residents were experiencing weight discrepancies. The facility ordered a new scale. Despite her knowledge of R38's significant weight loss on 07/26/18, the ADON did not notify the RD for another 8 days - 08/03/18. An interview of the Charge Nurse, LN19, on the afternoon of 09/26/18 at 01:53 PM found two TNAs (TNA1 and TNA2) do the tube feedings. LN19 reported that the licensed nurses do not observe the TNAs when they administer tube feedings. LN19 stated her documentation notes [DEVICE] feeding tolerated per report, since she doesn't actually observe the TNAs connecting/disconnecting residents to their tube feedings. An interview of two licensed nurses (LN18 and LN19) and the ADON on the afternoon of 09/26/18 at 02:25 PM revealed they do not oversee the TNAs unless a resident is experiencing problems. The LNs do 24 hour reviews and the TNA tube feedings is not something reviewed at that time. If a feeding was not provided, the computer will flag them to let them know. A review of R38's Treatment Administration Record (TAR), the number 1 was listed under the initials of the person who administered the tube feeding. LN18 and LN19 stated they were unsure what the number 1 meant. An interview of the DON and ADON on the morning of 09/27/18 at 10:04 AM revealed residents' weights were reviewed weekly by the ADON. When a resident is identified with significant weight loss, the Charge Nurse communicates the information to the ADON via a written note. The ADON reviews the information from the Charge Nurse then she will request for the resident to be re-weighed. On the morning of 09/27/18 at 10:10 AM the ADON informed the Surveyor they found the missing (MONTH) (YEAR) weight for R38. The ADON reported the Administrator keeps residents' weights in his own log for his information. The Administrator's weight for R38 was dated 06/30/18 - 121 pounds. With this added information, it was noted that R38 lost 5% of his body weight in one month (06/30/18 to 07/26/18). Despite his significant weight loss and being on [DEVICE] feedings, the facility did not notify the physician/RD immediately. The ADON stated the facility's policy was to immediately notify the RD if a resident has a significant weight loss. The RD was notified of R38's significant weight loss eight days after (08/03/18) the ADON was aware (07/26/18) of the weight loss. On the afternoon of 09/27/18, a review of the facility's policy titled, Nutrition and Hydration Policy with revision date 10/11 noted, 9. Resident with weight changes will be referred accordingly for timely intervention. The facility's policy titled, Weight Assessment and Intervention dated 08/2016 noted, 3. Any weight change of greater than 5 pounds within 30 days will be retaken the next day for confirmation with licensed nurse confirming reweigh. If the weight is verified, nursing will immediately notify the dietary manager and refer to RD in writing. Attending physician will be notified of unplanned significant weight changes as described below. 2. Resident 19 (R19) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of R19 on the morning of 09/26/18 at 07:33 AM found him up in bed ready for breakfast. His meal had double portions of food and appeared pureed. There were 2 pieces of Vienna sausage (soft, pureed textured processed sausage) which LN19 sent back to the kitchen to puree because his texture was supposed to be pureed. The meal ticket for R19's diet order noted Moist minced. An interview of the Certified Nurses Aide (CNA28) at 08:12 AM revealed her understanding was that R19 was on a pureed diet and she confirmed that his breakfast tray contained pureed food. Observation of R19 during the lunch meal on 09/26/18 at 12:00 PM found his meal was double portions and pureed texture. CNA28 stated R19 eats 100% of his meals, snacks, and drinks all of his Ensure. A review of R19's medical record on the afternoon of 09/26/18 at 02:00 PM revealed a physician's orders [REDACTED]. On 07/06/18 a physician's orders [REDACTED]. On the afternoon of 09/26/18 at 12:26 PM, a concurrent medical record review and RD interview found R19's admission weight on 06/08/18 was 149 pounds. On 06/13/18 R19 was 140 pounds (9 pound loss or 6% in 5 days). The facility immediately notified the RD on 06/13/18 and the RD came to see him that same day. The RD noted the staff reported R19 had 3 to 4+ [MEDICAL CONDITION] on 06/11/18. On 06/13/18 R19 had mild swelling and on a diuretic every other day. The RD noted R19 was eating 100% of his meals to include Supercereal and Magic Cup ice cream. On 07/04/18 the RD returned to evaluate R19 - weight was 123 pounds (17% loss over one month). At that time, the RD added Ensure Plus, 1/2 cup three times daily. On 08/01/18 the RD followed up and he maintained at 123 pounds. The RD noted R19 needs to be 125 pounds to be stable. She reported R19 eats 100% of his meals, drinks all his Ensure. At that time (08/01/18) the RD added snacks three times daily between meals. On 8/15/18 the RD noted R19 eats all his meals, drinks all his Ensure, eats his snacks between meals and eats his Magic Cup and Supercereal. On 9/23/18 R19 weighed 132 pounds, an increase of 9 pounds since the previous month. The RD noted his current order is moist minced diet. The RD further noted the texture looks like oatmeal. The RD stated R19 eats 100% of his meals and all of his Ensure and snacks. She says no matter what interventions are in place, R19 continues to lose weight. She noted, however, that his weight stabilized over the past month. R19 experienced severe weight loss (17%) within the first month following admission to the facility on [DATE]. During survey, R19's diet order was moist minced solids but he was receiving pureed solids. Observations found R19 eating most and sometimes all of his pureed meals despite his upgraded diet texture of moist minced solids.

1) Based on observations, medical record review and staff interviews, the facility failed to provide adequate supervision for Resident #90 (R#90). The facility must ensure that the resident's environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Findings include: A review of a self-reported incident report (IR) submitted to the State Agency (SA) was investigated through record review and staff interviews during the recertification survey. 04/20/2017 11:09 A.M. Record review revealed Resident #90 (R#90) was admitted to the facility on [DATE] with Alzheimer's dementia without behavior disturbance, failure to thrive, anorexia, cachexia. dysphagia and hospice. R#90 has a frail physique and very poor trunk control. Per the facility, R#90 has a tendency to bend over when sitting in a wheelchair and is kyphotic. R#90 has a history of falls and due to this is already a high fall risk. On 1/12/17 at 12:45, R#90 fell forward out of her wheelchair, hit her head on the floor and suffered an intracranial hemorrhage, subdural hematoma, laceration to the left eyebrow, bilateral peri-orbital contusions, contusion to upper lip, base of nose and abrasion to left eyelid. A staff member was putting R#90 back into bed. R#90 was placed next to the bed. The staff member stepped away from the wheelchair to draw the curtain closed. R#90 fell out of the wheelchair when the staff member drew the curtain. R#90 was sent to the emergency room by ambulance. On 4/20/2017 at 10:34 A.M. interview was done with staff #1. When R#90 came back, we provided a 1:1 sitter for close monitoring and until the daughter felt that her mom was stable. Staff #1 stated The CNA stated that R#90 was not restless at the time and this could have been prevented if the staff had placed the wheelchair in front of her and not stepped to the side. It was an attended fall. The daughter was really upset. On 04/21/2017 at 11:34 A.M. Interview with Staff #3 R#90 moved to the facility in 2015 because of a hip fracture and was hospice care for over a year. R#90 fell at home and suffered an intratrochanteric fracture and came here. She was cachectic. She requires extensive assist and one to two person assist with transfers. R#90 was able to use wheelchair but most of the time stays in her bed for comfort. She was careplanned for 1-2 person assist with transfers. Staff #3 was asked regarding R#90 that after the fall, they careplanned to make sure bed was in low position, staff will always stand in front of the wheelchair and hold the resident with one hand while pulling the curtain. Staff #3 was asked when R#90 came in presenting with kphyosis and poor trunk control, was safety measures care planned for wheelchair activity and safety, geri-chair or safety belt? Staff #3 answered no, we did not think of that and we felt that a belt would be a restraint. The facility failed to fully assess the resident's known predisposition to falls concomitant to her clinical condition and presentation on admission. This failure may have contributed to the resident's subsequent fall and injuries on 01/12/17. 2) Based on observations, staff interviews and medical record reviews the facility failed to evaluate and analyze hazards and risks in implementing the use of horizontal metal bar side rails (SRs) to promote the resident's function and/or safety for 3 of 6 residents ( R#17, #68 & #138) observed in Stage 1 of the survey, and of 28 residents sampled in Stage 2. Findings include: Cross to F272 Comprehensive Assessments On 04/18/2017 during Stage 1 of the survey, observed R#138, R#17, R#68 lying in bed with bilateral horizontal metal bar SRs with space between the SRs and mattress. On 04/19/2017 at 1:29 PM interviewed Staff#1 and went with her to the bedsides of R#138, R#17 and R#68 to demonstrate that the SRs were loose and shaky when shook and that the resident's limbs could fit through the bars and between the mattress and SRs. The SR safety issue was discussed with both Staff#1 and #2, and both were not aware of accident risk with horizontal metal bar SRs. Both Staff#1 & #2 were not aware that horizontal metal bar SRs were considered accident risk and just considered restraint issue. The online Food and Drug Administration (FDA.gov) guidance, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, was shared with Staff#1 & #2. On 04/19/2017 at 2:00 PM, R#138's MRR noted that the care plan (CP) Unsafe behaviors: At risk for injury including: Potential for falls related to : Cognitive loss resulting from vascular dementia with behavior disturbances; limited ROM to upper and lower extremities resulting from atrophy of muscles multiple sites; order of antianxiety; .as evidenced by: 15 points on fall risk assessment; episode of placing (dangling) both legs off edge of bed. (1/17/17). The interventions included that R#138 will use bilateral half rails up for safety and to assist with bed mobility. The facility interventions included: to reassess the appropriateness of SRs use every 3 months or as needed and offer total reduction when appropriate; provide/assist needs as appropriate; staff to make sure resident is in the middle of the bed to prevent rolling off the bed; turn and reposition every 2 hrs for comfort; and low bed for safety (1/17/17). The CP was last reviewed on 04/12/17. The Physician order [REDACTED]. The nursing assessment on 12/31/16 when R#138 was admitted from an acute hospital, described the resident's function in extremities as, Able to move both upper and lower extremities; both hands closed/clenched most of the time. The Restraint/Positioning Device Assessment form dated 12/31/16 documented, Restraints: both 1/2 Side Rails up; Bedrails Yes checked; Assist in transfer yes checked. On 04/20/2017 at 2:14 PM reviewed R#138's Hospice MRR and the CP dated 3/30/17 Problem Falls due to unsafe behavior as evidenced by her dangling both legs on edge of bed; with the goal that the resident would be without falls; and interventions included: Assess environment for adequate safety; Assesses need for DAME/Assistive; Ensure bilateral half rails up for safety and to assist with bed mobility. On 04/20/2017 at 7:39 AM the MRR on R#17 noted that the CP, Unsafe behaviors: At risk for injury including potential for falls r/t Cognitive loss secondary to old cerebral infarction and mixed dementia with behavioral disturbance; limited mobility as a result of old cerebral infarction, right sided hemiparesis; use of atidepressant as evidenced by: 12 points on fall risk assessment; fluctuating alertness; history of leaning on one side when up in her chair; trunk control issues, was last reviewed on 03/25/17. The interventions included: Provide 2 person assist in transfer; Allow her to sit on by the edge of the bed for at least 60 seconds to prevent dizziness; Use Gait belt at all times for safety; Res will use bilateral half rails up for safety and to assist her with bed mobility and transfer; Will reassess appropriateness of SRS use every 3 months or as needed and offer total reduction when appropriate. The PO dated 9/25/15 for R#17 documented, May use both 1/2 upper SR up while in bed for safety and mobility. The Restraint/Positioning Device assessment dated [DATE] documented, Restraints: Bilateral half SR up; Benefits: Enable bed mobility; Risks: Restrict circulation, pressure ulcer, B/B incontinent, anger. The evaluation summary noted, Resident is to continue using bilateral half rails up to assist her with bed mobility and safety. She has history of CVA with hemiparesis and her trunk balance is poor. She is not restless or attempting to get OOB therefore its not a restraint. No A/R (adverse reaction) from SR use so far. On 04/20/2017 at 1:41 PM, queried Staff#6 on R#17's ability to move. Staff#6 stated that R#17 had periods of restlessness and able to move upper body and sometimes observed with head leaning towards edge of bed. On 04/20/2017 11:02 AM, R#68's MRR documented on the PO dated 3/23/17, May transfer to low bed with/2 1/2 upper SR up for safety/mobility. On 04/20/2017 at 2:19 PM, Staff#3 provided R#68's Restraint/Positioning Device Assessment, dated 3/23/17, that noted, Restraints: Side Rail 1/2 SR; Benefits: Enable bed mobility; prevent rolling/falling out of bed; prevent elopement/fall; comfort/security; Risks: agitation/hostile behavior like kicking, biting; Assessment done: Bedrails yes Fall incident: No. Interviewed Staff#3 regarding the use of SRs for R#68 and whether assessment on safety with use of horizontal metal bar SRs were done. According to Staff#3, R#68 was placed on an adjustable bed that could be lowered and the SRs provided the R#68 bed mobility, sanitary reasons, (kept pillows on bed), and able to hang bed alarm from SR. Queried Staff#3 for SR CP and she could not provide it. The facility failed to evaluate and analyze hazards and risks with use of horizontal metal bar SRs and implement interventions to reduce hazards and risks for limb and head/neck entrapment between the loose SRs and mattress for R#138, #17 and #68.

Based on observations, record reviews and interviews, the facility failed to protect a high number of residents from gastrointestinal illness by failing to practice transmission based precautions, and failing to thoroughly investigate the outbreak of the gastrointestinal illness among residents, which as a result, made for additional residents to become ill with diarrhea/vomiting. Additionally, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Findings include: A) The facility failed to follow and implement their infection control policies and procedures, including the Norovirus Infection policy and procedure. On 3/15/16, during the morning entrance conference, the Administrator stated their facility currently had a suspected Norovirus outbreak. He presented the surveillance information and said as of 3/15/16, 12 residents were identified to be ill. The outbreak was initially identified with 4 residents who developed symptoms of diarrhea and/or vomiting on 3/8/16. He stated it was contained to the second floor nursing unit and was reported to the State epidemiology branch and the facility's Medical Director. However, during the initial tour of the second floor, it was found there was no signage on the unit to indicate that the 12 ill residents were on any form of transmission based and/or contact precautions due to the outbreak. There also was no EPA approved disinfectant wipes in or by the rooms, nor visible personal protective equipment (PPEs) for the staff and visitors to readily don/use at the entrance of the resident bedrooms. On 3/15/16 at 2:33 PM, the Director of Nursing produced an updated surveillance form which showed 4 of the 12 residents (Residents #147, #29, #63 and #16) had tested positive for the Norovirus in their stool sample. Yet, during the afternoon observations, staff and visitors were observed freely walking in and out of the rooms with no PPEs or monitoring on the unit. Please refer to second surveyors' observed findings below in Section B. On 3/16/16 at 7:22 AM, a morning tour of the second floor found Resident #16 had a red sign on her door which stated, Visitors: please report to the Nurses' station before entering the room. Otherwise, there still was no signage posted although the Norovirus was confirmed by lab results on the afternoon of 3/15/16. Another resident (Res #102) had no signage but was newly identified to have symptoms of diarrhea on 3/14/16 per the Administrator. Yet, this resident was found to be out of his room although ill, without staff monitoring him. Please refer to second surveyor's observed findings below in Section B. On 3/16/16 at 7:29 AM, a CNA walked into the room of Res #63 to deliver meal trays. This staff wore no PPEs. This resident had been identified to be positive for the Norovirus. Again, staff failed to adhere to their Norovirus policy and was not being monitored. On 3/16/16 at 8:08 AM, the Administrator produced an updated outbreak surveillance form and said another resident (Res #100) was newly identified just this morning. The total count now is 15 residents. He said he would report this update to the State epidemiology office. On 3/16/16 at 12:22 PM, Res #100's lunch meal was delivered with disposable items on a yellow tray. There also was a plastic bag containing PPE gowns on an overbed table at the foot of her bed. However, no staff were observed to wear them. The disinfecting wipes being used for the resident's surrounding area were found to be bleach free wipes. On 3/16/16 at 1:18 PM, during an interview with the Assistant Director of Nursing (ADON) and unit charge nurse, they stated their signage for No Visitors allowed 3/8/16 was only posted yesterday afternoon (3/15/16) by the Administrator. The ADON confirmed surveyors' observations that visitors were coming in and out of the residents' rooms, but we tell them they're not supposed to go into the residents' rooms. The ADON said there were 5 visitors that came in and one stopped by the charge nurse, but only after the surveyors queried what protocols were being implemented to prevent the spread of the Norovirus. Review of the visitor's log book from 3/15/16 still showed numerous visitors coming to visit the facility with no education or monitoring being provided by the staff. Please also refer to second surveyor's observed findings below in Section B. On 3/16/16 at 1:25 PM, during a walk through on the second floor with the ADON, she confirmed that Resident #100 is on contact precautions. Yet, there was no signage on the resident's bedroom door. The ADON stated she should have signage. In addition, the staff were still using the disinfectant wipes with no bleach to wipe down the resident's overbed table and surroundings. Although by this time, the second floor unit was to have no visitors per the sign posted on 3/15/16, there were two visitors who were noted to be in other residents' rooms. Staff continued to not monitor the visitations during the outbreak. The ADON and charge nurse stated, we just did contact precautions. The ADON said it was her responsibility to check the unit staff for handwashing and that they were following isolation contact precautions. When asked how this was being done, she said she told the staff verbally, and if they did not follow the protocol, she issued a warning slip to them. She did not have any documentation or line implementation/ tracking measures to show how she was monitoring and analyzing the potential for transmission due to breaks in technique/protocol. She also said they did not have a plan in place for staff cohorting on the unit during this outbreak. On 3/16/16 at 1:35 PM, an initial brief interview with the DON revealed she was not involved in monitoring this outbreak. She had been at a nursing conference on 3/8/16, and said the Administrator was the one who started the surveillance and taking the lead. She acknowledged however, that she is the facility's designated Infection Control Coordinator (ICC). The DON also said the ADON is the one who has been monitoring the residents and nursing staff for hand hygiene and use of PPEs. She stated she had no documentation for it. On 3/16/16 at 1:57 PM, an interview with the Administrator was done. He verified the Norovirus Infection policy and procedure is the current one that staff were to follow. He stated, it should be the nursing staff who has to ensure it is being implemented and (the DON), she is the infection coordinator for many years now. The Administrator stated he was the first one to identify the 4 residents on 3/8/16 with symptoms of foul-smelling, large watery stools and vomiting. He said for their initial precautions, it meant limited visitation and volunteers were not allowed to go to the suspected outbreak areas. The advice from their Medical Director at that time was follow your protocol. The Administrator was asked about the potential cross-transmission of infection by staff and how it was being monitored. He stated he was reinforcing the importance of handwashing and to clean with the bleach solution. He did not however, have an explanation for the spread and said my initial reaction was to contain the possible infection on the unit. I was so worried. We have to bring out all the PPEs that is needed and do everything to contain it. Upon query for those residents who did not get a specimen sent for testing, the Administrator said they could not collect it for everyone who became ill. He said he needed to discuss with the State epidemiology branch as to those residents without a stool culture done, when they would be considered cleared of infection. However, for the 4 residents with the positive Norovirus cultures, such as Res #29, whose last loose stool was on 3/11/16, the Administrator acknowledged they should have kept her on contact precautions until the culture results came back, but did not. In fact, Res #29 was observed to be out in activities with other residents on the unit on 3/15/16. Please also refer to second surveyor's observed findings below in Section B. On 3/16/16 at 4:14 PM, another interview with the DON was done. She has been the facility's ICC for [AGE] years. She has no certification, but receives CDC updates and IC information via webinars and conferences to maintain her role as the ICC. The DON was asked to produce her investigation or any documentation she had of this Norovirus outbreak from 3/8/16 to present. She stated, Actually when I received it from 8th, I got the information on the 9th, and then I was so busy during that time, I had to meet with the Chief Operating Officer for 2 days, so (Administrator) took over my place so that's why he did the reporting, gathering the data and communicating with the State and to (Medical Director) of what's going on. It's not really me--(Administrator) has been communicating with the nurses, he was the one who initiated the contact precaution right away for the residents. So the contact person on this one is (Administrator). She further stated, So today is the first time I have spoken with (individual) in the Department of Health, about the surveillance and what's happening. (Administrator) is still the one going to the nurse's station and doing the preventive measures. He talked to the CNAs, gave them instructions, posted signs. The DON was queried who was ensuring it is being implemented, and her response was, Him, ADON and me too, but I took over this Monday. I make sure that they have this one, the sanitizer, gloves, the disposable gowns, masks, it were all taken out the first day. This was not observed when the survey team entered on 3/15/16. The DON was asked what the facility's plan was to contain the outbreak. She said, the plan--it's all in the binder, the infection control and this one given by (consultant) regarding Norovirus. We were set to meet with her yesterday, but it was rescheduled. I never write anything about it, this is the only document I have (the Administrator's outbreak surveillance spreadsheet). I did not document the things that we did. She was asked what kind of precautions were implemented and responded, First, instructed all CNAs to observe handwashing use of gloves everytime they handled the patients, they have PPEs. Contact precaution at first, but CNAs advised not to bring them out of the room. All the patients listed in here with symptoms with vomiting and diarrhea cannot get out of the room. Yeah, they were instructed and charge nurse to keep the patients inside the room. I base it from the last symptoms, when they had symptoms on the 8th, they were not out until the 15th. Some came out because already free of symptoms. If still awaiting a stool culture result? Then these people--when we're waiting for the culture--well, we only sent for 4. Really, he (Administrator) is the one going in and out to the nurse's station as well. For the newly identified Res #100, the DON stated she was informed, only this morning about the loose BM. Did you check to see if she had the appropriate signage--everything as you stated? No, I did not, I did not check on her this morning. But because the nurse should put the sign. Really, I didn't check if the sign is posted. Actually, since (Administrator) is the one in communication with our staff all the time, I thought he did-- we work together and (ADON) too. The reason why too, I didn't really go that side, but I have to go up and down (the first and second floors). I didn't wear PPEs. The DON said if there is signage, if they are doing nursing care, they supposed to wear mask, gown, glove, but after touching the patient, they supposed to use hand sanitizer, before they touch any other residents. We just had inservice last week to use hand sanitizer after every patient after nursing care. Hand washing after 2 hand sanitizer use, they have to do handwashing as much as possible. She confirmed their staff should use the hand sanitizers alternating with hand washing (soap and water) by the third time. (Note: The final contact precaution sign posted on 3/18/16 stated, Handwashing To Be Done With Soap and Water Only). The DON was also asked if staff had to clean the residents' areas with the Sani-cloths and how she knew the appropriate ones were being used. She replied, Yeah, yeah. Actually, we let them know and on the container, we have 2 mins, 5 mins--the contact time. It's five minutes. She could not state that surveillance was being done for this because she stated she did enter the second floor nursing unit where the outbreak was. The DON confirmed she had no documentation or analysis of the Norovirus outbreak from the start. She also did not cohort staff and stated, No, I thought (Administrator) doing this. I did not really document on this .I made sure they have all preventive supplies what they need, like containers of their dirty items. I did not go up to the part there (the second floor unit) and because I saw already on floor the ADON making rounds during this time. Review of the facility's Norovirus Infection policy 2/08 (last reviewed 5/15), found: In the event that Norovirus infection is suspected, precautions will be initiated immediately to prevent or minimize the transmission of infection. Policy Implementation: 1. Norovirus infection will be suspected once there is a report of diarrhea and vomiting of at least 3 times per day on at least 3 residents. 2. Soon as Norovirus infection is suspected, facility must immediately initiate Contact Isolation precautions. 3. Residents showing signs of infection will be confined in their rooms to minimize the risk of transmission to other residents. 4. Limited or restricted visitation will be imposed immediately. 5. Stool specimen of residents showing signs of infection will be sent to lab for Norovirus testing. 6. Once confirmed, no resident will be allowed to go to other floor and staff will work only on the unit they are assigned. 7. All surfaces and equipment will be cleansed with bleach wipes or spray .11. Admissions will be closed and group activities on the unit will be discontinued until after 4 days of the last reported case . This policy was not consistently implemented such that by 3/9/16, 1 more resident became ill, but notably that all 5 residents at that point in time were in different rooms. Then on 3/10/16, 6 more residents came down with the gastrointestinal illness, with an additional 2 more residents by 3/11/16, 1 more resident on 3/14/16 and another resident on 3/15/16. An undated Infection Surveillance policy found: Procedures .6. If infection is confirmed, Charge Nurse initiating treatment should complete the Infection Report, filling up all details . The DON, with [AGE] years as the ICC, had no initial reports or documentation to produce regarding this outbreak within their facility. Another undated policy, Management of Outbreak of Communicable Diseases, found: Policy .5. Symptomatic residents and employees are considered potentially infected and are cultured and isolated as indicated .For Director of Nursing .3. Assigning nursing personnel to same residents group for the duration of the outbreak .For Nursing Staff .4. Initiating isolation barriers as directed or as necessary. 5. Confining symptomatic residents to their rooms for at least 72 hours after onset of infection .For the Medical Director .2. Overseeing the management of the outbreak. The Administrator said their Medical Director's response was if the residents had no fever and were asymptomatic, the residents would be in the clear. However, the Administrator noted that none of these residents had fever as one of their symptoms. As of the result of the lack of following their own policies and procedures to prevent the spread of the Norovirus, on 3/17/16 at 8:18 AM, the Administrator was notified of the IJ. He verified the LHC Norovirus Infection policy is current and is what the staff had to follow. The Administrator developed an initial abatement plan on 3/17/16 at 2:50 PM, which was not accepted by the survey team as it lacked immediate corrective measures to prevent further spread of the Norovirus. On 3/18/16 at 8:30 AM, the Administrator produced an acceptable IJ abatement plan. Some of the corrective measures were observed by surveyors on the unit as applicable, and included: - The facility contracted with an infection prevention consultant to review the entire infection control program. The consultant is to provide recommendations to correct areas related to staff knowledge of infection prevention, education needs, need for isolation signage, proper placement and care of residents. - New policies and procedures will be written and implemented. - Temporary isolation signs have been placed on rooms for residents who continue to be ill with Norovirus. - Rounds were completed by the IP consultant on the second floor on 3/17/16. - Inservicing to be conducted by the Administrator for evening and night staff and EVS/laundry staff. Cleaning of the unit, especially the bathrooms and floors to be more frequent, at least 3-4x/day. - PPEs placed outside the door of each room on isolation, to be used before entering the room. - Use of Sani cloths with bleach and Clorox solution to clean bathrooms and floors. - No admissions on the second floor while it is on lockdown; visitation is not allowed unless necessary and visitor instructed what to do and use PPE before entering the room. - Resident will be cleared of infection 72 hours after the last diarrhea and vomiting is noted. - Infection will be cleared after the last case has no symptoms for 72 hours. - Terminal cleaning of the unit done once lockdown is lifted before any further admissions occur. In addition, as verified by the DON during her interview, there was no documentation or active case finding upon her knowledge (and others) when the Norovirus outbreak was suspected. She stated she had knowledge of it on 3/9/16, but as the primary Infection Control Coordinator for the facility, failed to fully ensure the facility's policies were being implemented. As a result, additional residents became symptomatically ill. The facility only took corrective action to systemically implement measures once the IJ was identified and thus, failed to safeguard the health of the residents and visitors. B) A review of the facility's policy and procedures for Norovirus Infection notes when norovirus is suspected, precautions will be initiated immediately. Policy implementation includes the following: Residents showing signs of infection will be confined in their rooms to minimize the risk of transmission to other residents . The facility failed to implement its policy for residents on contact precaution with signs of infection and for residents not on contact precaution with signs and symptoms of infection. 1. Observation during the lunch meal on 3/15/16 found Resident #102's meal tray with clear liquids. The staff member delivering the trays reported the resident has diarrhea. On the afternoon of 3/15/16 a record review was done for Resident #102. A physician's orders [REDACTED].#102 a liquid diet until diarrhea stops and to place the resident on contact precaution. During the meal observation, Resident #102 was observed to be in the bathroom and used the toilet independently. On 3/15/16 at 2:10 P.M. an interview was done with the Licensed Nurse (LN). The LN confirmed Resident #102 was placed on contact precaution, inquired what does this mean, contact precaution. The LN responded it means strict hand washing and use of gloves. Further queried whether the resident is required to remain in his room, the LN reported that he usually mingles with the other residents and the staff members will keep an eye on him to ensure he doesn't mingle with the other residents. During the interview with the LN, Resident #102 was observed wheeling himself into the activity room. The resident went to the refrigerator, opened the door and wheeled himself to the front of the refrigerator. A staff member asked the resident what he wanted, the staff member was heard telling the resident to return to his room and they will bring him some juice. A staff member wheeled him back to his room. The staff member confirmed the refrigerator contained residents' food and drinks. The refrigerator was not sanitized after the resident on contact precaution went into the refrigerator. On 3/17/16 at 9:32 A.M. the DON was interviewed. Queried whether the refrigerator needed to be sanitized after the resident went into the refrigerator, the DON responded that she had heard about it. The DON did not confirm the refrigerator required sanitizing. 2. On the morning of 3/15/16, Resident #29 was observed seated on a large table with fell ow residents playing Bingo. Resident #29 was seated between two residents. During lunch, the resident was seated in the dining room with another resident. A review of the Outbreak Surveillance Form notes Resident #29's onset date of illness (diarrhea) was 3/10/16 with last date of illness on 3/11/16. A stool sample taken on 3/10/16 was found to be positive for norovirus on 3/15/16. Observations on 3/16/16 found Resident #29 confined to her room. 3. On 3/16/16 during the lunch meal, the following residents were observed dining the activity/dining room: Resident #86, Resident #89 and Resident #96. Resident #86's onset date of vomiting and diarrhea was 3/8/16 and date of last illness was 3/9/16. Resident #89's onset date of diarrhea was 3/11/16 with last date of illness documented as 3/12/16. Resident #96's onset date of diarrhea was 3/10/16 and last date of illness of 3/10/16. At this time, the Administrator and DON were unable to provide information related to discontinuation of limiting residents with signs and symptoms of illness with other residents. On 3/18/16, the Administrator reported residents without signs and symptoms of illness for 72 hours would be able to join residents in the dining/activity room. 4. On the afternoon of 3/15/16, Resident #147 was observed ambulating with a forward wheel walker with the assistance of a therapist. This resident was listed on the Outbreak Surveillance Form with onset date of vomiting and diarrhea of 3/9/16 with last date of illness of 3/10/16. The resident was not wearing personal protective equipment (gown, gloves and face mask) This resident's stool was noted to be positive for norovirus on 3/15/16. The resident was treated with [MEDICATION NAME]. On 3/17/16 at 2:00 P.M. an interview was done with the Speech Language Therapist (SLT). The SLT was able to confirm Resident #147 participated in occupational and physical therapy on 3/16/16 at 2:42 to 3:40 P.M. The SLT reviewed the therapist's note of 3/15/16 to confirm Resident #147 received therapy services for bed mobility and had complained of stomach pain. The facility failed to confine Resident #147 with signs of infection and failed to ensure communication with the therapy department was done to practice contact precautions (confine the resident to the room and to use appropriate personal protective equipment). 5. On 3/16/16 during the lunch meal, Residents #116 and #113 were found to have non-disposable plates/bowls and utensils. Resident #116 had an onset of vomiting and diarrhea on 3/8/16 and last date of illness on 3/9/16. Resident #116 was treated with [MEDICATION NAME]. Resident #113's onset date of vomiting and diarrhea was 3/10/16 with last date of illness of 3/13/16. Other residents (Resident #63, Resident #147 and Resident #102) identified on the surveillance form were provided meals on a yellow tray with disposable plates/bowls and utensils. Interview with the Administrator found residents with infections require a special tray (yellow) with disposable plates/bowls and utensils. 6. The facility failed to limit visitors to the unit during the outbreak of norovirus. On 3/16/16 during the lunch meal observation. There were three visitors present assisting residents with their meals. One visitor was observed to obtain a meal tray from the cart without hand sanitizing. On 3/16/16 at 12:05 P.M. a visitor was observed to enter the unit. The visitor reported she was going to visit a relative in room [ROOM NUMBER], Resident #146. Inquired what information was provided to her while visiting her family member. The visitor reported she was asked where and who she was going to visit and how long she was going to stay. The visitor reported she was told there is a virus on the second floor. Further queried what other instructions were provided. The visitor reported she is to take precautions, wear a mask and use the hand sanitizer. A review of the surveillance log found Resident #146's roommate with onset of illness, vomiting and diarrhea on 3/11/16 with last date of illness dated 3/10/16. C) A staff member failed to ensure hand hygiene/glove change was done during care of a resident on contact precaution. The facility also failed to provide appropriate disinfecting solution for this resident with positive culture for ESBL E.coli and ensure equipment use is designated for only this resident. On 3/16/16 at 9:40 A.M. observed a Certified Nurse Aide (CNA #1) bringing Resident #81 out of the shower. Resident #81 was seated in a shower commode. The CNA was wearing a yellow gown, booties, gloves and face mask. The CNA was placed the resident in her wheelchair at the foot of the bed. The CNA removed the resident's bed linen, put the resident's socks on, went to the covered shelf and brought out clean linen. The CNA then made up the resident's bed. Subsequently, another CNA provided assistance to transfer the resident to bed. CNA #1 removed a yellow gown from the plastic covering which was placed on the chair between two armoires. CNA #2 was observed to put on a yellow gown, gloves and face mask at the linen shelf. The two CNAs transferred the resident to bed. CNA #2 removed the gown, glove and face mask and tossed it in the receptacle in the resident's room. CNA #1 placed the shower commode back into the bathroom. A disinfectant wipe was used to wipe the top of the commode, the armrest and the plastic pipes at the base. CNA #1 did not change gloves during the observation period. At 9:50 A.M. the CNA confirmed the wipes used to clean the shower commode was from the commercial disinfectant wipes container and the equipment is wiped before and after the residents with a five minute wait time before using the equipment again. A record review was done on 3/17/16 at 8:39 A.M. Resident #81 was admitted to the facility on [DATE]. A review of the physician's orders [REDACTED]. Subsequent note for 2/4/16 documents the resident is positive for ESBL and e. coli from suctioned sputum. The resident was placed on contact isolation. The order for 3/17/16 notes to discontinue contact isolation. On 3/17/16 at 9:32 A.M. an interview was conducted with the Director of Nursing (DON). The care observation done on 3/16/16 from 9:40 A.M. to 9:50 A.M. was shared with the DON. Queried the DON whether a glove change was needed during the CNA's care of Resident #81. The DON replied a glove change is not needed when you go from a clean area to another clean area. Further queried whether a glove change was indicated following the removal of the bed linens and going into the clean linen storage. The DON responded a glove change was indicated. The DON reported the commercial disinfectant wipes with bleach is adequate to sanitize the shower commode; however, due to the resident's sputum being positive for ESBL and e.coli, the equipment should be designated for only Resident #81. The DON further stated the wipes that were provided to the rooms this week is adequate. The DON also confirmed the underside of the shower commode seat needed to be wiped down. A review by two surveyors found the commercial disinfectant wipes did not include bleach. Subsequent observation found the commercial disinfectant wipes were removed and replaced with a solution that includes bleach. D) On 3/15/2016 at approximately 12:30 PM, a physician was observed checking a resident's chest with a stethoscope. He then went and placed his hand on another resident's forehead to tilt her head backwards and used his other hand to touch the resident's eye area. He then went to the nurse's station and pulled a medical record out to write in. No hand washing or hand hygiene was observed to be done by this physician between his examination of the residents or thereafter.

Based on observation, record review, staff interviews and a review of the facility's policy and procedures, the facility did not ensure the resident's environment remained free of accident hazards and that each resident receives adequate supervision and assistive devices to prevent accidents for 5 of 37 residents in the sample. As a result, one resident had the potential for choking by aspirating food, one resident aspirated a foreign body, two residents who were in a wheelchair were being transported by one staff, and one resident who goes out on pass with a family member but the facility does not have a policy for resident who go out on pass to ensure that the resident's safety is maintained. Findings include: 1. Res #47 was admitted to the facility in October 2012 with several [DIAGNOSES REDACTED]. A 4/16/15 significant change in status assessment MDS coded the resident as being non-interviewable, is rarely, never understood with no behaviors. His functional status showed his bed mobility as extensive assist with total dependence for transfers with 2 plus person physical assistance needed. The CAA nutrition notes revealed he is on a mechanically altered diet of pureed solids and pudding thick liquids for safe swallowing and noted to be tolerating his diet well with no manifestations of coughing, choking or swallowing difficulty. However, during a 6/4/15 interview of the resident's roommate, the roommate stated for Res #47, staff used to get him up into his geri chair. Now he doesn't get up anymore, something about his chair not fitting him, but now they don't do it in the morning, and sometimes, recently in the afternoon they get him up. I asked them, how come you don't get him up anymore. They don't respond. A lot of time I do hear him like choking. They try to sit him up on a bigger pillow and feed him and they sit on their knees. It would seem to me that that's even harder. On 6/5/15 at 8:36 AM, it was observed the resident was in his low bed. LN #3 said he was fed at 8:05 AM and brought back to the room at 8:25 AM. She said Res #47 gets up for every meal because he is at risk for aspiration. He is, that's why we have his head elevated when we put him back to bed so that's why head is elevated and not like totally flat. LN #3 was asked if the resident was fed that fast, in 15 minutes and she said, he's a good eater. On 6/8/15 at 8:12 AM, LN #3 and CNA #4 brought Res #47 into the dining room in a geri chair covered with a white sheet. LN #3 lifted the back of the geri chair to position Res #47 into a high Fowler's. However, the geri chair did not hold this position and dropped down to a low Fowler's. LN #3 attempted it again, which held, and then said, okay, and left the resident to CNA #4. CNA #4 turned around to get a food item off the breakfast tray on the table behind her. Then, the back of the geri chair dropped back down to a low Fowler's position, observed to be at 30 degrees. Two other surveyors observed this angle as well. CNA #4 however, failed to notice that the geri chair had dropped down again with the resident reclined. Instead, CNA #4 proceeded to stand directly over him and started to feed him a cereal mush. Each spoonful was a large heaping amount which she spooned into his mouth. It was also 45 minutes after the breakfast trays came out, so the resident was hungry and swallowed quickly. CNA #4 did not attempt to slow him down. The following was observed: - At 8:17 AM, the resident finished the first bowl, then was started on pureed eggs and sausage. - At 8:21 AM, the resident coughed several times. CNA #4 said, you okay, and paused from feeding him. She then restarted with spoonfuls of thickened Ensure. - At 8:27 AM, he finished the Ensure, and CNA #4 started the pureed papaya. - At 8:30 AM, he finished the papaya and CNA #4 started the thickened coffee. She replies it's hot, then says no, a little bit warm. - At 8:33 AM, he finished the coffee and was started on juice, the last item on his tray. By this time, the resident involuntarily put his left arm under his head, had his eyes closed and only opened his mouth with verbal cueing. - At 8:36 AM, the resident finished the juice and CNA #4 said he ate everything. This took approximately 23 minutes. (The other day he was fed in approximately 15 minutes per LN #3.) On 6/8/15 at 8:37 AM, interview with LN #3 revealed that Res #47, supposed to be propped up higher because he has swallowing problems, because he's on pudding liquid and puree. It should be higher, because of the risk for aspiration. Should staff be sitting down and feeding the resident? Yes. Surveyor and LN #3 observed at 8:42 AM that CNA #4 pulled a chair next to the resident and sat next to him to talk with him. She also moved the geri chair to position him to a semi-Fowler's. She also used the edge of a dining room table to support the back of the geri chair to maintain it in this position. At 8:45 AM, LN #3 said, the head is elevated, but found the geri chair could not lock into the position without it being propped up. CNA #4 said, no lock to keep up. The last time I put a small table behind. Then both she and LN #3 tried to demonstrate how the geri chair worked, but confirmed that it does not lock to keep Res #47 upright when they feed him. At 8:55 AM CNA #4 was asked how long it has been this way. She stated in the presence of the DON, he has a permanent one but it's broken. This one is temporary and it's about 2 days--still new. Surveyor related this was the same torn geri chair seen in use last week, so 2 days was incorrect. CNA #4 then shrugged and said, this chair is broken. On 6/8/15 at 9:03 AM, the DON was queried and stated, He is aspiration risk. What is your expectation of your staff? They know if patient is monitored for aspiration, during feeding time they should sit patient upright during feeding and at least upright 30 mins after feeding. I think it's in the care plan too. Review of the Res #47's care plan revealed, At risk for nutritional fluid deficit an aspiration related to swallowing deficit possibly secondary to dementia, mental retardation, an/or effects of multiple use of psychotropic meds.as evidenced by - episodes of coughing when eating or swallowing. Nursing interventions included: 2. Nursing staff will provide verbal cueing to chew and swallow food slowly to prevent choking and aspiration. Make sure that the resident is on the geri chair during meals and will keep him in geri-chair for at least 20-30 mins. after each meal before placing him back to bed for aspiration precaution. The DON later said, The staff were aware this chair is broken, but I was not able to followup with the other chair and I didn't realize that they were using this geri-chair. We have been inserviced by our speech and consistency of feeding. I'm sure all CNAs taking care of him know he has to be 45 degrees and up. This is my first time to see him in the chair. She affirmed the staff should be educated on aspiration risk and not to use broken equipment. She also said, (MDS-C) saw Res #47 being fed by (CNA #4) this morning but she did not report any concerns and shook her head. The DON said she confirmed with LN #3, once you put someone into that geri chair, it cannot maintain the weight. The care plan was not followed by either licensed and unlicensed nursing staff during the 6/8/15 meal observation. In addition, on 6/5/15, the resident was observed being put back to bed. It was LN #3 who stated when he ate and finished (approximately 15 minutes), but did not keep the resident in the geri chair as the care plan intervention states. Thus, the potential for harm exists for Res #47 who requires feeding assistance and known to be at risk for aspiration: - The staff failed to follow the care plan for a resident known to be at risk for aspiration, placed the resident into a geri chair that was known to be broken by licensed, unlicensed staff and the maintenance supervisor, and fed an entire meal in a low Fowler's position. - CNA #4 continued to stand directly over him during the 6/8/15 observation. She did not sit and feed him at eye level, nor attempted to assess his swallowing ability. In fact, she continuously fed him large spoonfuls without stopping between the different food items, except for the time he coughed. - The method CNA #4 used to feed the resident placed him at greater risk for aspirating the food because by standing over him and spoon feeding him large portions, the food was going into the resident's mouth at a heightened angle. This did not minimize, but increased aspiration risk by this method of feeding. - On the 6/5/15 observation, the resident was placed back to bed right after he ate. This also placed him at aspiration risk by not following the care plan. The resident has involuntary spastic movements which prevent him from maintaining an upright position even while surrounded by pillows. He was not kept upright in his geri chair for approximately 20-30 minutes after his meal on this observation. - The DON said on 6/8/15, I really don't have time to follow-up on this, because when I'm making my rounds, they always tell me, but this one, nobody reported. (MDS-C) is the one who knows about the resident's care plan and watching the staff. - According to LN #3 however, it is the DON who provides the in-service training to the CNAs. Thus, if the DON does not observe the care being provided by licensed and unlicensed nursing staff, she would not know if the staff are trained to deliver the care. - Interview with the maintenance supervisor (MS) on 6/9/15 at 11:24 AM revealed the cable to the geri chair was broken. On 6/10/15, he confirmed he had no inventory on the facility's assistive devices nor had a preventive maintenance program on the geri chairs or wheelchairs. - On 6/9/15, the administrator produced a policy and procedure, Preventing Aspiration in Older Adults with Dysphagia. He said he just created it on 6/8/15 but that staff have been following this practice. The administrator was informed they had no policy and procedure prior to the survey and observation of Res #47. 2. Res #114 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The closed admission record review found the resident was transported via ambulance to an acute hospital's emergency department on 1/18/15 at 11:15 PM. The nursing note of 1/18/15 on the 3-11 shift stated the resident appears not looking good due to drink liquid w/out thickener from the faucet in the BR (bathroom). The emergency department physician noted on the facility's consultation form, aspirated toilet paper wad, elevated troponin. The resident was admitted . The 1/19/15 2:27 AM hospital admission report stated, .O2 sat was noted to be 95% but there was a loud audible wheeze.ER physician was able to extract a 3 cm paper ball that was lodged in the larynx. During the interview with LN #4 on 6/9/15 at 8:45 AM, he said after he gave Res #114 the updraft, he was okay, the paleness was gone. There was no documentation about this. LN #4 also stated, So every 30 minutes I was having my staff check the vitals and also updated the doctor. Because my shift about to end that time, I think I only rechecked and endorsed to (on-coming evening nurse) to continue to monitor the resident for any signs of distress. Record review found the evening shift nurse, LN #6 documented, O2 sat 95%. V/S - 185/101 -95 - 97.9. Breathing slightly labored.called ambulance.pick up at 11:15 AM. The resident's vitals signs were not being monitored every half hour per the day nurse's endorsement. There was no documentation to support this and per LN #4, he confirmed it was not in the record. On 6/5/15 at 1:44 PM, the DON was queried on her investigation of this incident and how this occurred. The DON said her investigation, it was not really in depth. The only mistake I made was I didn't write it down. I'm sure I asked the CNA where were you, or I did not really write because I was thinking my investigation was enough to explain what really happened. She stated, It's difficult for us to provide 1:1 because we only have 4 (CNAs in the evening shift). In my mind, it's not really the abuse I'm looking for, it's the neglect, you guys forgot to look at this patient. I was so scared, I relied on the CNAs telling me this. This case is really a concern because of what happened. So my concern is in the afternoon, it's really difficult, really really few staff to monitor patients. She further went on to say, I was told that this was a tissue paper which everybody cannot believe he can get the tissue paper and there are times when he's really good especially in afternoon and he can walk to the bathroom. In the afternoon I'm not really familiar with activities in afternoon, but in the morning he's being assisted in almost everything, even the feeding in the morning, we have to feed him. She said because he also drooled, he always had tissue paper in his hand to wipe his mouth. But see, I don't know why toilet paper, I don't know why. The DON was queried what she identified and what corrective measures she took as a result to protect other residents. She kept saying, I did an investigation and the CNA said that sometimes they see him inside the bathroom, but it never happened during the day because he's always in the activity area. But in the afternoon, I don't know what time in the afternoon he goes to the bathroom, but there are times that he can get up go to the sink wash hands and wipe and go to the bed. His bed is bed 1, close to the toilet. Only a few feet from the bed to the toilet. I am so alarmed because I'm thinking where did he get the toilet tissue. At the end of the interview, the DON identified there was a lack of monitoring residents due to a lack of staff. She did not have a corrective action plan except to state that she verbally inserviced the nursing staff. There was no staff inservice education to show how future accidents such as this one could be prevented. On 6/8/15 at 9:10 AM, the DON verified that she overlooked writing the interviews of the CNAs. She also confirmed she did not review the risk factors to determine what might have been the cause of this accident but ruled out abuse/neglect. The DON stated it was predetermined in her investigation report that it was not negligence on the part of staff because he was always being followed by the CNA, but then stated, I did not really write any documentation. She acknowledged she did not analyze why this accident happened and again, focused on the abuse/neglect and ruled it out. This was an avoidable accident if there was adequate supervision provided for Res #114. The DON verified they did not have adequate staffing nor accident prevention and supervision for Res #114. In addition, she confirmed the resident's care plan did not include safety for accident prevention for this resident who had alcoholic dementia, cognitive deficit with incomprehensible speech, short/long term memory impairment, required assistance in making his needs known, and had ADL deficits including extensive assist in bed mobility, eating and toileting as coded in his MDS. 3. On 6/09/2015 at 3:43 PM the Activity Aide #1 (AA#1) was observed pushing the wheelchair's for Resident #144 and Resident #88 at the same time from the activity room towards the hallway leading to the resident's rooms. The AA #1 was stopped and asked about safe practice in transporting residents on a wheelchair. The AA #1 called another staff to help with the transport. The other staff responded by taking one of the resident in the wheelchair from AA#1 to push down the hallway. Later on 6/10/2015 at 10:22 AM the AA#1 was interviewed about the incident. AA #1 stated both residents pointed to the hall they wanted go to their rooms. I did not want to leave them because both are prone to falls. I decided to push both residents hoping to locate a CNA for assistance, I did not want to yell. That was not safe, it was an honest mistake. 4. Upon clinical record review of Resident # 12, the facility has provided a Release of Responsibility for Resident Out on Pass form that indicates a time out, time return, destination, articles taken, signature of responsible party and the nurse's signature. Upon facility policy review the facility does not have a policy for residents to go out on pass. An interview was conducted with the DON on 6/10/15 at 01:00 P.M. and she acknowledged that there is a facility form as noted above but the facility does not have a policy for residents who go out on pass.

Based on observations, staff interviews, and record reviews the facility failed to provide sufficient nursing staff based on the staff's inability to provide needed care to residents that enable them to reach their highest practicable physical, mental and psychosocial well-being. Findings include: Cross-reference to findings at F323, F441, F456, and F371 Random staff interviews were conducted throughout the two nursing units of the facility on 6/9/15 at 3:20 P.M. All the staff who were interviewed acknowledged that they could use additional staff to help out in providing care to all residents. An interview was conducted with the Administrator and the DON on 6/9/2015 at 11:15 A.M. They both acknowledged they need additional staff.